Severe Acute Stroke Research Articles

Inpatient assessment of the neurological outcome of acute stroke patients based on the National Institute of Health Stroke Scale (NIHSS)

ObjectiveIdentify the association between stroke severity and the neurological outcome of an acute stroke using the National Institutes of Health stroke scale (NIHSS).Study designA descriptive cross-sectional study.Place and duration of study: Northwest hospital Hayatabad Peshawar.MethodologyA cross-sectional descriptive study was done in the general plus stroke unit of the northwest hospital in Peshawar, KPK during Jan 2022 to July 2022.400 admitted patients diagnosed with acute stroke in the past three months were included for NIHSS assessment and were classified as mild, moderate, or severe stroke. After entering all of the data from the collection into SPSS version 16, the information was transferred to an Excel spreadsheet. To further assess the results, the researcher and statistician evaluated all of the cases, radiological findings, and laboratory test data.ResultsIn this cross-sectional descriptive study, 400 individuals ranging from 30 to 90 years of age were divided into two groups: males and females. The survey was conducted by 49% of men and 51% of women. The stroke severity was assessed to be mild in 22% of cases, moderate in 49%, and severe in 29% of patients. As evaluated by the NIHSS, Patients with acute ischemic stroke were divided into four groups depending on their neurological outcomes: those who improved were 160 (40%), those who remained stable were 124 (31%), and those who deteriorated were 52 (13%), and those who died were 64 (16%). Patients with greater triglyceride levels were 88, while those with lower levels were 312. Acute stroke was also detected in 34% of patients with a covid history, 28% of patients who were covid positive, and 38% of patients who were covid free in this investigation.ConclusionAccording to our findings, the NIHSS is a reliable scale for evaluating patients' neurological outcomes and determining the association between acute stroke severity and cognitive functioning (NIHSS).

Deep profiling of multiple ischemic lesions in a large, multi-center cohort: Frequency, spatial distribution, and associations to clinical characteristics.

Background purposeA substantial number of patients with acute ischemic stroke (AIS) experience multiple acute lesions (MAL). We here aimed to scrutinize MAL in a large radiologically deep-phenotyped cohort.Materials and methodsAnalyses relied upon imaging and clinical data from the international MRI-GENIE study. Imaging data comprised both Fluid-attenuated inversion recovery (FLAIR) for white matter hyperintensity (WMH) burden estimation and diffusion-weighted imaging (DWI) sequences for the assessment of acute stroke lesions. The initial step featured the systematic evaluation of occurrences of MAL within one and several vascular supply territories. Associations between MAL and important imaging and clinical characteristics were subsequently determined. The interaction effect between single and multiple lesion status and lesion volume was estimated by means of Bayesian hierarchical regression modeling for both stroke severity and functional outcome.ResultsWe analyzed 2,466 patients (age = 63.4 ± 14.8, 39% women), 49.7% of which presented with a single lesion. Another 37.4% experienced MAL in a single vascular territory, while 12.9% featured lesions in multiple vascular territories. Within most territories, MAL occurred as frequently as single lesions (ratio ∼1:1). Only the brainstem region comprised fewer patients with MAL (ratio 1:4). Patients with MAL presented with a significantly higher lesion volume and acute NIHSS (7.7 vs. 1.7 ml and 4 vs. 3, pFDR < 0.001). In contrast, patients with a single lesion were characterized by a significantly higher WMH burden (6.1 vs. 5.3 ml, pFDR = 0.048). Functional outcome did not differ significantly between patients with single versus multiple lesions. Bayesian analyses suggested that the association between lesion volume and stroke severity between single and multiple lesions was the same in case of anterior circulation stroke. In case of posterior circulation stroke, lesion volume was linked to a higher NIHSS only among those with MAL.ConclusionMultiple lesions, especially those within one vascular territory, occurred more frequently than previously reported. Overall, multiple lesions were distinctly linked to a higher acute stroke severity, a higher total DWI lesion volume and a lower WMH lesion volume. In posterior circulation stroke, lesion volume was linked to a higher stroke severity in multiple lesions only.

Factors associated with favorable outcomes in acute severe stroke patients: A real-world, national database study.

Thrombolytic therapy is useful in severe stroke, but it increases the risk of intracerebral hemorrhage. In addition, it may have limited use in resource-limited due to a lack of trained neurologists and equipment to perform CT scans. There are limited data available from studies of national databases on stroke outcomes and predictors of severe stroke. This study, therefore, aimed to evaluate acute severe ischemic stroke outcomes in a real-world setting. Additionally, predictors of favorable stroke outcomes were explored using a retrospective cohort. Data were extracted from the National Health Security Office (NHSO) in Thailand. The inclusion criteria were: Aged ≥18 years or older, diagnosis of acute severe ischemic stroke (defined by an admission National Institutes of Health Stroke Scale score of 15-24), and available data on stroke outcomes. Outcomes were evaluated at discharge using a modified Rankin score at discharge. Factors associated with good outcomes were determined using multivariate logistic regression analysis. During the study period, 268 severe stroke patients met the inclusion criteria. Of those, 38 (14.18%) had good outcomes at discharge. A total of 223 patients received intravenous recombinant tissue plasminogen activator (83.21%). Of those, 38 (17.04%) had favorable outcomes. A predictive model for good outcomes revealed two independent factors: Male sex and atrial fibrillation with adjusted odds ratios (95% confidence interval) of 2.30 (1.10-4.82) and 0.38 (0.16-0.91), respectively. Predictors for good stroke outcomes in severe stroke patients included rtPA treatment, atrial fibrillation, and male sex.

Association of Stroke Lesion Pattern and White Matter Hyperintensity Burden With Stroke Severity and Outcome.

To examine whether high white matter hyperintensity (WMH) burden is associated with greater stroke severity and worse functional outcomes in lesion pattern-specific ways. MR neuroimaging and NIH Stroke Scale data at index stroke and the modified Rankin Scale (mRS) score at 3-6 months after stroke were obtained from the MRI-Genetics Interface Exploration study of patients with acute ischemic stroke (AIS). Individual WMH volume was automatically derived from fluid-attenuated inversion recovery images. Stroke lesions were automatically segmented from diffusion-weighted imaging (DWI) images, parcellated into atlas-defined brain regions and further condensed to 10 lesion patterns via machine learning-based dimensionality reduction. Stroke lesion effects on AIS severity and unfavorable outcomes (mRS score >2) were modeled within purpose-built Bayesian linear and logistic regression frameworks. Interaction effects between stroke lesions and a high vs low WMH burden were integrated via hierarchical model structures. Models were adjusted for age, age2, sex, total DWI lesion and WMH volumes, and comorbidities. Data were split into derivation and validation cohorts. A total of 928 patients with AIS contributed to acute stroke severity analyses (age: 64.8 [14.5] years, 40% women) and 698 patients to long-term functional outcome analyses (age: 65.9 [14.7] years, 41% women). Stroke severity was mainly explained by lesions focused on bilateral subcortical and left hemispherically pronounced cortical regions across patients with both a high and low WMH burden. Lesions centered on left-hemispheric insular, opercular, and inferior frontal regions and lesions affecting right-hemispheric temporoparietal regions had more pronounced effects on stroke severity in case of high compared with low WMH burden. Unfavorable outcomes were predominantly explained by lesions in bilateral subcortical regions. In difference to the lesion location-specific WMH effects on stroke severity, higher WMH burden increased the odds of unfavorable outcomes independent of lesion location. Higher WMH burden may be associated with an increased stroke severity in case of stroke lesions involving left-hemispheric insular, opercular, and inferior frontal regions (potentially linked to language functions) and right-hemispheric temporoparietal regions (potentially linked to attention). Our findings suggest that patients with specific constellations of WMH burden and lesion locations may have greater benefits from acute recanalization treatments. Future clinical studies are warranted to systematically assess this assumption and guide more tailored treatment decisions.

Multimodal assessment of intensive care unit-acquired weakness in severe stroke patients.

Intensive care unit-acquired weakness (ICUAW) defines generalized muscle weakness seen in critically ill patients in the absence of other causative factors. Herein, we aimed to evaluate ICUAW in stroke patients by electrodiagnostic testing, histopathology, and assessment of respiratory complex activities (RCA), to define the frequency of ICUAW in this patient group, and to reach new parameters for early prediction and diagnosis. We prospectively recruited twenty-four severe acute stroke patients during a sixteen-month period. In addition to serial nerve conduction studies (NCS), we performed muscle biopsy and RCA analysis on the non-paretic side when ICUAW developed. Patients undergoing orthopedic surgery without metabolic and neuromuscular diseases constituted the control group for RCA. Survival and longitudinal data were analyzed by joint modeling to determine the relationship between electrophysiological parameters and ICUAW diagnosis. Eight patients (33%) developed ICUAW, and six of them within the first two weeks. Extensor digitorum brevis, abductor digiti minimi (ADM), rectus femoris and vastus medialis (VM) compound muscle action potential (CMAP) amplitudes showed a significant decrease in the ICUAW group. VM CMAP amplitude (BIC = 358.1574) and ADM CMAP duration (BIC = 361.1028) were the best-correlated parameters with ICUAW diagnosis. The most informative electrophysiological findings during the entire study were obtained within the first 11days. Muscle biopsies revealed varying degrees of type 2 fiber atrophy. Complex I (p = 0.003) and IV (p = 0.018) activities decreased in patients with ICUAW compared to controls. VM CMAP amplitude and ADM CMAP duration correlate well with ICUAW diagnosis, and may aid in the early diagnosis.

Fatigue 7 years post-stroke: Predictors and correlated features.

BackgroundPost‐stroke fatigue (PSF) is common with great impact on quality of life. We explored predictive and cross‐sectionally correlated features in the long term after ischemic stroke.MethodsThis study comprises 430 participants of the prospective Sahlgrenska Academy Study on Ischemic Stroke (SAHLSIS), aged 18–69 years at index stroke. Information on acute stroke severity and cardiovascular risk factors was collected at index stroke. After 7 years, PSF was assessed by the Daily Fatigue Impact Scale (D‐FIS). Cognitive, neurological, and functional outcomes, and symptoms of depression and anxiety, pain, insomnia, and physical activity were also assessed. Associations between baseline variables and PSF were analyzed by ordinal regression. Correlations between PSF and cross‐sectionally assessed variables, and between PSF and baseline variables, were analyzed with Spearman's or point‐biserial correlation for the whole sample and in sex‐stratified analyses.ResultsAt 7 years post‐stroke, 80% of the participants reported some impact of fatigue. Female sex and stroke severity were independently associated with PSF, whereas no associations were detected with baseline cardiovascular risk factors. In cross‐sectional analyses at 7 years, we found correlations between PSF and poor functional, neurological, and cognitive outcomes, as well as depressive symptoms, anxiety, insomnia, pain, and low physical activity (p < .001 throughout). The correlation with insomnia was stronger in women than in men (two‐way ANOVA interaction test, p = .03).ConclusionsOur findings confirm that PSF is common in the long term after ischemic stroke and show a complex interplay with sex and several other outcomes. Future studies should address causal relationships and interventions towards fatigue and coexisting features.

Hospital-acquired infections after acute ischaemic stroke and its association with healthcare-related costs and functional outcome.

Acute ischaemic stroke is associated with important mortality, morbidity, and healthcare-related costs. Age, pre-stroke functionality and stroke severity are important contributors to functional outcome. Stroke patients also risk developing infections during hospitalization. We sought to explore possible predictors of post-stroke infections and the relationship of post-stroke infection with healthcare-related costs and functional outcome. This single-centre retrospective study included 530 patients treated for ischaemic stroke between January 2017 and February 2019. Antibiotics' administration was used as a proxy for post-stroke infection. Functional outcome at 90days was assessed by the modified Rankin Scale (mRS). Total healthcare-related costs were recorded for the index hospital stay. Multivariable analysis for post-stroke infection was done with the independent factors sex, age, pre-stroke mRS, National Institutes of Health Stroke Scale (NIHSS) and diabetes mellitus. Twenty percent of patients had a post-stroke infection. NIHSS (OR 1.10, 95%CI 1.06-1.13, p < 0.0001) and diabetes mellitus (OR 2.18, 95%CI 1.28-3.71, p = 0.0042) were independent predictors for post-stroke infection. Mean total healthcare-related costs were 15,374 euro (SD 19,968; IQR 3,380-18,165), with a mean of 31,061 euro (SD 29,995; IQR 12,584-42,843) in patients with infection, compared to 11,406 euro (SD 13,987; IQR 3,083-12,726) in patients without (p < 0.0001). Median 90-days mRS was 5 (IQR 3-6) in patients with infection versus 1 (IQR 0-3.5) in patients without (p < 0.0001). In patients, admitted for acute ischaemic stroke, stroke severity and diabetes mellitus were identified as the main predictors for post-stroke infection. Hospital-acquired infections were associated with increased costs and worse functional outcome.

Quality of Life in the First Year after Ischemic Stroke Treated with Acute Revascularization Therapy.

(1) Background: we aimed to describe the disease-specific quality of life (QoL) of ischemic stroke patients treated with acute revascularization therapy, its evolution from 6 months to 12 months, and associated factors. (2) Methods: QoL was assessed with the SS-QoL in consecutive patients treated with either intravenous thrombolysis (IVT) and/or mechanical thrombectomy (MT). Variables associated with QoL scores and its evolution were studied using multivariate mixed models, and interaction with time. Analyses were performed in four domains of SS-QoL: self-care, mobility, mood, and social roles. (3) Results: Among the 501 included patients (mean (sd) age 68.9 (14.5), 49% women), lower post-stroke QoL was independently related to lower level of school education, prestroke mRS > 2, and 24 h NIHSS score > 4. Independent predictors of unfavorable evolution of QoL over time were age <75 years (Mobility p = 0.0194 and Mood p = 0.0015), NIHSS score ≤ 4, (Self-care p = 0.0053 and Mood p = 0.0048), and modified Rankin Scale score ≤ 2 (Social roles, p = 0.0006). Revascularization therapy had no significant effect on the QoL scores, but patients treated with MT (alone or as bridging therapy) had significantly greater improvement in mobility score between 6 and 12 months than patients treated with IVT alone (p = 0.0072). (4) Conclusion: QoL evolution over one year had only slight variation and was associated with the modalities of acute treatment, age, and stroke severity.

Association of incomplete Circle of Willis with severity of acute ischaemic stroke

Background: The extent of damage by ischaemic stroke and the course of illness depend largely on the presence of collateral vessels around the affected area. The Circle of Willis (CoW), which serves as an important potential collateral pathway in maintaining adequate blood flow around the brain, is known to have variable patency. So the completeness of CoW is expected to influence the severity of ischaemic stroke. Objective: The objective of the study was to determine the association of completeness of Circle of Willis with severity of acute ischaemic stroke. Methods: It was a cross-sectional study done in Bangabandhu Sheikh Mujib Medical University, Dhaka from March, 2015 to August, 2017. A total of 42 patients of acute ischaemic stroke who were undergoing Digital Subtraction Angiography (DSA) for different reasons were selected by purposive sampling method. Data regarding completeness of Circle of Willis were obtained from DSA. National Institutes of Health Stroke Scale (NIHSS) score were measured to assess the severity of stroke. Then the severities of stroke between the complete and incomplete Circle of Willis groups were compared. Results: A total of 27 male and 15 female patients were enrolled. Among them, 47.6% (20) had complete CoW and it was incomplete in rest 52.4% (22). Median (range) of NIHSS scores of complete and incomplete CoW group was 4.5 (0-17) and 9.5 (3-21) respectively. Mean NIHSS (±SD) for the complete and incomplete CoW was 6.60 (±4.97) and 9.95 (±5.10) respectively. The difference of mean between the two groups was found to be statistically significant (p=0.037). Odd’s Ratio (OR) for development of more severe stroke in patients with incomplete CoW was 4.5, 95% Confidence Interval (CI) 1.18-18.13 which was statistically significant (p=0.029). Conclusion: It was concluded that incomplete Circle of Willis is associated with more severe stroke in acute ischaemic stroke patients. Bangladesh Med Res Counc Bull 2021; 47(2): 181-191

Factors associated with paid employment 12 months after stroke in A Very Early Rehabilitation Trial (AVERT).

Returning to work is an important outcome for stroke survivors. This sub-study of a randomised controlled trial aimed to provide characteristics of working-age stroke participants and identify factors associated with return to work at 12 months. We used paid employment data collected as part of A Very Early Rehabilitation Trial (AVERT, n=2104), an international randomised controlled trial studying the effects of very early mobilisation after stroke at 56 acute stroke units across Australia, New Zealand, the United Kingdom, Malaysia and Singapore. For the present analysis, data for trial participants < 65 years old were included if they were working at the time of stroke and had complete 12-month return-to-work data. The primary outcome was 12-month return to paid work. Univariable and multivariable logistic regression analyses were conducted to determine the association of multiple factors with return to work. In total, 376 AVERT participants met the inclusion criteria for this sub-study. By 12 months, 221 (59%) participants had returned to work at a median of 38 hr per week. Similar rates were found across geographic regions. On univariable analysis, the odds of returning to paid employment were increased with younger age (OR per year 0.95, 95%CI 0.92-0.97), no previous diabetes (0.4, 0.24-0.67), lower stroke severity (OR per National Institutes of Health Stroke Scale point 0.82, 0.78-0.86), less 3-month depressive traits (Irritability Depression Anxiety [IDA] scale) (OR per IDA point 0.87, 0.80-0.93), less 3-month disability (modified Rankin Scale), and prior full-time work (2.04, 1.23-3.38). On multivariable analysis, return to work remained associated with younger age (OR 0.94, 95%CI 0.91-0.98), lower stroke severity (0.92, 0.86-0.99), prior full-time work (2.33, 1.24-4.40), and less 3-month disability. Return to work at 12 months after stroke was associated with young age, acute stroke severity, 3-month disability and full-time employment before stroke. Greater understanding of this topic could help in developing programs to support successful resumption of work post-stroke.

Pattern and outcome of electrolytes imbalance in acute stroke patients admitted in a tertiary care hospital in Khulna city

Stroke is a major public health problem and a leading cause of chronic disability and death. There is scarcity of data about electrolytic disturbances in acute stroke, especially in developing countries. The objective of this study is to find out electrolyte disturbances among acute stroke patients and their association with severity of acute stroke and outcome. It was a cross-sectional study, conducted over a period of one year from 01/06/2018 to 31/05/2019, on 80 selected clinically and CT scan proven acute stroke patients at Gazi Medical College Hospital, Khulna. Out of 80 patients, 50 (62.5%) were male and 30 (37.5%) were female. Majority of the patients (38.7%) were above 70 years age group. CT scan findings revealed, 16 (20%) haemorrhagic, 60 (75%) ischaemic and 4 (05%) mixed (both haemorrhagic and ischaemic) stroke. Seventy-two (90%) of patients had unilateral and only 8 (10%) had bilateral lesion. Dyselectrolytemia was evident in 65% of total stroke patients. Thirty-five percent of all patients had hypokalaemia which was the most common dyselectrolytemia. Out of 20 patients with hyponatremia, 14 died and out of 28 patients with hypokalaemia, 14 died. Out of total 80 patients 48 (60%) had improved and 4 (5%) had been unchanged and referred to higher centre. Mediscope 2022;9(1): 20-24

A cross sectional study of correlation of serum ferritin levels with NIHSS scoring scale in patients of acute ischemic stroke

IStroke is one of the leading causes of mortality and morbidity in the world. The National Institutes of Health Stroke Scale (NIHSS) is one of the most common stroke scale used by neurologist around the world. Serum Ferritin is an acute phase reactant, which increases during acute conditions like inflammation and also in vascular events.This is a study that correlates the S.Ferritin levels with NIHSS scoring scale to assess the severity of stroke, which can also be used as an adjuvant tool for better assessment of severity of stroke in patients, which further helps in improving the management of patients with stroke.This study aims to estimate serum ferritin and the NIHSS stroke scale in patients with acute ischemic stroke, and then to correlate serum ferritin with NIHSS stroke scale.A cross sectional study was done during the period of November 2017-May 2019 in hospitals affiliated to Bangalore Medical College &amp; Research Institute , Bangalore on 106 patients with acute ischemic stroke at the time of admission. NCCT brain was done and Serum Ferritin levels determined for patients who fit into the inclusion and exclusion criteria. Data was analyzed using SPSS 21.0 software by descriptive statistics in the form of mean values, standard deviation and percentages. Chi Square test was used for association of qualitative variables.There was linear increase of S.Ferritin with increase in severity of stroke ( As determined by NIHSS scoring scale). It was a found that male sex had a higher increase in S.Ferritin levels compared to females, with statistically significant correlation. It was also found that the maximum number of patients with increase in S.Ferritin levels belonged to severe stroke category.As there was a linear increase of S.Ferritin with increase in severity of stroke (NIHSS scoring scale), we can conclude that Serum Ferritin level had a positive correlation with the severity of ischemic stroke indicating that S.Ferritin levels can also be used as an adjuvant tool for assessing the severity of stroke along with other tools and facilitate adequate and timely management of these patients. S Ferritin can be used as a Prognostic marker in predicting the severity of Acute Ischaemic stroke.

Inhibition of Autophagy Facilitates XY03-EA-Mediated Neuroprotection against the Cerebral Ischemia/Reperfusion Injury in Rats.

Objective L-3-n-Butylphthalide (NBP) is used to treat moderate and severe acute ischemia stroke. A previous screening study indicates that XY03-EA, a novel derivative of NBP, is more potent than NBP in the oxyradical scavenging capacity. In this study, in vivo and in vitro ischemia/reperfusion (I/R) models were used to test whether the XY03-EA offered therapeutic benefits in the ischemic stroke and explore the underlying mechanism of action. Methods For this purpose, behavioral scores, cerebral infarct volume, cerebral blood flow, oxidative stress levels, inflammatory factor expression, energy metabolism levels, and autophagy activation were estimated in the rat middle cerebral artery occlusion and reperfusion (MCAO/R) model. The nonhuman primate MCAO/R model was conducted to validate the therapeutic effect of XY03-EA applied for 3 weeks. The neurological deficit score (NDS) progression rate and the infarct volume were continuously recorded on days 3, 7, 14, and 21. The PC-12 cell OGD/R model was used to assess the cell survival rate, reactive oxygen species (ROS) levels, the expression of autophagy execution molecules, and the activation of autophagy-related signaling pathways. Results XY03-EA decreased the cerebral injuries and NDS by increasing cerebral blood flow, improving brain energy metabolism, accelerating ROS clearance, suppressing inflammatory responses, and inhibiting autophagy in the MCAO/R model rats. In the nonhuman primate MCAO/R model, the treatment of XY03-EA for 3 weeks could significantly inhibit the NDS progression rate and indicate a positive trend to reduce the infarct volume in a dose-dependent way. Mechanistically, XY03-EA inhibited ROS-dependent autophagy activation and thereby protected the PC-12 cells from the autophagic cell death induced by OGD/R. Conclusions In this study, we found that XY03-EA alleviated the cerebral I/R injuries in rats and nonhuman primates. Our results demonstrated that XY03-EA exerted neuroprotective effects against the ROS-mediated autophagic neurocyte death and had great potential for the treatment of ischemic stroke.

Safety and efficacy of three enteral feeding strategies in patients with severe stroke in China (OPENS): a multicentre, prospective, randomised, open-label, blinded-endpoint trial

Early enteral nutrition is crucial for preventing malnutrition and improving outcomes in patients with severe stroke, but previous trials have provided conflicting results regarding the optimal nutritional strategy. We aimed to compare the efficacy and safety of three enteral feeding strategies in patients with severe stroke. The Optimizing Early Enteral Nutrition in Severe Stroke (OPENS) study was a multicentre, investigator-initiated, prospective, open-label, randomised controlled trial, with blinded outcome assessment, in 16 tertiary and district general hospitals in the west of China. Adult patients with acute severe ischaemic or haemorrhagic stroke (Glasgow Coma Scale score ≤12 or National Institutes of Health Stroke Scale score ≥11 on admission) who were expected to receive enteral nutrition for more than 7 days were randomly assigned (1:1:1) to full enteral nutrition (70-100% of estimated caloric requirements), modified full enteral nutrition (full enteral nutrition plus prokinetic agents), or hypocaloric enteral nutrition (40-60% of estimated caloric requirements) via a centralised web-based randomisation system. The assigned nutrition was initiated within 24 h after enrolment and continued for 7 days. The computer-generated randomisation sequence was prepared by a statistician not involved with the rest of the study. Randomisation was done with an automated permuted block size of six. The allocation was unblinded to participants and investigators. The primary efficacy outcome was the proportion of participants with poor outcome (modified Rankin Scale score ≥3) at day 90 and the prespecified primary safety outcome was mortality at day 90, assessed in the intention-to-treat population. The trial is registered with ClinicalTrials.gov, NCT02982668. Between Jan 15, 2017, and Sept 23, 2020, 321 patients were randomly assigned (107 in each group) and 315 patients (175 [56%] men, median age 71 years, IQR 60-78) were included in the final analysis. The study was terminated ahead of schedule on Sept 23, 2020, because a significant difference between groups was detected in mortality. The proportion of participants with poor outcomes at 90 days did not differ (modified full enteral nutrition 86 [82%] of 105 patients vs full enteral nutrition 85 [80%] of 106 patients, adjusted odds ratio [OR] 0·87, 95% CI 0·41-1·86, p=0·721; hypocaloric enteral nutrition 76 [73%] of 104 patients vs full enteral nutrition 0·61, 0·30-1·27, p=0·186; hypocaloric enteral nutrition vs modified full enteral nutrition 0·70, 0·34-1·46, p=0·340). Hypocaloric enteral nutrition showed significantly higher 90-day mortality than did modified full enteral nutrition (35 [34%] of 104 patients vs 18 [17%] of 105 patients, adjusted OR 2·89, 95% CI 1·46-5·72; p=0·0023), whereas the difference was not significant between hypocaloric enteral nutrition and full enteral nutrition (24 [23%] of 106 patients; adjusted OR 1·92, 95% CI 1·00-3·69; p=0·049), and between modified full enteral nutrition and full enteral nutrition (adjusted OR 0·61, 0·29-1·28; p=0·187). The most common adverse event was pneumonia, the incidence of which showed no significant difference among groups (full enteral nutrition 82 [78%] of 105 patients, modified full enteral nutrition 83 [81%] of 103 patients, hypocaloric enteral nutrition 78 [75%] of 104 patients; p=0·625). In the early phase of severe stroke, modified full enteral nutrition or hypocaloric enteral nutrition did not significantly reduce the risk of a poor outcomes compared with full enteral nutrition over a 90-day period. Hypocaloric enteral nutrition might be associated with increased mortality compared with modified full enteral nutrition. Further studies are needed to investigate whether modified full enteral nutrition might be the optimal strategy. Shaanxi province Key Research and Development Project.

Sex-specific lesion pattern of functional outcomes after stroke.

Stroke represents a considerable burden of disease for both men and women. However, a growing body of literature suggests clinically relevant sex differences in the underlying causes, presentations and outcomes of acute ischaemic stroke. In a recent study, we reported sex divergences in lesion topographies: specific to women, acute stroke severity was linked to lesions in the left-hemispheric posterior circulation. We here determined whether these sex-specific brain manifestations also affect long-term outcomes. We relied on 822 acute ischaemic patients [age: 64.7 (15.0) years, 39% women] originating from the multi-centre MRI-GENIE study to model unfavourable outcomes (modified Rankin Scale >2) based on acute neuroimaging data in a Bayesian hierarchical framework. Lesions encompassing bilateral subcortical nuclei and left-lateralized regions in proximity to the insula explained outcomes across men and women (area under the curve = 0.81). A pattern of left-hemispheric posterior circulation brain regions, combining left hippocampus, precuneus, fusiform and lingual gyrus, occipital pole and latero-occipital cortex, showed a substantially higher relevance in explaining functional outcomes in women compared to men [mean difference of Bayesian posterior distributions (men – women) = −0.295 (90% highest posterior density interval = −0.556 to −0.068)]. Once validated in prospective studies, our findings may motivate a sex-specific approach to clinical stroke management and hold the promise of enhancing outcomes on a population level.

Plasma glutathione as a risk marker for the severity and functional outcome of acute atherothrombotic and cardioembolic stroke

ObjectiveGlutathione (GSH) is a major intracellular thiol-containing antioxidant. We tried to determine whether blood plasma GSH level is a marker for the severity of the two subtypes of acute stroke (large-artery atherosclerosis, LA and cardioembolic, CE). Forty-three patients with LA and 36 patients with CE aged 65 (47–82) years were included in the study. Thirty-one patients with cerebral microangiopathy were included for comparison. Total (t) and reduced (r) GSH levels were determined at admission. Neurological deficit was assessed by the National Institutes of Health Stroke Scale (NIHSS) on the first day, functional outcome and independence were assessed by the modified Rankin scale (mRs) and Bartel index (BI), respectively, after 21 days.ResultsThe tGSH and rGSH levels in acute stroke were significantly lower than cerebral microangiopathy patients. Low tGSH (≤ 1.45 μM) and rGSH (≤ 30 nM) levels were risk markers for stroke severity at admission (NIHSS > 10) in patients with LA: age and gender adjusted odds ratio (AOR) was 4.95, 95% coincidence interval (CI) 1.31–18.7, AOR = 9.141, CI 1.84–45.3 for t- and rGSH, respectively. A low level of rGSH (≤ 30 nM) was found as risk marker for functional independence (BI ≤ 60: AOR = 15.9, CI 2.22–114.2) in patients with LA. Low tGSH level (≤ 1.1 μM) was associated with the reduction of poor outcome risk (mRs > 2: AOR = 0.154, CI 0.029–0.809) in CE group.ConclusionsLow t- and rGSH levels may be considered potential risk markers for severity and insufficient functional independence in LA. Conversely, low tGSH level reduce the risk of poor stroke outcome only for CE.

Abstract 26: Timing The Optimal Transfer Modality For Suspected Large-vessel Stroke Patients: A Post-hoc Analysis Of The Racecat Trial

Introduction: Current recommendations for regional stroke destination suggest that patients with an acute severe stroke should be triaged based on estimated time to arrival to a thrombectomy-capable center. We aimed to evaluate which time period available at the time that patient is triaged is able to discriminate which transfer modality should be chosen. Methods: We built and ordered logistic regression model adjusted for multiple comparisons with the RACECAT trial population using time periods available during triage: time from onset to emergency medical services (EMS) evaluation, estimated time of arrival to the thrombectomy-capable center and between centers distance. Estimated times were computed using a distance matrix API. Primary outcome was disability at 90 days, as assessed by the shift analysis on the modified Rankin score. Results: Of the 1369 patients evaluated, median time from onset to EMS evaluation, estimated time to arrival to the thrombectomy-capable center and between centers distances were 65 minutes (interquartile ratio (IQR) 43 to 138), 61 minutes (IQR 36 to 80) and 62 minutes (IQR 36 to 73), respectively. In patients transferred to local stroke centers, delay in EMS evaluation was associated with higher degrees of disability (for each 30 minutes delay, adjusted common odds ratio (acOR) 1.035, 97.5% confidence interval (CI) 1.005 to 1.066), with no influence in patients directly transferred to thrombectomy-capable centers (for each 30 minutes delay, acOR 0.999, 97.5% CI 0.981 to 1.018) (p interaction =0.048). In patients evaluated by EMS above 120 minutes after stroke onset, direct transfer to a thrombectomy-capable center was associated with lower degrees of disability (acOR 1.494, 95% CI 1.026 to 2.174). Conclusion: In the RACECAT trial, delay in EMS evaluation was associated with higher degrees of disability in patients transferred to local stroke centers and may serve as a potential biomarker for prehospital triage optimization.

Association of Infarct Topography and Outcome After Endovascular Thrombectomy in Patients With Acute Ischemic Stroke.

The care of patients with large vessel occlusion (LVO) stroke has been revolutionized by endovascular thrombectomy (EVT). While EVT has a large effect size, most patients treated with EVT remain disabled or die within 90 days. A better understanding of outcomes may influence EVT selection criteria, novel therapies, and prognostication. We sought to identify associations between outcomes and brain regions involved in ischemic lesions. For this cohort study, consecutive patients with LVO who were treated with EVT and underwent post-EVT MRI were identified from a tertiary referral center (2011-2019). Acute ischemic lesions were manually segmented from diffusion-weighted imaging and spatially normalized. Individual lesions were parcellated (atlas-defined 94 cortical regions, 14 subcortical nuclei, 20 white matter tracts) and reduced to 10 essential lesion patterns with the use of unsupervised dimensionality reduction techniques. Ninety-day modified Rankin Scale (mRS) score (>2) was modeled via bayesian regression, taking the 10 lesion patterns as inputs and controlling for lesion size, age, sex, acute NIH Stroke Scale (NIHSS) score, alteplase, prior stroke, intracerebral hemorrhage, and good reperfusion (Thrombolysis in Cerebral Infarction 2b-3). In comparative analyses, 90-day mRS score was modeled considering covariates only, and compartment-wise relevances for acute stroke severity and 90-day mRS score were evaluated. There were 151 patients with LVO identified (age 68 ± 15 years, 52% female). The median NIHSS score was 16 (interquartile range 13-20); 56% had mRS score >2. Lesion locations predictive of 90-day mRS score involved bilateral but left hemispherically more pronounced precentral and postcentral gyri, insular and opercular cortex, and left putamen and caudate (area under the curve 0.91, highest probability density interval [HPDI] covering 90% certainty 0.90-0.92). The lesion location model outperformed the simpler model relying on covariates only (bayesian model comparison of 97% weight to the model with vs 3% weight to the model without lesion location). While lesions affecting subcortical nuclei had the highest relevance for stroke severity (posterior distribution mean 0.75, 90% HPDI 0.256-1.31), lesions affecting white matter tracts had the highest relevance for 90-day mRS score (0.656, 90% HPDI 0.0864-1.12). These data describe the significance for outcomes of specific brain regions involved in ischemic lesions on MRI after EVT. Future work in additional datasets is needed to confirm these granular findings.

Design and validation of a new scale for prehospital evaluation of stroke and large vessel occlusion.

Background:Rapid recognition of acute stroke and large vessel occlusion (LVO) is essential in prehospital triage for timely reperfusion treatment.Objective:This study aimed to develop and validate a new screening tool for both stroke and LVO in an urban Chinese population.Methods:This study included patients with suspected stroke who were transferred to our hospital by emergency medical services between July 2017 and June 2021. The population was randomly partitioned into training (70%) and validation (30%) groups. The Staring-Hypertension-atrIal fibrillation-sPeech-weakneSs (SHIPS) scale, consisting of both clinical and medical history information, was generated based on multivariate logistic models. The predictive ability of the SHIPS scale was evaluated and compared with other scales using receiver operating characteristic (ROC) curve comparison analysis.Results:A total of 400 patients were included in this analysis. In the training group (n = 280), the SHIPS scale showed a sensitivity of 90.4% and specificity of 60.8% in predicting stroke and a sensitivity of 75% and specificity of 61.5% in predicting LVO. In the validation group (n = 120), the SHIPS scale was not inferior to Stroke 1-2-0 (p = 0.301) in predicting stroke and was significantly better than the Cincinnati Stroke Triage Assessment Tool (C-STAT; formerly CPSSS) and the Prehospital Acute Stroke Severity scale (PASS) (all p < 0.05) in predicting LVO. In addition, including medical history in the scale was significantly better than using symptoms alone in detecting stroke (training group, 0.853 versus 0.818; validation group, 0.814 versus 0.764) and LVO (training group, 0.748 versus 0.722; validation group, 0.825 versus 0.778).Conclusion:The SHIPS scale may serve as a superior screening tool for stroke and LVO identification in prehospital triage. Including medical history in the SHIPS scale improves the predictive value compared with clinical symptoms alone.

Muscle loss after acute severe dysphagic stroke initial results of the muscle assessment in stroke study in Turkey-mass-TR

Rationale: The clinical spectrum, causes and prognostic significance of in-hospital skeletal muscle mass loss in patients with acute ischemic stroke have not been sufficiently elucidated.