Multiple hypointense vessels on susceptibility-weighted imaging predict early neurological deterioration in acute ischaemic stroke patients with severe intracranial large artery stenosis or occlusion receiving intravenous thrombolysis

Risk Factors and Prognosis of Early Neurological Deterioration after Bridging Therapy

BACKGROUND

Early neurological deterioration (END) after bridging therapy (BT) of acute ischemic stroke (AIS) patients is associated with poor outcomes.

OBJECTIVE

We aimed to study the incidence, risk factors and prognosis of END after BT.

METHODS

From January to December 2021, the clinical data of AIS patients treated by BT (intravenous thrombolysis with alteplase prior to mechanical thrombectomy) from three comprehensive stroke centers were analyzed. Patients were divided into non-END group and END group according to whether they developed END within 72 hours of symptom onset. Modified Rankin scale (mRS) was used to assess the patient's prognosis at 90 days, and favorable outcomes were defined as mRS≤2. The incidence of END was investigated, and binary logistic regression analysis was used to explore its associated factors.

RESULTS

The incidence of END after BT was 33.67%. The eligible 90 patients included 29 cases in the END group and 61 cases in the non-END group. Multivariate Logistic regression analysis showed that increase of systolic blood pressure (SBP) (OR=1.026, 95%CI:1.001-1.051, p =0.043), higher level of blood glucose at admission (OR=1.389, 95%CI:1.092-1.176, p =0.007) and large artery atherosclerosis (LAA) subtype (OR=8.009, 95%CI:2.357-27.223, p =0.001) were independent risk factors of END. Compared with the non-END group, the END group had significantly lower rates of good outcomes (6.90% versus 65.57%, p =0.001) while higher rates of mortality (44.83% versus 4.92%, p =0.001).

CONCLUSION

It was found that the incidence of END after BT in AIS patients was 33.67%. An increase in SBP, higher glucose levels at admission, and LAA were independent risk factors of END that predicted a poor prognosis.

Deep medullary veins as an important imaging indicator of poor prognosis in acute ischemic stroke: a retrospective cohort survey

Background

The deep medullary veins (DMVs), which constitute a component of the intracerebral venous circulation system and are part of intracerebral reperfusion mechanisms, have been suggested as a novel imaging marker for cerebral white matter hypersignal and cerebral small vessel disease based on their discontinuous and reduced visual representation. However, the correlation between the number and continuity of visible DMVs and the poor prognosis of acute ischemic stroke (AIS) remains undefined. Magnetic susceptibility-weighted imaging was applied in this study to assess the distribution and structural characteristics of DMVs in patients with AIS and to investigate its relationship with the poor prognosis of those with AIS.

Methods

This retrospective study included 90 patients diagnosed with AIS in the middle cerebral artery region by the Neurology Department of Liaoning Provincial People's Hospital. Clinical, laboratory, and cranial magnetic resonance imaging data were collected. After the 3-month follow-up visit, patients were dichotomized into good (0-2 points) and poor (≥3 points) prognosis groups based on the modified Rankin Scale score, and the DMV imaging characteristics were evaluated using a 3-level visual rating scale. The association between DMV and AIS prognosis was determined through Mann-Whitney test and multivariate logistic regression analysis.

Results

In univariate analysis, factors that were statistically significant between the different prognostic groups were DMV score (P=0.007), DMV symmetry (P=0.016), infarct size (P=0.029), and admission National Institutes of Health Stroke Scale (NIHSS) score (P<0.001). DMV score had a positive correlation with NIHSS score, (rs=0.209; P=0.048). Logistic regression analysis showed that the DMV score [odds ratio (OR), 1.356; 95% confidence interval (CI): 1.114-1.650; P=0.002], NIHSS score (OR, 1.280; 95% CI: 1.117-1.466; P<0.001), and fasting glucose (OR, 1.220; 95% CI: 1.023-1.456; P=0.027) were risk factors for poor prognosis in those with AIS.

Conclusions

Discontinuity in DMV visualization was found to be associated with an unfavorable prognosis for patients AIS. The visual assessment of DMV through susceptibility-weighted imaging has the potential to predict AIS prognosis and furnish valuable insights for clinical treatment.

Elevated NT-proBNP predicts unfavorable outcomes in patients with acute ischemic stroke after thrombolytic therapy

OBJECTIVE

Few studies correlated n-terminal pro-brain natriuretic peptide (NT-proBNP) with early neurological deterioration (END) and prognosis of acute ischaemic stroke (AIS) patients with rt-PA intravenous thrombolysis. Therefore this study aimed to investigate the relationship between NT-proBNP and END, and prognosis after intravenous thrombolysis in patients with AIS.

METHODS

A total of 325 patients with AIS were enrolled. We performed the natural logarithm transformation on the NT-proBNP [ln(NT-proBNP)]. Univariate and multivariate logistic regression analyses were performed to assess the relationship between ln(NT-proBNP) and END, and prognosis and receiver operating characteristic (ROC) curves were used to show the sensitivity and specificity of NT-proBNP.

RESULTS

After thrombolysis, among 325 patients with AIS, 43 patients (13.2%) developed END. In addition, three months follow-up showed a poor prognosis in 98 cases (30.2%) and a good prognosis in 227 cases (69.8%). Multivariate logistic regression analysis showed that ln(NT-proBNP) was an independent risk factor for END (OR = 1.450,95%CI:1.072 ~ 1.963, P = 0.016) and poor prognosis at three months follow-up (OR = 1.767, 95%CI: 1.347 ~ 2.317, P < 0.001) respectively. According to ROC curve analysis, ln(NT-proBNP) (AUC 0.735, 95%CI: 0.674 ~0.796, P < 0.001) had a good predictive value for poor prognosis, with a predictive value of 5.12 and sensitivity and specificity of 79.59% and 60.35% respectively. When combined with NIHSS to predict END(AUC 0.718, 95%CI: 0.631 ~ 0.805, P < 0.001) and poor prognosis(AUC 0.780, 95%CI: 0.724 ~ 0.836, P < 0.001), the predictive value of the model is further improved.

CONCLUSION

NT-proBNP is independently associated with END and poor prognosis in patients with AIS following intravenous thrombolysis and has a particular predictive value for END and poor prognosis.

Prognostic value of susceptibility-weighted imaging of prominent veins in acute ischemic stroke: A systematic review and meta-analysis

Background

The prominent veins sign (PVS) on susceptibility-weighted imaging (SWI) has been suggested to be related to the prognosis of patients with acute ischemic stroke (AIS). This meta-analysis aims to clarify the association between PVS and the prognosis of patients with AIS.

Methods

This meta-analysis was registered in PROSPERO (no. CRD42022343795). We performed systematic research in PubMed, Web of Science, EMBASE, and Cochrane Library databases for studies investigating the prognostic value of PVS. Based on the enrolled studies, patients were divided into two groups as follows: those with PVS cohort and those without PVS cohort. Outcomes were unfavorable functional outcome, early neurological deterioration (END), and hemorrhagic transformation (HT). The random-effects models were used for the meta-analytical pooled. Heterogeneity was estimated using Cochran's Q-test and I2 value. Subgroup and sensitivity analyses were also performed to explore the potential sources of heterogeneity. Publication bias was assessed with funnel plots and using Begger's and Egger's tests.

Results

A total of 19 studies with 1,867 patients were included. PVS was correlated with an unfavorable functional outcome in patients with AIS (risk ratio [RR] 1.61, 95% CI 1.28–2.02), especially in those receiving recanalization therapy (RR 2.00, 95% CI 1.52–2.63), but not in those treated conservatively (RR 1.33, 95% CI 0.87–2.04). Moreover, PVS was related to END (RR 2.77, 95% CI 2.21–3.46), while without an increased risk of HT (RR 0.97, 95% CI 0.64–1.47).

Conclusion

PVS was associated with an unfavorable prognosis of patients with AIS and increased the risk of END, while not correlated with an increased risk of HT. PVS might be useful for predicting functional outcomes of patients with AIS as a novel imaging maker.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42022343795.

Study on the Predictive Value of Thromboelastography in Early Neurological Deterioration in Patients with Primary Acute Cerebral Infarction

Objective

To investigate the predictive value of thromboelastography for the occurrence of early neurological deterioration (END) in patients with primary acute cerebral infarction (ACI).

Methods

150 patients who were hospitalized in the department of neurology of our hospital from September 2020 to September 2021 and were clearly diagnosed with primary ACI by head CT and head magnetic resonance imaging (MRI) were selected and divided into END and non-END groups according to the change in National Institute of Health Stroke Scale (NIHSS) score within 72 h of admission. The general baseline data and laboratory indexes of the first examination at admission were compared between the two groups, and the factors that may affect the occurrence of END were determined by univariate analysis and multivariate logistic regression analysis, and the predictive value of thromboelastography on the occurrence of END after ACI was analyzed by applying the receiver operating characteristic (ROC) curve.

Results

Time to onset, baseline NIHSS score, percentage of diabetes, white blood cell (WBC) levels, C-reactive protein (CRP), and apolipoprotein B (Apo B) levels were higher in the END group than in the non-END group (P < 0.05); coagulation reaction time (RT) (3.97 ± 1.16 vs. 5.49 ± 1.03) and kinetic time (KT) (1.32 ± 0.67 vs. 1.82 ± 0.58) were lower in the END group than in the non-END group (P < 0.05). Inthe END group (P < 0.05) diabetes, baseline NHISS score, CRP level, Apo B level, and RT were independent risk factors for the development of END in patients with ACI (P < 0.05). The AUC of RT to predict the occurrence of END in patients with ACI was 0.855 (95% CI: 0784 to 0925, P = 0.001), with a sensitivity of 81.70% and specificity of 78.00% when the optimal cut-off value was 0.597.

Conclusion

NIHSS score at admission, CRP, apolipoprotein B, RT shortening, and diabetes mellitus were independent risk factors for the development of END in ACI patients; RT shortening in TEG was predictive of END in ACI patients.

Effects of Early-Stage Blood Pressure Variability on the Functional Outcome in Acute Ischemic Stroke Patients With Symptomatic Intracranial Artery Stenosis or Occlusion Receiving Intravenous Thrombolysis

Background

Studies exploring the relationship between blood pressure (BP) fluctuations and outcome in acute ischemic stroke (AIS) patients treated with intravenous thrombolysis (IVT) are limited. We aimed to investigate the influence of blood pressure variability (BPV) during the first 24 h after IVT on early neurological deterioration (END) and 3-month outcome after IVT in terms of different stroke subtypes.

Methods

Clinical data from consecutive AIS patients who received IVT were retrospectively analyzed. The hourly systolic BP of all patients were recorded during the first 24 h following IVT. We calculated three systolic BPV parameters, including coefficient of variability (CV), standard deviation of mean BP (SD) and successive variation (SV), within the first 6, 12, and 24 h after IVT. END was defined as neurological deterioration with an increase in the National Institutes of Health Stroke Scale (NIHSS) score ≥ 4 points within the first 72 h after admission. Follow-up was performed at 90 days after onset, and favorable and poor outcomes were defined as a modified Rankin Scale scores (mRS) of ≤1 or ≥2, respectively.

Results

A total of 339 patients, which were divided into those with (intracranial artery stenosis or occlusion group, SIASO group) and without (non-SIASO group) SIASO, were included. Among them, 110 patients (32.4%) were with SIASO. Patients in SIASO group had higher NIHSS on admission and difference in term of mRS at 90 days compared with non-SIASO group (P < 0.001). In SIASO group, patients in favorable outcome group were younger and had lower NIHSS on admission, lower SV-24 h (14.5 ± 4.3 vs. 11.8 ± 3.2, respectively) and lower SD-24 h (12.7 ± 3.8 vs. 10.9 ± 3.3, respectively), compared with patients with poor outcome (all P < 0.05). In the multivariable logistic regression analysis, compared with the lowest SV (SV < 25% quartile), SV_50−75% [odds ratio (OR) = 4.449, 95% confidence interval (CI) = 1.231–16.075, P = 0.023] and SV_>75% (OR = 8.676, 95% CI = 1.892–39.775, P = 0.005) were significantly associated with poor outcome at 3 months in patients with SIASO, adjusted for age, NIHSS on admission and atrial fibrillation. No BPV parameters were associated with END in SIASO group. In non-SIASO group, there were no significant association between BPV patterns and END or 90-day outcome.

Conclusions

SV-24 h had a negative relationship with 3-month outcome in AIS patients with SIASO treated with IVT, indicating that BPV may affect the outcome of AIS.

Human urinary kallidinogenase may improve the prognosis of acute stroke patients with early neurological deterioration

OBJECTIVES

Some acute ischemic stroke (AIS) patients still suffer from early neurological deterioration (END) after receiving intravenous thrombolysis (IVT), and these patients often have a poor prognosis. The purpose of our study is to observe the efficacy and safety of human urinary kallidinogenase (HUK) treatment in patients with END.

METHODS

This was a retrospective analysis and 49 patients with END who met the inclusion criteria were divided into the observation group and the control group. All patients received routine treatment of AIS, while patients in the observation group were treated with HUK within 24 h after IVT and the other group without HUK.

RESULTS

There were 24 patients in the observation group and 25 patients in the control group. After treatment, favorable prognosis (mRS scores ≤2) at 3 months in the observation group with 13 cases (54.17%) was significantly better than that in the control group with four cases (16%) (p = .001), and there was no statistical difference between the two groups in any hemorrhagic complication.

CONCLUSION

HUK is considered to be safe and may improve the prognosis of AIS patients with END after IVT. More clinical trials are needed to validate these results in the future.

The Frequency and Associated Factors of Asymmetrical Prominent Veins: A Predictor of Unfavorable Outcomes in Patients with Acute Ischemic Stroke

Objectives

The present study is aimed at investigating the frequency and associated factors of asymmetrical prominent veins (APV) in patients with acute ischemic stroke (AIS).

Methods

Consecutive patients with AIS admitted to the Comprehensive Stroke Center of Shanghai Fourth People's Hospital between January 2013 and December 2017 were enrolled. MRI including diffusion-weighted imaging (DWI), perfusion-weighted imaging (PWI), and susceptibility-weighted imaging (SWI) was performed within 12 hours of symptom onset. The volume of asymmetrical prominent veins (APV) was evaluated using the Signal Processing In nuclear magnetic resonance software (SPIN, Detroit, Michigan, USA). Multivariate analysis was used to assess relationships between APV findings and medical history, clinical variables as well as cardio-metabolic indices.

Results

Seventy-six patients met the inclusion criteria. The frequency of APV ≥ 10 mL was 46.05% (35/76). Multivariate analyses showed that proximal artery stenosis or occlusion (≥50%) (P < 0.001, adjusted odds ratio (OR) = 660.0, 95%CI = 57.28-7604.88) and history of atrial fibrillation (P < 0.001, adjusted OR = 10.48, 95%CI = 1.78-61.68) were independent factors associated with high APV (≥10 mL).

Conclusion

Our findings suggest that the frequency of APV ≥ 10 mL is high in patients with AIS within 12 hours of symptom onset. History of atrial fibrillation and severe proximal artery stenosis or occlusion are strong predictors of high APV as calculated by SPIN on the SWI map.

Cortical Venous Changes on Susceptibility-Weighted Imaging Predict the Cerebral Collateral Circulation as Confirmed by Digital Subtraction Angiography

Objective: Asymmetrical cortical vein sign (ACVS) shown on susceptibility-weighted imaging (SWI) can reflect regional hypoperfusion. We investigated if ACVS could predict the cerebral collateral circulation (CC) as assessed by digital subtraction angiography (DSA) in acute ischemic stroke patients with ipsilateral severe stenosis/occlusion of the anterior circulation.

Methods: Clinical data and imaging data of 62 acute ischemic stroke patients with ipsilateral severe stenosis or occlusion of the anterior circulation confirmed by DSA were collected retrospectively. Participants underwent magnetic resonance imaging, including an SWI sequence. ACVS was defined as more and/or larger venous signals in the cerebral cortex of one side of SWI than that in the contralateral side. ACVS was measured using the Alberta Stroke Program Early Computed Tomography score based on SWI. The grading of the cerebral CC was judged using DSA.

Results: Of the 62 patients, 30 patients (48.4%) had moderate-to-severe ACVS. According to DSA assessment, 19 patients (30.6%) had a good CC (grade 3–4), and 43 (69.4%) patients had a poor-to-moderate CC (grade 0–2). Among the 30 patients with moderate-to-severe ACVS, only three (10%) patients had a good CC, and 27 (90%) patients had a poor-to-moderate CC; among the 32 patients with none or mild ACVS, 16 (50%) of them had a good CC, and the other 50% had a moderate-to-severe CC. We constructed two logistic regression models with ACVS grading and none or mild ACVS entered into the models, respectively, together with age and large-artery occlusion. In model 1, no ACVS (compared with severe ACVS; OR = 40.329, 95%CI = 2.817–577.422, P = 0.006), mild ACVS (compared with severe ACVS; OR = 17.186, 1.735–170.224, 0.015) and large-artery occlusion (OR = 45.645, 4.603–452.592, 0.001) correlated with a good CC. In model 2, none or mild ACVS (OR = 36.848, 95%CI = 5.516–246.171, P < 0.001) was significantly associated with a good CC as judged by DSA, adjusted by age and large-artery occlusion.

Conclusions: Cortical venous changes in SWI may be a useful indicator for the cerebral CC as confirmed by DSA.

The Prognostic Impact of Susceptibility-Weighted Imaging Prominent Veins in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

PURPOSE

We aimed to determine the prognostic impact of prominent veins (PVS) after an acute ischemic stroke identified on susceptibility-weighted imaging (PVS-SWI).

METHODS

We searched for studies published in PubMed, Embase, Cochrane Library and Chinese Biomedical Literature Database. Poor functional prognosis, early neurological deterioration, and hemorrhagic transformation were evaluated. Risk ratios (RR) were pooled implementing a random effect model. We performed a subgroup analysis by treatment, location (cortical/medullary) and a sensitivity analysis by follow-up time.

RESULTS

Sixteen studies were included (a total of 1605 patients) in the quantitative meta-analysis. PVS-SWI were related with a poor functional outcome (RR 1.62, 95% CI 1.25 to 2.10), especially in the patients receiving thrombolysis (RR 2.19, 95% CI 1.53 to 3.15) and an augmented risk of early neurological damage (RR 2.85, 95% CI 2.31 to 3.51). Both cortical and medullary prominent veins were accompanied by a poor functional outcome (RR 1.82, 95% CI 1.30 to 2.56/RR 2.59, 95% CI 1.98 to 3.38). PVS-SWI were not associated with poor functional outcomes when patients were treated conservatively (RR 1.35, 95% CI 0.82 to 2.22), or with an increased risk of hemorrhagic transformation (RR 0.97, 95% CI 0.64 to 1.47).

CONCLUSION

PVS-SWI were related to a poor functional prognosis and an increased risk of early neurological damage. In patients treated conservatively, PVS-SWI were not accompanied by a poor prognosis. PVS-SWI were not associated with an augmented risk of hemorrhagic transformation.