Management Of Ischemic Stroke Research Articles

Contemporary Management of Acute Ischemic Stroke.

In the past decade, adding mechanical thrombectomy (MT) of intracranial arterial occlusions to intravenous (IV) thrombolysis has revolutionized the treatment of acute ischemic stroke (AIS) by expanding the therapeutic window to 24h. Treatment decisions require establishing a high probability of AIS; confirming time since last known well (LKW); assessing severity of the neurological deficit; determining any contraindications to IV thrombolysis; and performing neuroimaging, usually noncontrast computed tomography (NCCT), to exclude intracerebral hemorrhage. If time since LKW is less than 4.5h, patients with disabling stroke without contraindications can proceed immediately to IV thrombolysis while the decision about MT is under way. For some patients, the MT decision can be made on the basis of clinical assessment, NCCT, and CT angiography showing a large vessel occlusion. Others may require additional neuroimaging. Patients who are not candidates for IV thrombolysis within 4.5h or MT should be immediately evaluated for eligibility for extended-window IV thrombolysis or early antiplatelet treatment.

A Hybrid Simulation‐Based Workshop Improves Knowledge and Confidence in the Management of Hemorrhagic Conversion of Stroke Among Interventional Neurology Trainees

Background Mechanical thrombectomy is the standard of care in acute ischemic stroke with anterior large vessel occlusion presenting within 6 hours of symptom onset, but complications do exist. We assessed the feasibility of a hybrid simulation‐based workshop at a national meeting for interventional neurology trainees focused on the management of acute ischemic stroke and tissue‐plasminogen activator‐related hemorrhage. Methods In this prospective, observational, hybrid simulation‐based study at a fellows’ workshop at a national conference, participants were asked to manage a patient with acute ischemic stroke in the neurointerventional suite followed by thrombolytic‐related hemorrhage leading to cerebral herniation during mechanical thrombectomy. We evaluated the participants’ ability to complete critical actions that were developed based on best practices and relevant American Heart Association guidelines and the Neurocritical Care Society's Emergency Neurological Life Support protocols. The primary outcome was the improvement in knowledge from a precourse to postcourse test. Secondary outcomes included participant reactions. Results Sixty trainees completed the simulation session in 8 groups. The mean sum of critical actions completed by trainees was 9.75/14 (70%). There was a moderate effect of the intervention on trainees’ knowledge from pretest (mean 3.8, SD = 0.3) to posttest (mean 4.3, SD = 0.3). The simulation scenario was described as moderately realistic, very engaging, and extremely satisfactory. Following the workshop, all fellows endorsed an increase in proficiency and confidence in neurological emergency management. Conclusion Simulation‐based workshops at national conferences are feasible and a potentially useful tool for safely educating a large audience of trainees who may not have access to high‐fidelity simulation platforms at their institutions.

Finding MeVO: Identifying Intracranial Medium-Vessel Occlusions at CT Angiography.

The development of methods to detect and treat intracranial large-vessel occlusions (LVOs) has revolutionized the management of acute ischemic stroke. CT angiography (CTA) of the head and neck is effective in depicting LVOs and widely used in the evaluation of patients who have had a stroke. Ongoing efforts are now focused on the potential to detect and treat intracranial medium-vessel occlusions (MeVOs), which by definition are smaller than LVOs and thus more difficult to detect with CTA. The authors review common and variant anatomies of medium-sized cerebral arteries and the appearance of a variety of MeVOs on CT angiograms. Possible pitfalls in MeVO detection include rare anatomic variants, calcified thrombi, and stump occlusions. Current recommendations for performing CTA and ancillary methods that might aid in MeVO detection are discussed. Understanding the relevant anatomy and the variety of appearances of MeVOs aids radiologists in identifying these occlusions, particularly in the setting of urgent stroke. ©RSNA, 2024 See the invited commentary by Ospel and Nguyen in this issue.

Deep Learning‐Based Prediction of Final Infarct Core from CT Perfusion Data: A Comparison to the Clinical Standard

Background In the management of acute ischemic stroke, computed tomography perfusion (CTP) is used to define the ischemic core and penumbra to estimate tissue fate after reperfusion therapy. The core/penumbra dichotomy uses single‐value thresholds, which potentially discards valuable data and oversimplifies the complexity of core and penumbral estimation. Advancing the dichotomous CTP output to a probability model has several advantages such as more sophisticated modeling of pathophysiology, supporting reader interpretation, and assessing a greater range of available data to estimate tissue fate. Methods In this retrospective study, we developed a CTP probability model to move away from single perfusion thresholds to estimate tissue fate. All patients from the International Stroke Perfusion Imaging Registry database had baseline CTP and were included in the current study if they had a large vessel occlusion that recanalized fully after thrombectomy and had follow‐up diffusion‐weighted imaging. Data were split into training, validation, and testing groups. Training and validation cohorts were used to develop a deep learning model in project MONAI (Medical Open Network for Artificial Intelligence) and performance metrics were derived from the testing set. Results In total, 243 patients were included in the study. The Attention U‐Net was the best performing deep learning model, producing the best prediction of follow‐up infarct core on the test set (n = 48): mean diverse counterfactual explanations score = 0.430±0.213, mean area under the curve = 0.765±0.095; better than the single‐value thresholding with a diverse counterfactual explanations scoreof 0.247±0.167 (paired t ‐test, P <0.0001) and area under the curveof 0.604±0.074 ( P <0.0001). Conclusion The deep learning probabilistic CTP model outperformed the current clinical standard, providing a more accurate core estimate than single‐threshold‐based measures.

Clinical Features, Management, and Recurrence of Acute Ischemic Stroke Occurring in Patients on Oral Anticoagulant Treatment for Nonvalvular Atrial Fibrillation: A Real-World Retrospective Study.

The optimal management of acute ischemic stroke (AIS) in patients with oral anticoagulation (OA) is challenging. Our study aimed to analyze the clinical characteristics and outcome of AIS in patients with OA for nonvalvular atrial fibrillation (NVAF). We retrospectively analyzed data on NVAF patients with AIS on direct oral anticoagulants (DOAC) or vitamin K antagonists (VKA) admitted to our Stroke Unit from 2017 to 2022. Ninety-day modified Rankin Scale (mRS), 90-day, and 12-month stroke recurrences were recorded. A total of 169 patients (53.2% female, mean age 82.8±6.7 y), 117 (69.2%) on DOAC, and 52 on VKA (30.8%), were enrolled. Mean age, in-hospital mortality, and 90-day mRS ≥4 were significantly higher in VKA patients. 63.4% of VKA patients had subtherapeutic INR, whereas 47.1% of DOAC patients were on low-dose (14.2% off-label). Large vessel occlusion and embolic etiology were more frequent in VKA patients (34.6% vs. 26.4%, P =0.358; 92.3% vs. 74.3%, P =0.007, respectively), whereas lacunar strokes were more frequent in DOAC patients (19.8% vs. 12.2%, P =0.366). Among patients on VKA before AIS 86.4% were switched to DOAC, whereas a DOAC-to-VKA and a DOAC-to-DOAC switch were done in 25.4% and 11.7%, respectively. Stroke recurrence occurred in 6.4% of patients at 90 days and 10.7% at 12 months. Anticoagulant switching was not associated with stroke recurrences. In our study, nonembolic etiology was more frequent in DOAC patients and anticoagulant switching did not reduce the risk of stroke recurrence. Prospective multicentric studies are warranted.

Rational development of fingolimod nano-embedded microparticles as nose-to-brain neuroprotective therapy for ischemic stroke.

Ischemic stroke is one of the major diseases causing varying degrees of dysfunction and disability worldwide. The current management of ischemic stroke poses significant challenges due to short therapeutic windows and limited efficacy, highlighting the pressing need for novel neuroprotective treatment strategies. Previous studies have shown that fingolimod (FIN) is a promising neuroprotective drug. Here, we report the rational development of FIN nano-embedded nasal powders using full factorial design experiments, aiming to provide rapid neuroprotection after ischemic stroke. Flash nanoprecipitation was employed to produce FIN nanosuspensions with the aid of polyvinylpyrrolidone and cholesterol as stabilizers. The optimized nanosuspension (particle size = 134.0 ± 0.6nm, PDI = 0.179 ± 0.021, physical stability = 72 ± 0h, and encapsulation efficiency of FIN = 90.67 ± 0.08%) was subsequently spray-dried into a dry powder, which exhibited excellent redispersibility (RdI = 1.09 ± 0.04) and satisfactory drug deposition in the olfactory region using a customized 3D-printed nasal cast (45.4%) and an Alberta Idealized Nasal Inlet model (8.6%) at 15L/min. The safety of the optimized FIN nano-embedded dry powder was confirmed in cytotoxicity studies with nasal (RPMI 2650 and Calu-3 cells) and brain related cells (SH-SY5Y and PC 12 cells), while the neuroprotective effects were demonstrated by observed behavioral improvements and reduced cerebral infarct size in a middle cerebral artery occlusion mouse stroke model. The neuroprotective effect was further evidenced by increased expression of anti-apoptotic protein BCL-2 and decreased expression of pro-apoptotic proteins CC3 and BAX in brain peri-infarct tissues. Our findings highlight the potential of nasal delivery of FIN nano-embedded dry powder as a rapid neuroprotective treatment strategy for acute ischemic stroke.

Temporal trends of the burden of ischemic stroke attributable to high low-density lipoprotein cholesterol in China from 1999 to 2019

BackgroundHigh levels of low-density lipoprotein cholesterol (LDL-C) can lead to the occurrence and development of atherosclerosis, which is one of the important risk factors for ischemic stroke (IS). However, details regarding the evolution of the IS burden attributable to high LDL-C in China has not been available. The objective of this study was to examine the changes over time, from 1990 to 2019, in the burden of IS attributed to high levels of LDL-C in China and to estimate the individual impacts of age, period, and cohort on the burden of IS associated with high LDL-C.MethodsDetailed data on IS burden attributable to high LDL-C from 1990 to 2019 in China were extracted from the Global Burden of Disease (GBD) Study 2019. The numbers and age-standardized rates of IS-related mortality and disability-adjusted life years (DALYs) attributable to high LDL-C were assessed by age and sex. The annual percentage change (APC) and average annual percentage change (AAPC) in the burden of IS due to high LDL-C were analyzed using Joinpoint regression model. The age-period-cohort analysis was carried out to assess the individual impacts of age, period, and cohort on the trends over time of mortality and DALY rate.ResultsThe number of IS-related deaths and DALYs due to high LDL-C in China were 182.7 thousand and 4.43 million in 2019, respectively, both more than double the corresponding numbers reported in 1990. However, despite these increased, the age-standardized mortality rate (ASMR) and age-standardized DALY rate (ASDR) remained unchanged. In 2019, men under 84 years of age had higher death and under 79 years of age had higher DALYs than women. However, above these ages, the gender disparities were reversed. Furthermore, age-specific rates of death, as well as DALY of IS attributable to high LDL-C in 2019 increased with age for both women and men, except for death in adults over 95 years old; and were greater in men than in women. From 1990 to 2019, males consistently had a higher ASMR and ASDR than females in China. During 1990–2019, the ASMR in women slightly decreased before 1997, sharply increased from 1997 to 2004, and then continuously decreased from 2004 to 2019, with an overall AAPC value of -0.4% (95% CI -0.8%, -0.0%). However, for the ASMR of men in China, the overall trend is upward and the AAPC is 0.5%(95% CI 0.1%, 0.8%). The ASDR in women and men had the similar trend as the ASMR over the time, with an AAPC of -0.4% (95% CI -0.7%, -0.1%) and 0.3% (95% CI 0.1%, 0.5%), respectively. The age-period-cohort analysis indicated a rise in period effects and a decline in cohort effects on mortality and DALY rate associated with IS caused by high LDL-C in both genders. Age effect on mortality rates from IS due to high LDL-C showed an exponential increased with age in all women and men except for the 60–69 age group and over 95 age group. The age relative risk of IS DALY rate due to high LDL-C increased with age in both genders except for 65–74 age group and over 95 age group.ConclusionsFrom 1990 to 2019, the burden of IS caused by high LDL-C in China significantly increased among both sexes combined and among men, while significantly decreased among women. Elderly have a substantial burden of IS attributable to high LDL-C. Therefore, effective and tailored strategies based on gender and age for IS primary prevention and management of IS and high LDL-C are urgently needed in China.

Evaluating Machine Learning Models for Stroke Prognosis and Prediction in Atrial Fibrillation Patients: A Comprehensive Meta-Analysis.

Atrial fibrillation (AF) complicates the management of acute ischemic stroke (AIS), necessitating precise predictive models to enhance clinical outcomes. This meta-analysis evaluates the efficacy of machine learning (ML) models in three key areas: stroke prognosis in AF patients, stroke prediction in AF patients, and AF prediction in stroke patients. The study aims to assess the accuracy and variability of ML models in forecasting AIS outcomes and detecting AF in stroke patients, while exploring the clinical benefits and limitations of integrating these models into practice. We conducted a systematic search of PubMed, Embase, and Cochrane databases up to June 2024, selecting studies that evaluated ML accuracy in stroke prognosis and prediction in AF patients and AF prediction in stroke patients. Data extraction and quality assessment were performed independently by two reviewers, with random-effects modeling applied to estimate pooled accuracy metrics. The meta-analysis included twenty-four studies comprising 7,391,645 patients, categorized into groups for stroke prognosis in AF patients (eight studies), stroke prediction in AF patients (thirteen studies), and AF prediction in stroke patients (three studies). The pooled AUROC was 0.79 for stroke prognosis and 0.68 for stroke prediction in AF, with higher accuracy noted in short-term predictions. The mean AUROC across studies was 0.75, with models such as Extreme Gradient Boosting (XGB) and Random Forest (RF) showing superior performance. For stroke prognosis in AF, the mean AUROC was 0.78, whereas stroke prediction yielded a mean AUROC of 0.73. AF prediction post-stroke had an average AUROC of 0.75. These findings indicate moderate predictive capability of ML models, underscoring the need for further refinement and standardization. The absence of comprehensive sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) metrics limited the ability to conduct full meta-analytic modeling. While ML models demonstrate potential for enhancing stroke prognosis and AF prediction, they have yet to meet the clinical standards required for widespread adoption. Future efforts should focus on refining these models and validating them across diverse populations to improve their clinical utility.

A Single-Center Retrospective Study of Bacterial Infections After Acute Ischemic Stroke: The Prevalence Before and During the COVID-19 Pandemic

Background and Objectives: The management of ischemic stroke involves care that is integrated and comprehensive, including the prevention of infection complications. This study aimed to investigate the prevalence and profile of bacterial infections after acute ischemic stroke both before and during the coronavirus disease 2019 (COVID-19) pandemic. Materials and Methods: A retrospective cross-sectional study examined the medical records of hospitalized acute ischemic stroke patients who had microbiological cultures taken at the National Brain Center Hospital Prof. Dr. dr. Mahar Mardjono, Jakarta, Indonesia, from 1 January 2018 to 31 December 2021. The percentage of positive bacterial growth in the microbiological cultures was used to determine the prevalence of bacterial infection after acute ischemic stroke. Results: A total of 519 patients met the study criteria, including 48 and 471 patients with infections before and during the COVID-19 pandemic. The prevalence of bacterial infection after acute ischemic stroke was 17.9%. There were significant differences in the prevalence of bacterial infection after acute ischemic stroke before and during the COVID-19 pandemic (87.5% vs. 10.8%). Staphylococcus sp. and Klebsiella sp. were the most frequently observed. The risk factors that influenced bacterial infection after acute ischemic stroke were intensive care stay (OR 0.22; 95%CI 0.13–0.39, p-value < 0.001), sepsis (OR 1.99; 95%CI 1.12–3.53, p-value = 0.019), COVID-19 infection (OR 4.81; 95%CI 2.64–8.76, p-value < 0.001), the use of steroids (OR 0.31; 95%CI 0.14–0.67, p-value = 0.003), and the use of TPN (OR 0.34; 95%CI 0.13–0.86, p-value = 0.022). Conclusions: Following the start of the COVID-19 pandemic, there was a decrease in the prevalence of bacterial infections after AIS. Patients with bacterial infections had different profiles before and during the COVID-19 pandemic.

Electroacupuncture pretreatment inhibits the TLR4/NF-κB/TXNIP/NLRP3 signaling pathway and modulates microglial polarization to alleviate cerebral ischemia-reperfusion injury in rats

Cerebral ischemia–reperfusion injury is frequently associated with neuroinflammation. The modulation of microglial polarization presents a promising approach for addressing cerebral ischemia–reperfusion injury. While electroacupuncture preconditioning has demonstrated efficacy in the management of ischemic stroke, the underlying therapeutic mechanisms remain inadequately understood. The investigation focused on elucidating the relationship between alterations in the TLR4/NF-κB/TXNIP/NLRP3 signaling pathway and microglial polarization subsequent to EA pretreatment. Established a middle cerebral artery occlusion (MCAO) rat model following electroacupuncture (EA) treatment at the Baihui (GV 20) acupoint. Male Sprague-Dawley rats were randomly assigned to the sham, Ischemia/Reperfusion (I/R), I/R + EA groups (n = 6). The results of Nissl Staining and TUNEL Stainingl showed that the number of curative neurons increased significantly after pretreatment, indicating an improvement in neuron formation and an increase in the number of austenite. The level of apoptosis in brain tissue in the I/R group was significantly higher than that in the sham operation group. Electroacupuncture pretreatment can effectively inhibit apoptosis occurrence. In addition, electric acupuncture pretreatment protects rat blood–brain barrier integrity and mitochondrial function. After treatment, the number of M1-type microglia decreased, while the number of M2-type microglia increased. These results suggest that EA preconditioning may alleviate neurological deficits and neuronal apoptosis caused by cerebral I/R injury, while maintaining the integrity of the blood–brain barrier and promoting microglial polarization through the TLR4/NF-κB/TXNIP/NLRP3 signaling pathway. Our findings establish a new molecular mechanism and theoretical foundation for electroacupuncture therapy of ischemic stroke.

APMCG-1 attenuates ischemic stroke injury by reducing oxidative stress and apoptosis and promoting angiogenesis via activating PI3K/AKT pathway

Ischemic stroke (IS) is a major cause of mortality and morbidity worldwide. Beyond thrombolysis, strategies targeting anti-oxidative apoptosis and angiogenesis are considered prospective therapeutic strategies. Nevertheless, existing natural and clinical remedies have limited efficacy in the management of IS. Moreover, despite their millennial legacy of IS remediation, natural remedies such as ginseng incur high production costs. The novel glycopeptide APMCG-1, extracted from mountain-cultivated ginseng dregs in our previous study, is a potent therapeutic candidate for IS. This study investigated APMCG-1's remedial mechanisms against IS injury using an H2O2-induced oxidative stress paradigm in human umbilical vein endothelial cells (HUVECs) emulating ischemic endothelial cells, in a ponatinib-induced zebrafish IS model, and in rat middle cerebral artery occlusion (MCAO) prototypes. Cellular assays confirmed the proficiency of APMCG-1 in preventing oxidative stress and cell death, fostering regeneration, and facilitating neovascularization within the H2O2-stressed HUVECs framework. Moreover, APMCG-1 augmented hemodynamic velocity, oxidative stress mitigation, apoptosis reduction, and motor enhancement in a zebrafish model of IS. In MCAO rats, APMCG-1 ameliorated neurological deficits and cerebral injury, as evidenced by increased neurological scores and diminished infarct dimensions. In cells and animal models, APMCG-1 activated the PI3K/AKT signaling pathway, modulating factors such as Nrf2, Bcl-2, Caspase 3, eNOS, and VEGFA, thereby ameliorating cellular oxidative distress and catalyzing angiogenesis. Collectively, these results demonstrate the potential protective effects of APMCG-1 in IS pharmacotherapy and its prospective utility as an herbal-derived IS treatment modality.

Stroke in twin pregnancy: a rare case of acute ischemic stroke management.

Stroke in twin pregnancy: a rare case of acute ischemic stroke management.

Incidence and risk factors associated with stroke when utilizing peripheral VA-ECMO

BackgroundMechanical circulatory support with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has brought forward a paradigm shift in the management of cardiogenic shock. Neurological complications associated with VA-ECMO represent a significant source of morbidity and mortality and serve as a limiting factor in its application and duration of use. MethodsWe performed a single-center retrospective case-control study of patients who developed stroke while managed with peripheral VA-ECMO from January 2018 to September 2022 at a quaternary center. We included consecutive patients above the age of 18 who were admitted to the cardiac intensive care unit and were managed with peripheral VA-ECMO. All patients who developed a stroke while on VA-ECMO were included in the case cohort, and compared to those who did not suffer stroke. Multivariable logistic regression was performed to identify risk factors associated with stroke on VA-ECMO. In-hospital outcomes were assessed out to 30 days. ResultsA total 244 patients were included in the final analysis, 36 (14.7 %) of whom developed stroke on VA-ECMO. Ischemic stroke was seen in 20 patients (55.6 %) whereas hemorrhagic stroke was seen in 16 patients (44.4 %). The use of P2Y12 antagonists (aOR 2.70, p = 0.019), limb ischemia (aOR 4.41, p = 0.002), and blood transfusion requirement (aOR 8.55, p = 0.041) were independently associated with development of stroke on VA-ECMO. Female sex trended towards statistical significance (aOR 2.19, p = 0.053) while age was not independently associated with development of stroke on VA-ECMO. There was no significant association between stroke development and outcomes of VA-ECMO duration, hospital length of stay, and all-cause mortality out to 30-days. ConclusionsVA-ECMO carried a considerable risk of neurological complications. Mortality and duration of hemodynamic support was not associated with stroke risk. Awareness regarding stroke risk is imperative in facilitating early identification and management of ischemic and hemorrhagic stroke. Research involving clinical trials and multicenter studies are necessary to empower centers in mitigating this source of significant morbidity and mortality in patients on mechanical circulatory support.

Mechanical Thrombectomy Versus Intravenous Thrombolysis in Distal Medium Vessel Acute Ischemic Stroke: A Multinational Multicenter Propensity Score-Matched Study.

The management of acute ischemic stroke (AIS) due to distal medium vessel occlusion (DMVO) remains uncertain, particularly in comparing the effectiveness of intravenous thrombolysis (IVT) plus mechanical thrombectomy (MT) versus IVT alone. This study aimed to evaluate the safety and efficacy in DMVO patients treated with either MT-IVT or IVT alone. This multinational study analyzed data from 37 centers across North America, Asia, and Europe. Patients with AIS due to DMVO were included, with data collected from September 2017 to July 2023. The primary outcome was functional independence, with secondary outcomes including mortality and safety measures such as types of intracerebral hemorrhage. The study involved 1,057 patients before matching, and 640 patients post-matching. Functional outcomes at 90 days showed no significant difference between groups in achieving good functional recovery (modified Rankin Scale 0-1 and 0-2), with adjusted odds ratios (OR) of 1.21 (95% confidence interval [CI] 0.81 to 1.79; P=0.35) and 1.00 (95% CI 0.66 to 1.51; P>0.99), respectively. Mortality rates at 90 days were similar between the two groups (OR 0.75, 95% CI 0.44 to 1.29; P=0.30). The incidence of symptomatic intracerebral hemorrhage was comparable, but any type of intracranial hemorrhage was significantly higher in the MT-IVT group (OR 0.43, 95% CI 0.29 to 0.63; P<0.001). The results of this study indicate that while MT-IVT and IVT alone show similar functional and mortality outcomes in DMVO patients, MT-IVT presents a higher risk of hemorrhagic complications, thus MT-IVT may not routinely offer additional benefits over IVT alone for all DMVO stroke patients. Further prospective randomized trials are needed to identify patient subgroups most likely to benefit from MT-IVT treatment in DMVO.

Performance of An Automated Algorithm in Large and Medium Vessel Occlusion Detection: A Real-World Experience.

Fast, accurate detection of large (LVO) and medium vessel occlusion (MeVO) is critical for triage and management of acute ischemic stroke. Multiple AIbased software products are commercially available. However, their strengths and limitations for detection of vessel occlusion in the context of expanding indications for mechanical thrombectomy are not entirely understood. We aimed to investigate the performance of a fully automated commercial detection algorithm to identify large and medium vessel occlusions in Code Stroke patients. We utilized a single-center, institutional, retrospective registry of all consecutive code stroke patients with CTA and automated processing using Viz.ai presenting at a comprehensive stroke center between March 2020 and February 2023. LVO was categorized as anterior LVO (aLVO), defined as occlusion of the intracranial internal cerebral artery or M1-middle cerebral artery (MCA), and posterior LVO (pLVO), defined as occlusion of the basilar artery or V4-vertebral artery. MeVO was defined as occlusion of the M2-MCA, A1/A2-anterior cerebral artery, or P1/P2-posterior cerebral artery. Reports from 12 board-certified radiologists were considered the gold standard. We analyzed the performance of the automated algorithm using STARD guidelines. Our primary outcome was accuracy of anterior LVO (aLVO) by the software. Secondary outcomes were accuracy of the software to detect three additional categories: all LVO (aLVO and pLVO), aLVO with M2-MCA, and aLVO with MeVO. Of 3,590 code stroke patients, 3,576 were technically sufficient for analysis by the automated software (median age 67 years; 51% female; 68% White), of which 616 (17.2%) had vessel occlusions. The respective sensitivity and specificity for all four pre-specified categories were: aLVO: 91% (87-94%), 93% (92-94%); all LVO: 73% (68-77%), 92% (91-93%); aLVO with M2-MCA:74% (70-78%), 93% (92-94%); aLVO with all MeVO: 65% (61-69%), and 93% (92-94%). The automated algorithm demonstrated high accuracy in identifying anterior LVO with lower performance for pLVO and MeVO. It is crucial for acute stroke teams to be aware of the discordance between automated algorithm results and true rates of LVO and MeVO for timely diagnosis and triage. LVO = large vessel occlusion; aLVO = anterior large vessel occlusion; pLVO = posterior large vessel occlusion; MeVO = medium vessel occlusion; EVT= endovascular thrombectomy; AI = artificial intelligence; ACA = anterior cerebral artery; PCA = posterior cerebral artery; BA = basilar artery; VA = vertebral artery.

Anesthetic Management of Acute Ischemic Stroke Undergoing Mechanical Thrombectomy: An Overview.

Ischemic stroke, caused by the interruption of the blood supply to the brain, requires prompt medical intervention to prevent irreversible damage. Anesthetic management is pivotal during surgical treatments like mechanical thrombectomy, where precise strategies ensure patient safety and procedural success. This narrative review highlights key aspects of anesthetic management in ischemic stroke, focusing on preoperative evaluation, anesthetic choices, and intraoperative care. A rapid yet thorough preoperative assessment is crucial, prioritizing essential diagnostic tests and cardiovascular evaluations to determine patient frailty and potential complications. The decision between general anesthesia (GA) and conscious sedation (CS) remains debated, with GA offering better procedural conditions and CS enabling continuous neurological assessment. The selection of anesthetic agents-such as propofol, sevoflurane, midazolam, fentanyl, remifentanil, and dexmedetomidine-depends on local protocols and expertise balancing neuroprotection, hemodynamic stability, and rapid postoperative recovery. Effective blood pressure management, tailored airway strategies, and vigilant postoperative monitoring are essential to optimize outcomes. This review underscores the importance of coordinated care, incorporating multimodal monitoring and maintaining neuroprotection throughout the perioperative period.

Comparison between "Mothership" and "Drip and Ship" models in the management of acute ischemic strokes eligible for mechanical thrombectomy in the Charleroi area, Belgium

BackgroundIn the management of acute ischemic stroke with large vessel occlusion (LVO-AIS), current data are conflicting as to whether a mothership model of management (MS) is associated with better functional recovery than a drip-and-ship model (DS). MethodFiles from LVO-AIS patients treated with MT at CHU Charleroi were analyzed between 01/01/2017 and 12/31/2022. Consecutive patients with a LVO-AIS of the anterior circulation and a prestroke modified Rankin Scale (mRS) ≤2 were included. The study's primary endpoint was the functional independence, defined as a mRS of 0-2 at 3 months post-stroke. Times metrics of MT and thrombolysis application, safety outcome including symptomatic intracranial hemorrhage and death were recorded. We conducted similar analyses by dividing DS patients, depending of their transfer time (less or >20 min). Logistic regression was used to assess if differences in baseline characteristics affected the primary outcome. Results366 patients were included: 229 in the DS group and 137 in the MS group. Demographic data showed a higher rate of tobacco use and lower functional status prestroke in the MS population. The MS group demonstrated better performance in time metrics related to thrombolysis and MT administration. The proportion of patients achieving an mRS of 0-2 at 3 months was similar in the DS and MS groups (50.22 % vs. 48.17 %, p = 0.706). The same conclusions were drawn from the subgroup analysis. Logistic regression analysis showed no impact of baseline characteristic differences on the primary outcome. ConclusionDespite faster access to MT in the MS model, our study did not find any significant differences in functional recovery at three months post-stroke between the MS and DS management models. Our data suggest further that the prestroke health status was an important factor influencing functional outcomes after LVO-AIS.

Evaluating Thrombolysis Rates and Emergency Department Time Targets in Acute Ischemic Stroke: Need for Personalized Medicine.

In the era of personalized medicine, standard protocols regarding the management of acute ischemic stroke (AIS) focus on time targets alone without tailoring the protocol to the specific patient and hospital characteristics to increase IV thrombolysis rates and improve outcomes for these patients by considering organizational differences and patient-related factors that influence adherence to target times at the emergency department level. With this in mind, we evaluate the effect of achieving ED time targets from standard protocol and patient-related risk factors on the intravenous (IV) thrombolysis rate in patients with AIS in the therapeutic window. For our research, we enrolled people who arrived at the ED with signs of recent AIS with an onset of less than 4.5 h. Initially, 355 patients were included in the study, but through careful screening, only 258 were considered eligible to participate. Of the final group of 258 patients, only 46 received intravenous thrombolysis treatment. In our study, when we are analyzing ED times in patients admitted with stroke symptoms in the therapeutic window, we found statistically significantly decreased ED times for patients that performed IV thrombolysis compared to patients not performing as follows: a median of 100 min in onset-to-ED door time (p < 0.001), a door-to-physician time (ED doctor) of 4 min (p = 0.009), door-to-blood-samples of 5 min (p = 0.026), a door-to-CT time of 15.5 min (p = 0.009), and door-to-CT results of 37 min (p < 0.001). In addition, patients who received intravenous thrombolysis were found to be significantly older (p < 0.001), with lower height and weight (p < 0.001 for both) and lower Glasgow Coma Scale (GCS) scores (9 ± 4.94 vs. 13.85 ± 2.41, p < 0.001). The logistic regression analysis indicated that the onset-to-ED time (p < 0.001) and the door-to-physician time (p = 0.014) for emergency medicine physicians are significant predictors of the likelihood of administering thrombolysis. By analyzing the impact of comorbidities, we observed that dyslipidemia, chronic arterial hypertension, and diabetes mellitus are significant predictive factors for performing IV thrombolysis (the presence of dyslipidemia and diabetes mellitus are predictive factors for performing IV thrombolysis, while the presence of arterial hypertension is not). The ED time targets that significantly influenced IV thrombolysis in our study were the onset-to-ED door time and the time it takes for the ED doctor to assess the AIS patient (door-to-physician time). The IV thrombolysis rate for these patients was 17.83%, lower than expected despite achieving most ED time targets, with the presence of chronic arterial hypertension as a significant predictive patient-related factor for not performing it. Even though our reported hospital's thrombolysis rate is favorable compared to international reports, there is always room for improvement. Based on our study results, it is necessary that new protocols to customized standard protocols and ED time targets for increasing IV thrombolysis rate in patients with AIS in the therapeutic window, focusing more on patient-related factors and type of hospitals, granting personalized medicine its right. Based on our study results, it is necessary that new protocols customize standard protocols and ED time targets for increasing IV thrombolysis rate in patients with AIS in the therapeutic window, focusing more on patient-related factors and type of hospitals, granting personalized medicine its right.

Study on the public awareness of stroke risk factors, symptoms, treatment and rehabilitation: A community based cross sectional survey from a tertiary referral centre in South India

Background: The incidence of Non communicable diseases (NCDs) including stroke is increasing in India over the past few years. Thrombolysis therapy has revolutionized management of acute ischemic stroke. In spite of such recent advances in stroke therapy, the public remains uninformed about stroke symptoms and management. Objective: To assess the public awareness of stroke risk factors, symptoms, treatment and rehabilitation measures. Methods: The study was a community-based cross-sectional study, designed as an online survey. The tool used for the survey was a semi-structured online questionnaire. Results: Regarding the risk factors of stroke, of the participants, 41 (14.8%) were aware of valvular heart diseases, 18 (6.5%) of lack of exercise, 238 (85.9%) of dyslipedemia, 236 (85.2%) of hypertension, 222 (80.1%) of smoking, and 154 (55.6%) of diabetes. Regarding symptoms of stroke, of the participants, 209 (75.5%) were aware of loss of balance, 240 (86.6%) of speech abnormalities, 261 (94.2%) of facial weakness, and 234 (84.5%) of weakness. Conclusion: Efforts should be made to educate the public regarding uncommon symptoms of stroke, thrombolysis treatment and rehabilitation measures, so that people make beneficial health care decisions in stroke management.

Successful Management of Ischemic Stroke : A Case Report and Literature Review

Introduction: Stroke is a clinical condition characterized by the sudden onset of focal (or global, in cases of coma) neurological symptoms that persist for over 24 hours or result in death, with no clear cause other than a vascular issue. Case Description: Male, 62 years old, with chief of complaint of mouth dropped to the right since 1 day before admission. Complaints made the patient speak more difficult, slow and unable to form sentences. Physical examination show parese CN. VII UMN dextra. Siriraj score -5 and Head NCCT show cerebral infarction in the internal capsula interna. Patient was diagnosed with ischemic stroke. Discussion: The use of a scoring system can be useful when there are no brain imaging facilities that can clearly distinguish the causative pathology of stroke. criteria for diagnosis of ischemic stroke are symptoms of global neurological deficits or one / several focal neurological deficits that occur suddenly with evidence of brain imaging images (CT scan or MRI). The most common differential diagnosis is hemorrhagic stroke. Conclusion. Early recognition and appropriate treatment is important to cure acute ischemic stroke to achieve good quality of life and prevent further infarct to brain tissue. Keyword: Craniotomy, Brain Metastases, Hepatocellular Carcinoma