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Stroke is a major cause of disability worldwide and a neurological emergency. Intravenous thrombolysis and mechanical thrombectomy are effective in the reperfusion of the parenchyma in distress, but the impossibility to determine the exact time of onset was an important cause of exclusion from treatment until a few years ago. To review the clinical and radiological profile of patients with unknown-onset stroke, the imaging methods to guide the reperfusion treatment, and suggest a protocol for the therapeutic approach. The different imaging methods were grouped according to current evidence-based treatments. Most studies found no difference between the clinical and imaging characteristics of patients with wake-up stroke and known-onset stroke, suggesting that the ictus, in the first group, occurs just prior to awakening. Regarding the treatment of patients with unknown-onset stroke, four main phase-three trials stand out: WAKE-UP and EXTEND for intravenous thrombolysis, and DAWN and DEFUSE-3 for mechanical thrombectomy. The length of the therapeutic window is based on the diffusion weighted imaging-fluid-attenuated inversion recovery (DWI-FLAIR) mismatch, core-penumbra mismatch, and clinical core mismatch paradigms. The challenges to approach unknown-onset stroke involve extending the length of the time window, the reproducibility of real-world imaging modalities, and the discovery of new methods and therapies for this condition. The advance in the possibilities for the treatment of ischemic stroke, while guided by imaging concepts, has become evident. New studies in this field are essential and needed to structure the health care services for this new scenario. O acidente vascular cerebral (AVC) é uma das principais causas de incapacidade em todo o mundo, e uma emergência neurológica. A trombólise intravenosa e a trombectomia mecânica são eficazes na reperfusão do parênquima em sofrimento, mas a impossibilidade de determinar o tempo exato de início era uma causa importante de exclusão ao tratamento até alguns anos atrás. Revisar o perfil clínico-radiológico dos pacientes com AVC de tempo indeterminado, os métodos de imagem para guiar o tratamento de reperfusão, e sugerir um protocolo para a abordagem terapêutica. MéTODOS: Os diferentes métodos de imagem foram agrupados de acordo com os tratamentos atuais baseados em evidências. A maioria dos estudos não encontrou diferença entre as características clínicas e de imagem dos pacientes com AVC reconhecido ao despertar e AVC de tempo definido, o que sugere que o icto, no primeiro grupo, ocorre próximo ao acordar. Quanto ao tratamento do AVC de tempo indeterminado, quatro grandes estudos na fase três sobressaem: WAKE-UP e EXTEND para trombólise intravenosa, e DAWN e DEFUSE-3 para trombectomia mecânica. A ampliação da janela terapêutica fundamenta-se nos paradigmas de incompatibilidade da imagem ponderada de difusão–recuperação da inversão atenuada por fluidos (

The NIH Stroke Scale (NIHSS) is widely adopted in clinical practice. Despite being originally designed for research use, the NIHSS is a valued resource for communication and prognostication, and it is useful for the decision-making process regarding reperfusion therapies and prophylaxis. However, its assessment can be laborious and complex among even certified healthcare providers. In the context of increasing telemedicine use, an accurate assessment of the NIHSS may be crucial in acute stroke management We aimed to create and validate an automated tool for the NIHSS (SPOKES) in a national telemedicine service. A board of five certified vascular neurologists created an NIHSS algorithm based on a tree decision, including tips and hints in the main questions and auxiliary boxes. We randomized 22 spoke hospitals using an automated tool to invite emergency physicians not certified in the NIHSS to use or not the SPOKES. NIHSS-certified and blinded neurologists from a hub hospital performed a double-check of each item of the NIHSS. From June to August 2022, we included 144 cases from 10 spoke hospitals. Our algorithm was fully adopted in 27 cases (19%). The median of reported NIHSS was 3 [1, 5] and 3 [2, 7] points among users and non-users, p=0.38. The general difference between the reported and the double-checked score was 0 [0, 1] points – there was no difference between those who used or did not the SPOKES (p=0.12). A complete concordant score was achieved at 66.7% (n=18/27) and 45.3% (n=53/117), χ 2 =0.036, among users and non-users, respectively. In a bivariate regression analysis, the SPOKES increased the chance of complete agreement [OR 2.4, 95%CI 1-5.8, p=0.049]. There was no difference regarding discrepant scores (≥4 points), χ 2 =0.46. Among SPOKES cases, treatment with tPA was indicated in 11.1%, versus 12.7% among non-users (p=0.59). Despite the small number of included cases, our algorithm seems to be a promising tool for the NIHSS assessment in a national telemedicine service, increasing the chance of a complete agreement with certified neurologists. The tool is free and available at www.spokes-nihss.com

Introduction: Both Machiafava-Bigmami disease (MBD) and Wernicke’s encephalopathy (WE) result from hypovitaminosis mainly associated with chronic alcoholism. The former affects the corpus callosum while the latter affects mostly the mammillary bodies. There are two main clinical subtypes for MBD in Heinrich’s classification. In type A the entire corpus callosum is affected and is characterized by acute or subacute lowering of consciousness and pyramidal deficits. A poor outcome is expected even with initial, prompt therapy. Methods: Case study with medical record review. Case report: Female patient, 53 years old, with subacute monoparesis in the right lower limb, progressing to generalized paresis, altered mental status and communication impairment. She reported smoking and chronic alcohol addiction for 30 years. She was emaciated, dehydrated, drowsy, sometimes agitated; she had eye opening to speech, dysarthric, bradypsychic, hypoactive pupils, bilateral evoked horizontal nystagmus, proximal paresis with dystonic posture. Impaired coordination and gait, with no other positive findings. Head-CT showed hypodensity in the corpus callosum, more pronounced in the splenium. Head- MRI indicated signs of abnormal impregnation in the mammillary bodies, cerebellar atrophy in the anterior vermis, diffuse cytotoxic lesion in the corpus callosum compatible with toxic demyelination. Conclusion: Although rare, such conditions must be recognized and treated promptly in order to delay progress and improve prognosis.