Acute Ischemic Stroke Research Articles

Preoperative management and anticoagulant efficacy in atrial myxoma-associated acute ischemic stroke: a case report and literature review

Acute ischemic stroke (AIS) is a common complication of atrial myxoma (AM), and most emboli originate from a thrombus attached to the surface of the myxoma, with occasional shedding of tumor fragments leading to stroke. Clinical manifestations of AM include mitral valve obstruction, systemic embolism, and weakness. However, neurological deficits and other nonspecific manifestations may mask the presence of AM. The surgical resection is the most effective treatment for these conditions. However, the main problem is the lack of consensus regarding the prevention and treatment of stroke complicated by myxoma during the perioperative period. This study aims to improve the diagnosis and treatment of AM and the associated AIS. Here, we report the case of a 27-year-old patient with AM who presented with chest pain, palpitations, and sudden dizziness and had a stroke under anticoagulant treatment during the admission period. We also reviewed and summarized the clinical presentations and characteristics of similar previously reported cases. Our review emphasized the importance of early diagnosis and appropriate perioperative management of AM and its associated AIS.

Abstract 4116285: Safety and Efficacy of Early Direct Oral Anticoagulants Versus Low Molecular Weight Heparin in Patients with Ischemic Stroke and Immobility: A Multi-National Database Study

Background: Low molecular weight heparin (LMWH) is the preferred anticoagulant for venous thromboembolism (VTE) prophylaxis in patients with ischemic stroke and reduced mobility. However, some patients may have indications for early direct oral anticoagulants (DOACs) and are continued on this therapy rather than transitioning to LMWH. Whether outcomes differ between these groups is unknown. We compared the safety and efficacy of early DOACs versus LMWH from a large retrospective database. Methods: Patients within the TriNetX Research Network receiving either DOACs or LMWH within 72 hours of ischemic stroke and a Modified Rankin Scale of 4-5 were included. A 1:1 propensity score matching analysis was performed using 27 covariables including demographic information, comorbidities, and medications. Chi-square and independent t -tests were used in bivariable analyses. Outcomes were all-cause mortality, VTE, intracranial and extracranial hemorrhage at 30 and 90 days. Results: Of 5,492 propensity-matched patients, mean age was 73±13, and 43% were male. Mortality in the DOAC group was significantly lower than in the LMWH group at 30 days (RR=0.59, 95% CI: 0.51-0.69) and 90 days (RR=0.63, 95% CI: 0.56-0.71). Risk of VTE was not significantly different at 30 days (RR=0.80, 95% CI: 0.43-1.50) or 90 days (RR=0.74, 95% CI: 0.45-1.22). Risk of intracranial hemorrhage was not significantly different at 30 days (RR=0.81, 95% CI: 0.36-1.80) or 90 days (RR=0.62, 95% CI: 0.34-1.15). Conclusions: In patients with acute ischemic stroke and reduced mobility, early use of DOACs was associated with lower mortality compared to early use of LMWH.

Abstract 4143281: The Influence of Personal and Family Support on Maternal Cardiovascular Health: Insights from a TriNetX Study

Background: Maternal cardiovascular health during and after pregnancy is influenced by various factors, including personal and family support. However, the specific impact of abnormal personal and family support on maternal outcomes remains understudied. Methods: Utilizing the TriNetX global health research network within the US Collaborative Network, we investigated the influence of abnormal personal and family support (ICD10CM:Z63) on maternal cardiovascular outcomes within one year post-pregnancy. Cohort 1 comprised women aged 15 to 60 with documented problems relating to primary and family support during or after childbirth between 2008 and 2023. Cohort 2 included a similar demographic with good primary and family support. Data were extracted from electronic health records, and the cohorts were matched based on diverse sociodemographic traits and medical comorbidities. Results: Our analysis revealed significant associations between problems relating to primary and family support during and after pregnancy and adverse maternal cardiovascular outcomes. Specifically, the presence of such challenges significantly increased the risk of major adverse cardiac and cerebrovascular events (MACCE) (OR: 4.823, 95% CI: 3.361 to 6.919, p<0.001) and all-cause mortality (OR: 8.461, 95% CI: 5.184 to 13.812, p<0.001). Interestingly, it was associated with a reduced risk of peripartum or postpartum preeclampsia (OR: 0.603, 95% CI: 0.403 to 0.903, p<0.001). However, no significant association was observed between these personal and family support challenges and acute MI (OR: 1.092, 95% CI: 0.482 to 2.747, p=NS), ischemic stroke (OR: 1.403, 95% CI: 0.623 to 3.160, p=NS), hemorrhagic stroke (OR: 1.000, 95% CI: 0.416 to 2.404, p=NS), heart failure (OR: 1.075, 95% CI: 0.636 to 1.817, p=NS), or peripartum cardiomyopathy (OR: 0.586, 95% CI: 0.322 to 1.068, p=NS). Conclusion: Our findings highlight the significant impact of abnormal personal and family support on maternal cardiovascular health outcomes during and one year after pregnancy. Addressing challenges related to primary and family support during and after pregnancy may be crucial for reducing adverse outcomes and enhancing overall maternal well-being.

Abstract 4119428: Monosialoganglioside-containing nanoliposomes protect against acute and chronic ischemic stroke injury

Background: Stroke remains a leading cause of mortality and disability. The narrow temporal window and limited availability of, and eligibility for thrombolytic therapy or endovascular thrombectomy are major therapeutic limitations in treating stroke. Neuroprotective therapies that could be given early to replace or augment these existing therapies are needed to improve stroke outcomes. We showed that monosialoganglioside (GM1) containing nanoliposomes composed of phosphatidylcholine, cholesterol and GM1 (70/25/5% molar ratios, NLGM1) protect against hypoxic injury likely through Nrf2-dependent upregulation of antoxidant enzymes. Aims: To test if post-occlusion NLGM1 treatment could reduce 1) acute stroke injury following middle cerebral artery occlusion (MCAO) and 2) chronic injury following photothrombotic (PT) stroke injury. Methods: 20 week old C57BL/6 mice underwent MCAO for 60 minutes and then injected with saline or NLGM1 (1 or 2 mg IV) prior to reperfusion. Neurologic deficit score and brain infarct % area were measured the next day. Separately, mice underwent PT injury followed by injection of saline or NLGM1 (1 or 2 mg immediately and 2 hours post-injury) and cognitive/behavior tests done 1-90 days post injury. Results: Following MCAO, there was reduced neurologic impairment, infarct volume and brain edema with NLGM1 versus saline control (Fig. 1). Following PT injury, there was reduced neurologic, cognitive and motor impairment from Day 2-90 post-injury with NLGM1 versus saline control (Fig. 2). In both stroke models, there was no difference in efficacy between 1 and 2 mg NLGM1 doses. Conclusions: Treatment of mice with NLGM1 following MCAO or PT stroke injury resulted in improved structural (infarct size, edema) and functional (cognitive, behavior, motor) outcomes in the acute (MCAO) and chronic (PT) timeframes. NLGM1 is a potential novel therapeutic agent for stroke.

Alpha‑Asarone Ameliorates Neuronal Injury After Ischemic Stroke and Hemorrhagic Transformation by Attenuating Blood-Brain Barrier Destruction, Promoting Neurogenesis, and Inhibiting Neuroinflammation.

Recombinant tissue-type plasminogen activator (rt-PA), the primary drug for acute ischemic stroke (IS), has a narrow therapeutic window and carries a potential risk of hemorrhagic transformation (HT). Without rt-PA administration, patients may suffer permanent cerebral ischemia. Alpha-asarone (ASA), a natural compound derived from Acorus tatarinowii Schott, exhibits diverse neuropharmacological effects. This study aims to investigate whether ASA could improve outcomes in IS and be used to mitigate HT induced by rt-PA. We employed models of permanent middle cerebral artery occlusion (pMCAO) and photothrombotic cortical injury (PCI) to investigate both the therapeutic efficacy and underlying mechanisms of ASA during the acute and recovery periods following IS, respectively. Additionally, Sprague-Dawley rats were subjected to rt-PA treatment at 6-h post-PCI to mimic HT (rt-PA-HT). Our results revealed three key findings: (1) ASA demonstrated therapeutic effects in the acute phase of pMCAO rats by alleviating blood-brain barrier damage through inhibition of glial cell-mediated neuroinflammation; (2) administration of ASA 24 h after stroke ameliorated the neurological damage during the recovery phase in PCI mice by promoting neurogenesis via activation of the BDNF/ERK/CREB signaling pathway; (3) ASA attenuated rt-PA-HT injury by modulating the NLRP3/Caspase1/IL-1β and IL-18 pathways. Overall, our findings suggest that ASA mitigates neuronal injury following IS and HT, positioning it as a promising candidate for treating these conditions.

NIMG-07. GLIOBLASTOMA AS A MIMIC OF ACUTE ISCHEMIC STROKE: AN UNDERRECOGNIZED PHENOMENON AND THE IMPACT ON PATIENT OUTCOMES

Abstract BACKGROUND Glioblastoma may present similarly to acute ischemic stroke. This study aims to determine characteristics and outcomes of patients with glioblastoma presenting with stroke-like symptoms. Our objective is to characterize patients with glioblastoma who present as mimics of acute ischemic stroke and identify differences in outcomes when compared to those diagnosed with glioblastoma only. METHODS The 2016-2019 National Inpatient Sample (NIS) database was queried for all patients who had a new diagnosis of glioblastoma. Patients with new glioblastoma who carried an admission diagnosis of acute ischemic stroke, but did not undergo thrombectomy, chemical thrombolysis, or hemicraniectomy were categorized as “GBM-Stroke Mimic”. The characteristics and comorbidities between GBM-Stroke Mimic and new glioblastoma patients were compared. Primary outcomes analyzed were discharge disposition and mortality. RESULTS Of 61,755 patients newly diagnosed with glioblastoma, 1,000 (1.6%) were GBM-Stroke Mimics. GBM-Stroke Mimic patients more commonly presented with aphasia (P < 0.001) and hemiplegia (P < 0.001). Age greater than 65, atrial fibrillation, diabetes mellitus, hypertension, hyperlipidemia, and long-term anticoagulation/antiplatelet therapy were more commonly associated with GBM-Stroke Mimic patients (all P < 0.001). GBM-Stroke Mimic patients were more likely to be discharged to skilled nursing facility, (p < 0.001), and a diagnosis of GBM-Stroke Mimic was an independent risk factor for inpatient death (P < 0.001). CONCLUSION To our knowledge, this is the first study formally investigating the clinical outcomes of glioblastoma when initially diagnosed as stroke. When this misdiagnosis is made, we found an association with increased inpatient mortality, delays of care, and inappropriate resource allocation.

Prolonged venous transit is associated with worse neurological recovery in successfully reperfused large vessel strokes.

Venous outflow (VO) impairment predicts unfavorable outcomes in patients with acute ischemic stroke caused by large vessel occlusion (AIS-LVO). Prolonged venous transit (PVT), a visual qualitative VO marker on CT perfusion (CTP) time to maximum (Tmax) maps, has been associated with unfavorable 90-day functional outcomes despite successful reperfusion. This study investigates the association between PVT and percent change on the National Institutes of Health Stroke Scale (NIHSS) among AIS-LVO patients who have undergone successful reperfusion. We performed a retrospective analysis of prospectively collected data from consecutive adult AIS-LVO patients with successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b/2c/3). PVT+ was defined as Tmax ≥10 s in the superior sagittal sinus, torcula, or both. The primary outcome was continuous NIHSS percent change and dichotomous NIHSS percent change ≥70%. Regression analyses were performed to assess the effect of PVT on NIHSS percent change. In 119 patients of median (IQR) age 71 (63-81) years, the admission and discharge NIHSS scores were significantly higher in PVT+ patients compared to PVT- patients (17 [14-23.5] vs. 13 [9.5-19], p = 0.011, and 7.5 [4-12] vs. 3 [1-7], p < 0.001, respectively). After adjusting for age, sex, hypertension, diabetes, atrial fibrillation, administration of intravenous thrombolysis (IVT), Alberta Stroke Program Early CT Scores (ASPECTS), mTICI 2c and/or 3, Tmax >6 s volume, and hemorrhagic transformation, PVT+ was significantly associated with lower NIHSS percent change (B = -0.163, 95%CI -0.326 to -0.001, p = 0.049) and was less likely to achieve higher than 70% NIHSS improvement (OR = 0.331, 95% CI 0.127-0.863, p = 0.024). PVT+ was significantly associated with reduced neurological improvement despite successful reperfusion in AIS-LVO patients, highlighting the critical role of VO impairment in short-term functional outcomes. These findings further validate PVT as a valuable adjunct imaging biomarker derived from CTP for assessing VO profiles in AIS-LVO.

Prognostic Value of Red Cell Distribution Width in Outcome of Acute Ischemic Stroke

Background: Red cell distribution width (RDW) is a haematological parameter that indicates the range of sizes of red blood cells. It is now widely acknowledged as a prognostic indicator for ischaemic stroke. Aim and Objective: To Study theprognostic value of red cell distribution width (RDW) in outcome of acute ischemic stroke. Materials and Method: The cross-sectional study was undertaken at Aarupadi Veedu Medical College in Puducherry. It included 61 patients, aged 18-80 years, who were diagnosed with acute ischemic stroke within 48 hours. Clinical assessment of patient by NIHSS Score and measuring the outcome by modified Rankin scale. The study took place in both the Outpatient and Inpatient in Department of General Medicine. Results: The study indicates a notable proportion of male more than female ,older participants (64.0% aged 56 years and above), There is a significant occurrence of hypertension (62.3%) and diabetes mellitus (63.9%) a substantial frequency of individuals who do not smoke (63.9%), and a majority of participants who do not use alcohol (77.0%). Levels of RDW exhibited significant positive relationships with stroke severity. Conclusion: The study highlights the potential of Red Cell Distribution Width (RDW) as a helpful predictive indicator in outcome of ischemic stroke. Increased RDW levels were observed to have a substantial correlate with more severe stroke and disability, as indicated by strong associations with NIHSS and mRS scores. The study emphasizes the usefulness of RDW in assessing the severity of ischaemic stroke and emphasizes the need for additional research to improve its clinical use.

Investigations of Acute Ischemic Stroke Detection Techniques from CT Images Using Machine Learning Approaches

Stroke is a kind of cerebrovascular accident (CVA) that primarily affects individuals over the age of 50, while it can afflict people of all ages. Stroke patients suffer from a chronic condition that leaves them physically unable till their death. To identify the onset of this illness, numerous studies have been carried out. Common signs of a stroke include stiffness, a shift in posture, and tremors in the arms and legs. Functional and emotional mediation are linked to a significant area of the brain. The symptoms of many brain disorders are similar in the early stages because of disruptions to dopamine and other regulating mechanisms. This is a crucial step in how stroke lesions develop. The CAD system is the most efficient method for identifying a stroke. By speeding up the analysis of the required aberration, the CAD system improves the process of illness diagnosis. The goal of the proposed study is to create a compact system that can lessen processing errors, false positive rates, and complexity—three major problems with the current system. The proposed study uses a machine learning model to interpret and classify a CT brain image that shows an Acute Ischaemic Stroke (AIS) lesion. To distinguish between normal and AIS stroke lesions, the pre-processed image is segmented and classed using a Random Forest classifier. Performance criteria like Peak signal ratio, average gradient, accuracy, specificity, sensitivity, and dice index are used to evaluate the experimental output of the proposed work. The suggested model has a straightforward processing structure and the highest efficiency.

NCOG-18. META-ANALYSIS OF DIRECT ENDOVASCULAR THROMBECTOMY VS BRIDGING THERAPY IN THE MANAGEMENT OF ACUTE ISCHEMIC STROKE WITH LARGE VESSEL OCCLUSION

Abstract Debates persist when using intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) for acute ischemic stroke (AIS) due to large-vessel occlusion (LVO). This systematic review and meta-analysis synthesized evidence on outcomes in patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO), comparing bridging therapy (BT) with MT alone. METHOD We conducted searches of PubMed, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials from inception to July 2023 to identify pertinent clinical trials and observational studies. RESULT 76 studies, involving 37,658 patients, revealed no significant difference in 90-day functional independence between DEVT and BT. However, a trend favoring BT for achieving functional independence with a modified Rankin Scale (mRS) of 0–1 was observed, having Odds ratio (OR) of 0.75 (95% CI 0.66–0.86; p &amp;lt; 0.001). DEVT was associated with higher postprocedural mortality (OR 1.44;95% CI 1.25–1.65; p &amp;lt; 0.001), but a lower risk of symptomatic intracranial hemorrhage compared to BT (OR 0.855; 95% CI 0.621–1.177; p = 0.327). Successful recanalization rates favored BT, emphasizing the importance of individualized treatment decisions (OR 0.759; 95% CI 0.594–0.969; p = 0.027). Sensitivity analyses were conducted to identify key contributors to heterogeneity. CONCLUSION Our meta-analysis underscores the intricate equilibrium between functional efficacy and safety in the evaluation of DEVT and BT for ACS-LVO. Fundamentally, while BT appears more efficacious, concerns about safety arise due to the superior safety profile demonstrated by DEVT. Individualized treatment decisions are imperative, and further trials are warranted to enhance precision in clinical guidance.

Neuroprotective Effects of Rapid Local Ischemic Postconditioning in Successful Endovascular Thrombectomy Patients.

We aim to assess the efficacy of rapid local ischemic postconditioning (RL-IPostC) following successful reperfusion in patients with acute ischemic stroke with anterior circulation large vessel occlusion who underwent endovascular thrombectomy. We conducted an ambidirectional cohort study with 78 prospectively enrolled patients with RL-IPostC and endovascular thrombectomy and 129 retrospectively enrolled patients with endovascular thrombectomy. The RL-IPostC procedure involved 5 cycles of 15-s balloon inflation and deflation in the ipsilateral internal carotid artery. The primary outcome was functional independence, defined as a modified Rankin Scale score of 0 to 2. Secondary outcomes included excellent outcomes (modified Rankin Scale score, 0-1) and early therapeutic response. Imaging outcomes involved infarct volume changes and cerebral edema measurements. Outcomes were compared with postpropensity score matching (1:1) and assessed using univariable and multivariable regression models. In the matched cohort of 136 patients (mean age, 71±14 years; 70 men [51%]), RL-IPostC was associated with a higher rate of functional independence (adjusted odds ratio, 2.47 [95% CI, 1.10-5.68]; P=0.030). The RL-IPostC group exhibited significantly reduced infarct volumes at 24 hours (difference, -12.2 [95% CI, -23.9 to -0.53]; P=0.041) and less infarct growth (difference, -12.2 [95% CI, -23.9 to -0.45]; P=0.042). Furthermore, RL-IPostC correlated with lower increases in net water uptake (difference, -0.04 [95% CI, -0.07 to -0.01]; P=0.018), lower decrease cerebrospinal fluid volume (difference, -7.75 [95% CI, -11.7 to -3.84]; P<0.001), and reduced midline shift at 24 hours (difference, -1.39 [95% CI, -2.48 to -0.30]; P=0.013). RL-IPostC tends to promote functional independence and reduces infarct growth and cerebral edema in patients with acute ischemic stroke post-reperfusion.

A ruptured aneurysmal subarachnoid hemorrhage and vasospasm initially manifesting as acute ischemic stroke: a case report

A ruptured aneurysmal subarachnoid hemorrhage and vasospasm initially manifesting as acute ischemic stroke: a case report

Euthyroid sick syndrome predicts the risk of ischemic stroke-associated pneumonia in the acute stage of ischemic stroke: a nested case-control study

ObjectiveIschemic stroke-associated pneumonia (iSAP) affects about 10% of acute ischemic stroke patients during hospitalization. Current prediction scales for iSAP are insufficient. Identifying early biomarkers for stroke-associated pneumonia is crucial for improving patient outcomes. This study aimed to investigate the predictive value of euthyroid sick syndrome (ESS) for iSAP in acute-stage of ischemic stroke patients.MethodsWe studied 1767 acute ischemic stroke patients within one week of symptom onset, categorizing them into an infection group (iSAP, n=376) and control group (control, n=1391). COX regression analysis was used to identify the potential risk and protected factors. Kaplan-Meier time-event curves and Log-Rank tests were performed to differentiate infection time in patients with ESS or normal T3 group.ResultsThe iSAP group had higher rates of risk factors like older age, atrial fibrillation, COPD, and ESS, along with elevated levels of WBC, CRP,and FT4 levels (all P &amp;lt; 0.001). Conversely, iSAP patients had lower GCS scores, eGFR, TSH, T3, FT3 (all P &amp;lt; 0.001) and T4 levels (P = 0.005) upon admission. No significant differences were observed in sex, smoking history, hypertension, diabetes, or LDL-C levels (P &amp;gt; 0.05). COX regression analysis identified age, KWST scores, leukocyte count, CRP, and ESS (all P &amp;lt; 0.001) as significantly correlated with iSAP. ROC analysis revealed ESS as a predictor with sensitivity of 35.64% and specificity of 87.92% for SAP prediction, like atrial fibrillation and higher than COPD and eGFR.ConclusionESS at admission predicts a higher risk of stroke-associated pneumonia in acute-stage of ischemic stroke.

The Relationship between Raised Mean Platelet Volume and Severity of Newly Diagnosed Acute Ischaemic Stroke

Introduction and Objective: Stroke is one of the leading causes of mortality and long-term disability throughout the world. Mean platelet volume (MPV), a marker of platelet activation, is calculated and provided by automatic blood cell count equipment during routine complete blood count analysis is a surrogate marker of platelet function and a potential mediator of the association between inflammation and thrombosis. So, to investigate MPV in ischaemic stroke and its role to discriminating more severe stroke from mild one the current study was done. Methods: This observational case control study was carried out in Department of Medicine, Dhaka Medical College Hospital (DMCH) from July 2015 to June 2016. 100 patients with attack of ischaemic stroke who presented within 24 hours of symptoms onset were divided into 2 groups (group-1: mRS score 0-2, and group-2: mRS score 3 or more) based on severity. Severity of ischaemic stroke was assessed by the modified Rankin Scale. At the same time 100 age and sex matched controls were taken. Blood samples were collected from both groups and MPV was measured. The results were statistically compared by SPSS 22.0. Statistical significance was accepted at &lt;0.05. Results: The MPV values were more in case group in comparison to control group (10.88±1.23 vs 10.03±1.03; z score-5.31; p value &lt;0.01). Comparison between the 2 groups revealed that MPV value was higher and more significant in group 2 of cases than group 1(10.15± 0.739 in group 1 versus 11.63± 1.04 in group having 2; z score-7.7, p value &lt;0.001). 6 patients of group 2, who could not overcome the situation and died within 24 hours of admission had MPV value of 12.92±0.30. After controlling the risk profiles associated with ischaemic stroke by means of binary logistic regression model, the effect of MPV in ischaemic stroke remained statistically significant (OR: 4.418, 95% CI 2.468-7.908, p= 0.000). ROC curve was 0.85 and standard error 0.039 (95% CI: 0.779-0.932; p&lt;0.01), ...

Beyond conventional imaging: A systematic review and meta-analysis assessing the impact of computed tomography perfusion on ischemic stroke outcomes in the late window.

Non-contrast cranial computed tomography (NCCT) and CT angiogram (CTA) have become essential for endovascular treatment (EVT) in acute stroke. Patient selection may improve when CT perfusion (CTP) imaging is also added for patient selection. We aimed to analyze the effects of implementing CTP in acute ischemic stroke (AIS) patients' treatment to assess whether stroke outcomes differ in the late window. We searched the PubMed, Embase, and Web of Sciences databases to obtain articles related to CTA and CTP in EVT. Collected patient data were split into two groups: the CTP and control (NCCT + CTA) cohorts. Primary outcomes evaluated were modified Rankin Scale (mRS) scores, symptomatic intracranial hemorrhages (sICHs), mortality, and successful recanalization. There were 14 studies with 5809 total patients in the final analysis: 2602 received CTP and 3202 were in the control group. CTP/CTA patients showed significantly lower rates of 90-day stroke-related mortality (odds ratio (OR) = 0.72, 95% confidence interval (CI) = 0.60-0.87, p < 0.01) and significantly higher successful recanalization (OR = 1.42, 95% CI = 1.06-1.94, p < 0.01) compared with CTA-only patients. Analysis of other outcomes including functional independence (mRS = 0-2), critical times, and intracranial hemorrhages was non-significant (p > 0.05). The study highlights the usefulness of CTP-guided therapy as a supplementary tool in EVT selection in the late window. Although the addition of CTP resulted in lower mortality, the favorable outcomes did not improve. Further evidence is required to establish a clearer understanding of the potential advantages or limitations of incorporating CTP in stroke imaging.

TICA-CLOP STUDY: Ticagrelor Versus Clopidogrel in Acute Moderate and Moderate-to-Severe Ischemic Stroke, a Randomized Controlled Multi-Center Trial.

Many studies evaluated the efficacy and safety of ticagrelor versus clopidogrel in patients with ischemic stroke; none of these trials included North African participants, and all of these trials comprised only participants who experienced transient ischemic attack (TIA) or minor stroke. We compared the efficacy and safety of ticagrelor versus clopidogrel in patients with first-ever noncardioembolic moderate or moderate-to-severe ischemic stroke. Our trial involved 900 first-ever noncardioembolic patients with acute ischemic stroke (AIS) who randomly received either loading and maintenance doses of ticagrelor or clopidogrel within the first 24 h of stroke onset. We involved 900 patients in the intention-to-treat analysis. A total of 39 (8.7%) patients in ticagrelor arm and 62 (13.8%) in clopidogrel arm experienced a new stroke [hazard ratio (HR) 0.46; 95% confidence interval (CI) 0.34-0.83; P value = 0.006]. A total of 57 (12.7%) patients in ticagrelor group and 80 (17.8%) patients in clopidogrel group experienced composite of new stroke, myocardial infarction (MI), or death due to vascular insults (HR 0.51; 95% CI 0.43-0.82; P value = 0.004). Participants who received ticagrelor experienced less frequent unfavorable outcomes. We found no significant variation between our study's two arms concerning the hemorrhagic and non-hemorrhagic complications. Patients with noncardioembolic moderate or moderate-to-severe ischemic stroke who received ticagrelor within the first 24 h after ischemic stroke had better clinical outcomes based on recurrent stroke rates and unfavorable modified Rankin Scale (mRS) rates compared with those who received clopidogrel. There were no significant variations between ticagrelor and clopidogrel regarding hemorrhagic and non-hemorrhagic complications. ClinicalTrials.gov identifier number NCT05553613.

Stroke in the young: infective endocarditis due to mitral valve prolapse leading to acute ischemic stroke and subsequent hemorrhagic transformation

BackgroundStroke in young needs an individualized approach before considering thrombolysis. Here we present a case of undiagnosed mitral valve prolapse presenting with stroke due to associated infective endocarditis. Young stroke patients presenting with fever need a panoramic approach.Case summaryThis 39-year-old female with a background history of fever and loss of weight for two months presented to the emergency department with a history of altered sensorium and aphasia. The Magnetic Resonance Imaging (MRI) showed a hyperacute infarct. Hence, thrombolysis with alteplase was considered. Post thrombolysis, the patient had a parenchymal bleed. The diagnostic evaluation yielded stroke secondary to infective endocarditis because of undiagnosed mitral valve prolapse.ConclusionMitral valve prolapse is not associated with stroke in young patients. However, the undiagnosed infective endocarditis and subsequent septic emboli led to an increased risk. Emergency physicians and intensivists should anticipate infective causes before considering thrombolysis, as the results could be counterproductive.

Changes in the functional connections of the brain in patients with hypersomnia in acute ischemic stroke

BACKGROUND: The Disorders of cerebral circulation and sleep are inextricably related, since sleep disorders, including hypersomnia, are closely intertwined with cardiovascular diseases and increase the risk of stroke. Research works on visualization of functional brain changes in patients with sleep disorders and acute ischemic stroke are very few and need more study. AIM: to determine the functional connections of the brain in hypersomnia in patients with acute ischemic stroke by performing functional magnetic resonance imaging at rest. A study of 40 patients with acute ischemic stroke and sleep disorders was performed on the basis of the Federal State Budgetary Institution Almazov Research Center of the Ministry of Health of the Russian Federation. All patients underwent neurological examination, assessment of sleepiness, worry and depression, magnetic resonance imaging was performed on tomographs with a magnetic field induction force of 1.5T, using a standard protocol and special pulse sequences of T-gradient echo 3D MPRAGE and BOLD. Functional magnetic resonance imaging of the brain at rest was used to assess functional connections. Postprocessing was performed using specialized CONN-TOOLBOX software with an appropriate graphical representation of quantitative results based on the selection of areas of interest. RESULTS: Among the examined patients, 23 had hypersomnolence; of these, 8 patients were diagnosed with secondary hypersomnia associated with sleep apnea syndrome. Thus, in the examined sample, post-stroke hypersomnolence was detected in 15 patients (34%). Patients with an unspecified subtype of stroke and right-sided lesions showed a high degree of drowsiness (p 0.05). With the help of functional magnetic resonance imaging of the brain at rest, changes in functional connections between the main nodes of the default mode network with the left temporal pole, cerebellum, central cerebral cortex on the left, angular gyrus on the left, with the dorsal attention network on the right are determined (p 0.05). CONCLUSION: The use of complex magnetic resonance imaging, which includes structural and functional magnetic resonance imaging in patients with acute ischemic stroke and sleep disorders, allows us to identify structural changes and changes in functional connectivity and identify neuroimaging markers of this pathology. Hypersomnolence is typical for patients with an unspecified subtype of ischemic stroke and damage to the right hemisphere of the brain.

Comparative analysis of risk factors and clinical outcomes in young patients with acute ischemic and hemorrhagic stroke

BackgroundStroke is a leading cause of death and disability worldwide and has significant socioeconomic impacts, particularly among young adults. This study focused on young adults (18–55 years) who experienced acute ischemic (AIS) or hemorrhagic stroke (HS) in Zanjan, Iran.MethodsA retrospective registry-based analysis was conducted using data from the Vali-e-Asr Hospital Stroke Center. A total of 5345 stroke patients were recorded between March 2016 and June 2023, and 616 young stroke survivors were included. Baseline demographic data, stroke risk factor data, functional status (modified Rankin scale (mRS) score, stroke severity (NIHSS score), treatment history, and mortality were analyzed. The statistical analyses included chi-square tests, independent t tests, and logistic regression.ResultsThe cohort comprised 525 AIS (85.23%) and 91 HS (14.77%) patients. Significant differences were observed between groups in terms of atrial fibrillation incidence, antiplatelet treatment history, hypertension, previous smoking, and recent stroke history. HS patients had a higher baseline NIHSS score (12.90 ± 6.04 vs. 7.69 ± 8.56, p < 0.05). In-hospital and three-month mortality rates were significantly greater in the HS group. Factors significantly associated with in-hospital mortality included hemorrhagic stroke, female sex, higher NIHSS score, and current smoking status. Lower odds of achieving excellent functional outcomes and functional independence at three months were noted for HS patients, influenced by NIHSS scores and prior health conditions.ConclusionYoung stroke patients, particularly those with hemorrhagic stroke, have higher mortality and poorer outcomes. The key risk factors included stroke type, NIHSS score, smoking status, and sex. Identifying and managing these factors could improve patient outcomes.

Early Acute Kidney Injury in Stroke Patients Submitted to Endovascular Treatment: A Cohort Study

Background/Objectives: Acute kidney injury (AKI) is a potential complication of cardiovascular disorders and is associated with worse outcome. The aim of this study was to assess the incidence of early AKI after endovascular therapy for acute ischemic stroke, identify predictors for this complication, and test the association between AKI and mortality or death or dependency. Methods: This was a single-center cohort study involving consecutive patients with acute ischemic stroke submitted to endovascular therapy between 2015 and 2022. AKI was defined according to the KDIGO criteria and evaluated at 48 h. Other outcomes of interest were vital status and functional dependency at 3 months using the modified Rankin Scale, with death or dependency being defined as a score &gt; 2. An adjustment for potential confounders was performed using logistic regression. Results: Overall, 1150 patients were included in the analysis, with a mean age of 74 years and a slight female preponderance (56%). The median NIHSS was 15, the mean onset-to-groin time was 392 min, and 92% of patients were successfully recanalized. The overall incidence rate of AKI was 6%. On univariate analysis, patients with AKI were older (p = 0.002), had a longer time to EVT (p = 0.042), higher NIHSS (p = 0.006), higher blood glucose (p = 0.033), and lower baseline glomerular filtration rate (GFR) (p &lt; 0.001). After adjustment for confounders, AKI was independently associated with NIHSS (p = 0.012), time to treatment (p = 0.004), and lower baseline GFR (p &lt; 0.001). AKI was also independently associated with higher mortality (OR = 2.302, p = 0.003). Conclusions: Patients with impaired baseline renal function and more severe stroke are at higher risk of AKI, and AKI begets worse stroke outcome. Better strategies are required to optimize treatment outcome in these patients and avert this vicious cycle.