Improving acute stroke assessment in non-enhanced computed tomography: automated tool for early ischemic lesion volume detection.

BACKGROUND AND OBJECTIVES: ASPECTs is a widely used marker to identify early stroke signs on non-enhanced computed tomography (NECT), yet it presents interindividual variability and it may be hard to use for non-experts. We introduce an algorithm capable of automatically estimating the NECT volumetric extension of early acute ischemic changes in the 3D space. We compared the power of this marker with ASPECTs evaluated by experienced practitioner in predicting the clinical outcome. METHODS: We analyzed and processed neuroimaging data of 153 patients admitted with acute ischemic stroke. All patients underwent a NECT at admission and on follow-up. The developed algorithm identifies the early ischemic hypodense region based on an automatic comparison of the gray level in the images of the two hemispheres, assumed to be an approximate mirror image of each other in healthy patients. RESULTS: In the two standard axial slices used to estimate the ASPECTs, the regions identified by the algorithm overlap significantly with those identified by experienced practitioners. However, in many patients, the regions identified automatically extend significantly to other slices. In these cases, the volume marker provides supplementary and independent information. Indeed, the clinical outcome of patients with volume marker = 0 can be distinguished with higher statistical confidence than the outcome of patients with ASPECTs = 10. CONCLUSION: The volumetric extension and the location of acute ischemic region in the 3D-space, automatically identified by our algorithm, provide data that are mostly in agreement with the ASPECTs value estimated by expert practitioners, and in some cases complementary and independent.

Multimodal CT pc-ASPECTS in infratentorial stroke: diagnostic and prognostic value.

BACKGROUND AND PURPOSE: Diagnosis of posterior circulation stroke may be challenged. National Institutes of Health Stroke Scale (NIHSS) and brain imaging (non-contrast brain computed tomography-CT) are used for diagnosis; evaluation on posterior circulation stroke remains a limit of NIHSS, and the value of non-contrast CT (NCCT) is limited due to artifacts caused by the bones of the base of the skull. We tested the validity and prognostic value of posterior circulation Alberta Stroke Program Early CT Score (pc-ASPECTS) in patients with posterior circulation stroke. METHODS: Pc-ASPECTS allots the posterior circulation 10 points. We studied 50 patients with posterior circulation stroke. We applied pc-ASPECTS to NCCT, CT angiography, and CT Perfusion. We evaluated the correlation of pc-ASPECT with outcome parameters for stroke. RESULTS: Out of 50 patients, CTP showed abnormalities in 34 cases. The pc-ASPECT score calculated on brain CT and on the brain CT + angio CT had a sensibility of 24%, calculated on brain CT, angio CT and CTPerfusion gain a sensibility of 72%. Pc-ASPECT MTT resulted to be the more reliable parameter: outcome given by NIHSS score at discharge, mRS at discharge, and at 3 months was more severe in patients with Pc-ASPECT MTT alteration. Outcome given by NIHSS score at discharge and mRS at discharge and 1 at 3 months was more severe in patients with higher NIHSS score at admission. CONCLUSION: We evaluated the usefulness of pc-ASPECTS on CTP in predicting functional outcome in acute posterior circulation stroke that appears to be a powerful marker for predicting functional outcome.

Wake-up stroke and CT perfusion: effectiveness and safety of reperfusion therapy.

OBJECTIVE: Ischemic stroke is a neuroemergency condition highly treatable with thrombolysis and thrombectomy. Recently, observational studies have brought insights into clinical and imaging characteristics of wake-up stroke, which interested up to 25% of ischemic stroke patients. In clinical practice, wake-up strokes are usually not considered for reperfusion therapy. The aim of this study was to investigate the use CT perfusion imaging in patients with wake-up stroke and to assess the effect of neuroimaging information provided by CT perfusion maps on the efficacy and safety of thrombolysis and thrombectomy. PATIENTS AND METHOD: We studied 22 wake-up stroke (WUS) patients (13F/9M mean age) who underwent reperfusion therapy after the eligibility assessed by the CT perfusion imaging (< 50% core-to-penumbra ratio and negative CT perfusion). RESULTS: Mean National Institutes of Health Stroke Scale (NIHSS) was 8.1 ± 4.9 at admission while 3.3 ± 5.1 at discharge, significantly different from admission (p < 0.001). As many as ten patients had mRS lower than 3 at discharge. Intracranial hemorrhage occurred in five patients and caused symptoms worsening only in two patients (decrease of NIHSS score of 4 points) of which one patient died. CONCLUSION: The main finding of this study is that wake-up stroke with adequate selection by CT perfusion may benefit reperfusion treatment.

Early Recovery of Aphasia through Thrombolysis: The Significance of Spontaneous Speech.

BACKGROUND: Aphasia is one of the most devastating stroke-related consequences for social interaction and daily activities. Aphasia recovery in acute stroke depends on the degree of reperfusion after thrombolysis or thrombectomy. As aphasia assessment tests are often time-consuming for patients with acute stroke, physicians have been developing rapid and simple tests. The aim of our study is to evaluate the improvement of language functions in the earliest stage in patients treated with thrombolysis and in nontreated patients using our rapid screening test. MATERIALS AND METHODS: Our study is a single-center prospective observational study conducted at the Stroke Unit of the University Medical Hospital of Trieste (January-December 2016). Patients treated with thrombolysis and nontreated patients underwent 3 aphasia assessments through our rapid screening test (at baseline, 24 hours, and 72 hours). The screening test assesses spontaneous speech, oral comprehension of words, reading aloud and comprehension of written words, oral comprehension of sentences, naming, repetition of words and a sentence, and writing words. RESULTS: The study included 40 patients: 18 patients treated with thrombolysis and 22 nontreated patients. Both groups improved over time. Among all language parameters, spontaneous speech was statistically significant between 24 and 72 hours (P value = .012), and between baseline and 72 hours (P value = .017). CONCLUSIONS: Our study demonstrates that patients treated with thrombolysis experience greater improvement in language than the nontreated patients. The difference between the 2 groups is increasingly evident over time. Moreover, spontaneous speech is the parameter marked by the greatest improvement.

Ischemic Volume and Neurological Deficit: Correlation of Computed Tomography Perfusion with the National Institutes of Health Stroke Scale Score in Acute Ischemic Stroke.

BACKGROUND: The National Institutes of Health Stroke Scale (NIHSS) is the most adopted stroke patients' evaluation tool in emergency settings to assess the severity of stroke and to determine the patients' eligibility for specific treatments. Computed tomography perfusion (CTP) is crucial to identify salvageable tissue that can benefit from the reperfusion treatment. The aim of this study is to identify the relation between the NIHSS scores and the hypoperfused volumes evaluated by CTP in patients with hyperacute ischemic stroke. METHODS: This retrospective study was conducted on 105 patients with ischemic stroke who underwent NIHSS assessment and CTP in the hyperacute phase. Hypoperfused volume was evaluated by CTP maps processed with semi-automatic algorithm. An analysis was conducted to determine the degree of correlation between the NIHSS scores and the ischemic lesion volumes and to investigate the relation between the anterior and the posterior circulation strokes, as well as between the right and the left hemispheric strokes. RESULTS: A significant correlation was found between ischemic volume and NIHSS score at baseline (r = .82; P < .0001) in the entire cohort. A high NIHSS-volume correlation was identified in the anterior circulation stroke (r = .76; P < .0001); whereas, it was nonsignificant in the posterior circulation stroke. NIHSS score and volume correlated for the left and the right hemispheric strokes (r = .83 and .81; P < .0001), showing a slightly higher slope in the left. CONCLUSION: This study showed a strong correlation between the baseline NIHSS score and the ischemic volume estimated by CTP. We confirmed that NIHSS is a reliable predictor of perfusion deficits in acute ischemic stroke. CTP allows fast imaging assessment in the hyperacute phase. The results highlight the importance of these diagnostic tools in the assessment of stroke severity and in acute decision-making.

Adaptation and latent structure of the Brazilian version of the Ego Dissolution Inventory (EDI-BR): An exploratory study.

INTRODUCTION: Existing scales that seek to measure alterations in self-experience were based on studies conducted in developed countries. Therefore, the aim of this study was to evaluate the psychometric properties of the Ego-Dissolution Inventory (EDI), translate and adapt it to the Brazilian context. METHODS: Translation of the measure was made by two translators fluent in both English and Portuguese, with back-translation into English to ensure there was no loss of meaning. The scale was included in an online survey exploring substance use. A total of 528 participants answered the full scale. We calculated the Kaiser-Meyer-Olkin (KMO) measure to evaluate sampling adequacy, then ran Exploratory Analysis Factor (EFAs) to investigate the factor structure of the EDI. RESULTS: The scale showed acceptable psychometric properties, with excellent internal consistency and sampling adequacy for a factor analysis. Kaiser-Gutman's criteria and Hull's method pointed to a three-factor solution, while Parallel Analysis suggested a two-factor solution. All items showed salient loadings, with two items exhibiting cross-loading. Positive but weak correlations were found between EDI factors 1 and 2 and nature-relatedness. CONCLUSIONS: The validated scale showed solid psychometric properties, with potential differences in factor structure in relation to the English version. Considering validation as ongoing process, it is recommended to conduct studies comparing the scores of ego dissolution across distinct substances and different regions of the country.

Very high-resolution ultrasound of the distal median nerve.

OBJECTIVE: A very high-resolution (70 MHz) ultrasound device (VHRUS) has recently been approved for use in humans. The aim of this study was to use VHRUS to collect data on healthy subjects to propose some reference values for the digital branches of the median nerves of the hand. METHODS: A VHRUS with 70 MHz linear array transducer was used to measure the cross sectional area of the median nerve at the wrist (CSAw) and digital branches (CSAf), largest and smallest fascicles, the fascicles number (Nfasc), the fascicle density (FD), the flattening ratio (FR) and CSAw/CSAf. RESULTS: Data from 20 healthy subjects were obtained for both hands. The median nerve at the wrist and digital branches were properly identified without anatomical alterations. No differences were found between the right and the left hand. In the dominant hand, CSAw was 9.35 mm2 (4.57-12.35) and Nfasc was 24 (18-38). FD and FR were respectively 2.94 (2.47-4.91) and 2.74 (1.70-4.90). CONCLUSION: VHRUS technology can visualize the median nerves at the wrist, their internal structure and their small branches at the fingers, providing both a qualitative and quantitative assessment. Results from this study provide preliminary reference values in a young healthy sample. SIGNIFICANCE: Most conventional ultrasound devices are not able to properly visualize the distal branches of the median nerve. In contrast, VHRUS allows to detect and measure smaller structures of the nerve, assisting in clinical practice.

Wake-up stroke: thrombolysis reduces ischemic lesion volume and neurological deficit.

BACKGROUNDS: Wake-Up Stroke (WUS) patients are generally excluded from thrombolytic therapy (rTPA) due to the unknown time of stroke onset. This study aimed to investigate the effects of rTPA in WUS patients during every day clinical scenarios, by measuring ischemic lesion volume and functional outcomes compared to non-treated WUS patients. METHODS: We retrospectively analyzed clinical and imaging data of 149 (75 rTPA; 74 non-rTPA) patients with acute ischemic WUS. Ischemic volume was calculated on follow-up CT and functional outcomes were the NIHSS and mRS comparing rTPA and non-rTPA WUS. Patients were selected using ASPECTS > 6 on CT and/or ischemic penumbra > 50% of hypoperfused tissue on CTP. RESULTS: A reduced volume was measured on the follow-up CT for rTPA (1 mL, 0-8) compared to the non-rTPA patients (10 mL, 0-40; p = 0.000). NIHSS at 7 days from admission was significantly lower in the rTPA (1, 0-4) compared to non-rTPA group (3, 1-9; p = 0.015), as was the percentage of improvement (ΔNIHSS) (70% vs 50%; p = 0.002). A higher prevalence of mRS 0-2 was observed in the rTPA compared to the non-rTPA (54% vs 39%; p = 0.060). Multivariate analysis showed that NIHSS at baseline and rTPA treatment are significant predictors of good outcome both in terms of NIHSS at 7 days and ischemic lesion volume on follow-up CT (p < 0.05). CONCLUSIONS: rTPA in WUS patients selected with CT and/or CTP resulted in reduced ischemic infarct volume on follow-up CT and better functional outcome without increment of intracranial hemorrhages and in-hospital mortality.

Thrombolysis safety and effectiveness in acute ischemic stroke patients with pre-morbid disability.

INTRODUCTION: Recombinant tissue plasminogen activator (rt-PA) is the first-line therapy demonstrated to be safe and effective in acute ischemic stroke. People with pre-existing severe dementia or physical disability are usually excluded from rt-PA. The aim of our study was to investigate rt-PA safety and effectiveness in acute stroke with pre-existing disability (mRS ≥ 2). METHODS: The study encompassed 35 acute ischemic stroke patients with mRS ≥ 2 treated with rt-PA. In order to assess the differences in clinical outcome in three disability groups (mRS = 2; 3; 4/5), the following parameters were evaluated: intracerebral hemorrhage, mortality, NIHSS, ΔNIHSS and mRS. RESULTS: Baseline-NIHSS and age were not significantly different among groups. Mortality was higher in the pre-morbid mRS 4/5 group (44%) than in the pre-morbid mRS2 (16.7%) and mRS 3 groups (21.4%). In survived patients, median ΔNIHSS% was higher in the mRS2 and 3 groups (-63.3% and -92.3%, respectively) than in the mRS4/5 group (-9.1%). The 247 rt-PA treated subjects with mRS < 2 in the same period showed lower mortality rate (4.7%), lower sICH (5%), lower mRS at discharge (median 1; range 0-6) and similar ΔNIHSS% (-75%). CONCLUSION: Patients with mRS 2 and 3 may benefit from rt-PA with a moderate risk of sICH and mortality.

A CT perfusion based model predicts outcome in wake-up stroke patients treated with recombinant tissue plasminogen activator.

OBJECTIVE: Advanced neuroimaging has proved to be pivotal in the management of acute ischemic stroke. The use of CT perfusion (CTP) core and penumbra parameters to predict the outcome in wake-up stroke (WUS) patients in everyday clinical scenarios has not yet been investigated. The aim of our study was to investigate the predictive power of CTP parameters on functional and morphological outcomes in WUS patients treated with recombinant tissue plasminogen activator (rTPA). APPROACH: We analyzed clinical data and processed CTP images of 83 consecutive WUS patients treated with rTPA. The predictive power of whole-brain CTP features and of the clinical stroke-related parameters to predict the National Institutes of Health Stroke Scale (NIHSS) score at the seventh day and ischemic lesion volume outcome was investigated by means of multivariate regression analysis as well as least absolute shrinkage and selection operator (LASSO) modeling. MAIN RESULTS: Multivariate analysis showed that CTP core volume (ß = 0.403, p = 0.000), NIHSS at admission (ß = 0.323, p = 0.005) and Alberta Stroke Program Early CT (ASPECT) score (ß = -0.224, p = 0.012) predict NIHSS at 7 days, while total hypoperfused volume (ß = 0.542, p = 0.000) and core volume on CTP (ß =0.441, p = 0.000) predict infarct lesion volume at follow-up CT. The LASSO modeling approach confirmed the significant predictive power of CTP core volume, total hypoperfused CTP volume, NIHSS at baseline and ASPECT score, producing a sparse model with adequate reliability (the root mean square error on a previously unseen testing dataset was 3.68). SIGNIFICANCE: Our findings highlight the importance of CT multimodal imaging features for decision-making and prediction in the hyperacute phase of WUS. The predictive model supports the hypothesis that an irreversible necrotic core rather than the extent of the penumbra is the main prognostic factor in WUS patients treated with rTPA.

Prevalence of hypohydration and its association with stroke severity and independence outcomes in acute ischemic stroke patients.

Hypohydration has been suggested increasing the risk of vascular diseases, and it is associated with poor prognosis and worse functional outcome in stroke. Most studies have used blood parameters to determine patients' hydration status. The aim of this study was to measure urine osmolality (uOsm) and its influence on stroke severity and independence. A prospective descriptive study was conducted in stroke patients admitted to a stroke unit. All patients underwent neurological evaluation at admission and discharge using the National Institute of Health Stroke Scale (NIHSS). Independence at discharge was evaluated with the Barthel Index (BI) and the modified Rankin Scale (mRS). uOsm was measured at admission. Patients were grouped in "poor fluid intake" (PF) and "euhydration" (EU), the latter if uOsm ≤ 500 mOsm/kg. Among 119 included patients, the prevalence of PF was 52%, with no difference observed between groups in demographics or blood samples analyses. PF had higher chances of NIHSS > 8 at admission (OR: 4.7 95% CI: 1.3-17.0; p = 0.02), lower BI at discharge (ß: -15.3 95% CI: -26.7 to -3.8; p = 0.01), and worse mRS at discharge (OR: 4.01 95% CI: 1.2-14.0; p = 0.02). These findings are consistent with previous results, suggesting that uOsm may be a factor significantly associated with stroke severity and independence outcome after acute ischemic stroke.

Safety of Early Repeated Thrombolysis: A Case Report.

INTRODUCTION: Intravenous thrombolysis within 4.5 hours from symptom onset improves functional outcome in acute ischemic stroke patients. Repeated intravenous tissue plasminogen activator (IVtPA) is contraindicated in patients presenting with early recurrent stroke (ERS) within 3 months from the initial stroke because of a greater risk of intracranial hemorrhage. CASE PRESENTATION: A 59-year-old man presented with ERS, National Institute of Health Stroke Scale of 16, 10 days after a previous stroke. Brain computed tomography (CT) showed a previous hypodensity with 4 cm volume. Angio-CT highlighted the left middle cerebral artery and left internal carotid occlusion. Perfusion CT showed small deep core and large penumbra. The patient underwent IVtPA. After 24 hours, the National Institute of Health Stroke Scale was 7, and CT scan showed an acute ischemic lesion in the left basal ganglia area and frontal lobe without hemorrhagic transformation. CONCLUSION: This case report suggests that further randomized studies may evaluate whether repeated IVtPA may be safe and effective in ERS occurring shortly after a previous stroke when patients experience a period of complete neurological regression, minor disability, and a small infarct volume. Should the hypothesis be confirmed, small volume core and wide volume penumbra at perfusion CT may support the decision of adopting IVtPA repetition.

Acute isolated aphasia as a challenging symptom in the emergency setting: Predictors of epileptic mimic versus ischemic stroke.

INTRODUCTION: Stroke mimics (SM) account for 1% to 41% of all AIS presentation. Seizures are the most frequent cause of mimic, but isolated speech impairment, among adult-onset epilepsy, is quite rare, while aphasia is more often due to an AIS. Prompt AIS/SM recognition is required to establish the most appropriate therapeutic management. We aimed at identifying some predictive clinical and anamnestic features useful to differentiate SM from AIS, particularly in patients presenting with aphasia. MATERIALS AND METHODS: A retrospective study of patients admitted for a suspected stroke, from January 2015 until January 2017 was performed. We identified patients discharged with a final diagnosis of aphasia and patients with seizures presenting with speech impairment. Anamnestic, clinical and diagnostic were reviewed. Univariate analyses determined key clinical features predictive of AIS versus an epileptic SM. RESULTS: 72 patients with sudden onset of aphasia were identified. A cerebrovascular etiology was diagnosed in 50 patients while an epileptic SM in 22. The presence of ischemic cardiopathy, atrial fibrillation and mild lateralizing signs were strongly suggestive of stroke. Otherwise, a previous history of epilepsy, alteration of consciousness, concomitant infection and electrolyte imbalance were predictors of a SM. CONCLUSIONS: Our study underscores the importance of an accurate clinical bed-side assessment as the first step in the diagnostic and therapeutic decision-making process for patients presenting with aphasia. The detection of clinical and anamnestic features associated with an epileptic SM could be useful for the diagnostic process and for time-critical treatments.

Cerebral hemodynamic changes during motor imagery and passive robot-assisted movement of the lower limbs.

BACKGROUND: Neurovascular Coupling is the cerebral mechanism responsible for linking neuronal activity, cerebral metabolism and regional cerebral blood flow (CBF). The direct relation between functional brain activity during active, passive and motor imagery paradigms and changes in CBF has been widely investigated using different techniques. However, CBF changes have not been investigated beat by beat during robot assisted passive movement (PM) and motor imagery (MI) of lower limb, yet. MATERIALS AND METHODS: We investigated beat-to-beat hemodynamic changes in 8 healthy subjects using TCD during MI and robot-assisted PM of lower limb. RESULTS: The results showed that MI and PM induce a significant CBFv increase and that PM and MI lead to similar hemodynamic changes in healthy subjects. CONCLUSIONS: The findings may be useful to better understand the variation of CBFv in brain pathology and to develop more specific and efficient rehabilitation therapy protocols in neurological diseases, such as stroke.

Thrombolysis' benefits on early post-stroke language recovery in aphasia patients.

INTRODUCTION: Thrombolysis may affect ischemic stroke-related size, pattern and nature of infarcts, and has the potential to change aphasia presentation and recovery. Data on evolution of post-stroke aphasia following thrombolysis are still scarce. The aim of this study was to determine the course of language recovery through a well-validated language assessment battery after acute ischemic stroke and investigate whether traditional categorical classifications of aphasia can describe the clinical picture in post-thrombolysis phase. MATERIALS AND METHODS: Demographic, clinical, and language assessment data of 116 patients presenting sub-acute ischemic stroke aphasia (41 treated with r-tPA; 75 non-treated) were retrospectively analyzed. The participants were assessed by a clinical neuropsychologist with a variety of subtests taken from a well-validated Italian language battery (Neuro-Psychological Aphasia Evaluation). RESULTS: The percentage of resolved aphasia was significantly higher in treated patients compared to non-treated patients (p = 0.005) and global aphasia was more common in the non-treated group (non-treated 30.7% vs treated 17.1%). Aphasia subtypes and stroke etiologies showed no significant association, except for small vessel etiology and resolved aphasia (p = 0.041). Reperfusion treatment, baseline NIHSS, and lacunar stroke were the predictors of aphasia recovery. CONCLUSION: The percentage of resolved aphasia was significantly higher in the treated patients compared to the non-treated, with the latter showing a higher percentage of global aphasia. Identifying classic aphasia subtypes after thrombolysis is still possible since reperfused areas do not necessary change the classification or lead to completely different aphasic syndromes. Reperfusion treatment, baseline NIHSS, and lacunar stroke were the main predictors of aphasia recovery.

Brain oscillatory activity and CT perfusion in hyper-acute ischemic stroke.

OBJECTIVES: The combined use of perfusion neuroimaging and brain oscillatory activity may provide a better clinical picture of neurovascular coupling of the injured area in ischemic stroke. The aim is to assess stroke-related topographic electroencephalography (EEG) changes during the earliest phase of ischemic stroke and to compare them with hypoperfusion identified by computer tomography perfusion (CTP). PATIENTS AND METHODS: The study included 15 patients with ischemic stroke, who underwent both CTP and EEG recording within 4.5 h. Topographic representation of power for each band was calculated and compared with hypoperfusion areas estimated by CTP maps. RESULTS: Predominance of slow delta frequencies was found in all patients. The main finding is the agreement between slow rhythms hemispheric prevalence on EEG maps and cerebral hypoperfusion area identified using CTP. CONCLUSION: The results of this preliminary study show that the combined use of EEG and CTP, as highly available techniques, in acute ischemic stroke may be helpful in clinical practice and provide information about functional and metabolic aspects of brain involvement. The joint use of these methodologies may give a better clinical insight of the functionality of injured area in the hyperacute phase.

CT perfusion and EEG patterns in patients with acute isolated aphasia in seizure-related stroke mimics.

PURPOSE: Isolated speech impairment is one of the most challenging clinical manifestations of stroke mimic (SM). We aimed to investigate perfusional and EEG pattern of isolated aphasia to better differentiate between vascular and epileptic etiology in emergency settings. METHOD: We retrospectively analyzed 481 cases with acute focal neurological symptoms admitted to our Stroke Unit. The patients showing isolated aphasia and confirmed ischemic infarction or SM with seizure etiology on follow-up were included for subsequent analysis of clinical, neuroimaging, and EEG data. We investigated differences in CT Perfusion maps between ROI in the anatomical area compatible with clinical presentation, contralateral ROI and EEG in order to evaluate perfusion and brain oscillatory activity abnormalities. RESULTS: 45 patients presented isolated aphasia as principal neurological symptom: 27 cases due to acute ischemic event, 11 due to seizure SM, while 7 were SM due to other etiologies. Out of 11 SM patients with seizure etiology, significant hyperperfusion on CTP maps (MTT AI%<-10%) and sharp EEG waves were observed in 8 patients, while in 3 patients slight hypoperfusion (MTT AI%<20%) and slow EEG rhythms were detected. 24 out of 27 ischemic stroke patients presented severe hypoperfusion with MTT AI above the stroke threshold (MTT AI > 45%). All ischemic stroke patients presented slower EEG rhythms. CONCLUSIONS: The main finding of this study is the identification of different clinical and neuroimaging patterns of isolated aphasia with epileptic or ischemic etiology in emergency settings.

Adaptation and latent structure of the Brazilian version of the Ego Dissolution Inventory (EDI-BR): an exploratory study

Abstract Objective Existing scales that seek to measure alterations in self-experience were developed based on studies conducted in developed countries. Therefore, the aim of this study was to evaluate the psychometric properties of the Ego Dissolution Inventory (EDI) after translating and adapting it for the Brazilian context. Methods The measure was translated by two translators fluent in both English and Portuguese, followed by back-translation into English to ensure there was no loss of meaning. The scale was used in an online survey exploring substance use. A total of 528 participants answered the full scale. We calculated the Kaiser-Meyer-Olkin (KMO) measure to evaluate sampling adequacy, then ran exploratory factor analysis (EFAs) to investigate the factor structure of the EDI. Results The scale showed acceptable psychometric properties, with excellent internal consistency and sampling adequacy for factor analysis. Kaiser-Guttman's criteria and Hull's method indicated a three-factor solution, while parallel analysis suggested a two-factor solution. All items showed salient loadings, with two items exhibiting cross-loading. Positive but weak correlations were found between EDI factors 1 and 2 and nature relatedness. Conclusions The validated scale showed solid psychometric properties, with potential differences in factor structure in relation to the English version. Considering validation is an ongoing process, it is recommended that studies be conducted comparing ego dissolution scores across distinct substances and different regions of the country.

Migrainous aura as stroke-mimic: The role of perfusion-computed tomography.

OBJECTIVES: The acute-onset of migrainuos aura (MA) can be erroneously diagnosed in Emergency Department (ED) as acute stroke (AS) and it can be classified as "stroke mimic" (SM). Perfusion computer tomography (PCT) may be useful to improve detection of infarcts. The aim of the study was to investigate the role in ED of PCT in improving diagnosis of migrainous aura. Data were compared with the well-defined perfusion patterns in patients with acute ischemic stroke. PATIENTS AND METHODS: A standardized Stroke Protocol was planned. The protocol consisted in centralizing in ED all the patients with acute-onset of neurological symptoms compatible with cerebrovascular disease and in performing a general and neurological examination, hematological tests, brain non-contrast computed tomography (NCCT), CT angiography (CTA) of the supra-aortic and intracranial arteries and cerebral PCT. Patients with diagnosis of definite or probable acute stroke were hospitalized in Stroke Unit (SU). A six-months retrospective analysis of all the patients included in the Stroke Protocol and discharged from ED or from SU with a diagnosis of migraine with aura was performed. RESULTS: 172 patients were included in the Stroke Protocol and 6 patients were enrolled. NCCT, CTA and PCT were performed after 60-90 min from symptoms onset and revealed normal perfusion. Intravenous thrombolysis was performed only in one patient. CONCLUSION: Patients with acute-onset of neurological symptoms, who have rapid progressive improvement of symptoms, normal neuroimaging, in particular PCT, and preceding episodes of migraine with aura, may be considered as suffering from MA. In these cases, even if thrombolysis is safe, clinicians may defer a prompt aggressive treatment.