Severity Of Acute Ischemic Stroke Research Articles

Vitamin D as a Predictor of Severity and Prognosis of Acute Ischemic Stroke

Vitamin D as a Predictor of Severity and Prognosis of Acute Ischemic Stroke

Comparison of Prognostic Scores for Upper Gastrointestinal Bleeding in the Hepato-Gastro-Enterology Department

Objectives: The goal of this study is to assess the relative value of individual UGIB prognostic scores in predicting patient outcomes. Patients and Methods: This study was a descriptive cross-sectional analysis of data collected before. Included were patients admitted to the Al Tibri Medical college and hospital Malir Karachi Center and Fauji foundation Rawalpindi with upper GI bleeding and treated in the Gastroenterology Division. Analyses in this study compared the predictive power of five different prognostic scores (the Glasgow Coma Scale, modified Glasgow Coma Scale, coagulation risk score, and acute ischemic stroke severity score; together, these scores are known as GBS, mGBS, FRS, CRS, and AIMS65) for the occurrence of death and rebleeding within 42 days. ROC (Receiver Operating Characteristic) curves were used to compare the various scores. Results: A total of 314 individuals were enrolled in the study, with a male-to-female sex ratio of 2.48. In 70.94% of cases, fibroscopy revealed UGIB due to portal hypertension unrelated to peptic ulcer disease. The "FRS" score was the most reliable predictor of mortality or rebleeding for all patients. Compared to other scores, the "FRS" provided the best reliable forecast of whether or not patients would have spots. The "FRS" score was the most reliable one for predicting mortality. Patients deemed to be at low risk (below the threshold value) had a mortality rate of 2.2% according to the "FRS," 9.3% according to the "CRS," 0% according to the "GBS" (p = 0.565), 50% according to the "mGBS," and 11.42% according to the "AIMS65." The predictive value of UGIB scores was higher for incidental portal hypertension. Conclusion: Upper gastrointestinal hemorrhage cases can be accurately predicted using the "FRS" and "CRS" scores. But in the setting of portal hypertension, these scores did badly. UGIB Keywords: Prognostic Scores, Upper Gastrointestinal Bleeding, Rockall, Glasgow-Blatchford

Correlation of Sodium and Serum Albumin Levels with the Severity of Acute Ischemic Stroke

Management of acute ischemic stroke patients based on their severity in emergency services is critical. One of the easy, fast, and affordable biochemical markers is serum sodium and albumin, which correlate with the severity of acute ischemic stroke. This research aimed to analyze the correlation of serum sodium and albumin levels with the severity of acute ischemic stroke. This retrospective study used medical record data of 165 acute ischemic stroke patients for the period January 2018-April 2021 at Dr. Wahidin Sudirohusodo Hospital, Makassar. Patients were classified according to the degree of mild, moderate, or severe stroke through the NIHSS score. Examination of serum sodium was done by Electrolyte Analyzer NOVA 5 and albumin with ABX Pentra 400. Data normality test Kolmogorov-Smirnov. The statistical test used the Kruskal-Wallis, Mann-Whitney, and Spearman (significant if p<0.05). There was a negative correlation between serum albumin levels and the severity of stroke patients (p<0.001; r= -0.327). There was no significant association between serum sodium and ischemic stroke severity. There was a statistically significant difference in serum albumin levels in patients with mild and moderate stroke (p=0.001), mild and severe (p=0.001). Albumin correlates the outcome of acute ischemic stroke patients (p<0.001), cut-off ≤ 3.25 g/dL (sensitivity 66.7%, specificity 50%). Hypoalbuminemia exacerbates cytotoxic edema by causing water and ions to cross the blood-brain barrier to the astrocytes resulting in further neuron damage. Albumin has a correlation with the NIHSS score (p<0.001; r= -0.327). The lower the albumin level, the higher the NIHSS score, indicating the ischemic stroke severity.

Analysis of severity in ischemic stroke patients with coronary artery disease in the telestroke network.

Aim: This study investigated demographic and clinical risk factors associated with severity in acute ischemic stroke (AIS) patients with a history of coronary artery disease (CAD). Materials & methods: Multivariate logistic regression models were used to determine specific factors associated with worsening or improving neurologic functions among AIS patients with CAD treated in the telestroke. Results: AIS patients with CAD, peripheral vascular disease (OR: 3.995;95% CI: 1.035-15.413;p=0.044) and hypertension (OR: 6.056;95% CI: 1.207-30.374;p=0.029) were associated with worsening neurologic functions. Conclusion: Our findings suggest the need to develop strategic management to improve the care of AIS patients with a history of CAD that present with hypertension and peripheral vascular disease in the telestroke network.

High systemic immune-inflammation index is associated with carotid plaque vulnerability: New findings based on carotid ultrasound imaging in patients with acute ischemic stroke.

Vulnerable carotid plaque is closely related to the occurrence of Ischemic stroke. Therefore, accurate and rapid identification of the nature of carotid plaques is essential. AS is a chronic immune inflammatory process. Systemic immune-inflammation index (SII) is a novel index of immune inflammation obtained from routine whole blood cell count analysis, which comprehensively reflects the state of inflammation and immune balance in the body. This study sought to explore the relationship between SII level and carotid plaque vulnerability, plaque composition characteristics, and acute ischemic stroke (AIS) severity. A total of 131 patients diagnosed with AIS presenting with a carotid atherosclerotic plaque were enrolled in this study. Using carotid ultrasound (CDU) to assess the carotid-responsible plaque properties, we divided the patients into stable plaques group and vulnerable plaques group, and analyzed the correlation between SII levels and plaque vulnerability. And we further analyzed to evaluate the correlation between high SII levels and plaque characteristics and AIS severity. In addition, Cohen's Kappa statistics was used to detect the consistency of Carotid ultrasound (US) and cervical High-resolution magnetic resonance imaging (HRMRI) in evaluating plaque vulnerability. The findings showed that the vulnerable group had higher levels of SII compared with the stable group. The high SII group had more vulnerable plaques and a high frequency of plaque fibrous cap rupture compared with the low SII group. Logistic analysis showed that a high SII level was an independent risk factor for vulnerable plaques (odds ratio [OR] = 2.242) and plaque fibrous cap rupture (OR=3.462). The results also showed a high consistency between Carotid US and HRMRI methods in the assessment of plaque vulnerability [Cohen's kappa value was 0.89 (95% CI = 0.78–0.97)] and the level of SII was positively associated with NIHSS score (r = 0.473, P < 0.001). Our study suggests that elevated levels of SII may have adverse effects on the vulnerability of carotid plaques, especially in stroke patients with vulnerable plaques with ruptured fibrous caps, which may aggravate the severity of AIS.

The outcomes of mechanical thrombectomy in patients with acute stroke with and without intravenous injection of tissue plasminogen activator

Background: Stroke is a major health problem and leading cause of mortality worldwide. This study aimed to evaluate the consequences of intravascular interventions in patients with acute ischemic stroke with and without intravenous tissue plasminogen activator (tPA) injection. Methods: This prospective cohort study was conducted on 120 patients with acute ischemic stroke. Patients were divided into three groups based on the type of disease treatment: angiography, tPA, and combined therapy (angiography + tPA). Patients in the tPA group were treated with a standard dose of intravenous alteplase (0.9 mg/kg). The severity of acute ischemic stroke was calculated on days 0, 14, and 90 after the interventions using the National Institutes of Health Stroke Scale (NIHSS) and Modified Rankin Scale (mRS) questionnaires. Results: All three groups were homogeneous regarding age, gender, location, job status, education, and body mass index (BMI) distribution. Coronary disease was the most common risk factor for stroke in 38.33% of patients. There was no significant difference in mean NIHSS and mRS scores between the groups on days 0, 14, and 90 after intervention (p &gt; 0.05). Mean NIHSS and mRS scores significantly decreased from the first time point (day 0), 10 days until 90 days after treatment in all three groups (p &lt; 0.001); however, there was no significant difference in treatment effect between the three groups at these time points (p &gt; 0.05). Conclusion: Treatment with angiography and tPA alone or with combined therapy significantly decreased the severity of acute ischemic stroke. A significant decrease was observed in the mean NIHSS and mRS scores in all therapy groups, indicating that these treatments were effective in mitigating acute ischemic stroke and improving functional independence in these patients. The eligibility criteria by which patients with acute ischemic stroke are selected for each specific therapy are essential to achieving better clinical outcomes.

Hepatic Fibrosis Is a Risk Factor for Greater Severity and Worse Outcome of Acute Ischemic Stroke.

Background: Nonalcoholic fatty liver disease, particularly in the presence of hepatic fibrosis, is associated with an increased risk of cardiovascular events, including ischemic stroke. However, it is unclear whether hepatic fibrosis is associated with the severity and outcome of acute ischemic stroke. Aim: To evaluate the relationship between hepatic fibrosis and the severity at admission and in-hospital outcome of acute ischemic stroke. Patients and methods: We prospectively studied all patients who were admitted to our department with acute ischemic stroke between September 2010 and February 2018 (n = 1107; 42.1% males, age 79.8 ± 7.2 years). The severity of stroke was assessed at admission with the National Institutes of Health Stroke Scale (NIHSS). Severe stroke was defined as NIHSS ≥ 21. The presence of hepatic fibrosis was evaluated with the Fibrosis-4 index (FIB-4). The outcome was assessed with dependency at discharge (modified Rankin Scale between 2 and 5) and with in-hospital mortality. Results: Patients with severe stroke had a higher FIB-4 index than patients with non-severe stroke (2.7 ± 1.7 and 2.3 ± 1.4, respectively; p < 0.05). Independent risk factors for severe IS were age (relative risk (RR) 1.064, 95% confidence interval (CI) 1.030–1.100, p < 0.001), female sex (RR 1.723, 95% CI 1.100–2.698, p = 0.012), atrial fibrillation (RR 1.869, 95% CI 1.234–2.831, p = 0.002), diastolic blood pressure (DBP) (RR 1.019, 95% CI 1.006–1.033, p = 0.001), and the FIB-4 index (RR 1.130, 95% CI 1.007–1.268, p = 0.022). At discharge, 64.2% of patients were dependent. The FIB-4 index did not differ between patients who were dependent and those who were independent at the time of discharge (2.3 ± 1.5 and 2.1 ± 1.2, respectively; p = 0.061). During hospitalization, 9.8% of patients died. Patients who died during hospitalization had a higher FIB-4 index than those who were discharged (2.9 ± 1.8 and 2.3 ± 1.4, respectively; p < 0.005). Independent risk factors for in-hospital mortality were DBP (RR 1.022, 95% CI 1.010–1.034, p < 0.001), serum glucose levels (RR 1.004, 95% CI 1.001–1.007, p = 0.007), serum triglyceride levels (RR 0.993, 95% CI 0.987–0.999, p = 0.023), NIHSS (RR 1.120, 95% CI 1.092–1.149, p < 0.001), and the FIB-4 index (RR 1.169, 95% CI 1.060–1.289, p = 0.002). Conclusions: Hepatic fibrosis, evaluated with the FIB-4 index, appears to be associated with more severe ischemic stroke and might also represent an independent risk factor for in-hospital mortality in patients admitted with acute ischemic stroke.

Deep Learning-Based Automatic Detection of ASPECTS in Acute Ischemic Stroke: Improving Stroke Assessment on CT Scans

(1) Background: The Alberta Stroke Program Early CT Score (ASPECTS) is a standardized scoring tool used to evaluate the severity of acute ischemic stroke (AIS) on non-contrast CT (NCCT). Our aim in this study was to automate ASPECTS. (2) Methods: We utilized a total of 258 patient images with suspected AIS symptoms. Expert ASPECTS readings on NCCT were used as ground truths. A deep learning-based automatic detection (DLAD) algorithm was developed for automated ASPECTS scoring based on 168 training patient images using a convolutional neural network (CNN) architecture. An additional 90 testing patient images were used to evaluate the performance of the DLAD algorithm, which was then compared with ASPECTS readings on NCCT as performed by physicians. (3) Results: The sensitivity, specificity, and accuracy of DLAD for the prediction of ASPECTS were 65%, 82%, and 80%, respectively. These results demonstrate that the DLAD algorithm was not inferior to radiologist-read ASPECTS on NCCT. With the assistance of DLAD, the individual sensitivity of the ER physician, neurologist, and radiologist improved. (4) Conclusion: The proposed DLAD algorithm exhibits a reasonable ability for ASPECTS scoring on NCCT images in patients presenting with AIS symptoms. The DLAD algorithm could be a valuable tool to improve and accelerate the decision-making process of front-line physicians.

Carotid artery type of Eagle syndrome: an uncommon cause of ischemic stroke.

Acute ischemic stroke in patients younger than the age of 50 years is a rare occurrence that results in high mortality and substantial loss of functional years of life. Internal carotid artery dissection (CAD) presents a rare, but serious condition that needs to be fully evaluated and carefully treated, as it may lead to an acute ischemic stroke in all, but mostly in younger patients. A possible cause for CAD, the carotid artery type of Eagle syndrome (ESy), is atypical and underrecognized. In this case report we present a case of a young patient with carotid artery type of ESy, resulting in a severe acute ischemic stroke. Only recognition of such a syndrome in its early symptomatic phase could allow appropriate management to prevent this kind of a deleterious outcome.

The triglyceride/glucose index is associated with more severe acute ischemic stroke

Background and Aims : The triglyceride/glucose index (TyG) is a marker of insulin resistance and is associated with increased cardiovascular risk. We aimed to evaluate whether TyG also predicts the severity of acute ischemic stroke.

Long Noncoding RNA NEAT1 Expression and Its Target miR-124 in Diabetic Ischemic Stroke Patients.

Background: Diabetes mellitus is a known risk factor for stroke and may be linked to poorer post-stroke outcomes. However, the underlying molecular mechanisms remain to be fully identified. In this study we assessed the association of the lncRNA Nuclear enriched abundant transcript 1 (NEAT1)'s expression and its target miRNA-124 with acute ischemic stroke (AIS) in type II diabetic patients (T2DM). Methods and Results: Diabetic patients with stroke, non-diabetics with stroke, diabetics without stroke, and controls were recruited. NEAT1 and miR-124 expression levels in plasma samples from the participants were investigated using real-time reverse transcription-polymerase chain reaction (RT-qPCR). C reactive protein (CRP) and tumor necrosis factor alpha (TNF-α) were measured using an enzyme linked immunosorbent assay (ELISA) technique. In the DM+AIS group, NEAT1 expression was considerably higher, compared with AIS group and with control group. In comparison to the AIS-only patients, DM patients and controls, miR-124 expression was considerably lower in the DM+AIS group. NEAT1 was shown to have good predictive value for AIS risk in diabetics, based on Receiver Operating Characteristic (ROC) curve analysis. In both the DM+AIS and the AIS group, NEAT1 levels was strongly linked with the National Institutes of Health Stroke Scale (NIHSS) score. Also, a significant positive correlation was observed between NEAT1 expression and the inflammatory markers CRP and TNF-α and significant negative association with miRNA-124 in patient groups. Conclusion: In diabetic patients, the lncRNA NEAT1 may influence the incidence, severity, inflammation, and prognosis of AIS. NEAT1 expression levels could be used as a diagnostic marker of stroke in diabetic patients.

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.

Efficacy of Cerebrolysin Treatment as an Add-On Therapy to Mechanical Thrombectomy in Patients With Acute Ischemic Stroke Due to Large Vessel Occlusion: Study Protocol for a Prospective, Open Label, Single-Center Study With 12 Months of Follow-Up.

This study is designed to determine the efficacy of Cerebrolysin treatment as an add-on therapy to mechanical thrombectomy (MT) in reducing global disability in subjects with acute ischemic stroke (AIS). We have planned a single center, prospective, open-label, single-arm study with a 12-month follow-up of 50 patients with moderate to severe AIS, with a small established infarct core and with good collateral circulation who achieve significant reperfusion following MT and who receive additional Cerebrolysin within 8 h of stroke onset compared to 50 historical controls treated with MT alone, matched for age, clinical severity, occlusion location, baseline perfusion lesion volume, onset to reperfusion time, and use of iv thrombolytic therapy. The primary outcome measure will be the overall proportion of subjects receiving Cerebrolysin compared to the control group experiencing a favorable functional outcome (by modified Rankin Scale 0–2) at 90 days, following stroke onset. The secondary objectives are to determine the efficacy of Cerebrolysin as compared to the control group in reducing the risk of symptomatic secondary hemorrhagic transformation, improving neurological outcomes (NIHSS 0–2 at day 7, day 30, and 90), reducing mortality rates (over the 90-day and 12 months study period), and improving: activities of daily living (by Barthel Index), health-related quality of life (EQ-5D-5L) assessed at day 30, 90, and at 12 months. The other measures of efficacy in the Cerebrolysin group will include: assessment of final stroke volume and penumbral salvage (measured by CT/CTP at 30 days) and its change compared to baseline volume, changes over time in language function (by the 15-item Boston Naming Test), hemispatial neglect (by line bisection test), global cognitive function (by The Montreal Cognitive Assessment), and depression (by Hamilton Depression Rating Scale) between day 30 and day 90 assessments). The patients will receive 30 ml of Cerebrolysin within 8 h of AIS stroke onset and continue treatment once daily until day 21 (first cycle) and they will receive a second cycle of treatment (30 ml/d for 21 days given in the Outpatient Department or Neurorehabilitation Clinic) from day 69 to 90.

Acute ischemic strokes in patients with developmental disabilities: A cross-sectional analysis.

Patients with developmental disabilities (DD) are frequently excluded from acute ischemic stroke (AIS) randomized control trials. We sought to evaluate the impact of having DD on this patient cohort. The National Inpatient Sample was analyzed to explore the impact of AIS and treatment on discharge dispositions in patients with DD. Clinical characteristics, treatments, and outcomes were compared to fully-abled patients with AIS. 1,605,723 patients with AIS were identified from 2010-2019, of whom 4094 (0.30%) had a DD. AIS patients with DD were younger (60.31 vs 70.93 years, p < 0.01), less likely to be Caucasian (66.37%vs 68.09%, p = 0.01), and had higher AIS severity (0.63 vs 0.58, p < 0.01). Tissue plasminogen activator (tPA) was administered in 99,739 (6.2%) fully-abled patients and 196 (4.79%) of patients with DD (p < 0.01). Endovascular thrombectomy (EVT) was performed in 21,066 (1.31%) of fully-abled patients and 35 (0.85%) of patients with DD (p < 0.01). The presence of developmental disabilities were predictive of lower rates of tPA (OR:0.71,CI:0.56-0.87,p < 0.01) and EVT (OR:0.24,CI:0.16-0.36,p < 0.01). In a propensity score-matched cohort of all AIS patients who underwent EVT, there was no difference in functional outcome (p = 0.41), in-hospital mortality (0.10), and LOS (p = 0.79). AIS patients with DD were less likely to receive tPA and EVT compared to fully-abled patients. Individuals with DD had higher mortality and worse discharge disposition. There was no significant difference in post-EVT outcomes between fully-abled patients and patients with developmental disabilities. In the absence of prospective clinical trials, population based cross-sectional analyses such as the present study provide valuable clinical insight.

Determinants of Prolonged Length of Hospital Stay in Patients with Severe Acute Ischemic Stroke.

Objective: Long hospitalizations are associated with a high comorbidity and considerable hospital cost. Admissions of severe acute ischemic stroke are prone to longer hospitalizations. We aimed to explore the issue and method for improving the length of stay. Methods: From the prospective Stroke Registry between January 2019 and June 2020, acute ischemic strokes with an admission National Institutes of Health Stroke Scale ≥ 15 were identified. Prolonged length-of-stay was defined as in-hospital-stay ≥ 30 days. All clinical characteristics were collected, and all do-not-resuscitate documentations were categorized if the order had been written within 7 days of onset. Results: A total of 212 patients were eligible for severe stroke. Of these, 42 (19.8%) had prolonged length-of-stay and 170 had non-prolonged length-of-stay (median 43 vs. 13 days). The prolonged group was younger, mostly men, and was more likely to be in an independent state and more likely to receive reperfusion therapy, and there was a higher frequency of late do-not-resuscitate orders if signed. Although there was a lower in-hospital mortality rate in the prolonged group (12% vs. 23%), there was a higher proportion with a severe functional state (Modified Rankin Scale = 4–5) among the survivors (97% vs. 87%). Conclusions: Severe acute ischemic stroke patients with a prolonged length-of-stay were younger, mostly male, more likely to receive reperfusion therapy, less likely to have an early do-not-resuscitate order if signed, and more likely to have poor functional status at discharge, although there was a lower rate of in-hospital mortality.

Platelets-Derived miR-200a-3p Modulate the Expression of ET-1 and VEGFA in Endothelial Cells by Targeting MAPK14.

The interaction between platelets and vascular endothelial cells plays a pivotal role in the pathophysiology of acute ischemic stroke (AIS), especially in atherosclerosis formation. However, the underlying mechanism is not entirely clear. The aim of this study was to elucidate the role of platelets-derived miRNA in the development of atherosclerosis and AIS. We evaluated the miRNA expression profiles of serum microvesicles (MV) in five AIS patients and five healthy controls using RNA-seq, and then measured the levels of selected platelets derived miRNAs by qRT-PCR. miR-200a-3p expression in the serum MV and platelets had increased to 1.41 (p < 0.05) and 3.29 times (p < 0.001), respectively, in AIS patients compared with healthy controls, and was modified by severity of AIS. We transferred Cy5-miR-200a-3p into platelets, collected and identified platelets-derived MV (PMVs). Then, the gene expression of p38 MAPK/c-Jun pathway was analyzed using both miR-200a-3p gain- and loss-of-function experiments and PMVs coincubation with HUVEC. The results showed that activated platelets remotely modulated endothelins 1 (ET-1) and vascular endothelial growth factor A (VEGFA) levels in HUVEC through the release of miR-200a-3p-containing PMVs via targeting MAPK14. The results of ROC analyses showed that combination of platelet miR-200a-3p, serum ET-1 and VEGFA levels had an AUC of 0.817, a sensitivity of 70%, and a specificity of 89%. Our results presented new evidence that activated platelets could remotely modulate ET-1 and VEGFA expression in HUVEC via releasing miR-200a-3p-enriched PMVs, which provides a potential miRNA-based predictive biomarker and therapeutic strategy for atherosclerosis and AIS.

SERUM URIC ACID LEVELS ARE NOT ASSOCIATED WITH THE SEVERITY OF ACUTE ISCHEMIC STROKE

Objective: Previous studies reported discrepant results regarding the association between serum uric acid levels and the severity of acute ischemic stroke. We aimed to evaluate this association. Design and method: We prospectively studied 1,107 consecutive patients who were admitted for acute ischemic stroke (42.1% males, age 79.8 ± 7.2 years). Stroke severity was evaluated at admission with the National Institutes of Health Stroke Scale (NIHSS) and severe stroke was defined as NIHSS &gt; = 21. Serum uric acid levels were measured at the second day after admission in the fasting state. Results: Serum uric acid levels did not correlated with the NIHSS (r = 0.018, p = NS) and did not differ between patients with severe stroke and those with non-severe stroke (5.9 ± 2.2 and 5.7 ± 1.8 mg/dl, respectively; p = NS). In binary logistic regression analysis, independent predictors of severe stroke were age (relative risk (RR) 1.079, 95% confidence interval (CI) 1.042–1.117, p &lt; 0.001), female gender (RR 1.841, 95% CI 1.138–2.980, p &lt; 0.05), atrial fibrillation (RR 1.678, 95% CI 1.076–2.618, p &lt; 0.05) and diastolic blood pressure at admission (RR 1.020, 95% CI 1.005–1.035, p &lt; 0.01). Conclusions: Serum uric acid levels do not appear to be associated with the severity of acute ischemic stroke.

Effect of Early vs Standard Approach to Tracheostomy on Functional Outcome at 6 Months Among Patients With Severe Stroke Receiving Mechanical Ventilation

ImportanceMany patients with severe stroke have impaired airway protective reflexes, resulting in prolonged invasive mechanical ventilation.ObjectiveTo test whether early vs standard tracheostomy improved functional outcome among patients with stroke receiving mechanical ventilation.Design, Setting, and ParticipantsIn this randomized clinical trial, 382 patients with severe acute ischemic or hemorrhagic stroke receiving invasive ventilation were randomly assigned (1:1) to early tracheostomy (≤5 days of intubation) or ongoing ventilator weaning with standard tracheostomy if needed from day 10. Patients were randomized between July 28, 2015, and January 24, 2020, at 26 US and German neurocritical care centers. The final date of follow-up was August 9, 2020.InterventionsPatients were assigned to an early tracheostomy strategy (n = 188) or to a standard tracheostomy (control group) strategy (n = 194).Main Outcomes and MeasuresThe primary outcome was functional outcome at 6 months, based on the modified Rankin Scale score (range, 0 [best] to 6 [worst]) dichotomized to a score of 0 (no disability) to 4 (moderately severe disability) vs 5 (severe disability) or 6 (death).ResultsAmong 382 patients randomized (median age, 59 years; 49.8% women), 366 (95.8%) completed the trial with available follow-up data on the primary outcome (177 patients [94.1%] in the early group; 189 patients [97.4%] in the standard group). A tracheostomy (predominantly percutaneously) was performed in 95.2% of the early tracheostomy group in a median of 4 days after intubation (IQR, 3-4 days) and in 67% of the control group in a median of 11 days after intubation (IQR, 10-12 days). The proportion without severe disability (modified Rankin Scale score, 0-4) at 6 months was not significantly different in the early tracheostomy vs the control group (43.5% vs 47.1%; difference, −3.6% [95% CI, −14.3% to 7.2%]; adjusted odds ratio, 0.93 [95% CI, 0.60-1.42]; P = .73). Of the serious adverse events, 5.0% (6 of 121 reported events) in the early tracheostomy group vs 3.4% (4 of 118 reported events) were related to tracheostomy.Conclusions and RelevanceAmong patients with severe stroke receiving mechanical ventilation, a strategy of early tracheostomy, compared with a standard approach to tracheostomy, did not significantly improve the rate of survival without severe disability at 6 months. However, the wide confidence intervals around the effect estimate may include a clinically important difference, so a clinically relevant benefit or harm from a strategy of early tracheostomy cannot be excluded.Trial RegistrationClinicalTrials.gov Identifier: NCT02377167

SERUM FERRITIN AS PROGNOSTIC MARKER IN ACUTE ISCHEMIC STROKE-AN OBSERVATIONAL STUDY

Background: Stroke is dened as "rapidly developing clinical evidence of focal (or global) impairment of brain function, with symptoms lasting 24 hours or more or leading to death, with no evident cause other than vascular origin," according to the World Health Organization. Many studies have suggested that serum ferritin may have a role in predicting iron-mediated free radical harm in the etiology of cerebrovascular disorders. A high serum ferritin level upon admission was linked to a poor prognosis in acute stroke patients (within 24-48 hours after start). The primary goal of this study is to evaluate the role of serum ferritin in patients with acute ischemic stroke. Settings and Design: It is observational study carried out in 50 cases with ischemic stroke. Severity of stroke was determined using CSS score. Laboratory investigations were done to estimate serum ferritin. Results: We found that the mean serum ferritin levels were signicantly increased among “more severe stroke” and deteriorated stroke patients than compared to “less severe stroke” and not-deteriorated stroke patients (p&lt;0.05). We found signicant negative correlation with spearman's rho of -0.7 between serum ferritin and CSS score. Conclusions:Serum ferritin plays a major role in predicting the severity and prognostic outcome of acute ischemic stroke.

Impact of COVID‐19 on thrombus composition and response to thrombolysis: Insights from a monocentric cohort population of COVID‐19 patients with acute ischemic stroke

BackgroundResistance to fibrinolysis, levels of procoagulant/antifibrinolytic neutrophil extracellular traps (NETs), and the severity of acute ischemic stroke (AIS) are increased by COVID‐19. Whether NETs are components of AIS thrombi from COVID‐19 patients and whether COVID‐19 impacts the susceptibility of these thrombi to thrombolytic treatments remain unknown, however. ObjectivesWe aimed to characterize AIS thrombi from COVID‐19 patients by immunohistology and to compare their response to thrombolysis to that of AIS thrombi from non‐COVID‐19 patients. Patients/MethodsFor this monocentric cohort study, 14 thrombi from COVID‐19 AIS patients and 16 thrombi from non‐COVID‐19 patients, all recovered by endovascular therapy, were analyzed by immunohistology or subjected to ex vivo thrombolysis by tissue‐type plasminogen (tPA)/plasminogen. ResultsCOVID‐19 AIS thrombi were rich in neutrophils and contained NETs, but not spike protein. Thrombolysis assays revealed a mean resistance profile to tPA/plasminogen of COVID‐19 AIS thrombi similar to that of non‐COVID‐19 AIS thrombi. The addition of DNase 1 successfully improved thrombolysis by potentiating fibrinolysis irrespective of COVID‐19 status. Levels of neutrophil, NETs, and platelet markers in lysis supernatants were comparable between AIS thrombi from non‐COVID‐19 and COVID‐19 patients. ConclusionsThese results show that COVID‐19 does not impact NETs content or worsen fibrinolysis resistance of AIS thrombi, a therapeutic hurdle that could be overcome by DNase 1 even in the context of SARS‐CoV‐2 infection.