The Oxfordshire Community Stroke Project classification system predicts clinical outcomes following intravenous thrombolysis: a prospective cohort study

Neuron-specific enolase as a prognostic biomarker in acute ischemic stroke patients treated with reperfusion therapies

Introduction

Ischemic stroke is a significant global health concern, with reperfusion therapies playing a vital role in patient management. Neuron-specific enolase (NSE) has been suggested as a potential biomarker for assessing stroke severity and prognosis, however, the role of NSE in predicting long-term outcomes in patients undergoing reperfusion therapies is still scarce.

Aim

To investigate the association between serum NSE levels at admission and 48 h after reperfusion therapies, and functional outcomes at 90 days in ischemic stroke patients.

Methods

This study conducted a prospective cross-sectional analysis on consecutive acute ischemic stroke patients undergoing intravenous fibrinolysis and/or endovascular thrombectomy. Functional outcomes were assessed using the modified Rankin Scale (mRS) at 90 days post-stroke and two groups were defined according to having unfavorable (mRS3-6) or favorable (mRS0-2) outcome. Demographic, clinical, radiological, and laboratory data were collected, including NSE levels at admission and 48 h. Spearman's coefficient evaluated the correlation between analyzed variables. Logistic regression analysis was performed to verify which variables were independently associated with unfavorable outcome. Two ROC curves determined the cut-off points for NSE at admission and 48 h, being compared by Delong test.

Results

Analysis of 79 patients undergoing reperfusion treatment following acute stroke revealed that patients with mRS 3-6 had higher NIHSS at admission (p < 0.0001), higher NIHSS at 24 h (p < 0.0001), and higher NSE levels at 48 h (p = 0.008) when compared to those with mRS 0-2. Optimal cut-off values for NSE0 (>14.2 ng/mL) and NSE48h (>26.3 ng/mL) were identified, showing associations with worse clinical outcomes. Adjusted analyses demonstrated that patients with NSE48h > 26.3 ng/mL had a 13.5 times higher risk of unfavorable outcome, while each unit increase in NIHSS24h score was associated with a 22% increase in unfavorable outcome. Receiver operating characteristic analysis indicated similar predictive abilities of NSE levels at admission and 48 h (p = 0.298). Additionally, a strong positive correlation was observed between NSE48h levels and mRS at 90 days (r = 0.400 and p < 0.0001), suggesting that higher NSE levels indicate worse neurological disability post-stroke.

Conclusion

Serum NSE levels at 48 h post-reperfusion therapies are associated with functional outcomes in ischemic stroke patients, serving as potential tool for patient long-term prognosis.

Intravenous thrombolysis for ischemic stroke in the posterior circulation: A systematic review and meta-analysis

OBJECTIVES

Intravenous thrombolysis (IVT) is recommended in patients with ischemic stroke in the anterior and posterior circulation. Neurological outcomes due to posterior circulation strokes (PCS) without treatment remain poor. Our aim was to overview the literature on outcomes of IVT and conservative treatment in PCS, based on a systematic review and meta-analysis.

METHODS

A systematic literature search was performed on February 27th 2023. Outcome measures included favorable functional outcome at 90 days (modified Rankin Scale [mRS] 0-2), mortality at 90 days, and symptomatic intracranial hemorrhages (sICH). Weighted averages with DerSimonian-Laird approach was used to analyze the data. Subgroup analyses by time window were performed: standard time window (<4.5 hours after symptom onset) and extended time window (>4.5 hours). Analyses were performed using R.

RESULTS

Eight prospective and four retrospective cohort studies were included (n = 1589 patients); no studies with conservative treatment were eligible. The pooled weighted probability regarding favorable functional outcome after IVT was 63 % (95 %CI:0.45-0.78), for mortality 19 % (95 %CI:0.11-0.30), and for sICH 4 % (95 %CI:0.02-0.07). Subgroup analyses showed higher probabilities on achieving favorable functional outcomes for patients treated in the standard (77 %; 95 %CI:0.62-0.88) compared to the extended time window (38 %; 95 %CI:0.29-0.48) with RR = 1.93 (95 %CI:1.66-2.24). Lower probabilities regarding mortality at 90 days and sICH were seen in patients treated in standard compared to extended time window (RR = 0.42, 95 %CI:0.34-0.51 and RR = 0.27, 95 %CI:0.16-0.45, respectively).

CONCLUSIONS

IVT in patients with PCS seems to be safe and effective in standard and extended time window. The effect of IVT is higher in the standard time window.

Subacute stroke: new-onset poststroke bladder and bowel dysfunctions and possible associated factors

PURPOSE

Bladder and bowel poststroke dysfunctions negatively impact patients' health. Stroke-related characteristics associated to these dysfunctions are poorly known. This study aims to estimate the prevalence of new-onset poststroke bladder and bowel dysfunctions, characterize their associated factors, and describe the dysfunctions' clinical approach.

MATERIALS AND METHODS

Cross-sectional study including 157 patients admitted to a single hospital's stroke unit with a first-ever stroke, during 3 months. An 18-item questionnaire was applied to assess dysfunctions pre and poststroke. The McNemar test was used to compare pre and poststroke prevalence. A logistic regression was used to estimate associations (OR, 95% CI) between individual characteristics and new-onset dysfunctions.

RESULTS

We had 113 (72%) respondents. There was a significant increase in the prevalence of bladder and bowel dysfunctions poststroke (p < 0.001). Higher stroke severity was significantly associated with both new-onset poststroke bladder and bowel dysfunctions (OR = 15.00, 95% CI [4.92,45.76] and OR = 5.87,95%CI [2.14,16.12], respectively). Total anterior circulation strokes, cardioembolic strokes, and lower functionality at discharge were also significantly associated with both dysfunctions. Thirteen patients (11.5%) reported that health professionals addressed these dysfunctions.

CONCLUSIONS

Poststroke bladder and bowel dysfunctions are highly prevalent. Being aware of their epidemiology helps draw attention to patients at higher risk of developing these dysfunctions, enhancing the rehabilitation process.IMPLICATIONS FOR REHABILITATIONPoststroke bladder and bowel dysfunctions are highly prevalent and under-recognised consequences of stroke.Being aware of their epidemiology and associated factors may help identify patients at higher risk of developing these dysfunctions.It is necessary to raise clinical awareness to ensure a more efficient diagnostic and therapeutic approach, enhancing patients' rehabilitation process, quality of life and lowering collateral societal burden.

A Rare Case of Contralateral Ischemic Stroke Recurrence Post-Reperfusion: Successful Management Through Timely Thrombectomy

Stroke is a predominant contributor to global mortality and disability and represents a complex and heterogeneous disease characterized by diverse risk factors and clinical presentations. The likelihood of stroke patients being at risk of a second stroke within the first five years is higher, especially within the initial two weeks. The distressing prospect of experiencing recurrent stroke shortly after reperfusion therapy adds an additional layer of complexity, potentially reversing prior progress. In the present case, we describe a patient who experienced a recurrent stroke within 24 hours, affecting the contralateral middle cerebral artery (MCA). This recurrence occurred after the individual underwent thrombolysis therapy for the initial stroke, emphasizing the intricate challenges associated with managing such cases and the imperative for targeted interventions to mitigate further risks and enhance patient outcomes.

The Pitfalls of NIHSS: Time for a New Clinical Acute Stroke Severity Scoring System in the Emergency?

Stroke is the second leading cause of death and a major cause of disability worldwide. Stroke severity scales serve as reliable means to track a patient's neurological deficit, predict outcome, and guide treatment decisions in clinical practice. The National Institute of Health Stroke Scale (NIHSS) was introduced over 30 years ago, marking a significant milestone in the field of stroke. Over the years, there have been notable advancements in acute stroke care. Despite several modifications made to NIHSS, none has yet succeeded in effectively capturing all the complex effects of a stroke. This review focuses on the pitfalls of NIHSS and emphasizes the need for a quick and comprehensive clinical and upgraded version of the stroke severity rating scale.

Amide proton transfer-weighted MRI features of acute ischemic stroke subtypes

Stroke is a highly heterogeneous disorder with distinct subtypes, and the stroke subtype influences the outcome. Amide proton transfer-weighted (APTW) MRI has been demonstrated to be promising in stroke patients, but the image characteristics of stroke subtypes have not been sufficiently investigated. The purpose of this study was to investigate the APTW MRI features of different subtypes of acute ischemic stroke (AIS). Ninety-two AIS patients presenting within 96 h of symptom onset were enrolled and examined with a 3.0-T MRI system. Patients were grouped into four subtypes: lacunar circulation infarcts (LACI, n = 33); total anterior circulation infarcts (TACI, n = 9); partial anterior circulation infarcts (PACI, n = 28); and posterior circulation infarcts (POCI, n = 22). APTW values in the lesion (APTWlesion ) and the contralateral normal-appearing region (APTWcontral ) were measured. The change in APTW values between the acute ischemic lesion and the contralateral normal-appearing region (APTWles-con ) was calculated. A two-sample t-test, one-way ANOVA, and the Chi-square method were used. There were significant differences between APTWlesion and APTWcontral in the three categories of nonlacunar strokes (TACI, PACI, and POCI, all p < 0.01), but not for lacunar strokes (LACI, p = 0.080). TACI patients had the lowest APTWlesion and APTWles-con in all groups (p < 0.05). In the POCI group, patients with supratentorial infarcts showed significant differences between APTWlesion and APTWcontral (p = 0.001), while the differences were not significant for infratentorial infarcts (p = 0.135). Our results suggest that the APT effect was heterogeneous in different stroke subtypes, and that APTW MRI gave an excellent performence in depicting nonlacunar AIS in supratentorial locations.

In-Hospital Aspirin Dose as a Risk Factor for Hemorrhagic Transformation in Patients Not Treated With Thrombolysis

BACKGROUND

Aspirin is widely used as secondary prophylaxis for acute ischemic stroke. However, its influence on the risk of spontaneous hemorrhagic transformation (HT) is still unclear. Predictive scores of HT have been proposed. We hypothesized that an increased aspirin dose might be harmful in patients at a high risk of HT. This study aimed to analyze the relationship between in-hospital daily aspirin dose (IAD) and HT in patients with acute ischemic stroke.

METHODS

We conducted a retrospective cohort study of patients admitted to our comprehensive stroke center between 2015 and 2017. The attending team defined IAD. All included patients underwent either computed tomography or magnetic resonance imaging within 7 days of admission. The risk of HT was assessed using the predictive score of HT in patients not undergoing reperfusion therapies. Regression models were used to evaluate the correlations between HT and IAD.

RESULTS

A total of 986 patients were included in the final analysis. The prevalence of HT was 19.2%, and parenchymatous hematomas type-2 (PH-2) represented 10% (n=19) of these cases. IAD was not associated with HT ( P =0.09) or PH-2 ( P =0.06) among all patients. However, in patients at a higher risk for HT (patients not undergoing reperfusion therapies ≥3), IAD was associated with PH-2 (odds ratio 1.01,95% CI 1.001-1.023, P =0.03) in an adjusted analysis. Taking 200 versus 300 mg aspirin was protective against PH-2 (odds ratio 0.102, 95% CI 0.018-0.563, P =0.009).

CONCLUSION

An increased in-hospital aspirin dose is associated with intracerebral hematoma in patients at a high risk of HT. Stratifying the risk of HT may lead to individualized daily aspirin dose choices. However, clinical trials on this topic are required.

Predictors of congruency between clinical and radiographic Oxfordshire Community Stroke Project Classification subtypes

BACKGROUND

The Oxfordshire Community Stroke Project (OCSP) classification has been widely used to assess ischemic stroke patients based on clinical characteristics alone. However, the correlation between the clinical presentation evaluated using OCSP and imaging findings is yet to be determined. Our study aimed to describe the baseline characteristics of the OCSP subtypes of patients admitted with ischemic stroke and evaluate the predictors of the relationship between clinical and neuroimaging findings.

METHODS

Patients with a confirmed diagnosis of ischemic stroke admitted to a comprehensive stroke center in Brazil between February 2015 and October 2017 were eligible for the study. All participants underwent computed tomography (CT) at admission and follow-up neuroimaging within seven days, per the institutional protocol. Trained staff classified patients according to the OCSP at hospital admission. The radiographic OCSP classification was retrospectively assessed based on the last follow-up neuroimaging by investigators unaware of the clinical classification.

RESULTS

The overall agreement rates ranged from 65.5% to 88.7%. Lower NIHSS scores, absent hyperdense MCA sign, higher ASPECTS, and absent brainstem symptoms were related to a higher risk of misclassification. Treatment with intravenous tPA was associated with reclassification in patients with total anterior circulation syndrome. For predicting radiographic posterior circulation involvement, vertigo (OR 2.9, 95% CI 1.7-5.1, p < 0.001) and brainstem symptoms (OR 35, 95% CI 20.5-60.2, p < 0.001) were directly associated with correct classification, but motor and higher cerebral function were not correlated.

CONCLUSION

The clinical OCSP classification presented good congruency rates with the neuroimaging findings. However, patients with lacunar syndromes are often misclassified when radiological criteria are considered.

Prognostic role of optic nerve sheath diameter in stroke in emergency department, A case control study

Background

Sonographic measurement of optic nerve sheath diameter (ONSD) can reflect intracranial pressure (ICP) indirectly and determine the neurology intensive care unit (NICU) requirement and mortality in acute ischemic stroke (AIS).

Aim

To demonstrate the effectiveness of ONSD to determine mortality, morbidity, and NICU requirement on patients with the AIS.

Methods

The sonographic ONSD measurements were performed on each patient with AIS, over 18 years old. All patients were categorized according to the Oxfordshire Community Stroke Project (OCSP) classification system. MRI images were examined for increased ICP, and the patients were categorized into two groups as increased ICP (i-ICP) and normal ICP. The ONSD results were evaluated in terms of classifications, outcomes, and prognosis of the patients.

Results

One hundred and five patients were included and 31 (35.2%) were in the i-ICP group. The median ONSDs were 5.26 mm in the i-ICP group and 4.62 mm in the normal ICP group (P < 0.001). The median ONSDs were 5.13 mm in the NICU group and 4.69 mm in the neurology ward (NW) group (P = 0.001). The total anterior circulation infarction (TACI) subgroup had higher ONSDs than the others (TACI: 5.27 mm; PACI: 4.73 mm; POCI: 4.77 mm; and LACI: 4.64 mm, P < 0.001). The NICU requirements were higher in the TACI subgroup. The median ONSD was 5.42 mm in the deceased group (survived: 4.77 mm, P < 0.001).

Conclusion

ONSD may be favorable for predicting the increased ICP and the NICU requirement in OCSP subgroups. Moreover, ONSD can be used to foresee the mortality of AIS.

Venous thromboembolism-related genetic determinant F11 rs4253417 is a potential prognostic factor in ischaemic stroke

Ischaemic stroke (IS) and venous thromboembolism (VTE) are two forms of thromboembolism that, although distinct, seem to share numerous risk factors. Concerning genetic risk factors, while many VTE genetic markers have been reported, inclusively by genome-wide association studies (GWAS), the identification and validation of genetic determinants underlying IS pathogenesis have been challenging. Considering that IS and VTE shared biological pathways and aetiological factors, the severity of IS might be also influenced by VTE-related genetic variants. Thus, the present study was designed to analyse the impact of six VTE GWAS-identified genetic variants on the clinical outcome of 363 acute IS patients. Results revealed that the single-nucleotide polymorphism (SNP) F11 rs4253417 was an independent predictor of the 5-year risk of death among patients with total anterior circulation infarct (TACI). Namely, the ones carrying the SNP C allele presented a fourfold increase in the 5-year risk of death compared to TT genotype carriers (CC/CT vs. TT; adjusted HR, 4.240; 95% CI, 1.260-14.270; P = 0.020). This SNP is known to be associated with coagulation factor XI (FXI) levels, thus with implications in haemostasis and inflammation. As such, F11 rs4253417 might be a promising prognostic biomarker among TACI patients to aid in clinical decision-making. However, additional investigation is required to confirm the study's results and dissect the underlying mechanisms.

Clinical and Imaging Phenotypes and Outcomes in a Costa Rican Cohort of Acute Ischemic Stroke Survivors: A Retrospective Study

BACKGROUND

We characterized clinical and imaging phenotypes and their association with clinical outcomes in acute ischemic stroke (AIS) survivors in the understudied region of Costa Rica.

METHODS

We conducted a retrospective cohort study in AIS patients treated at a tertiary stroke center in Costa Rica from 2011-2015. Participants underwent detailed phenotyping for cardiovascular risk factors and stroke etiology. We assessed the association of ischemic brain lesion features and clinical outcomes using the Oxfordshire Community Stroke Project (OCSP) classification.

RESULTS

We included 684 AIS survivors (60.2% males, aged 68.1 ± 13.6 years, mean ± SD). While the cardiovascular risk profiles and mortality rates of our patients were similar to populations in European and North American countries, only 20.2% of patients with atrial fibrillation (AF) received anticoagulation. On multivariable analysis, patients with total anterior circulation infarct (TACI) displayed an increased risk of complications (OR: 4.2; 95% CI: 2.2-7.8; p < 0.001), higher mortality (OR: 6.9; 95% CI: 2.9-16.1; p < 0.001) and lower chance of functional independence at discharge (OR: 8.9; 95% CI: 4.1-19; p < 0.001) compared to non-TACI. The comorbidity of bronchopneumonia increased the probability of death by 14.5 times.

CONCLUSIONS

Our observations in a Costa Rican cohort of AIS survivors might help improve local measures for preventing and managing AIS.

Clinical Characteristics of Patients with Acute Ischemic Stroke Previously Vaccinated Against COVID-19

Objectives

The aim of this study was to examine the clinical characteristics of patients with acute ischemic stroke which were previously vaccinated against Coronavirus Disease 2019 (COVID-19) and determine whether the vaccine had impact on outcome.

Materials and Methods

In this observational cohort study we analyzed the clinical characteristics of 58 patients with ischemic stroke, previously vaccinated against COVID-19. We analyzed demographic characteristics, risk factors, type of stroke and outcome. We also compared outcome of those patients with outcome in stroke patients hospitalized in the same period but not vaccinated, patients hospitalized during the pandemic, before vaccination began, and stroke patients hospitalized before the pandemic. Further, we compared mortality rate with mortality rate in patients who had acute ischemic stroke and COVID-19 simultaneously.

Results

The mean age of the patients was 71.0 years, most were male (58.6%), mostly with risk factors for stroke. In the largest number of patients, 17 (29.3%), the etiopathogenetic mechanism of stroke was atherosclerosis of the large arteries. Mortality in vaccinated patients was identical to mortality in stroke patients before pandemic, without significant difference from mortality in unvaccinated patients (13.8% versus 8.6%; p= 0.23). The mean NIHSS and mRS score at discharge for all examined groups were without significant difference. A significant difference in mortality was found between COVID-19 positive and COVID-19 negative stroke patients (37.8% versus 18.1%; p=0.001).

Conclusions

There are no significant differences in clinical characteristics of stroke in vaccinated compared to unvaccinated patients. We did not find a connection between vaccination and stroke.

The Diagnostic Value of Whole Blood lncRNA NR_120420 for Acute Ischemic Stroke

Objective

Current clinical practice based on CT or multimodal images to diagnose ischemic stroke always led to substantial treatment delay. We perform this study to explore possible circulating lncRNA biomarker to help promptly diagnose the disease.

Methods

We used microarray to identify the differentially expressed lncRNAs in the peripheral whole blood between AIS patients and controls and verified the results by quantitative polymerase chain reaction (qPCR). Multivariate logistic regressions were performed to determinate the lncRNAs independently associated with AIS occurrence. The ROC curve was used to detect the diagnostic accuracy of candidate lncRNAs in AIS and AIS subtypes, which was classified according to the Oxford Community Stroke Project (OCSP) criteria.

Results

The microarray analysis screened out 5686 differentially expressed lncRNAs. Among the nine selected lncRNAs verified by qPCR, NR_120420 (OR 1.29, 95% CI 1.02-1.65, P = 0.037) was found independently associated with AIS after balancing patient baseline characteristics. The receiver operating characteristic (ROC) analysis concerning NR_120420 in total anterior circulation infarction subgroup showed that the area under the curve was 0.86 (95% CI: 0.73-0.99, P = 0.003), and at the optimal cutoff point of 1.93, the sensitivity and specificity reached 85.7% and 84.6%, respectively.

Conclusion

Our study indicated that NR_120420 could predict the total anterior circulation infarction with high sensitivity and specificity and could be potentially used as a biomarker for total anterior circulation infarction in AIS patients.

Ischemic Stroke Subtypes: Socio-demographic Factors, Risk Factors, and Outcomes in Southern Sri Lanka

Background

Stroke is a heterogeneous, catastrophic disease. A comprehensive clinical analysis of ischemic stroke (IS) risk factors and outcomes is crucial for optimum management in resource-poor settings.

Methods

A prospective cross-sectional study of acute cerebrovascular disease (ACVD) involving 592 patients was conducted in a tertiary care center in Sri Lanka from November 2018 to May 2019. We aimed to describe the ACVD subtypes and the relationship of IS subtypes and subtype-categories (as defined by the Oxfordshire Community Stroke Project clinical classification) with risk factors, severity, and outcome.

Results

The majority (63.3%) had IS. Partial anterior circulation syndromes (PACS), total anterior circulation syndrome (TACS), posterior circulation syndromes (POCS), and lacunar syndromes (LACS) accounted for 102 (29.7%), 58 (16.9%), 88 (25.7%) and 95 (27.7%) of the cases, respectively. The most common PACS sub-category was higher-cerebral-dysfunction-with-homonymous-hemianopia (HCD+HH,39 cases;38.2%). Cerebellar-signs-without-long-tract-signs (CS-LTS) sub-category constituted the highest among POCS (47 cases; 53.4%). The leading sub-category within LACS was pure-motor (PM) strokes (43 cases; 45.3%).Patients aged ≥50 years (adjusted-OR [AOR]2.439; 95%CI,1.163-5.116;P=.018), IHD(AOR 2.520; 95%CI,1.347-4.713; P=.004) and BMI>23kg/m²(AOR 2.607; 95% CI,1.420-4.784; P=.002) were 2.5 times more likely to associate with TACS. Patients with a history of TIA (AOR 1.910; 95%CI,1.036-3.524; P=.038) and arrhythmias (AOR 5.933; 95%CI,3.294-10.684; P<.001) were 1.9 and 5.9 times more likely to be associated with POCS respectively. Those with hypertension were 2.3 times more likely to associate with LACS (AOR 2.233; 95%CI,1.270-3.926; P=.005).NIHSS(P<.001), mRS on admission (P=.001) and in 3 months (P<.001), deaths during hospital stay (P=.003) and within 28 days (P<.001) had a stronger relationship with individual stroke subtypes.

Conclusion

The comparative risk of different IS subtypes depends on different risk factors. The findings of this study demonstrate that sub-categories within each stroke subtype may behave independently with regard to risk factors and outcomes, thus warranting the need for individual assessment.

Convergent Validity and Test-Retest Reliability of Multimodal Ultrasonography and Related Clinical Measures in People With Chronic Stroke

OBJECTIVE

To assess the test-retest reliability of diagnostic ultrasonography measurements of the bilateral biceps brachii (BB), brachial artery, medial gastrocnemius (MG), and popliteal artery in survivors of stroke and their convergent validity with related clinical comparators.

DESIGN

Cross-sectional study.

SETTING

All procedures were conducted in a university laboratory.

PARTICIPANTS

Sixty-five community dwelling adults (N=65; 26 women, 39 men) with an average age of 60.9±7.7 years and stroke duration of 5.7±3.9 years participated in this study.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Measures of muscle structure (ie, thickness, cross-sectional area, fascicle length, pennation angle), stiffness, and intramuscular blood perfusion were conducted using B-mode, elastography and color flow Doppler ultrasonography modes, respectively. Convergent validity was assessed by examining correlations between ultrasonography measures and assessments of related constructs (ie, dynamic stiffness, isometric peak torque, spasticity, and systemic vascular function using myotonometry, dynamometry, the Composite Spasticity Scale, and the Ankle-Brachial Index, respectively). A 2-way random-effects intraclass correlation coefficient (ICC) model (ICC_2,3) was used to determine agreement between intersession measures among a smaller cohort of participants with stroke (n=20).

RESULTS

ICC estimates ranged from moderate to excellent for muscle stiffness (paretic: ICC=0.74-0.89; nonparetic: ICC=0.66-0.88), structure (paretic: ICC=0.87-0.99; nonparetic: ICC=0.81-0.98), and blood perfusion measures (paretic: ICC=0.74-0.84; nonparetic: ICC=0.73-0.88). Weak to moderate associations were found between myotonometry and elastography measures of the bilateral BB (r=0.29-0.52, P≤.05) and MG muscles (r=0.31-0.69, P≤.05). The correlations between elastography measures and spasticity scores for the paretic upper (r=0.35-0.63, P≤.05) and lower limbs (r=0.25-0.37, P≤.05) were also weak to moderate.

CONCLUSIONS

Elastography demonstrated mostly weak to moderate correlation with measures of stiffness using myotonometry as well as scores of paretic upper and lower limb spasticity. The results also indicate acceptable intersession reliability for muscle and vascular measures using several ultrasonography modalities among individuals with chronic stroke.

Oxfordshire Community Stroke Project Classification: A proposed automated algorithm

Introduction

The Oxfordshire Community Stroke Project (OCSP) proposed a clinical classification for Stroke patients. This classification has proved helpful to predict the risk of neurological complications. However, the OCSP was initially based on findings on the neurological assesment, which can pose difficulties for classifying patients. We aimed to describe the development and the validation step of a computer-based algorithm based on the OCSP classification.

Materials and methods

A flow-chart was created which was reviewed by five board-certified vascular neurologists from which a computer-based algorithm (COMPACT) was developed. Neurology residents from 12 centers were invited to participate in a randomized trial to assess the effect of using COMPACT. They answered a 20-item questionnaire for classifying the vignettes according to the OCSP classification. Each correct answer has been attributed to 1-point for calculating the final score.

Results

Six-two participants agreed to participate and answered the questionnaire. Thirty-two were randomly allocated to use our algorithm, and thirty were allocated to adopt a list of symptoms alone. The group who adopted our algorithm had a median score of correct answers of 16.5[14.5, 17]/20 versus 15[13, 16]/20 points, p = 0.014. The use of our algorithm was associated with the overall rate of correct scores (p = 0.03).

Discussion

Our algorithm seemed a useful tool for any postgraduate year Neurology resident. A computer-based algorithm may save time and improve the accuracy to classify these patients.

Conclusion

An easy-to-use computer-based algorithm improved the accuracy of the OCSP classification, with the possible benefit of further improvement of the prediction of neurological complications and prognostication.

Analysis of Prognostic Risk Factors Determining Poor Functional Recovery After Comprehensive Rehabilitation Including Motor-Imagery Brain-Computer Interface Training in Stroke Patients: A Prospective Study

Objective: Upper limb (UL) motor function recovery, especially distal function, is one of the main goals of stroke rehabilitation as this function is important to perform activities of daily living (ADL). The efficacy of the motor-imagery brain-computer interface (MI-BCI) has been demonstrated in patients with stroke. Most patients with stroke receive comprehensive rehabilitation, including MI-BCI and routine training. However, most aspects of MI-BCI training for patients with subacute stroke are based on routine training. Risk factors for inadequate distal UL functional recovery in these patients remain unclear; therefore, it is more realistic to explore the prognostic factors of this comprehensive treatment based on clinical practice. The present study aims to investigate the independent risk factors that might lead to inadequate distal UL functional recovery in patients with stroke after comprehensive rehabilitation including MI-BCI (CRIMI-BCI). Methods: This prospective study recruited 82 patients with stroke who underwent CRIMI-BCI. Motor-imagery brain-computer interface training was performed for 60 min per day, 5 days per week for 4 weeks. The primary outcome was improvement of the wrist and hand dimensionality of Fugl-Meyer Assessment (δFMA-WH). According to the improvement score, the patients were classified into the efficient group (EG, δFMA-WH > 2) and the inefficient group (IG, δFMA-WH ≤ 2). Binary logistic regression was used to analyze clinical and demographic data, including aphasia, spasticity of the affected hand [assessed by Modified Ashworth Scale (MAS-H)], initial UL function, age, gender, time since stroke (TSS), lesion hemisphere, and lesion location. Results: Seventy-three patients completed the study. After training, all patients showed significant improvement in FMA-UL (Z = 7.381, p = 0.000^**), FMA-SE (Z = 7.336, p = 0.000^**), and FMA-WH (Z = 6.568, p = 0.000^**). There were 35 patients (47.9%) in the IG group and 38 patients (52.1%) in the EG group. Multivariate analysis revealed that presence of aphasia [odds ratio (OR) 4.617, 95% confidence interval (CI) 1.435-14.860; p < 0.05], initial FMA-UL score ≤ 30 (OR 5.158, 95% CI 1.150-23.132; p < 0.05), and MAS-H ≥ level I+ (OR 3.810, 95% CI 1.231-11.790; p < 0.05) were the risk factors for inadequate distal UL functional recovery in patients with stroke after CRIMI-BCI. Conclusion: We concluded that CRIMI-BCI improved UL function in stroke patients with varying effectiveness. Inferior initial UL function, significant hand spasticity, and presence of aphasia were identified as independent risk factors for inadequate distal UL functional recovery in stroke patients after CRIMI-BCI.

Frequency, Determinants, and Outcomes of Emboli to Distal and New Territories Related to Mechanical Thrombectomy for Acute Ischemic Stroke

[Figure: see text].

Association between serum non-high-density lipoprotein cholesterol and cognitive dysfunction after acute ischemic stroke: a cross-sectional study

This study aimed to explore the association between serum non-high-density lipoprotein cholesterol (non-HDL-C) and cognitive dysfunction risk in patients with acute ischemic stroke (AIS). This cross-sectional study enrolled 583 AIS patients. Biochemical markers and lipid profile were collected after admission. AIS patients were classified into high group (non-HDL-C ≥3.4 mM) and normal group (non-HDL-C <3.4 mM). Mini-Mental State Examination scale (MMSE), Montreal Cognitive Assessment scale (MoCA), Activities of Daily Living (ADL) scale, Neuropsychiatric Inventory (NPI), and Hamilton Depression scale 21 version (HAMD-21) were applied on the third day after admission. Compared with the control group, patients of the high group had higher body mass index and higher frequency of intracranial artery stenosis, and exhibited higher levels of non-HDL-C, total cholesterol, triglycerides, low-density lipoprotein cholesterol, homocysteine, fasting blood glucose, and glycosylated hemoglobin (HbA1c), and lower levels of high-density lipoprotein cholesterol (all P<0.05). Compared with the control group, patients of the high group had significantly lower MMSE and MoCA scores (MMSE: 26.01±4.17 vs 23.12±4.73, P<0.001; MoCA: 22.28±5.28 vs 20.25±5.87, P<0.001) and higher scores on the NPI and HAMD-21 (both P<0.001). MMSE (r=-0.306, P<0.001) and MoCA scores (r=-0.251, P<0.001) were negatively associated with non-HDL-C level. Multivariate regression analysis revealed that non-HDL-C level (OR=1.361, 95%CI: 1.059-1.729, P=0.016) was independently associated with the presence of cognitive dysfunction after adjusting for confounding factors. High serum non-HDL-C level might significantly increase the risk of cognitive dysfunction after AIS.

Vascular endothelial growth factor and poor prognosis after ischaemic stroke

BACKGROUND AND PURPOSE

Systemic inflammation conveys information about ischaemic stroke prognosis. Growth factors with neurotrophic and angiogenesis-regulating properties might provide additional information about sequelae. The prognostic performance of circulating vascular endothelial growth factor (VEGF), placental growth factor, interleukin 6 and C-reactive protein measured after acute ischaemic stroke was evaluated.

METHODS

Blood samples were collected from n = 45 patients within 24-48 h of acute ischaemic stroke. The primary outcome was death or moderate to severe disability at 6 months (modified Rankin Scale >2). Logistic regression models were used to determine the area under the receiver operating characteristic curve (AUC). Correlation and principal component analyses were performed to examine interrelationships amongst biomarkers.

RESULTS

Vascular endothelial growth factor was elevated in ischaemic stroke patients who died or had moderate to severe disability at six months. Correlation analysis revealed interrelationships between VEGF and HbA1c, triglycerides, erythrocyte sedimentation rate and National Institutes of Health Stroke Scale and Rankin scores, whereas principal component analyses identified VEGF as a major loading factor that discriminated good from poor prognosis. There were no significant differences in AUC using each protein individually to identify patients who had modified Rankin Scale score >2 at 6 months (n = 15/41, AUC 0.61-0.74). However, the AUC increased significantly when combining VEGF with interleukin 6 and C-reactive protein compared to the VEGF-only model (AUC 0.92 vs. 0.67, p = 0.02).

CONCLUSION

Circulating VEGF was elevated 24-48 h after acute ischaemic stroke and conveyed prognostic information about moderate to severe disability at 6 months.

Outcome after intravenous thrombolysis in patients with acute lacunar stroke: An observational study based on SITS international registry and a meta-analysis

BACKGROUND

Intravenous thrombolysis (IVT) for lacunar stroke (LS) is debated, as the underlying pathophysiological mechanism may not be thrombogenic.

AIMS

To investigate outcomes after IVT in LS in the SITS International Stroke Thrombolysis Register and perform a meta-analysis.

METHODS

LS was identified by both baseline NIHSS-subscores and discharge ICD-10 codes, and contrasted by IVT to non-IVT treated. IVT patients were predominantly from Europe, non-IVT patients predominantly from South America and Asia. Outcome measurements were functional independence (modified Rankin Scale [mRS] score ≤2), excellent outcome (mRS ≤ 1), and mortality at three months. Matched-control comparisons of symptomatic intracerebral hemorrhage (SICH) between IVT-treated LS and IVT-treated non-LS patients were performed. Additionally, we performed a meta-analysis.

RESULTS

Median age for IVT-treated LS patients (n = 4610) was 66 years vs. 64 years and NIHSS score was 6 vs. 3, compared to non-IVT-treated LS (n = 1221). Univariate outcomes did not differ; however, IVT-treated LS patients had higher adjusted odds ratios (aOR) for functional independence (aOR = 1.65, 95% CI = 1.28-2.13) but similar mortality at three months (aOR = 0.57, 0.29-1.13) than non-IVT-LS. Propensity-score matched analysis showed that IVT-treated LS patients had a 7.1% higher chance of functional independency than non-IVT LS patients (p < 0.001). IVT-treated LS patients had lower odds for SICH (aOR = 0.33, 0.19-0.58 per SITS, aOR = 0.40, 0.27-0.57 per ECASS-2) than matched non-LS controls, which was mirrored in the meta-analysis.

CONCLUSIONS

Our adjusted results show that IVT treatment in LS patients was associated with better functional outcome than non-IVT-treated LS and less SICH than IVT-treated non-LS patients.

Recurrent thrombolysis of a stuttering lacunar infarction captured on serial MRIs

Lacunar strokes account for about a fourth of all ischemic strokes. Pontine infarcts often present with stuttering symptoms, referred to as pontine warning syndrome (PWS). Patients presenting with fluctuating symptoms can appear to have rapidly improving symptoms and thus often go untreated despite the risk of recurrent deficits. MRI carries a higher sensitivity in detecting posterior circulation strokes compared to computed topagraphy, but does not always indicate irreversible injury. Here we present the first description of a stuttering lacune, captured radiographically on serial magnetic resonance imaging (MRI), that was initially averted with the administration of intravenous (IV) tissue plasminogen activator (tPA), only to return a month later and progress on imaging despite re-administration of tPA. During the first admission, our patient had spontaneous resolution of symptoms with complete reversal on restricted diffusion soon after IV tPA administration. On the second admission, the stuttering symptoms returned as did the same pontine lesion. Although his stuttering lesions lasted for several days, and the pontine lesion did ultimately progress to partial infarction on MRI, he was discharged home without neurologic deficits. Our case suggests that tPA may be of benefit in patients with lacunar pontine strokes even if symptoms rapidly improve or resolve.

Alterations in optic nerve sheath diameter according to cerebrovascular disease sub-groups

BACKGROUND

ONSD (optic nerve sheath diameter) is a method used for indirect measurement of the increased intracranial pressure. In previous studies, the relation between the increased intracranial pressure and ONSD was analyzed in the patients suffering from cerebrovascular diseases (CVD). In our study, the patients suffering from ischemic CVD were categorized into 4 subgroups according to Oxfordshire Community Stroke Project classification (OCSP); the relationship between each group and ONSD, and the influence on each eye were analyzed.

METHODS

The study included the patients over the age of 18 applying to the emergency department of Malatya State Hospital with the symptoms of stroke between the dates of 1/1/2015 and 1/9/2016. The patients diagnosed with stroke by means of clinical and neuroradiological imaging were examined in 4 subgroups according to Oxfordshire Community Stroke Project. The aim of the study is to predict the intracranial pressure (ICP) levels of the patients through ONSD measurement and CT images.

RESULTS

In the comparison of the right and left optic nerve sheath diameters of CVD group and control group, the obtained results were found to be statistically significant (p<0.001). When the CVD subgroups were compared with the control group in terms of right and left optic nerve sheath diameters, the highest right-left optic nerve sheath diameter was detected to be in TACI (Total Anterior Circulation Infarction) group (p<0.001).

DISCUSSION/CONCLUSION

In the early cases of CVD, mortality and morbidity can be decreased through the early diagnosis of the possible existence of ICP increase according to ONSD level.

Plasma MicroRNA-16 Is a Biomarker for Diagnosis, Stratification, and Prognosis of Hyperacute Cerebral Infarction

Indices for the diagnosis of hyperacute cerebral infarction (HACI) and the prediction of prognosis are essential for timely and appropriate management. MicroRNAs (miRNAs) that regulate gene expression following stroke have potential use as prognostic markers of HACI. Here, we explored whether concentrations of circulating miRNAs correlate with clinical outcomes and thus form a system of stroke stratification. Plasma samples from patients with HACI (n = 7) and age-matched healthy volunteers (HVT, n = 4) were screened by microarray to find differentially expressed miRNAs, some of which were further verified by quantitative reverse transcription polymerase chain reaction (qRT-PCR) (HACI:HVT = 33:23). The target genes of the miRNAs with verified differential expression were investigated by GO and KEEG analyses. Using the TOAST (OCSP) criteria and the 3-month modified Rankin Score (mRS), relationships among the expression patterns of specific miRNAs, stroke stratification, and clinical prognosis were determined. The microarray analysis revealed 12 differentially expressed miRNAs. Among seven selected miRNAs verified with qRT-PCR, miR-16 expression in the HACI group was the most significantly different from the HVT group (P < 0.01). Bioinformatics analysis showed that the potential target genes of miR-16 were mainly involved in programmed cell death and the p53 signaling pathways. Receiver operating characteristic (ROC) analysis showed that the area under the curve (AUC) of miR-16 was 0.775 (sensitivity 69.7% and specificity 87%) and 0.952 (sensitivity 100% and specificity 91.3%) in overall patients and patients with large artery atherosclerosis (LAAS), respectively. Elevated miR-16 expression was associated with the stroke subtype of LAAS, total anterior circulation infarction, partial anterior circulation infarction, and poor prognosis (P < 0.05). A diagnostic method based on rapid measurement of plasma miR-16 has the potential to identify hyperacute cerebral infarction with LAAS with high sensitivity and specificity, which would inform and improve early treatment decisions and disease management.