The importance of CT perfusion for diagnosis and treatment of ischemic stroke in anterior circulation.

Computed tomography perfusion (CTP) is a functional examination of brain tissue that characterises the state of cerebral perfusion and provides information about the current status of the circulation. CTP can improve diagnostic accuracy of ischemic stroke. Published studies showed that perfusion imaging improves the prognosis of patients with acute ischemic stroke in anterior circulation and allows patients to be referred for treatment outside the time window for administration of intravenous thrombolysis (IVT) or mechanical thrombectomy (MT). In this review we discuss technical aspects of CTP, clinical significance of CTP in anterior circulation stroke (ACS) and its role in diagnostics of stroke mimics.

Machine learning volumetry of ischemic brain lesions on CT after thrombectomy-prospective diagnostic accuracy study in ischemic stroke patients.

PURPOSE: Ischemic lesion volume (ILV) is an important radiological predictor of functional outcome in patients with anterior circulation stroke. Our aim was to assess the agreement between automated ILV measurements on NCCT using the Brainomix software and manual ILV measurements on diffusion-weighted imaging (DWI). METHODS: This was a prospective single-center observational study of patients with CT angiography (CTA) proven anterior circulation occlusion treated with endovascular thrombectomy (May 2018 to May 2019). NCCT ILV was measured automatically by the Brainomix software. DWI ILV was measured manually. The McNemar's test was used to test sensitivity and specificity. The Somer's delta was used to test the differences between concordant and discordant ASPECTS regions. The Bland-Altman plot was calculated to compare the differences between Brainomix and DWI ILVs. RESULTS: Forty-five patients were included. Median Brainomix ILV was 23 ml (interquartile range [IQR], 15-39 ml), and median DWI ILV was 11.5 ml (IQR, 7-32 ml) in the TICI 2b-3 group. In the TICI 0-2a, the NCCT ILV was 39 ml (IQR, 18-62 ml) and DWI ILV was 30 (IQR, 11-105 ml). The DWI ILVs in patients with good clinical outcome (mRS 0-2) was significantly lower compared with patients with mRS ≥ 3 (10 mL vs 59 mL, p = 0.002). Similar trend was observed for Brainomix ILV measurements (21 mL vs 39 mL, p = 0.012). There was a high correlation and accuracy in the detection of follow-up ischemic changes in particular ASPECTS regions. CONCLUSION: NCCT ILV measured automatically by the Brainomix software might be considered a valuable radiological outcome measure.

Detection of ischemic changes on baseline multimodal computed tomography: expert reading vs. Brainomix and RAPID software.

PURPOSE: The aim of the study was to compare the assessment of ischemic changes by expert reading and available automated software for non-contrast CT (NCCT) and CT perfusion on baseline multimodal imaging and demonstrate the accuracy for the final infarct prediction. METHODS: Early ischemic changes were measured by ASPECTS on the baseline neuroimaging of consecutive patients with anterior circulation ischemic stroke. The presence of early ischemic changes was assessed a) on NCCT by two experienced raters, b) on NCCT by e-ASPECTS, and c) visually on derived CT perfusion maps (CBF<30%, Tmax>10s). Accuracy was calculated by comparing presence of final ischemic changes on 24-hour follow-up for each ASPECTS region and expressed as sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). The subanalysis for patients with successful recanalization was conducted. RESULTS: Of 263 patients, 81 fulfilled inclusion criteria. Median baseline ASPECTS was 9 for all tested modalities. Accuracy was 0.76 for e-ASPECTS, 0.79 for consensus, 0.82 for CBF<30%, 0.80 for Tmax>10s. e-ASPECTS, consensus, CBF<30%, and Tmax>10s had sensitivity 0.41, 0.46, 0.49, 0.57, respectively; specificity 0.91, 0.93, 0.95, 0.91, respectively; PPV 0.66, 0.75, 0.82, 0.73, respectively; NPV 0.78, 0.80, 0.82, 0.83, respectively. Results did not differ in patients with and without successful recanalization. CONCLUSION: This study demonstrated high accuracy for the assessment of ischemic changes by different CT modalities with the best accuracy for CBF<30% and Tmax>10s. The use of automated software has a potential to improve the detection of ischemic changes.

Single-Centre Experience with Patients Selection for Mechanical Thrombectomy Based on Automated Computed Tomography Perfusion Analysis-A Comparison with Computed TomographyCT Perfusion Thrombectomy Trials.

BACKGROUND: In randomized clinical trials, mechanical thrombectomy (MT) was proved to be a highly effective treatment of acute ischemic stroke which improved clinical outcomes. Some of the trials used automated computed tomography perfusion (CTP) analysis for selection of participants. We present a single-center experience with CTP selection and comparison with CTP trials. METHODS: Data of consecutive MT patients (from January 2016 to December 2017) were retrospectively reviewed. All patients with multiphase CT angiography confirmed the presence of anterior circulation large vessel occlusion/s in the intracranial internal carotid artery and/or middle cerebral artery (M1 or M2) and with admission brain CTP analyzed by RAPID software were included into the analysis. RESULTS: Sixty-two patients fulfilled the inclusion criteria (mean age was 70.1 ± 13.6 years, females 48.5%). At baseline, National Institutes of Health Stroke Scale score was 16 (IQR = 13-20), Alberta Stroke Program Early CT Score (ASPECTS) was 8 (IQR = 7-9), CTP core volume was 20 mL (IQR = 2-36), and CTP penumbra volume was 145.5 mL (IQR = 107-184). Time from stroke onset to imaging was 1 hour 32 minutes, time from stroke onset to reperfusion was 3 hours 50 minutes, and median time from CT to reperfusion was 1 hour 56 minutes. Modified thrombolysis in cerebral infarction 2b/3 was achieved in 42 patients (67.7%). Twenty-three patients (37%) had modified Rankin scale 0-2 at 90 days. CONCLUSIONS: Our analysis of CTP-selected patients for MT supports clinical applicability of automated CTP analysis into everyday clinical practice.

24-Hour Alberta Stroke Program Early CT Score Assessment in Post-Stroke Spasticity Development in Patients with a First Documented Anterior Circulation Ischemic Stroke.

BACKGROUND: Neuroanatomic substrates responsible for development of post-stroke spasticity are still poorly understood. The study is focused on identification of brain regions within the territory of the middle cerebral artery associated with spasticity development. METHODS: This is a single-center prospective cohort study of first documented anterior circulation ischemic strokes with a neurologic deficit lasting >7 days (from March 2014 to September 2016, all patients are involved in a registry). Ischemic cerebral lesions within the territory of middle cerebral artery were evaluated using the Alberta Stroke Program Early CT Score (ASPECTS) on control 24-hour computed tomography or magnetic resonance imaging. Spasticity was assessed with modified Ashworth scale. RESULTS: Seventy-six patients (mean age 72 years, 45% females; 30% treated with IV tissue plasminogen activator, 6.5% mechanical thrombectomy) fulfilled the study inclusion criteria. Forty-nine (64%) developed early elbow or wrist flexor spasticity defined as modified Ashworth scale >1 (at day 7-10), in 44 (58%) the spasticity remained present at 6 months. There were no differences between the patients who developed spasticity and those who did not when comparing admission stroke severity (National Institutes of Health Stroke Scale 5 [interquartile range {IQR} 4-8] versus 6 [IQR 4-10]) and vascular risk factors (hypertension, diabetes mellitus, dyslipidemia, atrial fibrillation, coronary artery disease). Nor was there a difference in 24-hour ASPECTS score (9 [IQR 8-10] versus 9 [IQR 7-10]). No differences were found between the groups with and without the early upper limb flexor spasticity of particular regions (M1, M2, M3, M4, M5, M6, lentiform, insula, caudate, internal capsule) and precentral-postcentral gyrus, premotor cortex, supplementary motor area, posterior limb of internal capsule, and thalamus were compared. CONCLUSIONS: We did not find any middle cerebral artery territory associated with post-stroke spasticity development by detailed evaluation of ASPECTS.

Inter-Rater Reliability for Thrombolysis in Cerebral Infarction with TICI 2c Category.

BACKGROUND AND PURPOSE: Thrombolysis in cerebral infarction (TICI) with 2b/3 (>50% of occluded territory/complete reperfusion) has been regarded as a successful angiographic outcome. To account for near-perfect angiographic results, the category TICI 2c (near-complete reperfusion) has been introduced. As the degree of inter-rater reliability for TICI with 2c category remains poorly studied, we strived to evaluate the agreement among stroke-treating specialists. METHODS: All consecutive patients, who underwent stent-retriever thrombectomy for acute ischemic stroke in the period between January 2014 and April 2016 at the Department of Neurointerventional Radiology, were analyzed. Digital subtraction angiography (DSA) images were interpreted using previously reported modified TICI score with TICI 2c (near-complete reperfusion). All DSA runs were scored independently by stroke-treating specialist, by consensus of neuroradiologist and stroke neurologist, and by consensus of neurointerventional fellow and attending. Reliability analysis was performed using Krippendorff's alpha (K-alpha). RESULTS: Sixty-one patients were included into analysis of inter-rater agreement. Mean age was 70 years (SD ± 12), 48% were women, and median admission National Institutes of Health Stroke Scale was 16 (IQR = 12-19). Median admission ASPECTS (Alberta Stroke Program Early CT Score) was 8 (IQR 7-9). Forty patients (65%) received intravenous thrombolysis. Agreement for complete modified TICI scale (compared with consensus of neurointerventional fellow and attending) was as follows: fair for stroke physician (K-alpha .36), moderate for neuroradiologist (K-alpha .48), and moderate for neurointerventional fellow (K-alpha .56). Agreement increased to almost perfect when evaluated by consensus of stroke neurologist and neuroradiologist (K-alpha .82). CONCLUSION: Inter-rater agreement for modified TICI increased to almost perfect when scored by consensus of stroke-treating specialists.

Single-Phase Versus Multiphase CT Angiography in Middle Cerebral Artery Clot Detection-Benefits for Less Experienced Radiologists and Neurologists.

OBJECTIVES: CT angiography (CTA) is recommended as a standard of stroke imaging. We investigated accuracy and precision of standard or single-phase CTA as compared with novel technique or multiphase CTA in clot detection in the middle cerebral artery. METHODS: Twenty single-phase CTA and twenty multiphase CTA with prevailing M2 occlusion were assessed by 10 radiologists and 10 neurologists blinded to clinical information (7 less experienced and 3 experienced). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated as compared with reading by two seniors. Reliability was calculated using Krippendorff's alpha (K-alpha). RESULTS: Sensitivity, specificity, PPV, and NPV of single-phase CTA compared with multiphase CTA for M2 clot presence were, respectively, .86, .75, .90, and .67 versus .88, .82, .92, and .72. For secondary or distal clots, sensitivity, specificity, PPV, and NPV of single-phase CTA compared with multiphase CTA were .41, .83, .50, and .78 versus .65, .77, .71, and .67. Agreement increased significantly in favor of multiphase CTA for detection of primary clots from moderate (.43) to substantial (.65) in less experienced radiologists and from slight (.10) to moderate (.30) in less experienced neurologists. Agreement significantly increased for distal or secondary clot detection in favor of multiphase CTA from fair (.24) to moderate (.49) in experienced radiologists and from slight (.12) to moderate (.46) in experienced neurologists. CONCLUSIONS: Multiphase CTA is a reliable imaging tool in M2 clot detection and might represent a beneficial imaging tool in clot detection for less experienced physicians.

Incidence of Hospitalized Stroke in the Czech Republic: The National Registry of Hospitalized Patients.

BACKGROUND: Contemporary stroke incidence data are not available in some countries and regions, including in Eastern Europe. Based on previous validation of the accuracy of the National Registry of Hospitalized Patients (NRHOSP), we report the incidence of hospitalized stroke in the Czech Republic (CR) using the NRHOSP. METHODS: The results of the prior validation study assessing the accuracy of coding of stroke diagnoses in the NRHOSP were applied, and we calculated (1) the overall incidence of hospitalized stroke and (2) the incidence rates of hospitalized stroke for the three main stroke types: cerebral infarction (International Classification of Diseases Tenth Revision, CI I63), subarachnoid hemorrhage (SAH I60), and intracerebral hemorrhage (ICH I61). We calculated the average annual age- and sex-standardized incidence. RESULTS: The overall incidence of hospitalized stroke was 241 out of 100,000 individuals. The incidence of hospitalized stroke for the main stroke types was 8.2 cases in SAH, 29.5 in ICH, and 211 in CI per 100,000 individuals. The standardized annual stroke incidence adjusted to the 2000 World Health Organization population for overall stroke incidence of hospitalized stroke was 131 per 100,000 individuals. Standardized stroke incidence for stroke subtypes was 5.7 cases in SAH, 16.7 in ICH, and 113 in CI per 100,000 individuals. CONCLUSIONS: These studies provide an initial assessment of the burden of stroke in this part of the world. The estimates of hospitalized stroke in the CR and Eastern Europe suggest that ICH is about three times more common than SAH, and hemorrhagic stroke makes up about 18% of strokes.

Ipsilateral Sinus Hypoplasia and Poor Leptomeningeal Collaterals as Midline Shift Predictors.

BACKGROUND: We explore the role of dural sinus morphology, leptomeningeal collaterals, and clot localization in the development of malignant brain edema in acute ischemic stroke in anterior circulation. METHODS: This is a single-center retrospective study of consecutive stroke patients with acute occlusion (middle cerebral artery M1 ± intracranial internal carotid artery) treated with intravenous thrombolysis (from November 2009 to November 2014). Admission computed tomography angiography data were evaluated for hypoplasia of dural sinuses, leptomeningeal collaterals, and clot location. Primary outcome was midline shift (<5 mm versus ≥5 mm) on follow-up computed tomography. Secondary outcomes were infarct volume and modified Rankin Scale score of 2 or lower at 90 days. Multivariate logistic regression was used. RESULTS: Of 86 patients (49 females), 36 (42%) had poor collaterals, 26 (30%) had ipsilesional sinus hypoplasia, and 38 (44%) had proximal clots. A midline shift of 5 mm or higher was diagnosed in 14 patients (16%). Infarct volume was larger in the group with midline shift (median: 318 mL [interquartile range {IQR} = 260-350]) than in the group without midline shift (median: 44 mL [IQR = 28-60]) (P = .007). In multivariate analysis, poor leptomeningeal collaterals (odds ratio [OR] = .11, 95% confidence interval [CI] = .03-.44, P = .002 for good collaterals) and ipsilesional sinus hypoplasia (OR = 6.43, 95% CI = 1.5-46.1, P = .008) were independently associated with a midline shift of 5 mm or higher. CONCLUSION: Patients with poor leptomeningeal collaterals and ipsilesional hypoplasia of dural sinuses are more likely to develop midline shift.

microRNAs in Cerebrovascular Disease.

Cardiovascular diseases are major causes of morbidity and mortality in developed countries. Cerebrovascular diseases, especially stroke, represent major burden of disability and economy impact. Major advances in primary and secondary prevention and therapy are needed in order to tackle this public health problem. Our better understanding of pathophysiology is essential in order to develop novel diagnostic and therapeutic tools and strategies. microRNAs are a family of important post-transcriptional regulators of gene expression and their involvement in the pathophysiology of cerebrovascular diseases has already been reported. Moreover, microRNAs may represent above-mentioned potential diagnostic and therapeutic tools in clinical practice. Within this chapter, we briefly describe basic epidemiology, aetiology and clinical manifestation of following cerebrovascular diseases: extracranial carotid atherosclerosis, acute stroke, intracranial aneurysms and cerebral arterio-venous malformations. Further, in each chapter, the current knowledge about the involvement of specific microRNAs and their potential use in clinical practice will be summarized. More specifically, within the subchapter "miRNAs in carotid atherosclerosis", general information about miRNA involvement in atherosclerosis will be described (miR-126, miR-17-92, miR-155 and others) with special emphasis put on miRNAs affecting carotid plaque progression and stability (e.g. miR-145, miR-146 or miR-217). In the subchapter "miRNAs in acute stroke", we will provide insight into recent knowledge from animal and human studies concerning miRNA profiling in acute stroke and their expression dynamics in brain tissue and extracellular fluids (roles of, e.g. let-7 family, miR-21, miR-29 family, miR-124, miR-145, miR-181 family, miR-210 and miR-223). Subchapters dealing with "miRNAs and AV malformations" and "miRNAs and intracranial aneurysms" will focus on miR-21, miR-26, miR-29 family and miR-143/145.

Validation of Stroke Diagnosis in the National Registry of Hospitalized Patients in the Czech Republic.

BACKGROUND: Stroke is a common cause of mortality and morbidity in Eastern Europe. However, detailed epidemiological data are not available. The National Registry of Hospitalized Patients (NRHOSP) is a nationwide registry of prospectively collected data regarding each hospitalization in the Czech Republic since 1998. As a first step in the evaluation of stroke epidemiology in the Czech Republic, we validated stroke cases in NRHOSP. METHODS: Any hospital in the Czech Republic with a sufficient number of cases was included. We randomly selected 10 of all 72 hospitals and then 50 patients from each hospital in 2011 stratified according to stroke diagnosis (International Classification of Diseases Tenth Revision [ICD-10] cerebrovascular codes I60, I61, I63, I64, and G45). Discharge summaries from hospitalization were reviewed independently by 2 reviewers and compared with NRHOSP for accuracy of discharge diagnosis. Any disagreements were adjudicated by a third reviewer. RESULTS: Of 500 requested discharge summaries, 484 (97%) were available. Validators confirmed diagnosis in NRHOSP as follows: transient ischemic attack (TIA) or any stroke type in 82% (95% confidence interval [CI], 79-86), any stroke type in 85% (95% CI, 81-88), I63/cerebral infarction in 82% (95% CI, 74-89), I60/subarachnoid hemorrhage in 91% (95% CI, 85-97), I61/intracerebral hemorrhage in 91% (95% CI, 85-96), and G45/TIA in 49% (95% CI, 39-58). The most important reason for disagreement was use of I64/stroke, not specified for patients with I63. CONCLUSIONS: The accuracy of coding of the stroke ICD-10 codes for subarachnoid hemorrhage (I60) and intracerebral hemorrhage (I61) included in a Czech Republic national registry was high. The accuracy of coding for I63/cerebral infarction was somewhat lower than for ICH and SAH.

Hypocretin-1/orexin-A, sleep and excessive daytime sleepiness in patients with nonconvulsive status epilepticus: A cross-sectional cohort study.

BACKGROUND AND OBJECTIVES: Nonconvulsive status epilepticus (NCSE) manifests as a change in mental status without a coma (NCSE proper) or comatose NCSE. Hypocretin-1/orexin-A (H/O) is involved in alertness and sleep maintenance. Sleep impairment and excessive daytime sleepiness (EDS) have a negative impact on cognitive functions and activities of daily living (ADL). METHODS: Patients meeting the NCSE criteria underwent cerebrospinal fluid and brain magnetic resonance imaging examinations, polysomnographies (PSG), multiple latency sleep tests (MSLT), and completed Epworth Sleepiness Scale (ESS). Montreal Cognitive Assessment was used to evaluate cognitive functions, and the Barthel Index was used to assess ADL in the acute phase (V1) and three months follow-up (V2). RESULTS: From May 2020 to May 2023, we enrolled 15 patients, eight (53.3 %) women, with a median age of 69 (14) years. The median H/O CSF concentration was 250 (63.6) pg/ml; however, only three CSF samples (20 %) decreased below the borderline concentration of 200 pg/ml. Fourteen out of 15 patients (93.3 %) completed the PSG study. The median of wakefulness after sleep onset was 167 (173.5) min, sleep efficiency (SE) was 62.9 (63) %, sleep latency (SL) was 6 (32) min, REM sleep was 2.85 (7.2) %, and REM first episode latency was 210.5 (196.5) minutes. The medians of the stages N1 NREM were 4.65 (15) %, N2 NREM 68.4 (29.9) %, and N3 NREM 21.8 (35.5) %. MSLT mean latency was 7.7 (12.6) minutes. A significant negative correlation exists between H/O CSF concentrations and the stage N1 NREM (rs = -0.612, p = 0.02), and the proportion of cumulative sleep time with oxygen saturation below 90 % in total sleep time (TST) t90 (rs = -0.57, p = 0.03). MSLT had significant negative correlation with TST (rs = -0.5369, p = 0.0478), with SE (rs = -0.5897, p = 0.0265), with apnea-hypopnea index (rs = -0.7631, p = 0.0002) and with deoxygenation index (rs = -0.8009, p = 0.0006). A positive correlation exists between MSLT and SL (rs = 0.6284, p = 0.0161) and between ESS and t90 (rs = 0.9014, p = 0.0004). The correlation between H/O CSF concentrations and EDS, cognitive performance, and ADL was not proved. CONCLUSIONS: Patients after NCSE exhibited sleep impairment and excessive daytime sleepiness. Hypocretin-1/orexin-A concentrations decreased only in 20 % of these cases.

Immunoablative therapy followed by autologous hematopoietic stem cell transplantation as the first-line disease-modifying therapy in patients with multiple sclerosis.

INTRODUCTION: Immunoablative therapy followed by autologous hematopoietic stem cell transplantation (AHSCT) is one of the possible disease-modifying therapies (DMTs) for patients with multiple sclerosis (MS). In this case series, we would like to present six patients with MS, who underwent AHSCT as the first-line DMT. CASE REPORTS: Six MS patients with a rapid progression of disability with or without relapses underwent AHSCT as the first-line DMT at the University Hospital Ostrava between 2018 and 2021. The conditioning regimens for AHSCT used were a medium-intensity regime BEAM (Carmustine, Etoposid, Cytarabin, Melphalan) and low-intensity regime based on Cyclophosphamide. Four out of six patients showed some disability progression after AHSCT, so the rapid progression of MS was just slowed down by AHSCT. One patient developed activity on magnetic resonance imaging three months after AHSCT, and two experienced mild relapses during the follow-up period. None of our patients developed grade 4 non-hematological toxicity; all infections were mild. In one patient, an allergic reaction probably to dimethyl sulfoxide was observed. CONCLUSION: Our case series of 6 patients shows that AHSCT is a promising therapeutic approach to slow down the rapid progression of clinical disability in MS patients with a good safety profile.

A comparison of measles-rubella-zoster reaction, oligoclonal IgG bands, oligoclonal kappa free light chains and kappa index in multiple sclerosis.

BACKGROUND AND OBJECTIVES: To evaluate the diagnostic performance of the measles-rubella-zoster reaction (MRZR) in a large real-world multiple sclerosis (MS) cohort. Second, to compare MRZR with the determination of oligoclonal IgG bands (OCB), oligoclonal kappa free light chain bands (oKFLC), and the KFLC index. METHODS: A single-center retrospective study was conducted at the University Hospital Ostrava (Czech Republic). Patients were eligible if aged ≥18 years with a determined clinical diagnosis. IgG antibodies against measles (M), rubella (R), and varicella zoster (Z) viruses were determined in paired CSF and serum using ELISA and MRZR indicated as positive if at least two components had an antibody index >1.4. OCB and oKFLC were detected by means of isoelectric focusing, and KFLC CSF and serum concentrations for calculation of the KFLC index were determined immunochemically. RESULTS: A total of 1,751 patients were included in the analyzed data set, which comprised 379 MS patients and 1,372 non-MS controls. The frequency of positive MRZR was higher in MS than in non-MS cases (MS 32.2 % vs non-MS 2.8 %; p < 0.001). This corresponded to a specificity of 97.2 % (95 % CI 96.1-98.0) and sensitivity of 32.2 % (95 % CI 27.5-37.2) and overall accuracy of 83.1 % (95 % CI 81.3-84.8). In comparison, the highest sensitivity of 95.6% (95 % CI 93.0-97.5) was for OCB with specificity of 86.9 % (95 % CI 84.9-88.7), followed by oKFLC with sensitivity and specificity of 94.7 % (95 % CI 91.5-96.9) and 78.4% (95 % CI 75.7-80.8), respectively, and the KFLC index with sensitivity of 92.5 % (95 % CI 86.6-96.3) and specificity of 93.5 % (95 % CI 90.5-95.9). DISCUSSION: MRZR remains a very specific test for the diagnosis of MS but has low sensitivity, which disallows its independent use. In contrast, OCB showed the highest sensitivity and thus remains the gold standard for the diagnosis of MS.

Decreased quality of life in Duchenne muscular disease patients related to functional neurological and cardiac impairment.

In this prospective study involving 37 Duchenne muscular dystrophy (DMD) patients aged 8-18 years and older, we examined the impact of neurological and cardiac factors on quality of life (QoL). Our findings revealed a negative correlation between upper limb movement and overall mobility, self-service, and usual activities. Ambulatory and non-ambulatory DMD patients showed significant differences in mobility-related parameters. Cardiac evaluations demonstrated associations between mitral annular plane systolic excursion (MAPSE) and mobility-related aspects. The PEDSQL 3.0 neuromuscular model questionnaire further highlighted age-related and movement-related correlations with QoL. The loss of ambulatory status and reduced upper limb movement were negatively associated with QoL, while upper limb movement positively correlated with septal MAPSE. However, no significant associations were found between MAPSE and anxiety/depression. These findings underscore the multifaceted impact of DMD on QoL and emphasize the importance of considering both neurological and cardiac factors in comprehensive patient care.

The importance of multimodal CT examination in stroke mimics diagnosis: design of prospective observational multicentre study.

Introduction: Non-contrast computed tomography (CT) and CT angiography are the gold standard in neuroimaging diagnostics in the case of suspected stroke. CT perfusion (CTP) may play an important role in the diagnosis of stroke mimics (SM), but currently, it is not a standard part of the stroke diagnostic procedure. The project is a multicentre prospective observational clinical research focused on refining the diagnostics of stroke and stroke mimics (SM) in hospital care. Aim: This study aimed to evaluate the degree of specificity and sensitivity of multimodal CT (NCCT, CTA, and CTP) in the diagnosis of SM versus stroke. Methodology: In this study, we will include 3,000 patients consecutively admitted to the comprehensive stroke centres with a diagnosis of suspected stroke. On the basis of clinical parameters and the results of multimodal CT and magnetic resonance imaging (MRI), the diagnosis of stroke and SM will be established. To clarify the significance of the use of the multimodal CT scan, the analysis will include a comparison of the blinded results for each imaging scan performed by radiologists and AI technology and a comparison of the initial and final diagnosis of the enrolled patients. Based on our results, we will compare the economic indicators and costs that would be saved by not providing inadequate treatment to patients with SM. Conclusion: The expected outcome is to present an optimised diagnostic procedure that results in a faster and more accurate diagnosis, thereby eliminating the risk of inadequate treatment in patients with SM. Clinical trial registration: clinicaltrials.gov, NCT06045455.

Total intracranial hemorrhage volume measurement summating all compartments best in traumatic and nontraumatic intracranial bleeding.

BACKGROUND AND PURPOSE: The ANNEXA-4 trial measured hemostatic efficacy of andexanet alfa in patients with major bleeding taking factor Xa inhibitors. A proportion of this was traumatic and nontraumatic intracranial bleeding. Different measurements were applied in the trial including volumetrics to assess for intracranial bleeding depending on the compartment involved. We aimed to determine the most reliable way to measure intracranial hemorrhage (ICrH) volume by comparing individual brain compartment and total ICrH volume. METHODS: Thirty patients were randomly selected from the ANNEXA-4 database to assess measurement of ICrH volume by compartment and in total. Total and compartmental hemorrhage volumes were measured by five readers using Quantomo software. Each reader measured baseline hemorrhage volumes twice separated by 1 week. Twenty-eight different ANNEXA-4 subjects were also randomly selected to assess intra-rater reliability of total ICrH volume measurement change at baseline and 12-h follow up, performed by three readers twice to assess hemostatic efficacy categories used in ANNEXA-4. RESULTS: Compartmental minimal detectable change percentages (MDC%) ranged between 9.72 and 224.13, with the greatest measurement error occurring in patients with a subdural hemorrhage. Total ICrH volume measurements had the lowest MDC%, which ranged between 6.57 and 33.52 depending on the reader. CONCLUSION: Measurement of total ICrH volumes is more accurate than volume by compartment with less measurement error. Determination of hemostatic efficacy was consistent across readers, and within the same reader, as well as when compared to consensus read. Volumetric analysis of intracranial hemostatic efficacy is feasible and reliable when using total ICrH volumes.

Prognostic value of intrathecal IgM synthesis determined by various laboratory methods in patients with early multiple sclerosis - a prospective observational study.

BACKGROUND: Intrathecal IgM synthesis has been identified as an adverse prognostic factor in patients with multiple sclerosis (MS); however, some studies have not confirmed this association. The objective of this study was to evaluate the clinical utility of intrathecal IgM synthesis for prediction of disease activity and disability in patients after the first demyelinating event of MS. METHODS: We conducted a single-centre prospective observational cohort study at the Department of Neurology, University Hospital Ostrava, Czech Republic. Intrathecal IgM synthesis was demonstrated by the presence of cerebrospinal fluid-restricted oligoclonal IgM bands and calculated using the Reiber, Auer, and Öhman formula and IgM index. RESULTS: A total of 61 patients with a clinically isolated syndrome or early relapsing-remitting MS were enrolled into the analysis of which 37 (61 %) were women. The median age at the disease onset was 32 years (interquartile range [IQR] 25 - 42), and the median disease duration was 2.8 years (IQR 2.4 - 3.5). Thirty-eight (62 %) patients experienced a second relapse of MS with a median of 312 days (IQR 192 - 424), and 29 (47.5 %) developed magnetic resonance imaging (MRI) activity during the follow-up. Intrathecal IgM synthesis did not affect the risk of a second relapse or evidence of MRI activity in univariate and multivariate Cox regression analysis. There was no significant difference in disability using the Expanded Disability Status Scale and progression index in patients with or without intrathecal IgM synthesis. CONCLUSION: This prospective cohort study did not demonstrate that intrathecal IgM synthesis is a risk factor for a second relapse or MRI activity. It was not associated with higher disability in patients after the first demyelinating event.

New Prehospital Triage for Stroke Patients Significantly Reduces Transport Time of EVT Patients Without Delaying IVT.

Background and Purpose: Ischemic stroke is a leading cause of mortality and morbidity worldwide. The time from stroke onset to treatment impacts clinical outcome. Here, we examined whether changing a triage model from "drip and ship" to "mothership" yielded significant reductions of onset-to-groin time (OGT) in patients receiving EVT and onset-to-needle time (ONT) in IVT-treated patients, compared to before FAST-PLUS test implementation. We also investigated whether the new triage improved clinical outcomes. Methods: In a before/after multicenter study, we evaluated the effects of changing the prehospital triage system for suspected stroke patients in the Moravian-Silesian region, Czech Republic. In the new system, the validated FAST PLUS test is used to differentiate patients with suspected large vessel occlusion and triage-positive patients are transported directly to the CSC. Time metrics and patient data were obtained from the regional EMS database and SITS database. Results: For EVT patients, the median OGT was 213 min in 2015 and 142 min in 2018, and the median TT was 142 min in 2015 and 47 min in 2018. For tPA patients, the median ONT was 110 min in 2015 and 109 min in 2018, and the median TT was 41 min in 2015 and 48 min in 2018. Clinical outcome did not significantly change. The percentages of patients with favorable clinical outcome (mRS 0-2) were comparable between 2015 and 2018: 60 vs. 59% in tPA patients and 40 vs. 44% in EVT patients. Conclusions: The new prehospital triage has yielded shorter OGTs for EVT patients. No changes were found in the onset-to-needle time for IVT-treated patients, or in the clinical outcome at 3 months after stroke onset.

Content Analysis of Stroke Teleconsultation Recordings in the Moravian-Silesian Region, Czech Republic.

Background: Direct teleconsultations between emergency medical services (EMS) crews and hospital-based stroke neurologists are mandated in the Czech Republic as triage and prenotification tool in acute stroke patients. The main aim of this study was to analyze the efficacy as well as quality of such teleconsultations in daily clinical practice. Methods: This is a descriptive analysis of teleconsultations between EMS paramedic crews and hospital-based neurologists in a geographically defined region of the Czech Republic (Moravian-Silesian region) between October 2018 to December 2018. All teleconsultations were analyzed for length and content. Content analysis included the following information: date, age, sex, prehospital neurological deficit(s), known/unknown time of symptom onset, anticoagulation status, vital signs, premorbid disability, and patient ID/insurance company number. Results: Within the study period, paramedics conducted 522 calls across 6 stroke centers. Of these, 334 (64%) calls were conducted because patients met pre-established prehospital criteria for suspected acute stroke. Median call duration was 1 min 44 s ± 56 s (minimum 50 s, maximum 5 min 5 s). Amongst the analyzed prehospital teleconsultations, stroke onset time was reported in 95% of cases, neurological deficit in 96%, significant co-morbidities in 53%, premorbid disability in 37%, and anticoagulation status in 53%. Conclusion: Teleconsultations between paramedics and hospital-based neurologists are not time-consuming. Stroke onset time and severity of neurological deficit are consistently communicated, however other important information such as comorbidities, premorbid disability, and anticoagulation status are reported inconsistently.