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Abstract Aims To explore the practice effect of establishing an integrated treatment process by stroke emergency nurses in general hospitals for acute ischaemic stroke (AIS). Design Compared the time spent in each link before and after the establishment of AIS integrated treatment. Methods Since March 2016, we set up a team of emergency stroke nurses (ESN), trained and assessed the knowledge of emergency stroke, and set up a post of ESN. Results The median time of admission‐judgement, admission‐establishment of venous access, admission‐cranial CT examination and admission‐intravenous thrombolytic therapy was statistically significantly shortened after the implementation of the integrated treatment process of AIS coordinated by stroke emergency nurses (p

Background and Purpose: The influence of intracranial arteriosclerosis (ICAR) on acute ischaemic stroke (AIS) prognosis is unclear. This study explored its impact, focusing on ICAR subtypes categorized by intracranial carotid artery calcification (ICAC) patterns: intimal or atherosclerotic versus internal elastic lamina calcification or non-atherosclerotic. The aim was to determine their effect on AIS prognosis in patients undergoing endovascular treatment (EVT)., Methods: This prospective cohort study included consecutive AIS patients with anterior circulation large vessel occlusion undergoing EVT. ICAC, the hallmark of ICAR, was assessed using non-contrast computed tomography to quantify volume and establish the predominant ICAR subtype. The primary outcome was long-term functional outcome, measured by the 90-day modified Rankin Scale score. Secondary outcomes included first-pass effect, revascularization degree, symptomatic intracranial haemorrhage and 24-h infarct volume. Multivariate-adjusted linear and logistic regression models were used to assess the association of ICAC volume and subtype with these outcomes., Results: From January 2021 to February 2022, 181 patients were included, of whom 172 (95%) had ICAC. Internal elastic lamina calcification was the predominant subtype in 103 (57%), intimal in 52 (29%) and mixed in 17 (9%). The intimal or atherosclerotic ICAC pattern was linked to poorer functional outcomes (adjusted odds ratio 2.12, 95% confidence interval [CI] 1.10-4.09), decreased first-pass effect probability (adjusted odds ratio 0.42, 95% CI 0.21-0.84) and higher infarct volume (adjusted β value 22.11, 95% CI 0.55-43.67)., Conclusions: A predominant intimal ICAC subtype, linked to underlying atherosclerosis, correlated with larger infarct volume and poorer 90-day functional outcomes in EVT-treated AIS patients. Intracranial atherosclerosis appears to be a relevant factor hampering clinical benefits post-EVT., (© 2024 The Author(s). European Journal of Neurology published by John Wiley & Sons Ltd on behalf of European Academy of Neurology.)

Abstract Aims Heart failure (HF) is frequent in patients with acute ischaemic stroke (AIS) and associated with higher morbidity and mortality. Assessment of cardiac function in AIS patients using cardiovascular MRI (CMR) may help to detect HF. We report the rate of systolic and diastolic dysfunction in a cohort of patients with AIS using CMR and compare cine real‐time (CRT) sequences with the reference of segmented cine steady‐state free precession sequences. Methods and results Patients with AIS without known atrial fibrillation were prospectively enrolled in the HEart and BRain Interfaces in Acute Ischemic Stroke (HEBRAS) study (NCT 02142413) and underwent CMR at 3 Tesla within 7 days after AIS. Validity of CRT sequences was determined in 50 patients. A total of 229 patients were included in the analysis (mean age 66 years; 35% women; HF 2%). Evaluation of cardiac function was successful in 172 (75%) patients. Median time from stroke onset to CMR was 82 h (interquartile range 56–111) and 54 h (interquartile range 31–78) from cerebral MRI to CMR. Systolic dysfunction was observed in 43 (25%) and diastolic dysfunction in 102 (59%) patients. Diagnostic yield was similar using CRT or segmented cine imaging (no significant difference in left ventricular ejection fraction, myocardial mass, time to peak filling rate, and peak filling rate ratio E/A). Intraobserver and interobserver agreement was high (κ = 0.78–1.0 for all modalities). Conclusions Cardiovascular MRI at 3 Tesla is an appropriate method for the evaluation of cardiac function in a selected cohort of patients with AIS. Systolic and diastolic dysfunction is frequent in these patients. CRT imaging allows reliable assessment of systolic and diastolic function.

Background and Purpose: The ratio of serum uric acid (SUA) to serum creatinine (SCr), representing normalized SUA for renal function, is associated with functional outcome in acute ischaemic stroke (AIS) patients. However, its effect on AIS patients undergoing mechanical thrombectomy (MT) remains unknown. This study aimed to investigate the influence of the SUA/SCr ratio on clinical outcome in MT-treated AIS patients., Methods: Acute ischaemic stroke patients who underwent MT were continuously enrolled from January 2018 to June 2023. Upon admission, SUA and SCr levels were recorded within the initial 24 h. Stroke severity was determined using the National Institutes of Health Stroke Scale (NIHSS) score. Clinical outcome included poor functional outcome (modified Rankin Scale score >2) at 90 days, symptomatic intracranial haemorrhage and death., Results: Amongst 734 patients, 432 (58.8%) exhibited poor functional outcome at 90 days. The SUA/SCr ratio exhibited a negative correlation with NIHSS score (ρ = -0.095, p = 0.010). Univariate analysis revealed a significant association between SUA/SCr ratio and poor functional outcome. After adjusting for confounders, the SUA/SCr ratio remained an independent predictor of functional outcome (adjusted odds ratio 0.348, 95% confidence interval 0.282-0.428, p < 0.001). Receiver operating characteristic curve analysis highlighted the ability of the SUA/SCr ratio to predict functional outcome, with a cutoff value of 3.62 and an area under the curve of 0.757 (95% confidence interval 0.724-0.788, p < 0.001)., Conclusion: The SUA/SCr ratio is correlated with stroke severity and may serve as a predictor of 90-day functional outcome in AIS patients undergoing MT., (© 2024 The Authors. European Journal of Neurology published by John Wiley & Sons Ltd on behalf of European Academy of Neurology.)

Background and Purpose: The present study analyzed the relationship between circulating trimethylamine N-oxide (TMAO) levels and stroke severity in diabetic patients with acute ischaemic stroke. A further aim was to investigate whether higher TMAO levels were associated with platelet aggregation and glycemic variability., Methods: This was a cross-sectional analysis of 108 patients with type 2 diabetes mellitus (DM) undergoing acute ischaemic stroke and 60 healthy controls. Fasting plasma TMAO was measured using high-performance liquid chromatography with online electrospray ionization tandem mass spectrometry., Results: Plasma TMAO levels of patients with acute ischaemic stroke were significantly higher than those of healthy controls. Amongst stroke patients, 50 were defined as undergoing mild stroke, and their plasma TMAO levels were lower compared to those with moderate to severe stroke. Platelet aggregation and mean amplitude of glycemic excursions were both correlated with plasma TMAO levels and these relationships remained significant in multiple linear regression analyses. Moreover, in streptozotocin-induced diabetic rats fed a diet enriched with choline to increase TMAO synthesis, platelet aggregation was significantly increased in the DM + choline and fluctuating DM (FDM) + choline groups compared to the control group. This increase was abolished in rats receiving oral antibiotics, which markedly reduced plasma TMAO levels. Importantly, compared with the DM + choline group, the FDM + choline group displayed significantly elevated TMAO levels and higher platelet aggregation., Conclusions: Our results demonstrated that higher plasma TMAO levels were associated with stroke severity and suggested a novel link between plasma TMAO levels and glycemic variability in diabetic patients with acute ischaemic stroke., (© 2022 European Academy of Neurology.)

Background and Purpose: The aim was to evaluate the temporal trends, characteristics and in-hospital outcomes of patients hospitalized with acute ischaemic stroke (AIS) between those with and without current or historical malignancies., Methods: Adult hospitalizations with a primary diagnosis of AIS were identified from the National Inpatient Sample database 2007-2017. Logistic regression was used to compare the differences in the utilization of AIS interventions and in-hospital outcomes. For further analysis, subgroup analyses were performed stratified by cancer subtypes., Results: There were 892,862 hospitalizations due to AIS, of which 108,357 (12.14%) had a concurrent diagnosis of current cancer (3.41%) or historical cancer (8.72%). After adjustment for confounders, patients with current malignancy were more likely to have worse clinical outcomes. The presence of historical cancers was not associated with an increase in poor clinical outcomes. Additionally, AIS patients with current malignancy were less likely to receive intravenous thrombolysis (adjusted odds ratio 0.66, 95% confidence interval 0.63-0.71). Amongst the subgroups of AIS patients treated with intravenous thrombolysis or mechanical thrombectomy, outcomes varied by cancer types. Notably, despite these acute stroke interventions, outcome remains poor in AIS patients with lung cancer., Conclusions: Although AIS patients with malignancy generally have worse in-hospital outcomes versus those without, there were considerable variations in these outcomes according to different cancer types and the use of AIS interventions. Finally, treatment of these AIS patients with a current or historical cancer diagnosis should be individualized., (© 2023 European Academy of Neurology.)

Background and Purpose: The aim was to investigate the associations of haemorrhagic transformation (HT) and its clinical and radiological subtypes with functional outcome, mortality, early neurological deterioration (END) and neurological complications in patients with acute ischaemic stroke (AIS)., Methods: A systematic review and meta-analysis of observational studies on the associations of overall HT, clinical HT subtypes (asymptomatic intracerebral haemorrhage [aICH] and symptomatic intracerebral haemorrhage [sICH]) or radiological HT subtypes (haemorrhagic infarction [HI-1 or HI-2] and parenchymal haemorrhage [PH-1 or PH-2]) with prognosis in patients with AIS was performed. PubMed, Web of Science and Embase were systematically searched. Random effects models were used to calculate pooled estimates., Results: Fifty-one studies with 100,510 patients were pooled in the meta-analysis. Overall HT was associated with worse functional outcome (odds ratio [OR] 2.12, 95% confidence interval [CI] 1.55-2.90), increased mortality (OR 1.87, 95% CI 1.52-2.30), END (OR 2.35, 95% CI 1.46-3.77), early-onset seizures (OR 2.58, 95% CI 1.63-4.10) and post-stroke epilepsy (OR 2.23, 95% CI 1.11-4.49). For clinical subtypes, sICH remained significantly associated with the aforementioned poor prognoses except post-stroke epilepsy, and aICH was associated with worse functional outcome but was unrelated to mortality. For radiological subtypes, PH (especially PH-2) was strongly associated with poor prognosis. HI-2 was associated with worse functional outcome, and HI-1 was associated with a lower risk of mortality and END., Conclusions: Regardless of whether AIS patients undergo thrombolysis or thrombectomy, overall HT, sICH and PH (especially PH-2) are associated with a substantially increased risk of worse functional outcome, mortality, END or neurological complications. The presence of aICH is related to worse functional outcome but is independent of increased mortality. HI-2 impairs functional independence, and HI-1 does not cause neurological impairment., (© 2022 European Academy of Neurology.)

Background and Purpose: We aimed to assess the association of diabetes mellitus (DM) and admission hyperglycaemia (AH), respectively, and outcome in patients with acute ischaemic stroke with large vessel occlusion in the anterior circulation treated with endovascular therapy (EVT) in daily clinical practice., Methods: Consecutive EVT patients admitted to our stroke centre between February 2015 and April 2020 were included in this observational cohort study. Patients with versus without DM and with versus without AH (glucose ≥ 7.8 mmol/L) were compared., Results: We included 1020 patients (48.9% women, median age = 73.1 years); 282 (27.6%) had DM, and 226 (22.2%) had AH. Patients with versus without DM less often showed successful reperfusion (odds ratio [OR] adjusted  = 0.61, p = 0.023) and worse 3-month functional outcome (modified Rankin Scale [mRS] = 0-2: 31.3% vs. 48%, OR adjusted  = 0.59, p = 0.004; death: 38.9% vs. 24.1%, OR adjusted  = 1.75, p = 0.002; mRS shift: p adjusted  < 0.0001; if moderate/good collaterals and mismatch, mRS = 0-2: OR adjusted  = 0.52, p = 0.005; death: OR adjusted  = 1.95, p = 0.005). If analysis was additionally adjusted for AH, only mRS shift was still significantly worse in patients with DM (p adjusted  = 0.012). Patients with versus without AH showed similar successful reperfusion rates and worse 3-month functional outcome (mRS = 0-2: 28.3% vs. 50.4%, OR adjusted  = 0.52, p < 0.0001; death: 40.4% vs. 22.4%, OR adjusted  = 1.80, p = 0.001; mRS shift: p adjusted  < 0.0001; if moderate/good collaterals and mismatch, mRS = 0-2: OR adjusted  = 0.38, p < 0.0001; death: OR adjusted  = 2.39, p < 0.0001). If analysis was additionally adjusted for DM, 3-month functional outcome remained significantly worse in patients with AH (mRS = 0-2: OR adjusted  = 0.58, p = 0.004; death: OR adjusted  = 1.57, p = 0.014; mRS shift: p adjusted  = 0.004). DM independently predicted recurrent/progressive in-hospital ischaemic stroke (OR = 1.71, p = 0.043) together with admission National Institutes of Health Stroke Scale score (OR = 0.95, p = 0.005), and AH independently predicted in-hospital symptomatic intracranial haemorrhage (OR = 2.21, p = 0.001). The association of admission continuous glucose levels and most outcome variables was (inversely) J-shaped., Conclusions: Hyperglycaemia more than DM was associated with worse 3-month outcome in the patients studied, more likely so in the case of moderate/good collaterals and mismatch in admission imaging., (© 2022 The Authors. European Journal of Neurology published by John Wiley & Sons Ltd on behalf of European Academy of Neurology.)

Background and Purpose: Some acute ischaemic stroke (AIS) patients do not display established vascular risk factors (EVRFs). The aim was to assess their clinical characteristics, stroke subtype etiological classification and long-term outcome., Methods: All consecutive AIS patients from the Acute Stroke Registry of Lausanne (2003-2018) were retrospectively analyzed with complete assessment of the following EVRFs: hypertension, diabetes, major cardioembolic sources, dyslipidemia, smoking, obesity, alcohol abuse, previous stroke/transient ischaemic attack and depression/psychosis. Patients without EVRFs were compared to patients with one or more EVRFs using appropriate statistical models., Results: Of 4889 included patients, 103 (2.1%) had no EVRFs. In multiple regression analysis, patients without EVRFs were significantly younger (odds ratio [OR] 0.13; 95% confidence interval [CI] 0.08-0.20) and had more multiterritorial strokes (OR 3.38; 95% CI 1.26-9.05). Strokes were more often related to patent foramen ovale (PFO) (OR 3.02; 95% CI 1.44-6.32) and less to atherosclerosis, cardioembolism or small vessel disease. In patients <55 years old, PFO (OR 2.76; 95% CI 1.50-5.08) and contraceptive use in females (OR 2.75; 95% CI 1.40-5.41) were more frequent, whereas sleep apnea syndrome (OR 0.09; 95% CI 0.01-0.63) was less. In patients ≥55 years, female sex (OR 2.84; 95% CI 1.43-5.65) and active cancer (OR 3.27; 95% CI 1.34-7.94) were more prevalent. At 12 months, patients without EVRFs had worse adjusted functional outcome (Rankin shift OR adj 0.63; 95% CI 0.42-0.95) and higher rate of recurrence and death (adjusted hazard ratio 2.11; 95% CI 1.19-3.74)., Conclusions: In a consecutive cohort of AIS patients, only 2% showed no EVRFs. PFO and contraceptive use exhibited a strong association with the absence of EVRFs in younger patients and female sex and active cancer in elderly patients. Our findings highlight the importance of searching for previously unknown risk factors and/or unusual stroke mechanisms in patients without EVRFs., (© 2020 European Academy of Neurology.)

Background and Purpose: This was an investigation of the differential effects of early intensive versus guideline-recommended blood pressure (BP) lowering between lacunar and non-lacunar acute ischaemic stroke (AIS) in the BP arm of the Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED)., Methods: In 1,632 participants classified as having definite or probable lacunar (n = 454 [27.8%]) or non-lacunar AIS according to pre-specified definitions based upon clinical and adjudicated imaging findings, mean BP changes over days 0-7 were plotted, and systolic BP differences by treatment between subgroups were estimated in generalized linear models. Logistic regression models were used to estimate the BP treatment effects on 90-day outcomes (primary, an ordinal shift of modified Rankin scale scores) across lacunar and non-lacunar AIS after adjustment for baseline covariables., Results: Most baseline characteristics, acute BP and other management differed between lacunar and non-lacunar AIS, but mean systolic BP differences by treatment were comparable at each time point (all p interaction  > 0.12) and over 24 h post-randomization (-5.5, 95% CI -6.5, -4.4 mmHg in lacunar AIS vs. -5.6, 95% CI -6.3, -4.8 mmHg in non-lacunar AIS, p interaction  = 0.93). The neutral effect of intensive BP lowering on functional outcome and the beneficial effect on intracranial haemorrhage were similar for the two subgroups (all p interaction  > 0.19)., Conclusions: There were no differences in the treatment effect of early intensive versus guideline-recommended BP lowering across lacunar and non-lacunar AIS., (© 2020 European Academy of Neurology.)

Background and Purpose: Endovascular therapy (EVT) has become standard care for acute ischaemic stroke caused by large-vessel occlusion in the anterior circulation. However, access to this treatment in Europe remains poor. The lack of operators is a contributing factor and there is on-going discussion as to whether other specialists, including neurologists, could contribute to the EVT workforce. The question remains whether the next generation of neurologists want to become 'interventional neurologists'. The aim of this study was to address this question., Methods: We conducted a short survey within the National Representatives Network (a division of the Resident and Research Fellow Section, European Academy of Neurology) in order to determine the interest of future neurologists in performing EVT., Results: A total of 1218 responses from 27 European countries were received, with some variation in the number of respondents and results among individual countries. In total, 568 neurology trainees (47%) stated that they would want to be an 'interventional neurologist'., Conclusion: Our findings suggest that neurologists could make a significant contribution to the workforce performing EVT and have important implications for the development and uptake of training programmes in Europe., (© 2020 European Academy of Neurology.)

Background and Purpose: 'Stroke chameleons' refer to a group of syndromes that initially are not diagnosed as cerebrovascular events but are then found to represent stroke. The objective of this study was to report on acute ischaemic stroke (AIS) patients with chest or epigastric pain of central origin, clinically resembling an acute coronary syndrome (ACS)., Methods: A prospective list was kept of AIS patients admitted to our institution between 2002 and 2014 with stroke symptoms appearing as an ACS on first clinical evaluation. For each identified patient, clinical and radiological features, delay to correct diagnosis, stroke etiology and 3-month functional outcome were reviewed. Data were mainly extracted from the Acute Stroke Registry and Analysis of Lausanne (ASTRAL)., Results: Five AIS patients presenting mainly with chest or epigastric pain leading to a wrong diagnosis of ACS were identified. Cardiac evaluation showed minor electrocardiogram changes in two patients and isolated troponin elevation in one, subsequently shown to be of non-coronary origin. The correct diagnosis of AIS was made only between 1 h and 72 h after hospital arrival. Four patients presented a vertebrobasilar stroke. None of the patients received acute stroke revascularization therapy despite two of them being in the time window for such treatment., Conclusion: Acute ischaemic stroke presentation can infrequently resemble an ACS. In cases of negative cardiac work-up, a central origin of chest pain should be considered, especially in the presence of subtle other neurological symptoms or signs. Appropriate diagnosis of stroke could avoid treatment delays and improve outcomes., (© 2020 European Academy of Neurology.)

Background and Purpose: Acute ischaemic stroke (AIS) is a vital cause of mortality and morbidity in China. Many AIS patients develop early neurological deterioration (END). This study aimed to construct a nomogram to predict END in AIS patients., Methods: Acute ischaemic stroke patients in Nanjing First Hospital were recruited as the training cohort. Additional patients in Nantong Third People's Hospital were enrolled as the validation cohort. Multivariate logistic regression was utilized to establish the nomogram. Discrimination and calibration performance of the nomogram were tested by concordance index and calibration plots. Decision curve analysis was employed to assess the utility of the nomogram., Results: In all, 1889 and 818 patients were recruited in the training and validation cohorts, respectively. Age [odds ratio (OR) 1.075; 95% confidence interval (CI) 1.059-1.091], diabetes mellitus (OR 1.673; 95% CI 1.181-2.370), atrial fibrillation (OR 3.297; 95% CI 2.005-5.421), previous antiplatelet medication (OR 0.473; 95% CI 0.301-0.744), hyper-sensitive C-reactive protein (OR 1.049; 95% CI 1.036-1.063) and baseline National Institutes of Health Stroke Scale (OR 1.071; 95% CI 1.045-1.098) were associated with END and incorporated in the nomogram. The concordance index was 0.826 (95% CI 0.785-0.885) and 0.798 (95% CI 0.749-0.847) in the training and validation cohorts. By decision curve analysis, the model was relevant between thresholds of 0.06 and 0.90 in the training cohort and 0.08 and 0.77 in the validation cohort., Conclusions: The nomogram composed of hyper-sensitive C-reactive protein, age, diabetes mellitus, atrial fibrillation, previous antiplatelet medication and baseline National Institutes of Health Stroke Scale may predict the risk of END in AIS patients., (© 2020 European Academy of Neurology.)

Background and Purpose: Post-stroke fatigue (PSF) is a common neuropsychiatric affective symptom occurring after stroke. Evidence indicates activated inflammatory pathways are involved in modulating the stroke and fatigue. High-sensitivity C-reactive protein (hs-CRP) is one of the most sensitive indicators of inflammation. Our aim was to estimate the association between plasma hs-CRP and PSF after acute ischaemic stroke., Methods: In all, 212 acute ischaemic stroke patients were consecutively recruited within the first 14 days after stroke onset and followed up for 6 months. Plasma hs-CRP levels were assayed by enzyme linked immunosorbent assay. Fatigue severity was assessed using the Fatigue Scale for Motor and Cognitive Functions. A score ≥ 43 is defined as PSF., Results: Sixty-eight stroke patients (32.1%) were diagnosed with PSF at 6 months' follow-up. In the patients with PSF, plasma hs-CRP levels were significantly higher compared with those in non-PSF patients (t = -8.524, P ≤ 0.001). In multivariate analyses, plasma levels of hs-CRP were independently associated with PSF at 6 months (odds ratio 3.435, 95% confidence interval 2.222-5.309; P ≤ 0.001) after adjusting other recorded variables. Based on the receiver operating characteristic curve, the optimal cut-off value of plasma hs-CRP levels as an indicator for the prediction of PSF was projected to be 0.52 mg/dl, which yielded a sensitivity of 77.9% and a specificity of 74.3%, with the area under the curve 0.794 (95% confidence interval 0.725-0.864; P ≤ 0.001)., Conclusion: Elevated plasma hs-CRP levels at admission were associated with PSF 6 months after stroke, suggesting that these alterations might predict the development of PSF in stroke patients., (© 2020 European Academy of Neurology.)

Background and Purpose: Tirofiban administration during mechanical thrombectomy (MT) remains controversial. The aim was to evaluate the safety and efficacy of a low-dose rescue tirofiban regimen during MT for Chinese acute ischaemic stroke (AIS) patients., Methods: Patients from the ANGEL study, a multicentric, prospective registry study that included AIS patients who underwent MT owing to proximal large-artery occlusion from June 2015 to December 2017, were collected. The patients were dichotomized into tirofiban and non-tirofiban groups according to whether rescue tirofiban was performed during MT. Safety outcomes [symptomatic intracerebral haemorrhage (sICH), total intracerebral haemorrhage (ICH) and distal embolization] and efficacy outcomes (artery recanalization and functional outcomes at 3-month follow-up) were compared between groups using logistic regression analysis., Results: A total of 662 patients were included in this study, and 230 (34.7%) were in the tirofiban group. No significant differences in safety outcomes on sICH, total ICH and distal embolization and efficacy outcomes on artery recanalization and 3-month functional independence were observed between the tirofiban and non-tirofiban group in the entire cohort or the anterior circulation stroke or posterior circulation stroke patients (P > 0.05 for all groups). However, low-dose rescue tirofiban was significantly correlated with 3-month mortality reduction for posterior circulation stroke patients [adjusted hazard ratio 0.35 (0.14-0.92), P = 0.03]., Conclusions: Low-dose rescue tirofiban during MT was not associated with increased risk of sICH, ICH and distal embolization for AIS patients, and may be correlated with 3-month mortality reduction for posterior circulation stroke., (© 2020 European Academy of Neurology.)

Background and Purpose: The rate at which the chance of a good outcome of endovascular stroke therapy (EVT) decays with time when eligible patients are selected by baseline diffusion-weighted magnetic resonance imaging (DWI-MRI) and whether ischaemic core size affects this rate remain to be investigated., Methods: This study analyses a prospective multicentre registry of stroke patients treated with EVT based on pretreatment DWI-MRI that was categorized into three groups: small [Diffusion-Weighted Imaging Alberta Stroke Program Early Computed Tomography Score (DWI-ASPECTS)] (8-10), moderate (5-7) and large (<5) cores. The main outcome was a good outcome at 90 days (modified Rankin Scale 0-2). The interaction between onset-to-groin puncture time (OTP) and DWI-ASPECTS categories regarding functional outcomes was investigated., Results: Ultimately, 985 patients (age 69 ± 11 years; male 55%) were analysed. Potential interaction effects between the DWI-ASPECTS categories and OTP on a good outcome at 90 days were observed (P interaction  = 0.06). Every 60-min delay in OTP was associated with a 16% reduced likelihood of a good outcome at 90 days amongst patients with large cores, although no associations were observed amongst patients with small to moderate cores. Interestingly, the adjusted rates of a good outcome at 90 days steeply declined between 65 and 213 min of OTP and then remained smooth throughout 24 h of OTP (P nonlinearity  = 0.15)., Conclusions: Our study showed that the probability of a good outcome after EVT nonlinearly decreased, with a steeper decline at earlier OTP than at later OTP. Discrepant effects of OTP on functional outcomes by baseline DWI-ASPECTS categories were observed. Thus, different strategies for EVT based on time and ischaemic core size are warranted., (© 2019 European Academy of Neurology.)

Background and Purpose: C-type lectin-like receptor 2 (CLEC-2) has prominent involvement in platelet activation, which is increased in coronary heart disease and acute ischaemic stroke (AIS) and is associated with stroke progression and stroke prognosis. Here, the aim was to examine the prognostic value of CLEC-2 in death and vascular event recurrence in AIS patients., Methods: In all, 352 patients with AIS were studied prospectively. All patients were followed up for 1 year. Death for all vascular events and a combination of death and vascular diseases (recurrent stroke, myocardial infarction, hospitalized and treated angina, hospitalized and treated peripheral arterial disease) were recorded., Results: During 1 year of follow-up, 46 patients (14.2%) experienced death or combined end-points (23 death and 46 combined end-points). Plasma CLEC-2 (pCLEC-2) was significantly associated with an increased risk of death and combined events of death and vascular diseases after adjusting for age, sex, history of hypertension, diabetes mellitus and coronary artery disease, and National Institutes of Health Stroke Scale scores. Each 1 SD higher log-transformed pCLEC-2 was associated with a 4.27-fold (hazard ratio 4.27, 95% confidence interval 1.71-10.65) increased risk for death and a 2.42-fold increased risk for combined end-points (hazard ratio 2.42, 95% confidence interval 1.52-3.86). The optimal cut-off point of pCLEC-2 for predicting death was 184.38 pg/ml., Conclusions: Higher pCLEC-2 levels at admission were associated with increased risk of death and combined events of death and vascular diseases in patients with AIS, which indicated that pCLEC-2 is an important prognostic factor for AIS., (© European Academy of Neurology 2019.)

Background and Purpose: Tirofiban is used off-label in clinical practice for acute ischaemic stroke (AIS). However, it is unknown whether tirofiban increases the bleeding risk or improves the outcome of endovascular treatment (EVT) in AIS. This study evaluated the efficacy and safety of tirofiban in combination with EVT for AIS., Methods: Consecutive patients with AIS receiving EVT were included in the prospective stroke registry from 2015 to 2018. The efficacy outcomes were modified Rankin Scale (mRS) score at 3 months and National Institutes of Health Stroke Scale (NIHSS) score at 24 h. The safety outcomes were symptomatic intracerebral hemorrhage (sICH), any in-hospital intracerebral hemorrhage, in-hospital death and 3-month death., Results: Of 211 patients, 82 (38.9%) received tirofiban. A total of 39 (48.1%) with tirofiban and 44 (36.1%) without tirofiban had mRS score 0-2 [adjusted odds ratio (OR), 2.41; 95% confidence interval (CI), 1.11-5.23, P = 0.026]. NIHSS score at 24 h was lower in the tirofiban group (9.5 vs. 12.0, adjusted P = 0.032). Five (6.1%) patients with tirofiban and 16 (12.4%) without tirofiban had sICH (adjusted OR, 0.54; 95% CI, 0.16-1.83, P = 0.32). In-hospital intracerebral hemorrhage occurred in 10 (12.2%) patients with tirofiban and 41 (31.8%) without tirofiban (adjusted OR, 0.32; 95% CI, 0.13-0.76, P = 0.01). In-hospital death occurred in 7 (8.5%) patients with tirofiban and 16 (12.4%) without tirofiban (adjusted OR, 0.69; 95% CI, 0.22-2.13, P = 0.52). A total of 13 (15.9%) patients with tirofiban and 22 (17.1%) without tirofiban were dead at 3 months (adjusted OR, 0.98; 95% CI, 0.40-2.40, P = 0.96)., Conclusions: Tirofiban in combination with EVT was associated with a lower mRS score at 3 months and NIHSS score at 24 h. It was not associated with a higher rate of sICH, in-hospital death and death at 3 months., (© 2019 EAN.)

Background and Purpose: High blood pressure (BP) at presentation is associated with poor outcomes in acute ischaemic stroke, but serial BP measurements may better delineate the clinical implications of BP. The aim was to investigate the association between various BP parameters and functional outcomes in acute ischaemic stroke patients treated with endovascular thrombectomy (EVT)., Methods: This study reports a retrospective analysis of a prospective registry of a comprehensive stroke centre. Patients treated with EVT due to large vessel occlusion in the anterior circulation were enrolled. BP was measured hourly during the first 24 h after admission. Associations of various BP parameters, including BP variability, with functional outcomes at 3 months, including good outcomes (modified Rankin Scale score of 0-2), were analysed., Results: Of the 378 enrolled patients (mean age 70 ± 11 years, male 54.2%), 313 (82.8%) achieved successful reperfusion after EVT, and 149 (39.4%) had good outcomes at 3 months. Higher mean systolic BP [each 10 mmHg increase, odds ratio 0.82 (0.69-0.97)] and higher systolic successive variation (SV) [each 10% increase, odds ratio 0.37 (0.18-0.76)] were associated with a reduced likelihood of achieving good outcomes. In addition, reperfusion status after EVT moderated the influence of higher systolic SV on good outcomes (P int  = 0.05)., Conclusion: The results showed that a higher mean systolic BP and systolic SV during the first 24 h of EVT reduced the likelihood of good outcomes at 3 months. The effects of these parameters on outcomes are more substantial amongst patients with successful reperfusion after EVT, suggesting that different BP control strategies should be employed according to reperfusion status., (© 2019 EAN.)

Background and Purpose: In 1995 intravenous recombinant tissue plasminogen activator (IVRTPA) was the first reperfusion therapy to be approved in patients with acute ischaemic stroke (AIS). The significance and impact of IVRTPA in times of modern endovascular stroke treatment (EST) were analysed in a German academic stroke centre., Methods: A retrospective observational cohort analysis of 1034 patients with suspected AIS presenting at the emergency department in 2014 was performed. Patients were evaluated for baseline characteristics, reperfusion procedures, IVRTPA eligibility, clinical outcome, symptomatic intracranial haemorrhage (sICH) and mortality. Data acquisition was part of an investigator-initiated, prospective and blinded end-point registry., Results: In 718 (69%) patients the diagnosis of symptomatic AIS was confirmed. 419 (58%) patients presented within 4.5 h of symptom onset and of those 260 (62%) received reperfusion therapy (IVRTPA alone, n = 183; combination or bridging therapy, n = 60; EST alone, n = 17). Subtracting cases with absolute contraindications for IVRTPA resulted in an effective thrombolysis rate of 82%. sICH occurred in two patients treated with IVRTPA alone (1.1%). The median door-to-needle interval was 30 min. Fifty (17%) non-EST eligible AIS patients presenting within 4.5 h without absolute contraindications did not receive IVRTPA mainly due to mild or regressive symptoms. Most of these untreated IVRTPA eligible patients (82%) were discharged with a good clinical outcome (modified Rankin Scale ≤ 2)., Conclusions: Intravenous recombinant tissue plasminogen activator remains the most frequently applied reperfusion therapy in AIS patients presenting within 4.5 h of onset in a tertiary stroke centre. An effective thrombolysis rate of over 80% can be achieved without increased rates of sICH., (© 2018 EAN.)

Background and Purpose: The DAWN trial recently showed compelling evidence in treating late window and wake-up stroke patients with thrombectomy using a clinical-imaging mismatch. The aim was to evaluate the results of thrombectomy for unknown-onset strokes (UOS) treated in our centres after a diffusion weighted imaging/fluid attenuated inversion recovery (DWI-FLAIR) mismatch based selection., Methods: A multicentre, cohort study was performed of consecutive UOS treated by thrombectomy between 2012 and 2016. UOS with proximal anterior circulation occlusion discovered beyond 6 h from 'last seen normal' were compared with known-onset strokes (KOS) for whom thrombectomy was started within 6 h from onset. Time intervals were recorded from first time found abnormal. Results were adjusted for age, diabetes, hypertension, National Institutes of Health Stroke Scale, site of occlusion, DWI Alberta Stroke Programme Early CT Score, intravenous thrombolysis and use of general anaesthesia., Results: Amongst 1246 strokes with anterior circulation occlusion treated by thrombectomy, 277 were UOS, with a 'last time seen well' beyond 6 h and DWI-FLAIR mismatch, and 865 were KOS who underwent groin puncture within 6 h. Favourable outcome was achieved less often in UOS than KOS patients (45.2% vs. 53.9%, P = 0.022). After pre-specified adjustment, this difference was not significant (adjusted relative risk 0.91; 95% confidence interval 0.80-1.04; P = 0.17). No differences were found in secondary outcomes. Time intervals from first found abnormal were significantly longer in UOS., Conclusion: Thrombectomy of UOS with anterior circulation occlusion and DWI-FLAIR mismatch appears to be as safe and efficient as thrombectomy of KOS within 6 h from onset. This pattern of imaging could be used for patient selection when time of onset is unknown., (© 2018 EAN.)

Background and Purpose: Neutrophils, a pivotal immune responder to ischaemic brain insult, have been involved in neuroplasticity and increase after stroke. Recombinant tissue plasminogen activator (r-tPA), a promising treatment improving neuroplasticity, promotes neutrophil degranulation. However, the dynamic profile of neutrophils after r-tPA treatment and their effect on neurological recovery after stroke are not well studied., Methods: Cell counts of neutrophils, lymphocytes and their ratio (NLR) were measured on admission and 24 h after r-tPA infusion in 372 consecutively recruited acute ischaemic stroke patients (mean age 64 years). Death or major disability at 3 months after stroke was diagnosed based on the modified Rankin Scale (mRS ≥ 3) obtained by neurologists who were blinded to any hospital records. The longitudinal associations of percentage increase in neutrophils, lymphocytes and the NLR with death or major disability were examined by logistic regression adjusting for covariates including neurological deficits at baseline., Results: Neutrophils exhibited a steeper increase after r-tPA infusion in patients with death or major disability than in those without (P < 0.001). A 10% increase in neutrophils after r-tPA infusion was associated with an 83% increased risk for death or major disability within 3 months after stroke onset [odds ratio (OR) 1.99, P = 0.009]. Increased neutrophils at 24 h after r-tPA (OR 6.30, P < 0.001 after log transformation) but not on admission significantly predicted increased risks for death or major disability within 3 months after stroke onset. A similar phenomenon was also observed for the NLR., Conclusions: A dynamic increase in neutrophils after stroke significantly predicts 3-month death or major disability in acute ischaemic stroke patients receiving r-tPA treatment., (© 2018 EAN.)

Background: The CHADS 2 and CHA 2 DS 2 -VASc scores are clinical risk stratification instruments that are used clinically to assess the risk of stroke in patients with atrial fibrillation (AF). The aim of this study was to evaluate whether the prestroke CHADS 2 and CHA 2 DS 2 -VASc scores could be useful for predicting infarction severity and long-term outcomes in patients with acute ischaemic stroke., Materials and Methods: This prospective study included all 1494 patients who had acute ischaemic stroke without haemorrhagic transformation which was evidenced with magnetic resonance (MR) imaging during hospitalization. Total infarction volume and arterial stenosis score were calculated based on MR imaging. National Institutes of Health Stroke Scale scores (NIHSSs) were obtained at admission and discharge by board-certified neurologists. The clinical outcomes were defined as composite endpoints of restroke and mortality and were recorded with the mean follow-up period of 37.5 months., Results: There were 195 (13.1%) patients with AF. The patients with AF had significantly higher median CHADS 2 and CHA 2 DS 2 -VASc scores than the patients without AF (P < .001). Patients with higher CHADS 2 and CHA 2 DS 2 -VASc scores had significantly higher total infarction volume, arterial stenosis score and NIHSS scores at discharge and poorer clinical outcomes. After adjusting for age, gender and AF, only CHA 2 DS 2 -VASc scores could predict both restroke and composite endpoints., Conclusions: Prestroke CHA 2 DS 2 -VASc scores appear to have better clinical value for predicting the severity of infarction and long-term clinical outcomes in acute ischaemic stroke patients with and without AF., (© 2017 Stichting European Society for Clinical Investigation Journal Foundation.)

Background and Purpose: Recent cross-sectional study data suggest that intravenous thrombolysis (IVT) in patients with in-hospital stroke (IHS) onset is associated with unfavorable functional outcomes at hospital discharge and in-hospital mortality compared to patients with out-of-hospital stroke (OHS) onset treated with IVT. We sought to compare outcomes between IVT-treated patients with IHS and OHS by analysing propensity-score-matched data from the Safe Implementation of Treatments in Stroke-East registry., Methods: We compared the following outcomes for all propensity-score-matched patients: (i) symptomatic intracranial hemorrhage defined with the safe implementation of thrombolysis in stroke-monitoring study criteria, (ii) favorable functional outcome defined as a modified Rankin Scale (mRS) score of 0-1 at 3 months, (iii) functional independence defined as an mRS score of 0-2 at 3 months and (iv) 3-month mortality., Results: Out of a total of 19 077 IVT-treated patients with acute ischaemic stroke, 196 patients with IHS were matched to 5124 patients with OHS, with no differences in all baseline characteristics (P > 0.1). Patients with IHS had longer door-to-needle [90 (interquartile range, IQR, 60-140) vs. 65 (IQR, 47-95) min, P < 0.001] and door-to-imaging [40 (IQR, 20-90) vs. 24 (IQR, 15-35) min, P < 0.001] times compared with patients with OHS. No differences were detected in the rates of symptomatic intracranial hemorrhage (1.6% vs. 1.9%, P = 0.756), favorable functional outcome (46.4% vs. 42.3%, P = 0.257), functional independence (60.7% vs. 60.0%, P = 0.447) and mortality (14.3% vs. 15.1%, P = 0.764). The distribution of 3-month mRS scores was similar in the two groups (P = 0.273)., Conclusions: Our findings underline the safety and efficacy of IVT for IHS. They also underscore the potential of reducing in-hospital delays for timely tissue plasminogen activator delivery in patients with IHS., (© 2017 EAN.)

Background and Purpose: The aim of the study was to analyze the effect of conventional glucose management, which aimed to maintain glucose levels <155 mg/dL (8.5 mmol/L), on glucose control and the outcomes of patients with acute ischaemic stroke (IS) in a clinical practice setting., Methods: This was a multicenter, prospective cohort study of patients with acute IS. Patients were classified into four groups based on their initial 48-h capillary glucose levels and the administration of and response to corrective treatment: (i) untreated and maximum glucose levels <155 mg/dL (8.5 mmol/L) within the first 48 h; (ii) treated and good responders [glucose levels persistently <155 mg/dL (8.5 mmol/L)]; (iii) treated and non-responders [any glucose values ≥155 mg/dL (8.5 mmol/L) during the 24 h after the start of corrective treatment]; and (iv) untreated with any glucose value ≥155 mg/dL (8.5 mmol/L). The primary outcome was death or dependence at 3 months (blinded rater)., Results: A total of 213 patients were included. Ninety-seven (45.5%) patients developed glucose levels ≥155 mg/dL (8.5 mmol/L), 69 (71.1%) underwent corrective treatment and 31 patients underwent no corrective treatment at the physician's discretion [28 of whom had isolated values ≥155 mg/dL (8.5 mmol/L)]. Only 11 (16%) patients responded to conventional treatment, whereas 58 (84%) patients were non-responsive. Non-responders showed a twofold higher risk of death or dependence at 3 months (odds ratio, 2.472; 95% confidence interval, 1.096-5.576; P = 0.029)., Conclusions: Lack of response to conventional treatment for glucose management in acute IS is frequent and associated with poor outcomes., (© 2017 EAN.)

Background and Purpose: The effect of the triglyceride (TG) to high-density lipoprotein cholesterol (HDL-C) ratio (TG/HDL-C) on clinical outcomes of acute ischaemic stroke (AIS) patients is unclear. This study sought to determine whether the TG/HDL-C ratio in AIS patients is associated with worse outcomes at 3 months., Methods: Acute ischaemic stroke patients who were admitted from 2011 to 2014 were enrolled in this study. TG, total cholesterol (TC), HDL-C and low-density lipoprotein cholesterol (LDL-C) were collected on admission. Three end-points were defined according to the modified Rankin scale (mRS) score at 3 months after symptom onset (excellent outcome, mRS 0-1; good outcome, mRS 0-2; and death, mRS 6)., Results: In all, 1006 patients were included (median age 68.5 years; 58.2% male). Higher TG, non-HDL-C and TG/HDL-C were strongly associated with the three end-points after adjustments: excellent [odds ratio (OR) = 1.39, OR 1.89 and OR 2.34, respectively] and good (OR 1.48, OR 2.90 and OR 4.12) outcomes, and death (OR 0.59, OR 0.29 and OR 0.26). According to receiver operating characteristic (ROC) analysis, the best discriminating factor was a TG/HDL-C ≥ 0.87 for excellent outcomes [area under the ROC curve (AUC) 0.596; sensitivity 73.3%; specificity 42.7%] and non-death (AUC 0.674; sensitivity 67.8%; specificity 60.6%) as well as a TG/HDL-C ≥ 1.01 for a good outcome (AUC 0.652; sensitivity 61.6%; specificity 63.2%). Patients with a TG/HDL-C < 0.87 had a 2.94-fold increased risk of death (95% confidence interval 1.89-4.55) compared with patients with a TG/HDL-C ≥ 0.87., Conclusions: A lower TG/HDL-C was independently associated with death and worse outcome at 3 months in AIS., (© 2016 EAN.)

Background and Purpose: Baseline collateral status has been correlated with outcomes of acute ischaemic stroke patients receiving intravenous thrombolysis (IVT) in previous studies. We carried out the current systematic review and meta-analysis to synthesize currently available evidence regarding such correlations., Methods: Full-text articles published since 2000 were retrieved and screened. The overall effect sizes of good versus poor collateral status over a series of outcomes and certain baseline features were estimated by random-effects models and presented in risk ratios (RRs) or mean differences., Results: Overall, 28 (3057 patients) and 14 (1584 patients) studies were included in qualitative and quantitative synthesis, respectively. Compared with poor pre-treatment collateral status, good collaterals showed a beneficial effect over the primary outcome of a favorable functional outcome at 3 or 6 months [RR, 2.45; 95% confidence interval, 1.94-3.09; P < 0.001] in acute ischaemic stroke patients receiving IVT treatment. However, such an effect tended to be different between studies with prescribed time windows of 3, 4.5 and > 4.5 h (up to 7 h), with the RRs being 2.21, 2.48 and 5.00, respectively (I 2  = 53%). Good pre-treatment collaterals were also associated with a smaller infarct size at baseline, and a lower rate of symptomatic intracranial hemorrhage and a higher rate of neurological improvement early after IVT treatment., Conclusions: The present study has demonstrated the prognostic value of baseline collateral circulation for outcomes of acute ischaemic stroke patients receiving intravenous reperfusion therapies, studied with different time windows of up to 7 h after ictus for IVT therapy., (© 2016 EAN.)

Background: Autoantibodies to apolipoprotein A-1 (anti-ApoA-1 IgG) were shown to predict major adverse cardiovascular events and promote atherogenesis. However, their potential relationship with clinical disability and ischaemic lesion volume after acute ischaemic stroke (AIS) remains unexplored., Materials and Methods: We included n = 76 patients admitted for AIS and we investigated whether baseline serum anti-ApoA-1 IgG levels could predict (i) AIS-induced clinical disability [assessed by the modified Rankin Scale (mRS)], and (ii) AIS-related ischaemic lesion volume [assessed by Computed Tomography (CT)]. We also evaluated the possible pro-apoptotic and pro-necrotic effects of anti-ApoA-1 IgG on human astrocytoma cell line (U251) using flow cytometry., Results: High levels of anti-ApoA-1 IgG were retrieved in 15·8% (12/76) of patients. Increased baseline levels of anti-ApoA-1 IgG were independently correlated with worse mRS [β = 0·364; P = 0·002; adjusted odds ratio (OR): 1·05 (95% CI 1·01-1·09); P = 0·017] and CT-assessed ischaemic lesion volume [β = 0·333; P < 0·001; adjusted OR: 1·06 (95% CI 1·01-1·12); P = 0·048] at 3 months. No difference in baseline clinical, biochemical and radiological characteristics was observed between patients with high vs. low levels of anti-ApoA-1 IgG. Incubating human astrocytoma cells with anti-ApoA-1 IgG dose dependently induced necrosis and apoptosis of U251 cells in vitro., Conclusion: Anti-ApoA-1 IgG serum levels at AIS onset are associated with poorer clinical recovery and worse brain lesion volume 3 months after AIS. These observations could be partly explained by the deleterious effect of anti-ApoA-1 IgG on human brain cell survival in vitro and may have clinical implication in the prediction of poor outcome in AIS., (© 2016 Stichting European Society for Clinical Investigation Journal Foundation.)

Background and Purpose: Our aim was to investigate whether pulsatile tinnitus (PT) in cervical artery dissection (CeAD) has prognostic significance., Methods: All CeAD patients from the CADISP (Cervical Artery Dissection and Ischemic Stroke Patients) study with documentation of PT were analysed. The presence of PT was systematically assessed using a standardized questionnaire. Stroke severity at admission was defined according to the National Institutes of Health Stroke Scale (NIHSS). Excellent outcome after 3 months was defined as a modified Rankin Scale of 0-1., Results: Sixty-three of 778 patients (8.1%) reported PT. PT+ patients presented less often with ischaemic stroke (41.3% vs. 63.9%, P < 0.001), more often with dissection in the internal carotid artery (85.7% vs. 64.2%, P = 0.001), less often with vessel occlusion (19.0% vs. 34.1%, P = 0.017) and more often with excellent outcome at 3 months (92.1% vs. 75.4%, P = 0.002). Logistic regression analysis identified PT as an independent predictor of excellent outcome after 3 months [odds ratio (OR) 3.96, 95% confidence interval (CI) 1.22-12.87] adjusted to significant outcome predictors NIHSS on admission (OR 0.82, 95% CI 0.79-0.86), Horner syndrome (OR 1.95, 95% CI 1.16-3.29) and vessel occlusion (OR 0.62, 95% CI 0.40-0.94) and to non-significant predictors age, sex, pain and location of CeAD., Conclusion: The presence of PT in CeAD is associated with a benign clinical course and predicts a favourable outcome., (© 2016 EAN.)

Background and Purpose: Stroke is a leading cause of death and severe disability worldwide. Serum biomarkers play a critical role in the assessment of the severity and prognosis in stroke patients., Methods: In this prospective cohort study, the measurement of serum progranulin (PGRN) was conducted in 316 participants, including 216 patients with an identified diagnosis of acute ischaemic stroke and 100 normal control subjects. The primary end-point was defined as all-cause mortality for a short-term follow-up of 6 months. Adverse functional outcome (modified Rankin Scale score ≥3) was considered as the secondary end-point., Results: The median value of serum PGRN for patients with acute ischaemic stroke was 64.2 ng/ml (interquartile range 54.6-73.7), which was significantly higher than the control group [59.7 (54.4-64.4) ng/ml; P < 0.001]. Multivariable linear regression suggested that PGRN levels were significantly correlated with body mass index, alcohol consumption, fasting blood glucose, total cholesterol, National Institutes of Health Stroke Scale (NIHSS) score and high-density lipoprotein cholesterol. Serum PGRN concentrations were independently associated with increased risks of all-cause mortality and adverse functional outcome after adjustment for clinical variables. In Cox proportional hazards models, PGRN levels were associated with the risk of mortality (hazard ratio 1.090, 95% confidence interval 1.033-1.150, P = 0.002). The net reclassification improvement of the model with added PGRN was 0.1902 (P = 0.0234) after adjustment for the variables in the Cox regression model for predicting all-cause mortality, and the integrated discrimination improvement was 0.1052 (P < 0.001)., Conclusions: Serum PGRN levels independently predicted all-cause mortality and adverse functional outcome in the short term in stroke patients. The discriminative power was improved by PGRN on the basis of NIHSS score., (© 2016 EAN.)

Patients who suffer acute ischaemic stroke can be treated with thrombolysis if therapy is initiated early. Radiological evaluation of the intracranial tissue before such therapy can be given is mandatory. In this review current radiological diagnostic strategies are discussed for this patient group. Beyond non-enhanced computed tomography (CT), the standard imaging method for many years, more sophisticated CT stroke protocols including CT angiography and CT perfusion have been developed, and additionally an increasing number of patients are examined with magnetic resonance imaging as the first imaging method used. Advantages and challenges of the different methods are discussed., (© 2015 EAN.)

Background and Aims: Different adipokines have been associated with atherosclerotic plaque rupture and cardiovascular events, such as acute ischaemic stroke (AIS). However, the potential role of these molecules in postischaemic brain injury remains largely unknown., Methods and Methods: We performed a substudy analysis on nonobese patients with first atherothrombotic stroke (n = 35) from a recently published prospective cohort. Primary endpoint was to investigate the predictive value of serum leptin/adiponectin ratio on neurological recovery at 90 days after AIS. The secondary endpoint was the predictive value of serum adipokine levels of clinical and radiological outcomes at a shorter follow-up (at days 1 and 7 after AIS). The radiological evaluation included ischaemic lesion volume and haemorrhagic transformation (HT). The clinical examination was based on National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS)., Results: At day 1 after AIS, serum leptin and leptin/adiponectin ratio were increased and inversely correlated with both radiological and clinical parameters at all follow-up time points. Once identified the best cut-off points by receiver operating characteristic (ROC) analysis, risk analysis showed that higher circulating leptin improved neurological recovery at day 90. In addition, leptin/adiponectin ratio maintained statistical significance after adjustment for age, gender and thrombolysis, also predicting the occurrence of HT in the first 7 days after AIS (adjusted OR 0·15 [95% CI 0·03-0·83); P = 0·030])., Conclusions: Higher leptin/adiponectin ratio at day 1 predicted better neurological outcomes in patients with atherothrombotic AIS and might be potentially useful as a prognostic biomarker of the disease., (© 2015 Stichting European Society for Clinical Investigation Journal Foundation.)

Background and Purpose: The CHA2DS2-VASc score is associated with severity and outcome of ischaemic stroke in patients with atrial fibrillation (AF). It was hypothesized that a high CHA2DS2-VASc score was related to severity and outcome because of its association with proximal artery occlusion (PAO). This study aimed to elucidate the relationship between the CHA2DS2-VASc score and PAO and to determine whether the effect of the CHA2DS2-VASc score on severity or outcome is independent of PAO., Methods: Acute stroke patients with AF were retrospectively enrolled. PAO was defined as occlusion at the internal carotid artery or proximal middle cerebral artery on admission magnetic resonance angiography. Multivariable analyses were performed to identify independent factors associated with PAO and determine the associations of the CHA2DS2-VASc score with the initial National Institutes of Health Stroke Scale (NIHSS) score and poor functional outcome (discharge modified Rankin scale score 4-6)., Results: In all, 213 patients [102 women; median age 80 (interquartile range 71-86) years; NIHSS score 16 (9-22)] were enrolled. On multivariable analysis, the CHA2DS2-VASc score (odds ratio 1.40, 95% confidence interval 1.12-1.76 per 1 point) was independently associated with PAO and correlated with the initial NIHSS score (standardized coefficient 0.198, P = 0.017). This association was not significant after further adjustment for PAO (0.080, P = 0.241). The CHA2DS2-VASc score was independently related to poor outcome even adjusted for PAO (odds ratio 1.39, 95% confidence interval 1.03-1.88)., Conclusion: The CHA2DS2-VASc score was associated with PAO in acute ischaemic stroke patients with AF. The CHA2DS2-VASc score may be correlated with the NIHSS score through the presence of PAO and with poor functional outcome independently of PAO., (© 2015 EAN.)

Background and Purpose: The direct bridging concept in acute stroke treatment combines intravenous thrombolysis (IVT) and endovascular treatment (EVT). The frequency and extent of reperfusion obtained already due to IVT were evaluated. Additionally undesired events and the clinical outcome were analysed., Methods: Fifty-seven acute stroke patients treated with direct bridging were analysed for this study. The response to IVT was evaluated according to the modified Thrombolysis in Cerebral Infarction scale (m-TICI). IVT responders (m-TICI ≥2B in digital subtraction angiography) were compared with IVT non-responders (m-TICI <2B in digital subtraction angiography) with respect to clinical outcome and occurrence of undesired events., Results: Fourteen patients (25%) got a change from TICI 0 to ≥2B due to IVT alone. There were otherwise no differences between the IVT responders and IVT non-responders., Conclusions: Intravenous thrombolysis pretreatment in the context of the bridging approach contributes substantially to revascularization., (© 2014 EAN.)

Background and Purpose: Patients with prior stroke within 3 months have been mostly excluded from randomized thrombolysis trials mainly because of the fear of an increased rate of symptomatic intracerebral hemorrhage (sICH). The aim of this study was to compare baseline characteristics and clinical outcome of thrombolyzed patients who had a previous stroke within the last 3 months with those not fulfilling this criterion (comparison group)., Methods: In all, 1217 patients were included in our analysis (42.2% women, mean age 68.8 ± 14.4 years)., Results: Patients with previous stroke within the last 3 months (17/1.4%) had more often a basilar artery occlusion (41.2% vs. 10.8%) and less frequently a modified Rankin scale (mRS) score 0-1 prior to index stroke (88.2% vs. 97.3%) and a higher mean time lapse from symptom onset to thrombolysis (321 min vs. 262 min) than those in the comparison group. Stroke severity was not different between the two groups. Rates of sICH were 11.8% vs. 6%. None of the sICHs and only one asymptomatic intracerebral hemorrhage occurred in the region of the former infarct. At 3 months, favorable outcome (mRS ≤ 2) in patients with previous stroke within 3 months was 29.4% (vs. 48.9%) and mortality 41.2% (vs. 22.7%)., Conclusions: In patients with prior stroke within the last 3 months, none of the sICHs and only one asymptomatic intracerebral hemorrhage occurred in the region of the former infarct. The high mortality was influenced by four patients, who died until discharge due to acute major index stroke. It is reasonable to include these patients in randomized clinical trials and registries to assess further their thrombolysis benefit-risk ratio., (© 2014 The Author(s) European Journal of Neurology © 2014 EAN.)

Background and Purpose: The characteristics of reverse magnetic resonance angiography and diffusion-weighted imaging (MRA-DWI) mismatch (RMM), defined as a large DWI lesion in the absence of major artery occlusion (MAO), remain unknown, especially in patients treated with intravenous recombinant tissue plasminogen activator (rt-PA)., Methods: Patients with stroke in the middle cerebral artery territory were included. Early ischaemic changes (EIC) were assessed with the Alberta Stroke Program Early CT Score on DWI (DWI-ASPECTS). All patients were divided into four groups based on the presence of MAO and a DWI-ASPECTS cut-off value of <7. RMM was defined as DWI-ASPECTS <7 without MAO. Clinical characteristics, symptomatic intracerebral hemorrhage (sICH) and favorable functional outcome (modified Rankin Scale score 0-2) at 90 days were compared amongst the four groups., Results: Of the 486 patients enrolled (167 women, median age 74 years, median initial National Institutes of Health Stroke Scale score 13), reverse MRA-DWI mismatch was observed in 24 (5%). Of the clinical characteristics, cardioembolism was the only factor that was independently associated with RMM [odds ratio (OR) 5.49, 95% confidence interval (CI) 1.25-24.1]. Multivariable analyses revealed that patients with RMM more commonly had sICH than those with DWI-ASPECTS ≥ 7 irrespective of the presence (OR 5.44, 95% CI 1.13-26.1) or absence (13.1, 2.07-83.3) of MAO, and they had a more favorable functional outcome than those with DWI-ASPECTS < 7 plus MAO (7.45, 2.39-23.2)., Conclusion: RMM was observed in 5% of patients treated with rt-PA and associated with cardioembolism. Patients with RMM may benefit from thrombolysis compared with those with EIC with MAO, although increment in the rate of sICH is a concern., (© 2013 The Author(s) European Journal of Neurology © 2013 EFNS.)

Background and Purpose: Hemorrhagic transformation (HT) is one of the most problematic complications to arise from intravenous thrombolysis (IVT). This study was conducted to assess whether micro- and macroalbuminuria could be associated with HT after IVT in patients with acute ischaemic stroke, and to investigate whether the value of urinary albumin-to-creatinine ratios would correlate with the degree of HT., Methods: This was a retrospective study of stroke patients who had undergone IVT within 3 h of symptom onset. Albuminuria assessment was based on random morning spot urine collection with patients in a fasting state, the first morning after IVT. Multiple logistic regression analysis was used to evaluate whether the presence of micro- and macroalbuminuria might be independent predictors of HT., Results: One-hundred and fifty-four patients were included in the study. Fifty-one patients had HT. The presence of micro- or macroalbuminuria was associated with HT after adjustment for variables with clinical significance (adjusting for age, atrial fibrillation, platelet counts, baseline National Institutes of Health Stroke Scale score, hypertension and diabetes mellitus; odds ratio, 2.542; 95% confidence interval, 1.106-5.841; P = 0.028). There were significant relationships between the presence of micro- and macroalbuminuria and types of HT., Conclusion: In conclusion, the results of this study suggest that the presence of micro- and macroalbuminuria after IVT could be a predictor of severe HT in patients with acute ischaemic stroke., (© 2013 The Author(s) European Journal of Neurology © 2013 EFNS.)