Moderate Stroke Research Articles

Correlation of Serum S-100 Protein Level with Severity of Ischaemic Stroke

Background: Stroke is currently the second leading cause of death worldwide and the first leading cause of death in Bangladesh. The National Institute of Health Stroke Scale is the most commonly used deficit rating scale to assess stroke severity. S-100 protein is a low molecular weight calcium-binding protein expressed mostly in glial cells like astrocytes, oligodendrocytes, and microglial cells. During the ischaemic process, S-100 protein is secreted from the glial cells into the extracellular space. After secretion, S-100 protein releases initially into the cerebrospinal fluid and then eventually into the bloodstream due to disruption of the blood-brain barrier. Aim of the study: To correlate serum S-100 protein level with the severity of ischaemic stroke. Methods: This cross-sectional study was conducted at the Department of Laboratory Medicine in collaboration with the Department of Neurology, BSMMU, Dhaka, Bangladesh from September 2018 to August 2019. A total of 70 ischaemic stroke patients were enrolled in this study. After taking proper history and neurological examination, the severity of ischemic stroke was assessed on the basis of NIHSS score. Then, serum S-100 protein levels were measured by the Electrochemiluminescence Immunoassay method. Statistical analysis was done by SPSS version 22.0. Results: According to the NIHSS scores, 35(50.0%) of the patients had moderate stroke (NIHSS score=5-15), 17(24.3%) had minor stroke (NIHSS=1-4), 12(17.1%) had moderate to severe stroke (NIHSS=16-20) and 4(5.0%) had severe stroke (NIHSS=21-42). The mean S-100 protein level was found 0.283±0.165 μg/L. Mean S-100 protein levels was assessed in different categories of severity of ischaemic stroke. Maximum Mean± SD value of serum S-100 protein was found in case of severe stroke (NIHSS score=21-42; Mean ± SD: 0.739±0.207, range: 0.523-1.019). The significance test was done by ANOVA test which was found statistically significant (p-value <0.001). Pearson’s correlation test revealed a significant strong positive correlation (r=+943, p<0.001) between serum S-100 protein level and NIHSS scores of ischaemic stroke patients. Conclusion: In the present study it was found that serum S-100 protein levels were higher in severe ischaemic stroke in relation to the ischaemic stroke of lower severity. S-100 protein level is rapidly determined by the method used in the present study. Serum S-100 protein level in this regard can be used as an important tool to predict the severity of ischaemic stroke. Further study is needed to confirm the findings of the present study.

Endovascular Thrombectomy Versus Medical Management in Isolated M2 Occlusions: Pooled Patient-Level Analysis from the EXTEND-IA Trials, INSPIRE, and SELECT Studies.

The objective of this study was to evaluate functional and safety outcomes of endovascular thrombectomy (EVT) versus medical management (MM) in patients with M2 occlusion and examine their association with perfusion imaging mismatch and stroke severity. In a pooled, patient-level analysis of 3 randomized controlled trials (EXTEND-IA, EXTEND-and IA-TNK parts 1 and 2) and 2 prospective nonrandomized studies (INSPIRE and SELECT), we evaluated EVT association with 90-day functional independence (modified Rankin Scale [mRS]=0-2) in isolated M2 occlusions as compared to medical management overall and in subgroups by mismatch profile status and stroke severity. We included 517 patients (EVT=195 and MM=322), baseline median (interquartile range [IQR]) National Institutes of Health Stroke Scale (NIHSS) was 13 (8-19) in EVT versus 10 (6-15) in MM, p < 0.001. Pretreatment ischemic core did not differ (EVT=10 [0-24] ml vs MM=9 [3-21] ml, p=0.59). Compared to MM, EVT was more frequently associated with functional independence (68.3 vs 61.6%, adjusted odds ratio [aOR]=2.42, 95% confidence interval [CI]=1.25-4.67, p=0.008, inverse probability of treatment weights [IPTW]-OR=1.75, 95% CI=1.00-3.75, p=0.05) with a shift toward better mRS outcomes (adjusted cOR=2.02, 95% CI:1.23-3.29, p=0.005), and lower mortality (5 vs 10%, aOR=0.32, 95% CI=0.12-0.87, p=0.025). EVT was associated with higher functional independence in patients with a perfusion mismatch profile (EVT=70.7% vs MM=61.3%, aOR=2.29, 95% CI=1.09-4.79, p=0.029, IPTW-OR=2.02, 1.08-3.78, p=0.029), whereas no difference was found in those without mismatch (EVT=43.8% vs MM=62.7%, p=0.17, IPTW-OR: 0.71, 95% CI=0.18-2.78, p=0.62). Functional independence was more frequent with EVT in patients with moderate or severe strokes, as defined by baseline NIHSS above any thresholds from 6 to 10, whereas there was no difference between groups with milder strokes below these thresholds. In patients with M2 occlusion, EVT was associated with improved clinical outcomes when compared to MM. This association was primarily observed in patients with a mismatch profile and those with higher stroke severity. ANN NEUROL 2022;91:629-639.

Ecological Momentary Assessment of Real-World Functional Behaviors in Individuals With Stroke: A Longitudinal Observational Study

ObjectiveTo validate and characterize real-world functional behaviors in individuals after stroke. DesignLongitudinal observational study using ecological momentary assessment (EMA) as a real-time assessment of functional behaviors in natural contexts. Wilcoxon rank-sum tests, Fisher exact tests, and Spearman correlations were used to analyze data. SettingCommunity. ParticipantsIndividuals with mild to moderate stroke (N=212). InterventionsNot applicable. Main Outcome MeasuresIndividuals were assessed 5 times daily for 14 days with EMA surveys to determine what, with whom, and where individuals were doing activities and appraise mental, somatic, and cognitive symptoms. Individuals also completed standardized assessments during laboratory visits, including Lawton Instrumental Activities of Daily Living Scale, Activity Card Sort, Patient-Reported Outcome Measurement Information System, and Quality of Life in Neurological Disorders. ResultsMost individuals (median age, 60 years; 55% male) were ischemic stroke (90%) and had mild stroke severity (median National Institutes of Health Stroke Scale, 2). A total of 14,140 EMA surveys were analyzed. Individuals were home 78% of the time; primarily participated in passive, unproductive activities (27%), especially watching television and resting; and participated least in physical activities (4%). EMA was sensitive to indicators of poststroke disability; unemployed individuals reported fewer vocational activities but more activities of daily living (ADL) and passive activities than employed counterparts. Users of mobility devices and individuals with cognitive problems spent significantly less time on vocational activities and more on ADL than nonusers and those without cognitive problems. Our data supported the validity of EMA methods in stroke, with small to moderate correlations of EMA with in-laboratory measures of daily functioning (r=−0.30 to 0.35, P<.05) and very large correlations between EMA and in-laboratory measures of symptoms, especially those measuring same constructs (r=−0.64 to 0.79, P<.0001). ConclusionsOur findings reveal that EMA tracked poststroke functioning precisely. EMA may be beneficial in examining poststroke functional recovery, in monitoring patients for home-based interventions, and for longitudinal research.

TO EVALUATE THE ROLE OF SERUM ALBUMIN AS A PREDICTOR OF FUNCTIONAL OUTCOME OF ACUTE ISCHEMIC STROKE

INTRODUCTION Stroke or cerebrovascular accident is a life threatening neurological disorder. It constitutes more than 50% of admissions in a hospital. Westernization of lifestyle and the resulting demographic transition might increase the burden of stroke even in the developing countries. Albumin is a multifunctional protein which has been proven to have neuroprotective effects in animal studies. There have been several studies in the western world including interventional studies trying to explore the scope of albumin as a neuroprotective agent. Some of these have shown that albumin therapy is capable of minimizing infarction volume and cerebral oedema. Therefore, the present study was conducted to evaluate the role of serum albumin as a predictor of functional outcome of acute ischemic stroke. AIMS &amp; OBJECTIES To determine the correlation between serum albumin level and functional outcome of acute ischemic stroke. MATERIALS &amp; METHODS This prospective, observational study was conducted at district hospital, JamKhambhalia, Dist. Devbhoomi Dwarka. 75 patients admitted with the diagnosis of acute ischemic stroke and meeting the inclusion and exclusion criteria. OBSERVATIONS &amp; RESULTS Most of the cases (58.66%) belonged to the age group of 51 to 70 years. There was a male preponderance. Majority of the cases of minor stroke had serum albumin level of more than 4.5 g/dL, those with moderate stroke had serum albumin of 4.0 to 4.49 g/dL while cases of severe stroke had serum albumin levels of less than 3.0 g/dL; P value: less than 0.001. DISCUSSION Globally, stroke is a leading cause of mortality and disability and there are substantial economic costs for post-stroke care. From the present study, it can be effectively concluded that acute ischemic stroke is prevalent in the older age groups with signicant male preponderance. Hypertension is the most commonly associated co-morbidity. Acute ischemic stroke affects the cerebral arteries more commonly than the cerebellar and lacunar circulation. Middle cerebral artery is the most commonly affected arterial territory. When assessed with the mean serum albumin levels, there was a signicant strong negative correlation with NIHSS score and MRS score. This indicates that low serum albumin levels are associated with increased severity of the stroke and increased/severe disability indicating poor recovery prole.

Influence of hospital capabilities and prehospital time on outcomes of thrombectomy for stroke in Japan from 2013 to 2016

To determine whether increasing thrombectomy-capable hospitals with moderate comprehensive stroke center (CSC) capabilities is a valid alternative to centralization of those with high CSC capabilities. This retrospective, nationwide, observational study used data from the J-ASPECT database linked to national emergency medical service (EMS) records, captured during 2013–2016. We compared the influence of mechanical thrombectomy (MT) use, the CSC score, and the total EMS response time on the modified Rankin Scale score at discharge among patients with acute ischemic stroke transported by ambulance, in phases I (2013–2014, 1461 patients) and II (2015–2016, 3259 patients). We used ordinal logistic regression analyses to analyze outcomes. From phase I to II, MTs increased from 2.7 to 5.5%, and full-time endovascular physicians per hospital decreased. The CSC score and EMS response time remained unchanged. In phase I, higher CSC scores were associated with better outcomes (1-point increase, odds ratio [95% confidence interval]: 0.951 [0.915–0.989]) and longer EMS response time was associated with worse outcomes (1-min increase, 1.007 [1.001–1.013]). In phase II, neither influenced the outcomes. During the transitional shortage of thrombectomy-capable hospitals, increasing hospitals with moderate CSC scores may increase nationwide access to MT, improving outcomes.

Triglyceride-Glucose Index and Intravenous Thrombolysis Outcomes for Acute Ischemic Stroke: A Multicenter Prospective-Cohort Study.

BackgroundThe triglyceride-glucose (TyG) index has recently been proposed as a reliable marker of insulin resistance. There is insufficient evidence to verify that the TyG index is correlated with functional outcomes and hemorrhagic transformation and in patients with stroke treated with intravenous thrombolysis (IVT).MethodsWe designed a multicenter cohort study, which enrolled patients with acute ischemic stroke treated with IVT between December 2004 and December 2016. The TyG index was divided into tertiles and calculated on a continuous scale. Unfavorable functional outcomes were defined by the modified Rankin Scale of 3–6 at 90 days and the incident rates of symptomatic intracranial hemorrhage (SICH) within 36 h of IVT onset were surveyed. Stroke severity was defined as mild (4–8), moderate (9–15), or high (≥16) based on the National Institutes of Health Stroke Scale (NIHSS) scores.ResultsAmong 914 enrolled patients, the tertiles of the TyG index were 8.48 for T1, 8.48–9.04 for T2, and 9.04 for T3. T3 showed an increased risk of unfavorable functional outcomes at 90 days [odds ratio (OR): 1.76; P = 0.0132]. The TyG index was significantly associated with unfavorable functional outcomes at 90 days (OR: 1.32; P = 0.0431 per unit increase). No association was found between the TyG index and SICH. These findings were applicable for T3 with stroke of moderate (OR, 2.35; P = 0.0465) and high severity (OR: 2.57, P = 0.0440) patients with stroke.ConclusionThis study supports the strong association between the increased TyG index and increased unfavorable functional outcomes at 90 days in patients with acute ischemic stroke treated with IVT. These findings were found to be robust in patients with moderate and high stroke severity.

Timely and Appropriate Administration of Inhaled Argon Provides Better Outcomes for tMCAO Mice: A Controlled, Randomized, and Double-Blind Animal Study.

Inhaled argon (iAr) has shown promising therapeutic efficacy for acute ischemic stroke and has exhibited impressive advantages over other inert gases as a neuroprotective agent. However, the optimal dose, duration, and time point of iAr for acute ischemic stroke are unknown. Here, we explored variable iAr schedules and evaluated the neuroprotective effects of acute iAr administration on lesion volume, brain edema, and neurological function in a mouse model of cerebral ischemic/reperfusion injury. Adult ICR (Institute of Cancer Research) mice were randomly subjected to sham, moderate (1.5h), or severe (3h) transient middle cerebral artery occlusion (tMCAO). One hour after tMCAO, the mice were randomized to variable iAr protocols or air. General and focal deficit scores were assessed during double-blind treatment. Infarct volume, overall recovery, and brain edema were analyzed 24h after cerebral ischemic/reperfusion injury. Compared with those in the tMCAO-only group, lesion volume (p < 0.0001) and neurologic outcome (general, p < 0.0001; focal, p < 0.0001) were significantly improved in the group administered iAr 1h after stroke onset (during ischemia). Short-term argon treatment (1 or 3h) significantly improved the infarct volume (1 vs. 24h, p < 0.0001; 3 vs. 24h, p < 0.0001) compared with argon inhalation for 24h. The concentration of iAr was confirmed to be a key factor in improving focal neurological outcomes relative to that in the tMCAO group, with higher concentrations of iAr showing better effects. Additionally, even though ischemia research has shown an increase in cerebral damage proportional to the ischemia time, argon administration showed significant neuroprotective effects on infarct volume (p < 0.0001), neurological deficits (general, p < 0.0001; focal, p < 0.0001), weight recovery (p < 0.0001), and edema (p < 0.0001) in general, particularly in moderate stroke. Timely iAr administration during ischemia showed optimal neurological outcomes and minimal infarct volumes. Moreover, an appropriate duration of argon administration was important for better neuroprotective efficacy. These findings may provide vital guidance for using argon as a neuroprotective agent and moving to clinical trials in acute ischemic stroke.

Practical "1-2-3-4-Day" Rule for Starting Direct Oral Anticoagulants After Ischemic Stroke With Atrial Fibrillation: Combined Hospital-Based Cohort Study.

Background:The “1-3-6-12-day rule” for starting direct oral anticoagulants (DOACs) in patients with nonvalvular atrial fibrillation after acute ischemic stroke or transient ischemic attack recommends timings that may be later than used in clinical practice. We investigated more practical optimal timing of DOAC initiation according to stroke severity.Methods:The combined data of prospective registries in Japan, Stroke Acute Management with Urgent Risk-factor Assessment and Improvement-nonvalvular atrial fibrillation (September 2011 to March 2014) and RELAXED (February 2014 to April 2016) were used. Patients were divided into transient ischemic attack and 3 stroke subgroups by the National Institutes of Health Stroke Scale score: mild (0–7), moderate (8–15), and severe (≥16). The early treatment group was defined as patients starting DOACs earlier than the median initiation day in each subgroup. Outcomes included a composite of recurrent stroke or systemic embolism, ischemic stroke, and severe bleeding within 90 days. Six European prospective registries were used for validation.Results:In the 1797 derivation cohort patients, DOACs were started at median 2 days after transient ischemic attack and 3, 4, and 5 days after mild, moderate, and severe strokes, respectively. Stroke or systemic embolism was less common in Early Group (n=785)—initiating DOACS within 1, 2, 3, and 4 days, respectively—than Late Group (n=1012) (1.9% versus 3.9%; adjusted hazard ratio, 0.50 [95% CI, 0.27–0.89]), as was ischemic stroke (1.7% versus 3.2%, 0.54 [0.27–0.999]). Major bleeding was similarly common in the 2 groups (0.8% versus 1.0%). On validation, both ischemic stroke (2.4% versus 2.2%) and intracranial hemorrhage (0.2% versus 0.6%) were similarly common in Early (n=547) and Late (n=1483) Groups defined using derivation data.Conclusions:In Japanese and European populations, early DOAC initiation within 1, 2, 3, or 4 days according to stroke severity seemed to be feasible to decrease the risk of recurrent stroke or systemic embolism and no increase in major bleeding. These findings support ongoing randomized trials to better establish the optimal timing of DOAC initiation.

Abstract TP121: Examination Of Initial NIHSS And Discharge Disposition In Patients Hospitalized With Acute Ischemic Stroke

Introduction: Acute ischemic stroke (AIS) patients require post-acute care (PAC) rehabilitation that is consistent with degree of stroke deficit. Appropriate PAC disposition for AIS patients varies widely. We examine the relationship between initial National Institutes of Health Stroke Scale (NIHSS) and discharge disposition to determine if stroke severity is associated with disposition. Methods: In our IRB-approved database, consecutive Emergency Department stroke code activations with confirmed diagnosis of AIS were retrospectively analyzed from January 2004-May 2021 at UC San Diego. Patients were grouped into mild (NIHSS 0-5), moderate (NIHSS 6-14), and severe (NIHSS &gt;14) stroke. Outcome variables were PAC disposition: Home, Inpatient Rehab Facility (IRF), Skilled Nursing Facility (SNF), Expired, and Other. Chi-squared and Kruskal-Wallis followed by pairwise proportion tests were used for analysis. Analyses were adjusted for age, sex, baseline modified Rankin score (mRS), and acute stroke treatment. Results: Total 2316 patients were included for analysis. There was a difference between initial stroke severity and discharge disposition overall (p&lt;0.001). (Table 1). Mild stroke patients had less discharges to IRF, SNF, Expired, or Other compared to moderate (p&lt;0.001) and severe (p&lt;0.001) strokes. There was no difference between moderate and severe stroke patients discharged to IRF (p=0.44) or SNF (p=0.48). Age, baseline mRS, and receiving acute stroke treatment were independent predictors for discharge to home, IRF, and SNF. Baseline mRS was an independent predictor for Expired patients. Conclusion: Patients with mild strokes are discharged home more than moderate and severe strokes, but there was no difference between moderate and severe stroke patients discharged to either IRF or SNF. This suggests PAC disposition is not consistent with stroke severity and further studies are needed to investigate other factors related to final disposition.

Abstract TP198: FIB-4 Index And Acute Ischemic Stroke Outcomes After Intravenous Thrombolysis

Introduction: It could be theorised that liver fibrosis and acute ischemic stroke (AIS) are related by inflammatory changes, but few studied this link, let alone in patients receiving intravenous thrombolysis (IVT). The Fibrosis (FIB)-4 index is an established rapid score to detect liver fibrosis. We aimed to understand the role of FIB-4 in predicting AIS subtype, severity and outcomes after IVT. Methods: AIS patients receiving IVT without severe liver derangement from 2006 to 2018 at a stroke centre were studied. Stroke subtype was defined using Trial of Org 10172 in Acute Stroke Treatment. Moderate and severe stroke was defined as National Institutes of Health Stroke Scale (NIHSS) ≥10. FIB-4 index was stratified into no advanced fibrosis (FIB-4 &lt;1.45) and advanced fibrosis (FIB-4 &gt;3.25). The primary outcome - functional outcome at 90-days using the modified Rankin Scale (mRS) - was analysed by ordinal shift analysis. Multivariable adjusted logistic regression evaluated associations of FIB-4 with stroke severity, functional independence (90-day mRS 0-2 vs 3-6), 90-day mortality, and symptomatic intracranial hemorrhage (SICH). Results: Among 900 patients, higher median FIB-4 was seen in cardioembolic stroke (CES) than non-CES (1.93 [IQR: 1.39-2.81] vs 1.27 [IQR: 0.92-1.90], p&lt;0.001). On multivariate analysis, higher FIB-4 predicted moderate and severe stroke (OR: 1.33, 95% CI: 1.08-1.68, p=0.012). On ordinal shift analysis, advanced fibrosis was associated with an unfavourable shift in 90-day mRS compared to no advanced fibrosis (OR: 1.75, 95% CI: 1.06-2.89, p=0.028). Advanced fibrosis was also associated with increased mortality (OR: 3.07, 95% CI: 1.47-6.48, p=0.003) and SICH (OR: 3.65, 95% CI: 1.21-11.17, p=0.022), but not functional independence (OR: 0.80, 95% CI: 0.40-1.55, p=0.512). Conclusion: Liver fibrosis was associated with higher rates of CES, more severe AIS, and poorer outcomes after IVT. This is a novel marker that could prognosticate IVT use in AIS.

Abstract WP197: Timing Of Anticoagulation After Ischemic Stroke In Patients With Atrial Fibrillation: An International Survey

Introduction: The timing of direct oral anticoagulant (DOAC) after atrial fibrillation (AF)-related stroke is unknown. Most guidelines are inconsistent and based on expert opinion. We conducted a survey to evaluate the global practice patterns of this common clinical scenario. Methods: We used an electronic survey with practice-related demographic and clinical questions of 10 cases with different stroke severities and sizes: transient ischemic attack, small, medium, large, and strokes with hemorrhagic infarction and parenchymal hematoma. Results: A total of 242 clinicians from 21 countries completed at least one clinical scenario. The majority of the respondents were from Australia (36.4%) or Canada (22.7%). Stroke-specific sub-specialty training was self-reported in 82.2% of the respondents. Median (IQR) time spent dedicated to stroke patient care/research was 70 (60) % of total working hours. Only 14% of responding clinicians reported current participation in a randomized trial of DOAC initiation timing after AF-related stroke. Stroke size, severity, and the grade of hemorrhage if present seem to be determinants of the decisions. Lack of consensus was observed in moderate stroke, multi-territory infarcts, large stroke, and in the presence of HT. The majority of respondents would be willing to randomize patients with different stroke sizes and severities with/without HT in a clinical trial of early versus delayed initiation of DOAC after AF-related stroke. Conclusions: Decisions related to the timing of DOAC initiation after AF-related stroke vary globally. The variability in clinical practice will continue until randomized controlled trials are completed.

Abstract 5: “Early Mobilization Protocol” Can Be Initiated In The Intensive Care Unit In Acute Ischemic Stroke Patients After Receiving Intravenous Alteplase

Context: Current guidelines recommend bed rest for 24 hours after receiving intravenous alteplase which may not be necessary and delay rehabilitation in a large proportion of acute ischemic stroke patients. Objective: To determine the feasibility of “early mobilization protocol” within the intensive care unit (ICU) in patients with acute ischemic stroke who received intravenous alteplase. Methods: All consecutive patients were admitted to the ICU with an acute ischemic stroke who received intravenous alteplase from October 2019-June 2021 were considered for “early mobilization protocol”. Patients≥18 years of age with minor, moderate or severe ischemic stroke (NIHSS score ≤22) were eligible and mobilization was initiated within 13-24 hours after intravenous alteplase administration. Exclusion criteria included hemodynamic instability, on mechanical ventilation, unstable neurological examination or progressive symptoms, or presence of external ventricular drain for hemorrhagic transformation within 24 hours of intravenous alteplase. Results: A total of 137 patients (56.8%) patients were eligible among 241 patients who were admitted to our institution with acute ischemic stroke after receiving intravenous alteplase. Mean age (±SD) was 63.4±16.6 and 66.2±17.0 years for the patients included and excluded in the early mobilization protocol, respectively. The mean NIHSS score (±SD) at baseline was 5.3±4.4 and 9.9±7.3 for the patients included and excluded in the early mobilization protocol, respectively. Early mobilization protocol was initiated at 18.3±3.6 hours in eligible patients compared with routine mobilization initiated at 41.6±19.8 hours in excluded patients (p&lt;0.001). The mean NIHSS score (±SD) at discharge (1.0±2.2 versus 4.2±7.0, p&lt;0.001) was significantly lower and rate of modified Rankin scale 0-1 at discharge (86.9% versus 67.3%, p=0.0003) was significantly higher in patients in the early mobilization protocol compared with those who were excluded. Conclusion: Early mobilization protocol in patients post intravenous alteplase treatment can be initiated in the ICU in appropriately selected patients without any adverse effects on neurological and functional outcomes.

The Evaluation of the Neuroprotective Effect of a Single High-Dose Vitamin D3 in Patients with Moderate Ischemic Stroke.

Introduction Vitamin D insufficiency is highly prevalent and is a negative predictor for survival in ischemic stroke patients. We evaluated the effect of a high dose of vitamin D3 on the Neuron-Specific Enolase (NSE) level, National Institute of Health Stroke Scale (NIHSS), and Barthel Index (BI) scoring system in moderate ischemic stroke patients. Methods This prospective, double-blind, randomized clinical trial (RCT) study was conducted from April 2020 to March 2021. Patients with moderate ischemic stroke (NIHSS 5 to 15) who had vitamin D deficiency (serum 25-OH vitamin D ≤30 ng/mL) were recruited and randomized into intervention and control groups. Subjects in the intervention group received a single dose, intramuscular (IM) injection of 600000 international unit (IU) vitamin D3, in addition to the standard treatment. NSE level and NIHSS were evaluated at baseline and 48 hours after the intervention. The BI was monitored three months after discharge. Results During the study period, 570 patients were assessed; finally, forty-one patients completed the study. Except for the age which was higher in the control group (p = 0.04), there were no statistically significant differences in other baseline characteristics between the two groups. After 48 hours, the NIHSS score was significantly lower in the intervention group (median 8 vs. 6.5, p = 0.008 in the control and intervention groups, respectively), but there was no significant difference in the NSE level (p = 0.80). Three months after discharge, the BI was significantly higher in the intervention group (median 8 vs. 9, p = 0.03 in the control and intervention groups, respectively). Conclusions Administration of a single 600000 IU of vitamin D3 could have neuroprotective effects in patients with moderate ischemic stroke, according to its significantly positive effects on functional clinical outcomes (NIHSS and BI), but this effect on the biomarker related to neural damage (NSE) was not significant.

A clinical study on stroke patients with emphasis on improvement pattern

Introduction: Stroke is a medical emergency and can cause permanent neurological damage, complication, and death if not promptly diagnosed and treated. It is also the third leading cause of death and serious disability, with major societal consequences. Materials and Methods: A prospective observational study on adult patients aged above 18 years diagnosed with acute ischemic stroke to understand the incidence and predictors of hemorrhagic transformation (HT) during hospital stay was conducted over a period of 18 months at a tertiary care hospital in Mangalore, India. The aim of this study was to find out the incidence of HT in acute ischemic stroke during the first week of hospitalization and to find out the predictors associated with the development of HT. Results: The mean age was 61.37 years, 59.28 years, 66.43 years and 48 years in those with mild stroke, moderate stroke, moderate to severe stroke and severe stroke respectively. Overall males had a higher incidence there was a statistically significant difference in the incidence of stroke, 53.33% were males. 16.67% had hemorrhagic transformation in ischemic stroke. Conclusion: Our study found that the risk of hemorrhagic transformation is higher in females than males.

Impact of Diabetes, Hypertension and Heart Failure on Stroke Rehabilitation Care

Background: Stroke patients who have multiple comorbidities at inpatient rehabilitation admission might experience poorer outcomes than those without comorbidities. Some differences in outcomes between these two groups may be based on age and type of comorbidity. Materials and Methods: Retrospective administrative data from an inpatient stroke rehabilitation unit in a Southwestern Ontario hospital were examined to determine the independent associations between diabetes, hypertension, and heart failure in stroke patients and rehabilitation length of stay (LOS), functional gains in rehabilitation, and discharge destination. We also examined the associations between CHADS2 score and rehabilitation LOS, functional gains in rehabilitation, and discharge destination. Results: Seven hundred and seven cases of stroke subcategorized as experiencing mild (n = 193), moderate (n = 454), and severe (n = 60) stroke were included in the study. Of these patients, 16.4% (n = 116) had type 2 diabetes, 58.7% (n = 415) had hypertension, and 5.8% (n = 41) had congestive heart failure (CHF) prior to stroke. CHF patients were significantly (p = 0.02) older, had significantly (p = 0.014) lower mean FIM gains and were discharged to residential care facilities compared to non-CHF cases. A higher CHADS2 score was significantly associated with Lower FIM gains and discharge to longer term settings. Conclusion: Significant differences exist in the functional gains and discharge disposition of stroke patients based on age of patient, type of comorbidity in stroke, and CHADS2 score.

轻中度急性缺血性脑卒中静脉溶栓序贯丁苯酞治疗与早期神经功能恶化影响的相关性

轻中度急性缺血性脑卒中静脉溶栓序贯丁苯酞治疗与早期神经功能恶化影响的相关性

Thrombolysis in Acute Ischemic Stroke at a Rural Tertiary Hospital: A Case Series of the First 50 Patients (2016–2021)

Objectives. To determine the outcomes for patients with acute stroke improve with early intervention in a series of the first 50 patients with acute ischemic stroke who were thrombolysed at our center. Methods. National Institutes of Health Stroke Scale (NIHSS) scores were recorded by NIHSS-certified nurses-on-duty in their appropriate monitoring sheets in the chart, which was double-checked by the neurology consultant co-author on duty. Source chart entries were cross-checked with logs from the CT scan, pharmacy, and other department records before being collated by the primary author. Means and averages were used to describe the patients’ data. Results. We included the first 50 patients with acute ischemic stroke, eligible for and who consented for thrombolysis. The patients had an average age of 61 years (range: 29 to 87); 32 (64%) were ≥ 60 years; 16 (32%) were male. Male gender (24/50), age ≥ 60 years old (32/50), hypertension (30/50), heart disease (6/30), smoking (7/30), and ethanol intake (9/30) were the most common risk factors. Thirty-five (70%) suffered a moderate stroke. The mean NIHSS of the 50 patients was 12.6 (range: 2 to 28). All but one received intravenous recombinant tissue plasminogen activator (IV rTPA) within 4.5 hours of onset, at a dose of 0.6 to 0.9 mg/kg. Symptomatic hemorrhagic transformation occurred in one (2%); asymptomatic hemorrhagic transformation was seen in three (6%). Fifteen of the 50 (30%) were NIHSS = 0 on discharge; another 18 (36%) showed clinical improvement compared to their status upon admission. Three patients (6%) were mRS = 0; and 30 (60%) were at least ambulatory (mRS ≤ 3) on discharge. Four patients (8%) died, one (2%) from fatal hemorrhagic transformation. Ten patients (20%) developed nosocomial pneumonia; two (4%) had catheter-related urinary tract infections More than half (52%) did not develop any in-hospital complications. The patients were admitted for a mean of 6.6 days (range &lt; 24 hours to 20 days). The average gross bill was ₱56,041.34 (range: ₱8,729.83 to ₱182,054.08); P32,194 was the average amount our Center shouldered per patient (range: zero to ₱154,272.88); almost all were Charity Service patients who used the ₱19,600 Philippine Health Insurance Corporation case rate and the 20% senior citizen discount to help defray the costs of their hospitalization. Conclusion. Stroke thrombolysis can be done in a rural tertiary hospital safely and effectively if with strong government, administration, health care workers, and community support.

RISK FACTORS FOR ISCHAEMIC STROKE: CORRELATON OF GENDER AND AGE WITH STROKE SEVERITY AND PATIENT OUTCOME

The risk of stroke exists regardless of gender, age, co-morbidities and lifestyle. Yet, research points out to significant differences concerning the severity of stroke and its functional outcome, correlated to gender, age as well as co-morbidities. The aim of our study is to analyse the stroke-related risk factors, as well as to createa correlation with gender and age respecting stroke severity and patient outcome. We conducted a retrospective analysis of 157 patients hospitalized at the Department for Urgent Neurology, at the University Clinic for Neurology in Skopje, N. Macedonia, during the period of October 2019- October2020.&nbsp; All of the included patients were diagnosed with ischemic stroke, confirmed by a computed tomography (CT scan) of the brain. Patient’s risk factors (hypertension, diabetes, atrial fibrillation, etc.) were analyzed in relation to gender (men and women) and age (over and under the age of 50). A comparison of stroke severity, assessed by the National Institutes of Health Stroke Scale (NIHSS) score was made, whereas the functional outcome was measured by the Modified Rankin Scale Score (mRS). All parameters were evaluated both on admission and upon discharging. Women over 50 years of age were more likely to develop severe stroke - 43.3% (29), whereas no symptoms of severe stroke were observed in the male group of patients under 50 years of age. Moderate stroke symptoms were noticed in the majority of female and male patients under and over the age of 50 – 29.85%(20), 46.05%(35), 50%(4), in 66.7%(4) of the examined subjects, respectively. The calculated difference of neurological deficit severity between female patients under the age of 50, female patients over 50 , male patients under50, and male patients over the age of 50, was statistically insignificant (p =0.32). Similarly, upon discharge, the preponderance of the patients from the four groups resulted with moderate neurological deficit – 47.4%(18) female patients over 50 , 46.3%(19) male patients over 50, and 66.7%(4) female patients under 50 years of age. Key words: Ischemic stroke, risk factors, gender, age

Heart Rate Variability and Recurrent Stroke and Myocardial Infarction in Patients With Acute Mild to Moderate Stroke.

Objectives: In patients with acute ischemic stroke, reduced heart rate variability (HRV) may indicate poor outcome. We tested whether HRV in the acute phase of stroke is associated with higher rates of mortality, recurrent stroke, myocardial infarction (MI) or functional outcome.Materials and Methods: Patients with acute mild to moderate ischemic stroke without known atrial fibrillation were prospectively enrolled to the investigator-initiated Heart and Brain interfaces in Acute Ischemic Stroke (HEBRAS) study (NCT 02142413). HRV parameters were assessed during the in-hospital stay using a 10-min section of each patient's ECG recording at day- and nighttime, calculating time and frequency domain HRV parameters. Frequency of a combined endpoint of recurrent stroke, MI or death of any cause and the respective individual events were assessed 12 months after the index stroke. Patients' functional outcome was measured by the modified Rankin Scale (mRS) at 12 months.Results: We included 308 patients (37% female, median NIHSS = 2 on admission, median age 69 years). Complete follow-up was achieved in 286/308 (93%) patients. At 12 months, 32 (9.5%), 5 (1.7%) and 13 (3.7%) patients had suffered a recurrent stroke, MI or death, respectively. After adjustment for age, sex, stroke severity and vascular risk factors, there was no significant association between HRV and recurrent stroke, MI, death or the combined endpoint. We did not find a significant impact of HRV on a mRS ≥ 2 12 months after the index stroke.Conclusion: HRV did not predict recurrent vascular events in patients with acute mild to moderate ischemic stroke.

Longitudinal assessment of depression during the first year after stroke: Dimensionality and measurement invariance

ObjectiveRepeated measurement of depression using summative scores of commonly used depression scales assumes that the construct is unidimensional and invariant across time, but little is known about the validity of these assumptions in stroke patients. The study examined the assumptions during the first year after mild to moderate stroke using the 8-item Patient Health Questionnaire (PHQ-8). MethodsData were obtained from the 2014–2016 Brain Attack Surveillance in Corpus Christi project, a population-based stroke surveillance study with longitudinal follow-up in Texas, United States. Depressive symptoms were assessed with the PHQ-8 at 3, 6, and 12 months post-stroke (n = 648, 542, 533, respectively). Dimensionality of the PHQ-8 was examined using exploratory bifactor analysis and confirmatory factor analysis (CFA). Based on a one-factor CFA model, longitudinal measurement invariance was examined by fitting configural, weak, strong and strict invariance models sequentially. ResultsMean age was 65.6 (SD = 11.2), half were women, and 56.7% were Mexican American. Reliability measures suggested a generally unidimensional construct (Omega Hierarchical: 0.79–0.86), good internal consistency (Cronbach's alpha: 0.84–0.88) and good temporal stability (intraclass correlation coefficient: 0.838). Configural invariance for equality of item-factor structure (RMSEA = 0.038, CFI = 0.982, WRMR = 0.970) was supported. Partial weak invariance for equality of factor loadings (p = 0.11) was supported by chi-square difference tests, whereas full longitudinal invariance was supported by changes in comparative fit index and root mean square error of approximation. ConclusionsThe findings suggest the PHQ-8 may be a reasonable tool for repeated measurement of depression in stroke patients, and more research on its longitudinal psychometric properties is needed.