Post-Stroke Resting-State EEG Connectivity: A Longitudinal Neuro-Rehabilitation Study.

Stroke is a leading cause of permanent disability worldwide. Even after adequate treatment, the majority of patients do not recover fully, making them dependent on others for carrying out Activities of Daily Living (ADL). An improved understanding of the underlying mechanism of plasticity will help us in customizing the translational approach for learning and rehabilitation following a stroke. For this study, a 2-minute resting state EEG data were recorded at 5 time-points for 3-months after stroke onset. Directed Transfer Function (DTF) was used to study neural reorganization for 3 months. DTF for different brain regions and sub-bands was correlated with FMA. The information flow was studied for different brain regions as well as Affected Region (AR). Occipital region showed good correlation (r = 0.45 to 0.47) with FMA. Contra-lesional and ipsi-lesional regions trajectories complement each other during acute and sub-acute phase. The information outflow vs inflow imbalance of AR was restored by the end of 3 months. DTF can be used as biomarker for studying neuroplasticity. Occipital, temporal and motor cortex regions play an important role during neuro-rehabilitation. The information about different regions during rehabilitation will help us in designing subject-specific interventions for better recovery.

Reliability of Instant Messaging-Based Evaluation of Brain Imaging in Acute Stroke.

BACKGROUND: The use of instant messenger applications among physicians has become common in acute stroke management, especially in developing countries. Photos or video sequences of brain computed tomography (CT) scans are being sent to receive real-time support in assessing radiological findings. We analyzed whether instant messaging-based evaluation is precise enough to extract relevant information from the images. METHODS: In this prospective study, anonymized videos and photos of CT and CT angiography scans of patients with symptoms of acute stroke were recorded from the diagnostic monitor using a smartphone. Two neurologists and 2 neuroradiologists performed evaluation of the images using WhatsApp. The gold standard was set by 2 experienced neuroradiologists who evaluated the CT images with their full radiological equipment. Statistical analysis included the calculation of Cohen kappa (κ). RESULTS: A total of 104 brain images (derived from 81 patients) were included. All 4 raters performed with a perfect (κ=1) interobserver reliability in diagnosing intracerebral hemorrhage. For subarachnoid hemorrhage, interobserver reliability was slightly lower (raters 1, 2, and 3, κ=1; rater 4, κ=0.88). For diagnosing stroke mimics, interobserver reliability showed considerable variations (κ between 0.32 and 1). Alberta Stroke Program Early CT Score differences overall were comparable between raters and did not exceed 3 to 4 points without noticeable outliers. All raters performed with a moderate-to-substantial interobserver reliability for detecting large vessel occlusions (κ=0.48 in rater 1, κ=0.62 in rater 2, and κ=0.63 in raters 3 and 4). CONCLUSIONS: Stroke neurologists can reliably extract information on intracerebral hemorrhage from CT images recorded via smartphone and sent through instant messaging tools. Remote diagnosis of early infarct signs and stroke mimics was less reliable. We developed a standard for the acquisition of images, taking data protection into account.

Eye Signs in Stroke.

A large part of the central nervous system is involved in the normal functioning of the vision, and hence vision can be affected in a stroke patient. Transient visual symptoms can likewise be a harbinger of stroke and prompt rapid evaluation for the prevention of recurrent stroke. A carotid artery disease can manifest as transient monocular visual loss (TMVL), central retinal artery occlusion (CRAO), anterior ischemic optic neuropathy or ocular ischemic syndrome (OIS). Stroke posterior to the optic chiasm can cause sectoranopias, quadrantanopias, or hemianopias, which can be either congruous or incongruous. Any stroke involving the dorsal stream (occipito-parietal lobe), or ventral stream (occipito-temporal lobe) can manifest with visuospatial perception deficits. Similarly, different ocular motility abnormalities can result from a stroke affecting the cerebrum, cerebellum, or brainstem. Among these deficits, vision and perception disorders are more difficult to overcome. Clinical, experimental, and neuroimaging studies have helped us to understand the anatomical basis, physiological dysfunction, and the underlying mechanisms of these neuro-ophthalmic signs.

Wavelet and Region-Specific EEG Signal Analysis for Studying Post-Stroke Rehabilitation.

Post-stroke monitoring is a crucial step for properly studying the progress of stroke patients. The rehabilitation process consists of exercise regimes that help in constantly engaging the affected part of the brain leading to faster recovery. The work here studies the effectiveness of the rehabilitation regime by investigating several parameters that can play important role in observing the immediate effect of the exercises. Various parameters from different wavelet coefficients were extracted for monitoring rehabilitation for up to 90 days. Energy and waveform length show maximum variation when monitoring pre and post-exercise changes. The parameters were correlated with clinical(FMA) score. Centroid Index gave high correlation value for beta band (r = -0.559). Alpha band on the other hand showed a good correlation with all the extracted fe atures, maximum being -0.6988 with energy. So for monitoring post-stroke rehabilitation alpha and beta bands should be focused. Region-specific analyses were also done to monitor changes in different parts of the brain.

Clinical profile and outcome of non-COVID strokes during pandemic and the pre pandemic period: COVID-Stroke Study Group (CSSG) India.

BACKGROUND: As the health systems around the world struggled to meet the challenges of COVID-19 pandemic, care of many non-COVID emergencies was affected. AIMS: The present study examined differences in the diagnosis, evaluation and management of stroke patients during a defined period in the ongoing pandemic in 2020 when compared to a similar epoch in year 2019. METHODS: The COVID stroke study group (CSSG) India, included 18 stroke centres spread across the country. Data was collected prospectively between February and July 2020 and retrospectively for the same period in 2019. Details of demographics, stroke evaluation, treatment, in-hospital and three months outcomes were collected and compared between these two time points. RESULTS: A total of 2549 patients were seen in both study periods; 1237 patients (48.53%) in 2019 and 1312 (51.47%) in 2020. Although the overall number of stroke patients and rates of thrombolysis were comparable, a significant decline was observed in the month of April 2020, during the initial period of the pandemic and lockdown. Endovascular treatment reduced significantly and longer door to needle and CT to needle times were observed in 2020. Although mortality was higher in 2020, proportion of patients with good outcome were similar in both the study periods. CONCLUSIONS: Although stroke admissions and rates of thrombolysis were comparable, some work flow metrics were delayed, endovascular stroke treatment rates declined and mortality was higher during the pandemic study period. Reorganization of stroke treatment pathways during the pandemic has likely improved the stroke care delivery across the globe.

Disseminated Strongyloidiasis: Breaking Brain Barriers.

Strongyloides stercoralis (SS) is one of the most overlooked helminthic infections despite being highly endemic in tropical and subtropical areas. In immunocompromised patients, especially those on long-term steroids, infection can often escalate to fatal dissemination into major organs. We present a compendium of two immunocompromised patients, who were on high-dose steroids and presented with worsening neurological status. Cerebrospinal fluid analysis was notable for larvae of SS as diagnosed by direct visualization. A syndrome of SS hyperinfection with dissemination was made after stool, and sputum samples also revealed SS larvae. SS is an elusive disease and should be considered early on, especially in endemic regions like India. Early diagnosis and prompt initiation of antihelminthic therapy is indispensable for favorable outcomes.

Quality Indicators of Intravenous Thrombolysis from North India.

BACKGROUND: Data on intravenous (IV) thrombolysis using tissue plasminogen activator (tPA) are limited from low- and middle-income countries. We aimed to assess the quality indicators of IV thrombolysis in our stroke unit. METHODS: All stroke patients admitted in our hospital from October 2008 to April 2017 were included in this study. Data were collected prospectively by trained research staff in a detailed case record form. Outcome was assessed using modified Rankin Scale (mRS, 0-1 good outcome). RESULTS: Of the total 4720 stroke patients seen, 944 (20%) came within window period (<4.5 h). Of these, 214 (4.5%) were eligible for thrombolysis and 170 (3.6%) were thrombolysed, relatives of 23 (23/214, 10.7%) patients denied consent, and 21 (9.8%) patients could not afford tPA. The mean age of thrombolysed patients was 58.4 (range 19-95) years. Median NIHSS at admission was 12 (interquartile range 2-24). Average onset-to-door (O-D) time was 76.8 (5-219) min, door-to-examination (D-E) time was 17.8 (5-105) min, door-to-CT (D-CT) time was 48 (1-205) min, and door-to-needle (D-N) time was 90 (20-285) min. At 6 months, 110 (64.7%) patients were contactable and 82 (74.5%) patients had good outcome (mRS 0-1). CONCLUSION: Thrombolysis rate has steadily increased at the center without undue adverse effects even in the elderly. D-E and D-CT times have reduced, but O-D and D-N times need further improvement. More patients could be thrombolysed if the cost of tPA is reduced and the consent process is waived.