Neutrophil Lymphocyte Ratio as a Predictor of Stroke Severity in Type 2 Diabetes Mellitus: A Single-Center Study.

INTRODUCTION: Type 2 diabetes mellitus (T2DM) is associated with various microvascular and macrovascular complications. Stroke, being a vascular complication, is associated with severe morbidity and mortality. Neutrophil lymphocyte ratio (NLR), a crude, inexpensive, and rather easily available modality to detect inflammation, has been utilized to find the extent of inflammation in type 2 diabetes mellitus patients. In this study, we find the effect of hemoglobin A1c (HbA1c) on NLR and the effect of NLR on stroke severity index. AIMS AND OBJECTIVES: This study aims to determine the use of the NLR in predicting stroke severity in a type 2 diabetes mellitus patient. MATERIALS AND METHODS: This study is an observational cross-sectional study. A total of 400 patients were enrolled, all of whom had type 2 diabetes mellitus, with 200 of them diagnosed with an ischemic stroke. The National Institute of Health stroke scale (NIHSS) was used to standardize stroke severity and NLR was calculated from differential counts. RESULTS: The mean NLR for patients with type 2 diabetes mellitus was 3.87 ± 0.76 (mean ± SD), while for those with type 2 diabetes mellitus and stroke, it was 7.89 ± 1.29 (mean ± SD), with a statistically significant p-value < 0.001. Additionally, for every 1 unit increase in HbA1c, the NLR increased by 0.38 in type 2 diabetes mellitus patients and 0.86 in type 2 diabetes mellitus patients with stroke. Furthermore, each 1-unit increase in NLR corresponded to a rise of 0.80 in the stroke severity index. CONCLUSION: The study shows a significant correlation between NLR in type 2 diabetes mellitus patients and stroke in type 2 diabetes mellitus patients. Also, it shows the significance of NLR in predicting stroke severity.

Development and validation of a novel clinical prediction model to predict the 90-day functional outcome of spontaneous intracerebral hemorrhage.

Background: Spontaneous intracerebral hemorrhage (SICH) is associated with high mortality and disability. Accurately predicting adverse prognostic risks of SICH is helpful in developing risk stratification and precision medicine strategies for this phenomenon. Methods: We analyzed 413 patients with SICH admitted to Hefei Second People's Hospital as a training cohort, considering 74 patients from the First Affiliated Hospital of Anhui Medical University for external validation. Univariate and multivariate logistic regression analyses were used to select risk factors for 90-day functional outcomes, and a nomogram was developed to predict their incidence in patients. Discrimination, fitting performance, and clinical utility of the resulting nomogram were evaluated through receiver operating characteristic (ROC) curves, accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), calibration plots, and decision curves analysis (DCA), respectively. Results: Of the 413 patients, 180 had a poor prognosis. Univariate analysis showed significant variance of age, systolic pressure, intraventricular hemorrhage (IVH), Glasgow Coma Scale (GCS) scores, National Institute of Health Stroke Scale (NIHSS) scores, and hematoma volume between the groups (p < 0.05). Logistic multivariate regression analysis showed that age, IVH, NIHSS, and hematoma volume were associated with unfavorable outcomes. Based on the results, a nomogram model was developed with an area under the ROC curve of 0.91 (95% CI; 0.88-0.94) and 0.89 (95% CI; 0.80-0.95) in the training and validation sets, respectively. In the validation set, the accuracy, sensitivity, specificity, PPV, and NPV of the model were 0.851, 0.923, 0.812, 0.727, and 0.951, respectively. The calibration plot demonstrates the goodness of fit between the nomogram predictions and actual observations. Finally, DCA indicated significant clinical adaptability. Conclusion: We developed and validated a short-term prognostic nomogram model for patients with SICH including NIHSS scores, age, hematoma volume, and IVH. This model has valuable potential in predicting the prognosis of patients with SICH.

Increased door-to-puncture time during off-duty hours results in poor treatment outcomes for acute ischemic stroke: A subanalysis of the K-NET registry.

BACKGROUND: For patients who undergo endovascular treatment for acute ischemic stroke, the total time for treatment may increase during off-duty hours leading to worse outcomes. The present study compared endovascular treatment outcomes for on-duty and off-duty hours and examined factors that could be responsible for the prolonged treatment of patients in a multicenter registry. METHODS: The study group comprised 1571 patients listed in the multicenter stroke registry (K-NET) who had undergone endovascular treatment between January 2018 and June 2020. The modified Rankin Scale (mRS), evaluated at 90 days after stroke onset, was utilized as the primary outcome. Patients were divided into on-duty and off-duty patients based on admission time. Multivariate logistic regression analysis was used to identify the independent factors that increased the time from admission to puncture during the off-duty period. RESULTS: The mean mRS score at 90 days after stroke onset was 2.9, similar in both on-duty and off-duty patients, with no significant difference (p = 0.77); however, significant differences were observed in time from door-to-puncture (74.7 vs. 88.8, p < 0.01). Additionally, the mRS score at 90 days worsened significantly for door-to-puncture time >60 min in the off-duty period. Multivariate logistic regression analysis revealed that a low National Institute of Health Stroke Scale (NIHSS) score, high pre-mRS score, posterior circulation, and diabetes were independent indicators of door-to-puncture time >60 min during the off-duty period. CONCLUSION: Door-to-puncture time >60 min during off-duty hours was associated with poor outcomes related to low NIHSS, high pre-mRS, posterior circulation, and diabetes.

Diagnosis and treatment of Watershed strokes: a narrative review.

Watershed strokes have been described previously as ischemic strokes located in vulnerable border zones between brain tissue supplied by the anterior, posterior, and middle cerebral arteries in the distal junction between two non-anastomotic arterial territories. Ischemic strokes in border zones are well-recognized entities and well-described in terms of imaging features, but the pathophysiological mechanism of brain injury production is not fully defined. Border zone ischemia is caused by cerebral hypoperfusion through decreased cerebral blood flow and arterial embolism in unstable atheroma plaque. It is often difficult to say which mechanisms are fully responsible for producing cerebral ischemic lesions. This review aimed to highlight the imaging aspect of watershed strokes and to correlate the clinical characteristics of this type of stroke with the diagnostic algorithm for optimal therapeutic management. Neurologists should promptly recognize this type of stroke and investigate its etiology in the shortest possible time.

Twenty-four-hour National Institute of Health Stroke Scale predicts short- and long-term outcomes of basilar artery occlusion after endovascular treatment.

Background: The present study aimed to evaluate the prognostic value of the 24-h National Institute of Health Stroke Scale (NIHSS) for short- and long-term outcomes of patients with basilar artery occlusion (BAO) after endovascular treatment (EVT) in daily clinical routine. Methods: Patients with EVT for acute basilar artery occlusion study registry with the 24-h NIHSS, and clinical outcomes documented at 90 days and 1 year were included. The NIHSS admission, 24-h NIHSS, NIHSS delta, and NIHSS percentage change, binary definitions of early neurological improvement [ENI; improvement of 4/(common ENI)/8 (major ENI)/10 (dramatic ENI)] NIHSS points were compared to predict the favorable outcomes and mortality at 90 days and 1 year. The primary outcome was defined as favorable if the modified Rankin Scale (mRS) score was 0-3 at 90 days. Results: Of the 644 patients treated with EVT, the 24-h NIHSS had the highest discriminative ability for favorable outcome prediction [receiver operator characteristic (ROC)NIHSS 24 h area under the curve (AUC): 0.92 (0.90-0.94)] at 90 days and 1 year [(ROCNIHSS 24 h AUC: 0.91 (0.89-0.94)] in comparison to the NIHSS score at admission [ROCNIHSS admission AUC at 90 days: 0.73 (0.69-0.77); 1 year: 0.74 (0.70-0.78)], NIHSS delta [ROCΔ NIHSS AUC at 90 days: 0.84 (0.81-0.87); 1 year: 0.81 (0.77-0.84)], and NIHSS percentage change [ROC%change AUC at 90 days: 0.85 (0.82-0.89); 1 year: 0.82 (0.78-0.86)]. Conclusion: The 24-h NIHSS with a threshold of ≤23 points was the best surrogate for short- and long-term outcomes after EVT for BAO in the clinical routine.

Validation of a cloud-based tele-stroke system reliability in determining national institutes of health stroke scale scores for acute ischemic stroke screening in the emergency department.

Background and purpose: The National Institutes of Health Stroke Scale (NIHSS) is the most recommended tool for objectively quantifying the impairment caused by a suspected stroke. Nevertheless, it is mainly used by trained neurologists in the emergency department (ED). To bring forward the NIHSS to the pre-hospital setting, a smartphone-based Telestroke system was developed. It captures the full NIHSS by video, transmits it off-line, and enables assessment by a distant stroke physician. We aimed to compare the reliability of an NIHSS score determined by a neurologist from afar, using the platform with a standard NIHSS assessment performed in the emergency departments. Methods: A multi-center prospective study was conducted in two centers (Vall d'Hebron, Barcelona, and Rambam, Israel). Patients admitted to the ED with suspected stroke had a neurological exam based on the NIHSS, while being recorded by the system. A skilled neurologist rated the NIHSS according to the videos offline. The results were compared with the NIHSS score given by a neurologist at the bedside. Results: A total of 95 patients with suspected stroke were included. The overall intraclass correlation coefficient was 0.936 (0.99 in VdH and 0.84 in Rambam), indicating excellent and good reliability, respectively. Conclusion: Remote stroke assessment based on the NIHSS, using videos segments collected by a dedicated platform, installed on a standard smartphone, is a reliable measurement as compared with the bedside evaluation.

Inpatient assessment of the neurological outcome of acute stroke patients based on the National Institute of Health Stroke Scale (NIHSS).

Objective: Identify the association between stroke severity and the neurological outcome of an acute stroke using the National Institutes of Health stroke scale (NIHSS). Study design: A descriptive cross-sectional study.Place and duration of study: Northwest hospital Hayatabad Peshawar. Methodology: A cross-sectional descriptive study was done in the general plus stroke unit of the northwest hospital in Peshawar, KPK during Jan 2022 to July 2022.400 admitted patients diagnosed with acute stroke in the past three months were included for NIHSS assessment and were classified as mild, moderate, or severe stroke. After entering all of the data from the collection into SPSS version 16, the information was transferred to an Excel spreadsheet. To further assess the results, the researcher and statistician evaluated all of the cases, radiological findings, and laboratory test data. Results: In this cross-sectional descriptive study, 400 individuals ranging from 30 to 90 years of age were divided into two groups: males and females. The survey was conducted by 49% of men and 51% of women. The stroke severity was assessed to be mild in 22% of cases, moderate in 49%, and severe in 29% of patients. As evaluated by the NIHSS, Patients with acute ischemic stroke were divided into four groups depending on their neurological outcomes: those who improved were 160 (40%), those who remained stable were 124 (31%), and those who deteriorated were 52 (13%), and those who died were 64 (16%). Patients with greater triglyceride levels were 88, while those with lower levels were 312. Acute stroke was also detected in 34% of patients with a covid history, 28% of patients who were covid positive, and 38% of patients who were covid free in this investigation. Conclusion: According to our findings, the NIHSS is a reliable scale for evaluating patients' neurological outcomes and determining the association between acute stroke severity and cognitive functioning (NIHSS).

Recurrent stroke in young adults caused by atypical fibromuscular carotid dysplasia.

Background: Carotid Web and focal carotid diaphragm are atypical fibromuscular dysplasia. The bilateral stroke due to this dysplasia is extremely rare. We will report a series of three young patients, admitted for a bilateral ischemic stroke caused by carotid bulb web and internal carotid diaphragm. Also, we will discuss their manifestations and treatment modalities. Case presentations: In our study, we will report a series of three North African patients, two females an one male, at the mean age of 37, admitted for an ischemic stroke caused by bilateral carotid bulb web and bilateral internal carotid diaphragm.All of our patients were young and didn't have a history of drug use. Conclusions: In our series, only end-vascular treatment was performed which was necessary to prevent any recurrence. Antiplatelet therapy was used in all cases to prevent any stroke during the follow-up.

Transcultural Adaptation and Validation of Kannada version of the National Institute of Health Stroke Scale (NIHSS).

Background and Purpose: The National Institute of Health Stroke Scale (NIHSS) is widely used in clinical practice to evaluate stroke-related neurological deficits. The aim of this study was to develop Kannada language version of the NIHSS (Ka-NIHSS) and determine its validity and reliability. Materials and Methods: In the first phase of the study, Ka-NIHSS was adapted based on cultural and linguistic peculiarities. In the next phase, 51 acute stroke patients were prospectively enrolled in the study. The concurrent validity of the Ka-NIHSS was evaluated by comparison with the Glasgow Coma Scale (GCS) and the modified Rankin Scale (mRS). The predictive validity was assessed by comparison with Barthel Index (BI) score and mRS at a 90-day telephonic follow-up. The reliability was evaluated using the kappa statistics for inter-rater agreement between two independent raters and intra-class correlation coefficient (ICC) analysis. The inter-rater agreement of videotaped assessment of items 9 and 10 between four independent raters was evaluated using kappa statistics. Results: Ka-NIHSS scores highly correlated with GCS (P = -0.74 P < 0.001) and mRS (P = 0.85, P < 0.001) at baseline. It moderately correlated with mRS (P = 0.67, P < 0.001) and BI (P = -0.64, P < 0.001) at 90 days follow up. Inter-rater reliability was high between the two examiners, with kappa values ranging from 0.66 to 0.95. The inter-rater agreements of the video assessment of items 9 and 10 for nine patients among four raters were 0.81 and 1 respectively. Conclusions: Ka-NIHSS is a valid and reliable tool for assessing neurological deficits in Kannada-speaking stroke patients.

Negative correlation between early recovery and lipoprotein-associated phospholipase A2 levels after intravenous thrombolysis.

OBJECTIVE: Lipoprotein-associated phospholipase A2 (Lp-PLA2) is considered a biomarker for systemic inflammation and the risk of myocardial infarction and stroke. However, little is known about the effect of acute vascular events on marker levels. The purpose of this study was to assess the potential association of early recovery with Lp-PLA2 levels in patients with acute ischemic stroke (AIS) after intravenous thrombolysis (IVT). METHODS: Forty-three consecutive AIS patients who had their first stroke and were hospitalized within 5 hours of the onset of stroke were enrolled. All patients were treated with IVT using alteplase or urokinase. Plasma Lp-PLA2 levels were measured within 24 hours after IVT. Variables that showed a significant association with Lp-PLA2 in univariate analysis were included in the multivariate ordered logistic regression model. RESULTS: Early recovery was associated with Lp-PLA2 levels after IVT, and Lp-PLA2 levels tended to decrease with increased probability of early recovery. This study is the first to report a negative correlation between early recovery and Lp-PLA2 levels after IVT. CONCLUSION: Early recovery after IVT was negatively correlated with Lp-PLA2 A2 levels.

Rebuilding hippocampus neural circuit with hADSC-derived neuron cells for treating ischemic stroke.

BACKGROUND: Human adipose-derived stem cells (hADSCs) have been demonstrated to be a promising autologous stem cell source for treating various neuronal diseases. Our study indicated that hADSCs could be induced into neuron-like cells in a stepwise manner that are characterized by the positive expression of MAP2, SYNAPSIN 1/2, NF-200, and vGLUT and electrophysiological activity. We first primed hADSCs into neuron-like cells (hADSC-NCs) and then intracerebrally transplanted them into MCAO reperfusion mice to further explore their in vivo survival, migration, integration, fate commitment and involvement in neural circuit rebuilding. RESULTS: The hADSC-NCs survived well and transformed into MAP2-positive, Iba1- or GFAP-negative cells in vivo while maintaining some proliferative ability, indicated by positive Ki67 staining after 4 weeks. hADSC-NCs could migrate to multiple brain regions, including the cortex, hippocampus, striatum, and hypothalamus, and further differentiate into mature neurons, as confirmed by action potential elicitation and postsynaptic currents. With the aid of a cell suicide system, hADSC-NCs were proven to have functionally integrated into the hippocampal memory circuit, where they contributed to spatial learning and memory rescue, as indicated by LTP improvement and subsequent GCV-induced relapse. In addition to infarction size shrinkage and movement improvement, MCAO-reperfused mice showed bidirectional immune modulation, including inhibition of the local proinflammatory factors IL-1α, IL-1ß, IL-2, MIP-1ß and promotion proinflammatory IP-10, MCP-1, and enhancement of the anti-inflammatory factors IL-15. CONCLUSION: Overall, hADSC-NCs used as an intermediate autologous cell source for treating stroke can rebuild hippocampus neuronal circuits through cell replacement.

Study of Intracranial Hematoma Removal and High Intracranial Pressure Reduction Using a Novel Three-Needle Brain Puncture Technique.

Objective: The present study aimed to evaluate the clinical value of minimally invasive surgery for intracranial hematoma removal and high intracranial pressure (ICP) reduction using a novel three-needle brain puncture technique. Methods: A total of 202 cases with supratentorial hematoma were analyzed, 54 of whom received three-needle brain puncture (study group), and the remaining cases received single-needle (control groups 1 and 2) and two-needle brain puncture (control group 3). The amount of intracranial hematoma removed, changes in ICP, retention time of puncture needle, volume of residual blood, the National Institute of Health Stroke Scale (NIHSS) score, and postoperative survival rate were used as indexes to evaluate patient outcomes. Results: We found that three-needle brain puncture (study group) can remove more intracranial hematoma (P < 0.05) and achieve lower ICP (P < 0.05) than single- and two-needle brain puncture (control group). The needle retention time and volume of residual blood significantly decreased in the study group. Additionally, a statistically significant difference was observed in the NIHSS scores and survival rates between the study and control groups (P < 0.05). Conclusion: These data suggest that three-needle minimally invasive stereotactic puncture can effectively remove hematoma, reduce ICP, decrease the degree of brain damage, and improve prognosis.

Delayed neurological improvement is predictive to long-term clinical outcome on endovascular thrombectomy patients.

OBJECTIVES: This study aims at exploring the 3-month outcome predicting ability of delayed neurological improvement and the cause of delayed neurological improvement. MATERIALS AND METHODS: Early neurological improvement and delayed neurological improvement were calculated to represent the neurological improvements. Good functional outcome was defined as a 90-day modified Rankin Scale score 0-2. We used multivariant logistic regression to explore the influential factors of good functional outcome as well as delayed neurological improvement. We applied net reclassification improvement and integrated discrimination improvement to assess the quantitative improvement of the predictive model. RESULTS: Early neurological improvement was observed in 50 (23%) patients and delayed neurological improvement exhibited in 67 (30%) patients. Early neurological improvement and delayed neurological improvement were both independent predictive factors to good functional outcome. In the basic model (adjusted for age, admission glucose level, baseline National Institute of Health Stroke Scale, and complications and number of retrieval attempts), early neurological improvement and delayed neurological improvement statistically improved the predictive ability (early neurological improvement: net reclassification improvement = 0.34, 95% confidence interval, 95% confidential interval (0.06, 0.69); integrated discrimination improvement = 0.05, p < 0.001; delayed neurological improvement: net reclassification improvement = 0.79, 95% confidential interval (0.47, 1.12); integrated discrimination improvement = 0.14, p < 0.001) delayed neurological improvement could predict clinical outcomes more accurately than early neurological improvement (early neurological improvement vs. delayed neurological improvement: integrated discrimination improvement = 0.09, p < 0.001). Moreover, delayed neurological improvement was affected by hypertension (odds ratio = 0.40, 95% CI (0.18, 0.88), p = 0.02), early neurological improvement (odds ratio = 20.10, 95% confidential interval (8.24, 19.02), p < 0.001), number of retrieval attempts (odds ratio = 0.39, 95% confidential interval (0.24, 0.66), p < 0.001), and complication (odds ratio = 0.25, 95% confidential interval (0.12, 0.54), p < 0.001). CONCLUSIONS: Delayed neurological improvement could predict clinical outcomes more accurately than early neurological improvement. Hypertension, early neurological improvement, numbers of retrieval attempts, and complications were all predicting factors to delayed neurological improvement.

Malnutrition could Predict 3-month Functional Prognosis in Mild Stroke Patients: Findings from a Nationwide Stroke Registry.

BACKGROUND: Previous studies showed the inconsistent effects of malnutrition contributing to the poor prognosis of stroke. This study aims to explore the effect of malnutrition on 3- month functional prognosis of stroke patients with different stroke severity assessed by the national institute of health stroke scale (NIHSS). METHODS: Patients with first-ever stroke were consecutively enrolled in a nationwide, multicenter, and prospective registry from March 2007 to January 2008. Nutritional status was assessed at admission. Malnutrition was defined by any abnormality of 6 nutrition indicators, including body mass index (BMI), mid-upper arm circumference (MUAC), triceps skinfold thickness (TSF), haemoglobin, albumin, and prealbumin. Stroke patients were classified into mild (NIHSS<8) and severe (NIHSS≥8) groups. Multivariable logistic regression was performed to assess the risk of poor functional prognosis (modified Rankin Scale (mRS) ≥3) at 3-month follow-up in the mild or severe patients with malnutrition at admission. RESULTS: A total of 755 patients with first-ever stroke were enrolled in the study. Multivariable analysis showed that malnutrition independently contributed to a higher risk of mRS 3-6 at 3-month for mild stroke patients [odds ratio (OR) 1.86, 95 % confidence interval (CI) 1.04-3.34], but didn't for severe stroke patients (OR 0.91, 95 % CI 0.53-1.54) after adjusting for confounders including age, NIHSS, and infection et al. After adjusting for the potential confounders, malnutrition was still an independent risk factor for 3-month poor functional prognosis in mild stroke patients. CONCLUSION: Further investigation may be needed to illustrate the effects of improving nutritional status on stroke patients.

Assessment of neurological function using the National Institute of Health Stroke Scale in patients with gliomas.

BACKGROUND: The evaluation of treatment response in patients with gliomas is performed using the Response Assessment in Neuro-Oncology (RANO) criteria. These criteria are based on cerebral magnetic resonance imaging (MRI), steroid use, and neurological function. However, a standardized tool for evaluating neurological function was lacking. We compared changes in the National Institute of Health Stroke Scale (NIHSS) to changes in the RANO categories to determine the relationship between clinical and neuroradiological findings. METHODS: We reviewed data on all adult patients with supratentorial gliomas WHO grade II-IV who were treated at the Cantonal Hospital St. Gallen from 2008 to 2015. The NIHSS was performed prospectively at baseline and at 3-month intervals simultaneously to MRI. Associations between changes in the NIHSS and RANO categories were assessed using the Stuart-Maxwell test. RESULTS: Our cohort consisted of 61 patients from which 471 observations were analyzed. The most common histological diagnosis was glioblastoma (49.2%). In total, 74% of RANO categories and 81% of the NIHSS scores remained stable on follow-up. Statistically, contemporaneous changes in the RANO category did not correlate with changes in the NIHSS (P < .0001). CONCLUSION: The application of the NIHSS is easy and feasible in the heterogeneous population of glioma patients. In our cohort, the RANO categories did not reflect contemporaneous changes in the NIHSS. A validated clinical outcome measure with a well-defined minimal clinically important difference is warranted in neuro-oncological research and clinical practice.

Ischemic stroke revealing COVID-19 infection: Case report.

INTRODUCTION: SARS-COV-2 viral infection primarily targets the respiratory system with a clinical picture that varies from simple symptoms to respiratory distress syndrome requiring hospitalization in the intensive care unit; SARS-CoV-2 also has neuro-invasive capabilities and could spread from the respiratory system to the central nervous system. Recently, some patients with COVID-19 have been shown to have neurological symptoms such as headache, anosmia, dysgeusia, dizziness, impaired consciousness, and ischemic stroke. CASE PRESENTATION: we describe a case of ischemic stroke as the main presentation of COVID-19 in a 68 years old man with no previous history, without any associated respiratory signs; clinical examination revealed left hemiparesis with dysarthria and left facial paralysis, NIHSS score was at 11, the brain CT scan performed 1h30min later, completed by a brain MRI that came back in favor of right frontal, temporal and parietal ischemic stroke. The decision of thrombolysis was indicated in urgency, and the patient benefited from thrombolysis, which proceeded without incidents; the outcome was favorable with regression of symptoms.Ischemic stroke has been widely described among the thromboembolic complications of COVID-19, but only a few papers have reported it as a primary manifestation of COVID-19. CONCLUSION: SARS-COV 2 infection can spread from the respiratory system to the central nervous system, resulting in an inflammatory response and excessive secretion of inflammatory markers, leading to ischemic stroke.

Mechanical thrombectomy in patients with stroke due to large vessel occlusion in the anterior circulation and low baseline NIHSS score.

We sought to verify the benefit of mechanical thrombectomy in patients with acute ischemic stroke due to large vessel occlusion in the anterior circulation and low National Institute of Health stroke scale score at presentation. The prospective database of our stroke center was screened for patients with acute ischemic stroke due to large vessel occlusion and a baseline National Institute of Health stroke scale score ≤5 that had undergone mechanical thrombectomy. Outcome measures were the modified Rankin Scale (mRS) score at 90 days, brain bleeding events and death at 90 days. Out of 459 patients, 17 (12 females, mean age 70 ± 14 years) with occlusion of M1 or M2 segment of middle cerebral artery and baseline National Institute of Health stroke scale score ≤5 underwent mechanical thrombectomy. Eight patients (47%) were treated within 6 hours from the onset, 5 (29%) were treated beyond 6 hours, and 4 (24%) were wake-up strokes. Effective mechanical thrombectomy was achieved in 16 patients (94%) and associated with excellent functional outcomes at 3 months (mRS 0-1) in 13 (76%). The asymptomatic brain-bleeding event was observed in one patient 4 days after effective mechanical thrombectomy concerning safety issues. One patient died 1 month after mechanical thrombectomy of a cause unrelated to stroke. Our findings favor a potential benefit of mechanical thrombectomy in patients with stroke due to large vessel occlusion and low National Institute of Health stroke scale score at presentation. These patients may also benefit from a prolonged time window for treatment.

Including Distal Motor Function within the NIHSS: Correlation with Motor Arm Function and IV rt-PA Treatment Response.

OBJECTIVES: The Distal Motor Function (DMF) sub-score of the NIH Stroke Scale (NIHSS) was measured in the NINDS rt-PA Stroke Trials but is currently not included in the NIHSS. The correlation of DMF with the NIHSS Motor Arm Function (MAF) sub-score, the effect of IV tPA treatment on DMF, and whether adding DMF changes the utility of the NIHSS have not been analyzed. MATERIALS AND METHODS: MAF and DMF sub-scores were retrieved from the original NINDS rt-PA Stroke Trials for both sides of the body at baseline, 2 hours, 24 hours, 7-10 days, and 3 months after IV tPA treatment. MAF and DMF scores were correlated using Spearman correlation. Clustering of DMF and MAF scores was determined using a Bentler Comparative Fit Index (CFI) to estimate variation in NIHSS when adding DMF. The effect of IV tPA on DMF and MAF was assessed using a linear model comparing changes in scores from baseline to 3 months. RESULTS: MAF and DMF were highly correlated (p < 0.0001) across all time points for both dichotomous and continuous data on both sides. Intravenous tPA accounted for 21% of the change in DMF (p < 0.014, R2 = 0.0157, N = 423) and 39% of the change in MAF (p < 0.093, R2 = 0.0125, N = 547) from 0 to 3 months. On adding DMF to NIHSS, CFI decreased from 0.98 to 0.80 and DMF clustered with MAF, indicating that addition of DMF is unlikely to produce any discrepancy to NIHSS. CONCLUSIONS: Including DMF to the NIHSS does not appear to be of additional value. After IV tPA treatment, proximal and distal motor function in upper extremity strongly correlate over time but greater improvement in MAF is noted. Further research is needed on the role of IV tPA on minor strokes with deficits of DMF.

Predictors of Stroke Subtype and Severity in Patients of a Tertiary Care Hospital, Dehradun.

CONTEXT: Stroke caused 6.7 million deaths worldwide in 2013. In India, the cumulated incidence of stroke was 105-152/100,000 persons per year in last decade. Dearth of data on predictors of stroke subtype and severity in India lead to this study. AIMS: (1) To categorize presenting stroke patients by subtype and severity. (2) To establish association of risk factors with above. (3) To predict subtype and severity by risk factors. SETTINGS AND DESIGN: Hospital-based cross-sectional analytic, retrospective study. SUBJECTS AND METHODS: A predesigned, pretested, semi-structured questionnaire with standard tool (National Institute of Health Stroke Scale Score), informed consent after prior approval of institutional ethics and research committees. STATISTICAL ANALYSIS USED: Percentages, proportions, Chi-square trends, linear regression, independent t-test, and analysis of variance (ANOVA). RESULTS: Mean age of 102 patients was 62.1 (±12.8 years). Stroke subtype associated with socioeconomic status (χ2 = 6.38775, P = 0.0115) and stroke severity (χ2 = 18.98, P = 0) and stroke severity associated with stroke subtype (χ2 = 9.79366, P = 0.0018). Stroke subtype could be predicted by stroke severity and stroke severity by subtype, sex, and dyslipidemia (regression models). Independent t-test revealed excessive alcohol intake was a significant predictor and one-way ANOVA revealed education was a significant predictor of severe stroke. CONCLUSIONS: Stroke subtype is significantly associated with higher socioeconomic status and severe stroke. Stroke severity is significantly associated with hemorrhagic stroke. Stroke subtype, sex, dyslipidemia, alcohol intake, and education may act as predictors of stroke severity.

The initial CT blend sign is not associated with poor patient outcomes after stereotactic minimally invasive surgery.

BACKGROUND: The initial CT blend sign is an imaging marker that has been used to predict haematoma expansion and poor outcomes in patients with small-volume intracerebral haemorrhage (ICH). However, the association of the blend sign with the outcomes of patients undergoing surgery remains unclear. The present study aimed to retrospectively evaluate the influence of the initial CT blend sign on short-term outcomes in patients with hypertensive ICH after stereotactic minimally invasive surgery (sMIS). METHODS: We enrolled 242 patients with spontaneous ICH. The patients were assigned to the blend sign group (91 patients) or non-blend sign (control) group (151 patients) based on the initial CT features. The NIHSS, GCS and mRS were used to assess the effects of sMIS. The rates of severe pulmonary infection and cardiac complications were also compared between the two groups. RESULTS: Statistically significant differences in the NIHSS and GCS scores were not observed between the blend sign group and the control group. No significant differences in the proportion of patients with good outcomes during the follow-up period were observed between the two groups. A higher rate of re-haemorrhage was noted in the blend sign group. Significant differences in the rates of severe pulmonary infection and cardiac complications were not observed between the two groups. CONCLUSIONS: The initial CT blend sign is not associated with poor outcomes in patients with hypertensive ICH after sMIS. ICH patients with the CT blend sign should undergo sMIS if they are suitable candidates for surgery.