Accuracy of FAST-ED for Assessment Large Vessel Occlusion of Acute Ischemic Stroke in Emergency Department.

Background: Acute large vessel occlusion stroke (LVOS) requires swift and precise assessment for effective treatment. The Field Assessment Stroke Triage for Emergency Destination (FAST-ED) protocol shows promise for rapid LVOS evaluation but lacks extensive validation. This study aims to assess the accuracy of FAST-ED in predicting LVOS and compare its predictive capability with the National Institute of Health Stroke Scale (NIHSS). Methods: This prospective cross-sectional study was conducted at Thammasat University Hospital. Participants included those aged 18 years or older who presented with symptoms of acute stroke syndrome within 24 hours of onset. The study focused on comparing FAST-ED assessments by emergency department physicians with NIHSS evaluations by neurologists, followed by vascular imaging, which included brain multiphase CT angiography, MRI with MRA, and transcranial Doppler ultrasound combined with carotid Doppler ultrasound. Statistical analyses included the use of AuROC to assess the effectiveness of FAST-ED and to compare FAST-ED with NIHSS. Results: 130 patients were included in the analysis, with 47 diagnosed with LVOS. No significant differences were found in most baseline characteristics between LVOS and non-LVOS groups, except for a higher prevalence of atrial fibrillation and lower systolic blood pressure in the LVOS group. The FAST-ED scale demonstrated a fair ability to predict LVOS with an AuROC of 0.79 (95% confidence interval (CI); 0.70, 0.87). A FAST-ED cut point of ≥4 showed improved specificity and likelihood ratio. Comparing FAST-ED≥4 with NIHSS≥6 revealed similar AuROC (0.74, 95% CI; 0.65, 0.82 and 0.72, 95% CI; 0.64, 0.80, respectively), with no significant statistical difference (p=0.661). Conclusion: FAST-ED scale, especially with a cut-off point of ≥4, exhibits fair overall accuracy in predicting LVOS in patients who presented with suspected acute stroke within 24 hours at the ED. This predictive capability is closely comparable to that of the NIHSS at a cut-off point of ≥6.

Stroke Awareness and Knowledge in the At-Risk Population: A Community-Based Study.

BACKGROUND: The BE-FAST (balance, eyes, face, arms, speech, and time) mnemonic helps to identify stroke symptoms, which has been publicized through social media in Thailand for a while. Timely access to medical care enhances the likelihood of receiving efficacious treatment, thereby mitigating the adverse consequences of the stroke. Thus, stroke awareness in the general population, especially in the population at risk, is crucial. The purpose of the study was to evaluate stroke awareness and the level of knowledge about stroke in Thailand. METHODS: Adult participants aged at least 40 years, without a history of stroke, were included, with exclusions limited to those unwilling to participate. Data were gathered from the survey during two community visits and through an electronic survey via Google Forms (Google LLC, Mountain View, California, United States). A pre-tested questionnaire was divided into three parts: symptoms of acute stroke, vascular risk factors, and response. Demographics were compared between participants with good and poor knowledge of stroke awareness. RESULTS: A total of 281 participants were included, with a mean age of 58 years and 60% (n=169) of participants having at least one vascular risk factor. Of the responders, 133 (47%) had good knowledge of stroke awareness. Older age (age > 50 years, OR 0.326, 95%CI 0.173-0.615, p-value = 0.001), higher education (> 6 years, OR 0.266, 95%CI 0.139-0.508, p-value < 0.001)), and being female (OR 0.474, 95%CI 0.252-0.891, p-value = 0.020) were related to good stroke knowledge. Participants with good knowledge of stroke awareness also had good knowledge of vascular risk factors (84%; n=112), knew that they should come to the hospital immediately (74%; n=98), and also correctly identified the emergency calling number (90%; n=119). CONCLUSIONS: Only half of the participants had good knowledge of stroke awareness. There is a need for improvement in the distribution of knowledge about stroke in Thailand.

The differences in clinical characteristics and natural history between essential tremor and essential tremor plus.

The diverse clinical manifestation of essential tremor (ET) has led to the question whether the different phenotypes may affect the clinical outcome and progression. This study aimed to estimate the clinical characteristics and natural history of ET and ET-plus. A total of 221 patients with ET were included, 117 (52.9%) reclassified as ET and 104 (47.1%) as ET-plus. Patients with ET-plus were significantly older in age at onset (P < 0.001); had a higher frequency of cranial tremors (P < 0.001), neurological comorbidities (P < 0.001) and psychiatric comorbidities (P = 0.025); more tremor progression (P < 0.001); and poorer response to medical treatment (P < 0.001) compared to ET patients. Regression analysis revealed that late-onset tremor (OR 11.02, 95% CI 2.79-43.53), neurological comorbidities (OR 3.38, 95% CI 1.56-7.31), psychiatric comorbidities (OR 4.29, 95% CI 1.48-12.44), cranial tremors (OR 2.10, 95% CI 1.02-4.30), and poor response to medical treatment (OR 3.67, 95% CI 1.87-7.19) were associated with ET-plus diagnosis. ET and ET-plus differ in the age of onset, tremor distribution, comorbidities, treatment response rate, and progression. Identifying the ET phenotypes may increase the clinical value in therapeutic strategies and clinical research in the future.

Fetal origin of posterior cerebral artery related to poor collaterals in patients with acute ischemic stroke.

The anatomic variation of Circle of Willis (CW) has been shown to have a great impact on its compensatory capacity during acute ischemic stroke. The purpose of the study was to evaluate the effect of variations in CW on collateral circulation in patients with acute ischemic stroke who had major artery occlusion. Patients with acute ischemic stroke within 4.5 h of stroke onset who had at least moderate severity of stroke (NIHSS ≥ 6), caused by major artery occlusion were included. Multiphase computed tomography angiography (CTA) was performed. Variations in CW on each patient were recorded and compared between those with poor collateral and intermediate-good collateral circulation. There were 66 patients. Mean NIHSS was 15. Forty patients had poor collateral circulation and 26 patients had intermediate-good collateral circulation. There were variations in CW: no visualized posterior communicating artery (PCOM) (31/66, 47%), fetal origin of posterior cerebral artery (25/66, 38%), one anterior cerebral artery, segment A1 (A1) hypoplasia or atresia (16/66, 24%), one PCOM (8/66, 12%), and complete CW (3/66, 5%). Fetal origin of posterior cerebral artery (PCA) was associated with poor collateral circulation (48% vs 23%, p-value = 0.046). This pilot study showed that the presence of fetal origin of PCA was associated with poor collateral circulation in patients with acute ischemic stroke caused by major artery occlusion.

Implementation of multiphase computed tomography angiography in management of patients with acute ischemic stroke in clinical practice.

Multiphase computed tomography angiography (CTA) provides information on the status of major cranial arteries and extent of brain collateralization. The purpose of the study was to determine whether implementation of multiphase CTA in routine clinical practice was feasible, safe and useful. Patients with acute ischemic stroke (NIHSS ≥ 6) were included. Multiphase CTA was performed. Duration of performing multiphase CTA, inter-rater correlation and incidence of contrast-induced nephropathy (CIN) were studied. Infarct volume, incidence of hemorrhagic transformation, the rates of favorable outcome and death were compared between those with poor and intermediate-good collateralization. Multiphase CTA was performed in 108 patients. Mean duration on each multiphase CTA study was 4.8 min. Inter-rater reliability was intermediate-good (weighted kappa 0.7569, p < 0.001). CIN occurred in 3 patients (2.8%). There were no major intracranial/extracranial artery occlusion in 31 patients (29%) and there were severe stenosis or occlusions in 77 patients (71%). In the subgroup of patients with major artery severe stenosis or occlusion, 36 patients (36/77, 47%) had poor collateralization. Despite non-significant difference in acute treatment, the patients with poor collateralization had larger infarct (123 vs 35 cc, p < 0.001) and poorer outcomes (mean modified Rankin scale 3.86 vs 2.73, p = 0.011), while the differences in symptomatic hemorrhagic transformation (2.6 vs 7%, p = 0.385) and death rate (14 vs 12%, p = 0.825) were non-significant, as compared to those with intermediate-good collateralization. Multiphase CTA was feasible and safe. Besides the status of major arteries, multiphase CTA provided information on collateralization, which was associated with the size of infarct and clinical outcomes.

Erratum to "Fat Embolism Syndrome: A Case Report and Review Literature".

[This corrects the article DOI: 10.1155/2018/1479850.].

Efficacy of High-Dose and Low-Dose Simvastatin on Vascular Oxidative Stress and Neurological Outcomes in Patient with Acute Ischemic Stroke: A Randomized, Double-Blind, Parallel, Controlled Trial.

BACKGROUNDS: Stroke is the leading cause of death and long-term disability. Oxidative stress is elevated during occurrence of acute ischemic stroke (AIS). Soluble LOX-1 (sLOX-1) and NO are used as biomarkers for vascular oxidative stress that can reflect stabilization of atherosclerotic plaque. Previous study showed that simvastatin can reduce oxidative stress and LOX-1 expression. OBJECTIVES: To evaluate neurological outcomes and serum sLOX-1 and NO levels in patients with AIS treatment with low dose 10 mg/day and high dose 40 mg/day of simvastatin. METHODS: 65 patients with AIS within 24 hours after onset were randomized to treatment with simvastatin 10 mg/day or 40 mg/day for 90 days. Personal data and past history of all patients were recorded at baseline. The blood chemistries were measured by standard laboratory techniques. Serum sLOX-1 and NO levels and neurological outcomes including NIHSS, mRS, and Barthel index were tested at baseline and Day 90 after simvastatin therapy. RESULTS: Baseline characteristics were not significantly different in both groups except history of hypertension. Serum sLOX-1 and NO levels significantly reduce in both groups (sLOX-1 = 1.19 ± 0.47 and 0.98 ± 0.37 ng/ml; NO = 49.28 ± 7.21 and 46.59 ± 9.36 µmol/l) in 10 mg/day and 40 mg/day simvastatin groups, respectively. Neurological outcomes including NIHSS, mRS, and Barthel index significantly improve in both groups. However, no difference in NO level and neurological outcomes was found at 90 days after treatment as compared between low dose 10 mg/day and high dose 40 mg/day of simvastatin. CONCLUSION: High-dose simvastatin might be helpful to reduce serum sLOX-1. But no difference in clinical outcomes was found between high- and low-dose simvastatin. Further more intensive clinical trial is needed to confirm the appropriate dosage of simvastatin in patients with acute ischemic stroke. This trial is registered with ClinicalTrials.gov ID: NCT03402204.

Fat Embolism Syndrome: A Case Report and Review Literature.

Fat embolism syndrome (FES) is a life-threatening complication in patients with orthopedic trauma, especially long bone fractures. The diagnosis of fat embolism is made by clinical features alone with no specific laboratory findings. FES has no specific treatment and requires supportive care, although it can be prevented by early fixation of bone fractures. Here, we report a case of FES in a patient with right femoral neck fracture, which was diagnosed initially by Gurd's criteria and subsequently confirmed by typical appearances on magnetic resonance imaging (MRI) of the brain. The patient received supportive management and a short course of intravenous methylprednisolone.

Accuracy of Carotid Duplex Criteria in Diagnosis of Significant Carotid Stenosis in Asian Patients.

BACKGROUND: Extracranial carotid stenosis can be diagnosed by velocity criteria of carotid duplex. Whether they are accurately applied to define severity of internal carotid artery (ICA) stenosis in Asian patients needs to be proved. The purpose of this study was to evaluate the accuracy of 2 carotid duplex velocity criteria in defining significant carotid stenosis. METHODS: Carotid duplex studies and magnetic resonance angiography were reviewed. Criteria 1 was recommended by the Society of Radiologists in Ultrasound; moderate stenosis (50%-69%): peak systolic velocity (PSV) 125-230 cm/s, diastolic velocity (DV) 40-100 cm/s; severe stenosis (>70%): PSV greater than 230 cm/s, DV greater than 100 cm/s. Criteria 2 used PSV greater than 140 cm/s, DV less than 110 cm/s to define moderate stenosis (50%-75%) and PSV greater than 140 cm/s, DV greater than 110 cm/s for severe stenosis (76%-95%). RESULTS: A total of 854 ICA segments were reviewed. There was moderate stenosis in 72 ICAs, severe stenosis in 50 ICAs, and occlusion in 78 ICAs. Criteria 2 had slightly lower sensitivity, whereas higher specificity and accuracy than criteria 1 were observed in detecting moderate stenosis (criteria 1: sensitivity 95%, specificity 83%, accuracy 84%; criteria 2: sensitivity 92%, specificity 92%, and accuracy 92%). However, in detection of severe ICA stenosis, no significant difference in sensitivity, specificity, and accuracy was found (criteria 1: sensitivity 82%, specificity 99.57%, accuracy 98%; criteria 2: sensitivity 86%, specificity 99.68%, and accuracy 99%). CONCLUSIONS: In the subgroup of moderate stenosis, the criteria using ICA PSV greater than 140 cm/s had higher specificity and accuracy than the criteria using ICA PSV 125-230 cm/s. However, there was no significant difference in detection of severe stenosis or occlusion of ICA.