Diabetes is an Independent Growth Factor of Ischemic Stroke During Reperfusion Phase Leading to Poor Clinical Outcome

ObjectivesDespite the success of recanalization by bridging therapy, about half of treated stroke patients remain disabled. While numerous reports propose clinical predictors of stroke clinical outcome in this context, we originally aimed to study pre-therapeutic factors influencing infarct growth (IG) and poor clinical outcome in strokes due to large vessel occlusion (LVO) successfully recanalized.Materials and methodsWe enrolled 87 consecutive successfully recanalized patients (mTICI: 2b/2c/3) by mechanical thrombectomy (±rt-PA) after stroke due to middle cerebral artery (M1) occlusion within 6 h according to AHA guidelines. IG was defined by subtracting the initial DWI volume to the final 24 h-TDM volume. Statistical associations between poor clinical outcome (mRS≥2), IG and pertinent clinico-radiological variables, were measured using logistic and linear regression models.ResultsAmong 87 enrolled patients (Age(y): 68.4 ± 17.5; NIHSS: 16.0 ± 5.4), 42/87 (48,28%) patients had a mRS ≥ 2 at 3 months. Diabetic history (OR: 3.70 CI95%[1.03;14.29] and initial NIHSS (/1 point: OR: 1.16 CI95%[1.05;1.27]) were independently associated with poor outcome. IG was significantly higher in stroke patients with poor outcome (+7.57 ± 4.52 vs ?7.81 ± 1.67; p = 0.0024). Initial volumes were not significantly different (mRS≥2: 16.18 ± 2.67; mRS[0–1]: 14.70 ± 2.30; p = 0.6771). Explanatory variables of IG in linear regression were diabetic history (β: 21.26 CI95%[5.43; 37.09]) and NIHSS (β: 0.83 CI95%[0.02; 1.64]). IG was higher in diabetic stroke patients (23.54 ± 1.43 vs ?6.20 ± 9.36; p = 0.0061).ConclusionsWe conclude that diabetes leads to continued IG after complete recanalization, conditioning clinical outcome in LVO strokes successfully recanalized by bridging therapy. We suggest that poor tissular reperfusion by diabetic microangiopathy could explain this result.     

Predictive factors for the development of epilepsy after ischemic stroke

ObjectivesIschemic stroke is one of the most common causes of epilepsy in adults. The incidence of post-stroke epilepsy (PSE) is approximately 7%. Risk factors are higher stroke severity, cortical localization, higher National Institute of Health Stroke Scale (NIHSS) upon admission and acute symptomatic seizures. We analyzed the predictive factors of PSE development in our population.Materials and methodsRetrospective observational cohort of adult patients (age ≥ 18 years) with ischemic stroke assessed between January 2012 and June 2020. Patients with personal history of epilepsy and potentially epileptogenic structural injury other than acute or chronic stroke were excluded. Demographic, clinical and imaging variables were evaluated in a multivariate analysis for independent risk factors associated with PSE.ResultsMedical records of 1586 stroke patients were reviewed, 691 met the inclusion criteria and had at least one year of follow-up. Of them, 428 (61.9%) were males. During follow-up, 6.2% had diagnosis of PSE (42/691) with a higher frequency of: previous ischemic stroke, higher NIHSS upon admission, treatment with rt-PA, higher Fazekas scale grade, cortical involvement, hemorrhagic transformation, acute symptomatic seizures, longer hospitalization and higher modified Rankin Scale (mRS) at discharge compared to the group without PSE. In a multivariate analysis, acute symptomatic seizures (OR=3.22, p: 0.033), cortical involvement (OR=0.274, p < 0.05), Fazekas scale score (OR=0.519, p < 0.05) and mRS at discharge (OR=1.33, p: 0.043) were independent risk factors.ConclusionsThe variables related to higher risk of PSE were similar to those reported in the literature, highlighting the importance of neuroimaging findings, acute symptomatic seizures during hospitalization and neurological deficit at discharge. The data obtained will serve as the basis for construction of predictive models, allowing to individualize PSE probability in our population.     

Cincinnati Prehospital Stroke Scale Implementation of an Urban County Severity-Based Stroke Triage Protocol: Impact and Outcomes on a Comprehensive Stroke Center

Background and purposeScreening scales are recommended to assist field-based triage of acute stroke patients to designated stroke centers. Cincinnati prehospital stroke scale (CPSS) is a commonly used prehospital stroke screening tool and has been validated to identify large vessel occlusion (LVO). This study addresses the impact of county-based CPSS implementation to triage suspected LVO patients to a comprehensive stroke center (CSC).Materials and methodsDekalb County in Atlanta, Georgia, implemented CPSS-based protocol with score of 3 and last seen normal time < 24 h mandating transfer to the nearest CSC if the added bypass time was <15 min. Frequency of stroke codes, LVO, IV-tPA use, and thrombectomy treatment were compared six months before and after protocol change (November 1, 2020).ResultsDuring the study period, 907 stroke patients presented to the CSC by EMS, including 289 (32%) with CPSS score 3. There was an increase in monthly ischemic stroke volume (pre-16 ± 2 vs.19 ± 3 p = 0.03), LVO (pre-4.3 ± 1.7 vs. post-7.0 ± 2.4; p = 0.03), EVT (pre-15% vs. post-30%; p = 0.001), without significant increase in stroke mimic volume or delay in mean time from last seen normal to IV-tPA (pre-165 ± 66, post-158 ± 49 min; p = 0.35). CPSS score 3 was associated with increased likelihood of LVO diagnosis (OR 8.5, 95% CI 5.0-14.4; p = 0.001) and decreased the likelihood of stroke mimics (OR 0.66, 95% CI 0.50-0.88; p = 0.004).ConclusionCPSS is a quick, easy to implement, and reliable prehospital severity scale for EMS to triage LVO to CSC without delaying IV-tPA treatment or significantly increasing stroke mimics.     

Predictive value of the combination between the intracranial arterial culprit plaque characteristics and the Essen Stroke Risk Score for short-term stroke recurrence

AimIn the current study we aim the identification of the culprit plaque characteristics of intracranial arteries using high-resolution magnetic resonance vessel wall imaging (HR-MR-VWI). Moreover, we target the evaluation of the predictive value of culprit plaque characteristics for short-term stroke recurrence combined with ESRS.Materials and methodsWe conducted a prospective cohort study on 342 patients diagnosed with symptomatic intracranial atherosclerotic stenosis (sICAS), out of which 243 were men and 99 were women with an average age of 64 ± 12 years. 184 cases of anterior circulation ischemia (ACIS) and 158 cases of posterior circulation ischemia (PCIS) were included in the study. All of them underwent HR-MR-VWI during the period between February 2020 and June 2021 in the Second Affiliated Hospital of Nantong University, Nantong, China. The culprit vessel and culprit plaque characteristics were assessed based on HR-MR-VWI images, and the patients' ESRS were obtained from the electronic medical records of the hospital. Concerning the obtained results from the 6-month follow-up, the patients were divided into the non-recurrence group and the recurrence group, and the differences in the above-mentioned features between the two groups were compared. The univariate Cox regression analysis combined with ESRS was performed to screen out the independent risk factors associated with recurrent stroke with P < 0.1. Receiver operating characteristic curves (ROC curves) were plotted to analyze the predictive performance of the culprit plaque characteristics, ESRS and combined variables for stroke recurrence. We used the area under the curve (AUC) ROC, while the sensitivity and specificity were calculated at the optimal threshold. The Delong test was employed to compare the quality of the AUC of the predictors.ResultsA total of 15.5% (53/342) of patients had a stroke recurrence within six months, with statistically significant differences (P < 0.05) between the two groups regarding the ESRS, medical history of diabetes mellitus, myocardial infarction, data for previous acute ischemic stroke (AIS) or transient ischemic attack(TIA), history of peripheral vascular disease, and serum brain natriuretic peptide level. In the patients with ACIS, the incidence of hyperintensity on the T1-weighted imaging (T1WI) was significantly different between the recurrence and the non-recurrence groups (P < 0.05). In the patients with PCIS, statistically significant differences between the recurrence and the non-recurrence group were detected in the culprit plaque burden, degree of enhancement, and incidence of hyperintensity on T1WI (P < 0.05). The ESRS (hazard ratios [HR], 1.598, 95% confidence interval [CI], 1.193–2.141, P = 0.002) ,degree of enhancement (HR = 1.764, 95% CI 0.985–3.087, P = 0.047) and hyperintensity on T1WI (HR = 2.745, 95% CI 1.373–5.488, P = 0.004) proved to be independent risk factors for stroke recurrence. The ESRS predicted stroke recurrence with AUC = 0.618 (95% CI 0.564–0.670), while the best cut-off value was 2 points. Furthermore, the registered sensitivity and specificity were 60.4% and 58.5%, respectively. Regarding the degree of enhancement in the culprit plaque, the prediction of stroke recurrence was with AUC = 0.628 (95% CI 0.574–0.679) as well as with sensitivities and specificities of 58.5% and 64.4%, respectively. Regarding the hyperintensity on T1WI in culprit plaque, the prediction of stroke recurrence was with AUC = 0.678 (95% CI 0.626–0.727) as well as with sensitivities and specificities of 66.0% and 70.0%, respectively. The ESRS combined with the degree of enhancement predicted stroke recurrence with an AUC = 0.685 (95CI% 0.633–0.734), while the recorded sensitivity and specificity were 56.6% and 73.4%, respectively. The ESRS combined with hyperintensity on the T1WI predicted stroke recurrence with an AUC = 0.745 (95CI% 0.696–0.791). The recorded sensitivity and specificity were 64.2% and 76.8%, respectively. The AUC quality of the ESRS combined with hyperintensity on T1WI was higher than that of other indices (P < 0.05).ConclusionsThe hyperintensity on T1WI of the culprit plaque in intracranial arteries combined with ESRS demonstrated better predictive ability for short-term stroke recurrence. We consider this of high importance for clinical application since it provides an easier way of obtaining data for precise diagnosis.     

Safety and effectiveness of mechanical thrombectomy for primary isolated distal vessel occlusions: A monocentric retrospective comparative study

BackgroundDistal vessel occlusions represent about 25-40% of acute ischemic stroke (AIS), either as primary occlusion or secondary occlusion complicating mechanical thrombectomy (MT) for large vessel occlusion.ObjectiveOur aim was to evaluate safety and effectiveness of MT associated with the best medical treatment (BMT) in the management of AIS patients with distal vessel occlusion in comparison with the BMT alone.MethodsRetrospective analysis was conducted on AIS patients treated by MT+BMT for primary distal vessel occlusion between 2015 and 2020, and were compared with a historic cohort managed by BMT alone between 2006 and 2015 selected based on the same inclusion criteria. A secondary analysis was conducted using propensity score matching (PSM) including the following: NIHSS, age and treatment with intravenous thrombolysis (IVT) as covariates.ResultsOf 650 patients screened, 44 patients with distal vessel occlusions treated by MT+BMT were selected and compared with 36 patients who received BMT alone. After PSM, 28 patients in each group were matched without significant difference. Good clinical outcome defined as mRS≤2 was achieved by 53.6% of the MT+BMT group and 57% of the BMT group (OR, 0.87; 95%CI, 0.3–2.4; p = 1.00). The mortality rate was comparable in both groups (7% vs. 10.7% in MT+BMT and BMT patients, respectively; OR=0.64; 95%CI, 0.1-4; p = 1.00). Symptomatic intracranial hemorrhage (ICH) was seen in only one patient treated by MT+BMT (3.6%).ConclusionMechanical thrombectomy seems to be comparable with the best medical treatment regarding the effectiveness and safety in the management of patients with distal vessel occlusions.     

Efficacy of pitolisant in patients with high burden of narcolepsy symptoms: pooled analysis of short-term,placebo-controlled studies

Study objectiveTo evaluate the efficacy of pitolisant, a histamine 3 (H₃)-receptor antagonist/inverse agonist, in adult patients with high burden of narcolepsy symptoms.MethodsData were pooled from two randomized, placebo-controlled, 7- or 8-week studies of pitolisant (titrated to a potential maximum dose of 35.6 mg/day) in adults with narcolepsy. Analyses included three independent patient subgroups: Epworth Sleepiness Scale (ESS) baseline score ≥16, Maintenance of Wakefulness Test (MWT) sleep latency ≤8 min, and ≥15 cataplexy attacks per week.ResultsThe analysis populations included 118 patients for ESS (pitolisant, n = 60; placebo, n = 58), 105 for MWT (pitolisant, n = 59; placebo, n = 46), and 31 for cataplexy (pitolisant, n = 20; placebo, n = 11). On the ESS, least-squares mean change from baseline was significantly greater for pitolisant (−6.1) compared with placebo (−2.3; P < 0.001). Significantly more pitolisant-treated patients were classified as treatment responders: ESS score reduction ≥3, 69.0% in the pitolisant group versus 35.1% in the placebo group (P = 0.001); final ESS score ≤10, 36.2% versus 10.5%, respectively (P = 0.005). On the MWT, mean sleep latency increased from 3.5 min to 10.4 min with pitolisant and from 3.4 min to 6.8 min with placebo (P = 0.017). Least-squares mean change in the weekly rate of cataplexy was significantly greater for pitolisant (−14.5; baseline, 23.9; final, 9.4) compared with placebo (−0.1; baseline, 23.1; final, 23.0; P = 0.004). Headache was the most common adverse event with pitolisant.ConclusionsPitolisant, at once-daily doses up to 35.6 mg, was efficacious for reducing excessive daytime sleepiness and cataplexy in patients with severe narcolepsy symptom burden.     

The evaluation of sleep disturbances for Chinese frontline medical workers under the outbreak of COVID-19

ObjectiveTo evaluate sleep disturbances of Chinese frontline medical workers (FMW) under the outbreak of coronavirus disease 2019 (COVID-19), and make a comparison with non-FMW.MethodsThe medical workers from multiple hospitals in Hubei Province, China, volunteered to participate in this cross-sectional study. An online questionnaire, including Pittsburgh Sleep Quality Index (PSQI), Athens Insomnia Scale (AIS) and Visual Analogue Scale (VAS), was used to evaluate sleep disturbances and mental status. Sleep disturbances were defined as PSQI>6 points or/and AIS>6 points. We compared the scores of PSQI, AIS, anxiety and depression VAS, as well as prevalence of sleep disturbances between FMW and non-FMW.ResultsA total of 1306 subjects (801 FMW and 505 non-FMW) were enrolled. Compared to non-FMW, FMW had significantly higher scores of PSQI (9.3 ± 3.8 vs 7.5 ± 3.7; P < 0.001; Cohen's d = 0.47), AIS (6.9 ± 4.3 vs 5.3 ± 3.8; P < 0.001; Cohen's d = 0.38), anxiety (4.9 ± 2.7 vs 4.3 ± 2.6; P < 0.001; Cohen's d = 0.22) and depression (4.1 ± 2.5 vs 3.6 ± 2.4; P = 0.001; Cohen's d = 0.21), as well as higher prevalence of sleep disturbances according to PSQI > 6 points (78.4% vs 61.0%; relative risk [RR] = 1.29; P < 0.001) and AIS > 6 points (51.7% vs 35.6%; RR = 1.45; P < 0.001).ConclusionFMW have higher prevalence of sleep disturbances and worse sleep quality than non-FMW. Further interventions should be administrated for FMW, aiming to maintain their healthy condition and guarantee their professional performance in the battle against COVID-19.     

Comparison of Transcallosal Inhibition Between Hemispheres and Its Relationship with Motor Behavior in Patients with Severe Upper Extremity Impairment After Subacute Stroke

ObjectiveTo compare corticospinal excitability and transcallosal inhibition between contralesional primary motor cortex (M1) and ipsilesional M1. We also investigated the correlation between transcallosal inhibition and upper extremity motor behavior.Materials and methods19 individuals with unilateral ischemic subacute stroke who had severe upper extremity impairment participated in this study. Corticospinal excitability was assessed by measuring the resting motor threshold, active motor threshold and motor evoked potential amplitude. Transcallosal inhibition was investigated by measuring the duration and depth of the ipsilateral silent period (ISP). The data from the two hemispheres were compared and the relationships of transcallosal inhibition with upper extremity motor impairment, grip strength and pinch strength were analyzed.ResultsResting motor threshold (p = 0.001) and active motor threshold (p = 0.001) were lower and motor evoked potential amplitude was higher (p = 0.001) in the contralesional M1 compared to the ipsilesional M1. However, there were no differences between the two M1s in ISP duration (p = 0.297) or ISP depth (p =0. 229). Transcallosal inhibition from the contralesional M1 was positively associated with motor impairment (ISP duration, p = 0.003; ISP depth, p = 0.017) and grip strength (ISP duration, p = 0.016; ISP depth, p = 0.045).ConclusionsSymmetric transcallosal inhibition between hemispheres and positive association of transcallosal inhibition from contralesional M1 with upper extremity motor behavior indicate that recruitment of contralesional M1 may be necessary for recovery in patients with severe upper extremity impairment after subacute ischemic stroke.     

Elevated Hypoperfusion Intensity Ratio (HIR) observed in patients with a large vessel occlusion (LVO) presenting in the evening

BackgroundCircadian variability has been implicated in timing of stroke onset, yet the full impact of underlying biological rhythms on acute stroke perfusion patterns is not known. We aimed to describe the relationship between time of stroke onset and perfusion profiles in patients with large vessel occlusion (LVO).MethodsA retrospective observational study was conducted using prospective registries of four stroke centers across North America and Europe with systematic use of perfusion imaging in clinical care. Included patients had stroke due to ICA, M1 or M2 occlusion and baseline perfusion imaging performed within 24h from last-seen-well (LSW). Stroke onset was divided into eight hour intervals: (1) Night: 23:00-6:59, (2) Day: 7:00-14:59, (3) Evening: 15:00-22:59. Core volume was estimated on CT perfusion (rCBF <30%) or DWI-MRI (ADC <620) and the collateral circulation was estimated with the Hypoperfusion Intensity Ratio (HIR = [Tmax>10s]/[Tmax>6s]). Non-parametric testing was conducted using SPSS to account for the non-normalized dependent variables.ResultsA total of 1506 cases were included (median age 74.9 years, IQR 63.0-84.0). Median NIHSS, core volumes, and HIR were 14.0 (IQR 8.0-20.0), 13.0mL (IQR 0.0-42.0), and 0.4 (IQR 0.2-0.6) respectively. Most strokes occurred during the Day (n = 666, 44.2%), compared to Night (n = 360, 23.9%), and Evening (n = 480, 31.9%). HIR was highest, indicating worse collaterals, in the Evening compared to the other timepoints (p = 0.006). Controlling for age and time to imaging, Evening strokes had significantly higher HIR compared to Day (p = 0.013).ConclusionOur retrospective analysis suggests that HIR is significantly higher in the evening, indicating poorer collateral activation which may lead to larger core volumes in these patients.     

Early mobilisation is associated with lower subacute blood pressure and variability in ICH: A retrospective cohort study✰

BackgroundVery early rehabilitation after stroke appears to worsen outcome, particularly in intracerebral haemorrhage (ICH). Plausible mechanisms include increased mean blood pressure (BP) and BP variability.AimsTo test associations between early mobilisation, subacute BP and survival, in observational data of ICH patients during routine clinical care.MethodsWe collected demographic, clinical and imaging data from 1372 consecutive spontaneous ICH patients admitted between 2 June 2013 and 28 September 2018. Time to first mobilisation (defined as walking, standing, or sitting out-of-bed) was extracted from electronic records. We evaluated associations between early mobilisation (within 24 h of onset) and both subacute BP and death by 30 days using multifactorial linear and logistic regression analyses respectively.ResultsMobilisation at 24 h was not associated with increased odds of death by 30 days when adjusting for key prognostic factors (OR 0.4, 95% CI 0.2 to 1.1, p = 0.07). Mobilisation at 24 h was independently associated with both lower mean systolic BP (−4.5 mmHg, 95% CI −7.5 to −1.5 mmHg, p = 0.003) and lower diastolic BP variability (−1.3 mmHg, 95% CI −2.4 to −0.2 mg, p = 0.02) during the first 72 h after admission.ConclusionsAdjusted analysis in this observational dataset did not find an association between early mobilisation and death by 30 days. We found early mobilisation at 24 h to be independently associated with lower mean systolic BP and lower diastolic BP variability over 72 h. Further work is needed to establish mechanisms for the possible detrimental effect of early mobilisation in ICH.     

Genetically Predicted Cardiac Troponin I Concentrations and Risk of Stroke and Atrial Fibrillation

ObjectivesObservational studies have shown that elevated circulating cardiac troponin I (cTnI) concentrations were linked to higher risk of stroke and atrial fibrillation, but the causality remains unclear. Therefore, we used mendelian randomization to assess the potential causal effects of cTnI concentrations on the risk of stroke, its subtypes and atrial fibrillation.Materials and methodsThe instrumental variables for circulating cTnI concentrations were selected from a genome-wide association study meta-analysis of 48,115 European individuals. We examined the associations of circulating cTnI concentrations with stroke, ischemic stroke, ischemic stroke subtypes (cardioembolic, large artery, small vessel stroke), intracerebral hemorrhage and atrial fibrillation.ResultsGenetically predicted elevated circulating cTnI concentrations were associated with higher risk of cardioembolic stroke (odds ratio [OR], 1.80; 95% confidence interval [CI], 1.20–2.68; P = 0.004), but not associated with large artery stroke, small vessel stroke, total stroke, ischemic stroke and intracerebral hemorrhage. Additionally, we also found that elevated cTnI concentrations were causally linked to higher risk of atrial fibrillation (OR, 1.30; 95% CI, 1.10–1.53; P = 0.003).ConclusionsThis study provides evidence that genetically predicted circulating cTnI concentrations are causally linked to higher risk of cardioembolic stroke and atrial fibrillation.     

Median somatosensory evoked potential as a predictor of clinical outcome after urgent surgical extracranial internal carotid artery recanalization

ObjectiveChanges in the N20/P25 amplitude of somatosensory evoked potentials (SEP) of the median nerve have been found to correlate with those in cortical regional cerebral blood flow (rCBF). Our study presents the use of median nerve SEP amplitude in predicting the clinical outcome of urgent surgical internal carotid artery (ICA) recanalization.MethodsA total of 27 patients suffering an acute ischemic stroke (AIS) with extracranial ICA occlusion within 24 h were prospectively recruited. The primary preoperative endpoints included the SEP amplitude absolute value (SEP-amp) and the SEP amplitude side-to-side ratio (SEP-ratio).Clinical outcome at 3 months postoperatively was assessed using the modified Rankin scale (mRS-3M).ResultsThe positive predictive values (PPVs) for SEP-amp and SEP-ratio were 95.5% and 100%, respectively, with the negative predictive values (NPVs) being 60.0% and 100%, respectively. The SEP-ratio correlated fully with mRS-3M.ConclusionThe median SEP side-to-side N20/P25 amplitude ratio seems to be a very strong positive and negative predictor of the clinical outcome of urgent recanalization of an extracranial ICA occlusion.SignificanceThe results suggest that cortical evoked activity may help in selection patient for surgical recanalization and predict clinical recovery after an acute ischemic stroke.     

Delayed neonatal visual evoked potentials are associated to asymmetric growth pattern in twins

ObjectivesTo study the association between intrauterine growth and visual pathways maturation by neonatal visual evoked potentials (VEPs) in twins, in view of a possible prognostic role.MethodsSeventy-four twin neonates from 37 pregnancies were selected based on gestational age of more than 30 weeks and uneventful perinatal clinical course. Flash VEPs were recorded at the same postmenstrual age in each twin pair. The association between P2 latency and anthropometric variables at birth was analyzed by comparison within each twin pair and regarding each variable as ordered difference between the two twins.ResultsAnalysis of differences within each twin pair highlighted that inter-twin difference in P2 latency was significantly related to difference in ponderal index (PI) (p = 0.048).Expressing the difference in latency as a categorical binary variable, the correlation was significant for both difference in PI, (median difference = −0.36, 95% CI −0.54 to −0.14, p = 0.001) and difference in body mass index (BMI), (median difference = −1.06, 95% CI −1.74 to −0.29, p = 0.006).ConclusionsLower values of PI and BMI differences are associated to delayed VEP latency in twin pairs.SignificanceVEP latency suggests reduced myelination of visual pathways when difference in growth pattern occurs in twins.     

Can We Learn from Our Children About stroke? Effectiveness of a School-Based Educational Programme in Greece

ObjectivesWe describe new findings from the implementation of an educational school-based stroke awareness programme, FAST (Face, Arm, Speech, Time) 112 Heroes, that teaches kindergarten children about stroke symptomatology and the appropriate action plan. The goal of our study was to examine whether the population mostly affected by stroke, i.e. the elderly, can be educated by young children, who have attended the programme.Materials and MethodsThe educational programme was implemented face-to-face in a kindergarten in Athens, Greece, once a week for five consecutive weeks for one hour per week. Preschoolers (n = 137, aged 4.1-7, mean age=5.3) were enrolled in the programme and nominated two elderly members of their extended family (grandparents) as their own superheroes. Family members received personalized stroke-related material. Stroke awareness of the grandparents was measured before programme implementation (phase 1), after (prior to receiving the printed personalized stroke-related material, phase 2) and three months after receiving the printed personalized stroke-related material (phase 3).ResultsData was obtained from 63 grandparents (48 women; aged 60-84, mean age=69.5 years). Family members demonstrated significant increases in stroke symptom knowledge (p < 0.001) and appropriate course of action (p ≤ 0.001) after participating in the program (phase 2) and receiving printed personalized stroke-related material (phase 3). The majority of the participants (86.84%) reported positive feedback about the received material, the programme, and their interaction with their grandchildren during the programme.ConclusionsElderly family members outside the nuclear family can be successfully educated about stroke through their grandchildren and the FAST 112 Heroes programme.     

Leukoaraiosis and earlier neurological outcome after mechanical thrombectomy in acute ischemic stroke

Background and purposeThe aim of the study was to evaluate whether leukoaraiosis (LA) severity is associated with earlier neurological outcome in acute stroke patients undergoing mechanical thrombectomy.Materials and methodsIn this retrospective multicenter study, we evaluated 273 acute stroke patients treated with mechanical thrombectomy. LA severity was graded as 0–2 (absent-to-moderate) versus 3–4 (severe) according to the van Swieten scale. The main clinical outcome was the proportion of early neurological improvement and early neurological deterioration. Early neurological improvement was defined as a decrease of ≥ 4 points on the NIHSS, or an NIHSS score of zero 24 hours after baseline assessment. Early neurological deterioration was defined as an increase of ≥ 4 points on the NIHSS 24 hours after baseline assessment.ResultsThere was a significantly lower early neurological improvement rate (17.1% versus 39.2%; P = 0.006) and non-significantly higher early neurological deterioration rate (29.3% versus 17.7%; P = 0.084) in patients with severe LA (sLA) compared with patients with absent-to-moderate LA. In multivariable analysis, sLA was inversely associated with early neurological improvement (OR, 0.31; 95% CI, 0.13–0.78; P = 0.012). There was no significant association of sLA with early neurological deterioration. However, in patients without symptomatic intracranial hemorrhage, sLA was an independent predictor of early neurological deterioration (OR, 2.65; 95% CI, 1.09–6.45; P = 0.032).ConclusionssLA is a significant negative predictor of early neurological improvement and is an independent predictor of early neurological deterioration in patients without symptomatic intracranial hemorrhage.     

Motor cortex transcranial direct current stimulation effects on knee osteoarthritis pain in elderly subjects with dysfunctional descending pain inhibitory system: A randomized controlled trial

BackgroundAlthough evidence has indicated a positive effect of transcranial direct current stimulation (tDCS) on reducing pain, few studies have focused on the elderly population with knee osteoarthritis (KOA).ObjectiveTo evaluate whether tDCS reduces KOA pain in elderly individuals with a dysfunctional descending pain inhibitory system (DPIS).MethodsIn a double-blind trial, individuals ≥ 60 years with KOA pain and a dysfunctional DPIS, we randomly assigned patients to receive 15 daily sessions of 2 mA tDCS over the primary motor cortex (anode) and contralateral supraorbital area (cathode) (M1-SO) for 20 min or sham tDCS. Change in pain perception indexed by the Brief Pain Inventory (BPI) at the end of intervention was the primary outcome. Secondary outcomes included: disability, quantitative sensory testing, pain pressure threshold and conditioned pain modulation (CPM). Subjects were followed-up for 2 months.ResultsOf the 104 enrolled subjects, with mean (SD) age of 73.9 (8.01) years and 88 (84.6%) female, 102 finished the trial. In the intention-to-treat analysis, the active tDCS group had a significantly greater reduction in BPI compared to the sham group (difference, 1.59; 95% CI, 0.95 to 2.23; P < 0.001; Cohen’s d, 0.58); and, also a significantly greater improvement in CPM-pressure in the knee (P = 0.01) and CPM-pain in the hand (P = 0.01). These effects were not sustained at follow-up. The intervention was well tolerated, with no severe adverse effects.ConclusionM1-SO tDCS is associated with a moderate effect size in reducing pain in elderly patients with KOA after 15 daily sessions of stimulation. This intervention has also shown to modulate the DPIS.     

Disparities in the symptomatic presentation of Moyamoya disease in the United States: A nationwide all-payer analysis

BackgroundMoyamoya disease is a chronic occlusive cerebrovascular disease that can present with either hemorrhagic or ischemic symptoms. The objective of this study was to evaluate whether the symptomatology of Moyamoya disease differs according to patient demographic groups.MethodsIn this study, we used the Nationwide Inpatient Sample (NIS) to investigate differences in the presentation of Moyamoya disease by age group, gender, and ethnicity from 2012 to 2016. After propensity score matching was utilized to control for overall comorbidity, the matched cohorts for each symptomatology were compared using a Chi-square test with respect to the potential risk factors of interest (i.e. age, sex, ethnicity) in order to generate multivariate reported P-values.ResultsA total of 4,474 patients met inclusion criteria. Patients presenting with ischemic stroke were more likely to be 65 years and older (p < 0.001); patients presenting with intracranial hemorrhage (ICH) were more likely to be 65 years and older (p < 0.001), male (p = 0.027), and Asian (p = 0.007); those presenting with seizure were more likely to be less than 10 years old (p = 0.002) and African American (p < 0.001); and those presenting with headache were more likely to be between 10 and 19 years old (p = 0.008).ConclusionsOur findings demonstrate that the distinct presentations of Moyamoya are associated with patient age, gender, and race. This is the largest study of its kind and adds to the collective understanding of this rare but life-threatening condition.     

Tendencia de la hospitalización por ictus isquémico en adultos jóvenes de la Región de Murcia durante el periodo 2006-2014

IntroductionRecent studies conducted in Europe and the United States suggest upward trends in both incidence and hospitalisation rates for ischaemic stroke in young adults; however, data for Spain are scarce. This study analyses the trend in hospitalisation due to ischaemic stroke in adults aged under 50 years in the region of Murcia between 2006 and 2014.MethodWe performed a retrospective study of patients discharged after hospitalisation due to cerebrovascular disease (CVD); data were obtained from the regional registry of the Minimum Basic Data Set. Standardised rates were calculated, disaggregated by age and CVD subtype. Time trends were analysed using joinpoint regression to obtain the annual calculated standardised rate and the annual percentage of change (APC).ResultsA total of 27 064 patients with CVD were discharged during the 9-year study period. Ischaemic stroke was the most frequent subtype (61.0%). In patients aged 18 to 49 years, the annual number of admissions due to ischaemic stroke increased by 26%, and rates by 29.2%; however, the joinpoint regression analysis showed no significant changes in the trend (APC = 2.74%, P≥.05). By contrast, a downward trend was identified in individuals older than 49 (APC = –1.24%, P<.05).ConclusionsNo significant changes were observed in the rate of hospitalisation due to ischaemic stroke among young adults, despite the decline observed in older adults. Identifying the causes of these disparate trends may be beneficial to the development of specific measures targeting younger adults.     

Improved detection and characterization of arterial occlusion in acute ischemic stroke using contrast enhanced MRA

Background and purposeTo compare the accuracy and utility of contrast enhanced magnetic resonance angiography (MRA) (CEMRA) to Time of Flight MRA (TOF MRA) during detection and evaluation of occlusions on patients diagnosed with acute ischemic stroke (AIS).MethodsThis single-center study was approved by our local institutional research ethics board. From August 2014 to July 2016, 131 consecutive adult patients with confirmed AIS were included. Detection of an arterial occlusion and its characterization were evaluated independently with CEMRA or TOF MRA by two blinded neuroradiologists, then by consensus using all available MR sequences. A Cohen's Kappa coefficient (κ) and intra-class correlation coefficients (ICC) were used to compare the two techniques.ResultsThere was substantial concordance in the detection of arterial occlusion between CEMRA and TOF MRA (κ = 0.75). TOF MRA was more likely to show an arterial occlusion than CEMRA (63 versus 52 patients respectively). There were 13 and 1 false positive arterial occlusion with TOF MRA and CEMRA respectively, and 1 false negative with TOF MRA. There was excellent concordance between the location of arterial occlusions and CEMRA and TOF MRA [κ = 0.89 (0.72–0.97)]. CEMRA was significantly more likely to allow measurement of the thrombus than was TOF MRA [38 (75%) versus 14 (22%)] (P < 0.0001).ConclusionsOur study showed that CEMRA imaging detected arterial occlusions better than TOF MRA in AIS patients and more precisely such that thrombus length and location could be known, which improves the patient's management and care.     

Trait self-acceptance mediates parental childhood abuse predicting depression and anxiety symptoms in adulthood

BackgroundBiopsychosocial models posit that experiencing parental childhood abuse increases vulnerability to psychopathology in adulthood. There are a lack of studies investigating mediators of the parental childhood abuse–adulthood psychopathology relation. The current study investigated if trait self-acceptance mediated the parental childhood abuse–adulthood major depressive disorder (MDD), generalized anxiety disorder (GAD), and panic disorder (PD) severity relations.MethodsParticipants (n = 3294) partook in the 18-year Midlife Development in the United States (MIDUS) study at three time-points. We conducted structural equation modeling analyses to test how maternal and paternal childhood abuse at Time 1 would independently positively predict MDD, GAD, and PD severity at Time 3, and if self-acceptance at Time 2 mediated those relations while controlling for adulthood MDD, GAD, and PD severity at Time 1.ResultsSelf-acceptance notably mediated the parental childhood abuse-adulthood MDD, GAD, and PD relations. Overall, higher paternal and maternal childhood abuse was associated with lower self-acceptance. Reduced self-acceptance predicted heightened adulthood MDD, GAD, and PD.ConclusionFindings highlight the importance of understanding the parental childhood abuse–adulthood psychopathology relation and the possible mechanisms of its long-term impact.