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Background and Purpose: Diagnosis of posterior circulation stroke may be challenged. National Institutes of Health Stroke Scale (NIHSS) and brain imaging (non-contrast brain computed tomography-CT) are used for diagnosis; evaluation on posterior circulation stroke remains a limit of NIHSS, and the value of non-contrast CT (NCCT) is limited due to artifacts caused by the bones of the base of the skull. We tested the validity and prognostic value of posterior circulation Alberta Stroke Program Early CT Score (pc-ASPECTS) in patients with posterior circulation stroke., Methods: Pc-ASPECTS allots the posterior circulation 10 points. We studied 50 patients with posterior circulation stroke. We applied pc-ASPECTS to NCCT, CT angiography, and CT Perfusion. We evaluated the correlation of pc-ASPECT with outcome parameters for stroke., Results: Out of 50 patients, CTP showed abnormalities in 34 cases. The pc-ASPECT score calculated on brain CT and on the brain CT + angio CT had a sensibility of 24%, calculated on brain CT, angio CT and CTPerfusion gain a sensibility of 72%. Pc-ASPECT MTT resulted to be the more reliable parameter: outcome given by NIHSS score at discharge, mRS at discharge, and at 3 months was more severe in patients with Pc-ASPECT MTT alteration. Outcome given by NIHSS score at discharge and mRS at discharge and 1 at 3 months was more severe in patients with higher NIHSS score at admission., Conclusion: We evaluated the usefulness of pc-ASPECTS on CTP in predicting functional outcome in acute posterior circulation stroke that appears to be a powerful marker for predicting functional outcome., (© 2021. Fondazione Società Italiana di Neurologia.)

Objective: Advanced neuroimaging has proved to be pivotal in the management of acute ischemic stroke. The use of CT perfusion (CTP) core and penumbra parameters to predict the outcome in wake-up stroke (WUS) patients in everyday clinical scenarios has not yet been investigated. The aim of our study was to investigate the predictive power of CTP parameters on functional and morphological outcomes in WUS patients treated with recombinant tissue plasminogen activator (rTPA)., Approach: We analyzed clinical data and processed CTP images of 83 consecutive WUS patients treated with rTPA. The predictive power of whole-brain CTP features and of the clinical stroke-related parameters to predict the National Institutes of Health Stroke Scale (NIHSS) score at the seventh day and ischemic lesion volume outcome was investigated by means of multivariate regression analysis as well as least absolute shrinkage and selection operator (LASSO) modeling., Main Results: Multivariate analysis showed that CTP core volume (β = 0.403, p = 0.000), NIHSS at admission (β = 0.323, p = 0.005) and Alberta Stroke Program Early CT (ASPECT) score (β = -0.224, p = 0.012) predict NIHSS at 7 days, while total hypoperfused volume (β = 0.542, p = 0.000) and core volume on CTP (β =0.441, p = 0.000) predict infarct lesion volume at follow-up CT. The LASSO modeling approach confirmed the significant predictive power of CTP core volume, total hypoperfused CTP volume, NIHSS at baseline and ASPECT score, producing a sparse model with adequate reliability (the root mean square error on a previously unseen testing dataset was 3.68)., Significance: Our findings highlight the importance of CT multimodal imaging features for decision-making and prediction in the hyperacute phase of WUS. The predictive model supports the hypothesis that an irreversible necrotic core rather than the extent of the penumbra is the main prognostic factor in WUS patients treated with rTPA.

Introduction: Recombinant tissue plasminogen activator (rt-PA) is the first-line therapy demonstrated to be safe and effective in acute ischemic stroke. People with pre-existing severe dementia or physical disability are usually excluded from rt-PA. The aim of our study was to investigate rt-PA safety and effectiveness in acute stroke with pre-existing disability (mRS ≥ 2)., Methods: The study encompassed 35 acute ischemic stroke patients with mRS ≥ 2 treated with rt-PA. In order to assess the differences in clinical outcome in three disability groups (mRS = 2; 3; 4/5), the following parameters were evaluated: intracerebral hemorrhage, mortality, NIHSS, ΔNIHSS and mRS., Results: Baseline-NIHSS and age were not significantly different among groups. Mortality was higher in the pre-morbid mRS 4/5 group (44%) than in the pre-morbid mRS2 (16.7%) and mRS 3 groups (21.4%). In survived patients, median ΔNIHSS% was higher in the mRS2 and 3 groups (-63.3% and -92.3%, respectively) than in the mRS4/5 group (-9.1%). The 247 rt-PA treated subjects with mRS < 2 in the same period showed lower mortality rate (4.7%), lower sICH (5%), lower mRS at discharge (median 1; range 0-6) and similar ΔNIHSS% (-75%)., Conclusion: Patients with mRS 2 and 3 may benefit from rt-PA with a moderate risk of sICH and mortality., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Hypohydration has been suggested increasing the risk of vascular diseases, and it is associated with poor prognosis and worse functional outcome in stroke. Most studies have used blood parameters to determine patients' hydration status. The aim of this study was to measure urine osmolality (uOsm) and its influence on stroke severity and independence. A prospective descriptive study was conducted in stroke patients admitted to a stroke unit. All patients underwent neurological evaluation at admission and discharge using the National Institute of Health Stroke Scale (NIHSS). Independence at discharge was evaluated with the Barthel Index (BI) and the modified Rankin Scale (mRS). uOsm was measured at admission. Patients were grouped in "poor fluid intake" (PF) and "euhydration" (EU), the latter if uOsm ≤ 500 mOsm/kg. Among 119 included patients, the prevalence of PF was 52%, with no difference observed between groups in demographics or blood samples analyses. PF had higher chances of NIHSS > 8 at admission (OR: 4.7 95% CI: 1.3-17.0; p = 0.02), lower BI at discharge (β: -15.3 95% CI: -26.7 to -3.8; p = 0.01), and worse mRS at discharge (OR: 4.01 95% CI: 1.2-14.0; p = 0.02). These findings are consistent with previous results, suggesting that uOsm may be a factor significantly associated with stroke severity and independence outcome after acute ischemic stroke., Competing Interests: Declaration of Competing Interest The authors declare no conflict of interest for this study, and this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. ACQUA@BRAIN was part of the standard care of the ASUITs stroke unit and was supported by regional fundings for quality improvement., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Objectives: The combined use of perfusion neuroimaging and brain oscillatory activity may provide a better clinical picture of neurovascular coupling of the injured area in ischemic stroke. The aim is to assess stroke-related topographic electroencephalography (EEG) changes during the earliest phase of ischemic stroke and to compare them with hypoperfusion identified by computer tomography perfusion (CTP)., Patients and Methods: The study included 15 patients with ischemic stroke, who underwent both CTP and EEG recording within 4.5 h. Topographic representation of power for each band was calculated and compared with hypoperfusion areas estimated by CTP maps., Results: Predominance of slow delta frequencies was found in all patients. The main finding is the agreement between slow rhythms hemispheric prevalence on EEG maps and cerebral hypoperfusion area identified using CTP., Conclusion: The results of this preliminary study show that the combined use of EEG and CTP, as highly available techniques, in acute ischemic stroke may be helpful in clinical practice and provide information about functional and metabolic aspects of brain involvement. The joint use of these methodologies may give a better clinical insight of the functionality of injured area in the hyperacute phase., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Purpose: Isolated speech impairment is one of the most challenging clinical manifestations of stroke mimic (SM). We aimed to investigate perfusional and EEG pattern of isolated aphasia to better differentiate between vascular and epileptic etiology in emergency settings., Method: We retrospectively analyzed 481 cases with acute focal neurological symptoms admitted to our Stroke Unit. The patients showing isolated aphasia and confirmed ischemic infarction or SM with seizure etiology on follow-up were included for subsequent analysis of clinical, neuroimaging, and EEG data. We investigated differences in CT Perfusion maps between ROI in the anatomical area compatible with clinical presentation, contralateral ROI and EEG in order to evaluate perfusion and brain oscillatory activity abnormalities., Results: 45 patients presented isolated aphasia as principal neurological symptom: 27 cases due to acute ischemic event, 11 due to seizure SM, while 7 were SM due to other etiologies. Out of 11 SM patients with seizure etiology, significant hyperperfusion on CTP maps (MTT AI%<-10%) and sharp EEG waves were observed in 8 patients, while in 3 patients slight hypoperfusion (MTT AI%<20%) and slow EEG rhythms were detected. 24 out of 27 ischemic stroke patients presented severe hypoperfusion with MTT AI above the stroke threshold (MTT AI > 45%). All ischemic stroke patients presented slower EEG rhythms., Conclusions: The main finding of this study is the identification of different clinical and neuroimaging patterns of isolated aphasia with epileptic or ischemic etiology in emergency settings., (Copyright © 2019 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

Introduction: Stroke mimics (SM) account for 1% to 41% of all AIS presentation. Seizures are the most frequent cause of mimic, but isolated speech impairment, among adult-onset epilepsy, is quite rare, while aphasia is more often due to an AIS. Prompt AIS/SM recognition is required to establish the most appropriate therapeutic management. We aimed at identifying some predictive clinical and anamnestic features useful to differentiate SM from AIS, particularly in patients presenting with aphasia., Materials and Methods: A retrospective study of patients admitted for a suspected stroke, from January 2015 until January 2017 was performed. We identified patients discharged with a final diagnosis of aphasia and patients with seizures presenting with speech impairment. Anamnestic, clinical and diagnostic were reviewed. Univariate analyses determined key clinical features predictive of AIS versus an epileptic SM., Results: 72 patients with sudden onset of aphasia were identified. A cerebrovascular etiology was diagnosed in 50 patients while an epileptic SM in 22. The presence of ischemic cardiopathy, atrial fibrillation and mild lateralizing signs were strongly suggestive of stroke. Otherwise, a previous history of epilepsy, alteration of consciousness, concomitant infection and electrolyte imbalance were predictors of a SM., Conclusions: Our study underscores the importance of an accurate clinical bed-side assessment as the first step in the diagnostic and therapeutic decision-making process for patients presenting with aphasia. The detection of clinical and anamnestic features associated with an epileptic SM could be useful for the diagnostic process and for time-critical treatments., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Introduction: Intravenous thrombolysis within 4.5 hours from symptom onset improves functional outcome in acute ischemic stroke patients. Repeated intravenous tissue plasminogen activator (IVtPA) is contraindicated in patients presenting with early recurrent stroke (ERS) within 3 months from the initial stroke because of a greater risk of intracranial hemorrhage., Case Presentation: A 59-year-old man presented with ERS, National Institute of Health Stroke Scale of 16, 10 days after a previous stroke. Brain computed tomography (CT) showed a previous hypodensity with 4 cm volume. Angio-CT highlighted the left middle cerebral artery and left internal carotid occlusion. Perfusion CT showed small deep core and large penumbra. The patient underwent IVtPA. After 24 hours, the National Institute of Health Stroke Scale was 7, and CT scan showed an acute ischemic lesion in the left basal ganglia area and frontal lobe without hemorrhagic transformation., Conclusion: This case report suggests that further randomized studies may evaluate whether repeated IVtPA may be safe and effective in ERS occurring shortly after a previous stroke when patients experience a period of complete neurological regression, minor disability, and a small infarct volume. Should the hypothesis be confirmed, small volume core and wide volume penumbra at perfusion CT may support the decision of adopting IVtPA repetition.

Objective: Ischemic stroke is a neuroemergency condition highly treatable with thrombolysis and thrombectomy. Recently, observational studies have brought insights into clinical and imaging characteristics of wake-up stroke, which interested up to 25% of ischemic stroke patients. In clinical practice, wake-up strokes are usually not considered for reperfusion therapy. The aim of this study was to investigate the use CT perfusion imaging in patients with wake-up stroke and to assess the effect of neuroimaging information provided by CT perfusion maps on the efficacy and safety of thrombolysis and thrombectomy., Patients and Method: We studied 22 wake-up stroke (WUS) patients (13F/9M mean age) who underwent reperfusion therapy after the eligibility assessed by the CT perfusion imaging (< 50% core-to-penumbra ratio and negative CT perfusion)., Results: Mean National Institutes of Health Stroke Scale (NIHSS) was 8.1 ± 4.9 at admission while 3.3 ± 5.1 at discharge, significantly different from admission (p < 0.001). As many as ten patients had mRS lower than 3 at discharge. Intracranial hemorrhage occurred in five patients and caused symptoms worsening only in two patients (decrease of NIHSS score of 4 points) of which one patient died., Conclusion: The main finding of this study is that wake-up stroke with adequate selection by CT perfusion may benefit reperfusion treatment.

Background: The National Institutes of Health Stroke Scale (NIHSS) is the most adopted stroke patients' evaluation tool in emergency settings to assess the severity of stroke and to determine the patients' eligibility for specific treatments. Computed tomography perfusion (CTP) is crucial to identify salvageable tissue that can benefit from the reperfusion treatment. The aim of this study is to identify the relation between the NIHSS scores and the hypoperfused volumes evaluated by CTP in patients with hyperacute ischemic stroke., Methods: This retrospective study was conducted on 105 patients with ischemic stroke who underwent NIHSS assessment and CTP in the hyperacute phase. Hypoperfused volume was evaluated by CTP maps processed with semi-automatic algorithm. An analysis was conducted to determine the degree of correlation between the NIHSS scores and the ischemic lesion volumes and to investigate the relation between the anterior and the posterior circulation strokes, as well as between the right and the left hemispheric strokes., Results: A significant correlation was found between ischemic volume and NIHSS score at baseline (r = .82; P < .0001) in the entire cohort. A high NIHSS-volume correlation was identified in the anterior circulation stroke (r = .76; P < .0001); whereas, it was nonsignificant in the posterior circulation stroke. NIHSS score and volume correlated for the left and the right hemispheric strokes (r = .83 and .81; P < .0001), showing a slightly higher slope in the left., Conclusion: This study showed a strong correlation between the baseline NIHSS score and the ischemic volume estimated by CTP. We confirmed that NIHSS is a reliable predictor of perfusion deficits in acute ischemic stroke. CTP allows fast imaging assessment in the hyperacute phase. The results highlight the importance of these diagnostic tools in the assessment of stroke severity and in acute decision-making., (Copyright © 2018 National Stroke Association. Published by Elsevier Inc. All rights reserved.)