National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke

Tenecteplase Plus Butyphthalide for Stroke Within 4.5-6 Hours of Onset (EXIT-BT): a Phase 2 Study

To date, the benefit of intravenous thrombolysis is confined to within 4.5 h of onset for acute ischemic stroke (AIS) without advanced neuroimaging selection. The current trial aimed to investigate the safety and efficacy of intravenous tenecteplase (TNK) plus Dl-3-n-Butylphthalide (NBP) in AIS within 4.5 to 6 h of onset. In this randomized, multicenter trial, eligible AIS patients were randomly assigned to receive intravenous TNK (0.25 mg/kg) plus NBP or NBP within 4.5 to 6 h of onset. The primary endpoint was symptomatic intracranial hemorrhage (sICH). Secondary endpoints included excellent functional outcome defined as a modified Rankin Scale score of 0 to 1 at 90 days. 100 patients diagnosed by non-contrast CT (NCCT) were enrolled, including 50 in TNK group and 50 in control group. sICH occurred in 2.0% (1/50) in TNK group and 0.0% (0/49) in control group with no difference (unadjusted P = 0.998). The proportion of excellent functional outcome was 77.6% (38/49) in TNK group and 69.4% (34/49) in control group with non-significance (absolute difference 8.2%, P = 0.36). A significant decrease in NIHSS score at 24 h (P = 0.004) and more early neurological improvement (20.4% vs 4.1%; P = 0.026) was observed in TNK vs control group, but there was no difference in other secondary outcomes. This phase 2 study suggests that intravenous TNK with adjuvant NBP seems safe, feasible and may improve early neurological function in AIS patients within 4.5 to 6 h of symptom onset selected using NCCT.Clinical Trials Registration: This trial was registered with ClinicalTrials.gov (NCT05189509).

Door-to-Diuretic Time and Outcomes in Acute Heart Failure: A Scoping Review

INTRODUCTION

Inadequate decongestion remains an unmet need in the management of patients with heart failure. The concept of door-to-diuretic (D2D) time to improve outcomes has been proposed for patients with heart failure (HF), but the trial results have been mixed.

METHODS

We utilized Preferred Reporting Instrument for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR) for scoping reviews with an extensive a priori search strategy for databases: PubMed and Scopus between January 2015 and November 2023. We used the key search terms "door-to-diuretic time" OR "door-to-furosemide time" OR "acute heart failure decongestion". Early D2D time was defined as intravenous (IV) diuretic administration within 30-120 min of patient arrival to the healthcare facility. Articles were included if they met our criteria, were written in the English language, and investigated door-to-diuretic or furosemide time as a decongestive strategy to improve outcomes in patients with acute HF.

RESULTS

From 588 articles, 13 articles fulfilled the inclusion criteria after excluding duplicates and articles that did not meet our inclusion criteria. Of these studies, there was 1 meta-analysis and 12 observational cohort/registry-based studies (10 were positive trials and 2 were neutral). The most common outcomes examined were mortality and rehospitalization with early diuretic administration. First, early treatment was associated with lower in-hospital mortality and shorter hospital length of stay. Second, higher doses of furosemide were associated with improved HF symptoms and decreased hospitalization, at the cost of transiently worsening renal function. Third, the evidence is mixed for long-term mortality benefits.

CONCLUSION

Although the impact of early D2D time on HF outcomes is mixed, early diuretic administration appears to be an effective and safe strategy that warrants further investigation in large-scale pragmatic comparative effectiveness trials. Future trials should consider utilizing diuretic efficiency-guided dose escalation and augmented diuresis using high-dose or combination diuretic therapy.

Fibrinogen depletion and the risk of intracerebral hemorrhage following endovascular mechanical thrombectomy

BackgroundIntravenous thrombolysis (IVT) and mechanical thrombectomy (MT) are the standard of care for select stroke patients with acute large vessel occlusion (LVO). Fibrinogen levels may drop after IVT, and a significant decrease in fibrinogen is associated with an increased risk of intracranial hemorrhage (ICH). Our pilot study aimed to explore the relationship between fibrinogen levels and the development of ICH in MT-treated patients and whether bridging with IVT further increases that risk.MethodsThis is a prospective pilot study that enrolled adults presenting with a diagnosis of LVO stroke and eligible to receive MT with or without IVT between April 2020 and May 2023. Fibrinogen levels were drawn before treatment with IVT or MT and immediately following MT.ResultsForty-one patients were enrolled. Median age was 68 years [interquartile range 56-79], 58.5% were females and 56.1% were black. Nineteen patients (46.3%) were treated with MT + IVT, and 22 (53.6%) were treated with MT-only. There was no difference in baseline characteristics between the two groups. Baseline fibrinogen levels were similar between MT + IVT and MT-only groups [391 vs. 352 mg/dL, p = 0.4]. Post MT, the MT + IVT group had lower fibrinogen levels compared to the MT-only group [224 vs. 303 mg/dL, p < 0.001]. Similarly, there was a significant change between baseline and follow-up levels in the MT + IVT vs. MT-only group [106 vs. 39.5 mg/dL, p = 0.001]. Eight patients (19.5%) developed ICH; 5 (26.3%) in the MT + IVT group and 3 (13.6%) in the MT-only group. No significant differences were seen in baseline, follow-up, or change in fibrinogen levels between patients who developed ICH and those who did not. However, when stratified by treatment group, postintervention fibrinogen levels were significantly lower in patients who developed an ICH in the MT + IVT group compared to those without ICH in the MT group (200 vs. 301 mg/dL, p = 0.006). There was also a negative correlation between the change in fibrinogen levels and the rate of first-pass recanalization (Spearman CC -0.33, p = 0.03).ConclusionThis pilot study's preliminary data showed an association between fibrinogen depletion and hemorrhagic transformation in MT-treated patients. Since intracerebral hemorrhage is the most dire side effect in stroke treatment, fibrinogen monitoring in patients undergoing MT after IVT may help identify patients with an increased risk of ICH. Larger, prospective, and multicenter studies are needed to confirm these findings and if fibrinogen repletion should be considered for dysfibrinogenemia.

Comparing Early National Institutes of Health Stroke Scale Versus 90-Day Modified Rankin Scale Outcomes in Acute Ischemic Stroke Trials: A Systematic Review and Analysis

BACKGROUND

Early National Institutes of Health Stroke Scale (NIHSS) assessment may provide practical benefits over 90-day modified Rankin Scale (mRS), but it is unclear how it compares in adjudicating randomized clinical trial (RCT) results in acute ischemic stroke.

METHODS AND RESULTS

We searched Ovid Medline (inception to April 1, 2023) and included RCTs of acute therapies for acute ischemic stroke with data for both 90-day mRS and NIHSS within 7 days. Primary outcome was agreement between trial results (classified as positive, negative, or neutral) based on 24-hour NIHSS and 90-day mRS scores. We additionally assessed agreement for 2-hour, 48-hour, 72- to 96-hour, and 5- to 7-day NIHSS scores. We aimed to validate our findings using individual patient data from the ESCAPE (Randomized Assessment of Rapid Endovascular Treatment of Ischemic Stroke) and ESCAPE-NA1 (Safety and Efficacy of Nerinetide [NA-1] in Subjects Undergoing Endovascular Thrombectomy for Stroke) RCTs. We included 116 trials (44 387 patients), contributing 165 NIHSS assessments. The 24-hour NIHSS scores resulted in the same classification as 90-day mRS scores in 61/73 (83.6%) trials (Cohen's kappa, 0.64 [95% CI: 0.45-0.83] and Gwet's agreement coefficient 1, 0.79 [95% CI: 0.67-0.90]). Agreement was not statistically different by timing of NIHSS assessments (range 75%-100%, P=0.33). Individual patient data showed higher agreement for assessments between 48 hours and 7 days, varying by NIHSS dichotomization cutoffs (NIHSS score, 0-2; 2 hours, 56.6%; 24 hours, 66.6%; 48 hours, 71.8%; 5-7 days: 76.5%, P<0.01; NIHSS score, 0-7; 2 hours, 72.8%; 24 hours, 80.5%; 48 hours, 83.1%; 5-7 days: 84.7%, P<0.01).

CONCLUSIONS

The 24-hour NIHSS scores aligned with 90-day mRS scores in 84% of RCT results, indicating intermediate-to-good agreement. However, individual patient data showed that early NIHSS risks misclassifying around 1/4 patients. These data contribute to a better understanding of the nuances of early NIHSS score as an outcome in acute ischemic stroke RCTs.

Social Determinants of Health Framework Identifies Patients at Risk for Loss to Follow-Up After Stroke

BACKGROUND

Poststroke follow-up is associated with decreased rehospitalization and improved long-term outcomes. However, rates are variable and dependent on numerous factors, some of which are fixed (age, sex) while others are potentially modifiable (medical knowledge, access to care). The National Institutes of Health has identified key factors for healthcare inequity using a framework based on Social Determinants of Health. It is currently unknown which of these factors are the largest drivers of poststroke follow-up.

METHODS

We evaluated a prospectively collected cohort of ≈2600 patients treated for ischemic stroke between 2014 and 2022. Potential variables were identified using the Social Determinants of Health framework and categorized as nonmodifiable or modifiable. T tests, χ2, and regression analyses were used to investigate their association with the likelihood of follow-up.

RESULTS

Fifty-six percent of patients returned to the clinic. Greater degrees of impairment (due to stroke severity, advanced age, and premorbid condition), less education, scheduling inflexibility (due to occupation and employment status), and lack of home support were nonmodifiable factors associated with decreased follow-up rates. Greater postdischarge needs (evaluated by rehabilitation status and discharge disposition) along with less family involvement during the discharge process were also associated with lower rates.

CONCLUSIONS

This study identifies key factors associated with poor follow-up, defining an at-risk population. Modifiable factors may serve as targets for enhanced postdischarge support, suggesting that patients may benefit from interventions aimed at family support and improved communication with rehabilitation facilities. The approach underscores the value of integrating Social Determinants of Health considerations into patient management to ensure equitable and effective healthcare delivery.

A facultative plasminogen-independent thrombolytic enzyme from Sipunculus nudus

Current thrombolytic therapies primarily function by converting plasminogen into plasmin, a process dependent on the fibrin-activator complex. This dependence, coupled with the substantial molecular size of plasmin, constrains its effectiveness in degrading D-dimer and restricts its diffusion within thrombi. Here, we introduce a small facultative plasminogen-independent thrombolytic enzyme, snFPITE, isolated from Sipunculus nudus. Compared to traditional thrombolytic agents, snFPITE does not require plasminogen for thrombolysis, although its presence enhances lytic activity. This enzyme fully degrades cross-linked fibrin without leaving residual nondegradable D-dimer and generates a smaller fibrinolytic-active agent from plasminogen. A series of male rats and mice models further confirm that snFPITE is a safety injectable thrombolytic agent. Mechanistically, snFPITE activates plasminogen and degrades fibrin(ogen) in a multisite cleavage manner. snFPITE is inhibited by plasminogen activator inhibitor 1 and α2-antiplasmin via a competitive inhibition. We further identify 28 snFPITE candidate sequences, of which 10 are confirmed as functional genes.

Targeting to miR-130b-5p/TLR4: How sodium danshensu suppresses inflammatory response of microglia in cerebral ischemia-reperfusion injury

Cerebral ischemia reperfusion injury (CIRI) is a crucial process in the inflammatory response. Sodium danshensu (SDSS) is of protective effects in cardiovascular and cerebrovascular diseases due to its anti-inflammatory properties. Studies have demonstrated that SDSS administration reduces infarct volume, attenuates neurological impairment, and inhibits microglia activation in rat models of CIRI. While it is well established that miRNAs play roles in a wide range of diseases through multiple pathways. However, the mechanism by which SDSS alleviates inflammatory injury after CIRI and its potential interaction with miRNAs remain unclear. Thus, we aimed to investigate the effectiveness and mechanism of SDSS in CIRI, and to verify whether it exerts anti-inflammatory effects by affecting miRNA. Through bioinformatics analysis and experimental validation, we identified miR-130b-5p is a key gene in the CIRI process, with SDSS administration leading to an upregulation of miR-130b-5p that is indispensable for its anti-inflammatory effects. Moreover, both SDSS and miR-130b-5p reduced the expression of TLR4. Overall, the beneficial effects of SDSS on CIRI can be attributed to the up-regulation of miR-130b-5p and the inhibition of TLR4, resulting in the attenuation of the inflammatory response.

Is the FIB-4 score a prognostic factor in acute ischemic stroke patients receiving intravenous thrombolytic therapy?

BACKGROUND

Liver dysfunction is recognized as a risk factor for poor outcome after. stroke. The FIB-4 index, a laboratory test for predicting liver fibrosis, has been shown to be. associated with poor prognosis in cardiovascular and cerebrovascular diseases. The aim of. this study was to explore the relationship between FIB-4 score and hemorrhagic. transformation, mortality, and prognosis in patients with acute ischemic stroke who received. intravenous thrombolytic therapy (IV tPA).

METHODS

The records of 255 consecutive patients who received IV tPA for acute. ischemic stroke were retrospectively reviewed. Patients were divided into two groups. according to their FIB-4 scores: group 1 (FIB-4 ≤ 2.67) and group 2 (FIB-4 > 2.67). The. demographic data, NIHSS scores at admission, THRIVE scores, intracranial bleeding rates, (using the Heidelberg Bleeding Classification, NINDS and ECASS criteria for symptomatic. intracranial hemorrhage), stroke etiology subtypes (using the automated Causative. Classification System), and mRS scores at the third month were recorded.

RESULTS

On logistic regression analysis, group 2 patients were older, had higher mRS. scores at the third month and had increased mortality within 3 months when compared with. group 1 (p ≤ 0.05). Although group 2 patients had a higher rate of intracranial hemorrhage, the difference was not statistically significant.

CONCLUSIONS

The FIB-4 index may serve as a a useful predictor of poor prognosis in patients with acute ischemic stroke who received IV tPA. Large-scale prospective studies are needed to confirm this relationship and provide valuable insights for clinical practice.

Pragmatic Clinical Trials in Neurology

The need for pragmatic clinical trials evaluating therapeutic interventions in patients with neurological disease is continually increasing due to availability of multiple therapeutic interventions (comparative effectiveness), multifaceted approaches (multiple concurrent synergistic therapeutic interventions), and gaps in trial-specific and real-world population outcomes. Several designs for pragmatic trials are available, including individual randomized trials with pragmatic characteristics, cluster-randomized and non-randomized trials, and observational prospective cohort studies. Cluster trials may have parallel cluster and crossover (unidirectional, bidirectional, and alternating crossover) designs. There are unique aspects of consenting and data collection leveraging existing registries, electronic health records (EHRs), and claims data that make pragmatic trials most suited to study the effectiveness of therapeutic interventions in patients with neurological diseases in real-world settings. ANN NEUROL 2025.

Acute ischemic stroke patient factors associated with poor outcomes in patients with favorable collaterals and successful thrombectomy

OBJECTIVES

Favorable arterial collaterals are correlated to favorable outcomes after endovascular thrombectomy (EVT), but many patients still have unfavorable outcomes despite favorable collaterals and successful reperfusion. We determined factors associated with favorable outcome in patients with good collaterals who had successful EVT.

MATERIALS AND METHODS

In a post hoc analysis of the prospective CRISP 2 study, we identified patients with good collaterals (Tan≥2) and successful reperfusion (TICI 2b-3). Favorable (mRS 0-2) and unfavorable outcome (mRS 3-6) groups were compared to identify clinical, imaging, and treatment predictors of favorable outcome.

RESULTS

92 patients were included. 33.7 % had favorable outcomes. There were no differences in sex (52 % females versus 54 % females; p = 0.821) or age (71 years [IQR 56-79] versus 68 years [IQR 57-79]; p = 0.859) in favorable versus unfavorable groups, respectively. Favorable outcome patients had more frequent intravenous thrombolysis (52 % versus 23 %; p = 0.006), shorter EVT procedures (27 min [IQR 23-40] versus 46 min ([IQR 27-64], and lower baseline NIHSS (12 [IQR 9-15] versus 16 [IQR 12-20]; p = 0.006). There were no differences in the frequency of TICI 3 rates (48 % vs. 38 %; p = 0.325) or first pass effect between the two groups (61 % vs. 57 %; p = 0.719). In a multivariable regression analysis, pre-stroke mRS 1 versus 0 versus (OR 0.15 [95 % CI: 0.03-0.78]; p = 0.024), pre-stroke mRS ≥3 versus 0 (OR 0.04 [95 % CI: 0.002-0.94]; p = 0.046), intravenous thrombolysis administration (OR 3.27 [95 % CI: 1.04-10.33]; p = 0.043) and EVT procedure time (OR for every 5 min 0.98 [95 % CI: 0.81-0.98]; p = 0.022) were modifiable predictors of favorable outcomes.

CONCLUSIONS

Among patients with good collaterals and successful reperfusion following EVT, favorable outcomes were associated with lower baseline mRS, intravenous thrombolysis administration, and shorter EVT procedure times.

Implementation of regional Acute Stroke Care Map increases thrombolysis rates in urban areas of China: an interrupted time series analysis

BACKGROUND

Stroke, a leading cause of global disability, where timely thrombolysis is crucial for favorable outcomes. Despite initiatives like Acute Stroke Care Maps (ASCaMs) in China aiming to improve care continuity and thrombolysis rates, the long-term effectiveness of these interventions in urban settings remains underexplored.

METHODS

This retrospective cohort study investigates the role of the Shenyang ASCaM in improving the thrombolysis rate with tissue plasminogen activator within 4.5 hours of ischemic stroke onset in 30 hospitals. Using interrupted time series (ITS) analysis, it compares outcomes before and after ASCaM's implementation from April 2019 to December 2021. The ASCaM strategy, featuring EMS prenotification, rapid triage, and immediate neuroimaging, is assessed. Regression models, adjusted for patient demographics and clinical scores, evaluate the intervention's impact, controlling for potential confounders.

RESULTS

In the study, 2676 patients were evaluated before the implementation of the Shenyang ASCaM, and 8277 patients were assessed during its implementation. Thrombolysis rates within the vital 4.5-hour window rose significantly from 59% before ASCaM to 72% during its implementation (P < .001), and door-to-needle time (DNT) decreased significantly by 12.269 minutes (P < .0001). Early neurological deterioration (END) incidents decreased significantly from 44% to 39.2% (adjusted OR = 0.820, P = .001), indicating improved stroke care efficiency and outcomes. ITS analysis showed a pre-implementation monthly decrease in thrombolysis rates of 0.95%, countered by a post-implementation immediate surge of 6.21% and a sustained improvement at a rate of 0.13% per month. Furthermore, Post-ASCaM, DNT reduced to 52.42 minutes, thrombolysis rates increased to 72.3%, and END incidence decreased (adjusted OR = 0.820, P = .001), indicating improved stroke care efficiency and outcomes.

CONCLUSION

Our findings confirm that China's ASCaMs significantly enhance thrombolysis rates and ensure care continuity in managing acute stroke, indicating their long-term effectiveness in urban settings. This contributes to global stroke care improvements, emphasizing the potential for wider application and further research on sustained interventions.

The effect of fibrinogen levels on three-month neurological recovery in acute ischemic stroke patients

The present study aims to examine the relationship between post-stroke fibrinogen levels and long-term (three-month) prognosis in patients who had their first ischemic stroke and to determine the effect of fibrinogen levels on morbidity and mortality. A prospective study was carried out on 100 patients presenting with their first ischemic stroke at the Neurology Clinic of Gaziantep City Hospital. Stroke severity was examined utilizing the National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin Scale (mRS) at initial admission and at third month post-stroke. Serum fibrinogen levels were recorded from routine blood tests, and the relationship between fibrinogen levels and clinical outcomes was analyzed statistically. Significant positive correlations were observed between fibrinogen levels and stroke severity and outcomes. Fibrinogen levels were associated with NIHSS admission scores (r = 0.371, p < 0.001) and mRS admission scores (r = 0.439, p < 0.001). At third month, fibrinogen levels were significantly related with NIHSS (r = 0.544, p < 0.001) and mRS (r = 0.538, p < 0.001) scores. Regression analysis revealed that a one-unit increase in fibrinogen levels resulted in a 0.018-unit increase in NIHSS scores and a 0.008-unit increase in mRS scores (p < 0.001). Elevated fibrinogen levels during the acute phase are related with poorer neurological outcomes and increased morbidity and mortality within the three-month follow-up period in patients with first-time ischemic stroke. These resultsindicate that fibrinogen could be considered a prognostic biomarker for stroke management and rehabilitation planning.

Acupuncture as adjunctive therapy for acute cerebral infarction: a randomized clinical trial

Background

Acute cerebral infarction (ACI) is the second leading cause of death and the major cause of disability worldwide, and there is an increasing interest in non-pharmacological treatments. Acupuncture has promising effects on ACI, but its efficacy and safety need to be verified through well-designed randomized clinical trials. We aimed to investigate the efficacy and safety of acupuncture as adjunctive therapy to improve neurological function in patients with ACI.

Methods

The multicenter, sham-controlled, patient- and assessor-blinded randomized controlled trial was conducted in 4 tertiary hospitals in China from January to September 2024. All participants received standard care as recommended by the guidelines and were randomly assigned (1:1:1) to manual acupuncture (MA), sham acupuncture (SA), or standard care (SC) only. Participants in the MA and SA groups received acupuncture treatment 6 times weekly for 2 weeks for a total of 12 sessions. The primary outcome was the change in the National Institutes of Health Stroke Scale score from baseline to 14 days. Safety outcomes included adverse events and serious adverse events.

Results

A total of 132 patients (median [IQR] age, 65 [58-69] years; 96 men [72.73%]), with a median (IQR) baseline National Institutes of Health Stroke Scale score of 11 (9-12) points, were included in the intention-to-treat analysis. Ten patients withdrew during the 14-day intervention, and another 7 patients withdrew during the 90-day follow-up. During the 14-day intervention, the median neurological impairment was significantly improved in the MA group compared to the SA group (4 [3, 5] vs. 3 [1.25, 4] points; Cohen's d, 0.76; 95% CI, 0.33 to 1.19; p = 0.001). Adverse events occurred relatively equally between the MA and SA groups (19 [43.2%] vs. 13 [29.5%]; relative risk, 1.46; 95% CI, 0.83 to 2.58; p = 0.184).

Conclusion

Twelve sessions of MA were safe and effective in improving the neurological function of patients with ACI. The results of this trial indicate that MA can be recommended as a routine, supplemental therapy for improving neurological function in patients with ACI.

Clinical trial registration

ChiCTR2300079204 (Chinese Clinical Trial Registry, http://www.chictr.org.cn, registered on 27/12/2023).

Correlation between systemic bleeding during thrombolysis and intracranial hemorrhage after thrombolysis in acute ischemic stroke

BACKGROUND

Current models primarily predict outcomes before thrombolytic therapy. This study explored if systemic bleeding during thrombolysis predicts hemorrhagic transformation (HT) within 36 hours post-thrombolysis.

RESEARCH DESIGN AND METHODS

Data from 591 acute ischemic stroke patients treated with rt-PA at Wenzhou Central Hospital (2016-2023) were prospectively collected and analyzed. The incidence of systemic bleeding was compared with the Stroke Prognostication using Age and the National Institutes of Health Stroke Scale (Span100) index, as well as the Hemorrhage After Thrombolysis (HAT) scale.

RESULTS

Systemic bleeding occurred in 285 patients, including 92 with HT. The HT rate was significantly higher in patients with late-onset oral bleeding (35.90%) or other systemic bleeding (38.89%) than in those without (p < 0.01). Late-onset oral and systemic bleeding during thrombolysis predicted HT in anterior circulation infarction (p < 0.001) but not in posterior circulation infarction (p = 0.70). The AUC for predicting HT was 0.578 for these bleeding types, versus 0.568 for Span-100 and 0.61 for HAT. Incorporating bleeding types increased Span-100 sensitivity to 0.623 and HAT to 0.648.

CONCLUSIONS

Late-onset oral and other systemic bleeding during thrombolysis effectively predict HT in anterior circulation infarction, enhancing the sensitivity of Span100 and HAT scales when combined.

The burden of common neurological disorders in Asia: insights from the Global Burden of Disease Study (1990-2021)

BACKGROUND

Neurological disorders represent a significant global health issue, leading to severe cognitive impairments and being a major cause of premature mortality and disability. This study aims to utilize data from the Global Burden of Disease (GBD) research website to assess the burden of neurological disorders in the Asian region and its individual countries and territory from 1990 to 2021, with the goal of providing reference for global efforts and decision-making in the prevention, treatment, and management of neurological disorders.

METHODS

Based on the Global Burden of Disease data, this study assessed the incidence, prevalence, mortality, and disability-adjusted life years (DALYs) of 13 neurological disorders in the Asian region from 1990 to 2021. The epidemiological characteristics of neurological disorders across these Asian regions were analyzed. Joinpoint regression analysis was employed to assess the temporal patterns of the burden of neurological disorders, and the average annual percent change (AAPC) was calculated to determine the overall trend throughout the study period.

RESULTS

In 2021, stroke, migraine, and Alzheimer's disease and other dementias emerged as the primary contributors to neurological burden in Asia, with stroke accounting for 112.87 million disability-adjusted life years (DALYs), followed by migraine (25.4 million) and Alzheimer's disease and other dementias (20.0 million). Stroke was also the leading cause of neurological mortality (5.03 million deaths), trailed by Alzheimer's disease and other dementias (1.0 million). Stroke, migraine, and tension-type headache had the highest prevalence rates among neurological disorders, with 57.3 million, 683.5 million, and 1130.2 million. Temporal trends from 1990 to 2021 revealed a significant decline in age-standardized DALY rates for stroke (estimated annual percentage change [EAPC]: - 1.65%), though absolute DALYs increased (EAPC: 0.06%). In contrast, Alzheimer's disease and other dementias exhibited rising age-standardized (EAPC: 0.14%) and absolute DALYs (EAPC: 2.8%), while infectious neurological diseases (e.g., meningitis, tetanus) demonstrated marked reductions in burden. Sex-specific disparities were evident, with males experiencing a higher total DALY burden (84.8 million vs. 77.05 million), driven by stroke and Parkinson's disease, whereas Alzheimer's disease and other dementias and migraine disproportionately affected females. Geographically, stroke dominated Southeast Asia (67.6% of regional DALYs), while migraine contributed most substantially to West Asia (16%). Nationally, stroke ranked as the leading cause of neurological DALYs in most Asian countries, contrasting with migraine in Israel, Kuwait, Qatar, and the United Arab Emirates. Longitudinal analyses highlighted accelerated declines in stroke DALYs post- 2004 but escalating burdens for Alzheimer's disease and other dementias after 2019, reflecting divergent epidemiological trajectories.

CONCLUSIONS

In 2021, the burden of neurological disorders in Asia remained substantial, with stroke, migraine, and Alzheimer's disease and other dementias being the top three contributors to DALYs. The study also revealed significant differences in the burden of neurological disorders across various subregions and countries in Asia, highlighting the need for enhanced international collaboration, sharing of best practices, provision of technical support, and optimization of healthcare resource allocation.

Association of Age, Sex and Education With Access to the Intravenous Thrombolysis for Acute Ischemic Stroke

BACKGROUND

Barriers to treatment with intravenous thrombolysis (IVT) for patients with acute ischemic stroke (AIS) in South Korea remain incompletely characterized. We analyze a nationwide prospective cohort to determine patient-level features associated with delayed presentation and non-treatment of potential IVT-eligible patients.

METHODS

We identified consecutive patients with AIS from 01/2011 to 08/2023 from a multicenter and prospective acute stroke registry in Korea. Patients were defined as IVT candidates if they presented within 4.5 hours from the last known well, had no lab evidence of coagulopathy, and had National Institute of Health Stroke Scale (NIHSS) ≥ 4. Multivariable generalized linear mixed regression models were used to investigate the associations between their characteristics and the IVT candidates or the use of IVT among the candidates.

RESULTS

Among 84,103 AIS patients, 41.0% were female, with a mean age of 69 ± 13 years and presentation NIHSS of 4 [interquartile range, 1-8]. Out of these patients, 13,757 (16.4%) were eligible for IVT, of whom 8,179 (59.5%) received IVT. Female sex (adjusted risk ratio [RR], 0.90; 95% confidence interval [CI], 0.86-0.94) and lower years of education (adjusted RR, 0.90; 95% CI, 0.84-0.97 for 0-3 years, compared to ≥ 13 years) were associated with a decreased likelihood of presenting as eligible for IVT after AIS; meanwhile, young age (adjusted RR, 1.12; 95% CI, 1.01-1.24 for ≤ 44 years, compared to 75-84 years) was associated with an increased likelihood of being an IVT candidate. Among those who were eligible for IVT, only age was significantly associated with the use of IVT (adjusted RR, 1.09; 95% CI, 1.03-1.16 for age 65-74 and adjusted RR, 0.83; 95% CI, 0.76-0.90 for ≥ 85 years, respectively).

CONCLUSION

Most patients with AIS present outside IVT eligibility in South Korea, and only 60% of eligible patients were ultimately treated. We identified increased age, female sex and lower education as key features on which to focus interventions for improving IVT utilization.

Tenecteplase is here: navigating the shift of a stroke thrombolytic in the United States prior to FDA approval: a mini-review on rationale, barriers, and pathways

The transition from alteplase (TPA) to tenecteplase (TNK) in acute ischemic stroke (AIS) management is gaining traction due to TNK's advantages in ease of administration and lower costs. Several studies have demonstrated at least comparable safety and efficacy profiles, culminating in TNK's Food and Drug Administration (FDA) approval in early March 2025. Prior to this, challenges related to regulatory approvals, operational barriers, logistical constraints, and current clinical guidelines hindered the adoption of TNK across U.S. stroke systems. This mini-review seeks to address the pre-FDA approval obstacles to implementing TNK in stroke care and specifies some key aspects that support a transition, drawing insights from the early adoption experience of a U.S. health system. The discussion focuses on stakeholder involvement, formulary approval, and operational considerations, providing practical recommendations for stroke programs. The experience at Geisinger showcases a deliberate execution of a comprehensive change management strategy that resulted in successful and lasting outcomes. It may further serve as a blueprint for implementation of next generation thrombolytics yet to come.

Intracerebral Transplantation of Autologous Mesenchymal Stem Cells Improves Functional Recovery in a Rat Model of Chronic Ischemic Stroke

While treatments exist for the acute phase of stroke, there are limited options for patients with chronic infarcts and long-term disability. Allogenic mesenchymal stem cells (alloMSCs) show promise for the treatment of stroke soon after ischemic injury. There is, however, no information on the use of autologous MSCs (autoMSCs), delivered intracerebrally in rats with a chronic infarct. In this study, rats underwent middle cerebral artery occlusion (MCAO) to induce stroke followed by bone marrow aspiration and MSC expansion in a closed bioreactor. Four weeks later, brain MRI was obtained and autoMSCs (1 × 106, 2.5 × 106 or 5 × 106; n = 6 each) were stereotactically injected into the peri-infarct and compared to controls (MCAO only; MCAO + PBS; n = 6-9). Behavior was assessed using the modified neurological severity score (mNSS). For comparison, an additional cohort of MCAO rats were implanted with 2.5 × 106 alloMSCs generated from a healthy rat. All doses of autoMSCs produced significant improvement (54-70%) in sensorimotor function 60 days later. In contrast, alloMSCs improved only 31.7%, similar to that in PBS controls 30%. Quantum dot-labeled auto/alloMSCs were found exclusively at the implantation site throughout the post-transplantation period with no tumor formation on MRI or Ki67 staining of engrafted MSCs. Small differences in stroke volume and no differences in corpus callosum width were observed after MSC treatment. Stroke-induced glial reactivity in the peri-infarct was long-lasting and unabated by auto/alloMSC transplantation. These studies suggest that intracerebral transplantation of autoMSCs as compared to alloMSCs may be a promising treatment in chronic stroke.

Real world clinical experience of using Brainomix e-CTA software in a medium size acute National Health Service Trust

OBJECTIVES

Artificial intelligence (AI) software including Brainomix "e-CTA" which detect large vessel occlusions (LVO) have clinical potential. We hypothesized that in real world use where prevalence is low, its clinical utility may be overstated.

METHODS

In this single centre retrospective service evaluation project, data sent to Brainomix from a medium size acute National Health Service (NHS) Trust hospital between January 3, 2022 and January 3, 2023 was reviewed. 584 intracranial computed tomography angiogram (CTA) datasets were analysed for LVO by e-CTA. The e-CTA output and radiology report were compared to ground truth, defined by a consultant radiologist with fellowship neuroradiology training, with access to subsequent imaging and clinical notes. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated.

RESULTS

Of 584 cases (45% female, mean age 70 ± 16 years), 9% (n = 50) had LVO. e-CTA had a sensitivity of 0.78 (95% CI 0.64-0.88), specificity of 0.93 (0.9-0.95), PPV of 0.5 (0.42-0.58), and NPV of 0.98 (0.96-0.99). e-CTA had an error rate of 9% (52/584). Erroneous cases were categorized into causes for error. Common causes for false positives included incorrect anatomy (21%, 8/39) and other pathology (13%, 5/39), with several uncategorizable cases (39%, 15/39). Common causes for false negatives included LVO within the terminal internal carotid artery (ICA) (55%, 6/11) and uncategorizable (18%, 2/11).

CONCLUSIONS

We demonstrated that PPV of e-CTA is poor in consecutive cases in a real-world NHS setting. We advocate for local validation of AI software prior to clinical use.

ADVANCES IN KNOWLEDGE

Common AI errors were due to anatomical misidentification, presence of other pathology, and misidentifying LVO in the terminal ICA.

Thrombolysis in lacunar stroke: Comparison of early neurological improvement and 90-day functional outcome with cardioembolic stroke without large-vessel occlusion

INTRODUCTION

Thrombolysis (IVT) is effective in the treatment of lacunar stroke (LAC). However, most studies compared the outcome of LAC to a heterogenous control group. We aimed to compare early neurological improvement (ENI) and late functional outcomes following thrombolysis for LAC with a homogenous control group of cardioembolic stroke (CE) without large-vessel occlusion (LVO).

PATIENTS AND METHODS

Patient data were obtained from the national multicentre STAY ALIVE Acute Stroke Registry. At each centre, a team of vascular neurologists determined the TOAST classification. ENI was defined as a minimum 4-point decrease in the NIHSS score between admission and discharge, or a complete resolution of symptoms. For late functional outcome, we analysed the dichotomised 90-day mRS scores (good outcome was mRS≤2).

RESULTS

142 LAC and 156 CE patients were analysed. Following IVT, the percentage of ENI did not differ significantly (LAC 41.1% vs CE 49.7%, p=0.154), and multivariable analysis did not identify any clinical parameters that would predict ENI after IVT in either group. LAC patients had unfavourable, albeit non-significant, odds of having good 90-day functional outcomes compared to CE patients (aOR 0.483, 95% CI 0.201-1.161, p=104).

CONCLUSIONS

We report the first analysis of short- and long-term outcomes of IVT in LAC, using a homogenous control group of CE patients without LVO. The prevalence of ENI and 90-day functional outcomes were similar. However, LAC patients had unfavourable odds of achieving good functional outcomes compared to the control group. Therefore, we emphasise that LAC should not be considered a minor stroke subtype.

A novel annexin dimer targets microglial phagocytosis of astrocytes to protect the brain-blood barrier after cerebral ischemia

Despite the vital role of astrocytes in preserving blood-brain barrier (BBB) integrity, their therapeutic potential as targets in ischemic stroke-induced barrier disruption remains underexplored. We previously reported externalization of phosphatidylserine (PS) on astrocytic membranes concurrent with the emergence of PS externalization in neurons. PS externalization of astrocytes induced microglial phagocytosis of astrocytes, resulting in reduced astrocyte-vascular coupling and subsequent BBB breakdown. Annexin A5 (ANXA5) belongs to the superfamily of calcium (Ca2+)- and phospholipid-binding proteins. Here, we report two X-ray structures of human ANXA5, including monomeric ANXA5 (1.42 Å) and dimeric ANXA5 (1.80 Å). Through the combination of molecular docking and functional analysis, we explored the mechanism of action of ANXA5 in stroke treatment. In addition, we observed a clear increase in therapeutic efficacy corresponding to the increased affinity of ANXA5 for PS. In summary, the phagocytosis of PS-externalized astrocytes by microglia has emerged as a critical mechanism driving BBB breakdown after ischemia. Our findings offer valuable structural insight into ANXA5 as an innovative pharmacological target for safeguarding blood-brain barrier integrity after cerebral ischemia. These insights may facilitate the development of novel PS-targeting medications aimed at achieving enhanced efficacy with minimal side effects.

The fuzzy MAD stroke conjecture, using Fuzzy C Means to classify multimodal apparent diffusion for ischemic stroke lesion stratification

BACKGROUND

In conjunction with an epidemiologically determined treatment window, current radiological acute ischemic stroke practice discerns two lesion (stage) types: core (dead tissue, identified by diffusion-weighted imaging (DWI)) and penumbra (tissue region receiving just enough blood flow to be potentially salvageable, identified by the perfusion diffusion mismatch). However, advancements in preclinical and clinical studies have indicated that this approach may be too rigid, warranting a more fine-grained patient-tailored approach. This study aimed to demonstrate the ability to noninvasively provide insights into the current in vivo stroke lesion cascade.

METHODS

To elucidate a finer-grained depiction of the acute focal ischemic stroke cascade in vivo, we retrospectively applied our multimodal apparent diffusion (MAD) method to multi-b-value DWI, up to a b-value of 10,000 s/mm2 in 34 patients with acute focal ischemic stroke. Fuzzy C Means was used to cluster the MAD parameters.

RESULTS

We discerned 18 clusters consistent with normal appearing tissue (NAT) types and 14 potential ischemic lesion (stage) types, providing insights into the variability and aggressiveness of lesion progression and current anomalous stroke-related imaging features. Of the 529 ischemic stroke lesion instances previously identified by two radiologists, 493 (92 %) were autonomously identified; 460 (87 %) were identified as efficaciously or better than the radiologists.

CONCLUSIONS

The data analyzed included a small number of clinical patients without follow-up or contemporaneous histology; therefor, the findings and theorizing should be treated as conjecture. Nevertheless, each identified NAT and lesion type is consistent with the known underpinnings of physiological tissues and pathological ischemic stroke lesion (stage) types. Several findings should be considered in current clinical imaging: WM fluid accumulation, BBB compromise conundrum, b1000 identified core may not be dead tissue, and a practical reason for DWI (pseudo) normalization.

Female Sex is associated with reduced thrombolytic administration in an Australian Stroke Cohort: A multicentre retrospective cohort study

BACKGROUND

Female patients with AIS may not receive thrombolytic equitably.

AIMS

We examined whether there were sex differences in the likelihood of receiving thrombolytic in South Australian AIS patients.

METHODS

In a retrospective cohort study, consecutive patients admitted to metropolitan stroke units within South Australia between January 2019 to December 2023 with AIS without contraindication to thrombolytic were included. Multivariable logistic regression was used to determine the relevance of demographic, clinical, imaging and service delivery parameters associated with intravenous thrombolytic non-administration.

RESULTS

A total of 3484 patients were included (1519 (43.59 %) female), of whom 744 (21.35%), including 304 (20.01%) females and 440 (22.39%) males received intravenous thrombolytic. A trend towards thrombolytic non-administration was observed in females during univariate analysis (OR 1.15, 95% CI 0.98-1.36, p=0.09). Female sex was associated with reduced odds of receiving thrombolytic in multivariate analysis (aOR 1.38, 95% CI 1.09-1.59). Other major factors associated with not receiving thrombolysis included lack of code stroke activation (OR 20.43, 95% CI 9.19-58.09), symptom onset-to-door time above 4.5 hours (OR 5.89, 95% CI 3.90-9.28), 'wake up' stroke (OR 3.72, 95% CI 2.90-4.82), in hospital stroke (OR 3.13, 95% CI 1.48-7.47), NIHSS below 5 (OR 2.61, 95% CI 2.05-3.33) and CT perfusion not performed (OR 2.58, 95% CI 1.76-3.87. Mediation analysis demonstrated a significant partial mediation effect of female sex on thrombolytic non-administration via CT perfusion imaging non-performance.

CONCLUSION

This study identified female sex was associated with a reduced likelihood of receiving thrombolytic in AIS. Further studies to determine the reason for these disparities are required.

New Wine in an Old Bottle: tPA for Ischemic Stroke Management

As the only clinical thrombolytic drug approved by the FDA, tissue-type plasminogen activator (tPA) is the good standard acute treatment against ischemic stroke (IS) during the super-early stage. tPA forms the active principle of alteplase, a recombinant tissue-type plasminogen activator (rtPA), which is well known for its intravascular thrombolytic activity. However, the multifaceted functions of tPA in the central nervous system (CNS) hold untapped potential. Currently, increasing studies have explored the neuroprotective function of tPA in neurological diseases, particularly in acute ischemic stroke (AIS). A series of studies have indicated that tPA has anti-excitotoxic, neurotrophic, and anti-apoptotic effects on neurons; it is also involved in neuronal plasticity, axonal regeneration, and cerebral inflammatory processes, but how to deeply understand the underlying mechanism and take maximum advantage of tPA seems to be urgent. Therefore, more work is needed to illuminate how tPA performs with more diverse functions after stroke onset. In this comment, we focus on possible hypotheses about why and how tPA promotes ischemic neuronal survival in a comprehensive view. The text provides a holistic picture of the functions of tPA and enlists the considerations for the future, which might attract more attention toward the therapeutic potential of tPA in AIS.

Strategies for the Discovery and Design of Tissue Plasminogen Activators: Insights Into Bioengineering Objectives

Tissue plasminogen activators (tPAs) are critical in fibrinolysis and have become central to treating thrombotic disorders, including heart attacks, strokes, and pulmonary embolisms. Despite their efficacy, challenges such as bleeding complications, limited fibrin specificity, and rapid clearance necessitate the discovery of novel tPAs and the engineering of improved variants. This review highlights strategies for the discovery of tPAs from natural sources, including human, bacterial, venom-derived, and bat saliva-derived agents, as well as enzyme engineering approaches that enhance functional characteristics such as half-life, fibrin specificity, resistance to inhibitors, and clot penetration. Furthermore, this review explores alternative therapeutic approaches independent of tPAs, focusing on nonplasminogen activator agents and strategies that target platelets. By addressing current challenges and identifying future opportunities, this review provides a comprehensive perspective on advancing thrombolytic therapies through innovative discovery and design strategies.

The relationship between blood urea nitrogen to creatinine ratio and hemorrhagic transformation in stroke patients treated with endovascular thrombectomy

BACKGROUND

This study aimed to determine the parameters associated with hemorrhagic transformation in EVT and its relationship with blood urea nitrogen to creatinine (BUN/Cr) ratio-based dehydration status.

METHODS

Patients' data treated with EVT in AIS were evaluated from the years 2018 to 2023. Venous blood samples were collected prior to operation and BUN/Cr ratio was calculated. Alberta stroke program early CT (ASPECT) and collateral scores were determined. Hemorrhagic transformation was assessed by brain computed tomography. Mortality and 90-day disability rates were determined. Parameters associated with hemorrhagic transformation were evaluated according to regression analysis models.

RESULTS

There were 146 patients with a mean age of 67.01 ± 14.34 in the study. The first-pass thrombectomy rate was 32.2 % (n = 47); and 80.8 % (n = 118) of all patients achieved complete recanalization. Symptom-to-puncture and puncture-to-recanalization times were associated with hemorrhagic transformation (p = 0.004, p = 0.012). In addition, initial NIHSS (p < 0.001), number of thrombectomy passes (p < 0.001), intra-arterial thrombolysis (p = 0.008), ASPECT score (p < 0.001), collateral score (p = 0.016), and serum glucose (p = 0.047) levels were associated with hemorrhagic transformation. Decreased glomerular filtration rate (p = 0.007) was associated with symptomatic hemorrhagic transformation. Multivariate regression analysis revealed that the major parameters for hemorrhagic transformation were initial NIHSS and number of thrombectomy passes (p = 0.035, p = 0.046). No relationship was observed between BUN/Cr ratio and hemorrhagic transformation (p = 0.910).

CONCLUSION

In this study, no relationship was detected between BUN/Cr ratio-based dehydration and hemorrhagic transformation in AIS patients treated with EVT. The main predictive factors for hemorrhagic transformation are high initial NIHSS and number of thrombectomy passes.

Sequential design for paired ordinal categorical outcome

This study addresses a critical gap in the design of clinical trials that use grouped sequential designs for one-sample or paired ordinal categorical outcomes. Single-arm experiments, such as those using the modified Rankin Scale in stroke trials, underscore the necessity of our work. We present a novel method for applying the Wilcoxon signed-rank test to grouped sequences in these contexts. Our approach provides a practical and theoretical framework for assessing treatment effects, detailing variance formulas and demonstrating the asymptotic normality of the U-statistic. Through simulation studies and real data analysis, we validate the empirical Type I error rates and power. Additionally, we include a comprehensive flowchart to guide researchers in determining the required sample size to achieve specified power levels while controlling Type I error rates, thereby enhancing the design process of sequential trials.

Effects of global Ripk2 genetic deficiency in aged mice following experimental ischemic stroke

Besides the loss of blood and oxygen reaching the ischemic tissue, many secondary effects of ischemic stroke can cause additional tissue damage, including inflammation, oxidative stress, and proteomic disturbances. Receptor-interacting serine/threonine kinase 2 (RIPK2) is an important mediator in the post-stroke inflammatory cascade that responds to signals and molecular patterns released by dead or dying cells in the ischemic area. We hypothesize that RIPK2 signaling worsens injury and neurological recovery post-stroke and that global deletion of Ripk2 is protective following ischemic stroke in aged mice. Aged (18-24 months) male mice were subjected to permanent middle cerebral artery occlusion (pMCAO). Vertical grid, weight grip, and open field were conducted at baseline and on days 1, 2, 3, 8, 15, and 22 post-stroke. Cognitive tests (novel object recognition and Y-maze) were performed at baseline and day 28 post-stroke. Infarct size was measured using cresyl violet staining, and reactive gliosis was measured using Iba1 and GFAP staining at day 28 post-stroke. Global deletion of Ripk2 (Ripk2-/- ) in aged mice resulted in smaller infarct volume and improved performance on vertical grid and weight grip tests compared to aged wildtype (WT) mice. Additionally, aged Ripk2 -/- mice had less Iba1 staining in the ipsilateral cortex than the aged WT control mice. This study further elucidates the role of RIPK2 signaling in the ischemic cascade and expands our knowledge of RIPK2 in stroke to aged mice. These results support the hypothesis that RIPK2 signaling worsens injury post-stroke and may be an attractive candidate for therapeutic intervention.

Tenecteplase versus alteplase in patients with acute ischemic stroke: An updated meta-analysis of randomized controlled trials

INTRODUCTION

Acute ischemic stroke (AIS) is a leading cause of morbidity and mortality worldwide. While alteplase has been widely used for acute management, recent clinical trials suggest that tenecteplase (TNK) may offer improved clinical outcomes. This study aims to compare the efficacy and safety of TNK compared with alteplase.

METHODS

A comprehensive literature search was conducted using PubMed, Embase and Cochrane Library from inception to October 2024 to identify randomized controlled trials that compared TNK at 0.25 mg/kg dosage with alteplase. Data about clinical outcomes was extracted from both groups and assessed by generating forest plots using the random-effects model and pooling odds ratios (ORs).

RESULTS

A total of 11 RCTs with 7,546 patients were included in the analysis. TNK showed statistically significant improvement in excellent functional outcome (mRS 0-1) compared with alteplase (OR= 1.14, 95 % CI= 1.03-1.25). No statistically significant difference was observed for good functional outcome (mRS 0-2) (OR= 1.11, 95 % CI= 0.9-1.25), early neurological improvement (OR=1.08, 95 % CI= 0.93-1.26), all-cause death (OR=0.99, 95 % CI= 0.81-1.19), symptomatic intracranial hemorrhage (OR=1.11, 95 % CI=0.81-1.52) and poor functional outcome (mRS=4-6) (OR=0.95, 95 % CI=0.79-1.14).

CONCLUSION

In patients with acute ischemic stroke, TNK demonstrated a significant advantage over alteplase in achieving excellent functional outcomes. The incidence of early neurological improvement, symptomatic intracranial hemorrhage, all-cause death, and poor functional outcome remained comparable across the two groups.

Outcomes of Revascularization for Peripheral Artery Disease in Aboriginal and Torres Strait Islander Peoples and Non-Indigenous Australians

BACKGROUND

Australia's Aboriginal and Torres Strait Islander Peoples are at high risk of peripheral arterial disease (PAD), but outcomes of revascularization are unknown. Revascularization outcomes were compared among Aboriginal and Torres Strait Islander and non-Indigenous Australians.

METHODS

A retrospective cohort study was conducted of patients who underwent lower limb revascularization between January 2015 and July 2023. PAD severity was defined using the Rutherford classification and angiographic scoring systems (ANGIO score, Global Limb Anatomic Staging System [GLASS], Trans-Atlantic Inter-Society Consensus). The primary outcome was major adverse limb events (MALE), that is, major amputation or repeat revascularization. The secondary outcomes were major adverse cardiovascular events (MACE), major amputation, and repeat revascularization alone.

RESULTS

A total of 504 patients were included. Fifty-seven (11.3%) were Aboriginal and Torres Strait Islander People, who were more likely to present with chronic limb-threatening ischemia (74% vs. 65%; P = 0.01) and have infrapopliteal disease (GLASS: odds ratio [OR] 1.93, 95% confidence interval 1.15-3.24; P = 0.013; ANGIO score: OR 1.97, 1.18-3.29; P = 0.01) compared to non-Indigenous Australians. Risk of MALE (rate ratio [RR] 1.39; 0.91-2.13; P = 0.126) and repeat revascularization (RR 1.18, 0.74-1.88; P = 0.493) were similar, but Aboriginal and Torres Strait Islander People had a higher risk of major amputation (RR 3.35; 1.66-6.75; P = 0.001) and MACE (RR 1.88, 1.17-3.03; P = 0.009) than non-Indigenous participants. Adjusted analyses suggested the increased risk of major amputation was due to Aboriginal and Torres Strait Islander People presenting with more severe PAD and tissue loss compared to non-Indigenous patients.

CONCLUSION

Aboriginal and Torres Strait Islander Peoples present with more severe PAD and have greater risk of major amputation. Culturally appropriate programs are needed to raise awareness and promote secondary prevention.

A connection between covariate adjustment and stratified randomization in randomized clinical trials

The statistical efficiency of randomized clinical trials can be improved by incorporating information from baseline covariates (i.e. pre-treatment patient characteristics). This can be done in the design stage using stratified (permutated block) randomization or in the analysis stage through covariate adjustment. This article makes a connection between covariate adjustment and stratified randomization in a general framework where all regular, asymptotically linear estimators are identified as augmented estimators. From a geometric perspective, covariate adjustment can be viewed as an attempt to approximate the optimal augmentation function, and stratified randomization improves a given approximation by moving it closer to the optimal augmentation function. The efficiency benefit of stratified randomization is asymptotically equivalent to attaching an optimal augmentation term based on the stratification factor. In designing a trial with stratified randomization, it is not essential to include all important covariates in the stratification, because their prognostic information can be incorporated through covariate adjustment. Under stratified randomization, adjusting for the stratification factor only in data analysis is not expected to improve efficiency, and the key to efficient estimation is incorporating prognostic information from all important covariates. These observations are confirmed in a simulation study and illustrated using real clinical trial data.

Anticoagulation therapy after reperfusion treatment for acute ischemic stroke with non-valvular atrial fibrillation: a multicenter retrospective study

To understand anticoagulation therapy in acute ischemic stroke (AIS) patients with non-valvular atrial fibrillation (NVAF) after receiving reperfusion treatments in the real world. This retrospective study collected basic clinical data, the initiation time of anticoagulation therapy, treatment plans, and prognosis of AIS patients with AF who underwent intravenous thrombolysis (IVT), and/or endovascular thrombectomy (EVT) from January 2019 to January 2022 in four tertiary hospitals in Jiangxi Province. A multivariate logistic regression analysis was used to analyze the factors influencing anticoagulation therapy in these patients. The reasons for delay or non-initiation of anticoagulation therapy were analyzed by questionnaire. A total of 410 patients met the selection criteria, including 168 (41.0%) in the IVT group, 144 (35.1%) in the EVT group, and 98 (23.9%) in the IVT + EVT group. Initiation of anticoagulation therapy within 14 days post-AIS was found in 175 patients in total (42.7%), which is significantly different in three groups (49.7% in IVT group, 30.3% in EVT group, and 20.0% in IVT + EVT groups, P < 0.01). Multivariate logistic regression analysis revealed that prior use of antiplatelet drugs was more common in patients receiving early anticoagulation therapy (OR = 0.122, 95% CI 0.065-0.228, P < 0.01). Patients receiving no anticoagulation had higher-3-days post-reperfusion NIHSS score (OR = 1.109, 95% CI 1.073-1.147, P < 0.01) and more in-hospital haemorrhagic transformation (OR = 2.572, 95% CI 1.423-4.648, P < 0.01). Of all patients, 281 had a favorable 90-day prognosis (mRS score 0-2), including 152 (86.9%) in the early anticoagulation group and 129 (54.9%) in the delay anticoagulation group (P < 0.01). Postoperative 90-day outcomes included 25 (6.1%) cases of recurrent ischemic stroke (P = 0.55) and 27 (6.6%) bleeding events (P = 0.32). Early initiation of anticoagulation therapy improves 90-day outcomes in NVAF post-related AIS patients with related AF after receiving reperfusion treatments; however, the initiation of anticoagulation in most patients might be much later than the currently recommended timing in real world.

A methodological assessment of randomization integrity in alteplase for acute ischemic stroke individual patient data meta-analyses

OBJECTIVES

Little is known about the integrity of randomization for randomized controlled trials (RCT) included in alteplase for stroke meta-analyses. If the RCTs were not properly randomized, the results could not be accepted at face value. The objective was to assess the integrity of randomization in individual patient data (IPD) meta-analyses supporting alteplase for acute ischemic stroke.

METHODS

We assessed randomization reporting, performed qualitative risk of bias assessments arising from the randomization process, and performed fixed effects meta-analyses of baseline variables for which zero heterogeneity is expected if all included RCTs have unbiased randomization. Fixed-effects meta-analyses of baseline age, weight, and National Institute of Health Stroke Scale (NIHSS) score were performed. If heterogeneity was present (I2 >  0%), trials were systematically removed, starting with the RCT with the largest t-statistic until the I2 value was 0%.

RESULTS

The NINDS rt-PA Stroke Study had a high risk of bias, the ECASS-3 RCT had some concerns, and all other trials were graded as low risk according to the Cochrane Risk of Bias (ROB-2) tool. The NINDS rt-PA Stroke Study contributed to heterogeneity in age and weight meta-analyses, and the ECASS-3 RCT contributed to heterogeneity in the NIHSS score meta-analysis. Removal of suspect trials resulted in the expected I2 value of 0%.

CONCLUSIONS

The NINDS rt-PA Stroke Study and ECASS-3 trials contributed to heterogeneity in fixed effects meta-analyses of baseline variables while there should have been none. These RCTs are likely a source of selection bias in IPD meta-analyses due to suspect randomization.

Shengui Sansheng San alleviates the worsening of blood-brain barrier integrity resulted from delayed tPA administration through VIP/VIPR1 pathway

BACKGROUND

Intravenous tissue plasminogen activator (tPA) is currently the only FDA-approved thrombolytic therapy for acute ischemic stroke (AIS), however, relative narrow therapeutic time window (within 4.5 h of AIS onset) and high risk of hemorrhagic transformation due to blood-brain barrier (BBB) disruption limit tPA therapeutic benefits for patients. In this study, we extended the time window of tPA administration (5 h after the occurrence of AIS) and investigated whether Chinese medicine classical formula Shengui Sansheng San (SSS) administration was able to alleviate BBB integrity worsening, and the mechanism was related to vasoactive intestinal peptide (VIP)/ VIP receptor 1 (VIPR1) pathway.

METHODS

SSS was extracted using aqueous heating method and SFE-CO2 technology, and quality control was performed using UHPLC/MS analysis. Male C57BL/6 mice were suffered from middle cerebral artery occlusion (MCAo), followed by the removal of a silicone filament after 5 h, then, t-PA was administered via tail vein injection at once, along with SSS administration by gavage. Hemoglobin levels and Evans blue leakage were measured to assess brain hemorrhagic transformation and BBB permeability, respectively. Transmission electron microscope (TEM) was utilized to present brain microvascular endothelial cells (BMECs) tight junction morphology. TTC staining and laser speckle contrast imaging were employed for infarct volume and cerebral blood flow measurements. The modified neurological severity score (mNSS) test was conducted to evaluate neurological function. The expressions of VIP, VIPR1, ZO-1, Occludin, Lectin, GFAP, NeuN were detected by immunofluorescence staining or western blotting. In vitro, bEnd.3 and N2a cells were insulted by oxygen-glucose deprivation (OGD), and VIPR1 siRNA, and VIP shRNA transfection were respectively performed, and the molecular docking was applied to verify the SSS in-serum active compounds interacted with VIPR1. The transwell system was utilized to detect OGD-insulted BMECs permeability.

RESULTS

SSS treatment significantly reduced the infarct area, cerebral hemorrhage, and neurological deficits, and enhanced cerebral blood flow in AIS mice received intravenous tPA beyond 4.5 h time window. Simultaneously, the permeability of BBB declined, with increased expressions of tight junction proteins ZO-1, and Occludin and proper BMECs tight junction morphology, and it suggested that VIP was released by neurons rather than astrocytes or BMECs. It also showed high expressions of VIP and VIPR1 in the penumbra area. The inhibition of VIP in N2a cells or VIPR1 in bEnd.3 cells abolished the viability and integrity of OGD-insulted bEnd.3 cells treated by tPA after SSS-containing serum administration, and the SSS in-serum active compounds were proved have high affinity to VIPR1 by molecular docking.

CONCLUSION

SSS alleviates the worsening of BBB integrity resulted from delayed tPA administration, reduces hemorrhagic transformation and infarction volume, and ameliorates brain blood flow and neurological function in AIS mice. The mechanisms are associated with the activation of VIP/VIPR1 pathway to enhance BMECs viability and maintain tight junction phenotype.

Group Sequential Test for Two-Sample Ordinal Outcome Measures

Group sequential trials include interim monitoring points to potentially reach futility or efficacy decisions early. This approach to trial design can safeguard patients, provide efficacious treatments for patients early, and save money and time. Group sequential methods are well developed for bell-shaped continuous, binary, and time-to-event outcomes. In this paper, we propose a group sequential design using the Mann-Whitney-Wilcoxon test for general two-sample ordinal data. We establish that the proposed test statistic has asymptotic normality and that sequential statistics satisfy the assumptions of Brownian motion. We also include results of finite sample simulation studies that show our proposed approach has the advantage over existing methods for controlling Type I errors while maintaining power for small sample sizes. A real data set is used to illustrate the proposed method and a sample size calculation approach is proposed for designing new studies.

Etiologic spectrum and neurological outcomes in pediatric arterial ischemic stroke and cerebral sinovenous thrombosis: A 15-Year retrospective study at a tertiary hospital

OBJECTIVES

To evaluate clinical and radiological features, risk factors, etiology, treatment approaches, and outcomes of pediatric arterial ischemic stroke (AIS) and cerebral sinovenous thrombosis (CSVT).

METHODS

Children beyond the neonatal period diagnosed with AIS or CSVT between 2002 and 2017 were retrospectively analyzed. Demographics, clinical presentations, radiological findings, risk factors, etiologies, treatments, and outcomes were reviewed.

RESULTS

A total of 94 patients with AIS and 27 with CSVT were included. The median age for AIS patients was 4.1 years (IQR:1.6-9.8). Focal neurological deficits were present in 81.7%, hemiparesis being the most common symptom. Seizures were noted in 30.4%. Cardiac abnormalities (39%) and arteriopathies (38%) were the most common etiologies, with prothrombotic conditions and rare genetic disorders also remarkable underlying risk groups. Antithrombotic therapy was administered without major complications to 89.3%. At a median three-year follow-up, 33.8% had no neurological deficits, 33.8% had moderate to severe deficits or died, 16.2% had epilepsy. For CSVT, the median age was 9.6 years (IQR:3.2-12.6). Diffuse neurological symptoms were present in 77.7%, primarily headaches and vomiting. Seizures occurred in 22.2%. All CSVT patients had at least one risk factor. Chronic systemic conditions (63%) and infections (44%) were the most common risk factors. During follow-up of a median of 43 months, 63.6% had no neurological deficits.

CONCLUSIONS

Pediatric stroke has a broad spectrum of risk factors. Our study contributes to the existing knowledge on pediatric AIS and CSVT, providing a detailed overview of pediatric AIS and CSVT at a tertiary center, reflecting the growing awareness of physicians in childhood cerebrovascular diseases.

Thrombolytic Imaging-to-Needle Time as a Metric for Comparing Telemedicine versus In-Person Evaluation in Acute Ischemic Stroke

OBJECTIVES

Door-to-needle time (DTN) is standard for measuring the efficiency of thrombolytic administration in acute ischemic stroke, with guidelines recommending DTN <60 minutes. DTN can be divided into door-to-imaging time (DIT) and imaging-to-needle time (ITN), separated by arrival at the CT scanner. We hypothesize that ITN is more accurate for comparing the mode of evaluation for stroke patients treated with thrombolytics.

METHODS

This is a retrospective cohort study of stroke patients treated with thrombolytics at Southern Illinois Health care. Data on demographics, clinical presentation, stroke metrics, thrombolytic complications, and mRS at 1-month were reviewed. Multivariate logistic regression models were applied to evaluate predictors of DTN, ITN, and DIT, with OR and 95% CI. P-value was set at 0.05.

RESULTS

Out of 287 patients, 170 were evaluated by telemedicine, 117 in-person. The 2 groups were comparable in demographics and stroke severity. Telemedicine had longer median DTN, in minutes [55 (43 to 70) vs. 42 (34 to 62), P<0.01], and median ITN, in minutes [43 (35-58) vs. 32 (25-48), P<0.01]. There was no statistical difference in DIT between the 2 groups. Adjusted for stroke severity and age, telemedicine was associated with lower odds of DTN <60 minutes (OR: 0.553, 95% CI: 0.328-0.931, P=0.026) and ITN <35 minutes (OR: 0.265, 95% CI: 0.159-0.441, P<0.01). However, telemedicine was not independently associated with DIT <25 minutes, which was instead inversely correlated with age (OR: 0.974, 95% CI: 0.951-0.997, P=0.03).

CONCLUSIONS

ITN represents a more accurate metric for comparing telemedicine and in-person evaluations than DTN, as it excludes stroke-specific processes of care and patient-specific factors that are intrinsic to DTN and unrelated to the modality of evaluation.

Clinical Predictors of Stroke Mimics in Code Stroke Patients Evaluated via Telemedicine and Treated With Thrombolytic Therapy

Background

Intravenous thrombolysis is an established treatment to improve functional outcomes in acute ischemic stroke. However, various acute central nervous system dysfunctions can mimic stroke, where thrombolytic therapy may provide no benefit and carries potential risks. The ability to accurately distinguish stroke mimics vs stroke by telemedicine evaluation is uncertain. This study aims to identify clinical predictors of stroke mimics in patients evaluated via telemedicine for suspected ischemic stroke and treated with thrombolytics.

Methods

We conducted a retrospective observational study of patients treated with thrombolytics for suspected acute ischemic stroke via telemedicine at Southern Illinois Healthcare between 2017 and 2024. Data on demographics, past medical history, clinical presentation, National Institutes of Health Stroke Scale (NIHSS), stroke metrics, and laboratory values were collected. Final diagnoses were categorized as cerebrovascular disease (CD), including acute ischemic stroke and transient ischemic attack, and stroke mimic (SM). Outcomes included hospital length of stay (LOS) and discharge disposition.

Results

Of 171 patients treated with thrombolytics via telemedicine, 128 (75%) were diagnosed with CD, and 43 (25%) were SM, with toxic-metabolic encephalopathy being the most common mimic (40%, n = 17). Adjusted forward logistic regression showed age (OR: 0.957, 95% CI: 0.931-0.984, P = .002) and NIHSS (OR: 1.098, 95% CI: 1.032-1.168, P = .003) remained independently associated with SM. The predictive TeleStroke Mimic was score performed with c-statistic of 0.61. SM had shorter median LOS (3 [2-3] vs 3 [2-6], P < .01) and higher rate of discharge home (86% vs 55%, P < .01).

Conclusions

In our population, younger age and higher NIHSS were associated with higher odds of SM diagnosis in patients treated with telemedicine-administered thrombolytics. These variables are insufficient to reliably identify a subgroup of patients evaluated via telemedicine for whom thrombolytics could be withheld. The poor performance of Telestroke Mimic score highlights the need for improved predictive tools. Until larger studies are conducted, telemedicine-administered thrombolytics should adhere to current in-person guidelines.

Sex differences in age-associated neurological diseases-A roadmap for reliable and high-yield research

Once taken into consideration, sex differences in neurological diseases emerge in abundance: (i) Stroke severity is significantly higher in females than in males, (ii) Alzheimer's disease (AD) pathology is more pronounced in females, and (iii) conspicuous links with hormonal cycles led to female-specific diagnoses, such as catamenial migraines and epilepsy. While these differences receive increasing attention in isolation, they likely link to similar processes in the brain. Hence, this review aims to present an overview of the influences of sex chromosomes, hormones, and aging on male and female brains across health and disease, with a particular focus on AD and stroke. The focus here on advancements across several fields holds promise to fuel future research and to lead to an enriched understanding of the brain and more effective personalized neurologic care for all.

A study of the safety and efficacy of multi-mode NMR-guided double-antiplatelet pretreatment combined with low-dose rtPA in the treatment of acute mild ischemic stroke

OBJECTIVE

The objective of this study was to evaluate the safety and efficacy of dual antiplatelet pretreatment combined with low-dose rtPA therapy in patients with acute mild ischemic stroke, guided by multimodal MRI.

METHODS

In this study, 383 patients with acute mild ischemic stroke (NIHSS ≤ 5) who had symptom onset within 4.5 hours of MRI screening were selected. Patients in the dual antiplatelet pretreatment plus low-dose rtPA group (164 cases) received dual antiplatelet therapy combined with low-dose (0.6 mg/kg) rtPA intravenous thrombolysis. Patients in the standard-dose group (112 cases) received conventional-dose (0.9 mg/kg) rtPA intravenous thrombolysis. Additionally, patients in the dual antiplatelet group who did not receive intravenous thrombolysis (107 cases) underwent 21 days of oral dual antiplatelet treatment.

RESULTS

There was no significant difference in the baseline NIHSS scores among the three groups before treatment (p > 0.05). The proportion of early neurological improvement within 24 hours and within 7 days was significantly higher in the DAPT plus low-dose group compared to both the standard-dose group and the DAPT group, with statistical significance (p < 0.05). After 90 days of follow-up, the proportion of good functional outcomes in the DAPT plus low-dose group was significantly higher than in both the standard-dose group and the DAPT group (p < 0.05), but there was no significant difference between the standard-dose group and the DAPT group. Safety studies indicated that, under MRI guidance, the DAPT plus low-dose group and the standard-dose group had lower incidences of intracranial hemorrhage transformation and symptomatic intracranial hemorrhage, with no statistical difference among the three groups (p > 0.05). Mortality rates were also similar across the three groups (p > 0.05), with only one patient passing away in the standard-dose group.

CONCLUSION

After dual antiplatelet pretreatment combined with low-dose rtPA intravenous thrombolysis for acute mild stroke under multimodal MRI guidance, the proportion of patients with good functional outcomes within 90 days was higher compared to the DAPT group and the standard-dose group, with statistical significance. There was no significant increase in the risk of cerebral hemorrhage compared to the standard-dose group and the DAPT group.

Intravenous Thrombolysis in Cervical Artery Dissection-Related Stroke: A Nationwide Study

BACKGROUND

Although intravenous thrombolysis (IVT) is safe and effective in populations with general stroke, its impact on cervical artery dissection-related acute ischemic stroke (CeAD-AIS) remains unclear. This retrospective study used the National Inpatient Sample to compare outcomes in patients with CeAD-AIS treated with and without IVT.

METHODS

We included adult patients with concurrent CeAD and AIS diagnoses (International Classification of Diseases, Tenth Revision [ICD-10], codes) hospitalized from 2016 to 2019. The primary outcome was home discharge; safety outcomes included inpatient death and intracerebral hemorrhage. We performed survey-weighted multivariable logistic regressions comparing IVT versus no IVT, followed by interaction analyses to examine effect modifications based on age, medical history, stroke severity, carotid artery involvement, and endovascular treatment.

RESULTS

Between 2016 and 2019, 1360 (12.1%) of 11 285 patients with CeAD-AIS received IVT. IVT-treated patients had higher median National Institutes of Health Stroke Scale scores (median [interquartile range], 8 [4-17] versus 3 [1-11]; P<0.001). Adjusted analyses showed IVT was associated with higher odds of home discharge (adjusted odds ratio [OR], 1.40 [95% CI, 1.01-1.92]; P=0.042), but not with inpatient death (adjusted OR, 1.29 [95% CI, 0.76-2.20]; P=0.347) or intracerebral hemorrhage (adjusted OR, 0.69 [95% CI, 0.32-1.48]; P=0.341). Stroke severity (P for interaction=0.001) and carotid artery involvement (P for interaction=0.021) significantly modified IVT's effect on home discharge, with IVT being associated with an increased likelihood of home discharge in patients with moderate to severe strokes (National Institutes of Health Stroke Scale score >4) and carotid artery involvement.

CONCLUSIONS

IVT improves the likelihood of home discharge in patients with CeAD-AIS without increasing the risk of inpatient death or intracerebral hemorrhage.

Asynchronous Distance Learning Performance and Knowledge Retention of the National Institutes of Health Stroke Scale Among Health Care Professionals Using Video or e-Learning: Web-based Randomized Controlled Trial

BACKGROUND

Stroke treatment has significantly improved over the last decades, but the complexity of stroke cases requires specialized care through dedicated teams with specific knowledge and training. The National Institutes of Health Stroke Scale (NIHSS), widely used to assess neurological deficits and make treatment decisions, is reliable but requires specific training and certification. The traditional didactic training method, based on a video, may not adequately address certain NIHSS intricacies nor engage health care professionals (HCPs) in continuous learning, leading to suboptimal proficiency. In the context of time-constrained clinical settings, highly interactive e-learning could be a promising alternative for NIHSS knowledge acquisition and retention.

OBJECTIVE

This study aimed to assess the efficacy of a highly interactive e-learning module compared with a traditional didactic video in improving NIHSS knowledge among previously trained HCPs. Furthermore, its impact on knowledge retention was also assessed.

METHODS

A prospective, multicentric, triple-blind, and web-based randomized controlled trial was conducted in 3 Swiss university hospitals, involving HCPs previously trained in NIHSS. Invitations were sent through email, and participants were randomized to either the e-learning or traditional didactic video group through a fully automated process upon self-registration on the website. A 50-question quiz was administered before and after exposure to the training method, and scores were compared to assess knowledge acquisition. The quiz was repeated after 1 month to evaluate retention. Subjective assessments of learning methods that is, user satisfaction, probability of recommendation, perceived difficulty, and perception of duration, were also collected through a Likert-scale questionnaire. A sample size of 72 participants were deemed necessary to have an 80% chance of detecting a difference of 2 points in the postcourse quiz between groups at the 5% significance level.

RESULTS

Invitations to participate were sent through email to an estimated 325 HCPs. 174 HCPs enrolled in the study, of which 97 completed the study course. Both learning methods significantly improved NIHSS knowledge, with an improvement of 3.2 (range 2.0-4.3) points in the e-learning group and of 2.1 (1.2-3.1) points in the video group. However, the e-learning group performed better, with higher scores in knowledge acquisition (median score 39.0, IQR 36.0-41.0 vs 37, IQR 34.0-39.0; P=.03) and in knowledge retention (mean score 38.2, 95% CI 36.7-39.7 vs 35.8, 95% CI 34.8-36.8; P=.007). Participants in the e-learning group were more likely to recommend the learning method (77% vs 49%, P=.02), while no significant difference was found for satisfaction (P=.17), perceived duration (P=.17), and difficulty (P=.32).

CONCLUSIONS

A highly interactive e-learning module was found to be an effective asynchronous method for NIHSS knowledge acquisition and retention in previously NIHSS-trained HCPs, and may now be considered for inclusion in NIHSS training programs for HCPs.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.3390/healthcare9111460.

[Acute ischemic stroke treatment]

Intravenous thrombolysis (IVT) and endovascular therapy (EVT) are the cornerstones of acute ischemic stroke treatment. While IVT has been an integral part of acute therapy since the mid-1990s, EVT has evolved as one of the most effective treatments in medicine over the past decade. Traditionally, systemic thrombolysis has been performed with alteplase (rtPA). More recently, tenecteplase (TNK) has been shown to be non-inferior to rtPA. TNK has some pharmacological advantages over rtPA and may lead to earlier recanalization, particularly in large vessel occlusions. All recanalization therapies are highly time dependent. To ensure rapid treatment, standard operating procedures (SOPs) should be established and followed in clinical practice. The optimal time window for IVT is 4.5 h after symptom onset and can be extended up to 9 h using specialized imaging techniques. For EVT, studies suggest a time window up to 24 h after symptom onset. In some cases, EVT has been successfully performed beyond this time window. To select patients for EVT, advanced imaging identifying salvageable brain tissue might be necessary. Even in large ischemic stroke, EVT can still improve outcome. Compared to EVT, IVT requires fewer technical and human resources, so more stroke patients can potentially be treated. In contrast, EVT requires highly trained personnel with sophisticated equipment and can, therefore, only be performed in specialized centers. Both procedures should be combined within the 4.5 h time window for patients without contraindications.

Intravenous Thrombolysis for Acute Ischemic Stroke Following Cervical Epidural Injection: A Case Report

A recent lumbar puncture (LP) is a relative contraindication for intravenous thrombolysis (IVT) due to the potential for the development of spinal hematoma. While there have been case reports of IVT administered without complications following LP or epidural anesthesia, there is limited data overall regarding the safety of IVT for acute ischemic stroke (AIS) in patients who have undergone a neuraxial procedure. We present a case report of an 83-year-old man who presented with a sudden onset of symptoms consistent with left middle cerebral artery (MCA) stroke after receiving a cervical epidural injection (CEI) earlier that same day. The patient received IVT after a comprehensive examination, including brain imaging that showed no intracranial hemorrhage and confirmed a large vessel occlusion (LVO), and a thorough assessment of the risks and benefits. There were no reported complications post treatment, and the patient showed improvement in symptoms on follow-up visits. This case report highlights the safe and successful administration of IVT for AIS following a recent CEI.

A Checklist to Improve Acute Stroke Evaluation and Treatment in the Emergency Department

Narrow therapeutic time windows and delays in assessing acute ischemic stroke patients limit the access to and effectiveness of reperfusion therapies. A 2-year quality improvement project codesigned and tested a checklist for quicker evaluation of suspected stroke cases in 2 emergency departments (EDs). Utility, feasibility, and implementation barriers were assessed through semistructured interviews. The impact on stroke quality metrics was analyzed using bivariate and multivariate regression models with data from the American Heart Association's Get With the Guidelines registry. Implementing the checklist was significantly associated with higher odds of receiving intravenous thrombolytics within 60 minutes of ED arrival (odds ratio: 6.4, 95% confidence interval: 1.1-68.7, P = 0.03). Users felt the checklist improved the standardization of stroke care and promoted teamwork, especially in a time of higher staff turnover. An ED-based stroke checklist resulted in timelier stroke care for acute ischemic stroke patients, meriting further testing in larger, more diverse settings.

Is NEWS of value for patients with acute stroke?

BACKGROUND

Patients with acute stroke are at risk of respiratory or circulatory compromise resulting in vital instability, which can be captured through the widely used aggregated National Early Warning Score (NEWS). We aimed to assess the relation between vital instability (defined as NEWS of five or higher) and death or dependency at 90 days after stroke.

METHODS

In this observational cohort study we studied 763 patients with ischaemic stroke (n = 400), intracerebral haemorrhage (ICH) (n = 146) or subarachnoid haemorrhage (SAH) (n = 217), hospitalized to a Dutch tertiary referral hospital from 1 January 2017 to 31 December 2018. We calculated NEWS for each 8 h time span during the first 72 h after hospitalization. We also decomposed NEWS into its three components respiration, circulation and consciousness. The primary outcome was death or dependency (modified Rankin Scale score ⩾3) at 90 days after stroke. The association of vital instability with functional dependency was examined using Poisson regression.

RESULTS

Two hundred and twenty-seven (58%) patients with ischaemic stroke, 101 (69%) with ICH and 142 (65%) with SAH had at least one episode of vital instability. In patients with ischaemic stroke or SAH, vital instability was associated after adjustment for confounders with death or dependency (adjusted relative risk 1.55 ((95% CI) 1.25-1.93 and 2.13 (1.35-3.36), respectively)). This was mainly driven by impaired consciousness, which was associated with death or dependency in all types of stroke. Respiratory insufficiency and circulatory instability were associated with death or dependency only in SAH.

CONCLUSION

Vital instability in the first 72 h of hospitalization for ischaemic stroke or SAH is associated with death or dependency at 90 days. Impaired consciousness was the main driver of this relationship. NEWS may not be appropriate for patients with acute stroke, mainly due to the dichotomous manner in which the level of consciousness is classified, and modification of NEWS should be considered for these patients.

Beyond conventional imaging: A systematic review and meta-analysis assessing the impact of computed tomography perfusion on ischemic stroke outcomes in the late window

BACKGROUND

Non-contrast cranial computed tomography (NCCT) and CT angiogram (CTA) have become essential for endovascular treatment (EVT) in acute stroke. Patient selection may improve when CT perfusion (CTP) imaging is also added for patient selection. We aimed to analyze the effects of implementing CTP in acute ischemic stroke (AIS) patients' treatment to assess whether stroke outcomes differ in the late window.

METHODS

We searched the PubMed, Embase, and Web of Sciences databases to obtain articles related to CTA and CTP in EVT. Collected patient data were split into two groups: the CTP and control (NCCT + CTA) cohorts. Primary outcomes evaluated were modified Rankin Scale (mRS) scores, symptomatic intracranial hemorrhages (sICHs), mortality, and successful recanalization.

RESULTS

There were 14 studies with 5809 total patients in the final analysis: 2602 received CTP and 3202 were in the control group. CTP/CTA patients showed significantly lower rates of 90-day stroke-related mortality (odds ratio (OR) = 0.72, 95% confidence interval (CI) = 0.60-0.87, p < 0.01) and significantly higher successful recanalization (OR = 1.42, 95% CI = 1.06-1.94, p < 0.01) compared with CTA-only patients. Analysis of other outcomes including functional independence (mRS = 0-2), critical times, and intracranial hemorrhages was non-significant (p > 0.05).

CONCLUSION

The study highlights the usefulness of CTP-guided therapy as a supplementary tool in EVT selection in the late window. Although the addition of CTP resulted in lower mortality, the favorable outcomes did not improve. Further evidence is required to establish a clearer understanding of the potential advantages or limitations of incorporating CTP in stroke imaging.