Stroke Research Articles

Prediction of stroke severity: systematic evaluation of lesion representations.

To systematically evaluate which lesion-based imaging features and methods allow for the best statistical prediction of poststroke deficits across independent datasets. We utilized imaging and clinical data from three independent datasets of patients experiencing acute stroke (N1 = 109, N2 = 638, N3 = 794) to statistically predict acute stroke severity (NIHSS) based on lesion volume, lesion location, and structural and functional disconnection with the lesion location using normative connectomes. We found that prediction models trained on small single-center datasets could perform well using within-dataset cross-validation, but results did not generalize to independent datasets (median R2 N1 = 0.2%). Performance across independent datasets improved using large single-center training data (R2 N2 = 15.8%) and improved further using multicenter training data (R2 N3 = 24.4%). These results were consistent across lesion attributes and prediction models. Including either structural or functional disconnection in the models outperformed prediction based on volume or location alone (P < 0.001, FDR-corrected). We conclude that (1) prediction performance in independent datasets of patients with acute stroke cannot be inferred from cross-validated results within a dataset, as performance results obtained via these two methods differed consistently, (2) prediction performance can be improved by training on large and, importantly, multicenter datasets, and (3) structural and functional disconnection allow for improved prediction of acute stroke severity.

Different expression patterns of inflammation-related genes and serum microRNAs in young-onset ischemic stroke

Brain ischemia results in the activation of a cascade of inflammatory responses, contributing to the pathogenesis of stroke. This study aimed to assess the patterns of possible changes in the expression of specific inflammation-associated protein-encoding genes and miRNAs in the peripheral blood between the acute and chronic phase of young-onset cryptogenic (Cryp) and large-artery atherosclerotic (LAA) stroke. Blood and serum were collected from patients with cryptogenic and large-artery atherosclerotic stroke at the stroke onset and 1-year follow-up. The relative expression of inflammation-related genes was analysed at the mRNA and miRNA levels using real-time quantitative PCR. Moreover, the relationship between the relative gene expression levels and clinical data was assessed using several different statistical approaches. Seventy-three patients were included in this study, with a median age of 47 (IQR, 9) years. Approximately 72% were men. In patients with cryptogenic stroke, at the mRNA level, ICAM1, CXCL8, TNF, NFKBIA, PYCARD, IL1B, and IL18 were observed to be upregulated at the stroke onset compared to the 1-year follow-up. In patients with LAA stroke, only the expression of NFKBIA was significantly higher during acute stroke. Further, the miRNA serum levels of miR-21, miR-122, and miR-155 were higher at the onset of stroke in patients with cryptogenic stroke but not in those with LAA stroke. The differences between the relative gene expression levels during acute stroke and at the 1-year follow-up were more pronounced in patients with cryptogenic stroke with no cardiovascular risk factors. The expression changes of inflammatory genes in whole blood and miRNAs in the serum differ in patients with cryptogenic and LAA stroke.

Endovascular thrombectomy for childhood stroke (Save ChildS Pro): an international, multicentre, prospective registry study.

Emerging evidence suggests that endovascular thrombectomy is beneficial for treatment of childhood stroke, but the safety and effectiveness of endovascular thrombectomy has not been compared with best medical treatment. We aimed to prospectively analyse functional outcomes of endovascular thrombectomy versus best medical treatment in children with intracranial arterial occlusion stroke. In this prospective registry study, 45 centres in 12 countries across Asia and Australia, Europe, North America, and South America reported functional outcomes for children aged between 28 days and 18 years presenting with arterial ischaemic stroke caused by a large-vessel or medium-vessel occlusion who received either endovascular thrombectomy plus best medical practice or best medical treatment alone. Intravenous thrombolysis was considered part of best medical treatment and therefore permitted in both groups. The primary outcome was the difference in median modified Rankin Scale (mRS) score between baseline (pre-stroke) and 90 days (±10 days) post-stroke, assessed by the Wilcoxon rank test (α=0·05). Efficacy outcomes in the endovascular thrombectomy and best medical treatment groups were compared in sensitivity analyses using propensity score matching. The Save ChildS Pro study is registered at the German Clinical Trials Registry, DRKS00018960. Between Jan 1, 2020, and Aug 31, 2023, of the 241 patients in the Save ChildS Pro registry, 208 were included in the analysis (115 [55%] boys and 93 [45%] girls). 117 patients underwent endovascular thrombectomy (median age 11 years [IQR 6-14]), and 91 patients received best medical treatment (6 years [3-12]; p<0·0001). The median Pediatric National Institutes of Health Stroke Scale (PedNIHSS) score on admission was 14 (IQR 10-19) in the endovascular thrombectomy group and 9 (5-13) in the best medical treatment group (p<0·0001). Both treatment groups had a median pre-stroke mRS score of 0 (IQR 0-0) at baseline. The change in median mRS score between baseline and 90 days was 1 (IQR 0-2) in the endovascular thrombectomy group and 2 (1-3) in the best medical treatment group (p=0·020). One (1%) patient developed a symptomatic intracranial haemorrhage (this patient was in the endovascular thrombectomy group). Six (5%) patients in the endovascular thrombectomy group and four (5%) patients in the best medical treatment group had died by day 90 (p=0·89). After propensity score matching for age, sex, and PedNIHSS score at hospital admission (n=79 from each group), the change in median mRS score between baseline and 90 days was 1 (IQR 0-2) in the endovascular thrombectomy group and 2 (1-3) in the best medical treatment group (p=0·029). Regarding the primary outcome for patients with suspected focal cerebral arteriopathy, endovascular thrombectomy (n=18) and best medical treatment (n=33) showed no difference in 90-day median mRS scores (2 [IQR 1-3] vs 2 [1-4]; p=0·074). Clinical centres tended to select children with more severe strokes (higher PedNIHSS score) for endovascular thrombectomy. Nevertheless, endovascular thrombectomy was associated with improved functional outcomes in paediatric patients with large-vessel or medium-vessel occlusions compared with best medical treatment. Future studies need to investigate whether the positive effect of endovascular thrombectomy is confined to older and more severely affected children. None.

Oxygen Extraction Fraction Mapping on Admission Magnetic Resonance Imaging May Predict Recovery of Hyperacute Ischemic Brain Lesions After Successful Thrombectomy: A Retrospective Observational Study.

In acute stroke, diffusion-weighted imaging (DWI) is used to assess the ischemic core. Dynamic-susceptibility contrast perfusion magnetic resonance imaging allows an estimation of the oxygen extraction fraction (OEF), but the outcome of DWI lesions with increased OEF postrecanalization is unclear. This study investigated the impact of OEF on the fate of DWI lesions in patients achieving recanalization after thrombectomy. This was a retrospective analysis of the HIBISCUS-STROKE cohort (Cohort of Patients to Identify Biological and Imaging Markers of Cardiovascular Outcomes in Stroke; NCT: 03149705), a single-center observational study that prospectively enrolled patients who underwent magnetic resonance imaging triage for thrombectomy and a day-6 T2-fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging. Automated postprocessing of admission dynamic-susceptibility contrast perfusion magnetic resonance imaging generated OEF maps. At visual analysis, the OEF status within DWI lesions was assessed in comparison to the contralateral side and correlated with volume changes (difference of ischemic lesion between admission DWI and registered day-6 T2-FLAIR). At voxel-based analysis, recovered DWI regions (lesions present on the admission DWI but absent on the registered day-6 T2-FLAIR) and nonrecovered regions were segmented to extract semiquantitative OEF values. Of the participants enrolled from 2016 to 2022, 134 of 321 (41.7%) were included (median age, 71.0 years; 58.2% male; median baseline National Institutes of Health Scale score, 15.0). At visual analysis, 46 of 134 (34.3%) patients had increased OEF within DWI lesions. These patients were more likely to show a reduction in ischemic lesion volumes compared with those without increased OEF (median change, -4.0 versus 4.8 mL; P<0.0001). Multivariable analysis indicated that increased OEF within DWI lesions was associated with a reduction in ischemic lesion volumes from admission DWI to day-6 T2-FLAIR (odds ratio, 0.68 [95% CI, 0.49-0.87]; P=0.008). At voxel-based analysis, recovered DWI regions had increased OEF, while nonrecovered regions had decreased OEF (median, 126.9% versus -27.0%; P<0.0001). Increased OEF within hyperacute DWI lesions was associated with ischemic lesion recovery between admission DWI and day-6 T2-FLAIR in patients achieving recanalization after thrombectomy. URL: https://www.clinicaltrials.gov; Unique identifier: NCT03149705.

Gait speed after mild stroke/transient ischemic attack was associated with long-term adverse outcomes: A cohort study.

The association between gait speed and adverse outcomes after stroke has not been fully illustrated. This study aimed to explore the association of gait speed on long-term outcomes in minor stroke or transient ischemic attack (TIA). We performed a longitudinal study with acute minor stroke or TIA based on a subgroup of the Third China National Stroke Registry data. The gait speed was evaluated using a 10-meter walking test at discharge and 3 months after the stroke onset. The primary outcomes were poor functional outcomes at 1 year, defined by a modified Rankin Score (mRS) of 2-6. Additional outcomes included all-cause death, ambulate dependency (mRS score 4-6), cognitive impairment (Montreal Cognitive Assessment <26), stroke recurrence, and composite vascular events. The study sample included a total of 1542 stroke patients with a median age of 60 (53-68). At 1-year follow-up, 140 (9.20%) patients experienced poor functional outcomes. Faster gait speed at discharge was associated with lower incidence of poor functional outcome (OR = 0.89; 95% CI, 0.84-0.94), cognitive impairment (OR = 0.93; 95% CI, 0.89-0.96), ischemic stroke recurrence (HR = 0.92; 95% CI, 0.87-0.98), and composite vascular events (HR =0.94; 95% CI, 0.89-0.99) at 1 year. Faster gait speed at 3 months was associated with lower incidence of poor functional outcome (OR = 0.90; 95% CI, 0.85-0.95), ambulate dependency (OR = 0.86; 95% CI, 0.77-0.97), and cognitive impairment (OR = 0.92; 95% CI, 0.88-0.95) at 1 year. Our findings indicated that slow gait speed after minor stroke or TIA may be an independent predictor for long-term poor outcomes. Gait speed may be considered as a vital sign during follow-up in post-stroke patients.

Bioelectrical impedance analysis (BIA) phase angle in stroke patients: A systematic review

Background and AimsPhase angle (PhA), a raw variable of bioelectrical impedance analysis (BIA), is an index of muscle structure and quality and might have a potential role in the evaluation of nutritional status.The aim of this systematic review was to evaluate in stroke patients: baseline PhA and its changes during hospital stay; the association of PhA with clinical features of patients, comorbidities, nutritional status or sarcopenia, and clinical outcomes. MethodsSystematic research on electronic databases (PubMed, Scopus, and Web of Science) up to June 14th, 2024 was performed according to PRISMA checklist.Using PECOS strategy, “P” (patients)=stroke patients, “E” (exposure)=lowest PhA values, “C” (comparison)=versus greatest PhA values, “O” (outcome)=nutritional and clinical outcomes, and “S” (study design)=all study types.Methodological quality was assessed using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies (NIH). ResultsEighteen papers met the inclusion criteria, with a low risk of bias. In stroke patients, evidence suggests that PhA was associated with malnutrition, sarcopenia and sarcopenic obesity, as well as with physical function. In addition, patients with low PhA had a longer hospital stay, higher inflammatory status and higher incidence of urinary tract infections and hospital-acquired pneumonia. ConclusionsSelected papers, although not conclusive, show that in acute and subacute stroke patients PhA was inversely associated with malnutrition and poor physical function. PhA could be a marker of health status and disease progression. PhA may be useful in a more comprehensive evaluation of nutritional status to be used for diagnosis and implementing therapy.

Navigating the aftermath: Risk factors of recurrence following coronary bypass surgery in Indonesia

Coronary heart disease (CHD) remains a leading cause of mortality in Indonesia, and coronary artery bypass graft (CABG) surgery is frequently employed to manage arterial blockages. Despite its efficacy, the recurrence of heart disease post-surgery is a significant concern, highlighting the need for a deeper understanding of its influencing factors. The aim of this study was to examine the factors associated with the incidence of heart disease recurrence after coronary bypass surgery. This study employed a prospective observational design, analyzing hospital claim data from Indonesia's Social Security Agency for Health, known as Badan Penyelenggara Jaminan Sosial (BPJS) Kesehatan, from 2017 to 2022. The analysis included 5,947 patients who survived CABG surgery. Multivariable logistic regression was utilized to assess the relationship between patient demographics, comorbidities, socioeconomic status, and compliance with follow-up visits, as well as their impact on the recurrence of cardiovascular disease. The study found that 24.1% of patients experienced hospitalization recurrence. Patients with irregular follow-ups were less likely to experience recurrence (adjusted odds ratio (AOR): 0.63; 95%CI: 0.51–0.78). Other significant risk factors for recurrence included being self-employed (AOR: 2.09; 95%CI: 1.72–2.55), having comorbid conditions such as disorders of fluid, electrolyte, and acid-base balance (AOR: 3.55; 95%CI: 2.97–4.24), and experiencing cerebral infarction or stroke (AOR: 10.85; 95%CI: 8.24–14.29). In contrast, older age (AOR: 0.89; 95%CI: 0.88–0.91) and the presence of non-insulin-dependent diabetes mellitus (AOR: 0.35; 95%CI: 0.29–0.42) were associated with a lower risk of recurrence. Sex did not significantly influence the risk of recurrence (AOR: 1.18; 95%CI: 0.86–1.62). In conclusion, the study indicates a considerable rate of cardiovascular disease recurrence post-CABG in Indonesia, highlighting several key risk factors. Tailored postoperative management and strict adherence to follow-up protocols are essential for mitigating recurrence. These findings offer crucial insights for improving post-CABG health management strategies in Indonesia.

Cystic cardiac myxoma: a rare variant of cardiac myxoma in a woman with acute stroke

BackgroundCardiac myxomas are the most common primary benign tumors of the heart usually presenting as an oval mass attached to the interatrial septum. Mild heterogenous enhancement is typically seen upon contrast administration. Myxomas are benign, however can present with embolic episodes necessitating prompt diagnosis and treatment.Case presentationA middle-aged woman presenting with acute ischemic stroke was detected to have a complex cystic mass in the left atrium on echocardiography. Further evaluation with cardiac magnetic resonance imaging narrowed a differential diagnosis to hemangioma, hemangioendothelioma, sarcoma, hydatid cysts, bronchogenic cysts, and cystic variant of cardiac myxoma. CTA demonstrated arterial supply from the left circumflex artery supplying the lesion. Following surgical excision, histopathology analysis suggested a cystic cardiac myxoma with secondary degeneration.ConclusionCystic masses in the heart are challenging to diagnose due to similar imaging characteristics, and misdiagnosis may lead to further major downstream complications such as stroke, hemorrhage, and hemodynamic alterations causing syncope. Therefore, surgical excision of a cystic cardiac mass is justified to establish a definitive histopathological diagnosis and prevent further downstream complications. We hereby report a rare case of cystic cardiac myxoma in the left atrium showing intense progressive enhancement in CMR and CTA in a middle-aged woman presenting with acute stroke. This case highlights an exceedingly rare variant of cystic cardiac myxoma.

Balance and Walking Speed Outcomes in Individuals Receiving Inpatient Rehabilitation for Acute Cerebellar Stroke.

Cerebellar strokes account for only 2-3% of all strokes occurring annually in the United States but represent a disproportionally higher share of morbidity and mortality. Evidence examining the effect of inpatient rehabilitation on functional outcomes following a cerebellar stroke is limited. This study aimed to examine the effects of inpatient rehabilitation on balance and walking speed in individuals with cerebellar stroke. A secondary purpose of this study was to examine the length of inpatient rehabilitation stay of the included patients. A retrospective analysis was conducted using review of patient records during their inpatient rehabilitation stay from January 2021 to February 2022 at a large hospital system in the southeast United States. Balance and gait outcomes were examined on admission and discharge from inpatient rehabilitation that included physical therapy interventions. A paired t-test examined for changes in outcomes from admission to discharge. Pearson correlation examined for the association between length of stay and outcomes. A total of 15 records were reviewed. There were significant improvements in the Berg Balance Scale (BBS), Postural Assessment Scale for Stroke (PASS), and the 10-Meter Walk Test (10MWT) (p's < 0.01) from admission to discharge with large effect sizes (range d = 0.70-1.67) following inpatient rehabilitation. The average length of stay was 12.67 days (SD = 6.5) and the mean total hours of combined occupational, physical, and speech therapy was 27.33 (SD = 6.52) h. There was a moderate association between length of stay and PASS (r = 0.525, p = 0.04) and BBS (r = 0.546, p = 0.04) outcomes. Patients who underwent inpatient rehabilitation following acute cerebellar strokes demonstrated improvements in balance and gait speed. Study results could assist clinicians designing interventions for patients with cerebellar strokes in the inpatient rehabilitation setting.

Mechanical Thrombectomy for Pediatric Stroke: Focal Cerebral Arteriopathy Versus Cardioembolic Etiologies-Pooled Analysis of the Save ChildS and KidClot Cohort.

The study aimed to compare outcomes of mechanical thrombectomy (MT) in pediatric patients with acute ischemic stroke (AIS) caused by focal cerebral arteriopathy (FCA) versus cardioembolism (CE). Data from the Save ChildS and KidClot cohorts were merged. Children with AIS because of FCA or CE that underwent MT were included. The study used the Childhood Arterial Ischemic Stroke Standardized Classification and Diagnostic Evaluation (CASCADE) for stroke cause assessment. Descriptive statistics and multivariable regression models were used to analyze final modified thrombolysis in cerebral infarction (mTICI) scores, periprocedural complications, and functional outcomes assessed by the modified Rankin scale (mRS) at 6 to 12 months. The analysis included 60 children with 14 FCA and 46 CE cases. CE etiology was associated with better revascularization (good to excellent thrombolysis in cerebral infarction scores) and shift toward better outcomes (common adjusted odds ratio of mRs for CE vs FCA: 0.27, 95% CI: [0.06-0.97], p = 0.039), with no difference in favorable outcome rates. FCA was associated with significantly lower rates of excellent revascularization (21% vs 65%, p < 0.001). No difference in complications' rates was observed between the groups (7.2% in FCA vs 5.5%, p = 0.69). We found that pediatric AIS because of CE etiology has more favorable procedural outcomes compared to FCA following MT. This translated to mixed functional outcomes that may be more favorable in the CE group. These findings highlight the need for further research to refine treatment protocols for pediatric stroke, particularly in understanding and managing FCA in children. ANN NEUROL 2024.

Clinicopathological Observations in Acute Stroke Patients Treated with Intravenous Thrombolysis.

Background: Ischemic stroke is a leading cause of mortality worldwide, and intravenous thrombolysis, while improving functional outcomes, still leaves a significant mortality rate. This study aimed to investigate the clinical and pathological data of thrombolysed stroke patients who subsequently died and underwent autopsy, focusing on hemorrhagic transformation (HT). Methods: Over a 10-year period, 1426 acute ischemic stroke patients received thrombolysis at our center, with an in-hospital mortality rate of 11.7%. Autopsies were performed on 98 of the 167 deceased patients. Results: HT was found in 47% of these cases, only less than half occurring within a day of thrombolysis. Significant independent predictors of HT included higher lactate dehydrogenase (LD) levels and higher INR values at admission. HT directly caused death in 30% of cases, often through herniation, while other complications (pulmonary embolism, pneumonia) were also common. Conclusions: These findings highlight the importance of postmortem investigations to accurately determine the incidence of HT and contributing factors. Our data indicate that in the vast majority of HT cases, the role of contributing factors other than rt-PA may be important. Of the routinely assessed clinical and laboratory parameters at admission, only LD and INR were found to be independent predictors of HT in the autopsied studied cohort.

Multicentric Pediatric Stroke Code: Insight to the first years after implementation

BackgroundThe development of unicentric pediatric acute stroke protocols has improved stroke diagnosis and treatment. The impact of the implementation of a multicentric Pediatric Stroke Code (PSC) remains unknown. Aimto describe the characteristics of the PSC activations and identify clinical features associated with stroke compared to stroke mimics in children in whom a multicentric PSC had been activated and compare them to reported monocentric PSC results. MethodsObservational, retrospective, case and control multicentric study, performed in the Pediatric Emergency Department (PED) of the three Primary Pediatric Stroke Centers (PPSCs) in Madrid (Spain). Study population corresponded to children between 28 days and 16 years old in whom PSC was activated that consulted or were referred to any of the PPSC PED between March 2019 and June 2022. The main outcome was to compare the characteristics of patients with final diagnosis of stroke versus stroke mimics, among all patients for which PSC had been activated. Logistic regression modeling was used to investigate associations between independent variables and stroke diagnosis. Odds ratio (ORs) and 95 % confidence intervals (95%CIs) were estimated. ResultsPSC was activated in 196 patients. Stroke was confirmed in 39 patients (19.9 %): 20 (10.2 %) had an ischemic stroke and 19 (9.7 %) a hemorrhagic stroke. Stroke mimics represented 80.1 % of the PSC activations. Migraine was the most frequent stroke mimic (38.3 %). Time from symptom onset to brain imaging was 233.00 min (IQR 153.00–373.00) when patients self-presented at the PPSC compared to 231.00 min (IQR 129.00–400.00) when PSC was triggered at other settings (p0.580). Five patients (25.3 %) were eligible for hyperacute recanalization treatment. Low level of consciousness (OR4.373, 95%IC 0.247–0.652, p < 0.001), sensory disruption/motor disability of face/limbs (OR3.633, 95%IC 0.103–0.349, p < 0.001), aphasia (OR2.311, 95%IC 0.023–0.284, p0.022) and altered mental status (OR2.517, 95%IC 0.043–0.357, p0.013) were associated with an increased probability of stroke. Conclusionmulticentric PSC achieved similar results to previously reported unicentric PSCs, showing the feasibility of such an organization.

Helicopter Emergency Medical Services (HEMS) Transportation Utilization for Acute Ischemic Strokes at a Community-Based Hospital in South Florida

Background: A comprehensive stroke center (CSC) servicing remote areas in South Florida became HEMS direct-from-field capable on October 15, 2020. This analysis reviews the utilization of this service and compares it to ground EMS (GEMS). Methods: This is a retrospective cohort study from October 15, 2020, to July 31, 2021, that collected HEMS adult stroke alert data and compared it to the prior year's summary GEMS stroke alert data. Using HEMS transportation logs, presenting stroke symptoms and prehospital assessment were abstracted, in addition to initial NIHSS, downgrade rate, stroke diagnosis percentage, treatment rate, and times. Results: The analysis included a total of 52 direct transport HEMS stroke alerts. Assessment tools utilized by HEMS included the Cincinnati stroke scale (4%) and the FAST-ED (37%); most cases (59%) did not document a stroke assessment tool. The median NIHSS was 10, with 37% presenting a score &lt;6. Cases were downgraded upon arrival in 27% and after CT imaging in 15% of cases. Significantly (p&lt;.001), more HEMS cases were diagnosed as stroke (69%) compared to GEMS (57%). Stroke treatment rates remained similar (HEMS=23%; GEMS=24%). Median door-to-needle times were significantly faster for HEMS (15 min) than GEMS (25 min) (p&lt;.05). Median door-to-puncture times were clinically faster for HEMS (61mins) than GEMS (66 mins). Conclusion: Prehospital triage could be improved to better detect the 77% of patients who are not eligible for acute stroke reperfusion treatments and may benefit from ground as opposed to air transportation. The current HEMS triage, although not consistently documented, appropriately selects stroke victims, but not necessarily those who need air transport to a higher care level. Patients arriving via HEMS receive similar access to stroke treatment and, if treated, significantly faster treatment times.

Utility of automated CT perfusion software in acute ischemic stroke with large and medium vessel occlusion.

Early diagnosis of large vessel occlusion (LVO) in acute stroke often requires CT angiography (CTA). Automated CT perfusion (CTP) software, which identifies blood flow abnormalities, enhances LVO diagnosis and patient selection for endovascular thrombectomy (EVT). This study evaluates the sensitivity of automated CTP images in detecting perfusion abnormalities in patients with acute ischemic stroke (AIS) and LVO or medium vessel occlusion (MeVO), compared to CTA. We screened acute ischemic stroke patients presenting within 24 h who underwent CT, CTA, and CTP as per institutional protocol. RAPID AI software processed CTP images, while neuroradiologists reviewed CTA for intracranial arterial occlusions. Sensitivity, specificity, and accuracy of automated CTP maps in detecting occlusions were assessed. Of 790 screened patients, 31 were excluded due to lack of RAPID CTP data or poor-quality scans, leaving 759 for analysis. The median age was 71 years (IQR: 61-81), with 47% female. Among them, 678 had AIS, and 81 had AIS ruled out. CTA identified arterial occlusion in 562 patients (74%), with corresponding CTP abnormalities in 537 patients (Tmax > 6 sec). In the 197 without occlusion, CTP was negative in 161. Automated CTP maps had a sensitivity of 95.55% (CI 95: 93.50-97.10%), specificity of 81.73% (CI 95: 75.61-86.86%), negative predictive value of 98.22% (CI 95: 97.39-98.79%), positive predictive value of 63.54% (CI 95: 56.46-70.09%), and overall accuracy of 85.18% (CI 95: 82.45-87.64%). Automated CTP maps demonstrated high sensitivity and negative predictive value for LVOs and MeVOs, suggesting their usefulness as a rapid diagnostic tool, especially in settings without expert neuroradiologists.

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 CT (NCCT) and CT angiogram (CTA) have become essential for endovascular treatment (EVT) in acute stroke. Patient selection may improve when CT perfusion imaging (CTP) 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 was split into two groups: the CTP and control (NCCT+CTA) cohorts. Primary outcomes evaluated were modified Rankin Scale (mRS) scores, symptomatic intracranial hemorrhages (sICH), mortality, and successful recanalization. There were 14 studies with 5,809 total patients in the final analysis: 2,602 received CTP and 3,202 were in the control group. CTP/CTA patients showed significantly lower rates of 90-day stroke-related mortality (OR: 0.72, 95% 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 to CTA-only patients. Analysis of other outcomes including functional independence (mRS 0-2), critical times, and intracranial hemorrhages were 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.

Expression of microRNA-21 in acute ischemic stroke: relationship with inflammatory cytokines, clinical severity, and clinical outcome

Background When the brain is deprived of oxygen and nutrients due to stenosis or arterial rupture, neurons in the affected area suffer irreversible damage and cellular death. MicroRNA has been shown to regulate target genes implicated in arterial hypertension, atherosclerosis, and diabetes mellitus, all of which influence the risk of ischemic stroke through inflammation, oxidative stress, cell proliferation, and apoptosis. The study aims to determine the changes in miRNA expression, namely miRNA-21, between acute ischemic stroke patients and controls and their relationship to proinflammatory cytokines, clinical severity, and outcome. Methods Serum samples from tertiary hospitals and controls were used to evaluate miRNA-21 expression as well as cytokines TNF-α, IL-10, ICAM-1, and CCL5 levels within 7 days of stroke onset. The 30-day clinical severity and outcome were assessed using the National Institute of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS), respectively. Result A total of 64 acute ischemic stroke patients and 22 age-matched controls were recruited, with median ages of 56 and 55.5 years old, respectively. There were more male subjects than females (35 to 29). A statistically significant difference was observed in miRNA-21 expression between patients and controls (p&lt;0.001). This finding implies that miRNA-21 expression may have a contribution in acute stroke patients. This was followed by an increase in proinflammatory markers TNF-α, IL-10, ICAM-1, and CCL5. However, no association was found between miRNA-21 and any pro-inflammatory cytokine. There was no significant correlation between miRNA-21 or cytokines markers with clinical severity or prognosis. Conclusion Our study demonstrated increased miRNA-21 expression and proinflammatory cytokine expression in acute ischemic stroke patients relative to controls. However, this was not related to clinical severity or clinical outcomes.

Secondary Sarcopenia in Patients with Locomotor Disorders: Prevalence, Diagnosis and Medical Rehabilitation. A Review

INTRODUCTION. The development of rehabilitation methods for patients with sarcopenia, a generalized age-associated loss of skeletal muscle mass and strength, is important, since sarcopenia leads to pronounced weakness, functional and motor disorders and an increased risk of death in the elderly. AIM. To analyze the prevalence, features of pathogenesis, diagnosis of secondary sarcopenia, including against the background of motor disorders due to stroke, as well as methods of treatment and medical rehabilitation of such patients. MAIN CONTENT. Among the secondary forms, sarcopenia is of the greatest clinical importance against the background of the consequences of acute cerebrovascular accident (ACA), due to muscular atrophy associated with paralysis and immobility, spasticity, inflammation and denervation of muscles, malnutrition and intestinal absorption of protein and vitamin D. Recent studies show that the prevalence of sarcopenia in stroke patients in emergency hospitals is 8.5–33.8 %, according to other data — more than 42 %. Muscle weakness after a stroke contributes to a decrease in physical functions and the development of disability, and sarcopenia leads to adverse outcomes 90 days after a stroke. According to the meta-analysis, which included 7 cohort studies with a total sample of 1,774 patients who underwent ACA, 27.1 % of them had sarcopenia. Moreover, the presence of sarcopenia negatively affected the clinical and functional outcomes of ACA, as well as the results of medical rehabilitation (odds ratio: 2.42, 95 % confidence interval: 1.76–3.33, p 0.001). CONCLUSION. Despite the prevalence and relevance of this pathology, rehabilitation programs for patients with sarcopenia against the background of the consequences of ACA have not been developed. Isolated foreign publications demonstrate the effectiveness of certain methods of physical therapy and electrical stimulation, but the evidence base for their effectiveness is low.

An observational study on the use of low-molecular-weight heparin for venous thromboembolism prophylaxis in acute stroke patients

Venous thromboembolism (VTE) including deep vein thrombosis (DVT) and pulmonary embolism (PE) are common complications post-stroke. The UK stroke guidelines recommend the early use of intermittent pneumatic compression devices (IPCDs). At our center, we noticed poor compliance with the use of these devices and sought to develop a pathway for early implementation of low-molecular-weight heparins (LMWH) instead. We retrospectively analyzed the data of 2351 patients in two separate groups and compared both groups to check the incidence of PEs and DVTs as stated on the discharge documentation. Group A consists of 1599 patients who used IPCDs as VTE prophylaxis, whereas Group B involved 752 patients who were placed on the new VTE prophylaxis protocol, which involved the early use of LMWH with enoxaparin delivered subcutaneously. It was observed that IPCDs were not well tolerated by patients, leading to poor compliance with VTE prophylaxis in Group A. VTE compliance was noted to be better in Group B in which the patients were given LMWH in the hospital. Furthermore, symptomatic DVT and PE were not found to be higher in Group B patients, but in fact, the incidence of these conditions was lower in this group. In conclusion, compared to IPCDs, LMWH appears to be well tolerated by patients during the admission period owing to acute stroke. It was observed that the incidence of VTE was reduced in patients who started on early LMWH in the post-stroke period. However, the long-term effects of LMWH prophylaxis, in terms of mortality and morbidity, need to be delineated. Therefore, an additional large trial on the early use of LMWH in comparison to IPCDs is warranted.

Effects of inhaled nitric oxide on endothelial function in patients with ischemic stroke

BACKGROUND: A crucial pathogenetic link in the development of stroke is the deterioration of endothelial function, which is a pathological condition characterized by an imbalance between endothelium-dependent relaxing and constricting factors. An example of an endothelium-dependent relaxing factor is nitric oxide, a substance synthesized by the body’s cells that has a vasodilating, antithrombogenic, anti-inflammatory, and antiproliferative effect. Studies have shown the neuroprotective function of inhaled nitric oxide after ischemia; however, determining the minimum effective dose of inhaled nitric oxide in patients who have suffered an acute cerebrovascular accident remains challenging. AIM: To analyze the protective effect of exogenous nitric oxide using the TIANOX device on the vascular endothelium in patients who have had an ischemic stroke in the early and late recovery period during medical rehabilitation. MATERIALS AND METHODS: The study involved 21 patients (10 people in the main group, 56.9±8.9 years old, 11 people in the control group, 57.2±8.8 years old) in the early or late recovery period after an ischemic stroke. Patients in the main group underwent an individual medical rehabilitation program and a course of 8–10 inhalations of a gas mixture with nitric oxide at 20 ppm for 20 minutes. Those in the control group underwent an individual rehabilitation course without nitric oxide therapy. Flow-dependent vasodilation of the brachial artery was evaluated to assess endothelial function. RESULTS: In the main group, a statistically insignificant (p 0.05) increase was found in the diameter of the brachial artery (3.68±0.64 mm), whereas in the control group, this indicator at rest during repeated diagnostics was less than the initial one (3.09±0.87 mm). During repeated diagnostics, the average endothelial shear velocity in patients of the control group increased from 141.53±52.62 to 159.3±82 versus from 143.17±43.53 to 143.48±46.37 in the main group; however, the results were not statistically significant (p=0.753). CONCLUSION: The increase in the diameter of the brachial artery during flow-dependent vasodilation in patients in the main group may indicate a prosthetic effect of the exogenous form of nitric oxide when using the Tianox device on the vascular endothelium, owing to the possibility of depositing nitric oxide in the body. To confirm the obtained data, a larger sample size of patients is critical in order to further divide the groups of patients into early and late recovery periods after ischemic stroke.

Large vessel occlusion mediated fluid attenuated inversion recovery signal intensity ratio is associated with stroke within 4.5 h.

The primary objective was to investigate the value of the fluid attenuated inversion recovery (FLAIR) signal intensity ratio (SIR) in identifying stroke within 4.5 h. The secondary objective was to ascertain whether large vessel occlusion (LVO) mediated the relationship between the SIR and stroke within 4.5 h. We analyzed 633 acute stroke patients within 24 h of clear symptom onset. The SIR and DWI-FLAIR mismatch were evaluated. First, we determined whether demographic variables, vascular risk factors and LVO were related to stroke within 4.5 h with multivariate logistic regression analyses and stratified regression analysis. Next, we used mediation analysis to determine whether LVO explained the association between SIR and stroke within 4.5 h. Finally, we used receiver operating characteristic (ROC) analysis to assess the value of SIR, independent variable, and multiparameter models in identifying stroke within 4.5 h and compared with DWI-FLAIR mismatch. Hyperlipemia, LVO and SIR were associated with stroke within 4.5 h. Mediation analysis revealed that LVO partially mediated the relationship between SIR and stroke within 4.5 h (p < 0.001). The multiparameter model (hyperlipemia, LVO and SIR) showed significantly improved performance (AUC 0.869) in identifying stroke within 4.5 h over DWI-FLAIR mismatch (0.684), hyperlipemia (0.632), LVO (0.667) and SIR (0.773) models. SIR is associated with stroke within 4.5 h, and LVO partially mediates this relationship. A multiparameter model combining hyperlipemia, LVO and SIR can more accurately identify stroke within 4.5 h than individual parameter models.