Introduction:Prevention of early recurrence of ischemic stroke after an initial event is a clinically important problem that has been the subject of a number of large clinical trials testing acute treatment interventions. Datasets of clinical trials provide a rich source of information beyond the primary research questions addressed. Merging of datasets, providing greater statistical power and wider applicability for novel exploratory analyses, requires careful harmonization of similar data elements. Methods:The Acute Stroke or Transient Ischaemic Attack Treated with Aspirin or Ticagrelor and Patient Outcomes (SOCRATES), Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke Trial (POINT), and Acute STroke or Transient IscHaemic Attack Treated with TicAgreLor and ASA for PrEvention of Stroke and Death (THALES) trials each examined the effects of early administration of enhanced antiplatelet therapy versus aspirin alone within 12-24 hours following minor ischemic stroke or transient ischemic attack. Results:The datasets of these 3 trials have been harmonized and merged into a single large data table comprising 26319 subjects with 75 clinical and demographic variables, 196 concomitant medication descriptors, and event flags and event timing variables for 20 clinical outcome events. A high degree of data completeness was attained for most variables. Conclusion:This merged data table provides a powerful resource of pooled clinical trial data to enable future large-scaled analyses for the study of stroke recurrence risks, and is now curated and available for other investigators.
Background:Current treatment paradigms for Chronic Subdural Hematoma (CSDH) include either medical management for mildly symptomatic patients or surgical evacuation for severely symptomatic patients. Middle Meningeal Artery Embolization (MMAE) has demonstrated potential to reduce rate of recurrence and rescue surgery as an adjunctive or standalone treatment for CSDH. However, there currently lacks randomized trial data to support the safety and efficacy of standalone MMAE in CSDH patients. Objective:The objective of Chronic Subdural Hematoma Treatment with Embolization versus Surgery Study (CHESS) is to compare standalone MMAE to conventional surgery for treatment of moderately symptomatic CSDH. Methods:CHESS is a prospective, multi-center, open-label randomized controlled trial. Eligible CSDH patients will be randomized 1:1 to either conventional surgery (burr holes or craniotomy) or standalone MMAE with either polyvinyl alcohol particles or microspheres. The follow-up duration will be for 180 days following randomization. Results:The primary endpoint is a composite measure, comprising of the centrally-adjudicated need of rescue surgery and/or mortality, assessed from randomization through 180 days. Safety outcomes include symptomatic ischemic stroke, serious/life threatening adverse events, worsening neurological status, seizures, and cranial neuropathy. Exploratory endpoints include hematoma volume reduction (at least 50%), functional outcome, as well as changes in quality of life, cognition, and headache severity. Conclusions:CHESS is the first randomized controlled trial to characterize the safety and efficacy of standalone MMAE compared to conventional surgery in a moderately-symptomatic CSDH patient population. Results of this trial will further advance the role of endovascular approaches to CSDH treatment.
Ankle hemiparesis is a common post-stroke problem that impairs walking and exoskeletal robots are an emerging joint-specific tool that can address ankle deficits and automate therapy. This single-blind randomized controlled trial compared 6-week treadmillankle robot (TMR) training to 6-week treadmill (TM) only training on paretic ankle motor control and gait performance. Fortyfive participants with chronic stroke (>5 months to 6+ years) trained three times per week for six weeks. The groups were not statistically different at baseline, however, more TMR participants used ankle foot orthosis (AFO) (61%TMR; 36% TM). The primary analysis was based on intention-to-treat using a longitudinal regression model and analyzed post-training outcomes at week-six and at retention six-weeks and three-months after training. We found no significant between group ankle dorsiflexion (DF) and gait velocity change at week-six or at retention. The six-week mean peak paretic DF swing angle was 4.84 degrees (SD 6.83) and 4.2 degrees (SD 6.83) p=0.63 and the DF angle at foot strike was -0.70 degrees (SD 6.55) and -0.46 degrees (SD 5.70) p=0.84, respectively, in TMR and TM. Within group gait velocity improvement was similar with a mean increase of 0.54 m/s (SD 0.24) and 0.56 m/s (SD 0.32) p=0.48 in TMR and TM respectively, that was durable through retention. Integrating ankle robot training with TM walking was not significantly better than treadmill training alone. Future larger studies with refined eligibility criteria and randomization strata that balance key gait determinates are needed to further determine effectiveness on ankle function and gait.
Background:Cerebral Venous Sinus Thrombosis (CVST) is a relatively rare type of stroke, accounting for less than 3% of all stroke cases, and is associated with significant morbidity and mortality in young females. However, when promptly diagnosed and treated, it can have favorable outcomes. Several knowledge gaps remain regarding pathophysiology, diagnosis, and management of CVST, so critical assessment of past and present research could help close these gaps or establish targeted future research goals. Methods:We screened Elsevier Scopus database articles with CVST as the primary topic. Clinical guidelines, abstracts, letters, and editorials were excluded. The top 100 articles, ordered by number of citations, were selected, and data collection and analysis were performed using Microsoft Excel, R software, and VOS viewer. Results:Out of 4,832 documents, the top 100 most-cited articles spanned the years of 1973 to 2021 and had a total citation frequency of 18,208. France and the United States were the top-contributing countries, and Stroke had the highest number of manuscripts published in the top 100 (n=30). Analysis of word-use trends over time showed increases in the mention of "vaccination" since 2021, "mechanical thrombectomy" since 2017, and "fibrinolytic therapy" since 2015. Conclusions:Our study detailed the 100 most-cited articles on CVST in the past 50 years. Understanding top-contributing countries, authors, and journals may help guide the direction of future research in CVST and encourage collaboration within the field. Areas of further research may include association with other pathologies (non-infectious and infectious) and advancements in acute therapies.
Background: Late hospital presentation after acute stroke is one of the main reasons for low rates of intravenous thrombolysis. This study aimed to investigate the factors associated with presentation delays after an acute stroke. Methods: A cross-sectional study with consecutive stroke patients from a Brazilian public university Stroke Center assisted from May 2018 to August 2019. Patients were interviewed from a structured questionnaire involving sociodemographic data, clinical history, the context in which the stroke occurred and knowledge about the disease. Results: Of the 154 patients interviewed, 78% had ischemic stroke and 14% hemorrhagic stroke. The mean age was 64.414, 53% were men and 43% patients arrived before 4.5h. Knowledge about the therapeutic window was low (59% of all patients). Decreased level of consciousness, concomitant psychiatric disease, transferred patients and not seeking immediate medical help were associated with late arrival. In multivariate analysis, males (OR 2.27,95%CI, 1.06-4.90) did not seek immediate medical help (OR 9.44, 95%CI 4.0-22.0) and transferred patients (OR 3.61, 95%CI, 1.64-7.92) were associated with arrival after 4.5h. Conclusions: Despite concerted efforts to raise public awareness, substantial delays in seeking care after a stroke persist within this population. Future initiatives should focus on comprehensive educational programs targeting both the general population and healthcare professionals across all levels of care to address and mitigate these delays.
Background: Ticagrelor is an antiplatelet agent widely used in the treatment of coronary acute syndrome and was recently found to be of interest in secondary prevention of minor stroke and transient ischemic attack. One retrospective study considers ticagrelor as a safe option for secondary prevention after moderate or severe acute ischemic stroke. The eligibility for intravenous thrombolysis in patients pretreated with ticagrelor is controversial. Literature on the safety of intravenous thrombolysis for ischemic stroke in patients taking ticagrelor is limited to eight cases, of which two cases of symptomatic intracranial hemorrhage, one case of asymptomatic intracranial hemorrhage and one case of retropharyngeal hematoma have been reported. Case presentation: We report a 57-year-old patient who was hospitalized for ST-segment elevation myocardial infarction and treated by ticagrelor. Four days later, he presented an anterior circulation ischemic stroke clinically expressed by right hemiparesis with mutism. The patient was successfully treated by intravenous thrombolysis with an improvement of the National Institutes of Health Stroke Scale from 12 to 1 at 24 hours0. No complications have been observed post-treatment. Conclusions: This is the second reported case of successful intravenous thrombolysis for an ischemic stroke of the anterior circulation in a patient pretreated with ticagrelor. This case reinforces the urgent need for further investigations on the safety of intravenous thrombolysis in patients pretreated with ticagrelor as the number of such cases is expected to increase in the future.
Background: Many balance and falls interventions mainly focus on training with voluntarily initiated movements. External perturbation training may be necessary for reducing falls since falls are equally likely to occur from either. Objectives: To determine the effects and generalizability of lateral perturbation training on paretic limb stepping after stroke. Whether sensorimotor impairments impact the ability to initiate paretic leg steps. Methods: Seventeen individuals >6 months post-stroke participated in a 6-week lateral perturbation training. Percent of paretic leg first steps and step type before and after training during the lateral treadmill and lateral waist-pull perturbation were recorded. Motor recovery and paretic foot cutaneous sensation were assessed. Results: Twelve participants (9 male/ 3 female) were recruited from a stroke registry with a mean age of 63.4 years (range 54-72) and completed treadmill perturbation training. They increased the percent of paretic leg steps. After training, fewer medial steps were taken during treadmill perturbations (P<0.02), translating to more lateral steps (P=0.04) and fewer medial steps (P=0.01) during the waist-pull perturbation. Significant correlations were found between foot cutaneous sensation and paretic steps taken during the treadmill perturbation (rs=-0.70, P=0.01) and motor recovery (rs=0.75, P=0.005) and paretic steps taken during the waist-pull perturbation. Conclusions: Transitioning from medial to lateral steps may be a more effective balance recovery strategy. Although, sensorimotor impairments may limit stepping with the paretic leg.
Cerebral microinfarcts are common in older adults and are associated with cognitive impairment. Less is known about sex-related variation in the relationship between cerebral microinfarcts and dementia in older adults, the examination of which was the objective of this study. This case-control study was based on the 727 participants (419 women) in the Adult Changes in Thought (ACT) autopsy data. Microinfarcts were ascertained by blinded board-certified neuropathologists, and dementia diagnoses were made by the ACT Consensus Diagnosis Conference per DSM-IV. Multivariable logistic regression models were used to estimate adjusted odds ratio (aOR) and 95% confidence interval (CI). Microinfarcts were present in 49% (356/727) of the participants, which was numerically higher in women: 51% (213/419) vs 46% (143/308). aOR (95% CI) for dementia associated with any microinfarct for female and male participants were 1.45 (0.91-2.30) and 1.24 (0.75-2.06), respectively (p for interaction, 0.34). Respective aORs (95%CIs) associated with ≥2 microinfarcts were 1.37 (0.79-2.36) and 1.53 (0.84-2.78), with interaction p, 0.84. Subcortical microinfarcts were present in 36% (138/381) and 23% (78/346) of patients with and without dementia (aOR, 1.65; 95% CI, 1.14-2.38). Respective aOR (95% CI) in female and male participants were 1.70 (1.03-2.82) and 1.59 (0.90-2.80), (p for interaction, 0.55). There was no association with cortical microinfarcts (aOR, 1.19; 95% CI, 0.83-1.69). These findings suggest that association between microinfarcts and dementia is primarily mediated by subcortical microinfarcts, but we found no evidence of sex-related variation. Future studies with greater power are needed to determine if the associations we found are replicable.
Introduction: Postpartum is the period following childbirth and during which the maternal body undergoes many physiological changes, sometimes exposing the mother to the risk of stroke. The aim of our work was to evaluate the clinical, etiological and progressive aspect of postpartum strokes. Material and Methods: This was a retrospective study of the descriptive type lasting 2 years from January 2020 to December 31, 2022, focusing on stroke. Postpartum in the neurology department of Ignace Deen University Hospital. The variables used were epidemiological, clinical, etiological and evolutionary. Results: Of 14 women admitted for stroke associated with pregnancy, 9 cases occurred in postpartum 64.3%. The average age was22 ± 10.9 years with a mean time to admission of postpartum vascular event was 13.5±5.2 days. In this study we noted chronic hypertension in 55.6% of cases. The reasons for consultation were dominated by motor deficit (100%); seizures (61.9%) and headaches (66.7%). The stroke type was dominated by cerebral infarction in 33.3% and cerebral venous thrombosis in 44.4%. Conclusion: Postpartum stroke, although rare, is potentially serious and often associated with significant maternal morbidity and mortality. However, a positive impact on risk factors could significantly reduce the mortality rate.
Background:The objectives were to assess the validity and reliability of the Greek version of the Sickness Impact Profile (SIP-GR) questionnaire.Methods: SIP-GR was tested for test-retest reliability, internal consistency and validity in 90 participants (54.4% males and 45.6% females) with obesity, cardiac, pulmonary and musculoskeletal problems.The questionnaire was administrated twice by one examiner, within an interval of 1-week.During this period, participants with cardiac, pulmonary and musculoskeletal problems underwent 2-weekly physiotherapy sessions.Treatment related effects were considered in the analysis.Results: SIP-GR demonstrated an excellent internal consistency.The overall Cronbach's alpha for SIP-Total score >0.9, for SIP-Psychological was >0.8 and for SIP-Physical >0.9.The categories scores were all >0.5 except for Communication and Work category.Test-retest reliability for the total score was ICC=0.691 for all subjects, 0.562 for those that reported a subjective change in their health status due to treatment and 0.999 for those that reported no change in health status.Similar results were found for the Physical and Psychological component.Strong negative correlation was found between SIP-Gr total score and Short Form Health Survey SF-36 (SF-36) total score (r=-0.66),physical component of ) and between psychological component of SIP-GR and Mental health of SF-36 (r=-0.61) at the initial assessment.At reassessment the same correlations were moderate due to different treatment effects in the scores of the two questionnaires.Finally, minimum detectable change (MDC) was 4.6-5.5 points for the overall score, 6.4-7 for Physical component and 3.5-4.9for psychosocial component, at initial assessment and re-assessment respectively.Conclusion: SIP-GR has shown to be valid and reliable for the assessment of patients with cardiac, pulmonary, musculoskeletal diagnosis and obesity.Further studies should assess its ability to identify clinically meaningful changes.
The combination of Lenvatinib and Pembrolizumab has benefited from Early Access Authorization in France since March 2022 in the treatment of advanced or recurrent endometrial cancer.We present a case of PRES secondary to the combination of Lenvatinib and Pembrolizumab in the treatment of an invasive endometrial serous adenocarcinoma.A 66-year-old woman with serous endometrial adenocarcinoma diagnosed two years earlier in the context of peritoneal carcinomatosis, with dissociated response after 6 courses of CARBOPLATIN TAXOL, was put on second-line treatment with LENVATINIB and PEMBROLIZUMAB.The patient presented, five days after the third course, headaches of rapidly increasing intensity.Cerebral imaging was performed revealing T2 hypersignals, bilateral, subcortical, posterior, asymmetrical, and predominant on the right without ADC restriction, in favor of a PRES, motivating the discontinuation of the two incriminated molecules.The evolution was marked by the regression of clinical and radiological signs.The patient subsequently underwent a Pet scan, which revealed progressive disease with uterine, peritoneal, hepatic, adrenal, lymph node and pulmonary lesions, indicating the use of third-line CAELYX.Our case highlights the importance of considering this new therapeutic combination (Lenvatinib and Pembrolizumab) as likely to be associated with PRES.Rigorous neurological clinical monitoring and the use of brain imaging in the face of signs suggestive of PRES are necessary in patients benefiting from this treatment.
Stroke is second leading cause of death and disability worldwide. Thus, it is critical to perform prompt workups when patients present with the concerning signs and symptoms. However, many other medical conditions mimic stroke and can account for hospitalizations where stroke and vascular workups are pursued, oftentimes being costly not only to the patient but to the medical system. One category of under recognized mimics is paraneoplastic neurologic syndromes, which are a variety of neurologic disorders associated with systemic malignancy. Kelch-like protein 11 antibody is a recently discovered antibody associated with paraneoplastic neurologic syndromes. Herein, we present a unique case of a patient presenting with recurrent and persistent cerebellar stroke-like symptoms found to have an underlying Kelch-like protein 11 antibody-associated paraneoplastic syndrome. We review the entirety of his presentation, review the current literature on this paraneoplastic syndrome, and discuss implications from this case that can be applied in future practice.
Congenital heart disease patients would have an elevated stroke risk compared to the general population. The prevalence of adults living with this condition is increasing, and knowledge of their risks and management should be of common knowledge to adult clinicians. The mechanisms of stroke implicate right to left shunt allowing paradoxical embolization. Anticoagulation of patients with complex congenital heart disease is preferred with vitamin K antagonist. We describe a successful thrombolysis case of a patient with Tetralogy of Fallot who presented at the emergency room with an ischemic stroke in time for intravascular thrombolysis treatment and had favorable outcomes.
We should confirm the placement of the nasogastric tube before using it.One of the way of confirming the placement is by the chest X-ray toll that should be done within the golden hours period ( 4 hours within its insertion) to use the tube safely as soon as possible.
Background: The burden and outcome of stroke in -Iindigenous populations is less well understood. This review evaluates ischemic stroke outcomes in Indigenous populations as compared to the general population in the context of recent advances in ischemic stroke therapy. Method: The OVID Medline and EMBASE databases were searched for this review. Clinical outcome was measured and compared using standardized outcome scale following stroke intervention in Indigenous as compared to nonIndigenous adult populations. Associated risk factors were also collected and compared. Results: 897 studies were identified, with 4 studies included in the final analysis. A total of (n=68895) patients were included who underwent thrombolysis. Study populations from Australia, New Zealand, United States, and Canada comprised of (n=2012) Indigenous patients. Mortality was significantly higher in Indigenous populations as compared to non-Indigenous (Odds Ratio-1.28, 95% CI-1.12; 1.46). The odds ratios of atrial fibrillation (1.26, 95% CI-1.12;– 1.41), diabetes (1.43, 95% CI- 1.27; 1.62), hypertension (1.33, 95% CI- 1.17; 1.51) and IHD (0.71, 95% CI- 0.62; 0.81) in Indigenous patients was significantly higher than in non-Indigenous patients. Conclusion: Indigenous populations undergoing stroke therapy have significantly higher mortality compared to non-Indigenous populations. Comorbidities including diabetes, atrial fibrillation, and hypertension are more prevalent in Indigenous populations.
Peripartum cardiomyopathy is a rare cause of pregnancy-related strokes.We present a case of cerebral infarction with multi-organ ischemic damage complicating peripartum cardiomyopathy.A 25-year-old patient, with no cardiovascular risk factor, was admitted to Neurology at the University Hospital of Guadeloupe, for phasic disorders occurring eleven weeks postpartum of a pregnancy marked by gravidic hypertension.The assessments carried out revealed cerebral, splenic, renal infarctions and mesenteric thrombosis on cardiomyopathy with 25% LVEF and left intraventricular thrombus.Curative anticoagulation and treatment of heart failure were initiated on the first day of hospitalization, with a favorable outcome.A cardiological follow-up was organised, noting a progressive clinical improvement at a distance.Our case recalls the importance of a systematic medical follow-up in postpartum, and raises the possible gravity of the infarctions related to the CMPP, requiring an optimal care involving Cardiologists and Neurologists.
Pulsatile tinnitus is often the initial presentation of a dural arteriovenous fistula, so a high index of suspicion is needed to avoid misdiagnoses and possible fatal consequences. Although pulsatile tinnitus commonly originates from a vascular malformation and non-pulsatile tinnitus from a neurodegenerative one, pulsatile and non-pulsatile presentations can result from other underlying pathologies. If a vascular pathology causes a non-pulsatile complaint that cannot be heard by the examiner or detected clinically or radiologically, it is bound to be misdiagnosed as central tinnitus. Herein, we report a rare presentation of a dural arteriovenous fistulas contributing to subjective, non-pulsatile tinnitus. The 50-year-old male patient in this case presented with 2 years of tinnitus, refractory to several treatment approaches that eventually lead to suicidal ideation. Magnetic resonance imaging of the head, magnetic resonance angiography of the head and neck, and computerized tomography scan of the temporal bone did not reveal any acute pathology. Cerebral angiogram revealed a dural arterio-venous malformation in the left sigmoid and transverse sinus. The patient was treated with transarterial Onyx18 embolization of the dural arterio-venous malformation. His symptoms resolved by 50% following treatment and by 80% at 6-month reevaluation. Dural arteriovenous fistulas are rare vascular malformations that, if left untreated, have fatal complications. These vascular malformations may not be detected by physical examination or audiometric evaluation alone. In the absence of neurologic deficits and retrograde leptomeningeal or cortical venous drainage, selective angiographic embolization appears to be an efficient and low-risk modality for symptomatic treatment.
The sensitivity of brain MRI, the gold standard for the early diagnosis of ischemic stroke, is not 100%. False negatives can account for up to 10% in some series.
Background and Objectives: Determining the etiopathogenesis of stroke is a cornerstone for correct secondary prophylaxis, however, in up to 40% the precise source of embolism cannot be determined.The aim of our study was to investigate histopathological differences of emboli retrieved during mechanical thrombectomy, and to investigate how radiological findings and ischemic stroke outcomes correlate with histopathological profile of thrombi.Materials and Methods: In total 40 stroke patients were included in the study.Histopathological examination was performed using Hematoxylin and Eosin staining.Subsequently, on the basis of hematoxylin-andeosin staining, the percentage and area of erythrocytes, leukocytes, and fibrin in investigated thrombi were measured.Thrombi were stained immunohistochemically, according to manufacturer`s instructions.The results were compared in supposed etiopathological stroke subtype groups as cardioembolic, atheroembolic and cryptogenic.Correlation between histopathology of thrombi and stroke outcomes, as well as radiological findings, that is hyperdense artery sign and presence of thrombi in left atrium appendage on nonenhanced thoracic Computed Tomography, was also performed.Results: There were 26 cardioembolic thrombi, 7 atheroembolic and 7 cryptogenic thrombi.Atheroembolic thrombi had a higher percentage of the fibrin area versus total thrombi area than cryptogenic thrombi (p=0.038) and similar tendency comparing with cardioembolic thrombi (p=0.099).Cryptogenic thrombi had statistically lower fibrin/leukocytes ratio than atheroembolic thrombi (p=0,026).As to radiological findings, hyperdense artery sign did not correlate with any specific histopathological composition of thrombi, but patients with CT visualized thrombus in the heart had larger erythrocyte area in thrombus than those without mentioned finding (p=0.047).The ischemic stroke outcome in patients after performed mechanical thrombectomy did not correlate with thrombus histopathology.Conclusion: We found partial histologic similarities of cryptogenic thrombi with cardioembolic thrombi.Therefore patients with cryptogenic stroke should probably undergo extensive cardiac examination including long-term heart rhythm monitoring.
Background: Tenecteplase offers several practical advantages over alteplase; recent comparative studies have demonstrated tenecteplase to be non-inferior to alteplase in terms of its safety and efficacy in acute ischemic stroke (AIS).We recently switched to Tenecteplase for AIS from alteplase and describe our real-world outcome data.Objectives: To compare the efficacy and safety of alteplase with tenecteplase for AIS.Methods: We conducted a retrospective study of patients' thrombolysis with alteplase or Tenecteplase from January 1 st , 2021, to December 31 st , 2021.Patients were included if they had received alteplase or tenecteplase within 4.5 hours of symptom onset.Patients with wake-up stroke were excluded.The primary outcome was a composite of bleeding-related adverse events.Secondary outcomes included door-to-needle (DTN) time, median 24-hour National Institute of Health Stroke Scale (NIHSS) score, discharge NIHSS score, and median discharge modified Rankin score (mRs).Data were assessed using the Mann-Whitney Rank Sum test and Chi-square test.Results: 62 patients were treated with Tenecteplase and 48 with alteplase.There was no difference in the primary outcome of bleeding-related adverse events.For the secondary outcome of DTN time, a significant difference was shown with tenecteplase compared to alteplase (32 minutes vs. 40 minutes, p=0.022).The other secondary endpoints were not statistically significant.Conclusion: There was no significant difference in safety endpoints between tenecteplase and alteplase.The efficacy endpoint of DTN time was greatly improved with tenecteplase.
