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Advances in the Diagnosis, Treatment, and Prognosis of Acute Stroke

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Clinical Neurology".

Deadline for manuscript submissions: closed (20 March 2024) | Viewed by 16359

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Dr. Ashkan Mowla

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Guest Editor

Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA
Interests: brain Ischemia; intracranial large vessel occlusion stroke; thrombolytic therapy; stroke; vascular neurology; artificial intelligence

Special Issue Information

Dear Colleagues,

Novel techniques and treatment modalities are emerging in the fields of stroke, vascular neurology, and interventional neuroradiology. Recent research breakthroughs have changed our understanding of stroke pathophysiology, imaging, and treatments. In addition, artificial intelligence has revolutionized the management of acute stroke.

In this Special Issue of JCM, we will cover the following topics and updates in the fields of stroke, vascular neurology, and interventional neuroradiology:

Updates on acute thrombolytic therapy, with a focus on intravenous tenecteplase;
Updates on patient selection based on imaging modalities for intravenous thrombolytic therapy and mechanical thrombectomy;
Updates on the role of mechanical thrombectomy for medium- and small-size intracranial vessel occlusion;
Updates on the role of mechanical thrombectomy in large-vessel occlusion strokes with large core infarct;
Updates on the management of intracranial atherosclerotic disease;
Updates on the management of vertebral artery atherosclerotic steno-occlusive disease;
Application of AI in the detection and management of acute ischemic stroke;
Management of complications of mechanical thrombectomy.

Dr. Ashkan Mowla
Guest Editor

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Keywords

stroke
mechanical thrombectomy
intravenous thrombolytic therapy
imaging selection for stroke
large-vessel occlusion
intracranial atherosclerotic disease
artificial intelligence

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Published Papers (8 papers)

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9 pages, 1111 KiB

Open AccessArticle

Analysis of Safety and Efficacy of the Early Initiation of Antithrombotic Secondary Prevention in Patients Treated with Intravenous Thrombolysis for Acute Ischemic Stroke

by Georgi Krastev, Miroslav Mako, Zuzana Števková, Romana Havranová and Kristína Andrášiková

J. Clin. Med. 2024, 13(9), 2710; https://doi.org/10.3390/jcm13092710 - 5 May 2024

Cited by 1 | Viewed by 1200

Abstract

Background and Objectives: Current guidelines and the alteplase product insert recommend that antithrombotic therapy be avoided within 24 h of intravenous thrombolytic therapy with rt-PA in acute ischemic stroke. Therefore, the rate of stroke recurrence is unclear in terms of early neurological deterioration, which we could prevent with the early administration of antithrombotic therapy. We do not know the effect of early antithrombotic therapy after intravenous thrombolysis with rt-PA in acute stroke on the outcome in patients after 90 days either. Design: Prospective monocentric observational cohort study. Methods: Data were collected from consecutive patients treated with alteplase for acute ischemic stroke between January 2015 and January 2023. We examined functional outcome at 90 days, including the risk of symptomatic intracranial hemorrhage and mortality rate as safety indicators and stroke recurrence events in both early and standard antithrombotic therapy at 24 h after intravenous thrombolysis. Results: A total of 489 patients were included, of which 278 (56.9%) were men. Of these, 407 (83.2%) patients received early antithrombotic therapy. No symptomatic intracranial hemorrhage occurred in any participants. There was a significantly higher number of patients with an excellent outcome (mRS 0-1) in early antithrombotic treatment (211 (53.1%) versus 28 (34.6%) in standard antithrombotic treatment (p = 0.002, OR 0.47, 95% CI: 0.28–0.76). Conclusions: Early antithrombotic treatment after intravenous therapy in patients with acute ischemic stroke revealed no safety concerns compared with standard antithrombotic therapy and resulted in a significantly higher proportion of patients with an excellent functional outcome. Full article

(This article belongs to the Special Issue Advances in the Diagnosis, Treatment, and Prognosis of Acute Stroke)

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12 pages, 3620 KiB

Open AccessArticle

The Relationship between CT Angiography Collateral Score and Biochemical Parameters during Acute Ischemic Stroke Caused by Middle Cerebral Artery Infarct

by Halil Güllüoğlu, Hasan Armağan Uysal and Erkan Şahin

J. Clin. Med. 2024, 13(8), 2443; https://doi.org/10.3390/jcm13082443 - 22 Apr 2024

Viewed by 1484

Abstract

Background/Objectives: Collateral development after AIS is important for prognosis and treatment. In this study, we aimed to investigate the relationship and correlation between biochemical parameters and CT angiography collateral score within the first 9 h and its effect on the neurological outcomes of patients with AIS due to MCA infarction. Methods: A total of 98 patients with MCA infarction were hospitalized for diagnosis and treatment after undergoing CT angiography within 9 h of suffering a stroke. Demographic data, admission biochemical parameters, hospitalization data, and discharge NIHSS scores were recorded. Souza’s scoring system for collateral distribution was used to evaluate collaterals. Souza CS system and clinical disability comparison outcomes identified. Results: According to the Souza CS system, 13 patients were in the malignant profile category, and 85 patients were in the good profile category. The NIHSS value of patients with a malignant profile was 27, while the mean NIHSS value of patients with a good profile was 9. There was a statistically significant difference in uric acid, total cholesterol, triglyceride, HDL cholesterol, CRP, hsCRP, D-Dimer, troponin I, vitamin B12, fibrinogen, NSE, homocysteine, aPTT, and INR levels according to collateral distribution. Conclusions: This study demonstrates that biochemical parameters can influence the distribution of malignant and benign collaterals in AIS independent of age and gender. Full article

(This article belongs to the Special Issue Advances in the Diagnosis, Treatment, and Prognosis of Acute Stroke)

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12 pages, 1103 KiB

Open AccessEditor’s ChoiceArticle

The Compensation Index Is Better Associated with DSA ASITN Collateral Score Compared to the Cerebral Blood Volume Index and Hypoperfusion Intensity Ratio

by Dhairya A. Lakhani, Aneri B. Balar, Manisha Koneru, Sijin Wen, Meisam Hoseinyazdi, Cynthia Greene, Risheng Xu, Licia Luna, Justin Caplan, Adam A. Dmytriw, Adrien Guenego, Max Wintermark, Fernando Gonzalez, Victor Urrutia, Judy Huang, Kambiz Nael, Ansaar T. Rai, Gregory W. Albers, Jeremy J. Heit and Vivek S. Yedavalli

J. Clin. Med. 2023, 12(23), 7365; https://doi.org/10.3390/jcm12237365 - 28 Nov 2023

Cited by 13 | Viewed by 1840

Abstract

Background: Pretreatment CT Perfusion (CTP) parameters serve as reliable surrogates of collateral status (CS). In this study, we aim to assess the relationship between the novel compensation index (CI, Tmax > 4 s/Tmax > 6 s) and already established CTP collateral markers, namely cerebral blood volume (CBV) index and Hypoperfusion Intensity Ratio (HIR), with the reference standard American Society of Interventional and Therapeutic Neuroradiology (ASITN) collateral score (CS) on DSA. Methods: In this retrospective study, inclusion criteria were the following: (a) CT angiography confirmed anterior circulation large vessel occlusion from 9 January 2017 to 10 January 2023; (b) diagnostic CT perfusion; and (c) underwent mechanical thrombectomy with documented DSA-CS. Student t-test, Mann–Whitney-U-test and Chi-square test were used to assess differences. Spearman’s rank correlation and logistic regression analysis were used to assess associations. p ≤ 0.05 was considered significant. Results: In total, 223 patients (mean age: 67.8 ± 15.8, 56% female) met our inclusion criteria. The CI (ρ = 0.37, p < 0.001) and HIR (ρ = −0.29, p < 0.001) significantly correlated with DSA-CS. Whereas the CBV Index (ρ = 0.1, p > 0.05) did not correlate with DSA-CS. On multivariate logistic regression analysis taking into account age, sex, ASPECTS, tPA, premorbid mRS, NIH stroke scale, prior history of TIA, stroke, atrial fibrillation, diabetes mellitus, hyperlipidemia, heart disease and hypertension, only CI was not found to be independently associated with DSA-CS (adjusted OR = 1.387, 95% CI: 1.09–1.77, p < 0.01). Conclusion: CI demonstrates a stronger correlation with DSA-CS compared to both the HIR and CBV Index where it may show promise as an additional quantitative pretreatment CS biomarker. Full article

(This article belongs to the Special Issue Advances in the Diagnosis, Treatment, and Prognosis of Acute Stroke)

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15 pages, 719 KiB

Open AccessArticle

The Role of Electrocardiographic Markers for Predicting Atrial Fibrillation in Patients with Acute Ischemic Stroke: Data from the BIOSIGNAL Cohort Study

by Valerie Schütz, Svetlana Dougoud, Katja Bracher, Markus Arnold, Juliane Schweizer, Christos Nakas, Laura P. Westphal, Corinne Inauen, Thomas Pokorny, Firat Duru, Jan Steffel, Andreas Luft, Katharina Spanaus, Ardan Muammer Saguner and Mira Katan

J. Clin. Med. 2023, 12(21), 6830; https://doi.org/10.3390/jcm12216830 - 29 Oct 2023

Cited by 2 | Viewed by 2877

Abstract

Background and Aims: P-wave abnormalities in the 12-lead electrocardiogram (ECG) have been associated with a higher risk of acute ischemic stroke (AIS) as well as atrial fibrillation (AF). This study aimed to assess pre-determined ECG criteria during sinus rhythm in unselected AIS patients and their value for predicting newly diagnosed atrial fibrillation (NDAF) after hospital admission. Methods: P-wave alterations were measured on 12-lead ECG on admission in all consecutively enrolled patients without known AF between October 2014 and 2017. The outcome of interest was NDAF, identified by prolonged electrocardiographic monitoring within one year after the index AIS. Univariable and multivariable logistic regression was applied to assess the magnitude and independence of the association between pre-selected ECG markers and NDAF. The discriminatory accuracy was evaluated with the area under the receiver operating characteristic curve (AUC), and the incremental prognostic value was estimated with the net reclassification index. Results: NDAF was detected in 87 (10%) of 856 patients during a follow-up of 365 days. Out of the pre-selected ECG parameters, advanced interatrial block (aIAB) and PR interval in lead II were independently associated with NDAF in univariable regression analysis. Only aIAB remained a significant predictor in multivariable analysis. Adding aIAB to the best-performing multivariable regression model improved the discriminatory accuracy to predict NDAF from an AUC of 0.78 (95%-CI 0.77–0.80) to 0.81 (95%-CI 0.80–0.83, p < 0.001). Conclusion: aIAB is independently and highly associated with NDAF in patients with AIS, has high inter-rater reliability, and therefore may be helpful to refine diagnostic work-up to search for AF in AIS. Full article

(This article belongs to the Special Issue Advances in the Diagnosis, Treatment, and Prognosis of Acute Stroke)

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12 pages, 1732 KiB

Open AccessArticle

Impact on Endovascular Thrombectomy for Acute Ischemic Stroke of Aortic Arch Calcification on Chest X-ray

by Hyeon Yeong Jeong, Taek Min Nam, Sang Hyuk Lee, Ji Hwan Jang, Young Zoon Kim, Kyu Hong Kim, Kyeong Hwa Ryu, Do-Hyung Kim, Byung Soo Kwan, Hyerang Bak and Seung Hwan Kim

J. Clin. Med. 2023, 12(19), 6115; https://doi.org/10.3390/jcm12196115 - 22 Sep 2023

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Abstract

Background: Vascular conditions can affect the recanalization rates after endovascular thrombectomy (EVT) for acute ischemic stroke (AIS). Chest radiography can assess the conditions of the aortic arch based on the presence or absence of aortic arch calcification (AoAC). The aim of this study was to investigate the relationship between AoAC on chest radiography and first-pass successful recanalization (modified thrombolysis in cerebral infarction 2b/3 after the first-pass). Methods: We compared the rate of first-pass successful recanalization between patients with and without AoAC. A total of 193 patients with anterior circulation occlusion who underwent EVT between January 2017 and December 2021 were included. Results: AoAC was observed in 80 (41.5%) patients. Patients with AoAC were older (74.5 ± 7.78 vs. 63.9 ± 12.4 years, p < 0.001), had more EVT attempts (3.04 ± 1.95 vs. 2.01 ± 1.34 times, p < 0.001), and a longer procedural time (71.7 ± 31.2 vs. 48.7 ± 23.1 min, p < 0.001) than those without AoAC. Moreover, Patients with AoAC showed a lower incidence of first-pass successful recanalization (18.8% vs. 47.8%, p < 0.001) and a higher incidence of postprocedural hemorrhage (45.0% vs. 27.7%, p = 0.015) than those without AoAC. On multivariate analysis, AoAC was independently associated with first-pass successful recanalization (odds ratio: 0.239 [0.121–0.475], p < 0.001). Conclusions: AoAC on chest radiography can be used as a preoperative predictor of successful first-pass recanalization in patients undergoing EVT for AIS. Full article

(This article belongs to the Special Issue Advances in the Diagnosis, Treatment, and Prognosis of Acute Stroke)

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10 pages, 246 KiB

Open AccessArticle

Primary Intracranial Hemorrhage: Characteristics, Distribution, Risk Factors, and Outcomes—A Comparative Study between Jewish and Arab Ethnic Groups in Northern Israel

by Jamal Saad, Chen Hanna Ryder, Mahmod Hasan, Galina Keigler and Samih Badarny

J. Clin. Med. 2023, 12(15), 4993; https://doi.org/10.3390/jcm12154993 - 29 Jul 2023

Cited by 2 | Viewed by 1875

Abstract

Background and purpose: This study aimed to investigate the differences in intracerebral hemorrhage (ICH) between Jews and Arabs residing in northern Israel, focusing on risk factors, hemorrhage volume, and functional outcome. Methods: A retrospective analysis was conducted utilizing a population-based registry to investigate intracerebral hemorrhage (ICH) characteristics, risk factors, and outcomes. The registry consisted of inpatients diagnosed with hemorrhagic stroke. Due to the wide variation in data on ICH characteristics and the limited availability of population-based data on predictors of ICH survival and functional outcomes, we collected retrospective data on all adult patients admitted to the Galilee Medical Center with a diagnosis of ICH. Data were obtained from the registry covering the period from 2013 to 2019. Ethnic differences and risk factors associated with intracranial hemorrhage (ICH) were examined within a diverse population of 241 patients, comprising 52.70% Jews (n = 127) and 47.30% Arabs (n = 114). Results: The results of this study revealed significant differences in age, obesity rates, and intracerebral hemorrhage (ICH) location between the two ethnic groups. Hypertension emerged as the most prevalent condition among ICH patients in both ethnic groups (76.70%), followed primarily by anticoagulant use (63.60%), dyslipidemia (60.70%), diabetes (44.60%), obesity (30.60%), smoking (24.60%), and a history of cardiovascular disease (21.80%). Furthermore, 20.90% of the patients had a history of previous cerebrovascular accidents (CVA). Arab patients with ICH were generally younger (62.90 ± 16.00 years) and exhibited higher rates of obesity (38.70%) compared to Jewish patients with ICH (70.17 ± 15.24 years, 23% obesity; p = 0.001, p = 0.013, respectively). Hemorrhage volume was identified as a crucial determinant of patient outcomes, with larger volumes associated with poorer Modified Rankin Scale (mRS) scores at discharge and higher mortality rates. Interestingly, patients without hypertension had higher hemorrhage volumes compared to those with hypertension. The extent of hemorrhage into the ventricles did not significantly correlate with mRS at discharge in our dataset. Conclusions: This study highlights significant differences in the characteristics and outcomes of intracranial hemorrhage (ICH) between Jews and Arabs in northern Israel. The findings reveal variations in age, obesity rates, and ICH location between the two groups. While hypertension was the most prevalent risk factor for both populations, other risk factors differed. Notably, hemorrhage volume emerged as a crucial prognostic factor, aligning with previously published data. These findings underscore the necessity for tailored approaches that consider ethnic-specific factors in the risk assessment, prevention, and management of ICH. Further research is warranted to elucidate the underlying mechanisms and develop interventions aimed at improving outcomes and enhancing healthcare practices in ICH management. Full article

(This article belongs to the Special Issue Advances in the Diagnosis, Treatment, and Prognosis of Acute Stroke)

15 pages, 1133 KiB

Open AccessArticle

Age Stratification and Stroke Severity in the Telestroke Network

by Cassie A. Simmons, Nicolas Poupore and Thomas I. Nathaniel

J. Clin. Med. 2023, 12(4), 1519; https://doi.org/10.3390/jcm12041519 - 14 Feb 2023

Cited by 16 | Viewed by 2904

Abstract

Background. Age is one of the most important risk factors for stroke, and an estimated 75% of strokes occur in people 65 years old and above. Adults > 75 years of age experience more hospitalizations and higher mortality. In this study, we aimed to investigate how age and various clinical risk factors affect acute ischemic stroke (AIS) severity in two age categories. Methods. This retrospective data analysis study was conducted using data collected from the PRISMA Health Stroke Registry between June 2010 and July 2016. Baseline clinical and demographic data were analyzed for 65–74-year-old patients and those ≥ 75 years of age. This study aimed to investigate risk factors associated with stroke severity in these two age categories of AIS patients treated in telestroke settings. Results. An adjusted multivariate analysis showed that the acute ischemic stroke (AIS) population of 65–74-year-old patients experiencing heart failure (odds ratio (OR) = 4.398, 95% CI = 3.912–494.613, p = 0.002) and elevated high-density lipoprotein (HDL) levels (OR = 1.066, 95% CI = 1.009–1.126, p = 0.024) trended towards worsening neurological function, while patients experiencing obesity (OR = 0.177, 95% CI = 0.041–0.760, p = 0.020) exhibited improved neurological functions. For the patients ≥ 75 years of age, direct admission (OR = 0.270, 95% CI = 0.085–0.856, p = 0.026) was associated with improved functions. Conclusions. Heart failure and elevated HDL levels were significantly associated with worsening neurologic functions in patients aged 65–74. Obese patients and individuals ≥ 75 years of age who were directly admitted were most likely to exhibit improving neurological functions. Full article

(This article belongs to the Special Issue Advances in the Diagnosis, Treatment, and Prognosis of Acute Stroke)

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9 pages, 2316 KiB

Open AccessCase Report

Tumor Embolic Stroke: The Importance of Pathological Assessment of Clots after Thrombectomy

by Richard Baker, Zohabe Bakali, Jeffrey S. Crocker, Ashkan Mowla, Matthew Smith, Aaron Grossman, Matthew C. Hagen, Charles J. Prestigiacomo and Peyman Shirani

J. Clin. Med. 2024, 13(7), 1834; https://doi.org/10.3390/jcm13071834 - 22 Mar 2024

Cited by 2 | Viewed by 1792

Abstract

While tumor emboli are a rare cause of stroke in cancer patients, they highlight the importance of gross observations and pathological assessments in the evaluation of clots. In this case report, a 70-year-old male with type 2 diabetes mellitus and coronary artery disease presented with acute left-sided weakness. He was clinically diagnosed with stroke and given alteplase at 1.5 h from last known normal. He then underwent CT angiography that showed right internal carotid artery occlusion and immediate thrombectomy. The recovered clot was white and lipid-like; due to its atypical appearance, it was sent for pathological assessment, where it was shown to bear features of malignancy. Subsequent imaging identified masses indicating malignancy in the left gluteus, right pleural hilum, and spine. Tumor embolic stroke is a rare pathology. Embolic diseases such as strokes and pulmonary embolisms are common in patients with cancer. Embolic stroke of undetermined source (ESUS) represents a significant portion of cancer strokes. Tumor emboli, though rare, may be an underappreciated source of ESUS in cancer patients. We intend for this case to demonstrate the value of pathological assessment for atypical thrombi as well as highlight the etiology of tumor embolic strokes. Full article

(This article belongs to the Special Issue Advances in the Diagnosis, Treatment, and Prognosis of Acute Stroke)

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