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There is a pressing clinical need for thrombolytic agents that can effectively disaggregate arterial thrombi in acute ischemic stroke without significantly increasing the risk of bleeding. This pilot study aimed to investigate the safety and efficacy of N-acetylcysteine (NAC) as an adjunctive therapy to intravenous recombinant tissue plasminogen activator (rtPA or alteplase). A randomized, open-label, blinded assessor pilot study was conducted. Patients presenting with an acute ischemic stroke within 4.5 h from onset were randomized into two groups: intravenous NAC and rtPA or rtPA alone. Primary outcomes included intracerebral hemorrhage, symptomatic intracerebral hemorrhage, extracranial bleeding, and adverse reactions. Secondary outcomes comprised major neurological improvement assessed by (National Institute of Health Stroke Scale) NIHSS at 24 h, recanalization on first run of angiography in patients who underwent thrombectomy or on repeat vascular imaging at 24 h, modified Rankin scale, and three-month mortality. Forty patients were enrolled, with 21 receiving only rtPA and 19 receiving NAC with rtPA. Baseline characteristics were comparable among groups. No significant differences were observed in adverse events (p = 0.99), intracranial hemorrhage (p = 0.21), symptomatic intracerebral hemorrhage (p = 0.47), or extracranial bleeding (p = 0.21). Median NIHSS at 24 h was significantly lower in the intervention group (p = 0.03). Functional outcomes and three-month mortality were similar between groups (p = 0.85 and p = 0.99 respectively). The co-administration of N-acetylcysteine with alteplase did not significantly alter safety profiles, morbidity, or mortality at 3 months. While no substantial differences were noted, a slightly improved early neurological outcome was observed in the intervention arm. The study's findings were constrained by a small sample size, emphasizing the necessity for future large-scale trials to comprehensively evaluate the safety and efficacy of N-acetylcysteine as a thrombolytic agent in acute ischemic stroke.Trial Registration Clinical Trials Registry India-CTRI/2019/05/019305., (© 2024. The Author(s).)

Introduction: Two pharmacological possibilities exist for an acute ischemic stroke (AIS): recanalization of the occluded artery and neuroprotection from ischaemic injury, the latter's efficacy being debatable. We sought to determine whether administration of Citicoline immediately after recanalization therapy for AIS would improve clinical and radiological outcome at three months compared to standard treatment alone., Patients and Methods: CAISR was a single centre, randomized, placebo-controlled, parallel-group trial with blinded endpoint assessment. It was approved by the All India Institute of Medical Sciences Institutional ethics committee and registered at the Clinical Trial Registry of India (CTRI/2018/011900). We recruited participants with AIS undergoing recanalization therapy and randomly assigned them to receive either Citicoline or placebo in 1:1 ratio. Citicoline arm patients received Citicoline 1gm BD intravenously for three days, followed by oral citicoline 1gm BD for 39 days. Placebo arm patients received 100ml intravenous normal saline for three days, followed by multivitamin tablet BD for 39 days. All patients received standard of care., Outcome: Blinded assessors did the follow-up assessment at six weeks (MRI Brain-stroke volume) and three months (NIHSS 0-2, mRS 0-2 and Barthel index> = 95)., Results: The infarct volume decreased from week 1 to week 6 by 2.6 cm3 on placebo versus 4.2 cm3 on Citicoline (p-0.483). The OR for achieving NIHSS 0-2, mRS 0-2 and Barthel index> = 95 with Citicoline was found to be 0.96(95%CI 0.39-2.40), 0.92(95%CI 0.40-2.05) and 0.87(95%CI 0.22-2.98) respectively., Conclusion: CAISR was the first to evaluate the role of Citicoline, when used immediately after recanalization therapy, when the penumbral tissue is the most susceptible either to be protected from injury or become ischemic. We did not find any significant difference between the Citicoline or placebo arms with respect to either our primary or secondary outcomes., Competing Interests: NO authors have competing interests.

Background: Pre-stroke anti-platelet (PAP) therapy can potentially influence the severity and outcome after ischemic stroke., Methods: We analyzed data from the prospective multicenter Indo-US collaborative stroke project for the impact of PAP therapy. Outcome measures included the admission National Institute of Health Stroke Scale (NIHSS) score, 3-month modified Rankin scale (mRS) score, and rates of in-hospital mortality and post-ischemic intracerebral hemorrhage., Results: Among 2048 of 2066 patients (M:F = 2:1) with known pre-stroke medication status, 336 (16.3%) were on PAP therapy. As compared to the non-PAP group, the PAP group had significantly higher mean age (62.2 vs 57.4 years, P < 0.001) and significantly more men, vascular risk factors, cerebral microbleeds (12.8% vs 6.2%, P = 0.001) and intravenous thrombolysis treatment (17% vs. 10.6%, P = 0.001). Cardioembolic strokes were significantly more in the PAP group (P < 0.001), but not large artery atherosclerosis. No significant differences were observed in the median NIHSS score (9 vs. 10, P = 0.274), 3-month mRS (score 0-2,51.4% vs. 49.0%, P = 0.428), in-hospital mortality (8.6% vs. 7.8%, P = 0.592), or symptomatic post ischemic intracerebral haemorrhage (12.2% vs. 10.6%, P = 0.382). The PAP group had more stroke recurrence (6.6% vs. 2.9%, P = 0.002) which was not significant (P = 0.065) after multivariate regression analysis adjusting for age, sex and vascular risk factors. PAP therapy was not an independent predictor of initial stroke severity or stroke outcome., Conclusion: PAP therapy has no significant effect on initial stroke severity, rates of post-ischemic hemorrhage with or without thrombolysis, in-hospital mortality, stroke recurrence, and 3-month outcome after ischemic stroke., Competing Interests: None

Introduction: Posterior circulation strokes (PCS) have been less extensively studied than anterior circulation strokes (ACS), especially regarding revascularization therapies. We analyzed the differences in baseline stroke characteristics, revascularization therapy and 3-month outcomes between PCS and ACS in a large prospective multicentre Indian stroke registry., Methods: Patients with acute ischemic stroke recruited in the Indo-US collaborative stroke project from January 2012 to August 2014 were classified into PCS and ACS based on imaging-confirmed infarct location. Demographics, stroke severity, risk factors, and mechanisms were compared. We further compared these parameters in the subgroups who received revascularization therapies (RT) and no revascularization therapies (NRT). The primary outcome was 3-month modified Rankin scale (mRS)., Results: Of 1889 patients (1270 males), 1478 (78.2%) had ACS and 411 (21.8%) PCS. The median NIHSS was lower in PCS (7 vs 11, p < 0.001). Diabetes mellitus and hypertension were more common in PCS and rheumatic heart disease in ACS. Small artery occlusion was higher in PCS (23.8% vs 12.9%, p < 0.001). Only 28 (6.8%) PCS received RT compared to 213 (14.4%) ACS. At 90 days, a good functional outcome (mRS 0-2) was more common in PCS (56.4% vs 45.9%, p < 0.001) in NRT group, while no significant difference was noted in RT group. Stroke territory was not an independent predictor of 3-month outcome in regression analysis. In-hospital mortality was not different between the groups., Conclusions: The 3-month functional outcome and in-hospital mortality were not different between ACS and PCS. Compared to ACS, PCS received revascularization therapies less often., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Stroke is a leading cause of morbidity and mortality in humans. Most strokes are ischemic in nature and early recanalization of occluded vessels determines good outcomes. Recanalization of occluded vessels depends on many angiographic and demographic features. These factors need to be identified for better patient overall outcomes. Better preoperative knowledge of factors can help in customizing our treatment approach and explaining the prognosis to the guardians of the patients. We aim to share our institutional experience with mechanical thrombectomy (MT) for stroke and studied factors that affect an angiographic recanalization of vessels. A retrospective single-center study was conducted involving 104 patients who underwent MT at our institution between January 2016 and December 2019. Patient demographics, baseline characteristics, pre- and postprocedural imaging findings, and other clinical data were meticulously reviewed. We divided patients into successful recanalization (modified thrombolysis in cerebral ischemia [mTICI] 2b or 3) and unsuccessful recanalization (mTICI 2a or 1) groups and various factors were analyzed to evaluate their impact on recanalization rates. In the univariate analysis, a significant association was observed between successful recanalization and several factors: the absence of rheumatic heart disease (RHD) as a risk factor (p = 0.035), the presence of a hyperdense vessel sign (p = 0.003), and the use of treatment methods including aspiration (p = 0.031), stent retriever (p = 0.001), and Solumbra (p = 0.019). However, in the multivariate analysis, none of these factors exhibited statistical significance. The presence of RHD is a risk factor associated with poor angiographic recanalization in all three MT treatment modalities. Based on the above variables we can guide the patients/relatives prior to MT procedure for their better outcome and risk–benefit ratio. [ABSTRACT FROM AUTHOR]

Introduction: Stroke is the most common cause of epilepsy in the adult population. Post-stroke seizures (PSSs) are classified into early-onset seizures (ES) and late-onset (LS). ES can significantly affect the clinical outcome and occurrence of LS. Methods: We analyzed data from a prospective cohort of acute ischemic stroke patients between June 2018 and May 2020 in a neurology unit at a tertiary hospital. We screened all acute stroke patients and included consecutive patients older than 18 years of age, presenting with acute, first-ever neuroimaging-confirmed ischemic stroke. We excluded patients with a previous stroke, transient ischemic attacks, hemorrhagic stroke, cerebral venous thrombosis, prior history of seizures, or any other epileptogenic comorbidity. ES were classified as spontaneous seizures occurring within 1 week of the stroke. The main outcome assessed was the occurrence of ES. The secondary outcome was to determine predictors of ES and create an ES prediction score. Results: We screened 432 patients; of them, 291 were enrolled. ES occurred in 37 patients (12.7%). Cortical location (OR: 4.2), large artery disease subtype (OR: 2.9), mRS at presentation (OR: 1.4), use of anticoagulants (OR: 2.6), and hypertension (OR: 0.3) were significantly associated with the occurrence of ES. Patients with ES had a statistically significant worse clinical outcome at 3 months follow-up (P = 0.0072). Conclusion: We could formulate an ES prediction tool using the following components: (a) cortical location, (b) large vessel stroke, (c) mRS at admission, (d) anticoagulant use, and (e) presence of hypertension. This tool might help in treating patients at high risk for ES with prophylactic ASD, thereby preventing seizures and their complications. [ABSTRACT FROM AUTHOR]

Background: Migraine is a common neurological disorder with significant morbidity and disability. There is growing evidence that migraine is associated with cardiovascular diseases and stroke.Objective: The aim of this study was to provide an update on the association of migraine with some common vascular diseases in persons suffering from the disease and discuss the clinical implications.Methods and Materials: We searched PUBMED database using the MeSH terms "Stroke", "Coronary Artery Disease", "Myocardial Ischemia", "Atrial Fibrillation", "White Matter" and "Dementia, Vascular", in combination with "Migraine Disorders", "Migraine with Aura" and "Migraine without Aura" and reviewed the relevant studies. We studied articles mostly in English for the past 10 years, without excluding older articles that were relevant to this review. We also searched the reference lists of articles obtained and included some insightful reviews on 'Migraine and Vascular Risk'.Results: The association between migraine and vascular diseases is strong and consistent for ischemic stroke and migraine with aura especially in young women, with oral contraceptive use and smoking. Although literature reports a higher prevalence of obesity, dyslipidemia, and family history of cardiovascular diseases in migraineurs, the 'migraine-vascular' connection persists in models where the traditional vascular risk factors are adjusted, implicating a migraine-specific pathophysiology at work. There is some evidence linking an adverse vascular risk factor profile to incident myocardial infarction in people with migraine. The association with hemorrhagic stroke is more variable.Conclusion: Although the absolute effect of migraine on 'vascular risks' is small, good practice parameters dwell on treating and reducing existing cardiovascular risk factors through lifestyle modification, encouraging smoking cessation, and advocating the wise use of agents like ergot alkaloids and oral contraceptives, after a risk-benefit analysis. [ABSTRACT FROM AUTHOR]

Vascular neurology is witnessing unprecedented innovations in the management of acute ischemic stroke, especially in reperfusion strategies. The emergence of mechanical thrombectomy with new generation devices has revolutionized the treatment of acute ischemic stroke with large vessel occlusion. The reperfusion strategies are evolving with the extension of the window period for thrombolysis and endovascular therapy through the concept of "tissue clock" in addition to the established "time clock." The newer generation of thrombolytic drugs like tenecteplase are promising exciting times ahead in acute stroke care. In this "viewpoint,'" the evolution of reperfusion therapy in acute ischemic stroke will be discussed followed by recent innovations in reperfusion strategies. [ABSTRACT FROM AUTHOR]

Background: Minocycline is a semisynthetic derivative of the tetracycline group of antibiotics, which have neuroprotective effects. In animal stroke models, minocycline had shown promising evidence to improve clinical and functional outcomes. Objective: To analyze the effect of oral minocycline in acute ischemic stroke patients. Materials and Methods: This was a randomized single-blinded open-label study. The study group received oral minocycline 200 mg/day for 5 days and the control group received oral vitamin B capsules. Baseline assessment included the following: National Institute of Health Stroke Scale (NIHSS) score, modified Barthel Index (mBI), modified Rankin Scale (mRS) score, Magnetic Resonance Imaging (MRI) of brain including Diffusion Weighted Imaging (DWI), chest X-ray, and routine laboratory investigations. The clinical scales were repeated at days 1, 7, and 30. The end point was outcomes at 3 months (90 days). Statistical analysis was done with SPSS 11.5 (P<0.05). Paired t-test and multiple-measures Analysis Of Variance (ANOVA) were used. Results: Fifty patients with acute ischemic stroke were included in the study. Of these, 23 patients received minocycline and 27 patients received placebo i.e., vitamin B capsules. NIHSS score in patients receiving minocycline had shown statistically significant improvement at day 30 and 90 as compared with the controls. Similarly, mRS scores and BI showed significant improvement in patients receiving minocycline at three months as compared to the control group. No mortality, myocardial infarctions, recurrent strokes, and hemorrhagic transformations were noted in both groups. Conclusions: Patients with acute ischemic stroke had significantly better outcome with minocycline treatment as compared with those administered placebo. The above findings suggest that minocycline can be helpful in reducing the clinical deficits after acute ischemic stroke. [ABSTRACT FROM AUTHOR]