Modified Rankin Score Research Articles

Spontaneous brain abscess formation: challenge of a shifting pathogen spectrum over the last 21 years - a single center experience.

Spontaneous intracerebral abscess formation is a rare condition presenting with a disabling sequela. The origin of infection can either be primary or secondary to an infection at another location. The site of primary infection - due to the proximity, often the oral cavity, the sinuses, and the orbit - determines the causative pathogens. Treatment often combines surgical and antimicrobial therapies. To determine the microbiology and respective changes and treatment outcome, we performed this retrospective monocentric cohort study of patients requiring surgical treatment of brain abscesses. Patients undergoing surgical treatment of a primary intracranial abscess between January 2000 and January 2021 in the Department of Neurosurgery, Freiburg University Hospital were included. Demographic, clinical and imaging data were extracted from patients' medical records and databases. Treatment approaches were also analyzed, and surgical therapy and antibiotic therapy were reported. Outcome was assessed by the modified Rankin score (mRS) and was dichotomized into good (mRS 0-3) and poor (mRS 4-6) outcome. We included 65 patients with spontaneous intracerebral abscess that were treated with neurosurgical intervention at our institution. Analysis of the causative pathogens showed an increasing dominance of rare pathogens such as fungi, parasites, mycobacteria and anaerobes. Outcome measured by the mRS was similar from 2005 to 2021. The pathogen spectrum of spontaneous intracerebral abscess at our institution is shifting with rarer pathogens being increasingly detected. This retrospective analysis highlights the need for microbiological diagnosis and of combined surgical and antibiological treatment.

Abstract 4119303: The New Strait-Jacket Designed for Endovascular Therapy Reduces the First Reperfusion Time of Emergency Thrombectomy for Stroke

Introduction: Conscious sedation during cerebrovascular interventional surgery can shorten the time of vascular recanalization and bring significant benefits to patients, but patients are often difficult to cooperate, which affects the operation of interventional surgery. This study aims to develop a novel cerebral vascular intervention strait-jacket and explore its safety and effectiveness in emergency cerebral vascular intervention surgery. Methods: Using the convenient sampling method, patients with acute large artery occlusion stroke who underwent emergency mechanical thrombectomy in Zhongnan Hospital of Wuhan University from September 2018 to March 2021 were selected as the research objects. The control group was treated with conventional restraint belt, and the experimental group was treated with new cerebrovascular interventional surgery strait-jacket. The first reperfusion time, total operation time, modified Rankin score (mRS) at 30 days, intraoperative limb prolapse rate, average surgical cost, and safety indicators were compared between the two groups. The t test, Mann-Whitney U test or Fisher exact test were used for comparison between groups according to the data type. A p<0.05 indicated statistical significance. Results: The new type of cerebrovascular interventional surgical strait-jacket developed in this study are shown in Figure 1, which have been patented and transformed into products. A total of 140 patients were included for mechanical thrombectomy, randomly divided into an experimental group (n=69) and a control group (n=71). Using the new strait-jacket significantly shortened the first reperfusion time (43.5±13.7 vs 50.7±15.7, P=0.039) and the total operation time (81.1±12.6 vs 93.2±21.1, P=0.027). There was a significant decrease in limb dislodgement rate (0% vs 35.2%, P<0.001) and a noticeable reduction in average surgical cost (76315±12400 vs 81462±14142 P=0.040) by using the strait-jacket. In terms of safety performance, using the strait-jacket significantly lower rates of skin redness than the control group (8.7% vs 42.3%, P<0.001). Conclusion: The new type of cerebrovascular interventional surgical strait-jacket is safe, which can effectively shorten the operation time, reduce the rate of intraoperative limb prolapse and the average operation cost, and can bring good social benefits.

Abstract 4120957: Endovascular Thrombectomy Versus Medical Management for Acute Ischemic Stroke with Large Infarct: An Updated Meta-Analysis of Randomized Controlled Trials

Background: Endovascular therapy (EVT) has revolutionized the treatment of acute ischemic stroke due to large vessel occlusions. Despite the increasing evidence for EVT, its efficacy remains understudied in patients with acute ischemic stroke with large infarcts. Patients with large-volume ischemic strokes are excluded from major randomized controlled trials (RCTs) despite contributing up to 25% of all acute ischemic strokes. Aim: This study aimed to compare clinical outcomes with endovascular thrombectomy versus medical management in patients with acute ischemic stroke with large infarct. Methods: We conducted a systematic literature review on PubMed, Embase, Scopus and Cochrane Library from inception to 15th May 2024 for RCTs. The inverse-variance random-effects model was used to pool odds ratio (OR) and risk ratio (RR) with 95% confidence intervals. The statistical significance was set at p<0.05. Results: 6 RCTs with 1887 patients (945: EVT and 942: medical management) were included. The mean age in both EVT and medical management groups was 70 ± 11.4 years. EVT was associated with a better modified Rankin Score (mRS) at 90 days [OR: 1.68; 95% CI: 1.38, 2.04; p<0.00001], mRS at 90 days (0-2) [OR: 2.47; 95% CI: 1.87, 3.27; p<0.00001], mRS at 90 days (0-3) [OR: 1.96; 95% CI: 1.56, 2.46; p<0.00001], and early neurological improvement [RR: 2.35; 95% CI: 1.79, 3.10; p<0.00001] compared to medical management. EVT was also associated with a higher risk of symptomatic intracranial hemorrhage [RR: 1.71; 95% CI: 1.09, 2.66; p=0.02]. The 90-day mortality [RR: 0.86; 95% CI: 0.72, 1.02; p=0.08] was comparable between the two groups. Conclusion: Patients with acute ischemic stroke with large infarct had superior functional outcomes with EVT as compared to medical management alone. However, EVT was associated with higher risks of symptomatic intracranial hemorrhage, with comparable 90-day mortality risk. Further large RCTs are warranted to evaluate the outcomes with EVT in acute ischemic stroke with large infarct.

Ảnh hưởng của bệnh đi kèm trên kết cục đột quỵ thiếu máu não cấp

Background: Comorbidities that help predict poor outcomes in patients with acute ischemic stroke play a part in treatment planning and provide necessary information for patients and their families. Objective: Identify comorbidities that can predict poor outcomes 90 days after the onset of acute ischemic stroke. Subjects and methods: Prospective study including 150 acute ischemic stroke patients at Trieu An Hospital, Ho Chi Minh City. Subjects recruited upon admission were collected NIHSS score and comorbidities. Subjects had modified Rankin scores collected 90 days after disease onset. Univariate analysis and multivariate regression analysis were used to determine the role of variables on stroke outcomes. Results: The mean age was 65, male accounts for 62.0%. There were 8 factors univariately associated with poor outcome after 90 days of acute ischemic stroke onset: NIHSS, age, atrial fibrillation, valvular heart disease, coronary artery disease, heart failure, extracranial atherosclerosis and dementia. Among them, dementia is an independent prognostic factor for poor outcomes through multivariate analysis. The number of comorbidities is closely related to poor outcomes, the number of comorbidities ≥ 3 predicts patients with poor outcomes after 90 days of disease onset with a sensitivity of 96.6%; Specificity was 88.0%; The area under the curve was 96.3%. Conclusion: In acute ischemic stroke patients with comorbidities ≥ 3, the patient's prognosis is poor. In addition, dementia is an independent prognostic factor of poor outcome after 90 days from disease onset.

Advancing Stroke Safety and Efficacy through Early Tirofiban Administration after Intravenous Thrombolysis: The multicenter, randomized, placebo-controlled, double-blind ASSET IT trial protocol.

Intravenous thrombolysis (IVT) is the cornerstone treatment for the acute ischemic stroke (AIS) within 4.5 hours after onset. Current guidelines recommend administering antiplatelet medications 24 hours after IVT. However, vascular re-occlusion is a common occurrence after IVT. Tirofiban, a platelet glycoprotein IIb/IIIa antagonist, can help deter macrovascular re-occlusion, prevent microvascular thrombosis, and enhance cerebral blood flow. This trial aims to assess whether early administration of tirofiban can improve clinical outcomes in patients with AIS who received IVT. The Advancing Stroke Safety and Efficacy through Early Tirofiban Administration after Intravenous Thrombolysis (ASSET IT) Trial is an investigator-initiated, randomized, placebo-controlled, double-blind, multi-center study. Up to 832 eligible patients will be consecutively randomized in a 1:1 ratio to receive either intravenous tirofiban or placebo over a period of 2 years across 38 stroke centers in China. The primary endpoint is excellent functional status at day 90, defined as a modified Rankin Score of 0-1. Primary safety endpoints include symptomatic intracerebral hemorrhage at 24 hours and mortality at 90 days.

Catatonia in anti-NMDA receptor encephalitis: a case series and approach to improve outcomes with electroconvulsive therapy

BackgroundAnti-N-methyl-D-aspartate (NMDA) receptor encephalitis has been recognised to present with the syndrome of catatonia. In severe cases dysautonomia is representative of malignant catatonia. The treatment with benzodiazepines (BZDs) and electroconvulsive therapy (ECT) may decrease morbidity and mortality in patients presenting with anti-NMDA receptor encephalitis and catatonia.MethodsThis is a retrospective case series of eight patients with anti-NMDA receptor encephalitis treated with ECT. We use clinical prediction scores (Clinical Assessment Scale for Autoimmune Encephalitis [CASE] and anti-NMDAR Encephalitis One-Year Functional Status scores) to compare expected outcomes and observed outcomes.ResultsCASE scores in our group ranged between 5 and 19, with a mean score of 13.8 (median 15.5). NEOS scores ranged from 2 to 4, with a mean and median of 3. Of the eight patients, six had a favourable modified Rankin Score (0–2) at a follow-up of 8 to 12 months. Patients received an average of 29.9 ECT treatments in total.ConclusionsBased on clinical prediction scores, this cohort had better than expected functional outcomes. We discuss the use of BZDs and ECT in these cases and propose a treatment algorithm for patients who present with catatonic syndrome in anti-NMDA receptor encephalitis.

Acute Reperfusion Therapies and Prognosis in Nonagenarian Stroke Patients

Introduction: Thrombolysis and endovascular thrombectomy (EVT) are standard treatments after stroke. We previously reported that these therapies benefit stroke patients over 80 years old. Now, we aimed to study reperfusion therapies specifically in nonagenarians, hypothesizing a poorer prognosis in this group. Methods: Nonagenarian stroke patients were identified from our prospective monocentric cohort, which included consecutive patients ≥80 years old treated with thrombolysis and/or EVT from 2015 to 2019. Baseline characteristics, treatments, and outcomes, as well as complications and mortality were analyzed. Results: Ninety-six nonagenarians were treated with thrombolysis (69.8%) and/or EVT (81.1%). A total of 51% had a pre-stroke modified Rankin score (mRS) ≤2. Cardioembolism was the most common etiology (67.7%). Age was associated with a higher mRS after stroke with a turning point at 90 years old: (90–99 years old: odds ratio [OR] = 0.33, 95% confidence interval [95% CI]: 0.13–0.83, p = 0.02) versus (85–89 years old: OR = 0.72, 95% CI: 0.34–1.50, p = 0.38), with 80- to 84-year-old patients as the reference. In nonagenarians, previous coronary artery disease (OR = 8.02, 95% CI: 1.66–38.68, p = 0.01), initial National Institute of Health Stroke Score (NIHSS) (OR = 1.11, 95% CI: 1.03–1.19, p = 0.01), pre stroke independence (OR = 0.25, 95% CI: 0.08–0.71, p = 0.01), and “drip-and-ship” status (OR = 3.35, 95% CI: 1.22–9.16, p = 0.02) were associated with 3-month mortality. Nonagenarians had more baseline comorbidities (p = 0.003) and lower levels of pre-stroke independence (p = 0.002) than octogenarians (n = 261). Despite no difference in the use of acute treatments, timelines, and rates of successful reperfusion, a good functional status at 3 months was less common in nonagenarians than octogenarians (14.3% vs. 34.0%, p < 0.001) with a higher mortality (60.2% vs. 16.4%, p < 0.001). A total of 9.5% of nonagenarians experienced a symptomatic intracranial hemorrhage. Conclusions: Age is a crucial factor affecting prognosis after stroke with a turning point at 90 years old. However, age alone should not be a limiting factor for treatment decision. Despite higher mortality and poorer functional prognosis overall, some nonagenarians may benefit from reperfusion therapies.

Mild intracerebral bleeding does not adversely affect survival and neurological outcome of surgical therapy for left-sided infective endocarditis

Abstract Background Intracerebral bleeding (IB) is a serious condition that requires increased attention and has implications for treatment options. For patients with infective endocarditis (IE), current guidelines recommend postponing surgery if IB is present. IB can be classified into four relevant groups (following European Cooperative Acute Stroke Study and Heidelberger Bleeding classification): hemorrhagic transformation (HT) 1 and 2, and parenchymal hemorrhage (PH) 1 and 2. PH2 is the only IB with neurological deterioration. These classifications were originally introduced for stroke patients following thrombolysis but without IE. The hypothesis tested in our study is that IB may influence IE treatment and thus outcome. Method Patients were retrospectively identifyied who were operated for left-sided IE, neuroradiologists re-evaluated and classified preoperative cerebral imaging for any IB. Outcome was quantified using the modified Rankin score (mRS), and mRS were extracted from the patients’ hospital chart at admission and by follow-up telephone call (FU), also including mortality. To ensure that the influence of IB was comparable, patients with IB (IB+) were propensity matched (EuroScore 2, Charlson Comorbidity Index, C-reactive protein; nearest neighbor match) to patients without IB (IB-) who also received surgical IE therapy. All IB+ patients underwent a careful risk-benefit analysis before therapy. Results Of 286 consecutive patients (January 2015 - November 2022) operated for left-sided IE, 36 had IB (65±13 years, 26% female): 11 with HT1, 9 with HT2, 8 with PH1, and 8 with PH2. These patients were matched with 36 operated IB- patients. Survival analysis showed no overall effect of IB+ vs. IB- (p = 0.112, 95% CI of hazard ratio was 0.246-1.243 vs. 0.709-3.572). Although there was no effect of IB on survival in the mild IB subgroup (HT1/2, Figure A), there was a difference in patients with severe IB (PH1/2) with less survival in IB+ (Figure B). Neurological outcome (ΔmRS) showed an effect of IB grade in the two-way ANOVA analysis (p = 0.029). Intergroup comparison showed a significantly better outcome for IB- (vs. IB+) in the PH2 subgroup (p = 0.034), but not in other subgroups. For all groups, the mean ΔmRS for IB+ was 1.1±1.6 vs. 0.70±1.4 for IB- (p = 0.256). The mean FU time was 2.6±2.1 years. Conclusion In patients operated for left-sided IE, mild IB did not affect survival or neurological outcome. In the more severe forms of IB, i.e. PH1 and PH2, survival was less favorable compared to matched controls. Furthermore, we observed a difference in neurological outcome in patients with severe IB. Thus, surgical therapy of left-sided IE should be avoided in patients with severe IB, whereas we can add evidence to the safety of surgical therapy in mild IB. Therefore, we recommend regular assessment of the degree of IB in such patients.Figure

A severity comparison of leukoaraiosis in ischemic and hemorrhagic stroke: a retrospective study.

Leukoaraiosis (LA) is a common neuroradiological finding in patients suffering from stroke. Cerebral small-vessel disease (SVD) is one of the primary causes of both ischemic stroke and hemorrhagic stroke (intracerebral hemorrhage, ICH) and the development of LA. Significant evidence that LA predicts the risk of functional dependency and mortality exists. However, studies examining the difference in LA severity between ischemic stroke and hemorrhagic stroke are lacking. We therefore aimed to compare the severity and abundance of LA in the two stroke subgroups. All patients admitted to the Department of Neurology, Haukeland University Hospital, with an ischemic stroke and intracerebral hemorrhagic (ICH) stroke diagnosed between 2006 and 2020 were included in the study. We collected patient data on risk factors and clinical and radiological findings and outcomes from our local stroke registry. The presence and severity of LA were assessed using the Fazekas score based on CT imaging. We evaluated the outcome using the modified Rankin Score (mRS) 7 days post-stroke. A total of 5,084 patients were included in our analyses: 4437 (87%) with ischemic stroke and 647 (13%) with ICH. LA was present in 2476 (45%) patients. In our ordinal logistic regression model, adjusting for age, sex, known hypertension, known diabetes mellitus, and smoking, LA was more severe and more abundant in ICH patients compared to ischemic stroke patients (Fazekas score: 1, OR: 1.54; Fazekas score: 2, OR: 1.88; and Fazekas score: 3, OR 2.13; p < 0.001). Increasing severity of LA was associated with worse functional outcomes in both groups (ischemic stroke, OR: 1.49; p < 0.001 and ICH, OR: 1.36; p < 0.025). In this study, LA was more severe and abundant in patients with ICH.

Role of clipping in aneurysmal subarachnoid hemorrhage: a post hoc analysis of the Earlydrain trial

The choice between clipping and coiling of ruptured cerebral aneurysms in subarachnoid hemorrhage (SAH) remains controversial. The recently published Earlydrain trial provides the opportunity to analyze the latest clip-to-coil ratio in German-speaking countries and to evaluate vasospasm incidence and explorative outcome measures in both treatment modalities. We performed a post hoc analysis of the Earlydrain trial, a multicenter randomized controlled trial investigating the use of an additional lumbar drain in aneurysmal SAH. The decision whether to clip or to coil the ruptured aneurysm was left to the discretion of the participating centers, providing a real-world insight into current aneurysm treatment strategies. Earlydrain was performed in 19 centers in Germany, Switzerland, and Canada, recruiting 287 patients with aneurysmal SAH of all severity grades. Of these, 140 patients (49%) received clipping and 147 patients (51%) coiling. Age and clinical severity based on Hunt-Hess/WFNS grades and radiological criteria were similar. Clipping was more frequently used for anterior circulation aneurysms (55%), whereas posterior circulation aneurysms were mostly coiled (86%, p < 0.001). In high-volume recruiting centers, 56% of patients were treated with clipping, compared to 38% in other centers. A per-year analysis showed a stable and balanced clipping/coiling ratio over time. Regarding vasospasm, 60% of clipped versus 43% of coiled patients showed elevated transcranial Doppler criteria (p = 0.007), reflected in angiographic vasospasm rates (51% vs. 38%, p = 0.03). In contrast to the Earlydrain main results establishing the superiority of an additional lumbar drain, explorative outcomes after clipping and coiling measured by secondary infarctions, mortality, modified Rankin Score, Glasgow Outcome Scale Extended, or Barthel-Index showed no significant differences after discharge and at six months. In clinical practice, aneurysm clipping is still a frequently used method in aneurysmal SAH. Apart from a higher rate of vasospasm in the clipping group, an exploratory outcome analysis showed no difference between the two treatment methods. Further development of periprocedural treatment modalities for clipped ruptured aneurysms to reduce vasospasm is warranted.

Thrombocytopenia as a Prognostic Marker in Patients with Acute Encephalitis at a Tertiary Care Center in Northern India.

Acute encephalitis (AE) is associated with a high burden of mortality and permanent disability and has a spectrum of underlying etiologies. The prognosis of encephalitis is difficult and almost all the patients seem to be at a high risk of poor outcomes. A number of physiological changes take place during encephalitis and have been evaluated for their prognostic value. Platelet count, which has been recognized as a surrogate prognostic marker in various viral illnesses, has recently been recognized to have a prognostic value in AE too. In the present study, we attempted to study the role of thrombocytopenia in the prognosis of AE. Total of 98 cases based on clinical, cerebrospinal fluid, and radiological profiles consistent with the diagnosis of AE were enrolled in the study. A clinical profile was noted, and platelet count was assessed. Thrombocytopenia was defined as platelet count <150,000/mm3. Platelet count 100,000-150,000, 50,000-99,999, and <50,000/mm3 were considered mild, moderate, and severe thrombocytopenia. The underlying etiology was explored, and patients were followed till discharge/outcome. The outcome was noted in terms of the Modified Rankin score (MRS). MRS 0-2 was considered good, 3-4 fair, and 5-6 as poor outcome. The mean age of patients was 34.06 ± 18.76 years. Majority of patients were women (54.1%). Prevalence of thrombocytopenia was 75.5%. A total of 34 (45.9%) had mild, 30 (40.5%) had moderate, and 10 (13.5%) had severe thrombocytopenia. Acute viral encephalitis (unclassified) was the most common etiology (33.7%), followed by scrub meningoencephalitis (24.5%) and Japanese encephalitis (12.2%), respectively. Good, fair, and poor outcomes were noted in 48 (49%), 21 (21.4%), and 29 (29.6%) cases. On univariate analysis, no significant association of poor outcome was seen with age, sex, duration of fever, and mechanical ventilation need (P > 0.05). Low Glasgow Coma Scale (GCS), splenomegaly, low platelet count, and Japanese encephalitis virus/scrub typhus etiologies were found to be significantly associated with poor outcomes (P < 0.05). Thrombocytopenia compared to normal platelet count and severe thrombocytopenia compared to mild and moderate thrombocytopenia were significantly associated with poor outcomes (P < 0.05). On multivariate analysis, GCS <8 (odds ratio [OR] =4.52; 95% confidence interval [CI] =1.56-13.20) and thrombocytopenia (OR = 11.92; 95% CI = 1.38-103.32) emerged as independent predictors of poor outcome. The findings of the study showed that low GCS and thrombocytopenia could be used as predictors of poor outcomes in AE cases.

Factors Influencing the Association of 24-hour National Institutes of Health Stroke Scale & 90-day Modified Rankin Score.

The modified Rankin Scale (mRS) at 90days is the primary outcome in most acute stroke studies, but the long follow-up period has disadvantages. The National Institutes of Health Stroke Scale (NIHSS) at 24 h shows astrong, but imperfect, association with 90-day mRS. This study examines the association between 24-hour NIHSS and 90-day mRS and reasons for discrepancies. Data are from the ESCAPE-NA1 thrombectomy patients. To address the non-normality distribution of the NIHSS and include deceased patients, a7-point ordinal score was generated by grouping 24-hour NIHSS. The association of ordinal 24-hour NIHSS and 90-day mRS was assessed with adjusted ordinal logistic regression. Differences in baseline and treatment/post-treatment variables were compared between patients with discordant and concordant outcomes. One-thousand-seventy-six patients with available 24-hour NIHSS and 90-day mRS were included (median 24-hour NIHSS6[IQR: 2-14], median 90-day mRS2[IQR: 1-4]). Ordinal 24-hour NIHSS was associated with 90-day mRS (adjusted cOR 2.53 [95%CI 2.33-2.74]). Forty-eight (4.5%) patients had discordant outcomes. Of those, 19(1.8%) had 24-hour NIHSS < 6 and 90-day mRS5-6; all of which had ≥ 1 severe adverse event, most commonly pneumonia (6[31.6%]) or recurrent stroke (4[21.1%]). Twenty-nine patients (2.7%) had 24-hour NIHSS > 14 and 90-day mRS 0-2. In these patients, baseline NIHSS and ASPECTS was lower, and collateral status was worse. An ordinal NIHSS score that includes death at 24 h shows astrong association with 90-day mRS, suggesting that it could be used as an alternative outcome. Patients with discrepant outcomes differed from the remaining patients regarding their baseline NIHSS, ASPECTS, collateral status, and post-stroke complications.

Gait speed after mild stroke/transient ischemic attack was associated with long-term adverse outcomes: A cohort study.

The association between gait speed and adverse outcomes after stroke has not been fully illustrated. This study aimed to explore the association of gait speed on long-term outcomes in minor stroke or transient ischemic attack (TIA). We performed a longitudinal study with acute minor stroke or TIA based on a subgroup of the Third China National Stroke Registry data. The gait speed was evaluated using a 10-meter walking test at discharge and 3 months after the stroke onset. The primary outcomes were poor functional outcomes at 1 year, defined by a modified Rankin Score (mRS) of 2-6. Additional outcomes included all-cause death, ambulate dependency (mRS score 4-6), cognitive impairment (Montreal Cognitive Assessment <26), stroke recurrence, and composite vascular events. The study sample included a total of 1542 stroke patients with a median age of 60 (53-68). At 1-year follow-up, 140 (9.20%) patients experienced poor functional outcomes. Faster gait speed at discharge was associated with lower incidence of poor functional outcome (OR = 0.89; 95% CI, 0.84-0.94), cognitive impairment (OR = 0.93; 95% CI, 0.89-0.96), ischemic stroke recurrence (HR = 0.92; 95% CI, 0.87-0.98), and composite vascular events (HR =0.94; 95% CI, 0.89-0.99) at 1 year. Faster gait speed at 3 months was associated with lower incidence of poor functional outcome (OR = 0.90; 95% CI, 0.85-0.95), ambulate dependency (OR = 0.86; 95% CI, 0.77-0.97), and cognitive impairment (OR = 0.92; 95% CI, 0.88-0.95) at 1 year. Our findings indicated that slow gait speed after minor stroke or TIA may be an independent predictor for long-term poor outcomes. Gait speed may be considered as a vital sign during follow-up in post-stroke patients.

Quantifying brain health in acute ischemic stroke through effective reserve.

To quantify brain health using a measure of reserve that incorporates pre-existing pathology. We analyzed two retrospective ischemic stroke cohorts (GASROS and SALVO) with neuroimaging and 90-day modified Rankin Scores (mRS) available. White matter hyperintensity (WMHv), brain, and intracranial volumes were automatically extracted, and brain parenchymal fraction (BPF) calculated. The latent variable effective reserve (eR) was modeled using age, WMHv, and BPF or brain volume in GASROS. Models were compared using Bayes Information Criterion (BIC). The best model's eR estimates were categorized into quartiles and evaluated in SALVO. GASROS included 476 (median age: 65.8; 65.3% male) and SALVO included 43 (median age: 69.2; 62.8% male) patients. Inverse associations between eR and mRS was seen in both models, with brain volume outperforming BPF (path coefficients: -0.67, -0.48, respectively; p < 0.001; |ΔBIC| = 362). Quartile-based eR stratification in SALVO showed a similar inverse trend, with worse outcomes in the low reserve group (mRS≤2 - highest vs lowest quartile: 85/90% vs 59/45% for GASROS/SALVO). Expanding the concept of eR, highlights its clinical translational potential. The strong link between higher eR and better outcomes underscores its value as a protective brain health metric.

High Hypoperfusion Intensity Ratio Is Independently Associated with Very Poor Outcomes in Large Ischemic Core Stroke.

Recent advances have highlighted the efficacy of endovascular thrombectomy (EVT) in patients with large ischemic core stroke, yet asignificant portion still experience very poor outcomes, defined as a90-day modified Rankin Score (mRS) of 5-6. This study aims to investigate the hypoperfusion intensity ratio (HIR) as aprognostic imaging parameter for these outcomes. In amulticenter retrospective cohort study, data from consecutive patients undergoing EVT for acute ischemic stroke with large vessel occlusion (AIS-LVO) at two comprehensive stroke centers were analyzed. The study included patients with an Alberta Stroke Program Early CT Score (ASPECTS) of5 or less and utilized pretreatment perfusion imaging to calculate HIR. The primary outcome was very poor outcomes (90days mRS 5-6). Among 102 patients included, 59 (57.8%) had very poor outcome (90days mRS 5-6). Multivariable logistic regression analysis adjusting for multiple covariates including admission National Institutes of Health Stroke Scale (NIHSS) and EVT revealed that higher admission NIHSS (adjusted odds ratio [aOR] 1.224, 95% CI 1.089-1.374, p = 0.001) and HIR (aOR per 0.1 incremental change, 1.34, 95% CI 1.02-1.82, P = 0.042) were independently associated with very poor outcomes. This study demonstrates that admission NIHSS and HIR are independently associated with very poor outcome (90days mRS 5-6) in patients with large ischemic core strokes. These findings highlight the importance of collateral status and perfusion imaging in predicting outcomes in this patient population, suggesting apotential role for HIR in the triage and management of large core stroke patients.

Jugular venous narrowing and spontaneous spinal cerebrospinal fluid leaks: A case-control study exploring association and proposed mechanism.

Spontaneous skull base cerebrospinal fluid leaks (CSFLs) are associated with increased intracranial pressure in idiopathic intracranial hypertension (IIH) and hypothesized to relate to skull base erosions due to increased CSF pressure. Given the increasing recognition of internal jugular venous stenosis (IJVS) as a cause of intracranial hypertension (IH), we evaluated the relationship between spinal CSFL and venous causes of IH. The spinal CSFL database at a single institution was assessed to identify 12 consecutive spontaneous, non-traumatic spinal CSFL patients with CTV data. Exclusion criteria included documented IIH and iatrogenic CSFL. Demographics, clinical parameters, imaging characteristics, and IJV manometry results were recorded. Internal jugular venous stenosis was graded as: none (0-10%), mild (10-50%), moderate (50-80%), severe (>80-99%), and occluded (100%). Twelve consecutive patients who presented with cerebrovascular accidents without CSFL, matched by age and sex, were similarly analyzed as a control group. STROBE guidelines were used in reporting results. All CSFL patients had IJVS (83.3% bilateral, 33.3% severe) compared to 41.7% of the control group (33.3% bilateral, 16.7% severe-occluded); p = 0.04. All CSFL patients with available venogram manometry data had at least unilateral IJV gradients. Most patients presented with modified Rankin score (mRS) of 1 (66.7%), but in those with higher mRS, medical and/or surgical interventions were associated with decreased morbidity. Spontaneous spinal CSFL was associated with IJVS in patients not meeting IIH criteria. Persistently high CSF pressure resulting in CSFL may cause opening pressure to be falsely normal or low. Internal jugular venous stenosis may be a viable target in recurrent CSFL management and improve morbidity.

Association of dynamic changes in arterial partial pressure of carbon dioxide with neurological outcomes in aneurysmal subarachnoid hemorrhage

BackgroundCerebral blood flow (CBF) is closely regulated by carbon dioxide (CO2). In patients with aneurysmal subarachnoid hemorrhage (aSAH), abnormal arterial partial pressure of CO2 (PaCO2) might deteriorate brain injuries. Nevertheless, the impact of dynamic PaCO2 fluctuations on neurological outcomes in aSAH patients has not been extensively studied. Our study aimed to investigate the association between dynamic PaCO2 levels and unfavorable neurological outcomes in aSAH patients. MethodsIn this retrospective observational study, we consecutively enrolled 159 aSAH patients from December 2019 to July 2021. Arterial blood gas measurements within 10 days after intensive care unit (ICU) admission for each patient were recorded to calculate the time-weighted average (TWA)-PaCO2, an indicator representing the dynamic changes in PaCO2 levels. For the association between TWA-PaCO2 levels and unfavorable neurological outcomes in aSAH patients, multivariable logistic analysis was used to explore TWA-PaCO2 levels as categorical variables, and restricted cubic spline (RCS) was used to explore TWA-PaCO2 levels as continuous variables. ResultsIn multivariable logistic analysis, after adjusting confounders, when TWA-PaCO2 35–45 mmHg was as a reference, TWA-PaCO2 < 35 mmHg (odds ratio [OR] 2.15, 95 % confidence interval [CI] 0.83–5.55, P = 0.113) and TWA-PaCO2 > 45 mmHg (OR 8.31, 95 % CI 0.72–96.14, P = 0.090) were not independently associated with unfavorable neurological outcomes (modified Rankin score of 3–6). The RCS shows a “U” shape curve between TWA-PaCO2 levels and unfavorable neurological outcomes, with a nonlinear P-value of 0.023. The lowest ORs of unfavorable neurological outcomes were within PaCO2 32.8–38.1 mmHg. ConclusionsBoth lower and higher PaCO2 levels are harmful to aSAH patients. PaCO2 in the range of 32.8–38.1 mmHg is associated with lowest unfavorable neurological outcomes.

Adherence to Secondary Preventative Medications One Year Post Stroke

Abstract Background Adherence to secondary preventative medications is critical to reduce subsequent vascular events after ischaemic stroke. Many stroke risk factors are modifiable, but adherence is poor in up to 40% of stroke survivors. Guidelines recommend the use of antithrombotic, lipid lowering and antihypertensive medication. We examined adherence to these medications one year post stroke. Methods This was a retrospective cohort study of patients admitted to an Irish level 3 hospital with an acute stroke between July 2022 and June 2023. Stroke survivors were interviewed a year after stroke onset, either in clinic or in their home, and asked to show the interviewer all current medications. Adherence to three categories of secondary prevention medications and knowledge of their indication was assessed. Results 172 stroke patients were contacted and 64% agreed to participate. The cohort included 62% males and average age was 69.9 years. The majority (72/110, 65%) had a modified Rankin score (mRS) of 0-2. The proportion of participants reporting full adherence to all prescribed medications was 81% (89/110) with adherence rates of 81% for lipid lowering agents and 88% for both antithrombotics and antihypertensives. Adherence was higher in participants who had an involved caregiver (85.9% vs 73.9%) and in those with mRS &amp;gt;2 (94.9% vs 73.2%). There was no significant difference between age or gender subgroups. Knowledge of the indication was 62% for antithrombotics and 55% for lipid-lowering drugs. Conclusion Self-reported adherence to secondary preventative medications was high in this cohort but one in five stroke survivors reported poor adherence increasing their risk for recurrent stroke. Adherence was highest for antithrombotics and lowest for lipid-lowering drugs. Adherence is higher in more dependent individuals and helped by an involved caregiver. We observed a deficit in patient understanding of secondary prevention medications. Improving this knowledge gap could increase adherence to secondary prevention post stroke.

Mortality and Place of Residence One Year Post Stroke in an Irish Cohort

Abstract Background Transition from hospital to community post stroke is a critical period in a patient's recovery. Understanding where post-stroke patients are living a year after discharge can provide valuable insights into the effectiveness of discharge planning and rehabilitation strategies. We aimed to identify location of patients one year post stroke and examine the influences on that location. Methods We performed a retrospective cohort study of stroke patients admitted to an acute hospital over a one-year period. Data on demographics, function, length of stay, stroke severity, mortality and discharge location were obtained from the in-hospital stroke registry. Patients were interviewed one year post stroke and follow up data on place of residence obtained. Results 260 strokes occurred during the 1-year period. 11% died as inpatients and 5% were uncontactable leaving 206 stroke patients included in this study. Twenty-five patients (12%) died between discharge and 1 year follow up. 150 (73%) returned home post discharge rising to 157 (76%) one year post stroke. 32 (16%) were discharged to nursing homes falling to 22 (11%) at one year. Patients in nursing homes were older (80 vs 68 years, p = 0.001), had longer inpatient stays (37 vs 9 days, p = 0.000) and had higher Modified Rankin Scores (5 vs 2, p=0.0001). Conclusion Almost one in four stroke patients died within the first year of stroke consistent with international data. Mortality was highest in the acute post stroke period, but half of all deaths occurred post hospital discharge highlighting the importance of secondary vascular prevention and advanced care planning in this population. Older age, higher functional dependence and longer length of hospital stay were all associated with nursing home admission. Post stroke morbidity and mortality remains high after hospital discharge. Further study is needed to understand cause of death in the post discharge period in this population.

An Evaluation of In-Hospital Stroke in Irish Acute Hospitals

Abstract Background Between 1 and 17% of strokes occur in-hospital in patients hospitalised for another reason. In-hospital strokes are associated with worse outcomes and poor performance on quality-of-care measures of stroke care. Methods A retrospective multi-centre cohort study comparing in-hospital and community-onset strokes was conducted using stroke data collected for the purposes of the Irish National Audit of Stroke from the 1st of January 2020 to the 31st of December 2021. Results Of 10,781 stroke cases, 618 occurred in-hospital stroke equating to 5.7%. In-hospital stroke patients were older (Median age 76 years versus 74 years in community-onset stroke). Patients with an in-hospital stroke were more likely to have an ischaemic stroke (90.0% versus 85.4%; p=0.002, pre-stroke disability (defined as modified Rankin score of 3 to 5) (30.6% versus 14.3%; p&amp;lt;.001), atrial fibrillation (40.6% versus 29.8%; p&amp;lt;.001). The median [IQR] length-of-stay was longer for in-hospital stroke (14 [6-30] versus 8 [4-16] days) and admission to the stroke unit was less frequent (44.2% versus 70.2% of community-onset strokes; adjusted odds ratio 0.46 95% CI 0.38-0.56; p&amp;lt;.001). Longer median [IQR] times to medical assessment (20 [5-84] versus 12 [0-100] minutes; p&amp;lt;.001) and thrombolysis (90 [63-135] versus 54 [37-80] minutes; p&amp;lt;.001) were observed for patients with in-hospital stroke onset. One in four (27.2%) in-hospital onset stroke cases die in-hospital compared with one in ten (10.4%) community-onset strokes (adjusted odds ratio 2.98 [2.37-3.75]; p&amp;lt;.001). Favourable functional ability was less likely at discharge for in-hospital onset stroke cases (28.9% versus 52.3% of community-onset strokes; adjusted odds ratio 0.38 [0.30-0.48]; p&amp;lt;.001). Conclusion The Irish cohort of in-hospital stroke patients reflect a distinct stroke subgroup. Longer delays to medical assessment and thrombolysis, poorer functional outcomes and increased in-hospital mortality were observed highlighting opportunities to improve care.