Abstract
Introduction
Stroke alters cortical disinhibition/excitability affecting motor control presumably increasing LMS. This study evaluates all LMS with durations accepted for PLMS (0.1 to 10s) ...for affected and unaffected side of early-phase stroke patients compared to matched controls
Methods
LMS from leg activity meters were obtained on 11 patients 3–19 days post stroke and 10 age and gender-matched controls. Average NIH stroke severity scale was 9.7 ± 4(range 4–18). Records were scored using revised PLM criteria that end a run of LMS whenever the inter-movement interval between onsets (IMI) is too short. This avoids erroneously accepting many closely spaced LMS with too short IMI as classical PLMS.
Results
The number and the standard deviation of durations of LMS with short IMI (<10 seconds) for stroke patients were larger but PLMS/hr with IMI >10, < 90 seconds did not differ compared to control. The difference between unaffected and affected sides in LMS/hr with IMI<10 s was high in cortical and subcortical stroke and minimal in brainstem stroke
Conclusion
LMS observed post-stroke are not typical PLMS in their characteristics nor is the density of PLMS significantly greater than normal healthy adults. Numbers of LMS packed closely together (onsets<10 s apart) are both excessive and more on the unaffected than affected side for cortical and subcortical but not brainstem stroke. These assessments of LMS with short intervals between onsets may provide objective motor output measures of disinhibition/excitability reflecting neural plasticity relevant for post-stroke recovery.
Support (If Any)
Gift account.
Trials of the efficacy and safety of endovascular thrombectomy in patients with large ischemic strokes have been carried out in limited populations.
We performed a prospective, randomized, ...open-label, adaptive, international trial involving patients with stroke due to occlusion of the internal carotid artery or the first segment of the middle cerebral artery to assess endovascular thrombectomy within 24 hours after onset. Patients had a large ischemic-core volume, defined as an Alberta Stroke Program Early Computed Tomography Score of 3 to 5 (range, 0 to 10, with lower scores indicating larger infarction) or a core volume of at least 50 ml on computed tomography perfusion or diffusion-weighted magnetic resonance imaging. Patients were assigned in a 1:1 ratio to endovascular thrombectomy plus medical care or to medical care alone. The primary outcome was the modified Rankin scale score at 90 days (range, 0 to 6, with higher scores indicating greater disability). Functional independence was a secondary outcome.
The trial was stopped early for efficacy; 178 patients had been assigned to the thrombectomy group and 174 to the medical-care group. The generalized odds ratio for a shift in the distribution of modified Rankin scale scores toward better outcomes in favor of thrombectomy was 1.51 (95% confidence interval CI, 1.20 to 1.89; P<0.001). A total of 20% of the patients in the thrombectomy group and 7% in the medical-care group had functional independence (relative risk, 2.97; 95% CI, 1.60 to 5.51). Mortality was similar in the two groups. In the thrombectomy group, arterial access-site complications occurred in 5 patients, dissection in 10, cerebral-vessel perforation in 7, and transient vasospasm in 11. Symptomatic intracranial hemorrhage occurred in 1 patient in the thrombectomy group and in 2 in the medical-care group.
Among patients with large ischemic strokes, endovascular thrombectomy resulted in better functional outcomes than medical care but was associated with vascular complications. Cerebral hemorrhages were infrequent in both groups. (Funded by Stryker Neurovascular; SELECT2 ClinicalTrials.gov number, NCT03876457.).
Background The efficacy of device closure for patent foramen ovale (PFO) for crypotenic stroke has been controversial. PFO closure was superior to medical therapy for prevention of stroke (HR 0.31, ...95% confidence interval (CI) 0.12 to 0.79, p=0.015, heterogeneity I2 = 69.8%).
Studies from early in the COVID-19 pandemic showed that patients with ischemic stroke and concurrent SARS-CoV-2 infection had increased stroke severity. We aimed to test the hypothesis that this ...association persisted throughout the first year of the pandemic and that a similar increase in stroke severity was present in patients with hemorrhagic stroke.
Using the National Institute of Health National COVID Cohort Collaborative (N3C) database, we identified a cohort of patients with stroke hospitalized in the United States between March 1, 2020 and February 28, 2021. We propensity score matched patients with concurrent stroke and SARS-COV-2 infection and available NIH Stroke Scale (NIHSS) scores to all other patients with stroke in a 1:3 ratio. Nearest neighbor matching with a caliper of 0.25 was used for most factors and exact matching was used for race/ethnicity and site. We modeled stroke severity as measured by admission NIHSS and the outcomes of death and length of stay. We also explored the temporal relationship between time of SARS-COV-2 diagnosis and incidence of stroke.
Our query identified 43,295 patients hospitalized with ischemic stroke (5765 with SARS-COV-2, 37,530 without) and 18,107 patients hospitalized with hemorrhagic stroke (2114 with SARS-COV-2, 15,993 without). Analysis of our propensity matched cohort revealed that stroke patients with concurrent SARS-COV-2 had increased NIHSS (Ischemic stroke: IRR=1.43, 95% CI:1.33–1.52, p<0.001; hemorrhagic stroke: IRR=1.20, 95% CI:1.08–1.33, p<0.001), length of stay (Ischemic stroke: estimate = 1.48, 95% CI: 1.37, 1.61, p<0.001; hemorrhagic stroke: estimate = 1.25, 95% CI: 1.06, 1.47, p=0.007) and higher odds of death (Ischemic stroke: OR 2.19, 95% CI: 1.79–2.68, p<0.001; hemorrhagic stroke: OR 2.19, 95% CI: 1.79–2.68, p<0.001). We observed the highest incidence of stroke diagnosis on the same day as SARS-COV-2 diagnosis with a logarithmic decline in counts.
This retrospective observational analysis suggests that stroke severity in patients with concurrent SARS-COV-2 was increased throughout the first year of the pandemic.
Tirofiban is a highly selective nonpeptide antagonist of glycoprotein IIb/IIIa receptor, which reversibly inhibits platelet aggregation. It remains uncertain whether intravenous tirofiban is ...effective to improve functional outcomes for patients with large vessel occlusion ischemic stroke undergoing endovascular thrombectomy.
To assess the efficacy and adverse events of intravenous tirofiban before endovascular thrombectomy for acute ischemic stroke secondary to large vessel occlusion.
This investigator-initiated, randomized, double-blind, placebo-controlled trial was implemented at 55 hospitals in China, enrolling 948 patients with stroke and proximal intracranial large vessel occlusion presenting within 24 hours of time last known well. Recruitment took place between October 10, 2018, and October 31, 2021, with final follow-up on January 15, 2022.
Participants received intravenous tirofiban (n = 463) or placebo (n = 485) prior to endovascular thrombectomy.
The primary outcome was disability level at 90 days as measured by overall distribution of the modified Rankin Scale scores from 0 (no symptoms) to 6 (death). The primary safety outcome was the incidence of symptomatic intracranial hemorrhage within 48 hours.
Among 948 patients randomized (mean age, 67 years; 391 41.2% women), 948 (100%) completed the trial. The median (IQR) 90-day modified Rankin Scale score in the tirofiban group vs placebo group was 3 (1-4) vs 3 (1-4). The adjusted common odds ratio for a lower level of disability with tirofiban vs placebo was 1.08 (95% CI, 0.86-1.36). Incidence of symptomatic intracranial hemorrhage was 9.7% in the tirofiban group vs 6.4% in the placebo group (difference, 3.3% 95% CI, -0.2% to 6.8%).
Among patients with large vessel occlusion acute ischemic stroke undergoing endovascular thrombectomy, treatment with intravenous tirofiban, compared with placebo, before endovascular therapy resulted in no significant difference in disability severity at 90 days. The findings do not support use of intravenous tirofiban before endovascular thrombectomy for acute ischemic stroke.
Chinese Clinical Trial Registry Identifier: ChiCTR-IOR-17014167.
To assess the association of baseline imaging markers of cerebral small vessel disease (SVD) and brain frailty with clinical outcome after acute stroke in the Efficacy of Nitric Oxide in Stroke ...(ENOS) trial.
ENOS randomized 4,011 patients with acute stroke (<48 hours of onset) to transdermal glyceryl trinitrate (GTN) or no GTN for 7 days. The primary outcome was functional outcome (modified Rankin Scale mRS score) at day 90. Cognition was assessed via telephone at day 90. Stroke syndrome was classified with the Oxfordshire Community Stroke Project classification. Brain imaging was adjudicated masked to clinical information and treatment and assessed SVD (leukoaraiosis, old lacunar infarcts/lacunes, atrophy) and brain frailty (leukoaraiosis, atrophy, old vascular lesions/infarcts). Analyses used ordinal logistic regression adjusted for prognostic variables.
In all participants and those with lacunar syndrome (LACS; 1,397, 34.8%), baseline CT imaging features of SVD and brain frailty were common and independently associated with unfavorable shifts in mRS score at day 90 (all participants: SVD score odds ratio OR 1.15, 95% confidence interval CI 1.07-1.24; brain frailty score OR 1.25, 95% CI 1.17-1.34; those with LACS: SVD score OR 1.30, 95% CI 1.15-1.47, brain frailty score OR 1.28, 95% CI 1.14-1.44). Brain frailty was associated with worse cognitive scores at 90 days in all participants and in those with LACS.
Baseline imaging features of SVD and brain frailty were common in lacunar stroke and all stroke, predicted worse prognosis after all acute stroke with a stronger effect in lacunar stroke, and may aid future clinical decision-making.
ISRCTN99414122.
In nonurban areas with limited access to thrombectomy-capable centers, optimal prehospital transport strategies in patients with suspected large-vessel occlusion stroke are unknown.
To determine ...whether, in nonurban areas, direct transport to a thrombectomy-capable center is beneficial compared with transport to the closest local stroke center.
Multicenter, population-based, cluster-randomized trial including 1401 patients with suspected acute large-vessel occlusion stroke attended by emergency medical services in areas where the closest local stroke center was not capable of performing thrombectomy in Catalonia, Spain, between March 2017 and June 2020. The date of final follow-up was September 2020.
Transportation to a thrombectomy-capable center (n = 688) or the closest local stroke center (n = 713).
The primary outcome was disability at 90 days based on the modified Rankin Scale (mRS; scores range from 0 no symptoms to 6 death) in the target population of patients with ischemic stroke. There were 11 secondary outcomes, including rate of intravenous tissue plasminogen activator administration and thrombectomy in the target population and 90-day mortality in the safety population of all randomized patients.
Enrollment was halted for futility following a second interim analysis. The 1401 enrolled patients were included in the safety analysis, of whom 1369 (98%) consented to participate and were included in the as-randomized analysis (56% men; median age, 75 IQR, 65-83 years; median National Institutes of Health Stroke Scale score, 17 IQR, 11-21); 949 (69%) comprised the target ischemic stroke population included in the primary analysis. For the primary outcome in the target population, median mRS score was 3 (IQR, 2-5) vs 3 (IQR, 2-5) (adjusted common odds ratio OR, 1.03; 95% CI, 0.82-1.29). Of 11 reported secondary outcomes, 8 showed no significant difference. Compared with patients first transported to local stroke centers, patients directly transported to thrombectomy-capable centers had significantly lower odds of receiving intravenous tissue plasminogen activator (in the target population, 229/482 47.5% vs 282/467 60.4%; OR, 0.59; 95% CI, 0.45-0.76) and significantly higher odds of receiving thrombectomy (in the target population, 235/482 48.8% vs 184/467 39.4%; OR, 1.46; 95% CI, 1.13-1.89). Mortality at 90 days in the safety population was not significantly different between groups (188/688 27.3% vs 194/713 27.2%; adjusted hazard ratio, 0.97; 95% CI, 0.79-1.18).
In nonurban areas in Catalonia, Spain, there was no significant difference in 90-day neurological outcomes between transportation to a local stroke center vs a thrombectomy-capable referral center in patients with suspected large-vessel occlusion stroke. These findings require replication in other settings.
ClinicalTrials.gov Identifier: NCT02795962.
The aim of the current study was to explore the whole‐brain dynamic functional connectivity patterns in acute ischemic stroke (AIS) patients and their relation to short and long‐term stroke severity. ...We investigated resting‐state functional MRI‐based dynamic functional connectivity of 41 AIS patients two to five days after symptom onset. Re‐occurring dynamic connectivity configurations were obtained using a sliding window approach and k‐means clustering. We evaluated differences in dynamic patterns between three NIHSS‐stroke severity defined groups (mildly, moderately, and severely affected patients). Furthermore, we built Bayesian hierarchical models to evaluate the predictive capacity of dynamic connectivity and examine the interrelation with clinical measures, such as white matter hyperintensity lesions. Finally, we established correlation analyses between dynamic connectivity and AIS severity as well as 90‐day neurological recovery (ΔNIHSS). We identified three distinct dynamic connectivity configurations acutely post‐stroke. More severely affected patients spent significantly more time in a configuration that was characterized by particularly strong connectivity and isolated processing of functional brain domains (three‐level ANOVA: p < .05, post hoc t tests: p < .05, FDR‐corrected). Configuration‐specific time estimates possessed predictive capacity of stroke severity in addition to the one of clinical measures. Recovery, as indexed by the realized change of the NIHSS over time, was significantly linked to the dynamic connectivity between bilateral intraparietal lobule and left angular gyrus (Pearson's r = −.68, p = .003, FDR‐corrected). Our findings demonstrate transiently increased isolated information processing in multiple functional domains in case of severe AIS. Dynamic connectivity involving default mode network components significantly correlated with recovery in the first 3 months poststroke.
By employing dynamic functional connectivity analyses, Bonkhoff et al. demonstrate that severe acute ischemic stroke is linked to transiently increased isolated information processing in multiple functional domains. Additionally, they show that dynamic connectivity involving default mode network components significantly correlates with recovery in the first three months poststroke.
Background
The Indian data concerning the endovascular mechanical thrombectomy (MT) in acute ischemic strokes (AIS) with large vessel occlusion (LVO) is still scarce and evolving. Tenecteplase (TNK) ...has been recently approved for intravenous stroke thrombolysis prior to the MT.
Methods
This study is a single-center retrospective study. We performed data analysis of the AIS patients who consecutively presented during the study period with LVO and underwent thrombectomy. Procedural success was defined by the post-thrombectomy angiographic picture of grades 2b and 3 on modified Thrombolysis in Cerebral Infarction (mTICI) scale. Primary efficacy outcome was defined as an improvement of ≥4 points in National Institute of Health Stroke Scale (NIHSS) score at 24 h. Secondary efficacy outcome was based on modified Rankin Scale (mRS) score at 90 days. We also performed a comparative analysis of TNK and alteplase subgroups.
Results
Successful recanalization (mTICI 2b/3) was achieved in 65 (86.67%) patients. There was a significant mean difference between the NIHSS scores on admission and at 24 h (P < .001). Likewise, mRS score at 3 months also showed a significant mean difference as compared to baseline (P < .001). A faster recanalization was observed in those who were thrombolyzed with TNK, needed fewer number of passes, and if the procedure was performed under conscious sedation.
Conclusion
This study further strengthens the Indian data on efficacy and safety of MT in LVO ischemic strokes. Besides, whether the observation of TNK resulting in a faster revascularization is due to some factors unaccounted in our study, or an actual effect on thrombus due to a high fibrin specificity, needs to be tested further in larger randomized studies with matched sample sizes.
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