Hypercoagulability on Thromboelastography Can Predict the Functional Outcomes in Patients with Acute Ischemic Stroke.

BACKGROUND: We investigated the association between the reaction time (R), a thromboelastography (TEG) parameter for hypercoagulability, and functional outcomes based on the occurrence of hemorrhagic transformation (HT) and early neurological deterioration (END). METHODS: We enrolled ischemic stroke patients and performed TEG immediately after the patients' arrival. The baseline characteristics, occurrence of HT and END, stroke severity, and etiology were compared according to the R. END was defined as an increase of ≥1 point in motor or ≥2 points in the total National Institute of Health Stroke Scale within 3 days after admission. The outcome was the achievement of functional independence (modified Rankin scale [mRS]: 0-2) at 3 months after stroke. Logistic regression analyses were performed to verify the association between R and outcome. RESULTS: HT and END were frequently observed in patients with an R of <5 minutes compared with the group with an R of ≥5 minutes (15 [8.1%] vs. 56 [21.0%], p < 0.001; 16 [8.6%] vs. 65 [24.3%], p = 0.001, respectively). In multivariable analysis, an R of <5 minutes was associated with decreased odds of achieving functional independence (0.58 [0.34-0.97], p = 0.038). This association was maintained when the outcome was changed to disability free (mRS 0-1) and when mRS was analyzed as an ordinal variable. CONCLUSION: Hypercoagulability on TEG (R <5 minutes) may be a negative predictor for functional outcome of stroke after 3 months, with more frequent HT, END, and different stroke etiologies. This study highlights the potential of TEG parameters as biomarkers for predicting functional outcomes in ischemic stroke patients.

Thromboelastography as a predictor of functional outcome in acute ischemic stroke patients undergoing endovascular treatment.

BACKGROUND: Thromboelastography (TEG) is a useful for predicting hemorrhagic transformation, early neurological deterioration, and functional outcome after stroke. We aimed to investigate whether TEG value could also be useful in predicting functional outcome via various intraprocedural and postprocedural factors in patients with acute large vessel occlusive stroke who underwent intraarterial thrombectomy (IAT). METHODS: Patients with ischemic stroke who underwent IAT between March 2018 and March 2020 at two tertiary hospitals were included. The association between reaction time (R) and functional outcome was evaluated. The primary outcome was the achievement of functional independence defined as the achievement of a modified Rankin Scale (mRS) score of 0-2 at 3 months after the index stroke. RESULTS: Among a total of 160 patients (mean age, 70.6 ± 12.3 years; 103 [64.4 %] men), 79 (49.3 %) achieved functional independence at 3 months. R, both as a continuous (odds ratio [OR]: 1.45, 95 % confidence interval [95 % CI]: 1.09-1.92, P = 0.011) and dichotomized parameters (R < 5 min [OR: 0.37, 95 % CI: 0.16-0.82, P = 0.014]), were inversely associated with increased odds of achieving functional independence (mRS score 0-2) after multivariable analysis. The association was still consistent when the outcome was the achievement of disability free (mRS score 0-1) or mRS score analyzed as an ordinal variable. CONCLUSIONS: Decreased R, especially R < 5 min, was inversely associated with functional outcome pf stroke after EVT.

Quantitative assessments of pupillary light reflexes in hospital-onset unresponsiveness.

BACKGROUND: Patients who develop hospital-onset unresponsiveness should be promptly managed in order to avoid clinical deterioration. Pupillary examination through pupillary light reflex is the gold standard method in the initial evaluation of unresponsive patients. However, the current method of shining light and subjective description often shows poor reliability. The objective of this study is to explore whether a quantitative measurement of pupillary light reflexes is useful in detecting brain herniation syndrome and predicting neurological outcomes in patients who developed hospital-onset unresponsiveness after admission for non-neurological reasons. METHODS: This was a registry-based observational study on patients who activated the neurological rapid response team at Asan Medical Center (Seoul, Korea). Hospital-onset unresponsiveness was defined as a newly developed unresponsive state as assessed by the ACDU (Alert, Confused, Drowsy, and Unresponsive) scale during the hospital stay. Demographics, comorbidities, pupillometry parameters including Neurological Pupil index, brain herniation syndrome, in-hospital mortality, and modified Rankin Scale at 3-months were analyzed. RESULTS: In 214 consecutive patients with hospital-onset unresponsiveness, 37 (17%) had brain herniation syndrome. The optimal cut-off value of Neurological Pupil index for detecting brain herniation syndrome was < 1.6 (specificity, 91% [95% confidence interval (CI) = 86-95]; sensitivity, 49% [95% CI = 32-66]). The in-hospital mortality rate was 28% (59/214); the Neurological Pupil index was negatively associated with in-hospital mortality after adjustments for the presence of brain herniation syndrome (adjusted odds ratio = 0.77, 95% CI = 0.62-0.96). Poor neurological outcomes (modified Rankin Scale ≥4) at 3 months was observed in 76% (152/201) of the patients; the Neurological Pupil index was negatively associated with poor neurological outcomes after adjustments for clinical variables (adjusted odds ratio = 0.67, 95% CI = 0.49-0.90). CONCLUSIONS: Quantitative measurements of pupillary light reflexes may be useful for early detection of potentially life-threatening neurological conditions in patients with hospital-onset unresponsiveness.

Continuous heart rate variability and electroencephalography monitoring in severe acute brain injury: a preliminary study.

BACKGROUND: Decreases in heart rate variability have been shown to be associated with poor outcomes in severe acute brain injury. However, it is unknown whether the changes in heart rate variability precede neurological deterioration in such patients. We explored the changes in heart rate variability measured by electrocardiography in patients who had neurological deterioration following severe acute brain injury, and examined the relationship between heart rate variability and electroencephalography parameters. METHODS: Retrospective analysis of 25 patients who manifested neurological deterioration after severe acute brain injury and underwent simultaneous electroencephalography plus electrocardiography monitoring. RESULTS: Eighteen electroencephalography channels and one simultaneously recorded electrocardiography channel were segmented into epochs of 120-second duration and processed to compute 10 heart rate variability parameters and three quantitative electroencephalography parameters. Raw electroencephalography of the epochs was also assessed by standardized visual interpretation and categorized based on their background abnormalities and ictalinterictal continuum patterns. The heart rate variability and electroencephalography parameters showed consistent changes in the 2-day period before neurological deterioration commenced. Remarkably, the suppression ratio and background abnormality of the electroencephalography parameters had significant reverse correlations with all heart rate variability parameters. CONCLUSIONS: We observed a significantly progressive decline in heart rate variability from the day before the neurological deterioration events in patients with severe acute brain injury were first observed.

Neurological and clinical status from early time point to long-term follow-up after in-hospital cardiac arrest.

AIM: We aimed to evaluate neurological profiles of patients with in-hospital cardiac arrest (IHCA) from early time points to long-term follow-up periods. METHODS: For this prospective cohort study, we established a neurological rapid response team, and serially evaluated the neurological status of patients with IHCA from the initial resuscitation to 12 months after the onset of IHCA. The primary outcome was good neurological status defined as a Clinical Performance Category score of 1-2 at 12 months after IHCA. The secondary outcomes included the awakening and neurological recovery during the first week, the survival and neurological status at hospital discharge, and the survival at 12 months. RESULTS: A total of 291 adult patients with IHCA were included. On the first day and during the first week after IHCA, the awakening was achieved in 61 (21.0 %) and 119 patients (40.9 %), respectively; and neurological recovery in 12 (4.1 %) and 46 patients (15.8 %), respectively. Epileptic seizures developed in 9.7 % following restoration of spontaneous circulation. At hospital discharge, 106 patients (36.4 %) had survived; among them, 63.2 % showed good neurological status. At 12 months, 63 (21.6 %) patients survived; among them, 81.7 % showed good neurological status (17.0 % among all patients with IHCA). Of patients without awakening during the first 3 and 7 days, 2.7 % and 1.2 % showed good neurological status at 12 months, respectively. CONCLUSIONS: Among patients with IHCA, awakening and neurological recovery were remarkable throughout the first week. Survival and good neurological status were substantial at 12 months after IHCA.

Neurological Emergencies in Patients Hospitalized With Nonneurological Illness.

OBJECTIVE: We aimed to present neurological profiles and clinical outcomes of patients with acute neurological symptoms, which developed during hospitalization with nonneurological illness. METHODS: We organized the neurological alert team (NAT), a neurological rapid response team, to manage in-hospital neurological emergencies. In this registry-based study, we analyzed the clinical profiles and outcomes of patients who were consulted to the NAT. We also compared the 3-month mortality of patients with acute neurological symptoms with that of patients without acute neurological symptoms. RESULTS: Among the 85,507 adult patients, 591 (0.7%) activated the NAT. The most common reason for NAT activation was stroke symptoms (37.6%), followed by seizures (28.6%), and sudden unresponsiveness (24.0%). The most common diagnosis by the NAT neurologists was metabolic encephalopathy (45.5%), followed by ischemic stroke (21.2%) and seizures or status epilepticus (21.0%). Patients with NAT activation had high rates in mortality before hospital discharge (22.5%) and at 3 months (34.7%), transfer to intensive care units (39.6%), and length of hospital stay (43.1 ± 57.1 days). They also had high prevalence of poor functional status (78.1%) and recurrence of neurological symptoms at 3 months (27.2%). In a Cox proportional hazards model, patients with in-hospital neurological emergencies had a hazard ratio of 13.2 in terms of mortality at 3 months (95% confidence interval, 11.5-15.3; P < 0.001). CONCLUSIONS: Occurrence of acute neurological symptoms during hospital admission was associated with high rate of mortality and poor functional status. These results call for enhanced awareness and hospital-wide strategies for managing in-hospital neurological emergencies.

Magnetic Resonance Imaging in Neurocritically Ill Patients: Who Fails and How?

OBJECTIVES: Performing magnetic resonance imaging (MRI) in neurocritically ill patients is challenging because it often requires sedation and withholding care in the neurological intensive care unit. This study investigated the incidence of and reasons for failed or complicated MRI (MRI-FC) in such patients. METHODS: A consecutive series of 218 neurocritically ill patients who underwent brain MRI were retrospectively evaluated. Failed or complicated MRI included failure to obtain all ordered sequences, unscheduled sedative administration, decrease in oxygen saturation to less than 90%, hypotension (≥40-mm Hg decrease and/or use of inotropic agents), and cardiac or respiratory arrest. RESULTS: Failed or complicated MRI occurred in 66 patients (30.3%) and included failure to obtain MRI sequences (n = 13), unscheduled use of sedatives (n = 62), oxygen desaturation (n = 9), and hypotension (n = 6). Cardiac or respiratory arrest did not occur. Use of sedative agents while in intensive care (P < 0.01), high Acute Physiology and Chronic Health Evaluation II score (P = 0.031), and low Glasgow Coma Scale score on admission (P = 0.047) were associated with MRI-FC. Scan times were longer (P = 0.004) and Glasgow Coma Scale (P < 0.001) and Richmond Agitation Sedation Scale (P = 0.003) scores were lower (P = 0.004) after imaging in patients with MRI-FC. Previous use of sedative agents was independently associated with MRI-FC (adjusted odds ratio = 3.57, 95% confidence interval = 1.78 to 7.24, P < 0.001). CONCLUSIONS: Failed or complicated MRI was common and was associated with the use of sedative agents, severity of illness, and lower level of consciousness. Studies to ensure effective and safe performance of MRI in neurocritically ill patients are needed.

Thromboelastography for prediction of hemorrhagic transformation in patients with acute ischemic stroke.

BACKGROUND: Thromboelastography (TEG) provides a rapid assessment of the hemostatic processes of a patient in emergency settings. There are limited data on TEG as a predictive tool for hemorrhagic transformation in patients with acute ischemic stroke. We investigated whether TEG values on admission could predict hemorrhagic transformation in patients with acute ischemic stroke. METHODS: TEG was performed prospectively in 772 patients who satisfied the criteria of the critical pathway for acute stroke that have neurologic symptoms in 6 h at the emergency department between March and December 2018. After excluding 114 patients, 628 patients were evaluated, and finally, 205 patients with acute ischemic stroke were included. The primary outcome is hemorrhagic transformation, defined as the presence of blood in brain on follow-up imaging study and secondary outcome is neurological deterioration, defined as a 2-point increase on the National Institutes of Health Stroke Scale (NIHSS) within 72 h of stroke onset. RESULTS: Of the 205 ischemic stroke patients (mean age 67 ±â€¯13 years, 66.3% male), hemorrhagic transformation was identified in 28 (13.7%) patients, and neurological deterioration was occurred in 24 (11.7%), and both events in 9 (4.4%). The TEG value of R (reaction time) <5 min was significantly higher in patients with hemorrhagic transformation than in patients without hemorrhagic transformation (81.1% vs. 60.5%, p = 0.027), and based on multivariable analysis, this was an independent predictor of hemorrhagic transformation (odds ratio 3.215 [95% confidence interval: 1.153-8.969]). CONCLUSIONS: In patients with acute ischemic stroke, TEG value of R < 5 min can identify patients who have an increased risk of hemorrhagic transformation during hospitalization.

The timelines of MRI findings related to outcomes in adult patients with new-onset refractory status epilepticus.

OBJECTIVE: To identify the timelines of magnetic resonance imaging (MRI) abnormalities and their relationships with the clinical outcomes of patients with new-onset refractory status epilepticus (NORSE). METHODS: This retrospective observational study enrolled patients with NORSE who were admitted from March 2008 to July 2018. MRI abnormalities were analyzed visually with the readers blinded to the clinical characteristics of the patients. Poor functional outcome was defined as a Glasgow Outcome Scale score ≤ 3 at discharge. Subsequent pharmacoresistant epilepsy was defined as seizures not controlled by two or more anti-seizure medications 6 months after discharge. RESULTS: Among 39 patients with NORSE, 32 (82.1%) exhibited an MRI abnormality. The most common abnormalities were persisting mesial temporal lobe signal abnormality (51.3%); initial diffuse leptomeningeal enhancement within 16 days from seizure onset (15/35, 42.9%); and hippocampal atrophy, which started to appear 26 days after seizure onset (15/26, 57.7%). Only three patients had claustrum abnormalities. Patients with insular involvement had longer treatment delay than those without (24.0 vs 5.5 hours, respectively, P = .02). Duration of status epilepticus (SE) tended to have a linear association with hippocampal atrophy (P = .055). Patients with diffuse leptomeningeal enhancement were more likely to have a poor functional outcome and to develop subsequent pharmacoresistant epilepsy than those without this finding (93.3% vs 15.0%, P < .001; 75.0% vs 22.2%, P = .004, respectively); the results were significant even after adjusting for age, sex, and duration of SE. Hippocampal atrophy and diffuse cortical atrophy were also significantly associated with poor functional outcomes (P = .001 and P = .002, respectively), and patients with these conditions were more likely to develop subsequent pharmacoresistant epilepsy than those without these conditions, after adjusting for age and sex (P = .035 and P = .048, respectively), but not after adjusting for duration of SE. SIGNIFICANCE: Initial diffuse leptomeningeal enhancement and later hippocampal atrophy were associated with a poor functional outcome and subsequent pharmacoresistant epilepsy.

Newly developed stroke in patients admitted to non-neurological intensive care units.

BACKGROUND: Little is known about newly developed stroke in patients admitted to the intensive care unit (ICU). OBJECTIVE: This study aimed to investigate characteristics and outcomes of newly developed stroke in patients admitted to the non-neurological intensive care units (ICU-onset stroke, IOS). METHODS: A consecutive series of adult patients who were admitted to the non-neurological ICU were included in this study. We compared neurological profiles, risk factors, and mortality rates between patients with IOS and those without IOS. RESULTS: Of 18,604 patients admitted to the ICU for non-neurological illness, 218 (1.2%) developed stroke (ischemic, n = 182; hemorrhagic, n = 36). The most common neurological presentation was altered mental status (n = 149), followed by hemiparesis (n = 55), and seizures (n = 28). The most common etiology of IOS was cardioembolism (50% [91/182]) for ischemic IOS and coagulopathy (67% [24/36]) for hemorrhagic IOS. In multivariable analysis, the Acute Physiology and Chronic Health Evaluation II (APACHE II) score (adjusted odds ratio [AOR] = 1.04, 95% CI = 1.03-1.06, P < 0.001), prothrombin time (AOR = 0.99, 95% CI = 0.98-0.99, P = 0.013), cardiovascular surgery (AOR = 1.84, 95% CI = 1.34-2.50, P < 0.001), mechanical ventilation (AOR = 6.75, 95% CI = 4.87-9.45, P < 0.001), and extracorporeal membrane oxygenation (AOR = 2.77, 95% CI = 1.62-4.55, P < 0.001) were related to the development of IOS. Stroke was associated with increased 3-month mortality after hospital discharge (AOR, 2.20; 95% CI, 1.58-3.05; P < 0.001), after adjustment for APACHE II and comorbidities. CONCLUSIONS: Patients who developed IOS had characteristics of initial critical illness and managements performed in the ICU as well as neurological presentations. The occurrence of IOS was related to high morbidity and mortality.

Diagnostic Usefulness of Cytokine and Chemokine Levels in the Cerebrospinal Fluid of Patients with Suspected Tuberculous Meningitis.

In this study, we investigated the diagnostic utility of the cytokine profile of the cerebrospinal fluid (CSF) and enzyme-linked immunospot (ELISPOT) assays of patients with suspected tuberculous meningitis (TBM). We prospectively enrolled adult patients with suspected TBM, and CSF specimens were analyzed for 18 cytokines/chemokines and soluble programmed death protein 1 (PD-1) and programmed death ligand 1 (PD-L1). Enzyme-linked immunospot assays were performed on mononuclear cells from the CSF (CSF-MCs) and peripheral blood (PBMCs). A total of 87 patients with meningitis, including 42 TBM-suspected patients and 45 non-TBM patients, were enrolled. Excluding the 32 patients with possible TBM, 10 patients with TBM and 45 patients with non-TBM were finally analyzed. Levels of adenosine deaminase (ADA), interleukin 12 subunit ß (IL-12p40), IL-13, macrophage inflammatory protein α (MIP-1α), and soluble PD-1 and PD-L1 in the CSF were significantly higher in the TBM group than in the non-TBM group (P < 0.05). The optimal cutoff values for the sensitivities and specificities of the test methods for diagnosing TBM with small samples of 10 cases of definite or probable TBM were as follows: ADA > 6.95 U/L, 70% and 81%; IL-12p40 > 52.04 pg/mL, 80% and 73%; IL-13 > 0.44 pg/mL, 90% and 47%; MIP-1α > 8.83 pg/mL, 80% and 62%; soluble PD-1 > 35.87 pg/mL, 80% and 63%; soluble PD-L1 > 24.19 pg/mL, 80% and 61%; CSF-MC ELISPOT > 13.5 spots/250,000 CSF-MC, 30% and 91%; and PBMC ELISPOT > 14 spots/250,000 PBMCs, 50% and 78%, respectively. Therefore, CSF IL-12p40, IL-13, MIP-1α, and soluble PD-1 and PD-L1 concentrations appear to be useful adjuncts for diagnosing TBM.

Effects of Appointing a Full-Time Neurointensivist to Run a Closed-Type Neurological Intensive Care Unit.

BACKGROUND AND PURPOSE: To investigate whether appointing a full-time neurointensivist to manage a closed-type neurological intensive care unit (NRICU) improves the quality of critical care and patient outcomes. METHODS: This study included patients admitted to the NRICU at a university hospital in Seoul, Korea. Two time periods were defined according to the presence of a neurointensivist in the preexisting open-type NRICU: the before and after periods. Hospital medical records were queried and compared between these two time periods, as were the biannual satisfaction survey results for the families of patients. RESULTS: Of the 15,210 patients in the neurology department, 2,199 were admitted to the NRICU (n=995 and 1,204 during the before and after periods, respectively; p<0.001). The length of stay was shorter during the after than during the before period in both the NRICU (3 vs. 4 days; p<0.001) and the hospital overall (12.5 vs. 14.0 days; p<0.001). Neurological consultations (2,070 vs. 3,097; p<0.001) and intrahospital transfers from general intensive care units to the NRICU (21 vs. 40; p=0.111) increased from the before to after the period. The mean satisfaction scores of the families of the patients also increased, from 78.3 to 89.7. In a Cox proportional hazards model, appointing a neurointensivist did not result in a statistically significant change in 6-month mortality (hazard ratio, 0.82; 95% confidence interval, 0.652-1.031; p=0.089). CONCLUSIONS: Appointing a full-time neurointensivist to manage a closed-type NRICU had beneficial effects on quality indicators and patient outcomes.

Intra-arterial thrombectomy for acute ischaemic stroke patients with active cancer.

BACKGROUND AND PURPOSE: This study aimed to evaluate the efficacy of intra-arterial thrombectomy (IAT) and prognosis for acute ischaemic stroke patients with active cancer. METHODS: We retrospectively reviewed 253 patients who underwent IAT within 24 h after stroke onset between January 2012 and August 2017. We classified the patients into active cancer (n = 26) and control groups (n = 227) and compared clinical data. Primary outcome was a modified Rankin scale score at 3 months with ordinal logistic regression (shift analysis). RESULTS: Initial National Institutes of Health Stroke Scale (NIHSS) and rate of successful recanalisation did not differ between groups, but the active cancer group showed poor outcomes at 3 months on shift analysis (P = 0.001). The independent predictors of poor prognosis were age [adjusted common odds ratio (aOR) 1.03, 95% confidence interval (CI) 1.01-1.05], baseline NIHSS (aOR 1.14, 95% CI 1.09-1.19), baseline C-reactive protein level (aOR 1.14, 95% CI 1.03-1.25), any cerebral haemorrhage (aOR 1.92, 95% CI 1.21-3.06), and active cancer (aOR 2.35, 95% CI 1.05-5.25). Mortality at 90 days was 30.8% in the cancer group and 8.8% in the control group (P = 0.003). CONCLUSIONS: Although baseline characteristics and recanalisation rate after IAT up to 24 h after stroke onset were similar between acute ischaemic stroke patients with active cancer and without any cancer, stroke-related death and short-term outcome were significantly poorer in patients with active cancer than the controls. Post-procedural haemorrhage and active cancer itself were independent predictors of a decrease in functional independence at 3 months.

Combination of Dexmedetomidine and Ketamine for Magnetic Resonance Imaging Sedation.

Objectives: The use of dexmedetomidine and ketamine (DEX-KET) combination for magnetic resonance imaging (MRI) sedation has not been evaluated. We investigated the efficacy and safety of DEX-KET for sedation of patients undergoing MRI of the brain. Methods: This quasi-experimental study was conducted to compare the DEX-KET combination and midazolam for MRI sedation. We included 72 patients undergoing brain MRI following bolus injection of midazolam or DEX-KET. In August 1, 2016 a new MRI sedation protocol was implemented. After protocol implementation, bolus doses of DEX-KET were administered (DEX-KET group). Thirty-six patients from the MIDA group and 36 patients from the DEX-KET group underwent MRI sequences and were compared regarding the MRI scan time and sedation-related complications (desaturation, hypotension, cardiorespiratory arrest, and aspiration pneumonia). Results: All MRI sequences were completed for 30 patients (83.3%) from the MIDA group and for 33 patients (91.7%) from the DEX-KET group (P = 0.476). The median MRI scan time was 100.0 min (interquartile range, 87.0-111.5 min) in the MIDA group and 53.5 min (interquartile range, 45.0-60.5 min) in the DEX-KET group (P < 0.001). Complications occurred in 24 (66.7%) and 8 (22.2%) patients of the MIDA and DEX-KET group, respectively (P < 0.001). Conclusions: The efficacy of DEX-KET sedation was comparable to that of midazolam for MRI examination. DEX-KET was related to shorter scan time and lower occurrence of complications compared to midazolam.

Postreperfusion Blood Pressure Variability After Endovascular Thrombectomy Affects Outcomes in Acute Ischemic Stroke Patients With Poor Collateral Circulation.

Background and Purpose: We evaluated the effect of 24 h blood pressure variability (BPV) on clinical outcomes in acute ischemic stroke patients with successful recanalization after endovascular recanalization therapy (ERT). Methods: Patients with anterior circulation occlusion were evaluated if they underwent ERT based on multiphase computed tomography angiography and achieved successful recanalization (≥thrombolysis in cerebral ischemia 2b). Collateral degrees were dichotomized based on the pial arterial filling score, with a score of 0-3 defined as a poor collateral status. BPV parameters include mean, standard deviation, coefficient of variation, and variation independent of the mean (VIM) for systolic blood pressure (SBP), diastolic blood pressure (DBP), mean blood pressure, and pulse rate (PR). These parameters were measured for 24 h after ERT and were analyzed according to occlusion sites and stroke mechanisms. Associations of BPV parameters with clinical outcomes were investigated with stratification based on the baseline collateral status. Results: BPV was significantly different according to the occlusion sites and stroke mechanisms, and higher BPV was observed in patients with internal carotid artery occlusion or cardioembolic occlusion. After adjustment for confounders, most BPV parameters remained significant to predict functional outcomes at 3 months in patients with poor collateral circulation. However, no significant association was found between BPV parameters and clinical outcomes in patients with good collateral circulation. Conclusion: Postreperfusion BP management by decreasing BPV may have influence on improving clinical outcome in cases of poor collateral circulation among patients achieving successful recanalization after ERT.

Cigarette Smoking Preferentially Affects Intracranial Vessels in Young Males: A Propensity-Score Matching Analysis.

PURPOSE: Cigarette smoking (CS) is one of the major risk factors of cerebral atherosclerotic disease, however, its level of contribution to extracranial and intracranial atherosclerotic stenosis (ECAS and ICAS) was not fully revealed yet. The purpose of our study was to assess the association of CS to cerebral atherosclerosis along with other risk factors. MATERIALS AND METHODS: All consecutive patients who were angiographically confirmed with severe symptomatic cerebral atherosclerotic disease between January 2002 and December 2012 were included in this study. Multivariate logistic regression analyses were performed to identify risk factors for ECAS and ICAS. Thereafter, CS group were compared to non-CS group in the entire study population and in a propensity-score matched population with two different age-subgroups. RESULTS: Of 1709 enrolled patients, 794 (46.5%) had extracranial (EC) lesions and the other 915 (53.5%) had intracranial (IC) lesions. CS group had more EC lesions (55.8% vs. 35.3%, P<0.001) whereas young age group (<50 years) had more IC lesion (84.5% vs. 47.6%, P<0.001). In multivariate analysis, seven variables including CS, male, old age, coronary heart disease, higher erythrocyte sedimentation rate, multiple lesions, and anterior lesion were independently associated with ECAS. In the propensity-score matched CS group had significant more EC lesion compared to non-CS group (65.7% vs. 47.9%) only in the old age subgroup. CONCLUSION: In contrast to a significant association between CS and severe symptomatic ECAS shown in old population, young patients did not show this association and showed relatively higher preference of ICAS.

A Simple Microfluidic Assay for Diagnosing Tuberculous Meningitis in HIV-Uninfected Patients.

We evaluated the diagnostic performance of a simple and label-free pathogen enrichment method using homobifunctional imidoesters (HI) and a microfluidic system, called the SLIM assay, followed by real-time PCR from cerebrospinal fluid (CSF) in human immunodeficiency virus (HIV)-uninfected patients with suspected tuberculous meningitis (TBM). Patients with suspected TBM were prospectively enrolled in a tertiary hospital in an intermediate tuberculosis (TB)-burden country during a 30-month period. TBM was classified according to the uniform case definition. Definite and probable TBM were regarded as the reference standards for TBM, and possible TBM and not-TBM as the reference standards for not-TBM. Of 72 HIV-uninfected patients with suspected TBM, 10 were diagnosed with definite (n = 2) and probable (n = 8) TBM by the uniform case definition. The sensitivity of the SLIM assay was 100% (95% confidence interval [CI], 69 to 100%) compared with definite or probable TBM, and it was superior to those of mycobacterial culture (20% [95% CI, 3 to 56%]) and the Xpert MTB/RIF assay (0% [95% CI, 0 to 31%]). Of 21 possible TBM and 41 not-TBM patients by the uniform case definition, 5 possible TBM and no not-TBM patients gave positive results in the SLIM assay. The specificity of the SLIM assay was 92% (95% CI, 82 to 97%; 5/62). We demonstrated that the SLIM assay had a very high sensitivity and specificity with small samples of 10 cases of definite or probable TBM. Further studies are needed to confirm this finding and to compare the SLIM assay with mycobacterial culture, Xpert MTB/RIF, and Xpert MTB/RIF Ultra assays in a larger prospective cohort of patients with suspected TBM, including both HIV-infected and HIV-uninfected cases.

Perioperative rupture risk of unruptured intracranial aneurysms in cardiovascular surgery.

Although unruptured intracranial aneurysms are increasingly being diagnosed incidentally, perioperative rupture risk of unruptured intracranial aneurysm in patients undergoing cardiovascular surgery remains unclear. Therefore, we conducted an observational study to assess the prevalence and perioperative rupture risk of unruptured intracranial aneurysm in patients undergoing cardiovascular surgery. Adult patients (n = 4864) who underwent cardiovascular surgery between January 2010 and December 2016 were included. We assessed the prevalence of unruptured intracranial aneurysms in these patients using preoperative neurovascular imaging. The incidence of postoperative 30-day subarachnoid haemorrhage from aneurysmal rupture was investigated in patients undergoing cardiovascular surgery with unruptured intracranial aneurysm. Postoperative outcomes were compared between patients with unruptured intracranial aneurysm and those without unruptured intracranial aneurysm. Of the 4864 patients (39.6% females; mean ± standard deviation age, 62.3 ± 11.3 years), 353 patients had unruptured intracranial aneurysms (prevalence rate, 7.26%; 95% confidence interval, 6.52-8.06%). Of these, eight patients received surgical or endovascular treatment before surgery and 345 patients underwent cardiovascular surgery with unruptured intracranial aneurysms. Within 30 days postoperatively, subarachnoid haemorrhage occurred only in one patient, and the cumulative postoperative 30-day subarachnoid haemorrhage incidence was 0.29% (95% confidence interval, 0.01% to 1.61%). The Kaplan-Meier estimated subarachnoid haemorrhage probabilities according to the unruptured intracranial aneurysm rupture risk scores were not higher than the previously reported risk in the general population. There were no significant differences in postoperative subarachnoid haemorrhage-free survival, haemorrhagic stroke-free survival, in-hospital mortality, and hospital length of stay between patients with unruptured intracranial aneurysm and those without unruptured intracranial aneurysm. In conclusion, the prevalence of unruptured intracranial aneurysm in patients undergoing cardiovascular surgery is higher than in the general population. However, incidentally detected unruptured intracranial aneurysms are not linked to an increased risk of subarachnoid haemorrhage or adverse postoperative outcomes. These findings may help determine the optimal management of unruptured intracranial aneurysms before cardiovascular surgery.

Reliability of fast magnetic resonance imaging for acute ischemic stroke patients using a 1.5-T scanner.

OBJECTIVES: To determine whether fast scanned MRI using a 1.5-T scanner is a reliable method for the detection and characterization of acute ischemic stroke in comparison with conventional MRI. METHODS: From May 2015 to June 2016, 862 patients (FLAIR, n = 482; GRE, n = 380; MRA, n = 190) were prospectively enrolled in the study, with informed consent and under institutional review board approval. The patients underwent both fast (EPI-FLAIR, ETL-FLAIR, TR-FLAIR, EPI-GRE, parallel-GRE, fast CE-MRA) and conventional MRI (FLAIR, GRE, time-of-flight MRA, fast CE-MRA). Two neuroradiologists independently assessed agreements in acute and chronic ischemic hyperintensity, hyperintense vessels (FLAIR), microbleeds, susceptibility vessel signs, hemorrhagic transformation (GRE), stenosis (MRA), and image quality (all MRI), between fast and conventional MRI. Agreements between fast and conventional MRI were evaluated by generalized estimating equations. Z-scores were used for comparisons of the percentage agreement among fast FLAIR sequences and fast GRE sequences and between conventional and fast MRA. RESULTS: Agreements of more than 80% were achieved between fast and conventional MRI (ETL-FLAIR, 96%; TR-FLAIR, 97%; EPI-GRE, 96%; parallel-GRE, 98%; fast CE-MRA, 86%). ETL- and TR-FLAIR were significantly superior to EPI-FLAIR in the detection of acute ischemic hyperintensity and hyperintense vessels, while parallel-GRE was significantly superior to EPI-GRE in the detection of susceptibility vessel sign (p value < 0.05 for all). There were no significant differences in the other scores and image qualities (p value > 0.05). CONCLUSIONS: Fast MRI at 1.5 T is a reliable method for the detection and characterization of acute ischemic stroke in comparison with conventional MRI. KEY POINTS: • Fast MRI at 1.5 T may achieve a high intermethod reliability in the detection and characterization of acute ischemic stroke with a reduction in scan time in comparison with conventional MRI.