Peripheral Lymphocyte-to-Monocyte Ratio as a Predictive Factor for Early Neurological Deterioration in Patients with Acute Ischemic Stroke.

Purpose: Previous studies have reported that lymphocyte-to-monocyte ratio (LMR) is associated with the prognosis of patients with acute ischemic stroke (AIS); however, the relationship between LMR and early neurological deterioration (END) in AIS patients has not been elucidated. Patients and Methods: Patients were divided into two groups according to LMR by using receiver operating characteristic (ROC) curve analysis. Patients with END were confirmed as the National Institutes of Health Stroke Scale (NIHSS) increased ≥ 4 points between hospital days 0 and 5. Multivariate logistic regression analysis was used to analyze the factors independently related to END in patients with AIS. Results: In total, 202 patients diagnosed with AIS were enrolled in this retrospective study. Using ROC curve analysis, patients were divided into two groups according to LMR: low LMR group (LMR < 3.24, n = 95) and high LMR group (LMR ≥ 3.24, n = 107). The frequencies of END were significantly higher in the low LMR group compared to the high LMR group (41.05 vs.15.89%, p < 0.001). Multivariate logistic regression showed that age (OR = 1.03, 95% CI 1.01-1.06, p = 0.04), infarct volume (OR = 1.01, 95% CI 1.00-1.02, p = 0.001), neutrophil count (OR = 1.17, 95% CI 1.03-1.33, p = 0.018), and LMR (OR = 2.49, 95% CI 1.01-9.11, p = 0.018) were independently associated with END in AIS patients. Conclusion: A peripheral LMR levels at admission were significantly associated with END and LMR < 3.24 is an independent predictive factor of END in patients with AIS.

The Radio of RDW/ALB: A Cost-Effective Biomarker for Early-Stage Risk Stratification in Acute Ischemic Stroke.

Background and Aims: The red blood cell distribution width (RDW) to albumin (ALB) ratio (RAR) has been identified as a prognostic indicator for mortality in critically ill patients across various diseases. Nevertheless, the impact of RAR on clinical functional prognosis in Acute ischemic stroke (AIS) remains uncertain. This study aimed to evaluate the prognostic significance of RAR in AIS patients. Methods: A secondary analysis was performed on a cohort study, involving 1906 AIS patients recruited from a South Korean academic hospital. Both univariate and multivariate logistic regression was employed to assess the connections between RAR and negative functional results in AIS. To explore potential non-linear relationships in this association, a generalized additive model (GAM) and smooth curve fitting were utilized. Further, a mediation analysis was performed to identify possible mediators. Results: Out of the 1906 eligible patients, 546 (28.65%) were found to have an unfavorable prognosis. Patients with elevated RAR had a higher likelihood of facing a negative prognosis in AIS (all P<0.001). RAR demonstrated a dose-response relationship with the probability of poor functional prognosis. When analysis of RAR as a continuous variable, an increase in RAR was correlated with a higher risk of adverse prognosis.When RAR was analyzed as quartile variables, the highest RAR remained an independent contributing factor for both 3-month unfavorable outcomes (adjusted OR, 1.4; 95% CI: 1.0-2.1, P=0.046) and 3-month mortality (adjusted OR, 5.2; 95% CI, 2.0-13.9; p<0.001). More interestingly, the presence of a pro-inflammatory state may serve as a mediator in the connections between RAR and adverse functional outcomes. Conclusion: Given its cost-effectiveness and ease of measurement, baseline RAR holds promise as a valuable biomarker for early risk assessment in AIS patients.

Fluoxetine promotes the recovery of dysphagia and improves nutritional status and neurotrophic status in dysphagia patients after acute ischemic stroke.

This study aimed to investigate the effects of fluoxetine on swallowing function, neurotrophic factors, and psychological status in patients with dysphagia after acute ischemic stroke (AIS). A total of 118 patients with dysphagia after AIS who were diagnosed and treated in our hospital from July 2020 to March 2022 were selected as the study objects with 59 cases in each group. Patients in the control group underwent routine treatment and swallowing rehabilitation without fluoxetine. Patients in the study group received routine treatment, swallowing rehabilitation, and fluoxetine treatment. The quality of life was compared according to the Generic Quality of Life Inventory-74 (CQOLI-74). Patients were followed for 90 days, and the grades were compared with the Modified Rankin Scale (mRS). The total effective rate of the study group was 84.75%, which was higher than that of the control group with 62.71% (χ2 = 7.394, P < 0.05). The life quality scores of the two groups were both dramatically elevated compared to those before the treatment, and the study group had a sensibly higher life quality score than the control group (P < 0.05). The proportion of grade 4~5 in the study group was significantly lower than that in the control group (χ2 = 492, P < 0.05). The total incidence of adverse reactions in the control group was 5.08% (3/59), which was significantly lower than that in the study group with 11.86% (7/59) (χ2 = 1.748, P = 0.186). Fluoxetine has a significant effect on the treatment of dysphagia after AIS by enhancing the recovery of dysphagia and promoting the recovery of neurological function.

Association of Alkaline Phosphatase Level with Futile Recanalization in Acute Ischemic Stroke Patients Treated with Endovascular Thrombectomy.

OBJECTIVE: Nearly half of Acute Ischemic Stroke (AIS) patients failed to achieve favorable outcomes despite successful reperfusion treatment. This phenomenon is referred to as Futile Recanalization (FR). Screening patients at risk of FR is vital for stroke management. Previous studies reported the diagnostic value of alkaline phosphatase (ALP) levels in certain aspects of stroke prognosis. However, the association between serum ALP level and FR among AIS patients treated with thrombectomy remained unclear. METHODS: We screened stroke patients who underwent thrombectomy at our center from January 2017 to June 2021, and those who achieved successful reperfusion (modified Thrombolysis in Cerebral Infarction score=3) were ultimately analyzed. Demographic information, vascular risk factors, and laboratory test results were collected at admission. The 3-month unfavorable outcome was defined as a modified Rankin Scale score of 3 to 6. The effect of ALP levels on FR was investigated with a logistic regression model. RESULTS: Of 788 patients who underwent thrombectomy, 277 achieved successful reperfusion. Among them, 142 patients (51.3%) failed to realize favorable outcomes at 3 months. After adjusting for confounding variables, higher ALP levels (p =0.002) at admission were independently associated with unfavorable outcomes at three months. Adding ALP values to conventional risk factors improved the performance of prediction models for FR. CONCLUSION: The current study found that the serum ALP levels at admission emerged as a potential biomarker for futile reperfusion in stroke patients undergoing thrombectomy. Further studies are warranted to confirm the clinical applicability of ALP level for futile recanalization prediction.

Impact of non-traditional lipid profiles on 1-year vascular outcomes in ischemic stroke patients with prior statin therapy and LDL-C < 100 mg/dL.

This study aimed to investigate the association between non-traditional lipid profiles and the risk of 1-year vascular events in patients who were already using statins before stroke and had admission LDL-C < 100 mg/dL. This study was an analysis of a prospective, multicenter, nationwide registry of consecutive patients with acute ischemic stroke patients who treated with statin before index stroke and LDL-C < 100 mg/dL on admission. Non-traditional lipid profiles including non-HDL, TC/HDL ratio, LDL/HDL ratio, and TG/HDL ratio were analyzed as a continuous or categorical variable. The primary vascular outcome within one year was a composite of recurrent stroke (either hemorrhagic or ischemic), myocardial infarction (MI) and all-cause mortality. Hazard ratios (95% Cis) for 1-year vascular outcomes were analyzed using the Cox PH model for each non-traditional lipid profiles groups. A total of 7028 patients (age 70.3 ± 10.8years, male 59.8%) were finally analyzed for the study. In unadjusted analysis, no significant associations were observed in the quartiles of LDL/HDL ratio and 1-year primary outcome. However, after adjustment of relevant variables, compared with Q1 of the LDL/HDL ratio, Q4 was significantly associated with increasing the risk of 1-year primary outcome (HR 1.48 [1.19-1.83]). For the LDL/HDL ratio, a linear relationship was observed (P for linearity < 0.001). Higher quartiles of the LDL/HDL ratio were significantly and linearly associated with increasing the risk of 1-year primary vascular outcomes. These findings suggest that even during statin therapy with LDL-C < 100 mg/dl on admission, there should be consideration for residual risk based on the LDL/HDL ratio, following stroke.

Effect of teleneurology on door-to-needle times for tenecteplase in acute ischemic stroke.

INTRODUCTION: Intravenous thrombolysis remains the primary treatment for acute ischemic stroke (AIS); however, administration is time sensitive. Teleneurology services have increased in popularity in recent years due to their ability to aid in triaging patients with neurological conditions. Teleneurology services were implemented at this comprehensive stroke center, in August 2023 to aid in streamlining the administration of tenecteplase in AIS patients. Currently, there are no studies assessing whether the implementation of teleneurology services at a comprehensive stroke center influences tenecteplase door-to-needle time. The purpose of this study is to evaluate the difference in door-to-needle times when tenecteplase is administered with versus without a teleneurology consult. METHODS: This was an institutional review board approved, retrospective cohort study conducted at a single comprehensive stroke center. Adult patients who presented to the emergency department between January 1st, 2022 and April 1st, 2023 were included if they received tenecteplase for the treatment of AIS. The primary outcome was door-to-needle time, defined as the moment the patient first enters the door of the emergency department to the moment the IV bolus of fibrinolytic is administered. Secondary outcomes included the proportion of patients with door-to-needle time within 45 min, neurological improvement at 24 h and discharge, and rate of hemorrhagic conversion. RESULTS: A total of 93 patients were included with 43 patients in the pre-teleneurology group and 50 patients in the post-teleneurology group. Baseline characteristics were comparable between both treatment groups. The median door-to-needle time was significantly reduced in the post-teleneurology group (49 minutes [IQR, 40.0-70.0] preintervention vs. 34.5 minutes [IQR, 23.8-43.0] postintervention, p < 0.01). For secondary outcomes, the post-teleneurology group had more patients with a door-to-needle time within 45 minutes (44.2% vs. 80.0%, p < 0.01). There was no significant difference in early neurological improvement (58.1% vs. 54.0%), neurological improvement at discharge (60.5% vs. 62.0%), or hemorrhagic conversion (7.0% vs. 12.0%). CONCLUSION: Among patients who received tenecteplase for the treatment of AIS, there was a significant reduction in door-to-needle time with the use of teleneurology services. There was no difference in neurological improvement or rate of hemorrhagic conversion.

Effect of coastal and island geographic environments on patients with acute ischemic stroke in southeastern China.

OBJECTIVE: To analyze the geographic variation in characteristics and treatment processes of patients with acute ischemic stroke (AIS) in coastal, island, and inland regions. METHODS: We conducted a retrospective, cross-sectional analysis of data from patients with AIS in southeastern China. We collected demographic and clinical information, including the time from stroke onset to treatment for those receiving reperfusion therapy, using a time-tracking table. RESULTS: Among 8069 patients with AIS, 26.6% received reperfusion therapy, with a higher proportion undergoing endovascular therapy in maritime hospitals than in inland hospitals (14.2% vs. 6.7%). Maritime hospitals had a higher prevalence of atrial fibrillation (15.1% vs. 11.9%) and cardioembolism (17.2% vs. 13.6%) than inland hospitals. Patients in maritime hospitals had shorter in-hospital processing times than those in inland hospitals (39 vs. 46 minutes). Island hospitals showed different patterns, with a shorter time from stroke onset to emergency room arrival (80 vs. 120 minutes) but a longer in-hospital process time (51 vs. 36 minutes), than coastline hospitals. CONCLUSIONS: Our study suggests geographic variation in AIS characteristics and treatment processes across southeastern China, emphasizing the need for region-specific strategies. These findings are essential for tailoring public health policies and guidelines to improve stroke outcomes in various regions.

Efficacy and Safety of Intravenous Tenecteplase Versus Alteplase in Treating Acute Ischemic Stroke With Diabetes and Admission Hyperglycemia.

BACKGROUND: The aim of this study was to investigate the efficacy and safety of tenecteplase versus alteplase in patients with acute ischemic stroke, considering their diabetes history and admission hyperglycemia status. METHODS AND RESULTS: This was a post hoc analysis of the TRACE-2 (Tenecteplase Reperfusion Therapy in Acute Ischemic Cerebrovascular Events-2) randomized clinical trial that enrolled patients in China between June 2021 and May 2022. Eligible patients with acute ischemic stroke for standard intravenous thrombolysis, but ineligible for endovascular thrombectomy, were randomly assigned (1:1) to tenecteplase or alteplase within 4.5 hours of symptom onset. Admission hyperglycemia was defined as plasma glucose >7.8 mmol/L. The primary efficacy and safety outcome were excellent functional outcome at 90 days (modified Rankin Scale score of 0-1) and symptomatic intracranial hemorrhage within 36 hours, respectively. The Cochran-Mantel-Haenszel χ2 test was used for the outcomes. Of the 1382 patients included, 369 (26.7%) had a history of diabetes, and 482 (34.9%) experienced admission hyperglycemia. The primary efficacy outcome, comparing tenecteplase to alteplase, was achieved in 93 (56.7%) versus 97 (48.3%) among patients with a history of diabetes (P=0.11) and 335 (64.6%) versus 300 (62.2%) among those without diabetes (P=0.45), respectively. The primary efficacy outcome for tenecteplase versus alteplase was comparable among patients with and without admission hyperglycemia (57.5% versus 53.9%, P = 0.44; 65.4% versus 60.4%, P=0.12, respectively). No significant difference in the risk of symptomatic intracranial hemorrhage within 36 hours was observed between tenecteplase and alteplase, regardless of diabetes history or admission hyperglycemia. CONCLUSIONS: This study demonstrated that intravenous tenecteplase exhibits similar clinical outcomes compared with alteplase, irrespective of the patient's glucose metabolism status. REGISTRATION: URL: https://clinicaltrials.gov; Unique identifier: NCT04797013.

Middle cerebral artery hypodense dot sign in iatrogenic air embolism.

Air embolism is a rare cause of stroke, usually associated with medical procedures, with gastrointestinal endoscopy rarely implicated. Here, we present a case of a patient who experienced cerebral air embolism post-gastroscopy, presenting with aphasia and right hemiparesis due to left M2 occlusion with spontaneous and complete recovery. CT scan revealed a hypodense defect in the left Sylvian fissure, representing a "hypodense dot sign" suggestive of an air embolism. The hypodense MCA sign, previously described in fat embolism cases, could also indicate air embolism, supporting prompt diagnosis and proper intervention.

Stroke: Evolution of newer treatment modalities for acute ischemic stroke.

Acute ischemic stroke is one of the leading causes of morbidity and mortality worldwide. Restoration of cerebral blood flow to affected ischemic areas has been the cornerstone of therapy for patients for eligible patients as early diagnosis and treatment have shown improved outcomes. However, there has been a paradigm shift in the management approach over the last decade, and with the emphasis currently directed toward including newer modalities such as neuroprotection, stem cell treatment, magnetic stimulation, anti-apoptotic drugs, delayed recanalization, and utilization of artificial intelligence for early diagnosis and suggesting algorithm-based management protocols.

Elevated Serum HMGB1 Levels and Their Association with Recurrence of Acute Ischaemic Stroke.

Purpose: The study aimed to investigate the correlation between baseline serum levels of high mobility group box 1 (HMGB1) and the recurrence of acute ischemic stroke (AIS). Patients and Methods: A total of 544 AIS patients were enrolled and followed up monthly. Serum HMGB1 levels were measured using enzyme-linked immunosorbent assay (ELISA). The primary endpoint was the first recurrence of AIS. Results: During a median follow-up period of 43 months, 62 of the 544 AIS patients experienced a recurrence. Both HMGB1 levels and national institute of health stroke scale (NIHSS) scores were significantly higher in the recurrence group compared to the no-recurrence group (p<0.05). According to the receiver operating characteristic curve analysis, the combination (0.855, 95% CI: 0.800-0.911) of HMGB1 (0.745, 95% CI: 0.663-0.826) and NIHSS (0.822, 95% CI: 0.758-0.886) had a higher value for predicting AIS recurrence than either of them (p<0.05). Kaplan-Meier analyses demonstrated that the cumulative survival without AIS recurrence was significantly lower in patients in the high HMGB1 level group than in the low HMGB1 level group (p<0.05). The multifactorial Cox analyses indicated that elevated baseline serum HMGB1 levels (HR: 7.489, 95% CI:4.383-12.795) were a highly effective predictor of recurrence in AIS. Conclusion: Elevated baseline serum HMGB1 levels were found to be a highly effective predictor of recurrence in AIS.

Beyond Conventional Imaging: A Systematic Review and Meta-Analysis Assessing the Impact of Computed Tomography Perfusion on Ischemic Stroke Outcomes in the Late-Window.

BACKGROUND: Non-contrast CT (NCCT) and CT angiogram (CTA) have become essential for endovascular treatment (EVT) in acute stroke. Patient selection may improve when CT perfusion imaging (CTP) is also added for patient selection. We aimed to analyze the effects of implementing CTP in acute ischemic stroke (AIS) patients' treatment to assess whether stroke outcomes differ in the late window. METHODS: We searched the PubMed, Embase, and Web of Sciences databases to obtain articles related to CTA and CTP in EVT. Collected patient data was split into two groups: the CTP and control (NCCT+CTA) cohorts. Primary outcomes evaluated were modified Rankin Scale (mRS) scores, symptomatic intracranial hemorrhages (sICH), mortality, and successful recanalization. RESULTS: There were 14 studies with 5,809 total patients in the final analysis: 2,602 received CTP and 3,202 were in the control group. CTP/CTA patients showed significantly lower rates of 90-day stroke-related mortality (OR: 0.72, 95% CI 0.60-0.87, p<0.01) and significantly higher successful recanalization (OR: 1.42, 95% CI 1.06-1.94, p<0.01) compared to CTA-only patients. Analysis of other outcomes including functional independence (mRS 0-2), critical times, and intracranial hemorrhages were non-significant (p > 0.05). CONCLUSION: The study highlights the usefulness of CTP-guided therapy as a supplementary tool in EVT selection in the late window. Although the addition of CTP resulted in lower mortality, the favorable outcomes did not improve. Further evidence is required to establish a clearer understanding of the potential advantages or limitations of incorporating CTP in stroke imaging.

Thrombolysis in wake-up stroke based on MRI mismatch.

OBJECTIVES: Wake-up stroke (WUPS) patients can be selected to intravenous thrombolysis (IVT) treatment based on the Magnetic Resonance Imaging (MRI) mismatch concept. However, recent studies suggest the introduction of modified MRI mismatch criteria, allowing IVT in WUPS patients with a partial mismatch. MATERIAL AND METHODS: WUPS patients treated with IVT in the NOR-TEST trial and consecutively thereafter at Stavanger University Hospital were included in this study. Patient selection for treatment was performed based on the clinical presentation and the MRI DWI/FLAIR mismatch criteria. MRI examinations were reassessed according to the modified DWI-FLAIR mismatch criteria, allowing partial mismatch. Improvement in NIHSS and mRS at 3 months were used to analyze clinical outcome, and the rate of intracranial hemorrhage (ICH) to analyze safety. RESULTS: 78 WUPS patients were treated with IVT. Only 68 of these patients were independent pre-stroke and included in the clinical analysis. When reassessing the MRI examinations, 41 (60 %) were rated as DWI/ FLAIR mismatch, 14 (21 %) as partial mismatch and 13 (19 %) as match. The results show that the patient groups had a mRS score 0-1 at 3 months measured as primary outcome to respectively 27 (65.9 %), 11 (78.6 %) and 8 (61.5 %); (P = 0.629). The mismatch group showed the best clinical improvement (3-points NIHSS reduction, p = 0.005). No ICH was seen in any of the groups. CONCLUSION: Our study extended the mismatch concept in clinical praxis to treat WUPS patients with partial mismatch, showing the best clinical outcome in the mismatch group.

Target-based deep learning network surveillance of non-contrast computed tomography for small infarct core of acute ischemic stroke.

Purpose: Rapid diagnosis of acute ischemic stroke (AIS) is critical to achieve positive outcomes and prognosis. This study aimed to construct a model to automatically identify the infarct core based on non-contrast-enhanced CT images, especially for small infarcts. Methods: The baseline CT scans of AIS patients, who had DWI scans obtained within less than 2 h apart, were included in this retrospective study. A modified Target-based deep learning model of YOLOv5 was developed to detect infarctions on CT. Randomly selected CT images were used for testing and evaluated by neuroradiologists and the model, using the DWI as a reference standard. Intraclass correlation coefficient (ICC) and weighted kappa were calculated to assess the agreement. The paired chi-square test was used to compare the diagnostic efficacy of physician groups and automated models in subregions. p < 0.05 was considered statistically significant. Results: Five hundred and eighty four AIS patients were enrolled in total, finally 275 cases were eligible. Modified YOLOv5 perform better with increased precision (0.82), recall (0.81) and mean average precision (0.79) than original YOLOv5. Model showed higher consistency to the DWI-ASPECTS scores (ICC = 0.669, κ = 0.447) than neuroradiologists (ICC = 0.452, κ = 0.247). The sensitivity (75.86% vs. 63.79%), specificity (98.87% vs. 95.02%), and accuracy (96.20% vs. 91.40%) were better than neuroradiologists. Automatic model had better diagnostic efficacy than physician diagnosis in the M6 region (p = 0.039). Conclusion: The deep learning model was able to detect small infarct core on CT images more accurately. It provided the infarct portion and extent, which is valuable in assessing the severity of disease and guiding treatment procedures.

The use of a (non-) balloon guide catheter in endovascular stroke treatment, a registry of real-life use and nationwide questionnaire.

INTRODUCTION: Despite literature suggesting benefits of a balloon guide catheter (BGC) in stroke thrombectomy, BGCs are not routinely used. This study aimed to get insights in the use of a BGC and the reasons (not) to inflate the balloon. METHODS: Data were used of the Maastricht Stroke Quality Registry (MaSQ-Registry), a prospective registry for quality purposes of stroke patients treated between September 2020-February 2023. Additionally, a Dutch nationwide questionnaire was sent among all stroke treating physicians of the Dutch Society of Interventional Radiology (NVIR). Information on the use and reasons for selecting a (non-)BGC and using the BGC was collected. RESULTS: Out of 511 patients registered in the MaSQ-Registry, 458 were included. In 69% (n=317) of the patients a BGC was used; in 68% (n=214) the balloon was not inflated. In 95% of the posterior circulation occlusions a non-BGC was used. In total 47 treating physicians from sixteen stroke centers responded to the questionnaire. 51% (n=24) preferred a non-BGC and 30% (n=14) never used a BGC. 52% and 18% of the BGC-users estimated they inflate the balloon in 80-100% and 0-20% of the times, respectively. The main reasons reported for not inflating the balloon were when the BGC was occlusive (47%) or not placeable (34%) in the carotid artery. CONCLUSION: This study shows variation in the use of (non-)BGC use with and without inflated balloon among treating physicians in the Netherlands, highlighting current limited consensus regarding the use of (non-)BGCs among stroke treating physicians.

The association between serum S100ß levels and prognosis in acute stroke patients after intravenous thrombolysis: a multicenter prospective cohort study.

BACKGROUND: S100ß is a biomarker of astroglial damage, the level of which is significantly increased following brain injury. However, the characteristics of S100ß and its association with prognosis in patients with acute ischemic stroke following intravenous thrombolysis (IVT) remain unclear. METHODS: Patients in this multicenter prospective cohort study were prospectively and consecutively recruited from 16 centers. Serum S100ß levels were measured 24 h after IVT. National Institutes of Health Stroke Scale (NIHSS) and hemorrhagic transformation (HT) were measured simultaneously. NIHSS at 7 days after stroke, final infarct volume, and modified Rankin Scale (mRS) scores at 90 days were also collected. An mRS score ≥ 2 at 90 days was defined as an unfavorable outcome. RESULTS: A total of 1072 patients were included in the analysis. The highest S100ß levels (> 0.20 ng/mL) correlated independently with HT and higher NIHSS at 24 h, higher NIHSS at 7 days, larger final infarct volume, and unfavorable outcome at 3 months. The patients were divided into two groups based on dominant and non-dominant stroke hemispheres. The highest S100ß level was similarly associated with the infarct volume in patients with stroke in either hemisphere (dominant: ß 36.853, 95% confidence interval (CI) 22.659-51.048, P < 0.001; non-dominant: ß 23.645, 95% CI 10.774-36.516, P = 0.007). However, serum S100ß levels at 24 h were more strongly associated with NIHSS scores at 24 h and 3-month unfavorable outcome in patients with dominant hemisphere stroke (NIHSS: ß 3.470, 95% CI 2.392-4.548, P < 0.001; 3-month outcome: odds ratio (OR) 5.436, 95% CI 2.936-10.064, P < 0.001) than in those with non-dominant hemisphere stroke (NIHSS: ß 0.326, 95% CI  - 0.735-1.387, P = 0.547; 3-month outcome: OR 0.882, 95% CI 0.538-1.445, P = 0.619). The association of S100ß levels and HT was not significant in either stroke lateralization group. CONCLUSIONS: Serum S100ß levels 24 h after IVT were independently associated with HT, infarct volume, and prognosis in patients with IVT, which suggests the application value of serum S100ß in judging the degree of disease and predicting prognosis.

Transradial versus transfemoral artery access in mechanical thrombectomy for acute ischemic stroke: An updated systematic review and meta-analysis.

INTRODUCTION: Recently, transradial access (TRA) for mechanical thrombectomy in acute ischemic stroke has been proposed as an alternative due to potential advantages such as reduced access site complications. However, its safety and efficacy compared to the traditional transfemoral access (TFA) remain debated. METHODS: We conducted a comprehensive search on PubMed, Scopus, Web of Science, Cochrane Library, and Embase from inception to May 15, 2024. We included all randomized controlled trials and observational studies. The primary outcome was successful recanalization, defined as achieving Thrombolysis in Cerebral Infarction (TICI) grades 2b-3. Secondary outcomes included complete recanalization (TICI grade 3), achieving TICI 2c or higher, functional outcomes (modified Rankin Score (mRS) at discharge and 90 days, mRS 0-2 at 90 days, National Institutes of Health Stroke Scale (NIHSS) at discharge, Length of hospital stay (LOS)), procedural efficiency (access-to-perfusion time, first-pass reperfusion, mean number of passes, crossover to alternate approach), and safety/survival outcomes (access site complications, symptomatic intracranial hemorrhage, in-hospital and 90-day mortality). This study was registered in PROSPERO (CRD42023462293). RESULTS: The meta-analysis included 13 studies with a combined total of 4759 patients. No statistically significant difference was found between TRA and TFA for successful recanalization (RR = 1.00 [95 % CI, 0.97-1.04], P = 0.88). Analysis also showed no significant difference in favorable functional outcomes between groups (RR = 0.88, [95 % CI, 0.71-1.09], P = 0.25) with significant heterogeneity (P = 0.008, I² = 71 %), which was resolved by excluding the study of Phillips et al., 2020 (P = 0.58, I² = 0 %), then favoring TFA over TRA (RR = 0.80, [95 % CI, 0.70-0.92], P = 0.002). TFA also had a statistically significant lower risk of crossover to TRA (RR = 1.68, [95 % CI, 0.99-2.86], P = 0.05). Overall, TRA was associated with a significantly shorter length of stay (MD = -1.49, 95 % CI [-2.93 to -0.05], P = 0.04, I² = 75 %), though sensitivity analysis showed a non-significant mean difference still favoring TRA (MD = -0.59; 95 % CI: [-1.28 to -0.10], P = 0.09, I² = 0 %). There was no difference between TRA and TFA regarding complete recanalization, achieving TICI 2c or higher, procedural efficiency, functional outcomes, safety, and survival. CONCLUSION: Our updated meta-analysis demonstrates that TRA is comparable to TFA, except for a higher proportion of patients achieving mRS 0-2 at 90 days with TFA, lower crossover rates with TFA, and possibly a shorter length of stay (LOS) with TRA. Further research, particularly randomized studies, is needed to confirm these findings due to the observational nature of included studies.

Outcome of intravenous thrombolysis in acute ischemic stroke patients with small vessel disease.

INTRODUCTION: Lacunar stroke (LS) subtype accounts for a quarter of ischemic strokes. Intravenous thrombolysis (IVT) is known to improve overall stroke outcomes. Very few studies have focused on the outcome of IVT in lacunar strokes. AIM: To detect the outcome of IVT in LS patients compared to non-thrombolysed LS patients. METHODS: Fifty patients presenting with LS received the standard protocol of IVT (Group I). They were compared to fifty matched LS patients who presented beyond the time window and were selected as the control group (Group II). Clinical outcome was measured using NIHSS within 24 h, NIHSS at discharge, and MRS after 3 months. Risk factors that could have affected clinical outcomes were compared in the thrombolysis group. RESULTS: The short-term clinical outcome of Group I showed statistically significant improvement of NIHSS after 24 hrs compared to Group II (mean NIHSS = 5.52±3.89 and 7.44±1.82 respectively), as well as on discharge (mean NIHSS = 3.88±3.50 and 5.78±2.97) respectively. For long-term outcomes, 94 % of GroupⅠ reached MRS 0, 1, and 2 (n = 47/50) versus 74 % (n = 36/50) in Group II. Longer door-to-needle time, severe WMCs (Fazekas score), and pneumonia were shown to be significant predictor factors for the worst outcome. CONCLUSION: IVT has improved short- and long-term outcomes in LS patients. Longer door-to-needle time, severe WMCs, and pneumonia were shown to be significant predictor factors for the worst outcome.

Predicting 3-month poor functional outcomes of acute ischemic stroke in young patients using machine learning.

BACKGROUND: Prediction of short-term outcomes in young patients with acute ischemic stroke (AIS) may assist in making therapy decisions. Machine learning (ML) is increasingly used in healthcare due to its high accuracy. This study aims to use a ML-based predictive model for poor 3-month functional outcomes in young AIS patients and to compare the predictive performance of ML models with the logistic regression model. METHODS: We enrolled AIS patients aged between 18 and 50 years from the Third Chinese National Stroke Registry (CNSR-III), collected between 2015 and 2018. A modified Rankin Scale (mRS) ≥ 3 was a poor functional outcome at 3 months. Four ML tree models were developed: The extreme Gradient Boosting (XGBoost), Light Gradient Boosted Machine (lightGBM), Random Forest (RF), and The Gradient Boosting Decision Trees (GBDT), compared with logistic regression. We assess the model performance based on both discrimination and calibration. RESULTS: A total of 2268 young patients with a mean age of 44.3 ± 5.5 years were included. Among them, (9%) had poor functional outcomes. The mRS at admission, living alone conditions, and high National Institutes of Health Stroke Scale (NIHSS) at discharge remained independent predictors of poor 3-month outcomes. The best AUC in the test group was XGBoost (AUC = 0.801), followed by GBDT, RF, and lightGBM (AUCs of 0.795, 0, 794, and 0.792, respectively). The XGBoost, RF, and lightGBM models were significantly better than logistic regression (P < 0.05). CONCLUSIONS: ML outperformed logistic regression, where XGBoost the boost was the best model for predicting poor functional outcomes in young AIS patients. It is important to consider living alone conditions with high severity scores to improve stroke prognosis.

Thrombectomy for patients with a large infarct core: a study-level meta-analysis with trial sequential analysis.

Background: The effectiveness and safety of endovascular treatment compared with medical management alone regarding outcomes for patients with a large infarct core remain uncertain. Objectives: To juxtapose the clinical outcomes of thrombectomy versus the best medical care in patients with a large infarct core. Design: Systematic review and meta-analysis. Data sources and methods: We conducted searches in PubMed, Cochrane, and Embase for articles published up until November 8, 2023. Randomized trials were selected for inclusion if they encompassed patients with large vessel occlusion and sizable strokes receiving thrombectomy. The primary outcome was functional outcomes at 3 months after pooling data using random-effects modeling. Safety outcomes included mortality at 3 months, symptomatic intracranial hemorrhage (SICH), and decompressive craniectomy. We performed a trial sequential analysis to balance type I and II errors. Results: From 904 citations, we identified six randomized trials, involving a cohort of 1897 patients with a large ischemic region. Of these, 953 individuals underwent endovascular thrombectomy. At 3 months, thrombectomy was significantly correlated with better neurological prognosis, as evidenced by the increased odds of good functional outcomes (odds ratio (OR), 2.90; 95% confidence interval (CI), 2.08-4.05) and favorable functional outcomes (OR, 2.40; 95% CI, 1.86-3.09). Mortality rates did not demonstrably diminish as a consequence of the endovascular management (OR, 0.78; 95% CI, 0.58-1.06). However, the incidence of SICH was greater in the thrombectomy group compared to those with only medical treatment (5.5% vs 3.2%; OR, 1.77; 95% CI, 1.11-2.83). The application of trial sequential analysis yielded definitive evidence regarding favorable function outcomes and a shift in the distribution of modified Rankin scale scores at 3 months; however, others remained inconclusive. Conclusion: The results from most of the included trials display consistency. Meta-analysis of these six randomized trials offers high-quality evidence that thrombectomy significantly mitigates disability in patients with a large infarction, while also increasing the risk of SICH. Trial registration: PROSPERO, CRD42023480359.