Diagnosis Of Acute Stroke Research Articles

Study to estimate the NIHS score and volume of stroke in predicting 30-day mortality in acute ischemic stroke patients

Background. Stroke is defined as a sudden onset of a neurological deficit attributed to a focal vascular cause. It is one of the leading causes of mortality and morbidity all over the world. The present study aimed to estimate the NIHS score and volume of stroke in predicting 30-day mortality in acute ischemic stroke patients. Material and methods. The present study was a prospective cross-sectional study conducted in 100 patients above 18 years old, of either gender, with symptoms of stroke for less than 24 hours, diagnosis of acute ischemic stroke based on history, physical examination, CT scan and/or diffusion weighted MRI scan performed during the first 24 hours. Results. In the present study, the mean age was 57.4±13.36 years. The volume of stroke on 1st day was 40.75±38.51, and on 30th day it was reduced to 31.94±33.20 which was statistically significant. NIHSS (National Institutes of Health Stroke Scale) score on day 1 was 9.70±5.22, and on day 30 it was 7.77±5.25, with a statistically significant difference (p=0.000). At the end of the 30 days, 10% mortality was observed. NIHSS score and volume of stroke were significantly associated with the 30-day outcome. Conclusion. In conclusion, integrating NIHSS scoring and stroke volume assessment into routine clinical practice enhances predictive accuracy for 30-day mortality in acute ischemic stroke patients. These findings advocate for early intervention strategies aimed at reducing stroke volume and improving neurological outcomes. Further research is recommended to validate these findings across diverse populations and settings, potentially refining acute stroke management protocol.

ISCHEMIC STROKE SECONDARY DUE TO BLUNT CAROTID ARTERY INJURY A CASE REPORT AND LITERATURE REVIEW

Ischemic stroke secondary due to blunt cerebrovascular injury is a rare complication, with high morbidities, severity neurological outcome. However, we do not pay enough attention to the diagnosis and treatment of acute ischemic stroke due to blunt cerebrovascular injury. We report a typical case of acute ischemic stroke due to blunt cerebrovascular injury. Unfortunately, this patient did not receive timelineless emergency and treatment, suffered from severe neurological deficit. These patients suffered from blunt cerebrovascular injury required to be careful screening, prompt diagnosis, and aggressive treatment with therapies such as anticoagulants, endovascular intervention, and surgery to reduce mortality and severe neurological deficit.

Modern methods of neuroimaging in the diagnosis of acute ischemic stroke

Ischemic stroke is one of the leading causes of morbidity and mortality worldwide, resulting in significant social and economic consequences for the healthcare system. Moreover, ischemic stroke has a devastating psycho-emotional impact on both the patient and their family, causing anxiety and depressive disorders. To reduce the severity of neurological deficit, increase the percentage of patients returning to their previous level of social and daily activity, and decrease the rates of disability after a cerebrovascular catastrophe, it is necessary to provide the full spectrum of therapeutic and diagnostic assistance in the shortest possible time. Developing neuroimaging techniques help to timely and accurately diagnose cerebral stroke, differentiate ischemic damage from hemorrhagic, and also establish the time of onset of acute cerebrovascular accident.

Concordance between risk scales for venous thromboembolism in patients treated in emergency departments.

To evaluate agreement between risk-assessment models for venous thromboembolism (VTE) in patients hospitalized for medical conditions and to analyze variables associated with the decision to prescribe pharmacological thromboprophylaxis in hospital emergency departments (EDs). Conclusions. Prospective observational multicenter cohort study. We included adults attended in 15 hospital EDs who were hospitalized for medical conditions, calculating VTE risk according to the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) score, the Padua Prediction Score (PPS), and the National Institute for Health and Care Excellence (NICE) score. In addition to assessing interscore concordance, we analyzed variables associated with the prescription of thromboprophylaxis in the ED. A total of 1203 patients were included. The PADUA, IMPROVE, and NICE scales assigned high risk scores for 68.7%, 47.4%, and 69.5% of the patients, respectively. The κ statistic for agreement between the PADUA and NICE scores was 0.80 (95% CI, 0.76-0.84); 102 patients (8.5%) had discordant scores. The κ statistics for agreement between the IMPROVE score and the PADUA and NICE classifications were 0.47 (95% CI, 0.43-0.52) and 0.37 (95% CI, 0.33-0.42), respectively; 322 (26.8%) and 384 patients (31.9%), respectively, had discordant scores. Variables associated with starting thromboprophylaxis in the ED were a diagnosis of acute myocardial infarction or stroke (adjusted odds ratio [aOR], 4.26), immobility in the last 2 months (aOR, 2.19), chronic obstructive pulmonary disease (aOR, 1.97), ischemic heart disease (aOR, 1.51), reduced mobility of 3 days or longer (aOR, 1.14), body mass index (aOR, 1.04), age (aOR, 1.02), recent trauma or surgery (aOR, 0.40), and risk for bleeding (aOR, 0.56). There is disagreement among the recommended models for predicting risk for VTE in patients hospitalized for medical conditions. The basis for emergency physicians' clinical judgment regarding thromboprophylaxis extends beyond risk scales to include multiple risk factors for VTE and bleeding.

Hybrid CNN-Transformer Network With Circular Feature Interaction for Acute Ischemic Stroke Lesion Segmentation on Non-Contrast CT Scans.

Lesion segmentation is a fundamental step for the diagnosis of acute ischemic stroke (AIS). Non-contrast CT (NCCT) is still a mainstream imaging modality for AIS lesion measurement. However, AIS lesion segmentation on NCCT is challenging due to low contrast, noise and artifacts. To achieve accurate AIS lesion segmentation on NCCT, this study proposes a hybrid convolutional neural network (CNN) and Transformer network with circular feature interaction and bilateral difference learning. It consists of parallel CNN and Transformer encoders, a circular feature interaction module, and a shared CNN decoder with a bilateral difference learning module. A new Transformer block is particularly designed to solve the weak inductive bias problem of the traditional Transformer. To effectively combine features from CNN and Transformer encoders, we first design a multi-level feature aggregation module to combine multi-scale features in each encoder and then propose a novel feature interaction module containing circular CNN-to-Transformer and Transformer-to-CNN interaction blocks. Besides, a bilateral difference learning module is proposed at the bottom level of the decoder to learn the different information between the ischemic and contralateral sides of the brain. The proposed method is evaluated on three AIS datasets: the public AISD, a private dataset and an external dataset. Experimental results show that the proposed method achieves Dices of 61.39% and 46.74% on the AISD and the private dataset, respectively, outperforming 17 state-of-the-art segmentation methods. Besides, volumetric analysis on segmented lesions and external validation results imply that the proposed method is potential to provide support information for AIS diagnosis.

Diffusion-Weighted Imaging Fluid-Attenuated Inversion Recovery Mismatch on Portable, Low-Field Magnetic Resonance Imaging Among Acute Stroke Patients.

For stroke patients with unknown time of onset, mismatch between diffusion-weighted imaging (DWI) and fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI) can guide thrombolytic intervention. However, access to MRI for hyperacute stroke is limited. Here, we sought to evaluate whether a portable, low-field (LF)-MRI scanner can identify DWI-FLAIR mismatch in acute ischemic stroke. Eligible patients with a diagnosis of acute ischemic stroke underwent LF-MRI acquisition on a 0.064-T scanner within 24 h of last known well. Qualitative and quantitative metrics were evaluated. Two trained assessors determined the visibility of stroke lesions on LF-FLAIR. An image coregistration pipeline was developed, and the LF-FLAIR signal intensity ratio (SIR) was derived. The study included 71 patients aged 71 ± 14 years and a National Institutes of Health Stroke Scale of 6 (interquartile range 3-14). The interobserver agreement for identifying visible FLAIR hyperintensities was high (κ = 0.85, 95% CI 0.70-0.99). Visual DWI-FLAIR mismatch had a 60% sensitivity and 82% specificity for stroke patients <4.5 h, with a negative predictive value of 93%. LF-FLAIR SIR had a mean value of 1.18 ± 0.18 <4.5 h, 1.24 ± 0.39 4.5-6 h, and 1.40 ± 0.23 >6 h of stroke onset. The optimal cut-point for LF-FLAIR SIR was 1.15, with 85% sensitivity and 70% specificity. A cut-point of 6.6 h was established for a FLAIR SIR <1.15, with an 89% sensitivity and 62% specificity. A 0.064-T portable LF-MRI can identify DWI-FLAIR mismatch among patients with acute ischemic stroke. Future research is needed to prospectively validate thresholds and evaluate a role of LF-MRI in guiding thrombolysis among stroke patients with uncertain time of onset. ANN NEUROL 2024;96:321-331.

Acute Ischemic Stroke and Metabolic Syndrome Comorbidity

Aim Cerebrovascular diseases (CVD) lead to serious disabilities and loss of labor in societyin addition to mortality. Metabolic syndrome (MetS) is a group of known metabolic risk factors such as high blood pressure, dyslipidemia, glucose intolerance, or high blood sugar, due to insulin resistance. The present study aimed to investigate MetS and its components in acute ischemic stroke patients and analyze these components as risk factors. MATERIAL-METHOD The study was conducted with 80 patients, 46 males and 34 females, who were admitted to the Taksim Training and Research Hospital Neurology Clinic with acute ischemic stroke diagnosis between April and October 2007 within the first 48 hours of the disease onset. The presence of MetS was investigated in 80 patients, including large artery atherosclerosis (BAA), small artery occlusion (CAO), and cardioembolic disease (CE). FINDINGS MetS was determined in 48 patients out of 80. TheMetSpresence rate was 60%. The analysis of the MetS rates in disease groups revealed that the highest rate was in 30 of 39 BAA patients (76.90%). The mean MS criterion count was statistically significantly higher in theBAA group when compared to the CE and CAO groups. A statistically significant difference was determined between the abdominal obesity distributionsin BAA, CE, KAO groups. A statistically significant difference was determined between the MS presence in the BAA, CE, CAO groups. CONCLUSION Certain modifiable stroke risk factors are included in a cluster of risk factors called MetS. Efforts to reduce theMetS parameters could be effective in stroke prevention.

The influence of diagnostic subgroups, patient- and hospital characteristics for the validity of cardiovascular diagnoses-Data from a Norwegian hospital trust.

Cardiovascular discharge diagnoses may serve as endpoints in epidemiological studies if they have a high validity. Aim was to study if diagnoses-specific characteristics like type, sub-categories, and position of cardiovascular diagnoses affected diagnostic accuracy. Patients (n = 7,164) with a discharge diagnosis of acute myocardial infarction, heart failure or cerebrovascular disease were included. Data were presented as positive predictive values (PPV) and sensitivity. PPV was high (≥88%) for acute myocardial infarction (n = 2,189) (except for outpatients). For heart failure (n = 4,026) PPV was 67% overall, but higher (>99%) when etiology or echocardiography was included. For hemorrhagic (n = 257) and ischemic (n = 1,034) strokes PPVs were 87% and 80%, respectively, with sensitivity of 79% and 75%. Transient ischemic attacks (n = 926) had PPV 56%, but sensitivity 86%. Primary diagnoses showed higher validity than subsequent diagnoses and inpatient diagnoses were more valid than outpatient diagnoses (except for transient ischemic attack). The diagnoses of acute myocardial infarction and heart failure where most valid when placed at cardiology units, while ischemic stroke when discharged from an internal medicine unit. The diagnoses of acute myocardial infarction and stroke had excellent validity when placed during hospital stays. Similarly, heart failure diagnoses had excellent validity when echocardiography was performed before placing the diagnosis, while overall the diagnoses of heart failure and transient ischemic attack were less valid. In conclusion, the results indicate that cardiovascular diagnoses based on objective findings such as acute myocardial infarction and stroke have excellent validity and may be used as endpoints in clinical epidemiological studies with less rigid validation.

Current State of Evidence for Neuroimaging Paradigms in Management of Acute Ischemic Stroke.

Stroke is the chief differential diagnosis in patient presenting to the emergency room with abrupt onset focal neurological deficits. Neuroimaging, including non-contrast computed tomography (CT), magnetic resonance imaging (MRI), vascular and perfusion imaging, is a cornerstone in the diagnosis and treatment decision-making. This review examines the current state of evidence behind the different imaging paradigms for acute ischemic stroke diagnosis and treatment, including current recommendations from the guidelines. Non-contrast CT brain, or in some centers MRI, can help differentiate ischemic stroke and intracerebral hemorrhage (ICH), a pivotal juncture in stroke diagnosis and treatment algorithm, especially for early window thrombolytics. Advanced imaging such as MRI or perfusion imaging can also assist making a diagnosis of ischemic stroke versus mimics such as migraine, Todd's paresis, or functional disorders. Identification of medium-large vessel occlusions with CT or MR angiography triggers consideration of endovascular thrombectomy (EVT), with additional perfusion imaging help identify salvageable brain tissue in patients who are likely to benefit from reperfusion therapies, particularly in the ≥6 h window. We also review recent advances in neuroimaging and ongoing trials in key therapeutic areas and their imaging selection criteria to inform the readers on potential future transitions into use of neuroimaging for stroke diagnosis and treatment decision making. ANN NEUROL 2024;95:1017-1034.

Multiple techniques to evaluate the relationship between carotid artery plaque and acute stroke.

To evaluate the important characteristics of the plaque vulnerability using multimodal ultrasound imaging methods (2D, contrast-enhanced ultrasound, and elastography), and to explore the relationship between plaque and acute stroke. A total of 244 patients with carotid plaque were enrolled, including 104 patients with acute stroke ipsilateral to the plaque as the case group and 140 patients as the control group. All patients underwent conventional carotid ultrasound, contrast-enhanced ultrasound (CEUS) and elastography (SWE). The results of each examination were compared and analyzed, and the relationship between the results and the occurrence of stroke was discussed. In the acute stroke group, the men, with a history of alcohol consumption the direction of contrast media diffusion was higher than that in the control group, but the plaque gray value (GSM), maximum, average and minimum Young's elastic modulus imaging values (YM) were slightly lower than those in the control group (P < 0.05). Logistic regression analysis showed that waist to body ratio (WHtR), GSM, YM, neovascularization density and contrast diffusion direction were independent risk factors for predicting acute ischemic stroke. The influence degree of each factor from strong to weak was waist to body ratio, neovascularity density, GSM and YM, respectively. The area under the curve (AUC) for the diagnosis of acute ischemic stroke by regression model was 0.746. The combination of multiple ultrasound techniques to evaluate the vulnerability of carotid plaque and predict the occurrence of acute stroke provides valuable information for clinical decision making.

A Study to Estimate the Red Cell Width Distribution and the Mean Platelet Volume in Predicting the 30-Day Mortality in Acute Ischemic Stroke Patients.

Background Acute ischemic stroke, a clinical disorder caused by nontraumatic cerebrovascular disease, has an acute onset,frequently causesneurological deficit, and may persist for >24 hours or can be fatal in <24 hours. This studyaimed to assess the red cell width distribution (RDW) and the mean platelet volume (MPV) in predicting 30-day mortality in acute ischemic stroke patients. In general, patients with acute ischemic stroke have a rather high mortality rate in the first 30 days due to various complications, but post the 30-day mark, the prognosis is comparatively better. Material and methods The present study was conducted on patients with a confirmed diagnosis of acute ischemic stroke based on history, physical examination, CT scan, and/or diffusion-weighted MRI scan performed during the first 24 hours. It was a prospective and cross-sectional study done at Saveetha Medical College over a period of two years. The data was collected by using the intra-hospital network and was analyzed using the IBM SPSS Statistics for Windows, Version 20 (Released 2011; IBM Corp., Armonk, New York, United States). Results In the present study, among 100 patients, the mean agewas57.4 ± 13.36 years. About 55% of our subjects were males in our study. The RDW on the 1stday was 14.17 ± 0.708, and it reduced drastically on the 30thday to1st 13.55 ± 1.11, and it was statically significant (p = 0.000). The MPVon day 1 was 11.11 ± 0.969 and, on day 30, was 10.82 ± 0.90; the MPV was reduced considerably on day 30, which was statistically significant (p = 0.000). RDW on the 1stday was significantly correlated with the MPV and the volume ofstroke. Thecorrelation wassignificant at the 0.01 level (two-tailed). On the 30thday of acute ischemic stroke patients, the red blood cell (RBC)width was significantly correlated with the MPV. The correlation was significant at the 0.01 level (two-tailed). At the end of 30 days, 10% mortality was observed in the present study. Day 30 saw a significant decrease in the MPV and RDW, particularly in the moderate to severe and severe categories. The National Institutes of Health Stroke Scale (NIHSS) score and the volume of stroke were significantly associated with the 30-dayoutcome. Conclusion The RDW and the MPV are well correlated in predicting the 30-day mortality in acute ischemic stroke patients. This could potentially be used as a significant marker for predicting mortality in stroke patients in the future, but to increase the generalization, further studies need to be carried out at other demographically distinct medical centers.

Artery of Percheron Infarction: Clinical Presentation and Outcomes.

Occlusion of the artery of Percheron (AOP) produces bilateral thalamic infarction classically leading to deficits of arousal. This nonspecific presentation complicates the diagnosis of acute ischemic stroke. We sought to describe the spectrum of clinical presentation, diagnostic neuroimaging findings, and outcomes in AOP infarction (AOPi). We conducted a keyword search of our health system's neuroimaging database from 2014 to 2022 to identify patients with AOPi. We abstracted patient demographics, clinical presentation, neuroimaging findings, acute treatment, and modified Rankin Scale (mRS) scores (at baseline, 3 months, and 12 months). We used descriptive statistics to report our findings. Our initial keyword search identified 192 potential AOPi cases. Fifteen cases of AOPi were confirmed and included in our study (8 female [53%], median age 65 years [interquartile range (IQR): 59.5-79.5], median presenting NIHSS 6 [IQR: 2-22]). Common clinical findings on presentation were systolic blood pressure (SBP) > 140: 12 patients (80%); decreased level of consciousness (LOC): 11 patients (73%); diplopia: 8 patients (57%); disorientation: 6 patients (42%); dysarthria: 4 patients (28%); and acute memory/cognitive disturbance: 3 patients (21%). Twelve cases (80%) presented to the emergency department (ED). Median time from symptom onset to ED arrival was 774.5 minutes (IQR: 202.25-3789.0), 4 cases (27%) arrived within 4.5 hours, and one patient (7%) received intravenous thrombolysis. The median time from ED arrival to stroke diagnosis was 519.0 minutes (IQR: 227.5-1307). Head CT was only diagnostic when obtained >570 minutes from time last known well; MRI was diagnostic at all time points. Rates of functional independence (mRS ≤2) at baseline, 3 months, and 12 months were 64%, 21%, and 18%, respectively. The diagnosis of stroke was considerably delayed in patients with AOPi, and only one patient received IV thrombolysis. SBP >140, impaired consciousness, and diplopia were the most common findings at presentation. CT was often nondiagnostic, but MRI demonstrated bilateral thalamic infarct in all cases. AOPi caused considerable long-term morbidity. Clinicians should maintain a high degree of suspicion for AOP stroke and consider thrombolysis in appropriately selected patients.

Alberta Stroke Program Early CT Score 활용한 급성 및 만성 뇌경색 차이 분석

This study aimed to analyze the effect of CT images including old infarction on the Alberta stroke program early CT score (ASPECTS) for acute stroke diagnosis. Location of acute and old infarction through automatically calculated ASPECTS and diffusion weighted image interpretation of patients who have undergone both CT scan and diffusion weighted image MRI for acute stroke diagnosis among patients with suspected cerebral infarction who visited the emergency room After comparison, it was determined whether the location of old infarction had an effect on ASPECTS. The Pearson chi-square test was analyzed for the ASPECT score according to the presence or absence of cerebral infarction, and SPSS version 28.0 was used as the analysis program, and it was judged to be significant when the P value was less than 0.05. As a result of this study, in the analysis of whether old infarction affects ASPECTS, chronic cerebral infarction showed an effect on ASPECTS in the group divided into 10, 9, 8, and 7 points or less, and the group divided into 10 and 9 points. However, in the analysis of the groups with scores of 9, 8, and 7 or less, excluding 10, and the group divided into 8 or more and 7 or less, old infarction did not show any effect on ASPECTS. In conclusion, it is believed that complementary research is needed to diagnose acute stroke and predict prognosis in patients with various brain diseases using an improved artificial intelligence program through large-scale research in ASPECTS.

The role of stroke care infrastructure on the effectiveness of a hub-and-spoke telestroke model in South Carolina

ObjectiveTo examine the relationship between stroke care infrastructure and stroke quality-of-care outcomes at 29 spoke hospitals participating in the Medical University of South Carolina (MUSC) hub-and-spoke telestroke network. Materials and methodsEncounter-level data from MUSC's telestroke patient registry were filtered to include encounters during 2015-2022 for patients aged 18 and above with a clinical diagnosis of acute ischemic stroke, and who received intravenous tissue plasminogen activator. Unadjusted and adjusted generalized estimating equations assessed associations between time-related stroke quality-of-care metrics captured during the encounter and the existence of the two components of stroke care infrastructure—stroke coordinators and stroke center certifications—across all hospitals and within hospital subgroups defined by size and rurality. ResultsTelestroke encounters at spoke hospitals with stroke coordinators and stroke center certifications were associated with shorter door-to-needle (DTN) times (60.9 min for hospitals with both components and 57.3 min for hospitals with one, vs. 81.2 min for hospitals with neither component, p <.001). Similar patterns were observed for the percentage of encounters with DTN time of ≤60 min (63.8% and 68.9% vs. 32.0%, p <.001) and ≤45 min (34.0% and 38.4% vs. 8.42%, p <.001). Associations were similar for other metrics (e.g., door-to-registration time), and were stronger for smaller (vs. larger) hospitals and rural (vs. urban) hospitals. ConclusionsStroke coordinators or stroke center certifications may be important for stroke quality of care, especially at spoke hospitals with limited resources or in rural areas.

Incidence of Symptomatic Venous Thromboembolisms in Stroke Patients.

Venous thromboembolism (VTE) is a common but preventable complication observed in critically ill patients. Deep vein thrombosis (DVT) is the most common type of VTE, with clinical significance based on location and symptoms. There is an increased incidence of DVT and pulmonary embolism (PE) in ischemic stroke patients using unfractionated heparin (UFH) for VTE prophylaxis compared with those using enoxaparin. However, UFH is still used in some patients due to its perceived safety, despite conflicting literature suggesting that enoxaparin may have a protective effect. The current study aimed to determine the incidence of VTEs in patients with acute ischemic strokes on UFH versus enoxaparin for VTE prophylaxis, subclassifying the VTEs depending on their location and symptoms. It also aimed to examine the safety profile of both drugs. A total of 909 patients admitted to the Neuro-ICU with the diagnosis of acute ischemic stroke were identified, and 634 patients were enrolled in the study-170 in the enoxaparin group and 464 in the UFH group-after applying the exclusion criteria. Nineteen patients in the UFH group (4.1%) and 3 patients in the enoxaparin group (1.8%) had a VTE. The incidence of DVT in the UFH group was 12 (2.6%), all of which were symptomatic, compared with 3 (1.8%) in the enoxaparin group, wherein one case was symptomatic. Nine patients (1.9%) in the UFH group developed a PE during the study period, and all of them were symptomatic. No patients in the enoxaparin group developed PE. No statistically significant difference was found between both groups. However, 18 patients in the UFH group (3.9%) experienced intracranial hemorrhage compared with none in the enoxaparin group, and this difference was statistically significant. Enoxaparin was found to be as effective as and potentially safer than UFH when used for VTE prophylaxis in stroke patients.

Enhancing the evaluation of acute ischemic stroke risk in individuals with non-valvular atrial fibrillation by including laboratory indicators

To investigate the clinical significance of the CHA2DS2-VASc-60 score, lipoprotein (a) [Lp(a)], red blood cell distribution width (RDW), and their combined effect in patients with non-valvular atrial fibrillation (NVAF) who experience acute ischemic stroke (AIS). This retrospective analysis was conducted on the clinical data of hospitalized patients with NVAF at the Third Affiliated Hospital of Anhui Medical University between April 1, 2020, and April 1, 2023. Based on the diagnosis of acute ischemic stroke (AIS), the patients were divided into two groups: the AIS group (150 cases of NVAF patients with comorbid AIS) and the non-AIS group (163 cases of NVAF patients without AIS). We performed CHA2DS2-VASc-60 scoring for all patients and collected their laboratory indicators and echocardiographic indicators during hospitalization. The study comprised 313 individuals with NVAF in total. There is a statistically significant difference (P < 0.05) in the comparison of CHA2DS2-VASc-60 score (5.68 ± 1.12 vs. 3.67 ± 1.47), Lp(a) [23.98 (13.28, 42.22) vs. 14.32 (7.96, 21.91)] and RDW (13.67 ± 1.25 vs. 12.94 ± 0.76) between NVAF patients with and without concomitant AIS. The results of the Spearman correlation analysis demonstrate a positive association between Lp(a) and RDW levels and both the CHA2DS2-VASc score and the CHA2DS2-VASc-60 score in patients with NVAF. Multivariate logistic regression analysis revealed that CHA2DS2-VASc-60 score [OR = 6.549, 95% CI: 4.110–10.433, P < 0.05], Lp(a) [OR = 1.023, 95% CI: 1.005–1.041, P < 0.05], and RDW [OR = 1.644, 95% CI: 1.071–2.525, P < 0.05] were independent risk factors for AIS in patients with non-valvular atrial fibrillation (NVAF). The receiver operator characteristic (ROC) curves showed that the area under the curve of CHA2DS2-VASc-60 score, Lp(a), RDW, and CHA2DS2-VASc-60 score combined with Lp(a) and RDW predicted that NVAF patients with AIS were 0.881 [95% CI: 0.804–0.906], 0.685 [95% CI: 0.626–0.744], 0.695 [95% CI: 0.637–0.754], and 0.906 [95% CI: 0.845–0.921], respectively. The CHA2DS2-VASc-60 score, Lp(a), and RDW were significantly increased in NVAF patients with AIS, which were independent risk factors for NVAF patients with AIS. The combination of the three has a high predictive capacity for NVAF patients with AIS.

Heterogeneity of State Stroke Center Certification and Designation Processes.

Stroke centers are critical for the timely diagnosis and treatment of acute stroke and have been associated with improved treatment and outcomes; however, variability exists in the definitions and processes used to certify and designate these centers. Our study categorizes state stroke center certification and designation processes and provides examples of state processes across the United States, specifically in states with independent designation processes that do not rely on national certification. In this cross-sectional study from September 2022 to April 2023, we used peer-reviewed literature, primary source documents from states, and communication with state officials in all 50 states to capture each state's process for stroke center certification and designation. We categorized this information and outlined examples of processes in each category. Our cross-sectional study of state-level stroke center certification and designation processes across states reveals significant heterogeneity in the terminology used to describe state processes and the processes themselves. We identify 3 main categories of state processes: No State Certification or Designation Process (category A; n=12), State Designation Reliant on National Certification Only (category B; n=24), and State Has Option for Self-Certification or Independent Designation (category C; n=14). Furthermore, we describe 3 subcategories of self-certification or independent state designation processes: State Relies on Self-Certification or Independent Designation for Acute Stroke Ready Hospital or Equivalent (category C1; n=3), State Has Hybrid Model for Acute Stroke Ready Hospital or Equivalent (category C2; n=5), and State Has Hybrid Model for Primary Stroke Center and Above (category C3; n=6). Our study found significant heterogeneity in state-level processes. A better understanding of how these differences may impact the rigor of each process and clinical performance of stroke centers is worthy of further investigation.

Non-coding RNAs in acute ischemic stroke: from brain to periphery.

Acute ischemic stroke is a clinical emergency and a condition with high morbidity, mortality, and disability. Accurate predictive, diagnostic, and prognostic biomarkers and effective therapeutic targets for acute ischemic stroke remain undetermined. With innovations in high-throughput gene sequencing analysis, many aberrantly expressed non-coding RNAs (ncRNAs) in the brain and peripheral blood after acute ischemic stroke have been found in clinical samples and experimental models. Differentially expressed ncRNAs in the post-stroke brain were demonstrated to play vital roles in pathological processes, leading to neuroprotection or deterioration, thus ncRNAs can serve as therapeutic targets in acute ischemic stroke. Moreover, distinctly expressed ncRNAs in the peripheral blood can be used as biomarkers for acute ischemic stroke prediction, diagnosis, and prognosis. In particular, ncRNAs in peripheral immune cells were recently shown to be involved in the peripheral and brain immune response after acute ischemic stroke. In this review, we consolidate the latest progress of research into the roles of ncRNAs (microRNAs, long ncRNAs, and circular RNAs) in the pathological processes of acute ischemic stroke-induced brain damage, as well as the potential of these ncRNAs to act as biomarkers for acute ischemic stroke prediction, diagnosis, and prognosis. Findings from this review will provide novel ideas for the clinical application of ncRNAs in acute ischemic stroke.

Subtle white matter intensity changes on fluid-attenuated inversion recovery imaging in patients with ischaemic stroke.

Leukoaraiosis is a neuroimaging marker of small-vessel disease that is characterized by high signal intensity on fluid-attenuated inversion recovery MRI. There is increasing evidence from pathology and neuroimaging suggesting that the structural abnormalities that characterize leukoaraiosis are actually present within regions of normal-appearing white matter, and that the underlying pathophysiology of white matter damage related to small-vessel disease involves blood-brain barrier damage. In this study, we aim to verify whether leukoaraiosis is associated with elevated signal intensity on fluid-attenuated inversion recovery imaging, a marker of brain tissue free-water accumulation, in normal-appearing white matter. We performed a cross-sectional study of adult patients admitted to our hospital with a diagnosis of acute ischaemic stroke or transient ischaemic attack. Leukoaraiosis was segmented using a semi-automated method involving manual outlining and signal thresholding. White matter regions were segmented based on the probabilistic tissue maps from the International Consortium for Brain Mapping 152 atlas. Also, normal-appearing white matter was further segmented based on voxel distance from leukoaraiosis borders, resulting in five normal-appearing white matter strata at increasing voxel distances from leukoaraiosis. The relationship between mean normalized fluid-attenuated inversion recovery signal intensity on normal-appearing white matter and leukoaraiosis volume was studied in a multivariable statistical analysis using linear mixed modelling, having normal-appearing white matter strata as a clustering variable. One hundred consecutive patients meeting inclusion and exclusion criteria were selected for analysis (53% female, mean age 68 years). Mean normalized fluid-attenuated inversion recovery signal intensity on normal-appearing white matter was higher in the vicinity of leukoaraiosis and progressively lower at increasing distances from leukoaraiosis. In a multivariable analysis, the mean normalized fluid-attenuated inversion recovery signal intensity on normal-appearing white matter was positively associated with leukoaraiosis volume and age (B = 0.025 for each leukoaraiosis quartile increase; 95% confidence interval 0.019-0.030). This association was found similarly across normal-appearing white matter strata. Voxel maps of the mean normalized fluid-attenuated inversion recovery signal intensity on normal-appearing white matter showed an increase in signal intensity that was not adjacent to leukoaraiosis regions. Our results show that normal-appearing white matter exhibits subtle signal intensity changes on fluid-attenuated inversion recovery imaging that are related to leukoaraiosis burden. These results suggest that diffuse free-water accumulation is likely related to the aetiopathogenic processes underlying the development of white matter damage related to small-vessel disease.

Novel artificial intelligence-based hypodensity detection tool improves clinician identification of hypodensity on non-contrast computed tomography in stroke patients.

In acute stroke, identifying early changes (parenchymal hypodensity) on non-contrast CT (NCCT) can be challenging. We aimed to identify whether the accuracy of clinicians in detecting acute hypodensity in ischaemic stroke patients on a non-contrast CT is improved with the use of an Artificial Intelligence (AI) based, automated hypodensity detection algorithm (HDT) using MRI-DWI as the gold standard. The study employed a case-crossover within-clinician design, where 32 clinicians were tasked with identifying hypodensity lesions on NCCT scans for five a priori selected patient cases, before and after viewing the AI-based HDT. The DICE similarity coefficient (DICE score) was the primary measure of accuracy. Statistical analysis compared DICE scores with and without AI-based HDT using mixed-effects linear regression, with individual NCCT scans and clinicians as nested random effects. The AI-based HDT had a mean DICE score of 0.62 for detecting hypodensity across all NCCT scans. Clinicians' overall mean DICE score was 0.33 (SD 0.31) before AI-based HDT implementation and 0.40 (SD 0.27) after implementation. AI-based HDT use was associated with an increase of 0.07 (95% CI: 0.02-0.11, p = 0.003) in DICE score accounting for individual scan and clinician effects. For scans with small lesions, clinicians achieved a mean increase in DICE score of 0.08 (95% CI: 0.02, 0.13, p = 0.004) following AI-based HDT use. In a subgroup of 15 trainees, DICE score improved with AI-based HDT implementation [mean difference in DICE 0.09 (95% CI: 0.03, 0.14, p = 0.004)]. AI-based automated hypodensity detection has potential to enhance clinician accuracy of detecting hypodensity in acute stroke diagnosis, especially for smaller lesions, and notably for less experienced clinicians.