Efficacy and safety outcomes of Tenecteplase versus Alteplase for thrombolysis of acute ischemic stroke: A meta-analysis of 9 randomized controlled trials.

BACKGROUND: In recent years, Tenecteplase (TNK), a genetically modified variant of alteplase, has been verified as a potential substitute for alteplase in the reperfusion therapy of acute ischemic stroke (AIS). Given the emergence of new randomized controlled trials (RCTs) of this subject, a meta-analysis was conducted to evaluate the present comparative evidence regarding the efficacy and safety outcomes of TNK and alteplase in thrombolysis for AIS. METHODS: Following predefined inclusion criteria, we searched the databases of PubMed, Web of Science, and Cochrane Library. RCTs satisfying our inclusion criteria were selected for meta-analysis. Outcome indicators were categorized into efficacy outcomes (early vessel recanalization, excellent recovery, good recovery and early neurological improvement) and safety outcomes (poor recovery, symptomatic intracerebral hemorrhage, parenchymal hemorrhage type 2(PH2) post thrombolysis, and mortality). We extracted data on efficacy outcomes and safety outcomes for patients with AIS in the TNK group at a dose of 0.25 mg/kg and the alteplase group at a dose of 0.9 mg/kg, and expressed the relative risks between the 2 groups as odds ratios (ORs) and 95% confidence intervals (CIs) using the Mantel-Haenszel method. For further insight, we performed a network meta-analysis using a Bayesian framework to compare different doses of TNK (0.1, 0.25, 0.32, and 0.4 mg/kg) with alteplase (0.9 mg/kg). RESULTS: A total of 2994 patients in 9 RCTs comparing efficacy and safety outcomes in patients with AIS treated with TNK and alteplase were included. In a pairwise analysis of TNK 0.25 mg/kg and alteplase 0.9 mg/kg, regarding efficacy outcomes, the aggregated results show that TNK 0.25 mg/kg statistically significant increased early vessel recanalization (N = 368, TNK vs. alteplase, OR: 2.07,95%CI: [1.19,3.59], I2 = 0%) and excellent recovery (N = 3548, TNK vs. alteplase, OR: 1.15,95%CI: [1.01,1.32], I2 = 0%). There was no significant difference in good recovery (N = 3486, TNK vs. alteplase, OR: 1.38,95%CI: [0.89,2.15], I2 = 84%) or early neurological improvement (N = 1686, TNK vs. alteplase, OR: 1.06,95%CI: [0.87,1.28], I2 = 24%) between the TNK 0.25 mg/kg group and the alteplase 0.9 mg/kg group. In the safety outcomes, pooled results showed no significant difference in poor recovery (N = 3548, TNK vs. alteplase, OR: 0.94,95%CI: [0.81,1.10], I2 = 0%) and symptomatic intracerebral hemorrhage (N = 3567, TNK vs. alteplase, OR: 1.06,95%CI: [0.70,1.60], I2 = 0%) and PH2(N = 3103, TNK vs. alteplase, OR: 1.26,95%CI:[0.39,4.07], I2 = 56%)and mortality (N = 3447, TNK vs. alteplase, OR: 0.99,95%CI: [0.80,1.23], I2 = 33%) between the TNK group and the alteplase group. In a network meta-analysis, competing treatments were not significantly different from one another (TNK 0.1 mg/kg, TNK 0.25 mg/kg, TNK 0.32 mg/kg, TNK 0.4 mg/kg, alteplase 0.9 mg/kg) in either efficacy outcomes or safety outcomes. CONCLUSION: In this analysis of 9 RCTs in patients with AIS, TNK 0.25 mg/kg was comparable to alteplase 0.9 mg/kg from the perspective of efficacy outcomes and safety outcomes after thrombolysis within 4.5 h of AIS occurrence.

A Nomogram Prediction Model Based on Tissue Window for the Prognosis of Patients with Acute Ischemic Stroke Undergoing Thrombectomy.

OBJECTIVE: Thrombectomy greatly improves the clinical prognosis of patients with acute ischemic stroke (AIS). The aim of this study is to develop a nomogram model that can predict the prognosis of patients with acute ischemic stroke undergoing thrombectomy. METHODS: We retrospectively collected information of patients with acute ischemic stroke who were admitted to the stroke Green Channel of the First Affiliated Hospital of Soochow University from September 2018 to May 2022. The main outcome was defined as a three-month unfavorable outcome (modified Rankin Scale 3-6). Based on the results of multivariate regression analysis, a nomogram was established. We tested the accuracy and discrimination of our nomogram by calculating the consistency index (C-index) and plotting the calibration curve. RESULTS: National Institutes of Health Stroke Scale (NIHSS) score (OR, 1.418; 95% CI, 1.177-1.707; P＜0.001), low density lipoprotein cholesterol (LDL-C) (OR, 2.705; 95% CI, 1.203-6.080; P = 0.016), Alberta Stroke Program Early Computed Tomography Score (ASPECTS) (OR, 0.633; 95% CI, 0.421-0.952; P = 0.028), infarct core volume (OR, 1.115; 95% CI, 1.043-1.192; P = 0.001) and ischemic penumbra volume (OR, 1.028; 95% CI, 1.006-1.050; P = 0.012) were independent risk factors for poor clinical prognosis of AIS patients treated with thrombectomy. The C-index of our nomogram was 0.967 and the calibration plot revealed a generally fit in predicting three-month unfavorable outcomes. Based on this nomogram, we stratified the risk of thrombectomy population. We found that low-risk population is less than or equal to 65 points, and patients of more than 65 points tend to have a poor clinical prognosis. CONCLUSION: The nomogram, composed of NIHSS, LDL-C, ASPECTS, infarct core volume and ischemic penumbra volume, may predict the clinical prognosis of cerebral infarction patients treated with thrombectomy.

Relationship between triglyceride-glucose index and carotid plaques in a high-stroke-risk population in southeast china: A population-based cross-sectional survey.

Background: Cervical arterial atherosclerosis (CAA) is an important risk factor of stroke in China. The triglyceride-glucose (TyG) index is a simple and low-cost marker for ischemic stroke. Whether the TyG index predicts cervical arterial atherosclerosis remains uncertain. This study aimed to investigate the relationship between the TyG index and cervical arterial atherosclerosis. Methods: This cross-sectional study was conducted in residents aged ≥40 years in the general population of southeast China. All participants completed a detailed questionnaire and provided blood samples. The high-stroke-risk groups further completed cervical artery ultrasonography. The TyG index was calculated using a well-established formula and analyzed in quartiles (Q1-Q4). Multivariate logistic regression was used to investigate the relationship between the TyG index and cervical arterial atherosclerosis. Results: A total of 4,499 participants aged ≥40 years were finally included, with 23.47% comprising the high-stroke-risk population. The prevalence rates of increased intima-media thickness (IMT), carotid plaque, and cervical artery stenosis (CAS) in the high-stroke-risk population were 21.97%, 39.3%, and 6.1%, respectively. Subjects with higher TyG were still more likely to have carotid plaque. After adjusting for several established risk factors, compared with the TyG-Q1 group, the TyG-Q2, TyG-Q3, and TyG-Q4 groups were more likely to have carotid plaque (OR = 1.85, 95%CI = 1.28-2.67; OR = 1.51, 95%CI = 1.05-2.18; and OR = 1.29, 95%CI = 0.90-1.84). TyG was an independent predictor of the presence of plaque in the carotid artery of the high-stroke-risk population. Conclusions: An elevated TyG index is a potential predictor of carotid plaques in the high-stroke-risk population older than 40 years.

Astrocyte-Derived Neuronal Transdifferentiation as a Therapy for Ischemic Stroke: Advances and Challenges.

After the onset of ischemic stroke, ischemia-hypoxic cascades cause irreversible neuronal death. Neurons are the fundamental structures of the central nervous system, and mature neurons do not renew or multiply after death. Functional and structural recovery from neurological deficits caused by ischemic attack is a huge task. Hence, there remains a need to replace the lost neurons relying on endogenous neurogenesis or exogenous stem cell-based neuronal differentiation. However, the stem cell source difficulty and the risk of immune rejection of the allogeneic stem cells might hinder the wide clinical application of the above therapy. With the advancement of transdifferentiation induction technology, it has been demonstrated that astrocytes can be converted to neurons through ectopic expression or the knockdown of specific components. The progress and problems of astrocyte transdifferentiation will be discussed in this article.

Higher Plasma Fibrinogen Level at Admission Is Associated with Post-Stroke Depression at Discharge.

Background: Post-stroke depression (PSD) is a common complication of stroke, which seriously affects the functional outcome of patients. Systemic low-grade inflammation associated with PSD has been shown to occur at several months to years, however, whether these inflammatory markers predicted PSD at an acute stage of stroke is controversial. Method: A total of 625 patients with acute ischemic stroke (219 female, 35.40%) were included in this study. PSD was diagnosed using the 17-item Hamilton depression scale (HAMD) at 7 days following discharge (7−14 days after stroke onset). Multivariable logistic regression analysis was applied to build a prediction model for PSD at discharge. Discrimination and calibration of the model were assessed by C-index, calibration plot. Internal validation was conducted using bootstrapping validation. Results: At discharge of hospitalization, 95 patients (15.20%) were diagnosed with PSD. Multivariable logistic regression suggested that female gender (OR = 2.043, 95% CI = 1.287−3.245, p = 0.002), baseline NIHSS (OR = 1.108, 95% CI = 1.055−1.165, p < 0.001) and fibrinogen (OR = 1.388, 95% CI = 1.129−1.706, p = 0.002) were independent predictors for PSD at discharge. The cut-off of the fibrinogen plasma level was 3.08 g/L. These predictors were included in the nomogram. The model displayed good discrimination, with a C-index of 0.730 (95% CI = 0.683−0.777) and good calibration. Conclusion: Female gender, baseline stroke severity and a higher level of fibrinogen were independently associated with PSD at discharge. A nomogram based on these three predictors can be used to provide an individual, visual prediction of the risk probability of PSD.

The effect of coupled inhibitory-facilitatory repetitive transcranial magnetic stimulation on shaping early reorganization of the motor network after stroke.

Neural plasticity is a major factor driving cortical reorganization after stroke. This study aimed to evaluate functional connectivity (FC) changes in the cortical motor network after coupled inhibitory-facilitatory repetitive transcranial magnetic stimulation (rTMS) treatment and to assess the correlation between FC changes and functional recovery, further characterizing the neural mechanisms underlying the beneficial effects of rTMS. We randomly divided 63 patients with acute stroke into four groups: (1) Group A received coupled inhibitory-facilitatory rTMS [1 Hz over the contralesional primary motor cortex (M1) and 10 Hz over ipsilesional M1]; (2) Group B received a contralesional sham stimulation and ipsilesional 10 Hz stimulation; (3) Group C received a contralesional 1 Hz rTMS and ipsilesional sham stimulation; and (4) Group D received bilateral sham stimulation only. Standardized rehabilitation therapy was performed immediately after rTMS, and each group was treated with their respective treatment modalities for 4 weeks. Twenty-four hours before and after the intervention, participants underwent resting-state functional magnetic resonance imaging. Additional functional assessments were conducted at baseline, after treatment, and at the 3 month follow-up. The rTMS treatment significantly changed the FCs of intra- and inter-hemispheric cortical motor networks in the rTMS groups (A and B) compared with the sham group (Group D). This effect was more pronounced in Group A, which displayed a changed FC between the contralesional postcentral gyrus and contralesional superior parietal gyrus, between the contralesional precentral gyrus and contralesional postcentral gyrus, and between the ipsilesional postcentral gyrus and contralesional superior parietal gyrus, when compared with Groups B and C. Importantly, FC changes were significantly correlated with improvement of motor function. In the early stages of ischemic stroke, coupled rTMS was more conducive to motor recovery by modulating the FCs of intra-hemispheric and inter-hemispheric motor networks. Our results suggested that FC changes were related to motor function recovery for early-stage cerebral stroke patients treated with coupled rTMS. These findings could help to understand the mechanism of coupled rTMS and further the use of this therapy as an adjunct rehabilitation technique in motor recovery.

High-sensitivity C-reactive protein as a better predictor of post-thrombolytic functional outcome in patients with previous antiplatelet therapy.

BACKGROUND: C-reactive protein (CRP) is an important biomarker of inflammation and plays a pivotal role in predicting the clinical prognosis of cardiovascular and cerebrovascular diseases. However, the mechanism of inflammation influencing the outcome of patients with ischemic stroke are unknown. AIMS: We aim to investigate the association between hsCRP and mRS in 194 eligible patients by therapy-stratified analyses. METHODS: The modification effects of antiplatelet therapy on the association between mRS and different exposure variables were analyzed. The retained variables were analyzed in the receiver operating characteristic (ROC) curve to discriminate patients with poor outcome. RESULTS: hsCRP was positively correlated with mRS in therapy-stratified analyses. There was a statistical modification effect of antiplatelet therapy on the association of hsCRP and mRS (P for interaction = 0.0101). The discriminative effect of poor outcome was further verified by ROC curve analyses (AUCwith from 0.758 to 0.872, AUCwithout from 0.709 to 0.713). CONCLUSIONS: hsCRP is correlated with the clinical outcome of patients treated with IVrt-PA, and may be a better predictor of post-thrombolytic functional outcome in patients with previous antiplatelet therapy than in non-used patients.

Electroacupuncture Promotes Autophagy by Regulating the AKT/mTOR Signaling Pathway in Temporal Lobe Epilepsy.

Temporal lobe epilepsy (TLE) is a complex neurological disease, and its occurrence and development are closely related to the autophagy signaling pathway. However, the mechanism by which electroacupuncture (EA) affects the regulation of autophagy has not been fully elucidated. TLE gene chip dataset GSE27166 and data from rats without epilepsy (n = 6) and rats with epilepsy (n = 6) were downloaded from Gene Expression Omnibus. The differentially expressed genes (DEGs) in the TLE and control groups were identified with the online tool GEO2R. Gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) databases were used to analyse the functional and pathway enrichment of genes in the most important modules. A rat model of TLE induced by lithium-pilocarpine treatment was established. EA treatment at DU20 and DU14 in TLE rats was performed for 2 weeks. Neuronal regeneration was determined using immunofluorescence staining. The protein levels of AKT/mTOR signaling pathway and autophagy markers were detected through western blotting and immunohistochemistry. This study identified 1837 DEGs, including 798 upregulated genes and 1039 downregulated genes. GO enrichment and KEGG analyses were performed on DEGs and revealed functional enrichment mainly in the mTOR signaling pathway and autophagy-animal. Furthermore, the number of mature neurons was significantly increased upon coexpressing BrdU/NeuN in TLE rats treated with EA. Western blotting and immunohistochemistry results showed significantly decreased levels of the phosphorylated-AKT and p-mTOR in the hippocampal CA3 and DG regions of TLE rats with EA treatment. And increased p-ULK1/ULK1, LC3-II/LC3-I and p62 levels in TLE rats with EA stimulation. Therefore, this study suggested that EA promoted autophagy in hippocampal neurons during the onset of epilepsy by regulating the AKT/mTOR signaling pathway to treat epilepsy.

A New Nomogram Model for Individualized Prediction of Cognitive Impairment in Patients with Acute Ischemic Stroke.

BACKGROUND: Cognitive impairment is a common symptom after ischemic stroke. Such symptom can cause effect on rehabilitation of patients and their quality of life and. As stroke rapidly growth on nowadays, a reliable scoring tool to detect the risk of cognitive impairment after stroke is now being put on the first place. METHODS: We enrolled patients with acute ischemic stroke (AIS) as samples and hospitalized all at the First Affiliated Hospital of Soochow University between October 2018 and June 2020. All patients were assessed by the Montreal Cognitive Assessment (MoCA) scales and MoCA score < 26 was defined as standard to have having cognitive impairment. All patients were randomly (7:3) divided into two cohorts: the primary ones and the validated ones. Based on multivariate logistic model, the independent predictors of cognitive impairment in the acute phase were identified. The predictive nomogram was generated and evaluated by Harrell's concordance index (C-index) and calibration plot both in two cohorts, respectively. RESULTS: A total of 191 patients were enrolled, of whom 135 comprised the primary cohort and 56 comprised the validated cohort. Gender, age, baseline NIHSS score, hyperhomocysteinemia (HHcy) and multiple lesions were independently associated with acute cognitive impairment after stroke and included to construct the nomogram. The nomogram derived from the primary cohort had an Area Under Curve (AUC) of 0.773 and the validated ones had an AUC of 0.859. Calibration plot revealed adequate fit of the nomogram in predictive value. CONCLUSION: The new nomogram based on gender, age, baseline NIHSS score, HHcy and multiple lesions gave rise to an accurate and comprehensive prediction for cognitive impairment in AIS patients. After further validation, it could potentially be a reliable forecasting tool.

Total magnetic resonance imaging of cerebral small vessel disease burden predicts dysphagia in patients with a single recent small subcortical infarct.

BACKGROUND: This study was performed to identify the association between the total magnetic resonance imaging burden of small vessel disease and the occurrence of post-stroke dysphagia in patients with a single recent small subcortical infarct (RSSI). METHODS: We retrospectively identified all patients with a magnetic resonance imaging-confirmed single RSSI. The water-swallowing test and volume-viscosity swallow test were performed within the first 24 h following admission to assess swallowing. Demographic and clinical data were extracted from our stroke database. Based on brain magnetic resonance imaging, we independently rated the presence of cerebral microbleeds, lacunes, white matter hyperintensities and enlarged perivascular spaces. The presence of each small vessel disease feature was summed to determine the total small vessel disease burden, ranging from 0 to 4. RESULTS: In total, 308 patients with a single RSSI were enrolled. Overall, 54 (17.5%) were diagnosed with post-stroke dysphagia. The risk factors related to post-stroke dysphagia included the following: older age, higher National Institute of Health Stroke Scale scores, higher C-reactive protein level and higher fibrinogen level. Based on multiple logistic regression, National Institute of Health Stroke Scale scores and total small vessel disease burden were independent risk factors of post-stroke dysphagia in patients with a single RSSI, after adjusting for age, gender, history of hypertension, C-reactive protein level and fibrinogen level. CONCLUSIONS: Dysphagia in patients with a single RSSI was associated with a more severe total small vessel disease burden as reflected by MRI. Total MRI of cerebral small vessel disease burden may predict dysphagia in these patients. Furthermore, more severe total small vessel disease burden was associated with systemic inflammation.

Combining inhibitory and facilitatory repetitive transcranial magnetic stimulation (rTMS) treatment improves motor function by modulating GABA in acute ischemic stroke patients.

BACKGROUND: The combination of inhibitory and facilitatory repetitive transcranial magnetic stimulation (rTMS) can improve motor function of stroke patients with undefined mechanism. It has been demonstrated that rTMS exhibits a neuro-modulatory effect by regulating the major inhibitory neurotransmitter γ-aminobutyric acid (GABA) in other diseases. OBJECTIVES: To evaluate the effect of combined inhibitory and facilitatory rTMS on GABA in the primary motor cortex (M1) for treating motor dysfunction after acute ischemic stroke. METHODS: 44 ischemic stroke patients with motor dysfunction were randomly divided into two groups. The treatment group was stimulated with 10 Hz rTMS at the ipsilesional M1 and 1 Hz rTMS at the contralesional M1. The sham group received bilateral sham stimulation at the motor cortices. The GABA level in the bilateral M1 was measured by proton magnetic resonance spectroscopy (1H-MRS) at 24 hours before and after rTMS stimulation. Motor function was measured using the Fugl-Meyer Assessment (FMA). The clinical assessments were performed before and after rTMS and after 3 months. RESULTS: The treatment group exhibited a greater improvement in motor function 24 hours after rTMS compared to the sham group. The increased improvement in motor function lasted for at least 3 months after treatment. Following 4 weeks of rTMS, the GABA level in the ipsilesional M1 of the treatment group was significantly decreased compared to the sham group. Furthermore, the change of FMA score for motor function was negatively correlated to the change of the GABA:Cr ratio. Finally, the effect of rTMS on motor function outcome was partially mediated by GABA level change in response to the treatment (27.7%). CONCLUSIONS: Combining inhibitory and facilitatory rTMS can decrease the GABA level in M1, which is correlated to the improvement of motor function. Thus, the GABA level in M1 may be a potential biomarker for treatment strategy decisions regarding rTMS neuromodulatory interventions.

Predictive Model of Dysphagia and Brain Lesion-Symptom Mapping in Acute Ischemic Stroke.

Background and purpose: Early recognition and management of post-stroke dysphagia (PSD) based on MRI may reduce the incidence of complications. Combining clinical symptoms with applications of MRI, we aimed to identify the risk factors of PSD, develop a prediction scale with high accuracy and map key dysphagia brain areas. Methods: A total of 275 acute ischemic stroke patients were enrolled in this study, and 113 (41.1%) patients were diagnosed with PSD. All patients underwent the water-swallowing test (WST) and volume-viscosity swallow test (V-VST) within first 24 h following admission to assess swallowing. Vascular factors were evaluated and MRI brain scans were obtained within 3 days after symptom onset for each participant admitted to the hospital. T-test, chi-squared test and Fisher's exact test were used to investigate the associations of various patient characteristics with dysphagia, and multivariable logistic regression models were used to construct a prediction scale. Scale accuracy was assessed using receiver operating characteristic (ROC) analysis. We extracted white matter hyperintensities for each patient as potential brain lesions. Voxel-based lesion-symptom mapping (VLSM) was used to identify key brain areas for dysphagia. Results: Risk factors related with PSD were older age, history of atrial fibrillation, higher fasting blood glucose, NIH stroke scale, TOAST classification, progressive stroke, middle cerebral artery lesion and anterior cerebral artery lesion. Three variables with most significant associations, including NIH stroke scale, TOAST classification and progressive stroke, combined with age and gender, were used to construct a dysphagia prediction scale with high accuracy (AUC = 0.86). VLSM identified left inferior parietal gyrus as a key brain region for PSD. Conclusion: Risk factors of PSD were identified and a predictive model of dysphagia was constructed intelligently and automatically. The left inferior parietal gyrus was identified as a key brain area for dysphagia, which provides a new symptom-based treatment target for early rehabilitation in the future.

[Intraoperative arthrography monitoring assisted closed reduction and internal fixation for intercondylar fracture of humerus in children].

OBJECTIVE: To investigate clinical effects of intraoperative arthrography monitoring assisted closed reduction and internal fixation for intercondylar fracture of humerus in children. METHODS: From January 2013 to July 2018, 18 children with intercondylar fracture of humerus were treated by operation, including 13 males and 5 females aged from 3 to 12 years old with an average age of (8.50±2.57) years old. According to Toniolo & Wilkinson classification, 8 children were typeⅠand 10 children were typeⅡ. During the operation, closed reduction and internal fixation were performed under the monitoring of intraoperative radiography, open reduction and internal fixation were performed in necessity. Mayo score of elbow joint was used to evaluate clinical effect at 6 months after operation. RESULTS: All children were underwent arthrography monitoring during operation, 5 children were treated with closed reduction and internal fixation for intraoperative arthrography found no fracture of articular cartilage, 11 children by closed reduction and internal fixation because of fracture of articular cartilage involving the joint space with displacement less than 2 mm, and 2 children by closed or open reduction and internal fixation for fracture of articular cartilage surface with displacement above 2 mm, which 1 child with smooth of joint surface was performed closed reduction and internal fixation, 1 child without smooth of joint surface and displacement above 2 mm was performed open reduction and internal fixation. All children were followed up from 8 to 26 months with an average of (20.28±4.40) months. All factures were healed from 6 to 9 weeks with an average of (7.33±0.77) weeks. Postoperative Mayo score of elbowjoint at 6 months was (89.44±11.36), and 12 patients got excellent results, 5 good and 1 poor. One patient occurred partial limitation of flexion or extension of elbow joint. No elbow deformity and other complications occurred. CONCLUSION: The treatment of intercondylar fracture of humerus in children under monitoring of intraoperative radiography could reduce opertaion injuries and complications, confirm the reduction effect of articular surface of cartilage in time and clearly, and promote recovery of elbow joint function.

Effects of mirror therapy on motor aphasia after acute cerebral infarction: A randomized controlled trial.

BACKGROUND: Mirror therapy (MT) has proven to be beneficial for treating patients suffering from motor aphasia after stroke. However, the impacts of MT on neuroplasticity remain unexplored. OBJECTIVE: In this paper we conducted a randomized controlled trial to evaluate the treatment using the MT on motor aphasia following acute cerebral infarction. METHODS: We randomly assigned 30 patients into test and control groups, with test group patients treated with MT, whereas control group patients were treated with sham MT. At 24 hours prior to and after the intervention, we obtained functional magnetic resonance imaging (fMRI) data from study subjects. At baseline, after treatment and 12-week follow-up, we additionally evaluated patients with the Modified Rankin Scale (mRS), the National Institutes of Health Stroke Scale (NIHSS), and the aphasia quotient (AQ) in the western aphasia test. RESULTS: After 2 weeks of treatment, the test group demonstrated significant improvements in AQ values, naming, repetition, spontaneous speech, and mRS scores compared to the control group (P < 0.05). Furthermore, in the follow-up time point (12 weeks), we found that the test group exhibited significantly better NIHSS scores and AQ evaluation indicators than the control group (P < 0.05). Specifically, the fMRI study shows that functional connectivity significantly improved in test group patients mainly among frontal, temporal, and parietal lobes of the left hemisphere with each other than controls group. Meanwhile, we found significantly enhanced functional connectivity with the hippocampus (P < 0.01). CONCLUSIONS: Our results indicate that the MT can expedite the recovery of language function during the early phases of stroke recovery. These findings may elucidate the underlying mechanism of MT and the application of this therapy as an adjunct rehabilitation technique in language recovery.

Effects of repetitive transcranial magnetic stimulation combined with transcranial direct current stimulation on motor function and cortex excitability in subacute stroke patients: A randomized controlled trial.

OBJECTIVE: To explore effects of repetitive transcranial magnetic stimulation (rTMS) combined with transcranial direct current stimulation (tDCS) on motor function and cortex excitability in subacute stroke patients. DESIGN: Randomized controlled trial. SETTING: Inpatient hospitals. SUBJECTS: Sixty-five participants were randomly assigned to four groups: sham, 1Hz rTMS, cathodic tDCS combined with 1Hz rTMS (tDCS-/rTMS-) and anodic tDCS combined with 1Hz rTMS (tDCS+/rTMS-). INTERVENTIONS: Four interventions were used, including sham, 1Hz rTMS, and cathodal or anodal tDCS, followed by 1Hz rTMS over contralesional motor cortex, which continued for four weeks. MAIN MEASURES: Outcome measures were motor function and cortical excitability, evaluated by Fugl-Meyer Assessment, National Institutes of Health Stroke Scale and Barthel Index, resting Motion Threshold, Motor Evoked Potentials and Central Motor Conduction Time, assessed at baseline, four weeks and eight weeks. RESULTS: At four weeks after interventions, Fugl-Meyer Assessment lower limb change score in tDCS+/rTMS- group was significantly larger than other three groups (P < 0.001). There were significant differences in bilateral Motor Evoked Potentials changes between tDCS+/rTMS- group and sham group (P < 0.05). At eight weeks, compared to other groups, National Institutes of Health Stroke Scale (P = 0.003), Barthel Index (P = 0.002), FMA lower limb score (P < 0.001), and bilateral resting Motion Threshold, Motor Evoked Potentials (P < 0.05) showed significant changes in tDCS+/rTMS- group. Furthermore, Fugl-Meyer Assessment lower limb change score was associated with increased ipsilesional Motor Evoked Potentials (r = 0.703 P < 0.001) in tDCS+/rTMS- group. CONCLUSION: 1Hz rTMS combined with anode tDCS stimulation protocol could be a preferable rehabilitative strategy for motor recovery in subacute stroke patients.

A new nomogram for individualized prediction of the probability of hemorrhagic transformation after intravenous thrombolysis for ischemic stroke patients.

BACKGROUND: A reliable scoring tool to detect the risk of intracerebral hemorrhage (ICH) after intravenous thrombolysis for ischemic stroke is warranted. The present study was designed to develop and validate a new nomogram for individualized prediction of the probability of hemorrhagic transformation (HT) in patients treated with intravenous (IV) recombinant tissue plasminogen activator (rt-PA). METHODS: We enrolled patients who suffered from acute ischemic stroke (AIS) with IV rt-PA treatment in our emergency green channel between August 2016 and July 2018. The main outcome was defined as any type of intracerebral hemorrhage according to the European Cooperative Acute Stroke Study II (ECASS II). All patients were randomly divided into two cohorts: the primary cohort and the validation cohort. On the basis of multivariate logistic model, the predictive nomogram was generated. The performance of the nomogram was evaluated by Harrell's concordance index (C-index) and calibration plot. RESULTS: A total of 194 patients with complete data were enrolled, of whom 131 comprised the primary cohort and 63 comprised the validation cohort, with HT rate 12.2, 9.5% respectively. The score of chronic disease scale (CDS), the global burden of cerebral small vascular disease (CSVD), National Institutes of Health Stroke Scale (NIHSS) score ≥ 13, and onset-to-treatment time (OTT) ≥ 180 were detected important determinants of ICH and included to construct the nomogram. The nomogram derived from the primary cohort for HT had C- Statistics of 0.9562 and the calibration plot revealed generally fit in predicting the risk of HT. Furthermore, we made a comparison between our new nomogram and several other risk-assessed scales for HT with receiver operating characteristic (ROC) curve analysis, and the results showed the nomogram model gave an area under curve of 0.9562 (95%CI, 0.9221-0.9904, P < 0.01) greater than HAT (Hemorrhage After Thrombolysis), SEDAN (blood Sugar, Early infarct and hyper Dense cerebral artery sign on non-contrast computed tomography, Age, and NIHSS) and SPAN-100 (Stroke Prognostication using Age and NIHSS) scores. CONCLUSIONS: This proposed nomogram based on the score of CDS, the global burden of CSVD, NIHSS score ≥ 13, and OTT ≥ 180 gives rise to a more accurate and more comprehensive prediction for HT in patients with ischemic stroke receiving IV rt-PA treatment.

Intravenous Thrombolysis Benefits Mild Stroke Patients With Large-Artery Atherosclerosis but No Tandem Steno-Occlusion.

At present, there is controversy regarding whether thrombolysis is beneficial for patients suffering from a mild stroke. In this study, we therefore sought to determine whether the therapeutic benefit of thrombolysis is dependent upon stroke subtype for those with mild stroke. We conducted a retrospective analysis of data from consecutive mild stroke patients (National Institutes of Health Stroke Scale ≤5) with and without recombinant tissue plasminogen activator (rt-PA) therapy. The TOAST (Trial of Org 10172 in acute stroke treatment) criteria was used to determine stroke subtypes. Patients suffering from large-artery atherosclerosis (LAA) were subdivided based upon whether or not they exhibited tandem steno-occlusion, as defined by the association of a proximal intracranial occlusion and a cervical internal carotid artery lesion (complete occlusion or severe stenosis ≥ 90%). For this study, favorable outcomes at 90 days of onset (modified Rankin Scale Score [mRS] of 0-1) were the primary measured outcome. Three hundred thirty-nine patients were included in the study. For patients with non-LAA, there were not statistically significant improvements in favorable outcomes for rt-PA treatment (p = 0.889, 0.929, 0.708; respectively). For patients with LAA, compared with non-treated group, rt-PA-treated patients had a significant in the rate of favorable outcomes at 90 days (82.8 vs. 64.9%; OR 2.59; 95%CI, 1.13-5.92; P = 0.024). Among LAA patients exhibiting tandem lesions, favorable outcomes were observed in 66.7% of rt-PA-treated patients, with no significant differences to those observed in untreated patients (OR 1.00; 95%CI, 0.23-4.28; p = 1.000). Among LAA patients without tandem lesions, compared with non-treated group, we found that rt-PA treatment was associated with a significant beneficial impact on favorable outcomes after 90 days (64.4 vs. 88.4%; OR 4.20; 95%CI, 1.43-12.30; p = 0.009). Our findings suggest that intravenous rt-PA is only beneficial in mild stroke patients with LAA-type strokes that do not exhibit tandem steno-occlusion.

H-Type Hypertension Is a Risk Factor for Cerebral Small-Vessel Disease.

BACKGROUND: The correlation between H-type hypertension and cerebral small-vessel diseases (CSVD) remains uncertain. OBJECTIVE: The present study was designed to explore the possible relationship between H-type hypertension and CSVD spectrum and total burden. METHOD: We included 329 patients in the present study and divided them into four groups: the H-type hypertension group, isolated hypertension group, isolated hyperhomocysteinemia (HHcy) group, and control group. Clinical variables of interest and the MR examination sequences were obtained. We counted the presence of each CSVD feature and rated the total burden of CSVD on an ordinal scale from 0 to 4 according to a recent described score rule. RESULT: The results showed that H-type hypertension was associated with the presence of cerebral microbleeds (CMBs), and the severity of white-matter hyperintensities (WMHs) and peripheral vascular space (PVS). CSVD total burden was significantly related to age (OR: 1.059, 95% CI: 1.037-1.082), systolic pressure (OR: 1.122, 95% CI: 1.007-1.136), triglycerides (OR: 1.386, 95% CI: 1.037-1.854), isolated HHcy (OR: 4.154, 95% CI 1.836-9.401), and H-type hypertension (OR: 5.028, 95% CI: 2.323-10.883). Also, we further observed hypertension and HHcy had a synergistic effect on CSVD total burden (OR: 2.776, 95% CI: 1.564-4.927). CONCLUSION: H-type hypertension was associated with CSVD total burden and CSVD spectrum, which deserves further prevention measures. Furthermore, hypertension and HHcy had a synergistic effect on CSVD total burden.

Value of thrombus imaging in predicting the outcomes of patients with large-vessel occlusive strokes after endovascular therapy.

BACKGROUND: Acute ischemic stroke leads to serious long-term disability and high mortality, especially in patients with large-vessel occlusive strokes. Nowadays, endovascular therapy is considered as an alternative treatment for these patients. Several studies have used thrombus characteristics based on non-contrast computed tomography (NCCT) and computed tomography angiography (CTA) to predict prognosis in ischemic stroke. We conducted a systematic review to identify potential imaging predictive factors for successful recanalization and improved clinical outcome after endovascular therapy in patients with large-vessel occlusion (LVO) in anterior arterial circulation. METHODS: The PubMed databases were searched for related studies reported between September 18, 2009, and September 18, 2019. RESULTS: We selected 11 studies on revascularization and 12 studies on clinical outcome. Patients with thrombus of higher Hounsfield unit (HU), shorter length, higher clot burden score, and increased thrombus permeability may achieve higher recanalization and improved clinical outcome, but the matter is still under debate. CONCLUSION: Imaging of thrombus can be used as an aseessment tool to predict the outcomes and it needs further studies in the future.