Signs Of Stroke Research Articles

Validity of Computed Tomography in Evaluation of Acute Ischaemic Stroke in Comparison to Magnetic Resonance Imaging: A Cross-sectional study

Introduction: Cerebrovascular disease represents a major reason for mortality and morbidity worldwide. Imaging plays a pivotal role in the management of stroke patients. Haemorrhagic stroke diagnosis is straightforward using a Computed Tomography (CT) scan whereas early ischaemic strokes are sometimes difficult to diagnose by imaging. The use of Magnetic Resonance Imaging (MRI) may diagnose ischaemic stroke more convincingly; however MRI remains less available, time consuming and complicated. Unenhanced CT can be performed quickly; can help to identify early signs of stroke. Aim: To determine the validity of CT in the evaluation of acute ischaemic stroke compared to MRI for early diagnosis. Materials and Methods: The study was a cross-sectional study conducted in the Department of Radiodiagnosis, Agartala Government Medical College and GB Pant Hospital, Agartala, Tripura, India. The study period was from December 2018 to December 2020 and included 70 patients. The instruments used were SIEMENS 128 slice CT-SOMATOM model definition AS and SIEMENS 3.0 Tesla MRI-SKYRA model. Statistical Package for Social Sciences (SPSS) for Windows, version 25.0 (SPSS Inc, Chicago, USA) was used for data analysis. Results: Out of all patients (n=70) 63 patients were ultimately found to have infarction. Out of these 63 cases of infarction 69.84%(n=44) were male and 30.16% (n=19) were female. Sensitivity of CT scan was 87.3%, specificity was 71.4%, positive predictive value was 96.4%, negative predictive value was 38.4% and accuracy was 85.7%. The p-value was 0.002. In all patients who presented before six hours (n=15) showed decreased creatinine value during Magnetic Resonance Spectroscopy (MRS) in the lesion area compared to the normal side of brain. None of the patients showed variation in the lactate value. Those presenting after 6 hours (n=48), creatinine was reduced in all the cases (100%), Choline was increased in 89.6%. Conclusion: Sensitivity and specificity of CT scan is lower than MRI. Diffusion-Weighted Imaging (DWI) has 100% sensitivity in diagnosing acute infarction.

Stroke in patients with COVID-19: Clinical and neuroimaging characteristics

Acute cerebrovascular disease, particularly ischemic stroke, has emerged as a serious complication of infection by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the etiologic agent of the Coronavirus disease‐2019 (COVID-19).Accumulating data on patients with COVID-19-associated stroke have shed light on specificities concerning clinical presentation, neuroimaging findings, and outcome.Such specificities include a propensity towards large vessel occlusion, multi-territory stroke, and involvement of otherwise uncommonly affected vessels. Conversely, small-vessel brain disease, cerebral venous thrombosis, and intracerebral hemorrhage appear to be less frequent. Atypical neurovascular presentations were also described, ranging from bilateral carotid artery dissection to posterior reversible encephalopathy syndrome (PRES), and vasculitis. Cases presenting with encephalopathy or encephalitis with seizures heralding stroke were particularly challenging. The pathogenesis and optimal management of ischemic stroke associated with COVID-19 still remain uncertain, but emerging evidence suggest that cytokine storm-triggered coagulopathy and endotheliopathy represent possible targetable mechanisms. Some specific management issues in this population include the difficulty in identifying clinical signs of stroke in critically ill patients in the intensive care unit, as well as the need for a protected pathway for brain imaging, intravenous thrombolysis, and mechanical thrombectomy, keeping in mind that “time is brain” also for COVID-19 patients. In this review, we discuss the novel developments and challenges for the diagnosis and treatment of stroke in patients with COVID-19, and delineate the principles for a rational approach toward precision medicine in this emerging field.

Commentary to: Garbled and Incoherent Text Messages Are a Sign of Acute Ischemic Stroke: A New Sign of Aphasia in the Era of Chat Applications.

Commentary to: Garbled and Incoherent Text Messages Are a Sign of Acute Ischemic Stroke: A New Sign of Aphasia in the Era of Chat Applications.

EVALUATION OF THE FREQUENCY OF DEVELOPMENT OF POSTOPERATIVE CEREBRAL DYSFUNCTION DEPENDING ON THE METHOD OF PROSTHETICS OF THE AORTAL VALVE OF THE HEART

The worldwide trend towards an increase in average life expectancy is associated with an increase in the prevalence of acquired heart defects, which at a certain stage dictates the need for cardiac surgery. We examined 72 patients (52 men and 20 women) who underwent planned aortic valve prosthetics. All patients were divided into two groups depending on the method of implantation of the prosthesis: the first group-aortic valve replacement when performing open surgery using cardiopulmonary bypass, the second group-endovascular prosthetics. The first group included 48 men and 18 women, whose average age was 66 years old; the second group included 4 men and 2 women, whose average age was 73 years. All patients underwent a comprehensive examination in the preoperative and postoperative periods, including an anamnesis assessment, a neurological examination using the NIHSS and Rankin scales, neuropsychological (Montreal Cognitive Assessment and frontal dysfunction battery) and psychometric (Hospital anxiety and depression scale) tests, as well as computed tomography the head in identifying clinical signs of perioperative stroke. Postoperative cerebral dysfunction was diagnosed in 44.4% (n = 32) of patients. The overall incidence of clinical types of postoperative cerebral dysfunction was as follows: perioperative stroke - 2.8% (n = 2), symptomatic delirium of the early postoperative period - 13.9% (n = 10), delayed cognitive impairment - 33.3% (n = 24) There were no acute clinical types of postoperative cerebral dysfunction in the endovascular treatment group. Delayed cognitive impairment in both groups were detected in 33.3% (in the first group n = 22, in the second group n = 2). According to the results of the study, acute clinical types of postoperative cerebral dysfunction were absent in the endovascular treatment group, cognitive impairment was detected in 1/3 of the patients in both groups.

Knowledge, attitude and practice about the risk factors of ischemic stroke and warning symptoms- A case control study

Introduction: Stroke is a neurological defect that could result in death thus the importance of evaluating the existing knowledge, attitude, and practice (KAP) is essential for stroke control. Objective: Our study objective was to assess the knowledge, attitude and perception of risk factors and warning symptoms of ischemic stroke among controls and caregivers attending in a tertiary care hospital. Materials and Methods: A matched (age and sex) case control study was planned to assess the knowledge, attitude and perception of risk factors and warning symptoms of Ischemic stroke among controls and caregivers in a tertiary care centre for a period of one year. The Sample size was calculated for matched case control (1:1 ratio) by n-master software and came out to be 189 pairs. Consecutive sampling method was used to select caregivers and controls. The controls were selected from the same hospital. The association between various risk factor and warning symptoms of ischemic stroke has been investigated. Z-test was implemented to estimate risk factor and warning symptom of Ischemic stroke among caregivers and controls. Results: Our result revealed that most of subjects were aged 40-59 years, males (69.8%), and (77.2%) was literate. The KAP questionnaire was administered to 189 participants each from both groups. Majority (69.84%) among caregiver while only 48.67% in control group knew about the risk factors of stroke. Majority (65.6%) among the caregiver while only 30% in control knew about the warning signs of stroke. Majority of the respondents believed that ischemic stroke is preventable and stroke can occur more than one time and affects daily activity. Conclusions: The level of KAP toward stroke risk factors and warning symptoms was inadequate among the majority of control participants. Though it was observed that good KAP was associated with high education and young age. Keywords: Ischemic stroke, Risk factors, Warning symptoms.

An ecological approach to understanding stroke experience and access to rehabilitation services in Ghana: A cross-sectional study.

Despite a growing burden of stroke in low-middle-income countries, research on patient's experiences and access to rehabilitation services remains limited. This study explores the experiences of stroke patients in relation to access and use of stroke rehabilitation services, coping strategies and strategies to improve care in Ghana. A cross-sectional study was conducted. A total of 136 adult stroke patients hospitalised and subsequently discharged in three major referral hospitals in Ghana participated in the study. A paper-based questionnaire was used to collect data. Data were inputted into STATA version 12, cleaned and analysed using descriptive statistics and Chi-Square tests. Findings showed that stroke patients experience stroke differently. Early detection (awareness) of stroke symptoms at onset was low (29.4%). Hypertension was the major (58.1%) predisposing risk factor for stroke, followed by diabetes (14.7%). Multiple barriers impede access to outpatient rehabilitation services: high cost of medications (43.4%), transportation constraints (10.3%), long waiting time (6.6%), forgetfulness about appointment (4.4%), limited education on rehabilitation (20.6%), lack of community support (12.5%) and ineffective communication with healthcare providers (5.2%). Recommended strategies to improve access to rehabilitation care included public education on stroke and its associated risk, reduction in the cost of drugs and increased stroke rehabilitation funding by the NHIS, especially for physiotherapy consultation and training support to caregivers on patient care. Given the difference in stroke experience and barriers in accessing rehabilitation care, multi-level health policy and service delivery reforms are needed to improve access to rehabilitation care, including national public awareness campaigns on early signs of stroke and subsidised cost of stroke rehabilitation.

Assessment of Nurses ’Performance Regarding Care for Elderly Stroke Patients

Background: Aging is a natural process of accumulation of diverse deleterious change occurring in cells and tissue with advancing age that are responsible for the increased risk of chronic disease as stroke. Aim: To assess nurses’ performance regarding care for elderly stroke patients. Methods: a descriptive research design was performed on a convenient sample consisted of 68 nurses were available at four departments which are male neurological department, female neurological department, neurological care unit, and medical care unit in Beni-Suef University Hospital, Egypt. Tools: Two tools were used to carry out this study. Tool I: Questionnaire sheet which consisted of two parts: Part (1) Nurses Socio-Demographic characteristics, Part (2) Assessment Nurses Knowledge. Tool II Nurses performance Checklist. Results: Study results reveals that, 100 % of studied nurses had correct knowledge regarding items: description of elderly stroke, the most important diagnostic test, healthy lifestyle of elderly stroke patients, and mortality probability from complications. On the other hand (39.7%, 36.8%, 33.8 %) of studied nurses had incorrect knowledge regarding items: warning signs of elderly stroke, specialty of follow up physician after discharge & information source about elderly stroke patients, and the main types of elderly stroke respectively. Present finding shows that, 100% of studied nurses had adequate performance regarding observation of changes in conscious level, and observation of mental status in sensation, 94.1 % of them had adequate performance regarding observation of the ability of talking, and observation of mental status in talking and awareness. 89.7% of nurses had adequate performance regarding observation of mental status in memory, concentration, as well as urination & defecation control. Conclusion: There is a statistically significant relation between nurses’ total knowledge & performance and their ages & years of experiences. There is no statistically significant relation between total nurses’ knowledge& performance and their gender & qualifications. There is a highly statistically correlation between total nurses’ knowledge and their total performance. Recommendations: Periodic assessment for nurses' performance regarding care for elderly stroke patients, provide continuous support for staff nurses to enhance their nurses' performance regarding care for elderly stroke patients, investigate the effect of proper nurses' performance regarding care for elderly stroke patients satisfaction and replicate this study on larger probability sample in different hospitals in order to generalize the result

THE UTILIZATION OF GOLDEN PERIOD OF ISCHEMIC STROKE IN PATIENTS IN PRODUCTIVE AGES

The 2007 Basic Health Survey shows the highest number of deaths in Indonesia rural and urban areas was caused by stroke. In 2007-2013, the stroke prevalence in productive age increased up to 22‰. Stroke that attacks productive age can impair individual’s ability to do activities, and thus they might have family financial constraint. Disabilities can be prevented and minimized if patients utilize a golden period of an ischemic stroke. This study identified the utilization of golden period of ischemic stroke in patients and analyzed causes of delayed patient admission to the Neurology Clinic of Sidoarjo Hospital. This study was a descriptive study conducted to 39 post-stroke ischemic patients in productive ages under further therapy at the Neurology Clinic of Sidoarjo Hospital in 2016. The data were collected through interview from January-February 2017. The results present 62% of stroke ischemic patients utilized the golden period of a ischemic stroke. The average respondents' admission took 29.87±47.46 hours after patients experienced first stroke ischemic attacks (ranging from 1-168 hours). The respondents were admitted to the hospital late or >4.5 hours after the stroke attacks because most of them did not know stroke signs and symptoms. Therefore, hospitals or health care providers have to provide counseling service to patients and family members about stroke signs and symptoms, as well as the importance of early admission for treatment as soon as patient gets the first stroke attack. Keywords: utilization of the golden period, ischemic stroke, productive age.

Stroke Recognition for First Aid Providers: A Systematic Review and Meta-Analysis.

AimTo perform a systematic review of the literature on the effectiveness of existing stroke recognition scales used in a prehospital setting and suitable for use by first aid providers. The systematic review will be used to inform an update of international first aid guidelines.MethodsWe followed the Cochrane Handbook for Systematic Reviews of Interventions methodology and report results according to PRISMA guidelines. We searched Medline, Embase and CENTRAL on May 25, 2020 for studies of stroke recognition scales used by first aid providers, paramedics and nurses for adults with suspected acute stroke in a prehospital setting. Outcomes included change in time to treatment, initial recognition of stroke, survival and discharge with favorable neurologic status, and increased layperson recognition of the signs of stroke. Two investigators reviewed abstracts, extracted and assessed the data for risk of bias. The certainty of evidence was evaluated using GRADE methodology.ResultsWe included 24 observational studies with 10,446 patients evaluating 10 stroke scales (SS). All evidence was of moderate to very low certainty. Use of the Kurashiki Prehospital SS (KPSS), Ontario Prehospital SS (OPSS) and Face Arm Speech Time SS (FAST) was associated with an increased number of suspected stroke patients arriving to a hospital within three hours and, for OPSS, a higher rate of thrombolytic therapy. The KPSS was associated with a decreased time from symptom onset to hospital arrival. Use of FAST Emergency Response (FASTER) was associated with decreased time from door to tomography and from symptom onset to treatment. The Los Angeles Prehospital Stroke Scale (LAPSS) was associated with an increased number of correct initial diagnoses. Meta-analysis found the summary estimate sensitivity of four scales ranged from 0.78 to 0.86. The FAST and Cincinnati Prehospital Stroke Scale (CPSS) were found to have a summary estimated sensitivity of 0.86, 95% CI [0.69-0.94] and 0.81, 95% CI [0.70-0.89], respectively.ConclusionStroke recognition scales used in the prehospital first aid setting improves the recognition and diagnosis of stroke, thereby aiding the emergency services to triage stroke victims directly down an appropriate stroke care pathway. Of those prehospital scales evaluated by more than a single study, FAST and Melbourne Ambulance Stroke Screen (MASS) were found to be the most sensitive for stroke recognition, while the CPSS had higher specificity. When blood glucose cannot be measured, the simplicity of FAST and CPSS makes these particular stroke scales appropriate for non-medical first aid providers.

Sociodemographic and Geographic Variation in Awareness of Stroke Signs and Symptoms Among Adults - United States, 2017.

Stroke is the fifth leading cause of death in the United States (1). In 2017, on average, a stroke-related death occurred every 3 minutes and 35 seconds in the United States, and stroke is a leading cause of long-term disability (1). To prevent mortality or long-term disability, strokes require rapid recognition and early medical intervention (2,3). Common stroke signs and symptoms include sudden numbness or weakness of the face, arm, or leg, especially on one side; sudden confusion or trouble speaking; sudden trouble seeing in one or both eyes; sudden trouble walking, dizziness, or loss of balance; and a sudden severe headache with no known cause. Recommended action at the first sign of a suspected stroke is to quickly request emergency services (i.e., calling 9-1-1) (2). Public education campaigns have emphasized recognizing stroke signs and symptoms and the importance of calling 9-1-1, and stroke knowledge increased 14.7 percentage points from 2009 to 2014 (4). However, disparities in stroke awareness have been reported (4,5). Knowledge of the five signs and symptoms of stroke and the immediate need to call emergency medical services (9-1-1), collectively referred to as "recommended stroke knowledge," was assessed among 26,076 adults aged ≥20 years as part of the 2017 National Health Interview Survey (NHIS). The prevalence of recommended stroke knowledge among U.S. adults was 67.5%. Stroke knowledge differed significantly by race and Hispanic origin (p<0.001). The prevalence of recommended stroke knowledge was highest among non-Hispanic White adults (71.3%), followed by non-Hispanic Black adults (64.0%) and Hispanic adults (57.8%). Stroke knowledge also differed significantly by sex, age, education, and urbanicity. After multivariable adjustment, these differences remained significant. Increasing awareness of the signs and symptoms of stroke continues to be a national priority. Estimates from this report can inform public health strategies for increasing awareness of stroke signs and symptoms.

Comparison between transthoracic echocardiography and transcranial Doppler for detection of PFO in patients in the acute phase of a pulmonary embolism. A Post-hoc analysis of EPIC-FOP

Abstract Introduction Patent foramen ovale is a fairly common defect found in a quarter of the population. PFO has always been associated with an increased risk of stroke, the mechanism of which has been attributed to the paradoxical embolism of venous thrombi passing through the PFO directly into the left atrium, however this mechanism remains debated to date. For the detection of PFO, several modalities exist including transcranial doppler (TCD), transthoracic echocardiography (TTE) and transoesophageal echocardiography. This raises the question of the examination with the best diagnostic performance for its detection. Purpose The majority of studies comparing the different modalities of patient PFO diagnosis have been conducted in the context of stroke assessment. Very few studies have focused on the acute PE patient population. The interest of our study is therefore to evaluate the diagnostic performance of two modalities (TTE versus TCD) for the detection of shunts, especially since this population is at risk of stroke by paradoxical embolism due to the phenomenon of hyperpressure in the right heart chambers increasing the chances of having a paradoxical embolism. Methods We performed a post HOC analysis of the EPIC-FOP study which is a multicenter, prospective, French cohort study. Patients were recruited within 3 days of diagnosis of PE. Patients included were given a transthoracic echocardiography (TTE) with PFO screening by injection of saline contrast and magnetic resonance imaging (MRI) within 7 days of inclusion to look for signs of recent stroke. A proportion of the patients included in this study also received a transcranial doppler in search of PFO, the results of which were used in our study. Results The mean age of the patients was 62±14.66 years with a slight male predominance (55.6%). TCD was able to detect 97 right-left shunts while the TTE detected only 25 shunts. Concordance analysis by Cohen's Kappa Coefficient: 0.1767 [0.0427; 0.3107–p&amp;lt;0.001] is considered poor. Using TTE as the reference examination, transcranial Doppler has a very good sensitivity 96.00% (79.65% to 99.90%) and a poor specificity 42.06% (33.33% to 51.18%). A good negative likelihood ratio 0.10 (0.01 to 0.66). Using TCD, incidence of stroke in the acute phase of PE was significantly higher in the PFO population. In the ten strokes detected 9 had occurred in patients with PFO, RR=1.43 IC95% (1.1169 to 1.8228) p=0. 0044. The difference in proportion is calculated to be 26.92%. Conclusion It is the first study that compared TCD vs TEE in the setting of acute phase of PE for detection of PFO. TCD showed a good sensitivity and negative likelihood ratio that can be used as a first means to rule out PFO or associated with TTE. Also, our analysis confirms the increased risk of stroke following a PE episode when a PFO is present. Funding Acknowledgement Type of funding source: None

Simultaneous cardio-cerebral embolization. A prospective study

Abstract Background Atrial Fibrillation (AF) is a common cause of ischemic stroke but also the most common cause of Coronary Artery Embolism (CE). Many previous case of coexistence of coronary and cerebral embolism have been reported in the literature but in specific situations were clinical signs of stroke but also indisputable clinical and/or electrocardiographic (ECG) signs leaded to the realization of coronarography in emergency. Objectives The aim of the study was to determine the existence of simultaneous cardio-cerebral embolization associated in patients with ischemic embolic stroke on de novo AF, in the absence of clinical and/or ECG signs evocative of myocardial infarction (MI). Methods We prospectively included patients hospitalized in our institution for ischemic embolic stroke on de novo AF. Patients with history of ischemic disease were excluded. All patients had: 1/ troponin assay; 2/ Cardiac Magnetic Resonance (CMR) imaging with Late-Gadolinium Enhancement (LGE) in order to detect myocardial infarction; 3/ coronary exploration by cardiac CT scan or coronarography to exclude patients with significant coronary lesion. Results Between January and December 2019, 32 patients were included. Of them, 15 had subendocardial or transmural LGE on CMR, evocative of MI. Among these 15 MIs we classified acute MIs according to the level of troponin at the admission in stroke unit, the coronarography and T2 hypersignal on cardiac MRI. Median delay of cardiac MRI was 6 days for acute MIs. CE was clearly identified by coronarography for 4 patients with acute simultaneous cardio-cerebral infarction (56%). The MRI abnormalities showed that lesions of all MIs were transmural, relatively small (average 1.3±0.44 segments) and in most cases in the inferior cardiac wall (47%) and these abnormalities were comparable in sequelae and acute MI. Moreover, the left appendage morphology was a “cactus” in 62.7% of simultaneous acute cardio-cerebral infarction and only 33% in patients without MI or sequelae MI. Strokes were mainly localized in the superficial territory of the middle cerebral artery, and were similar in patients with or without MI. In addition, the rate of sequelae strokes was higher in isolated stroke group than “cardiocerebral infarction” (29.5% versus 13.3%). Conclusion Simultaneous acute cardio-cerebral infarction is not uncommon, diagnosed in 22% of our prospective cohort of embolic stroke. Cardiac MRI may help us to diagnose a concomitant cardiac embolization and evaluate the prognosis. Unfortunately optimal therapeutic strategy of these patients is still unknown. Flow Chart Funding Acknowledgement Type of funding source: None

Correlation between self-perceived burden and self-management behavior in elderly stroke survivors: A longitudinal observational study.

The aim of this study was to assess the levels of self-perceived burden (SPB) and self-management behavior in elderly stroke survivors during the first 3 months after acute stroke, and to explore the correlation between them.A total of 203 consecutive hospitalized elderly patients diagnosed with stroke were recruited. Self-perceived Burden Scale and Stroke Self-management Scale in 1 month (T1) and 3 months (T2) post-stroke were assessed and compared.The score of SPB in elderly stroke survivors was 28.96 ± 5.50 and 27.25 ± 6.17 at T1 and T2, respectively. Stroke self-management scale scored 165.93 ± 9.82 at T1 and 167.29 ± 10.60 at T2. In the first 3 months post-stroke, the physical burden was dominant (T1 14.73 ± 3.07, T2 14.40 ± 3.13), and the behavior of stroke symptoms and signs monitoring (T1 27.58 ± 6.56, T2 28.64 ± 6.43) and rehabilitation exercise management (T1 21.40 ± 3.28, T2 20.74 ± 3.15) was the worst. SPB was negatively correlated with self-management behavior (T1 r = -.202, T2 r = -.511).Elderly stroke survivors experienced a medium level of SPB and self-management behavior in the first 3 months post-stroke. There is a positive relationship between reduced SPB and improved self-management behavior. Addressing the characteristics and correlations as well as development of targeted interventions for SPB decreasing is beneficial to improving self-management behavior for elderly survivors.

Creation of a Dataset of MSCT-Images and Clinical Data for Acute Cerebrovascular Events

Background The use of neuroimaging methods is an integral part of the process of assisting patients with acute cerebrovascular events (ACVE), and computed tomography (CT) is the «gold standard» for examining this category of patients. The capabilities of the analysis of CT images may be significantly expanded with modern methods of machine learning including the application of the principles of radiomics. However, since the use of these methods requires large arrays of DICOM (Digital Imaging and Communications in Medicine)-images, their implementation into clinical practice is limited by the lack of representative sample sets. Inaddition, at present, collections (datasets) of CT images of stroke patients, that are suitable for machine learning, are practically not available in the public domain.Aim of study Regarding the aforesaid, the aim of this work was to create a DICOM images dataset of native CT and CT-angiography of patients with different types of stroke. Material and meth ods The collection was based on the medical cases of patients hospitalized in the Regional Vascular Center of the N.V. Sklifosovsky Research Institute for Emergency Medicine. We used a previously developed specialized platform to enter clinical data on the stroke cases, to attach CT DICOMimages to each case, to contour 3D areas of interest, and to tag (label) them. A dictionary was developed for tagging, where elements describe the type of lesion, location, and vascular territory.Results A dataset of clinical cases and images was formed in the course of the work. It included anonymous information about 220 patients, 130 of them with ischemic stroke, 40 with hemorrhagic stroke, and 50 patients without cerebrovascular disorders. Clinical data included information about type of stroke, presence of concomitant diseases and complications, length of hospital stay, methods of treatment, and outcome. The results of 370 studies of native CT and 102 studies of CT-angiography were entered for all patients. The areas of interest corresponding to direct and indirect signs of stroke were contoured and tagged by radiologists on each series of images.Conclusion The resulting collection of images will enable the use of various methods of data analysis and machine learning in solving the most important practical problems including diagnosis of the stroke type, assessment of lesion volume, and prediction of the degree of neurological deficit.

Moyamoya: An Update and Review.

This article is a clinical review of Moyamoya disease (MMD) and Moyamoya syndrome (MMS). We review the incidence, epidemiology, pathology, historical context, clinical and radiographic findings, diagnostic imaging modalities, radiographic grading systems, the effectiveness of medical, interventional, and surgical treatment, and some of the nuances of surgical treatment options. This article will help pediatricians, neurologists, neurosurgeons, and other clinical practitioners who are involved in caring for patients with this rare clinical entity.MMD is an intrinsic primary disease process that causes bilateral progressive stenosis of the anterior intracranial circulation with the involvement of the proximal portions of the intracranial internal carotid artery (ICA) extending to involve the proximal portions of the anterior cerebral artery (ACA) and middle cerebral artery (MCA); posterior circulation involvement is very rare. This causes a compensatory response where large numbers of smaller vessels such as the lenticulostriate arteries begin to enlarge and proliferate, which gives the angiographic appearance of a "Puff of Smoke", which is translated into Japanese as "Moyamoya”. MMS is a secondary process that occurs in response to another underlying pathological process that causes stenosis of intracranial blood vessels, such as radiation. For example, an external source of radiation causes stenosis of the ICA with a compensatory response of smaller blood vessels, which then enlarge and proliferate in response and has the same "Puff of Smoke" appearance on the diagnostic cerebral angiogram (DCA).Histological findings include an irregular internal elastic lamina with luminal narrowing, hyperplasia of the tunica media, and intimal thickening with vacuolar degeneration in smooth muscle cells in the tunica media. Compensation for diminishing blood supply occurs through angiogenesis, which causes the proliferation and enlargement of smaller collateral blood vessels to increase blood supply to under-perfused areas of the brain.MMD is rare in the United States, with just 0.086 newly diagnosed cases per 100,000 individuals per year, which is approximately one per million new cases annually. Risk factors for MMD include Eastern Asian ancestry and predisposing conditions such as neurofibromatosis and Down's syndrome.Clinically, patients often present with stroke signs and symptoms from cerebral ischemia. The proliferation of collateral blood vessels within the basal ganglia can produce movement disorders. Catheter-based DCA is the current gold standard for obtaining a diagnosis. CT perfusion allows preoperative identification of ischemic vascular territories, which may be amenable to surgical intervention. MRI enables rapid detection of acute ischemic stroke using diffusion-weighted Imaging (DWI) and apparent diffusion coefficient (ADC) sequences to assess for any diffusion restriction. Non-contrast CT of the head is used to rule out acute hemorrhage in the presentation of a progressive neurological deficit.The treatment option for Moyamoya is generally surgical; medical treatment has failed to halt disease progression and neuro-interventional techniques such as attempted stenting of stenosed vessels have failed. Surgical options include direct and indirect cerebrovascular bypass.

Optimal slice thickness of brain computed tomography using a hybrid iterative reconstruction algorithm for identifying hyperdense middle cerebral artery sign of acute ischemic stroke.

To determine the optimal slice thickness of brain non-contrast computed tomography using a hybrid iterative reconstruction algorithm to identify hyperdense middle cerebral artery sign in patients with acute ischemic stroke. We retrospectively enrolled 30 patients who had presented hyperdense middle cerebral artery sign and 30 patients who showed no acute ischemic change in acute magnetic resonance imaging. Reformatted axial images at an angle of the orbitomeatal line in slice thicknesses of 0.5, 1, 3, 5, and 7mm were generated. Optimal slice thickness for identifying hyperdense middle cerebral artery sign was evaluated by a receiver operating characteristics curve analysis and area under the curve (AUC). The mean AUC value of 0.5-mm slice (0.921; 95% confidence interval (95% CI), 0.868 to 0.975) was significantly higher than those of 3-mm (0.791; 95% CI, 0.686 to 0.895; p = 0.041), 5-mm (0.691; 95% CI, 0.583 to 0.799, p < 0.001), and 7-mm (0.695; 95% CI, 0.593 to 0.797, p < 0.001) slices, whereas it was equivalent to that of 1-mm slice (0.901; 95% CI, 0.837 to 0.965, p = 0.751). Thin slice thickness of ≤ 1mm has a better diagnostic performance for identifying hyperdense artery sign on brain non-contrast computed tomography with a hybrid iterative reconstruction algorithm in patients with acute ischemic stroke.

The Quantitative Evaluation of the Density of the Segmental Branches of the MCA in Acute Ischemic Stroke Patients.

AimThe aim of this study was to assess the density of the segmental branches of the middle cerebral artery (MCA) quantitatively as a predictor of acute ischemic stroke in patients without definitive infarct findings at cerebral parenchyma by non-contrast computed tomography (CT).Clinical rationale for the studyThe clinical rationale for the study is to evaluate if the measurement of Sylvian fissure dot sign (SDS) would help early management of patients with stroke at the emergency department.MethodsComputed tomography scans of 101 patients admitted to the emergency department with stroke symptoms and/or signs were included in the study, retrospectively. In the patient group, the quantitative density of the segmental branches of the MCA in the Sylvian fissure was measured on the affected side and the contralateral side.ResultsQuantitative density of SDS was significantly higher on the ischemic side of the brain. Receiver operating characteristic (ROC) analysis showed a cut-off value of 38.5 Hounsfield units (HU) as a predictor for acute ischemic stroke, with a sensitivity and specificity of 79% and 92%, respectively.ConclusionQuantitative density of SDS on the affected side in patients without definitive cerebral infarct findings of parenchyma can be used in the emergency room as an objective predictor sign for the diagnosis of acute ischemic stroke. Considering this finding in the differential diagnosis of acute stroke patients in the emergency room has the potential to improve their clinical management, particularly for the patients without early parenchymal and vascular signs of stroke.

Disruptions of Anaerobic Gut Bacteria Are Associated with Stroke and Post-stroke Infection: a Prospective Case\u2013Control Study

In recent years, preclinical studies have illustrated the potential role of intestinal bacterial composition in the risk of stroke and post-stroke infections. The results of these studies suggest that bacteria capable of producing volatile metabolites, including trimethylamine-N-oxide (TMAO) and butyrate, play opposing, yet important roles in the cascade of events leading to stroke. However, no large-scale studies have been undertaken to determine the abundance of these bacterial communities in stroke patients and to assess the impact of disrupted compositions of the intestinal microbiota on patient outcomes. In this prospective case–control study, rectal swabs from 349 ischemic and hemorrhagic stroke patients (median age, 71 years; IQR: 67–75) were collected within 24 h of hospital admission. Samples were subjected to 16S rRNA amplicon sequencing and subsequently compared with samples obtained from 51 outpatient age- and sex-matched controls (median age, 72 years; IQR, 62–80) with similar cardiovascular risk profiles but without active signs of stroke. Plasma protein biomarkers were analyzed using a combination of nuclear magnetic resonance (NMR) spectroscopy and liquid chromatography–mass spectrometry (LC-MS). Alpha and beta diversity analyses revealed higher disruption of intestinal communities during ischemic and hemorrhagic stroke compared with non-stroke matched control subjects. Additionally, we observed an enrichment of bacteria implicated in TMAO production and a loss of butyrate-producing bacteria. Stroke patients displayed two-fold lower plasma levels of TMAO than controls (median 1.97 vs 4.03 μM, Wilcoxon p < 0.0001). Finally, lower abundance of butyrate-producing bacteria within 24 h of hospital admission was an independent predictor of enhanced risk of post-stroke infection (odds ratio 0.77, p = 0.005), but not of mortality or functional patient outcome. In conclusion, aberrations in trimethylamine- and butyrate-producing gut bacteria are associated with stroke and stroke-associated infections.

Recognition of stroke-related knowledge among community residents and the improvement after intensive health education: a cross-sectional study

BackgroundThe high morbidity, mortality, and disability rates of stroke constitute a heavy burden to the society. The level of understanding about stroke warning symptoms and first aid systems among community residents was generally low. The aim of our work is to investigate stroke-related knowledge in community residents of Jinjiang district of Chengdu and to raise public awareness about stroke through an intensive educational program.MethodsNine communities in Jinjiang district were sampled and a questionnaire about stroke-related knowledge was applied before and after stroke educational activities. We analyzed the impact of such activities in stroke recognition and management.ResultsWe collected 1685 valid questionnaires. The awareness about stroke risk before educational activities was 11.4%. The recognition of stroke warning signs among community residents was 29.8–59.5%. Among them, the recognition of major signs, such as limb weakness, language disorder, and imbalance was more than 50%. When faced with five stroke warning signs, the proportion of participants who chose to make an emergency call was 41.5%. Less than 10% of the participants chose to consult a doctor, take medicine, or wait. After strengthening publicity and educational activities regarding stroke, there was a significant improvement in the identification of stroke risk factors, warning signs, and stroke management. The percentage of participants who chose to make an emergency call increased from 53.2 to 82.7%.ConclusionsThe knowledge about stroke among community residents in Jinjiang District of Chengdu was low. Strengthening publicity and educational activities may raise awareness about stroke prioritizing call emergency after the onset of stroke signs.

UNEXPECTED ACUTE AORTA DISSECTION WITH ISCHEMIC STROKE

Introduction: Both acute aorta dissection and ruptured aorta aneurism are prominent causes of death in cardiovascular diseases. The frequency of developing neurological complications in aortic dissections is reported to be between 2 to 8%. Stroke is more common in dissections involving the proximal aorta, but paraparesis is more common in distal aortic dissections due to circulatory impairment in the spinal arteries. Case: The 70-year-old male patient was referred to our emergency service from an external center with diagnosis of acute ischemic stroke. The patient had experienced loss of strength on his left side and had syncope one hour before. After his physical examination, the patient received computerized brain tomography and diffusion MR imaging with the pre-diagnosis of acute stroke. For the patient who had an appearance of acute diffusion restriction in the right parietal region in the diffusion MRI and had a chance of thrombolytic treatment, thrombolytic treatment was planned. However, the general status of the patient was worsened in this checkup examination, and his GCS score regressed down to 7. The poor current condition of the patient could not be explained by the acute ischemic stroke in the right parietal region. Aorta dissection, which may progress with clinical signs of stroke, was considered for the patient, and as an advanced test, dynamic thorax CT angiography was taken. In the dynamic thorax CT angiography of the patient, aneurism in the ascending aorta, dissection and fluid around the pericardium and left lung (hemorrhage?) were observed. The echocardiography of the patient revealed that the fluid around the pericardium caused tamponade. Discussion: Cardiovascular system diseases are the most common cause of natural sudden deaths and are mostly seen in middle and older ages. Acute myocardial infarction and coronary artery disease are the most common cardiovascular diseases, however, sudden deaths due to aortic dissection and rupture have been reported less frequently. The most typical symptom is the sudden start of severe chest or back pain. Patients typically visit with complaints of tearing chest and back pain, while they may visit with atypical clinical pictures wementioned in our cases such as abdominal pain, syncope, stroke. Sensory loss may also be seen in patients, and this is a neurological symptom which may extend from falling as leep to deep coma. Conclusion: Patients who visit emergency services with symptoms that are not expected for aorta dissection such as syncope, altered consciousness, hypotension, atypical abdominal pain and loss of strength in the extremities.