Association between Rapid Ventricular Response and Stroke Outcomes in Atrial Fibrillation-Related Cardiac Embolic Stroke.

INTRODUCTION: Patients with atrial fibrillation-related stroke (AF-stroke) are prone to developing rapid ventricular response (RVR). We investigated whether RVR is associated with initial stroke severity, early neurological deterioration (END) and poor outcome at 3 months. METHODS: We reviewed patients who had AF-stroke between January 2017 and March 2022. RVR was defined as having heart rate >100 beats per minute on initial electrocardiogram. Neurological deficit was evaluated with National Institutes of Health Stroke Scale (NIHSS) score at admission. END was defined as increase of ≥2 in total NIHSS score or ≥1 in motor NIHSS score within first 72 h. Functional outcome was score on modified Rankin Scale at 3 months. Mediation analysis was performed to examine potential causal chain in which initial stroke severity may mediate relationship between RVR and functional outcome. RESULTS: We studied 568 AF-stroke patients, among whom 86 (15.1%) had RVR. Patients with RVR had higher initial NIHSS score (p < 0.001) and poor outcome at 3 months (p = 0.004) than those without RVR. The presence of RVR [adjusted odds ratio (aOR) = 2.13; p = 0.013] was associated with initial stroke severity, but not with END and functional outcome. Otherwise, initial stroke severity [aOR = 1.27; p = <0.001] was significantly associated with functional outcome. Initial stroke severity as a mediator explained 58% of relationship between RVR and poor outcome at 3 months. CONCLUSION: In patients with AF-stroke, RVR was independently associated with initial stroke severity but not with END and functional outcome. Initial stroke severity mediated considerable proportion of association between RVR and functional outcome.

Relative score of early neurological deterioration in perforator artery infarction: a retrospective study.

BACKGROUND AND AIMS: Compared to small vessel occlusion (SVO) patients, branch atheromatous disease (BAD) patients are more likely to develop early neurological deterioration (END). Stroke patients with END have a poor prognosis. Initial clinical features/radiological findings are often insufficient to distinguish between BAD and SVO; therefore, they may not detect END. In this retrospective study, we investigated relative factors for END in perforator artery infarction and created a scoring system for END in these patients. METHODS: We extracted data from stroke patients with perforator artery infarction admitted to the Department of Neurology at Juntendo University between January 2016 and December 2022. We examined factors, such as the presence of SVO and BAD, leading to END. Variables with a P-value < 0.1 on univariate analysis were entered into binominal logistic regression analysis. RESULTS: Of the 1,420 stroke patients admitted over a 7-year period, 201 with perforator infarction were included in this study. END was found in 27 of 201 patients (13.4%). Binominal logistic regression analysis of background factors less than p < 0.1 revealed that age > 69 (P = 0.032; odds ratio [OR], 3.941; 95% confidence interval [CI], 1.126-13.769), body mass index < 23.8 (P = 0.041; OR, 3.183; 95%CI, 1.049-9.654), and pretreatment with anti-platelets (P = 0.003; OR, 5.183; 95%CI, 1.783-15.071) were significant factors. Regarding anti-platelet therapy, END was observed in 34.4% of patients administered aspirin and 35.0% administered clopidogrel. Initial infarct lesion size over 15 mm on initial MRI had a P value of 0.076 in univariate analysis and an odds ratio of 1.330 (95% CI 0.471-3.755; P = 0.590) in binomial logistic regression analysis. The length of stay and modified Rankin Scale at discharge were significantly exacerbated in the END group. Creating a scoring system with 1 point for each relevant factor (pEND score), significant correlations were obtained with ROC curves, and over 2 points produced the highest sensitivity and specificity for detecting END. CONCLUSION: Patients with high pEND scores may require intensive care from early hospitalization. In addition, the occurrence of stroke during anti-platelet therapy suggests the need for alternative treatment.

Rescue therapy of early neurological deterioration in lacunar stroke.

BACKGROUND: Early neurological deterioration (END) occurs in many patients with acute ischemic stroke due to a variety of causes. Although pharmacologically induced hypertension (PIH) and anticoagulants have been investigated in several clinical trials for the treatment of END, the efficacy and safety of these treatments remain unclear. Here, we investigated whether PIH or anticoagulation is better as a rescue therapy for the progression of END in patients with lacunar stroke. METHODS: This study included patients with lacunar stroke who received rescue therapy with END within 3 days of symptom onset between April 2014 and August 2021. In the PIH group, phenylephrine was administered intravenously for 24 h and slowly tapered when symptoms improved or after 5 days of PIH. In the anticoagulation group, argatroban was administered continuously intravenously for 2 days and twice daily for next 5 days. We compared END recovery, defined as improvement in NIHSS from baseline, excellent outcomes (0 or 1 mRS at 3 months), and safety profile. RESULTS: Among the 4818 patients with the lacunar stroke, END occurred in 147 patients. Seventy-nine patients with END received PIH (46.9%) and 68 patients (46.3%) received anticoagulation therapy. There was no significant difference in age (P = 0.82) and sex (P = 0.87) between the two groups. Compared to the anticoagulation group, the PIH group had a higher incidence of END recovery (77.2% vs. 51.5%, P < 0.01) and excellent outcomes (34.2% vs. 16.2%, P = 0.04). PIH was associated with END (HR 2.49; 95% CI 1.06-5.81, P = 0.04). PIH remained associated with END recovery (adjusted HR 3.91; 95% CI 1.19-12.90, P = 0.02). Safety outcomes, like hemorrhagic conversion and mortality, were not significantly different between the two groups. CONCLUSIONS: As a rescue therapy for the progression of END in lacunar stroke patients, PIH with phenylephrine was more effective with similar safety compared to anticoagulation with argatroban.

MRI-based clinical-radiomics nomogram to predict early neurological deterioration in isolated acute pontine infarction: a two-center study in Northeast China.

OBJECTIVE: To predict the appearance of early neurological deterioration (END) among patients with isolated acute pontine infarction (API) based on magnetic resonance imaging (MRI)-derived radiomics of the infarct site. METHODS: 544 patients with isolated API were recruited from two centers and divided into the training set (n = 344) and the verification set (n = 200). In total, 1702 radiomics characteristics were extracted from each patient. A support vector machine algorithm was used to construct a radiomics signature (rad-score). Subsequently, univariate and multivariate logistic regression (LR) analysis was adopted to filter clinical indicators and establish clinical models. Then, based on the LR algorithm, the rad-score and clinical indicators were integrated to construct the clinical-radiomics model, which was compared with other models. RESULTS: A clinical-radiomics model was established, including the 5 indicators rad-score, age, initial systolic blood pressure, initial National Institute of Health Stroke Scale, and triglyceride. A nomogram was then made based on the model. The nomogram had good predictive accuracy, with an area under the curve (AUC) of 0.966 (95% confidence interval [CI] 0.947-0.985) and 0.920 (95% [CI] 0.873-0.967) in the training and verification sets, respectively. According to the decision curve analysis, the clinical-radiomics model showed better clinical value than the other models. In addition, the calibration curves also showed that the model has excellent consistency. CONCLUSION: The clinical-radiomics model combined MRI-derived radiomics and clinical metrics and may serve as a scoring tool for early prediction of END among patients with isolated API.

FLAIR signal intensity ratio predicts small subcortical infarct early neurologic deterioration: a cross-sectional study.

PURPOSE: Prior studies have used the fluid-attenuated inversion recovery sequence signal intensity ratio (FLAIR-SIR) to predict those with an incomplete infarct that may safely receive acute thrombolytics. Clinical early neurologic deterioration (END) of small subcortical infarcts (SSIs) is suspected to occur due to delayed infarct completion. We aimed to understand if a lower FLAIR-SIR, suggestive of an incomplete infarct, would have a higher likelihood of SSI-related END. METHODS: A cross-sectional retrospective study was performed of those with an acute SSI (anterior or posterior circulation) without significant parent vessel steno-occlusive disease. END was defined as a new or worsened disabling neurologic deficit during the index hospitalization. Standard-of-care brain MRIs were reviewed from the hospitalization, and a FLAIR-SIR cutoff of ≤ 1.15 was used based on prior studies. Adjusted logistic regression models were used for analysis. RESULTS: We identified 252 patients meeting inclusion criteria: median (IQR) age 68 (12) years, 38.5% (97/252) female, and 11% (28/252) with END. Tobacco use was more common in those without END (32%) compared with END (55%, p = 0.03). In adjusted analyses, a FLAIR-SIR cutoff of ≤ 1.15 yielded an odds ratio of 2.8 (95% CI 1.23-6.13, p = 0.012) of early neurological deterioration. CONCLUSION: Those with a FLAIR-SIR ≤ 1.15 are nearly threefold more likely to develop SSI-related END.

Very early neurological deterioration during intravenous thrombolysis in patients with acute ischemic stroke.

BACKGROUND: Neurological deterioration within 24 h after intravenous thrombolysis with tissue plasminogen activator (tPA) is associated with poor outcomes in patients with acute ischemic stroke (AIS). This study aimed to elucidate the features of neurological deterioration specifically during tPA infusion in these patients. METHODS: We analyzed patients with AIS receiving thrombolysis between January 2018 and December 2021. Very early neurological deterioration (VEND) was defined as an increase of 4 or more points in the National Institutes of Health Stroke Scale (NIHSS) score during tPA infusion. Poor functional outcome was defined as a modified Rankin Scale score of 3-6 at three months. RESULTS: Among the 345 patients with AIS who received tPA, 8.4% had VEND; all of which were caused by ischemic progression. Patients with VEND had a higher prevalence of intracranial atherosclerotic disease (41% vs. 17%, P = 0.005). VEND independently predicted poor functional outcome in both groups with minor (NIHSS score <6) and non-minor (NIHSS score >6) stroke. Among patients with minor stroke, those with VEND were more likely to undergo endovascular thrombectomy (EVT) than those without (38% vs. 5%, P = 0.019). In patients receiving EVT after VEND, the NIHSS scores at 24 h, which were correlated with 3-month functional outcome, were lower in those with successful recanalization than in those without (12 ± 9 vs. 26 ± 7, P = 0.047). CONCLUSION: VEND predicted poor functional outcomes in patients with AIS. Timely and successful recanalization using EVT potentially alleviates the negative impact of VEND on long-term outcomes.

Predictive value of serum MDA and 4-HNE levels on the occurrence of early neurological deterioration after intravenous thrombolysis with rt-PA IVT in patients with acute ischemic stroke.

OBJECTIVE: This study investigated the predictive value of serum MDA and 4-HNE levels on early neurological deterioration (END) after recombinant tissue plasminogen activator (rt-PA) intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) patients. METHODS: This study analyzed 287 AIS patients with standard-dose rt-PA IVT. Clinical baseline and pathological data were recorded before rt-PA IVT, and neurologic deficit was assessed by NIHSS. AIS patients were classified into Non-END and END groups. Serum MDA and 4-HNE levels were determined by ELISA and their correlations with NIHSS scores were evaluated. AIS patients were allocated into groups with high and low MDA or 4-HNE expression, and post-IVT END incidence was compared. Independent risk indexes for post-IVT END and the predictive value of serum MDA+4-HNE levels on post-IVT END were assessed. RESULTS: Serum MDA and 4-HNE were higher in AIS patients with post-IVT END. NIHSS score showed a positive correlation with serum MDA and 4-HNE levels. MDA levels were positively correlated with 4-HNE levels in AIS patients. END after IVT was increased in AIS patients with high MDA/4-HNE expression. FBG, lymphocyte percentage, PLR, NIHSS score, serum MDA, and 4-HNE levels were independent risk factors for END after IVT. The diagnostic efficacy of MDA+4-HNE in assessing post-IVT END in AIS patients (sensitivity 92.00 %, specificity 82.70 %) was higher than MDA or 4-HNE alone. CONCLUSION: Serum MDA and 4-HNE levels were higher in AIS patients with post-IVT END than in those with non-END, and MDA+4-HNE possessed a higher predictive value for post-IVT END in AIS patients.

Association of perfusion variables with functional outcome in acute mild ischemic stroke patients or transient ischemic attack.

OBJECTIVE: Some patients with acute minor stroke or transient ischemic attack (TIA) are at risk for a poor prognosis. There are a limited number of studies that have investigated the functional prognosis of acute mild ischemic stroke or TIA based on imaging indicators. This study aims to explore the relationship between Perfusion Variables and poor prognosis in patients with mild ischemic stroke or TIA. MATERIALS AND METHODS: A retrospective analysis was conducted on a cohort of 344 patients with mild ischemic stroke or TIA, who were admitted and treated at the First Affiliated Hospital of Soochow University between January 2016 and March 2022. The criteria were National Institutes of Health Stroke Scale (NIHSS) scores of ≤5. Poor outcome was defined as a modified Rankin Scale (mRS) score of ≥2 points at 90 days. Multivariate logistic regression was performed to identify the risk factors associated with clinical outcomes. The receiver operating characteristic (ROC) analysis was used to explore the cutoff value of factors. RESULTS: Following a 3-month follow-up period, 49 (12.4 %) out of the 344 patients with mild stroke or TIA demonstrated a poor prognosis. Multivariable regression analysis identified mismatch volume as independent predictors of a poor 90-day prognosis. The ROC curve analysis indicated that a mismatch volume exceeding 16.5 ml was associated with a higher risk of unfavorable functional outcomes. CONCLUSION: A mismatch volume of ≥16.5mL predicted poor functional outcome in mild stroke or TIA patients.

Urinary Microalbumin Predicts Early Neurological Deterioration in Acute Ischemic Stroke: A Study Based on Etiological Classification: Urinary Microalbumin Predicts Early Neurological Deterioration in Acute Ischemic Stroke.

INTRODUCTION: To investigate the correlation between urinary microalbumin (U-Alb) levels and early neurological deterioration (END), as well as its predictive ability, in patients with acute ischemic stroke (AIS) under different etiological subtypes. MATERIALS AND METHODS: We consecutively enrolled AIS patients within 72 hours of onset, collecting relevant clinical characteristics and baseline laboratory data including U-Alb. END was defined as an increase of ≥4 points in NIHSS score within 72 hours of onset, and TOAST criteria were used for stroke etiologic typing. Binary logistic regression analysis was employed to clarify the association between baseline U-Alb and the occurrence of END under different stroke etiological subtypes. ROC analysis was conducted to evaluate its predictive ability under different etiological subtypes. RESULTS: Finally, 615 patients were included, with 104 (16.9%) developed END. Binary logistic regression analysis revealed that baseline U-Alb was independently associated with END occurrence (OR=1.009, 95% CI 1.002-1.016, p=0.009). ROC analysis revealed that U-Alb had the best predictive ability for patients with small artery occlusion (AUC=0.707, p<0.001), followed by large artery atherosclerosis (AUC=0.632, p=0.006), with corresponding optimal diagnostic cutoff points of 31.11 and 25.71 mg/L, respectively. However, U-Alb was not an independent risk factor for END in cardioembolic stroke patients (OR=1.011, 95% CI 0.980-1.043, p=0.478). MAU was associated with stroke progression(p=0.023), and U-Alb was positively correlated with increased infarct volume (r=0.516, p<0.01). CONCLUSION: U-Alb is closely associated with END in AIS patients, serving as a potential indicator for predicting END, especially among those with small artery occlusion mechanisms.

Prehospital Ultra-Early Neurological Deterioration in Intracerebral Hemorrhage: Definition, Prevalence, and Association with Outcomes.

INTRODUCTION: The objective of this study was to define prehospital ultra-early neurological deterioration (UND) and to investigate the association with functional outcomes in patients with intracerebral hemorrhage (ICH). METHODS: We conducted a prospective cohort study of consecutive acute ICH patients. The stroke severity at onset and hospital admission was assessed using the Chongqing Stroke Scale (CQSS), and prehospital UND was defined as a CQSS increase of ≥2 points between symptoms onset and admission. Early neurological deterioration (END) was defined as the increase of ≥4 points in NIHSS score within the first 24 h after admission. Poor outcome was defined as a modified Rankin Scale (mRS) of 4-6 at 3 months. RESULTS: Prehospital UND occurred in 29 of 169 patients (17.2%). Patients with prehospital UND had a median admission NIHSS score of 17.0 as opposed to those without prehospital UND with a median NIHSS score of 8.5. There were three patterns of neurological deterioration: prehospital UND only in 21 of 169 patients (12.4%), END but without prehospital UND in 20 of 169 patients (11.8%), and continuous neurological deterioration in both phases in 8 patients (4.7%). Prehospital UND was associated with worse 3-month outcomes (median mRS score, 4.0 vs. 2.0, p = 0.002). After adjusting for age, time from onset to admission, END, and systolic blood pressure, prehospital UND was an independent predictor of poor outcome (odds ratio [OR] 3.27, 95% confidence interval [CI] 1.26-8.48, p = 0.015). CONCLUSION: Prehospital UND occurs in approximately 1 in 7 patients between symptom onset and admission and is associated with poor functional outcome in patients with ICH. Further research is needed to investigate the prehospital UND in the prehospital phase in the triage of patients with ICH.

Early Response to Endovascular Thrombectomy after Stroke: Early, Late, and Very Late Time Windows.

BACKGROUND AND PURPOSE: Endovascular thrombectomy (EVT) has benefits in selected patients 6-24 h after stroke onset. However, the response to EVT >24 h after stroke onset is still unclear. We compared the early response to EVT in patients with different time windows. METHODS: Patients who underwent EVT in an emergency setting were enrolled and categorized according to when EVT was performed: within 6 (early), 6-24 (late), and >24 h (very late) after stroke onset. Early neurological improvement (ENI) and deterioration (END) were defined as improvement and worsening, respectively, of National Institutes of Health Stroke Scale (NIHSS) score by ≥4 points after EVT. The three groups' clinical characteristics and response to EVT were compared. We also investigated factors associated with ENI and END. RESULTS: During study period, 274 patients underwent EVT (109 early, 104 late, and 61 very late). Patients who underwent EVT very late were younger (p = 0.007), had smaller ischemic cores, and had lower initial NIHSS scores (8 ± 5) than those who underwent EVT early (14 ± 6) and late (13 ± 7; p < 0.001). Stroke mechanisms also differed according to the time window (p < 0.001): cardioembolism was more common after early EVT, whereas large-artery atherosclerosis was more prevalent among patients who underwent EVT very late. ENI was significantly more common after early (60.6%) and late EVT (51.0%) than after very late EVT (29.5%; p = 0.001); however, rates of END did not differ (11.0%, 13.5%, and 4.9%, respectively). ENI was independently associated with male, higher NIHSS score, and early and late EVT. END was associated with failure of recanalization. CONCLUSIONS: ENI was more observed and associated with early and late EVT. Highly selected patients receiving very late EVT may not benefit from ENI but may still have a chance to prevent END. The occurrence of END was associated not with time window but with failure of recanalization.

Risk factors for early neurologic deterioration in single small subcortical infarction without carrier artery stenosis: predictors at the early stage.

OBJECTIVES: This study aimed to assess the epidemiological features and explore the potential risk factors for early neurological deterioration (END) in patients with acute single small subcortical infarction (SSSI) who underwent antiplatelet therapy without carotid artery stenosis. MATERIALS & METHODS: Patients with SSSI, as confirmed by cranial magnetic resonance imaging (MRI), who were hospitalized within 48 h after the onset of symptoms were enrolled. END was mainly defined as increment in the National Institutes of Health Stroke Scale (NIHSS) score of ≥ 2 points or any new neurological deficit. Poor functional outcome was defined as modified Rankin Scale (mRS) score of > 2 points at 3-month after the onset. The association of END with multiple indicators was assessed at the early stage of admission using multivariate logistic regression analysis, and adjusted odds ratios (aORs) were calculated. RESULTS: A total of 280 patients were enrolled from June 2020 to May 2021, of whom, END occurred in 44 (15.7%) patients (median age, 64 years; 70.5% male), while END occurred during sleep in 28 (63.6%) patients. History of hypertension (aOR: 4.82, p = 0.001), infarction in internal capsule (aOR: 3.35, p = 0.001), and elevated level of low-density lipoprotein cholesterol (LDL-C; aOR: 0.036, p = 0.0016) were significantly associated with the risk of END. Patients with END (aOR: 5.74, p = 0.002), history of diabetes (aOR: 2.61, p = 0.020), and higher NIHSS scores at discharge (per 1-score increase, aOR: 1.29, p = 0.026) were associated with the poor functional outcome at 3-month after the onset. CONCLUSION: Patients with a history of hypertension, infarction in internal capsule or a higher level of LDL-C were found to be at a higher risk of END.

Elevated NT-proBNP predicts unfavorable outcomes in patients with acute ischemic stroke after thrombolytic therapy.

OBJECTIVE: Few studies correlated n-terminal pro-brain natriuretic peptide (NT-proBNP) with early neurological deterioration (END) and prognosis of acute ischaemic stroke (AIS) patients with rt-PA intravenous thrombolysis. Therefore this study aimed to investigate the relationship between NT-proBNP and END, and prognosis after intravenous thrombolysis in patients with AIS. METHODS: A total of 325 patients with AIS were enrolled. We performed the natural logarithm transformation on the NT-proBNP [ln(NT-proBNP)]. Univariate and multivariate logistic regression analyses were performed to assess the relationship between ln(NT-proBNP) and END, and prognosis and receiver operating characteristic (ROC) curves were used to show the sensitivity and specificity of NT-proBNP. RESULTS: After thrombolysis, among 325 patients with AIS, 43 patients (13.2%) developed END. In addition, three months follow-up showed a poor prognosis in 98 cases (30.2%) and a good prognosis in 227 cases (69.8%). Multivariate logistic regression analysis showed that ln(NT-proBNP) was an independent risk factor for END (OR = 1.450,95%CI:1.072 ~ 1.963, P = 0.016) and poor prognosis at three months follow-up (OR = 1.767, 95%CI: 1.347 ~ 2.317, P < 0.001) respectively. According to ROC curve analysis, ln(NT-proBNP) (AUC 0.735, 95%CI: 0.674 ~0.796, P < 0.001) had a good predictive value for poor prognosis, with a predictive value of 5.12 and sensitivity and specificity of 79.59% and 60.35% respectively. When combined with NIHSS to predict END(AUC 0.718, 95%CI: 0.631 ~ 0.805, P < 0.001) and poor prognosis(AUC 0.780, 95%CI: 0.724 ~ 0.836, P < 0.001), the predictive value of the model is further improved. CONCLUSION: NT-proBNP is independently associated with END and poor prognosis in patients with AIS following intravenous thrombolysis and has a particular predictive value for END and poor prognosis.

Early antithrombotic therapy in patients with postinterventional cerebral hyperdensity reduces early neurological deterioration after mechanical thrombectomy.

BACKGROUND: Initiation of early antithrombotic therapy after acute ischemic stroke (AIS) is crucial. We aimed to investigate whether early antithrombotic therapy influences early neurological deterioration (END) in AIS patients with postinterventional cerebral hyperdensity (PCHD) immediately after mechanical thrombectomy (MT). METHODS: We retrospectively analyzed 108 consecutive anterior circulation AIS patients with PCHD immediately after MT. All patients were divided into END group and non-END group and END was defined as an increase of four points or more on the postinterventional National Institutes of Health Stroke Scale (NIHSS) score within the first 72 h after MT. Early antithrombotic therapy was defined as patients with PCHD who received antithrombotic therapy within 24 h after MT. Statistical analyses were performed to evaluate the association between early antithrombotic therapy and the risk of END. RESULTS: Among 108 patients, 27 (25%) patients developed END. Multivariate regression analysis revealed that early use of antithrombotic therapy (OR = 0.229, 95%CI = 0.083-0.626, P = 0.004) was an independent protector of END and postinterventional low density shadow exceeding 1/3 of the vascular territory (OR = 4.000, 95%CI = 1.157-13.834, P = 0.029) was an independent risk factor for END. CONCLUSION: Antithrombotic therapy within 24 h after MT maybe associated with the reduced risk of END in anterior circulation AIS patients with PCHD.

The "island sign" on diffusion-weighted imaging predicts early neurological deterioration in penetrating artery territory infarctions: a retrospective study.

BACKGROUND: Early neurological deterioration (END) sometimes occurs in patients with penetrating artery territory infarction (PATI) and leads to poor prognosis. In this study, we analyzed clinical and neuroimaging characteristics of PATI, and focused on the infarct patterns on diffusion-weighted imaging (DWI). We tried to investigate whether the "island sign" pattern is associated with END. METHODS: We enrolled consecutive patients admitted with acute PATI within 48 h after onset from May 2020 to July 2022. They were divided into with and without the "island sign" pattern on DWI. According to infarct location, all the patients were classified into two groups: the territories of the lenticulostriate arteries (LSA) and paramedian pontine arteries (PPA). The patients in each group were further divided into two groups according to whether they developed END or not. Through analyzing the clinical and neuroimaging characteristics of the patients, we tried to identify the factors that might associated with the "island sign" pattern and the potential predictors of END within the LSA and PPA groups. RESULTS: Out of the 113 patients enrolled in this study, END was found in 17 patients (27.9%) in the LSA group and 20 patients (38.5%) in the PPA group. The "island sign" was found in 26 (23%) patients. In the multivariate analysis, the independent predictors of END in the LSA group were the "island sign" (OR 4.88 95% CI 1.03-23.2 P = 0.045) and high initial National Institute of Health Stroke Scale (NIHSS) (OR 1.79 95% CI 1.08-2.98 P = 0.024) and in the PPA group was the presence of lesions extending to the ventral pontine surface (OR 7.53 95% CI 1.75-32.37 P = 0.007). CONCLUSIONS: The predictive factors for END were different in the LSA and PPA groups. The "island sign" was particularly associated with END in the LSA group.

Clinical significance of D-dimer levels during acute period in ischemic stroke.

BACKGROUND: Initial D-dimer level is a well-known prognostic parameter in patients with acute ischemic stroke (AIS). However, there have been no studies on the clinical significance of follow-up D-dimer levels. In this study, we evaluated the association between initial and follow-up D-dimer levels and early neurological deterioration (END) in patients with AIS. METHODS: We included consecutive patients with AIS who had a positive initial D-dimer test (> 0.55 mg/L) between March 2021 and November 2022. The follow-up D-dimer test was performed on the 7th day after hospitalization and on the day of discharge if discharged earlier. END was defined as an increase of ≥ 2 in the total NIHSS score, or ≥ 1 in the motor NIHSS score within the first 7 days of admission. As medical conditions closely associated with the initial and follow-up D-dimer levels in AIS patients, we also evaluated the history of cancer, active cancer, and venous thromboembolism (VTE) that occurred during hospitalization together. RESULTS: A total of 246 patients with AIS were evaluated (median age: 87 years, male: 56.5%). In multivariable logistic regression analysis, the initial D-dimer level was closely associated with END after adjusting for confounders (adjusted odds ratio [aOR]: 1.48, 95% CI: 1.06-2.05). The follow-up D-dimer level also showed a close correlation with END (aOR: 1.60, 95% CI: 1.16-2.20). Regarding the analysis of the association between D-dimer levels and underlying cancer or VTE, the initial D-dimer level showed a statistically significant positive relationship only with active cancer (P = 0.024). On the other hand, the follow-up D-dimer level was found to be statistically significantly associated with a history of cancer (P = 0.024), active cancer (P = 0.001), and VTE (P = 0.001). CONCLUSIONS: Initial and follow-up D-dimer levels were associated with END in AIS patients. Particularly, the follow-up D-dimer level showed a clear correlation not only with END but also with the underlying cancer or the occurrence of VTE during the acute period.

Neuroimaging markers of early neurological deterioration in acute isolated pontine infarction.

BACKGROUND: Imaging indicators of early neurological deterioration (END) in patients with acute isolated pontine infarctions (AIPI) remained ambiguous. We aimed to find more specific neuroimaging markers for the development of END in patients with AIPI. METHODS: Patients with AIPI within 72 h of stroke onset were screened from a stroke database from January 2018 to July 2021 in the First Affiliated Hospital of Zhengzhou University. Clinical characteristics, laboratory tests, and imaging parameters were collected. The layers having the largest infarct area on diffusion-weighted imaging (DWI) and T2 sequences were chosen. On the transverse plane of DWI and sagittal plane of T2-Flair images, the maximum length (a, m) and maximum width (b, n) vertical to the length of the infarcted lesions were measured respectively. On the sagittal plane of T2-Flair image, the maximum ventrodorsal length (f) and rostrocaudal thickness (h) were measured. On the sagittal plane, lesions were evenly split into upper, middle, and lower types based on the lesion's location in the pons. The ventral and dorsal types of location were separated based on whether the ventral borders of the pons were involved on transvers plane. END was defined as a ≥2 point increase in the National Institutes of Health Stroke Scale (NIHSS) total score or a ≥1 point increase in the motor items within 72 h after admission. Multivariate logistic regression analyses were used to explore risk factors associated with END. The receiver operating characteristic (ROC) curve analysis and the area under the curve (AUC) was performed to estimate the discriminative power and determine the optimal cut-off points of imaging parameters on the prediction of END. RESULTS: A total of 218 patients with AIPI were included in the final analysis. END occurred in 61 cases (28.0%). Multivariate logistic regression analysis showed that the ventral type of lesion location was associated with END in all models adjusted. In addition, in Model 1, b (odds ratio (OR) 1.145, 95% confidence interval (95% CI), 1.007-1.301) and n (OR 1.163, 95% CI 1.012-1.336); in Model 2, b*n (OR 1.010, 95% CI 1.002-1.018); in Model 3, n (OR 1.179, 95% CI, 1.028-1.353); and in Model 4, b (OR 1.143, 95% CI 1.006-1.298) and n (OR 1.167, 95% CI 1.016-1.341) were found to be associated with END respectively after different adjustments. ROC curve analysis with END showed that the AUC, the optimal cut-off value, and its sensitivity and specificity were 0.743 (0.671-0.815), 9.850 mm, and 68.9% and 79.0% for b; 0.724 (0.648-0.801), 10.800 mm, and 57.4% and 80.9% for n; and 0.772 (0.701-0.842), 108.274 mm2, and 62.3% and 85.4% for b*n, respectively (b*n vs b: P =0.213; b*n vs n: P =0.037; b vs n: P =0.645). CONCLUSIONS: Our study revealed that besides the ventral type of lesion location, the maximum width of lesion on the transverse plane of DWI and sagittal plane of T2 image (b, n) may be imaging markers for the development of END in AIPI patients, and the product of the two (b*n) showed a better prediction value on the risks of END.

Predictors of Early Neurological Deterioration Occurring within 24 h in Acute Ischemic Stroke following Reperfusion Therapy: A Systematic Review and Meta-Analysis.

BACKGROUND: Early neurological deterioration (END), generally defined as the increment of National Institutes of Health Stroke Scale (NIHSS) score ≥4 within 24 hours, lead to poor clinical outcome in acute ischemic stroke (AIS) patients receiving reperfusion therapies including intravenous thrombolysis (IVT) and/or endovascular treatment (EVT). This systematic review and meta-analysis aimed to explore multiple predictors of END following reperfusion therapies. METHODS: We searched PubMed, Web of Science and EBSCO for all studies on END in AIS patients receiving IVT and/or EVT published between January 2000 and December 2022. A random-effects meta-analysis was conducted and presented in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The quality of each included studies was assessed by calculating a total score according to the STROBE or CONSORT criteria. Publication bias and heterogeneity were also evaluated using the Eggers/Peters test, funnel plots and sensitivity analysis. RESULTS: A total of 29 studies involving 65,960 AIS patients were included. The quality of evidence is moderate to high, and all studies have no publication bias. The overall incidence of END occurring after reperfusion therapy in AIS patients was 14% ((95% confidence intervals (CI), 12%-15%)). Age, systolic blood pressure (SBP), glucose levels at admission, the onset to treatment time (OTT), hypertension, diabetes mellitus, arterial fibrillation, and internal cerebral artery occlusion were significantly associated with END following reperfusion therapy. CONCLUSIONS: Numerous factors are associated with END occurrence in AIS patients receiving reperfusion therapy. Management of the risk factors of END may improve the functional outcome after reperfusion treatment.

Incidence and predictors of poor functional outcome despite complete recanalisation following endovascular thrombectomy for acute ischaemic stroke.

BACKGROUND: Numerous ischaemic stroke patients experience poor functional outcome despite successful recanalisation following endovascular thrombectomy (EVT). We aimed to identify the incidence and predictors of futile complete recanalisation (FCR) in a national stroke registry. METHODS: Patients who achieved complete recanalisation (mTICI 3) following EVT, between October 2015 and March 2020, were included from a United Kingdom national stroke registry. Modified Rankin Scale of 4-6 at discharge was defined as a 'poor/futile outcome'. Backward stepwise multivariable logistic regression analysis was performed with FCR as the dependent variable, incorporating all baseline characteristics, procedural time metrics and post-procedural events. RESULTS: We included 2132 of 4383 patients (48.8%) with complete recanalisation post-EVT, of which 948 patients (44.4%) developed FCR. Following multivariable regression analysis adjusted for potential confounders, patients with FCR were associated with multiple baseline patient, imaging and procedural factors: age (p=0.0001), admission NIHSS scores (p=0.0001), pre-stroke disability (p=0.007), onset-to-puncture (p=0.0001) and procedural times (p=0.0001), presence of diabetes (p=0.005), and use of general anaesthesia (p=0.0001). Although not predictive of outcome, post-procedural events including development of any intracranial haemorrhage (ICH) (p=0.0001), symptomatic ICH (sICH) (p=0.0001) and early neurological deterioration (END) (p=0.007) were associated with FCR. CONCLUSION: Nearly half of patients in this national registry experienced FCR following EVT. Significant predictors of FCR included increasing age, admission NIHSS scores, pre-stroke disability, onset-to-puncture and procedural times, presence of diabetes, atrial fibrillation, and use of general anaesthesia. Post procedural development of any ICH, sICH, and END were associated with FCR.

Prognostic utility of sTREM-1 in predicting early neurological deterioration in patients with acute ischemic stroke treated without reperfusion therapy.

OBJECTIVE: Serum triggering receptor expressed on myeloid cells type 1 (sTREM-1) is a new type of immunoglobulin superfamily receptor related to inflammation that aggravates brain injury. This study aimed to assess the clinical value of sTREM-1 in predicting early neurological deterioration in patients with acute ischemic stroke (AIS) treated without reperfusion therapy. METHODS: This prospective cohort study enrolled 315 patients with acute ischemic stroke admitted to the Affiliated Taizhou People's Hospital of Nanjing Medical University between October 2020 and October 2022. The study excluded patients treated with reperfusion therapy. sTREM-1 levels were evaluated within 24 h of the acute ischemic stroke. Early neurological deterioration (END) was defined as an increase in the National Institutes of Health Stroke Scale (NIHSS) score ≥ 4 points within three days after admission. Multivariable analyses were used to investigate the relationship between sTREM-1 levels and END. RESULTS: A total of 81 (25.7 %) patients had early neurological deterioration. Patients in the END group had a higher NIHSS score at admission (P =0.007), CRP levels (P =0.011), white blood cell count (P =0.002), fasting blood glucose levels (P =0.028), and sTREM-1 levels (P <0.001). After adjusting for confounders, higher sTREM-1 levels were significantly associated with an increased risk of early neurological deterioration (OR, 1.98; 95 % CI, 1.17-3.38, P=0.012). Moreover, sTREM-1 levels efficiently differentiated END (area under the curve: 0.779; 95 % CI: 0.731-0.822). Furthermore, the results showed significant differences between the high sTREM-1 group and the low sTREM-1 group in NIHSS scores (P=0.019), C-reactive protein (P=0.018), white blood cell count (P=0.013), and the incidence of early neurological deterioration (P<0.001). According to the multivariate logistic regression model, we discovered that the high sTREM-1 group was a significant independent predictor of early neurological deterioration incidence (OR, 4.19; 95 % CI, 1.46-9.84; P= 0.003). CONCLUSION: sTREM-1 could be a potential biomarker for predicting early neurological deterioration in AIS patients not treated with reperfusion therapy.