Management Of Acute Ischemic Stroke Research Articles

Predictors of Early Neurological Deterioration Following Intravenous Thrombolysis: Difference between Risk Factors for Ischemic and Hemorrhagic Worsening.

Background:Prevention of early neurological deterioration (END) is becoming an important therapeutic target in acute ischemic stroke management. The aim of the study is to ascertain the causes and predictors of early neurological deterioration following thrombolysis and determine the predictive value of IScore.Methods:In this single center prospective study, we analyzed clinical, imaging and outcome data in 168 patients thrombolyzed intravenously ≤4.5 hours from onset of stroke. Early neurological deterioration was defined as worsening ≥2 points in the NIHSS score at 24 hours.Results:END occurred in 34 patients (20%) and caused significantly worse short term outcome. Ischemic END (ENDi) (n = 23) was twice as common as symptomatic hemorrhage (ENDh) (n = 11). Ischemia progression (n = 15) was the most common cause. Early malignant edema was another major cause. On multivariate analysis, significant predictors (p <.05) were proximal artery occlusion [all END (p <.001), ENDi and ENDh], previous ischemic insults (all END) and raised diastolic blood pressure (ENDh). ENDi was more common in those with carotid artery occlusion, large vessel disease and previous ischemic insults. ENDh was more common in those with raised diastolic blood pressure and NIHSS-ASPECTS mismatch. For patients with NIHSS <14, IScore >105 and for NIHSS ≥14, IScore >175 was associated with higher risk of END.Conclusion:END occurs in one fifth of patients after intravenous thrombolysis; ENDi outnumbers ENDh. Proximal artery occlusion is a major predictor for END. Potentially modifiable risk factors include admission hyperglycemia and elevated blood pressures. Distinct factors characterize ENDh and ENDi and can guide prevention and management strategies. IScore identifies patients at risk for END.

Endovascular Treatment of Acute Ischemic Stroke in Patients Younger than 18 Years

Abstract Purpose Rapid and effective revascularization is very important in the treatment of acute ischemic stroke (AIS). Endovascular treatment is a promising modality in the management of AIS in young patients. Methods We evaluated the clinical and imaging records in 14 patients younger than 18 years presenting within 6 hours of AIS. They received endovascular therapy (ET) either by mechanical thrombectomy, thromboaspiration, or both (Solumbra) between July 2017 and June 2021. The National Institute of Health Stroke Scale (NIHSS) score was calculated on admission and before the discharge of all patients. The 90-day modified Rankin Scale (mRS) score on disability-free outcome was also evaluated. Results The mean preprocedure NIHSS score was 10.78 ± 2.11 that improved to 4.5 ± 1.88 after the procedure. Thrombolysis in cerebral infarction (TICI) grade 2b and 3 blood flow could be established in 12 (85.72%) patients. One patient had TICI 2a flow and one patient had recurrent occlusion despite repeated recanalization (TICI grade 0). The disability-free outcome, mRS score at 90 days was 0 to 1 in 12 (85.72%) patients, mRS score 2 in one (7.14%) patient, and mRS score 3 in one patient (7.14%). We did not have any major complication related to the procedure. Conclusion ET provides high rates of arterial recanalization and favorable disability-free outcomes in young patients with AIS.

The clinical value of long noncoding RNA GAS5 in acute ischemic stroke: Correlation with disease risk, inflammation, severity, and risk of recurrence.

BackgroundLong noncoding RNA growth arrest‐specific 5 (lnc‐GAS5) is involved in the pathophysiology of acute ischemic stroke (AIS) by regulating vascular stenosis, inflammation, and neurocyte apoptosis. This study aimed to explore the clinical value of lnc‐GAS5 in patients with AIS.MethodsPlasma samples were collected from 120 patients with AIS at admission and 60 controls after enrollment, and lnc‐GAS5 expression in the plasma of all participants was assessed by reverse transcription quantitative polymerase chain reaction. In patients with AIS, disease severity was evaluated using National Institute of Health Stroke Scale (NIHSS) score, and plasma inflammatory cytokine levels were measured by enzyme‐linked immunosorbent assay. Recurrence‐free survival (RFS) was calculated during a 36‐month follow‐up period.ResultsLnc‐GAS5 expression levels were higher in patients with AIS than in the controls (p < 0.001), and it had the potential to discriminate the controls from patients with AIS (area under the curve: 0.893, 95% confidence interval: 0.849–0.938). In patients with AIS, elevated lnc‐GAS5 levels were positively correlated with NIHSS score (r = 0.397, p < 0.001), diabetes mellitus (p = 0.046), and higher levels of tumor necrosis factor alpha (TNF‐α; r = 0.374, p < 0.001), interleukin‐6 (IL‐6; r = 0.223, p < 0.001), and interleukin‐17A (IL‐17A; r = 0.222, p = 0.015). The expression levels of lnc‐GAS5 were also negatively correlated with the levels of interleukin‐10 (IL‐10; r = −0.350, p < 0.001) and RFS (p = 0.036).ConclusionLnc‐GAS5 is correlated with higher susceptibility to AIS, inflammation, and severity, and can predict an increased risk of AIS recurrence, indicating that monitoring of lnc‐GAS5 might improve the management of AIS.

The impact of home quarantine during COVID-19 lockdown on neurological hospitalizations, in-hospital mortality, and acute ischemic stroke management in older patients without COVID-19

IntroductionThis study aimed to investigate the impact of home quarantine in older patients without COVID-19 hospitalized due to neurological disorders. MethodsWe consecutively enrolled 255 elderly patients(median age: 75 years, female: 54%), including 180 (70%) in the pre-home quarantine period and 75 (30%) home quarantine period from January to May 2020 (ten weeks before and ten weeks after the March 21, 2020, lockdown for older patients in Turkey) in a tertiary referral neurological center. ResultsIn the home quarantine period, we documented a fall in the number of neurological admissions by 58.3%, but an increased need for intensive care in older patients. Patients in the home quarantine period were younger [73 (65−91) vs 76 (65−95), p = 0.005], had worse Glasgow Coma Scores (12.3 ± 3.6 vs 13.7 ± 2.5, p = 0.007), higher in-hospital mortality rate (21.3% vs. 6.7%, p = 0.001), had a lower prevalence of comorbidities such as diabetes mellitus, hypertension, and cardiovascular disease, and chronic neurologic disease, albeit had a higher prevalence of the acute cerebrovascular disease (hemorrhagic/ ischemic stroke)(90.7% vs 78.9, p = 0.025). In this period, even there was an increase in the proportion of the patients undergoing reperfusion therapy, it wasn’t statistically significant (20.3% vs. 10.1%, p: 0.054). Multivariate analysis revealed that high NIHSS (The National Institutes of Health Stroke Scale) score (OR=1.25; p < 0.001) and hospitalization in the home quarantine period (OR=3.21; p = 0.043) were independently associated with in-hospital mortality. ConclusionOur study indicated that during the COVID-19 home quarantine period, despite a significantly fewer number of patients admitted to the hospitalization, there was a higher percentage of those hospitalized needing intensive care and an overall worse prognosis.

Stroke Aetiology and Collateral Status in Acute Ischemic Stroke Patients Receiving Reperfusion Therapy-A Meta-Analysis.

Background: The interplay between collateral status and stroke aetiology may be crucial in the evaluation and management of acute ischemic stroke (AIS). Our understanding of this relationship and its level of association remains sub-optimal. This study sought to examine the association of pre-intervention collateral status with stroke aetiology, specifically large artery atherosclerosis (LAA) and cardio-embolism (CE), in AIS patients receiving reperfusion therapy, by performing a meta-analysis. Methods: Relevant search terms were explored on Medline/PubMed, Embase and Cochrane databases. Studies were included using the following inclusion criteria: (a) patients aged 18 or above; (b) AIS patients; (c) patients receiving reperfusion therapy; (d) total cohort size of >20, and (e) qualitative or quantitative assessment of pre-intervention collateral status on imaging using a grading scale. Random-effects meta-analysis was performed to investigate the association of aetiology with pre-intervention collateral status, and forest plots of risk ratio (RR) were generated. Results: A meta-analysis was conducted on seven studies, with a cumulative cohort of 1235 patients, to assess the association of pre-intervention collateral status with stroke aetiology. Patients with LAA were associated significantly with an increased rate of good collaterals (RR 1.24; 95% CI 1.04–1.50; p = 0.020, z = 2.33). Contrarily, CE aetiology was associated significantly with a decreased rate of good collaterals (RR 0.83; 95% CI 0.71–0.98; p = 0.027, z = −2.213). Conclusions: This study demonstrates that, in AIS patients receiving reperfusion therapy, LAA and CE aetiologies are associated significantly with collateral status.

Abstract 1122‐000121: Integrated Geomapping Tool of Certified Stroke Centers in United States: A SVIN MT2020+ Committee Collaboration

Introduction : Stroke is a leading cause of morbidity, mortality and healthcare spending in the United States. Acute management of ischemic stroke is time‐dependent and evidence suggests improved clinical outcomes for patients treated at designated certified stroke centers. There is an increasing trend among hospitals to obtain certification as designated stroke centers. A common source or integrated tool providing both information and location of all available stroke centers in the US irrespective of the certifying organization is not readily available. The objective of our research is to generate a comprehensive and interactive electronic resource with combined data on all geographically‐coded certified stroke centers to assist in pre‐hospital triage and study healthcare disparities in stroke including availability and access to acute stroke care by location and population. Methods : Data on stroke center certification was primarily obtained from each of the three main certifying organizations: The Joint Commission (TJC), Det Norske Veritas (DNV) and Healthcare Facilities Accreditation Program (HFAP). Geographic mapping of all stroke center locations was performed using the ArcGIS Pro application. The most current data on stroke centers is presented in an interactive electronic format and the information is frequently updated to represent newly certified centers. Utility of the tool and its analytics are shown. Role of the tool in improving pre‐hospital triage in the stroke systems of care, studying healthcare disparities and implications for public health policy are discussed. Results : Aggregate data analysis at the time of submission revealed 1,806 total certified stroke centers. TJC‐certified stroke centers represent the majority with 106 Acute Stroke Ready (ASR), 1,040 Primary Stroke Centers (PSCs), 49 Thrombectomy Capable Centers (TSCs) and 197 Comprehensive Stroke Centers (CSCs). A total of 341 DNV‐certified programs including 36 ASRs, 162 PSCs, 16 PSC Plus (thrombectomy capable) and 127 CSCs were identified. HFAP‐certified centers (75) include 16 ASRs, 49 PSCs, 2 TSCs and 8 CSCs. A preliminary map of all TJC‐certified CSCs and TSCs is shown in the figure (1). Geospatial analysis reveals distinct areas with currently limited access to certified stroke centers and currently, access to certified stroke centers is extremely limited to non‐existent in fe States (for example: Idaho, Montana, Wyoming, New Mexico and South Dakota). Conclusions : Stroke treatment and clinical outcomes are time‐dependent and prompt assessment and triage by EMS directly to appropriate designated stroke centers is therefore critical. A readily available electronic platform providing location and treatment capability for all nearby certified centers will enhance regional stroke systems of care, including enabling more rapid inter‐hospital transfers for advanced intervention. Identifying geographic areas of limited access to treatment can also help improve policy and prioritize the creation of a more equitable and well‐distributed network of stroke care in the United States.

Descriptive analysis of Acute Ischemic stroke in COVID-19 patients through the course of the COVID-19 pandemic

Coronavirus disease 2019 (COVID-19) has been associated with Acute Ischemic Stroke (AIS). Here, we characterize our institutional experience with management of COVID-19 and AIS. Baseline demographics, clinical, imaging, and outcomes data were determined in patients with COVID-19 and AIS presenting within March 2020 to October 2020, and November 2020 to August 2021, based on institutional COVID-19 hospitalization volume. Of 2512 COVID-19 patients, 35 (1.39%, mean age 63.3 years, 54% women) had AIS. AIS recognition was frequently delayed after COVID-19 symptoms (median 19.5 days). Four patients (11%) were on therapeutic anticoagulation at AIS recognition. AIS mechanism was undetermined or due to multiple etiologies in most cases (n = 20, 57%). Three patients underwent IV TPA, and three underwent mechanical thrombectomy, of which two suffered re-occlusion. Three patients had incomplete mRNA vaccination course. Fourteen (40%) died, with 26 (74%) having poor outcomes. Critical COVID-19 severity was associated with worsened mortality (p = 0.02). More patients (12/16; 75%) had either worsened or similar 3-month functional outcomes, than those with improvement, indicating the devastating impact of co-existing AIS and COVID-19. Comparative analysis showed that patients in the later cohort had earlier AIS presentation, fewer stroke risk factors, more comprehensive workup, more defined stroke mechanisms, less instance of critical COVID-19 severity, more utilization of IV TPA, and a trend towards worse outcomes for the sub-group of mild-to-moderate COVID-19 severity. AIS incidence, NIHSS, and overall outcomes were similar. Further studies should investigate outcomes beyond 3 months and their predictive factors, impact of completed vaccination course, and access to neurologic care.

Simulation-Based Assessment of Graduate Neurology Trainees' Performance Managing Acute Ischemic Stroke.

Multidisciplinary acute stroke teams improve acute ischemic stroke management but may hinder trainees' education, which in turn may contribute to poorer outcomes in community hospitals on graduation. Our goal was to assess graduate neurology trainee performance independently of a multidisciplinary stroke team in the management of acute ischemic stroke, tissue plasminogen activator (tPA)-related hemorrhage, and cerebral herniation syndrome. In this prospective, observational, single-center simulation-based study, participants (subinterns to attending physicians) managed a patient with acute ischemic stroke followed by tPA-related hemorrhagic conversion leading to cerebral herniation. Critical actions were developed by a modified Delphi approach based on relevant American Heart Association guidelines and the Neurocritical Care Society's Emergency Neurologic Life Support protocols. The primary outcome measure was graduate neurology trainees' critical action item sum score. We sought validity evidence to support our findings by comparing performance across 4 levels of training. Fifty-three trainees (including 31 graduate neurology trainees) and 5 attending physicians completed the simulation. The mean sum of critical actions completed by graduate neurology trainees was 15 of 22 (68%). Ninety percent of graduate neurology trainees properly administered tPA; 84% immediately stopped tPA infusion after patient deterioration; but only 55% reversed tPA according to guidelines. There was a moderately strong effect of level of training on critical action sum score (level 1 mean [SD] score 7.2 [2.8] vs level 2 mean [SD] score 12.3 [2.6] vs level 3 mean [SD] score 13.3 [2.2] vs level 4 mean [SD] score 16.3 [2.4], p < 0.001, R 2 = 0.54). Graduate neurology trainees reassuringly perform well in initial management of acute ischemic stroke but frequently make errors in the treatment of hemorrhagic transformation after thrombolysis, suggesting the need for more education surrounding this low-frequency, high-acuity event. High-fidelity simulation holds promise as an assessment tool for acute stroke management performance.

Molecular Magnetic Resonance Imaging of Vascular Inflammation After Recanalization in a Rat Ischemic Stroke Model.

Brain imaging has become central in the management of acute ischemic stroke. Detection of parenchymal injury and perfusion enables characterization of the extent of ischemic damage, which guides treatment decision-making. Additional assessment of secondary events, such as inflammation, which may particularly arise after recanalization, may improve diagnosis and (supplementary) treatment selection. Therefore, we developed and tested a molecular magnetic resonance imaging (MRI) approach for in vivo detection of vascular inflammation after transient middle cerebral artery occlusion in rats. Molecular MRI of VCAM-1 (vascular cell adhesion molecule-1) expression was performed with a targeted contrast agent, in addition to MR angiography, and diffusion-, T2- and perfusion-weighted MRI, from 1 hour until 96 hours after transient middle cerebral artery occlusion in rats. VCAM-1 expression, detected with susceptibility-weighted MRI, was significantly enhanced at 6 hours after recanalization as compared with 1-hour postrecanalization, coinciding with a transient decline in perfusion after initial hyperperfusion. VCAM-1 levels declined after 24 hours, but remained elevated, particularly in lesion borderzones. The implementation of molecular MRI of vascular inflammation into imaging protocols after acute ischemic stroke could provide complementary information that may guide treatment decision-making before and after recanalization therapy.

Overview of Acute Ischemic Stroke Evaluation and Management.

Stroke is a major contributor to death and disability worldwide. Prior to modern therapy, post-stroke mortality was approximately 10% in the acute period, with nearly one-half of the patients developing moderate-to-severe disability. The most fundamental aspect of acute stroke management is “time is brain”. In acute ischemic stroke, the primary therapeutic goal of reperfusion therapy, including intravenous recombinant tissue plasminogen activator (IV TPA) and/or endovascular thrombectomy, is the rapid restoration of cerebral blood flow to the salvageable ischemic brain tissue at risk for cerebral infarction. Several landmark endovascular thrombectomy trials were found to be of benefit in select patients with acute stroke caused by occlusion of the proximal anterior circulation, which has led to a paradigm shift in the management of acute ischemic strokes. In this modern era of acute stroke care, more patients will survive with varying degrees of disability post-stroke. A comprehensive stroke rehabilitation program is critical to optimize post-stroke outcomes. Understanding the natural history of stroke recovery, and adapting a multidisciplinary approach, will lead to improved chances for successful rehabilitation. In this article, we provide an overview on the evaluation and the current advances in the management of acute ischemic stroke, starting in the prehospital setting and in the emergency department, followed by post-acute stroke hospital management and rehabilitation.

Long non-coding RNA Plasmacytoma variant 1 in acute ischemic stroke: association with disease risk, severity, and recurrence-free survival and relation with inflammatory cytokines.

Long non-coding RNA plasmacytoma variant 1 (Lnc-PVT1) is implied with neuron apoptosis, inflammatory cytokines recruitment, endothelial cell proliferation, and angiogenesis; the latter are closely implicated in acute ischemic stroke (AIS) pathology. However, clinical significance of Lnc-PVT1 in AIS management remains unexplored. Thus, this study aimed to investigate this topic. In total, 110 patients AIS and 110 controls were enrolled. Peripheral blood mononuclear cells (PBMCs) and serum were extracted from AIS patients and controls. Then, RT-qPCR was performed to determine the PBMC Lnc-PVT1 expression in AIS patients and controls. Besides, we used ELISA to evaluate serum interferon gamma (INF-γ), tumor necrosis factor alpha (TNF-α), interleukin-6 (IL-6), and IL-17A in AIS patients. Additionally, in terms of recurrence-free survival (RFS) analysis, the Lnc-PVT1 expression was classified from quantile 1 to quantile 4 regarding the Lnc-PVT1 expression in AIS patients. AIS patients had higher Lnc-PVT1 expression compared with that in controls (P < 0.001) with a good supplementary diagnostic value for AIS (area under the curve (AUC) = 0.916 (95%CI 0.881-0.951). Furthermore, Lnc-PVT1 expression was positively linked with NIHSS score (r = 0.380, P < 0.001), IFN-γ (r = 0.217, P = 0.023), TNF-α (r = 0.311, P = 0.001), IL-6 (r = 0.235, P = 0.014), and IL-17A (r = 0.253, P = 0.008), separately. RFS of AIS patients with Lnc-PVT1 quantile 1-2 was higher than that of patients with Lnc-PVT1 quantile 3-4 somehow (P = 0.050). Lnc-PVT1 not only correlates with AIS risk, inflammation, and disease severity, but also reveals a dependable value for AIS prognostication, which still needs further studies for validation.

Progress and challenges in preclinical stroke recovery research.

Significant innovations in the management of acute ischemic stroke have led to an increased incidence in the long-term complications of stroke. Therefore, there is an urgent need for improvements in and refinement of rehabilitation interventions that can lead to functional and neuropsychological recovery. The goal of this review is to summarize the current progress and challenges involved with preclinical stroke recovery research. Moving forward, stroke recovery research should be placing an increased emphasis on the incorporation of comorbid diseases and biological variables in preclinical models in order to overcome translational roadblocks to establishing successful clinical rehabilitation interventions.

Management of acute ischemic strokes in patients with developmental disorders the national inpatient sample

A large publicly-available nationwide hospital database was analyzed to explore the impact of acute ischemic stroke (AIS) and its treatment on mortality and discharge dispositions in patients with developmental disorders.

Overview of imaging choices for thrombectomy patients

Neuroimaging Predictors for the Outcome of Acute Interventions-Marc Fisher, M.D. Boston MA USA Brain imaging plays a key role in the diagnosis and management of acute ischemic stroke. All patients are imaged with either CT or MRI to exclude a hemorrhage and vessel imaging is necessary to identify patients with large vessel occlusion that are candidates for thrombectomy. The extent of ischemic injury early after stroke onset can also be estimated by various CT and MRI approaches. On routine CT imaging, the ASPECTS score provides information about the extent of ischemic injury and is widely used to identify thrombectomy candidates in the early time window after stroke onset.

ALTEPLASE-ASSOCIATED ANGIOEDEMA: NEW TREATMENT OPTIONS

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Alteplase (recombinant tissue plasminogen activator or tPA) has revolutionized the management of acute ischemic stroke since its FDA approval in 1995. Intracerebral bleed is the most known and feared complication after tPA administration. tPA-associated orolingual angioedema (TAOA) is a less common but potentially fatal complication of tPA. We report a patient who developed hemi-orolingual angioedema after receiving tPA. CASE PRESENTATION: A 79-year-old female presented with sudden onset right-sided weakness with initial National Institutes of Health Stroke Scale score of 4. CT head was negative for intracranial bleed and a CT angiogram with perfusion of the head showed occlusion of P2 segment of the left posterior cerebral artery. She received tPA bolus followed by infusion and was transferred to the intensive care unit. She developed right hemi-orolingual angioedema without evidence of airway compromise one and half hours after tPA initiation. Administration of intravenous corticosteroids and antihistamines failed to improve angioedema. She was subsequently treated with 2 units of fresh frozen plasma (FFP) with complete resolution of swelling within 2 hours. DISCUSSION: Alteplase cleaves plasminogen to plasmin which degrades thrombus-bound fibrin. Plasmin also activates the kinin and complement pathways causing increased bradykinin and histamine release respectively. Bradykinin-mediated vasodilation appears to be the primary cause of TAOA. TAOA has an incidence of 0.2-5.1%. It usually develops hemi-lingually and tends to be contralateral to the ischemic side possibly due to autonomic dysfunction from insular cortex ischemia. However, this may not always be true since our patient had contralateral angioedema without insular cortex involvement. Initial management includes corticosteroids and antihistamines which are less effective for bradykinin-mediated angioedema. FFP contains kininase 2 which degrades bradykinin and hence is effectively used off label for angiotensin-converting enzyme inhibitor-induced angioedema. As TAOA also follows the bradykinin pathway, we treated our patient with FFP. To our knowledge, this is the first-ever case of TAOA treated with FFP. Other potential treatment options include C1 esterase inhibitor, icatibant (bradykinin receptor antagonist), and ecallantide (kallikrein inhibitor) which are being used for hereditary angioedema and need to be studied for TAOA. CONCLUSIONS: TAOA is a life-threatening complication that typically occurs in the first 4 hours after tPA administration. Physicians should be aware of this uncommon side effect for early recognition and treatment. Treatment targeting the bradykinin pathway like FFP might be more effective and needs further investigation. REFERENCE #1: Rathbun KM. Angioedema after thrombolysis with tissue plasminogen activator: an airway emergency. Oxf Med Case Reports. 2019;2019(1):omy112. Published 2019 Jan 24. doi:10.1093/omcr/omy11 REFERENCE #2: Hemi-orolingual angioedema and ACE inhibition after alteplase treatment of stroke. M. D. Hill, T. Lye, H. Moss, P. A. Barber, A. M. Demchuk, N. J. Newcommon, T. L. Green, C. Kenney, A. Cole–Haskayne, A. M. Buchan. Neurology May 2003, 60 (9) 1525-1527; DOI: 10.1212/01.WNL.0000058840.66596.1A DISCLOSURES: No relevant relationships by Robert Caldera, source=Web Response No relevant relationships by Kristin Fless, source=Web Response No relevant relationships by Bilal Khan, source=Web Response No relevant relationships by Nirav Mistry, source=Web Response No relevant relationships by Vagram Ovnanian, source=Web Response No relevant relationships by Fariborz Rezai, source=Web Response No relevant relationships by Aditi Saha, source=Web Response No relevant relationships by Sohaib Tariq, source=Web Response No relevant relationships by Lalithaa Thirunavukarasu Murugan, source=Web Response No relevant relationships by Paul Yodice, source=Web Response

Acute ischemic stroke management in early pregnancy: What's different?

We present a case of acute ischemic stroke (AIS) in a pregnant woman treated with recombinant tissue plasminogen activator (rt-PA) and mechanical thrombectomy (MT).

Modified 8Ds algorithm improves door-to-needle time in patients with acute ischemic stroke eligible for alteplase or thrombectomy: A prospective Cohort study

Timely restoration of cerebral blood flow using reperfusion therapy (RT) is the most effective strategy for salvaging ischemic brain tissue that is not already dead. There is a narrow window for RT since its benefit decreases over time. Intravenous thrombolysis (IVT) and mechanical thrombectomy (MTE) are key elements of acute ischemic stroke (AIS) management resulting in more favorable outcomes. Herein, we aimed to monitor risk factors, management, and outcome of patients with AIS eligible for IVT/MTE.

The relationship of long non-coding RNA maternally expressed gene 3 with microRNA-21 and their correlation with acute ischemic stroke risk, disease severity and recurrence risk

ObjectiveLong non-coding RNA maternally expressed gene 3 (lnc-MEG3) directly targets microRNA-21 (miR-21) to regulate the vascular microenvironment, and is closely implicated in the pathology of acute ischemic stroke (AIS). However, no research regarding the interaction of lnc-MEG3 and miR-21 in AIS patients has been conducted, to the best of our knowledge. Therefore, we performed this study to evaluate the correlation of lnc-MEG3 with miR-21, and to explore their clinical role for AIS management. MethodsA total of 170 AIS patients and 100 controls with at least two high-risk factors for stroke were enrolled. The expression of lnc-MEG3 and miR-21 in peripheral blood mononuclear cells was detected by reverse transcription-quantitative polymerase chain reaction. ResultsLnc-MEG3 expression was increased in AIS patients and could differentiate AIS patients from controls using receiver operating characteristic (ROC) curve analysis with area under the curve (AUC) of 0.874 and a 95% confidence interval (CI) of 0.833–0.914. Lnc-MEG3 expression was positively correlated with tumor necrosis factor (TNF)-α, interleukin (IL)-6, IL-17A and the National Institutes of Health Stroke Scale (NIHSS) score, and its high expression was also correlated with elevated accumulating recurrence rate in AIS patients. In addition, lnc-MEG3 expression was negatively correlated with miR-21 expression in AIS patients. Regarding miR-21, it was reduced in AIS patients and could differentiate AIS patients from controls with AUC of 0.889 (95% CI: 0.850–0.927). Also, miR-21 expression was negatively correlated with TNF-α, IL-17A, NIHSS score and accumulating recurrence rate in AIS patients. ConclusionLnc-MEG3 is negatively correlated with miR-21, and both factors are related to disease risk, inflammatory cytokines, disease severity and recurrence risk of AIS.

Cerebral Autoregulation and Neurovascular Coupling in Acute and Chronic Stroke.

Stroke is currently the second leading cause of death worldwide, and results in significant morbidity, and poorer quality of life for those affected (1). Stroke can be classified under two major sub-types: ischaemic and haemorrhagic. Ischaemic stroke accounts for ~70% of all stroke, and results from arterial occlusion, usually through embolism or small vessel thrombosis (2). Haemorrhagic stroke is a result of arterial rupture in the brain (2). However, the two sub-types frequently co-exist, with similar risk factors (e.g., hypertension), and overlap in pathological mechanisms (3). Although stroke incidence has declined in high-income countries, it remains a prevalent issue amongst low and middle-income countries, disproportionately affecting a younger, working age population in these areas (1). The treatment of acute ischaemic stroke (AIS) has advanced over recent decades. Notably, the advent of both thrombolysis and mechanical thrombectomy has revolutionised the management of AIS, associated with reduced mortality, and improved functional outcome (2, 4, 5). Despite these advances, the management of haemorrhagic stroke has lagged behind, and treatment options are largely confined to reversal of anticoagulants and intensive blood pressure (BP) lowering (2). Conversely, in AIS, the target for BP management remains uncertain, and trials have largely shown equivalence (6, 7), or harm (8), associated with aggressive BP management strategies. To understand the mechanistic implications of BP lowering in AIS, studies have investigated the temporal changes in cerebral autoregulation (CA) following stroke (9). In healthy states, CA maintains a constant cerebral perfusion, despite fluctuations in systemic BP (10). However, the ability of the brain maintain CA may be compromised in the acute phase of stroke, increasing the vulnerability of the brain to hypoperfusion with intensive BP management strategies (11, 12). Conversely, surges in BP during this vulnerable phase may risk haemorrhagic transformation of the infarct, resulting in poorer outcomes (11, 12). Thus, understanding the temporal nature of CA in the acute phase of stroke could provide important mechanistic insights to guide BP management strategies in the clinical setting. A related concept to CA is the physiological mechanism of neurovascular coupling (NVC). Under healthy conditions, neuronal activity is tightly coupled to cerebral blood flow (CBF), such that increases in neuronal activity will result in increases in CBF to ensure the metabolic demands of the brain are met. Intact NVC is integral to maintain optimal cognitive function, and thus may be an important physiological mechanism in the chronic or rehabilitation phase of stroke. The following sections consider the evidence to support a role for CA and NVC as important mechanistic factors in the acute and chronic phases of stroke, and the key clinical and research implications going forward.

Ischemic Stroke Risk Among Adult Brain Tumor Survivors: Evidence to Guide Practice.

INTRODUCTION: Primary brain tumors are the leading cause of cancer mortality in the United States affecting approximately 90,000 Americans each year. A major complication for brain tumor survivors is acute ischemic stroke (AIS). Currently, there are limited research to provide guidelines for AIS prevention and management in adult brain tumor survivors. The purpose of this review is to discuss the most common risk factors for AIS in adult brain tumor survivors along with best evidence for assessment, screening, and strategies to prevent AIS in this population. METHODS: Relevant literature was identified by searching CINAHL and PubMed databases using the following keywords: "brain tumor survivors," "adults," "stroke," "risk factors," "guidelines," "prevention," and "management". Articles not pertaining to adult brain tumor survivors and AIS were excluded. RESULTS: The location of the tumor, dose, extent, and type of radiation contribute to the development of vascular injury and subsequent carotid stenosis among brain tumor survivors. Endothelial growth factor inhibitor and chemotherapy drugs induces vascular remodeling. Other symptoms such as neurological impairments and co-morbidities are also present among brain tumor survivors. Furthermore, AIS increases from the time of primary brain tumor diagnosis and incidence further increases among patients who were diagnosed with a brain tumor as a child. CONCLUSION: Nurses play a key role in the assessment, prevention, and identifying individuals who are at risk of AIS during brain tumor survivorship. Engaging patients and their caregivers on minimizing their risks of AIS is crucial in the outpatient setting. Annual surveillance visits that include intracranial artery imaging should be used to identify individuals considered most at risk for developing AIS symptoms.