Acute ischaemic stroke associated with SARS-CoV-2 infection in North America.

BACKGROUND: To analyse the clinical characteristics of COVID-19 with acute ischaemic stroke (AIS) and identify factors predicting functional outcome. METHODS: Multicentre retrospective cohort study of COVID-19 patients with AIS who presented to 30 stroke centres in the USA and Canada between 14 March and 30 August 2020. The primary endpoint was poor functional outcome, defined as a modified Rankin Scale (mRS) of 5 or 6 at discharge. Secondary endpoints include favourable outcome (mRS ≤2) and mortality at discharge, ordinal mRS (shift analysis), symptomatic intracranial haemorrhage (sICH) and occurrence of in-hospital complications. RESULTS: A total of 216 COVID-19 patients with AIS were included. 68.1% (147/216) were older than 60 years, while 31.9% (69/216) were younger. Median [IQR] National Institutes of Health Stroke Scale (NIHSS) at presentation was 12.5 (15.8), and 44.2% (87/197) presented with large vessel occlusion (LVO). Approximately 51.3% (98/191) of the patients had poor outcomes with an observed mortality rate of 39.1% (81/207). Age >60 years (aOR: 5.11, 95% CI 2.08 to 12.56, p<0.001), diabetes mellitus (aOR: 2.66, 95% CI 1.16 to 6.09, p=0.021), higher NIHSS at admission (aOR: 1.08, 95% CI 1.02 to 1.14, p=0.006), LVO (aOR: 2.45, 95% CI 1.04 to 5.78, p=0.042), and higher NLR level (aOR: 1.06, 95% CI 1.01 to 1.11, p=0.028) were significantly associated with poor functional outcome. CONCLUSION: There is relationship between COVID-19-associated AIS and severe disability or death. We identified several factors which predict worse outcomes, and these outcomes were more frequent compared to global averages. We found that elevated neutrophil-to-lymphocyte ratio, rather than D-Dimer, predicted both morbidity and mortality.

Learning from Gamers: Integrating Alternative Input Devices and AutoHotkey Scripts to Simplify Repetitive Tasks and Improve Workflow.

Radiologists rely heavily on the digital radiology workstation. They spend most of their time interacting with software applications that use multiple input devices, including mice, keyboards, and microphones. The efficiency of this relationship depends on the interface of the different software applications, their interoperability, and input device effectiveness. Because of the repetition of a radiologic workflow, even small inefficiencies can accumulate into significant losses of time and productivity and contribute to user fatigue. Alternative input devices (AIDs) with onboard memory can be used as ergonomic human-computer interfaces. These devices can also be coupled with AutoHotkey scripts to complete complex tasks in one keystroke. Radiologists can use modern AIDs and simple scripts to minimize frustration, improve and personalize their routines, and streamline interactions with the workstation. The authors discuss hardware and software features that do not require support from information technology professionals and can be implemented with any software that relies on user input.Online supplemental material is available for this article.©RSNA, 2020.

The role of microRNA in neuronal inflammation and survival in the post ischemic brain: a review.

Each year, more than 790 000 people in the United States suffer from a stroke. Although progress has been made in diagnosis and treatment of ischemic stroke (IS), new therapeutic interventions to protect the brain during an ischemic insult is highly needed. MicroRNAs (miRNAs) are small, non-coding RNAs that regulate gene expression post-transcriptionally. Growing evidence suggests that miRNAs have a profound impact on ischemic stroke progression and are potential targets of novel treatments. Notably, inflammatory pathways play an important role in the pathogenesis of ischemic stroke and its pathophysiologic progression. Experimental and clinical studies have illustrated that inflammatory molecular events collaboratively contribute to neuronal and glial cell survival, edema formation and regression, and vascular integrity. In the present review, we examine recent discoveries regarding miRNAs and their roles in post-ischemic stroke neuropathogenesis.

Age and Acute Ischemic Stroke Outcome in North American Patients With COVID-19.

Background Acute ischemic stroke (AIS) in the context of COVID-19 has received considerable attention for its propensity to affect patients of all ages. We aimed to evaluate the effect of age on functional outcome and mortality following an acute ischemic event. Methods and Results A prospectively maintained database from comprehensive stroke centers in Canada and the United States was analyzed for patients with AIS from March 14 to September 30, 2020 who tested positive for SARS-CoV-2. The primary outcome was Modified Rankin Scale score at discharge, and the secondary outcome was mortality. Baseline characteristics, laboratory values, imaging, and thrombectomy workflow process times were assessed. Among all 126 patients with COVID-19 who were diagnosed with AIS, the median age was 63 years (range, 27-94). There were 35 (27.8%) patients with AIS in the aged ≤55 years group, 47 (37.3%) in the aged 56 to 70 group, and 44 (34.9%) in the aged >70 group. Intravenous tissue plasminogen activator and thrombectomy rates were comparable across these groups, (P=0.331 and 0.212, respectively). There was a significantly lower rate of mortality between each group favoring younger age (21.9% versus 45.0% versus 48.8%, P=0.047). After multivariable adjustment for possible confounders, a 1-year increase in age was significantly associated with fewer instances of a favorable outcome of Modified Rankin Scale 0 to 2 (odds ratio [OR], 0.95; 95 CI%, 0.90-0.99; P=0.048) and higher mortality (OR, 1.06; 95 CI%, 1.02-1.10; P=0.007). Conclusions AIS in the context of COVID-19 affects young patients at much greater rates than pre-pandemic controls. Nevertheless, instances of poor functional outcome and mortality are closely tied to increasing age.

Unfractionated Heparin in SARS-CoV-2 Pneumonia: Ischemic Stroke Case Report.

Thromboembolism is a known phenomenon in patients with Coronavirus disease 2019 (COVID-19). Recent investigations have revealed that a significant proportion of those hospitalized with severe COVID-19 demonstrate clinical and laboratory markers compatible with hypercoagulability, which is differentiated from disseminated intravascular coagulation (DIC), termed COVID-associated coagulopathy. Additionally, there is increasing concern for development of acute ischemic stroke because of this hypercoagulable state. We present a patient with COVID-19 pneumonia who was managed with unfractionated heparin (UFH) infusion and developed a large ischemic infarct shortly after cessation of the infusion. In retrospect, the patient's coagulation parameters were consistent with overt DIC, although some of these parameters are easily masked by the effects of UFH. These findings emphasize the importance of anticoagulation as well as its careful discontinuation, as failure to do so may result in a significant thromboembolic event.

Transforaminal lumbar puncture for intrathecal access: Case series with literature review and comparison to other techniques.

Fluoroscopic-guided lumbar puncture (LP) is a procedure commonly performed by radiologists, which in some circumstances may be difficult or impossible using a traditional posterior interspinous or interlaminar approach. Alternatives to LP include cervical and cisternal punctures, placement of an Ommaya reservoir, and lumbar laminectomy. More recently, however, there has been a move toward access of the thecal sac through a transforaminal approach in patients with challenging anatomy. This report outlines our approach and experience using transforaminal LP (TFLP) in patients with spinal muscular atrophy (SMA) with a 100% success rate. We discuss its utility in other patients with difficult access and compare TFLP with other techniques to access the intrathecal space.

Thyroid acropachy: A rare skeletal manifestation of autoimmune thyroid disease.

Thyroid acropachy is a rare complication of autoimmune thyroid disease with characteristic imaging findings. Clinically, it presents as nail clubbing, swelling of digits and toes, almost always in association with thyroid ophthalmopathy and dermopathy. On radiographs, it manifests as prominent irregular and spiculated periosteal new bone formation in the hands and feet. We present a 52-year-old man with history of Graves' disease who presented with swelling of the hands and feet. Radiographs of the hands and feet revealed marked diffuse soft tissue edema and characteristic periosteal new bone formation most consistent with thyroid acropachy.

Spontaneous intracranial hypotension in a patient with systemic lupus erythematosus.

Spontaneous intracranial hypotension (SIH) associated with cerebrospinal fluid leak classically presents with postural headache. It is most commonly caused by the spontaneous dehiscence of a meningeal diverticulum or as a consequence of dural tears. The association between connective tissue disease and SIH is well known. However, the occurrence of SIH associated with systemic lupus erythematosus has rarely been reported. We present a 53 years old female with a history of systemic lupus erythematosus who was diagnosed with SIH. The patient was worked up with Magnetic resonance imaging and Computed tomographic myelography, and successfully treated with a nontargeted epidural blood patch. Furthermore, we review the current literature and focus on the various imaging techniques that can be used in the workup of a cerebrospinal fluid leak.

The role of Akt (protein kinase B) and protein kinase C in ischemia-reperfusion injury.

Stroke is a leading cause of long-term disability and death in the United States. Currently, tissue plasminogen activator (tPA), is the only Food and Drug Administration-approved treatment for acute ischemic stroke. However, the use of tPA is restricted to a small subset of acute stroke patients due to its limited 3-h therapeutic time window. Given the limited therapeutic options at present and the multi-factorial progression of ischemic stroke, emphasis has been placed on the discovery and use of combination therapies aimed at various molecular targets contributing to ischemic cell death. Protein kinase C (PKC) and Akt (protein kinase B) are serine/threonine kinases that play a critical role in mediating ischemic-reperfusion injury and cellular growth and survival, respectively. The present review will examine the role of PKC and Akt in the cellular response to ischemic-reperfusion injury.