Modified Rankin scale assessment by telephone using a simple questionnaire.

PURPOSE: The modified Rankin Scale (mRS) is widely used as a measure of post-stroke physical disability in clinical stroke trials; however, it is affected by inter-rater discrepancies. A Japanese version of the simplified mRS questionnaire (J-RASQ) has the potential to overcome the inter-rater discrepancies and might be feasible for clinical surveys. We aimed to determine the reliability of J-RASQ in a telephone survey administered by non-medical staff. METHODS: We recruited 103 patients (age = 73 ± 11 years; 57% males) with a history of ischemic stroke who visited the outpatient clinic of the department of neurology at our hospital between March and May, 2021. After obtaining informed consent for participation in the study, a stroke neurologist assessed the mRS score during the visit using the Japanese version of mRS. On the same day, a clerk telephoned the patient or his/her family members to administer the J-RASQ. The percentage of agreement between mRS and J-RASQ scores was evaluated using the kappa coefficient and weighted kappa coefficient. RESULTS: The median time for the telephone survey was 85 s (interquartile range = 70-135 s). The mRS and J-RASQ scores had an agreement of 63.1%, with a kappa statistic of 0.51 (95% confidence interval [CI] = 0.39-0.63). The weighted kappa statistic, which takes into account the extent of disagreement, was 0.81 (95% CI = 0.75-0.88). CONCLUSION: J-RASQ is easy to administer and reliable for assessment in telephone-based surveys performed by non-medical staff.

Alberta Stroke Program Early CT Score Calculation Using the Deep Learning-Based Brain Hemisphere Comparison Algorithm.

OBJECTIVES: The Alberta Stroke Program Early Computed Tomography Score (ASPECTS) is a promising tool for the evaluation of stroke expansion to determine suitability for reperfusion therapy. The aim of this study was to validate deep learning-based ASPECTS calculation software that utilizes a three-dimensional fully convolutional network-based brain hemisphere comparison algorithm (3D-BHCA). MATERIALS AND METHODS: We retrospectively collected head non-contrast computed tomography (CT) data from 71 patients with acute ischemic stroke and 80 non-stroke patients. The results for ASPECTS on CT assessed by 5 stroke neurologists and by the 3D-BHCA model were compared with the ground truth by means of region-based and score-based analyses. RESULTS: In total, 151 patients and 3020 (151 × 20) ASPECTS regions were investigated. Median time from onset to CT was 195 min in the stroke patients. In region-based analysis, the sensitivity (0.80), specificity (0.97), and accuracy (0.96) of the 3D-BHCA model were superior to those of stroke neurologists. The sensitivity (0.98), specificity (0.92), and accuracy (0.97) of dichotomized ASPECTS > 5 analysis and the intraclass correlation coefficient (0.90) in total score-based analysis of the 3D-BHCA model were superior to those of stroke neurologists overall. When patients with stroke were stratified by onset-to-CT time, the 3D-BHCA model exhibited the highest performance to calculate ASPECTS, even in the earliest time period. CONCLUSIONS: The automated ASPECTS calculation software we developed using a deep learning-based algorithm was superior or equal to stroke neurologists in performing ASPECTS calculation in patients with acute stroke and non-stroke patients.

Reliability of the Modified Rankin Scale Assessment Using a Simplified Questionnaire in Japanese.

OBJECTIVES: We developed a Japanese version of the simplified modified Rankin Scale questionnaire, of which the agreement between patients or their family members and neurologists was verified in a previous single-center study. In the present study, the reliability of the questionnaire was evaluated in another hospital. MATERIALS AND METHODS: The participants were prospectively-registered patients with acute ischemic stroke admitted to Saiseikai Kumamoto Hospital. The questionnaire was administered to the patients or their family members at discharge. At the same time, the attending physician assessed the Japanese version of a guidance scheme for the modified Rankin Scale. The agreement rate between the scores from both assessments was examined using the κ statistic and weighted κ statistic. We examined the factors related to disagreement between the modified Rankin Scale score by the attending physicians and the questionnaire score by patients/family members. RESULTS: A total of 146 patients (age 77 ± 12 years; 53% men) were included. Agreement between the raters was 39%; the κ statistic was 0.27, but the weighted κ statistic, taking into account the extent of disagreement, was 0.81. In multivariate analysis, the disagreement between the modified Rankin Scale score and the questionnaire score was negatively associated with a modified Rankin Scale score of 5 at discharge (odds ratio, 0.02 per score point; 95% confidence interval, 0.00-0.34). CONCLUSION: The questionnaire showed decent reliability and similarity to the modified Rankin Scale assessed by physicians. The questionnaire could be a reliable indicator for assessing stroke functional outcomes even when implemented by non-medical staff.

Cerebral embolism accompanied by remarkable diffusion-weighted imaging reversal in a 10 month-old infant with congenital heart disease.

•The case of infant ischemic stroke with remarkable DWI reversal.•A mismatch between core volume and visually DWI lesion predicts DWI reversal.•Chronic hypoxia and early recanalization may contribute to large DWI reversal.•Mismatch between DWI-ASPECTS and core volume may occur in infant brain.

Tissue Plasminogen Activator for Cortical Embolism Stroke with Magnetic Resonance Perfusion Imaging: A Report of Two Cases.

Computerized tomography (CT) or magnetic resonance imaging (MRI) is indispensable for diagnosing acute ischemic stroke (AIS) patients who are candidates for recombinant tissue plasminogen activator (rt-PA) therapies, but further investigation concerning appropriate selection of therapy following advanced imaging including perfusion imaging has not yet been done. The 2018 AHA guidelines have recommended not to perform excessive time-consuming imaging before rt-PA. Here we describe two cases in which reperfusion therapy was decided based on advanced imaging. The first case was a 70-year-old woman with complaints of total aphasia and right unilateral spatial neglect. Her MRI revealed no apparent high signal area in diffusion-weighted image (DWI), and her magnetic resonance angiography (MRA) showed no large vessel occlusion. Subsequent perfusion-weighted image (PWI) analysis showed a unilateral perfusion deficit in the left middle cerebral artery (MCA) region. The other case was an 88-year-old man with complaints of minor unilateral spatial neglect, right conjugate deviation of the eyes, and dysarthria. His MRI also revealed no apparent high signal area in DWI, and MRA showed slight stenosis in the right middle MCA. Subsequent PWI analysis showed a unilateral perfusion deficit in the right MCA region. In both cases, intravenous rt-PA therapy was administered after the diagnosis of AIS and the patients responded well to the reperfusion therapy. When DWI is performed too early, detecting the ischemic core and differentiating between a diagnosis of stroke and stroke mimics is sometimes difficult. Evaluation of perfusion abnormalities in acute cases can be performed quickly, as shown in these cases. Although rt-PA can be given just by non-contrast CT with no hemorrhage, advanced imaging may be an option to identify difficult-to-diagnose patients who require reperfusion therapy.

[Reliability of modified Rankin Scale assessment with a Japanese version of simplified modified Rankin Scale Questionnaire (J-RASQ)].

Modified Rankin Scale (mRS) is widely used as an indicator of physical disability after the onset of stroke and a main evaluation scale in clinical stroke trials but sometimes has discrepancies among raters. We designed a Japanese version of simplified mRS questionnaire (J-RASQ) to evaluate mRS using closed question to assess the difference from the original. Currently there are no Japanese version of mRS questionnaire and its validity and reliability assessment has been warranted. Patients with planned visit to our hospital between 60 and 120 days after the onset of cerebral hemorrhage or infarction between August 2017 and March 2018 were recruited. J-RASQ was distributed before the outpatient visit to stroke patients, families or caregivers, and response was obtained. Thereafter, outpatient attending physicians qualified as stroke or neurological specialists evaluated mRS according to the Japanese version of guidance scheme for mRS. Subsequently, 130 patients (mean age, 72 ± 12 years old) were enrolled, and the difference between the two scale scores (mRS vs. J-RASQ) were statistically examined by the κ statistic and the weighted κ statistic. The κ statistic was 0.42 (95% CI, 0.31-0.52), and the weighted κ statistic calculated taking into account the extent of disagreement was 0.78 (95% CI, 0.70-0.86). We conclude that the J-RASQ appears to have decent reliability and is similar to the existing mRS.

Detection of Stenosis Progression in Intracranial Vertebral Artery Dissection Using Carotid Ultrasonography.

BACKGROUND: The purpose of this study was to assess whether carotid ultrasonography indices detect arterial stenosis progression in patients with vertebral artery (VA) dissection. METHODS: This was a retrospective, single-center, observational study that enrolled patients with intracranial VA dissection who were admitted from January 2011 to June 2017. Magnetic resonance angiography (MRA) was done on admission and followed up at a median 20 days after onset (interquartile range [IQR] 9-58 days), and ultrasonography was performed at a median of 22 (interquartile range 7-56) days. Peak systolic velocity (PSV), end-diastolic velocity (EDV), mean velocity (MV), and pulsatility index (PI) were measured by ultrasonography, and the ratio of each follow-up value to the baseline (follow-up/baseline) value was calculated. Two stroke neurologists categorized into 3 groups by morphological changes of the dissected vessel: patients with stenosis progression (progression group: P-group); those with no remarkable change or dilatation improved (stable group: S-group); and those with stenosis regression or dilatation enlargement (enlargement group: E-group). Ultrasonography indices were compared among the groups. RESULTS: Of the 42 patients who were enrolled to this study, 39 patients underwent ultrasonography and MRA on both admission and follow-up. The PI ratio was significantly higher in the P-group than in the S-group (1.96 ± .80 versus .98 ± .44, P = .02) and in the E-group (versus .65 ± .35, P < .01). There were no significant differences in the PSV ratio, EDV ratio, and MV ratio. CONCLUSIONS: In patients with VA dissection, the PI ratio on ultrasonography is a promising index to detect stenosis progression.

Clinical and Radiological Characteristics of Intracranial Artery Dissection Using Recently Proposed Diagnostic Criteria.

BACKGROUND: Data on the clinical and radiological characteristics of intracranial artery dissection (IAD) have remained limited. Our purpose was to reveal the clinical and radiological characteristics of IAD according to diagnostic criteria for IAD as recently reported by a group of international experts. METHODS: Patients were retrospectively enrolled using a prospective single-center stroke registry between 2011 and 2016. Baseline characteristics and radiological findings including conventional magnetic resonance imaging (MRI) sequences, magnetic resonance angiography (MRA), high-resolution 3-dimensional T1-weighted imaging (HR-3D-T1WI), and digital subtraction angiography were reviewed. We performed statistical comparisons to determine which findings from which modalities are useful. RESULTS: We identified 118 patients with suspected artery dissection, with 64 patients (median age, 51 [interquartile range, 45-56) years; 16 women) finally meeting the criteria for definite (n = 47), probable (n = 15), or possible (n = 2) idiopathic IAD. Ischemic stroke alone was found in 31 patients (48%) on admission. There were 36 patients (56%) suffering from hypertension and 39 (61%) with smoking history. The vertebral artery alone was the most affected in 42 patients (66%). Intramural hematoma (IMH) was more frequently detected on HR-3D-T1WI than on conventional MRI/MRA (odds ratio, 4.72; 95% confidence interval, 1.71-13.00). In 54 patients (84%), the modified Rankin Scale score after 3 months was 0-1. CONCLUSIONS: Male dominance and age at IAD onset were similar to previous studies, and more than half had hypertension and smoking history. We confirmed that HR-3D-T1WI is useful for detecting IMH in the diagnostic criteria.