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Diagnosis, Prevention and Treatment for 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 (31 July 2020) | Viewed by 38684

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Special Issue Editor

Dr. Aristeidis H. Katsanos

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Guest Editor

Population Health Research Institute, McMaster University, Hamilton, ON, Canada
Interests: prevention; neurosonology; epidemiology; evidence-based medicine

Special Issue Information

Dear Colleagues,

In recent years, there have been outstanding achievements in stroke diagnosis and care. Our better understanding of the pathophysiological mechanisms and the advances in neuro-imaging have enabled us to diagnose stroke syndromes with remarkable precision and uncover underlying vessel pathologies that can be directly correlated to the stroke event. Within a short period of time, mechanical thrombectomy became the standard of care for patients with large vessel occlusions and symptom onset up to 24 hours, while other recent trials also suggest the use of perfusion imaging to guide intravenous thrombolysis in the extended time window. In this Special Issue, we will also discuss extensively relevant topics on secondary stroke prevention, including the prompt use of nonvitamin k oral anticoagulants and the potential effect of reversal agents in patients with intracerebral hemorrhage related to their use. We will also delineate treatment options for stroke patients with indication for long-term anticoagulation and high bleeding risk. Finally, a particular mention will be made for young patients with stroke, the extent of the diagnostic work-up, and the selection of those who would be benefit from patent foramen ovale closure.

Dr. Aristeidis H. Katsanos
Guest Editor

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Keywords

ischemic stroke
intracerebral hemorrhage
nonvitamin k oral anticoagulants
cerebral microbleeds
high-resolution vessel wall imaging
transcranial doppler ultrasound
patent foramen ovale closure
left atrial appendage closure
rhythm monitoring
thrombolysis
tenecteplase
mechanical thrombectomy
perfusion imaging

Published Papers (14 papers)

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Editorial

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7 pages, 202 KiB

Open AccessEditorial

Updates in Stroke Treatment, Diagnostic Methods and Predictors of Outcome

by Aristeidis H. Katsanos

J. Clin. Med. 2020, 9(9), 2789; https://doi.org/10.3390/jcm9092789 - 29 Aug 2020

Cited by 3 | Viewed by 1660

Abstract

In recent years, there have been outstanding achievements in stroke diagnosis and care [...] Full article

(This article belongs to the Special Issue Diagnosis, Prevention and Treatment for Stroke)

Research

Jump to: Editorial, Review

11 pages, 1063 KiB

Open AccessArticle

Utility of Leptomeningeal Collaterals in Predicting Intracranial Atherosclerosis-Related Large Vessel Occlusion in Endovascular Treatment

by Jang-Hyun Baek, Byung Moon Kim, Jin Woo Kim, Dong Joon Kim, Ji Hoe Heo, Hyo Suk Nam and Young Dae Kim

J. Clin. Med. 2020, 9(9), 2784; https://doi.org/10.3390/jcm9092784 - 28 Aug 2020

Cited by 15 | Viewed by 2122

Abstract

Earlier or preprocedural identification of occlusion pathomechanism is crucial for effective endovascular treatment. As leptomeningeal collaterals tend to develop well in chronic ischemic conditions such as intracranial atherosclerosis (ICAS), we investigated whether leptomeningeal collaterals can be a preprocedural marker of ICAS-related large vessel occlusion (ICAS-LVO) in endovascular treatment. A total of 226 patients who underwent endovascular treatment were retrospectively reviewed. We compared the pattern of leptomeningeal collaterals between patients with ICAS-LVO and without. Leptomeningeal collaterals were assessed by preprocedural computed tomography angiography (CTA) and basically categorized by three different collateral assessment methods. Better leptomeningeal collaterals were significantly associated with ICAS-LVO, although they were not independent for ICAS-LVO. When leptomeningeal collaterals were dichotomized to incomplete (<100%) and complete (100%), the latter was significantly more frequent in patients with ICAS-LVO (52.5% versus 20.4%) and remained an independent factor for ICAS-LVO (odds ratio, 3.32; 95% confidence interval, 1.52–7.26; p = 0.003). The area under the curve (AUC) value of complete leptomeningeal collateral supply was 0.660 for discrimination of ICAS-LVO. Incomplete leptomeningeal collateral supply was not likely ICAS-LVO, based on the high negative predictive value (88.6%). Considering its negative predictive value and the independent association between complete leptomeningeal collateral supply and ICAS-LVO, leptomeningeal collaterals could be helpful in the preprocedural determination of occlusion pathomechanism. Full article

(This article belongs to the Special Issue Diagnosis, Prevention and Treatment for Stroke)

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14 pages, 1445 KiB

Open AccessArticle

Endothelial Progenitor Cells as a Marker of Vascular Damage But not a Predictor in Acute Microangiopathy-Associated Stroke

by Adam Wiśniewski, Joanna Boinska, Katarzyna Ziołkowska, Adam Lemanowicz, Karolina Filipska, Zbigniew Serafin, Robert Ślusarz, Danuta Rość and Grzegorz Kozera

J. Clin. Med. 2020, 9(7), 2248; https://doi.org/10.3390/jcm9072248 - 15 Jul 2020

Cited by 2 | Viewed by 1837

Abstract

Background: The aim of the study was to assess the number of endothelial progenitor cells (EPCs) in patients with acute stroke due to cerebral microangiopathy and evaluate whether there is a relationship between their number and clinical status, radiological findings, risk factors, selected biochemical parameters, and prognosis, both in ischemic and hemorrhagic stroke. Methods: In total, 66 patients with lacunar ischemic stroke, 38 patients with typical location hemorrhagic stroke, and 22 subjects from the control group without acute cerebrovascular incidents were included in the prospective observational study. The number of EPCs was determined in serum on the first and eighth day after stroke onset using flow cytometry and identified with the immune-phenotype classification determinant (CD)45−, CD34+, CD133+. Results: We demonstrated a significantly higher number of EPCs on the first day of stroke compared to the control group (med. 17.75 cells/µL (0–488 cells/µL) vs. 5.24 cells/µL (0–95 cells/µL); p = 0.0006). We did not find a relationship between the number of EPCs in the acute phase of stroke and the biochemical parameters, vascular risk factors, or clinical condition. In females, the higher number of EPCs on the first day of stroke is related to a favorable functional outcome on the eighth day after the stroke onset compared to males (p = 0.0355). We found that a higher volume of the hemorrhagic focus on the first day was correlated with a lower number of EPCs on the first day (correlation coefficient (R) = −0.3378, p = 0.0471), and a higher number of EPCs on the first day of the hemorrhagic stroke was correlated with a lower degree of regression of the hemorrhagic focus (R = −0.3896, p = 0.0367). Conclusion: The study showed that endothelial progenitor cells are an early marker in acute microangiopathy-associated stroke regardless of etiology and may affect the radiological findings in hemorrhagic stroke. Nevertheless, their prognostic value remains doubtful in stroke patients. Full article

(This article belongs to the Special Issue Diagnosis, Prevention and Treatment for Stroke)

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12 pages, 1241 KiB

Open AccessArticle

Timing of Transfusion, not Hemoglobin Variability, Is Associated with 3-Month Outcomes in Acute Ischemic Stroke

by Chulho Kim, Sang-Hwa Lee, Jae-Sung Lim, Mi Sun Oh, Kyung-Ho Yu, Yerim Kim, Ju-Hun Lee, Min Uk Jang, San Jung and Byung-Chul Lee

J. Clin. Med. 2020, 9(5), 1566; https://doi.org/10.3390/jcm9051566 - 21 May 2020

Cited by 4 | Viewed by 2381

Abstract

Objectives: This study aimed to investigate whether transfusions and hemoglobin variability affects the outcome of stroke after an acute ischemic stroke (AIS). Methods: We studied consecutive patients with AIS admitted in three tertiary hospitals who received red blood cell (RBC) transfusion (RBCT) during admission. Hemoglobin variability was assessed by minimum, maximum, range, median absolute deviation, and mean absolute change in hemoglobin level. Timing of RBCT was grouped into two categories: admission to 48 h (early) or more than 48 h (late) after hospitalization. Late RBCT was entered into multivariable logistic regression model. Poor outcome at three months was defined as a modified Rankin Scale score ≥3. Results: Of 2698 patients, 132 patients (4.9%) received a median of 400 mL (interquartile range: 400–840 mL) of packed RBCs. One-hundred-and-two patients (77.3%) had poor outcomes. The most common cause of RBCT was gastrointestinal bleeding (27.3%). The type of anemia was not associated with the timing of RBCT. Late RBCT was associated with poor outcome (odd ratio (OR), 3.55; 95% confidence interval (CI), 1.43–8.79; p-value = 0.006) in the univariable model. After adjusting for age, sex, Charlson comorbidity index, and stroke severity, late RBCT was a significant predictor (OR, 3.37; 95% CI, 1.14–9.99; p-value = 0.028) of poor outcome at three months. In the area under the receiver operating characteristics curve comparison, addition of hemoglobin variability indices did not improve the performance of the multivariable logistic model. Conclusion: Late RBCT, rather than hemoglobin variability indices, is a predictor for poor outcome in patients with AIS. Full article

(This article belongs to the Special Issue Diagnosis, Prevention and Treatment for Stroke)

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12 pages, 870 KiB

Open AccessArticle

Predicting Stroke Outcomes Using Ankle-Brachial Index and Inter-Ankle Blood Pressure Difference

by Minho Han, Young Dae Kim, Jin Kyo Choi, Junghye Choi, Jimin Ha, Eunjeong Park, Jinkwon Kim, Tae-Jin Song, Ji Hoe Heo and Hyo Suk Nam

J. Clin. Med. 2020, 9(4), 1125; https://doi.org/10.3390/jcm9041125 - 15 Apr 2020

Cited by 6 | Viewed by 4171

Abstract

Background: This study investigated the association of high ankle-brachial index difference (ABID) and systolic inter-ankle blood pressure difference (IAND) with short- and long-term outcomes in acute ischemic stroke patients without peripheral artery disease (PAD). Methods: Consecutive patients with acute ischemic stroke who underwent ankle-brachial index (ABI) measurement were enrolled. ABID was calculated as |right ABI-left ABI|. IAND and systolic inter-arm blood pressure difference (IAD) were calculated as |right systolic blood pressure – left systolic blood pressure|. Poor functional outcome was defined as modified Rankin Scale score ≥3 at 3 months. Major adverse cardiovascular events (MACEs) were defined as stroke recurrence, myocardial infarction, or death. Results: A total of 2901 patients were enrolled and followed up for a median of 3.1 (interquartile range, 1.6–4.7) years. Among them, 2643 (84.9%) patients did not have PAD. In the logistic regression analysis, ABID ≥ 0.15 and IAND ≥ 15 mmHg were independently associated with poor functional outcome (odds ratio (OR), 1.970, 95% confidence interval (CI), 1.175‒3.302; OR, 1.665, 95% CI, 1.188‒2.334, respectively). In Cox regression analysis, ABID ≥0.15 and IAND ≥ 15 mmHg were independently associated with MACEs (hazard ratio (HR), 1.514, 95% CI, 1.058‒2.166; HR, 1.343, 95% CI, 1.051‒1.716, respectively) and all-cause mortality (HR, 1.524, 95% CI, 1.039‒2.235; HR, 1.516, 95% CI, 1.164‒1.973, respectively) in patients without PAD. Conclusion: High ABID and IAND are associated with poor short-term outcomes, long-term MACE occurrence, and all-cause mortality in acute ischemic stroke without PAD. Full article

(This article belongs to the Special Issue Diagnosis, Prevention and Treatment for Stroke)

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10 pages, 1528 KiB

Open AccessArticle

Interhemispheric Functional Connectivity in the Primary Motor Cortex Assessed by Resting-State Functional Magnetic Resonance Imaging Aids Long-Term Recovery Prediction among Subacute Stroke Patients with Severe Hand Weakness

by Yu-Sun Min, Jang Woo Park, Eunhee Park, Ae-Ryoung Kim, Hyunsil Cha, Dae-Won Gwak, Seung-Hwan Jung, Yongmin Chang and Tae-Du Jung

J. Clin. Med. 2020, 9(4), 975; https://doi.org/10.3390/jcm9040975 - 1 Apr 2020

Cited by 14 | Viewed by 2557

Abstract

This study aimed to evaluate the usefulness of interhemispheric functional connectivity (FC) as a predictor of motor recovery in severe hand impairment and to determine the cutoff FC level as a clinically useful parameter. Patients with stroke (n = 22; age, 59.9 ± 13.7 years) who presented with unilateral severe upper-limb paresis and were confirmed to elicit no motor-evoked potential responses were selected. FC was measured using resting-state functional magnetic resonance imaging (rsfMRI) scans at 1 month from stroke onset. The good recovery group showed a higher FC value than the poor recovery group (p = 0.034). In contrast, there was no statistical difference in FC value between the good recovery and healthy control groups (p = 0.182). Additionally, the healthy control group showed a higher FC value than that shown by the poor recovery group (p = 0.0002). Good and poor recovery were determined based on Brunnstrom stage of upper-limb function at 6 months as the standard, and receiver operating characteristic curve indicated that a cutoff score of 0.013 had the greatest prognostic ability. In conclusion, interhemispheric FC measurement using rsfMRI scans may provide useful clinical information for predicting hand motor recovery during stroke rehabilitation. Full article

(This article belongs to the Special Issue Diagnosis, Prevention and Treatment for Stroke)

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12 pages, 2356 KiB

Open AccessArticle

The Prognostic Value of High Platelet Reactivity in Ischemic Stroke Depends on the Etiology: A Pilot Study

by Adam Wiśniewski, Karolina Filipska, Joanna Sikora, Robert Ślusarz and Grzegorz Kozera

J. Clin. Med. 2020, 9(3), 859; https://doi.org/10.3390/jcm9030859 - 20 Mar 2020

Cited by 9 | Viewed by 2115

Abstract

Background: Reduced aspirin response may result in a worse prognosis and a poor clinical outcome in ischemic stroke. The aim of this prospective pilot study was to assess the relationship between platelet reactivity and early and late prognosis, and the clinical and functional status in ischemic stroke, with the role of stroke etiology. Methods: The study involved 69 subjects with ischemic stroke, divided into large and small vessel etiological subgroups. Platelet function testing was performed with two aggregometric methods—impedance and optical—while the clinical condition was assessed using the National Institute of Health Stroke Scale (NIHSS) and the functional status was assessed using the modified Rankin Scale (mRS) on the first and eighth day (early prognosis) and the 90th day of stroke (late prognosis). Results: The initial platelet reactivity was found to be higher in patients with severe neurological deficits on the 90th day after stroke, than in the group with mild neurological deficits (median, respectively, 40 area under the curve (AUC) units vs. 25 AUC units, p = 0.033). In the large vessel disease group, a significant correlation between the platelet reactivity and the functional status on the first day of stroke was found (correlation coefficient (R) = 0.4526; p = 0.0451), the platelet reactivity was higher in the subgroup with a severe clinical condition compared to a mild clinical condition on the first day of stroke (p = 0.0372), and patients resistant to acetylsalicylic acid (aspirin) had a significantly greater possibility of a severe neurological deficit on the first day of stroke compared to those who were sensitive to aspirin (odds ratio (OR) = 14.00, 95% confidence interval (CI) 1.25–156.12, p = 0.0322). Conclusion: High on-treatment platelet reactivity in ischemic stroke was associated with a worse late prognosis regardless of the etiology. We demonstrated a significant relationship between high platelet reactivity and worse early prognosis and poor clinical and functional condition in the large vessel etiologic subgroup. However, due to the pilot nature of this study, its results should be interpreted with caution and further validation on a larger cohort is required. Full article

(This article belongs to the Special Issue Diagnosis, Prevention and Treatment for Stroke)

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10 pages, 1745 KiB

Open AccessArticle

To Treat or Not to Treat: Importance of Functional Dependence in Deciding Intravenous Thrombolysis of “Mild Stroke” Patients

by Giovanni Merlino, Carmelo Smeralda, Simone Lorenzut, Gian Luigi Gigli, Andrea Surcinelli and Mariarosaria Valente

J. Clin. Med. 2020, 9(3), 768; https://doi.org/10.3390/jcm9030768 - 12 Mar 2020

Cited by 10 | Viewed by 2222

Abstract

Intravenous thrombolysis (IVT) in patients with a low National Institutes of Health Stroke Scale (NIHSS) score of 0–5 remains controversial. IVT should be used in patients with mild but nevertheless disabling symptoms. We hypothesize that response to IVT of patients with “mild stroke” may depend on their level of functional dependence (FD) at hospital admission. The aims of our study were to investigate the effect of IVT and to explore the role of FD in influencing the response to IVT. This study was a retrospective analysis of a prospectively collected database, including 389 patients stratified into patients receiving IVT (IVT⁺) and not receiving IVT (IVT ⁻) just because of mild symptoms. Barthel index (BI) at admission was used to assess FD, dividing subjects with BI score < 80 (FD⁺) and with BI score ≥ 80 (FD⁻). The efficacy endpoints were the rate of positive disability outcome (DO⁺) (3-month mRS score of 0 or 1), and the rate of positive functional outcome (FO⁺) (mRS score of zero or one, plus BI score of 95 or 100 at 3 months). At the multivariate analysis, IVT treatment was an independent predictor of DO⁺ (OR 3.12, 95% CI 1.34−7.27, p = 0.008) and FO⁺ (OR: 4.70, 95% CI 2.38−9.26, p = 0.001). However, FD⁺ IVT⁺ patients had a significantly higher prevalence of DO⁺ and FO⁺ than those FD⁺ IVT^–. Differently, IVT treatment did not influence DO⁺ and FO⁺ in FD^– patients. In FD⁺ patients, IVT treatment represented the strongest independent predictor of DO⁺ (OR 6.01, 95% CI 2.59–13.92, p = 0.001) and FO⁺ (OR 4.73, 95% CI 2.29–9.76, p = 0.001). In conclusion, alteplase seems to improve functional outcome in patients with “mild stroke”. However, in our experience, this beneficial effect is strongly influenced by FD at admission. Full article

(This article belongs to the Special Issue Diagnosis, Prevention and Treatment for Stroke)

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15 pages, 6557 KiB

Open AccessArticle

Improving the Clinical Outcome in Stroke Patients Receiving Thrombolytic or Endovascular Treatment in Korea: from the SECRET Study

by Young Dae Kim, Ji Hoe Heo, Joonsang Yoo, Hyungjong Park, Byung Moon Kim, Oh Young Bang, Hyeon Chang Kim, Euna Han, Dong Joon Kim, JoonNyung Heo, Minyoung Kim, Jin Kyo Choi, Kyung-Yul Lee, Hye Sun Lee, Dong Hoon Shin, Hye-Yeon Choi, Sung-Il Sohn, Jeong-Ho Hong, Jang-Hyun Baek, Gyu Sik Kim, Woo-Keun Seo, Jong-Won Chung, Seo Hyun Kim, Tae-Jin Song, Sang Won Han, Joong Hyun Park, Jinkwon Kim, Yo Han Jung, Han-Jin Cho, Seong Hwan Ahn, Sung Ik Lee, Kwon-Duk Seo and Hyo Suk Nam Show full author list Hide full author list

J. Clin. Med. 2020, 9(3), 717; https://doi.org/10.3390/jcm9030717 - 6 Mar 2020

Cited by 10 | Viewed by 3516

Abstract

We investigated whether there was an annual change in outcomes in patients who received the thrombolytic therapy or endovascular treatment (EVT) in Korea. This analysis was performed using data from a nationwide multicenter registry for exploring the selection criteria of patients who would benefit from reperfusion therapies in Korea. We compared the annual changes in the modified Rankin scale (mRS) at discharge and after 90 days and the achievement of successful recanalization from 2012 to 2017. We also investigated the determinants of favorable functional outcomes. Among 1230 included patients, the improvement of functional outcome at discharge after reperfusion therapy was noted as the calendar year increased (p < 0.001). The proportion of patients who were discharged to home significantly increased (from 45.6% in 2012 to 58.5% in 2017) (p < 0.001). The successful recanalization rate increased over time from 78.6% in 2012 to 85.1% in 2017 (p = 0.006). Time from door to initiation of reperfusion therapy decreased over the years (p < 0.05). These secular trends of improvements were also observed in 1203 patients with available mRS data at 90 days (p < 0.05). Functional outcome was associated with the calendar year, age, initial stroke severity, diabetes, preadmission disability, intervals from door to reperfusion therapy, and achievement of successful recanalization. This study demonstrated the secular trends of improvement in functional outcome and successful recanalization rate in patients who received reperfusion therapy in Korea. Full article

(This article belongs to the Special Issue Diagnosis, Prevention and Treatment for Stroke)

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13 pages, 2521 KiB

Open AccessArticle

High On-Treatment Platelet Reactivity Affects the Extent of Ischemic Lesions in Stroke Patients Due to Large-Vessel Disease

by Adam Wiśniewski, Joanna Sikora, Agata Sławińska, Karolina Filipska, Aleksandra Karczmarska-Wódzka, Zbigniew Serafin and Grzegorz Kozera

J. Clin. Med. 2020, 9(1), 251; https://doi.org/10.3390/jcm9010251 - 17 Jan 2020

Cited by 11 | Viewed by 2437

Abstract

Background: Excessive platelet activation and aggregation plays an important role in the pathogenesis of ischemic stroke. Correlation between platelet reactivity and ischemic lesions in the brain shows contradictory results and there are not enough data about the potential role of stroke etiology and its relationships with chronic lesions. The aim of this study is to assess the relationship between platelet reactivity and the extent of ischemic lesions with the particular role of etiopathogenesis. Methods: The study involved 69 patients with ischemic stroke, including 20 patients with large-vessel disease and 49 patients with small-vessel disease. Evaluation of platelet reactivity was performed within 24 h after the onset of stroke using two aggregometric methods (impedance and optical), while ischemic volume measurement in the brain was performed using magnetic resonance imaging (in diffusion-weighted imaging (DWI) and fluid-attenuated inversion recovery (FLAIR) sequences) at day 2–5 after the onset of stroke. Results: In the large-vessel disease subgroup, a correlation was found between platelet reactivity and acute ischemic focus volume (correlation coefficient (R) = 0.6858 and p = 0.0068 for DWI; R = 0.6064 and p = 0.0215 for FLAIR). Aspirin-resistant subjects were significantly more likely to have a large ischemic focus (Odds Ratio (OR) = 45.00, 95% Confidence Interval (CI) = 1.49–135.36, p = 0.0285 for DWI; OR = 28.00, 95% CI = 1.35–58.59, p = 0.0312 for FLAIR) than aspirin-sensitive subjects with large-vessel disease. Conclusion: In patients with ischemic stroke due to large-vessel disease, high on-treatment platelet reactivity affects the extent of acute and chronic ischemic lesions. Full article

(This article belongs to the Special Issue Diagnosis, Prevention and Treatment for Stroke)

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13 pages, 956 KiB

Open AccessArticle

One-Stop Management of 230 Consecutive Acute Stroke Patients: Report of Procedural Times and Clinical Outcome

by Marios-Nikos Psychogios, Ilko L. Maier, Ioannis Tsogkas, Amélie Carolina Hesse, Alex Brehm, Daniel Behme, Marlena Schnieder, Katharina Schregel, Ismini Papageorgiou, David S. Liebeskind, Mayank Goyal, Mathias Bähr, Michael Knauth and Jan Liman

J. Clin. Med. 2019, 8(12), 2185; https://doi.org/10.3390/jcm8122185 - 11 Dec 2019

Cited by 40 | Viewed by 4105

Abstract

Background and purpose: Rapid thrombectomy for acute ischemic stroke caused by large vessel occlusion leads to improved outcome. Optimizing intrahospital management might diminish treatment delays. To examine if one-stop management reduces intrahospital treatment delays and improves functional outcome of acute stroke patients with large vessel occlusion. Methods: We performed a single center, observational study from June 2016 to November 2018. Imaging was acquired with the latest generation angiography suite at a comprehensive stroke center. Two-hundred-thirty consecutive adults with suspected acute stroke presenting within 6 h after symptom onset with a moderate to severe National Institutes of Health Stroke Scale (≥10 in 2016; ≥7 since January 2017) were directly transported to the angiography suite by bypassing multidetector CT. Noncontrast flat-detector CT and biphasic flat-detector CT angiography were acquired with an angiography system. In case of a large vessel occlusion patients remained in the angiography suite, received intravenous rtPA therapy and underwent thrombectomy. As primary endpoints, door-to-reperfusion times and functional outcome at 90 days were recorded and compared in a case-control analysis with matched prior patients receiving standard management. Results: A total of 230 patients (123 women, median age of 78 years (Interquartile Range (IQR) 69–84)) were included. Median symptom-to-door time was 130 min (IQR 70–195). Large vessel occlusion was diagnosed in 166/230 (72%) patients; 64/230 (28%) had conditions not suitable for thrombectomy. Median door-to-reperfusion time for M1 occlusions was 64 min (IQR 56–87). Compared to 43 case-matched patients triaged with multidetector CT, median door-to-reperfusion time was reduced from 102 (IQR 85–117) to 68 min (IQR 53–89; p < 0.001). Rate of good functional outcome was significantly better in the one-stop management group (p = 0.029). Safety parameters (mortality, sICH, any hemorrhage) did not differ significantly between groups. Conclusions: One-stop management for stroke triage reduces intrahospital time delays in our specific hospital setting. Full article

(This article belongs to the Special Issue Diagnosis, Prevention and Treatment for Stroke)

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11 pages, 1156 KiB

Open AccessArticle

Potential Utility of Neurosonology in Paroxysmal Atrial Fibrillation Detection in Patients with Cryptogenic Stroke

by Chrissoula Liantinioti, Lina Palaiodimou, Konstantinos Tympas, John Parissis, Aikaterini Theodorou, Ignatios Ikonomidis, Maria Chondrogianni, Christina Zompola, Sokratis Triantafyllou, Andromachi Roussopoulou, Odysseas Kargiotis, Aspasia Serdari, Anastasios Bonakis, Konstantinos Vadikolias, Konstantinos Voumvourakis, Leonidas Stefanis, Gerasimos Filippatos and Georgios Tsivgoulis

J. Clin. Med. 2019, 8(11), 2002; https://doi.org/10.3390/jcm8112002 - 16 Nov 2019

Cited by 8 | Viewed by 2765

Abstract

Background: Occult paroxysmal atrial fibrillation (PAF) is a common and potential treatable cause of cryptogenic stroke (CS). We sought to prospectively identify independent predictors of atrial fibrillation (AF) detection in patients with CS and sinus rhythm on baseline electrocardiogram (ECG), without prior AF history. We had hypothesized that cardiac arrhythmia detection during neurosonology examinations (Carotid Duplex (CDU) and Transcranial Doppler (TCD)) may be associated with higher likelihood of AF detection. Methods: Consecutive CS patients were prospectively evaluated over a six-year period. Demographics, clinical and imaging characteristics of cerebral ischemia were documented. The presence of arrhythmia during spectral waveform analysis of CDU/TCD was recorded. Left atrial enlargement was documented during echocardiography using standard definitions. The outcome event of interest included PAF detection on outpatient 24-h Holter ECG recordings. Statistical analyses were performed using univariate and multivariate logistic regression models. Results: A total of 373 patients with CS were evaluated (mean age 60 ± 11 years, 67% men, median NIHSS-score 4 points). The rate of PAF detection of any duration on Holter ECG recordings was 11% (95% CI 8%–14%). The following three variables were independently associated with the likelihood of AF detection on 24-h Holter-ECG recordings in both multivariate analyses adjusting for potential confounders: age (OR per 10-year increase: 1.68; 95% CI: 1.19–2.37; p = 0.003), moderate or severe left atrial enlargement (OR: 4.81; 95% CI: 1.77–13.03; p = 0.002) and arrhythmia detection during neurosonology evaluations (OR: 3.09; 95% CI: 1.47–6.48; p = 0.003). Conclusion: Our findings underline the potential utility of neurosonology in improving the detection rate of PAF in patients with CS. Full article

(This article belongs to the Special Issue Diagnosis, Prevention and Treatment for Stroke)

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11 pages, 852 KiB

Open AccessArticle

Impact of the Total Number of Carotid Plaques on the Outcome of Ischemic Stroke Patients with Atrial Fibrillation

by Hyungjong Park, Minho Han, Young Dae Kim, Joonsang Yoo, Hye Sun Lee, Jin Kyo Choi, Ji Hoe Heo and Hyo Suk Nam

J. Clin. Med. 2019, 8(11), 1897; https://doi.org/10.3390/jcm8111897 - 7 Nov 2019

Cited by 4 | Viewed by 2662

Abstract

Background: Atrial fibrillation (AF) shares several risk factors with atherosclerosis. We investigated the association between total carotid plaque number (TPN) and long-term prognosis in ischemic stroke patients with AF. Methods: A total of 392 ischemic stroke patients with AF who underwent carotid ultrasonography were enrolled. TPN was assessed using B-mode ultrasound. The patients were categorized into two groups according to best cutoff values for TPN (TPN ≤ 4 vs. TPN ≥ 5). The long-term risk of major adverse cardiovascular events (MACE) and mortality according to TPN was investigated using a Cox hazard model. Results: After a mean follow-up of 2.42 years, 113 patients (28.8%) had developed MACE and 88 patients (22.4%) had died. MACE occurred more frequently in the TPN ≥ 5 group than in the TPN ≤ 4 group (adjusted hazard ratio [HR], 1.50; 95% confidence interval [CI], 1.01–2.21; p < 0.05). Moreover, the TPN ≥ 5 group showed an increased risk of all-cause mortality (adjusted HR, 2.69; 95% CI, 1.40–5.17; p < 0.05). TPN along with maximal plaque thickness and intima media thickness showed improved prognostic utility when added to the variables of the CHAD₂DS₂-VASc score. Conclusion: TPN can predict the long-term outcome of ischemic stroke patients with AF. Adding TPN to the CHAD₂DS₂-VASc score increases the predictability of outcome after stroke. Full article

(This article belongs to the Special Issue Diagnosis, Prevention and Treatment for Stroke)

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Review

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13 pages, 2837 KiB

Open AccessFeature PaperReview

Twenty Years of Cerebral Ultrasound Perfusion Imaging—Is the Best yet to Come?

by Jens Eyding, Christian Fung, Wolf-Dirk Niesen and Christos Krogias

J. Clin. Med. 2020, 9(3), 816; https://doi.org/10.3390/jcm9030816 - 17 Mar 2020

Cited by 10 | Viewed by 2967

Abstract

Over the past 20 years, ultrasonic cerebral perfusion imaging (UPI) has been introduced and validated applying different data acquisition and processing approaches. Clinical data were collected mainly in acute stroke patients. Some efforts were undertaken in order to compare different technical settings and validate results to gold standard perfusion imaging. This review illustrates the evolution of the method, explicating different technical aspects and milestones achieved over time. Up to date, advancements of ultrasound technology as well as data processing approaches enable semi-quantitative, gold standard proven identification of critically hypo-perfused tissue in acute stroke patients. The rapid distribution of CT perfusion over the past 10 years has limited the clinical need for UPI. However, the unexcelled advantage of mobile application raises reasonable expectations for future applications. Since the identification of intracerebral hematoma and large vessel occlusion can also be revealed by ultrasound exams, UPI is a supplementary multi-modal imaging technique with the potential of pre-hospital application. Some further applications are outlined to highlight the future potential of this underrated bedside method of microcirculatory perfusion assessment. Full article

(This article belongs to the Special Issue Diagnosis, Prevention and Treatment for Stroke)

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