A National, Electronic Health Record-Based Study of Perinatal Hemorrhagic and Ischemic Stroke

BACKGROUND

Perinatal stroke occurs in approximately 1 in 1100 live births. Large electronic health record (EHR) data can provide information on exposures associated with perinatal stroke in a larger number of patients than is achievable through traditional clinical studies. The objective of this study is to assess prevalence and odds ratios of known and theorized comorbidities with perinatal ischemic and hemorrhagic stroke.

METHODS

The data for patients aged 0-28 days with a diagnosis of either ischemic or hemorrhagic stroke were extracted from the Cerner Health Facts Electronic Medical Record (EMR) database. Incidence of birth demographics and perinatal complications were recorded. Odds ratios were calculated against a control group.

RESULTS

A total of 535 (63%) neonates were identified with ischemic stroke and 312 (37%) with hemorrhagic stroke. The most common exposures for ischemic stroke were sepsis (n = 82, 15.33%), hypoxic injury (n = 61, 11.4%), and prematurity (n = 49, 9.16%). The most common comorbidities for hemorrhagic stroke were prematurity (n = 81, 26%) and sepsis (n = 63, 20%). No perinatal ischemic stroke patients had diagnosis codes for cytomegalovirus disease. Procedure and diagnosis codes related to critical illness, including intubation and resuscitation, were prominent in both hemorrhagic (n = 46, 15%) and ischemic stroke (n = 45, 8%).

CONCLUSION

This electronic health record-based study of perinatal stroke, the largest of its kind, demonstrated a wide variety of comorbid conditions with ischemic and hemorrhagic stroke. Sepsis, prematurity, and hypoxic injury are associated with perinatal hemorrhagic and ischemic stroke, though prevalence varies between types. Much of our data were similar to prior studies, which lends validity to the electronic health record database in studying perinatal stroke.

Abstract WMP36: Pain In Stroke Patients At Hospital Discharge

Introduction: Persistent pain after stroke significantly impacts patients’ function, ability to participate in rehabilitation, and quality of life. We examined characteristics of stroke survivors discharged with pain.

Methods: The sample consisted of 824 stroke patients admitted to a large, urban university based acute care facility in Texas with a completed pain assessment (numeric rating scale or Behavior Pain Scale) at discharge. Descriptive analysis of means and frequency distributions was conducted using a two-sided t-test for continuous variables and a Chi-squared test for categorical variables. Univariable and multivariable logistic regression models were used to determine the association between pain at discharge and type of stroke, adjusting for age, sex, race, smoking status, prevalent hypertension, BMI, and length of stay (LOS). We also tested for statistical interactions between stroke type and age, sex, and race.

Results: The mean age was 64 years, with 56% (n=462) being males. Of the 824 stroke patients, 584 (71%) had ischemic stroke while 237 (29%) had hemorrhagic (ICH) stroke. At discharge, 43% (n=358) reported pain. In unadjusted analyses, those reporting pain were younger (p<0.001), had a higher BMI (p=0.009), had longer LOS (p<0.001), and were less likely to have ischemic stroke (p<0.001). Only sex modified the association between stroke type and pain at discharge (p=0.002; AUC=0.716). In sex-stratified analysis females with ischemic stroke had lowered odds of reporting pain at discharge by 75% compared to those having ICH (OR=0.25; 95% CI: 0.15-0.41).

Conclusions: Our study finds that 43% of stroke survivors reported pain at discharge. Younger females with an increased BMI and an increased LOS were more likely to report pain. Our model AUC suggests that post stroke pain may be a complicated phenomenon that requires more complex models.

Abstract WMP23: Dynamic Imaging Of Blood Coagulation Within The Hematoma Of Patients With Acute Intracerebral Hemorrhage

Objective: To serially quantify the blood coagulation within hematoma of patients with hyper-acute intracerebral hemorrhagic (ICH) stroke using non-invasive quantitative susceptibility mapping (QSM) MRI.

Introduction: A blood clot is a combination of aggregated red blood cells, fibrin, platelets, hemosiderin, and other cell debris. An accurate evaluation of clot formation within hematoma could advance the clinical management of hematoma expansion, blood pressure management, and reversal of anticoagulants. Post-ICH hemolysis changes the heme iron oxidation state from oxy to deoxyhemoglobin (deoxy-Hb) resulting in unpaired iron electrons on aggregated RBC’s deoxy-Hb inducing magnetic susceptibility (χ). Therefore, a region with a higher number of aggregated RBC deoxy-Hb molecules, the dominant component of clots, will exhibit a higher positive χ susceptibility. We hypothesized that coagulated blood within hematoma will exhibit a higher positive χ in comparison to the non-clotted which can be quantified using quantitative susceptibility mapping (QSM), which is an advanced MRI image-processing algorithm.

Methods: For proof of concept, we measured susceptibilities of 5 human blood phantoms with various percentages of the clot. Twenty-four patients with acute spontaneous ICH were enrolled and serially imaged 3 times within 12-24 (T1), 36-48 (T2), and 60-72(T3) hours of last known well (LNW). A 3D anatomical and multi-echo gradient echo images were obtained using a 3T MRI system. Hematoma and edema volumes were segmented and used as a region of interest (ROI). The rate of coagulation was assessed by measuring the change in susceptibilities within the hematoma.

Results: The blood phantom exhibited a linear relationship between the percent coagulation and χ (R 2 =0.91). The QSM maps showed a significant increased in hematoma susceptibility over time (T1=0.29 ± 0.04, T2=0.36 ± 0.04, T3= 0.45 ± 0.04 ppm, p<0.0001). The overall average rate of coagulation was 0.00290 ± 0.0029 ppm per hour. No significant change in hematoma volume (18.9 ±3.1 cc) over time. A significant edema growth over time (T1=25.3 ± 3.6, T2= 28.1 ± 3, T3= 32.37 cc, p<0.05).

Conclusion: In conclusion, we present novel surrogate imaging markers of coagulation within the hematoma of ICH.

Abstract WP54: Factors Associated With First Year Inpatient And Outpatient Rehabilitation Use Among Acute Ischemic Stroke Patients

Introduction: Stroke is a leading cause of long-term disability in the U.S., and 90% of stroke survivors have residual movement impairment. Inpatient and outpatient rehabilitation is critical for restoring functionality and quality of life among survivors. However, there are few studies evaluating the patterns and predictors of rehabilitation use among stroke survivors.

Methods: This study used 947 tPA-eligibe patients from an observational, prospective, multicenter, clinical trial in the U.S., who had complete 1 year follow-up utilization data, collected quarterly as self-reported surveys. We determined the occurrence and length of stay for inpatient rehabilitation, and occurrence and number of visits for outpatient rehabilitation. Logistic and linear regressions were used to examine predictors associated with these occurrences and intensities.

Results: The majority of rehabilitation use occurred during the first quarter with 19% and 33% of patients using inpatient and outpatient rehabilitation respectively, and rehabilitation use fell considerably over the rest of the year (Table 1). Higher disability at baseline (mRS≥2 and not living at home) reduced rehabilitation use, and higher disability at discharge increased rehabilitation use. Being uninsured reduced rehabilitation use. Other socio-demographic characteristics (such as age, gender and race-ethnicity), baseline comorbidities, and type and timeliness of therapies after stroke did not have an effect on rehabilitation use.

Conclusion: Rehabilitation use is highest during the first 3 months after discharge. Patients with higher discharge disability are more in need of rehabilitation, hence receive it. Patients already disabled at baseline are often excluded, probably due to a combination of rehabilitation entry requirements and perceived lack of potential benefits. Access barriers, such as lack of insurance reduced rehabilitation use suggesting an unmet need among stroke survivors.

Abstract TMP118: Brain Derived Neurotrophic Factor Secretion From Lungs Mediate The Post-stroke Functional Recovery After Systemic Administration Of MSCs

Background: Bone marrow derived mesenchymal stromal cells (MSCs) have been actively tested in clinical trials. After intravenous (IV) administration, vast majority of them are trapped in lung vasculature, with only few reaching brain. Even though MSCs are short-lived in the lungs, their beneficial effects on post-stroke recovery extends for weeks, suggesting a paracrine mechanism of action. Integrins expression on MSCs is known to mediate the lung entrapment by binding to ICAM1-expressing endothelial cells (ECs). Furthermore, ECs can perform paracrine functions by releasing neurotrophins, such as brain derived neurotrophic factor (BDNF). We explored EC-MSC interaction in lungs, and its effect on BDNF release from lung ECs, in an experimental stroke model.

Methods: Human lung ECs (Cell Biologics) were cultured at P3. Human MSCs were isolated from bone marrow of healthy donor and P3 MSCs were used for experiments. Serum from stroke patients with NIH Stroke Scale (NIHSS) severity ranging from 0 to 10 was collected at 24 hours after stroke. Co-culture experiments were done in trans-well plates. BDNF mRNA was isolated using Qiagen RNeasy kit. Middle Cerebral Artery Occlusion model (filament model) was used in C57BL/6 mice. Modified Neurological Severity Score (mNSS) was used for functional assessment in mice stroke model.

Results: Human primary lung ECs exposed to plasma from stroke patients as well as recombinant TNF-α showed robust increase in BDNF secretion, with MSCs enhancing the secretion furthermore. BDNF mRNA was robustly increased in whole mouse lungs as well as lung ECs. IV MSC administration robustly increased plasma BDNF and BDNF mRNA expression in mouse lung ECs. Furthermore, IV MSCs provided better functional recovery as compared to IV BDNF.

Conclusion: BDNF is already known to be neuroprotective. Our results show that BDNF secretions increase from lung ECs after IV MSC administration, which could mediate functional recovery in mice after stroke.

Abstract TP123: Natural Rate Of Hematoma And Edema Resolution In Patients With Intracerebral Hemorrhage Using Serial Magnetic Resonance Imaging

Objective: Serially measure the rate of hematoma volume (HV) and edema volume (EV) resolution in patients with acute-to-early chronic ICH

Background: After ICH, the primary cause of brain injury is the mechanical force from the compression of the brain tissue. The secondary damage involves (bio)chemical injury produced by the toxicity of components of extravasated blood, which directly compromises surrounding tissue by oxidative stress, cell death, neuroinflammation, and brain edema. There is very little known about the rate of HV and EV resolution within one month of ictus.

Methods: Twelves patients, a placebo sub-cohort of a previous clinical trial, were serially imaged on day-1, 14, and 28 of initial ictus. Anatomical (FLAIR, T1W, and T2W) images were obtained on a 3T MRI system. HV and EV were segmented using semiautomated seed growing algorithm. The prediction of HV and EV resolution rate was calculated using the Bayesian model and compared across the different time points.

Results: There were 7M/5F with the average age of 57 ± 9y. The baseline average HV/NIHSS 22,998 mm 3 /11. All patients with deep ICH and 6 extended to IVH. The multilevel Bayesian analysis showed the rate of HV resolution -327.90 mm 3 (95% CrI = -475.37- -181.86; Posterior Probability b < 0 ≥ 0.99) with 14 days acceleration of -17.67 mm 3 (95% CrI = -35.89- 1.21; Posterior Probability b < 0 = 0.97). The rate of EV resolution -341.44 mm 3 (95% CrI = -736.32- 60.98; Posterior Probability b < 0 = 0.96) with 14 days acceleration -34.63 mm 3 (95% CrI = -85.47- 16.61; Posterior Probability b < 0 = 0.91). Overall the decrease in HV over time was an offsetting deceleration which increases over time. The overall trend of HV resolution is shown in Fig-1

Conclusion: There was a high variance in the rate of HV and EV resolution, but overall all the patients exhibited a similar trend. The rates of HV and EV resolution can help us provide optimal patient care.

Abstract WP60: Greater Enrichment Of Neuronal Function Can Be Reflected In Blood Plasma Samples Following The Stroke

Acute ischemic stroke induces widespread cellular necrosis and apoptosis and activation of inflammation. These mediate release of cell-free DNA (cfDNA) into the circulation. Although increased cfDNA concentrations have been associated with clinical outcome in stroke, data concerning neuronal cfDNA is rare. In this study, we assessed the association of cfDNA with neuron biomarkers in patients with acute ischemic stroke.

Methods: Thirteen patients without stroke and four patients with middle cerebral artery occlusion were recruited at UT Memorial Hermann Hospital. Blood plasma samples were collected and cfDNA samples were prepared for whole-genome bisulfite sequencing (WGBS) in order to generate quantitative DNA methylation datasets. The resulting WGBS data were analyzed for epigenetic biomarker identification using bioinformatic statistical approaches. CelFiE was used for cell deconvolution, designed to accurately estimate the relative abundances of cell types and tissues present in plasma cfDNA from methylation sequencing, a technique frequently referred to as cell deconvolution.

Results: Differential methylation statistical analysis comparing the stroke against the non-stroke group of samples found 3493 DNA methylation differences. Pathway Analysis discovered greater enrichment for neuronal function with the top hit being “Neuronal System” followed by activity surrounding synapses, demonstrating that a clear enrichment of methylation change in neuronal pathways can be reflected from blood plasma samples following the stroke. Cell deconvolution showed trends of increased megakaryocyte and neutrophils which are involved in the post-stroke immune response. It may be that the secreted neutrophil nuclear DNA in blood plasma drives the increase in the observed proportion of neutrophil cell type in the stroke group samples. Principal Component Analysis demonstrated good separation between the stroke and normal groups.

Conclusion: Blood sample can be used for circulating cfDNA analysis and neuron biomarker discovery for acute ischemic stroke prediction/recovery.

Abstract WMP33: Cognitive Outcomes In Patients With A Prior History Of Stroke Participating In Inpatient Rehabilitation

Introduction: We sought to investigate the impact of prior stroke on cognitive improvement in stroke patients participating in inpatient rehabilitation.

Methods: This was a retrospective review of clinical data from inpatient stroke rehabilitation (ISR) units collected from 09/2017- 08/2019. Age at onset, stroke type (ischemic or intracerebral hemorrhage (ICH)), therapy days, sex, and past medical history of stroke, diabetes, hypertension (HTN) were extracted as predictors of outcome in ISR. The baseline level of disability upon admission to acute stroke care was accounted for with pre-morbid modified Rankin scale (mRS) score and initial NIH Stroke Scale (NIHSS). The outcome variable of interest was total discharge cognitive functional independence measure (TDC-FIM) from ISR. FIM admission to ISR was controlled for in the model.

Results: The data of 681 patients were used in a Lasso regression analysis (Figure 1), and of these patients there were 202 patients with a history of prior stroke. Univariate analysis showed a significant difference between prior stroke and first-time stroke groups with respect to pre-morbid mRS (p<0.001), initial NIHSS (p = 0.003), HTN (p=0.004), and stroke type (p=0.023). Lasso regression indicated that patients with diabetes had a 0.58 point decrease in TDC-FIM while those with HTN had a 0.38 point decrease as compared to patients who did not have these vascular risk factors. Patients with ischemic stroke type had a 0.73 point decrease in the TDC-FIM as compared to those who had an ICH. Prior stroke and the patient’s sex had no effect on TDC-FIM. The R-squared of the model was 0.74.

Conclusion: By controlling for vascular risk factors, our findings show no difference in TDC-FIM with respect to prior stroke. This is different from prior studies that found prior stroke was associated with worse cognitive outcomes at discharge from ISR. Our results indicate that managing HTN and diabetes is imperative for post-stroke cognitive rehabilitation

Abstract WP123: Machine Learning To Predict High Risk Adverse Events In Treatment Trials For Intracerebral Hemorrhage

Background: ICH clinical trials have shown that aggressive blood pressure (BP) lowering can lead to adverse events (AEs) such as renal failure (RF) or new stroke. These studies focused on whether the study intervention causes AEs on average. By combining trials, we estimate each individual’s risk of developing AEs with BP lowering.

Methods: We augmented data from ATACH2 by adding patients from the observational ERICH study and performed propensity score matching with a radius (radius=0.4, ratio=1). We estimated the individualized counterfactual outcome of renal AEs using augmented ATACH2. ERICH had 127 patients (out of 1,706) with new onset of RF during hospital stay. ATACH2 had 68 patients (out of 1000) with renal AEs (recorded by MedDRA) within 7d. We built the counterfactual prediction model using a neural network model (FlexTENet). We extracted feature importance score using Shap Deep Explainer.

Results: We borrowed 1,706 patients to augment ATACH2. The augmented cohort had 2706 patients in total. FlexTENet captured the heterogeneity fairly. For factual outcome prediction accuracy, the FlexTENet achieved the best area under precision-recall curve (0.203) and the area under receiver operating curve (0.703). High diastolic BP at admission and low platelets increased the counterfactual effect of BP reduction on occurrence of renal AEs. In addition, high systolic BP and high glucose decreased the counterfactual effect on the occurrence of renal AEs.

Conclusions: Identifying treatment-related AEs at an individual level has rarely been studied. Our counterfactual machine learning shows potential to predict individual patient’s risk of treatment-related adverse events.

Abstract TMP82: Changes In DTI Metrics In The Lateral Ventricle Of Patients With Intraventricular Hemorrhage (IVH)

Objective: To evaluate a non-invasive surrogate imaging marker for blood evacuation in patients with IVH.

Clinical Relevance: Extension of intracerebral hemorrhage (ICH) to the ventricles increases the 48 hours mortality by 43%, requiring external ventricular drains (EVD) to mitigate hydrocephalus and monitor intracranial pressures. Blood increases CSF viscosity, altering the diffusion coefficient. We hypothesize change in lateral ventricle (LV) DTI metrics, fractional anisotropy (FA) and mean diffusivity (MD), can be used as a marker for blood removal after IVH.

Methods: A sub-cohort of 20 patients in SHRINC trial with ICH and IVH were serially imaged at day 1 (T1=20), 14 (T1=20), 28 (T3=16), and 42 (T4=13) on a 3T MRI system. The serial T1w, segmented LV (JHU WM atlas) volumes, FA, and MD maps were registered. The FA and MD of ipsi and contralesional LV were recorded. Clinical assessment (NIHSS) was associated with the change in FA and MD of LV. A mixed model statistical analysis was performed.

Results: We serially imaged 11M/9F with average age 55.4±8.7 years. The baseline hematoma volume and NIHSS were 22.1±18.5 cc and 16.1±8.7 respectively. The patients had basal ganglia (n=12) and thalamic (n=8) ICH extended into LV. The ipsilesional FA was significantly (T1=0.24, T4=0.15, p<0.001) decreased (1.17% /day), and MD was significantly (T1 = 1.49*10 -3 mm 2 /sec, T4 = 2.37 *10 -3 mm 2 /sec, p<0.001) increased (2.4 x 10 -5 mm 2 /sec/day). At T4, there was no relationship (p=0.919) between ipsilesional and contra-MD of LV (Fig-1). Patients with higher baseline NIHSS had a significant temporal decline in FA than those with lower NIHSS (p<0.05). Temporally, ipsilesional MD was negatively associated with the baseline NIHSS (p=0.039).

Conclusion: The data suggest that DTI metrics of FA and MD are associated with blood clearance from the ipsilesional ventricle.

Abstract 145: Dietary Intake And Quality Among Stroke Survivors Compared To Matched Controls Who Participated In The National Health And Nutrition Examination Survey: 1999 - 2018

Introduction: Nutrition is an important modifiable risk factor for the prevention and treatment of stroke. However, the examination of nutrient intake and diet quality in stroke survivors is limited. The purpose of this study was to estimate usual nutrient intake and diet quality in a nationally representative sample of US adults who have a history of stroke and compare to controls.

Methods: National Health and Nutrition Examination Survey 1999-2018 data were used to examine 1,626 stroke survivors matched for age, gender, and survey cycle to their respective controls (n=1,621), with no history of stroke. Data were collected on demographics and dietary intake and quality (assessed by Healthy Eating Index [HEI] 2015) from at least one reliable 24-h dietary recall. Estimates were reported as mean[SE]. Differences in continuous and categorical variables were assessed using independent-samples t-tests and Rao-Scott Chi-Squared tests, respectively.

Results: In comparison to controls, stroke survivors were more likely to report excessive (% > Acceptable Macronutrient Distribution Range) intake for total fat (50.9%[2.7] vs. 40.4%[2.2], p<.001), and inadequate intake (% < Estimated Average Requirement) for calcium (54.6%[1.8] vs. 43.5%[2.4], p=.001) and magnesium (66%[1.8] vs. 53.6%[1.8], p<.001). In addition, stroke survivors were less likely to report adequate intakes (% > Adequate Intake) for fiber (6.8%[0.9] vs. 11.9%[1.3]) and potassium (0.8%[0.3] vs. 1.0%[0.4]) (p<.001, all comparisons). Finally, stroke survivors reported lower HEI scores than controls (49.8 vs. 51.9, p<.001) which indicates lower diet quality, and were more likely to be food insecure, and report physical and mental limitations including difficulty preparing and eating meals compared to controls (p<.001, all comparisons).

Conclusions: Stroke survivors had lower overall diet quality and greater prevalence of inadequate nutrient intake profiles typically associated with increased risk of cardiovascular diseases including higher total fat intake and lower intake of key micronutrients and fiber compared to matched controls. Stroke survivors were also more likely to experience food insecurity and have physical and mental limitations that may directly impact dietary intake.

Feasibility of a meditation intervention for stroke survivors and informal caregivers: a randomized controlled trial

BACKGROUND

Depressive symptoms are a significant psychological complication of stroke, impacting both survivors and informal caregivers of survivors. Randomized controlled trials are needed to determine optimal non-pharmacological strategies to prevent or ameliorate depressive symptoms in stroke survivors and their informal caregivers.

METHODS

A prospective, randomized, parallel-group, single-center, feasibility study. Participants were assigned to a 4-week meditation intervention or expressive writing control group. The intervention comprised four facilitator-led group meditation sessions, one session per week and building upon prior session(s). Descriptive statistics were used to examine the proportion of eligible individuals who enrolled, retention and adherence rates, and the proportion of questionnaires completed. Data were collected at baseline, immediately after the 4-week intervention period, and 4 and 8 weeks after the intervention period. Secondary analysis tested for changes in symptoms of depression (Center for Epidemiologic Studies-Depression [CES-D]), anxiety [State-Trait Anxiety Inventory for Adults (STAI)], and pain (Brief Pain Inventory-Short Form) in the intervention group via paired t tests. Linear mixed models were used to compare longitudinal changes in the measures between the groups. Intervention and trial design acceptability were preliminary explored.

RESULTS

Seventy-one (77%) individuals enrolled and 26 (37%) completed the study (baseline and 8-week post-intervention visits completed). Forty-two (66%) participants completed baseline and immediate post-intervention visits. Mean questionnaire completion rate was 95%. The median meditation group session attendance rate for the intervention group was 75.0%, and the mean attendance rate was 55%. Non-significant reductions in CES-D scores were found. Paired t tests for stroke survivors indicated a significant reduction from baseline through week 8 in BPI-sf severity scores (p = 0.0270). Repeated measures analysis with linear mixed models for informal caregivers indicated a significant reduction in in STAI-Trait scores (F [3,16.2] = 3.28, p = 0.0479) and paired t test showed a significant reduction from baseline to week 4 in STAI-Trait scores (mean = - 9.1250, 95% CI [- 16.8060 to 1.4440], p = 0.0262). No between-group differences were found.

CONCLUSIONS

Future trials will require strategies to optimize retention and adherence before definitive efficacy testing of the meditation intervention.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03239132. Registration date: 03/08/2017.

An Intervention Mapping Approach to Developing a Stroke Literacy Video for Recent Stroke Survivors: Development and Usability Study

BACKGROUND

Most vascular events after stroke may be prevented by modifying vascular risk factors through medical and behavioral interventions. Stroke literacy-an understanding of stroke symptoms, risk factors, and treatment-likely contributes to vascular risk factor control and in turn stroke recurrence risk. Stroke literacy is the lowest among adults belonging to racial and ethnic minority populations in the United States. Video-based interventions targeting stroke literacy may help acute stroke survivors understand stroke and subsequently reduce the risk of stroke recurrence. However, the failure of prior stroke literacy interventions may be due in part to the fact that the interventions were not theory-driven. Intervention mapping (IM) provides a framework for use in the development, implementation, and evaluation of evidence-informed, health-related interventions.

OBJECTIVE

We aimed to develop a video-based educational intervention to improve stroke literacy in hospitalized patients with acute stroke.

METHODS

The 6-step iterative process of IM was used to develop a video-based educational intervention and related implementation and evaluation plans. The six steps included a needs assessment, the identification of outcomes and change objectives, the selection of theory- and video-based intervention methods and practical applications, the development of a video-based stroke educational intervention, plans for implementation, and evaluation strategies.

RESULTS

A 5-minute video-based educational intervention was developed. The IM approach led to successful intervention development by emphasizing stakeholder involvement, generation and adoption, and information retainment in the planning phase of the intervention. A planned approach to video adoption, implementation, and evaluation was also developed.

CONCLUSIONS

An IM approach guided the development of a 5-minute video-based educational intervention to promote stroke literacy among acute stroke survivors. Future studies are needed to assess the use of technology and digital media to support widespread access and participation in video-based health literacy interventions for populations with acute and chronic stroke. Studies are needed to assess the impact of video-based educational interventions that are paired with stroke systems of care optimization to reduce the risk of stroke recurrence. Furthermore, studies on culturally and linguistically sensitive video-based stroke literacy interventions are needed to address known racial and ethnic disparities in stroke literacy.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1371/journal.pone.0171952.

Cell-based therapies for neurological disorders - the bioreactor hypothesis

Cell-based therapies are an emerging biopharmaceutical paradigm under investigation for the treatment of a range of neurological disorders. Accumulating evidence is demonstrating that cell-based therapies might be effective, but the mechanism of action remains unclear. In this Review, we synthesize results from over 20 years of animal studies that illustrate how transdifferentiation, cell replacement and restoration of damaged tissues in the CNS are highly unlikely mechanisms. We consider the evidence for an alternative model that we refer to as the bioreactor hypothesis, in which exogenous cells migrate to peripheral organs and modulate and reprogramme host immune cells to generate an anti-inflammatory, regenerative environment. The results of clinical trials clearly demonstrate a role for immunomodulation in the effects of cell-based therapies. Greater understanding of these mechanisms could facilitate the optimization of cell-based therapies for a variety of neurological disorders.

Inpatient Teleneurology Follow-up Has Comparable Outcomes to In-Person Neurology Follow-up

Objective:

Community emergency departments often transfer patients for lack of neurology coverage, potentially burdening patients and accepting facilities. Telestroke improves access to acute stroke care, but there is a lack of data on inpatient teleneurology and telestroke care.

Methods:

From our prospective telestroke registry, we retrospectively reviewed 3702 consecutive patients who were seen via telestroke between 9/2015 and 12/2018. Patients who required transfer after initial telestroke evaluation or who were kept at hospitals without consistent neurology coverage were excluded from analysis. We compared baseline demographics, clinical characteristics, and hospital outcomes in patients who were subsequently followed remotely by a teleneurology neurohospitalst and those followed in-person by a neurohospitalist.

Results:

There were 447 (23%) patients followed by a teleneurology neurohospitalist and 1459 (77%) patients followed in-person by a neurohospitalist. Both groups presented with similar stroke severity. In multivariate analysis, there were no significant differences in discharge disposition, stroke readmission rates, or 90-day mRS. Length of stay was shorter with teleneurology follow-up. In the subgroup of patients who received tPA, patients showed no differences in outcomes and had similar complication rates. Teleneurology follow-up resulted in a 3% transfer rate for higher level of care after admission. There remained no difference in outcomes in a sub-analysis without Comprehensive Stroke Centers. A higher proportion of non-Hispanic Black patients and lower proportion of Hispanic patients in the teleneurology follow-up group were possibly due to spoke location demographics.

Conclusion:

Teleneurology follow-up resulted in comparable outcomes to in-person neurology follow-up, with few transfers after admission. For select neurology and ischemic stroke patients, teleneurology follow-up provides an alternative to transfer for hospitals lacking neurology coverage.

Peripheral blood monocytes as a therapeutic target for marrow stromal cells in stroke patients

Background

Systemic administration of marrow stromal cells (MSCs) leads to the release of a broad range of factors mediating recovery in rodent stroke models. The release of these factors could depend on the various cell types within the peripheral blood as they contact systemically administered MSCs. In this study, we assessed the immunomodulatory interactions of MSCs with peripheral blood derived monocytes (Mϕ) collected from acute stroke patients.

Methods

Peripheral blood from stroke patients was collected at 5–7 days (N = 5) after symptom onset and from age-matched healthy controls (N = 5) using mononuclear cell preparation (CPT) tubes. After processing, plasma and other cellular fractions were removed, and Mϕ were isolated from the mononuclear fraction using CD14 microbeads. Mϕ were then either cultured alone or co-cultured with MSCs in a trans-well cell-culture system. Secretomes were analyzed after 24 h of co-cultures using a MAGPIX reader.

Results

Our results show that there is a higher release of IFN-γ and IL-10 from monocytes isolated from peripheral blood at day 5–7 after stroke compared with monocytes from healthy controls. In trans-well co-cultures of MSCs and monocytes isolated from stroke patients, we found statistically significant increased levels of IL-4 and MCP-1, and decreased levels of IL-6, IL-1β, and TNF-α. Addition of MSCs to monocytes increased the secretions of Fractalkine, IL-6, and MCP-1, while the secretions of TNF-α decreased, as compared to the secretions from monocytes alone. When MSCs were added to monocytes from stroke patients, they decreased the levels of IL-1β, and increased the levels of IL-10 significantly more as compared to when they were added to monocytes from control patients.

Conclusion

The systemic circulation of stroke patients may differentially interact with MSCs to release soluble factors integral to their paracrine mechanisms of benefit. Our study finds that the effect of MSCs on Mϕ is different on those derived from stroke patients blood as compared to healthy controls. These findings suggest immunomodulation of peripheral immune cells as a therapeutic target for MSCs in patients with acute stroke.

Effects of escitalopram therapy on functional brain controllability in major depressive disorder

Antidepressant drugs are the mainstay of treatment for patients with major depressive disorders (MDD). Given the critical role of the underlying neural control mechanism in the physiopathology of depression, this study aims to investigate the effects of escitalopram, a type of antidepressant drug, on the changes of functional brain controllability throughout the escitalopram treatment for MDD. We collected resting-state functional magnetic resonance imaging data from 20 unmedicated major depressive patients at baseline (visit 1, pre-treatment), one week (visit 2, 1-week after the onset of the treatment) and six weeks (visit 3, after the 6-week escitalopram treatment). Our results revealed that the global average and modal controllability of MDD patients were significantly larger and smaller, respectively, compared to healthy subjects (P < 0.01). Furthermore, the modal controllability rank of the frontoparietal network in depression patients was also significantly smaller than the healthy subjects (P < 0.01). However, throughout the escitalopram treatment, the global average and modal controllability, and the controllability of the default mode network and frontoparietal network of MDD patients were consistently changed to the healthy subjects' level. Our results also showed that the changes of global average and modal controllability measures can predict the improvements of clinical scores of the MDD patients as the escitalopram treatment advanced (P < 0.05). In conclusion, this study reveals promising brain controllability-based biomarkers to mechanistically understand and predict the effects of the escitalopram treatment for depression and maybe extended to predict and understand the effects of other interventions for other neurological and psychiatric diseases.

A multitask deep learning approach for pulmonary embolism detection and identification

Pulmonary embolism (PE) is a blood clot traveling to the lungs and is associated with substantial morbidity and mortality. Therefore, rapid diagnoses and treatments are essential. Chest computed tomographic pulmonary angiogram (CTPA) is the gold standard for PE diagnoses. Deep learning can enhance the radiologists’workflow by identifying PE using CTPA, which helps to prioritize important cases and hasten the diagnoses for at-risk patients. In this study, we propose a two-phase multitask learning method that can recognize the presence of PE and its properties such as the position, whether acute or chronic, and the corresponding right-to-left ventricle diameter (RV/LV) ratio, thereby reducing false-negative diagnoses. Trained on the RSNA-STR Pulmonary Embolism CT Dataset, our model demonstrates promising PE detection performances on the hold-out test set with the window-level AUROC achieving 0.93 and the sensitivity being 0.86 with a specificity of 0.85, which is competitive with the radiologists’sensitivities ranging from 0.67 to 0.87 with specificities of 0.89–0.99. In addition, our model provides interpretability through attention weight heatmaps and gradient-weighted class activation mapping (Grad-CAM). Our proposed deep learning model could predict PE existence and other properties of existing cases, which could be applied to practical assistance for PE diagnosis.

Personalizing repetitive transcranial magnetic stimulation for precision depression treatment based on functional brain network controllability and optimal control analysis

Brain neuromodulation effectively treats neurological diseases and psychiatric disorders such as Depression. However, due to patient heterogeneity, neuromodulation treatment outcomes are often highly variable, requiring patient-specific stimulation protocols throughout the recovery stages to optimize treatment outcomes. Therefore, it is critical to personalize neuromodulation protocol to optimize the patient-specific stimulation targets and parameters by accommodating inherent interpatient variability and intersession alteration during treatments. The study aims to develop a personalized repetitive transcranial magnetic stimulation (rTMS) protocol and evaluate its feasibility in optimizing the treatment efficiency using an existing dataset from an antidepressant experimental imaging study in depression. The personalization of the rTMS treatment protocol was achieved by personalizing both stimulation targets and parameters via a novel approach integrating the functional brain network controllability analysis and optimal control analysis. First, the functional brain network controllability analysis was performed to identify the optimal rTMS stimulation target from the effective connectivity network constructed from patient-specific resting-state functional magnetic resonance imaging data. The optimal control algorithm was then applied to optimize the rTMS stimulation parameters based on the optimized target. The performance of the proposed personalized rTMS technique was evaluated using datasets collected from a longitudinal antidepressant experimental imaging study in depression (n = 20). Simulation models demonstrated that the proposed personalized rTMS protocol outperformed the standard rTMS treatment by efficiently steering a depressive resting brain state to a healthy resting brain state, indicated by the significantly less control energy needed and higher model fitting accuracy achieved. The node with the maximum average controllability of each patient was designated as the optimal target region for the personalized rTMS protocol. Our results also demonstrated the theoretical feasibility of achieving comparable neuromodulation efficacy by stimulating a single node compared to stimulating multiple driver nodes. The findings support the feasibility of developing personalized neuromodulation protocols to more efficiently treat depression and other neurological diseases.

Autologous cellular therapy for cerebral palsy: a randomized, crossover trial

We examined an autologous mononuclear-cell-therapy-based approach to treat cerebral palsy using autologous umbilical cord blood or bone-marrow-derived mononuclear cells. The primary objective was to determine if autologous cells are safe to administer in children with cerebral palsy. The secondary objectives were to determine if there was improvement in motor function of patients 12 months after infusion using the Gross Motor Function Measure and to evaluate impact of treatment on corticospinal tract microstructure as determined by radial diffusivity measurement. This Phase 1/2a trial was a randomized, blinded, placebo-controlled, crossover study in children aged 2-10 years of age with cerebral palsy enrolled between November 2013 and November 2016. Participants were randomized to 2:1 treatment:placebo. Treatment was either autologous bone-marrow-derived mononuclear cells or autologous umbilical cord blood. All participants who enrolled and completed their baseline visit planned to return for follow-up visits at 6 months, 12 months and 24 months after the baseline visit. At the 12-month post-treatment visit, participants who originally received the placebo received either bone-marrow-derived mononuclear cell or umbilical cord blood treatment. Twenty participants were included; 7 initially randomized to placebo, and 13 randomized to treatment. Five participants randomized to placebo received bone-marrow-derived mononuclear cells, and 2 received umbilical cord blood at the 12-month visit. None of the participants experienced adverse events related to the stem cell infusion. Cell infusion at the doses used in our study did not dramatically alter motor function. We observed concordant bilateral changes in radial diffusivity in 10 of 15 cases where each corticospinal tract could be reconstructed in each hemisphere. In 60% of these cases (6/10), concordant decreases in bilateral corticospinal tract radial diffusivity occurred post-treatment. In addition, 100% of unilateral corticospinal tract cases (3/3) exhibited decreased corticospinal tract radial diffusivity post-treatment. In our discordant cases (n = 5), directionality of changes in corticospinal tract radial diffusivity appeared to coincide with handedness. There was a significant improvement in corticospinal tract radial diffusivity that appears related to handedness. Connectivity strength increased in either or both pathways (corticio-striatal and thalamo-cortical) in each participant at 12 months post-treatment. These data suggest that both stem cell infusions are safe. There may be an improvement in myelination in some groups of patients that correlate with small improvements in the Gross Motor Function Measure scales. A larger autologous cord blood trial is impractical at current rates of blood banking. Either increased private banking or matched units would be required to perform a larger-scale trial.