Hemorrhagic Transformation Research Articles

Underlying cerebrovascular pathology causing secondary psychosis

Case Background Psychosis can be classified as primary if it is caused by a psychiatric disorder or secondary if it is due to a specific medical condition. Despite there being multiple identified causes of secondary psychosis, making such a diagnosis can prove challenging. Case Details This case report presents a 57-year-old male who was brought by ambulance to the emergency department following an intentional jump from a first story window due to visual and auditory hallucinations and persecutory paranoid delusions. MRI findings on admission were consistent with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). The patient’s background included an ischaemic stroke with haemorrhagic transformation five years previously. He experienced psychotic symptoms during the immediate recovery period. Prior to this he had no psychiatric history. Discussion Post-stroke psychosis and the condition of CADASIL are both entities that are relatively rarely described in the literature. However, this may be due to missed diagnosis and therefore not reflective of true prevalence. Conclusion Identifying a cause-effect relationship and establishing a diagnosis of secondary psychosis can be confounded by many factors. Nevertheless, this patient’s case demonstrates the importance of considering an underlying cause, particularly when the presentation is atypical and there is a temporal relationship between the proposed medical condition and the symptoms of psychosis. Patient Consent Obtained: Yes

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.

8012 A Severe Thrombotic Event Following Blood Thinner Interruption for Thyroid Fine Needle Aspiration Biopsy: A Case Report

Abstract Disclosure: V.A. Mendpara: None. P.P. Rao: None. M.V. Kellis: None. M.D. Lundholm: None. Background: This case highlights the potential severe thrombotic consequences of blood thinner medication interruption for thyroid fine needle aspiration (FNA). Case Presentation: A 77-year-old woman came to the endocrinology clinic for follow-up on thyroid nodules. She was a former smoker with controlled type 2 diabetes, hypertension, hyperlipidemia, and atrial fibrillation with patent foramen ovale on apixaban. She had no family history of thyroid cancer and no radiation exposure. Thyroid nodules were found incidentally, and she denied compressive symptoms. She had annual surveillance for the past 4 years, and her latest thyroid US redemonstrated 4 solid, hypoechoic nodules. The largest nodule, previously biopsied and benign in 2020, remained stable on the right. The next largest nodule in the left mid-thyroid was now 1.1 x 0.8 x 0.9 cm—a 30% growth from the previous year—with new punctate echogenic foci consistent with the TIRADS 5 classification. This finding was shared with the patient, who favored investigating with an FNA. At the recommendation of her PCP and the performing provider, she held her apixaban for approximately 48 hours before the FNA procedure.The US-guided thyroid FNA biopsy was uneventful, and the results indicated a benign nodule. However, 4 hours post-procedure, the patient suddenly became unresponsive while in the middle of cooking dinner. She was taken to the ED and found to have an ischemic stroke by basilar embolism, attributed to her interruption in apixaban therapy. Tenectaplase led to initial improvement but had subsequent hemorrhagic transformations affecting the midbrain, thalamus, and pons. This marked the beginning of a complex 2-month hospitalization requiring tracheostomy and percutaneous endoscopic gastrostomy (PEG) placement, followed by nearly a year of physical, occupational, and speech rehabilitation. Despite these efforts, she has not been able to return to her pre-stroke level of function and independence. Discussion: There is no consensus on the safety of performing a thyroid fine needle aspiration (FNA) biopsy for patients on blood thinner medications. Providers who favor holding blood thinners before FNA cite concerns for post-procedural hematoma formation or increased risk of non-diagnostic results. However, there is less discussion about the risks of interrupting these medications. This case emphasizes the potential for severe consequences from interrupting medically-indicated blood thinner therapy. The temporary discontinuation of apixaban for a routine thyroid FNA led to a life-threatening thrombotic event in our patient’s case. This outcome highlights the importance of carefully weighing the risks and benefits of medication interruptions for vulnerable populations. Further study is needed to investigate the safety of thyroid FNA on uninterrupted blood thinner therapy. Presentation: 6/2/2024

Cerebral blood flow from arterial spin labeling as an imaging biomarker of outcome after endovascular therapy for ischemic stroke.

Arterial spin labeling (ASL) is a contrast agent-free magnetic resonance imaging (MRI) technique to measure cerebral blood flow (CBF). We sought to investigate effects of CBF within the infarct on outcome and risk of hemorrhagic transformation (HT). In 111 patients (median age: 74 years, 50 men) who had undergone mechanical thrombectomy (MT) for ischemic stroke of the anterior circulation (median interval: 4 days between MT and MRI), post-stroke %CBF difference from pseudo-continuous ASL was calculated within the diffusion-weighted imaging (DWI)-positive infarct territory following lesion segmentation in relationship to the unaffected contralateral side. Functional independence was defined as a modified Rankin Scale (mRS) of 0-2 at 90 days post-stroke. %CBF difference, pre-stroke mRS, and infarct volume were independently associated with functional independence in a multivariate regression model. %CBF difference was comparable between patients with and without HT. A subcohort of 10 patients with decreased infarct-CBF despite expanded Treatment in Cerebral Infarction (eTICI) 2c or 3 recanalization was identified (likely related to the no-reflow phenomenon). Outcome was significantly worse in this group compared to the remaining cohort. In conclusion, ASL-derived %CBF difference from the DWI-positive infarct territory independently predicted functional independence, but %CBF difference was not significantly associated with an increased risk of HT.

Large right middle cerebral artery stroke with hemorrhagic transformation

The authors present a case of an acute right middle cerebral artery infarct in a 65-year-old male with a history of diabetes, hypertension, and cardiovascular disease. The timeline of treatment and the evolution of the stroke is described. This case highlights the significant burden of right-sided cerebral artery stroke, even when intervention is swift.

The association between serum S100β levels and prognosis in acute stroke patients after intravenous thrombolysis: a multicenter prospective cohort study

BackgroundS100β is a biomarker of astroglial damage, the level of which is significantly increased following brain injury. However, the characteristics of S100β and its association with prognosis in patients with acute ischemic stroke following intravenous thrombolysis (IVT) remain unclear.MethodsPatients in this multicenter prospective cohort study were prospectively and consecutively recruited from 16 centers. Serum S100β levels were measured 24 h after IVT. National Institutes of Health Stroke Scale (NIHSS) and hemorrhagic transformation (HT) were measured simultaneously. NIHSS at 7 days after stroke, final infarct volume, and modified Rankin Scale (mRS) scores at 90 days were also collected. An mRS score ≥ 2 at 90 days was defined as an unfavorable outcome.ResultsA total of 1072 patients were included in the analysis. The highest S100β levels (> 0.20 ng/mL) correlated independently with HT and higher NIHSS at 24 h, higher NIHSS at 7 days, larger final infarct volume, and unfavorable outcome at 3 months. The patients were divided into two groups based on dominant and non-dominant stroke hemispheres. The highest S100β level was similarly associated with the infarct volume in patients with stroke in either hemisphere (dominant: β 36.853, 95% confidence interval (CI) 22.659–51.048, P < 0.001; non-dominant: β 23.645, 95% CI 10.774–36.516, P = 0.007). However, serum S100β levels at 24 h were more strongly associated with NIHSS scores at 24 h and 3-month unfavorable outcome in patients with dominant hemisphere stroke (NIHSS: β 3.470, 95% CI 2.392–4.548, P < 0.001; 3-month outcome: odds ratio (OR) 5.436, 95% CI 2.936–10.064, P < 0.001) than in those with non-dominant hemisphere stroke (NIHSS: β 0.326, 95% CI − 0.735–1.387, P = 0.547; 3-month outcome: OR 0.882, 95% CI 0.538–1.445, P = 0.619). The association of S100β levels and HT was not significant in either stroke lateralization group.ConclusionsSerum S100β levels 24 h after IVT were independently associated with HT, infarct volume, and prognosis in patients with IVT, which suggests the application value of serum S100β in judging the degree of disease and predicting prognosis.

68Ga-FAPI PET in Visualizing Acute Ischemic Stroke at Risk of Hemorrhagic Transformation.

Hemorrhagic transformation is a serious complication of ischemic stroke, which occurs at a rate of between 18% and 42%. 68Ga-FAPI PET can visualize acute cerebral infarction at risk of hemorrhagic transformation in the brain. We report a case of 68Ga-FAPI PET imaging in a patient with recurrent ischemic stroke. 68Ga-FAPI PET imaging revealed FAPI uptake in acute ischemic stroke with hemorrhagic transformation, but did not in some acute infarction and chronic infarction without hemorrhagic transformation. These findings suggest potential role of 68Ga-FAPI PET in the evaluation of acute ischemic stroke with the risk of hemorrhagic transformation.

A reproducible murine model of studying HIV-associated brain damage in stroke

BackgroundEmerging clinical and epidemiological data indicates that human immunodeficiency virus (HIV) is associated with an increased risk of stroke and aggravated brain damage. We aimed to develop a reproducible murine model of photothrombotic-stroke with HIV infection that mimics the clinical situation. MethodTo evaluate the impact of HIV infection on stroke, male C57BL/6 mice were infected with EcoHIV (p24 2-4 × 106/mouse; i.v.) or mock control. Four weeks post-infection, a stroke was induced by the photothrombotic method (pt-MCAO). After 72 h, a catwalk test was performed for gait impairments, and mice were euthanized for stroke outcomes. ResultsEcoHIV-infection exhibited a larger infarction, brain edema, higher IgG extravasation, hemorrhagic transformation, and gait impairments following pt-MCAO vs mock control. EcoHIV-infected mice showed higher levels of IFN-y and lower levels of IL-6, indicating immune activation without affecting IL-1β and MCP-1 in plasma and brain compared to mock pt-MCAO, suggesting unaltered inflammation. EcoHIV-infection showed increased oxidative stress markers (nitrotyrosine, and 4-hydroxynonenal) and thioredoxin interacting protein expression. Further, EcoHIV-infection significantly activated the microglia and astrocyte cells. ConclusionsThis animal model would be reliable and clinically relevant to future studies investigating pathophysiological mechanisms and developing new therapeutic approaches in stroke patients with HIV conditions.

Association Between Blood-Brain Barrier Disruption and Stroke-Associated Pneumonia in Acute Ischemic Stroke Patients After Endovascular Therapy: A Retrospective Cohort Study.

Stroke, particularly due to large vessel occlusion (LVO), is a major cause of mortality and disability globally. Endovascular therapy (ET) significantly improves outcomes for acute ischemic stroke (AIS) patients, but complications such as stroke-associated pneumonia (SAP) increase mortality and healthcare costs. This study investigates the association between blood-brain barrier (BBB) disruption and the increased risk of SAP and explores the relationship between BBB disruption and medium-term functional outcomes. The retrospective cohort study was performed on AIS patients enrolled between January 2019 to February 2023 who underwent ET. Patients were divided into two groups: BBB disruption and without BBB disruption. Multiple logistic regression model was conducted to measure the association between BBB disruption and SAP. Mediation analysis was used to estimate the potential mediation effects on the associations of BBB disruption with SAP. A restricted cubic spline (RCS) regression model was used to further outline the connection between the highest CT value of hyperattenuated lesions areas and the risk of SAP. The study included 254 patients who underwent endovascular therapy, with 155 patients in the BBB disruption group (exposure) and 99 patients in the without BBB disruption group (control). Multiple logistic regression analysis revealed a significantly increased risk of SAP in patients with BBB disruption (OR = 2.337, 95% CI: 1.118-4.990, p = 0.025). Furthermore, mediation analysis suggested that this association may be partly due to malignant cerebral oedema and haemorrhagic transformation. The study found an inverse L-shaped dose-response relationship between the maximum CT values of BBB disruption areas and the incidence of SAP. SAP partially mediated the association between BBB disruption and 3-month poor functional outcome. BBB disruption are a potential risk factor for SAP. BBB disruption may affect short- and medium-term prognosis of patients after ET in part through SAP.

Cooperation Between Platelet β1 and β3 Integrins in the Arrest of Bleeding Under Inflammatory Conditions in Mice-Brief Report.

Platelets prevent bleeding in a variety of inflammatory settings, the adhesion receptors and activation pathways involved being highly context-dependent and functionally redundant. In some situations, platelets recruited to inflammatory sites act independently of aggregation. The mechanisms underlying stable platelet adhesion in inflamed microvessels remain incompletely understood, in particular, whether and if so, how β1 and β3 integrins are involved. The impact of isolated or combined platelet deficiency in β1 and β3 integrins on inflammation-associated hemostasis was investigated in 3 models of acute inflammation: immune complex-based cutaneous reverse passive Arthus reaction, intranasal lipopolysaccharide-induced lung inflammation, and cerebral ischemia-reperfusion following transient (2-hour) occlusion of the middle cerebral artery. Mice with platelet-directed inactivation of Itgb1 (PF4Cre-β1-/-) displayed no bleeding in any of the inflammation models, while mice defective in platelet Itgb3 (PF4Cre-β3-/-) exhibited bleeding in all 3 models. Remarkably, the bleeding phenotype of PF4Cre-β3-/- mice was exacerbated in the reverse passive Arthus model by the concomitant deletion of β1 integrins, PF4Cre-β1-/-/β3-/- animals presenting increased bleeding. Intravital microscopy in reverse passive Arthus experiments highlighted a major defect in the adhesion of PF4Cre-β1-/-/β3-/- platelets to inflamed microvessels. Unlike PF4Cre-β1-/- and PF4Cre-β3-/- mice, PF4Cre-β1-/-/β3-/- animals developed early hemorrhagic transformation 6 hours after transient middle cerebral artery occlusion. PF4Cre-β1-/-/β3-/- mice displayed no more bleeding in lipopolysaccharide-induced lung inflammation than PF4Cre-β3-/- animals. Altogether, these results show that the requirement for and degree of functional redundancy between platelet β1 and β3 integrins in inflammation-associated hemostasis vary with the inflammatory situation.

Characteristics, clinical profiles, and outcomes of patients undergoing endovascular thrombectomy: A retrospective study, Saudi Arabia

BackgroundStroke is a significant contributor to both mortality and compromised physical function. Endovascular thrombectomy (EVT) is now the recognized standard of care for anterior circulation acute ischemic stroke (AIS) with large vessel occlusion (LVO), especially when favorable brain images are evident within 24 h of symptom onset. This study elucidated the characteristics, clinical profiles, and outcomes of patients who underwent EVT for AIS. MethodologyIn this retrospective record-based cohort study, we reviewed the medical records of individuals who underwent EVT for AIS at King Fahad General Hospital in Jeddah, Saudi Arabia. The study, conducted from July 2022 through October 2023, encompassed a comprehensive analysis of clinical, radiological, and time-related factors and diverse outcomes. ResultsIn a cohort of 117 patients with a mean age of 58.5 years, 81 (69.2%) were male. Hypertension and diabetes mellitus were the most common risk factors, affecting 48.7% and 41% of the cohort, respectively. Approximately half of the patients had a favorable ASPECT Score (7–10), and 45.3% received intravenous tissue plasminogen activator (tPA). Nearly two-thirds achieved a modified thrombolysis in cerebral infarction (mTICI) score of 2b or higher, and 39.3% exhibited M1-middle cerebral artery (MCA) occlusion. The incidence of symptomatic hemorrhagic transformation was about 13%, whereas one-third of the patients attained a favorable mRs outcome (0–2). Factors such as advanced age, higher NIH Stroke Scale (NIHSS) scores, and prolonged hospital stays were associated with poorer outcomes. Conversely, the absence of hypertension and atrial fibrillation, along with higher TICI scores, significantly increased the likelihood of favorable outcomes, with P values of 0.015, 0.0490, and 0.025, respectively. ConclusionsIn our study, the examined patients who underwent EVT were younger in age, with clinical and radiological outcomes showing some degree of comparability to other publications. Notably, the absence of hypertension and atrial fibrillation, combined with a higher TICI score, was associated with an increased likelihood of achieving a favorable outcome.

Analysis of Factors Associated to Hemorrhagic Transformation After Recanalization of Acute Ischemic Stroke

Ischemic stroke is associated with high rates of mortality and disability, making it an urgent issue that requires immediate attention. However, patients with acute ischemic stroke (AIS) can open the occluded cerebral vessels timelier, restore cerebral perfusion, save the ischemic penumbra, and bring better prognosis. However, a considerable number of patients still have poor clinical outcome due to complications such as hemorrhagic transformation (HT) after vascular reopening. The specific mechanism of HT after recanalization treatment is currently not fully understood. Studies have shown that multiple factors are associated with bleeding transformation after mechanical thrombectomy in AIS patients. Some studies suggest that the damage of ischemia and reperfusion and vascular permeability may play a role. This paper summarizes the possible mechanisms and related influencing factors of HT after vascular recanalization treatment of AIS patients to further guide the treatment and management decisions of AIS patients.

Engineering hirudin encapsulation in pH-responsive antioxidant nanoparticles for therapeutic efficacy in ischemic stroke model mice

This study introduces a novel pH-sensitive, hirudin-loaded antioxidant nanoparticle (HD@iNanoAOX) aimed at addressing the challenges of hirudin's short half-life and hemorrhagic transformation. HD@iNanoAOX was engineered to safeguard and prolong hirudin's bioactivity by encapsulating it within antioxidative nanoparticles, facilitating its gradual release in acidic environments. The efficacy of this approach was validated through both ex vivo and in vivo experiments. Ex vivo thrombolytic assays demonstrated that HD@iNanoAOX maintained effective clot lysis activity under acidic conditions. In vivo assessments revealed that HD@iNanoAOX significantly prolonged hirudin's half-life and reduced cerebral infarct volume in a mouse model of middle cerebral artery occlusion (MCAO). Furthermore, HD@iNanoAOX treatment mitigated cerebral oxidative stress, suppressed hemorrhagic transformation, and prevented blood-brain barrier (BBB) disruption. These findings suggest that the combined thrombolytic and antioxidative properties of HD@iNanoAOX offer a promising therapeutic approach for ischemic stroke. Nonetheless, further research is warranted to optimize the formulation and assess its safety and efficacy in clinical settings.

Poria cocos Extract Alleviates tPA-Induced Hemorrhagic Transformation after Ischemic Stroke through Regulation of Microglia M1/M2 Phenotypes Polarization.

Delayed thrombolytic therapy with tissue plasminogen activator (tPA), the only FDA-approved drug for ischemic stroke, can cause catastrophic hemorrhagic transformation (HT) after ischemic stroke. However, it remains largely unknown how microglial polarization dynamically changes in HT. Poria cocos is a widely used functional edible fungus in Asia and has been used for more than 2000 years as a food and medicine in China. Our preliminary study found that P. cocos extract (PCE) significantly reduced the volume of cerebral infarction. We performed the effects of PCE on tPA-induced HT in rat models of autologous thromboembolism middle cerebral artery occlusion in vivo and BV-2 cells injured by oxygen-glucose deprivation/reperfusion in vitro. Hemorrhage test and triphenyltetrazolium chloride staining were performed to examine the efficiency of PCE. The expression level of proteins associated with microglia polarization was detected using Western blotting and immunofluorescence staining. Small interfering RNA transfection reveals the regulatory mechanism of PCE on microglia polarization. PCE plus tPA reduced hemorrhage and infarct volumes after ischemic stroke. During tPA-induced HT, M1 microglia increased over time from 3 days onward and remained high for at least 7 days, reaching the peak at 7 days, M2 microglia gradually increased after 3 days and continued to increase for at least 14 days. Furthermore, PCE inhibited the secretion of pro-inflammatory cytokines in M1 microglia and improved the secretion of anti-inflammatory cytokines in M2 microglia, which related to the regulation of the IRF5-IRF4 axis. This current study indicates that PCE alleviates tPA-induced HT after ischemic stroke by modulating microglia M1/M2 phenotype polarization.

Factors associated with oropharyngeal dysphagia and unsuccessful nasogastric tube removal after endovascular thrombectomy for anterior circulation stroke.

To identify the predictive variables for post-stroke dysphagia (PSD) among anterior circulation large vessel occlusion (LVO) stroke patients who underwent endovascular thrombectomy (EVT). This retrospective cohort study enrolled hospitalized patients with anterior LVO stroke who underwent EVT between January 1, 2018 and October 31, 2022. PSD was defined as the unsuccessful removal of the nasogastric (NG) tube. Factors, such as premorbid characteristics, laboratory results, EVT, rehabilitation-related parameters, and neuro-imaging, were analyzed for correlations to PSD at 4 and 12weeks. The study enrolled 136 patients, with a mean age of 72.9 ± 13.0years, and 59 patients (43.4%) were male. At 4weeks, 47.1% of the patients needed an NG tube, and at 12weeks, 16.2% still required an NG tube. We found that lower albumin, lower body mass index (BMI), higher initial and 24-h post-EVT National Institute of Health Stroke Scale (NIHSS) scores, stroke-associated pneumonia, poor initial sitting balance and ability to sit up, insula or frontal operculum lesions, and bilateral hemisphere involvement were all associated with PSD at both 4 and 12weeks in the univariate logistic regression. Multivariate analysis revealed that significant predictors of unsuccessful NG tube removal at 4weeks included lower BMI (adjusted OR [aOR] 0.73, p = 0.005), hemorrhagic transformation (aOR 4.01, p = 0.0335), higher NIHSS scores at 24h post-EVT (aOR 1.13, p = 0.0288), poor initial sitting ability (aOR 0.52, p = 0.0231), insular cortex ischemia (aOR 7.26, p = 0.0056), and bilateral hemisphere involvement (aOR 41.19, p < 0.0001). At 12weeks, lower BMI (aOR 0.78, p = 0.0098), poor initial sitting balance (aOR 0.57, p = 0.0287), insular cortex lesions (aOR 4.83, p = 0.0092), and bilateral hemisphere involvement (aOR 4.07, p = 0.0139) remained significant predictors. In patients with anterior LVO following EVT, PSD was associated with lower BMI, higher NIHSS scores, poor initial sitting balance and sitting ability, insular lesions, and bilateral hemisphere involvement.

Platelet-to-neutrophil ratio predicts hemorrhagic transformation and unfavorable outcomes in acute ischemic stroke with intravenous thrombolysis.

Acute ischemic stroke (AIS) retains a notable stance in global disease burden, with thrombolysis via recombinant tissue plasminogen activator (rtPA) serving as a viable management approach, albeit with variable outcomes and the potential for complications like hemorrhagic transformation (HT). The platelet-to-neutrophil ratio (P/NR) has been considered for its potential prognostic value in AIS, yet its capacity to predict outcomes following rtPA administration demands further exploration. To elucidate the prognostic utility of P/NR in predicting HT and clinical outcomes following intravenous rtPA administration in AIS patients. Data from 418 AIS patients treated with intravenous rtPA at Thammasat University Hospital from January 2018 to June 2021 were retrospectively analyzed. The relationship between P/NR and clinical outcomes [early neurological deterioration (E-ND), HT, delayed ND (D-ND), and 3-mo outcomes] was scrutinized. Notable variables, such as age, diabetes, and stroke history, exhibited statistical disparities when comparing patients with and without E-ND, HT, D-ND, and 3-mo outcomes. P/NR prognostication revealed an optimal cutoff of 43.4 with a 60.3% sensitivity and a 52.5% specificity for 90-d outcomes. P/NR prognostic accuracy was statistically significant for 90-d outcomes [area under the curve (AUC) = 0.562], D-ND (AUC = 0.584), and HT (AUC = 0.607). P/NR demonstrated an association with adverse 3-mo clinical outcomes, HT, and D-ND in AIS patients post-rtPA administration, indicating its potential as a predictive tool for complications and prognoses. This infers that a diminished P/NR may serve as a novel prognostic indicator, assisting clinicians in identifying AIS patients at elevated risk for unfavorable outcomes following rtPA therapy.

Two Patients With Ipsilateral Cerebellar Hemorrhage After Superficial Temporal Artery-Middle Cerebral Artery Bypass Grafting.

To summarize the clinical experience of ipsilateral cerebellar hemorrhage after superficial temporal artery-middle cerebral artery bypass surgery. The clinical data of 2 patients with cerebellar hemorrhage after superficial temporal artery-middle cerebral artery bypass grafting were retrospectively collected, including 1 case with left cerebellar hemorrhage after left cerebral artery bypass grafting and 1 case with right cerebellar hemorrhage after right cerebral artery bypass grafting. The perioperative blood pressure, laboratory, and imaging data were analyzed. All patients had a history of hypertension, and their perioperative blood pressure was stable. Low-density lipoprotein cholesterol and high-density lipoprotein cholesterol were normal before the operation. Cerebral magnetic resonance imaging showed cerebral atherosclerosis and multiple ischemic cerebral infarcts. At 24 hours after surgery, the patients' continuous epidural low drainage was 260 mL and 160 mL, respectively. The amount of cerebellar bleeding was small, and no new sequelae were left after conservative treatment with drugs. Cerebellar hemorrhage after superficial temporal artery-middle cerebral artery bypass grafting is related to perioperative blood pressure fluctuation, hemodynamic changes, hemorrhagic transformation of ischemic lesions, and excessive cerebrospinal fluid drainage. Maintaining stable blood pressure during the perioperative period and avoiding excessive and rapid loss of cerebrospinal fluid after operation can reduce the occurrence of this complication.

ROS exhaustion reverses the effects of hyperbaric oxygen on hemorrhagic transformation through reactivating microglia in post-stroke hyperglycemic mice

Acute ischemic stroke (AIS) is a major global health concern due to its high mortality and disability rates. Hemorrhagic transformation, a common complication of AIS, leads to poor prognosis yet lacks effective treatments. Preclinical studies indicate that hyperbaric oxygen (HBO) treatment within 12 h of AIS onset alleviates ischemia/reperfusion injuries, including hemorrhagic transformation. However, clinical trials have yielded conflicting results, suggesting some underlying mechanisms remain unclear. In this study, we confirmed that HBO treatments beginning within 1 h post reperfusion significantly alleviated the haemorrhage and neurological deficits in hyperglycemic transient middle cerebral arterial occlusion (tMCAO) mice, partly due to the inhibition of the NLRP3 inflammasome-mediated pro-inflammatory response in microglia. Notably, reactive oxygen species (ROS) mediate the anti-inflammatory and protective effect of early HBO treatment, as edaravone and N-Acetyl-l-Cysteine (NAC), two commonly used antioxidants, reversed the suppressive effect of HBO treatment on NLRP3 inflammasome-mediated inflammation in microglia. Furthermore, NAC countered the protective effect of early HBO treatment in tMCAO mice with hyperglycemia. These findings support that early HBO treatment is a promising intervention for AIS, however, caution is warranted when combining antioxidants with HBO treatment. Further assessments are needed to clarify the role of antioxidants in HBO therapy for AIS.

Magnetic resonance imaging features and stroke etiology of ischemic stroke in essential thrombocythemia

BackgroundVarious essential thrombocythemia (ET)-related stroke mechanisms have been proposed, including microcirculatory disturbance due to coagulopathy, vasculitis, and embolism due to thrombus formation in large vessels. However, the stroke mechanism in ET remains largely unexplored. The purpose of this study was to evaluate magnetic resonance image (MRI) features of ischemic stroke in ET and determine the potential stroke mechanism. MethodsWe retrospectively collected data from 21 acute ischemic stroke patients with ET who were admitted to two stroke centers between 2010 and 2023. ET was diagnosed according to the World Health Organization criteria. We evaluated MRI features including the diffusion-weighted image (DWI) lesion pattern, and the presence of hemorrhagic transformation and intracranial artery steno-occlusive lesion, as well as other etiological workup results. ResultsOf 21 patients, 20 exhibited multiple ischemic lesions on DWI, mainly within a single vascular territory. Cortical infarcts were observed in 19 patients. Hemorrhagic transformation occurred in 15 patients. Additionally, 15 patients had intracranial steno-occlusive arteries, which regressed to normal in 11 patients during follow-up. Out of all patients, only 2 had potential causes of stroke other than ET (1 with atrial fibrillation and 1 with intracranial atherosclerotic stenosis). The remaining 19 patients had ET as the only identified potential cause. ConclusionsMRI features, including DWI lesion pattern in ischemic stroke patients with ET, suggested embolic etiology despite the absence of major embolic sources. Intra-arterial thrombus appears to be part of the stroke mechanism related to ET and may contribute to ischemic stroke in ET.

Association between ASPECTS region of infarction and clinical outcome in non-acute large vessel occlusion ischaemic stroke after endovascular recanalisation

PurposeThis study retrospectively investigated whether infarction in specific Alberta Stroke Program Early CT Score (ASPECTS) regions is associated with clinical outcome in patients with symptomatic non-acute internal carotid or middle...