Assessment of computed tomography perfusion RAPID estimated core volume accuracy in patients following thrombectomy.

Background: Computed Tomography Perfusion (CTP) maps ischemic core volume (CV) and penumbra following a stroke; however, its accuracy in early symptom onset is not well studied. We compared the accuracy of CTP RAPID estimated CV with diffusion weighted imaging (DWI) infarct volume (IV) in patients following thrombectomy. Methods: Charts of anterior circulation large vessel occlusion post-thrombectomy cases with thrombolysis in cerebral infarction (TICI) 2b/3 reperfusion from 2017 to 2019 were reviewed. CTP time was dichotomized as 0-3 hours and ≥ 3 hours from the last known normal (LKN) cognition. The volumetric difference (VD), defined as DWI IV minus CTP CV, core volume overestimation (CVO), defined as CTP CV minus DWI IV and Alberta stroke programme early CT score (ASPECTS) were calculated. Large CV was defined as ≥ 50 ml CV. Modified Rankin Score (mRS) at 90 days were reviewed. We performed independent sample t-test and Spearman correlation coefficient test. Results: Total cases (n) were 61. In < 3 hours window from LKN (n = 27), the mean VD was 58.3 ± 0.1 ml (P = 0.990) and CVO (n = 11; 40.7%) was 39.6 ± 35.7 ml (P = 0.008). Mean large CV (n = 8) was 78.3 ± 25.4 ml with median ASPECTS of 8 [interquartile range (IQR) = 6.5-9.0] and median mRS at 90 days of 2 (IQR = 0.8-3.3). In ≥ 3 hours window from LKN (n = 34), CVO (n = 5) was uncommon and large CV had median mRS at 90 days of 5 (IQR = 4.0-6.0). Conclusion: CTP more frequently overestimates CV in patients who are < 3 hours from LKN. The treated patients with large CV in < 3 hours and > 3 hours had good and poor functional outcomes, respectively.

A case of aphemia following non-dominant sub-insular stroke: unveiling the Foix-Chavany-Marie phenomenon.

Aphemia refers to the clinical syndrome of inability to orally produce speech with intact comprehension and written expression. Aphemia has been primarily reported in dominant frontal lobe strokes resulting in apraxia of speech (AoS), and in Foix-Chavany-Marie (FCM) syndrome where bilateral opercular or sub-opercular lesions result in anarthria due to deafferentation of brainstem nuclei supplying the oro-facio-lingual and pharyngeal musculature. Aphemia is not reported in non-dominant sub-insular strokes. Here, we present a case of aphemia following non-dominant sub-insular stroke in a patient who had previously recovered from a homologous dominant sub-insular stroke without any apparent residual deficits. We discuss the accepted definitions, theories and controversies in the use of the terminology - aphemia, apraxia of speech (AoS), anarthria related to FCM syndrome, a concomitant pathology - unilateral upper motor neuron (UUMN) dysarthria, and their neuro-anatomical bases. We also highlight the importance of attributing localization value to sequential homologous lesions of the brain that can unveil symptoms due to a "loss of compensation phenomenon" that we propose be termed as "FCM phenomenon." These pathological mechanisms may alone or in certain combinations contribute to the clinical syndrome of aphemia included in the diagnostic approach proposed here. The distinction between these mechanisms requires serial careful neurological examination and detailed speech evaluation including in the recovery phase.

Gasperini Syndrome: A Case Report and Systematic Review and Proposing a New Definition.

Gasperini syndrome (GS), a rare brainstem syndrome, is featured by ipsilateral cranial nerves (CN) V-VIII dysfunction with contralateral hemibody hypoesthesia. While there have been 18 reported cases, the GS definition remains ambiguous. We report a new case and reviewed the clinical features of this syndrome from all published reports to propose a new definition. A 57-year-old man with acute brainstem stroke had right CN V-VIII and XII palsies, left body hypoesthesia and ataxia. Brain MRI showed an acute stroke in the right caudal pons and bilateral cerebellum. After a systematic review, we classified the clinical manifestations into core and associate features based on the frequencies of occurring neurological deficits. We propose that a definitive GS requires the presence of ipsilateral CN VI and VII palsies, plus one or more of the other three core features (ipsilateral CN V, VIII palsies and contralateral hemibody hemihypalgesia). Additionally, GS, similar to Wallenberg's syndrome, represents a spectrum that can have other associated neurological features. The revised definition presented in this study may enlighten physicians with the immediate recognition of the syndrome and help improve clinical localization of the lesions and its management.

Isolated oculomotor nerve palsy as a manifestation of diffuse large B cell lymphoma: A case report.

An isolated third nerve palsy presenting as the primary manifestation of a lymphoma is rare, with only few cases having been described. The present study reports an unusual case of a healthy 67-year old male diagnosed with isolated right oculomotor nerve palsy (ONP), who was found to have an underlying B cell lymphoma. The patient's medical records were accessed upon consent. A thorough physical examination, including stroke and infections work-ups were performed. A chest computerized tomography (CT), brain magnetic resonance imaging and positron emission tomography (PET) scans and a mediastinal tissue biopsy, were performed as part of systematic diagnostic evaluations. The current report suggests that a PET fluorodeoxyglucose study or a CT scan of the chest, abdomen and pelvis (with contrast) may help in the early diagnosis of a cancer responsible for ONP, particularly if brain vessel imaging does not show a posterior cerebral artery aneurysm as a cause for the defect.

A Case of Isolated Dysarthria in a COVID-19 Infected Stroke Patient: A Nondisabling Neurological Symptom With Grave Prognosis.

Isolated dysarthria is a speech abnormality characterized by slurring without any language dysfunction, or other neurological deficits. In an acute setting, it is commonly associated with stroke. In the context of social distancing during the current corona virus disease 2019 (COVID-19) pandemic, nondisabling symptoms such as isolated dysarthria can delay a patient's perception to seek immediate medical care. We present a rare case of isolated dysarthria in a COVID-19 infected stroke patient with a grave prognosis. A 79-year-old African American male presented with isolated dysarthria that manifested two days prior to his hospital visit. The dysarthria assessment showed impaired articulation, phonation, and prosody. Other neurological examinations were normal. He tested positive for the COVID-19 infection. His pulmonary CT scan showed bilateral ground glass opacities. An electrocardiogram showed atrial fibrillation (AF). Brain MRI revealed a punctate acute infarction in the left frontal lobe. Initially, he was treated with IV anticoagulation, oral beta-blocker, azithromycin and hydroxychloroquine, but he dramatically deteriorated within a week exhibiting a highly elevated cytokine level eventually resulting in multi-system organ failure. Despite aggressive treatment with steroids, tocilizumab and other supportive measures, the patient died of cardiac arrest. Our case highlights that acute stroke could manifest as an isolated dysarthria, which is an indicator of increased severity and high mortality with COVID-19 infection. Public awareness about the stroke symptom awareness should be emphasized.

Blood Pressure Management Following Large Vessel Occlusion Strokes: A Narrative Review

Stroke is one of the leading causes of morbidity and mortality worldwide. Intravenous tissue plasminogen activator and mechanical thrombectomy comprise the two major treatments for acute ischemic stroke. Tissue plasminogen activator has been used for more than two decades and guidelines for hemodynamic management following tissue plasminogen activator administration are well established. However, mechanical thrombectomy is a relatively newer therapy and there is a paucity of evidence regarding hemodynamic management following large vessel occlusion strokes. The important tenets guiding the pathophysiology of large vessel occlusion strokes include understanding of cerebral autoregulation, collateral circulation, and blood pressure variability. In this narrative review, we discuss the current American Heart Association-American Stroke Association guidelines for the early management of acute ischemic stroke during different phases of the illness, encountered at different sections of a hospital including the emergency room, the neuro-interventional suite, and the intensive care unit. There is emerging evidence with regard to post-recanalization blood pressure management following large vessel occlusion strokes. Future research directions will include rea-ltime blood pressure variability assessments, identifying the extent of impaired autoregulation, and providing guidelines related to range and personalized blood pressure trajectories for patients following large vessel occlusion strokes.

Association of Early Oxygenation Levels with Mortality in Acute Ischemic Stroke - A Retrospective Cohort Study.

BACKGROUND: Ischemic stroke is an emergency with elevated risk for morbidity and mortality. Hypoxia is harmful in acute ischemic stroke. Recent evidence raises concerns regarding hyperoxia as well in acute illness, and for supplemental oxygen therapy when SpO2greater than 92%. Current AHA/ASA guidelines recommend maintaining SpO2greater than 94%. In this study, we aimed to assess the relationship between the oxygenation levels within the first 6-hour of ischemic stroke admission and mortality. METHODS: With the approval of the Human Studies Committee (IRB #: 13.0396), we performed a retrospective cohort study of ischemic stroke patients consecutively admitted to our hospital in the years 2013-14 and 2017-18 (n = 1479). Relationship between the first 6 hours oxygenation status and in-house mortality was assessed. SpO2/FiO2 ratio was used as the oxygenation outcome parameter. Patients who were intubated at admission were excluded. Additionally, demographics, baseline confounding factors, neurological status, and laboratory values on admission were examined for their association with mortality in a multivariate logistic regression analysis. RESULTS: Mean age of patients was 64 ± 15 years. Time interval from last seen normal to hospital admission was 7 ± 5 hours (mean ± standard deviation). NIHSS on arrival was 41-9 (median-IQR). Fourteen percent of patients received IV alteplase and 6% were treated with mechanical thrombectomy. Baseline SpO2 was 97 ± 2%, and 47% of the patients required supplemental oxygen treatment per AHA/ASA guidelines. In hospital mortality rate of this cohort was 5.7%. Lower mean SpO2 /FiO2 levels were strongly correlated with increasing mortality rates (R2 = .973). Age (1.048 [1.028-1.068]), NIHSS (1.120 [1.088-1.154]), WBC (1.116 [1.061-1.175]) and Mean SpO2/FiO2 (.995 [.992-.999]) independently risk associated with mortality. CONCLUSIONS: Baseline oxygenation varies within the acute ischemic stroke patient population. In this retrospective cohort study, we are reporting a strong association between lower SpO2/FiO2 levels in the first few hours of admission and mortality. In the light of these results, we plan to prospectively assess the role of oxygenation further in the context of recanalization status of stroke.

Early Prediction of Prognosis in Elderly Acute Stroke Patients.

Acute stroke has a high morbidity and mortality in elderly population. Baseline confounding illnesses, initial clinical examination, and basic laboratory tests may impact prognostics. In this study, we aimed to establish a model for predicting in-hospital mortality based on clinical data available within 12 hours of hospital admission in elderly (≥ 65 age) patients who experienced stroke. DESIGN: Retrospective observational cohort study. SETTING: Academic comprehensive stroke center. PATIENTS: Elderly acute stroke patients-2005-2009 (n = 462), 2010-2012 (n = 122), and 2016-2017 (n = 123). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: After institutional review board approval, we retrospectively queried elderly stroke patients' data from 2005 to 2009 (training dataset) to build a model to predict mortality. We designed a multivariable logistic regression model as a function of baseline severity of illness and laboratory tests, developed a nomogram, and applied it to patients from 2010 to 2012. Due to updated guidelines in 2013, we revalidated our model (2016-2017). The final model included stroke type (intracerebral hemorrhage vs ischemic stroke: odds ratio [95% CI] of 0.92 [0.50-1.68] and subarachnoid hemorrhage vs ischemic stroke: 1.0 [0.40-2.49]), year (1.01 [0.66-1.53]), age (1.78 [1.20-2.65] per 10 yr), smoking (8.0 [2.4-26.7]), mean arterial pressure less than 60 mm Hg (3.08 [1.67-5.67]), Glasgow Coma Scale (0.73 [0.66-0.80] per 1 point increment), WBC less than 11 K (0.31 [0.16-0.60]), creatinine (1.76 [1.17-2.64] for 2 vs 1), congestive heart failure (2.49 [1.06-5.82]), and warfarin (2.29 [1.17-4.47]). In summary, age, smoking, congestive heart failure, warfarin use, Glasgow Coma Scale, mean arterial pressure less than 60 mm Hg, admission WBC, and creatinine levels were independently associated with mortality in our training cohort. The model had internal area under the curve of 0.83 (0.79-0.89) after adjustment for over-fitting, indicating excellent discrimination. When applied to the test data from 2010 to 2012, the nomogram accurately predicted mortality with area under the curve of 0.79 (0.71-0.87) and scaled Brier's score of 0.17. Revalidation of the same model in the recent dataset from 2016 to 2017 confirmed accurate prediction with area under the curve of 0.83 (0.75-0.91) and scaled Brier's score of 0.27. CONCLUSIONS: Baseline medical problems, clinical severity, and basic laboratory tests available within the first 12 hours of admission provided strong independent predictors of in-hospital mortality in elderly acute stroke patients. Our nomogram may guide interventions to improve acute care of stroke.

Right-Sided Pleural Effusion in a Critically Ill Stroke Patient.

Pleural fluid collections are common in those critically ill. We report the case of a left middle cerebral artery stroke patient who developed respiratory distress and required intubation and mechanical ventilation. Although the patient's clinical status and oxygenation improved, there was persistence of right-sided opacity in the chest radiograph. Further workup proved a right-sided pleural effusion, which was drained and managed. Following extubation, a swallow study was ordered, which led to a fluoroscopic examination that demonstrated esophageal perforation. Thoracic surgery was consulted and did a primary repair of perforation and noted non-small cell carcinoma on the perforated site.

Ventilator-associated pneumonia in critically ill stroke patients: frequency, risk factors, and outcomes.

PURPOSE: Our main objective was to assess incidence, risk factors, and outcomes of ventilator-associated pneumonia (VAP) in stroke patients. MATERIALS AND METHODS: After obtaining approval from the Human Studies Committee, we reviewed the electronic records from our intensive care unit database of 111 stroke patients on mechanical ventilation for more than 48 hours. Thirty-six risk factors related to disease and general health status, and 8 related to care-all assigned a priori-were collected and analyzed. Selected factors with univariate statistical significance (P < .05) were then analyzed with multivariate logistic regression. RESULTS: Thirty-one patients developed pneumonia (28%). Methicillin-resistant Staphylococcus aureus (n = 12) and methicillin-sensitive S aureus (n = 7) were the most common pathogenic bacteria. Chronic lung disease, neurological status at admission as assessed by the National Institutes of Health Stroke Scale, and hemorrhagic transformation were the independent risk factors contributing to VAP. Worsening oxygenation index (arterial partial pressure of oxygen/fraction of inspired oxygen) and proton pump inhibitor use for ulcer prophylaxis were other potentially important factors. CONCLUSIONS: Pneumonia appears as a frequent problem in mechanically ventilated stroke patients. Chronic lung disease history, severity of stroke level at admission, and hemorrhagic transformation of stroke set the stage for developing VAP. The duration of both mechanical ventilation and intensive care unit stay gets significantly prolonged by VAP, but it does not affect mortality.

Clinical usefulness of a biomarker-based diagnostic test for acute stroke: the Biomarker Rapid Assessment in Ischemic Injury (BRAIN) study.

BACKGROUND AND PURPOSE: One of the significant limitations in the evaluation and management of patients with suspected acute cerebral ischemia is the absence of a widely available, rapid, and sensitive diagnostic test. The objective of the current study was to assess whether a test using a panel of biomarkers might provide useful diagnostic information in the early evaluation of stroke by differentiating patients with cerebral ischemia from other causes of acute neurological deficit. METHODS: A total of 1146 patients presenting with neurological symptoms consistent with possible stroke were prospectively enrolled at 17 different sites. Timed blood samples were assayed for matrix metalloproteinase 9, brain natriuretic factor, d-dimer, and protein S100beta. A separate cohort of 343 patients was independently enrolled to validate the multiple biomarker model approach. RESULTS: A diagnostic tool incorporating the values of matrix metalloproteinase 9, brain natriuretic factor, d-dimer, and S-100beta into a composite score was sensitive for acute cerebral ischemia. The multivariate model demonstrated modest discriminative capabilities with an area under the receiver operating characteristic curve of 0.76 for hemorrhagic stroke and 0.69 for all stroke (likelihood test P<0.001). When the threshold for the logistic model was set at the first quartile, this resulted in a sensitivity of 86% for detecting all stroke and a sensitivity of 94% for detecting hemorrhagic stroke. Moreover, results were reproducible in a separate cohort tested on a point-of-care platform. CONCLUSIONS: These results suggest that a biomarker panel may add valuable and time-sensitive diagnostic information in the early evaluation of stroke. Such an approach is feasible on a point-of-care platform. The rapid identification of patients with suspected stroke would expand the availability of time-limited treatment strategies. Although the diagnostic accuracy of the current panel is clearly imperfect, this study demonstrates the feasibility of incorporating a biomarker based point-of-care algorithm with readily available clinical data to aid in the early evaluation and management of patients at high risk for cerebral ischemia.

Acute ischemic stroke and hypothyroidism.

BACKGROUND: In Kentucky, the incidence and mortality associated with stroke are among the highest in the United States. Treatment of modifiable risk factors can significantly prevent stroke. Identification of additional risk factors may further reduce stroke risk. Hypothyroidism is linked to altered lipid metabolism and is associated with hyperhomocysteinemia. In this study, we examined a possible association between acute ischemic stroke (AIS) and hypothyroidism. METHODS: Records were reviewed on all consecutive patients admitted to the University of Louisville Stroke Center with a diagnosis of AIS or transient ischemic attack (TIA). RESULT: Our data revealed that 12% of patients with AIS or TIA had hypothyroidism. A significant difference was found between the prevalence of hyperhomocysteinemia in patients with hypothyroidism (45.4%) compared with the prevalence of hyperhomocysteinemia in euthyroid patients (27.8%). CONCLUSION: Hypothyroidism is common in patients with AIS and TIA. Elevated homocysteine levels associated with hypothyroidism suggest that hypothyroidism may represent a modifiable stroke risk factor. Prospective studies are needed to verify this association.