Incidence, causes and predictors of neurological deterioration occurring within 24 h following acute ischaemic stroke: a systematic review with pathophysiological implications

Study protocol of Branch Atheromatous Disease-related stroke (BAD-study): a multicenter prospective cohort study

BACKGROUND

As a meaningful subtype of ischemic stroke in Asians, Branch atheromatous disease (BAD)-related stroke is associated with high early neurological deterioration (END) and disability, but is understudied and without recommended therapy. The mechanism of END still remains unclear. Branch atheromatous disease-related stroke study (BAD-study) therefore aims to investigate demographic, clinical and radiological features, and prognosis of BAD-related stroke in Chinese patients.

METHODS/DESIGN

BAD-study is a nationwide, multicenter, consecutive, prospective, observational cohort study enrolling patients aged 18-80 years with BAD-related stroke within 72 h after symptom onset. Initial clinical data, laboratory tests, and imaging data are collected via structured case report form, and follow-ups will be performed at 7 days, 30 days, 90 days, 6 months and 12 months after enrollment. The primary outcome is the score on modified Rankin Scale at 90-day follow-up with single-blinded assessment. Secondary outcomes include END within 7 days, and National institute of health stroke scale score, Barthel index, cerebrovascular events, major bleeding complications, and all-cause mortality during 90-day follow-up. Characteristics of penetrating and parent artery will be assessed by high-resolution magnetic resonance imaging combined with other imaging techniques.

DISCUSSION

BAD-study can provide demographic, clinical, radiological, and prognostic characteristics of BAD-related stroke, and thereby potentially figure out the vascular mechanism of early neurological deterioration and optimize therapy strategy with the aid of advanced imaging technique. Baseline data and evidence will also be generated for randomized controlled trials on BAD-related stroke in the future.

Clinical Application of Thromboelastography in Acute Ischemic Stroke

Acute ischemic stroke (AIS), characterized by high morbidity and mortality, has imposed a considerable burden on society. Despite rapid development in the treatment of AIS, there is still a high risk of recurrence. Furthermore, there is a time delay in waiting for the results of conventional coagulation tests in candidate patients for intravenous thrombolysis therapy. Heterogeneous responses to antiplatelet, intravascular thrombolysis, and endovascular therapies also worsen the situation. Thromboelastography (TEG), as a global and portable detection method for hemostasis, facilitates clinicians in disease monitoring, treatment evaluation, and prognosis prediction in AIS. In this narrative review, we provided a comprehensive summary of the clinical application of TEG in ischemic stroke and gave insights to further studies.

Fasting blood glucose as a predictor of progressive infarction in men with acute ischemic stroke

Objective

Blood glucose is related to early neurological deterioration in acute ischemic stroke, but multiple mechanisms are involved in early neurological deterioration, such as progressive infarction. This study aimed to determine whether fasting blood glucose (FBG) is an independent predictor of progressive infarction.

Methods

From April 2017 to December 2020, we retrospectively enrolled 477 patients with acute ischemic stroke within 48 hours of onset. Demographic characteristics, clinical information, neuroimaging characteristics, and laboratory data were collected after admission.

Results

We found that 147 (30.8%) patients had progressive infarction. Multiple regression analysis showed that high FBG concentrations (>7.66 mmol/L) were independently associated with progressive infarction. Sex subgroup analysis showed that high FBG concentrations were an independent predictor of progressive infarction in male patients (odds ratio, 2.559; 95% confidence interval, 1.279–5.121). In a receiver operating characteristic curve analysis, FBG concentrations were a predictor of progressive infarction in all cases, especially in male patients. The cutoff value of FBG in all patients and men was 7.155 mmol/L.

Conclusions

FBG is an independent predictor of progressive infarction in patients with acute ischemic stroke within 48 hours of onset, especially in men. Patients with FBG concentrations ≥7.155 mmol/L are more likely to develop progressive infarction.

Analysis of influencing factors of early neurological improvement after intravenous rt-PA thrombolysis in acute anterior circulation ischemic stroke

Background and objective

It has been widely reported that Early neurological improvement (ENI) after rt-PA intravenous thrombolysis contributes to a good long-term prognosis in patients experiencing acute ischemic stroke (AIS). However, which clinical factors influence after intravenous administration of recombinant tissue-type plasminogen activator (IV-rt PA) in AIS patients ENI is still unclear. This study aimed to evaluate the impact of influencing factors on the benefit of ENI after intravenous thrombolysis neurological improvement after IV-rt PA.

Methods

The data of 73 patients with acute anterior circulation ischemic stroke who received intravenous thrombolysis with rt-PA in Chongqing University Jiangjin Hospital from January 2021 to July 2022 were retrospectively studied. According to the change rate of 24 h NISHH score, the research subjects were divided into the recovery group, the significant curative effect group, the curative effect group and the no curative effect group, the ENI after intravenous thrombolysis with rt-PA was defined as the improvement rate of National Institutes of Health Stroke Scale (NIHSS)score >46% at 24 h after IV-rt PA, and univariate factor analysis was used Clinical factors associated with ENI after intravenous thrombolysis.

Results

According to the 24-h NIHSS improvement rate of rt-PA intravenous thrombolysis in patients with acute anterior circulation ischemic stroke, 35 cases (47.95%) of the study population had ENI. There was no statistical difference between the improvement and non-improvement group in general demographic data, stroke TOAST classification, stroke risk factors (history of stroke, heart disease, hyperlipidemia, hypertension), and laboratory test data. There was a statistically significant difference in the random blood glucose levels between the two groups (p < 0.001, t = 3.511).

Conclusion

The effect of rt-PA intravenous thrombolysis within the time window of patients with acute anterior circulation ischemic stroke is significant, but the ENI after thrombolysis is easily affected by the level of blood glucose; diabetes is the most important factor affecting the acute anterior circulation ischemic stroke patients Clinical factors of ENI after intravenous thrombolysis with rt-PA.

Prospective pilot study of tirofiban in progressive stroke after intravenous thrombolysis

Background

Intravenous thrombolysis (IVT) is a standard procedure for the treatment of patients with acute ischemic stroke (AIS). Improving the therapeutic efficacy of IVT is an important task for neurologists. The aim of this study was to evaluate the efficacy and safety of early low-dose tirofiban treatment in AIS patients with early neurological deterioration (END) after IVT.

Methods

In this prospective and randomized pilot study, 73 AIS patients with END were recruited from a local hospital in China. Of these, 14 patients were treated with regular antiplatelet agents (aspirin plus clopidogrel) and 59 patients were treated with tirofiban within 24 h of IVT, followed by regular antiplatelet therapy. Neurological deficits and functional recovery were assessed with NIHSS and modified Rankin Scale (mRS) at 7 and 90 days. During the 90-day follow-up period, both hemorrhagic (e.g., intracerebral hemorrhage) and non-hemorrhagic (e.g., pneumonia) events were recorded.

Results

Treatment with tirofiban compared with regular antiplatelet therapy: (1) improved functional recovery of AIS patients to mRS (≤2) at both 7 and 90 days (odds ratios [ORs], 1.37 and 1.64; 95% confidence interval [CI], 1.16–1.61 and 1.26–2.12; P = 0.008 and < 0.001, respectively), and (2) reduced NIHSS scores from 11.14 ± 2.38 to 5.95 ± 3.48 at day 7 (P < 0.001) and from 8.14 ± 2.74 to 4.08 ± 3.50 at day 90 (P < 0.001). Tirofiban treatment did not increase the risk of hemorrhagic complications. Multivariate regression analysis showed that tirofiban treatment independently predicted a favorable functional outcome (P ≤ 0.001).

Conclusion

Early treatment with low-dose tirofiban in AIS patients with neurologic deterioration after IVT potentially improved functional recovery and attenuated neurologic deficits as early as 7 days and did not increase the risk of various hemorrhagic complications. However, the therapeutic efficacy of tirofiban treatment in END patients needs to be determined by future randomized clinical trials with a large study population.

Clinical trial registration

http://www.chictr.org.cn/, Identifier ChiCTR2200058513.

Association of the stress hyperglycemia ratio and clinical outcomes in patients with stroke: A systematic review and meta-analysis

Objective

Stress hyperglycemia (SH) is common in patients with acute diseases, such as stroke and myocardial infarction. Stress hyperglycemia ratio (SHR) is calculated by glucose/glycated hemoglobin and has been widely used for evaluating SH. But whether SHR is associated with clinical outcomes in stroke patients remains unclear so far. Although many studies have shown that higher SHR means poor outcomes, there is still no absolute evidence that SHR plays a critical role in stroke patients. Hence, we performed a systematic review and meta-analysis aiming to investigate the association between SHR and clinical outcomes in stroke patients.

Methods

We performed a comprehensive literature search of the PubMed, Embase, Cochrane Library databases, Clinicaltrials.gov, and WHO-ICTRP. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), we performed our study. The Newcastle-Ottawa Scale (NOS) tool was used to examine the potential bias of included studies. The endpoints including poor outcome, mortality, neurological deficit, hemorrhagic transformation (HT), and infectious complications were statistically analyzed.

Results

Sixteen retrospective studies met the eligibility criteria, and a number of 183,588 patients were included. Our meta-analysis demonstrated a significant increase in the incidence of poor outcome, according to assessment by the modified Rankin Scale (mRS) ≥ 3 points [odds ratio (OR) 2.53, 95% confidence interval (CI) 1.99–3.22, P < 0.00001, I² = 68%], mortality (OR 1.96, 95% CI 1.58–2.44, P < 0.00001, I² = 61%), neurological deficit (OR 1.99, 95% CI 1.47–2.70, P < 0.00001, I² = 75%), hemorrhagic transformation (HT) (OR 3.70, 95% CI 2.69–5.08, P < 0.00001, I² = 0%), and infectious complications [(Pneumonia) OR 2.06, 95% CI 1.57–2.72, P < 0.00001, I² = 24%; (Urinary tract infection) OR 2.53, 95% CI 1.45–4.42, P = 0.001, I² = 57%] in stroke patients with higher SHR. However, no significant influence was observed for recanalization rate (OR 0.86, 95% CI 0.54–1.38, P = 0.53, I² = 0%).

Conclusion

With or without diabetes, no matter whether undergoing intravenous thrombolysis or mechanical thrombectomy, higher SHR significantly increased the occurrence of poor outcomes, mortality, neurological deficit, HT, and infectious complications. The recanalization rate was not statistically significant between the two groups. More attention must be paid in clinical practice to SH. Future investigation should focus on the diagnostic value of SHR and the early control of hyperglycemia. Meanwhile, whether SHR could become a novel and promising target for early intervention is worthy of attention in further research. Besides, the influence of the dynamic change of glucose-to-HbA1c ratio, namely SHR, on intracerebral hemorrhage outcomes requires further investigation in future research. Although no randomized double-blind studies have been conducted, the available massive sample studies reflect the actual situation in the clinic and assist clinical decision makers.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42022345587.

The role of asymmetrical prominent veins sign in early neurological deterioration of acute ischemic stroke patients

Background and purpose

Asymmetrical prominent veins sign (APVS) often appears on susceptibility-weighted angiography (SWAN) images in patients with acute stroke. Early neurological deterioration (END) is highly correlated with survival prognosis in patients with ischemic stroke. This study sought to explore the relationship between APVS and END in patients with acute stroke.

Methods

The subjects retrospectively enrolled in this study were patients with acute ischemic stroke in the middle cerebral artery supply area. All patients underwent head MRI, including the SWAN sequence, within 7 days of stroke symptom onset. END was defined as clinical deterioration or recurrence within 72 h after ischemic stroke. The volume of infarction on diffusion-weighted imaging was measured. Univariate and multivariate analyses were used to analyze the relationship between APVS and END. Spearman correlation between APVS grades and infarct volume, white matter hyperintensity (WMH) volume, and offending vessel were also analyzed.

Results

A total of 157 patients with middle cerebral artery infarct between September 2018 and April 2020 were included in the study. APVS appeared on MRI in 84 of 157 patients, and 34 of 157 patients were diagnosed with END. In patients with END, the proportion of severe APVS was higher than in patients without END (P = 0.001, x² = 14.659). Patients with END were older and had a larger volume of infarct and WMH than patients without END (all P < 0.05). After adjustments were made for related risk factors of END, the severity of APVS was still related to END (OR = 2.56, 95% CI, 1.38–4.75; P for trend = 0.003). Spearman correlation showed that APVS grades were positively related to infarct volume (r = 0.289, P < 0.001) and 3-month modified Rankin Scale score (r = 0.203, P = 0.011) and negatively related to offending vessels (r = −0.170, P = 0.034).

Conclusion

APVS may be an important predictor of END in patients with acute ischemic stroke.

Unsupervised Deep Learning for Stroke Lesion Segmentation on Follow-up CT Based on Generative Adversarial Networks

BACKGROUND AND PURPOSE

Supervised deep learning is the state-of-the-art method for stroke lesion segmentation on NCCT. Supervised methods require manual lesion annotations for model development, while unsupervised deep learning methods such as generative adversarial networks do not. The aim of this study was to develop and evaluate a generative adversarial network to segment infarct and hemorrhagic stroke lesions on follow-up NCCT scans.

MATERIALS AND METHODS

Training data consisted of 820 patients with baseline and follow-up NCCT from 3 Dutch acute ischemic stroke trials. A generative adversarial network was optimized to transform a follow-up scan with a lesion to a generated baseline scan without a lesion by generating a difference map that was subtracted from the follow-up scan. The generated difference map was used to automatically extract lesion segmentations. Segmentation of primary hemorrhagic lesions, hemorrhagic transformation of ischemic stroke, and 24-hour and 1-week follow-up infarct lesions were evaluated relative to expert annotations with the Dice similarity coefficient, Bland-Altman analysis, and intraclass correlation coefficient.

RESULTS

The median Dice similarity coefficient was 0.31 (interquartile range, 0.08-0.59) and 0.59 (interquartile range, 0.29-0.74) for the 24-hour and 1-week infarct lesions, respectively. A much lower Dice similarity coefficient was measured for hemorrhagic transformation (median, 0.02; interquartile range, 0-0.14) and primary hemorrhage lesions (median, 0.08; interquartile range, 0.01-0.35). Predicted lesion volume and the intraclass correlation coefficient were good for the 24-hour (bias, 3 mL; limits of agreement, -64-59 mL; intraclass correlation coefficient, 0.83; 95% CI, 0.78-0.88) and excellent for the 1-week (bias, -4 m; limits of agreement,-66-58 mL; intraclass correlation coefficient, 0.90; 95% CI, 0.83-0.93) follow-up infarct lesions.

CONCLUSIONS

An unsupervised generative adversarial network can be used to obtain automated infarct lesion segmentations with a moderate Dice similarity coefficient and good volumetric correspondence.

Safety and efficacy of low-dose rt-PA with tirofiban to treat acute non-cardiogenic stroke: a single-center randomized controlled study

BACKGROUND AND PURPOSE

The recanalization rate after intravenous thrombolysis (IVT) is not enough and there is still the possibility of re-occlusion. We aim to investigate the effectiveness and safety of infusing tirofiban after IVT.

METHODS

We performed a prospective controlled study of 60 patients with acute non-cardiogenic ischemic stroke who were hospitalized in Yantai Yuhuangding Hospital from January 2018 to December 2019. The patients were divided into 2 groups: those who received tirofiban for 24 h after IVT (rt-PA + T group) and those who did not receive postprocedural intravenous tirofiban (rt-PA group). The rt-PA + T group received low-dose rt-PA (0.6 mg/kg). The rt-PA group received standard dose rt-PA (0.9 mg/kg). The main outcome measure were safety, included the symptomatic intracranial hemorrhage (sICH), any ICH, severe systemic bleeding, and mortality. The secondary outcome measure is curative efficacy which were evaluated by the 7d-NIHSS score and functional outcomes at 90 days. During hospitalization, the deterioration of neurological function was recorded.

RESULTS

All patients completed the follow-up with complete data, there were 30 patients in each of groups. The general characteristics between the two group patients had no statistically significant differences. Compared with the rt-PA + T group and the rt-PA group, in terms of safety, the rates of the sICH, severe systemic bleeding, and mortality in both groups were 0, and there was no statistically significant difference in the rates of any ICH between the two groups (10.0% vs. 3.3%, P = 0.306). In terms of efficacy, the rate of the early neurological deterioration events (END) was no statistical significance (0 vs. 6.6%, P = 0.246). There was no significant difference in the NIHSS score between the two groups before the IVT, and also at 24 h, however, the 7d-NIHSS score was lower in the rt-PA + T group compared with the rt-PA group (2.33 ± 1.85 vs. 4.80 ± 4.02, P = 0.004). At 90 days, 83.3% of patients in the rt-PA + T group had favorable functional outcomes compared with 60.0% of patients in the rt-PA group (P = 0.045).

CONCLUSIONS

Low-dose rt-PA combined with tirofiban in acute non-cardiogenic ischemic stroke did not increase the risk of ICH, and mortality, and it was associated with neurological improvement.

TRIAL REGISTRATION

The trial has been registered at the ChiCTR and identified as ChiCTR1800014666 (28/01/2018).

Higher serum occludin after successful reperfusion Is associated with early neurological deterioration

Aims

Early neurological deterioration (END) is an important factor that affects prognosis in patients with acute ischemic stroke. We explored the relationship between serum occludin levels after successful reperfusion and END in patients treated with endovascular thrombectomy (EVT).

Methods

We prospectively enrolled 120 stroke patients who underwent EVT with successful reperfusion. Enzyme‐linked immunosorbent assay was used to detect the serum occludin levels on admission and within 1 h after successful reperfusion. Receiver operating characteristic curves (ROC) and regression analysis were used to compare the relationship between serum occludin and END after thrombectomy.

Results

Among the 120 patients, 36 (30%) experienced END. The END group had higher serum occludin levels than the non‐END group after successful reperfusion [4.31 (3.71–5.38) vs 6.32 (5.88–6.99), p < 0.001]. The ROC curve showed that postoperative serum occludin levels had a significant prediction value for END (AUC: 0.86, p < 0.001). Regression analysis showed that serum occludin was an independent risk factor for END in EVT patients (adjusted odds ratio: 4.46, 95% confidence interval: 1.92–10.32; p < 0.001).

Conclusions

The higher serum occludin levels were strongly related to END after successful reperfusion. Serum occludin may be an independent risk factor for END in EVT patients.

Circular RNA FUNDC1 for Prediction of Acute Phase Outcome and Long-Term Survival of Acute Ischemic Stroke

Circular RNAs (CircRNAs) have shown promising potential in the diagnosis and the prediction of outcomes of stroke. This study aimed to explore the potential value of circRNAs for identifying acute neurological deterioration and estimating long-term survival for acute ischemic stroke (AIS). One hundred healthy controls and 200 patients with AIS within 72 h were recruited, 140 of whom were admitted within 24 h after onset. CircRNA levels in peripheral blood were measured by quantitative polymerase chain reaction (qPCR). Compared to the controls, the levels of three circRNAs were significantly increased in three subgroups of patients, including large artery atherosclerosis (LAA) stroke, small artery occlusion (SAO) stroke, and cardioembolism (CE) stroke (all P < 0.001). Among, LAA stroke patients had higher levels of circular RNA FUNDC1 (circFUNDC1) compared to SAO stroke patients (P = 0.015). CircFUNDC1 levels were positively correlated with National Institutes of Health Stroke Scale (NIHSS) scores on the 7th day only in LAA patients (P = 0.048, r = 0.226). It should be noted that the levels of circFUNDC1 in patients with early neurological deterioration (END), admitted within 24 h after onset, were significantly higher than those without END (P = 0.013). In addition, circFUNDC1 levels positively correlated with baseline NIHSS scores (P = 0.016, r = 0.203) or the 7th day NIHSS scores (P = 0.001, r = 0.289) in patients within 24 h after onset. Importantly, after 18 months of follow-up, a significant difference was observed on survival Kaplan-Meier curves (P = 0.042) between AIS patients with low (below cut-off) or high circFUNDC1 levels (above cut-off). Circulating circFUNDC1 could be a potential biomarker for predicting acute-phase outcome and long-term survival in AIS.

A Systematic Review of Body Fluids Biomarkers Associated With Early Neurological Deterioration Following Acute Ischemic Stroke

Biomarkers are objectively measured biological properties of normal and pathological processes. Early neurological deterioration (END) refers to the deterioration of neurological function in a short time after the onset of acute ischemic stroke (AIS) and is associated with adverse outcomes. Although multiple biomarkers have been found to predict END, there are currently no suitable biomarkers to be applied in routine stroke care. According to the Preferred Reporting Items for Systematic Review standards, we present a systematic review, concentrating on body fluids biomarkers that have shown potential to be transferred into clinical practice. We also describe newly reported body fluids biomarkers that can supply different insights into the mechanism of END. In our review, 40 scientific papers were included. Depending on the various mechanisms, sources or physicochemical characteristics of body fluids biomarkers, we classified related biomarkers as inflammation, protease, coagulation, metabolism, oxidative stress, and excitatory neurotoxicity. The body fluids biomarkers whose related articles are limited or mechanisms are unknown are categorized as other biomarkers. The inflammation-related biomarkers, such as neutrophil-to-lymphocyte ratio and hypersensitive C-reactive protein, play a crucial role among the mentioned biomarkers. Considering the vast heterogeneity of stroke progression, using a single body fluids biomarker may not accurately predict the risk of stroke progression, and it is necessary to combine multiple biomarkers (panels, scores, or indices) to improve their capacity to estimate END.

Ischemic Brain Stroke and Mesenchymal Stem Cells: An Overview of Molecular Mechanisms and Therapeutic Potential

Ischemic brain injury is associated with a high rate of mortality and disability with no effective therapeutic strategy. Recently, a growing number of studies are focusing on mesenchymal stem cell-based therapies for neurodegenerative disorders. However, despite having the promising outcome of preclinical studies, the clinical application of stem cell therapy remained elusive due to little or no progress in clinical trials. The objective of this study was to provide a generalized critique for the role of mesenchymal stem cell therapy in ischemic stroke injury, its underlying mechanisms, and constraints on its preclinical and clinical applications. Thus, we attempted to present an overview of previously published reports to evaluate the progress and provide molecular basis of mesenchymal stem cells (MSCs) therapy and its application in preclinical and clinical settings, which could aid in designing an effective regenerative therapeutic strategy in the future.

Predictors of early neurologic deterioration (END) following stroke thrombectomy

BACKGROUND

Early neurologic deterioration (END) following ischemic stroke is a serious event and is associated with poor outcomes. However, the incidence and predictors of END after stroke thrombectomy for emergent large vessel occlusion are largely unknown.

METHODS

The baseline characteristics of patients enrolled in the COMPASS trial (NCT02466893) were analyzed. The primary outcome was worsening of ≥4 National Institutes of Health Stroke Scale (NIHSS) points 24 hours post thrombectomy (4+ END₂₄) and the secondary outcome was deterioration of ≥2 points (2+ END₂₄).

RESULTS

Among 270 patients, 27 (10%) developed 4+ END₂₄ and 42 (16%) had 2+ END₂₄. Those with 4+ END₂₄ were older (76.4±12.9 vs 70.9±12.9 years; p=0.04), had a higher prevalence of hypertension (96% vs 69%; p=0.003), diabetes (41% vs 27%; p=0.13) and higher pretreatment systolic blood pressure (SBP) (170.4±32.6 vs 157.6±28.1 mmHg; p=0.03). More 4+ END₂₄ patients had failed reperfusion: Thrombolysis in Cerebral Infarction ≤2a (26% vs 8%; p=0.003). In unadjusted analysis, older patients and those with hypertension, diabetes, elevated SBP and failed reperfusion had higher odds of 4+ END₂₄. In adjusted analysis, age increase by 5 years led to an increase in 4+ END₂₄ of 28%, diabetes increased odds of 2.6 and failed reperfusion increased odds of 4.5. In the multivariable analysis for the secondary outcome, age (OR 1.33; 95% CI 1.109 to 1.593), diabetes (OR 2.7; 95% CI 1.247 to 5.764) and failed reperfusion (OR 7.2; 95% CI 0.055 to 0.349) were also significant predictors of 2+ END₂₄.

CONCLUSIONS

Older patients with acute ischemic stroke who have a history of diabetes or hypertension, with elevated pretreatment SBP and failed reperfusion are at a higher risk of END following stroke thrombectomy for emergent large vessel occlusion.

Impact of Stress Hyperglycemia on Early Neurological Deterioration in Acute Ischemic Stroke Patients Treated With Intravenous Thrombolysis

Background and Purpose

It has been widely reported that stress hyperglycemia contributes to poor prognosis in patients experiencing acute ischemic stroke (AIS). However, its predictive value for early neurological deterioration (END) after intravenous administration of recombinant tissue-type plasminogen activator (IV-rtPA) in AIS patients is still unclear. The aim of this study was to evaluate the impact of stress hyperglycemia on the risk of END after IV-rtPA.

Methods

A total of 798 consecutive patients treated with IV-rtPA were included in this study. The stress hyperglycemia ratio (SHR) was calculated as fasting plasma glucose level at admission (mg/dl)/glycosylated hemoglobin (HbAlc) (%). END was defined as a National Institutes of Health Stroke Scale Score (NIHSS) ≥ 4 points 24 h after IV-rtPA, and poor functional outcome at discharge was defined as a modified Rankin Scale (mRS) score of 3–6 at discharge. Patients with a prior history of diabetes or HbAlc ≥ 6.5% were considered to have diabetes mellitus. Patients were grouped according to SHR values. Multivariate logistical regression was used to evaluate the risk of END for patients within specific SHR categories.

Results

In total, 139 (17.4%) patients had END. After adjusting for confounders, the highest tertile group had higher risks of END and poor functional outcome at discharge than those of patients in the lowest tertile group (OR, 1.95; 95% CI, 1.21–3.15; p = 0.006) (OR, 1.85; 95% CI, 1.163–2.941; p = 0.009), and the predictive value of high SHR for END was also significant in patients with diabetes mellitus (OR, 3.05; 95% CI, 1.29–7.21; p = 0.011). However, a significant association of high SHR and poor functional outcome was only found in patients without diabetes (OR, 1.85; 95% CI, 1.002–3.399; p = 0.045).

Conclusion

A higher SHR predicted that patients with severe stress hyperglycemia had higher risks of END and poor functional outcome at discharge after IV-rtPA.

The intensive care management of acute ischaemic stroke

PURPOSE OF REVIEW

To discuss recent advances in the critical care management of acute ischaemic stroke patients and highlight controversies and consensus.

RECENT FINDINGS

Intravenous thrombolysis and endovascular thrombectomy are standard of care reperfusion therapies that have revolutionized the management of acute ischaemic stroke and transformed outcomes for patients. They can now be delivered in extended time windows and to those previously ineligible for intervention based on advanced neuroimaging criteria. Secondary systemic insults, such as hypo- and hypertension, hyperthermia or hyperglycaemia, which can extend the area of ischaemia must also be prevented or corrected to minimize infarct progression. Meticulous blood pressure management is of central importance, particularly in patients that have undergone reperfusion therapies. Neurological deterioration can occur because of infarct extension, haemorrhagic transformation or worsening cerebral oedema. Transcranial Doppler ultrasonography allows bedside, noninvasive evaluation of cerebral haemodynamics and is increasingly used in acute stroke triage, management and recovery prediction. The management of acute ischaemic stroke raises several ethical issues, and shared decision making is essential to ensure outcomes that are compatible with an individual patient's expectations.

SUMMARY

A bundle of medical, endovascular and surgical strategies implemented by a multidisciplinary team working to locally agreed protocols can improve long-term stroke outcomes.

Streamlining Acute Stroke Care by Introducing National Institutes of Health Stroke Scale in the Emergency Medical Services: A Prospective Cohort Study

National Institutes of Health Stroke Scale (NIHSS) is the most validated clinical scale for stroke recognition, severity grading, and symptom monitoring in acute care and hospital settings. Numerous modified prehospital stroke scales exist, but these scales contain less clinical information and lack compatibility with in-hospital stroke scales. In this real-life study, we aimed to investigate if NIHSS conducted by paramedics in the field is a feasible and accurate prehospital diagnostic tool.

Isolating the Superficial Peroneal Nerve Motor Branch to the Peroneus Longus Muscle with Concentric Stimulation during Diagnostic Motor Nerve Biopsy

Motor nerve biopsies are performed in the workup of neuropathies of unknown origin when motor neuron disease is suspected. Biopsy of a motor branch of the superficial peroneal nerve innervating the peroneus longus muscle has been described as a convenient alternative to other commonly biopsied motor nerves. To date, neuromonitoring techniques have not been described for this procedure. We describe the surgical neurophysiology techniques necessary for preservation of motor function and associated data during muscle biopsy of a motor branch of the superficial peroneal nerve innervating the peroneus longus muscle. We present a case of a patient who underwent uncomplicated biopsy of the motor branch of the superficial peroneal nerve innervating the peroneus longus muscle during workup for suspected motor neuropathy. The surgical neurophysiology techniques and data are presented in detail. No postsurgical sensory or motor deficit was related to the procedure. Surgical neurophysiology is critical to confirm the appropriate motor branch to the peroneus longus muscle and facilitates safe and accurate motor nerve biopsy.

Rt-PA thrombolytic therapy in patients with acute posterior circulation stroke: A retrospective study

At present, recombinant tissue-type plasminogen activator (rt-PA) thrombolytic therapy is widely used in patients with acute ischemic stroke within 4.5 h following stroke onset. However, the efficacy of intravenous alteplase thrombolytic therapy for posterior circulation stroke (PCS) has been rarely described. The present study aimed to predict the outcome of patients with PCS following rt-PA thrombolytic therapy in a more efficient manner. Data were collected from patients who had suffered from posterior circulation ischemic stroke, who had been treated with rt-PA over a period of 4 years (2016-2020), and had been treated at a stroke center. All patients were treated with alteplase at a standard dose of 0.9 mg/kg. According to the onset to needle time (ONT), these patients were divided into the 0-3 and 3-4.5 h groups, and the National Institutes of Health Stroke Scale (NIHSS) score was compared before thrombolysis and at 24 h after thrombolysis. Subsequently, the patients with acute PCS whose ONT was ≤3 h were divided into the NIHSS score >3 points and NIHSS score ≤3 points groups, and the NIHSS score improvement rate was compared 24 h later. A total of 989 patients were included in the study; there were 783 patients with acute anterior circulation stroke (ACS) and 203 patients with acute PCS (of note, 2 patients had negative results from brain magnetic resonance imaging); 63 patients were treated with urokinase (UK) thrombolysis and 140 patients were treated with alteplase intravenous thrombolysis. The 140 patients that received alteplase thrombolytic therapy were divided into two groups, namely the ≤3 h group and 3-4.5 h group, which, on the basis of the ONT, no significant differences were found between the two the groups according to the NIHSS score before thrombolysis (P>0.05). The NHISS scores in the ≤3 h group were significantly lower than those in the 3-4.5 h group following thrombolysis therapy, and the differences between the two groups were statistically significant (P<0.05); the patients with acute PCS treated with rt-PA in the ≤3 h group were divided into the NIHSS score ≤3 points group and the NIHSS score >3 points group. In this ≤3 h group, the average NIHSS score improvement rate following rt-PA thrombolysis was 0.535 (53.5%) in the NIHSS score ≤3 points group and that in the NIHSS score >3 points group was 0.336 (33.6%); the difference between the two groups was statistically significant (P<0.05). The patients treated with intravenous alteplase thrombolysis within 3 h following stroke onset benefited more than those treated with thrombolysis therapy within 3 to 4.5 h after stroke onset. On the whole, the present study demonstrates that the patients with mild stroke (NIHSS score ≤3 points) who were treated at an earlier stage (received alteplase thrombolysis therapy within 3 h after stroke onset) benefited to a greater extent from the therapy.

Early neurological deterioration after intravenous thrombolysis of anterior vs posterior circulation stroke: a secondary analysis of INTRECIS

Anterior circulation stroke (ACS) differs from posterior circulation stroke (PCS) in many ways, but it remains unclear whether there is any difference in early neurological deterioration (END) in two stroke territories. We compared post-thrombolytic END between ACS and PCS based on the data from INTRECIS. We screened patients receiving intravenous 0.9 mg/kg alteplase within 4.5 h in the INTRECIS cohort. According to stroke territory, patients were divided into ACS and PCS groups. The primary outcome was incidence of END, which was defined as an increase in NIHSS score ≥ 4 or death within 24 h from baseline. The secondary outcomes were associated factors of END and 90-day modified Rankin Scale (mRS) distribution. Overall, 1194 patients were enrolled in this study: 942 in ACS group and 252 in PCS group. There was no significant difference in the incidence of END between two groups (3.8% vs 5.2%, adjusted p = 0.406). Atrial fibrillation (adjusted p = 0.012) and TOAST classification (adjusted p = 0.009) were associated with END in ACS, while hypertension history (adjusted p = 0.046) and baseline NIHSS score (adjusted p = 0.011) with END in PCS. END was associated with worse outcome on 90-day mRS in ACS and PCS (adjusted p < 0.001). Based on a prospective nationwide cohort, we provided first report for similar incidence, but different risk factors of post-thrombolytic END in ACS vs PCS patients.

Trial Registration-URL: https://www.clinicaltrials.gov; Unique identifier: NCT02854592.

Relationship Between Body Temperature and Early Neurological Deterioration after Endovascular Thrombectomy for Acute Ischemic Stroke with Large Vessel Occlusion

BACKGROUND

Early neurological deterioration (END) after endovascular thrombectomy (EVT) is strongly associated with poor prognosis in patients with large vessel occlusion. The relationship between body temperature and END after EVT is unknown, which we aimed to investigate in this study.

METHODS

END was defined as an increase of four or more points on the National Institutes of Health Stroke Scale score compared with the baseline assessment within 24 h. Logistic regression and restricted cubic spline models were used to assess the relationship between body temperature and END.

RESULTS

Among 7741 consecutive patients with ischemic stroke, 406 patients with large vessel occlusion who underwent EVT were enrolled. In total, 88 (21.7%) patients developed END. Logistic regression showed that the maximum body temperature within 24 h (odds ratio [OR] = 1.97 per °C, 95% confidence interval [CI] 1.17-3.32, p = 0.010) was independently associated with END. This association was nonlinear and J shaped (p for nonlinearity = 0.010), and the risk of END increased when the maximum body temperature within 24 h was lower or higher than 37.0 °C. Fever burden is also independently associated with END (OR = 1.06 per °C  × hour, 95% CI 1.01-1.11, p = 0.012). In addition, the timing of fever onset was independently associated with END, and the highest risk of END was associated with fever onset within 6 h after EVT (OR = 3.92, 95% CI 1.25-12.27, p = 0.019).

CONCLUSIONS

In summary, there is a J-shaped association between the maximum body temperature within 24 h after EVT and END. Moreover, the risk of END differed according to the timing of fever onset.

Predictors of Early Neurological Deterioration and Functional Outcome in Acute Ischemic Stroke: The Importance of Large Artery Disease, Hyperglycemia and Inflammatory Blood Biomarkers

BACKGROUND

Early neurological deterioration (END) in acute ischemic stroke (AIS) can be associated with poor outcome. The aim of this study was to investigate the association between infarction subtypes, biomarkers and END, and to identify patients with risk of unfavorable functional outcome.

MATERIALS AND METHODS

This prospective study enrolled 101 patients with AIS. Neurological status was evaluated according to NIHSS at acute onset, on days 2, 3, and 90. END was defined as ≥2-point increase of NIHSS within 72 hours. Functional outcome was assessed using NIHSS and the modified Rankin Scale (mRS) at day 90.

RESULTS

END was observed in 20, 8%. Patients with large artery disease had higher risk of developing END compared with patients with cardioembolism or small vessel disease (p <0.01). Significant higher blood glucose level and leukocytes were observed in the END group. Patients with END had higher scores of mRS at day 90 (p <0.01). Levels of NSE, IL-6, hsCRP and NT-proBNP were higher in the patients with unfavorable compared with favorable functional outcome.

CONCLUSION

Large artery disease, high blood glucose and leukocytes levels are associated with END. Elevated levels of blood markers NSE, IL-6, HsCRP and NT-proBNP indicate poor functional outcome at 90 days after AIS. These patients must be identified and be offered treatment immediately in order to improve the functional outcome after AIS.

OUP accepted manuscript

The management of patients with stroke is often multidisciplinary, involving various specialties and healthcare professionals. Given the common shared risk factors for stroke and cardiovascular disease, input may also be required from the cardiovascular teams, as well as patient caregivers and next-of-kin. Ultimately, the patient is central to all this, requiring a coordinated and uniform approach to the priorities of post-stroke management, which can be consistently implemented by different multidisciplinary healthcare professionals, as part of the patient ‘journey’ or ‘patient pathway,’ supported by appropriate education and tele-medicine approaches. All these aspects would ultimately aid delivery of care and improve patient (and caregiver) engagement and empowerment. Given the need to address the multidisciplinary approach to holistic or integrated care of patients with heart disease and stroke, the European Society of Cardiology Council on Stroke convened a Task Force, with the remit to propose a consensus on Integrated care management for optimizing the management of stroke and associated heart disease. The present position paper summarizes the available evidence and proposes consensus statements that may help to define evidence gaps and simple practical approaches to assist in everyday clinical practice. A post-stroke ABC pathway is proposed, as a more holistic approach to integrated stroke care, would include three pillars of management:

A: Appropriate Antithrombotic therapy.

B: Better functional and psychological status.

C: Cardiovascular risk factors and Comorbidity optimization (including lifestyle changes).

Malnutrition and the Risk of Early Neurological Deterioration in Elderly Patients with Acute Ischemic Stroke

BACKGROUND AND PURPOSE

This study aimed to investigate the relationship between malnutrition and early neurological deterioration (END) in elderly patients with acute ischemic stroke in China.

METHODS

We used the registry data in the Third Affiliated Hospital of Nantong University and Nanjing Brain Hospital from June 2019 to January 2021. Malnutrition risk was evaluated by controlling nutritional status score (CONUT), geriatric nutritional risk index (GNRI) and prognostic nutritional index (PNI) score, respectively. END was defined as an increment of at least two points in the total NIHSS score within three days after admission. We evaluated the relationship between malnutrition and END with multivariable logistic regression models and reclassification indexes.

RESULTS

A total of 732 elderly patients with first-ever acute ischemic stroke were included in the study. 243 patients developed END. 5.7%, 21.4%, 4.6% patients were classified as moderate to severe malnutrition by CONUT, GNRI and PNI, respectively. Malnutrition was associated with the risk of END for CONUT (odds ratio [OR], 1.210; 95% confidence interval [CI] 1.092-1.341; P < 0.001), for GNRI (OR, 0.943; 95% CI, 0.919-0.967; P < 0.001), and for PNI (OR, 0.936; 95% CI, 0.908-0.965; P < 0.001) in multivariable logistic regression models using the back-ward selection method. The discriminative ability was 0.763 (95% CI, 0.727-0.798) for CONUT, 0.769 (95% CI, 0.733-0.805) for GNRI and 0.769 (95% CI, 0.733-0.805) for PNI after adjusting for confounders. Besides, adding malnutrition indexes into models made the prediction of END more accurate.

CONCLUSION

Malnutrition was associated with END in elderly Chinese patients with acute ischemic stroke.

Safety and Efficacy of Endovascular Treatment for Progressive Stroke in Patients With Acute Basilar Artery Occlusion

Background and Purpose: It is unknown the benefit of endovascular therapy (EVT) for progressive stroke in patients with basilar artery occlusion (BAO). The aim of this study was to compare the efficacy and safety of EVT with standard medical therapy (SMT) in a population of BAO patients with progressive stroke.

Methods: The EVT for Acute Basilar Artery Occlusion Study (BASILAR) is a national prospective registry of consecutive patients with acute BAO within 24 h of symptom onset. According to the applied therapy, all patients were divided into SMT and EVT groups. Subsequently, the EVT group was divided into early (≤6 h) and late groups (>6 h) according to the time window. The efficacy outcome was favorable functional outcomes (modified Rankin Scale score ≤ 3) at 90 days. The safety outcomes included mortality within 90 days and symptomatic intracerebral hemorrhage (sICH) after EVT.

Results: The EVT cohort presented more frequently with a favorable functional outcome (adjusted odds ratio, 5.49; 95% confidence interval, 2.06–14.61, p = 0.01) and with a decreased mortality (adjusted odds ratio, 0.3; 95% confidence interval, 0.17–0.54, p < 0.001). What's more, EVT still safe (P = 0.584, P = 0.492, respectively) and effective (P = 0.05) in patients with progressive stroke when the treatment time window exceeds 6 h.

Conclusions: EVT was more effective and safer than SMT for progressive stroke in patients with BAO. Besides, EVT remains safe and effective in patients with progressive stroke when the treatment time window exceeds 6 h. Predictors of desirable outcome in progressive stroke patients undergoing EVT included lower baseline NIHSS score, higher baseline pc-ASPECTs, successful recanalization and shorter puncture to recanalization time.

An Internet of Medical Things-Based Model for Real-Time Monitoring and Averting Stroke Sensors

In recent years, neurological diseases have become a standout amongst all the other diseases and are the most important reasons for mortality and morbidity all over the world. The current study's aim is to conduct a pilot study for testing the prototype of the designed glove-wearable technology that could detect and analyze the heart rate and EEG for better management and avoiding stroke consequences. The qualitative, clinical experimental method of assessment was explored by incorporating use of an IoT-based real-time assessing medical glove that was designed using heart rate-based and EEG-based sensors. We conducted structured interviews with 90 patients, and the results of the interviews were analyzed by using the Barthel index and were grouped accordingly. Overall, the proportion of patients who followed proper daily heart rate recording behavior went from 46.9% in the first month of the trial to 78.2% after 3-10 months of the interventions. Meanwhile, the percentage of individuals having an irregular heart rate fell from 19.5% in the first month of the trial to 9.1% after 3-10 months of intervention research. In T5, we found that delta relative power decreased by 12.1% and 5.8% compared with baseline at 3 and at 6 months and an average increase was 24.3 ± 0.08. Beta-1 remained relatively steady, while theta relative power grew by 7% and alpha relative power increased by 31%. The T1 hemisphere had greater mean values of delta and theta relative power than the T5 hemisphere. For alpha (p < 0.05) and beta relative power, the opposite pattern was seen. The distinction was statistically significant for delta (p < 0.001), alpha (p < 0.01), and beta-1 (p < 0.05) among T1 and T5 patient groups. In conclusion, our single center-based study found that such IoT-based real-time medical monitoring devices significantly reduce the complexity of real-time monitoring and data acquisition processes for a healthcare provider and thus provide better healthcare management. The emergence of significant risks and controlling mechanisms can be improved by boosting the awareness. Furthermore, it identifies the high-risk factors besides facilitating the prevention of strokes. The EEG-based brain-computer interface has a promising future in upcoming years to avert DALY.

Interpretable machine learning for early neurological deterioration prediction in atrial fibrillation-related stroke

We aimed to develop a novel prediction model for early neurological deterioration (END) based on an interpretable machine learning (ML) algorithm for atrial fibrillation (AF)-related stroke and to evaluate the prediction accuracy and feature importance of ML models. Data from multicenter prospective stroke registries in South Korea were collected. After stepwise data preprocessing, we utilized logistic regression, support vector machine, extreme gradient boosting, light gradient boosting machine (LightGBM), and multilayer perceptron models. We used the Shapley additive explanation (SHAP) method to evaluate feature importance. Of the 3,213 stroke patients, the 2,363 who had arrived at the hospital within 24 h of symptom onset and had available information regarding END were included. Of these, 318 (13.5%) had END. The LightGBM model showed the highest area under the receiver operating characteristic curve (0.772; 95% confidence interval, 0.715–0.829). The feature importance analysis revealed that fasting glucose level and the National Institute of Health Stroke Scale score were the most influential factors. Among ML algorithms, the LightGBM model was particularly useful for predicting END, as it revealed new and diverse predictors. Additionally, the effects of the features on the predictive power of the model were individualized using the SHAP method.

Glycemic variability of acute stroke patients and clinical outcomes: a continuous glucose monitoring study

Introduction:

Glycemic variability (GV) has been associated with worse prognosis in critically ill patients. We sought to evaluate the potential association between GV indices and clinical outcomes in acute stroke patients.

Methods:

Consecutive diabetic and nondiabetic, acute ischemic or hemorrhagic stroke patients underwent regular, standard-of-care finger-prick measurements and continuous glucose monitoring (CGM) for up to 96 h. Thirteen GV indices were obtained from CGM data. Clinical outcomes during hospitalization and follow-up period (90 days) were recorded. Hypoglycemic episodes disclosed by CGM but missed by finger-prick measurements were also documented.

Results:

A total of 62 acute stroke patients [48 ischemic and 14 hemorrhagic, median NIHSS score: 9 (IQR: 3–16) points, mean age: 65 ± 10 years, women: 47%, nondiabetic: 79%] were enrolled. GV expressed by higher mean absolute glucose (MAG) values was associated with a lower likelihood of neurological improvement during hospitalization before and after adjusting for potential confounders (OR: 0.135, 95% CI: 0.024–0.751, p = 0.022). There was no association of GV indices with 3-month clinical outcomes. During CGM recording, 32 hypoglycemic episodes were detected in 17 nondiabetic patients. None of these episodes were identified by the periodic blood glucose measurements and therefore they were not treated.

Conclusions:

Greater GV of acute stroke patients may be related to lower odds of neurological improvement during hospitalization. No association was disclosed between GV indices and 3-month clinical outcomes.

Course of Early Neurologic Symptom Severity after Endovascular Treatment of Anterior Circulation Large Vessel Occlusion Stroke: Association with Baseline Multiparametric CT Imaging and Clinical Parameters

Background: Neurologic symptom severity and deterioration at 24 hours (h) predict long-term outcomes in patients with acute large vessel occlusion (LVO) stroke of the anterior circulation. We aimed to examine the association of baseline multiparametric CT imaging and clinical factors with the course of neurologic symptom severity in the first 24 h after endovascular treatment (EVT). Methods: Patients with LVO stroke of the anterior circulation were selected from a prospectively acquired consecutive cohort of patients who underwent multiparametric CT, including non-contrast CT, CT angiography and CT perfusion before EVT. The symptom severity was assessed on admission and after 24 h using the 42-point National Institutes of Health Stroke Scale (NIHSS). Clinical and imaging data were compared between patients with and without early neurological deterioration (END). END was defined as an increase in ≥4 points, and a significant clinical improvement as a decrease in ≥4 points, compared to NIHSS on admission. Multivariate regression analyses were used to determine independent associations of imaging and clinical parameters with NIHSS score increase or decrease in the first 24 h. Results: A total of 211 patients were included, of whom 38 (18.0%) had an END. END was significantly associated with occlusion of the internal carotid artery (odds ratio (OR), 4.25; 95% CI, 1.90–9.47) and the carotid T (OR, 6.34; 95% CI, 2.56–15.71), clot burden score (OR, 0.79; 95% CI, 0.68–0.92) and total ischemic volume (OR, 1.01; 95% CI, 1.00–1.01). In a comprehensive multivariate analysis model including periprocedural parameters and complications after EVT, carotid T occlusion remained independently associated with END, next to reperfusion status and intracranial hemorrhage. Favorable reperfusion status and small ischemic core volume were associated with clinical improvement after 24 h. Conclusions: The use of imaging parameters as a surrogate for early NIHSS progression in an acute LVO stroke after EVT reached limited performance with only carotid T occlusion as an independent predictor of END. Reperfusion status and early complications in terms of intracranial hemorrhage are critical factors that influence patient outcome in the acute stroke phase after EVT.

Causes, Predictors, and Timing of Early Neurological Deterioration and Symptomatic Intracranial Hemorrhage After Administration of IV tPA

Background

Acute ischemic stroke (AIS) is a major contributor toward healthcare-associated costs and services. Symptomatic intracranial hemorrhage (sICH) and early neurologic decline (END), defined as a National Health Institute Stroke Scale score decline of ≥ 4 within 24 h (with or without sICH), remain major concerns when administering intravenous tissue plasminogen activator (IV tPA) despite improved functional neurologic outcomes with its use. Given these risks, current guidelines recommend comprehensive stroke care (most often in an intensive care unit setting) for 24 h posttreatment. However, a number of patients may remain stable after IV tPA and thus not require such intensive resources. We sought to determine causes of END, along with timing and predictors of both sICH and END, to identify patients at lower risk of neurological deterioration and those suitable for earlier transition to a lower level of care.

Methods

This present study analyzed patients with AIS that presented within 4.5 h of being last seen well and received IV tPA. Baseline demographic, clinical, and radiographic findings were collected. Outcomes included END from any cause, parenchymal hemorrhage (PH1 or PH2), sICH, and mortality at 90 days.

Results

A total of 1238 patients with AIS without acute treatment of large vessel occlusion received IV tPA. 9.4% (116) had presence of any degree of ICH on noncontrast computed tomography head and 7.4% (91) experienced associated END. 2.7% (33) of patients experienced sICH, while 6.7% (83) experienced asymptomatic ICH. Of the patients with END, 63.7% did not have ICH. Predictive factors at presentation for END included an older age (72.6 ± 16.1 vs. 69.1 ± 14.8, p = 0.03), history of tobacco use (odds ratio [OR] 2.1 [1.1–4.3], p = 0.04), and hyperlipidemia (OR 1.7 [1.1–2.8], p = 0.02), along with the presence of an untreated large vessel occlusion (OR 2.1 [1.4–3.1], p = 0.02). Most END occurred within a mean time of 242 ± 251 min (4 ± 4 h). Because of the small proportion of patients suffering from sICH (33), predictors could not be determined; however, for patients with any ICH, predictive factors included an older age (74.6 ± 12.4 vs. 68.8 ± 15.1, p = 0.001), higher baseline National Health Institute Stroke Scale score (14.6 ± 7.3 vs. 10.8 ± 7.9, p = 0.002), and higher baseline glucose levels (155.1 ± 87.5 vs. 140.4 ± 70.5, p = 0.04).

Conclusions

In this study, only a small proportion suffered from either sICH and/or END, typically within 12 h of tPA administration. These findings may support earlier deescalation of higher acuity monitoring in clinically stable post-IV tPA patients without large vessel occlusion.

Monocyte to High-Density Lipoprotein Ratio Is Associated With Early Neurological Deterioration in Acute Isolated Pontine Infarction

Objectives: The monocyte to high-density lipoprotein ratio (MHR) has been considered to be a novel inflammatory marker of atherosclerotic cardiovascular disease. However, its role in the acute phase of acute isolated pontine infarctions remains elusive. We explored whether an association existed between elevated MHR levels and early neurological deterioration (END) in patients with isolated pontine infarction.

Methods: Data from 212 patients with acute isolated pontine infarction were retrospectively analyzed. We examined the MHR in quartiles of increasing levels to evaluate for possible threshold effects. END was defined as an elevation in the total National Institutes of Health Stroke Scale (NIHSS) score ≥2 or an increase in NIHSS score ≥1 in motor power within the first week after symptom onset. Patients were divided into an END group and a non-END group. The association of MHR on END following pontine infarction was examined by logistic regression models after adjusting for age, NIHSS at admission, basilar artery stenosis, history of hypertension or hyperlipidemia or stroke, infarct size, fasting blood glucose, and paramedian pontine infarction.

Results: The mean MHR was 0.44 ± 0.22. A total of 58 (27.36%) patients were diagnosed with END. END occurred within the first 48 h after hospitalization in 38 patients (65.52%). After adjusting for confounding and risk factors, the multivariate logistic regression analysis showed NIHSS at admission [odds ratio (OR), 1.228; 95% confidence interval (CI), 1.036–1.456], basilar artery stenosis (OR, 2.843; 95% CI, 1.205–6.727), and fasting blood glucose (OR, 1.296; 95% CI, 1.004–1.672) were independently associated with END. The odds ratio of END increased as the quartile level of MHR increased, with the lowest quartile used as the reference value. Compared to the first quartile of MHR, the third and fourth quartiles were associated with 4.847-fold (95% CI, 1.532–15.336) and 5.824-fold (95% CI, 1.845–18.385) higher odds of END in multivariate analysis.

Conclusions: Elevated MHR levels may be valuable as a biomarker of END in patients with isolated pontine infarction. The elevated MHR was independently associated with END in isolated pontine infarction.

Trans-cranial Doppler predicts early neurologic deterioration in anterior circulation ischemic stroke after successful endovascular treatment

Background

Early neurologic deterioration (END) may occur in patients with anterior circulation ischemic stroke (ACIS) after receiving endovascular treatment (EVT). Hemodynamic insufficiency, re-occlusion, and post-re-canalization hyper-perfusion are likely to play a critical role in END. We hypothesized that hemodynamic changes can predict END in patients with ACIS post-successful EVT using trans-cranial Doppler (TCD).

Methods

We utilized a prospectively maintained database of ACIS patients treated with EVT between September 2016 and June 2018 in the Xuanwu Hospital, Capital Medical University. TCD parameters including peak systolic velocity (PSV), bilateral mean flow velocity (MFV), and pulse index (PI) were determined via the middle cerebral arteries within 72 h post-EVT. A logistic regression model was applied to detect independent predictors for END.

Results

Totally, 112 EVT patients were included in this study and 80/112 patients experienced successful re-canalization with <50% residual stenosis, while 17/80 (21.3%) patients suffered END, for which vasogenic cerebral edema (11/17) was considered as a leading role and followed by symptomatic intra-cranial hemorrhage (4/17) and ischemia progression (2/17). For the 80 patients, the PSV (median: 127 cm/s vs. 116 cm/s, P = 0.039), the ratio of ipsilateral-MFV/contra-lateral-MFV (iMFV/cMFV) (median: 1.29 vs. 1.02, P = 0.036) and iMFV/mean blood pressure (MBP) (median: 0.97 vs. 0.79, P = 0.008) in END patients were higher than those of non-END. Using the receiver-operating characteristic curve to obtain cut-off values for PSV, PI, iMFV/cMFV, and iMFV/MBP for END, we found that PI ≥0.85 (odds ratio: 11.03, 95% confidence interval: 1.92–63.46, P = 0.007) and iMFV/MBP ≥0.84 (odds ratio: 9.20, 95% confidence interval: 2.07–40.84, P = 0.004) were independent predictors of END in a multivariate logistic regression model, with a sensitivity of 82.4% and 76.5% and a specificity of 42.9% and 66.7%, respectively, and had the positive predictive values of 29.0% and 38.2%, and negative predictive values of 90.0% and 91.3%, with an area under the receiver-operating characteristic curve of 0.57 and 0.71, respectively.

Conclusion

TCD examination of EVT patients may be used as a real-time tool to detect END predictors, such as the higher PI and iMFV/MBP, allowing for better post-thrombectomy management in ACIS patients.

Mechanical Thrombectomy in Nighttime Hours: Is There a Difference in 90-Day Clinical Outcome for Patients with Ischemic Stroke?

BACKGROUND AND PURPOSE

Few data are available regarding the influence of the timing of ischemic stroke management, such as daytime and nighttime hours, on the delay of mechanical thrombectomy, the effectiveness of revascularization, and clinical outcomes. We aimed to investigate whether admission during nighttime hours could impact the clinical outcome (mRS at 90 days) of patients with acute ischemic stroke treated by mechanical thrombectomy.

MATERIALS AND METHODS

We retrospectively analyzed 169 patients (112 treated during daytime hours and 57 treated during nighttime hours) with acute ischemic stroke in the anterior cerebral circulation. The main outcome was the rate of patients achieving functional independence at 90 days (mRS ≤2), depending on admission time.

RESULTS

In patients admitted during nighttime hours, the rate of mRS ≤ 2 at 90 days was significantly higher (51% versus 35%, P = .05) compared with those admitted in daytime hours. Patients in daytime and nighttime hours were comparable regarding admission and treatment characteristics. However, patients in nighttime hours tended to have a higher median NIHSS score at admission (P = .08) and to be younger (P = .08), especially among the mothership group (P = .09). The multivariate logistic regression analysis confirmed that patients in nighttime hours had better functional outcomes at 90 days than those in daytime hours (P = .018; 95% CI, 0.064-0.770; OR = 0.221).

CONCLUSIONS

In a highly organized stroke care network, mechanical thrombectomy is quite effective in the nighttime hours among acute ischemic stroke presentations. Unexpectedly, we found that those patients achieved favorable clinical outcomes more frequently than those treated during daytime hours. Larger series are needed to confirm these results.

Prediction of Early Neurological Deterioration in Individuals With Minor Stroke and Large Vessel Occlusion Intended for Intravenous Thrombolysis Alone

Importance

The best reperfusion strategy in patients with acute minor stroke and large vessel occlusion (LVO) is unknown. Accurately predicting early neurological deterioration of presumed ischemic origin (ENDi) following intravenous thrombolysis (IVT) in this population may help to select candidates for immediate transfer for additional thrombectomy.

Objective

To develop and validate an easily applicable predictive score of ENDi following IVT in patients with minor stroke and LVO.

Design, Setting, and Participants

This multicentric retrospective cohort included 729 consecutive patients with minor stroke (National Institutes of Health Stroke Scale [NIHSS] score of 5 or less) and LVO (basilar artery, internal carotid artery, first [M1] or second [M2] segment of middle cerebral artery) intended for IVT alone in 45 French stroke centers, ie, including those who eventually received rescue thrombectomy because of ENDi. For external validation, another cohort of 347 patients with similar inclusion criteria was collected from 9 additional centers. Data were collected from January 2018 to September 2019.

Main Outcomes and Measures

ENDi, defined as 4 or more points' deterioration on NIHSS score within the first 24 hours without parenchymal hemorrhage on follow-up imaging or another identified cause.

Results

Of the 729 patients in the derivation cohort, 335 (46.0%) were male, and the mean (SD) age was 70 (15) years; of the 347 patients in the validation cohort, 190 (54.8%) were male, and the mean (SD) age was 69 (15) years. In the derivation cohort, the median (interquartile range) NIHSS score was 3 (1-4), and the occlusion site was the internal carotid artery in 97 patients (13.3%), M1 in 207 (28.4%), M2 in 395 (54.2%), and basilar artery in 30 (4.1%). ENDi occurred in 88 patients (12.1%; 95% CI, 9.7-14.4) and was strongly associated with poorer 3-month outcomes, even in patients who underwent rescue thrombectomy. In multivariable analysis, a more proximal occlusion site and a longer thrombus were independently associated with ENDi. A 4-point score derived from these variables-1 point for thrombus length and 3 points for occlusion site-showed good discriminative power for ENDi (C statistic = 0.76; 95% CI, 0.70-0.82) and was successfully validated in the validation cohort (ENDi rate, 11.0% [38 of 347]; C statistic = 0.78; 95% CI, 0.70-0.86). In both cohorts, ENDi probability was approximately 3%, 7%, 20%, and 35% for scores of 0, 1, 2 and 3 to 4, respectively.

Conclusions and Relevance

The substantial ENDi rates observed in these cohorts highlights the current debate regarding whether to directly transfer patients with IVT-treated minor stroke and LVO for additional thrombectomy. Based on the strong associations observed, an easily applicable score for ENDi risk prediction that may assist decision-making was derived and externally validated.

Fatal and Nonfatal Events Within 14 days After Early, Intensive Mobilization Poststroke

OBJECTIVE

This tertiary analysis from A Very Early Rehabilitation Trial (AVERT) examined fatal and nonfatal serious adverse events (SAEs) at 14 days.

METHOD

AVERT was a prospective, parallel group, assessor blinded, randomized international clinical trial comparing mobility training commenced <24 hours poststroke, termed very early mobilization (VEM), to usual care (UC). Primary outcome was assessed at 3 months. Patients with ischemic or hemorrhagic stroke within 24 hours of onset were included. Treatment with thrombolytics was allowed. Patients with severe premorbid disability or comorbidities were excluded. Interventions continued for 14 days or hospital discharge if less. The primary early safety outcome was fatal SAEs within 14 days. Secondary outcomes were nonfatal SAEs classified as neurologic, immobility-related, and other. Mortality influences were assessed using binary logistic regression adjusted for baseline stroke severity (NIH Stroke Scale [NIHSS] score) and age.

RESULTS

A total of 2,104 participants were randomized to VEM (n = 1,054) or UC (n = 1,050) with a median age of 72 years (interquartile range [IQR] 63-80) and NIHSS 7 (IQR 4-12). By 14 days, 48 had died in VEM, 32 in UC, age and stroke severity adjusted odds ratio of 1.76 (95% confidence interval 1.06-2.92, p = 0.029). Stroke progression was more common in VEM. Exploratory subgroup analyses showed higher odds of death in intracerebral hemorrhage and >80 years subgroups, but there was no significant treatment by subgroup interaction. No difference in nonfatal SAEs was found.

CONCLUSION

While the overall case fatality at 14 days poststroke was only 3.8%, mortality adjusted for age and stroke severity was increased with high dose and intensive training compared to usual care. Stroke progression was more common in VEM.

REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12606000185561.

CLASSIFICATION OF EVIDENCE

This study provides Class I evidence that very early mobilization increases mortality at 14 days poststroke.

The association of neutrophil to lymphocyte ratio, platelet to lymphocyte ratio, and lymphocyte to monocyte ratio with post-thrombolysis early neurological outcomes in patients with acute ischemic stroke

Background and purpose

To investigate the association of neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), and lymphocyte to monocyte ratio (LMR) with post-thrombolysis early neurological outcomes including early neurological improvement (ENI) and early neurological deterioration (END) in patients with acute ischemic stroke (AIS).

Methods

AIS patients undergoing intravenous thrombolysis were enrolled from April 2016 to September 2019. Blood cell counts were sampled before thrombolysis. Post-thrombolysis END was defined as the National Institutes of Health Stroke Scale (NIHSS) score increase of ≥ 4 within 24 h after thrombolysis. Post-thrombolysis ENI was defined as NIHSS score decrease of ≥ 4 or complete recovery within 24 h. Multinomial logistic regression analysis was performed to explore the relationship of NLR, PLR, and LMR to post-thrombolysis END and ENI. We also used receiver operating characteristic curve analysis to assess the discriminative ability of three ratios in predicting END and ENI.

Results

Among 1060 recruited patients, a total of 193 (18.2%) were diagnosed with END and 398 (37.5%) were diagnosed with ENI. Multinomial logistic model indicated that NLR (odds ratio [OR], 1.385; 95% confidence interval [CI] 1.238–1.551, P = 0.001), PLR (OR, 1.013; 95% CI 1.009–1.016, P = 0.001), and LMR (OR, 0.680; 95% CI 0.560–0.825, P = 0.001) were independent factors for post-thrombolysis END. Moreover, NLR (OR, 0.713; 95% CI 0.643–0.791, P = 0.001) served as an independent factor for post-thrombolysis ENI. Area under curve (AUC) of NLR, PLR, and LMR to discriminate END were 0.763, 0.703, and 0.551, respectively. AUC of NLR, PLR, and LMR to discriminate ENI were 0.695, 0.530, and 0.547, respectively.

Conclusions

NLR, PLR, and LMR were associated with post-thrombolysis END. NLR and PLR may predict post-thrombolysis END. NLR was related to post-thrombolysis ENI.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12974-021-02090-6.

European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke

Intravenous thrombolysis is the only approved systemic reperfusion treatment for patients with acute ischaemic stroke. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist physicians in their clinical decisions with regard to intravenous thrombolysis for acute ischaemic stroke. These guidelines were developed based on the ESO standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote recommendations. Expert consensus statements were provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found high quality evidence to recommend intravenous thrombolysis with alteplase to improve functional outcome in patients with acute ischemic stroke within 4.5 h after symptom onset. We also found high quality evidence to recommend intravenous thrombolysis with alteplase in patients with acute ischaemic stroke on awakening from sleep, who were last seen well more than 4.5 h earlier, who have MRI DWI-FLAIR mismatch, and for whom mechanical thrombectomy is not planned. These guidelines provide further recommendations regarding patient subgroups, late time windows, imaging selection strategies, relative and absolute contraindications to alteplase, and tenecteplase. Intravenous thrombolysis remains a cornerstone of acute stroke management. Appropriate patient selection and timely treatment are crucial. Further randomized controlled clinical trials are needed to inform clinical decision-making with regard to tenecteplase and the use of intravenous thrombolysis before mechanical thrombectomy in patients with large vessel occlusion.

Differences between predictive factors for early neurological deterioration due to hemorrhagic and ischemic insults following intravenous recombinant tissue plasminogen activator

Early neurological deterioration (END) following intravenous recombinant tissue plasminogen activator (rt-PA) treatment is a serious clinical event that can be caused by hemorrhagic or ischemic insult. We investigated the differences in predictive factors for END due to hemorrhagic and END due to ischemic insults. Consecutive patients from four hospitals who received 0.6 mg/kg intravenous rt-PA for acute ischemic stroke were retrospectively recruited. END was defined as a National Institutes of Health Stroke Scale (NIHSS) score ≥ 4 points within 24 h compared with baseline. END was classified into those due to hemorrhagic (END_h) or ischemic (END_i) insult based on computed tomography (CT) or magnetic resonance imaging. Risk factors associated with END_h and END_i were investigated by comparison with non-END cases. A total of 744 patients (452 men, median 75 years old) were included. END was observed in 79 patients (10.6%), including 22 END_h (3.0%) and 57 END_i (7.7%), which occurred within a median of 7 h after treatment. Multivariate analyses showed that higher pretreatment NIHSS score (odds ratio [OR] 1.06, 95% confidence interval [CI] 1.00–1.13) and pretreatment with antiplatelets (OR 2.84, 95% CI 1.08–7.72) were associated with END_h. Extensive early ischemic change (Alberta Stroke Program Early CT Score ≤ 7 on CT or ≤ 6 on diffusion-weighted imaging; OR 2.80, 95% CI 1.36–5.64) and large artery occlusions (OR 3.09, 95% CI 1.53–6.57) were associated with END_i. Distinct factors were predictive for the END subtypes. These findings could help develop preventative measures for END in patients with the identified risk factors.

Intravenous thrombolysis in stroke with admission NIHSS score 0 or 1

BACKGROUND

Up to 30% of stroke patients initially presenting with non-disabling or mild deficits may experience poor functional outcome. Despite, intravenous thrombolysis remains controversial in this subgroup of stroke patients due to its uncertain risk benefit ratio.

AIM

We aimed to analyze the real-world experience with intravenous thrombolysis in stroke patients presenting with very low NIHSS.

METHODS

Data of stroke patients presenting with mild initial stroke severity (NIHSS 0-5) including vascular risk factors, stroke syndrome and etiology, early neurological deterioration, symptomatic intracerebral haemorrhage (sICH), and functional outcome by modified Rankin Scale were extracted from a large nationwide stroke registry and analysed. Patients were categorized and compared according to admission severity NIHSS 0-1 versus NIHSS 2-5 and intravenous thrombolysis use.

RESULTS

Seven hundred and three (2%) of 35,113 patients presenting with NIHSS 0-1 and 6316 (13.9%) of 45,521 of patients presenting with NIHSS 2-5 underwent intravenous thrombolysis. In the NIHSS 0-1 group, intravenous thrombolysis was associated with early neurological deterioration (adjusted OR 8.84, CI 6.61-11.83), sICH (adjusted OR 9.32, CI 4.53-19.15) and lower rate of excellent outcome (mRS 0-1) at three months (adjusted OR 0.67, CI 0.5-0.9). In stroke patients with NIHSS 2-5, intravenous thrombolysis was associated with early neurological deterioration (adjusted OR 1.7, 1.47-1.98), sICH (adjusted OR 5.75, CI 4.45-7.45), and higher rate of excellent outcome (mRS 0-1) at three months (adjusted OR 1.21, CI 1.08-1.34).

CONCLUSIONS

Among patients with NIHSS 0-1, intravenous thrombolysis did not increase the likelihood of excellent outcome. Moreover, potential signals of harm were observed. Further research seems to be warranted.

Tissue no-reflow despite full recanalization following thrombectomy for anterior circulation stroke with proximal occlusion: A clinical study

Despite early thrombectomy, a sizeable fraction of acute stroke patients with large vessel occlusion have poor outcome. The no-reflow phenomenon, i.e. impaired microvascular reperfusion despite complete recanalization, may contribute to such "futile recanalizations". Although well reported in animal models, no-reflow is still poorly characterized in man. From a large prospective thrombectomy database, we included all patients with intracranial proximal occlusion, complete recanalization (modified thrombolysis in cerebral infarction score 2c-3), and availability of both baseline and 24 h follow-up MRI including arterial spin labeling perfusion mapping. No-reflow was operationally defined as i) hypoperfusion ≥40% relative to contralateral homologous region, assessed with both visual (two independent investigators) and automatic image analysis, and ii) infarction on follow-up MRI. Thirty-three patients were eligible (median age: 70 years, NIHSS: 18, and stroke onset-to-recanalization delay: 208 min). The operational criteria were met in one patient only, consistently with the visual and automatic analyses. This patient recanalized 160 min after stroke onset and had excellent functional outcome. In our cohort of patients with complete and stable recanalization following thrombectomy for intracranial proximal occlusion, severe ipsilateral hypoperfusion on follow-up imaging associated with newly developed infarction was a rare occurrence. Thus, no-reflow may be infrequent in human stroke and may not substantially contribute to futile recanalizations.

Early neurological deterioration in cardiogenic cerebral embolism due to nonvalvular atrial fibrillation: Predisposing factors and clinical implications

PURPOSE

The aim of the study was to investigate factors which may predispose patients to early neurological deterioration (END) and explore peripheral biomarkers for the prediction of END in cardiogenic cerebral embolism (CCE) patients.

METHODS

Patients diagnosed with CCE within 24 hr of onset between January 2017 and January 2019 were included in this study. END was defined as an increase of ≥2 on the National Institutes of Health Stroke Scale (NIHSS) or the emergence of new neurological symptoms within 3 days of admission. Binary logistic regression was used to investigate the factors associated with END. Receiver operating characteristic (ROC) curves were then generated to determine the predictive value of the potential biomarkers and the optimal cutoff values.

RESULTS

Of the 129 (male, 55.81%; mean age 71.85 ± 11.99 years) CCE patients, 55 patients with END were identified. Hemorrhage transformation (HT), coronary heart disease (CHD), diastolic blood pressure, cystatin C levels, NIHSS score, and platelet-to-lymphocyte ratio (PLR) at admission were independently associated with END. A peripheral cystatin C level ≥ 1.41 mg/L and a PLR ≥ 132.97 were predictive factors for END in CCE patients. The lymphocyte-to-monocyte ratio (LMR) was negatively independently associated with HT, and LMR < 2.31 may predict the occurrence of HT in patients with CCE.

CONCLUSIONS

Of the potential predisposing factors considered, increased cystatin C and PLR were associated with END within 3 days of CCE, and a decreased LMR may have predictive value for HT in CCE patients.

A Novel Scale for Assessment of Stroke Severity at Symptom Onset: Correlation With Neurological Deterioration and Outcome

Objective: To propose a novel scale for the assessment of stroke severity at symptom onset and to investigate whether it is associated with ultra-early neurological deterioration (UND) and functional outcomes.

Methods: The Chongqing Stroke Scale (CQSS) was constructed based on key aspects of history, emphasizing language, motor function, and level of consciousness to yield a total 0–11 scale. The diagnostic performance of the CQSS was assessed in 215 ischemic stroke patients between June 2017 and October 2017 in a tertiary hospital. Patients were included if they presented within 24 h after onset of symptoms and they or their witness can recall the scenario at symptom onset. UND was defined as an increase ≥2 points on the CQSS between symptom onset and admission. Functional outcomes were assessed using the 3-month modified Rankin scale. The correlation between the CQSS score and baseline National Institutes of Health Stroke Scale (NIHSS) score was assessed. The sensitivity, specificity, and positive and negative predictive values of CQSS for the outcomes were calculated. Logistic regression was used to test the association between the CQSS score and functional outcomes.

Results: A total of 215 patients with available CQSS scores were included. Baseline CQSS scores at symptom onset were correlated with the admission NIHSS score (r = 0.56, p < 0.001) and functional outcome at 3 months (r = 0.47, p < 0.001). Baseline CQSS ≥ 6 was an independent predictor of functional outcome at 3 months (odds ratio, 12.61; 95% confidence interval 5.68–27.97, p < 0.001). UND was observed in 20 (9.30%) patients. The 90-day mortality was significantly higher in patients with UND than those without UND (25.0 vs. 8.2%, p < 0.001). After adjusting for age, admission systolic blood pressure, hypertension, and diabetes, UND independently predicted poor functional outcome in the multivariate logistic regression model (odds ratio, 9.69; 95% confidence interval 3.19–29.45, p < 0.001).

Conclusions: The newly developed CQSS is a simple and easy-to-perform scale that allows a quantitative evaluation of the stroke severity at symptom onset and an assessment of UND before hospital admission. It is associated with NIHSS and predicts functional outcome in patients with acute ischemic stroke.

Impact of aging and comorbidities on ischemic stroke outcomes in preclinical animal models: A translational perspective

Ischemic stroke is a highly complex and devastating neurological disease. The sudden loss of blood flow to a brain region due to an ischemic insult leads to severe damage to that area resulting in the formation of an infarcted tissue, also known as the ischemic core. This is surrounded by the peri-infarct region or penumbra that denotes the functionally impaired but potentially salvageable tissue. Thus, the penumbral tissue is the main target for the development of neuroprotective strategies to minimize the extent of ischemic brain damage by timely therapeutic intervention. Given the limitations of reperfusion therapies with recombinant tissue plasminogen activator or mechanical thrombectomy, there is high enthusiasm to combine reperfusion therapy with neuroprotective strategies to further reduce the progression of ischemic brain injury. Till date, a large number of candidate neuroprotective drugs have been identified as potential therapies based on highly promising results from studies in rodent ischemic stroke models. However, none of these interventions have shown therapeutic benefits in stroke patients in clinical trials. In this review article, we discussed the urgent need to utilize preclinical models of ischemic stroke that more accurately mimic the clinical conditions in stroke patients by incorporating aged animals and animal stroke models with comorbidities. We also outlined the recent findings that highlight the significant differences in stroke outcome between young and aged animals, and how major comorbid conditions such as hypertension, diabetes, obesity and hyperlipidemia dramatically increase the vulnerability of the brain to ischemic damage that eventually results in worse functional outcomes. It is evident from these earlier studies that including animal models of aging and comorbidities during the early stages of drug development could facilitate the identification of neuroprotective strategies with high likelihood of success in stroke clinical trials.

Decreased Serum Total Bilirubin Level Predicts Early Neurological Deterioration in Patients with Acute Ischemic Stroke

OBJECTIVE

This study aimed to investigate the relationship between serum total bilirubin (TBil) level and early neurological deterioration (END) in patients with acute ischemic stroke of large artery atherosclerosis.

PATIENTS AND METHODS

In this retrospective study, a total of 291 patients with acute ischemic stroke were enrolled. The demographic and laboratory dates were collected. Stroke severity had been assessed using the National Institutes of Health Stroke Scale (NIHSS). Multivariable logistic regression was used to examine the independent association between TBil and END.

RESULTS

Approximately 63 (21.6%) of the patients were diagnosed with END within the first seven days. The proportion of hypertension, diabetes mellitus (DM) and previous stroke/transient ischemic attack (TIA) was significant greater in the lowest quartile (<9.8 μmol/l) of TBil. The proportion of patients with an elevated TBil levels was significantly lower in the END group than in the non-END group. After controlling for covariates, the first quartiles (<9.8 μmol/l) of TBil were still associated with END. In addition, an increased level of CRP and age were also associated with an increased risk of END.

CONCLUSION

The TBil levels in patients with acute cerebral infarction may be a useful biomarker for the prediction of END.

Early Neurological Change After Ischemic Stroke Is Associated With 90-Day Outcome

BACKGROUND AND PURPOSE

Large-scale observational studies of acute ischemic stroke (AIS) promise to reveal mechanisms underlying cerebral ischemia. However, meaningful quantitative phenotypes attainable in large patient populations are needed. We characterize a dynamic metric of AIS instability, defined by change in National Institutes of Health Stroke Scale score (NIHSS) from baseline to 24 hours baseline to 24 hours (NIHSSbaseline - NIHSS24hours = ΔNIHSS6-24h), to examine its relevance to AIS mechanisms and long-term outcomes.

METHODS

Patients with NIHSS prospectively recorded within 6 hours after onset and then 24 hours later were enrolled in the GENISIS study (Genetics of Early Neurological Instability After Ischemic Stroke). Stepwise linear regression determined variables that independently influenced ΔNIHSS6-24h. In a subcohort of tPA (alteplase)-treated patients with large vessel occlusion, the influence of early sustained recanalization and hemorrhagic transformation on ΔNIHSS6-24h was examined. Finally, the association of ΔNIHSS6-24h with 90-day favorable outcomes (modified Rankin Scale score 0-2) was assessed. Independent analysis was performed using data from the 2 NINDS-tPA stroke trials (National Institute of Neurological Disorders and Stroke rt-PA).

RESULTS

For 2555 patients with AIS, median baseline NIHSS was 9 (interquartile range, 4-16), and median ΔNIHSS6-24h was 2 (interquartile range, 0-5). In a multivariable model, baseline NIHSS, tPA-treatment, age, glucose, site, and systolic blood pressure independently predicted ΔNIHSS6-24h (R2=0.15). In the large vessel occlusion subcohort, early sustained recanalization and hemorrhagic transformation increased the explained variance (R2=0.27), but much of the variance remained unexplained. ΔNIHSS6-24h had a significant and independent association with 90-day favorable outcome. For the subjects in the 2 NINDS-tPA trials, ΔNIHSS3-24h was similarly associated with 90-day outcomes.

CONCLUSIONS

The dynamic phenotype, ΔNIHSS6-24h, captures both explained and unexplained mechanisms involved in AIS and is significantly and independently associated with long-term outcomes. Thus, ΔNIHSS6-24h promises to be an easily obtainable and meaningful quantitative phenotype for large-scale genomic studies of AIS.