Early and continuous neurologic improvements after intravenous thrombolysis are strong predictors of favorable long-term outcomes in acute ischemic stroke

Association of higher triglyceride-glucose index and triglyceride-to-high-density lipoprotein cholesterol ratio with early neurological deterioration after thrombolysis in acute ischemic stroke patients

Background

Insulin resistance (IR) can predict the prognosis of patients suffering from cerebrovascular disorders. The triglyceride-glucose (TyG) index and triglyceride-to-high-density lipoprotein cholesterol (TG/HDL-C) ratio have been confirmed to be easy and reliable indicators of IR. However, the relationships between the TyG index or TG/HDL-C ratio and early neurological deterioration (END) after thrombolysis in patients with acute ischemic stroke (AIS) are uncertain.

Methods

A retrospective analysis of 1,187 patients diagnosed with AIS who underwent intravenous thrombolysis between January 2018 and February 2024 was performed. Post-thrombolysis END was defined as an increase in the National Institutes of Health Stroke Scale (NIHSS) score of ≥4 within 24 h after thrombolysis. Logistic regression analysis was performed to explore the relationships of the TyG index and TG/HDL-C ratio with post-thrombolysis END. Receiver operating characteristic (ROC) analysis was used to assess the ability of the TyG index and TG/HDL-C ratio to discriminate post-thrombolysis END.

Results

Among the 1,187 recruited patients, 179 (15.08%) were diagnosed with post-thrombolysis END, and 1,008 (84.92%) were diagnosed with non-END. A binary logistic regression model indicated that the TyG index (odds ratio [OR], 2.015; 95% confidence interval [CI] 1.964-2.414, p = 0.015) and TG/HDL-C ratio (OR, 1.542; 95% CI, 1.160-2.049, p = 0.004) were independent factors for post-thrombolysis END. The area under the curve (AUC) values for the TyG index, TG/HDL-C ratio, and TyG index combined with the TG/HDL-C ratio for post-thrombolysis END were 0.704, 0.674, and 0.755, respectively.

Conclusion

This study indicates that the TyG index and TG/HDL-C ratio can be used as prognostic factors to predict post-thrombolysis END.

Higher fibrinogen and neutrophil-to-lymphocyte ratio are associated with the early poor response to intravenous thrombolysis in acute ischemic stroke

Background

Inflammation and platelet activation play pivotal roles in acute ischemic stroke (AIS) pathogenesis. Early response to thrombolysis is a vital indicator for the long-term prognosis of AIS. However, the correlation between fibrinogen or the neutrophil-to-lymphocyte ratio (NLR) and the early response to intravenous thrombolysis in patients with AIS remains unclear.

Methods

AIS patients undergoing intravenous thrombolysis were enrolled between January 2018 and May 2023. Blood cell counts were sampled before thrombolysis. A good response was defined as a National Institutes of Health Stroke Scale (NIHSS) score decreased ≥4 or complete recovery 24 h after thrombolysis treatment. A poor response was defined as any increase in the NIHSS score or a decrease in the NIHSS score <4 at the 24 h after thrombolysis treatment compared with that at admission. Logistic regression analysis was performed to explore the relationship of the fibrinogen level and NLR with a poor thrombolysis response. Receiver operating characteristic (ROC) analysis was used to assess the ability of the fibrinogen level and NLR to discriminate poor responders.

Results

Among 700 recruited patients, 268 (38.29%) were diagnosed with a good response, and 432 (61.71%) were diagnosed with a poor response to intravenous thrombolysis. A binary logistic regression model indicated that an elevated fibrinogen level (odds ratio [OR], 1.693; 95% confidence interval [CI] 1.325-2.122, P < 0.001) and NLR (OR, 1.253; 95% CI, 1.210-2.005, P = 0.001) were independent factors for a poor response. The area under the curve (AUC) values for the fibrinogen level, NLR and fibrinogen level combined with the NLR for a poor response were 0.708, 0.605, and 0.728, respectively.

Conclusions

Our research indicates that the levels of fibrinogen and NLR at admission can be used as a prognostic factor to predict early poor response to intravenous thrombolysis.

Association between Triglyceride-Glucose Index and Early Neurological Outcomes after Thrombolysis in Patients with Acute Ischemic Stroke

BACKGROUND

The triglyceride-glucose (TyG) index is a novel biomarker of insulin resistance which might plausibly influence endogenous fibrinolysis and thus early neurological outcomes in patients with acute ischemic stroke (AIS) treated with intravenous thrombolysis using recombinant tissue-plasminogen activator.

METHODS

We included consecutive AIS patients within 4.5 h of symptom onset undergoing intravenous thrombolysis between January 2015 and June 2022 in this multi-center retrospective observational study. Our primary outcome was early neurological deterioration (END), defined as ≥2 (END₂) or ≥ 4 (END₄) National Institutes of Health Stroke Scale (NIHSS) score worsening compared to the initial NIHSS score within 24 h of intravenous thrombolysis. Our secondary outcome was early neurological improvement (ENI), defined as a lower NIHSS score at discharge. TyG index was calculated using the log scale of fasting triglyceride (mg/dL) × fasting glucose (mg/dL)/2. We evaluated the association of END and ENI with TyG index using a logistic regression model.

RESULTS

A total of 676 patients with AIS were evaluated. The median age was 68 (Interquartile range, IQR (60-76) years old), and 432 (63.9%) were males. A total of 89 (13.2%) patients developed END₂, 61 (9.0%) patients developed END₄, and 492 (72.7%) experienced ENI. In multivariable logistic regression analysis, after adjustment for confounding factors, TyG index was significantly associated with increased risks of END₂ (categorical variable, vs. lowest tertile, medium tertile odds ratio [OR] 1.05, 95% confidence interval, CI 0.54-2.02, highest tertile OR 2.94, 95%CI 1.64-5.27, overall p < 0.001) and END₄ (categorical variable, vs. lowest tertile, medium tertile OR 1.21, 95%CI 0.54-2.74, highest tertile OR 3.80, 95%CI 1.85-7.79, overall p < 0.001), and a lower probability of ENI (categorical variable, vs. lowest tertile, medium tertile OR 1.00, 95%CI 0.63-1.58, highest tertile OR 0.59, 95%CI 0.38-0.93, overall p = 0.022).

CONCLUSIONS

Increasing TyG index was associated with a higher risk of END and a lower probability of ENI in patients with acute ischemic stroke treated with intravenous thrombolysis.

Predictors of Early Neurological Improvement and Its Relationship to Thrombolysis Treatment and Long-Term Outcome in the WAKE-UP Study

INTRODUCTION

The aims of this study were to evaluate the relationship of clinical and imaging baseline factors and treatment on the occurrence of early neurological improvement (ENI) in the WAKE-UP trial of MRI-guided intravenous thrombolysis in unknown onset stroke and to examine the association of ENI with long-term favorable outcome in patients treated with intravenous thrombolysis.

METHODS

We analyzed data from all patients with at least moderate stroke severity, reflected by an initial National Institutes of Health Stroke Scale (NIHSS) score ≥4 randomized in the WAKE-UP trial. ENI was defined as a decrease in NIHSS of ≥8 or a decline to zero or 1 at 24 h after initial presentation to the hospital. Favorable outcome was defined as a modified Rankin Scale score of 0-1 at 90 days. We performed group comparison and multivariable analysis of baseline factors associated with ENI and performed mediation analysis to evaluate the effect of ENI on the relationship between intravenous thrombolysis and favorable outcome.

RESULTS

ENI occurred in 93 out of 384 patients (24.2%) and was more likely to occur in patients who received treatment with alteplase (62.4% vs. 46.0%, p = 0.009), had smaller acute diffusion-weighted imaging lesion volume (5.51 mL vs. 10.9 mL, p ≤ 0.001), and less often large-vessel occlusion on initial MRI (7/93 [12.1%] versus 40/291 [29.9%], p = 0.014). In multivariable analysis, treatment with alteplase (OR 1.97, 95% confidence interval [CI] 0.954-1.100), lower baseline stroke volume (OR 0.965, 95% CI: 0.932-0.994), and shorter time from symptom recognition to treatment (OR 0.994, 95% CI: 0.989-0.999) were independently associated with ENI. Patients with ENI had higher rates of favorable outcome at 90-day follow-up (80.6% vs. 31.3%, p ≤ 0.001). The occurrence of ENI significantly mediated the association of treatment with a good outcome, with ENI at 24 h explaining 39.4% (12.9-96%) of the treatment effect.

CONCLUSION

Intravenous alteplase increases the odds of ENI in patients with at least moderate stroke severity, especially when given early. In patients with large-vessel occlusion, ENI is rarely observed without thrombectomy. ENI represents a good surrogate early marker of treatment effect as more than a third of good outcome at 90 days is explained by ENI at 24 h.

Engaging social activities prevent stroke and myocardial infraction by raising awareness of warning symptoms: A cross-sectional survey study

Background

Stroke and myocardial infarction (MI) are medical emergencies, and early treatment within the golden hour is crucial for good prognosis. Adequate knowledge about the warning symptoms can shorten the onset-to-door time. Various factors affect the level of awareness, including social activity. This study aimed to determine if engaging in social activity is associated with the awareness of the warning symptoms of stroke and MI.

Methods

This cross-sectional study analyzed 451,793 participants from the 2017 and 2019 Korea Community Health Survey. Based on five questions for each of stroke and MI symptoms, participants were divided into an awareness group (replied "Yes" to all five questions) and unawareness group. Engagement in social activities (i.e., religious, friendship, leisure, and volunteer activity) was evaluated through a questionnaire. Multiple logistic regression analysis was performed to evaluate the relation between social activity and awareness of warning symptoms.

Results

Overall, 52.6% participants were aware of the warning symptoms of stroke, and 45.8% of MI. Regular engagement in at least one social activity, particularly friendship or volunteer activity, was associated with better awareness of the warning symptoms, both stroke (OR: 1.21, 95% CI: 1.20-1.23) and MI (OR: 1.22, 95% CI: 1.20-1.24). Additionally, more diverse types of social activities were associated with higher levels of awareness. Relationship between social activity and awareness showed positive association with participants older than 60 years, rural residents, or with low socioeconomic status.

Conclusion

Engagement in social activity was significantly associated with better knowledge about the warning symptoms of stroke and MI. For early hospital treatment after symptom onset, participation in social activities could be beneficial.

High ratio of C-reactive protein to albumin is associated with hemorrhagic transformation and poor functional outcomes in acute ischemic stroke patients after thrombolysis

Background

In patients with acute ischemic stroke, hemorrhagic transformation (HT) is a common complication after intravenous thrombolysis (IVT). In this study, we evaluated the relationship between the ratio of C-reactive protein to albumin (CAR) before thrombolysis, HT, and functional outcomes in patients with acute ischemic stroke.

Methods

We retrospectively analyzed data from 354 patients who received thrombolytic therapy at the Second Affiliated Hospital of the Wenzhou Medical University in China between July 2014 and May 2022. CAR was measured on admission, and HT was identified by cranial computed tomography (CT) within 24-36 h after treatment. Poor outcome was defined as a score on the modified Rankin Scale (mRS) > 2 at discharge. The multivariate logistic regression model was used to investigate the association between CAR, HT, and poor outcome after thrombolysis, respectively.

Results

A total of 354 patients were analyzed, and their median CAR was 0.61 (interquartile range, 0.24-1.28). CAR was significantly higher in the 56 patients (15.8%) who experienced HT than in those who did not (0.94 vs. 0.56, p < 0.001), and the 131 patients (37.0%) who experienced poor outcome than in those who did not (0.87 vs. 0.43, p < 0.001). Multivariate logistic regression indicated that CAR was an independent risk factor for both HT and poor outcome. The risk of HT was significantly higher among patients whose CAR fell in the fourth quartile than among those with CAR in the first quartile (OR 6.64, 95% CI 1.83 to 24.17, p = 0.004). Patients with CAR in the third quartile were more likely to experience poor outcome (OR 3.35, 95% CI 1.32 to 8.51, p = 0.01), as were those in the fourth quartile (OR 7.33, 95% CI 2.62 to 20.50, p < 0.001), compared to patients with CAR in the first quartile.

Conclusion

High ratio of C-reactive protein to albumin in individuals with ischemic stroke is associated with an increased risk of HT and poor functional outcomes after thrombolysis.

7-Day National Institutes of Health Stroke Scale as a surrogate marker predicting ischemic stroke patients' outcome following endovascular therapy

Background

Early neurological deterioration after endovascular thrombectomy (EVT) is associated with poor prognosis. National Institutes of Health Stroke Scale (NIHSS) score measured at 24 h after EVT may be a better outcome predictor than other methods that focus on changes in NIHSS. Nevertheless, clinical fluctuations in ischemic stroke patients during the immediate phase after symptoms onset are well recognized. Therefore, a delayed NIHSS evaluation may improve prognostic accuracy. We evaluate the 7-day NIHSS in predicting long-term patient outcomes after EVT.

Methods

This was a multi-center retrospective cohort study of 300 consecutive ischemic stroke patients with large vessel occlusion who underwent EVT at three-stroke centers in China from August 2018 to March 2022. NIHSS was recorded on admission, pre-EVT, 24 h, and 7 days after EVT.

Results

A total of 236 eligible patients were subdivided into two groups: 7-day NIHSS ≤6 and NIHSS >6 post-EVT. 88.29% achieved a favorable outcome (modified Rankin Scale 0-2) in the NIHSS ≤6 group compared to 15.20% in the NIHSS >6 group at 90 days, and an improved favorable outcome in the former group was observed after adjusting for potential confounding factors (adjusted odds ratio 39.7, 95% confidence interval, 17.5-89.7, p < 0.001).

Conclusion

The 7-day NIHSS score may be a reliable predictor of 90-day stroke patient outcome after EVT.

DWI-FLAIR mismatch guided thrombolysis in patients without large-vessel occlusion: real-world data from a comprehensive stroke centre

Introduction

A significant proportion of ischaemic stroke patients present with unknown symptom onset time. DWI-FLAIR mismatch on MRI can help to identify those eligible for thrombolysis. We set out to analyse the short-term efficacy and safety of thrombolysis in a real-world setting.

Methods

A retrospective single-centre observational study was conducted. We collected data between January 2017 and April 2020. Patients with a large vessel occlusion (LVO) were excluded. Outcomes were compared between thrombolysed patients and those who did not receive alteplase due to lack of DWI-FLAIR mismatch or other contraindications. We analysed baseline and discharge NIHSS scores for efficacy and defined good outcome as any neurological improvement (ANI) on the NIHSS. In terms of safety, the presence and severity of intracerebral haemorrhage on follow-up imaging was analysed, and mortality at 90 days assessed.

Results

Seventy-one patients were included in this study, of whom 29 received thrombolysis. Significantly more patients had ANI in the thrombolysed group (OR, 3.16; 95% CI, 1.178-8.479; p = 0.020). In a multivariable logistic regression analysis, only thrombolysis correlated with ANI (OR, 3.051; 95% CI, 1.135-8.206; p = 0.027). Two thrombolysed patients suffered intracerebral haemorrhage (6.90%), of whom one was symptomatic and eventually fatal. We did not find a significant difference in 90-day mortality between the two groups (OR, 0.81, 95% CI, 0.134-4.856; p = 1.000).

Conclusions

Our real-world data demonstrate that thrombolysis based on DWI-FLAIR mismatch in patients without LVO has an early beneficial effect. The rate of intracerebral haemorrhage was similar to this complication reported in large thrombolysis trials with known onset times.

Association of serum biomarkers with early neurologic improvement after intravenous thrombolysis in ischemic stroke

BACKGROUND

Early neurologic improvement (ENI) after intravenous thrombolysis is associated with favorable outcome, but associated serum biomarkers were not fully determined. We aimed to investigate the issue based on a prospective cohort.

METHODS

In INTRECIS study, five centers were designed to consecutively collect blood sample from enrolled patients. The patients with ENI and without ENI were matched by propensity score matching with a ratio of 1:1. Preset 49 biomarkers were measured through microarray analysis. Enrichment of gene ontology and pathway, and protein-protein interaction network were analyzed in the identified biomarkers.

RESULTS

Of 358 patients, 19 patients with ENI were assigned to ENI group, while 19 matched patients without ENI were assigned to Non ENI group. A total of nine biomarkers were found different between two groups, in which serum levels of chemokine (C-C motif) ligand (CCL)-23, chemokine (C-X-C motif) ligand (CXCL)-12, insulin-like growth factor binding protein (IGFBP)-6, interleukin (IL)-5, lymphatic vessel endothelial hyaluronan receptor (LYVE)-1, plasminogen activator inhibitor (PAI)-1, platelet-derived growth factor (PDGF)-AA, suppression of tumorigenicity (ST)-2, and tumor necrosis factor (TNF)-α were higher in the ENI group, compared with those in the Non ENI group.

CONCLUSIONS

We found that serum levels of CCL-23, CXCL-12, IGFBP-6, IL-5, LYVE-1, PAI-1, PDGF-AA, ST-2, and TNF-α at admission were associated with post-thrombolytic ENI in stroke. The role of biomarkers warrants further investigation.

TRIAL REGISTRATION

Clinical Trial Registration: https://www.clinicaltrials.gov; identifier: NCT02854592.

β-Caryophyllene suppresses ferroptosis induced by cerebral ischemia reperfusion via activation of the NRF2/HO-1 signaling pathway in MCAO/R rats

BACKGROUND

Ischemic stroke is a complex brain disease regulated by several cell death processes, including apoptosis, autophagy, and ferroptosis. β-Caryophyllene (BCP), a natural bicyclic sesquiterpene abundantly found in essential oils, has been demonstrated to have potential pharmacological benefits in many diseases, including ischemic stroke.

PURPOSE

This research was to determine the existence of ferroptosis in the pathogenesis of acute ischemic stroke and investigate whether BCP can inhibit ferroptosis to improve cerebral ischemia injury by activating the NRF2/HO-1 signaling pathway in rats.

METHODS

First, we verified ferroptosis by assessing proferroptotic changes after middle cerebral artery occlusion reperfusion (MCAO/R), along with protein and lipid peroxidation levels. Then male rats were divided randomly into Sham, MCAO/R, ML385 (NRF2-specific inhibitor) and BCP groups. The effects of BCP on cerebral injury were detected by the modified neurological severity score, TTC staining, and hematoxylin-eosin staining. We conducted western blotting analyzes of proteins, including those involved in ferroptosis and related signaling pathways. To demonstrate the neuroprotective effect of BCP in vitro, primary astrocytes were pretreated with different concentrations of BCP (10, 20, and 40 μM) for 24 h before oxygen-glucose deprivation/re-oxygenation (ODG/R).

RESULTS

We concluded that ferroptosis was engaged in the process of I/R-induced neurological damage, implying that this novel type of cell death might provide new therapeutic options for the clinical treatment of ischemic stroke. In vivo study proved that BCP improved neurological scores, infarct volume, and pathological features after MCAO/R. We demonstrated that BCP evidently enhanced NRF2 nuclear translocation, activated the NRF2/HO-1 pathway, which protected against ferroptosis. In vitro investigation revealed the same results. BCP decreased OGD/R-induced ROS generation and iron accumulation. Furthermore, the neuroprotective effects of BCP were reversed by the NRF2 inhibitor ML385.

CONCLUSION

Our results indicated the critical role of ferroptosis in cerebral I/R injury. For the first time, we showed that the significant neuroprotective effects of BCP in attenuating ischemic stroke injury are correlated with ferroptosis regulation, and its mechanism is associated with activation of the NRF2/HO-1 axis.

Association of Medicare-Medicaid Dual Eligibility and Race and Ethnicity With Ischemic Stroke Severity

Importance

Black and Hispanic US residents are disproportionately affected by stroke incidence, and patients with dual eligibility for Medicare and Medicaid may be predisposed to more severe strokes. Little is known about differences in stroke severity for individuals with dual eligibility, Black individuals, and Hispanic individuals, but understanding hospital admission stroke severity is the first important step for focusing strategies to reduce disparities in stroke care and outcomes.

Objective

To examine whether dual eligibility and race and ethnicity are associated with stroke severity in Medicare beneficiaries admitted to acute hospitals with ischemic stroke.

Design, Setting, and Participants

This retrospective cross-sectional study was conducted using Medicare claims data for patients with ischemic stroke admitted to acute hospitals in the United States from October 1, 2016, to November 30, 2017. Data were analyzed from July 2021 and January 2022.

Exposures

Dual enrollment for Medicare and Medicaid; race and ethnicity categorized as White, Black, Hispanic, and other.

Main Outcomes and Measures

Claim-based National Institutes of Health Stroke Scale (NIHSS) categorized into minor (0-7), moderate (8-13), moderate to severe (14-21), and severe (22-42) stroke.

Results

Our sample included 45 459 Medicare fee-for-service patients aged 66 and older (mean [SD] age, 80.2 [8.4]; 25 303 [55.7%] female; 7738 [17.0%] dual eligible; 4107 [9.0%] Black; 1719 [3.8%] Hispanic; 37 715 [83.0%] White). In the fully adjusted models, compared with White patients, Black patients (odds ratio [OR], 1.21; 95% CI, 1.06-1.39) and Hispanic patients (OR, 1.54; 95% CI, 1.29-1.85) were more likely to have a severe stroke. Using White patients without dual eligibility as a reference group, White patients with dual eligibility were more likely to have a severe stroke (OR, 1.75; 95% CI, 1.56-1.95). Similarly, Black patients with dual eligibility (OR, 2.15; 95% CI, 1.78-2.60) and Hispanic patients with dual eligibility (OR, 2.50; 95% CI, 1.98-3.16) were more likely to have a severe stroke.

Conclusions and Relevance

In this cross-sectional study, Medicare fee-for-service patients with ischemic stroke admitted to acute hospitals who were Black or Hispanic had a higher likelihood of worse stroke severity. Additionally, dual eligibility status had a compounding association with stroke severity regardless of race and ethnicity. An urgent effort is needed to decrease disparities in access to preventive and poststroke care for dual eligible and minority patients.

Multi-ancestry GWAS reveals excitotoxicity associated with outcome after ischaemic stroke

During the first hours after stroke onset, neurological deficits can be highly unstable: some patients rapidly improve, while others deteriorate. This early neurological instability has a major impact on long-term outcome. Here, we aimed to determine the genetic architecture of early neurological instability measured by the difference between the National Institutes of Health Stroke Scale (NIHSS) within 6 h of stroke onset and NIHSS at 24 h. A total of 5876 individuals from seven countries (Spain, Finland, Poland, USA, Costa Rica, Mexico and Korea) were studied using a multi-ancestry meta-analyses. We found that 8.7% of NIHSS at 24 h of variance was explained by common genetic variations, and also that early neurological instability has a different genetic architecture from that of stroke risk. Eight loci (1p21.1, 1q42.2, 2p25.1, 2q31.2, 2q33.3, 5q33.2, 7p21.2 and 13q31.1) were genome-wide significant and explained 1.8% of the variability suggesting that additional variants influence early change in neurological deficits. We used functional genomics and bioinformatic annotation to identify the genes driving the association from each locus. Expression quantitative trait loci mapping and summary data-based Mendelian randomization indicate that ADAM23 (log Bayes factor = 5.41) was driving the association for 2q33.3. Gene-based analyses suggested that GRIA1 (log Bayes factor = 5.19), which is predominantly expressed in the brain, is the gene driving the association for the 5q33.2 locus. These analyses also nominated GNPAT (log Bayes factor = 7.64) ABCB5 (log Bayes factor = 5.97) for the 1p21.1 and 7p21.1 loci. Human brain single-nuclei RNA-sequencing indicates that the gene expression of ADAM23 and GRIA1 is enriched in neurons. ADAM23, a presynaptic protein and GRIA1, a protein subunit of the AMPA receptor, are part of a synaptic protein complex that modulates neuronal excitability. These data provide the first genetic evidence in humans that excitotoxicity may contribute to early neurological instability after acute ischaemic stroke.

Clinical Outcomes after Intravenous Alteplase in Elderly Patients with Acute Ischaemic Stroke: A Retrospective Analysis of Patients Treated at a Tertiary Neurology Centre in England from 2013 to 2018

Intravenous thrombolysis with alteplase within 4.5 hours from symptom onset is a well-established treatment of acute ischaemic stroke (AIS). The aim was to compare alteplase for AIS between patients aged >80 and ≤80 years in our registry data, from 2013 to 2018. Mechanical thrombectomy cases were excluded. We assessed clinical outcomes over the six-year period and between patients aged over 80 and ≤80 years, using measures including the discharge modified Rankin Scale (mRS), 24-hour National Institutes of Health Stroke Scale (NIHSS) improvement, and symptomatic intracerebral haemorrhage (sICH) rate. Of a total of 805 AIS patients who received intravenous alteplase, 278 (34.5%) were over 80 years old, and 527 (65%) were younger. 616 (76.5%) received thrombolysis ≤ 3 hours after symptom onset and 189 (23.5%) within 3-4.5 hours. Median baseline mRS and NIHSS of the elderly cohort were 1 (IQR 0-5) and 13 (IQR 2-37), respectively, compared to the younger cohort 0 (IQR 0-5) and 9 (IQR 0-29). The sICH rate was 7.2% in the elderly and 4.6% in those ≤80 years, p = 0.05. NIHSS improved within 24 hours in 34% of the elderly cohort compared to 35% in the younger cohort. At hospital discharge, the mortality rate was 9% in the elderly cohort compared to the 6% in the younger cohort, p = 0.154. 25% of patients aged >80 years had mRS ≤ 2 compared to 47% in the younger patients (p < 0.0001). In conclusion, thrombolysis in elderly patients results in clinical improvement comparable to younger patients.

Clinical-CT mismatch defined NIHSS ≥ 8 and CT-ASPECTS ≥ 9 as a reliable marker of candidacy for intravenous thrombolytic therapy in acute ischemic stroke

Background

Clinical-diffusion mismatch between stroke severity and diffusion-weighted imaging lesion volume seems to identify stroke patients with penumbra. However, urgent magnetic resonance imaging is sometimes inaccessible or contraindicated. Thus, we hypothesized that using brain computed tomography (CT) to determine a baseline “clinical-CT mismatch” may also predict the responses to thrombolytic therapy.

Methods

Brain CT lesions were measured using the Alberta Stroke Program Early CT Score (ASPECTS). A total of 104 patients were included: 79 patients with a baseline National Institutes of Health Stroke Scale (NIHSS) score ≥ 8 and a CT-ASPECTS ≥ 9 who were defined as clinical-CT mismatch-positive (P group) and 25 patients with an NIHSS score ≥ 8 and a CT-ASPECTS < 9 who were defined as clinical-CT mismatch-negative (the N group). We compared their clinical outcomes, including early neurological improvement (ENI), early neurological deterioration (END), delta NIHSS score (admission NIHSS—baseline NIHSS score), symptomatic intracranial hemorrhage (sICH), mortality, and favorable outcome at 3 months.

Results

Patients in the P group had a greater proportion of favorable outcome at 3 months (p = 0.032) and more frequent ENI (p = 0.038) and a greater delta NIHSS score (p = 0.001), as well as a lower proportion of END (p = 0.004) than those in the N group patients. There were no significant differences in the incidence rates of sICH and mortality between the two groups.

Conclusions

Clinical-CT mismatch may be able to predict which patients would benefit from intravenous thrombolysis.

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.

Predictor of 90-day functional outcome after mechanical thrombectomy for large vessel occlusion stroke: NIHSS score of 10 or less at 24 hours

OBJECTIVE

Mechanical thrombectomy is the established treatment for acute ischemic stroke due to large vessel occlusion (LVO). The authors sought to identify early predictors of a favorable outcome in stroke patients treated with mechanical thrombectomy.

METHODS

Consecutive patients with ischemic stroke due to LVO who underwent mechanical thrombectomy at a Comprehensive Stroke Center in the US between 2016 and 2018 were retrospectively reviewed. Demographics, stroke and treatment characteristics, as well as functional outcome at 90 days were collected. Clinical predictors of 90-day functional outcome were assessed and compared to existing indices for prompt neurological improvement. Analyses of area under the receiver operating characteristic curve were performed to estimate the optimal thresholds for absolute 24-hour and delta (change in) National Institutes of Health Stroke Scale (NIHSS) scores for functional outcome prediction.

RESULTS

A total of 156 patients (median age 71.5 years) underwent 159 mechanical thrombectomies. The M1 segment of the middle cerebral artery was the most frequent site of occlusion (57.2%). The median NIHSS score before thrombectomy was 18 (IQR 14-24). A postthrombectomy Thrombolysis in Cerebral Infarction score of 2B or 3 was achieved in 147 procedures (92.4%). The median NIHSS score 24 hours after thrombectomy was 14 (IQR 6-22). Good functional outcome at 90 days (modified Rankin Scale score 0-2) was achieved in 37 thrombectomies (23.9%). An absolute 24-hour NIHSS score ≤ 10 (OR 25.929, 95% CI 8.448-79.582, p < 0.001) and a delta NIHSS score ≥ 8 between baseline and 24 hours (OR 4.929, 95% CI 2.245-10.818, p < 0.001) were associated with good functional outcome at 90 days. The 24-hour NIHSS score cutoff of 10 outperformed existing indices for prompt neurological improvement in the ability to predict 90-day functional outcome.

CONCLUSIONS

An NIHSS score ≤ 10 at 24 hours after mechanical thrombectomy was independently associated with good functional outcome at 90 days.

Multi-ancestry genetic study in 5,876 patients identifies an association between excitotoxic genes and early outcomes after acute ischemic stroke

During the first hours after stroke onset neurological deficits can be highly unstable: some patients rapidly improve, while others deteriorate. This early neurological instability has a major impact on long-term outcome. Here, we aimed to determine the genetic architecture of early neurological instability measured by the difference between NIH stroke scale (NIHSS) within six hours of stroke onset and NIHSS at 24h (ΔNIHSS). A total of 5,876 individuals from seven countries (Spain, Finland, Poland, United States, Costa Rica, Mexico and Korea) were studied using a multi-ancestry meta-analyses. We found that 8.7% of ΔNIHSS variance was explained by common genetic variations, and also that early neurological instability has a different genetic architecture than that of stroke risk. Seven loci (2p25.1, 2q31.2, 2q33.3, 4q34.3, 5q33.2, 6q26 and 7p21.1) were genome-wide significant and explained 2.1% of the variability suggesting that additional variants influence early change in neurological deficits. We used functional genomics and bioinformatic annotation to identify the genes driving the association from each loci. eQTL mapping and SMR indicate that ADAM23 (log Bayes Factor (LBF)=6.34) was driving the association for 2q33.3. Gene based analyses suggested that GRIA1 (LBF=5.26), which is predominantly expressed in brain, is the gene driving the association for the 5q33.2 locus. These analyses also nominated PARK2 (LBF=5.30) and ABCB5 (LBF=5.70) for the 6q26 and 7p21.1 loci. Human brain single nuclei RNA-seq indicates that the gene expression of ADAM23 and GRIA1 is enriched in neurons. ADAM23 , a pre-synaptic protein, and GRIA1 , a protein subunit of the AMPA receptor, are part of a synaptic protein complex that modulates neuronal excitability. These data provides the first evidence in humans that excitotoxicity may contribute to early neurological instability after acute ischemic stroke.

RESEARCH INTO CONTEXT

Evidence before this study: No previous genome-wide association studies have investigated the genetic architecture of early outcomes after ischemic stroke.Added Value of this study: This is the first study that investigated genetic influences on early outcomes after ischemic stroke using a genome-wide approach, revealing seven genome-wide significant loci. A unique aspect of this genetic study is the inclusion of all of the major ethnicities by recruiting from participants throughout the world. Most genetic studies to date have been limited to populations of European ancestry.Implications of all available evidence: The findings provide the first evidence that genes implicating excitotoxicity contribute to human acute ischemic stroke, and demonstrates proof of principle that GWAS of acute ischemic stroke patients can reveal mechanisms involved in ischemic brain injury.

Nonatrial Fibrillation was Associated With Early Neurological Improvement After Intravenous Thrombolysis With rt-PA in Patients With Acute Ischemic Stroke

BACKGROUND

Intravenous thrombolysis is the only approved pharmacological treatment for acute ischemic stroke (AIS) patients, but the immediate response to thrombolysis varies by patient.

OBJECTIVE

To investigate the factors associated with early neurological improvement (ENI) after the administration of intravenous recombinant tissue plasminogen activator (rt-PA) treatment to AIS patients within 4.5 hours of onset.

METHODS

Demographics, onset to treatment time, risk factors, and clinical and laboratory data of 209 AIS patients undergoing intravenous rt-PA therapy at a Chinese hospital between January 2013 and August 2016 were retrospectively analyzed. The National Institutes of Health Stroke Scale (NIHSS) score was recorded before thrombolytic therapy, 24 hours after the treatment, and 7 days after the treatment to evaluate the recovery of neurological function. ENI was defined as a ≥4-point decrease in NIHSS score compared with baseline or a score of 0 or 1 at 24 hours and 7 days. A multivariate logistic regression analysis was performed to assess the outcomes.

RESULTS

Of the 209 AIS patients treated by intravenous thrombolysis with rt-PA, low-density lipoprotein (LDL) levels were significantly lower (P<0.05) in patients with ENI. The multivariable analysis showed that non-atrial fibrillation (AF) was independently associated with ENI at 24 hours and 7 days after thrombolysis. An overall 40.3% non-AF patients had ENI 24 hours after thrombolysis (odds ratio=2.501, 95% confidence interval: 1.204-5.198; P=0.014), and 65.9% non-AF patients had ENI 7 days after thrombolysis (odds ratio=2.953, 95% confidence interval: 1.434-6.081; P=0.003). Onset to treatment time was an independent predictor (P<0.05) for ENI at 7 days after thrombolysis. The NIHSS score and diastolic blood pressure on admission were associated with symptomatic intracerebral hemorrhagic transformation.

CONCLUSIONS

Non-AF was independently associated with ENI after intravenous thrombolysis in AIS patients, but non-AF was not associated with the occurrence of symptomatic intracerebral hemorrhage. Onset to treatment time was an independent predictor of ENI at 7 days after thrombolysis in AIS patients.

Redefined Measure of Early Neurological Improvement Shows Treatment Benefit of Alteplase Over Placebo

Background and Purpose- The first of the 2 NINDS (National Institute of Neurological Disorders and Stroke) Study trials did not show a significant increase in early neurological improvement, defined as National Institutes of Health Stroke Scale (NIHSS) improvement by ≥4, with alteplase treatment. We hypothesized that early neurological improvement defined as a percentage change in NIHSS (percent change NIHSS) at 24 hours is superior to other definitions in predicting 3-month functional outcomes and using this definition there would be treatment benefit of alteplase over placebo at 24 hours. Methods- We analyzed the NINDS rt-PA Stroke Study (Parts 1 and 2) trial data. Percent change NIHSS was defined as ([admission NIHSS score-24-hour NIHSS score]×100/admission NIHSS score] and delta NIHSS as (admission NIHSS score-24-hour NIHSS score). We compared early neurological improvement using these definitions between alteplase versus placebo patients. We also used receiver operating characteristic curve to determine the predictive association of early neurological improvement with excellent 3-month functional outcomes (Barthel Index score of 95-100 and modified Rankin Scale score of 0-1), good 3-month functional outcome (modified Rankin Scale score of 0-2), and 3-month infarct volume. Results- There was a significantly greater improvement in the 24-hour median percent change NIHSS among patients treated with alteplase compared with the placebo group (28% versus 15%; P=0.045) but not median delta NIHSS (3 versus 2; P=0.471). Receiver operating characteristic curve comparison showed that percent change NIHSS (ROC_percent) was better than delta NIHSS (ROC_delta) and admission NIHSS (ROC_admission) with regards to excellent 3-month Barthel Index (ROC_percent, 0.83; ROC_delta, 0.76; ROC_admission, 0.75), excellent 3-month modified Rankin Scale (ROC_percent, 0.83; ROC_delta, 0.74; ROC_admission, 0.78), and good 3-month modified Rankin Scale (ROC_percent, 0.83; ROC_delta, 0.76; ROC_admission, 0.78). Conclusions- In the NINDS rt-PA trial, alteplase was associated with a significant percent change improvement in NIHSS at 24 hours. Percent change in NIHSS may be a better surrogate marker of thrombolytic activity and 3-month outcomes.

Circulating Aquaporin-4 as A biomarker of early neurological improvement in stroke patients: A pilot study

Patients' outcome prediction after ischemic stroke is still challenging. Aquaporin-4 (AQP4) is a water channel that is up-regulated in the brain after the ischemic event, but its presence in bloodstream of stroke patients has not been previously studied. The aim of this pilot study was to investigate circulating AQP4 levels after stroke and its correlation with infarct growth and neurological outcome. AQP4 level was determined by ELISA in serum from 42 t-PA-treated ischemic stroke patients at admission (before t-PA) and 13 healthy subjects. To assess infarct growth, serial brain diffusion-weighted magnetic resonance images were performed at hospital admission and 1-3 days after. Neurological improvement was defined as a ≥4-point decrease in NIHSS score compared to baseline score. Despite stroke patients and healthy controls had similar baseline circulating AQP4 levels, among strokes AQP4 level negatively correlated with NIHSS score at admission (R= -0.34, p = 0.029) and with infarct growth after 1-3 days of stroke onset (R=-0.36; p = 0.018). Furthermore, baseline AQP4 level was higher in those stroke patients showing a neurological improvement 48 h after stroke onset (p = 0.030) and at hospital discharge (p = 0.037). Baseline AQP4 levels also resulted to be an independent predictor of good neurological outcome at both studied time points (OR_adj: 14.33[1.82-112.92], p = 0.012 at 48 h; OR_adj: 4.86[0.98-24.12], p = 0.053 at discharge) in logistic regression analysis, adjusted by age, sex, baseline NIHSS and significant variables in the univariate analysis. Overall, we have explored circulating AQP4 levels, and our data suggest that AQP4 could be used as a biomarker of neurological recovery in the acute-subacute phase of ischemic stroke.

Clinical Variables and Genetic Risk Factors Associated with the Acute Outcome of Ischemic Stroke: A Systematic Review

Stroke is a complex disease and one of the main causes of morbidity and mortality among the adult population. A huge variety of factors is known to influence patient outcome, including demographic variables, comorbidities or genetics. In this review, we expound what is known about the influence of clinical variables and related genetic risk factors on ischemic stroke outcome, focusing on acute and subacute outcome (within 24 to 48 hours after stroke and until day 10, respectively), as they are the first indicators of stroke damage. We searched the PubMed data base for articles that investigated the interaction between clinical variables or genetic factors and acute or subacute stroke outcome. A total of 61 studies were finally included in this review. Regarding the data collected, the variables consistently associated with acute stroke outcome are: glucose levels, blood pressure, presence of atrial fibrillation, prior statin treatment, stroke severity, type of acute treatment performed, severe neurological complications, leukocyte levels, and genetic risk factors. Further research and international efforts are required in this field, which should include genome-wide association studies.

Differences in the awareness of stroke symptoms and emergency response by occupation in the Korean general population

We evaluated the difference in awareness of stroke warning signs (SWS) and emergency response among occupational groups in the community-dwelling population. From the 2016 Korea Community Health Survey, a total of 10,445 individuals without stroke were included in the analysis. Multiple logistic regression analysis was used to explore the association of occupation with awareness of SWS and correct emergency response. SWS included the following: sudden numbness or weakness, sudden difficulty speaking or understanding speech, sudden dizziness, sudden visual impairment, and sudden severe headache. Respondents’ occupation was classified into six groups: managers and professionals (MP); clerks; service and sales workers (SSW); agricultural, forestry, and fishery workers (AFFW); mechanical and manual laborers (MML); or housewives and unemployed people (HUP). Awareness of each SWS was the same with the highest for MP and lowest for AFFW. After adjusting for socio-demographic factors, compared to MP (reference), AFFW (odds ratio 0.49; 95% confidence interval 0.36–0.67), HUP (0.55; 0.40–0.75), MML (0.57; 0.42–0.79), and SSW (0.62; 0.45–0.86) had significantly lower ORs for knowing at least one of the SWS. Additionally, AFFW (0.79; 0.66–0.96) and MML (0.76; 0.63–0.91) had significantly lower ORs for knowing all five SWS compared to MP. However, there was no significant occupational difference in correct emergency response when a stroke occurred. To improve stroke literacy and to reduce the disparity of awareness of SWS in community settings, public health efforts with an emphasis on AFFW and MML are needed.

Overlap in the Genetic Architecture of Stroke Risk, Early Neurological Changes, and Cardiovascular Risk Factors

Background and Purpose- The genetic relationships between stroke risk, stroke severity, and early neurological changes are complex and not completely understood. Genetic studies have identified 32 all stroke risk loci. Polygenic risk scores can be used to compare the genetic architecture of related traits. In this study, we compare the genetic architecture of stroke risk, stroke severity, and early neurological changes with that of 2 stroke risk factors: type 2 diabetes mellitus (T2DM) and hypertension. Methods- We assessed the degree of overlap in the genetic architecture of stroke risk, T2DM, hypertension, and 2 acute stroke phenotypes based on the National Institutes of Health Stroke Scale (NIHSS), which ranges from 0 for no stroke symptoms to 21 to 42 for a severe stroke: baseline (within 6 hours after onset) and change in NIHSS (ΔNIHSS=NIHSS at baseline-NIHSS at 24 hours). This was done by (1) single-nucleotide polymorphism by single-nucleotide polymorphism comparison, (2) weighted polygenic risk scores with sentinel variants, and (3) whole-genome polygenic risk scores using multiple P thresholds. Results- We found evidence of genetic architecture overlap between stroke risk and T2DM ( P=2.53×10^-169), hypertension ( P=3.93×10^-04), and baseline NIHSS ( P=0.03). However, there was no evidence of overlap between ΔNIHSS and stroke risk, T2DM, or hypertension. Conclusions- The genetic architecture of stroke risk is correlated with that of T2DM, hypertension, and initial stroke severity (NIHSS within 6 hours of stroke onset). However, the genetic architecture of early neurological change after stroke (ΔNIHSS) is not correlated with that of ischemic stroke risk, T2DM, or hypertension. Thus, stroke risk and early neurological change after stroke have distinct genetic architectures.

Predictors of functional outcome in patients with stroke thrombolysis in a tertiary hospital in Malaysia

INTRODUCTION

Intravenous (IV) thrombolysis with alteplase (rt-PA) is effective in ischaemic stroke. The primary objective was to evaluate predictors of functional outcome in acute ischaemic stroke (AIS) patients treated with IV rt-PA. The secondary objective was to assess the outcome with the modified Rankin scale (mRS). We also examined the predictive value of the Totaled Health Risks in Vascular Events (THRIVE) score.

METHODS

AIS patients treated with IV rt-PA from February 2012 to August 2016 were recruited. Demographic data, National Institutes of Health Stroke Scale (NIHSS) scores, timing and neuroradiological findings were recorded. Patients received a dose of 0.9 mg/kg IV rt-PA within 4.5 hours of symptom onset. mRS score was evaluated at discharge and three months, and good and poor clinical outcomes were defined as scores of 0-2 and 3-6, respectively. Baseline THRIVE scores were assessed.

RESULTS

36 patients received IV rt-PA. 20 (55.6%) patients had an mRS score of 0-2 at three months. Based on THRIVE score, 86.1% had a good or moderately good prognosis. On univariate analysis, poor outcome was associated with NIHSS score before rt-PA (p = 0.03), THRIVE score (p = 0.02), stroke subtype (p = 0.049) and diabetes mellitus (DM; p = 0.06). Multiple logistic regression showed that outcome was significantly associated with NIHSS score before rt-PA (p = 0.032) and DM (p = 0.010).

CONCLUSION

Our newly developed Malaysian IV rt-PA service is safe, with similar outcomes to the published literature. Functional outcome after thrombolysis was associated with baseline NIHSS score and DM.

Can early neurological improvement after mechanical thrombectomy be used as a surrogate for final stroke outcome?

Background and purpose

We aimed to identify the best definition of early neurological improvement (ENI) at 2 and 24 hours after mechanical thrombectomy (MT) and determine its ability to predict a good functional outcome at 3 months.

Methods

This retrospective analysis was based on a prospectively collected registry of patients treated by MT for ischemic stroke from May 2010 to March 2017. We included patients treated with stent-retrievers with National Institute of Health Stroke Scale (NIHSS) score before treatment and at 2 and/or 24 hours after treatment and modified Rankin Score (mRS) at 3 months. Receiver operating characteristic curve analysis was performed to estimate optimal thresholds for ENI at 2 and 24 hours. The relationship between optimal ENI definitions and good outcome at 3 months (mRS 0–2) was assessed by logistic regression.

Results

The analysis included 246 patients. At 2 hours, the optimal threshold to predict a good outcome at 3 months was improvementin the NIHSS score of >1 point (AUC 0.83,95% CI 0.77 to 0.87), with sensitivity and specificity 78.3% (62.2–85.7%) and 84.6% (77.2–90.3%), respectively, and OR 12.67 (95% CI 4.69 to 31.10, p<0.0001). At 24 hours, the optimal threshold was an improvementin the NIHSS score of >4 points (AUC 0.93, 95% CI 0.89 to 0.96), with sensitivity and specificity 93.8% (87.7–97.5%) and 83.2% (75.7–89.2%), respectively, and OR 391.32 (95% CI 44.43 to 3448.35, p<0.0001).

Conclusions

ENI 24 hours after thrombectomy appears to be a straightforward surrogate of long-term endpoints and may have value in future research.

Predictive values of CSS and NIHSS in the prognosis of patients with acute cerebral infarction: A comparative analysis

This study aims to investigate the predictive values of the Chinese Stroke Scale (CSS) and National Institutes of Health Stroke Scale (NIHSS) in the prognosis of patients with acute cerebral infarction.A total of 399 patients with acute cerebral infarction were assessed using CSS and NIHSS within 1 day after admission. Then, the receiver operating characteristic (ROC) curves were established, and the area under the curves of these 2 scoring systems was compared.The area under the curve of CSS and NIHSS was 0.796 and 0.794, respectively.CSS and NIHSS have good predictive values for the prognosis of patients with acute cerebral infarction.

Reperfusion therapy in acute ischemic stroke: dawn of a new era?

Following the success of recent endovascular trials, endovascular therapy has emerged as an exciting addition to the arsenal of clinical management of patients with acute ischemic stroke (AIS). In this paper, we present an extensive overview of intravenous and endovascular reperfusion strategies, recent advances in AIS neurointervention, limitations of various treatment paradigms, and provide insights on imaging-guided reperfusion therapies. A roadmap for imaging guided reperfusion treatment workflow in AIS is also proposed. Both systemic thrombolysis and endovascular treatment have been incorporated into the standard of care in stroke therapy. Further research on advanced imaging-based approaches to select appropriate patients, may widen the time-window for patient selection and would contribute immensely to early thrombolytic strategies, better recanalization rates, and improved clinical outcomes.

The UCP2-866G/A Polymorphism Could be Considered as a Genetic Marker of Different Functional Prognosis in Ischemic Stroke After Recanalization

Recent studies based on experimental animal models of stroke have suggested that uncoupling protein 2 (UCP2), an inner mitochondrial membrane protein that is thought to regulate energy metabolism and reduce reactive oxygen species generation, provides protection against reperfusion damage. We aimed to investigate whether -866G/A polymorphism in the promoter of the UCP2 gene, which enhances its transcriptional activity, is associated with functional prognosis in patients with embolic ischemic stroke after early recanalization. We investigate a hospital-based prospective cohort of patients with acute ischemic stroke due to occlusion of the middle cerebral artery diagnosed by transcranial Doppler who obtained a partial/complete recanalization 24 h after administration of intravenous thrombolysis. The main end point of the study was functional independence defined as modified Rankin Scale 0-2 on day 90. A total of 80 patients were enrolled. The UCP2-866G/A polymorphism was determined by polymerase chain reaction-restriction fragment length polymorphism technique (14 genotype A/A (18%), 45 genotype A/G (56%) and 21 genotype G/G (26%). The percentage of patients with good functional outcome at 3 months was significantly higher in patients harboring the A/A genotype than in those with A/G or G/G genotypes (85 vs 41%, p = 0.01). The A/A genotype was found to be an independent marker of good prognosis after adjustment for secondary variables (age, sex, glucose level, NIHSS score at baseline, complete recanalization and early neurological improvement) in a logistic regression analysis (OR 0.05, 95% CI 0.01-0.48, p = 0.01). Our results suggest that the AA genotype of UCP2-866 may predict a better functional outcome in ischemic stroke after recanalization of proximal MCA occlusion.

Sex Differences in rt-PA Utilization at Hospitals Treating Stroke: The National Inpatient Sample

Background and purpose

Sex and race disparities in recombinant tissue plasminogen activator (rt-PA) use have been reported. We sought to explore sex and race differences in the utilization of rt-PA at primary stroke centers (PSCs) compared to non-PSCs across the US.

Methods

Data from the National (Nationwide) Inpatient Sample (NIS) 2004–2010 was utilized to assess sex differences in treatment for ischemic stroke in PSCs compared to non-PSCs.

Results

There were 304,152 hospitalizations with a primary diagnosis of ischemic stroke between 2004 and 2010 in the analysis: 75,160 (24.7%) patients were evaluated at a PSC. A little over half of the patients evaluated at PSCs were female (53.8%). A lower proportion of women than men received rt-PA at both PSCs (6.8 vs. 7.5%, p < 0.001) and non-PSCs (2.3 vs. 2.8%, p < 0.001). After adjustment for potential confounders the odds of being treated with rt-PA remained lower for women regardless of presentation to a PSC (OR 0.87, 95% CI 0.81–0.94) or non-PSC (OR 0.88, 95% CI 0.82–0.94). After stratifying by sex and race, the lowest absolute treatment rates were observed in black women (4.4% at PSC, 1.9% at non-PSC). The odds of treatment, relative to white men, was however lowest for white women (PSC OR = 0.85, 95% CI 0.78–0.93; non-PSC OR = 0.80, 95% CI 0.75–0.85). In the multivariable model, sex did not modify the effect of PSC certification on rt-PA utilization (p-value for interaction = 0.58).

Conclusion

Women are less likely to receive rt-PA than men at both PSCs and non-PSCs. Absolute treatment rates are lowest in black women, although the relative difference in men and women was greatest for white women.

Paradigm Shift for Thrombolysis for Patients with Acute Ischaemic Stroke, from Extension of the Time Window to the Rapid Recanalisation After Symptom Onset

Intravenous thrombolysis (IVT) and intra-arterial thrombolysis (IAT) are useful therapeutic tools to improve functional outcomes after recanalisation of occluded vessels in patients with acute ischaemic stroke. IVT could be performed for more patients by extending the time interval to 4.5 hours from onset to IVT initiation; however, this does not significantly improve functional outcomes. Recent studies indicated that IAT, particularly intra-arterial thrombectomy (IA-thrombectomy), significantly improved functional outcomes after recanalisation of occluded vessels, particularly when the recanalisation was performed within 6 hours of symptom onset. The focus of thrombolysis for acute ischaemic stroke patients is changing from extending the time window for IVT to successfully achieving good functional outcomes with IA-thrombectomy, by performing it within the 6-hour time limit. In this review, we discuss the present status of and limitations of extending IA-thrombectomy for improved functional outcomes after thrombolysis.

CT and MRI-based door-needle-times for acute stroke patients a quasi-randomized clinical trial

OBJECTIVES

Door-Needle-times (DNT) of 20min are feasible when Computer Tomography (CT) is used for first-line brain-imaging to assess stroke-patients' eligibility for intravenous-tissue-Plasminogen-Activator (iv-tPA), but the more time-consuming Magnetic Resonance Imaging (MRI)-based-evaluation is superior in detecting acute ischaemia.

Intravenous Tissue Plasminogen Activator for Wake-Up Stroke: A Propensity Score-Matched Analysis

GOAL

To evaluate the safety and efficacy of intravenous (IV) tissue plasminogen activator (tPA) in the treatment of wake-up stroke (WUS) using propensity score (PS) analysis.

MATERIALS AND METHODS

Consecutive acute ischemic stroke patients meeting inclusion criteria were retrospectively identified from our stroke registry between July 2008 and May 2014, and classified as stroke onset less than or equal to 4.5 hours treated with tPA (control; n = 369), tPA-treated WUS (n = 46), or nontreated WUS (n = 154). The primary outcome of interest for safety was symptomatic intracerebral hemorrhage (sICH), defined as parenchymal hemorrhage associated with a greater than or equal to 4-point increase in National Institutes of Health Stroke Scale (NIHSS) score. Multivariate logistic regression with adjustment for confounders and PS for receiving IV tPA assessed outcomes, along with PS-matched average treatment effect on the treated (ATT).

FINDINGS

No significant difference was found in rates of sICH between tPA-treated WUS, nontreated WUS, and controls (2.2%, .7%, and 3%, respectively), or in the odds of sICH between tPA-treated WUS and controls (OR = .53, 95% CI = .06-4.60, P = .568). Among WUS patients, tPA treatment was significantly associated with higher odds of good functional outcome in fully adjusted analyses (OR = 7.22, 95% CI = 2.28-22.88, P = .001). The ATT of tPA for WUS patients demonstrated a significantly greater decrease in NIHSS score at discharge when compared to nontreated WUS patients (-4.32 versus -.34, P = .032).

CONCLUSIONS

Comparable rates of sICH between treated WUS and stroke onset less than or equal to 4.5 hours treated with tPA suggest that tPA may be safely used to treat WUS. Superior outcomes for tPA-treated versus nontreated WUS subjects may suggest clinical efficacy of the treatment.

Racial Disparity in Stroke Awareness in the US: An Analysis of the 2014 National Health Interview Survey

BACKGROUND/AIMS

Stroke is a leading cause of premature death and disability, and increasing the proportion of individuals who are aware of stroke symptoms is a target objective of the Healthy people 2020 project.

METHODS

We used data from the 2014 Supplement of the National Health Interview Survey (NHIS) to assess the prevalence of stroke symptom knowledge and awareness. We also tested, using a logistic regression model, the hypothesis that individuals who have knowledge of all 5 stroke symptoms will be have a greater likelihood to activate Emergency Medical Services (EMS) if a stroke is suspected.

RESULTS

From the 36,697 participants completing the survey 51% were female. In the entire sample, the age-adjusted awareness rate of stroke symptoms/calling 911 was 66.1%. Knowledge of the 5 stroke symptoms plus importance of calling 911 when a stroke is suspected was higher for females, Whites, and individuals with health insurance. Stroke awareness was lowest for Hispanics, Blacks, and survey participants from Western US region.

CONCLUSION

The findings allude to continuing differences in the knowledge of stroke symptoms across race/ethnic and other demographic groups. Further research will confirm the importance of increased health literacy for Stroke management and prevention in minority communities.

Implementation of Computerized Physician Order Entry Is Associated With Increased Thrombolytic Administration for Emergency Department Patients With Acute Ischemic Stroke

STUDY OBJECTIVE

Electronic health record systems with computerized physician order entry and condition-specific order sets are intended to standardize patient management and minimize errors of omission. However, the effect of these systems on disease-specific process measures and patient outcomes is not well established. We seek to evaluate the effect of computerized physician order entry electronic health record implementation on process measures and short-term health outcomes for patients hospitalized with acute ischemic stroke.

METHODS

We conducted a quasi-experimental cohort study of patients hospitalized for acute ischemic stroke with concurrent controls that took advantage of the staggered implementation of a comprehensive computerized physician order entry electronic health record across 16 medical centers within an integrated health care delivery system from 2007 to 2012. The study population included all patients admitted to the hospital from the emergency department (ED) for acute ischemic stroke, with an initial neuroimaging study within 2.5 hours of ED arrival. We evaluated the association between the availability of a computerized physician order entry electronic health record and the rates of ED intravenous tissue plasminogen activator administration, hospital-acquired pneumonia, and inhospital and 90-day mortality, using doubly robust estimation models to adjust for demographics, comorbidities, secular trends, and concurrent primary stroke center certification status at each center.

RESULTS

Of 10,081 eligible patients, 6,686 (66.3%) were treated in centers after the computerized physician order entry electronic health record had been implemented. Computerized physician order entry was associated with significantly higher rates of intravenous tissue plasminogen activator administration (rate difference 3.4%; 95% confidence interval 0.8% to 6.0%) but not with significant rate differences in pneumonia or mortality.

CONCLUSION

For patients hospitalized for acute ischemic stroke, computerized physician order entry use was associated with increased use of intravenous tissue plasminogen activator.

Sedation vs. Intubation for Endovascular Stroke TreAtment (SIESTA) – A Randomized Monocentric Trial

Background

The optimal peri-interventional management of sedation and airway for endovascular stroke treatment (EST) appears to be a crucial factor for treatment success. According to retrospective studies, the widely favored general anesthesia with intubation seems to be associated with poor functional outcome compared to a slightly sedated non-intubated condition (conscious sedation).

Method

SIESTA is a monocentric, prospective, randomized parallel-group, open-label treatment trial with blinded endpoint evaluation (PROBE design). The study compares the non-intubated with the intubated state in patients receiving endovascular treatment of acute ischemic anterior circulation stroke. The primary endpoint is early neurological improvement as by National Institutes of Health Stroke Scale (NIHSS) after 24 h (difference between NIHSS on admission and NIHSS after 24 h). Secondary endpoints include: functional outcome after three-months as by modified Rankin Scale (mRS), mortality, parameters of ventilation and critical care, feasibility, and safety, i.e. complications related to endovascular stroke treatment.

Conclusion

The aims of this study are to prospectively clarify whether the non-intubated state of conscious sedation is feasible, safe, and superior with regard to early neurological improvement compared to the intubated state of general anesthesia in patients receiving acute endovascular stroke treatment.

Predictors of major improvement after intravenous thrombolysis in acute ischemic stroke

BACKGROUND

Intravenous thrombolysis improves outcomes of stroke patients. The immediate response to thrombolysis is variable and few studies attempted to identify predictors of major neurological improvement (MNI) 24 h following thrombolysis. Our objective is to determine predictors of MNI 24 h following thrombolysis.

METHODS

We reviewed the prospective database of patients treated through our telestroke network and at our institution between November 2008 and June 2012. We included all patients who received IV t-PA and had a 24-h NIHSS score available. Similar to previous studies, we defined MNI as a reduction in NIHSS score by ≥8 points, or a score of 0 or 1 at 24 h. Demographics, risk factors, time to treatment, and clinical and laboratory data, were compared between MNI present or absent. Baseline predictors were compared using t- and Fisher's exact tests, and outcomes using multivariate logistic regression analysis.

RESULTS

Out of 316 patients, 306 had 24-h NIHSS scores and 38% of them experienced MNI. Patients with MNI were less likely to be older than 80 years (16% vs. 29%, p = 0.008) and to have atrial fibrillation (9% vs. 24%, p = 0.001) compared to those without; we found no other predictors of MNI. After adjusting for baseline demographics and risk factors, age less than 80 years (OR = 1.9, 95% CI 1.1-3.6) and absence of atrial fibrillation (OR = 3.0, 95% CI: 1.4-6.2) predicted MNI.

CONCLUSION

Major neurological improvement within 24 h after thrombolysis is more likely in younger patients and those without atrial fibrillation.

Correlation between the Occlusion Site and Clinical Outcome after Acute Ischemic Stroke

OBJECTIVE

The significance of early mild clinical improvement after intravenous tissue plasminogen activator (IVtPA) treatment is unclear. Therefore, we examined whether the timing of clinical improvement after IVtPA predicted the clinical outcome at 3 months.

METHODS

Consecutive patients with acute cerebral infarction in the anterior circulation who received IVtPA treatment within 3 hours of the onset of symptoms were enrolled in the study. Patients were classified according to the timing of clinical improvement [early responder (ER), National Institutes of Health Stroke Scale (NIHSS) score improved ≥4 points or who had a score of 0 within 2 hours after IVtPA; late responder (LR), a similar improvement between 2 and 24 hours; and non-responder (NR)] and according to the arterial occlusion site (P group, internal carotid artery and proximal middle cerebral artery M1 region; and D group, distal M1 and M2).

RESULTS

Ninety-three patients [median age, 74 (67-79) years; 54 men (58%); median NIHSS score, 11 (7-16)] were enrolled in the study. The P group consisted of 48 (52%) patients and the D group consisted of 45 (48%) patients. Thirty-eight patients (41%) were classified as ERs, 20 (22%) as LRs, and 35 (38%) as NRs. On a multivariate regression analysis, the P group [odds ratio (OR), 3.24; 95% confidence interval (CI), 1.08-10.45; p=0.036] and NR (OR, 4.04; 95% CI, 1.29-14.27; p=0.016) were independent predictors of a poor outcome. ER (47%, p=0.01) and LR (45%, p=0.01) patients showed fewer poor outcomes than NR (77%) patients, but the rate did not differ significantly between the ER and LR patients.

CONCLUSION

Early mild clinical recovery did not predict a good outcome. The occlusion site was a stronger predictor of clinical improvement after IVtPA administration.

Aging, the metabolic syndrome, and ischemic stroke: redefining the approach for studying the blood-brain barrier in a complex neurological disease

The blood-brain barrier (BBB) has many important functions in maintaining the brain's immune-privileged status. Endothelial cells, astrocytes, and pericytes have important roles in preserving vasculature integrity. As we age, cell senescence can contribute to BBB compromise. The compromised BBB allows an influx of inflammatory cytokines to enter the brain. These cytokines lead to neuronal and glial damage. Ultimately, the functional changes within the brain can cause age-related disease. One of the most prominent age-related diseases is ischemic stroke. Stroke is the largest cause of disability and is third largest cause of mortality in the United States. The biggest risk factors for stroke, besides age, are results of the metabolic syndrome. The metabolic syndrome, if unchecked, quickly advances to outcomes that include diabetes, hypertension, cardiovascular disease, and obesity. The contribution from these comorbidities to BBB compromise is great. Some of the common molecular pathways activated include: endoplasmic reticulum stress, reactive oxygen species formation, and glutamate excitotoxicity. In this chapter, we examine how age-related changes to cells within the central nervous system interact with comorbidities. We then look at how comorbidities lead to increased risk for stroke through BBB disruption. Finally, we discuss key molecular pathways of interest with a focus on therapeutic targets that warrant further investigation.