Mean Modified Rankin Scale Score Research Articles

Clinical Presentation, Management, and Diagnostic Performance of 2021 Criteria for Paraneoplastic Neurologic Syndromes in Childhood.

Paraneoplastic neurologic syndromes (PNSs) are remote neurologic immune-related effects of tumors. The clinical characteristics of pediatric PNSs remain unclear. We retrospectively examined the clinical characteristics of cases of pediatric PNSs and assessed the performance of the 2021 diagnostic criteria in children. Patients hospitalized in the Beijing Children's Hospital between June 2015 and June 2023 and fulfilling the description of definite by 2004 diagnostic criteria of PNSs were included. A retrospective analysis of clinical characteristics was conducted, and the 2021 diagnostic criteria were applied to rediagnostic stratification. Among the 42 patients included, the most common neurologic syndrome was opsoclonus-myoclonus syndrome (OMS) (62%), followed by rapidly progressive cerebellar syndrome (26%). Most tumors were neuroblastomas (88%), with few being ovarian teratomas (10%). Approximately 71% (30/42) of patients were classified as definite and 24% (10/42) as probable according to the 2021 criteria. All cases judged as probable exhibited rapidly progressive cerebellar ataxia with neuroblastoma. For OMS, chemotherapy was administered based on the tumor's risk stage, accompanied by regular infusion of IV gamma globulin and oral steroids following tumor diagnosis. Twenty-one patients underwent regular follow-ups over 4.92 (0.58-7.58) years. The initial hospitalization recorded a median score of 12 (7-14) on the Mitchell and Pike OMS rating scale, decreasing to 0 (0-5) at the final follow-up. In cases of rapidly progressive cerebellar syndrome, a similar therapeutic regimen was used. Nine patients underwent regular follow-ups over 4.42 (1.17-7.50) years. The mean modified Rankin scale score at first hospitalization was 4 (3-4), reducing to 1 (0-4) at the final follow-up. Only 17% (5/30) of patients across both groups exhibited poor response to this regimen. Among these 5 patients, 4 belonged to the low-risk group (without chemotherapy). OMS followed by rapidly progressive cerebellar ataxia are the most common forms of PNSs in children and are associated with neuroblastoma. An aggressive approach with multiple immunotherapies may improve the prognosis of neuroblastoma-associated PNSs. The 2021 criteria perform well in pediatric PNSs. However, we propose upgrading the classification of antibody-negative rapidly progressive cerebellar ataxia with neuroblastoma to definite diagnosis. This adjustment aims to further improve the diagnostic efficacy of this diagnostic criterion in childhood.

Surgical Outcomes of Low-Flow Bypass Surgery in Intracranial Atherosclerotic Steno-Occlusive Diseases.

The role of bypass surgery in intracranial atherosclerotic steno-occlusive diseases (ICADs) remains controversial. We aimed to analyze the surgical outcomes of bypass surgery in patients with the ICADs in a single tertiary institution. Among 1018 cases of low-flow bypass surgery between 2003 and 2022, 215 patients with the ICAD refractory to medical treatment were finally enrolled in this study. Clinical and radiological outcomes were retrospectively evaluated, with survival analyses. All strokes, cerebral infarctions, and intracranial hemorrhages occurred in 12.1% (n = 26), 9.8% (n = 21), and 2.3% (n = 5), respectively, during the clinical follow-up of 54.6 ± 47.6 months (range, 0.6-237.8 months). Among all stroke events, 84.6% (n = 22) occurred within 30 postoperative days. The 2-year and 5-year cumulative risks of all strokes were 12.1% each. The mean modified Rankin Scale scores were 1.6 ± 1.1 (range, 0-5) preoperatively and 0.8 ± 1.2 (range, 0-6) at last (P < .01). The patency of direct bypass was 99.1% (n = 213) just before discharge and 96.3% (n = 184 of 191 patients with available tests) at the last angiographic follow-up of 27.0 ± 27.3 months (range, 2.3-97.3 months). All the patients with available data (n = 190) showed hemodynamic improvement on acetazolamide-challenged single-photon emission computed tomography with 99mTc-hexamethylpropyleneamine oxime during the follow-up of 38.6 ± 36.7 months (range, 2.3-158.6 months). Low-flow bypass surgery showed acceptable treatment outcomes in the prevention of recurrent stroke.

Abstract 14130: Efficacy and Safety of Endovascular Therapy in Stroke Patients With Large Ischemic Core in Comparison to Medical Management: Meta-Analysis of Randomized Control Studies

Introduction: Endovascular therapy (EVT) is a treatment recommended for stroke patients with large vessel occlusion and an Alberta Stroke Program Early Computed Tomography Score (ASPECTS) ≥6. However, the utility of EVT in patients with large core ischemic stroke has not been well established. Methods: This meta-analysis assesses EVT's efficacy and safety using available trials comparing EVT to medical management (MM) in stroke patients with large ischemic core. Eligibility criteria: 1) were randomized controlled trials, 2) compared EVT with MM alone, 3) studied patients presenting with LIC cerebrovascular events, and 4) reported outcomes of interest. We extracted data for the major imaging inclusion criteria, the National Institutes of Health Stroke Scale (NIHSS) score, pre-stroke mRs score, and occlusion site. We also extracted outcome data for the EVT groups vs MM groups, including measurement of early neurological recovery, and definition of sICH. Results: Our primary end point was the mean modified Rankin scale score (RSS) at 90-day follow up. EVT was associated with higher odds of significant improvement in functional status with reduction in mean mRS by -0.31 [-0.47; -0.14]) compared to MM. The odds of achieving mRS 0 to 2 was higher in the EVT arm compared to the MM arm (2.53 [1.59; 4.02]). There was no difference in achieving mRS 0 to 3, early neurologic improvement defined according to NIHSS score, overall 90-day mortality and risk of symptomatic ICH between patients treated with EVT or MM in our analysis. Conclusions: Our study suggests that EVT may lead to improved outcomes in stroke patients with large core ischemia.

The effect of discharge training and telephone counseling service on patients’ functional status and caregiver burden after stroke: A randomized controlled trial

Objective: This study aimed to determine the effect of discharge training and telephone counseling service on patients’ functional status and caregiver burden after stroke. Methods: This study was conducted as a randomized controlled trial in 69 stroke patients and their caregivers. Discharge training and telephone counseling were given to the caregivers in the intervention group. Caregivers also received telephone counseling by calling researcher when needed. Information form for participants, Modified Rankin Scale, Barthel Index and The Zarit Caregiver Burden Scale were used for data collection. Pre-tests were applied to the intervention and control groups before discharge. Three months after discharge post-tests were performed for the two groups. Results: Three months after discharge, caregivers’ burden was significantly lower in the intervention group compared to the control group. The mean Modified Rankin Scale score of the patients in the intervention group was significantly lower than the control group three months after discharge. Although the mean Barthel Index score of the patients in the intervention group was statistically significant higher than before discharge, but the difference between the groups was not statistically significant. Conclusion: Discharge training and telephone counseling provided to the caregivers of stroke patients reduced the caregiver burden and had a positive effect on the improvement of the functional status of the patients.

Mechanical Thrombectomy for Acute Common Carotid Artery Occlusion.

Mechanical thrombectomy (MT) is the standard treatment for acute large occlusion of the cerebral artery. Evidence for the success of this procedure was based on the treatment of patients with internal carotid artery and middle cerebral artery thrombi. There are a few reports on thrombi extending to the common carotid artery (CCA). We document our endovascular procedure and the clinical outcome in seven consecutive patients who underwent MT for CCA thrombi between September 2016 and April 2021. Their mean National Institutes of Health Stroke Scale score was 20.0 (range, 9-30), and the mean diffusion-weighted imaging Alberta Stroke Program Early Computed Tomography Score on magnetic resonance images was 8.7 (range, 7-10). In six patients, MT of the CCA occlusion was successful, and the mean puncture-to-reperfusion time was 84 minutes (range, 39-211 minutes). In five patients, successful reperfusion was obtained. The mean total pass number was 4.1 (range, 2-7). Due to large thrombi, we performed balloon guide catheter (BGC) occlusion in three patients. Sheath occlusion occurred in two, and thrombus migration into the femoral artery around the sheath was observed in two patients. The mean modified Rankin Scale score 3 months post-stroke was 3.6 (range, 2-5). When the removal of a large CCA thrombus is attempted in a single step, catheter and sheath occlusion may occur, and this increases the risk for critical systemic artery occlusion. Therefore, we suggest that MT be combined with the BGC technique and propose the use of a large aspiration catheter to decrease the volume of the thrombus.

Influence of Patient and Technical Variables on Combined Direct and Indirect Cerebral Revascularization: Case Series.

Cerebral bypass for flow augmentation is an important technique for selected neurosurgical patients, with multiple techniques used (direct, indirect, or combined). To assess the impact of patient and technical variables on direct and indirect bypass flow after combined revascularization. This was a retrospective, single-institution review of patients undergoing direct superficial temporal artery-to-middle cerebral artery bypass with indirect encephaloduro-myosynangiosis for moyamoya disease and steno-occlusive cerebrovascular disease over a 2-year period. We evaluated the effect of baseline patient characteristics, preoperative imaging characteristics, and operative variables on direct and indirect patency grades. Twenty-six hemispheres (8 moyamoya disease and 18 steno-occlusive cerebrovascular disease) in 23 patients were treated with combined revascularization. The mean patient age was 53.4 ± 19.1 years. Direct bypass patency was 96%. Over a mean follow-up of 8.3 ± 5.4 months, there were 3 strokes in the treated hemispheres (11.5%). The mean modified Rankin Scale score improved from 1.3 ± 1.1 preoperatively to 0.7 ± 0.8 postoperatively. Preservation of the nondonor superficial temporal artery branch was associated with a lower direct bypass grade ( P < .01), whereas greater mean time to maximum perfusion (Tmax)> 4 and >6 seconds and mismatch volumes were associated with higher direct bypass grades ( P < .05). Tmax >4-second volume inversely predicted indirect bypass patency. Patient and technical variables may influence the relative contributions of the direct and indirect components of combined revascularizations.

How effective is occipital transtentorial approach for pineal region lesions? An assessment of occipital lobe functions & surgical outcome

Background and objectivesThe occipital transtentorial approach (OT) is a useful surgical approach for the treatment of lesions of the pineal region. Because the approach provides wide operative views of superior cerebellar, splenium, quadrigeminal regions can also be operated using this technique. However it may be associated with complications due to damage to the occipital lobe, which can be caused by brain retraction injury. The study evaluates the effectiveness of the OT approach in terms of surgical outcome with special emphasis on occipital lobe functions which may be affected using this approach. MethodologySeventeen patients of pineal region lesions were operated by OT approach, and preoperative evaluation of the anatomy of the tentorial angle was performed and its significance was studied. Various occipital lobe functions were evaluated postoperatively and compared with preoperative status. Surgical outcome was evaluated in terms of extent of tumour resection, postoperative occipital lobe functions and modified Rankin scale. ResultsThe mean angle between the tentorium and occipital surface of cerebellum (tentorial angle) was 62.08 ± 7.17 degrees. The maximum and minimum tentorial angle was 83 and 51 degrees respectively. Out of 13 patients in which the postoperative functional assessment of occipital lobe functions was possible, 2 patients developed homonymous hemianopia (one transient, one permanent). Other functions remain unaffected. Near and gross total resection was possible in 4 (23.5 %) and 8 (47.1 %) patients respectively. The mean modified Rankin scale score was 1.8 indicating slight post-operative disability. ConclusionsAmongst the various occipital lobe functions, the visual field defects are the most common functions affected postoperatively in the occipital transtentorial approach. The OT approach is an appropriate and reasonable approach for the surgical management of pineal region lesions where high resectability rates can be achieved irrespective of the status of anatomical factors like tentorial angle; with slight postoperative morbidity with respect to occipital lobe functions.

Anterior Circulation Fusiform Aneurysms Have a Lower Occlusion Rate After Pipeline Embolization Device Treatment Than Posterior Circulation Fusiform Aneurysms: A Multicenter Cohort Study.

Objective:Intracranial fusiform aneurysms are uncommon and can occur in vessels of the anterior circulation (AC) or posterior circulation (PC). While flow diversion is one treatment option, research into Pipeline Embolization Device (PED) treatment is lacking. This study explored the efficacy and safety of PED treatment for intracranial fusiform aneurysms, and compared therapeutic effects between AC and PC aneurysms.MethodsIn the post-market multi-center cohort study of embolization of intracranial aneurysms with PED in China (PLUS) registry study, we retrospectively analyzed 71 fusiform aneurysms in 67 patients among 1,171 patients treated with a PED from November 2014 to October 2019. The general characteristics, perioperative status, aneurysm occlusion rate at the last follow-up angiography, and changes in modified Rankin Scale scores were analyzed. Aneurysms were divided into AC and PC groups, and univariate and multivariate analyses were conducted.ResultsThe study included 26 AC (25 patients) and 45 PC (42 patients) aneurysms. A total of 75 PEDs were used, an average of 1.1 PEDs were used, and the median follow-up was 6.7 months. Fifty aneurysms (71.4%) were occluded and twenty (28.5%) were incompletely occluded. There were significantly more occluded aneurysms in the PC group than in the AC group (12 vs. 38; P = 0.001). Risk factors for incomplete occlusion were AC aneurysms (P = 0.001) and a perforating artery originating from the aneurysm (P = 0.006). The mean modified Rankin Scale score was significantly lower at the last follow up than preoperatively (0.58 vs. 0.21; P = 0.0001).ConclusionNon-overlapping PED is a safe and effective treatment for both AC and PC fusiform aneurysms. The occlusion rate of AC fusiform aneurysms is lower than that of PC.

Effect of supraglottic airway devices versus endotracheal intubation general anesthesia on outcomes in patients undergoing mechanical thrombectomy: A prospective randomized clinical trial.

Background:There are still controversies about the optimal anesthesia protocol for patients with acute ischemic stroke (AIS) undergoing mechanical thrombectomy (MT). The aim of this study was to explore the effect of supraglottic airway device (SAD) versus endotracheal intubation (EI) general anesthesia on clinical and angiographic outcomes in patients with AIS undergoing MT.Methods:One hundred sixteen patients with large-vessel occlusion stroke were randomized to receive either SAD or EI general anesthesia. The primary outcome was the rate of occurrence of >20% fall in mean arterial pressure (MAP). Secondary outcomes included hemodynamics, successful recanalization, time metrics, satisfaction score of neurointerventionalist, number of passes performed, the conversion rate from SAD to EI, the National Institutes of Health Stroke Scale score, and Alberta Stroke Program Early CT Score before and 24 hours after surgery, length of stay in the stroke unit and hospital, complications and functional independence at discharge, and 90 days after stroke.Results:Both the lowest systolic blood pressure and lowest diastolic blood pressure were significantly lower in the EI group (P = .001). The consumption of vasoactive agents, the occurrence of >20% reduction in MAP and time spent with >20% fall in MAP were significantly higher in the EI group (P < .05). Compared with the EI group, the time for door-to-puncture was significantly shorter in the SAD group (P = .015). There were no significant differences with respect to puncture-to-reperfusion time, number of passes performed, rates of successful recanalization, National Institutes of Health Stroke Scale score, and Alberta Stroke Program Early CT Score 24 hours after surgery. The satisfaction score of neurointerventionalist was significantly lower in the EI group (P = .043). Conversion rate from SAD to EI was 7.41%. There were no significant differences with respect to complications, mortality, and mean Modified Rankin Scale scores both at discharge and 90-day after stroke. However, length of stroke unit and hospital stays were significantly shorter in the SAD group (P < .05).Conclusion:AIS patients undergoing MT with SAD general anesthesia led to more stable hemodynamics, higher satisfaction score of neurointerventionalist, shorter door-to-puncture time, length of stroke unit, and hospital stay. However, there were no significant differences between the 2 groups on the angiographic and functional outcomes both at discharge and 90 days after stroke.

Posterior circulation collateral flow modifies the effect of thrombectomy on outcome in acute basilar artery occlusion.

In basilar artery occlusion stroke, the impact of the collateral circulation on infarct progression in the context of endovascular treatment is yet poorly studied. This study investigates the impact of the posterior circulation collateral score (PCCS) on functional outcome according to the extent of early ischemic changes and treatment. We hypothesized that the presence of collaterals, quantified by the PCCS, mediates the effect of endovascular treatment on functional outcome in patients with acute basilar artery occlusion. In this multicenter observational study, patients with basilar artery occlusion and admission computed tomography were analyzed. At baseline, Posterior circulation Acute Stroke Prognosis Early Computed Tomography score (pcASPECTS) was assessed and PCCS was quantified using an established 10-point grading system. Logistic regression analyses were performed to identify factors associated with good functional outcome (modified Rankin Scale scores 0-2 at day 90). A total of 151 patients were included, of which 112 patients (74%) underwent endovascular treatment. In patients with a better PCCS (&gt;5), the rate of good outcome was significantly higher (55% vs. 11%; p = 0.001). After adjusting for PCCS, vessel recanalization was significantly associated with improved functional outcome (aOR: 4.53, 95%CI: 1.25-16.4, p = 0.02), while there was no association between recanalization status and outcome in univariable analysis. Patients with low pcASPECTS generally showed very poor outcomes (mean modified Rankin Scale score 5.3, 95%CI: 4.9-5.8). PCCS modified the effect of recanalization on functional outcome, particularly in patients with less pronounced ischemic changes in admission computed tomography. These results should be validated to improve patient selection for endovascular treatment in basilar artery occlusion, particularly in uncertain indications, or to triage patients at risk for very poor outcomes.

Taking a Chance to Recover: Families Look Back on the Decision to Pursue Tracheostomy After Severe Acute Brain Injury.

BackgroundTracheostomy represents one important and value-laden treatment decision after severe acute brain injury (SABI). Whether to pursue this life-sustaining treatment typically hinges on intense conversations between family and clinicians. The aim of this study was, among a cohort of patient who had undergone tracheostomy after SABI, to explore the long-term reflections of patients and their families as they look back on this decision.MethodsFor this qualitative study, we reviewed the electronic medical records of patients with SABI who underwent tracheostomy. We included all patients who were admitted to our 30-bed neuro-intensive care unit with SABI and underwent tracheostomy between November 2017 and October 2019. Using purposive sampling, we invited survivors and family members to participate in telephone interviews greater than 3 months after SABI until thematic saturation was reached. Interviews were audiotaped, transcribed, and analyzed by using thematic analysis.ResultsOverall, 38 patients with SABI in the neuro-intensive care unit underwent tracheostomy. The mean age of patients was 49 (range 18–81), with 19 of 38 patients diagnosed with traumatic brain injury and 19 of 38 with stroke. We interviewed 20 family members of 18 of 38 patients at a mean of 16 (SD 9) months after hospitalization. The mean patient age among those with an interview was 50 (range 18–76); the mean modified Rankin Scale score (mRS) was 4.7 (SD 0.8) at hospital discharge. At the time of the interview, ten patients lived at home and two in a skilled nursing facility and had a mean mRS of 2.6 (SD 0.9), and six had died. As families reflected on the decision to proceed with a tracheostomy, two themes emerged. First, families did not remember tracheostomy as a choice because the uncertain chance of recovery rendered the certain alternative of death unacceptable or because they valued survival above all and therefore could not perceive an alternative to life-sustaining treatment. Second, families identified a fundamental need to receive supportive, consistent communication centering around compassion, clarity, and hope. When this need was met, families were able to reflect on the tracheostomy decision with peace, regardless of their loved one’s eventual outcome.ConclusionsAfter SABI, prognostic uncertainty almost transcends the concept of choice. Families who proceeded with a tracheostomy saw it as the only option at the time. High-quality communication may mitigate the stress surrounding this high-stakes decision.Supplementary InformationThe online version contains supplementary material available at 10.1007/s12028-021-01335-9.

Comparison of Sub-Types and Severity of Ischemic Stroke among Both Genders

Background: It has been noted that there is an increased prevalence and serious clinical implications of stroke in women. However, local studies focused on stroke among female gender are still scarce. Aim: To find frequency of female patients with ischemic stroke and to compare the sub-types of ischemic stroke, mean NIHSS score and mean MRS scores among both genders. Methodology: This descriptive case series was conducted in indoor and outdoor department of Neurology at Mayo Hospital, Lahore for six months [Feb 6, 2018 till August 6, 2018]. After taking demographics and clinical characteristics of patients, the severity of stroke was taken using National Institute of Health Stroke Scale (NIHSS) at admission in hospital. The functional outcome was measured using Modified Rankin Scale (MRS). Subtype of acute ischemic stroke was assigned using Oxfordshire classification for acute ischemic stroke. All data was taken on a structured proforma and was entered and analyzed using SPSS version 21. Results: The mean age of cases was 53.58 ± 9.42 years with 73(60.83%) male and 47(39.17%) female cases. Among TACS, there were 15(50%) female cases whereas 9(34.6%) female case were found in PACS and 10(33.3%) female cases were found in LACS. The frequency of gender in all subtypes was statistically same in both groups, p-value &gt; 0.05. The mean modified Rankin scale in male and female cases was 2.93 ± 1.58 and 4.30 ±1.50 respectively with significantly higher mean MMR score in females than male cases, p-value &lt; 0.05. Conclusion: This study concludes that females make up a considerable percentage of patients with ischemic stroke. Though, no statistically significant difference could be found in terms of subtypes of ischemic stroke, the mean NIHSS score and mean MRS were statistically higher among females compared to male cases. Keywords: Stroke, subtypes, severity, ischemia, gender difference, NIHSS, MRS

Cerebral Venous Thrombosis Associated with COVID-19 Infection: An Observational, Multicenter Study

Background and Purpose: Coronavirus disease 2019 (CO­VID-19) has an increased propensity for systemic hypercoagulability and thromboembolism. An association with cerebrovascular diseases, especially cerebral venous thrombosis (CVT), has been reported among these patients. The objective of the present study was to identify risk factors for CVT as well as its presentation and outcome in COVID-19 patients. Methods: This is a multicenter and multinational observational study. Ten centers in 4 countries (Pakistan, Egypt, Singapore, and the United Arab Emirates) participated in this study. The study included patients (aged >18 years) with symptomatic CVT and recent COVID-19 infection. Results: Twenty patients (70% men) were included. Their mean age was 42.4 years, with a male-to-female ratio of 2.3:1. Headache (85%) and seizures (65%) were the common presenting symptoms, with a mean admission Glasgow Coma Scale (GCS) score of 13. CVT was the presenting feature in 13 cases (65%), while 7 patients (35%) developed CVT while being treated for COVID-19 infection. Respiratory symptoms were absent in 45% of the patients. The most common imaging finding was infarction (65%), followed by hemorrhage (20%). The superior sagittal sinus (65%) was the most common site of thrombosis. Acute inflammatory markers were raised, including elevated serum D-dimer (87.5%), erythrocyte sedimentation rate (69%), and C-reactive protein (47%) levels. Homocysteine was elevated in half of the tested cases. The mortality rate was 20% (4 patients). A good functional outcome was seen in the surviving patients, with a mean modified Rankin Scale score at discharge of 1.3. Nine patients (45%) had a modified Rankin Scale score of 0–1 at discharge. Conclusion: COVID-19-related CVT is more common among males at older ages when compared to previously reported non-COVID-19-related CVT cases. CVT should be suspected in COVID-19 patients presenting with headache or seizures. Mortality is high, but functional neurological outcome is good among survivors.

Neurological outcomes of untreated brainstem cavernous malformations in a prospective observational cohort and literature review

BackgroundHaemorrhages of brainstem cavernous malformations (CMs) can lead to neurological deficits, the natural history of which is uncertain. The study aimed to evaluate the neurological outcomes of untreated brainstem CMs...

Assessment of leptomeningeal collateral status using single-phase computed tomography angiography and its clinical value

At present, there is a lack of consensus regarding the high-cost performance method for evaluating the leptomeningeal collateral (LMC) status, and there are only few reports on the relationship between the LMC status and short-term neurological improvements in patients with acute middle cerebral artery (MCA) stroke. To evaluate the LMC status using single-phase computed tomography angiography (CTA) and assess the effect of the LMC status on short-term outcomes in patients with acute MCA regional ischemic stroke without reperfusion therapy. Thirty patients with acute MCA regional ischemic stroke without reperfusion therapy were sampled prospectively. Then, 256-layer single-phase CTA (using enhanced computed tomography, maximal intensity projection technology and multi-plane volume reconstruction) was used to measure each patient’s LMC status using the MCA regional collateral score. The correlation between the LMC status and changes in the National Institutes of Health Stroke Scale (NIHSS) score was assessed. Differences in the modified Rankin scale score at 3 months after discharge between patients with a good (MCA territory collateral score ≥2) and those with a poor (MCA territory collateral score 0–1) LMC status were assessed. The NIHSS score change between admission and discharge correlated with the LMC status at admission (r = 0.88, p = 0.03). Three months after discharge, the mean modified Rankin scale scores in the poor and good LMC status groups were 1.91 ± 1.65 and 1.03 ± 1.36, respectively (p = 0.0394). The NIHSS scores at 3 months after discharge in the poor and good LMC status groups were 4.31 ± 4.29 and 2.16 ± 2.06, respectively (p = 0.0489). Our findings can further reinforce the understanding of the appropriate assessment of LMCs and its clinical value. A 256-slice single-phase CTA-maximal intensity projection can provide good assessment of the LMC status. In patients with MCA regional acute ischemic stroke, the LMC status may predict the short-term prognosis. Further research is needed to confirm these findings.

Microcatheter infusion of bolus-dose tirofiban for acute ischemic stroke due to distal intracranial artery occlusion

The utility of endovascular thrombectomy for acute occlusion of the distal intracranial artery (A2/A3/M2/M3/P2/P3) is unclear, and aspiration and stent thrombectomy are associated with risk of bleeding. We analyzed patients with acute occlusion of the distal intracranial artery to assess the safety and efficacy of microcatheter-based tirofiban infusion.We retrospectively reviewed data of the endovascular thrombectomy registry of our center between January 2018 and June 2019. Patients with distal intracranial artery occlusion who underwent endovascular thrombectomy with microcatheter-based infusion of tirofiban were recruited.Of 13 patients included, 1 presented with anterior cerebral artery occlusion, 2 with posterior cerebral artery occlusion, 2 with posterior inferior cerebellar artery occlusion, and 7 with middle cerebral artery M2 occlusion. The mean National Institute of Health Stroke scale score was 10.1 (3–19). Three patients (23.1%) underwent bridging treatment of intravenous thrombolysis with recombinant plasminogen activator and endovascular thrombectomy. The arithmetic mean onset-to-recanalization time was 696.3 minutes (140–1440) and average operating time was 47.1 minutes (30–80). After treatment, 10 patients (76.9%) underwent revascularization. No operative complications were observed in any case. All patients underwent angiography and were reviewed 7 to 14 days after surgery. Imaging revealed significant improvements in recanalization compared with the immediate postoperative period, with no reoccurrence of occlusion. The mean modified Rankin scale score at the 3-month follow-up was 0.54 (0–2).Microcatheter-based infusion of bolus-dose tirofiban can result in safe and effective recanalization of acute occlusion of the distal artery in the case of a relatively light thrombotic load.

Emergent carotid artery stenting in patients with acute ischemic stroke due to cervical internal carotid artery steno-occlusive lesion: Comparison of tandem intracranial occlusion and isolated cervical internal carotid artery occlusion

Acute ischemic strokes caused by steno-occlusive lesion of the cervical internal carotid artery are associated with poor clinical outcome. We evaluated the clinical efficacy of emergent carotid artery stenting for the management of these lesions. We compared the clinical outcomes regarding the intracranial lesion, namely tandem occlusions versus isolated cervical internal carotid artery occlusion. We retrospectively reviewed patients with acute ischemic stroke who underwent carotid artery stenting for cervical internal carotid artery steno-occlusive lesion between 2011 and 2018. After dividing the patients into two groups according to the presence or absence of intracranial lesions (tandem group and isolated cervical group), we analyzed demographic data, angiographic findings, and clinical outcomes. A modified Rankin Scale score ≤2 was defined as a favorable clinical outcome. Of 75 patients, 46 patients (61.3%) had tandem lesions, and the remaining 29 had only cervical internal carotid artery steno-occlusive lesion. Successful stenting was performed in all patients with favorable clinical outcomes (64.0%). Successful reperfusion score (thrombolysis in cerebral infarction ≥2 b) was 84.0%; tandem group (76.1%) versus isolated cervical group (96.6%) of cases. Mean modified Rankin Scale score at 90-days was 2.09. The rate of favorable clinical outcome showed no statistically significant difference between the two groups (p = 0.454). Endovascular treatment in patients with acute ischemic stroke due to cervical internal carotid artery steno-occlusive lesion is a technically feasible and clinically effective intervention regardless of intracranial occlusion. Therefore, we recommend endovascular treatment regardless of the presence of concomitant intracranial artery occlusion for patients with acute ischemic stroke caused by cervical internal carotid artery steno-occlusive lesion.

Two weeks of intensive sit-to-stand training in addition to usual care improves sit-to-stand ability in people who are unable to stand up independently after stroke: a randomised trial.

Does intensive sit-to-stand training in addition to usual care improve sit-to-stand ability in people who are unable to stand up independently after stroke? A multi-centre randomised controlled trial with concealed allocation, assessor blinding and intention-to-treat analysis. Thirty patients from two Sydney hospitals, < 3 months after stroke, with a mean Modified Rankin Scale score of 4 points (SD0.5). All participants received usual care. Participants in the experimental group attended two additional sessions of physiotherapy per day for 2 weeks. These sessions were individualised totheneeds of each participant in order to increase the amount and intensity of sit-to-stand training. Outcome measures were taken at baseline and at 2 weeks. The primary outcome was clinicians' impressions of sit-to-stand change, measured using videos and a 15-point Global Impressions of Change Scale. Secondary outcomes were sit-to-stand ability, composite strength of key muscles of the affected lower limb, gross lower limb extension strength, the Goal Attainment Scale, and ranking of change in ability to move from sitting to standing. All participants completed the trial. The mean between-group difference for clinicians' impressions of sit-to-stand change was 1.57/15 points (95% CI 0.02 to 3.11). The secondary outcomes that indicated a treatment effect were gross lower limb extension strength and ranking of change in ability to move from sitting to standing, with mean between-group differences of 6.2 deg (95% CI 0.5 to 11.8) and-7 (95% CI-1 to-13), respectively. Two weeks of intensive sit-to-stand training in addition to usual care improves sit-to-stand ability in people who are unable to stand up independently after stroke. ANZCTR12616001288415.

Microsurgical Management of Ruptured Blood Blister Aneurysms of the Internal Carotid Artery without Bypass: A Retrospective Single-Center Study of 36 Patients over 20 Years

Microsurgical management of blood blister aneurysms of the internal carotid artery is challenging because of the special characteristics of these aneurysms. We reviewed our diverse surgical methods with long-term clinical and radiologic follow-up. We retrospectively reviewed all patients with blood blister aneurysms presenting with subarachnoid hemorrhage that were treated with microsurgical obliteration between 1993 and 2017. Baseline characteristics of patients and aneurysms, surgical methods, and clinical and radiologic outcomes were analyzed. This study included 36 patients. The patients were treated using microsurgery with direct clipping (2 patients; 5.6%), cotton-assisted clipping (24 patients; 66.7%), wrapping-clipping (5 patients; 13.9%), or wrapping-clipping with suturing (5 patients; 13.9%). Complete occlusion of aneurysm was achieved in 34 of 36 patients (94.4%). Severe vasospasm developed in 18 of 36 patients (50%). Ischemic events occurred in 8 patients (22.2%), 2 of whom remained with severe disability. Regrowth or recurrence occurred in 1 patient (0.28%), which required additional stent-assisted coil embolization. Mean modified Rankin Scale score was 2.0 (median, 1.0; range, 0-4) at discharge and 1.3 (median, 1.0; range, 0-4) at the last follow-up. Direct clipping is ideal if possible; however, direct clipping is challenging in most blood blister aneurysms. Assisted clipping with cotton is mainly used and could be an effective technique for reinforcement of the friable wall, with good clinical outcomes in our series. Moreover, suturing followed by wrapping-clipping is also useful for managing intraoperative rupture.

Endovascular therapy of acute ischemic stroke related to tandem occlusion: comparison of occlusion and severe stenosis of the proximal cervical internal carotid artery

We retrospectively reviewed 42 patients with acute ischemic stroke who underwent endovascular treatment for tandem lesions between January 2011 and April 2017. After dividing the patients into two groups according to lesion type of the proximal cervical ICA (complete occlusion and severe stenosis), we analyzed demographic data, angiographic findings and clinical outcomes. A modified Rankin Scale score ≤2 was defined as a favorable clinical outcome. Of 42 patients, 27 patients (64.3%) had complete occlusion of the cervical ICA, and the remaining 15 had high-grade stenosis. Successful stenting was performed in all patients with favorable clinical outcomes (27/42, 64.3%). Successful reperfusion score (thrombolysis in cerebral infarction ≥2b) was 78.6%; occlusion group (18/27, 66.7%) vs stenosis group (15/15, 100%) of cases. Mean modified Rankin Scale score at 90 days was 2.36 ± 1.83. The rate of favorable clinical outcome was higher in stenosis group (11/15, 73.3%) than that of occlusion group (16/27, 59.3%) with no statistically significant difference (p = 0.506). Acute endovascular treatment of carotid artery tandem lesions is a technically feasible and clinically effective intervention regardless of the lesion type in proximal cervical ICA. Our study supports the results of previous studies in which endovascular therapy has a favorable clinical outcome in carotid artery tandem occlusion.