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Introduction: Poststroke apathy (PSA) is a common neuropsychiatric disorder that may affect up to 30% of stroke patients. Despite the difficulties of investigating this condition (overlapping with depression, heterogeneity of diagnostic criteria, a small number of studies), some recent diffusion tensor imaging studies have suggested that widespread microstructural white matter (WM) disruption plays a key role in the development of PSA. Therefore, we intended to investigate this hypothesis by evaluating the relationship between WM hyperintensities (WMH) and apathy in patients with cerebrovascular disease. Methods: We studied patients with apathy (n = 7), depression (n = 13), comorbid apathy and depression (n = 13), and controls (n = 20), and we investigated the variables associated with the volume of WMH measured by an automated brain MRI segmentation software. Results: The overall prevalence of PSA was 37.7% (pure and comorbid). Patients with apathy presented a higher volume of WMH in comparison to controls. Mini-Mental State Examination (MMSE), NPI-A, and the number of cerebral microbleeds were the only variables associated with WMH. Conversely, NPI-D did not correlate to WMH. Discussion/Conclusion: This is an exploratory study that supports the view of PSA as a distinct syndrome from PSD mediated mainly by diffuse white matter hyperintensities, which suggests that WM disruption is an important pathway to the development of apathy in stroke patients.

Introduction: Cerebral small vessel disease (cSVD) involves a myriad of pathogenic mechanisms affecting small vessels of the brain, leading to a significant impact on motor and cognitive functions, and it is the main cause of Vascular cognitive impairment (VCI). The endothelial glycocalyx (EG), the layer lining the vascular endothelium, has a pivotal player in maintaining the proper function of neurovascular unit, and its degradation may be involved in VCI due to cSVD. Objectives: to investigate the relationship between markers of EG damage and VCI related to cSVD. Methods: Cross-sectional study based on clinical data and serum samples for the quantification of EG damage markers (syndecan-1, hyaluran) of VCI related to cSVD patients and of a control group derived from a dataset of healthy workers from the same institution. We used an automatic logarithm for segmentation and volumetric evaluation of white matter lesions on brain MRI of the patients. Logistic regression models and c-statistics were used to identify the independent variables related to VCI and investigate the accuracy of syndecan-1 to detect VCI. We studied the association of thebiomarkers and MoCA scores, index of independence in activities of daily living and whitematter lesion burden respectively. Results: Between July 2019 and March 2020, we studied 22 patients with VCI associated with cSVD and compared them with a dataset of 22 healthy workers from the same institution. Patients with VCI were older, had a higher prevalence of diabetesmellitus and hypertension, had a worse index of independence for daily activities, and higherlevels of syndecan-1 (78,4 vs 24; p < 0,01). There was no difference in hyaluran levels between both groups. In multivariate analysis, only age (OR 1,35;CI 1,04 - 1,76; p = 0,02) and syndecan-1 levels (OR 1,08;CI 1,01 - 1,15;p = 0,01) related to VCI. The ROC curve ofsyndecan-1 levels to predict VCI had a area under de curve of 0,78 (CI 0,64 - 0,92) and there was a correlation between syndecan-1 levels and MoCA scores (rho = - 0,34;p = 0,02). There were no correlations between syndecan-1 and hyaluran levels and index of independence and white matter lesion burden respectively. Conclusions: Syndecan-1, but not hyaluran, is a potential biomarker for VCI associated with cSVD.

Introduction: The damage in the endothelium and the neurovascular unit appears to play a key role in the pathogenesis of vascular cognitive impairment (VCI). Although there have been many advances in understanding the physiopathology of this disease, several questions remain unanswered. The association with other degenerative diseases and the heterogeneity of its clinical spectrum establish a diagnostic problem, compromising a better comprehension of the pathology and halting the development of effective treatments. The investigation of biomarkers is an important movement to the development of novel explicative models and treatment targets involved in VCI. Methods: We searched MEDLINE considering the original research based on VCI biomarkers in the past 20 years, following prespecified selection criteria, data extraction, and qualitative synthesis. Results: We reviewed 42 articles: 16 investigated plasma markers, 17 analyzed neuropathological markers, 4 studied CSF markers, 4 evaluated neuroimaging markers (ultrasound and MRI), and 1 used peripheral Doppler perfusion imaging. Conclusions: The biomarkers in these studies suggest an intrinsic relationship between endothelial dysfunction and VCI. Nonetheless, there is still a need for identification of a distinctive set of markers that can integrate the clinical approach of VCI, improve diagnostic accuracy, and support the discovery of alternative therapies.

Background Assessment of the impact of the thrombectomy learning curve on clinical outcomes is essential for developing healthcare system protocols. Aims The aim of this study was to assess the effect of thrombectomy case volume on procedural and clinical outcomes in a Brazilian registry. Methods A total of 645 patients with acute ischemic stroke treated by thrombectomy were included in the analysis. Patients were divided into two groups regarding the period of treatment: the early period group and the late period group. Results In the adjusted analysis, treatment in the late period was an independent predictor of recanalization (odds ratio 1.91, 95% CI 1.28–2.86) and excellent neurologic outcomes at three months (odds ratio 1.77, 95% CI 1.04–3.01). Treatment in the late period had no significant association with mortality (odds ratio 0.88, 95% CI 0.55–1.41). Conclusions An increase in thrombectomy case volume for the treatment of AIS over time was an independent predictor of recanalization and excellent neurologic outcome.

Background Acute basilar artery occlusion is a devastating life-threatening condition. Early recanalization is the therapeutic goal in patients with acute ischemic stroke. Despite the high rates of recanalization achieved with modern devices for basilar occlusions, many patients have had poor clinical outcomes. This study aimed to assess the predictors of good and poor outcomes among patients with basilar artery occlusion treated with thrombectomy. Methods A consecutive registry of 80 patients was included in this retrospective study. The primary end point was to access variables associated with neurologic outcomes defined by a modified Rankin Scale (mRS) score of 0–2, symptomatic intracranial hemorrhage (sICH), and mortality at 3 months follow-up. Results Recanalization was achieved in 86.2%, and the sICH rate was 8.7%. A good neurologic outcome (mRS score 0–2) was observed in 26.2% and a moderate outcome (mRS score 0–3) in 32.5% of patients. The mortality was 38.7% at 3 months follow-up. Conclusions After thrombectomy for posterior circulation strokes, young patients, V4–proximal basilar occlusion, (high) baseline posterior circulation Alberta Stroke Program Early CT Score, and complete recanalization were independent predictors of good neurologic outcomes. Failure to recanalize was strongly related to sICH and mortality. In addition, diabetes, atrial fibrillation, and baseline National Institutes of Health Stroke Scale scores ≥10 had an independent association with mortality. This study contributes to the knowledge required to optimize recanalization treatments for posterior circulation strokes and may help to improve future clinical studies.

Background: The increasing demand and shortage of experts to evaluate and treat acute stroke patients has led to the development of remote communication tools to aid stroke management. We aimed to describe the experience of the Brazilian Stroke Network in the implementation of a telemedicine stroke program using a low-cost smartphone application system (JOIN App, Allm, Japan) for rapid sharing of clinical and neuroimaging patient data. Methods: We evaluated the initial experience of the telestroke program using a smartphone app measuring its feasibility, safety and speed in the acute stroke decision-making process, with a particular focus on intravenous thrombolysis. The App was implemented in hospitals without neurologists available for acute stroke evaluation and was connected with a stroke team to support the decision for thrombolysis. We analyzed the times of acute treatment and safety through the rate of symptomatic intracranial hemorrhage (sICH) in 24hours. The program was implemented as part of the partnership with the Angels Initiative in Brazil supported by Boehringer Ingelheim to improve stroke care across the globe. Results: The telestroke program started in May 2019 and since then 7 hospitals, in 5 Brazilian states, were included. Only 2 of these hospitals had previous experience with stroke thrombolysis. In all hospitals, the patients were assisted by emergency physicians with eventual support of local neurologists. The telestroke program was activated for 58 patients. The median age was 68yo (IQR58-72), 47% were female and the baseline NIHSS was 11 (IQR8-16). In 69% of the activation the diagnosis was ischemic stroke (IS), 7% hemorrhagic, 5% TIA and 28% other diagnosis. Thrombolysis was suggested in 48% of all evaluations (70% of IS patients). A total of 53% of IS were actually treated with thrombolys. The response-time of the stroke experts was 2.6 minutes (2-6), door-to-CT scan 20min (15-31) and door-needle time 59min (27-81). None of the patients had sICH. Conclusion: In a telestroke program using a smartphone App, thrombolysis performed by emergency physicians was feasible and safe. This mobile low cost technology can increase the possibility of patients with stroke to receive treatment in regions without neurologists across the globe.

Background: Despite evidence supporting the overall efficacy of mechanical thrombectomy (MT) in acute ischemic stroke (AIS) due to large vessel occlusion (LVO) of the anterior circulation, it is unclear whether the treatment effect of MT differs by sex in different populations. We assessed the impact of sex differences in the treatment effect of MT in the RESILIENT trial. Methods: RESILIENT was a prospective, multicenter, randomized phase III trial that was designed to assess the safety, efficacy, and cost-effectiveness of mechanical thrombectomy as compared to medical treatment alone in patients treated under the less than ideal conditions typically found in the public healthcare system of a developing country. Results: Among 221 patients enrolled in the trial, 104 (47,1%) were female. Baseline characteristics were well balanced between sexes, except for a higher prevalence of hypertension (76% vs. 57.4%; p=0.004) and diabetes (34.3% vs. 21.7%; p=0.039) and a lower frequency of alcohol abuse (4% vs. 28.9%; p=0.001) in females. After adjustment for baseline characteristics, we found a significant interaction (p=0.026) between sex and the effect of MT with a lower efficacy of MT for functional independency at 90 days among women (aOR=1.13;95%CI:0.42-3.02) compared to men (aOR=4.78; 95%CI:1.88-12.15). Conclusions: In our study population of patients with AIS caused by LVO of the anterior circulation, women were less likely to benefit from MT than men. Further studies are necessary to investigate these findings.

Background: The results of recent trials of mechanical thrombectomy for acute ischemic stroke have increased the demand for identification of patients with large vessel occlusion (LVO) at the primary stroke center, where a prompt detection may expedite transfer to a comprehensive stroke center for endovascular treatment. However, in developing countries, a noncontrast computed tomography (NCCT) may be the only neuroimaging modality available at the primary stroke center scenario, what calls for a screening strategy accurate enough to avoid unnecessary transfers of noneligible patients for endovascular therapy. Algorithms based on National Institute of Health Stroke Scale (NIHSS) and NCCT findings can be used to screen for LVO in patients with anterior circulation stroke (ACS). Objective: To test the accuracy of a score based on NIHSS and NCCT to detect LVO in patients with ACS. Methods: We evaluated 178 patients from a prospective stroke registry of patients admitted to an academic tertiary emergency unit. NIHSS and vessel attenuation values of the middle cerebral artery on NCCT absolute vessel attenuation (VA) were collected by 2 investigators that were blind to CT angiography (CTA) findings. We used receiver operating characteristics curve analysis and C-statistics to predict LVO on CTA. Results: NIHSS and vessel attenuation were highly associated with LVO with an area under the curve (AUC) of .86 and .77. The LVO score, built by logistic regression coefficients of the NIHSS and VA, showed the highest accuracy for the presence of LVO on CTA (AUC of .91). Conclusion: The LVO score may be a useful screening approach to identify LVO in patients with ACS.