Cases Of Acute Ischemic Stroke Research Articles

Endovascular Recanalization of Tandem Internal Carotid Occlusions Using the Balloon-assisted Tracking Technique.

Tandem occlusive lesions are responsible for up to 20% of acute ischemic stroke cases and are associated with poor prognosis if complete recanalization cannot be achieved. Endovascular recanalization might be challenging due to difficulties in the safe passage of the occluded plaque at the origin of the internal carotid artery (ICA). The balloon-assisted tracking technique (BAT), where apartially deflated balloon is exposed out of the catheter tip to facilitate its passage through stenosed or spastic arterial segments was introduced by interventional cardiologists and the applicability of the technique has been recently proposed in the field of neurointervention as well. Here we describe our experience using the BAT technique in the endovascular recanalization of tandem occlusive lesions. Procedures were performed from June 2013 to December 2020 in asingle center. Baseline clinical and imaging data, procedural and follow-up details and clinical outcomes were retrospectively collected. In this study 107 patients, median age66 years, median admission NIHSS14 and median ASPECTS8 were included. Successful recanalization of the ICA using the BAT technique was achieved in 100 (93%) and successful intracranial revascularization in88 (82%) patients. There were no complications attributable to the BAT technique. Intraprocedural complications occurred in9 (8%) patients. Emergent stenting was performed in40 (37%) at the end of the procedure. Postprocedural adverse events (intracerebral hemorrhage [ICH], malignant infarction) occurred in6 (5%) patients. Good clinical outcome at 3months (modified Rankin scale [mRS] 0-2) was54 (50%) and mortality26 (24%). Delayed stent placement during follow-up occurred in 21cases. Application of BAT technique in tandem occlusions appears feasible, safe, and efficient. Further evaluation of this technique is awaited.

The level of urbanization influences acute ischemic stroke care: A nationwide ecological study from Germany

Background and purposeRegional differences in acute ischemic stroke (AIS) care are still reported for Germany but not fully understood. We aimed to analyze the impact of the level of urbanization on the application of proved treatment procedures and the incidence of hospitalized AIS cases in Germany. MethodsThe level of urbanization of the 401 districts and district-free cities in Germany was defined according to the Federal Institute for Building, Urban Affairs and Spatial Research classification. Using nationwide administrative data, the application of intravenous thrombolysis (IVT), mechanical thrombectomy (MT), and the incidence of hospitalizations for AIS, were analyzed according to the place of residence of the patients. Data included all patients hospitalized for AIS in 2019 (n = 224,274) and sociodemographic information of 83,019,213 residents in Germany. ResultsSparsely populated districts had a significantly higher incidence of hospitalizations for AIS than cities (age-standardized: 271.8 versus 242.3 per 100,000 inhabitants, P < 0.001), but a lower use of MT (5.7% versus 8.4%, P < 0.001). In the adjusted negative binomial regression model, rurality remained an independent predictor for MT use and the incidence of AIS hospitalizations. The proportion of IVT did not significantly differ between sparsely populated districts and cities (15.6% versus 17.2%, P = 0.021). ConclusionsAlthough there is a dense network of stroke units in Germany, the level of urbanization still influences AIS care, as we found a lower proportion of MT and a higher incidence of AIS hospitalizations in Germany's rural areas.

English

BACKGROUND World Health Organization (WHO) defines stroke as “rapidly developing clinical signs of focal (or global) disturbance of cerebral function, lasting more than 24 hours or leading to death, with no apparent cause other than that of vascular origin.” Low serum 25 hydroxy vitamin D is associated with large infarct volume, which worsens the outcome in ischemic stroke patients. In this study, we wanted to evaluate serum vitamin D levels in acute ischaemic stroke (AIS) patients and correlate the severity of stroke with lipid profile &amp; central nervous system (CNS). METHODS It was a cross sectional comparative study, conducted in Department of Medicine in SGRDIMSR, Sri Amritsar from December 2018 to June 2020. A total of 100 subjects, 50 cases of AIS, diagnosed by history, clinical examination and supported by magnetic resonance imaging (MRI) of brain and 50 age and sex matched healthy controls were enrolled for the present study to estimate serum vitamin D level in AIS. Detailed clinical history and clinical examination were done on all participating subjects and relevant investigations were done. Diagnosis was confirmed by MRI brain in acute ischemic stroke cases. The severity of neurological impairment was evaluated as per Canadian neurological stroke scale within 24 hours of admission of the cases. RESULTS Mean age of cases was 62.06 ± 10.52 years and mean age of control was 59.14 ± 11.36 with maximum number of subjects were in age group of 61 - 70 years. The mean value of vitamin D in study group was 19.31 ± 9.24 while in control group, mean value was 36.42 ± 8.33, showing more serum vitamin D deficiency in cases having AIS than controls. (P value 0.021). CONCLUSIONS The present study suggests that the low serum vitamin D levels in the body is associated with more severe neurological deficit. KEYWORDS Stroke, Serum Vitamin D, Acute Ischemic Stroke, Canadian Neurological Scale

RELATIONSHIP BETWEEN HS-CRP AND ACUTE ISCHEMIC STROKE EVENT IN A SAMPLE POPULATION IN RAJASTHAN

Use of serum markers has been a established practice in medicine. CRP levels have been known to provide a estimate of inflammation. The present study was formulated to ascertain if levels of CRP in acute ischaemic stroke cases can be a prognostic or diagnostic marker for the condition. The study was a prospective case control format and utilized a subject pool of 50 subjects as case and control each. The study observed a significantly elevated level of CRP in cases with an acute ischaemic stroke. The study concluded that use of CRP can be a an effective modality in clinical practice in managing such cases. Keywords: CRP, Acute Ischaemic Stroke, TOAST

Concomitant Acute Ischemic Stroke and Upper Extremity Arterial Occlusion: Feasibility of Mechanical Thrombectomy of the Upper Limb Using Neurointerventional Devices and Techniques.

Background: Concomitant acute ischemic stroke (AIS) caused by large vessel occlusion (LVO), and acute upper extremity arterial occlusion causing upper limb ischemia (ULI) is a rarely observed coincidence. The first-line treatment for AIS is mechanical thrombectomy (MT), with or without additional intravenous thrombolysis, while there are different pharmacological, surgical and endovascular treatment options for an acute occlusion of the UL arteries. Here, we describe the practicability, efficacy and safety of neurointerventional devices and techniques for MT of upper extremity arterial occlusions. Materials and Methods: A retrospective analysis of prospectively collected patient databases from four neurovascular centers was performed. Clinical and imaging data, as well as procedural parameters, were assessed. Results: Seven out of 6138 patients (incidence: 0.11%) presenting with an AIS due to the occlusion of craniocervical arteries requiring MT and a concomitant occlusion of the brachial (4/7), axillary (2/7), or ulnar (1/7) artery causing acute ULI were identified. Craniocervical MT was technically successful in all cases. Subsequent MT of the upper limb was performed using neurointerventional thrombectomy techniques, most frequently stent retriever thrombectomy (in 4/7 cases) and direct aspiration (in 7/7 cases). MT achieved successful recanalization in 6/7 cases, and the UL completely recovered in all six cases. In one case, recanalization was not successful, and the patient still had a marginally threatened extremity after the procedure, which improved after pharmacological therapy. Conclusion: In the rare case of AIS requiring MT and concomitant acute upper extremity arterial occlusion, MT of the UL arteries using neurointerventional devices and techniques is practical, effective, and safe.

Stroke education focusing on recognition and response to decrease pre-hospital delay in India: Need of the hour to save hours

BackgroundPre-hospital delays contribute to late arrival for acute ischemic stroke (AIS) treatment in the emergency department and are an important barrier preventing people from receiving thrombolytic therapy. This study looked into the factors causing pre-hospital delay in a tertiary care centre in South India with the aim of identifying measures to decrease pre-hospital delay. MethodsConsecutive cases of AIS from October 2018 to June 2019 were included. A structured questionnaire was used to collect data regarding demographic details, presenting symptoms, time of stroke onset and arrival, mode of transport and knowledge about stroke and thrombolysis. Pre-hospital delay was defined as > 4 h (Considering our door-to-needle time of 30 min) between stroke onset or the time point of wake‐up and the time of arrival. ResultsOverall, 505 patients were enrolled. Prehospital delay was observed in 352patients (69.7%). The median pre-hospital delay was 9.5 h. In the multivariable analysis, the odds of early arrival were increased in patients who perceived the initial symptoms as serious (OR: 45.57; 95%CI, 11.43–181.63), those with prior knowledge of stroke symptoms (OR: 4.64; 95% CI, 1.86–11.55), those using ambulance services (OR: 3.11; 95% CI, 1.39–6.95), and those developing hemiparesis (OR: 2.50; 95% CI, 1.25–4.97). The odds of early arrival were lower in those visiting their family doctor after the stroke (OR: 0.17; 95%CI, 0.05–0.51). ConclusionsModifiable factors related to stroke recognition and response behavior continue to cause significant pre-hospital delay in India. There is an immediate need for a strong education campaign focusing on stroke specific knowledge to decrease pre-hospital delay.

Characteristics, comorbidities, and outcomes of acute ischemic stroke cases treated with thrombolysis in Sanglah General Hospital Bali: A case series

Background: Intravenous recombinant tissue plasminogen activator (IV rt-PA) in eligible patient groups is the main therapy for acute phase ischemic stroke within 4.5 hours of symptom onset which can significantly improve functional outcome. However, not all patients who underwent thrombolysis had a good outcome. Case: We report a series of seven patients cases undergoing IV thrombolysis from 2019-2020 at Sanglah General Hospital with varying baseline conditions and outcomes. Most cases benefit from IV rt-PA administration. There was one case with a poor outcome and one case with a rare anaphylactic reaction following alteplase administration. Conclusion: The number of thrombolysis procedure which is the main treatment of acute ischemic stroke is quite small. It is necessary to increase public education and understanding regarding the rapid response to acute stroke symptoms. Most of the cases yielded good outcomes while several cases had unfavorable outcomes related to variable factors. Hemorrhagic transformation does not directly associate with poor outcome. Clinicians also need to increase awareness of allergic reactions risk to rt-PA and provide prompt treatment.

Calcium Channel Subunit α2δ-1 as a Potential Biomarker Reflecting Illness Severity and Neuroinflammation in Patients with Acute Ischemic Stroke

BackgroundVoltage-gated calcium channels (VGCCs) dysfunction is involved in the development of acute ischemic stroke (AIS). As a subunit of VGCC complexes, we detected the levels of α2δ-1 subunit in serum and cerebrospinal fluid (CSF) specimens from AIS patients. MethodsThe study included 105 patients with first-ever AIS, who were admitted within 48 hours after stroke onset. The serum and CSF levels of α2δ-1 were measured with ELISA and the severity of AIS patients was evaluated according to the National Institutes of Health Stroke Scale (NIHSS) score. The cerebral infarct volume was calculated through the Pullicino formula based on the cranial CT or MRI scan. C-reactive protein (CRP) and serum amyloid A (SAA) were measured using the latex-enhanced immunoturbidimetric assay. ResultsCompared to the control subjects, the serum α2δ-1 level was significantly increased in AIS patients with large infarct volume and in severe AIS cases with high NIHSS score, which correlated positively with the inflammatory markers CRP and SAA. Furthermore, the concentration of α2δ-1 in CSF was elevated with the infarct volume, which was higher in severe AIS patients. ConclusionOur study suggests that the increased α2δ-1 levels in serum and CSF specimens may be used as a potential marker for reflecting VGCCs dysfunction, illness severity and neuroinflammation in AIS patients.

Management dilemmas in acute ischemic stroke and concomitant acute pulmonary embolism: Case series and literature review.

BackgroundPulmonary embolism (PE) and acute ischemic stroke (AIS) are common disorders with high morbidity and mortality, rarely presenting simultaneously. There is a paucity of data regarding the management of this uncommon presentation. The treatment of these two entities is complex in the acute phase due to the concomitant need for thrombolysis in AIS and anticoagulation for PE.MethodsWe retrospectively reviewed confirmed ischemic stroke cases to identify patients presented with simultaneous PE from June 2018 to May 2019. Additionally, a literature review was performed. Two reviewers assessed the manuscripts' quality, and relevant data regarding clinical course and management was extracted.ResultsWe reviewed 439 patient charts, identifying two cases of concomitant AIS and PE. Additionally, twelve articles (n = 15 subjects) fulfilled our literature review criteria for a total of 17 cases, including ours. Intravenous anticoagulation (70.5%) was the most frequent intervention targeting both disorders. Therapies such as intravenous thrombolysis (23.53% (n = 4)) and mechanical thrombectomy (23.53% (n = 4)) were specific in AIS. Catheter-directed thrombolysis (5.88%) was used for PE. Clinical outcomes were favorable (asymptomatic or mild disable symptoms) in 47.05% (N = 8) of patients, while 41.17% had poor outcomes (severe disable symptoms or death).ConclusionsAIS and PE stand for a challenge when they present simultaneously. The evaluation of risks and benefits of therapies such as intravenous thrombolysis, mechanical thrombectomy, and catheter-directed-thrombolysis in the clinical context is essential. According to our review, the ischemic stroke burden guides systemic anticoagulation decisions over interventional procedures when the hemodynamic status remains unaffected.

Frequency of Hypoalbuminemia and In-Hospital Mortality in Acute Ischemic Stroke Patients Presenting at a Tertiary Care Hospital, Hyderabad.

BackgroundThe aim of this study was to determine the frequency of hypoalbuminemia and in-hospital mortality in acute ischemic stroke patients at a tertiary care hospital in Hyderabad.MethodologyThis was a prospective observational study conducted at the Department of Medicine, Isra University Hospital, Hyderabad, from February 17, 2017 to August 18, 2017. A total of 196 consecutive cases of acute ischemic stroke were included. Hypoalbuminemia was defined as serum albumin of <3.5 mg/dL. In-hospital outcome in terms of survival or death within seven days of admission was assessed and recorded. Data were analyzed using SPSS, version 20.0. (IBM Corp., Armonk, NY, US). Chi-square test was applied, and p-value of ≤0.05 was considered significant.ResultsOut of the 196 acute ischemic stroke cases, 146 (74.5%) were males and 50 (25.5%) were females. The mean age was 49.31 ± 10.46 years. A total of 90 (45.9%) cases had hypoalbuminemia. Out of these 196 cases, 22 (11.2%) expired within seven days of presentation of acute ischemic stroke, and out of these 22 expired cases, 18 (81.8%) had hypoalbuminemia. In-hospital mortality was found to be strongly associated with hypoalbuminemia (p < 0.001).ConclusionsFrequency of hypoalbuminemia was significantly higher in ischemic stroke patients and was found to be associated with in-hospital mortality, warranting monitoring at regular intervals, as well as recognizing and treating it early for risk stratification.

Utilization and Availability of Advanced Imaging in Patients With Acute Ischemic Stroke.

Recent clinical trials have established the efficacy of endovascular stroke therapy and intravenous thrombolysis using advanced imaging, particularly computed tomography perfusion (CTP). The availability and utilization of CTP for patients and hospitals that treat acute ischemic stroke (AIS), however, is uncertain. We performed a retrospective cross-sectional analysis using 2 complementary Medicare datasets, full sample Texas and 5% national fee-for-service data from 2014 to 2017. AIS cases were identified using International Classification of Diseases, NinthRevision and International Classification of Diseases, Tenth Revision coding criteria. Imaging utilization performed in the initial evaluation of patients with AIS was derived using Current Procedural Terminology codes from professional claims. Primary outcomes were utilization of imaging in AIS cases and the change in utilization over time. Hospitals were defined as imaging modality-performing if they submitted at least 1 claim for that modality per calendar year. The National Medicare dataset was used to validate state-level findings, and a local hospital-level cohort was used to validate the claims-based approach. Among 50 797 AIS cases in the Texas Medicare fee-for-service cohort, 64% were evaluated with noncontrast head CT, 17% with CT angiography, 3% with CTP, and 33% with magnetic resonance imaging. CTP utilization was greater in patients treated with endovascular stroke therapy (17%) and intravenous thrombolysis (9%). CT angiography (4%/y) and CTP (1%/y) utilization increased over the study period. These findings were validated in the National dataset. Among hospitals in the Texas cohort, 100% were noncontrast head CT-performing, 77% CT angiography-performing, and 14% CTP-performing in 2017. Most AIS cases (69%) were evaluated at non-CTP-performing hospitals. CTP-performing hospitals were clustered in urban areas, whereas large regions of the state lacked immediate access. In state-wide and national Medicare fee-for-service cohorts, CTP utilization in patients with AIS was low, and most patients were evaluated at non-CTP-performing hospitals. These findings support the need for alternative means of screening for AIS recanalization therapies.

Decompressive hemicraniectomy for acute ischemic stroke associated with coronavirus disease 2019 infection: Case report and systematic review

Background: Decompressive hemicraniectomy (DH) has been performed for some cases of acute ischemic stroke in patients with coronavirus disease 2019 (COVID-19) infection, but there is little information about the clinical course and outcomes of these patients.Case Description: We report a case of a 36-year-old woman with COVID-19 infection who developed stroke like symptoms while under home quarantine. Cranial CT scan showed an acute left internal carotid artery (ICA) infarct. She subsequently underwent an emergent left DH. Despite timely surgical intervention, she succumbed to chronic respiratory failure. A systematic review of SCOPUS and PubMed databases for case reports and case series of patients with COVID-19 infection who similarly underwent a DH for an acute ischemic infarct was performed. There were eight other reported cases in the literature. The patients’ age ranged from 33 to 70 years (mean 48), with a female predilection (2:1). Respiratory preceded neurologic symptoms in 83% of cases. The ICA was the one most commonly involved in the stroke, and the mean NIHSS score was 20. DH was performed at a mean of 1.8 days post-ictus. Only four out of the nine patients were reported alive at the time of writing. The most common cause of death was respiratory failure (60%).Conclusion: Clinicians have to be cognizant of the neurovascular complications that may occur during the course of a patient with COVID-19. DH for acute ischemic stroke associated with the said infection was reported in nine patients, but the outcomes were generally poor despite early surgical intervention.

ISCHEMIC STROKE IN COVID-19 PATIENT: A RARE CASE REPORT.

Background: COVID-19 is shown to be associated with hypercoagulable state which may cause neurological and cardiovascular complications. COVID-19 has been represented as an independent risk factor for acute ischemic stroke. Objective:We report a case of acute ischemic stroke as a COVID-19 complication. Material and methods: A 62-year-old known hypertensive male was diagnosed with COVID-19. He developed neurological symptoms 10 days after being tested positive. On doing an NC-CT head, a large acute ischemic stroke involving left Middle Cerebral Artery infarct was detected. Result and Conclusion: Our case represents the development of acute ischemic stroke as a neurological manifestation in patient with COVID-19. Early evaluation for acute neurological changes and timely management may reduce morbidity and mortality in such cases.

Abstract P591: A Significant Dose-Response in Elevated Troponin Levels for Case-Fatality Among Patients With Acute Ischemic Stroke

Introduction: About 21% of acute ischemic stroke (AIS) patients present to medical attention with an elevated cardiac troponin (cTn). Previously, we described that elevated cTn is associated with an increased case-fatality at 1 year. However, it is not clear if there is a dose-dependent relationship between cTn and case-fatality, or if this effect is related to causes of death. Methods: Within a catchment area of 1.3 million we screened local hospital admissions using ICD-9/10 codes 430-436/I60-I68, G45-46 in 2014/2015, and ascertained all physician-confirmed AIS cases by retrospective chart review. Positive cTn was defined by the standard 99th percentile. To account for by hospital variance in cTn results in machine brands and normal ranges, cTn values were log-transformed and centered. Case fatality at 1 year and cause of death was obtained from the National Death Index database. Logistic regression evaluated the impact of cTn on case fatality, and included demographic and clinical risk factors in the model. The percentage with all-cause and cardiac/non-cardiac case-fatality was computed by quartiles of centered cTn levels and compared using the chi-square test. Results: In 2014/2015, there were 2989 AIS cases ascertained, which were 53% female, 30% black, with a mean age of 70 (SD 14). 441 patients with hypertropinemia were included in the analysis. See Table for case fatality at 1 year by quartile of centered cTn levels. There was no association between cTN and non-cardiac case-fatality. After adjustment for demographic and clinical characteristics, every 0.5 point increase in the centered cTn level increased the cardiac case-fatality by OR 1.19 (1.09, 1.31), p&lt;0.01. Discussion: We found that the impact of hypertropinemia on case fatality after AIS appears to be a dose-dependent association: as cTn increases, so does the cardiac case-fatality. This suggests that the degree of cTn elevation is likely an important prognostic marker for cardiac death in AIS patients.

Abstract P85: Impact of Covid-19 Pandemic on Hospitalizations and Outcomes of Acute Ischemic Stroke Patients, Paul Coverdell National Acute Stroke Program (pcnasp)

Introduction: Studies suggest a significant reduction in emergency department visits and hospitalizations for acute ischemic stroke (AIS) during the COVID-19 pandemic in the United States. Few studies have examined AIS hospitalizations, treatments, and outcomes during the pandemic period. The present study compared the demographic and clinical characteristics of patients hospitalized with AIS before and during the COVID-19 pandemic (weeks 11-24 in 2019 vs. 2020). Method: We identified 42,371 admissions with a clinical diagnosis of AIS, from 370 participating hospitals who contributed data during weeks 11-24 in both 2019 and 2020 to the Paul Coverdell National Acute Stroke Program (PCNASP). Results: During weeks 11-24 of the COVID-19 period, AIS hospitalizations declined by 24.5% compared to the same period in 2019 (18,233 in 2020 vs. 24,138 in 2019). In 2020, the percentage of individuals aged &lt;65 years who were hospitalized with AIS was higher compared with the same period in 2019 (34.6% vs. 32.7%, p&lt;0.001); arriving by EMS were higher in 2020 compared with 2019 (47.7% vs. 44.8%, p&lt;0.001). Individuals admitted with AIS in 2020 had a higher mean National Institutes of Health Stroke Scale (NIHSS) score compared with 2019 (6.7 vs. 6.3, p&lt;0.001). In 2020, the in-hospital death rates increased by 16% compared to 2019 (5.0% vs. 4.3%, p&lt;0.001). However, there were no differences in rates of alteplase use, achievement of door to needle in 60 minutes, or complications from reperfusion therapy between the two time periods. Conclusion: A higher percentage of younger (&lt;65 years) individuals and more severe AIS cases were admitted to the participating hospitals during weeks 11 to 24 of the COVID-19 pandemic in 2020 compared to the same period in 2019. The AIS in-hospital death rate increased 16% during the pandemic weeks as compared to the same weeks in 2019. Additional studies are needed to examine the impacts of the COVID-19 pandemic on stroke treatment and outcomes.

Abstract P32: Advanced Practice Provider-Based Acute Stroke Protocol Performs Well Compared to a Resident-Based Protocol

Introduction: The administration of intravenous tissue plasminogen activator (IVtPA) for acute ischemic stroke (AIS) is typically done by neurology resident physicians at academic stroke centers. We sought to compare the performance of an advanced practice provider (APP)-based IVtPA protocol to a resident-based protocol. Methods: We performed a retrospective review of Emergency Room (ER) acute stroke codes from January 1, 2018 to January 1, 2019 that received AIS reperfusion therapy, including IVtPA or mechanical thrombectomy (MT). Inpatient AIS were excluded. During this timeframe, 5 acute stroke-trained nurse practitioners covered the daytime shifts for acute stroke codes on a rotating basis (during the hours of 7:00 am -4:00 pm, Monday through Friday). The neurology residents continued to cover all other stroke code shifts. We collected data on baseline demographics, initial National Institutes of Health Stroke Scale (NIHSS), door to needle (DTN) time, and door to groin puncture (DTG) time. Statistical analyses were performed using JMP software package (version 14). All tests were 2-sided, and a P value was considered significant at &lt;0.05. Results: Among 322 AIS case who received acute reperfusion therapy, 133 (41.4%) received IVtPA, 200 (62.3%) received MT, and 11 (3.4%) received both. Among the 133 IVtPA patients, there was no difference in age (62.2 vs 59.9, p 0.56) or mean initial NIHSS (7.7 vs 8.2, p 0.75) when comparing the APP-based protocol to the resident-based protocol group, but patients seen by the APP were more likely to be male (78.3 vs 42.7%, p 0.0015). Compared to the resident-based protocol, the APP-based protocol had faster mean DTN times (38.9 vs 54.7 minutes, p 0.0374) and were more likely to have final diagnosis of stroke (95.7% vs 70%, p 0.0034). Among the 200 MT patients, the DTG time showed a trend for faster times for the APP-based protocol, although this was not significant (60.5 vs 76.5, p 0.0083). Conclusion: At our academic comprehensive stroke center, APP driven acute stroke code protocols perform as well as resident-based protocols in terms of time to reperfusion therapy.

Using ESN-Smartphone Application to Maximize AIS Reperfusion Therapy in Alexandria Stroke Network: A Stroke Chain of Survival Organizational Model.

Background: In developing countries like Egypt, the clinical workflow of stroke management is poorly established due to the lack of awareness of the stroke patients concerning their need of therapeutic intervention and the poor identification of facilities equipped to treat stroke. Hence, establishing a stroke system of care in developing countries that can efficiently and rapidly triage patients to the appropriate reperfusion therapy center is imperative to improving stroke management and outcomes.Aims: To evaluate a pilot experience in stroke hospital identification and expediting decision-making in AIS treatment through the Alexandria stroke network and Egyptian Stroke Network (ESN)-app.Methods: Between 2017 and 2019, seven hospitals registered themselves on the AS-Network as pilot hospitals. The ESN-application was used to detect stroke type, tele-connect stroke teams and hospitals, track triage of patients to equipped facility in real time, and streamline stroke workflow. The quality of and time required for stroke management were compared between 84 patients with acute ischemic stroke (AIS) whose treatment involved the ESN-app and 276 patients whose treatment did not.Results: During this pilot study, 360 AIS cases received reperfusion therapy, 84 of which were indicated by the ESN-app. The use of the application was associated with the significant drop in time metrics for the reperfusion AIS-patients (door-in-door-out time; 56 ± 34 min vs. 96 ± 45 min, door-to-groin puncture time; 50 ± 7 min vs. 120 ± 25 min, door-to-needle time; 55 ± 12 min vs. 78 ± 16 min with p < 0.0001). Its use was also associated with higher rates of excellent outcomes at the 90-day follow-up (without ESN-app vs. with ESN-app, 67.9 vs. 47.1%, p = 0.001) but no difference in 90-day mortality or symptomatic intracerebral hemorrhage (without ESN-app vs. with ESN-app, 9.5 vs. 11.2% and 4.8 vs. 5.1%, p > 0.05).Conclusion: Our pilot experience demonstrated that the use of the ESN-app expedited the stroke treatment workflow and facilitated tele-connection between registered stroke facilities. Additionally, its use might be associated with achieving higher rates of excellent outcomes at 90 days, where a larger scale study is needed for more confirmation.

Role of ACE Polymorphism in Acute Ischemic Stroke.

Stroke is one of the leading causes of death and disability in India. Angiotensin-converting enzyme (ACE) is involved in the development of hypertension, atherosclerosis, cardio, and cerebrovascular disease and is a plausible genetic candidate for stroke. The role of ACE polymorphism is still uncertain and requires further investigation. The aim of this study was to study the role of ACE insertion/deletion polymorphism in acute ischemic stroke (AIS). One hundred thirty AIS cases and 130 age and sex matched healthy controls were recruited. Ten milliliters venous blood was drawn and 6 mL of blood was used for routine hematological, biochemical tests. Remaining 4 mL of EDTA blood was used for DNA extraction, PCR amplification, and restriction digestion. Three genotypes (II, ID, and DD) were visualized on 3% agarose gel. Association between genotypes among stroke case was done by Chi-square test with P value <0.05 taken as significant. DD genotype was significantly associated with the risk of stroke with P value of 0.0001. Both the dominant and recessive models showed that the DD genotype was independently associated with an increased risk of ischemic stroke (OR = 20.732; 95% CI: 2.7241-157.7864; P value = 0.003 for the recessive model and OR = 2.848; 95% CI: 1.5127-5.3649; P value = 0.001 for dominant model). Our study showed a strong association between ACE polymorphism and the risk of AIS. This study paves the way for further studies to confirm the role of ACE polymorphism as genetic risk factors for AIS.

Endothelial Nitric Oxide Synthase (Glu298Asp) Polymorphism is Associated Significantly with Ischemic Stroke Presenting with Seizures and Altered Sensorium.

Endothelial nitric oxide synthase (eNOS) is an enzymatic marker whose genetic polymorphism might predispose to acute ischemic stroke (AIS) via vascular endothelial dysfunction. It has a potential role in atherosclerosis, making it a plausible risk factor for stroke. Prior studies have failed to prove a conclusive relationship between eNOS polymorphism and AIS. The aim of this study is to find an association between the presence of eNOS polymorphism (Glu298Asp) and the risk of developing AIS. We recruited 307 subjects including 153 AIS cases and 154 healthy controls. The eNOS (Glu298Asp) polymorphism was identified in EDTA blood by PCR amplification of the target region followed by restriction enzyme digestion, and genotyping on Agarose gel. GG, GT and TT genotypes were obtained. Statistical analysis was done using SPSS software version 20. A significant association was found between the presence of TT genotype and the risk of AIS (Odd's ratio (OR): 2.43, P-value = 0.038). There was no significant association between the TT genotype and the traditional stroke risk factors. However, the TT genotype was significantly associated with the presence of altered consciousness (OR: 5.27, 95% CI: 1.59-17.04, P-value = 0.003) and with the occurrence of seizures at presentation (OR: 7.98, 95% CI: 1.99-32.09, P-value = 0.007). There is a significant association between the presence of eNOSpolymorphism (Glu298Asp) and the risk of AIS, and the TT genotype may predispose to a more severe initial presentation of ischemic stroke.

The association of lipoprotein (a) and acute ischemic stroke cases admitted in tertiary care center

Background: Lipoprotein (a) (Lp[a]) is a thrombogenic and atherogenic molecule. Several studies have shown Lp(a) as an independent risk factor for stroke. The case–control study was done in West Godavari district of Andhra Pradesh. Aims and Objectives: To estimate the levels of serum lipoprotein (a) in patients with acute ischemic stroke and the association. Materials and Methods: Lp(a) was quantified by immunoturbidimetric method and lipid profile by enzymatic method. Results: The serum Lp(a) levels were significantly elevated (P < 0.001) in cases (62.5 ± 18.3 mg/dl) as compared to controls (21.7 ± 7.1 mg/dl). Conclusion: Elevated Lp(a) is a risk factor for stroke and might play an important role in the genesis of cerebrovascular thrombosis. It may be appropriate to assess Lp(a) levels in Indians along with routine lipid profile testing in subjects with other risk factors.