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Kawasaki-like disease (KLD) and multisystem inflammatory syndrome in children (MIS-C) are considered as challenges for pediatric patients under the age of 18 infected with coronavirus disease 2019 (COVID-19). A systematic search was performed on July 2, 2020, and updated on December 1, 2020, to identify studies on KLD/MIS-C associated with COVID-19. The databases of Scopus, PubMed, Web of Science, Embase, and Scholar were searched. The hospitalized children with a presentation of Kawasaki disease (KD), KLD, MIS-C, or inflammatory shock syndromes were included. A total number of 133 children in 45 studies were reviewed. A total of 74 (55.6%) cases had been admitted to pediatric intensive care units (PICUs). Also, 49 (36.8%) patients had required respiratory support, of whom 31 (23.3%) cases had required mechanical ventilation/intubation, 18 (13.5%) cases had required other oxygen therapies. In total, 79 (59.4%) cases had been discharged from hospitals, 3 (2.2%) had been readmitted, 9 (6.7%) had been hospitalized at the time of the study, and 9 (6.7%) patients had expired due to the severe heart failure, shock, brain infarction. Similar outcomes had not been reported in other patients. Approximately two-thirds of the children with KLD associated with COVID-19 had been admitted to PICUs, around one-fourth of them had required mechanical ventilation/intubation, and even some of them had been required readmissions. Therefore, physicians are strongly recommended to monitor children that present with the characteristics of KD during the pandemic as they can be the dominant manifestations in children with COVID-19., (© 2021 Wiley Periodicals LLC.)

Stroke has a deleterious impact on quality of life. However, it is less well known if stroke lesions in different brain regions are associated with reduced quality of life (QoL). We therefore investigated this association by multivariate lesion-symptom mapping. We analyzed magnetic resonance imaging and clinical data from the WAKE-UP trial. European Quality of Life 5 Dimensions (EQ-5D) 3 level questionnaires were completed 90 days after stroke. Lesion symptom mapping was performed using a multivariate machine learning algorithm (support vector regression) based on stroke lesions 22-36 h after stroke. Brain regions with significant associations were explored in reference to white matter tracts. Of 503 randomized patients, 329 were included in the analysis (mean age 65.4 years, SD 11.5; median NIHSS = 6, IQR 4-9; median EQ-5D score 90 days after stroke 1, IQR 0-4, median lesion volume 3.3 ml, IQR 1.1-16.9 ml). After controlling for lesion volume, significant associations between lesions and EQ-5D score were detected for the right putamen, and internal capsules of both hemispheres. Multivariate lesion inference analysis revealed an association between injuries of the cortico-spinal tracts with worse self-reported quality of life 90 days after stroke in comparably small stroke lesions, extending previous reports of the association of striato-capsular lesions with worse functional outcome. Our findings are of value to identify patients at risk of impaired QoL after stroke.

Non-hemorrhagic brain infarction (BI) is a recognized complication in adults treated with extracorporeal membrane oxygenation (ECMO) and associated with increased mortality. However, predictors of BI in these patients are poorly understood. The aim of this study was to identify predictors of BI in ECMO-treated adult patients. We conducted an observational cohort study of all adult patients treated with venovenous or venoarterial (VA) ECMO at our center between 2010 and 2018. The primary endpoint was a computed tomography (CT) verified BI. Logistic regression models were employed to identify BI predictors. In total, 275 patients were included, of whom 41 (15%) developed a BI. Pre-ECMO Simplified Acute Physiology Score III, pre-ECMO cardiac arrest, VA ECMO and conversion between ECMO modes were identified as predictors of BI. In the multivariable analysis, VA ECMO demonstrated independent risk association. VA ECMO also remained the independent BI predictor in a sub-group analysis excluding patients who did not undergo a head CT scan during ECMO treatment. The incidence of BI in adult ECMO patients may be higher than previously believed and is independently associated with VA ECMO mode. Larger prospective trials are warranted to validate these findings and ascertain their clinical significance.

Introduction: The incidence of lung cancer and acute ischemic stroke remains high in recent years, both of which occur mostly in people over 60 years old. In the present study, we aimed to further clarify the pathogenesis of lung cancer-associated acute ischemic stroke (LCA-AIS) by comparing and analyzing clinical characteristics of stroke patients with or without lung cancer., Methods: A total of 51 patients with lung cancer were selected as the case group (LCSG), and 78 patients without cancer history were adopted as the control group (SG). The data collected in this study included sex, age, traditional cerebrovascular disease risk factors (TCDRFs), blood test index, imaging findings, etiological typing, and prognosis evaluation. SPSS21.0 software was used for statistical analysis. Normally distributed data were analyzed by t-test, and count data were analyzed by chi-square test or exact probability method. P < 0.05 was considered statistically significant., Results: In the case group, the levels of plasma D-dimer, fibrinogen degradation products (FDPs) and NIHSS, as well as the mRS score and mortality of patients, were higher, while the levels of RBC, Hb and Hcy were lower compared with the control group. Imaging findings showed that multivessel involvement was more common in the case group, and the infarcts were more likely to be multiple and involved in both the anterior and posterior circulations. The TOAST classification of LCSG was dominated by stroke of undetermined etiology (SUE) and stroke of other determined etiology (SOE). Statistical analysis showed that the patients were more likely to suffer from acute ischemic stroke within 1 year after the diagnosis of lung cancer (41 cases, 80.39%)., Conclusions: Hypercoagulability and acute multiple brain infarcts were more common in patients with LCA-AIS, and hypoproteinemia and hyponatremia were more likely to occur in these patients, leading to worse prognosis. Patients were most likely to have a stroke within 1 year after the diagnosis of lung cancer., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Aims: To investigate the relationship between peripheral leukocyte dynamics and the outcome of large hemispheric infarction (LHI) patients., Methods: Patients with acute LHI admitted to the neuro-intensive care unit of Xuanwu Hospital from 2013 to 2017 were prospectively enrolled and followed up for 6 months after LHI., Results: A total of 84 LHI patients were included, 38 patients suffered brain herniation and 20 patients died from stroke. Compared to patients with benign course, LHI patients with fatal outcome showed larger infarcts and more severe brain edema (P < .01), as well as increased WBC and neutrophil counts throughout the first week after stroke (P < .05). Correlation analysis revealed that neutrophil counts on D2 after LHI positively correlated with infarct and edema volumes measured from CT/MRI (R 2  = 0.22 and R 2  = 0.15, P < .01) and negatively correlated with Glasgow Coma Scale (ρ = -0.234, P < .05). Patients with D2 neutrophils > 7.14 × 10 9 /L had higher risk of brain herniation [odds ratio (OR) = 7.5, 95% CI: 2.0-28.1, P = .001], and patients with D2 neutrophils > 7.79 × 10 9 /L had a higher risk of death (OR = 5.8, 95% CI: 1.2-27.0, P = .015)., Conclusion: Early peripheral neutrophil count after stroke relates to infarct size and the fatal outcome of LHI patients, which might help guiding acute LHI management such as reduction of intracranial pressure and potential antiinflammatory therapy in the future., (© 2020 The Authors. CNS Neuroscience & Therapeutics Published by John Wiley & Sons Ltd.)

Mechanical thrombectomy (MT) has been demonstrated as an effective treatment for acute ischemic stroke (AIS), thanks to large vessel occlusion (LVO), especially in case of anterior cerebral artery with many randomized clinical trials (RCTs) every year. On the other hand, there is a limited number of basilar artery occlusion (BAO)-related studies which have been conducted. The fact prompts our range of case studies, which furnish BAO understanding with our experience, results and some prognosis factors of MT. This retrospective and single-center study was conducted on 22 patients who were diagnosed with BAO and underwent the treatment of MT from October 2012 to January 2018. Clinical feature such as radiological imaging, procedure complications, and intracranial hemorrhage were all documented and evaluated. All the studies' results based on performance using modified Rankin scale score (mRS) and mortality at 90 days. The results from these BAO patients study indicated that the posterior circulation Acute Stroke Prognosis Early CT Score (pcASPECTS) recorded before the intervention was 7.7 ± 1.6, while the admission National Institutes of Health Stroke Scale (NIHSS) was 17.5 ± 5.4. 15/22 cases achieved successful recanalization (TICI, Thrombolysis in Cerebral Infarction scale, of 2b-3), accounting for 68.2%. The results highlighted 50% of the favorable outcome (mRS 0-2) occupying 11 out of 22 patients in total and the overall mortality was 36.4%. The intracranial hemorrhagic complication was detected in three cases (13.6%). Placing in juxtaposition the poor-outcome group and the favorable-outcome group, we could witness statistically significant difference (P < 0.05) suggesting both good baseline image (pc-ASPECTS ≥ 7) and recanalization (TICI 2b-3) were two good prognosis factors. Our case series showed that MT would be an effective and feasible treatment for BAO. The pre-procedural pcASPECTS ≥ 7 and post-procedural good recanalization (TICI 2b-3) were two important prognosis factors for predicting good clinical outcome.

Background and Purpose- In pediatric moyamoya disease, there are few reports on the efficacy of surgical intervention for stroke prevention. We evaluated the long-term outcomes of indirect bypass surgery on a relatively large number of children with moyamoya disease in a single center. Methods- From August 1988 to December 2012, 772 children underwent indirect bypass surgery. This study included 629 patients who were followed up for >5 years, excluding patients with moyamoya syndrome. The mean clinical follow-up duration was 12 years (range, 5-29 years). Cross-sectional analysis was performed based on either Karnofsky Performance Scale or Lansky Play Performance Scale to evaluate overall clinical outcomes and factors associated with unfavorable outcomes. To analyze the longitudinal effect of surgery, the annual risk of symptomatic infarction or hemorrhage on the operated hemisphere after indirect bypass surgery was calculated with a person-year method, and the event-free survival rate was evaluated using the Kaplan-Meier method. Results- The overall clinical outcome was favorable in 95% of the patients. The annual risks of symptomatic infarction and hemorrhage on the operated hemispheres were 0.08% and 0.04%, respectively. Furthermore, the 10-year event-free survival rates for symptomatic infarction and hemorrhage were 99.2% and 99.8%. Conclusions- Indirect bypass surgery could provide satisfactory long-term improvement in overall clinical outcome and prevention of recurrent stroke in children with moyamoya disease.

Background and Aims: Increasingly, insertable cardiac monitors (ICM) have been used to detect Atrial Fibrillation (AF) in patients with cryptogenic stroke or embolic strokes of undetermined source (ESUS). We aim to examine the characteristics of these patients who were subsequently found to have AF., Methods: We studied 83 consecutive patients who were comprehensively evaluated using neuroimaging and vessel imaging (computed tomography angiography, magnetic resonance angiography, or transcranial and extracranial Doppler sonography) to have met the previously established ESUS criteria. All 83 patients had ICM implanted between 2015 and 2017. All patients were followed up for at least 1 year, with a median follow-up period of 1.5 ± .5 years. We compared the baseline clinical, laboratory, echocardiographic, neuro-imaging profiles, and clinical outcomes in terms of functional recovery, recurrent stroke, and mortality in patients with and without detected AF., Results: AF detection rate in this ESUS cohort was 12% over the study period. Patients with detected AF were associated with bilateral infarcts pattern at presentation (30% versus 5.5%, P = .035). Infarcts involving multiple vascular territories was not significantly associated with the detection of AF. There were no significant differences in the other clinical characteristics and outcomes between the AF group compared to the group without detected AF. Echocardiographic parameters including left ventricular ejection fraction and left atrial diameter were also not shown to be significantly different., Conclusion: Our study found that a neuroimaging profile of bilateral infarcts was associated with AF detection using insertable cardiac monitor in ESUS patients. Larger prospective studies are needed to validate our findings., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Backgrounds and Purpose: Hemorrhagic transformation (HT) following stroke of the posterior circulation is a rare occurrence, and its risk factors remain relatively unknown. This study aimed at examining the rate of HT and its risk factors in patients enduring acute ischemic stroke in the territories of the vertebral, basilar, and posterior-cerebral arteries., Materials and Methods: A total of 217 consecutive patients the risk factors for ischemic stroke were recorded and comprehensive biochemical, cardiac assessments, and neuroimaging were performed. National Institutes of Health Stroke Scale (NIHSS) scores were calculated for each patient. Those with HT as documented with neuroimaging based on the European Cooperative Acute Stroke Study criteria and potential risk factors were assessed., Results: There were 217 participants with a mean age of 67.33 ± 12.44 years. Among 17 patients (7.8%) developing HT, 8 (47%) had parenchymal hematoma, and 9(53.5%) had hemorrhagic infarction. Cardioembolism was the most frequent etiological factor both in the overall group (31.0%) as well as in those with HT (41.2%). Factors that emerged as significant predictors of HT included high systolic (odds ratio [OR] 1.14; 95% confidence interval [CI] 1.08-1.20; P< .001) and diastolic blood pressure (P= .001) on the day of admission and the infarction volume of greater than or equal to 3.60 ± 3.29 cm³(OR 1.00, 95% CI 1.00-1.01; P< .001). While NIHSS scores were not significantly different on Day 1, HT patients had higher NIHSS scores at Day 10(OR 1.22; 95% CI 1.09-1.36; P< .001), and this difference was also reflected in mRS at the end of the 3 month period., Conclusion: HT is a rare complication of the infarction of the posterior circulation that is associated with increased morbidity and mortality. Identification of predictive factors for HT in patients with the acute infarction of the posterior circulation may facilitate patient selection for thrombolytic treatment., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Quantitative electroencephalography (QEEG) data are useful to predict outcomes of cerebral infarction patients. This study was performed to establish the value of QEEG in the prediction of outcomes in patients with large hemispheric infarction (LHI)., Methods: A prognostic blinded cohort study was conducted on patients diagnosed with LHI in our neurocritical care unit. The electroencephalography (EEG) was recorded at the bedside within 3 days of LHI onset. Each EEG expert scored the raw EEG, and QEEG parameters including the absolute power, (delta + theta)/ (alpha + beta) ratio and brain symmetry index were obtained afterwards. Baseline data including Glasgow Coma Scale (GCS) was recorded at the meantime. Outcomes included survival or non-survival at the time of discharge and 6 months after the onset of LHI., Results: A total of 50 patients entered into the final analysis. There were no differences in baseline data or visual EEG grades between survival and non-survival groups. QEEG analysis showed that the absolute theta power of all of the electrodes and the contralateral electrodes was significantly higher in the non-survival group than in the survival group at discharge. Multivariable logistic regression analysis demonstrated that theta power of the contralateral electrodes was an independent predictor of death at discharge and at 6 months. Compared to the GCS and EEG grading, the QEEG index exhibited higher accuracy in predicting non-survival outcomes., Conclusions: Among QEEG indices, theta power is valuable in predicting non-survival outcome in participants and is superior to visual EEG and GCS., (Copyright © 2019. Published by Elsevier B.V.)

Background and Purpose- Stroke at midlife has a disproportionately large impact on disability-adjusted life-years lost. Ischemic stroke incidence may be increasing at this age. We investigated long-term trends in ischemic stroke incidence and changes in stroke risk factors in a community sample stratified by stroke onset at middle and older age. Methods- In the Framingham Study, surveillance for incident stroke is ongoing since 1948. We examined age-adjusted and sex-adjusted 10-year incidence of ischemic stroke using Cox models in persons aged 35 to 54 and ≥55 years at start of follow-up. Tests for linear trend were performed over 4 epochs, controlling for the distance in time between intervals. Further, we calculated the mean 10-year risk of stroke at each epoch and for both age groups, based on vascular risk factors from the Framingham Stroke Risk Profile. Results- There were 153, 197, 176, and 165 incident ischemic strokes within each epoch beginning in 1962 (n=3966), 1971 (n=5779), 1987 (n=5133), and 1998 (n=6964). Most ischemic strokes at midlife (n=71) were because of atherosclerotic brain infarction (n=50) or cardioembolism (n=19). Using the risk in the 1962 epoch as the reference, the risk of ischemic stroke at midlife did not significantly decline (hazard ratio, 0.87; 95% CI, 0.74-1.02; P trend =0.09). Incidence of ischemic stroke declined in the older group (hazard ratio, 0.82; 95% CI, 0.77-0.88; P trend <0.001). Between epochs 1 and 4, the average 10-year risk of stroke, as estimated by the Framingham Stroke Risk Profile, declined by 0.7% at midlife and 1.1% at older age. Conclusions- Long-term rates of ischemic stroke declined in our community sample; the decline was greater in older as compared with younger adults. Early prevention, focused on modification of cardiovascular risk factors, is important to see sustained declines in stroke incidence and mortality at midlife.

Background: Mechanical thrombectomy (MT) in association with intravenous thrombolysis is recommended for treatment of acute ischemic stroke (AIS), with large vessel occlusion (LVO) in the anterior circulation. Because MT is only available in comprehensive stroke centers (CSC), the challenge of stroke organization is to ensure equitable access to the fastest endovascular suite. Our aim was to evaluate the feasibility, efficacy, and safety of MT in patients initially managed in 1 CSC (mothership), compared with patients first managed in primary stroke center (PSC), and then transferred to the CSC for MT (drip-and-ship)., Methods: We retrospectively analyzed 179 consecutive patients (93 in the mothership group and 86 in the drip-and-ship group), with AIS secondary to LVO in the anterior cerebral circulation and a clinical-radiological mismatch (NIHSS ≥ 8 and DWI-ASPECT score ≥5), up to 6 hours after symptoms onset. We evaluated 3-month functional modified Rankin scale (mRS), periprocedural time management, mortality, and symptomatic intracranial haemorrhage (sICH)., Results: Despite significant longer process time in the drip-and-ship group, mRS ≤ 2 at 3 months (39.8% versus 44.1%, P = .562), Thrombolysis in cerebral infarction 2b-3 (85% versus 78%, P = .256), and sICH (7.0% versus 9.7%, P = .515) were similar in both group regardless of baseline clinical or radiological characteristics. After multivariate logistic regression, the predictive factors for favorable outcome were age (odds ratio [OR] -5years = 1.32, P < .001), initial NIHSS (OR -5points  = 1.59, P = .010), absence of diabetes (OR = 3.35, P = .075), and the delay magnetic resonance imagining-puncture (OR -30min  = 1.16, P = .048)., Conclusions: Our study showed encouraging results from a regional protocol of MT comparing patients transferred from PSC or brought directly in CSC., (Copyright © 2018. Published by Elsevier Inc.)

Objective: We aimed to investigate age-specific clinical characteristics in patients aged >60 years with large hemispheric infarction (LHI)., Methods: We prospectively enrolled consecutive patients with LHI. Patients were divided into two groups: ≤60 vs. >60 years, and demographics, vascular risk factors, clinical feature, in-hospital treatment, 3-month mortality, and unfavorable outcome (defined as a mRS score of 4-6) rate were compared., Results: Of the 256 cases included, 140 (54.7%) were older than 60 years. Compared with the younger, the older patients had higher rates of hypertension (66.4% vs. 31.0%), coronary heart disease (19.3% vs. 2.6%), atrial fibrillation (53.6% vs. 31.0%; all p < 0.001), more history of stroke (21.4% vs. 5.2%, p < 0.001), less history of rheumatic heart disease (16.4% vs. 30.1%, p = 0.009), and alcohol consumption (12.1% vs. 21.6%, p = 0.043). Cardio-embolism is the most common stroke etiology regardless of age (55.7% and 38.8%, respectively). Furthermore, the elderly less frequently received decompressive hemicraniectomy (4.3% vs. 15.5%, p = 0.005) and mechanical ventilation (7.9% vs. 16.4%, p = 0.035) and had a higher frequency of stroke-related complication (83.6% vs. 66.4%, p = 0.001). A total of 26 (18.6%) older patients and 15 (12.9%) younger patients died during hospitalization (p = 0.221), and 59 (42.1%) older patients and 35 (30.2%) younger patients died at 3 months (p = 0.061). Patient aged >60 years had significantly higher unfavorable outcome rate at 3 months (adjusted odds ratio, OR 4.30, 95% confidence interval [CI] 2.08-8.88; p < 0.05]. However, older age is not independently associated with 3-month mortality (42.1% vs. 30.2%, p = 0.095 [log-rank test])., Conclusions: Large hemispheric infarction patients over 60 years old were a little more than those aged ≤60 years and constitute more than half of those suffered from malignant brain edema and two thirds of in-hospital death and 3-month mortality. The elderly had more cardio-origin risk factors, received less aggressive hospital treatment, and showed higher risk of unfavorable outcome than the younger., (© 2018 The Authors. Brain and Behavior published by Wiley Periodicals, Inc.)

Background: Tumor necrosis factor-a-induced protein 8-like 2 (TIPE2) is a novel regulator of immunity and protects against experimental stroke. However, the expression and function of TIPE2 in patients with acute ischemic stroke has not been well demonstrated. Methods: A total of 182 consecutive patients with acute ischemic stroke and 40 healthy controls were included during November 2015 to June 2016. The mRNA levels of TIPE2, interleukin(IL)-1β, IL-10, IL-6, nuclear factor(NF)-κβ, activator protein(AP)-1, interferon(IFN)-γ and tumor necrosis factor(TNF)-α from peripheral blood mononuclear cells were determined using real time quantitative reverse transcriptase polymerase chain reaction. The severity of stroke was assessed using the National Institutes of Health Stroke Scale (NIHSS) score. Results: The median mRNA levels of TIPE2, TNF-α, AP-1, IFN-γ and NF-κβ in patients with acute ischemic stroke were significantly higher than healthy controls (all P <0.001, respectively). Of note, TIPE2 mRNA showed an increasing trend on a time-dependent manner after the onset of stroke. Furthermore, TIPE2 mRNA was negatively associated with lesion volumes (r=-0.23, P <0.01), NIHSS(r=-0.15, P <0.05), TNF-α(r=-0.33, P <0.001), AP-1(r=-0.28, P <0.001), IFN-γ (r=-0.16, P <0.05) and NF-κβ (r=-0.13, P <0.05), but positively associated with IL-6(r=0.14, P <0.05) and IL-10(r=-0.31, P <0.001). Hierarchy cluster analysis showed that TIPE2 mRNA has nearest membership with TNF-α, followed by IL-6, NF-κβ, AP-1, IL-10, IL-1β and IFN-γ. In addition, TIPE2 mRNA in survivals (n=149) was significantly higher than nonsurvivals (n=33) ( P <0.001), and showed a great odd ratio (0.52, 95% confidence interval: 0.349-0.760, P <0.001) on 3-month mortality. Conclusions: TIPE2 mRNA contributed to the immune response of stroke and might be a potential biomarker for the mortality of acute ischemic stroke., Competing Interests: Competing Interests: The authors have declared that no competing interest exists.

Background: The optimization of medical treatment regularly challenges the role of carotid surgery for asymptomatic patients. Current research seeks to determine which of these patients will benefit most from surgery. The goal of this study was to identify in a multicenter study, using magnetic resonance imaging (MRI), the risk factors for postoperative silent cerebral ischemic lesions after carotid surgery for asymptomatic stenosis., Methods: The multicenter, retrospective study included patients with asymptomatic severe carotid stenosis suitable for surgical treatment and who did not have a history of cerebral ischemia. A diffusion MRI scan was performed the day before and in the 3 days after the procedure. An analysis by an independent neuroradiologist determined the presence of preoperative silent ischemia and the appearance of new lesions postoperatively. The analysis also took into account the plaque type, lesions of supra-aortic trunks, the circle of Willis, the type of surgery, and anesthesia, shunt use, and clamp time., Results: Between April 2011 and November 2015, 141 patients were included. The mean degree of carotid stenosis in the patients who underwent surgery was 78.2% ± 6.5, with 9 (6.4%) cases of contralateral stenosis ≥70% and 6 (4.3%) of which were thrombosis. The circle of Willis was incomplete in 23 (16.3%) patients. Twenty-one (14.9%) plaques were of high embolic risk. The preoperative MRI found 34 (24.1%) patients with embolic ischemic lesions. The majority of procedures were eversions performed under general anesthesia, 7 (5%) required a shunt, and the mean clamp time was 39 ± 16 min. The postoperative MRI revealed that 10 (7%) patients had a new ischemic lesion on the operated side. None of these lesions were symptomatic. On multivariate analysis, the risk factors for appearance of a new ischemic lesion on the operated side were significant severe stenosis of the vertebral artery ipsilateral to the lesion (odds ratio [OR] = 9.2, 95% confidence interval [CI] [2.1-39.8], P = 0.003) and insertion of a shunt (OR = 9.1, 95% CI [1.1-73.1], P = 0.039). The 30-day follow-up showed one death at D4 due to hemorrhagic stroke on the operated side and one contralateral stroke. None of the study patients had a myocardial infarction., Conclusions: In this multicenter study, the rate of silent ischemic lesions in asymptomatic carotid surgery showed 43.3% of preoperative silent ischemic lesions and 9.2% of new silent lesions after surgery. The use of a shunt and presence of ipsilateral vertebral stenosis are risk factors for perioperative embolism., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: Aneurysmal subarachnoid hemorrhage (aSAH) is an acute cerebrovascular event that leads to devastating consequences. Early brain infarction (EBI) develops very early, within the first 72 hours after bleeding, and may have a significant impact on long-term outcomes. The incidence and impact of EBI in the prognosis of aSAH remain uncertain. We performed a systematic review and meta-analysis to evaluate the incidence of EBI in patients with aSAH and determine its effect on mortality and functional outcomes., Methods: We performed a systematic review and meta-analysis. Inclusion criteria were 1) studies that evaluated aSAH within 72 hours after bleeding; 2) performed a brain imaging study up to 72 hours of hemorrhage; 3) used computed tomography or magnetic resonance imaging; and 4) included a description of the findings of the brain imaging study (whether or not an infarct was present)., Results: Ten studies that met the criteria were included. The incidence of EBI was 17%. The risk ratio for 3-month mortality was 2.18 (95% confidence interval 1.48-3.30). The overall risk ratio for poor outcome was 2.26 (95% confidence interval 1.75-2.93)., Conclusions: EBI plays an important role in the outcome of patients with aSAH. Its significant impact could represent a new therapeutic frontier for improving outcomes of these patients., (Copyright © 2018 Elsevier Inc. All rights reserved.)

The decision to perform decompressive hemicraniectomy (DHC) by default in malignant hemispheric stroke (MHS) remains controversial. Even under ideal conditions, DHC usually results in moderate to severe disability. The present study for the first time uses neuroimaging to identify independent outcome predictors in a prospective cohort of 96 MHS patients undergoing DHC. The primary outcome was functional status according to the modified Rankin Scale (mRS) at 12 months and categorized as favorable (mRS 0-3) or unfavorable (mRS 4-6). At 12 months, 19 patients (20%) reached favorable and 77 patients (80%) unfavorable outcome. The overall mean infarct volume was 328 ± 114 ml. Multivariable logistic regression identified age per year (OR 1.14, 95% CI 1.04-1.24; p = 0.005), infarct volume per cm 3 (OR 1.012, 95% CI 1.003-1.022; p = 0.013), thalamic involvement (OR 8.65, 95% CI 1.04-72.15; p = 0.046) and postoperative pneumonia (OR 5.52, 95% CI 1.03-29.57; p = 0.046) as independent outcome predictors, which was confirmed by multivariable ordinal regression for age ( p = 0.004) and infarct volume ( p = 0.015). The infarct volume threshold for reasonable prediction of unfavorable outcome in our patients was 270 cm 3 , which in the future may help prognostication and development of clinical trials on DHC and outcome in MHS.

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: Suboccipital decompressive craniectomy (SDC) for cerebellar infarction has been traditionally performed with minimal high-quality evidence. The aim of this systematic review and meta-analysis is to investigate the impact of SDC on functional outcomes, mortality, and adverse events in patients with cerebellar infarcts., Methods: A systematic review and meta-analysis in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Our primary outcome was the proportion of patients with moderate-severe disability after SDC. Secondary outcomes included mortality and adverse events. A sensitivity analysis was conducted to examine the roles of age, preoperative neurologic status, external ventricular drain insertion, and debridement of infarcted tissue on SDC outcomes., Results: Eleven studies (with 283 patients) met our inclusion criteria. The pooled event rate for moderate-severe disability was 28% (95% confidence interval [CI], 20%-37%) and for mortality, it was 20% (95% CI, 12%-31%). The estimated overall rate of adverse events for SDC was 23% (95% CI, 14%-35%). Sensitivity analysis found less mortality with mean age <60 years, higher rates of concomitant external ventricular drain insertion, and debridement of infarcted tissue. Several factors were identified for heterogeneity between studies, including follow-up time, outcomes scale, extent of infarction, and other neuroimaging features., Conclusions: The best available evidence for SDC is based on retrospective observational studies. SDC for cerebellar infarction is associated with better outcomes compared with decompressive surgery for hemispheric infarctions. Lack of standardized reporting methods for SDC is a considerable drawback to the development of a better understanding of the impact of this surgery on patient outcomes., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To analyze the positive predictive value of large artery occlusion and clinical prognosis in acute ischemic stroke patients with total anterior circulation infarct (TACI) who underwent endovascular treatment in the absence of multimodal CT angiography or CT perfusion., Methods: The inclusion criteria for the acute ischemic stroke patients to receive endovascular treatment were as the follows: the Oxfordshire Community Stroke Project classification was TACI, Alberta Stroke Program Early Computed Tomography Score (ASPECTS) ≥ 6, National Institutes of Health stroke scale (NIHSS) score ≥8, and less than 4.5 hours since stroke onset. The endovascular treatment was performed on patients who met the inclusion criteria. The endovascular treatment included intra-arterial thrombolysis, mechanical treatments, or both. A retrospective analysis was performed on all eligible acute ischemic stroke patients who underwent endovascular treatment from January 1, 2015 to December 31, 2015., Results: A total of 17 patients met the inclusion criteria and underwent endovascular treatment. The median age was 76 years (range, 59-88 years). 12 patients (70.6%) were diagnosed with atrial fibrillation. 16 patients were diagnosed with large artery occlusion by digital subtraction angiography, and the positive predictive value was 94.1%. 16 patients (94.1%) had recanalization (TICI Grade 3); 12 patients (70.6%) had a modified Rankin Scale score of 0-2, and 1 patient (5.9%) died 90 days after treatment., Conclusions: In the absence of multimodal CT, endovascular treatment might be beneficial to patients with TACI acute ischemic stroke within 4.5 hours of stroke onset, who had NIHSS score of 8 or greater and ASPECTS of 6 or greater. These inclusion criteria have a high positive predictive value for anterior circulation large artery occlusion., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The effects of white matter hyperintensity volume and subclinical brain infarcts on the risk of incident stroke, its ischemic subtypes, and mortality require further study in diverse samples., Methods and Results: Stroke-free participants in the Northern Manhattan Study underwent magnetic resonance imaging (N=1287; mean age 71±9 years, 60% women, 15% non-Hispanic white, 17% non-Hispanic black, 68% Hispanic) and were followed for a median of 8 years (interquartile range: 6-9 years). Cox models estimated proportional hazards of incident stroke of all types, ischemic stroke (and its subtypes), and mortality and stratified by race/ethnicity. In total 72 participants (6%) had incident strokes and 244 died (19%). In fully adjusted models, those with larger white matter hyperintensity volume had greater risk of all stroke types (hazard ratio [HR]: 1.4; 95% CI, 1.1-1.9), ischemic stroke (HR: 1.3; 95% CI, 1.0-1.8), and cryptogenic stroke (HR: 2.2; 95% CI, 1.1-4.4). White and black but not Hispanic participants had increased stroke risk ( P <0.05 for heterogeneity for all and ischemic stroke). Those with subclinical brain infarct had greater risk for all stroke types (HR: 1.9; 95% CI, 1.1-3.3), ischemic stroke (HR: 2.2; 95% CI, 1.3-3.8), lacunar (HR: 4.0; 95% CI, 1.3-12.3), and cryptogenic stroke (HR: 3.6; 95% CI, 1.0-12.7), without significant heterogeneity across race/ethnic groups. Greater white matter hyperintensity volume increased both vascular (HR: 1.3; 95% CI, 1.1-1.7) and nonvascular (HR: 1.2; 95% CI, 1.0-1.5) mortality among Hispanic and white but not black participants ( P =0.040 for heterogeneity). Subclinical brain infarct was associated with increased vascular mortality among Hispanic participants only (HR: 2.9; 95% CI, 1.4-5.8)., Conclusions: In this urban US sample, subclinical cerebrovascular lesions increased the risk of clinical stroke and vascular mortality and varied by race/ethnicity and lesion type., (© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

Objectives: Posterior circulation ischemic stroke (PCIS), accounting for approximately 20% of total ischemic stroke, is a sever disease that associated with high rate of morbidity and mortality. Though the effectiveness of endovascular mechanical thrombectomy has been well demonstrated in many types of ischemic stroke, it is still unclear what the outcome is in posterior circulation ischemic stroke., Methods and Materials: In current study, data was collected from 139 Chinese patients who received endovascular mechanical thrombectomy treatment with Solitaire device after acute posterior circulation ischemic stroke. We measured the mortality, symptomatic intracranial hemorrhage (SICH) and National Institutes of Health Stroke Scale (NIHSS) to evaluate the safety of endovascular mechanical thrombectomy. Meanwhile, the clinical outcome of endovascular mechanical thrombectomy was also evaluated based on recanalisation rate, HIHSS, and the modified Rankin Scale (mRS)., Results: Recanalisation was successful in 124 (89.3%) patients after surgery. Herniation was the second fatal stroke complication, out of the 6 patients suffered from herniation, 3 patients (50%) died during surgery and 2 (33%) died after surgery. As for other stroke complications such as pulmonary infection, 1 patient (4.3%) died during surgery and 1 patient (4.3%) died 3 days after surgery., Conclusion: Our findings indicate that endovascular mechanical treatment is a safe treatment which brings clear benefit to patients suffered from posterior circulation ischemic stroke, in both the recanalisation rate and functional outcomes., (Copyright © 2017. Published by Elsevier Urban & Partner Sp. z o.o.)

The aim of our study was to investigate the relationship between the waist-to-height ratio (WHR) and all-cause mortality and functional outcomes after acute ischemic stroke in a prospective cohort study.A total of 2076 patients (36.66% females) with ischemic stroke were analyzed from ACROSS-China, which is a nationwide, prospective, hospital-based stroke registry aimed to detect the glucose abnormality in China. One-year follow-up evaluation was done by telephone interview. Outcome measures were all-cause mortality and functional outcome defined as modified Rankin score being 6 and from 0 to 6, respectively. We identified predictors for functional outcomes using logistic regression analysis, and mortality outcome using Cox proportional hazards model which incorporated covariates with P value of < 0.2 in the univariate analysis and those of clinical importance.The higher WHR was associated with worse functional outcome, but not predictive of the patients' mortality outcomes. Compared with the first quartile (≤0.48), the fourth quartile of the WHR was more likely to be associated with poor functional recovery (fourth quartile (≥0.56), OR = 1.38, CI: 1.08-1.77, P = 0.01; third quartile OR = 1.10, CI: 0.86-1.40, P = 0.45; second quartile OR = 1.05, CI: 0.83-1.33, P = 0.71).Our findings suggest that abdominal fat accumulation may be associated with functional recovery after stroke, and is not associated with mortality after stroke. Compared with the lowest quartile, the highest quartile of WHR at admission was possibly associated with worse postacute ischemic stroke functional recovery.

Backgrounds and Purpose: This study was aimed at investigating the outcomes and predictors for the poor functional outcome after endovascular treatment (EVT) in a large, mostly Asian population., Methods: Between January 2014 and June 2016, acute stroke patients with anterior circulation occlusion and EVT were retrospectively enrolled from 21 stroke centers in China. The main outcomes were modified Rankin Scale (0-2 as functional independence, 3-6 as poor) at 90 days, symptomatic intracranial hemorrhage (sICH) at 72 h, and death at 90 days. Logistic regression was used to identify predictors for poor functional outcome at 90 days., Results: Of the 698 patients, 304 (43.6%) patients had functional independence at 90 days. The sICH rate was 15.5% (108/698) and mortality rate at 90 days was 25.4% (177/698). Age (OR 1.04, 95% CI 1.02-1.07), National Institutes of Health Stroke Scale score at admission (11-20 vs. ≤10, OR 2.38, 95% CI 1.23-4.59; ≥21 vs. ≤10, OR 3.66, 95% CI 1.72-7.80), baseline glucose level (OR 1.09, 95% CI 1.01-1.18), onset to groin puncture >6 h (OR 1.88, 95% CI 1.06-3.31), sICH (OR 15.49, 95% CI 5.16-46.43), and pneumonia (OR 3.15, 95% CI 1.86-5.32) were independent predictors of poor functional outcomes, while good recanalization (OR 0.26, 95% CI 0.13-0.54), preoperative Alberta Stroke Program Early CT Score 8-10 (OR 0.48, 95% CI 0.28-0.83), and good collateral flow (OR 0.50, 95% CI 0.32-0.79) were protective factors., Conclusions: This study provides evidence in real world to support the performance of EVT in acute anterior circulation stroke patients in Chinese population. Patients with small infarct core, successful recanalization, good collateral status, and short treatment delay without sICH or pneumonia may benefit from EVT., (© 2017 S. Karger AG, Basel.)

Background and Purpose: Brain infarct patterns that are observed via diffusion-weighted imaging are useful for classifying stroke subtypes. However, it is unclear whether infarct patterns can predict long-term outcomes in cryptogenic stroke patients. Herein, we investigated the association between acute brain infarct patterns and long-term stroke outcomes in cryptogenic stroke patients., Methods: Acute cryptogenic stroke patients were consecutively enrolled between April 2008 and March 2012. Diffusion-weighted imaging ischemic lesion patterns were classified as single lesions, scattered lesions in one vascular territory, or multiple lesions in multiple vascular territories. Survivors (at discharge) were followed up for 3 years after stroke onset., Results: A total of 272 cryptogenic stroke patients (132 women; aged 72±13 years) were enrolled. Among these patients, 169 (62.1%) had a single lesion, 38 (14.0%) had scattered lesions, and 65 (23.9%) had multiple lesions. Next, 261 patients (96.0%) were evaluated to assess right-to-left shunting, and 61 patients (23.4%) exhibited right-to-left shunting. On patient admission, right-to-left shunting and increased D-dimer levels were independently associated with multiple lesions but not single or scattered lesions. During the follow-up period (median, 1093 days), 30 patients (11.0%) developed recurrent stroke and 35 patients (12.9%) died. Multivariate Cox proportional hazard analyses showed that multiple infarcts were independently associated with recurrent stroke and all-cause mortality (hazard ratio, 3.79; 95% confidence interval, 2.24-6.37; P<0.001)., Conclusions: Multiple brain infarcts on diffusion-weighted imaging were independently associated with long-term stroke outcomes in cryptogenic stroke patients., (© 2016 American Heart Association, Inc.)

Objective: The evaluation of postoperative magnetic resonance imaging (MRI) in glioma with no or minimal enhancement is controversial because the evaluation of residual tumor volume can be biased. The purpose of this study was to clarify the value of early postoperative and 3-month MRI regarding its validity in predicting recurrent disease., Methods: For this retrospective, single-center study, overall fluid attenuated inversion recovery (FLAIR) volumes (early postoperative [<48 hours] and 3-month MRI including FLAIR and T1-weighted sequences with and without contrast agent) of 99 patients were assessed using manual segmentation. FLAIR volume dynamic over the first 3 months after surgery and its effect on disease recurrence were evaluated while considering histopathologic features., Results: Overall FLAIR-hyperintense volume significantly decreased between early postoperative and 3-month follow-up MRIs (P < 0.001). Early FLAIR volume increase had a high positive predictive value for overall disease recurrence after resection (85.71% [95%-CI: 62.64-96.24]). Early FLAIR volume dynamic (P < 0.001), isocitrate dehydrogenase 1/2 status (P = 0.002), and preoperative Karnofsky Performance Status (P = 0.012) were observed as independent factors for progression-free survival in multivariate analysis., Conclusion: Early postoperative FLAIR volume assessment in gliomas with no or minimal enhancement is susceptible to a systematic overestimation of residual tumors. Nevertheless, early FLAIR volume dynamic is an independent factor for tumor recurrence that should be evaluated in order timely adapt surveillance and therapy regimens accordingly., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: In patients with large vessel occlusions, endovascular treatment has been shown to be superior to intravenous thrombolysis in recent trials., Aims: The aim of this study was to analyze the impact of endovascular treatment on clinical and radiological outcome in everyday clinical practice., Methods: We compared the rates of good outcome (modified Rankin scale ≤ 2 at discharge), in-hospital death, symptomatic intracranial hemorrhages, and infarct sizes in patients with distal intracranial carotid artery, M1 and M2 occlusions during two time periods., Results: From January 2008 to October 2012, a total of 509 patients were treated with intravenous thrombolysis and from November 2012 to December 2014, a total of 270 patients received endovascular treatment with stent retrievers (with or without intravenous thrombolysis). Significantly, more patients in the endovascular treatment group than in the intravenous thrombolysis group had a good outcome (37% vs. 27%, p < 0.01). The infarct sizes were significantly smaller after endovascular treatment than intravenous thrombolysis, whereas the symptomatic intracranial hemorrhages rates and in-hospital mortality were comparable between both treatment groups. The positive impact of endovascular treatment on clinical outcome was most pronounced in patients ≥75 years (31% endovascular treatment vs. 19% intravenous thrombolysis, p < 0.01), in patients with M1 occlusions (43% endovascular treatment vs. 25% intravenous thrombolysis, p < 0.01) and in patients with an admission National Institutes of Health Stroke Scale ≥ 14 (24% endovascular treatment vs. 11% intravenous thrombolysis, p < 0.05)., Conclusion: In everyday clinical practice and compared with intravenous thrombolysis, endovascular treatment significantly improved clinical outcome and was associated with smaller infarctions. This beneficial effect appeared to be highest in older patients, more severely affected patients, and in those with M1 occlusions., (© 2016 World Stroke Organization.)

Background and Purpose: The diagnosis of cerebellar infarction (CBI) is often challenging due to non-specific or subtle presenting symptoms and signs. We aimed to determine whether a common syndromic cluster of symptoms, signs or vascular risk factors were associated with delayed presentation or misdiagnosis to an Emergency Department (ED). The degree of misdiagnosis between ED and neurology physicians and the influence of delayed presentation or misdiagnosis on outcome were also investigated., Methods: A prospective study of CBI patients at a large tertiary-referral hospital with a comprehensive stroke service. Data are reported with OR and 95% CIs., Results: Of 115 consecutive CBI patients (mean age ± SD 66 ± 14 years, 51% male), infarction was isolated to the cerebellum in 46%; the remainder had additional vascular territory involvement ('mixed CBI'). Most patients (n = 79, 69%) had a mild stroke (National Institute of Health Stroke Scale score ≤4), and tended to present late to ED (>4.5 h; p = 0.05). Dysarthria (OR 3.9, 95% CI 1.6-9.6, p = 0.003) and prior history of atrial fibrillation (AF; OR 3.0, 95% CI 1.02-9.1, p = 0.047) predicted early presentation (<4.5 h; in 52%). Neurological signs (as determined by neurology physicians) were more commonly absent in patients with isolated CBI (OR 4.0, 95% CI 1.2-13.3, p = 0.03) who were also less likely to receive acute stroke therapy (p = 0.03). ED physicians detected fewer neurological signs than neurology physicians (mean 1 vs. 2 signs, p < 0.001), and 34% of CBI patients were misdiagnosed, with peripheral vestibulopathy being the most common alternative diagnosis. Nausea and vomiting (OR 2.3, 95% CI 1.01-5.5, p = 0.046), absence of neurological signs as determined by ED physicians (OR 3.5, 95% CI 1.5-8.0, p = 0.003) and isolated CBI (OR 2.2, 95% CI 1.01-4.8, p = 0.047) correlated with misdiagnosis. Vascular territory involvement did not correlate with time to presentation or misdiagnosis. At 3 months, 65% of patients were functionally independent (modified Rankin Scale (mRS) score 0-2). History of hypertension (p = 0.008), AF (p = 0.012), mixed CBI (p = 0.004) and in-hospital stroke-related complications (p < 0.001) were associated with patients having a poor outcome (mRS ≥3). At 3 months, mortality was 16%, and AF was the only predictor of death (OR 3.2, 95% CI 1.1-8.9, p = 0.03). Late presentation to ED and misdiagnosis did not significantly influence 3-month functional outcome., Conclusions: Late ED presentation and misdiagnosis are common for CBI. Timely diagnosis of CBI may increase opportunity for acute stroke therapies and reduce risk of stroke-related complications., (© 2016 S. Karger AG, Basel.)

Background and Purpose: The posterior circulation Acute Stroke Prognosis Early CT Score (pc-APECTS) applied to CT angiography source images (CTA-SI) predicts the functional outcome of patients in the Basilar Artery International Cooperation Study (BASICS). We assessed the diagnostic and prognostic impact of pc-ASPECTS applied to perfusion CT (CTP) in the BASICS registry population., Methods: We applied pc-ASPECTS to CTA-SI and cerebral blood flow (CBF), cerebral blood volume (CBV), and mean transit time (MTT) parameter maps of BASICS patients with CTA and CTP studies performed. Hypoattenuation on CTA-SI, relative reduction in CBV or CBF, or relative increase in MTT were rated as abnormal., Results: CTA and CTP were available in 27/592 BASICS patients (4.6%). The proportion of patients with any perfusion abnormality was highest for MTT (93%; 95% confidence interval [CI], 76%-99%), compared with 78% (58%-91%) for CTA-SI and CBF, and 46% (27%-67%) for CBV (P < .001). All 3 patients with a CBV pc-ASPECTS < 8 compared to 6/23 patients with a CBV pc-ASPECTS ≥ 8 had died at 1 month (RR 3.8; 95% CI, 1.9-7.6)., Conclusion: CTP was performed in a minority of the BASICS registry population. Perfusion disturbances in the posterior circulation were most pronounced on MTT parameter maps. CBV pc-ASPECTS < 8 may indicate patients with high case fatality., (Copyright © 2014 by the American Society of Neuroimaging.)

Background: The epidemiology of stroke in sub-Saharan African populations and variation of subtypes between communities are not well understood. Our aim was to ascertain prospectively the incidence of first-ever stroke and ischemic stroke subtypes in an urban city population of Southwestern Nigeria., Methods: A community-based stroke registry was set up to enroll hospitalized and nonhospitalized first-ever stroke cases at all health care facilities located in the assigned community. The study was conducted between November 1, 2010, and October 31, 2011, in Akure North and South Local Government Areas of Ondo State, Southwestern Nigeria., Results: We identified 298 incidents of strokes in patients presenting for the first time ever. Pathologic diagnosis was confirmed in 75% of the cases. Adjusted age-standardized incidence rate was 60.67 per 100,000 per year after adjustment to the World Health Organization World Population. Incidence of cerebral infarction and intracerebral hemorrhage increased with age in both men and women., Conclusions: The incidence of stroke in our population-based study ranks low compared with high-income countries. However, when incidence rates were compared by pathologic type, our rates for intracerebral hemorrhage and that of subarachnoid hemorrhage are comparable with those of high-income countries., (Published by Elsevier Inc.)

Objectives: To study whether hand osteoarthritis (OA) is associated with increased mortality and cardiovascular events in a large community based cohort (Framingham Heart Study) in which OA, mortality and cardiovascular events have been carefully assessed., Methods: We examined whether symptomatic (≥1 joint(s) with radiographic OA and pain in the same joint) and radiographic hand OA (≥1 joint(s) with radiographic OA without pain) were associated with mortality and incident cardiovascular events (coronary heart disease, congestive heart failure and/or atherothrombotic brain infarction) using Cox proportional hazards models. In the adjusted models, we included possible confounding factors from baseline (eg, metabolic factors, medication use, smoking/alcohol). We also adjusted for the number of painful joints in the lower limb and physical inactivity., Results: We evaluated 1348 participants (53.8% women) with mean (SD) age of 62.2 (8.2) years, of whom 540 (40.1%) and 186 (13.8%) had radiographic and symptomatic hand OA, respectively. There was no association between hand OA and mortality. Although there was no significant relation to incident cardiovascular events overall or a relation of radiographic hand OA with events, we found a significant association between symptomatic hand OA and incident coronary heart disease (myocardial infarction/coronary insufficiency syndrome) (HR 2.26, 95% CI 1.22 to 4.18). The association remained after additional adjustment for pain in the lower limb or physical inactivity., Conclusions: Symptomatic hand OA, but not radiographic hand OA, was associated with an increased risk of coronary heart disease events. The results suggest an effect of pain, which may be a possible marker of inflammation., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: Little attention has been paid to the epidemiological characteristics of lacunar infarction (LAC) in China before. This study aimed to examine the incidence and survival of LAC in a southern Chinese population., Methods: From 2004-2010 in Changsha, two communities with a registered population of ∼100 000 were selected and data from first-ever ischaemic stroke (IS) cases were prospectively collected. Then the epidemiological characteristics of LAC and non-LAC were evaluated., Results: During the study period, the age-standardized incidence increased at an annual rate of 0.7% (p < 0.001) for LAC and 2.0% (p < 0.001) for non-LAC. The mean annual age-standardized incidence of LAC and non-LAC was 28.2/100 000 and 45.0/100 000, respectively. Compared with non-LAC patients, the prevalence of hypertension, diabetes and hyperlipidemia was significantly higher in patients with LAC (p < 0.05). Although the 30-day fatality rate was significantly lower in patients with LAC than non-LAC (0.5% vs. 14.9%, p < 0.001), there was no significant difference in survival between the two groups (96.7% vs. 95.2%, p = 0.203) after excluding the patients who died within 1 year of stroke onset., Conclusion: LAC is a common stroke sub-type in southern China and the long-term prognosis is not benign.

Objective: To study the relationship between dyslipidemia and outcome in patients with acute ischemic stroke., Methods: Data about 1 568 patients with acute ischemic stroke were collected from 4 hospitals in Shandong Province from January 2006 to December 2008. National Institute of Health Stroke Scale (NIHSS) >10 at discharge or death was defined as the outcome. Effect of dyslipidemia on outcome in patients with acute ischemic stroke was analyzed by multivariate logistic regression analysis and propensity score-adjusted analysis, respectively., Results: The serum levels of TC, LDL-C, and HDL-C were significantly associated with the outcome in patients with acute ischemic stroke. Multivariate logistic regression analysis and propensity score-adjusted analysis showed that the ORs and 95% CIs were 3.013 (1.259, 7.214)/2.655 (1.298, 5.43), 3.157 (1.306, 7.631)/3.405 (1.621, 7.154), and 0.482 (0.245, 0.946)/0.51 (0.282, 0.921), respectively, for patients with acute ischemic stroke. Hosmer-Lemeshow goodness-of-fit test showed no significant difference in observed and predicted risk in patients with acute ischemic stroke (chi-square=8.235, P=0.411)., Conclusion: Serum levels of TC, LDL-C, and HDL-C are positively related with the outcome in patients with acute ischemic stroke., (Copyright © 2014 The Editorial Board of Biomedical and Environmental Sciences. Published by China CDC. All rights reserved.)

Objective: The aim of this study was to evaluate the relationship between ambulance distance to hospitals and mortality from acute diseases using the national database in Japan., Design: Geospatial ecological study., Setting: We collected the data of transport distance to hospitals from the Diagnosis Procedure Combination database and that of mortality per 100 000 from some acute diseases from the database of life tables by the Ministry of Health, Labour and Welfare in Japan., Participants: A total of 108 314 patients (40 882 patients with acute myocardial infarction, 31 632 patients with brain infarction, 4992 patients with subarachnoid hemorrhage, and 30 808 patients with pneumonia) were referred in Japan in 2008., Main Outcome Measures: We evaluated the association between the mean transport distance to hospitals and the mortality from acute diseases using simple linear regression analysis. This correlation was evaluated separately for each acute disease., Results: The mean transport distances to hospitals were 8.1 km for acute myocardial infarction, 8.3 km for brain infarction, 9.5 km for subarachnoid hemorrhage, and 7.6 km for pneumonia, whereas the mortalities per 100,000 were 34.6 for acute myocardial infarction, 60.4 for brain infarction, 11.2 for subarachnoid hemorrhage, and 91.6 for pneumonia. Simple linear regression analysis revealed significant positive correlations between transport distance and mortality per 100,000 for acute myocardial infarction and brain infarction (R2 = 0.315 and 0.398, P < .001, respectively). Otherwise, moderate positive correlations between transport distance and mortality per 100,000 were shown for subarachnoid hemorrhage and pneumonia (R2 = 0.112, P < .012 and .233, P < .001, respectively)., Conclusions: This study suggests that the ambulance distance to hospitals significantly influences the risk of mortality for some acute diseases in Japan. Further studies are needed to confirm this association.

In patients with space-occupying hemispheric infarction, surgical decompression within 48 h after stroke onset increases the chance of a good functional outcome, but also the chance of survival with severe disability. Until now, cognitive outcome in these patients has not been reported in a consecutive series. Participants of the hemicraniectomy after middle cerebral artery infarction with life-threatening edema trial (HAMLET; ISRCTN94237756) underwent detailed neuropsychological examination at a median of 14.5 months after stroke onset. 'Global cognitive impairment' was defined as a score on the Cambridge cognitive examination (CAMCOG) ≤ 83. Impairment on an individual neuropsychological task was defined as a score below the 2.5th percentile or more than two standard deviations below standard norms. The association between cognitive and functional outcome was analysed with linear regression. Twenty patients were tested. Fifteen (75 %) had global cognitive impairment or such poor performance that assessment of global cognitive performance by the CAMCOG was not feasible. Five had only focal cognitive deficits. Still, detailed neuropsychological examination was feasible in 18 patients. Patients with aphasia performed worse than those without on both verbal and non-verbal tasks. Poorer cognitive performance was associated with worse functional outcome as assessed with the modified Rankin scale (β -0.4, 95 % CI -0.6 to -0.1). No differences were observed between operated and non-operated patients. The majority of survivors of space-occupying hemispheric infarction suffered from long-term global cognitive impairment. Isolated focal neuropsychological deficits were found in only a quarter. Impaired cognitive outcome was associated with worse functional outcome.

Background: Iatrogenic cerebral arterial gas embolism (CAGE) is an uncommon but potentially a fatal condition. Hyperbaric oxygen (HBO2) therapy is the only definitive treatment for patients with CAGE presenting with acute neurologic deficits., Methods: We reviewed medical records and neuroimaging of consecutive CAGE patients treated with HBO2 at a state referral hyperbaric facility over a 22-year period. We analyzed the effect of demographics, source of intra-arterial gas, signs and symptoms, results of imaging studies, time between event and HBO2 treatment, and response to HBO2 treatment in 36 consecutive patients. Favorable outcome was defined by complete resolution or improvement of CAGE signs and symptoms at 24 h after HBO2 treatment. Unfavorable outcome was defined by unchanged or worsened neurologic signs and symptoms or in hospital death., Results: A total of 26 (72%) of the 36 patients had favorable outcome. Patients with favorable outcome were younger compared to those with unfavorable outcome (mean age [years, SD] 44.7 ± 17.8 vs. 58.1 ± 24.1, p = 0.08). Cardiopulmonary symptoms were significantly more common in CAGE related to venous source of gas compared to arterial source (p = 0.024) but did not influence the rate of favorable outcomes. Adjusted multivariate analysis demonstrated that time from event to HBO2 ≤ 6 h (positively) and the presence of infarct/edema on head computerized tomography (CT)/magnetic resonance imaging (MRI) before HBO2 (negatively) were independent predictors of favorable outcome at 24 h after HBO2 treatment [odds ratio (OR) 9.08 confidence interval (CI) (1.13-72.69), p = 0.0376, and (OR) 0.034 (CI) (0.002-0.58), p = 0.0200, respectively]. Two of the 36 patients were treated with thrombolytics because of acute focal deficits and suspected ischemia-one with intravenous and the second with intra-arterial thrombolysis. The latter patient developed fatal intracerebral hemorrhage., Conclusions: A high proportion of CAGE patients treated with HBO2 had favorable outcomes. Time-to-HBO2 ≤ 6 h increased the odds of favorable outcome, whereas the presence of infarct/edema on CT/MRI scan before HBO2 reduced the odds of a favorable outcome. Timely diagnosis and differentiation from thrombo-embolic ischemic events appears to be an important determinant of successful HBO2 treatment.

Background and Purpose: There are little data on the etiology of multiple brain infarcts (MBI) and their impact on clinical outcome in young patients., Methods: We studied 548 MRI-imaged patients (15-49 years) with a first-ever ischaemic stroke. Ischaemic lesions were categorized into three groups: single lesions, MBI in one or >1 circulation territories. Outcomes were unfavorable 3-month modified Rankin Scale (mRS) score of ≥ 2 and, during long-term follow-up (mean 8.20 ± 4.01 years), recurrent ischaemic stroke or death from any cause., Results: Multiple brain infarcts occurred in 185 patients (33.8%; mean age 39.2 ± 8.2), of which 144 patients (26.3%) had lesions located in a single territory and 41 patients (7.5%) in multiple territories. Patients with MBI in a single territory were more likely than patients with single lesions to have a high-risk source of cardioembolism (CE) (9.0% vs. 3.0%; P = 0.001), large-artery atherosclerosis (8.3% vs. 4.9%; P = 0.012), vertebral (22% vs. 10%; P < 0.001) or carotid artery dissections (8.3% vs. 6.3%; P = 0.036), and MBI in multiple territories a high-risk source of CE (34% vs. 3.0%, P < 0.001). Adjusted for age, gender, baseline stroke severity, size of the largest lesion, and stroke subtype, MBI remained independently associated with an unfavorable 3-month outcome (odds ratio 2.84, 95% confidence interval 1.22-6.61). In multivariate Cox proportional hazards analysis, MBI had independent influence on the risk for death (hazard ratio 3.75, 1.58-8.86), but not on recurrent ischaemic stroke., Conclusions: Compared with the elderly, young stroke patients have a distinct stroke etiology underlying MBI, being an independent indicator of poor short-term outcome and long-term risk of death., (© 2012 The Author(s) European Journal of Neurology © 2012 EFNS.)

Inflammation plays a key role in ischemic stroke pathophysiology: microglial/macrophage cells and type-1 helper cells (Th1) seem deleterious, while type-2 helper cells (Th2) and regulatory T cells (Treg) seem protective. CD4 Th0 differentiation is modulated by microglial cytokine secretion. Glatiramer Acetate (GA) is an immunomodulatory drug that has been approved for the treatment of human multiple sclerosis by means of a number of mechanisms: reduced microglial activation and pro-inflammatory cytokine production, Th0 differentiation shifting from Th2 to Th2 and Treg with anti-inflammatory cytokine production and increased neurogenesis. We induced permanent (pMCAo) or transient middle cerebral artery occlusion (tMCAo) and GA (2 mg) or vehicle was injected subcutaneously immediately after cerebral ischemia. Mice were sacrificed at D3 to measure neurological deficit, infarct volume, microglial cell density and qPCR of TNFα and IL-1β (pro-inflammatory microglial cytokines), IFNγ (Th2 cytokine), IL-4 (Th2 cytokine), TGFβ and IL-10 (Treg cytokines), and at D7 to evaluate neurological deficit, infarct volume and neurogenesis assessment. We showed that in GA-treated pMCAo mice, infarct volume, microglial cell density and cytokine secretion were not significantly modified at D3, while neurogenesis was enhanced at D7 without significant infarct volume reduction. In GA-treated tMCAo mice, microglial pro-inflammatory cytokines IL-1β and TNFα were significantly decreased without modification of microglial/macrophage cell density, cytokine secretion, neurological deficit or infarct volume at D3, or modification of neurological deficit, neurogenesis or infarct volume at D7. In conclusion, Glatiramer Acetate administered after cerebral ischemia does not reduce infarct volume or improve neurological deficit in mice despite a significant increase in neurogenesis in pMCAo and a microglial pro-inflammatory cytokine reduction in tMCAo., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Complete middle cerebral artery (MCA) stroke is a life-threatening condition, which can lead to death in the form of "malignant MCA syndrome"; characterized by massive brain edema and cerebral herniation. Moreover, patients with complete MCA infarct have high mortality due to complications. The aim of this study was to evaluate the clinical predictors of in-hospital mortality in patients with complete MCA stroke. Consecutive patients with complete MCA stroke were enrolled in a prospective single center in-hospital outcome study having mortality as its end point. Among 780 ischemic stroke patients, 125 had complete MCA strokes (16%) and 44 (35.2%) of these died in hospital. A high NIHSS-score (OR 1.17 95%CI 1.03-1.34, P=0.013) and high diastolic blood pressure on admission (OR 1.05 95%CI 1.01-1.09) resulted being independent predictors of in-hospital mortality in patients with complete MCA stroke. The median value of diastolic blood pressure at admission was 90 mmHg in patients who died and 80 mmHg in survivors (P=0.01). The risk of death increased by 5% for each mmHg increase in diastolic blood pressure on admission after adjusting for other risk factors. The rate of mortality was 22% in patients with diastolic blood pressure lower than 90 mmHg, 56% for those with diastolic blood pressure between 90 and 109 mmHg and 67% for those with diastolic blood pressure higher than 110 mmHg. This study suggests that high diastolic blood pressure on admission in acute MCA stroke patients is linearly correlated with in-hospital mortality.

The prevalence and implications of vertebrobasilar dolichoectasia (VBD), a causative arteriopathy of stroke are unclear in Asian stroke patients. Through a comparative study of VBD and non-VBD stroke patients, we aimed to elucidate the clinicoradiologic features of VBD patients in Japan. A total of 481 consecutive patients (302 men and 179 women) with acute stroke were admitted to our department between 2007 and 2008. Of these 481 inpatients, 374 (231 men and 143 women) had brain infarct (BI), and 107 (71 men and 36 women) had brain hemorrhage (BH). We reviewed medical records, and VBD was diagnosed by magnetic resonance angiography. Cardiovascular disease (CVD) risk profile, modified Rankin scale score at 30 days poststroke, and stroke lesions were compared among 4 groups: the VBD BI group, the VBD BH group, the non-VBD BI group, and the non-VBD BH group. The diameter, height, and lateral displacement of the basilar artery (BA) were analyzed in the VBD patients. Statistical analyses used multivariate logistic regression analysis. VBD was found in 37 patients (34 men and 3 women). Mean age (± SD) was 64.4 ± 14.7 years (63.4 ± 14.6 years in men and 65.3 ± 6.1 years in women). Twenty-four patients (21 men and 3 women) had BI, and 13 men had BH. There were significant male preferences in VBD BI (P < .01) and VBD BH patients (P < .01). Mean age (± SD) was 67.7 ± 14.3 years in BI patients and 56.7 ± 12.7 years in BH patients. The VBD BH men were significantly younger than the non-VBD BH men (P < .05) and VBD BI men (P < .01). Frequency of current smoking was significantly greater in VBD BI patients compared with non-VBD BI patients (P < .05). Other CVD risk factors did not differ among the 4 groups. Mean modified Rankin Scale score was significantly higher in VBD BH men compared with non-VBD BH men and VBD BI men (P < .01). The height and lateral displacement of the BA were scored more severely in BH patients than in BI patients (P < .01), but BA diameter did not differ between BH and BI patients. The frequency of pontine infarct and hemorrhage was 3-fold greater in VBD BI (P < .05) and VBD BH patients (P < .005) compared with non-VBD BI and BH patients. Our findings indicate a VBD prevalence of 7.7% in stroke patients, 6.4% in BI patients, and 12.1% in BH patients. Our clinicoradiologic analyses suggest male predominance, younger onset of BH, and higher frequency of pontine lesions in VBD patients. Significant BA changes and poor outcome of stroke were found in patients with hemorrhagic VBD rather than ischemic VBD. Thus, more attention should be paid to risk and care of BH in VBD patients, in addition to those of BI., (© 2012 National Stroke Association.)

Aims: This study explored the association between income and stroke mortality in the total working population in Sweden and examined whether the associations differ by gender or for stroke subtypes intracerebral haemorrhage (ICH) or brain infarction (BI)., Methods: This was a register-based study among nearly 3 million working women and men (30-64 years in 1990) with a 12-year follow up (1991-2002) for mortality from stroke (4886 deaths). Income was measured as annual registered income from work in 1990. Gender-specific Cox regressions were applied with adjustments for sociodemographic covariates., Results: The age-adjusted hazard ratio (95% confidence interval) of lowest versus highest income quartile was 1.80 (1.48-2.19) for any stroke, 1.68 (1.29-2.17) for ICH and 2.23 (1.53-3.22) for BI in women, and the corresponding figures for men were 2.12 (1.92-2.34), 2.02 (1.77-2.31), and 2.09 (1.77-2.46). Adjustment for covariates attenuated these associations to 1.69 (1.33-2.15) for any stroke and 1.56 (1.14-2.14) for ICH in women and to 1.98 (1.74-2.24) for any stroke and 1.77 (1.44-2.19) for BI in men. In contrast, adjustment for covariates amplified the estimates to 2.36 (1.52-3.66) for BI in women and to 2.05 (1.73-2.44) for ICH in men., Conclusions: Risk of stroke mortality was highest in the lowest income group, with a gradient for the intermediate groups, in both women and men. The risk of mortality from BI was highest in women with the lowest income and the risk of ICH was highest in men with the lowest income.

Background and Purpose: Cerebral microbleeds (CMB) are common in stroke survivors and the community-dwelling elderly. The clinical significance of CMB in the development of depression after a stroke is unknown. This study examined the association between poststroke depression (PSD) and CMB., Methods: A cohort of 235 patients with acute lacunar stroke admitted to the stroke unit of a university-affiliated regional hospital in Hong Kong was recruited. Three months after the onset of the index stroke, a research assistant administered the locally validated 15-item Geriatric Depression Scale. PSD was defined as a Genetic Depression Scale score of ≥7. The presence and location of CMB were evaluated with MRI., Results: In comparison with the non-PSD group, PSD patients were more likely to have lobar CMB (33.3% versus 19.9%; P=0.022). Lobar CMB remained an independent predictor of PSD in the multivariate analysis, with an odds ratio of 2.08 (P=0.032)., Conclusions: The results suggest that lobar CMB may play a role in the development of PSD. The importance of CMB in the pathogenesis of depression in stroke survivors and the general elderly population warrants further investigation.

Background: Treatment of acute cerebral infarction has greatly improved over the last 15 years. The purpose of this article is to describe patients with acute cerebral infarction admitted to a stroke unit from a geographically well defined population between 2007 and 2009., Material and Method: All patients were included aged over 15 years with acute cerebral infarction living in a well defined geographical area and admitted to Haukeland University Hospital between August 2007 and October 2009. Risk factors, neurological status, treatment, complications, results of evaluation, and outcome were registered in a stroke database (Bergen Stroke Registry). Data on mortality as of November 2009 were provided by the official population registry., Results: In total, 553 patients with acute cerebral infarction were included: 260 (47%) females and 293 (53%) men. The mean age was 74.2 years. The incidence of patients admitted with acute cerebral infarction was 105 per 100,000 citizens per year. Thrombolysis was administered to 15%. Duplex sonography of neck vessels disclosed plaques in 68%. Atrial fibrillation was known before admission in 20%. Evaluation disclosed atrial fibrillation in another 12%. Recurrence of cerebral infarction occurred in 1% during the hospital stay. Estimated survival after one year was 82%., Conclusion: The incidence of acute cerebral infarction in Bergen is low. Systematic evaluation discloses risk factors with therapeutic consequences in many patients.

Dipyridamole (DP) is a platelet inhibitor with known antithrombotic benefits in stroke prevention. In addition to its anti-aggregant properties, recent studies have reported that DP promotes anti-inflammatory, anti-oxidative and neuroprotective effects. We aimed to test whether post-treatment with DP may exert protection after ischemic cerebral injury in the rat. For this purpose, rats were subjected to 120 min or 90 min of middle cerebral artery occlusion (MCAO) followed by 24 or 48 h of reperfusion, respectively. Either DP (100mg/kg) or vehicle was administered i.v. at the onset of reperfusion; rats subjected to 90 min MCAO also received additional doses of DP orally (60 mg/kg) at 24 and 36 h after ischemia. Matrix metalloproteinases, extravasated hemoglobin content and IL-6, MIP-1α and MCP-1 cytokine level were examined in brain tissue by zymography, western blot and multiple ELISA, respectively. DP post-treatment led to a neurological improvement in both models (p < 0.05) and a significant reduction in the infarct volume of rats subjected to 90 min of ischemia, as compared to vehicle group (7.9% vs. 24.4%, p = 0.03). This neuroprotection was accompanied by a modest increase in expression of MMP-9 pro-form and a significant attenuation of MIP-1α levels in the infarcted hemisphere. These results provide support for the development of novel therapies based on DP for acute treatment of stroke. In selected animals, intravenous administration of high dose DP induced an adverse hypotensive effect leading to rapid death. Thus, alternative ways of acute administration must be examined in order to avoid this unfavorable effect., (Copyright © 2010 Elsevier B.V. All rights reserved.)

Carotid intervention in severe carotid stenosis after an anterior circulation ischemic event reduces the risk of further infarcts if the surgery is performed soon after the incident event. At present, there is no recommendation to differentiate among subtypes of anterior circulation infarcts or transient ischemic events. However, evidence is mounting that demonstrates a difference in pathophysiology of lacunar and nonlacunar (large artery) infarcts. The natural history of lacunar strokes is different from large artery infarcts for recurrence and mortality. Stroke is a heterogenous disease and consideration needs to be directed to manage different stroke subtypes differently. Lacunar infarcts mostly do not arise from large artery atheromatous disease or by cardioembolic phenomena, and there is a negative predictive value for severe carotid stenosis in lacunar strokes. Thus, current evidence suggests that lacunar strokes may not warrant investigation for carotid stenosis.

Background: There are limited data on the effectiveness of organized stroke care in different ischemic stroke subtypes in the real-world setting. We analyzed the effect of organized stroke care in all stroke subtypes in a longitudinal cohort study using data from the Registry of the Canadian Stroke Network., Methods: Between July 2003 and September 2007, there were 6,223 consecutive patients with ischemic stroke subtype information by Trial of Org 10172 in Acute Stroke Treatment criteria. Subtypes were categorized as large artery atherosclerotic disease, lacunar, cardioembolic, or other. The amount of organized stroke care was quantified using the previously published organized care index (OCI), graded 0-3 based on the presence or absence of occupational therapy or physiotherapy, stroke team assessment, and admission to a stroke unit., Results: Mortality at 30 days was associated with both stroke subtype and OCI. Higher OCI (defined as score 2-3 compared to 0-1) was strongly associated with lower odds of 30-day mortality in each ischemic stroke subtype (adjusted odds ratio estimates ranged from 0.16 to 0.43, p < 0.001, controlling for age, gender, stroke severity, and medical comorbidities by logistic regression). These estimates were essentially unchanged after excluding patients treated with palliative care. Numbers needed to treat, to prevent 1 death at 30 days, ranged from 4 to 9 across the subtypes., Conclusions: A strong association between higher OCI and lower 30-day mortality was apparent in each ischemic stroke subtype. These data suggest that organized stroke care should be provided to stroke patients regardless of stroke subtype.

Background and Purpose: Thrombosis of the cerebral venous sinus may cause venous congestion, cerebral edema, and infarction. The role of cerebrovenous disorders in arterial ischemic stroke is unknown. The objective of this study was to examine the contribution of ipsilateral cranial venous abnormalities to the development of cerebral edema in middle cerebral artery infarction., Methods: This is a retrospective study of consecutive patients with large middle cerebral artery infarction admitted to our neurocritical care unit from January 2007 to October 2008. Medical records, laboratory data, and imaging of cerebral edema and cranial venous sinuses were analyzed., Results: Of the 14 patients identified to have large middle cerebral artery infarction and images of cranial venous drainages, 5 (35.7%) had fatal edema with clinical signs of transtentorial herniation. Four of the 5 patients developed fatal edema within 48 hours of ictus and were found to have abnormal ipsilateral cranial venous drainage, including atresia of the transverse sinus (one), occlusion of the internal jugular vein (one), and hypoplasia of the transverse sinus and internal jugular vein (2). The fifth patient had symmetrical bilateral cranial venous drainages and fatal edema at Day 5. Of the 9 patients with nonmalignant middle cerebral artery infarction, all had ipsilateral dominant or symmetrical bilateral venous drainages., Conclusions: In this small case series, we demonstrated that only the patients with hypoplasia or occlusion of the ipsilateral cranial venous drainage developed early fatal edema after large middle cerebral artery infarction. Our results suggest a role of cranial venous outflow abnormalities in the development of brain edema after arterial ischemic stroke.