Stroke has become the single leading neurological illness that results in neurological disability and is the second most common cause of death worldwide. Approximately 85% of strokes are ischemic, whereas the remaining 15% are hemorrhagic. With the advent of increasingly effective treatment modalities, such as intravenous thrombolytics and endovascular mechanical thrombectomy, there has been a growing disparity in the ability to provide standard of care, despite substantial efforts made in lower- and middle-income countries. substantial effort in high-income countries to provide the current standard of care to patients with stroke, with the hope of improving outcomes. Extensive research has shown that the disparities in treatment among various countries stem from multiple sociocultural barriers and the lack of robust healthcare infrastructure. The societal influences in play include the lack of knowledge of stroke symptoms, cultural beliefs, health, and spiritual fatalism, which are then associated with delayed healthcare-seeking behaviors. As a result, it is imperative to increase access to treatment for patients with stroke to address inequities in stroke care and diminish the global burden of stroke. This narrative review highlights causes of major gaps in stroke treatment infrastructure in several global communities and examines the pertinent sociocultural factors that impede progress in stroke treatment.

BACKGROUND:Clinicians require a simple way to estimate prognosis after acute ischemic stroke (AIS). Existing models are complex and difficult to apply at bedside. We hypothesized that, after accounting for premorbid health, stroke severity predicts survival, and that the National Institutes of Health Stroke Scale (NIHSS) could serve as the basis for clinically intuitive mortality estimation. METHODS:We conducted a retrospective ecological cohort study using the TriNetX Research Network, a federated database of electronic health records from more than 100 healthcare organizations. Adults (≥18 years) with AIS and a documented admission NIHSS were included. Propensity score matching aligned each NIHSS level with NIHSS= 0 on demographics and comorbidities. The primary outcome was 90-day mortality. Linear regression models, trained on odd NIHSS values and tested on even values, evaluated performance. Functional outcomes were analyzed with competing-risk methods. RESULTS:Among 147,391 eligible patients (median NIHSS=4), mortality increased linearly with severity: 90-day mortality (%) ≈ 1.7 × NIHSS. Model performance was strong (training R2=0.993; testing R2=0.986). Overall predicted and observed mortality were similar (13.3% vs 12.6%, P = .22), and discrimination was high (AUC=0.96). Functional outcomes displayed an inverted "u" pattern, driven by the competing risk of mortality at higher NIHSS levels. CONCLUSIONS:In this large ecological analysis, stroke severity predicted mortality after accounting for pre-stroke health. A single equation based solely on NIHSS accurately approximated 90-day mortality after AIS. While subject to the limitations of population-level inference, this "1.7% equation" offers a transparent, scalable framework that may support bedside communication and guide future prospective validation.

Traumatic brain injury (TBI) is a major cause of morbidity and mortality, and cognitive impairment can be devastating among survivors. The objective was to assess an association between gabapentin and cognitive impairment after TBI. This retrospective cohort study used the multinational TriNetX Research Network (>150 million patients). Adults (≥18 years) with a first TBI and Glasgow Coma Scale (GCS) score recorded on the day of injury were included. Patients with known cognitive impairment or gabapentin exposure were excluded. The cohort (n = 49,925) was stratified into mild (GCS 13-15; n = 34,376), moderate (9-12; n = 4035), and severe (3-8; n = 12,845) TBI. The risk of cognitive impairment and mortality were assessed using Cox proportional hazard models adjusted for known predictors. Secondary analyses examined levetiracetam use (as seizure prophylaxis) and long-term medical and functional outcomes. Among 49,925 included patients w, 3.5% received gabapentin on the day of TBI. After adjustment, gabapentin was associated with a 22% lower risk of cognitive impairment in mild TBI (HR = 0.78; 95% CI, 0.62-0.98; P = .03) and a 46% lower risk of mortality in severe TBI (HR = 0.54; 95% CI, 0.40-0.72; P < .001). Levetiracetam showed no protective association with cognition. Long-term follow-up associated gabapentin use with lower mortality but higher rates of psychiatric/sleep diagnoses, reduced mobility, atrial fibrillation, and pulmonary embolism. Although causality cannot be inferred, these findings suggest gabapentin warrant prospective investigation as a candidate neuroprotective therapy.

Abstract Background and aims Despite the fact that a large proportion of patients with acute ischemic stroke (AIS) who undergo endovascular thrombectomy (EVT) for large vessel occlusion (LVO) achieve successful recanalization, they continue to experience poor functional outcomes due to microvascular failure. Adjunctive intra-arterial tenecteplase (IA-TNK) has been proposed as a promising strategy to address this phenomenon of futile recanalization. Methods We performed a comprehensive search of seven databases for clinical trials of IA-TNK after successful EVT for AIS. Eligible studies compared combined IA-TNK and EVT versus EVT only. Data were pooled using random-effects models, risk of bias was assessed with RoB-2 and RoB-1, and certainty of evidence was graded using GRADE Results Overall analysis showed that IA-TNK administered after successful EVT was associated with significantly higher rates of mRS 0–1 compared to control (risk difference [RD] = 0.08, 95% CI [0.02, 0.14], p = 0.004; I2 = 0%). The number needed to treat was 13. Subgroup analysis revealed some benefits across different TNK dosing strategies. There was no significant increase in symptomatic intracranial hemorrhage (sICH) (RD = 0.02, 95% CI [-0.01, 0.05], p = 0.13) or mortality (RD = -0.02, 95% CI [-0.07, 0.02], p = 0.36). Conclusions Adjunctive IA-TNK after successful EVT is associated with significant improvement in functional outcomes without increasing the risk of sICH or mortality. These findings suggest that IA-TNK may be considered as promising therapy to overcome microvascular failure in patients achieving successful EVT. Conflict of interest Nothing to disclose

Cardiomyopathy (CM) is a common cause of heart failure (HF), and those with HF have up to a 3-fold increased risk of stroke. This study aims to examine the incidence of intravascular thrombolysis and endovascular thrombectomy and the functional outcomes in acute ischemic stroke (AIS) patients with CM and HF. International Classification of Diseases-10 codes were used to query the National Inpatient Sample database for patients with AIS and concurrent CM and HF from 2016 to 2019. Incidence of reperfusion therapy, medical complications, discharge disposition, length of hospital stay, and mortality between patients with and without CM and HF were compared using propensity score matching and multivariable logistic regression analysis. Of 2,939,160 patients identified with AIS, 80,915 (2.8%) had concomitant diagnoses of CM and HF. Patients in this population had more severe strokes (25.9% vs 19.6%, P < 0.001) and received endovascular thrombectomy at higher rates (8.8% vs 5.6%, P < 0.001) but equivalent rates of intravascular thrombolysis (3.0% vs 2.9%, P = 0.107). Additionally, CM/HF patients were more likely to experience inpatient death (6.6% vs 5.4%, P < 0.001). Despite this, those who survived were statistically more likely to have a favorable discharge disposition (45.7% vs 43.9%, P < 0.001). Although CM and HF patients are more likely to experience complications, prolonged length of stay, and inpatient death, those who survive have higher rates of favorable discharge disposition. These results suggest that stroke intervention is safe and efficacious in patients with CM and HF.

BACKGROUND:Despite the fact that a large proportion of patients with acute ischemic stroke (AIS) who undergo endovascular thrombectomy (EVT) for large vessel occlusion (LVO) achieve successful recanalization, they continue to experience poor functional outcomes due to microvascular failure. Adjunctive intra-arterial tenecteplase (IA-TNK) has been proposed as a promising strategy to address this phenomenon of futile recanalization. OBJECTIVE:To evaluate the effectiveness and safety of intra-arterial tenecteplase (IA-TNK) after successful EVT in ischemic stroke. METHODS:We performed a comprehensive search of seven databases for clinical trials of IA-TNK after successful EVT for AIS. Eligible studies compared combined IA-TNK and EVT versus EVT only. Data were pooled using random-effects models, risk of bias was assessed with RoB-2 and RoB-1, and certainty of evidence was graded using GRADE. RESULTS:Overall analysis showed that IA-TNK administered after successful EVT was associated with significantly higher rates of mRS 0-1 compared to control (risk difference [RD] = 0.08, 95% CI [0.02, 0.14], p = 0.004; I2 = 0%). The number needed to treat was 13. Subgroup analysis revealed some benefits across different TNK dosing strategies. There was no significant increase in symptomatic intracranial hemorrhage (sICH) (RD = 0.02, 95% CI [-0.01, 0.05], p = 0.13) or mortality (RD = -0.02, 95% CI [-0.07, 0.02], p = 0.36). CONCLUSION:Adjunctive IA-TNK after successful EVT is associated with significant improvement in functional outcomes without increasing the risk of sICH or mortality. These findings suggest that IA-TNK may be considered as promising therapy to overcome microvascular failure in patients achieving successful EVT.

Stroke is a leading cause of neurological disability and mortality worldwide, with acute ischemic strokes caused by large-vessel occlusions presenting significant health care challenges. While endovascular thrombectomy has emerged as a gold standard treatment, access to timely stroke care remains severely limited, especially in low- and middle-income countries. This review examines the multifaceted social, cultural, and systemic barriers that impede effective stroke care globally. We performed a comprehensive search of PubMed from 2004 to 2024, using keywords of acute stroke care, low-middle-income countries, social barriers, cultural barriers, and access. There are several recognized obstacles to stroke treatment, especially in the acute settings, including health fatalism, spiritual and religious beliefs that discourage medical intervention, and widespread lack of public awareness about stroke symptoms and urgency. Cultural misconceptions often lead individuals to delay or avoid seeking medical care, with some communities attributing stroke to supernatural forces or divine punishment. Language barriers, insufficient health care infrastructure, and socioeconomic challenges further compound these issues, particularly in regions such as sub-Saharan Africa and parts of Asia. Furthermore, there are critical infrastructural barriers to delivering acute stroke in a timely manner, including limited transportation to health care facilities and inadequate stroke centers in rural areas. A comprehensive strategy to address these challenges should focus on culturally sensitive education, community engagement, and infrastructure development. Recommendations include cooperating with religious and community leaders, developing targeted awareness campaigns, and creating inclusive health care approaches that respect local cultural contexts. Overall, addressing the global stroke burden not only requires technological interventions but also demands a holistic approach that bridges cultural understanding, challenges misconceptions, and empowers communities to recognize and respond to stroke as a critical medical emergency.

Intraneural perineuriomas are tumors originating from the perineurial cells surrounding nerve sheath fascicles. Intraneural perineuriomas represent about 1% of peripheral nerve tumors and are often misdiagnosed due to their rarity. In this case, we report a pediatric patient with a radial nerve perineurioma, in which ultrasound played a key role in diagnosis. We present the case of a 4-year-old male with over 6 months of progressive left upper extremity weakness found to have chronic left radial neuropathy distal to the triceps branch of the radial nerve on electromyography/nerve conduction study. Ultrasound showed a well-defined fusiform hypoechoic mass of approximately 1.5 × 0.5 × 0.8 cm, with the radial nerve noted to enter and exit the mass. Magnetic resonance imaging (MRI) did not encompass the pathology. The mass was excised with small margins, and pathology was consistent with perineurioma. The resultant 3 cm gap was repaired through nerve grafting. Surveillance MRI showed no recurrence of the perineurioma over time. Ultrasound served as a necessary adjunct in the workup of upper extremity weakness despite negative MRI findings. This imaging modality should be considered if there is high clinical suspicion of a peripheral nerve lesion.

BackgroundSpinal dural arteriovenous fistulas (SDAVFs) are the most common type of spinal arteriovenous malformation. Typically, these malformations present with a wide range of nonspecific symptoms indicative of thoracolumbar myelopathy. However, patients with spinal dural arteriovenous fistulas may rarely present with subarachnoid hemorrhage.MethodsA systematic review of MEDLINE and Embase databases was performed querying for cases of spinal dural arteriovenous fistulas with subarachnoid hemorrhage. Patient characteristics and outcomes investigated included spinal level of the fistula, delay of diagnosis, Hunt and Hess grade, interventions, recurrence of the fistula, and postoperative disability. Additionally, we present a unique case in which subarachnoid hemorrhage resulted from a spinal dural arteriovenous fistula that was refractory to multiple endovascular and open surgical interventions.ResultsOf 116 records identified, 45 studies were included comprising 80 patients with spinal dural arteriovenous fistula and subarachnoid hemorrhage. The most common locations of the spinal dural arteriovenous fistula were in the cervical spine (57.5%) and at the craniocervical junction (35%). Patients were treated with open surgical ligation (60.0%), endovascular embolization (22.5%), or an open surgical procedure following persistent symptoms after endovascular treatment (10.0%). Overall, the prognoses among the treated patients were favorable with only two reported (2.5%) mortalities. Rates of neurologic recovery were similar when comparing endovascular and open surgical treatment. Endovascular treatment with coil embolization of a C1-C2 spinal dural arteriovenous fistula presenting as subarachnoid hemorrhage is also described.ConclusionSpinal dural arteriovenous fistulas, particularly in the cervical spine, could be considered as a potential etiology for subarachnoid hemorrhage patients with no obvious intracranial cause. Treatment with either open surgery or embolization appears to offer a positive prognosis for both functional and angiographic outcomes.

PurposeThis study aimed to investigate in-patient mortality and predictors of death associated with convulsive status epilepticus (CSE) in a large nationwide cohort and create a simplified predictive score for in-hospital mortality.MethodsRetrospective data from the National Inpatient Sample (NIS) database between 2007 and 2014 were analyzed, including 123,082 adults with CSE. Univariate logistic testing identified admission variables, neurological and medical complications associated with mortality. A simplified clinical prediction score, called M3A2S2H, was generated using variables that were frequent (>1%) and had a significant impact on mortality.ResultsThe overall hospital mortality rate was 3.5%. Univariate analysis revealed that older age, female gender, past medical history, and acute hospital conditions were related to mortality. After reclassification, a final multivariable model with 27 clinical variables was constructed, and the eight strongest predictors were included in the M3A2S2H score: hypoxic-ischemic encephalopathy/cardiac arrest (2 points); age >60 years, acute symptomatic CSE, invasive mechanical ventilation, sepsis, metastases, and chronic liver failure (all 1 point); and medication nonadherence (-1 point). The mortality rate among patients with ≤0, 1, 2, 3, 4, or ≥5 of these risk factors progressively increased from 0.2%, 2.1%, 7.8%, 20.3%, 31.9%, to 50.0% (P < 0.0001). Additionally, a similar stepwise trend was observed regarding discharge to a facility versus home without services (P < 0.0001).ConclusionsThis study demonstrates that mortality in CSE cases occurs in 3.5% of adult hospital admissions. Identification of specific acute and chronic conditions using the standardized M3A2S2H score can help predict the risk of death or disability even in hospitals without advanced brain monitoring.

BackgroundDespite the widespread use of heparin during and following endovascular procedures in the management of aneurysmal subarachnoid hemorrhage (SAH) patients, limited research has explored the incidence and impact of heparin-induced thrombocytopenia (HIT) on SAH.MethodsDescriptive statistics, multivariate regressions, and propensity score-matching were employed to compare clinical characteristics, comorbidities, interventions, complications, and outcomes of HIT in SAH patients identified within the US National Inpatient Sample database from 2010 to 2019.ResultsAmong 76 387 SAH patients from 2010 to 2019, 166 (0.22%) developed HIT. HIT was identified as a significant predictor of prolonged length of stay (OR 6.799, 95% CI 3.985 to 11.6, P<0.01) and poor functional outcomes (OR 2.541, 95% CI 1.628 to 3.966, P<0.01) after adjusting for relevant factors. HIT incidence was higher in patients with elevated SAH severity scores (1.42 vs 1.06, P<0.01), younger patients (58.04 vs 61.39 years, P=0.01), overweight individuals (0.4% vs 0.2%, P<0.01), those on long-term anticoagulants (10.84% vs 5.72%, P<0.01), or with a cerebrospinal fluid drainage device (external ventricular drain, ventriculoperitoneal shunt; P<0.01). HIT patients showed increased rates of endovascular coiling, ventricular drain placement, shunt placement, deep vein thrombosis, urinary tract infection, acute kidney injury, pulmonary embolism, venous sinus thrombosis, pneumonia, and cerebral vasospasm (all P<0.01).ConclusionSAH patients with HIT exhibited various comorbidities and increased rates of complications, which may contribute to extended hospital stays. This nationwide study aids clinical suspicion and highlights HIT’s impact on SAH patients.

Background: Migraine prevalence has been estimated to be as high as 25% during reproductive years. Despite this, and the known significantly lower odds of acute stroke being correctly diagnosed among women versus men, little is known about the migraine-stroke connection in this vulnerable population. Our study seeks to provide a consolidated examination of cerebrovascular and obstetric complications of migraines in pregnant women and to evaluate the role of concurrent comorbidities.Methods: We utilized the 2016-2020 Healthcare Cost and Utilization Project's National Inpatient Sample with the International Classification of Diseases, 10th Revision diagnostic codes to compare pregnant patients with migraines with those without migraines. Multivariable logistic regression was used to examine the incidence of subtypes of stroke while controlling for confounding variables.Results: Overall, 19,825,525 pregnant patients were evaluated; 219,175 (1.1%) had a concomitant diagnosis of migraine. Pregnant patients with migraines were more likely to suffer ischemic (0.1% versus 0.0%) or hemorrhagic stroke (0.3% versus 0.1%). On multivariate analysis, acute ischemic stroke was most strongly associated with migraine with aura (odds ratio [OR], 23.26; 95% confidence interval [CI], 18.46-29.31), followed by migraine without aura (OR, 8.15; 95% CI, 4.79-13.88).Conclusions: Pregnant women with migraine are at a significantly increased risk for both ischemic and hemorrhagic stroke. Pregnant women with migraines should be cautioned that they may be at an increased risk of stroke, particularly if they are experiencing an aura, and encouraged to contact their medical providers to rule out neurological complications.

Transcriptional targets of TOP2B based on gene lists from MsigDB

BACKGROUND: Intracranial abscess (IA) causes significant morbidity and mortality. The impact of baseline frailty status on post-operative outcomes of IA patients remains largely unknown. The present study evaluated if frailty status can be used to prognosticate outcomes in IA patients. METHODS: We retrospectively reviewed all IA patients undergoing craniotomy at our institution from 2011 to 2018 (N.=18). These IA patients were age and gender matched with patients undergoing craniotomy for intracranial tumor (IT), an internal control for comparison. Demographic and clinical data were collected to measure frailty, using the modified frailty index-11 (mFI-11) and pre-operative American Society of Anesthesiologists Physical Status Classification System (ASA). Post-operative complications were measured by the Clavien-Dindo Grade (CDG). RESULTS: No significant difference in mFI-11 or ASA score was observed between the IA and IT groups (P=0.058 and P=0.131, respectively). IA patients had significantly higher CDG as compared with the control IT patients (P<0.001). There was a trend towards increasing LOS in the IA group as compared to the IT group (P=0.053). Increasing mFI and ASA were significant predictors of LOS by multiple linear regression in the IA group (P=0.006 and P=0.001, respectively), but not in the control IT group. Neither mFI-11 nor ASA were found to be predictors for CDG in either group. Within this case-control group of patients, we found an increase for odds of having IA with increasing mFI (OR=1.838, 95% CI: 1.016-3.362, P=0.044). CONCLUSIONS: Frail IA patients tend to have more severe postoperative complications. The mFI-11 seems to predict increased resource utilization in the form of LOS. This study provides the initial retrospective data of another neurosurgical pathology where frailty leads to significantly worse outcomes. We also found that mFI may serve as a potential risk factor for severe disease.

We aim to better understand the effectiveness of revascularization therapies in central retinal artery occlusion (CRAO) patients compared to acute ischemic stroke (AIS) patients.

Detailed quality metrics report with the Library complexity and PCR Bottleneck Coefficient (PBC)

Central retinal artery occlusion (CRAO) is a rare and visually debilitating vascular condition characterized by sudden and severe vision loss. CRAO is a compelling target for intravenous alteplase (tPA) and endovascular mechanical thrombectomy (MT) due to pathophysiological similarities with acute ischemic stroke; however, the utility of these interventions in CRAO remains dubious due to limited sample sizes and potential risks. To assess usage and outcomes of tPA and MT in CRAO, we queried the National Inpatient Sample database using International Classification of Disease, Ninth and Tenth edition for patients with CRAO and acute ischemic stroke between 2010 and 2019. Our cohort of 5009 CRAO patients were younger with higher rates of obesity, hypertension, long-term anticoagulant use, and tobacco use compared to acute ischemic stroke patients. CRAO patients had lower rates of tPA administration (3.41% vs 6.21%) and endovascular MT (0.38% vs 1.31%) but fewer complications, including deep vein thrombosis, pneumonia, urinary tract infection, acute kidney injury, and acute myocardial infarction (all P < 0.01). CRAO patients had lower rates of poor functional outcome (31.74% vs 58.1%) and in-hospital mortality (1.2% vs 5.64%), but higher rates of profound blindness (9.24% vs 0.58%). A multivariate regression showed no relationship between tPA and MT and profound blindness, although the limited sample size of patients receiving interventions may have contributed to this apparent insignificance. Further investigation of larger patient cohorts and alternative treatment modalities could provide valuable insights for revascularization therapies in CRAO to optimize visual restoration and clinical outcomes.