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Purpose: Identifying current practices in acute stroke imaging is essential for establishing optimal imaging protocols. We surveyed and assessed the current status of acute stroke imaging for endovascular thrombectomy (EVT) at tertiary hospitals throughout South Korea.Materials and Methods: An electronic questionnaire on imaging protocols for EVT in patients with acute ischemic stroke was e-mailed to physicians at 42 registered tertiary hospitals, and their responses were collected between February and March 2020.Results: Of the 36 hospitals participating in the survey, 69% (25/36) adopted computed tomography (CT)-based protocols, whereas 31% (11/36) adopted magnetic resonance (MR)-based protocols. Non-enhanced CT (NECT) was the initial imaging study at 28%, NECT with CT angiography (CTA) at 36%, and NECT with CTA and CT perfusion (CTP) at 33% of hospitals. Perfusion imaging was performed at 61% (22/36), CTP at 44% (16/36), and MR perfusion at 17% (6/36) of hospitals. Multiphase CTA was performed at 67%, single-phase CTA at 11%, time-of-flight MR angiography (MRA) at 8%, contrast-enhanced MRA at 8%, and both at 6% of hospitals. For late time window stroke, 50% of hospitals used identical imaging protocols to those for early time window stroke, 39% used additional MR imaging (MRI), and 6% converted the imaging strategy from CT to MRI. Post-processing programs were used at 28% (10/36), and RAPID software at 14% (5/36) of hospitals, respectively. Most hospitals (92%) used the same imaging protocols for posterior and anterior circulation strokes.Conclusion: Our multicenter survey demonstrated considerable heterogeneity in acute stroke imaging protocols across South Korean tertiary hospitals, suggesting that hospitals refine their imaging protocols according to hospital-specific conditions.

Purpose: Red blood cell distribution width (RDW) evaluates the variation (size heterogeneity) in red blood cells. Elevated RDW has been identified as a predictor of poor functional outcomes for acute ischemic stroke. The association between elevated RDW level and poor functional outcome in stroke patients undergoing mechanical thrombectomy has not been reported before. This study aims to investigate this relationship.Materials and Methods: This was a multicenter retrospective study involving the prospectively and consecutively collected data of 205 adult stroke patients who underwent mechanical thrombectomy for anterior circulation large vessel occlusion (middle cerebral artery M1, anterior cerebral artery A1, tandem ICA-MCA, carotid T) between July 2017 and December 2019. RDW cut off levels were accepted as >16%. The effect of elevated RDW on poor functional outcome (modified Rankin scale 3–6) was investigated using bivariate and multivariate regression analysis.Results: Elevated RDW was significantly associated with poor functional outcome in bivariate and multivariate analysis (odds ratio [OR] for RDW >16%, 2.078; 95% confidence interval [95% CI], 1.083–3.966; P=0.027 and OR for RDW >16%, 2.873; 95% CI, 1.342–6.151; P=0.007; respectively).Conclusion: These findings suggest that elevated RDW may be an independent predictor of poor functional outcomes in ischemic stroke patients undergoing mechanical thrombectomy.

Background: Use of non-vitamin K antagonist oral anticoagulants (NOACs) for stroke prevention in non-valvular atrial fibrillation (NVAF) is common and significantly reduces stroke occurrence. Yet little is known about patients who have a stroke despite treatment. Objective: The aim of this work was to study the epidemiology of patients with stroke despite being treated with NOACs. Methods: We identified a cohort of patients with NVAF admitted to the United Christian Hospital for acute ischemic stroke (AIS) or transient ischemic attack (TIA) while on NOACs. The baseline characteristics, type of NOAC, compliance, duration of use, and dosage were reviewed. Results: Of 2,090 patients admitted for AIS/TIA from 2012 to 2019, 143 were on NOACs before the index episode. After excluding patients with non-compliance and incomplete data, 109 patients were included in the analysis; 65.1% were female and 79.8% were never smokers, with a mean age of 78 years. The mean CHA2DS2-VASc score was 5; 83.5% had hypertension, 59.3% had hyperlipidemia, and 30.3% had diabetes mellitus. Overall, 52.9% presented with lacunar syndrome, suggesting an atherosclerotic cause of stroke. However, their risk factor control was unexpectedly good; none had HbA1c >7% and only 23.9% had a low-density lipoprotein cholesterol level higher than 2.6 mmol/L. Conclusions: Stroke developed in NVAF patients despite being on NOACs, with the majority being female, older, and hypertensive. Surprisingly, in general they had reasonable lipid and diabetic control.

Background: Sleep is a complex process involving the interactions of several brain regions, which play a key role in regulating the sleep process, particularly the brainstem, thalamus, and anterior basal brain regions. The process of sleep is accompanied by a change in body functions, as well as a change in cerebral electrical activity, which is under the control of the autonomic nervous system. Objective: The aim of the study was to analyze the frequency of stroke recurrence and disability of patients with stroke and apnea. Methods: It was analyzed 110 acute stroke patients with sleep apnea. All patients were evaluated with: Glasgow scale, The American National Institutes of Health Scale Assessment, Mini Mental Test, The Sleep and snoring Questionnaire Test, The Berlin Questionnaire Test, The Epworth Sleepiness Scale, The Stanford Sleepiness Scale, and The general sleep questionnaire. Results: The largest number of patients with apnea on admission had a degree of disability of 4, and on discharge of 1. There was a statistically significant difference between the mean values of incapacity for admission and discharge. The student’s t - test did not determine a statistically significant difference in disability according to the Rankin scale between patients with and without apnea at admission (t = 0.059, p = 0.95) and discharge (t = 0.71, p = 0.48). According to the NIHS scale, patients of both sexes with apnea had a neurological deficit of 7.55 ± 5.22 on admission and 7.1 ± 4.3 without apnea. Statistically significant difference was not found on the neurological deficit of both sexes, with and without apnea, at admission and discharge. With apnea, there were 13 relapses of stroke during one year, and without apnea in only 3 patients. Conclusion: Patients with acute stroke have a significantly higher correlation rate according to sleep apnea. There is no significant correlation in the degree of disability between patients with and without apnea.

Aims: To investigate the potential mechanism of ventricular arrhythmias (VAs) after acute ischemic stroke and explore the effects of left stellate gangling (LSG) ablation on VAs induced by stroke in canines. Materials and Methods: Twenty canines were randomly divided into the sham-operated group (n=6), AS group (n=7) and SGA group (n=7). Cerebral ischemic model was established in the AS group and the SGA group by right acute middle cerebral artery occlusion (MCAO). LSG ablation was performed in the SGA group as soon as MCAO. After 3 days, atrial electrophysiology and neural activity were measured in vivo. The levels of norepinephrine (NE) in plasma and ventricle were detected by ELISA. The levels of monocyte chemotactic protein-1 (MCP-1), tumor necrosis factor-α (TNF-α) and NF-κB p65 in ventricle were detected by western blotting. The pro-inflammatory polarization of macrophages in ventricle was detected by immunofluorescence. Results: Higher ventricular tachycardia (VT) inducibility and lower ventricular fibrillation threshold (VFT) were observed in the AS group compared with those in the sham-operated group, associated with higher LSG activity and NE levels, increased number of M1 macrophages and secretion of inflammatory cytokines in ventricle (all P

Background: Measurement of optic nerve sheath diameter (ONSD) by means of ocular ultrasound (US), can diagnose elevated intracranial pressure (ICP). Stroke accompanied by elevated ICP might have a worse prognosis. Objective: To determine the relationship of ONSD in ocular US with prognosis in acute stroke in the emergency department (ED). Methods: Patients with acute presentations of stroke, presenting to the ED in 2017 (during six months), were enrolled in our study. US exam was performed on all of them and ONSD was determined in two longitudinal and transverse dimensions. Demographic data, rate of patients' admission in the ward or intensive care unit, one-month patients’ outcome and type of stroke were recorded. The relationship of mean ONSD was evaluated with study variables. Results: In this study, 60 patients were enrolled. The mean ± SD ONSD in the deceased cases was 4.40 ± 0.64 mm and in the survived patients was 3.83 ± 0.56 mm. Youden index calculated ONSD>3.9 mm as the best cut-off point in mortality prognosis. It has a sensitivity of 83.3% and a specificity of 59.2%. Conclusions: Increased ONSD had a direct relationship with mortality rate in acute stroke. Keywords: Stroke, Optic nerve sheath diameter, Prognosis, Ultrasound

BackgroundIn 2010, Greater Manchester (GM) and London centralized acute stroke care services into a reduced number of hyperacute stroke units, with local stroke units providing on‐going care nearer patients’ homes.ObjectiveTo explore the impact of centralized acute stroke care pathways on the experiences of patients.DesignQualitative interview study. Thematic analysis was undertaken, using deductive and inductive approaches. Final data analysis explored themes related to five chronological phases of the centralized stroke care pathway.Setting and participantsRecruitment from 3 hospitals in GM (15 stroke patients/8 family members) and 4 in London (21 stroke patients/9 family members).ResultsParticipants were impressed with emergency services and initial reception at hospital: disquiet about travelling further than a local hospital was allayed by clear explanations. Participants knew who was treating them and were involved in decisions. Difficulties for families visiting hospitals a distance from home were raised. Repatriation to local hospitals was not always timely, but no detrimental effects were reported. Discharge to the community was viewed less positively.Discussion and conclusionsPatients on the centralized acute stroke care pathways reported many positive aspects of care: the centralization of care pathways can offer patients a good experience. Disadvantages of travelling further were perceived to be outweighed by the opportunity to receive the best quality care. This study highlights the necessity for all staff on a centralized care pathway to provide clear and accessible information to patients, in order to maximize their experience of care.

Background and Purpose: Subject retention into clinical trials is vital, and prehospital enrollment may be associated with higher rates of subject withdrawal than more traditional methods of enrollment. We describe rates of subject retention in a prehospital trial of acute stroke therapy. Methods: All subjects were enrolled into the NIH Field Administration of Stroke Therapy-Magnesium (FAST-MAG) phase 3 clinical trial. Paramedics screened eligible subjects and contacted the physician-investigator using a dedicated in-ambulance cellular phone. Physician-investigators obtained explicit informed consent from the subject or on-scene legally authorized representative (LAR) who reviewed and signed a consent form. Exception from informed consent (EFIC) was utilized in later stages of the study. Results: There were 1,700 subjects enrolled; 1,017 provided consent (60%), 662 were enrolled via LAR (39%), and 21 were enrolled via EFIC (1%). Of the 1,700 patients, 1,413 (83%) completed the 90-day visit, 265 (16%) died prior to the 90-day visit, and 22 (1.3%) withdrew from the study before completion. There were no differences in rates of withdrawal by method of study enrolment, i.e., self-consent (n = 14), 1.4%; LAR (n = 8), 1.2%; EFIC (n = 0) 0%. Conclusion: There was a high rate of retention when subjects were enrolled into prehospital stroke research using a phone-based method to obtain explicit consent.

Acute ischemic stroke (AIS) is a major public health problem in China. Impaired angiogenesis plays crucial roles in the development of ischemic cerebral injury. Recent studies have identified that microRNAs (miRNAs) are important regulators of angiogenesis, but little is known the exact effects of angiogenesis-associated miRNAs in AIS. In the present study, we detected the expression levels of angiogenesis-associated miRNAs in AIS patients, middle cerebral artery occlusion (MCAO) rats, and oxygen-glucose deprivation/reoxygenation (OGD/R) human umbilical vein endothelial cells (HUVECs). MiR-191 was increased in the plasma of AIS patients, OGD/R HUVECs, and the plasma and brain of MCAO rats. Over-expression of miR-191 promoted apoptosis, but reduced the proliferation, migration, tube-forming and spheroid sprouting activity in HUVECs OGD/R model. Mechanically, vascular endothelial zinc finger 1 (VEZF1) was identified as the direct target of miR-191, and could be regulated by miR-191 at post-translational level. In vivo studies applying miR-191 antagomir demonstrated that inhibition of miR-191 reduced infarction volume in MCAO rats. In conclusion, our data reveal a novel role of miR-191 in promoting ischemic brain injury through inhibiting angiogenesis via targeting VEZF1. Therefore, miR-191 may serve as a biomarker or a therapeutic target for AIS.

Computed tomography angiography (CTA) collateral scoring can identify patients most likely to benefit from mechanical thrombectomy and those more likely to have good outcomes and ranges from 0 (no collaterals) to 3 (complete collaterals). In this study, we used a machine learning approach to categorise the degree of collateral flow in 98 patients who were eligible for mechanical thrombectomy and generate an e-CTA collateral score (CTA-CS) for each patient (e-STROKE SUITE, Brainomix Ltd., Oxford, UK). Three experienced neuroradiologists (NRs) independently estimated the CTA-CS, first without and then with knowledge of the e-CTA output, before finally agreeing on a consensus score. Addition of the e-CTA improved the intraclass correlation coefficient (ICC) between NRs from 0.58 (0.46–0.67) to 0.77 (0.66–0.85, p = 0.003). Automated e-CTA, without NR input, agreed with the consensus score in 90% of scans with the remaining 10% within 1 point of the consensus (ICC 0.93, 0.90–0.95). Sensitivity and specificity for identifying favourable collateral flow (collateral score 2–3) were 0.99 (0.93–1.00) and 0.94 (0.70–1.00), respectively. e-CTA correlated with the Alberta Stroke Programme Early CT Score (Spearman correlation 0.46, p < 0.001) highlighting the value of good collateral flow in maintaining tissue viability prior to reperfusion. In conclusion, ­e-CTA provides a real-time and fully automated approach to collateral scoring with the potential to improve consistency of image interpretation and to independently quantify collateral scores even without expert rater input.

Purpose: According to guidelines, to shorten the treatment window, acute ischaemic stroke (AIS) treatment by intravenous thrombolysis (IVT) can be done based on the results of head computed tomography (CT) without contrast. The impact of large vessel occlusion (LVO) on computed tomography angiography (CTA) in stroke prognosis in patients treated IVT or IVT and mechanical thrombectomy (MT), where indicated, has not yet been studied systematically. We investigated the influence of LVO in consecutive AIS patients on haemorrhagic transformation (HT) on CT 24 h after treatment, mRS < 2 on discharge (unfavourable outcome), and in-hospital mortality. Material and methods: We analysed several parameters within 24 h after AIS: demographics, risk factors, mRS score pre-stroke, NIHSS upon admission and 24 h later, several clinical and biochemical parameters, and chronic treatment. Results: We registered 1209 patients, of whom 362 (29.9%) received IVT and 108 had MT, where indicated. Admission CTA showed LVO in 197 patients (54.4%). Multivariate regression analysis showed that the presence of LVO and lower delta NIHSS (NIHSS on admission minus NIHSS 24 hours later) were independent parameters affecting HT risk. Multivariate analysis showed that the presence LVO and also older age, female sex, lower delta NIHSS, HT, stroke-associated infection, CRP levels ≥ 10 mg/L, and higher WBC count affected unfavourable outcome on discharge. LVO did not affect in-hospital mortality. Conclusions: LVO in AIS patients treated by IVT or IVT and MT affects the risk of HT and unfavourable short-term outcome but not in-hospital mortality.

Purpose: In acute middle cerebral artery (MCA) occlusion, collateral vessels provide retrograde supply to the occluded territory. We hypothesized that such collateral flow reduces perfusion of the non-occluded donor region (steal effect).Materials and Methods: Patients with an MCA occlusion with opacification of both ipsi- and contralateral anterior cerebral arteries (ACA) on angiography prior to endovascular treatment were selected. Arteriovenous transit time (AVTT) for both ACA territories was compared for different grades of collateral supply to the MCA territory. In addition, the influence of diabetes and hypertension was analyzed. After successful revascularization, AVTT was re-assessed to determine reversibility.Results: Forty-one patients were analyzed. An AVTT of 8.6 seconds (standard deviation [SD] 2.4 seconds) was seen in the ACA territory of the affected hemisphere in comparison to 6.6 seconds (SD 2.1 seconds) for the contralateral side (P

Background: Application of direct aspiration catheters has revolutionized acute stroke care and has led to significant improvement in clinical outcome with a good safety profile. Catheter fracture and retention is a rare but potentially devastating complication. Case Description: Here we present two cases of acute stroke complicated by aspiration catheter fracture and retention. Successful catheter retrieval and revascularization was achieved in both cases. The stenosis or tortuosity of vascular anatomy appears to be the probable contributor to catheter breakage by anchoring the catheter with resultant fracture at the constraint point from catheter withdrawal tensile stress. Conclusion: This report describes application of snare devices in retrieving a broken catheter during thrombectomy in the anterior and posterior circulation, and therefore presents a technique that can be safely utilized to address catheter breakage complicating thrombectomy in different vascular anatomic locations.

Objective: We conducted an online survey to gauge the acceptance of sending acute stroke patients with suspected large vessel occlusion (LVO) directly to an endovascular-capable hospital (ECH) even if that means bypassing a closer alteplase-capable hospital (ACH) without endovascular capability. Methods: The survey was composed of two cases of acute stroke, one with cortical symptoms suggestive of LVO and the other without. In each case, responders were asked to choose between triaging to a closer ACH or an ECH that is further away and to provide an opinion regarding the maximum extra travel time they would tolerate if they chose the ECH. The survey was sent electronically to national groups of neurologists, emergency department (ED) physicians, emergency medical service (EMS) directors, and stroke coordinators. Results: There were 320 responders from 44 states, most of them with 10 years or more of experience. Most of the responders, 72.5%, chose ECH for the LVO case, while 56% chose ACH for the non-LVO case. There were marked differences in responses by specialty: neurology strongly supported ECH for LVO and strongly supported ACH for non-LVO, most ED and EMS chose ECH for both cases, and stroke coordinators were the least supportive of bypassing ACH. Almost all groups agreed on 30 min as the acceptable extra transfer time to ECH. Conclusion: Among the survey responders, there is a broad acceptance of the idea of bypassing ACH and going straight to ECH when LVO is suspected; however, there is less agreement on triaging patients with non-LVO stroke.

// Cheng-Di Chiu 1, 3, 4, 5 , Nai-Wei Yao 1, 2, 5 , Jeng-Hung Guo 4 , Chiung-Chyi Shen 6 , Hsu-Tung Lee 7 , You-Pen Chiu 1, 5 , Hui-Ru Ji 3, 5 , Xianxiu Chen 1, 4, 5 , Chun-Chung Chen 1, 4, 5 and Chen Chang 2 1 School of Medicine, China Medical University, Taichung, Taiwan 2 Institute of Biomedical Sciences, Academic Sinica, Taipei, Taiwan 3 Graduate Institute of Biomedical Science, China Medical University, Taichung, Taiwan 4 Department of Neurosurgery, China Medical University Hospital, Taichung, Taiwan 5 Stroke Center, China Medical University Hospital, Taichung, Taiwan 6 Department of Minimally Invasive Skull Base Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan 7 Department of Neurosurgical Oncology, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan Correspondence to: Cheng-Di Chiu, email: cdchiu4046@gmail.com Keywords: acute stroke; intracerebral hemorrhage; astrocyte; blood–brain barrier; MRI Received: August 02, 2017 Accepted: September 22, 2017 Published: October 24, 2017 ABSTRACT Neurological deterioration of intracerebral hemorrhage (ICH) mostly occurs within the first 24 hours. Together with the microglia/macrophages (MMΦ), astrocytes are important cell population responsible for many brain injuries but rarely being highlighted in acute stage of ICH. In present study, we induced rats ICH either by collagenase or autologous blood injection. Experimental groups were classified as vehicle or Ethyl-1-(4-(2,3,3-trichloroacrylamide)phenyl)-5-(trifluoromethyl)-1H-pyrazole-4-carboxylate (Pyr3) treatment group ( n = 9, each group). MRI assessments after ICH were used to evaluate the hematoma progression and blood–brain barrier (BBB) integrity. The glia cells accumulations were examined by GFAP and Iba1 immunohistochemistry, respectively. Abundant astrocytes but few MMΦ were observed in hyperacute and acute ICH. Upon suppression of astrocyte activity, ICH rats exhibited decreased size of hematoma expansion, less BBB destruction, reduced astrocyte accumulation in perihematomal regions, postponed course of hemoresolution and gain better outcomes. These finding provide evidence that activated astrocytes are crucial cell populations in hyperacute and acute ICH, and their modulation may offer opportunities for novel therapy and patient management.

Background and Purpose: Following transient ischemic attack (TIA), there is increased risk for ischemic stroke. The American Heart Association recommends admission of patients with ABCD2 scores ≥3 for observation, rapid performance of diagnostic tests, and potential acute intervention. We aimed to determine if there is a relationship between ABCD2 scores, in-hospital ischemic events, and in-hospital treatments after TIA admission. Methods: We reviewed consecutive patients admitted between 2006 and 2011 following a TIA, defined as transient focal neurological symptoms attributed to a specific vascular distribution and lasting 2 scores. Results: Of 249 patients, 11 patients (4.4%) had recurrent TIAs or strokes during their stay (8 TIAs, 3 strokes). All 11 had ABCD2 scores ≥3, and no neurological events occurred in patients with lower scores (5.1 vs. 0%; p = 0.37). Twelve patients (4.8%) underwent revascularization for large artery stenosis, 16 (6.4%) were started on anticoagulants, and no patient received intravenous or intra-arterial reperfusion therapy. The ABCD2 score was not associated with anticoagulation (p = 0.59) or revascularization (p = 0.20). Conclusions: Higher ABCD2 scores may predict early ischemic events after TIA but do not predict the need for intervention. Outpatient evaluation for those with scores

OBJECTIVES: High blood pressure (BP) is associated with a poor outcome after acute stroke. Early reduction in BP may be associated with fewer early adverse events and deaths, and improved functional outcome.METHODS: Analyses used data from the Efficacy of Nitric Oxide in Stroke trial, a multicentre randomized single-masked and outcome-masked trial of glyceryl trinitrate vs. no glyceryl trinitrate in 4011 patients recruited within 48 h of an ischaemic or haemorrhagic stroke and with raised SBP (140-220 mmHg). Change in SBP from baseline to day 1 was categorized as: more than 15% decrease, 15-5% decrease, 5% decrease to 5% increase (no change - reference) and more than 5% increase. The primary outcome was functional outcome (modified Rankin scale) score at 90 days.RESULTS: Across all patients, both moderate (5-15%) and large (>15%) decreases in SBP were associated with beneficial shifts in the modified Rankin scale relative to patients with no change in BP: adjusted common odds ratio (OR) 0.81 [95% confidence interval (CI) 0.70-0.90] and OR 0.84 (95% CI 0.71-1.00), respectively. A moderate decrease in SBP was also associated with a lower risk of early adverse events, adjusted OR 0.69 (95% CI 0.52-0.90).CONCLUSION: Modest decreases in SBP in acute stroke appear to be associated with fewer early events and better long-term functional outcome.

Directing attention to movement outcomes (external focus; EF), not body movements (internal focus; IF), is a better cognitive strategy for motor performance. However, EF is not effective in some healthy individuals or stroke patients. We aimed to identify the neurological basis reflecting the individual optimal attentional strategy using functional near-infrared spectroscopy. Sixty-four participants (23 healthy young, 23 healthy elderly, and 18 acute stroke) performed a reaching movement task under IF and EF conditions. Of these, 13 healthy young participants, 11 healthy elderly participants, and 6 stroke patients showed better motor performance under EF conditions (EF-dominant), whereas the others showed IF-dominance. We then measured prefrontal activity during rhythmic hand movements under both attentional conditions. IF-dominant participants showed significantly higher left prefrontal activity than EF-dominant participants under IF condition. In addition, receiver operating characteristic analysis supported that the higher activity in the left frontopolar and dorsolateral prefrontal cortices could detect IF-dominance as an individual's optimal attentional strategy for preventing motor performance decline. Taken together, these results suggest that prefrontal activity during motor tasks reflects an individual's ability to process internal body information, thereby conferring IF-dominance. These findings could be applied for the development of individually optimized rehabilitation programs.

Background: Thrombolysis is the only approved therapy for acute stroke. However, life-threatening complications such as intracerebral hemorrhage (ICH) can develop after intravenous administration of tissue plasminogen activator (tPA). Both infection and thrombolysis during cerebral ischemia disrupt the blood-brain barrier (BBB). tPA can induce matrix metalloproteinase-9 (MMP-9), which is known to be involved in BBB disruption. However, it has still not been investigated whether preexisting influenza virus infection during thrombolysis after acute stroke affects systemic levels of MMP-9 and its inhibitor TIMP-1 and whether increased systemic MMP-9 levels affect ICH. This study aimed to investigate the influence of influenza virus infection on plasma levels of MMP-9 and TIMP-1 after thrombolysis in acute stroke, and to determine whether the infection correlates with intracerebral bleeding. Methods: C57BL/6 mice were infected by administering 1 × 105 plaque-forming units of human influenza (H1N1) virus intranasally. After 3 days of infection the middle cerebral artery was occluded for 45 min and then reperfused. Intravenous tPA (10 mg/kg) treatment was started 10 min after stroke onset. Twenty-four hours after stroke onset, mice were deeply anesthetized with ketamine, venous blood was drawn from the caval vein and centrifuged at 2,000 rpm, and the supernatant was collected and frozen at -80°C. Plasma levels of MMP-9 and TIMP-1 were quantified by using ELISA. Results: After stroke, plasma MMP-9 was significantly increased in mice with a concomitant influenza infection that were treated with tPA (9.99 ± 0.62 ng/ml, n = 7) as compared to noninfected control mice that were treated with tPA (4.74 ± 0.48 ng/ml, n = 8). Moreover, plasma levels of TIMP-1, an inhibitor of MMP-9, were also significantly increased in mice treated with tPA after concomitant infection and stroke (42.17 ± 7.02 ng/ml, n = 7) as compared to noninfected control mice that were treated with tPA after stroke (20.22 ± 2.12 ng/ml, n = 8). MMP-9 values significantly correlated with intracerebral hemoglobin levels in animals treated with tPA after stroke (p = 0.028, r = 0.76, n = 8) and after concomitant stroke and infection (p = 0.039, r = 0.78, n = 7). Conclusion: Preexisting influenza A virus infection led to increased plasma MMP-9 and TIMP-1 levels in mice undergoing thrombolysis after induced stroke. MMP-9 levels closely correlated with intracerebral bleeding after thrombolysis during concomitant infection and stroke. Thus, our data indicate that thrombolysis may be dangerous during influenza infection. MMP-9 inhibitors might be considered to reduce the side effects of thrombolysis during concomitant infection and stroke.

Background: Most stroke recovery occurs by 90 days after onset, with proportional recovery models showing an achievement of about 70% of the maximal remaining recovery. Little is known about recovery during the acute stroke period. Moreover, data are described for groups, not for individuals. In this observational cohort study, we describe for the first time the daily changes of acute stroke patients with motor and/or language deficits over the first week after stroke onset. Methods: Patients were enrolled within 24-72 h after stroke onset with upper extremity hemiparesis, aphasia, or both, and were tested daily until day 7 or discharge with the upper-extremity Fugl-Meyer Assessment of Motor Recovery after Stroke, the Boston Naming Test, and the comprehension domain from the Western Aphasia Battery. Discharge scores, and absolute and proportional changes were examined using t-tests for pairwise comparisons and linear regression to determine relative contributions of initial impairment, lesion volume, and age to recovery over this period. Results: Thirty-four patients were enrolled: 19 had motor deficits alone, 8 had aphasia alone, and 7 had motor and language deficits. In a group analysis, statistically significant changes in absolute scores were found in the motor (p < 0.001) and comprehension (p < 0.001) domains but not in naming. Day-by-day recovery curves for individual patients displayed wide variation with comparable initial impairment. Proportional recovery calculations revealed that, on average, patients achieved less than 1/3 of their potential recovery by the time of discharge. Multivariate regression showed that the amount of variance accounted for by initial severity, age, and lesion volume in this early time period was not significant for motor or language domains. Conclusions: Over the first week after stroke onset, recovery of upper extremity hemiparesis and aphasia were not predictable on the basis of initial impairment, lesion volume, or age. In addition, patients only achieved about 1/3 of their remaining possible recovery based on the anticipated 70% proportion found at 90 days. These findings suggest that the complex interaction between poststroke structural repair, regeneration, and functional reorganization during the first week after stroke has yet to be elucidated.

Background and Purpose: We have observed that large vessel occlusion acute strokes (LVOS) due to intracranial atherosclerotic disease (ICAD) present with more benign CT perfusion (CTP) profiles, which we presume to potentially represent enhanced collateralization compared to embolic LVOS. We aim to determine if CTP profiles can predict ICAD in LVOS. Methods: Retrospective review of a prospectively collected interventional stroke database from September 2010 to March 2015. Patients with intracranial ICA/MCA-M1/M2 occlusions and CTP were dichotomized into ICAD versus non-ICAD etiologies. Ischemic core (relative cerebral blood flow < 30%) and hypoperfusion volumes were estimated by automated CTP. Results: A total of 250 patients met the inclusion criteria, comprised of 21 (8%) ICAD and 229 non-ICAD etiologies. Baseline characteristics were similar between groups, except for higher HbA1c levels (p < 0.01), LDL cholesterol (p < 0.01), systolic blood pressure (p < 0.01), and lower rate of atrial fibrillation (p < 0.01) in ICAD patients. There were no significant differences in volumes of baseline ischemic core (p = 0.54) among groups. ICAD patients had smaller Tmax > 4 s, Tmax > 6 s, and Tmax > 10 s absolute lesions, and a higher ratio of Tmax > 4 s/Tmax > 6 s volumes (median 2 [1.6–2.3] vs. 1.6 [1.4–2.0]; p = 0.02). A Tmax > 4 s/Tmax > 6 s ratio ≥2 showed specificity = 73%/sensitivity = 52% for ICAD and was observed in 47.6% of ICAD versus 26.1% of non-ICAD patients (p = 0.07). Clinical outcomes were comparable amongst groups. Multivariate logistic regression revealed that Tmax > 4 s/Tmax > 6 s ratio ≥2 (OR 3.75, 95% CI 1.05–13.14, p = 0.04), higher LDL cholesterol (OR 1.1, 95% CI 1.01–1.03, p = 0.01), and higher systolic pressure (OR 1.03, 95% CI 1.01–1.04, p = 0.01) were independently associated with ICAD. Conclusion: An automated CTP Tmax > 4 s/Tmax > 6 s ratio ≥2 profile was found independently associated with underlying ICAD LVOS.

Background: Various techniques are used to enhance the results of mechanical thrombectomy with stent-retrievers, including proximal arrest with balloon guide catheter (BGC), conventional large bore proximal catheter (CGC), or in combination with local aspiration through a large-bore catheter positioned at the clot interface (Aspiration-Retriever Technique for Stroke [ARTS]). We evaluated the impact of ARTS in the North American Solitaire Acute Stroke (NASA) registry. Summary: Data on the use of the aspiration technique were available for 285 anterior circulation patients, of which 29 underwent ARTS technique, 131 CGC, and 125 BGC. Baseline demographics were comparable, except that ARTS patients are less likely to have hypertension or atrial fibrillation. The ARTS group had more ICA occlusions (41.4 vs. 22% in the BGC, p = 0.04 and 26% in CGC, p = 0.1) and less MCA/M1 occlusions (44.8 vs. 68% in BGC and 62% in CGC). Time from arterial puncture to reperfusion or end of procedure with ARTS was shorter than with CGC (54 vs. 91 min, p = 0.001) and was comparable to the BGC time (54 vs. 67, p = 0.11). Final degree of reperfusion was comparable among the groups (TICI [modified Thrombolysis in Cerebral Infarction] score 2b or higher was 72 vs. 70% for CGC vs. 78% for BGC). Procedural complications, mortality, and good clinical outcome at 90 days were similar between the groups. Key Messages: The ARTS mechanical thrombectomy in acute ischemic stroke patients appears to yield better results as compared to the use of CGCs with no significant difference when compared to BGC. This early ARTS technique NASA registry data are limited by the earlier generation distal large bore catheters and small sample size. Future studies should focus on the comparison of ARTS and BGC techniques.

Background: Anemia will negatively affect cerebral collaterals and penumbra. Eventually, it may cause worse clinical outcomes and even increase mortality rates in stroke patients. Anemia has recently been suggested to be an independent risk factor for ischemic stroke. Therefore, we aimed to investigate the effects of the presence of anemia on clinical outcomes in ischemic stroke patients undergoing mechanical thrombectomy. Methods: This was a retrospective study involving the prospectively and consecutively collected data of 90 adult patients between January 2015 and August 2016. Hemoglobin (Hb) cutoff levels were accepted as 12 g/dL for women and 13 g/dL for men. Patients having anemia were further divided into three subgroups as severe anemia (Hb Results: Forty of the subjects (44.4%) had anemia. Moderate anemia was detected in 14 out of 90 patients (15.5%) and severe anemia was found in only four of them (4.4%). Poor functional outcome (mRS 3-6) was similar in both anemic and non-anemic patients (37.5% vs. 38%, respectively, p = 0.08), but poor functional outcome was found to be statistically significant with severe anemic group (Hb p = 0.003). In multiple logistic regression analysis, moderate and severe anemia has been found to increase the mortality (p = 0.032). Conclusions: Our study demonstrated a poor functional outcome only in moderate to severe anemic patients. Clinicians should keep in mind the negative effect of moderate to severe anemia in the clinical course of acute stroke patients treated with mechanical thrombectomy.

Background: Scarce reports exist of permanent deployment of Solitaire FR™ devices for arterial steno-occlusive disease as it is primarily indicated for temporary deployment for thrombectomy in large-vessel, anterior-circulation ischemic strokes. Even more scarce are reports describing permanent deployment of the Solitaire device for posterior circulation strokes. Summary: We present 2 cases where the Solitaire device was electrolytically detached to re-establish flow in an occluded or stenotic basilar artery in acutely symptomatic patients. In both cases, a 4 × 15 mm Solitaire device was positioned across the stenotic or occluded portion of the basilar artery and electrolytically detached to maintain vessel patency. Both cases had good clinical outcomes with a National Institutes of Health Stroke Scale (NIHSS) score of 1 (from 24) on 90-day follow-up and an NIHSS score of 2 (from 7) on 30-day follow-up. Key Messages: Permanent deployment of the Solitaire device may potentially be a safe and effective means of maintaining vessel patency in an occluded or stenotic basilar artery.

Background: Acute ischaemic stroke (AIS) patients often show impaired cerebral autoregulation (CA). We tested the hypothesis that CA impairment and other alterations in cerebral haemodynamics are associated with stroke subtype and severity. Methods: AIS patients (n = 143) were amalgamated from similar studies. Data from baseline (< 48 h stroke onset) physiological recordings (beat-to-beat blood pressure [BP], cerebral blood flow velocity (CBFV) from bilateral insonation of the middle cerebral arteries) were calculated for mean values and autoregulation index (ARI). Differences were assessed between stroke subtype (Oxfordshire Community Stroke Project [OCSP] classification) and severity (National Institutes of Health Stroke Scale [NIHSS] score < 5 and 5–25). Correlation coefficients assessed associations between NIHSS and physiological measurements. Results: Thirty-two percent of AIS patients had impaired CA (ARI < 4) in affected hemisphere (AH) that was similar between stroke subtypes and severity. CBFV in AH was comparable between stroke subtype and severity. In unaffected hemisphere (UH), differences existed in mean CBFV between lacunar and total anterior circulation OCSP subtypes (42 vs. 56 cm•s–1, p < 0.01), and mild and moderate-to-severe stroke severity (45 vs. 51 cm•s–1, p = 0.04). NIHSS was associated with peripheral (diastolic and mean arterial BP) and cerebral haemodynamic parameters (CBFV and ARI) in the UH. Conclusions: AIS patients with different OCSP subtypes and severity have homogeneity in CA capability. Cerebral haemodynamic measurements in the UH were distinguishable between stroke subtype and severity, including the association between deteriorating ARI in UH with stroke severity. More studies are needed to determine their clinical significance and to understand the determinants of CA impairment in AIS patients.

Background/Aim: The hyperdense middle cerebral artery sign (HMCAS) is a useful clinical sign in the management of acute stroke and may alter time-critical decisions within an emergency setting. Though gold standards have been published, these are rarely used in clinical practice and scans tend to be reported subjectively. It is therefore possible that the level of experience of the doctor reporting the scan may impact on the accuracy of the reporting and hence patient management. This study was designed to evaluate the accuracy in detecting HMCAS across doctors with varying levels of experience. Methods: Forty doctors were recruited into four categories of experience. Each subject received a brief computer-based tutorial on how to identify an HMCAS and was then asked to report on the presence or absence of an HMCAS in 19 pre-prepared CT scans using a standardised viewing template. Results: The mean (±SE) percentage correct scores increased with experience from 76.8 ± 3.69 among interns and residents to 90.1 ± 2.23 (neurologists and radiologists; p < 0.01). Sensitivity and specificity as well as positive and negative predictive values all increased with experience. In addition, more experienced clinicians were better able to distinguish scans which met the radiological criteria for HMCAS from those which only just failed to do so. Conclusions: Experienced neurologists and radiologists consistently and accurately reported the presence or absence of HMCAS, whereas less experienced clinicians tended to over-report the presence of HMCAS. This may have implications for the acute management of thromboembolic stroke.

Purpose The primary correlate to survival and preservation of neurologic function in patients suffering from an acute ischemic stroke is time from symptom onset to initiation of therapy and reperfusion. Communication and coordination among members of the stroke team are essential to maximizing efficiency and subsequently early reperfusion. In this work, we aim to describe our preliminary experience using the Join mobile application as a means to improve interdisciplinary team communication and efficiency. Materials and methods We describe our pilot experience with the initiation of the Join mobile application between July 2015 and July 2016. With this application, a mobile beacon is transported with the patient on the ambulance. Transportation milestone timestamps and geographic coordinates are transmitted to the treating facility and instantly communicated to all treatment team members. The transport team / patient can be tracked en route to the treating facility. Results During our pilot study, 62 patients were triaged and managed using the Join application. Automated time-stamping of critical events, geographic tracking of patient transport and summary documents were obtained for all patients. Treatment team members had an overall favorable impression of the Join application and recommended its continued use. Conclusion The Join application is one of several components of a multi-institutional, interdisciplinary effort to improve the treatment of patients with acute ischemic stroke. The ability of the treatment team to track patient transport and communicate with the transporting team may improve reperfusion time and, therefore, improve neurologic outcomes.

OBJECTIVE: To evaluate the accuracy of perfusion CT (pCT) in the definition of the infarcted core and the penumbra, comparing the data obtained from the evaluation of parametric maps [cerebral blood volume (CBV), cerebral blood flow (CBF) and mean transit time (MTT)] with software-generated colour maps. METHODS: A retrospective analysis was performed to identify patients with suspected acute ischaemic strokes and who had undergone unenhanced CT and pCT carried out within 4.5 h from the onset of the symptoms. A qualitative evaluation of the CBV, CBF and MTT maps was performed, followed by an analysis of the colour maps automatically generated by the software. RESULTS: 26 patients were identified, but a direct CT follow-up was performed only on 19 patients after 24-48 h. In the qualitative analysis, 14 patients showed perfusion abnormalities. Specifically, 29 perfusion deficit areas were detected, of which 15 areas suggested the penumbra and the remaining 14 areas suggested the infarct. As for automatically software-generated maps, 12 patients showed perfusion abnormalities. 25 perfusion deficit areas were identified, 15 areas of which suggested the penumbra and the other 10 areas the infarct. The McNemar's test showed no statistically significant difference between the two methods of evaluation in highlighting infarcted areas proved later at CT follow-up. CONCLUSION: We demonstrated how pCT provides good diagnostic accuracy in the identification of acute ischaemic lesions. The limits of identification of the lesions mainly lie at the pons level and in the basal ganglia area. Qualitative analysis has proven to be more efficient in identification of perfusion lesions in comparison with software-generated maps. However, software-generated maps have proven to be very useful in the emergency setting. Advances in knowledge: The use of CT perfusion is requested in increasingly more patients in order to optimize the treatment, thanks also to the technological evolution of CT, which now allows a whole-brain study. The need for performing CT perfusion study also in the emergency setting could represent a problem for physicians who are not used to interpreting the parametric maps (CBV, MTT etc.). The software-generated maps could be of value in these settings, helping the less expert physician in the differentiation between different areas.

Background: Endovascular therapy has been proven effective for the treatment of large vessel occlusion strokes (LVOS). However, the feasibility and potential benefits of repeat thrombectomy for recurrent stroke is unclear. We aim to report our experience with repeat thrombectomy for recurrent LVOS. Methods: We reviewed our prospectively collected endovascular database for patients who underwent repeated mechanical thrombectomy. Baseline characteristics, procedural data and outcomes were evaluated. Patients with repeat thrombectomy were compared to patients with single thrombectomy. For patients with repeat thrombectomy, imaging and procedural variables were compared between first and last procedures. Results: Out of 697 patients treated within the study period, 15 patients (2%) had repeat thrombectomies (14 treated twice and one thrice). The mean age was 63 ± 15 years and 40% were males. The median time between the first and last procedure was 18 (1-278) days. Cardioembolism (66%) was the most common etiology, followed by intracranial atherosclerosis (13%) and large vessel atherosclerosis (6%). At 90 days after the last thrombectomy, 60% of patients achieved a modified Rankin Scale score of 0-2 and 20% were deceased. There were no statistically significant differences in demographics, stroke severity, time from last known normal to puncture, reperfusion rates, hemorrhagic complications, good clinical outcomes and mortality between patients who underwent repeat thrombectomy and those who had a single thrombectomy. Conclusion: In properly selected patients suffering recurrent LVOS, repeated mechanical thrombectomy appears to be feasible and safe. A previous thrombectomy should not discourage aggressive treatment as these patients may achieve similar rates of good clinical outcomes as those who undergo single thrombectomy.

Good collateral circulation (CC) is associated with favorable outcomes in acute stroke, but the best technique to evaluate collaterals is controversial. Single-phase computed tomography angiography (sCTA) is widely used but lacks temporal resolution. We aim to compare CC evaluation by sCTA and multiphase CTA (mCTA) as predictors of outcome in endovascular treated patients. Methods: Consecutive endovascular treated patients with M1 middle cerebral artery (MCA) or terminal intracranial carotid artery (TICA) occlusion confirmed by sCTA were included. Two more CTA acquisitions with 8- and 16-second delays were performed for mCTA. Endovascular thrombectomy was performed independently of the CC status according to a local protocol [Alberta Stroke Program Early CT score (ASPECTS) >6, modified Rankin scale (mRS) score Results: 108 patients were included. Their mean age was 69.6 ± 13 years and their median National Institutes of Health Stroke Scale (NIHSS) score was 17 (interquartile range 8). 79 (73.1%) had M1 MCA and 29 (26.9%) TICA occlusions. The mean time from symptom onset to CTA was 146.8 ± 96.5 min. On sCTA, 50.9% patients presented good CC vs. 57.5% on mCTA. Good CC status in both sCTA and mCTA had a lower 24-hour infarct volume (27.4 vs. 74.8 cm3 on sCTA, p = 0.04; 17.2 vs. 97.8 cm3 on mCTA, p < 0.01). However, only good CC on mCTA was associated with lower 24-hour (5 vs. 8.5, p = 0.04) and median discharge NIHSS (2 vs. 4.5, p = 0.04) scores and functional independency (mRS score Conclusion: CC evaluation by mCTA is a better prognostic marker than CC evaluation by sCTA for clinical and functional endpoints in acute stroke patients treated with endovascular thrombectomy.

The aim of this study was to analyze one year outcome of the acute stroke patients with sleep apnea in order to gender and age. Methods: It was analyzed 110 patients with acute stroke and sleep apnea. Among them 65(59%) were men. Average age of all participant was 65.13±9.27 years. The same number and gender distribution of participants with stroke and without apnea were in control group. Evaluation of sleep apnea has been done with: “The Sleep Disorders Questionnaire”, “Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome” and “The Epworth Sleepiness Scale”. Results: One year after stroke onset survived 91 (82.7%) out of 110 patients with apnea. Average age of survived patients was 63.66±8.78 years. Among them 52(80%) were men. In control group, without apnea survived 104 (94.5%) patients with average age of 65.00±8.62 years. Among them 62 (95.4%) were men. In men with apnea there is significantly lower survival range in order to patients without apnea (X2=8.22, p=0.004). In women there is no difference. Survival of both gender in patients with apnea (22; 64.7%) was the lowest in group older than 70 years of age. Sex ratio (men : women) was 15 (68.2%):7(58.3%). Survival in both gender in patients without apnea was the same in group older than 70 years of age: 27 (81.2%) out of 33. Average age of patients who died with apnea was significantly higher in order to patients without (t=1.97, p=0.03). Conclusion: One year after stroke, significantly more patients survived without (94.5%) than with apnea (82.7%) (p=0.01). In order to sex survived range was significantly (p=0.004) lover in men with apnea than without but in women there is no difference. Survival range of both gender in patients with apnea was the lowest in group older than 70 years (p=0.03).