External validation of stroke mimic prediction scales in the emergency department.

BACKGROUND: Acute ischemic stroke is a time-sensitive emergency where accurate diagnosis is required promptly. Due to time pressures, stroke mimics who present with similar signs and symptoms as acute ischemic stroke, pose a diagnostic challenge to the emergency physician. With limited access to investigative tools, clinical prediction, tools based only on clinical features, may be useful to identify stroke mimics. We aim to externally validate the performance of 4 stroke mimic prediction scales, and derive a novel decision tree, to improve identification of stroke mimics. METHODS: We performed a retrospective cross-sectional study at a primary stroke centre, served by a telestroke hub. We included consecutive patients who were administered intravenous thrombolysis for suspected acute ischemic stroke from January 2015 to October 2017. Four stroke mimic prediction tools (FABS, simplified FABS, Telestroke Mimic Score and Khan Score) were rated simultaneously, using only clinical information prior to administration of thrombolysis. The final diagnosis was ascertained by an independent stroke neurologist. Area under receiver operating curve (AUROC) analysis was performed. A classification tree analysis was also conducted using variables which were found to be significant in the univariate analysis. RESULTS: Telestroke Mimic Score had the highest discrimination for stroke mimics among the 4 scores tested (AUROC = 0.75, 95% CI = 0.63-0.87). However, all 4 scores performed similarly (DeLong p > 0.05). Telestroke Mimic Score had the highest sensitivity (91.3%), while Khan score had the highest specificity (88.2%). All 4 scores had high positive predictive value (88.1 to 97.5%) and low negative predictive values (4.7 to 32.3%). A novel decision tree, using only age, presence of migraine and psychiatric history, had a higher prediction performance (AUROC = 0.80). CONCLUSION: Four tested stroke mimic prediction scales performed similarly to identify stroke mimics in the emergency setting. A novel decision tree may improve the identification of stroke mimics.

The Clot Strikes Thrice: Case Report of a Patient with 3 Concurrent Embolic events.

PURPOSE: Concurrent cerebral and systemic embolism are unusual occurrences. Acute myocardial infarction secondary to coronary embolism are particularly rare with only isolated reports in the literature. CASE REPORT: A 49-year old Chinese man presented with right posterior cerebral artery infarction to our hospital. He developed chest pain and ST-elevation on ECG the next morning. Urgent cardiac catheterization showed a right coronary artery as well as a right profunda femoris artery occlusion. The cause of these 3 concurrent emboli was a large mobile left ventricular thrombus seen on echocardiography. Urgent anticoagulation was initiated, and the patient returned home after 1 month of rehabilitation with no further ischemic events. CONCLUSION: In selected patients with high embolic risks, urgent anticoagulation after acute ischemic stroke can be a possible treatment option.

Triaging Medical Referrals Based on Clinical Prioritisation Criteria Using Machine Learning Techniques.

Triaging of medical referrals can be completed using various machine learning techniques, but trained models with historical datasets may not be relevant as the clinical criteria for triaging are regularly updated and changed. This paper proposes the use of machine learning techniques coupled with the clinical prioritisation criteria (CPC) of Queensland (QLD), Australia, to deliver better triaging for referrals in accordance with the CPC's updates. The unique feature of the proposed model is its non-reliance on the past datasets for model training. Medical Natural Language Processing (NLP) was applied in the proposed approach to process the medical referrals, which are unstructured free text. The proposed multiclass classification approach achieved a Micro F1 score = 0.98. The proposed approach can help in the processing of two million referrals that the QLD health service receives annually; therefore, they can deliver better and more efficient health services.

Intracranial Large Artery Disease is Independently Associated with Poor Functional Outcome in a Cohort of Ethnic South Asian Ischemic Stroke Patients.

BACKGROUND: Intracranial large artery disease (ICLAD) in ischemic stroke patients is associated with an increased risk for recurrent stroke; however, it is not known if ICLAD influences functional status following stroke. We studied the 6-month functional outcome in south Asian ischemic stroke patients and compared those with and without ICLAD. MATERIALS AND METHODS: This is a prospective cohort study of consecutive south Asian ischemic stroke patients. ICLAD was assessed with transcranial color-coded Doppler ultrasound or magnetic resonance angiography. Functional outcomes were obtained via telephone interviews with poor outcome defined as modified Rankin scale of 3-6. RESULTS: Of 216 ischemic stroke patients studied, 203 (93.9%) had follow-up data, of whom 50.7% (103) had ICLAD. Patients with ICLAD had a higher prevalence of hypertension (P < 0.001), hyperlipidemia (P = 0.047), ischemic heart disease (P = 0.030), and extracranial carotid disease (P = 0.005). A higher proportion of patients with ICLAD had poor functional outcome at 6 months (30.1%) versus those without ICLAD (13.0%) (P = 0.004). After adjusting for age, sex, hypertension, hyperlipidemia, diabetes, ischemic heart disease, atrial fibrillation, extracranial carotid stenosis, and recurrent vascular events, patients with ICLAD were 3.01 (95% confidence interval: 1.35-7.10) times more likely than those without ICLAD to have poor functional outcome. CONCLUSIONS: The presence of ICLAD rendered poorer functional prognosis after stroke. These findings support the specific evaluation of the benefits of known acute stroke treatments such as thrombolysis, as well as investigation of potential novel strategies such as acute stenting.

Post-thrombolysis rupture of small lenticulostriate aneurysms: A report of 2 consecutive cases.

The 2018 American Heart Association/American Stroke Association (AHA/ASA) guidelines stated that the administration of intravenous recombinant tissue-type plasminogen activator (rTPA) for acute ischaemic stroke is probably safe for patients with small (i.e. <10 mm) unruptured intracranial aneurysms. We present 2 cases of small (2 and 5 mm) lenticulostriate artery (LSA) aneurysms which ruptured immediately following rtPA infusion. The ensuing acute intracranial haemorrhages resulted in the death of one patient and severe functional impairment for the other. Given the limited literature available, the natural history of LSA aneurysms is largely unknown. This report suggests that LSA aneurysms, regardless of size, be considered separately from other conventional aneurysms as "high-risk" lesions and a contraindication to thrombolysis.

Prevalence of anti-aquaporin 4 antibody in a diagnostic cohort of patients being investigated for possible neuromyelitis optica spectrum disorder in Western Australia.

OBJECTIVE: To evaluate the prevalence of anti-AQP4 antibody in serum and CSF samples from patients being investigated for possible neuromyelitis optica spectrum disorder (NMOSD) referred to the PathWest State reference laboratory using a sensitive cell-based assay (CBA). BACKGROUND: NMOSD is an inflammatory CNS disease distinct from MS, which is relatively rare in Western countries. A proportion of patients with NMOSD have detectable serum IgG antibodies that target the water channel aquaporin-4 (AQP4-IgG), but the frequency varies in different populations studied and according to the assay method employed. METHODS: Sera or CSF from a diagnostic cohort of 196 consecutive patients with possible NMOSD which had previously been screened by indirect immunofluorescence (IIF) on primate cerebellum were re-tested for AQP4-IgG reactivity to the M1 and M23 isoforms of AQP4 using a commercial CBA. A control group of 205 patients with definite MS was also included in the study. RESULTS: Of the 196 patients, only 5 sera were AQP4-IgG positive, representing 2.6% of patients in the diagnostic cohort. All 5 AQP4-IgG positive patients fulfilled the 2015 revised diagnostic criteria for NMOSD and were females of varied ethnic origins, 4 of whom had longitudinally extensive transverse myelitis. The CBA confirmed AQP4-IgG positivity in the four patients previously reported as positive by IIF, and an additional patient with NMOSD who had previously been diagnosed as MS was also identified. None of the 205 MS sera were AQP4-IgG positive. CONCLUSIONS: Our study confirms the utility and greater reliability of the M1/M23 CBA for detecting AQP4-IgG in patients with possible NMOSD, and indicates a prevalence of seropositive NMOSD in the Western Australian population similar to that in other Western populations.

Outcomes of Endovascular Thrombectomy with and without Thrombolysis for Acute Large Artery Ischaemic Stroke at a Tertiary Stroke Centre.

BACKGROUND AND PURPOSE: Endovascular thrombectomy (EVT) improves the functional outcome when added to best medical therapy, including alteplase, in patients with acute ischaemic stroke secondary to large vessel occlusion (LVO) in the anterior circulation. However, the evidence for EVT in alteplase-ineligible patients is less compelling. It is also uncertain whether alteplase is necessary in patients with successful recanalization by EVT, as the treatment effect of EVT may be so powerful that bridging alteplase may not add to efficacy and may compromise safety by increasing bleeding risks. We aimed to survey the proportion of patients suitable for EVT who are alteplase-ineligible and to compare the safety and effectiveness of standard care of acute large artery ischaemic stroke by EVT plus thrombolysis with that of EVT alone in a tertiary hospital clinical stroke service. METHODS: We performed a retrospective analysis of acute ischaemic stroke patients treated with EVT at our centre between October 2013 and April 2016, based on a registry with prospective and consecutive patient collection. Individual patient records were retrieved for review. Significant early neurological improvement was defined as a NIHSS score of 0-1, or a decrease from baseline of ≤8, at 24 h after stroke onset. RESULTS: Fifty patients with acute ischaemic stroke secondary to LVO in the anterior circulation received EVT in this period, of whom 21 (42%) received concurrent alteplase and 29 (58%) EVT alone. The 2 groups had similar baseline characteristics and similar outcomes. Significant neurological improvement at 24 h occurred in 47.6% of the patients with EVT and bridging alteplase and in 51.7% of the patients with EVT alone (p = 0.774). Mortality during acute hospitalization was 20% for the bridging alteplase group versus 7.1% for EVT alone (p = 0.184). Intracranial haemorrhage rates were 14.3% for bridging alteplase versus 20.7% for EVT alone (p = 0.716). Local complications, groin haematoma (23.8 vs. 10.3%) and groin pseudoaneurysms (4.8 vs. 0%) (p = 0.170), were not significantly different. CONCLUSION: Our study highlights the relatively large proportion of patients suitable for EVT who have a contraindication to alteplase and raises the hypothesis that adding alteplase to successful EVT may not be necessary to optimize functional outcome. The results are consistent with observational data from other endovascular centres and support a randomised controlled trial of EVT versus EVT with bridging alteplase.

Unusual case of hypomagnesaemia induced seizures.

Alterations in electrolyte homeostasis associated with major surgery and critical illness are common but usually non-specific. We report an unusual case of hypomagnesaemia induced seizures in a 73-year-old woman who was recovering from ileal resection and limited right hemicolectomy for small bowel volvulus. Hypomagnesaemia as a de novo cause of seizures is rarely reported.

Factors associated with hypospadias in Asian newborn babies.

AIMS: Previous studies reported an increasing temporal trend of hypospadias and a significant association with poor intrauterine growth. It remains unclear whether the association relates to birth weight, degree of prematurity or intra-uterine growth. The objective was to study the incidence of hypospadias and to examine the association with various risk factors. METHODS: A retrospective case-control study was carried out of infants admitted to a neonatal unit from January 1st, 1999 to December 31st, 2005. RESULTS: Of 6538 male live births, 27 (0.41%) infants had hypospadias. Incidence increased from 2.85 per thousand in 1999 to 6.89 per thousand in 2005. Hypospadias occurred significantly more frequently in babies born small for gestational age (SGA), in very low birth weight (VLBW) infants, those born preterm and to mothers with preeclampsia (PET). Logistic regression revealed that VLBW (OR 14.12, CI 5.48-36.39), maternal PET (OR 3.90, CI 1.50-10.14) and SGA (OR 3.23, CI 1.25-8.37) as independent risk factors. CONCLUSIONS: Hypospadias is associated with VLBW, maternal PET and poor intra-uterine growth, but not with preterm birth. A rising trend in the incidence of hypospadias was noted in our population of Asian babies, suggesting a universal phenomenon.