In patients who had a stroke or TIA, enlarged perivascular spaces in basal ganglia may cause future haemorrhagic strokes.

INTRODUCTION: It remains unclear whether enlarged perivascular spaces (EPVS) predict poor clinical outcomes in patients with acute ischaemic stroke (AIS) or transient ischaemic attack (TIA). METHOD: Data were obtained from the Third China National Stroke Registry study. We estimated EPVS in basal ganglia (BG) and centrum semiovale (CSO) using a semiquantified scale (Grade from 0 to 4). Using Cox and logistic regression analyses, the associations of EPVS with 3-month and 1-year adverse outcomes (including recurrent stroke, ischaemic stroke, haemorrhagic stroke, combined vascular event, disability and mortality) were explored. Sensitivity analyses of any association of cerebral small vessel disease at baseline and development of a small arterial occlusion (SAO) were conducted. RESULT: Among 12 603 patients with AIS/TIA, median age was 61.7±11.6 years, and 68.2% were men. After adjusting for all potential confounders, frequent-to-severe BG-EPVS was associated with a decreased risk of recurrent ischaemic stroke (HR 0.71, 95% CI 0.55 to 0.92, p=0.01) but an increased risk of haemorrhagic stroke (HR 1.99, 95% CI 1.11 to 3.58, p=0.02) at 1 year after AIS/TIA, compared with none-to-mild BG-EPVS. Patients with frequent-to-severe CSO-EPVS had a decreased risk of disability (OR 0.76, 95% CI 0.62 to 0.92, p=0.004) and all-cause death (HR 0.55, 95% CI 0.31 to 0.98, p=0.04) within 3-month but not 1-year follow-ups, compared with those with none-to-mild BG-EPVS. Sensitivity analyses showed that both BG-EPVS (HR 0.43, 95% CI 0.21 to 0.87, p=0.02) and CSO-EPVS (HR 0.58, 95% CI 0.35 to 0.95, p=0.03) were associated with a decreased risk of subsequent ischaemic stroke in patients with SAO during 1-year follow-up. CONCLUSION: BG-EPVS increased the risk of haemorrhagic stroke in patients already with AIS/TIA within 1 year. Therefore, caution is recommended when selecting antithrombotic agents for secondary stroke prevention in patients with AIS/TIA and more severe BG-EPVS.

Machine learning based reanalysis of clinical scores for distinguishing between ischemic and hemorrhagic stroke in low resource setting.

BACKGROUND: Identifying ischemic or hemorrhagic strokes clinically may help in situations where neuroimaging is unavailable to provide primary-care prior to referring to stroke-ready facility. Stroke classification-based solely on clinical scores faces two unresolved issues. One pertains to overestimation of score performance, while other is biased performance due to class-imbalance inherent in stroke datasets. After correcting the issues using Machine Learning theory, we quantitatively compared existing scores to study the capabilities of clinical attributes for stroke classification. METHODS: We systematically searched PubMed, ERIC, ScienceDirect, and IEEE-Xplore from 2001 to 2021 for studies that validated the Siriraj, Guys Hospital/Allen, Greek, and Besson scores for stroke classification. From included studies we extracted the reported cross-tabulation to identify and correct the above listed issues for an accurate comparative analysis of the performance of clinical scores. RESULTS: A total of 21 studies were included. Comparative analysis demonstrates Siriraj Score outperforms others. For Siriraj Score the reported sensitivity range (Ischemic Stroke-diagnosis) 43-97% (Median = 78% [IQR 65-88%]) is significantly higher than our calculated range 40-90% (Median = 70% [IQR 57-73%]), also the reported sensitivity range (Hemorrhagic Stroke-diagnosis) 50-95% (Median = 71% [IQR 64-82%]) is higher than our calculated range 34-86% (Median = 59% [IQR 50-79%]) which indicates overestimation of performance by the included studies. Guys Hospital/Allen and Greek Scores show similar trends. Recommended weighted-accuracy metric provides better estimate of the performance. CONCLUSION: We demonstrate that clinical attributes have a potential for stroke classification, however the performance of all scores varies across demographics, indicating the need to fine-tune scores for different demographics. To improve this variability, we suggest creating global data pool with statistically significant attributes. Machine Learning classifiers trained over such dataset may perform better and generalise at scale.

Microvascular rarefaction in patients with cerebrovascular events.

Capillary density rarefaction and endothelial dysfunction contribute to chronic hypoperfusion and cerebral small vessel disease. Previous animal experiments revealed spatiotemporal microvascular remodeling directing post-stroke brain reorganization. We hypothesized that microcirculatory changes during acute cerebrovascular events could be reflected systemically and visualized sublingually. In a prospective observational trial in vivo sublingual sidestream darkfield videomicroscopy was performed in twenty-one patients with either acute stroke (n = 13 ischemic, n = 1 ischemic with hemorrhagic transformation and n = 2 hemorrhagic stroke) or transitory ischemic attacks (n = 5) within 24 h after hospital admission and compared to an age- and sex-matched control group. Repetitive measurements were performed on the third day and after one week. Functional and perfused total capillary density was rarefied in the overall patient group (3060 vs 3717 µm/mm2, p = 0.001 and 5263 vs 6550 µm/mm2, p = 0.002, respectively) and in patients with ischemic strokes (2897 vs. 3717 µm/mm2, p < 0.001 and 5263 vs. 6550 µm/mm2, p = 0.006, respectively) when compared to healthy controls. The perfused boundary region (PBR), which was measured as an inverse indicator of glycocalyx thickness, was markedly related to red blood cell (RBC) filling percentage (regarded as an estimate of microvessel perfusion) in the overall patient group (r = -0.843, p < 0.001), in patients with ischemic strokes (r = -0.82, p = 0.001) as well as in healthy volunteers (r = -0.845, p < 0.001). In addition, there were significant associations between platelet count or platelet aggregation values (as measured by whole blood impedance aggregometry) and microvascular parameters in the overall patient collective, as well as in patients with ischemic strokes. In conclusion, cerebrovascular events are associated with altered systemic microvascular perfusion.

A stroke detection and discrimination framework using broadband microwave scattering on stochastic models with deep learning.

Stroke poses an immense public health burden and remains among the primary causes of death and disability worldwide. Emergent therapy is often precluded by late or indeterminate times of onset before initial clinical presentation. Rapid, mobile, safe and low-cost stroke detection technology remains a deeply unmet clinical need. Past studies have explored the use of microwave and other small form-factor strategies for rapid stroke detection; however, widespread clinical adoption remains unrealized. Here, we investigated the use of microwave scattering perturbations from ultra wide-band antenna arrays to learn dielectric signatures of disease. Two deep neural networks (DNNs) were used for: (1) stroke detection ("classification network"), and (2) characterization of the hemorrhage location and size ("discrimination network"). Dielectric signatures were learned on a simulated cohort of 666 hemorrhagic stroke and control subjects using 2D stochastic head models. The classification network yielded a stratified K-fold stroke detection accuracy > 94% with an AUC of 0.996, while the discrimination network resulted in a mean squared error of < 0.004 cm and < 0.02 cm, for the stroke localization and size estimation, respectively. We report a novel approach to intelligent diagnostics using microwave wide-band scattering information thus circumventing conventional image-formation.

Hemorrhagic stroke associated to COVID-19 infection in Mexico General Hospital.

INTRODUCCIÓN: en la actual pandemia de COVID-19, existe evidencia creciente que ha identificado el neurotropismo del virus SARS-CoV-2 y sus complicaciones neurológicas, incluida la enfermedad cerebrovascular isquémica y escasamente hemorragia cerebral (HC). OBJETIVO: describir las características clínicas, radiológicas, de laboratorio y pronósticas de los pacientes con HC asociada al SARS-CoV-2. MÉTODOS: se incluyeron pacientes consecutivos con prueba de PCR confirmatoria para infección por SARS-CoV-2 y HC. RESULTADOS: en un período de 90 días, en un centro de referencia COVID-19 en México, de 1108 pacientes con infección por SARS-CoV-2, se encontraron 4 pacientes (0.36%) con HC. Tenían una edad de 71(±12.2) años, 2 eran mujeres. Se encontró que dos tenían factores de riesgo cardiovascular previos. En dos casos se encontró el origen en el núcleo dentado mientras que los otros dos correspondieron al tálamo. Tres de los cuatro pacientes murieron. Postulamos que el descontrol hipertensivo, coagulopatía, trombocitopenia y la respuesta inmune inducida por el virus SARS-CoV-2 podrían desencadenar HC en un paciente con riesgo previo. CONCLUSIONES: la HC se asocia a la infección por SARS-CoV-2 con mal pronóstico cuando se presenta. Los equipos de neurocirugía deben estar preparados para el tratamiento oportuno de estos pacientes. INTRODUCTION: In the current COVID-19 pandemic, there is a growing body of evidence that has identified the neurotropism of the SARS-CoV-2 virus and its neurological complications, including cerebrovascular disease, focusing mainly in ischemic and scarcely about hemorrhagic stroke (HS). OBJECTIVE: The objective of the study was to describe clinical, radiological, laboratory tests, and prognostic characteristics of patients with SARS-CoV-2 associated HS. METHODS: Consecutive patients with a confirmatory PCR test for SARS-CoV-2 infection and a HS demonstrated by head CT were included in the study. RESULTS: Over a period of 90 days, in a COVID-19 reference center in Mexico, out of a total of 1108 patients with SARS-CoV-2 infection, it found 4 patients (0.36%) who meet criteria. They had an age of 71 (±12.2) years, 2 were women. It was found that two had prior cardiovascular risk factors. Two of the HS originated in the dentate nucleus while the other two corresponded to the thalamus. Three of the four patients died. We suggest that catastrophic uncontrolled blood pressure, coagulopathy, thrombocytopenia, and immune response induced by SARS-CoV-2 could in a specific patient trigger HS. CONCLUSIONS: HS is associated to SARS-CoV-2 infection with poor prognosis when it presented. Neurosurgery teams should prepare for the timely and appropriate treatment of this patients.

Crossed Choreoathetosis Caused by Unilateral Thalamic Hemorrhage.

In general, involuntary movements after stroke are due to a disturbance in the unilateral cortico-basal ganglia loop and appear contralateral to stroke lesions. Crossed involuntary movements after unilateral stroke are very rare. We observed a case of crossed involuntary movements in the left upper limb and right lower limb after a right thalamic hemorrhage expanded to the right subthalamic nucleus. We considered a possible three-step theory as the basis of crossed choreoathetosis. This case informs our better understanding of the cortico-basal ganglia loop and involuntary movements after stroke.

A Novel Afrocentric Stroke Risk Assessment Score: Models from the Siren Study.

BACKGROUND: Stroke risk can be quantified using risk factors whose effect sizes vary by geography and race. No stroke risk assessment tool exists to estimate aggregate stroke risk for indigenous African. OBJECTIVES: To develop Afrocentric risk-scoring models for stroke occurrence. MATERIALS AND METHODS: We evaluated 3533 radiologically confirmed West African stroke cases paired 1:1 with age-, and sex-matched stroke-free controls in the SIREN study. The 7,066 subjects were randomly split into a training and testing set at the ratio of 85:15. Conditional logistic regression models were constructed by including 17 putative factors linked to stroke occurrence using the training set. Significant risk factors were assigned constant and standardized statistical weights based on regression coefficients (ß) to develop an additive risk scoring system on a scale of 0-100%. Using the testing set, Receiver Operating Characteristics (ROC) curves were constructed to obtain a total score to serve as cut-off to discriminate between cases and controls. We calculated sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) at this cut-off. RESULTS: For stroke occurrence, we identified 15 traditional vascular factors. Cohen's kappa for validity was maximal at a total risk score of 56% using both statistical weighting approaches to risk quantification and in both datasets. The risk score had a predictive accuracy of 76% (95%CI: 74-79%), sensitivity of 80.3%, specificity of 63.0%, PPV of 68.5% and NPV of 76.2% in the test dataset. For ischemic strokes, 12 risk factors had predictive accuracy of 78% (95%CI: 74-81%). For hemorrhagic strokes, 7 factors had a predictive accuracy of 79% (95%CI: 73-84%). CONCLUSIONS: The SIREN models quantify aggregate stroke risk in indigenous West Africans with good accuracy. Prospective studies are needed to validate this instrument for stroke prevention.

Maternal near-miss attributable to haemorrhagic stroke in patients with hypertensive disorders of pregnancy in Japan: A national cohort study.

OBJECTIVES: To investigate the epidemiologic and clinical characteristics of maternal near-misses attributable to haemorrhagic stroke (HS) occurring in patients with hypertensive disorders of pregnancy (HDP), with a focus on severe neurological morbidity. METHODS: A national retrospective cohort study was conducted using the national database of health insurance claims for the period 2010 to 2017. The subjects were all insured women with a diagnosis of both HDP and HS. Severe neurological morbidity requiring rehabilitation, types of HDP, types of HS, and magnesium sulphate use were tabulated. RESULTS: The number of women with HDP who were diagnosed with HS was 3.4 per 100,000 deliveries between 2010 and 2017. Forty percent of HDP-related HS cases had neurological morbidities requiring rehabilitation (1.4 per 100,000 deliveries), and 4.4% were in a persistent vegetative state after HS. Of the HDP cases who developed HS, 69.2% were severe HDP, of which 55.6% were without eclampsia. The most common type of HS was intracerebral haemorrhage (2.5 per 100,000 deliveries), followed by subarachnoid haemorrhage due to cerebral aneurysm (1.2 per 100,000 deliveries). The frequency of magnesium sulphate use increased in all patients with HDP-related HS in the second half of the study period (2014-2017) compared with the first half (2010-2013) (p < 0.0001). This was more evident in cases of HDP-related HS with eclampsia (31.9% to 83.8%) compared to those without eclampsia (25.0% to 42.9%). CONCLUSION: Of the maternal near-miss cases due to HDP-related HS, 40.0% were rehabilitated and 69.2% were HDP without either eclampsia or severe hypertension.

Relationship Between Motor Function, DTI, and Neurophysiological Parameters in Patients with Stroke in the Recovery Rehabilitation unit.

OBJECTIVES: We investigated the relationship between pyramidal tract evaluation indexes (i.e., diffusion tensor imaging, transcranial magnetic stimulation (TMS)-induced motor-evoked potential (MEP), and central motor conduction time (CMCT) on admission to the recovery rehabilitation unit) and motor functions at discharge in patients with ischemic or hemorrhagic stroke. MATERIALS AND METHODS: Seventeen patients were recruited (12 men; 57.9 ± 10.3 years). The mean fractional anisotropy (FA) values of the right and left posterior limbs of the internal capsule were estimated using a computer-automated method. We determined the ratios of FA values in the affected and unaffected hemispheres (rFA), TMS-induced MEP, and the ratios of CMCT in the affected and unaffected hemispheres (rCMCT) and examined their association with motor functions (Fugl-Meyer Assessment (FMA) and Action Research Arm Test (ARAT)) at discharge. RESULTS: Higher rFA values of the posterior limb of the internal capsule on admission to the recovery rehabilitation unit led to a better recovery of upper limb function (FMA: r = 0.78, p < 0.001; ARAT: r = 0.74, p = 0.001). Patients without MEP had poorer recovery of upper limb function than those with MEP (FMA: p < 0.001; ARAT: p = 0.001). The higher the rCMCT, the poorer the recovery of upper limb function (ARAT: r = -0.93, p < 0.001). However, no association was observed between the pyramidal tract evaluation indexes and recovery of lower limb motor function. CONCLUSIONS: Evaluating the pyramidal tract is useful for predicting upper limb function prognosis, but not for lower limb function prognosis.

A Cost Utility Analysis of Minimally Invasive Surgery with Thrombolysis Compared to Standard Medical Treatment in Spontaneous Intracerebral Haemorrhagic Stroke.

OBJECTIVES: Standard medical management of spontaneous intracerebral haemorrhage (ICH) and surgical hematoma evacuation starkly differ, and whilst landmark randomised control trials report no clinical benefit of early surgical evacuation compared with medical treatment in supratentorial ICH, minimally invasive surgery (MIS) with thrombolysis has been neglected within these studies. However, recent technological advancements in MIS have renewed interest in the surgical treatment of ICH. Several economic evaluations have focused on the benefits of MIS in ischaemic stroke management, but no economic evaluations have yet been performed comparing MIS to standard medical treatment for ICH. MATERIALS AND METHOD: All costs were sourced from the UK in GBP. Where possible, the 2019/2020 NHS reference costs were used. The MISTIE III study was used to analyse the outcomes of patients undergoing either MIS or standard medical treatment in this economic evaluation. RESULTS: The incremental cost-effectiveness ratio (ICER) for MIS was £485,240.26 for every quality-adjusted life year (QALY) gained. Although MIS resulted in a higher QALY compared to medical treatment, the gain was insignificant at 0.011 QALY. Four sensitivity analyses based on combinations of alternative EQ-5D values and categorisation of MIS outcomes, alongside alterations to the cost of significant adverse events, were performed to check the robustness of the ICER calculation. The most realistic sensitivity analysis showed a potential increase in cost effectiveness when clot size is reduced to <15ml, with the ICER falling to £74,335.57. DISCUSSION: From the perspective of the NHS, MIS with thrombolysis is not cost-effective compared to optimal medical treatment. ICER shows that intention-to-treat MIS would require a cost of £485,240.26 to gain one extra QALY, which is significantly above the NHS threshold of £30,000. Further UK studies with ICH survivor utilities, more replicable surgical technique, and the reporting of clot size reduction are indicated as the present sensitivity analysis suggests that MIS is promising. Greater detail about outcomes and complications would ensure improved cost-benefit analyses and support valid and efficient allocation of resources by the NHS.

Hemorrhagic stroke treated by transcranial neuroendoscopic approach.

Hemorrhagic stroke (HS) is usually treated under microscopy, but recently, an increasing number of cases have been treated under neuroendoscopy. The objective of this study was to explore the feasibility and efficacy of a transcranial neuroendoscopic approach for HS. Based on etiology and clinical features, 203 HS patients were classified into two groups, with 100 patients in the primary HS (PHS) group and 103 patients in the secondary HS (SHS) group. All patients were treated either by full neuroendoscopy (FNE) or by neuroendoscopy combined with microsurgery (ECM). Outcomes were assessed according to the Glasgow Coma Scale (GCS) at discharge, and the rate of good plus excellent results was recorded as the GE rate to assess the treatment effect. All 203 patients underwent surgery successfully, with 165 patients who underwent FNE and 38 patients who underwent ECM. No patients died within 3 days after surgery, and the surgery-related mortality rate was 0%, but a total of 4 patients died by discharge, and the overall mortality rate was 1.97%. A total of 133 patients showed an excellent result and 16 showed a good result, for a total GE rate of 73%. Neuroendoscopy can provide excellent illumination, clear visualization, and multiangle views in HS. The transcranial neuroendoscopic approach is feasible and safe for both PHS and SHS and is very effective for hematoma evacuation. However, some aneurysms and most arteriovenous malformations and arteriovenous fistulas require ECM.

Mutation analysis of the GLA gene in Chinese patients with intracerebral hemorrhage.

Fabry disease (FD) is an important underlying condition in young cryptogenic stroke patients and has also been implicated in cerebral small vessel disease. However, the contributions of causative GLA mutations in patients with intracerebral hemorrhage (ICH) remain unclear. In this study, GLA sequences were analyzed in a Chinese ICH cohort comprising 373 patients with computed tomography-confirmed ICH and 563 in-house controls and East Asians from public databases. Only one previously reported mutation, p. Ala15Val, responsible for Fabry disease was identified in a female patient with nonlobar ICH. Therefore, this definitive GLA mutation accounted for 0.27% (1/373) of Chinese patients with ICH. Another functional variant, rs2071225 (c.-10C>T), was present at minor allele frequency (MAF) of 9.1%, indicating no association with ICH, despite a trend of an association for male patients with lobar ICH. In conclusion, our results indicate that the GLA mutation is an uncommon genetic etiology of ICH in China.

An fMRI, DTI and Neurophysiological Examination of Atypical Organization of Motor Cortex in Ipsilesional Hemisphere Following Post-Stroke Recovery.

OBJECTIVES: We report a 61-year-old woman who developed left hemiparesis following a right frontal stroke. She underwent rehabilitation and regained function of the left side of her body. Three years after her first stroke, she developed a large left subdural hematoma and again presented with left hemiparesis. MATERIALS AND METHODS: Prior to the cranioplasty, an fMRI scan involving left and right hand movement, arm movement, and foot peddling were conducted in order to determine whether the patient showed ipsilateral activation for the motor tasks, thus explaining the left hemiparesis following the left subdural hematoma. Diffusion tensor imaging (DTI) tractography was also collected to visualize the motor and sensory tracts. RESULTS: The fMRI results revealed activation in the expected contralateral left primary motor cortex (M1) for the right-sided motor tasks, and bilateral M1 activation for the left-sided motor tasks. Intraoperative neurophysiology confirmed these findings, whereby electromyography revealed left-sided (i.e., ipsilateral) responses for four of the five electrode locations. The DTI results indicated that the corticospinal tracts and spinothalamic tracts were within normal limits and showed no displacement or disorganization. CONCLUSIONS: These results suggest that there may have been reorganization of the M1 following her initial stroke, and that the left hemisphere may have become involved in moving the left side of the body thereby leading to left hemiparesis following the left subdural hematoma. The findings suggest that cortical reorganization may occur in stroke patients recovering from hemiparesis, and specifically, that components of motor processing subserved by M1 may be taken over by ipsilateral regions.

Prediction of the motor prognosis with diffusion tensor imaging in hemorrhagic stroke: a meta-analysis.

This paper investigates whether diffusion tensor imaging performed within 2 weeks of intracerebral hemorrhage onset could predict the motor outcome by categorizing previous diffusion tensor imaging studies based on the time-point of performing diffusion tensor imaging (<2 weeks and ≥2 weeks after intracerebral hemorrhage onset). A comprehensive database search on PubMed, Embase, Cochrane Library, and SCOPUS was conducted. The pooled estimate was acquired using correlation analysis between the diffusion tensor imaging parameters of fractional anisotropy and motor recovery based on the period of stroke onset. In the results, out of 511 retrieved articles, eight were finally included in the meta-analysis. In patients who underwent diffusion tensor imaging within 2 weeks of intracerebral hemorrhage onset, a random-effects model revealed that the ratio of fractional anisotropy is a significant predictor of motor recovery of the hemi-side extremity after intracerebral hemorrhage (p = 0.0015). In patients who underwent diffusion tensor imaging after 2 weeks of intracerebral hemorrhage onset, a fixed-effects model revealed that the ratio of fractional anisotropy was also a significant predictor of motor recovery of the hemi-side extremity after intracerebral hemorrhage (p < 0.0001). Our meta-analysis revealed that ratio of fractional anisotropy (rFa) calculated from diffusion tensor imaging (DTI) performed ≥2 weeks of intracerebral hemorrhage onset had a positive correlation with the motor outcomes after intracerebral hemorrhage (ICH). Also, although diffusion tensor imaging was performed <2 weeks after intracerebral hemorrhage onset, the ratio of fractional anisotropy calculated from diffusion tensor imaging helped predict the motor outcome. Further analyses, including a more significant number of studies focused on this topic, are warranted.

Intracerebral Nontraumatic Hemorrhagic Stroke in Children: Case Series and Literature Review.

Pediatric stroke is an event caused by disturbance of cerebral circulation that occurs in individuals between 28 days and 18 years of age. Although an uncommon event, pediatric stroke still carries significant morbidity and mortality. Unlike adults, causes of pediatric stroke are various and include vascular, infectious, hematologic, neoplastic, and toxic etiologies. Clinical presentation of nontraumatic intracerebral hemorrhages in older children is similar to adults, however in neonates and infants signs and symptoms can be more subtle, especially with smaller hemorrhages. Management of nontraumatic intracerebral hemorrhage consists of stabilizing the patient, management of the hemorrhage itself, and reduction of the rebleeding risk. Even so, when child reaches a medical care, morbidity and mortality rates are still high. We described a case series of pediatric patients with intracerebral nontraumatic hemorrhagic stroke from different etiologies. Although increasingly recognized, such situations are still poorly described in children and our report offers a good overview on this topic.

Differentiation Between Ischemic and Hemorrhagic Strokes - A Pilot Study with Transtemporal Investigation of Brain Parenchyma Elasticity Using Ultrasound Shear Wave Elastography.

INTRODUCTION: Ultrasound shear wave elastography is well established in diagnostics of several parenchymatous organs and is recommended by respective guidelines. So far, research about applications in relevant neurological conditions is missing, especially in adults. Here we aimed to examine the method for the differentiation of ischemic (IS) and hemorrhagic strokes (HS) and cerebral mass effects. MATERIALS & METHODS: 50 patients with a confirmed diagnosis of HS or IS were enrolled in this prospective study. 2D shear wave elastography was performed on the ipsilateral and the contralateral side with a modified acoustic radiation force impulse (ARFI) technique (ElastPQ mode, Philips). Lesion volumetry was conducted based on computed tomography data for correlation with elastography results. RESULTS: Elastography measurements (EM) revealed a highly significant difference between IS and HS with mean values of 1.94 and 5.50 kPa, respectively (p < 0.00 001). Mean values of brain tissue on the non-affected side were almost identical (IS 3.38 (SD = 0.63); HS 3.35 (SD = 0.66); p = 0.91). With a sensitivity of 0.98 and a specificity of 0.99, a cut-off value of 3.52 kPa for discrimination could be calculated. There was a significant correlation of mass effect represented by midline shift and EM values on the contralateral side (Pearson correlation coefficient = 0.68, p < 0.0003). CONCLUSION: Ultrasound brain parenchyma elastography seems to be a reliable sonographic method for discriminating between large IS and HS and for detecting and tracking conditions of intracerebral mass effects.

Association between Computed Tomographic Biomarkers of Cerebral Small Vessel Diseases and Long-Term Outcome after Spontaneous Intracerebral Hemorrhage.

OBJECTIVE: A study was undertaken to assess whether cerebral small vessel disease (SVD) computed tomographic (CT) biomarkers are associated with long-term outcome after intracerebral hemorrhage. METHODS: We performed a prospective, community-based cohort study of adults diagnosed with spontaneous intracerebral hemorrhage between June 1, 2010 and May 31, 2013. A neuroradiologist rated the diagnostic brain CT for acute intracerebral hemorrhage features and SVD biomarkers. We used severity of white matter lucencies and cerebral atrophy, and the number of lacunes to calculate the CT SVD score. We assessed the association between CT SVD biomarkers and either death, or death or dependence (modified Rankin Scale scores = 4-6) 1 year after first-ever intracerebral hemorrhage using logistic regression, adjusting for known predictors of outcome. RESULTS: Within 1 year of intracerebral hemorrhage, 224 (56%) of 402 patients died. In separate models, 1-year death was associated with severe atrophy (adjusted odds ratio [aOR] = 2.54, 95% confidence interval [CI] = 1.44-4.49, p = 0.001) but not lacunes or severe white matter lucencies, and CT SVD sum score ≥ 1 (aOR = 2.50, 95% CI = 1.40-4.45, p = 0.002). Two hundred seventy-seven (73%) of 378 patients with modified Rankin Scale data were dead or dependent at 1 year. In separate models, 1-year death or dependence was associated with severe atrophy (aOR = 3.67, 95% CI = 1.71-7.89, p = 0.001) and severe white matter lucencies (aOR = 2.18, 95% CI = 1.06-4.51, p = 0.035) but not lacunes, and CT SVD sum score ≥ 1 (aOR = 2.81, 95% CI = 1.45-5.46, p = 0.002). INTERPRETATION: SVD biomarkers on the diagnostic brain CT are associated with 1-year death and dependence after intracerebral hemorrhage, independent of known predictors of outcome. ANN NEUROL 2021;89:266-279.

Acute Ischemic Hemorrhagic Stroke in Two COVID-19 Patients.

Coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). First identified in December 2019, in Wuhan, China, it has since become a global pandemic. Complications of COVID-19 are not limited to the pulmonary system, but also include neurologic manifestations such as stroke. We report two cases of coincidental presentation of COVID-19 and cerebrovascular accident. Further studies are needed for a comprehensive understanding of the neurological pathology of COVID-19 and its effects on the nervous system, but stroke teams should be wary of the fact that COVID-19 patients may present with cerebrovascular accidents.