Thrombectomy in Patients With Ischemic Stroke Without Salvageable Tissue on CT Perfusion.

BACKGROUND: Computed tomography perfusion (CTP) imaging is regularly used to guide patient selection for mechanical thrombectomy (MT). However, the effect of MT in patients without salvageable tissue on CTP has not been investigated. The purpose of this study was to assess the effect of MT in patients with stroke without perfusion mismatch profiles. METHODS: This observational study analyzed patients with ischemic stroke consecutively treated between March 1, 2015, and January 31, 2022, triaged by multimodal-computed tomography undergoing MT. CTP lesion-core mismatch profiles were defined using a mismatch volume/ratio of ≥10 mL/1.2, respectively. The primary end point was the rate of functional independence at 90 days, defined as the modified Rankin Scale score of 0 to 2. Recanalization was evaluated with the modified Thrombolysis in Cerebral Infarction scale. The effect of baseline variables on functional outcome was assessed using multivariable logistic regression analysis. Outcomes of patients with and without CTP-mismatch profiles were compared using 1:1 propensity score matching. RESULTS: Of 724 patients who met the inclusion criteria of this retrospective observational study, 110 (15%) patients had no CTP mismatch and were analyzed. The median age was 74 (interquartile range, 62-80) years and 53% were women. Successful recanalization (modified Thrombolysis in Cerebral Infarction score, ≥2b) was achieved in 66% (73) and associated with functional independence at 90 days (adjusted odds ratio, 7.33 [95% CI, 1.22-43.70]; P=0.03). A significant interaction was observed between recanalization and age, as well as the extent of infarction, indicating MT to be most effective in patients <70 years and with a baseline Alberta Stroke Program Early Computed Tomography Score range between 3 and 7. These findings remained stable after propensity score matching, analyzing 152 matched pairs with similar rates of functional independence between patients with and without CTP-mismatch profiles (17% versus 23%; P=0.42). CONCLUSIONS: In patients without CTP-mismatch profiles defined according to the EXTEND (Extending the Time for Thrombolysis in Emergency Neurological Deficits) criteria, recanalization was associated with improved functional outcomes. This effect was associated with baseline Alberta Stroke Program Early Computed Tomography Score and age, but not with the time from onset to imaging.

Thrombectomy in ischemic stroke patients with large core but minor ischemic changes on non-enhanced computed tomography.

PURPOSE: The Alberta Stroke Program Early CT Score (ASPECTS) is regularly used to guide patient selection for mechanical thrombectomy (MT). Similarly, penumbral imaging based on computed tomography perfusion (CTP) may serve as neuroimaging tool to guide treatment. Yet, patients with a large ischemic core on CTP may show only minor ischemic changes resulting in a high ASPECTS. AIM: We hypothesized twofold: (1) the treatment effect of vessel recanalization in patients with core volume > 50 mL but ASPECTS ⩾ 6 is not different compared to high ASPECTS patients with core volume < 50 mL, and (2) recanalization is associated with core overestimation. METHODS: We conducted an observational study analyzing ischemic stroke patients consecutively treated with MT after triage by multimodal CT. Functional endpoint was the rate of functional independence at Day 90 defined as modified Rankin Scale (mRS) 0-2. Imaging endpoint was core overestimation, which was considered when CTP-derived core was larger than the final infarct volume assessed on follow-up imaging. Recanalization was evaluated with the extended Thrombolysis in Cerebral Infarction (eTICI) scale. Multivariable logistic regression analysis and propensity score matching (PSM) were used to assess the association of recanalization (eTICI ⩾ 2b) with functional outcome and core overestimation. RESULTS: Of 630 patients with ASPECTS ⩾ 6, 91 patients (14.4%) had a large ischemic core. Following 1:1 PSM, the treatment effect of recanalization was not different in patients with large core and ASPECTS ⩾ 6 (+ 25.8%, 95% CI: 16.3-35.4, p < 0.001) compared to patients with ASPECTS ⩾ 6 and core volume < 50 mL (+ 14.9%, 95% CI: 5.7-24.1, p = 0.002). Recanalization (aOR: 3.46, 95% CI: 1.85-6.47, p < 0.001) and higher core volume (aOR: 1.03, 95% CI: 1.02-1.04, p < 0.001) were significantly associated with core overestimation. CONCLUSION: In patients with ASPECTS ⩾ 6, core volumes did not significantly modify outcomes following recanalization. Reperfusion and higher core volume were significantly associated with core overestimation which may explain the treatment effect of MT for patients with a large ischemic core but minor ischemic changes on non-enhanced CT. DATA ACCESS STATEMENT: The data analyzed in this study will be available and shared on reasonable request from any qualified researcher for the purpose of replicating the results after clearance by the local ethics committee.

Endovascular Thrombectomy for Large Ischemic Strokes with ASPECTS 0-2: a Meta-analysis of Randomized Controlled Trials.

PURPOSE: Randomized controlled trials (RCTs) demonstrated a treatment effect of endovascular thrombectomy in acute ischemic stroke with large infarct, commonly defined as an Alberta Stroke Program Early CT Score (ASPECTS) of 3-5. However, data on endovascular thrombectomy in patients with very low ASPECTS of 0-2 remain scarce. METHODS: We conducted a systematic review and meta-analysis of RCTs comparing endovascular thrombectomy versus medical treatment alone in acute ischemic anterior circulation stroke with very large infarct, defined as ASPECTS of 0-2. The primary outcome was the shift toward better functional outcomes on the 90-day modified Rankin Scale (mRS). Random effects meta-analysis was performed using the generic inverse variance method. RESULTS: Literature research identified four RCTs which evaluated the treatment effect of endovascular thrombectomy for large infarcts and provided a subgroup analysis of the mRS shift in patients with ASPECTS of 0-2. The pooled analysis showed a significant shift toward better 90-day mRS scores in favor of endovascular thrombectomy (pooled odds ratio, 1.62, 95% confidence interval, 1.29-2.04, P < 0.001). CONCLUSION: This meta-analysis suggests a treatment effect of endovascular thrombectomy in specific patients with very low ASPECTS of 0-2, challenging the use of ASPECTS for treatment selection in acute ischemic stroke due to large vessel occlusion. An individual patient meta-analysis of RCTs would strengthen evidence in the treatment of patients with ASPECTS of 0-2.

Effect of short- versus long-term serum glucose levels on early ischemic water homeostasis and functional outcome in patients with large vessel occlusion stroke.

BACKGROUND AND PURPOSE: In ischemic stroke, the impact of short- versus long-term blood glucose level (BGL) on early lesion pathophysiology and functional outcome has not been assessed. The purpose of this study was to directly compare the effect of long-term blood glucose (glycated hemoglobin [HbA1c]) versus serum BGL on early edema formation and functional outcome. METHODS: Anterior circulation ischemic stroke patients who underwent mechanical thrombectomy after multimodal computed tomography (CT) on admission were analyzed. Endpoints were early ischemic cerebral edema, measured by quantitative net water uptake (NWU) on initial CT and functional independence at Day 90. RESULTS: A total of 345 patients were included. Patients with functional independence had significantly lower baseline NWU (3.1% vs. 8.3%; p < 0.001) and lower BGL (113 vs. 123 mg/dL; p < 0.001) than those without functional independence, while HbA1c levels did not differ significantly (5.7% vs. 5.8%; p = 0.15). A significant association was found for NWU and BGL (ß = 0.02, 95% confidence interval [CI] 0.006-0.03; p = 0.002), but not for HbA1c and NWU (ß = -0.16, 95% CI -0.53-0.21; p = 0.39). Mediation analysis showed that 67% of the effect of BGL on functional outcome was mediated by early edema formation. CONCLUSION: Aggravated early edema and worse functional outcome was associated with elevated short-term serum BGL, but not with HbA1c levels. Hence, the link between short-term BGL and early edema development might be used as a target for adjuvant therapy in patients with ischemic stroke.

Haemorrhage after thrombectomy with adjuvant thrombolysis in unknown onset stroke depends on high early lesion water uptake.

BACKGROUND AND PURPOSE: In wake-up stroke, CT-based quantitative net water uptake (NWU) might serve as an alternative tool to MRI to guide intravenous thrombolysis with alteplase (IVT). An important complication after IVT is symptomatic intracerebral haemorrhage (sICH). As NWU directly implies ischaemic lesion progression, reflecting blood-brain barrier injury, we hypothesised that NWU predicts sICH in patients who had a ischaemic stroke undergoing thrombectomy with unknown onset. METHODS: Consecutive analysis of all patients who had unknown onset anterior circulation ischaemic stroke who underwent CT at baseline and endovascular treatment between December 2016 and October 2020. Quantitative NWU was assessed on baseline CT. The primary endpoint was sICH. The association of NWU and other baseline parameters to sICH was investigated using inverse-probability weighting (IPW) analysis. RESULTS: A total of 88 patients were included, of which 46 patients (52.3%) received IVT. The median NWU was 10.7% (IQR: 5.1-17.7). The proportion of patients with any haemorrhage and sICH were 35.2% and 13.6%. NWU at baseline was significantly higher in patients with sICH (19.1% vs 9.6%, p<0.0001) and the median Alberta Stroke Program Early CT Score (ASPECTS) was lower (5 vs 8, p<0.0001). Following IPW, there was no association between IVT and sICH in unadjusted analysis. However, after adjusting for ASPECTS and NWU, there was a significant association between IVT administration and sICH (14.6%, 95% CI: 3.3% to 25.6%, p<0.01). CONCLUSION: In patients with ischaemic stroke with unknown onset, the combination of high NWU with IVT is directly linked to higher rates of sICH. Besides ASPECTS for evaluating the extent of the early infarct lesion, quantitative NWU could be used as an imaging biomarker to assess the degree of blood-brain barrier damage in order to predict the risk of sICH in patients with wake up stroke.

Investigating Neurologic Improvement After IV Thrombolysis: The Effect of Time From Stroke Onset vs Imaging-Based Tissue Clock.

BACKGROUND AND OBJECTIVES: Time from stroke onset is associated with clinical response to intravenous thrombolysis (IVT) with alteplase and is therefore used to select patients for treatment. Alternatively, neuroimaging may be used for treatment in the uncertain or extended time window. We hypothesized that the patient-specific imaging indicator of ischemic lesion progression ("tissue clock") using CT perfusion (CTP) or quantitative net water uptake (NWU) is a predictor of early neurologic improvement (ENI) independent of time. METHODS: Observational study of anterior circulation ischemic stroke patients with proximal vessel occlusion and known time from symptom onset triaged by multimodal CT undergoing endovascular treatment. Quantitative NWU using an established threshold (11.5%) or CTP lesion core mismatch (EXTEND criteria) was used to estimate ischemic lesion progression. The treatment effect of IVT depending on lesion progression defined by tissue clock vs time clock was assessed by inverse probability weighting (IPW). End points were binarized ENI and functional independence at day 90. RESULTS: Four hundred nine patients were included, of which 223 (54.5%) received IVT. The proportion of patients within an early time window (<4.5 hours), low NWU, and CTP mismatch were 45.0%, 86.5%, and 80.3%. In IPW, IVT was associated with higher rates of ENI (%-difference: 7.3%, p = 0.02). For patients with CTP mismatch or low NWU, IVT was associated with a 9.6% or 7.2% higher rate of ENI, which was different than the effect of IVT in patients without CTP mismatch or high NWU (-9.3%/-7.3%; p = 0.004/p = 0.03), whereas early treatment window did not modify the effect of IVT. DISCUSSION: CT-based measures of the "tissue clock" might identify patients who benefit from IVT more accurately than conventional time windows. Considering the high number of patients with early "tissue clock" (low NWU/CTP mismatch) within an extended time window, considerable benefit from IVT using imaging indicators of the "tissue clock" may be achieved.

Edema Reduction versus Penumbra Salvage: Investigating Treatment Effects of Mechanical Thrombectomy in Ischemic Stroke.

OBJECTIVE: Mechanical thrombectomy (MT) is of benefit to patients with ischemic stroke; however, the effect of recanalization on lesion pathophysiology is not yet well understood. The aim of this study was to quantitatively assess how the effect of vessel recanalization on clinical outcome is mediated by edema reduction versus penumbra salvage. METHODS: Consecutive analysis was made of anterior circulation ischemic stroke patients triaged by multimodal computed tomography (CT) undergoing MT. Edema reduction was defined using the difference of quantitative net water uptake (NWU) determined on baseline and follow-up CT (∆NWU). Penumbra salvage volume (PSV) was defined as the difference between admission penumbra and net infarct growth volumes to follow-up. Mediation analyses were performed with vessel recanalization as independent variable (modified Thrombolysis in Cerebral Infarction ≥ 2b) and ∆NWU/PSV as mediator variables. Modified Rankin Scale scores at 90 days served as endpoint. RESULTS: Of 422 included patients, 321 (76%) achieved successful recanalization. The median ∆NWU was 6.8% (interquartile range [IQR] = 3.9-10.4), and the median PSV was 66ml (IQR = 8-124). ∆NWU, PSV, and recanalization were significantly associated with functional outcome in logistic regression analysis. ∆NWU and PSV partially mediated the relationship between recanalization and outcome. Sixty-six percent of the relationship between recanalization and functional outcome could be explained by treatment-induced edema reduction, whereas 22% was mediated by PSV (p < 0.0001). INTERPRETATION: Compared to penumbra salvage, edema reduction was a stronger mediator of the effect of recanalization on functional outcome. Given the current trials on adjuvant neuroprotectants also targeting ischemic edema formation, combining reperfusion with antiedematous neuroprotectants may have synergistic effects resulting in better outcomes in patients with ischemic stroke. ANN NEUROL 2023.

Cerebellar Modulation of Sensorimotor Associative Plasticity Is Impaired in Cervical Dystonia.

BACKGROUND: In recent years, cervical dystonia (CD) has been recognized as a network disorder that involves not only the basal ganglia but other brain regions, such as the primary motor and somatosensory cortex, brainstem, and cerebellum. So far, the role of the cerebellum in the pathophysiology of dystonia is only poorly understood. OBJECTIVE: The objective of this study was to investigate the role of the cerebellum on sensorimotor associative plasticity in patients with CD. METHODS: Sixteen patients with CD and 13 healthy subjects received cerebellar transcranial direct current stimulation (ctDCS) followed by a paired associative stimulation (PAS) protocol based on transcranial magnetic stimulation that induces sensorimotor associative plasticity. Across three sessions the participants received excitatory anodal, inhibitory cathodal, and sham ctDCS in a double-blind crossover design. Before and after the intervention, motor cortical excitability and motor symptom severity were assessed. RESULTS: PAS induced an increase in motor cortical excitability in both healthy control subjects and patients with CD. In healthy subjects this effect was attenuated by both anodal and cathodal ctDCS with a stronger effect of cathodal stimulation. In patients with CD, anodal stimulation suppressed the PAS effect, whereas cathodal stimulation had no influence on PAS. Motor symptom severity was unchanged after the intervention. CONCLUSIONS: Cerebellar modulation with cathodal ctDCS had no effect on sensorimotor associative plasticity in patients with CD, in contrast with the net inhibitory effect in healthy subjects. This is further evidence that the cerebello-thalamo-cortical network plays a role in the pathophysiology of dystonia. © 2023 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Evaluation of a Child-centred Psychosocial Healthcare Intervention (KIDPROTEKT) - Results of a Cluster Randomized Controlled Trial in Paediatric and Gynaecologic Practices.

KID-PROTEKT is a child-centred psychosocial healthcare intervention which aims at improving the identification of psychosocial needs and navigation in the outpatient gynaecologic and paediatric setting. In this cluster randomized-controlled trail we examined the effect of KID-PROTEKT on the referrals (to support services) in comparison to the regular gynaecologic and paediatric outpatient healthcare . A variant based on the qualification of the healthcare providers (qualified treatment, QT) and a variant with social worker (supported treatment, ST) were compared to the regular healthcare (treatment as usual, TAU). Twenty-four gynaecologic and paediatric practices were randomized to one of three study arms. Therefore 8,458 pregnant women and families recruited in one of these practices were enrolled in the study. Participating patients reported on average 1.73 (SD = 1.34) psychosocial risks. In total 522 patients were linked to a support service. Compared to TAU, the probability of a referral was significantly higher in QT (OR = 10.70) and ST (OR = 11.28). Also, a higher number of psychosocial risks were linked to a referral (OR = 2.72). These findings support the importance of a psychosocial assessment in the gynaecologic and paediatric setting.

KID-PROTEKT es una intervención en asistencia sanitaria psicosocial centrada en el niño, cuyo objetivo es mejorar la detección de las necesidades psicosociales y la navegación en un entorno ambulatorio ginecológico y pediátrico. En este ensayo clínico aleatorizado por conglomerados analizamos el efecto de KID-PROTEKT en las derivaciones (a los servicios de apoyo) en comparación con la asistencia ginecológica y pediátrica externa periódica. Se comparó una variante basada en la cualificación de los proveedores de asistencia sanitaria (tratamiento cualificado, TC) y otra variante con trabajador social (tratamiento de apoyo, TA) con la asistencia sanitaria periódica (tratamiento habitual, TH). Se aleatorizaron 24 servicios ginecológicos y pediátricos en una de las tres ramas del estudio. De este modo participaron en el estudio 8,458 mujeres gestantes y familias reclutadas en una de estas prácticas. Los pacientes participantes notificaron una media de 1.73 (DT = 1.34) riesgos psicosociales. En total se vinculó a 522 pacientes a un servicio de apoyo. En comparación con el tratamiento habitual, la probabilidad de una derivación fue significativamente elevada en el tratamiento cualificado (OR = 10.70) y de apoyo (OR = 11.28). Igualmente se vinculó un elevado número de riesgos psicosociales a una derivación (OR = 2.72). Los resultados confirman la importancia de la evaluación psicosocial en el tratamiento ginecológico y pediátrico.

Effect of geometric distortion correction on thickness and volume measurements of cortical parcellations in 3D T1w gradient echo sequences.

OBJECTIVE: Automated brain volumetric analysis based on high-resolution T1-weighted MRI datasets is a frequently used tool in neuroimaging for early detection, diagnosis, and monitoring of various neurological diseases. However, image distortions can corrupt and bias the analysis. The aim of this study was to explore the variability of brain volumetric analysis due to gradient distortions and to investigate the effect of distortion correction methods implemented on commercial scanners. MATERIAL AND METHODS: 36 healthy volunteers underwent brain imaging using a 3T magnetic resonance imaging (MRI) scanner, including a high-resolution 3D T1-weighted sequence. For all participants, each T1-weighted image was reconstructed directly on the vendor workstation with (DC) and without (nDC) distortion correction. For each participant's set of DC and nDC images, FreeSurfer was used for the determination of regional cortical thickness and volume. RESULTS: Overall, significant differences were found in 12 cortical ROIs comparing the volumes of the DC and nDC data and in 19 cortical ROIs comparing the thickness of the DC and nDC data. The most pronounced differences for cortical thickness were found in the precentral gyrus, the lateral occipital and postcentral ROI (2.69, -2.91% and -2.79%, respectively) while cortical volumes differed most prominently in the paracentral, the pericalcarine and lateral occipital ROI (5.52%, -5.40% and -5.11%, respectively). CONCLUSION: Correcting for gradient non-linearities can have significant influence on volumetric analysis of cortical thickness and volume. Since the distortion correction is an automatic feature of the MR scanner, it should be stated by each study that applies volumetric analysis which images were used.

Penumbra salvage in extensive stroke: exploring limits for reperfusion therapy.

BACKGROUND: The effect of thrombectomy in patients presenting with extensive ischemic stroke at baseline is currently being investigated; it remains uncertain to what extent brain tissue may be saved by reperfusion in such patients. Penumbra salvage volume (PSV) has been described as a tool to measure the volume of rescued penumbra. OBJECTIVE: To assess whether the effect of recanalization on PSV is dependent on the extent of early ischemic changes. METHODS: Observational study of patients with anterior circulation ischemic stroke triaged by multimodal-CT undergoing thrombectomy. PSV was defined as the difference between baseline penumbra volume and net infarct growth to follow-up. The effect of vessel recanalization on PSV depending on the extent of early ischemic changes (defined using Alberta Stroke Program Early CT Score (ASPECTS) and core volumes based on relative cerebral blood flow) was determined using multivariable linear regression analysis, and the association with functional outcome at day 90 was tested using multivariable logistic regression. RESULTS: 384 patients were included, of whom 292 (76%) achieved successful recanalization (modified Thrombolysis in Cerebral Infarction ≥2b). Successful recanalization was independently associated with 59 mL PSV (95% CI 29.8 to 88.8 mL) and was linked to increased penumbra salvage up to an ASPECTS of 3 and core volume up to 110 mL. Recanalization was associated with a higher probability of a modified Rankin Scale score of ≤2 up to a core volume of 100 mL. CONCLUSIONS: Recanalization was associated with significant penumbra salvage up to a lower ASPECTS margin of 3 and upper core volume margin of 110 mL. The clinical benefit of recanalization for patients with very large ischemic regions of >100 mL or ASPECTS <3 remains uncertain and requires prospective investigation.

Speech assessment following microsurgical soft palate repair.

The aim of this study was to analyze speech intelligibility of children, who had undergone microsurgical soft palate repair according to Sommerlad. Cleft palate patients were treated by closure of the soft palate according to Sommerlad at about 6 months of age. At the age of 11, their speech was evaluated through automatic speech recognition. Word recognition rate (WR) was used as the outcome parameter of automatic speech recognition. To validate automatic speech results, an institute for speech therapy evaluated the speech samples for perceptual intelligibility. The results of this study group were compared to an age-matched control group. A total of 61 children were evaluated in this study, 29 in the study group and 32 in the control group. Study group patients had a lower word recognition rate (mean 43.03, SD 12.31) compared to the control group (mean 49.98, SD 12.54, p = 0.033). The magnitude of the difference was considered small (95% CI of the difference 0.6-13.3). The study group patients received significantly lower scores in the perceptual evaluation (mean 1.82, SD 0.58) compared to the control group mean (mean 1.51, SD 0.48, p = 0.028). Again, the magnitude of the difference was small (95% CI of the difference 0.03-0.57). Within the limitations of the study it seems that microsurgical soft palate repair according to Sommerlad at the age of 6 months might be a relevant alternative to other well established surgical techniques.

Evaluation of a Child-centred Psychosocial Healthcare Intervention (KIDPROTEKT) – Results of a Cluster Randomized Controlled Trial in Paediatric and Gynaecologic Practices / La evaluación de la asistencia sanitaria psicosocial centrada en el niño (KIDPROTEKT): resultados de un ensayo clínico aleatorizado por conglomerados en clínicas pediátricas y ginecológicas

KID-PROTEKT is a child-centred psychosocial healthcare intervention which aims at improving the identification of psychosocial needs and navigation in the outpatient gynaecologic and paediatric setting. In this cluster randomized-controlled trail we examined the effect of KID-PROTEKT on the referrals (to support services) in comparison to the regular gynaecologic and paediatric outpatient healthcare . A variant based on the qualification of the healthcare providers (qualified treatment, QT) and a variant with social worker (supported treatment, ST) were compared to the regular healthcare (treatment as usual, TAU). Twenty-four gynaecologic and paediatric practices were randomized to one of three study arms. Therefore 8,458 pregnant women and families recruited in one of these practices were enrolled in the study. Participating patients reported on average 1.73 (SD = 1.34) psychosocial risks. In total 522 patients were linked to a support service. Compared to TAU, the probability of a referral was significantly higher in QT (OR = 10.70) and ST (OR = 11.28). Also, a higher number of psychosocial risks were linked to a referral (OR = 2.72). These findings support the importance of a psychosocial assessment in the gynaecologic and paediatric setting. (AU)

KID-PROTEKT es una intervención en asistencia sanitaria psicosocial centrada en el niño, cuyo objetivo es mejorar la detección de las necesidades psicosociales y la navegación en un entorno ambulatorio ginecológico y pediátrico. En este ensayo clínico aleatorizado por conglomerados analizamos el efecto de KID-PROTEKT en las derivaciones (a los servicios de apoyo) en comparación con la asistencia ginecológica y pediátrica externa periódica. Se comparó una variante basada en la cualificación de los proveedores de asistencia sanitaria (tratamiento cualificado, TC) y otra variante con trabajador social (tratamiento de apoyo, TA) con la asistencia sanitaria periódica (tratamiento habitual, TH). Se aleatorizaron 24 servicios ginecológicos y pediátricos en una de las tres ramas del estudio. De este modo participaron en el estudio 8,458 mujeres gestantes y familias reclutadas en una de estas prácticas. Los pacientes participantes notificaron una media de 1.73 (DT = 1.34) riesgos psicosociales. En total se vinculó a 522 pacientes a un servicio de apoyo. En comparación con el tratamiento habitual, la probabilidad de una derivación fue significativamente elevada en el tratamiento cualificado (OR = 10.70) y de apoyo (OR = 11.28). Igualmente se vinculó un elevado número de riesgos psicosociales a una derivación (OR = 2.72). Los resultados confirman la importancia de la evaluación psicosocial en el tratamiento ginecológico y pediátrico. (AU)

Association Between Net Water Uptake and Functional Outcome in Patients With Low ASPECTS Brain Lesions: Results From the I-LAST Study.

BACKGROUND AND OBJECTIVES: The effect of mechanical thrombectomy (MT) on functional outcome in patients with ischemic stroke with low ASPECTS is still uncertain. ASPECTS rating is based on the presence of ischemic hypoattenuation relative to normal; however, the degree of hypoattenuation, which directly reflects net uptake of water, is currently not considered an imaging biomarker in stroke triage. We hypothesized that the effect of thrombectomy on functional outcome in low ASPECTS patients depends on early lesion water uptake. METHODS: For this multicenter observational study, patients with anterior circulation stroke with ASPECTS ≤5 were consecutively analyzed. Net water uptake (NWU) was assessed as a quantitative imaging biomarker in admission CT. The primary end point was the rate of favorable functional outcome defined as modified Rankin Scale score 0-3 at day 90. The effect of recanalization on functional outcome was analyzed according to the degree of NWU within the early infarct lesion. RESULTS: A total of 254 patients were included, of which 148 (58%) underwent MT. The median ASPECTS was 4 (interquartile range [IQR] 3-5), and the median NWU was 11.4% (IQR 8.9%-15.1%). The rate of favorable outcome was 27.6% in patients with low NWU (<11.4%) vs 6.3% in patients with high NWU (≥11.4%; p < 0.0001). In multivariable logistic regression analysis, NWU was an independent predictor of outcome, whereas vessel recanalization (modified thrombolysis in cerebral infarction ≥2b) was only significantly associated with better outcomes if NWU was lower than 12.6%. In inverse-probability weighting analysis, recanalization was associated with 20.7% (p = 0.01) increase in favorable outcome in patients with low NWU compared with 9.1% (p = 0.06) in patients with high NWU. DISCUSSION: Early NWU was independently associated with clinical outcome and might serve as an indicator of futile MT in low ASPECTS patients. NWU could be tested as a tool to select low ASPECTS patients for MT. TRIAL REGISTRATION INFORMATION: The study is registered within the ClinicalTrials.gov Protocol Registration and Results System (NCT04862507).

Assessment of Irreversible Tissue Injury in Extensive Ischemic Stroke-Potential of Quantitative Cerebral Perfusion.

Computed tomography perfusion (CTP) is used as a tool to select ischemic stroke patients for endovascular treatment (EVT) and is currently investigated in the setting of extensive stroke with low Alberta Stroke Program Early CT scores (ASPECTS). The purpose of this study was to perform a comprehensive quantitative analysis of cerebral blood flow within the ischemic lesion compared to threshold-derived core lesion volumes. We hypothesized that the degree of cerebral blood volume (CBV) reduction within the ischemic lesion is predictive of irreversible tissue injury and functional outcome in patients with low ASPECTS. Ischemic stroke patients with an ASPECTS ≤ 5 who received multimodal CT on admission and underwent thrombectomy were analyzed. The ischemic lesion on CTP was identified, and CTP-derived parameters were measured as absolute means within the lesion and relative to the physiological perfusion measured in a contralateral region of interest. The degree of irreversible tissue injury was assessed using quantitative net water uptake (NWU). Functional endpoint was good outcome defined as modified Rankin Scale (mRS) scores 0-3 at day 90. One hundred eleven patients were included. The median core lesion volume was 71 ml (IQR: 25-107), and the median quantitative NWU was 9.5% (IQR: 6-13). Relative CBV (rCBV) reduction and ASPECTS at baseline were independently associated with NWU in multivariable linear regression analysis (ß: 12.4, 95%CI: 6.0-18.9, p < 0.0001) and (ß: - 0.78, 95% CI: - 1.53 to - 0.02; p = 0.045), respectively. Furthermore, rCBV was significantly associated with good outcome in patients with core volumes > 50 ml (OR: 0.16, 95% CI: 0.05-0.49, p = 0.001). Our study shows that rCBV reduction serves as an early surrogate for increase of NWU as a marker of irreversible tissue injury and lesion progression. Thus, the analysis of rCBV reduction within ischemic lesions may add another dimension to acute stroke triage in addition to core volumes or ASPECTS as indicators of the infarct extent and viability.

Post-traumatic stress disorder in refugee minors in an outpatient care center: prevalence and associated factors.

Due to their likelihood for experiencing a number of traumatic events, refugee minors have an increased risk of developing post-traumatic stress disorder (PTSD). However, the prevalence of PTSD in refugee children varies widely between studies, and it remains somewhat unclear what factors increase children's risk of PTSD. This study aimed to assess the prevalence of PTSD in a clinical outpatient sample of refugee minors, and to evaluate the association of different risk factors with a PTSD diagnosis. N = 417 refugee minors were recruited from an outpatient clinical center in Hamburg, Germany. The median age was 15.4 years and 74.6% of the minors were male. As part of the standard diagnostic process, their social history and a potential PTSD diagnosis using the Module K of the Mini-International Neuropsychiatric Interview for Children and Adolescents (MINI-KID) was assessed. The predictive value of age, gender, number of interpersonal traumatic events, un-/accompanied status, presence of family member in the host country, flight duration, residence status, and time since arrival in the host country were investigated using logistic regression analysis. The prevalence of PTSD among the young refugee patients was 61.6%. Significant predictors of a PTSD diagnosis were number of interpersonal traumatic life events, age, residence status, and time since arrival in the host country. The prediction model explained 33.8% of variance of the outcome with the number of interpersonal traumatic events having the largest contribution (20.8%). The high prevalence of PTSD among refugee minors in outpatient care emphasizes the need to establish appropriate care structures and train specialists in the treatment of PTSD.

CMR feature tracking in patients with dilated cardiomyopathy: patterns of myocardial strain and focal fibrosis.

BACKGROUND: There is a paucity of data on cardiovascular magnetic resonance feature tracking (CMR-FT) in patients with dilated cardiomyopathy (DCM). We aimed at describing global and segmental myocardial strain patterns and a potential association with the presence of focal myocardial scarring in DCM patients by CMR-FT. METHODS: Thirty-nine patients with DCM and reduced left ventricular (LV) ejection fraction (mean 21±8%) underwent CMR including standard cine steady-state free precession (SSFP) sequences and late gadolinium enhancement (LGE). We measured global LV longitudinal as well as global and segmental circumferential and radial strain. The presence of focal myocardial fibrosis was assessed on LGE images. RESULTS: Nineteen patients had focal myocardial fibrosis on LGE images with the highest prevalence in the basal septal segments II and III, which were affected in 12 (63%) and 13 (68%) patients. Furthermore, there was a significantly lower average short-axis LV radial strain (LVSAX-RS) in these segments (4.89 (-1.55 to 11.34) %) compared with the average of the other myocardial segments (21.20 (17.36 to 25.05)%; p<0.001) after adjusting for LGE and left-bundle branch block (LBBB). In general, LV segments with LGE had lower model-based mean LVSAX-RS values (17.65 (10.37 to 24.93) %) compared with those without LGE (19.40 (15.43 to 23.37) %), but this effect was not significant after adjusting for the presence of LBBB (p=0.630). CONCLUSION: Our findings revealed a coincidence of impaired radial strain and focal myocardial fibrosis in the basal septal LV myocardial segments of patients with DCM. Regardless of this pattern, we did not find a general, significant effect of myocardial fibrosis on strain in our cohort. Future studies are required to assess the potential prognostic implications of myocardial strain patterns in addition to the assessment of myocardial fibrosis in patients with DCM.

Low baseline ischemic water uptake is directly related to overestimation of CT perfusion-derived ischemic core volume.

Computed-tomography perfusion (CTP) is frequently used to screen acute ischemic stroke (AIS) patients for endovascular treatment (EVT), despite known problems with ischemic "core" overestimation. This potentially leads to the unfair exclusion of patients from EVT. We propose that net water uptake (NWU) can be used in addition to CTP to more accurately assess the extent and/or stage of tissue infarction. Patients treated for AIS between 06/2015 and 07/2020 were retrospectively analyzed. Baseline CTP-derived core volume (pCore) and NWU were determined. Logistic regression tested the relationship between baseline clinical and imaging variables and core-overestimation (primary outcome). The secondary outcomes comprised 90-day functional independence (modified Rankin score) and lesion growth. 284 patients were included. Median NWU was 7.2% (IQR 2.6-12.8). ASPECTS (RR 1.28, 95% CI 1.09-1.51), NWU (RR 0.94, 95% CI 0.89-0.98), onset to recanalization (RR 1.00, 95% CI 0.99-1.00) and imaging (RR 1.00, 95% CI 1.00-1.00) times, and pCore (RR 1.02, 95% CI 1.01-1.02) were significantly associated with core overestimation. Core-overestimation was more likely to occur in patients with large pCores and low NWU at baseline. NWU was significantly correlated with lesion growth. We conclude that NWU can be used as a supplemental tool to CTP during admission imaging to more accurately assess the extent of ischemia, particularly relevant for patients with large CTP-defined cores who would otherwise be excluded from treatment.

Structural cerebellar reserve positively influences outcome after severe stroke.

The concept of brain reserve capacity positively influencing the process of recovery after stroke has been continuously developed in recent years. Global measures of brain health have been linked with a favourable outcome. Numerous studies have evidenced that the cerebellum is involved in recovery after stroke. However, it remains an open question whether characteristics of cerebellar anatomy, quantified directly after stroke, might have an impact on subsequent outcome after stroke. Thirty-nine first-ever ischaemic non-cerebellar stroke patients underwent MRI brain imaging early after stroke and longitudinal clinical follow-up. Structural images were used for volumetric analyses of distinct cerebellar regions. Ordinal logistic regression analyses were conducted to associate cerebellar volumes with functional outcome 3-6 months after stroke, operationalized by the modified Rankin Scale. Larger volumes of cerebellar lobules IV, VI, and VIIIB were positively correlated with favourable outcome, independent of the severity of initial impairment, age, and lesion volume (P < 0.01). The total cerebellar volume did not exhibit a significant structure-outcome association. The present study reveals that pre-stroke anatomy of distinct cerebellar lobules involved in motor and cognitive functioning might be linked to outcome after acute non-cerebellar stroke, thereby promoting the emerging concepts of structural brain reserve for recovery processes after stroke.

Association of Thrombectomy With Functional Outcome for Patients With Ischemic Stroke Who Presented in the Extended Time Window With Extensive Signs of Infarction.

Importance: Only limited data are available about a potential benefit associated with endovascular treatment (EVT) for patients with ischemic stroke presenting in the extended time window who also show signs of extensive infarction. Objective: To assess the association of recanalization after EVT with functional outcomes for patients with ischemic stroke presenting in the extended time window who also show signs of extensive infarction. Design, Setting, and Participants: This retrospective, multicenter cohort study included patients enrolled in the German Stroke Registry-Endovascular Treatment with an Alberta Stroke Program Early CT Score (ASPECTS) of 5 or less who presented between 6 and 24 hours after stroke onset and underwent computed tomography and subsequent EVT between July 1, 2015, and December 31, 2019. Main Outcomes and Measures: The primary end point was a modified Rankin Scale (mRS) score of 3 or less at day 90. The association between recanalization (defined as the occurrence of a modified Thrombolysis in Cerebral Infarction Scale score of 2b or 3) and outcome was assessed using logistic regression and inverse probability weighting analysis. Intervention: Endovascular treatment. Results: Of 5853 patients, 285 (5%; 146 men [51%]; median age, 73 years [IQR, 62-81 years]) met the inclusion criteria and were analyzed. Of these 285 patients, 79 (27.7%) had an mRS score of 3 or less at day 90. The rate of successful recanalization was 75% (215 of 285) and was independently associated with a higher probability of reaching an mRS score of 3 or less (adjusted odds ratio, 4.39; 95% CI, 1.79-10.72; P < .001). In inverse probability weighting analysis, a modified Thrombolysis in Cerebral Infarction Scale score of 2b or 3 was associated with a 19% increase (95% CI, 9%-29%; P < .001) in the probability for an mRS score of 3 or more. Multivariable logistic regression analysis suggested a significant treatment benefit associated with vessel recanalization in a time window of up to 17.6 hours and ASPECTS of 3 to 5. The rate of secondary symptomatic intracerebral hemorrhage was 6.3% (18 of 285). Conclusions and Relevance: In this cohort study reflecting daily clinical practice, vessel recanalization for patients with a low ASPECTS and extended time window was associated with better functional outcomes in a time window up to 17.6 hours and ASPECTS of 3 to 5. The results of this study encourage current randomized clinical trials to enroll patients with a low ASPECTS, even within the extended time window.