Glycated serum protein is independently associated with progressive infarction in patients with acute ischemic stroke.

OBJECTIVE: This study investigated the relationship between glycated serum protein (GSP) and progressive infarction (PI). METHODS: From April 2017 to December 2020, we recruited 477 patients within 48 hours after the onset of acute ischemic stroke into this case-control study. Demographic characteristics, clinical information, and laboratory and neuroimaging data were recorded after admission. RESULTS: PI occurred in 144 (30.8%) patients. Patients with PI had higher initial National Institute of Health Stroke Scale (NIHSS) scores, higher discharge NIHSS scores, higher modified Rankin scale scores at 3 months after onset, higher GSP levels, lower prothrombin times, and lower creatinine levels than patients without PI. The likelihood of PI increased with increases in the GSP quartile. Multiple regression analysis revealed that high GSP levels (>2.14 mmol/L) were independently associated with PI. Subgroup analyses identified high GSP levels as an independent predictor of PI in patients with large artery atherosclerosis (third quartile: odds ratio [OR] = 3.793; 95% confidence interval [CI] = 1.555-9.250; fourth quartile: OR = 2.675; 95% CI = 1.056-6.776) and anterior circulation small vessel occlusion (fourth quartile: OR = 13.859; 95% CI = 2.024-94.885). CONCLUSIONS: GSP might be an independent predictor for PI in certain patients with acute ischemic stroke.

Utilization of a Supraglottic Airway Device for Airway Rescue and Tamponade of an Oropharyngeal Hemorrhage After Systemic Thrombolysis for an Acute Ischemic Stroke: A Case Report.

A 39-year-old man presented for mechanical thrombectomy after receiving systemic tissue plasminogen activator (tPA) for a basilar artery occlusion. The anesthesiology team was initially unable to intubate the patient due to oropharyngeal bleeding and a large epiglottis. Two-handed, 2-provider mask ventilation with an oral airway proved difficult. The team successfully placed a supraglottic airway (SGA) through which an oral endotracheal tube (ETT) was advanced over a fiberoptic bronchoscope into the trachea. The SGA remained overnight with the cuff inflated to tamponade the bleeding. The ETT was exchanged over an airway exchange catheter on postoperative day 1 without further airway complications.

Thrombectomy vs Medical Management for Posterior Cerebral Artery Stroke: Systematic Review, Meta-Analysis, and Real-World Data.

BACKGROUND AND OBJECTIVES: There is a paucity of high-level evidence for endovascular thrombectomy (EVT) in posterior cerebral artery (PCA) strokes. METHODS: The MEDLINE, Embase, and Web of Science databases were queried for well-conducted cohort studies comparing EVT vs medical management (MM) for PCA strokes. Outcomes of interest included 90-day functional outcomes, symptomatic intracranial hemorrhage (sICH), and death. The level of evidence was determined per the Oxford Centre for Evidence-Based Medicine criteria. We also conducted a propensity score matched (PSM) analysis of the 2016-2020 National Inpatient Sample (NIS) to provide support for our findings with real-world data. RESULTS: A total of 2,095 patients (685 EVT and 1,410 MM) were identified across 5 well-conducted cohort studies. EVT was significantly associated with higher odds of no disability at 90 days (odds ratio [OR] 1.25, 95% CI 1.04-1.50, p = 0.015) but not functional independence (OR 0.87, 95% CI 0.72-1.07, p = 0.18). EVT was also associated with higher odds of sICH (OR 2.48, 95% CI 1.55-3.97, p < 0.001) and numerically higher odds of death (OR 1.32, 95% CI 0.73-2.38; p = 0.35). PSM analysis of 95,585 PCA stroke patients in the NIS showed that EVT (n = 1,540) was associated with lower rates of good discharge outcomes (24.4% vs 30.7%, p = 0.037), higher rates of in-hospital mortality (8.8% vs 4.9%, p = 0.021), higher rates of ICH (18.2% and 11.7%, p = 0.008), and higher rates of subarachnoid hemorrhage (3.9% vs 0.6%, p < 0.001). Among patients with moderate to severe strokes (NIH Stroke Scale 5 or greater), EVT was associated with significantly higher rates of good outcomes (21.7% vs 13.8%, p = 0.023) with similar rates of mortality (7.6% vs 6.6%, p = 0.67) and ICH (17.8% vs, 13.1%, p = 0.18). DISCUSSION: Our meta-analysis revealed that while EVT may be effective in alleviating disabling deficits due to PCA strokes, it is not associated with different odds of functional independence and may be associated with higher odds of sICH. These findings were corroborated by our large propensity score matched analysis of real-world data in the United States. Thus, the decision to pursue PCA thrombectomies should be carefully individualized for each patient. Future randomized trials are needed to further explore the efficacy and safety of EVT for the treatment of PCA strokes. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that in patients with acute PCA ischemic stroke, treatment with EVT compared with MM alone was associated with higher odds of no disabling deficit at 90 days and higher odds of sICH.

Glucose Control and Risk of Symptomatic Intracerebral Hemorrhage Following Thrombolysis for Acute Ischemic Stroke: A SHINE Trial Analysis.

BACKGROUND AND OBJECTIVES: Baseline hyperglycemia is associated with worse outcomes in acute ischemic stroke (AIS), including higher risk of symptomatic intracerebral hemorrhage (sICH) following treatment with thrombolysis. Prospective data are lacking to inform management of post-thrombolysis hyperglycemia. In a prespecified analysis from the Stroke Hyperglycemia Insulin Network Effort (SHINE) trial of hyperglycemic stroke management, we hypothesized that post-thrombolysis hyperglycemia is associated with a higher risk of sICH. METHODS: Hyperglycemic AIS patients <12 hours onset were randomized to intensive insulin (target range 80-130 mg/dL) vs standard sliding scale (80-179 mg/dL) over a 72-hour period, stratified by treatment with thrombolysis. Three board-certified vascular neurologists independently reviewed all sICH events occurring within 7 days, defined by neurologic deterioration of ≥4 points on the NIH Stroke Scale (NIHSS). Associations between blood glucose control and sICH were analyzed using logistic regression accounting for NIHSS, age, systolic blood pressure, onset to thrombolysis time, and endovascular therapy (odds ratios [OR], 95% CI). Additional analysis compared patients in a high-risk group (age older than 60 years and NIHSS ≥8) vs all others. Categorical variables and outcomes were compared using the χ2 test (p < 0.05). RESULTS: Of 1151 SHINE participants, 725 (63%) received thrombolysis (median age 65 years, 46% women, 29% Black, 18% Hispanic). The median NIHSS was 7, baseline blood glucose was 187 (interquartile range 153-247) mg/dL, and 80% were diabetic. Onset to thrombolysis time was 2.2 hours (1.6-2.9). Post-thrombolysis sICH occurred in 3.6% (3.0% intensive vs 4.3% standard glucose control, OR 1.10, 0.60-2.01, p = 0.697). In the first 12 hours, every 10 mg/dL higher glucose increased the odds of sICH (OR 1.08, 1.03-1.14, p = 0.004), and a greater proportion of glucose measures in the normal range (80-130 mg/dL) decreased the odds of sICH (0.89, 0.80-0.99, p = 0.030). These associations were strongest in the high-risk group (age older than 60 years and NIHSS ≥8). DISCUSSION: In this prespecified analysis from the SHINE trial, intensive insulin therapy was not associated with a reduced risk of post-thrombolysis sICH compared with standard sliding scale. However, early post-thrombolysis hyperglycemia was associated with a higher risk of sICH overall, particularly in older patients with more severe strokes. Further prospective research is warranted to address the risk of sICH in hyperglycemic stroke patients undergoing endovascular therapy. TRIAL REGISTRATION INFORMATION: NCT01369069.

Risk Factors Associated With Exclusion of Obese Patients Ischemic Stroke With a History of Smoking From Thrombolysis Therapy.

The objective of this study is to determine risk factors that may contribute to exclusion decision from recombinant tissue plasminogen activator (rtPA) in patients with acute ischemic stroke (AIS) with a combined current or history of smoking and obesity. This study was conducted on data from 5469 patients with AIS collected from a regional stroke registry. Risk factors associated with inclusion or exclusion from rtPA were determined using multivariate logistic regression analysis. The adjusted odds ratios and 95% confidence interval for each risk factor were used to predict the increasing odds of an association of a specific risk factor with exclusion from rtPA. In the adjusted analysis, obese patients with AIS with a history of smoking (current and previous) excluded from rtPA were more likely to present with carotid artery stenosis (OR = 0.069, 95% CI 0.011-0.442), diabetes (OR = 0.604, 95% CI 0.366-0.997), higher total cholesterol (OR = 0.975, 95% CI 0.956-0.995), and history of alcohol use (OR = 0.438, 95% CI 0.232-0.828). Higher NIHSS score (OR = 1.051, 95% CI 1.017-1.086), higher triglycerides (OR = 1.004, 95% CI 1.001-1.006), and higher high-density lipoprotein (OR = 1.028, 95% CI 1.000-1.057) were associated with the inclusion for rtPA. Our findings reveal specific risk factors that contribute to the exclusion of patients with AIS with a combined effect of smoking and obesity from rtPA. These findings suggest the need to develop management strategies to improve the use of rtPA for obese patients with AIS with a history of smoking.

Rare instances of concomitant acute myocardial infarction and stroke.

Cardio-cerebral infarction (CCI) is a term coined to describe concomitant myocardial infarction and acute ischemic stroke. Acute myocardial infarction and stroke, as separate events, constitute some of the most important causes for disability and mortality in aging societies. Stroke can either occur simultaneously with myocardial infarction or become a serious complication of myocardial infarction and/or its treatment. The frequency of CCI has been reported at a 0.009% incidence rate in stroke patients and is associated with an extremely high mortality. Because of the rare occurrence of CCI, there are currently no guidelines for assessing its diagnosis and optimal treatment. Therefore, currently, the management of CCI cases needs to be individualized. Hopefully, in the future, the results of large clinical trials or prospective registries are expected to enhance our understanding of managing concomitant acute MI and stroke. In this review we have focused on the current literacy in the diagnosis and treatment of CCIs. The paper illustrates potential distinct scenarios of CCI through the analysis of three patient cases (Fig. 5, Ref. 65). Text in PDF www.elis.sk Keywords: myocardial infarction, stroke, cardio-cerebral infarction, carotid artery stenting, cardiac surgery.

Data Extraction from Free-Text Reports on Mechanical Thrombectomy in Acute Ischemic Stroke Using ChatGPT: A Retrospective Analysis.

Background Procedural details of mechanical thrombectomy in patients with ischemic stroke are important predictors of clinical outcome and are collected for prospective studies or national stroke registries. To date, these data are collected manually by human readers, a labor-intensive task that is prone to errors. Purpose To evaluate the use of the large language models (LLMs) GPT-4 and GPT-3.5 to extract data from neuroradiology reports on mechanical thrombectomy in patients with ischemic stroke. Materials and Methods This retrospective study included consecutive reports from patients with ischemic stroke who underwent mechanical thrombectomy between November 2022 and September 2023 at institution 1 and between September 2016 and December 2019 at institution 2. A set of 20 reports was used to optimize the prompt, and the ability of the LLMs to extract procedural data from the reports was compared using the McNemar test. Data manually extracted by an interventional neuroradiologist served as the reference standard. Results A total of 100 internal reports from 100 patients (mean age, 74.7 years ± 13.2 [SD]; 53 female) and 30 external reports from 30 patients (mean age, 72.7 years ± 13.5; 18 male) were included. All reports were successfully processed by GPT-4 and GPT-3.5. Of 2800 data entries, 2631 (94.0% [95% CI: 93.0, 94.8]; range per category, 61%-100%) data points were correctly extracted by GPT-4 without the need for further postprocessing. With 1788 of 2800 correct data entries, GPT-3.5 produced fewer correct data entries than did GPT-4 (63.9% [95% CI: 62.0, 65.6]; range per category, 14%-99%; P < .001). For the external reports, GPT-4 extracted 760 of 840 (90.5% [95% CI: 88.3, 92.4]) correct data entries, while GPT-3.5 extracted 539 of 840 (64.2% [95% CI: 60.8, 67.4]; P < .001). Conclusion Compared with GPT-3.5, GPT-4 more frequently extracted correct procedural data from free-text reports on mechanical thrombectomy performed in patients with ischemic stroke. © RSNA, 2024 Supplemental material is available for this article.

Large variations in atrial fibrillation screening practice after ischemic stroke and transient ischemic attack in Sweden: a survey study.

BACKGROUND: Atrial fibrillation (AF) screening after ischemic stroke or transient ischemic attack (TIA) is given high priority in clinical guidelines. However, patient selection, electrocardiogram (ECG) modality and screening duration remains undecided and current recommendations vary. METHODS: The aim of this study was to investigate the clinical practice of AF screening after ischemic stroke or TIA at Swedish stroke units. In collaboration with the stakeholders of the Swedish Stroke Register (Riksstroke) a digital survey was drafted, then tested and revised by three stroke consultants. The survey consisted of 17 multiple choice/ free text questions and was sent by e-mail to the medical directors at all stroke units in Sweden. RESULTS: All 72 stroke units in Sweden responded to the survey. Most stroke units reported that ≥ 75% of ischemic stroke (69/72 stroke units) or TIA patients (67/72 stroke units), without previously known AF, were screened for AF. Inpatient telemetry ECG was the method of first-choice in 81% of the units, but 7% reported lack of access. A variety of standard monitoring durations were used for inpatient telemetry ECG. The second most common choice was Holter ECG (17%), also with considerable variations in monitoring duration. Other AF screening modalities were used as a first-choice method (handheld and patch ECG) but less frequently. CONCLUSIONS: Clinical practice for AF screening after ischemic stroke or TIA differed between Swedish stroke units, both in choice of AF screening methods as well as in monitoring durations. There is an urgent need for evidence and evidence-based recommendations in this field. TRIAL REGISTRATION: Not applicable.

General anesthesia versus conscious sedation in mechanical thrombectomy for patients with acute ischemic stroke: systematic review and meta-analysis.

BACKGROUND: After recently published randomized clinical trials, the choice of the best anesthetic procedure for mechanical thrombectomy (MT) in acute ischemic stroke (AIS) due to large vessel occlusion (LVO) is not definite. OBJECTIVE: To compare the efficacy and safety of general anesthesia (GA) versus conscious sedation (CS) in patients with AIS who underwent MT, explicitly focusing on procedural and clinical outcomes and the incidence of adverse events. METHODS: PubMed, Embase, and Cochrane were systematically searched for randomized controlled trials (RCTs) comparing GA versus CS in patients who underwent MT due to LVO-AIS. Odds ratios (ORs) were calculated for binary outcomes, with 95% confidence intervals (CIs). Random effects models were used for all outcomes. Heterogeneity was assessed with I2 statistics. RESULTS: Eight RCTs (1,300 patients) were included, of whom 650 (50%) underwent GA. Recanalization success was significantly higher in the GA group (OR 1.68; 95% CI 1.26-2.24; p < 0.04) than in CS. No significant difference between groups were found for good functional recovery (OR 1.13; IC 95% 0.76-1.67; p = 0.56), incidence of pneumonia (OR 1.23; IC 95% 0.56- 2,69; p = 0.61), three-month mortality (OR 0.99; IC 95% 0.73-1.34; p = 0.95), or cerebral hemorrhage (OR 0.97; IC 95% 0.68-1.38; p = 0.88). CONCLUSION: Despite the increase in recanalization success rates in the GA group, GA and CS show similar rates of good functional recovery, three-month mortality, incidence of pneumonia, and cerebral hemorrhage in patients undergoing MT.

ANTECEDENTES: A trombectomia mecânica (TM) é o padrão de tratamento para pacientes com acidente vascular cerebral isquêmico agudo (AVCI) devido à oclusão de grandes vasos (OGV). No entanto, ainda não está claro qual é o procedimento anestésico mais benéfico para a TM. OBJETIVO: Nosso objetivo foi comparar a eficácia e a segurança da anestesia geral (AG) versus sedação consciente (SC) em pacientes com AVCI submetidos à TM, focando especificamente nos resultados procedimentais e clínicos, bem como na incidência de eventos adversos. MéTODOS: Foram realizadas buscas sistemáticas nas bases PubMed, Embase e Cochrane por ensaios clínicos randomizados (ECRs) comparando AG versus SC em pacientes submetidos à TM devido a AVCI por OGV. Razões de chances (ORs) foram calculadas para desfechos binários, com intervalos de confiança de 95% (ICs). Modelos de efeitos aleatórios foram usados para todos os resultados. A heterogeneidade foi avaliada com estatísticas I2. RESULTADOS: Oito ensaios clínicos randomizados (1.300 pacientes) foram incluídos, dos quais 650 (50%) foram submetidos à AG. O sucesso da recanalização foi significativamente maior no grupo AG (OR 1,68; IC 95% 1,26­2,24; p < 0,04) em comparação com SC. No entanto, não houve diferença significativa entre os grupos para recuperação funcional adequada (OR 1,13; IC 95% 0,76­1,67; p = 0,56), incidência de pneumonia (OR 1,23; IC 95% 0,56- 2,69; p = 0,61), mortalidade em três meses (OR 0,99; IC 95% 0,73- 1,34; p = 0,95) ou hemorragia cerebral (OR 0,97; IC 95% 0,68- 1,38; p = 0,88). CONCLUSãO: Apesar do aumento significativo nas taxas de sucesso de recanalização no grupo AG, AG e SC mostram taxas semelhantes de recuperação funcional, mortalidade, pneumonia e hemorragia em pacientes com AVCI submetidos à TM.

TRIGLYCERIDE - GLUCOSE INDEX, REMNANT CHOLESTEROL AND COMMON CAROTID ARTERY INTIMA-MEDIA THICKNESS AS AN ATHEROSCLEROTIC MARKER IN ISCHEMIC STROKE PATIENTS.

Ischemic stroke (IS) is a major global health concern, often resulting from atherosclerosis and insulin resistance (IR). The triglyceride-glucose index (TyG index), remnant cholesterol (RC), and common artery intima-media thickness (CIMT) are potential markers for assessing atherosclerosis and cardiovascular risk in IS patients. A cross-sectional study was conducted to investigate the association between TyG index, RC, CIMT, and IS in adult patients recruited from a hospital. Demographic, clinical, and laboratory data were collected, and statistical analysis was performed. The study included 50 participants with a balanced gender distribution and a mean age of 57.64 years. Laboratory characteristics showed notable values, and CIMT > 0.6 mm was associated with higher NIH Stroke Scale scores. RC exhibited significant correlations with age, CIMT, lipid profile, and TyG index. The study highlights the potential of TyG index, RC, and CIMT as atherosclerotic markers in IS patients. Favorable prognostic outcomes were observed, emphasizing the importance of early diagnosis and management to improve patient outcomes.

Air Embolism-Induced Ischemic Stroke Following Orthognathic Surgery in a Patient With Goldenhar Syndrome.

Goldenhar syndrome, a rare congenital anomaly, manifests as craniofacial malformations often necessitating intricate surgical interventions. These procedures, though crucial, can expose patients to diverse postoperative complications, including hemorrhage or infection. A noteworthy complication is stroke, potentially linked to air embolism or local surgical trauma. We highlight a case of a male patient, aged 20 years, who experienced a significant postoperative complication of an ischemic stroke, theorized to be due to an air embolism, after undergoing orthognathic procedures for Goldenhar syndrome. The patient was subjected to LeFort I maxillary osteotomy, bilateral sagittal split ramus osteotomy of the mandible, and anterior iliac crest bone grafting to the right maxilla. He suffered an acute ischemic stroke in the left thalamus post-surgery, theorized to stem from an air embolism. Advanced imaging demonstrated air pockets within the cavernous sinus, a rare and concerning finding suggestive of potential air embolism. This case underscores the intricate challenges in treating Goldenhar syndrome patients and the rare but significant risk of stroke due to air embolism or surgical trauma. Limited literature on managing air embolism complications specific to Goldenhar syndrome surgeries exists. Generally, management includes immediate recognition, positional adjustments, air aspiration via central venous catheters, hyperbaric oxygen therapy, hemodynamic support, and high-flow oxygen administration to expedite air resorption. Our patient was conservatively managed post-surgery, and at a 3-month neurology follow-up, he showed significant improvement with only residual right arm weakness. It emphasizes the imperative of a comprehensive, multidisciplinary approach.

Association between serum calcium and prognosis in patients with acute ischemic stroke in ICU: analysis of the MIMIC-IV database.

BACKGROUND: While serum Ca has proven to be a reliable predictor of mortality across various diseases, its connection with the clinical outcomes of ischemic stroke (IS) remains inconclusive. Our research aimed to explore the relationships between serum total Ca (tCa) and serum ionized Ca (iCa) and mortality among acute IS (AIS) patients. METHODS: We gathered data from 1773 AIS patients in the Medical Information Mart for Intensive Care Database IV, including baseline demographic data, comorbidities, vital signs, laboratory-based data, and scoring systems. Endpoints for the study encompassed 30-d, 90-d, and 365-d all-cause mortalities. Employing restricted cubic spline Cox regression, we explored potential nonlinear relationships between admission serum iCa and tCa levels and mortality. Participants were categorized into four groups based on serum iCa and tCa quartiles. Multivariable Cox regression analysis was then conducted to evaluate the independent association of iCa and tCa quartiles with all-cause mortality. RESULTS: The restricted cubic spline revealed a U-shaped association between iCa and 30-d and 90-d mortality (P<0.05), while the relationship between iCa and 365-d mortality was linear (P<0.05). After adjusting for confounders, multivariable Cox analysis demonstrated that the lowest serum iCa level quartile was independently associated with increased risks of 30-d, 90-d, and 365-d mortality. Similarly, the highest serum iCa level quartile was independently associated with increased risks of 30-d and 90-d mortality, but not 365-d mortality. Notably, serum tCa level showed no association with increased risks of 30-d, 90-d, and 365-d mortality. CONCLUSIONS: Our findings suggest that serum iCa, rather than tCa, is linked to ischemic stroke prognosis. Both high and low serum iCa levels are associated with poor short-term prognosis, while only low serum iCa is associated with poor long-term prognosis in AIS patients.

Red blood cell distribution width as a predictor of mortality and poor functional outcome after acute ischemic stroke: a meta-analysis and meta-regression.

BACKGROUND: This study aimed to review evidence on the ability of red cell distribution width (RDW) to predict mortality and poor functional outcomes after acute ischemic stroke (AIS). METHODS: Databases of PubMed, CENTRAL, Scopus, Embase, and Web of Science were searched online from inception to 25th Jul 2023 for all studies reporting the association between RDW and outcomes as adjusted ratios. A random-effects meta-analysis was done. Meta-regression was conducted using multiple moderators. RESULTS: 15 studies with 14,968 patients were included. Meta-analysis found that RDW, both as a categorical variable (OR: 2.10 95% CI: 1.74, 2.55 I2 = 42%) and continuous variable OR: 1.16 95% CI: 1.05, 1.28 I2 = 64%) was a significant predictor of mortality after AIS. Age and number of hypertensives were found to be significant moderators in the meta-regression. Also, high RDW, as a categorical variable (OR: 1.68 95% CI: 1.20, 2.35 I2 = 84%), was associated with significantly higher odds of poor functional outcomes after AIS, but not as a continuous variable (OR: 1.07 95% CI: 0.99, 1.16 I2 = 61%). Meta-regression showed that the association was stronger in small sample-sized studies. CONCLUSION: RDW can be a useful, readily available, and cost-effective biomarker to rapidly stratify AIS patients at risk of poor outcomes. High RDW was consistently associated with an increased risk of mortality after AIS, however, its ability to predict poor functional outcomes needs to be verified by further studies.

Factors Associated With Premature Termination of Hyperacute Stroke Trials: A Review.

BACKGROUND: We performed a review of acute stroke trials to determine features associated with premature termination of trial enrollment, defined by the authors as not meeting preplanned sample size. METHODS AND RESULTS: MEDLINE was searched for randomized clinical stroke trials published in 9 major clinical journals between 2013 and 2022. We included randomized clinical trials that were phase 2 or 3 with a preplanned sample size ≥100 and a time-to-treatment within 24 hours of onset for transient ischemic attack, ischemic stroke, or intracerebral hemorrhage. Data were abstracted on trial features including trial design, inclusion criteria, imaging, location and number of sites, masking, treatment complexity, control group (standard therapy, placebo), industry involvement, and preplanned stopping rules (futility and efficacy). Least absolute shrinkage and selection operator regression was used to select the most important factors associated with premature termination; then, a multivariable logistic regression was fit including only the least absolute shrinkage and selection operator selected variables. Of 1475 studies assessed, 98 trials met eligibility criteria. Forty-five (46%) trials were prematurely terminated, of which 27% were stopped for benefit/efficacy, 20% for lack of money/slow enrollment, 18% for futility, 16% for newly available evidence, 17% for other reasons, and 4% due to harm. Complex trials (adjusted odds ratio [aOR], 2.76 [95% CI, 1.13-7.49]), presence of a futility rule (aOR, 4.43 [95% CI, 1.62-17.91]), and exclusion of prestroke dependency (none/slight disability only; aOR, 2.19 [95% CI, 0.84-6.72] versus dependency allowed) were identified as the strongest predictors. CONCLUSIONS: Nearly half of acute stroke trials were terminated prematurely. Broadening inclusion criteria and simplifying trial design may decrease the likelihood of unplanned termination, whereas planned futility analyses may appropriately terminate trials early, saving money and resources.

Bibliometric analysis: Hot spots and frontiers in acupuncture treatment of cerebral infarction.

OBJECTIVE: CiteSpace6.1.R2 is used to analyze the research status of acupuncture in the treatment of cerebral infarction, and to find relevant hot spots and frontiers. METHODS: The researchers searched the Web of Science Core Collection database. The search date is from the establishment of the database to August 31, 2023. The search terms and expressions are: ("Cerebral Infarction" OR "Ischemic stroke") AND ("Acupuncture" OR "fire needle"). The researchers used CiteSpace software to draw a knowledge map to explore the hot spots and frontiers of acupuncture in treating cerebral infarction. RESULTS: We screened 414 articles in the Web of Science Core Collection database. China is the country with the largest number of publications, with a total of 343 papers published. China's institutions cooperate most closely, and cooperation between countries is less and more scattered. The author with the highest number of published articles is Chen L, with a total of 31 published articles. The research focus mainly revolves around the mechanism of acupuncture treatment of cerebral infarction and electroacupuncture treatment of cerebral infarction. Among them, acupuncture treatment of cerebral infarction is the most. CONCLUSION: According to CiteSpace's analysis results, China is at the forefront of this research field, while other countries have less research in this field and little cooperation among countries. At present, the mainstream aspect of research is the mechanism of acupuncture treatment of cerebral infarction electroacupuncture and acupuncture points. Therefore, in future research, we should pay more attention to the treatment of cerebral infarction mechanism of acupuncture, problems with the type of acupuncture used, and acupuncture points.

The Janus face of endogenous neuronal tPA: promoting self-protection and worsening the death of neighboring neurons.

Recombinant tissue-type plasminogen activator (r-tPA/Actilyse) stands as the prevailing pharmacological solution for treating ischemic stroke patients, of whom because their endogenous circulating tPA alone is not sufficient to rescue reperfusion and to promote favorable outcome. Beyond the tPA contributed by circulating endothelial cells and hepatocytes, neurons also express tPA, sparking debates regarding its impact on neuronal fate ranging from pro-survival to neurotoxic properties. In order to investigate the role of neuronal tPA during brain injuries, we developed models leading to its conditional deletion in neurons, employing AAV9-pPlat-GFP and AAV9-pPlat-Cre-GFP along with tPA floxed mice. These models were subjected to N-methyl-D-aspartate (NMDA)-induced excitotoxicity or thromboembolic ischemic stroke in mice. Initially, we established that our AAV9 constructs selectively transduce neurons, bypassing other brain cell types. Subsequently, we demonstrated that tPA-expressing neurons exhibit greater resistance against NMDA-induced excitotoxicity compared to tPA negative neurons. The targeted removal of tPA in neurons heightened the susceptibility of these neurons to cell death and prevented a paracrine neurotoxic effect on tPA non-expressing neurons. Under ischemic conditions, the self-neuroprotective influence of tPA encompassed both excitatory (GFP+/Tbr1+) and inhibitory (GFP+/GABA+) neurons. Our data indicate that endogenous neuronal tPA is a protective or deleterious factor against neuronal death in an excitotoxic/ischemic context, depending on whether it acts as an autocrine or a paracrine mediator.

Lipoprotein(a) as a blood marker for large artery atherosclerosis stroke etiology: validation in a prospective cohort from a swiss stroke center.

BACKGROUND: Lipoprotein (a) [Lp(a)] serum levels are highly genetically determined and promote atherogenesis. High Lp(a) levels are associated with increased cardiovascular morbidity. Serum Lp(a) levels have recently been associated with large artery atherosclerosis (LAA) stroke. We aimed to externally validate this association in an independent cohort. METHODS: This study stems from the prospective multicentre CoRisk study (CoPeptin for Risk Stratification in Acute Stroke patients [NCT00878813]), conducted at the University Hospital Bern, Switzerland, between 2009 and 2011, in which Lp(a) plasma levels were measured within the first 24 hours after stroke onset. We assessed the association of Lp(a) with LAA stroke using multivariable logistic regression and performed interaction analyses to identify potential effect modifiers. RESULTS: Of 743 patients with ischaemic stroke, 105 (14%) had LAA stroke aetiology. Lp(a) levels were higher for LAA stroke than non-LAA stroke patients (23.0 nmol/l vs 16.3 nmol/l, p = 0.01). Multivariable regression revealed an independent association of log10and#xA0;Lp(a) with LAA stroke aetiology (aOR 1.47 [95% CI 1.03and#x2013;2.09], p = 0.03). The interaction analyses showed that Lp(a) was not associated with LAA stroke aetiology among patients with diabetes. CONCLUSIONS: In a well-characterised cohort of patients with ischaemic stroke, we validated the association of higher Lp(a) levels with LAA stroke aetiology, independent of traditional cardiovascular risk factors. These findings may inform randomised clinical trials investigating the effect of Lp(a) lowering agents on cardiovascular outcomes. The CoRisk (CoPeptin for Risk Stratification in Acute Patients) study is registered on ClinicalTrials.gov. REGISTRATION NUMBER: NCT00878813.

The association of CYP2C19 LoF alleles with adverse clinical outcomes in stroke patients taking clopidogrel: An updated meta-analysis.

The aggregated risk of recurrent stroke in stroke/transient ischemic attack (TIA) patients carrying CYP2C19 LoF alleles who take clopidogrel has not been investigated recently, and the available research is limited. This study aimed to perform an updated meta-analysis to assess the association between CYP2C19 LoF alleles and the risk of recurrent stroke in patients taking clopidogrel. Databases were searched for the literature on eligible studies. The end points were recurrent stroke, composite vascular events, and bleeding events. Odds ratios (ORs) were calculated using RevMan software, where p < 0.05 was considered statistically significant. Patients carrying CYP2C19 LoF alleles who were treated with clopidogrel had a significantly increased risk of recurrent ischemic stroke compared with non-carriers (OR 2.18, 96% CI 1.80-2.63; p < 0.00001). The risk of recurrent stroke was only significantly different in Asian patients (OR 2.29, 96% CI 1.88-2.80; p < 0.00001) but not in patients of other ethnicities; however, there were a limited number of studies in other ethnic groups. Both observational studies (OR 2.83, 96% CI 2.20-3.65; p < 0.00001) and RCTs (OR 1.48, 96% CI 1.10-1.98; p = 0.009) found associations with a significantly increased risk of recurrent ischemic stroke. Asian stroke patients or TIA patients carrying CYP2C19 LoF alleles and taking clopidogrel were at a significantly higher risk of recurrent ischemic stroke than non-carriers. Significantly increased risk of recurrent ischemic stroke was found in both observational studies and RCTs.

Intraoperative intensive blood pressure management strategy and the outcome of patients who had an acute ischaemic stroke undergoing endovascular treatment under general anaesthesia: study protocol for a prospective randomised controlled trial.

BackgroundEndovascular thrombectomy is the recommended treatment for acute ischaemic stroke, but the optimal blood pressure management strategy during the procedure under general anaesthesia remains controversial. In this study protocol, we propose an intraoperative intensive blood pressure range (110-140 mm Hg systolic blood pressure) based on a retrospective analysis and extensive literature review. By comparing the outcomes of patients who had an acute ischaemic stroke undergoing mechanical thrombectomy under general anaesthesia with standard blood pressure management (140-180 mm Hg systolic blood pressure) versus intensive blood pressure management, we aim to determine the impact of intraoperative intensive blood pressure management strategy on patient prognosis. METHODS AND ANALYSIS: The study is a double-blinded, randomised, controlled study, with patients randomised into either the standard blood pressure management group or the intensive blood pressure management group. The primary endpoint of the study will be the sequential analysis of modified Rankin Scale scores at 90 days after mechanical thrombectomy. ETHICS AND DISSEMINATION: The study has been approved by the ethics committee of Shanghai Changhai Hospital with an approval number CHEC2023-015. The results of the study will be published in peer-reviewed international journals. TRIAL REGISTRATION NUMBER: ChiCTR2300070764.

MicroRNA Regulatory Pattern in Diabetic Mouse Cortex at Different Stages Following Ischemic Stroke.

After ischemic stroke, microRNAs (miRNAs) participate in various processes, including immune responses, inflammation, and angiogenesis. Diabetes is a key factor increasing the risk of ischemic stroke; however, the regulatory pattern of miRNAs at different stages of diabetic stroke remains unclear. This study comprehensively analyzed the miRNA expression profiles in diabetic mice at 1, 3, and 7 days post-reperfusion following the middle cerebral artery occlusion (MCAO). We identified differentially expressed (DE) miRNAs in diabetic stroke and found significant dysregulation of some novel miRNAs (novel_mir310, novel_mir89, and novel_mir396) post-stroke. These DEmiRNAs were involved in apoptosis and the formation of tight junctions. Finally, we identified three groups of time-dependent DE miRNAs (miR-6240, miR-135b-3p, and miR-672-5p). These have the potential to serve as biomarkers of diabetic stroke. These findings provide a new perspective for future research, emphasizing the dynamic changes in miRNA expression after diabetic stroke and offering potential candidates as biomarkers for future clinical applications.