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ADC (apparent coefficient diffusion) value has been known to predict hemorrhage transformation (HT) after thrombolysis and recently, after mechanical thrombectomy (MT). We aimed to evaluate that utility separately in basal ganglia and superficial territory. We used HT occurrence with or without NIHSS change as primary outcome measures.This single-center retrospective study included consecutive stroke patients receiving MT for internal carotid artery (ICA) or middle cerebral artery (M1 or M2) occlusion. In patient with or without HT, using the Heidelberg Bleeding Classification, on follow-up CT scan at 24-48 h, we assessed the ADC value separately in basal ganglia and superficial territory on MRI before MT to search for the correlation. Multivariable analysis was performed using variables with significant differences between the HT group and non-HT group.One hundred seventeen patients were included in the final analysis. HT distribution was as follows: 9 patients (7.69%) HI1 or 2; 14 patients (11.97%) PH1; 21 patients (17.95%) PH2; 29 patients (24.79%) subarachnoid hemorrhage; and 21 patients (17.95%) symptomatic intracranial hemorrhage (sICH). Mean ADC minimal value in basal ganglia in the HT group was significantly lower than in the non-HT group (377.6 × 10ADC value in basal ganglia, unlike brain superficial territory, are correlated to HT risk after MT.

Anemia is a frequently observed condition, but its clinical impact on large vessel occlusion (LVO) remains unclear. We examined the association between anemic status on admission and clinical outcomes of LVO in a real-world setting.We conducted a post-hoc analysis of the RESCUE-Japan Registry 2, a nationwide registry which enrolled 2408 consecutive patients with LVO who were admitted within 24 h of onset. The patients were classified into anemia (11 g/dL) and no-anemia (≥11 g/dL) groups according to their hemoglobin level on admission. The primary outcome was defined as a modified Rankin Scale of 0-2 at day 90.Among the 2373 patients with available baseline hemoglobin data, 307 (13.0%) were classified in the anemia group. Anemia was associated with a lower likelihood of the primary outcome (adjusted odds ratio [OR]: 0.68; 95% confidence interval [CI]: 0.47-0.98) and higher mortality within 90 days (adjusted OR: 1.48; 95% CI: 1.01-2.17). Subgroup analyses showed that the likelihood of achieving the primary outcome between the two groups was different between men and women (P for interaction = 0.049), those with Alberta Stroke Program Early CT Score (ASPECTS)6 and ASPECTS ≥6 (P for interaction = 0.02), and those with National Institute of Health Stroke Scale (NIHSS) ≥16 and NIHSS 16 (P for interaction = 0.005).Anemic state on admission was associated with poorer clinical outcomes of LVO in real-world clinical practice. The effects of anemic status were larger in LVO patients with lower NIHSS or higher ASPECTS.

Although hypercoagulability using D-dimer levels may be a useful marker for predicting outcomes in ischemic stroke patients with cancer, other biological markers for predicting outcomes are unclear. We aimed to investigate the associations between several biological markers and short-term or long-term outcomes among ischemic stroke patients with cancer.Consecutive acute ischemic stroke patients with cancer (n = 309) were registered. Biological markers such as hemoglobin, albumin, C-reactive protein and D-dimer levels were assessed. Stroke outcomes, namely, a 3-month modified Rankin Scale score indicating poor functional outcome (mRS score of 3-6) and 1-year survival, were assessed.Of the 277 patients who could be assessed for 3 months outcome, 131 patients (47.3%) had a poor outcome at 3 months. Multivariable analysis revealed that increased D-dimer levels and decreased albumin levels were independently associated with poor stroke outcomes (adjusted odds ratio [aOR]: 1.04, 95% confidence interval [CI]: 1.00-1.08, and aOR: 0.50, 95% CI: 0.31-0.80, respectively). Of 309 patients, 70 patients (22.7%) died during the follow-up period (median, 241 days). Multivariate Cox proportional hazard analyses showed that high D-dimer levels and hypoalbuminemia were independently associated with mortality (adjusted hazard ratio [aHR]: 2.65, 95% CI: 1.37-5.12, and aHR: 2.29, 95% CI: 1.21-4.49, respectively). The effect of each biological marker on mortality was notably observed among patients with active cancer but not among those with nonactive cancer.Low albumin levels were independently associated with short- and long-term outcomes, as were D-dimer levels, in acute ischemic stroke patients with cancer.

Diffusion imaging (DWI) is considered an optimal technique to detect hyperacute cerebral ischemia and has thus enriched the clinical management of patients with suspected stroke. Researchers have taken this technique beyond with Diffusion Tensor Imaging (DTI)-extracted measures, which have been proposed as biomarkers of stroke progression. A large body of literature report on the correlates between pathophysiological events, such as cytotoxic and vasogenic edema, and diffusion changes in the brain. However, a unified picture of these changes, and their exploration as stroke pathology progression biomarkers, remains to be done. We present here a narrative review on the different pathophysiological events underlying stroke from onset until late subacute stages and its relation to different brain edema forms. Studies included in this review used either DWI and/or DTI analysis in hyperacute (

The efficacy and safety of periprocedural anticoagulant therapy are still controversial. We investigated the effects of periprocedural anticoagulation on patients who underwent endovascular therapy (EVT) for acute ischemic stroke (AIS). The patients were dichotomized into two groups according to the use of intravenous anticoagulant during or within 24 h after EVT (AC or non-AC group). Primary outcome was defined as a modified Rankin Scale (mRS) score of 0-2 at 90 days. Safety outcomes were defined as any or symptomatic intracerebral hemorrhages (ICH). Among 1278 enrolled patients, 740 patients (57.9%) were in the AC group and the remaining 538 patients (42.1%) were in the non-AC group. The median dose of heparin was 5000 units intraoperatively, and 10,000 units /day postoperatively. In the AC group, hypercholesterolemia, higher pre-stroke modified Rankin Scale score, non-cardiac embolism etiology, higher rate of anticoagulant premedication, non-administration of t-PA (tissue plasminogen activator), later admission, and longer procedure time were observed. The rate of primary outcomes was not significantly different between the AC and non-AC groups (40.1% vs. 43.9%; adjusted odds ratio, 1.29; 95% CI, 0.96-1.73; p = 0.09). The incidence of any (26.2% vs. 25.7%; p = 0.80; adjusted odds ratio, 0.97; 95% CI, 0.72-1.22) and symptomatic (4.3% vs. 5.0%; p = 0.52; adjusted OR, 0.83; 95% CI, 0.46-1.51) intracranial hemorrhage within 72 h were not significantly different between the groups. Periprocedural anticoagulant therapy after acute revascularization did not relate to prognosis and intracranial hemorrhage after EVT.

The impact of prior antiplatelet therapy (APT) on clinical outcomes of endovascular therapy (EVT) for large vessel occlusion (LVO) on clinical outcomes is uncertain. We explored the associations between prior APT and in-hospital and 90-day outcomes in a real-world setting.The RESCUE-Japan Registry 2 is a physician-initiated registry of 2408 consecutive patients with acute LVO admitted to hospital within 24 h of stroke onset. We compared 1281 patients who received EVT with and without APT before stroke onset (APT group and No-APT group) in terms of intracranial hemorrhage (ICH) within 72 h after the onset, successful recanalization after EVT, and the modified Rankin Scale (mRS) score 0-2 at 90 days were also evaluated. Among the 254 patients (19.8%) in the APT group, 68 (27%) patients presented any ICH and 265 (26%) patients in the No-APT group (adjusted odds ratio [OR], 1.04; 95% confidence interval [CI], 0.71-1.53). The incidence of symptomatic ICH and successful recanalization were also similar between the APT and No-APT groups. The adjusted ORs of the APT group for mRS of 0-2 and death were 0.93 (95% CI, 0.62-1.41) and 0.59 (95% CI, 0.3-1.19), respectively. In patients with an onset to door time ≥ 180 min, any ICH tended to be more prevalent in the APT group than in their counterparts (P for interaction = 0.008).The risk of ICH after EVT was not different between patients with and without APT before EVT for acute LVO.

BACKGROUND Patients with stroke secondary to occlusions of the anterior cerebral artery (ACA) often have poor outcomes. The optimal acute therapeutic intervention for these patients remains unknown. METHODS Patients with isolated ACA-stroke were identified from 10 centers participating in the EndoVascular treatment And ThRombolysis in Ischemic Stroke Patients (EVATRISP) prospective registry. Patients treated with endovascular thrombectomy (EVT) were compared to those treated with intravenous thrombolysis (IVT). Odds ratios with 95% confidence intervals (OR; 95%CI) were calculated using multivariate regression analysis. RESULTS Included were 92 patients with ACA-stroke. Of the 92 ACA patients, 55 (60%) were treated with IVT only and 37 (40%) with EVT (��bridging IVT). ACA patients treated with EVT had more often wake-up stroke (24% vs. 6%, p��=��0.044) and proximal ACA occlusions (43% vs. 24%, p��=��0.047) and tended to have higher stroke severity on admission [NIHSS: 10.0 vs 7.0, p��=��0.054). However, odds for favorable outcome, mortality or symptomatic intracranial hemorrhage did not differ significantly between both groups. Exploration of the effect of clot location inside the ACA showed that in patients with A1 or A2/A3 ACA occlusions the chances of favorable outcome were not influenced by treatment allocation to IVT or EVT. DISCUSSION Treatment with either IVT or EVT could be safe with similar effect in patients with ACA-strokes and these effects may be independent of clot location within the occluded ACA.

Elevation of blood pressure (BP) after mechanical thrombectomy (MT) can theoretically restore perfusion to the ischemic brain tissue, but it comes at a risk of causing reperfusion injury. We aim to determine the association of 24-h post-MT BP parameters with clinical outcomes depending on the pre-MT collateral status.We performed a retrospective chart review of patients who underwent MT at a comprehensive stroke center from 7/2014 to 12/2020. The patients were divided into good versus poor collateral groups depending on their collateral status. A board-certified neuroradiologist, who was blinded to the clinical outcomes, used collateral grading score of Miteff ≥3 to designate good collaterals on the pre-MT CT Angiogram. A binary logistic regression analysis was performed, controlling for baseline parameters, with the 24-h post-MT BP parameters as predictors. The outcomes were functional dependence [3-month mRS (3-6)] and mortality.A total of 220 met the inclusion criteria. In the multivariable analysis, for patients with poor collaterals, the parameters of higher mean SBP (131.7 ± 12.7 vs. 122.3 ± 14.2; OR, 1.06; 95% CI, 1.01-1.11; P 0.022), higher mean MAP (91.2 ± 8.2 vs. 86.1 ± 6.3; OR, 1.13; 95% CI, 1.03-1.23; P 0.015) and a higher maximum SBP (156.3 ± 13.7 vs. 145.3 ± 19.1; OR, 1.05; 95% CI, 1.01-1.1; P 0.019) were significantly associated with functional dependence at 3-months. For patients with good collaterals, the parameters of lower 24-h mean DBP (69.1 ± 11.1 vs. 73.8 ± 11 95% CI, OR, 0.96; 95% CI, 0.92-1; P 0.025) was significantly associated with higher mortality at 3-months.Our study demonstrates that there is a significant difference with respect to certain 24-h post-MT BP parameters in patients on clinical outcomes depending on their collateral status. In our study, some higher BP parameters were associated with worse outcomes in patients with a poor collateral profile, however, this effect was not replicated in patients with a good collateral profile.

Recent studies suggest only a third of posterior circulation stroke patients have a good functional outcome with a high mortality after mechanical thrombectomy. To mitigate mortality rates and increase functional outcomes, we investigated the safety and efficacy of high-flow, normobaric oxygen (NBO) after endovascular recanalization in posterior circulation stroke.This is a prospective randomized controlled study. Eligible patients were randomized to receive high-flow NBO by a Venturi mask (FiOWhile we assessed 122 patients for eligibility, 87 patients were randomly assigned (44 patients to the NBO group). Post operatively there was no significant difference in distribution of global disability scores on the mRS at 90 days or functional independence between the two groups. We did observe a trend suggesting reduced mortality at 90 days with reduced infarct volume in the NBO group, however this was not statistically significant. No significant differences were seen in the rate of sICH, pneumonia or urinary infection between the two groups. When comparing our results with the BASICS and BEST study, our study did reveal a significantly better prognosis after endovascular therapy.Our results indicate that high-flow adjuvant NBO therapy was safe. However, the current study does not provide evidence for a significant neuroprotection effect in posterior circulation stroke patients after endovascular recanalization.

Data are limited on the ability of dipyridamole to additionally inhibit platelet function/reactivity in ischaemic cerebrovascular disease (CVD) patients on aspirin.To assess inhibition of platelet function/reactivity and platelet activation with dipyridamole in CVD.This prospective, observational study assessed TIA/ischaemic stroke patients before (baseline; N = 60), at 14 ±7 days (14d, N = 39) and ≥ 90 days (90d, N = 31) after adding dipyridamole to aspirin. Platelet function/reactivity at high shear stress (PFA-100® C-ADP) and low shear stress (VerifyNow® P2Y12 and Multiplate® ADP assays), and platelet activation status (% expression of CD62P, CD63 and leucocyte-platelet complexes on whole blood flow cytometry) were quantified. 'Dipyridamole-high on-treatment platelet reactivity (HTPR)' was defined as failure to inhibit ADP-induced platelet aggregation +/- adhesion compared with the patient's baseline on aspirin monotherapy by more than twice the coefficient-of-variation of the assay after adding dipyridamole to aspirin.Dipyridamole-HTPR was identified in 71.4-75% of patients on PFA-100 C-ADP, 83.9-86.8% of patients on VerifyNow P2Y12, and 81.5-83.3% of patients on Multiplate ADP assays. There were no changes in CD62P/CD63 expression (P ≥ 0.18), or consistent changes in leucocyte-platelet complexes in CVD patients overall at 14d or 90d vs. baseline after commencing dipyridamole. Monocyte-platelet complexes increased in the patient subgroup with dipyridamole-HTPR at 14d and 90d on PFA-100, and at 14d on VerifyNow (P ≤ 0.04), but not in those without dipyridamole-HTPR.Additional antiplatelet effects of dipyridamole are detectable under high and low shear stress conditions with user-friendly platelet function/reactivity tests ex vivo. Increasing circulating monocyte-platelet complexes over time are associated with dipyridamole-HTPR.

The safety and efficacy of intravenous thrombolysis (IVT) before endovascular thrombectomy (EVT) for large vessel occlusion stroke remains a highly contested and unanswered clinical question. We aim to characterize the clinical profile, complications, and discharge disposition of EVT patients treated with and without preceding IVT using a large, nationally-representative sample.The National Inpatient Sample was queried from 2015 to 2018 to identify adult patients with anterior circulation stroke treated with EVT with and without preceding IVT. Multivariable logistic regression analysis and propensity-score matching were employed to assess adjusted associations with clinical endpoints and to address confounding by indication for IVT, respectively.Among 48,525 patients identified, 40.7% (n = 19,735) received IVT prior to EVT. On unadjusted analysis, patients treated with IVT bridging therapy experienced higher rates of intracranial hemorrhage (26% vs. 24%, p = 0.003) and routine discharge to home with or without services (33% vs. 27%, p 0.001), a lower frequency of thromboembolic complications (3% vs. 5%, p 0.001), and lower rates of extended hospital stays (eLOS) (20% vs. 24%, p 0.001). Multivariable logistic regression analysis adjusting for demographic and baseline clinical characteristics demonstrated independent associations of IVT bridging therapy with intracranial hemorrhage (aOR 1.28, 95% CI 1.15, 1.43; p 0.001), thromboembolic complications (aOR 0.66, 95% CI 0.53, 0.83; p 0.001), routine discharge (aOR 1.27, 95% CI 1.15, 1.40; p 0.001), and eLOS (aOR 0.76, 95% CI 0.68, 0.85; p 0.001). Sensitivity testing confirmed these findings.Preceding IVT was associated with favorable functional outcomes following endovascular therapy. Prospective randomized clinical trials are warranted for further evaluation.

To evaluate whether arterial and venous color-coded mCTA score may predict clinical outcome in anterior circulation acute ischemic stroke.Consecutive patients referred to the emergency department with anterior circulation acute ischemic stroke (AIS) were retrospectively reviewed at our center. All patients underwent multimodal brain computed tomography (CT) imaging, including non-contrast CT (NCCT) and multiphase computed tomography angiography (mCTA). Baseline collateral scores of color-coded mCTA, also known as ColorViz, and conventional mCTA were recorded. mCTA was assessed by a 6-point scale whereas color-coded mCTA was assessed by a 3-point scale. In the Color-coded maps, a different color is assigned to intracranial vessels based on the arrival time of the contrast medium and on a per-person adaptive threshold technique. We compared the radiological and clinical features of a group of patients who reached independency (defined as modified Rankin Scale score ≤ 2) with those of patients who did not. A multivariate logistic regression model was then used to assess the potential of color-coded mCTA scores to predict patients' outcome after AIS.A total of 86 patients (36 M, 50 F) were enrolled in the study. Multivariate logistic regression showed that score 3 at Color-coded mCTA was a good predictor of favorable outcome (p = 0.003). Moreover, NIHSS at onset (p = 0.004) and discharge (p 0.001) along with ischemic core area (p = 0.011) were significant predictors of favorable prognosis.our data confirm that ColorViz is a useful and easily understandable neuroimaging tool that might have a predictive role in assessing the outcome of anterior circulation acute ischemic stroke patients regardless of revascularization therapy.

Objective To investigate the effect of general anesthesia (GA) on functional outcomes and complications rates in acute ischemic stroke (AIS) patients treated with mechanical thrombectomy (MT) compared to the use of local anesthesia (LA) at the puncture site. Methods This observational study was based on a prospectively registry study. AIS patients underwent MT with GA or LA from January 2013 to October 2017 were included. The primary outcome was the modified Rankin Scale (mRS) score at 90 days post-intervention. Furthermore, we assessed the long-term outcome of these patients. Multivariable logistic regression analysis was conducted to adjust for confounders. Results We enrolled 187 AIS patients in this study, patients in GA group had a similar mRS score compared to LA group at 90 days (2 [IQR, 1–4] vs 2.5 [IQR, 1–4], P = .917). No differences were found in the rates of functional independence (mRS 0–2), no or minimal disability (mRS 0–1), and mortality (mRS 6) between the 2 groups at 90 days post-intervention as well as long-term follow-up. The procedure-related complications and serious adverse events were similar between the LA group and GA group (P > .05 each). In multivariable analysis, GA use was not associated with functional outcomes. Conclusion AIS patients who received GA during MT had similar functional outcomes and complications rates compared to patients received LA.

National institutes of Health Stroke Scale (NIHSS) score and the presence of successful recanalization are crucial determinants of clinical outcome in patients with major artery occlusion. However, it is unknown whether successful recanalization rate after endovascular therapy (EVT) depends on NIHSS score.From our prospective EVT registry, data on patients with an occlusion at the internal carotid artery or middle cerebral artery were analyzed. Successful recanalization was judged as positive when reperfusion of the thrombolysis in cerebral infarction (TICI) scale ≥2b was observed. Successful recanalization rate was also evaluated based on the NIHSS score subgroups: 0-8, 9-16, 17-24, and24. Multivariate regression analysis was used to evaluate the impact of NIHSS score on successful recanalization.We studied 183 patients (age 76 [68-83], male 110 [60%], NIHSS score 19 [14-24]). One hundred and forty-six (80%) patients had the successful recanalization. Patients achieved the recanalization had lower NIHSS score as 18 (12-23), contrary those failed it had higher NIHSS score as 24 (20-27) (p .001). Successful recanalization rate was correlated to the NIHSS score grade; 100% in the NIHSS 0-8 group, 88% in 9-16, 81% in 17-24, and only 60% in24 (p .001). Multivariate regression analysis showed NIHSS score was an independent parameter of recanalization (odds ratio 0.905 [95%CI 0.837-0.979], p = .013).NIHSS score may serve as a predictor of successful recanalization. Recanalization is relatively easier in mild stroke than in those with severe stroke.

Background Chagas disease (CD) and ischemic stroke (IS) have a significant but poorly understood correlation. There is paucity of evidence regarding secondary prophylaxis of IS and etiological causes. Objectives To compare arterial stroke topography and the respective morbidities and mortality in patients with CD of undetermined and cardioembolic etiologies and with cardioembolic IS (atrial fibrillation [AF]). Methods We compared vascular topography and outcomes using data obtained from the electronic medical records of all patients with IS with either CD (with cardioembolic or undetermined etiology) or AF, admitted to SARAH Hospital Brasilia between 2009 and 2013. Results A total of 115 patients were investigated: 49 involving AF, 23 involving CD of unclear etiology, and 43 involving CD of cardioembolic etiology. Middle cerebral artery stroke was predominant in all groups, although more frequent in patients with CD of undetermined etiology. No significant difference was found in the arterial territories. Hemodynamic stroke was predominant among CD patients who experienced cardioembolic events. AF patients had worse modified Rankin scale scores upon admission and a higher mortality rate than CD patients in both categories. Conclusions Stroke topography is not useful in determining the etiological diagnosis. Patients with AF and IS are more likely to have worse outcomes than are those with CD and IS. The autonomic nervous system could be affected in patients with CD.

Purpose: The aim of this study was to identify whether diastolic dysfunction predicts death at 90 days after acute ischemic stroke.Methods: We retrospectively analyzed patients with ischemic stroke. All patients underwent transthoracic echocardiography to evaluate systolic function and diastolic function by means of assessing ejection fraction and septal E/e’.We evaluated the initial National Institute of Health Stroke Scale (NIHSS) score,arterial occlusion, and laboratory data. We used multivariate regression models to identify independent predictors of 90-day mortality. Results: Among 1208 patients, the overall 90-day mortality rate was 8%. In multivariate logistic regression analysis, a higher initial NIHSS score,plasma D-dimer level and E/e’ and occlusion of internal carotid artery or basilar artery were independent predictors of 90-day mortality.The DONE score derived from these valuables showed good discrimination with area under the curve (AUC) value of 0.82 (95% confidence interval [CI],0.78?0.87) to predict 90-day mortality. The DONE score also predicted poor outcome (modified Rankin scale score, 4?6) at 90 days (AUC, 0.82;95% CI 0.80?0.85). Conclusions: Higher E/e’ indicating diastolic dysfunction,may be associated with 90-day mortality in patients with acute ischemic stroke. The DONE score could readily predict poor outcome after acute ischemic stroke., Journal of the Neurological Sciences, 398, pp.157-162; 2019

Objective To examine whether cognitive impairment, deep white matter hyperintensity (DWMH) on brain MRI, and shorter telomere length would be predictors of mortality in community-dwelling Japanese elderly. Methods We followed 259 individuals (74% of all the residents at age 70) from age 70 to 83 years. The mean observation period was 133 ± 34 months. The key clinical characteristics examined included DWMH on brain MRI and cognitive function. Telomere length was also measured in 81 subjects. Both univariate and multivariate analyses were performed. Results Of the 259 subjects, 69 subjects (30 men, 39 women; 26.6%) died during the follow-up period. Cognitive impairment, smoking habits, diabetes mellitus, and moderate to severe DWMH were significant predictors of total mortality in univariate analysis. However, only cognitive impairment and moderate to severe DWMH remained as significant independent predictors of death in multivariate analysis. The rate of mortality increased with additional number of risk factors (cognitive impairment and DWMH). The total mortality of subjects with both cognitive impairment and DWMH was 71.4%. The median telomere length was 7.8 kb in the deceased and 8.2 kb in the living subjects. The deceased subjects had significantly shorter telomere length (P = .0025) than the living subjects. Telomere length with moderate to severe DWMH was higher than without moderate to severe DWMH on brain MRI (P = .017). Conclusions The present study revealed that cognitive impairment, DWMH, and shorter telomere length were significant predictors of total mortality in the community-dwelling Japanese elderly. Furthermore, the combination of cognitive impairment and DWMH increased the mortality rate, as compared with a single risk factor. It is also clarified that a significant difference was present in telomere length by severity of DWMH.

Background Previous studies have reported that extreme low and high hemoglobin levels are positively associated with the risk of ischemic stroke. However, there are few reports on the relationship between hemoglobin at acute phase and clinical outcomes after ischemic stroke and the results of their association to date are inconsistent. We aimed to investigate the association between them in a large prospective cohort of ischemic stroke patients. Methods Baseline hemoglobin levels were measured in 3881 patients with acute ischemic stroke. The primary outcome was defined as composite outcome of major disability and death (modified Rankin Scale score ≥ 3) at 3 months after stroke onset. Secondary outcomes were separately those of major disability and death. Results Compared with the lowest quartile of hemoglobin, the multivariate adjusted odds ratios (95% confidence intervals) associated with the highest quartile were 1.38 (1.03–1.86), 1.49 (1.11–1.99), 0.79 (0.41–1.52) for primary outcome, major disability and death, respectively. Multiple-adjusted spline regression model showed linear associations of hemoglobin levels with primary outcome (P for linearity =0.037) and major disability (P for linearity =0.004). Subgroup analyses further confirmed the positive association between high hemoglobin and poor prognosis of ischemic stroke. Conclusions Elevated hemoglobin levels in the acute phase were associated with poor prognosis at 3 months after ischemic stroke. Further prospective studies from other samples of ischemic stroke patients are needed to validate our findings.

Acute ischemic stroke (AIS) may experience early neurological deterioration (END) and have high risks of recurrent ischemic strokes (RIS), which are often associated with a poor outcome. Post-stroke prognosis is associated with autonomic status. Recently, studies showed that heart rate variability (HRV) is an early outcome predictor in acute stroke patients. The purpose of our study was to investigate association decreased HRV by fractal dimension (FD) with early END within 72 h of admission and 1-year RIS. In this study, we assessed autonomic function of ischemic stroke patients within 24 h from symptom onset by FD. Receiver operating characteristic (ROC) curve was utilized to determine the optimal cut point of FD for END and RIS. 516 patients (mean age 66.14 ± 10.11) with acute ischemic stroke underwent a comprehensive clinical investigation and FD test. According to the data of FD, we investigated association with END within 72 h of admission and the 1-year RIS. ROC curve analysis shown that the optimal cut point of FD for END and RIS were FD ≤ 1.05 and FD ≤ 1.15 respectively. In fully adjusted models, there was an association between FD ≤ 1.05 and END (adjusted odds ratio, 2.64; 95% confidence interval, 1.55-4.49; P 0.001), there was an association between FD ≤ 1.15 and RIS (adjusted odds ratio,5.40; 95% confidence interval, 3.02-9.64; P .001). These findings indicate that FD ≤ 1.05 and FD ≤ 1.15 were independently associated with increased risk of END and RIS respectively, which may have predictive value in END and RIS.

Despite the wide utilization of mechanical thrombectomy (MT) for acute ischemic stroke treatment, little is known about the incidence of early post-thrombectomy seizures, its predictors, and association with long-term outcome.Using a prospective registry of mechanical thrombectomy in ischemic stroke between January 2013 and July 2017, we identified patients who developed a seizure within 7 days (early seizure) of qualifying event. Backward stepwise regression analysis was used to assess independent predictors of seizure occurrence and the association between seizure and functional outcome (modified Rankin scale of 0-2 vs. ≥3).A total of 459 patients were included in the final analysis. Mean age was 67.5 (SD 15.1), and 49.9% of patients were female. Successful recanalization (TICI≥2B) was achieved in 92.8% of patients. Eleven (2.4%) patients developed at least one seizure. Only an Alberta Stroke Program Early CT (ASPECT) score of6 was independently associated with the occurrence of early seizures [Odds ratio, 95% confidence interval: 8.188, (2.219-30.214); P = .002]. On multivariate analysis, early seizures were associated with 90-day mortality rate [OR,6.487; 95% confidence interval, (1.481-28.405); P = .013] and poor functional outcome (OR, 4.7; 95% confidence interval (1.08-20.83); p = .039).In the studied cohort, 2.4% of ischemic stroke patients treated with MT developed at least one seizure within 7 days of stroke onset. A low ASPECT score was associated with the occurrence of early seizures. The occurrence of seizures was associated with 90-day mortality and poor functional outcome.

Background There is limited research on the provision of evidence-based care and its association with outcomes after aneurysmal subarachnoid hemorrhage (aSAH). Aims We examined adherence to evidence-based care after aSAH and associations with survival and discharge destination. Also, factors associated with evidence-based care including age, sex, Charlson comorbidity index, severity scores, and delayed cerebral ischemia and infarction were examined for association with survival and discharge destination. Methods In a retrospective cohort (2010–2016) of all aSAH cases across two comprehensive cerebrovascular centres, we extracted 3 indicators of evidence-based aSAH care from medical records: (1) antihypertensives prior to aneurysm treatment, (2) nimodipine, and (3) aneurysm treatment (coiling/clipping). We defined ‘optimal care’ as receiving all eligible processes of care. Survival at 1 year was obtained by data linkage. We estimated (1) proportion of patients and characteristics associated with receiving processes of care, (2) associations between processes of care with 1-year mortality using cox-proportional hazard model and discharge destination with log binomial regression adjusting for age, sex, severity of aSAH, delayed cerebral ischemia and/or cerebral infarction and comorbidities. Sensitivity analyses explored effect modification of the association between processes of care and outcome by management type (active versus comfort measures). Results Among 549 patients (69% women), 59% were managed according to the guidelines. Individual indicators were associated with lower 1-year mortality but not discharge destination. Optimal care reduced mortality at 1 year in univariable (HR 0.24 95% CI 0.17–0.35) and multivariable analyses (HR 0.51 95% CI 0.34–0.77) independent of age, sex, severity, comorbidities, and hospital network. Conclusion Adherence to processes of care reduced 1-year mortality after aSAH. Many patients with aSAH do not receive evidence-based care and this must be addressed to improve outcomes.

This study analyzed the topography of acute ischemic stroke in the posterior cerebral artery (PCA) territory. We studied 84 patients with unilateral ischemic PCA stroke. Patients were classified according to lesion levels as cortico-subcortical (superficial), combined (cortical and mesodiencephalic) or isolated thalamic. To receive a lesion map, data from acute MR and CT imaging were normalized and labelled automatically by mapping to stereotaxic anatomical atlases. Cortical lesions accounted for 41.7%, combined for 36.9%, and isolated thalamic lesions for 21.4%. The maximum overlay of ischemia and, thus, highest occurrence of PCA ischemic stroke was found in the ventral and medial occipito-temporal cortex and adjacent white matter association tracts. Dorsal and peripheral segments of the occipito-temporo-parietal region were only rarely lesioned. This configuration was similar in both hemispheres. Consistent with this lesion pattern, visual field defects (VFD) were the most frequent signs, followed by sensorimotor signs, dizziness and sopor, cognitive and oculomotor deficits, and ataxia. The three vascular subgroups differed not only by their anatomical lesion profile and lesion load, but also by their clinical manifestation; although patients with combined and thalamic lesions were sigificantly younger, they were more disabled than participants with cortical lesions. VFD were only found in cortical and combined, and oculomotor deficits only in mesodiencephalic lesions. White matter lesions were common in the cortico-subcortical and the combined group. Basal occipito-temporal and calcarine regions, and neighbouring white matter tracts have the highest risk of ischemia in acute PCA stroke.

Adrenomedullin (ADM) has been identified as a promising biomarker of mortality and outcome in sepsis, heart failure and after major surgery. A recently developed assay specific for bioactive adrenomedullin (bio-ADM) has not yet been assessed in aneurysmal subarachnoid hemorrhage (aSAH). The objective of this prospective trial was to assess the time course of bio-ADM after aSAH in relation to the development of delayed cerebral ischemia (DCI) and its association with clinical outcome.Bio-ADM levels in plasma and cerebrospinal fluid (CSF) were measured during five predefined epochs, for up to 21 days in 30 aSAH patients: early, (day 0 to day 3); acute, (day 4 to day 8); early critical, (day 9 to day 12); late critical, (day 13 to day 15), and late (day 16 to day 21). DCI was diagnosed clinically or based on multimodal monitoring and imaging, and the occurrence of DCI-related cerebral infarction, and outcome after 12 months (extended Glasgow outcome scale), was noted.Higher median bio-ADM levels in plasma during the acute phase were predictive of long-term unfavorable outcome (AUC = 0.97; 95% CI 0.91 to 1.00; p 0.001). Early critical bio-ADM levels during DCI were lower in CSF and confirmed DCI occurrence (AUC = 0.80; 95% CI 0.59 to 1.00; p = 0.044).The dynamics of bio-ADM levels in CSF present a fairly different course compared to plasma with observed higher bio-ADM concentrations in patients spared from DCI and/or developing favorable outcome.

Background and purpose Carotid webs (CaW) may be an under-recognized cause of anterior circulation cryptogenic ischemic stroke (ACIS). Prevalence is still unknown in European patients with ACIS. Objective To evaluate the prevalence of CaW in ACIS and describe patients with CaW phenotype in a cohort of patients from a French stroke center. Methods We conducted a retrospective monocentric cohort study from 01/01/2015 to 31/12/2019 (Montpellier University Hospital, France), in consecutive anterior ischemic stroke (AIS) patients ≤65 years old from a prospective stroke database. Using ASCOD phenotyping, ACIS patients were selected and cervical CTA were reviewed to find CaW. Results Among 1053 consecutive AIS patients, 266 ACIS patients with CTA were included. Among patients included (mean age 50, women 58%), CaW was in the ipsilateral carotid (iCaW) in 21 patients: 7.9% (95%CI [4.6–11.1]), (mean age 51, 11 women, 16 Caucasian). iCaW were uncovered during study review of CTA in 6/21 (29%) patients. Comparison between patients with iCaW and those without iCaW showed no differences except that of a higher rate of intracranial large vessel occlusion (LVO) (62.4 vs 37.6%; p = 0.03). Patients with iCaW under conservative medical therapy had an annualized stroke recurrence rate (SRR) of 11.4% (95%CI [8.4–15.1]. Conclusions iCaW was identified as a source of stroke in about 8% of a French population ≤65 years with ACIS. iCaW was associated with a higher rate of LVO and a high SRR under conservative medical therapy.

Background and purpose Combining intra-arterial mechanical thrombectomy (IAMT) and intravenous thrombolysis (IVT) has shown to have an excellent recanalization rate and better clinical outcome in acute ischemic stroke (AIS) patients. Hyperdense middle cerebral artery sign (HMCAS) on pretreatment non-contrast head CT scan of AIS patients is one of the early ischemic radiological findings in middle cerebral artery territory AIS. We aimed to evaluate whether the presence of HMCAS predicts the outcome of AIS patients receiving combination therapy with IAMT and IVT. Methods We retrospectively reviewed medical records and cerebrovascular images of the patients treated with IAMT and IVT for AIS in our center. Patients with occlusion in the terminal internal carotid artery or middle cerebral artery on pretreatment CT angiogram of the head were included. Clinical outcome was compared between subjects with HMCAS and those without. Modified Rankin Score (mRS) and symptomatic intracranial hemorrhage (sICH) were used as measures of efficacy and safety, respectively. Results Of 93 patients, 46 (49%) had HMCAS on their initial head CT scan. Both groups had comparable baseline characteristics and stroke severity. After adjusting for age, NIHSS score, time from symptom onset to starting IVT, and history of diabetes mellitus in multivariate logistic regression analysis, there was no difference in terms of a poor outcome (mRS >2) (OR = 0.5 [CI 0.2–1.4], p = 0.188) or rate of sICH (OR = 3.3 [CI 0.6–19.0], p = 0.190) between the two groups. Conclusions HMCAS is not a predictor of poor outcome in AIS patients receiving combination therapy with IAMT and IVT and does not affect treatment safety.

Introduction Atrial remodeling due to high-burden atrial fibrillation (AF) is associated with cardioembolic stroke (CES). As not all CESs is caused by AF, we analyzed the diagnostic values of each echocardiographic parameter to distinguish likely AF-related CES in acute stroke patients while in non-AF rhythm. Methods The data of consecutive patients with acute ischemic stroke in sinus rhythm between 2012 and 2015 were obtained. The echocardiographic parameters of patients with CES due to underlying AF (n = 61) and control patients (n = 319) with either large artery atherosclerosis or small-vessel occlusion were compared using receiver operating characteristic curves and logistic regression analyses. Each parameter was reassessed in acute stroke patients through a validation study using the same database with different periods of generalization. Results CES patients with underlying AF showed a significantly larger left atrial volume index (LAVi), higher mitral inflow E wave (E), and lower A wave (A) than the controls. The area under the curve (AUC) (95% confidence interval) for diagnosing CES due to underlying AF was significantly higher for LAVi/A than for LAVi (0.785 versus 0.696, P 60 years, the E/A ratio had the highest AUC (0.857) of the parameters. The cut-off values were ≥ 0.70 (sensitivity, 55.7%; specificity, 90.9%) and ≥ 0.82 (sensitivity, 71.4%; specificity, 84.1%) for LAVi/A and the E/A ratio, respectively, in patients >60 years. The cut-off values of all parameters showed similar trends in a validation study. Conclusion LAVi/A is a useful indicator for distinguishing CES patients with underlying AF regardless of age, and the E/A ratio is reliable among patients aged >60 years in evaluation during acute stroke admission.

Introduction Delayed cerebral ischemia (DCI) is a common complication after aneurysmal subarachnoid hemorrhage (aSAH) that can culminate in secondary brain damage. Although it remains one of the main preventable causes of aSAH-related morbidity, there is still a lack of prognostic criteria for identification of patients at risk of developing DCI. Because elevated circulatory levels of the enzyme dipeptidyl peptidase 3 (cDPP3) were recently identified as a potential biomarker for outcome prediction in critically ill patients, we evaluated the time-course of changes in cDPP3 levels after aSAH. Materials and methods cDPP3 levels were quantified in serum obtained from 96 confirmed aSAH patients during the early (EP: d1–4), critical (CP: d5–8, d9–12, d13–15) and late (LP: d16–21) phase after aSAH onset. Associations between cDPP3 levels and demographic or clinical parameters were evaluated. The relations between cDPP3 levels and DCI, DCI-related infarctions and long-term clinical outcomes were examined by receiver operating characteristics (ROC) curve analysis and multivariate logistic regression. Results Significantly higher cDPP3 levels during CP (d5–8, d9–12, d13–15) were observed in patients with poor clinical (p Conclusion Our results provide first evidence that cDPP3 could serve as a promising biomarker for early diagnosis of DCI-related infarctions in poor grade aSAH patients.

Diffusion weighted imaging (DWI) is a widely used imaging technique to evaluate patients with stroke. It can detect brain ischemia within minutes of stroke onset. However, DWI has few potential pitfalls that should be recognized during interpretation. DWI lesion could be reversible in the early hours of stroke and the entire lesion may not represent ischemic core. False negative DWI could lead to diagnosis of DWI negative stroke or to a missed stroke diagnosis. Ischemic stroke mimics can occur on DWI with non-cerebrovascular neurological conditions. In this article, the history of DWI, its clinical applications, and potential pitfalls for use in acute ischemic stroke are reviewed. Advanced diffusion imaging techniques with reference to Diffusion Kurtosis Imaging and Diffusion Tensor Imaging that has been studied to evaluate ischemic core are discussed.

Background: Although delayed cerebral ischemia (DCI) commonly complicates recovery in survivors of aneurysmal subarachnoid hemorrhage (aSAH), its pathophysiology is incompletely understood. Previous studies examining the association of DCI and platelet count have demonstrated contradictory results. This study aimed to investigate this association in a cohort of aSAH patients using the 2010 consensus definition of DCI. Methods: We conducted a retrospective single-center observational study of consecutive adult aSAH patients admitted to the intensive care unit from January 2010 to December 2014. Platelet count and DCI evaluations were performed daily in the first 14 days after admission. DCI was defined according to the 2010 consensus criteria. Results: A total of 340 patients were included for analysis. DCI incidence was 37.1%. Platelet count was not significantly associated with occurrence of DCI on any day. Mean platelet count was lowest on day 3 after aSAH and then increased to exceed the count at admission on day 6. Treatment modality and use of dual antiplatelet therapy were not associated with DCI. Conclusions: Platelet count was not associated with DCI as defined by the 2010 consensus criteria. Future studies adhering to the 2010 consensus definition of DCI are needed to clarify the role of platelets and platelet function in DCI pathophysiology. publishedVersion

Cerebral edema (CED) is a common complication of ischemic stroke in Intensive Care Unit. Although frequently observed in patients undergoing intravenous thrombolytic (IVT) treatment, the pathogenic role of recombinant tissue plasminogen activator (rtPA) in CED induction has not yet been definitively clarified. The aim of our study is to verify the relationship between CED and rtPA in patients affected by acute ischemic stroke, without reperfusion signs, evaluating the CED growth rate in the first week after stroke onset. In this single-center, retrospective observational study, we included all consecutive patients with acute stroke undergone multi-parameter monitoring of vital signs in the sub-intensive care Unit. We included both patients undergoing systemic IVT and standard medical treatment (n-IVT) with the following time of CT scan: within 4.5 h onset, 24 ± 12 h, 72 ± 24 h and 120 ± 24 h from the stroke onset. Of 1753 with acute ischemic stroke patients screened, 810 patients were included in the study (218 IVT and 592 n-IVT). No significant difference was observed at baseline in age, gender, NIHSS score or infarcted area, while hemorrhagic transformation rate was significantly higher in IVT than in n-IVT group. We observed a significant increase of CED growth rate in IVT patients compared to n-IVT patients only between 24 and 72 h from the ischemic event (respectively 1.85cm

Data regarding repeated reperfusion therapy (rRT) in acute ischemic stroke (AIS), including intravenous thrombolysis and endovascular treatment (EVT), are quite poor. To date, there are only few case reports and five larger studies on repeated EVT. We aimed to report our single-center experience and describe different clinical scenarios of recurrent AIS with emergent large vessel occlusion (LVO), for which the decision-making process could be challenging in the emergency setting. We retrospectively reviewed 765 consecutive AIS patients with LVO, who underwent reperfusion procedures at our comprehensive stroke center, from 2014 to 2020, and identified rRT patients. We identified and reviewed the medical records of eight patients (1.05%), who repeated reperfusive treatment for recurrent stroke within 30 days (early arterial reocclusion, EAR) and after 30 days (late arterial reocclusion, LAR). We assigned collected data to three clinical scenarios, each divided into EAR and LAR cases. All patients had recurrent emergent LVO in the same vessel territory previously affected, both in EAR and LAR patients. A good clinical outcome has been achieved in EAR patients (modified Rankin Score ≤ 2). Artery-to-artery embolic mechanism was more common in the EAR group, while LAR was more frequently associated with cardioembolic source. RRT appears to be an effective treatment option for recurrent LVO, and it should not be withheld in carefully selected patients. EVT should be considered, including aspiration-only and stenting procedures in patients with AIS and recurrent LVO after previous reperfusive treatments, even after a very short time.

INTRODUCTION: Posterior circulation strokes (PCS) have been less extensively studied than anterior circulation strokes (ACS), especially regarding revascularization therapies. We analyzed the differences in baseline stroke characteristics, revascularization therapy and 3-month outcomes between PCS and ACS in a large prospective multicentre Indian stroke registry. METHODS: Patients with acute ischemic stroke recruited in the Indo-US collaborative stroke project from January 2012 to August 2014 were classified into PCS and ACS based on imaging-confirmed infarct location. Demographics, stroke severity, risk factors, and mechanisms were compared. We further compared these parameters in the subgroups who received revascularization therapies (RT) and no revascularization therapies (NRT). The primary outcome was 3-month modified Rankin scale (mRS). RESULTS: Of 1889 patients (1270 males), 1478 (78.2%) had ACS and 411 (21.8%) PCS. The median NIHSS was lower in PCS (7 vs 11, p

Abtract Background Posterior reversible encephalopathy syndrome (PRES) is associated with arterial hypertension. Our aim was to investigate whether induced hypertension (IH) as therapy for delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH) is associated with PRES and to identify risk factors for PRES. Material and methods We retrospectively searched our database for patients with SAH and IH in our institution between 2009 and 2018 and identified additional cases of PRES after SAH with IH from the literature. We then analyzed demographic findings and clinical features of these patients. Results 172 patients with acute SAH received IH. PRES was diagnosed in 3/172 (1.7%) patients. Our literature search revealed 17 additional cases. The pooled PRES group (n = 20) was non-significantly older than the non-PRES group (n = 169) (median, 62.5 years vs. 52 years, p = 0.06). No significant differences were found between both groups with regard to sex (p = 0.73), Hunt & Hess-Score (p = 0.9), aneurysm treatment (p = 0.13), and time from diagnosis of SAH to the start of IH (p = 0.14). Conclusions PRES after IH in SAH patients occurred in 1.7% of our patients. Our results imply that it is important to be aware of a possible development of a PRES in older SAH patients with IH, irrespective of sex, initial clinical status, and treatment modality.

Laboratory factors associated with hemorrhagic conversion (HC) after Intravenous thrombolysis with rtPA (IVT) for Acute Ischemic Stroke (AIS) remain nebulous despite advances in our knowledge of AIS. This study aimed to investigate the laboratory factors predisposing to HC in AIS patients receiving IVT.We retrospectively reviewed the medical records of patients who received IV tPA for AIS at our comprehensive stroke center over a 9.6-year period. Besides age, gender, NIHSS, history of diabetes mellitus (DM), history of atrial fibrillation (Afib), we gathered their laboratory data including International Normalized Ratio (INR), lipid panel, serum albumin, serum creatinine, hemoglobin A1c (HbA1c), and admission blood glucose. Post-thrombolysis brain imagings were reviewed to evaluate for symptomatic ICH (sICH). The mean values of above mentioned laboratory data were compared between the group with sICH and patients with no sICH. Univariate and multivariate logistic regression were performed to evaluate the association of the laboratory findings with presence of sICH. sICH was defined as ICH causing an increase in NIHSS ≥4.Of the 794 subjects in this study 51 (6.4%) had sICH. In the univariate analysis, patients who developed sICH had significantly higher NIHSS on admission (14.2 ± 5.4 vs 11.2 ± 6.5, p .001), LDL-cholesterol (113.3 mg/dl ±36.9 vs. 101.8 mg/dl ± 38.2, p = .032), HbA1c (6.9% ± 2.3 vs. 6.1 ± 1.3, p = .003) and lower levels of Albumin (3.5 g/dl ±0.4 vs. 3.9 g/dl ± 0.5, p .001). Furthermore, a higher prevalence of history of DM (45% vs. 21.6%, p = .020) and Afib (25.4% vs. 10.4%, p = .028) was found in subjects who developed sICH. There were no significant group differences regarding age, sex, total cholesterol, blood glucose on admission, serum creatinine or INR levels (p .05). After adjusting for multiple covariates, lower Albumin level and and higher HbA1c were significantly associated with an increased risk for sICH development (p .05). Chances of sICH increased by 33% for every 1 g/dl below a normal albumin level of 4.0 g/dl (p .05).Lower endogenous albumin level and higher HbA1c have shown to predispose to a higher risk of sICH after IVT for AIS and might be good predictors of sICH post IVT.

Background Inflammation is emerging as an essential trigger for thrombosis. In the interplay between innate immunity and coagulation cascade, neutrophils and neutrophil extracellular traps (NETs) can promote thrombus formation and stabilization. In ischemic stroke, it is uncertain whether the involvement of the inflammatory component may differ in thrombi of diverse etiology. We here aimed to evaluate the presence of neutrophils and NETs in cerebral thrombi of diverse etiology retrieved by endovascular thrombectomy (EVT). Methods We performed a systematic histological analysis on 80 human cerebral thrombi retrieved through EVT in acute ischemic stroke patients. Thrombus composition was investigated in terms of neutrophils (MPO+ cells) and NET content (citH3+ area), employing specific immunostainings. NET plasma content was determined and compared to NET density in the thrombus. Results Neutrophils and NETs were heterogeneously represented within all cerebral thrombi. Thrombi of diverse etiology did not display a statistically significant difference in the number of neutrophils (p = 0.51). However, NET content was significantly increased in cardioembolic compared to large artery atherosclerosis thrombi (p = 0.04), and the association between NET content and stroke etiology remained significant after adjusted analysis (beta coefficient = −6.19, 95%CI = −11.69 to −1.34, p = 0.01). Moreover, NET content in the thrombus was found to correlate with NET content in the plasma (p ≤ 0.001, r = 0.62). Conclusion Our study highlights how the analysis of the immune component within the cerebral thrombus, and specifically the NET burden, might provide additional insight for differentiating stroke from diverse etiologies.

Background and purpose Delayed cerebral ischemia (DCI) complicates the recovery of approximately 30% of patients with aneurysmal subarachnoid hemorrhage (aSAH). The definition of DCI widely varies, even though a consensus definition has been recommended since 2010. This study aimed to evaluate the prognostic value of the 2010 consensus definition of DCI in a cohort of patients with aSAH. Methods We conducted a single-center, retrospective, observational study that included consecutive adult patients with aSAH who were admitted to the intensive care unit from January 2010 to December 2014. DCI was evaluated 48 h to 14 days after onset of aSAH symptoms using the 2010 consensus criteria and outcome was assessed by the Glasgow Outcome Scale (GOS) at discharge from hospital. Results A total of 340 patients were analyzed and the incidence of DCI was 37.1%. The median time from primary hemorrhage to the occurrence of DCI was 97 h. Neurological deterioration was observed in most (89.7%) of the patients who fulfilled the DCI criteria. The occurrence of DCI was strongly associated with an unfavorable outcome (GOS 1–3) at hospital discharge (OR 2.65, 95% CI 1.69–4.22, p Conclusions The incidence of DCI after aSAH is high and its occurrence is strongly associated with an unfavorable neurological outcome. This finding adds to the previous literature, which has shown that DCI appears to be a major contributor affecting the functional ability of survivors of aSAH. To further advance reliable knowledge of DCI, future studies should adhere to the consensus definition of DCI.

Apraxia of eyelid opening (AEO) refers to impaired voluntary eyelid elevation of supranuclear origin. AEO is well-described in neurodegenerative disorders, but its frequency in stroke is unknown.To investigate the frequency of AEO after stroke, we enrolled patients with an anterior circulation occlusion admitted for endovascular thrombectomy (EVT). Exclusion criteria were posterior circulation stroke, impaired consciousness and ophthalmological disorders. Forty-eight hours after EVT, patients were screened for AEO, conjugated gaze palsies and cortical ptosis. Neurological deficits were classified using the National Institute of Health Stroke Scale (NIHSS). A blinded neuroradiologist analyzed CT brain 24 h after EVT using the Alberta Stroke Program Early CT Score.Ninety-eight EVT patients were included in 9 months. Six patients had AEO (6%), 37 conjugated gaze palsy (38%) and 16% cortical ptosis (16%). AEO was associated with higher median NIHSS compared to no eye symptoms (18.5 vs. 3; p 0.001) and gaze palsy or cortical ptosis (18.5 vs. 7; p = 0.003). The median modified Rankin Scale (mRS) after 3 months was 2 in patients without AEO, but 6 in patients with AEO (mRS in AEO patients nr. 1-6: 3, 4, 6, 6, 6, and 6; p = 0.015; no longer significant after adjustment for stroke severity), including 4 deaths (66%) in AEO patients. All patients with AEO had right hemisphere stroke (6/6 vs. 43/98 in total, p = 0.006).AEO was observed in 6% of EVT patients who showed poor survival and outcome. AEO occurred exclusively in right hemispheric infarctions, suggesting that supranuclear eyelid control is under the influence of the right cerebral hemisphere.

Introduction The association of malnutrition on stroke subtypes has not been well established. We investigated the relationship between malnutrition and functional outcome according to stroke subtypes. Methods Acute consecutive ischemic stroke patients (n = 1915, 73 ± 12 years) were analysed. The nutritional status was evaluated using the Controlling Nutritional Status (CONUT) score, which was calculated from the serum albumin level, lymphocyte count, and total cholesterol level; malnutrition was defined as a CONUT score of 5 to 12. A poor outcome was defined as a modified Rankin Scale score ≥ 3 at 3 months. Results Of the 1518 patients, 113 (7.4%) had malnutrition, and 533 (33.1%) had a poor outcome. Among the patients with cardioembolic stroke and stroke of other etiologies, those with malnutrition had higher rates of poor outcomes than those without. After adjusting for age, sex, and baseline stroke severity, malnutrition was independently associated with poor outcomes in patients with cardioembolic stroke and other stroke etiologies (odds ratio 3.25, 95% confidence interval 1.02–10.4, p = .044; 6.22, 2.71–14.3, p Conclusions Considering stroke subtype, malnutrition determined using the CONUT score was independently associated with poor outcomes in the patients with cardioembolic stroke or stroke of other etiologies.

To examine 1) the major drivers of index hospitalization and 3-year post-acute follow-up care, 2) cost for rehabilitation and homecare, and 3) indirect cost from lost productivity after acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH).Retrospective study of adults hospitalized with AIS (n = 811) and ICH (N = 145) between 2003 and 2014. Direct costs standardized to Medicare reimbursement rates were captured for hospitalization and 3-year follow-up or death. Adjusted cost estimates were assessed using generalized linear modeling with gamma distribution. Costs for rehabilitation, home healthcare, and lost productivity were assessed using sets of cost captured through literature review.Calculated as mean cost per person: hospitalization $18,154 for AIS and $24,077 for ICH; monthly 3-year aggregate $5138 for AIS and $8172 for ICH; 3-year inpatient rehabilitation $4185 for AIS and $4196 for ICH; homecare $19,728 for AIS and $14,487 for ICH; indirect cost from lost productivity $77,078 for AIS and $56,601 for ICH. Age 55 years, being non-white, and stroke severity were strongly associated with greater hospitalization cost for AIS and ICH. Hyperlipidemia incurred lower while cancer, coronary artery disease, asthma/chronic obstructive pulmonary disease, heart failure, and anemia incurred higher 3-year aggregate cost for AIS. Cancer and diabetes mellitus incurred higher 3-year aggregate cost for ICH.We provide estimates of direct and indirect costs incurred for acute and continuing post-acute care through a 3-year follow-up period after first-ever AIS and ICH with important comparisons for predictors between index hospitalization and 3-year post-stroke costs.

Healthy brain tissue pulsates with the cardiac cycle, but whether brain tissue pulsations (BTPs) are impaired by tissue ischemia due to ischemic stroke is currently unclear. This study is the first to explore the clinical potential of measuring BTPs using ultrasound in acute ischemic stroke patients. BTPs were measured in 24 healthy volunteers (aged 52–82 years) and 14 acute ischemic stroke patients (aged 51–86 years) using a novel Transcranial Tissue Doppler (TCTD) method. Measurements were quick to perform and were well tolerated by all subjects. A mixed-methods approach was used for blinded analysis of recordings. This identified qualitative disruption of BTPs in acute stroke patients, which were used to create an analysis checklist. Blinded BTP analysis by novices using the checklist resulted in high sensitivity but low specificity for stroke detection. Quantitative analysis also identified differences between stroke and healthy participants, including weaker BTPs in stroke patients. This first study reporting BTP characteristics in acute ischemic stroke revealed weaker brain tissue pulsations and waveform disruption in acute stroke patients. However, further clinical evaluation using a larger sample size is required to confirm these findings and to explore whether TCTD monitoring might be beneficial for clinical neuromonitoring.

Elderly cryptogenic ischemic stroke (IS) patients with embolic stroke of undetermined source (ESUS) have a high risk of recurrent IS (RIS) compared to other stroke subtypes. In young ESUS patients, different sources of embolism may be a cause and the risk of RIS remains not enough established. The aim was to assess and compare risk of RIS between ESUS and non ESUS patients50 years.The study set consisted of young acute IS patients50 years enrolled in the prospective HISTORY (Heart and Ischemic STrOke Relationship studY) study registered on ClinicalTrials.gov (NCT01541163). In all analyzed patients, the brain ischemia was confirmed on CT or MRI. All patients underwent identical diagnostic protocol including TEE and long-term ECG-Holter. Cause of IS was assessed according to the ASCOD classification.Of 320 enrolled patients50 years, 219 (68.4%) were identified as cryptogenic (119 males, mean age 41.4 ± 7.2 years) and 122 (38.1%) patients fulfilled the ESUS criteria. During the follow-up with a median of 34 months, three (2.5%) ESUS and 5 (5.2%) non-ESUS patients suffered from RIS (p = .471). One-year risk of RIS was 0.008 (95% CI: 0-0.025) for ESUS and 0.036 (95% CI: 0-0.076) for non-ESUS patients (p = .262).The risk of RIS was very low in ESUS patients and did not differ from those with non-ESUS. Our finding may indicate that antiplatelet therapy can be effective in the secondary prevention in young ESUS patients if high-risk sources of embolization are excluded extensively.

Background and Purpose: We evaluated optimal transcranial Doppler (TCD) measures for predicting delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). Material and Methods: Consecutive patients with aSAH and daily middle cerebral artery (MCA) TCD recordings were retrospectively analyzed. Change in TCD velocity was obtained by creating a smoothing curve. Change in TCD velocity was determined with a linear regression model that confirmed greatest change in velocity associated with DCI occurred at days 2–7. Multivariate logistic regression analysis was then completed. Results: 95 patients were evaluated. Increase in TCD velocity at days 2–7 proved to be the best predictor for DCI with an optimal cutoff of 8.9 cm/s/day (p = .019) and AUC 0.651. Multivariate logistic regression analysis using DCI as outcome showed that poor admission Hunt-Hess scores (OR 5.02, 95%CI 1.22–22.67, p = .028) and increases in TCD velocity (OR 5.32, 95%CI 1.41–23.33, p = .018) were independently associated with DCI. Conclusions: We found that relative increases in TCD velocities in the MCAs during the first 7 days (with a threshold increase of 53.4 cm/s from days 2 to 7) after aSAH admission were independently associated with DCI. This association requires independent confirmation.