Impact of prior oral anticoagulation on admission stroke severity in patients with atrial fibrillation.

BACKGROUND AND AIMS: In patients with atrial fibrillation, oral anticoagulation therapy is indicated for both primary and secondary prevention of stroke/systemic embolism. Though direct oral anticoagulants with greater safety and efficacy than warfarin were introduced into clinical practice at the beginning of the last decade, even now not all patients with AF have adequate preventative anticoagulant treatment. The primary goal of this study was to evaluate the impact of prior use of oral anticoagulants on admission stroke severity in those with AF. Other aims were, inter alia, to assess the trend in atrial fibrillation prevalence in the years of the HISTORY trials 2012-2021 carried out in the Czech Republic and use of oral anticoagulants (OAC) in ischemic stroke (IS) patients. METHODS: We analyzed consecutive ischemic stroke patients who had been enrolled in the HISTORY (Heart and Ischemic STrOke Relationship studY) study registered on ClinicalTrials.gov (identifier NCT01541163) in the year 2012 and carried out a yearly comparison (detailed in the text). RESULTS: In total, there were 1059 patients (55.9% males, mean age 71.7±12.8). There was no significant difference over the time period in rate of known (18.3 vs. 16.5%, P=0.442) or newly detected AF (17.0 vs. 16.0%, P=0.665), but sigificantly more patients with known AF were treated with oral anticoagulants before IS in the year 2021 (32.1 vs. 70.7%, P<0.0001), and direct oral anticoagulants (3.6 vs. 35.4%, P<0.0001). The number of patients with atrial fibrillation had not changed significantly over the years (26.2 vs. 31.3%). Patients on OAC had a lower median admission score on the National Institutes of Health Stroke Scale (NIHSS) than those not using an oral anticoagulant (6 vs. 16, P=0.0004) in 2021. CONCLUSIONS: There was no significant upward trend in atrial fibrillation in stroke patients admitted between 2012 and 2021, but patients with known AF were significantly more frequently treated with oral anticoagulants and direct oral anticoagulants (DOAC) in 2021. Patients on OAC had lower admission NIHSS scores than those not using any anticoagulent in the year 2021. The difference in the median admission NIHSS between the patients on OAC and those without OAC treatment was not significant in the year 2012 (6 vs. 12, P=0.066). This might be related to the fact that substantially fewer patients in 2012 were on DOACs, which are considered more effective than warfarin.

Role of Stroke Scales and Scores in Cerebrovascular Disease.

This article provides a comprehensive review of widely utilized stroke scales in both routine clinical settings and research. These scales are crucial for planning treatment, predicting outcomes, and helping stroke patients recover. They also play a pivotal role in planning, executing, and comprehending stroke clinical trials. Each scale presents distinct advantages and limitations, and the authors explore these aspects within the article. The authors' intention is to provide the reader with practical insights for a clear understanding of these scales, and their effective use in their clinical practice.

Association of α-HBDH levels with the severity and recurrence after acute ischemic stroke.

OBJECTIVE: α-HBDH serves as a biomarker of myocardial damage and is implicated in adverse outcomes across various critical illnesses. Our study aimed to assess the correlation between α-HBDH levels, and severity and recurrence of acute ischemic stroke (AIS). METHODS: We enrolled patients with mild-to-moderate AIS within 72 h of onset. Based on the baseline score of the National Institutes of Health Stroke Scale (bNIHSS) at registration, patients were categorized into mild (bNIHSS ≤ 4 points) and moderate AIS groups (4 < bNIHSS ≤ 10 points). Subsequently, based on the normal upper limit of α-HBDH, patients were divided into low-level α-HBDH (≤ 180 U/L) and high-level α-HBDH (> 180 U/L) groups. Multivariate logistic regression analysis and Cox proportional hazard regression analysis were employed to evaluate the relationship between α-HBDH levels and bNIHSS scores as well as the risk of recurrent AIS within 90 days. RESULTS: We observed a significant association between higher baseline levels of α-HBDH and increased bNIHSS scores, indicating a more severe AIS (odds ratio = 24.449; 95% confidence interval [CI], 8.749-68.324; p < 0.01). Additionally, the risk of recurrent AIS within 90 days was 4.666 times higher in the high-level α-HBDH group compared to the low-level group (hazard ratio = 4.666; 95% CI, 2.481-8.777; p < 0.01). CONCLUSIONS: The baseline level of α-HBDH is significantly correlated with the severity of AIS and the risk of recurrent AIS within 90 days.

Development and Validation of a Fusion Model Based on Carotid Plaques and White Matter Lesion Burden Imaging Characteristics to Evaluate Ischemic Stroke Severity in Symptomatic Patients.

BACKGROUND: The diagnostic value of carotid plaque characteristics based on higher-resolution vessel wall MRI (HRVW-MRI) combined with white matter lesion (WML) burden for the risk of ischemic stroke is unclear. PURPOSE: To combine carotid plaque features and WML burden to construct a hybrid model for evaluating ischemic stroke severity and prognosis in patients with symptomatic carotid artery stenosis. STUDY TYPE: Retrospective. SUBJECTS: One hundred and ninty-three patients with least one confirmed carotid atherosclerotic stenosis ≥30% and cerebrovascular symptoms within the last 2 weeks (136 in the training cohort and 57 in the test cohort). FIELD STRENGTH/SEQUENCE: 3.0T, T2-weighted fluid attenuated inversion recovery (T2-FLAIR) and diffusion-weighted imaging (DWI); HRVW-MRI: 3D T1-weighted variable flip angle fast spin-echo sequences (VISTA), T2-weighted VISTA, simultaneous noncontrast angiography and intraplaque hemorrhage (SNAP), and contrast-enhanced T1-VISTA. ASSESSMENT: The following features of the plaques or vessel wall were assessed by three MRI readers independently: calcification (CA), intraplaque hemorrhage (IPH), lipid-rich necrotic core (LRNC), ulceration, plaque enhancement (PE), maximum vessel diameter (Max VD), maximum wall thickness (Max WT), total vessel area (TVA), lumen area (LA), plaque volume, and lumen stenosis. WMLs were graded visually and categorized as absent-to-mild WMLs (Fazekas score 0-2) or moderate-severe WMLs (Fazekas score 3-6). WML volumes were quantified using a semiautomated volumetric analysis program. Modified Rankin scores (mRS) were assessed at 90 days, following an outpatient interview, or by telephone. STATISTICAL TESTS: LASSO-logistic regression analysis was performed to construct a model. The performance of the model was evaluated using receiver operating characteristic (ROC) curve analyses, calibration curves, decision curve analyses, and clinical imaging curves. Conditional logistic regression analysis was used to explore the associations between the hybrid model-derived score and the modified Rankin Scale (mRS) score at 90 days. RESULTS: The model was constructed using five selected features, including IPH, plaque enhancement, ulceration, NWI, and total Fazekas score in deep WMLs (DWMLs). The hybrid model yielded an area under the curve of 0.92 (95% confidence interval [CI] 0.87-0.97) in the training cohort and 0.88 (0.80-0.96) in the test cohort. Furthermore, the hybrid model-derived score (odds ratio = 1.28; 95% CI 1.06-1.53) was independently associated with the mRS score 90 days after stroke. DATA CONCLUSIONS: The hybrid model constructed using MRI plaque characteristics and WML burden has potential to be an effective noninvasive method of assessing ischemic stroke severity. The model-derived score has promising utility in judging neurological function recovery. TECHNICAL EFFICACY: Stage 2.

Ethnic and Gender Variations in Ischemic Stroke Patterns among Arab Populations in Northern Israel: A Preliminary Exploration towards Culturally Aware Personalized Stroke Care.

The Galilee region of Israel boasts a rich ethnic diversity within its Arab population, encompassing distinct Muslim, Christian, Druze, and Bedouin communities. This preliminary exploratory study uniquely examined potential ethnic and gender differences in ischemic stroke characteristics across these Arab subgroups, which are seldom investigated separately in Israel and are typically studied as a homogeneous "Arab" sector, despite significant variations in their ethnicity, culture, customs, and genetics. The current study aimed to comparatively evaluate stroke characteristics, including recurrence rates, severity, and subtypes, within and across these distinct ethnic groups and between genders. When examining the differences in stroke characteristics between ethnic groups, notable findings emerged. The Bedouin population exhibited significantly higher rates of recurrent strokes than Muslims (M = 0.55, SD = 0.85 vs. M = 0.25, SD = 0.56; p < 0.05). Large vessel strokes were significantly more prevalent among Christians (30%) than Druze (9.9%; p < 0.05). Regarding gender differences within each ethnic group, several disparities were observed. Druze women were six times more likely to experience moderate to severe strokes than their male counterparts (p < 0.05). Interestingly, Druze women also exhibited a higher representation of cardio-embolic stroke (19.8%) compared with Druze men (4.6%; p < 0.001). These findings on the heterogeneity in stroke characteristics across Arab ethnic subgroups and by gender underscore the need to reconsider the approach that views all ethnic groups comprising the Arab sector in Israel as a homogeneous population; instead, they should be investigated as distinct communities with unique stroke profiles, requiring tailored culturally aware community-based prevention programs and personalized therapeutic models. The identified patterns may guide future research to develop refined, individualized, and preventive treatment approaches targeting the distinct risk factors, healthcare contexts, and prevention needs of these diverse Arab populations.

Modified rankin scale is a reliable tool for the rapid assessment of stroke severity and predicting disability outcomes.

Background: 'Time is brain' goes the adage. Rapid and precise management of stroke is of the utmost essence. The modified National Institutes of Health Stroke Scale (mNIHSS) and the modified Rankin Scale (mRS) predict stroke severity and functional disability outcomes. However, the mRS can be administered more rapidly than the mNIHSS and therefore might be better to assess patient outcomes. Hence, the aim of this study was to assess the correlation of stroke severity on admission and functional disability outcomes on the day of discharge or on the 8th day of hospitalization. Materials and Methods: This was an observational, cross-sectional study with a sample size of 61 participants. The mNIHSS score was calculated on admission for patients with clinical features suggestive of stroke and mRS was calculated on the 8th day of hospitalization or on discharge. Evaluation of the association between continuous variables was done using Spearman's correlation analysis. Results: Correlation between mNIHSS and mRS was positive and statistically significant (rho = 0.866, 95% CI [0.751, 0.925]. For each point increase in the mNIHSS, the odds of having higher mRS scores are 153% more than the odds of having lower mRS scores (aOR = 2.534, 95% CI [1.904, 3.560]). Conclusion: Our study concluded that mRS can be reliably used to predict the functional outcomes for patients with stroke in circumstances where the mNIHSS may prove to be lengthy. Thus, where 'time is brain', the mRS can be used with a similar power to predict the outcome.

Lower serum uric acid to serum creatinine ratio as a predictor of poor functional outcome after mechanical thrombectomy in acute ischaemic stroke.

BACKGROUND AND PURPOSE: The ratio of serum uric acid (SUA) to serum creatinine (SCr), representing normalized SUA for renal function, is associated with functional outcome in acute ischaemic stroke (AIS) patients. However, its effect on AIS patients undergoing mechanical thrombectomy (MT) remains unknown. This study aimed to investigate the influence of the SUA/SCr ratio on clinical outcome in MT-treated AIS patients. METHODS: Acute ischaemic stroke patients who underwent MT were continuously enrolled from January 2018 to June 2023. Upon admission, SUA and SCr levels were recorded within the initial 24 h. Stroke severity was determined using the National Institutes of Health Stroke Scale (NIHSS) score. Clinical outcome included poor functional outcome (modified Rankin Scale score >2) at 90 days, symptomatic intracranial haemorrhage and death. RESULTS: Amongst 734 patients, 432 (58.8%) exhibited poor functional outcome at 90 days. The SUA/SCr ratio exhibited a negative correlation with NIHSS score (ρ = -0.095, p = 0.010). Univariate analysis revealed a significant association between SUA/SCr ratio and poor functional outcome. After adjusting for confounders, the SUA/SCr ratio remained an independent predictor of functional outcome (adjusted odds ratio 0.348, 95% confidence interval 0.282-0.428, p < 0.001). Receiver operating characteristic curve analysis highlighted the ability of the SUA/SCr ratio to predict functional outcome, with a cutoff value of 3.62 and an area under the curve of 0.757 (95% confidence interval 0.724-0.788, p < 0.001). CONCLUSION: The SUA/SCr ratio is correlated with stroke severity and may serve as a predictor of 90-day functional outcome in AIS patients undergoing MT.

Trends in stroke severity at hospital admission and rehabilitation discharge before and during the COVID-19 pandemic in Hesse, Germany: a register-based study.

BACKGROUND: The COVID-19 pandemic has affected acute stroke care, resulting in a decrease in stroke admissions worldwide. We examined trends in stroke severity at hospital admission, including (1) probable need for rehabilitation (National Institutes of Health Stroke Scale score > 6 points) and (2) probable need for assistance (modified Rankin Scale score > 2 points), and discharge to rehabilitation after acute care among inpatients with acute ischemic stroke and intracerebral hemorrhage. METHODS: We compared quality assurance data for acute ischemic stroke and intracerebral hemorrhage during the pandemic with the period before the pandemic in Hesse, Germany, using logistic regression analyses. RESULTS: Fewer inpatients with a probable need for rehabilitation were present at the beginning of the second wave of the COVID-19 pandemic in September 2020 (adjusted OR (aOR) 0.85, 95% CI [0.73, 0.99]), at the end of the second national lockdown in May 2021 (aOR 0.81, 95% CI [0.70, 0.94]), and at the approaching peak of COVID-19 wave 4 in November 2021 (aOR 0.79, 95% CI [0.68, 091]). Rates of probable need for assistance were significantly lower at the beginning of COVID-19 wave 2 in August 2020 (aOR 0.87, 95% CI [0.77, 0.99]) and at the beginning of COVID-19 wave 3 in March 2021 (aOR 0.80, 95% CI [0.71, 0.91]). Rates of discharge to rehabilitation were lower from the beginning in October 2020 to the peak of COVID-19 wave 2 in December 2020 (aOR 0.83, 95% CI [0.77, 0.90]), at the beginning and end of COVID-19 wave 3 in March 2021 and May 2021 (aOR 0.86, 95% CI [0.79, 0.92]), respectively, and at the beginning of COVID-19 wave 4 in October 2021 (aOR 0.86, 95% CI [0.76, 0.98]). CONCLUSIONS: The results suggest that the COVID-19 pandemic had an impact on stroke management during the pandemic, but the absolute difference in stroke severity at hospital admission and discharge to rehabilitation was small.

Pre-Stroke Antihypertensive Therapy Affects Stroke Severity and 3-Month Outcome of Ischemic MCA-Territory Stroke.

OBJECTIVES: Whether different antihypertensive drug classes in high blood pressure (HBP) pre-stroke treatment affect dynamic cerebral autoregulation (dCA), stroke severity, and outcome. METHODS: Among 337 consecutive ischemic stroke patients (female 102; median age 71 years [interquartile range, [IQR 60; 78]; NIHSS median 3 [IQR 1; 6]) with assessment of dCA, 183 exhibited the diagnosis of HBP. dCA parameters' gain and phase were determined by transfer function analysis of spontaneous oscillations of blood pressure and cerebral blood flow velocity. RESULTS: Patients used beta-blockers (n = 76), calcium channel blockers (60), diuretics (77), angiotensin-converting enzyme inhibitors (59), or angiotensin-1 receptor blockers (79), mostly in various combinations of two or three drug classes. dCA parameters did not differ between the non-HBP and the different HBP medication groups. Multinomial ordinal logistic regression models revealed that the use of diuretics decreased the likelihood of a less severe stroke (odds ratio 0.691, 95% CI 0.493; 0.972; p = 0.01) and that beta-blockers decreased the likelihood of a better modified Rankin score at 3 months (odds ratio 0.981, 95% CI 0.970; 0.992; p = 0.009). Other independent factors associated with stroke outcome were penumbra and infarct volume, treatment with mechanical thrombectomy, and the initial National Institute of Health Stroke Scale score. INTERPRETATION: In this cohort of ischemic minor to moderate stroke patients, pre-stroke antihypertensive treatment with diuretics was associated with a more severe neurological deficit on admission and pre-stroke treatment with beta-blockers with a poorer 3-month outcome. The antihypertensive drug class used pre-stroke did not impact dCA.

Automatic quantitative stroke severity assessment based on Chinese clinical named entity recognition with domain-adaptive pre-trained large language model.

BACKGROUND: Stroke is a prevalent disease with a significant global impact. Effective assessment of stroke severity is vital for an accurate diagnosis, appropriate treatment, and optimal clinical outcomes. The National Institutes of Health Stroke Scale (NIHSS) is a widely used scale for quantitatively assessing stroke severity. However, the current manual scoring of NIHSS is labor-intensive, time-consuming, and sometimes unreliable. Applying artificial intelligence (AI) techniques to automate the quantitative assessment of stroke on vast amounts of electronic health records (EHRs) has attracted much interest. OBJECTIVE: This study aims to develop an automatic, quantitative stroke severity assessment framework through automating the entire NIHSS scoring process on Chinese clinical EHRs. METHODS: Our approach consists of two major parts: Chinese clinical named entity recognition (CNER) with a domain-adaptive pre-trained large language model (LLM) and automated NIHSS scoring. To build a high-performing CNER model, we first construct a stroke-specific, densely annotated dataset "Chinese Stroke Clinical Records" (CSCR) from EHRs provided by our partner hospital, based on a stroke ontology that defines semantically related entities for stroke assessment. We then pre-train a Chinese clinical LLM coined "CliRoberta" through domain-adaptive transfer learning and construct a deep learning-based CNER model that can accurately extract entities directly from Chinese EHRs. Finally, an automated, end-to-end NIHSS scoring pipeline is proposed by mapping the extracted entities to relevant NIHSS items and values, to quantitatively assess the stroke severity. RESULTS: Results obtained on a benchmark dataset CCKS2019 and our newly created CSCR dataset demonstrate the superior performance of our domain-adaptive pre-trained LLM and the CNER model, compared with the existing benchmark LLMs and CNER models. The high F1 score of 0.990 ensures the reliability of our model in accurately extracting the entities for the subsequent automatic NIHSS scoring. Subsequently, our automated, end-to-end NIHSS scoring approach achieved excellent inter-rater agreement (0.823) and intraclass consistency (0.986) with the ground truth and significantly reduced the processing time from minutes to a few seconds. CONCLUSION: Our proposed automatic and quantitative framework for assessing stroke severity demonstrates exceptional performance and reliability through directly scoring the NIHSS from diagnostic notes in Chinese clinical EHRs. Moreover, this study also contributes a new clinical dataset, a pre-trained clinical LLM, and an effective deep learning-based CNER model. The deployment of these advanced algorithms can improve the accuracy and efficiency of clinical assessment, and help improve the quality, affordability and productivity of healthcare services.

Unveiling the negative association of Faecalibacterium prausnitzii with ischemic stroke severity, impaired prognosis and pro-inflammatory markers.

Background: The correlation between acute ischemic stroke (AIS) and gut microbiota has opened a promising avenue for improving stroke prognosis through the utilization of specific gut bacterial species. This study aimed to identify gut bacterial species in AIS patients and their correlation with stroke severity, 3-month prognosis, and inflammatory markers. Methods: We enrolled 59 AIS patients (from June 2021 to July 2022) and 31 age-matched controls with similar cerebrovascular risk profiles but no stroke history. Fecal samples were analyzed using 16 S rDNA V3-V4 sequencing to assess α and ß diversity and identify significant microbiota differences. AIS cases were categorized based on the National Institute of Health Stroke Scale (NIHSS) scores and 3-month modified Rankin Scale (mRS) scores. Subgroup analyses were performed, and correlation analysis was used to examine associations between flora abundance, inflammatory markers and stroke outcome. Results: Significant differences in ß-diversity were observed between case and control groups (P < 0.01). Bacteroides dominated AIS samples, while Clostridia, Lachnospirales, Lachnospiraceae, Ruminococcaceae, Faecalibacterium, and Faecalibacterium prausnitzii were prominent in controls. Faecalibacterium and Faecalibacterium prausnitzii were significantly reduced in non-minor stroke and 3-month poor prognosis groups compared to controls, while this difference was less pronounced in patients with minor stroke and 3-month good prognosis. Both Faecalibacterium and Faecalibacterium prausnitzii were negatively correlated with the NIHSS score on admission (r = -0.48, -0.48, P < 0.01) and 3-month mRS score (r = -0.48, -0.44, P < 0.01). Additionally, they showed negative correlations with pro-inflammatory factors and positive correlations with anti-inflammatory factors (both P < 0.01). Conclusions: Faecalibacterium prausnitzii is negatively associated with stroke severity, impaired prognosis, and pro-inflammatory markers, highlighting its potential application in AIS treatments.

Clinical Benefits of Oral Anticoagulants for Elderly Patients With Cardioembolic Stroke at High Bleeding Risk.

BACKGROUND/AIM: The relationship between the severity of cardioembolic stroke (CES) and oral anticoagulant (OAC) treatment before stroke onset in very elderly (≥80 years) patients with nonvalvular atrial fibrillation (NVAF) at high bleeding risk remains unknown. PATIENTS AND METHODS: A total of 364 consecutive patients (≥80 years) with CES and NVAF within 48 h following stroke onset were investigated. High bleeding risk was defined as follows: Bleeding history, renal dysfunction (creatinine clearance <30 ml/min), low body weight (≤45 kg), and antiplatelet or nonsteroidal anti-inflammatory drug use. Patients were divided into two groups: High bleeding risk (n=214) and non-high bleeding risk (n=150). We assessed stroke severity and functional outcome between the two groups, and evaluated the effect of therapy with direct OAC (DOAC) on stroke severity in the high-risk group. RESULTS: The high-risk group had a worse modified Rankin Scale (mRS) at discharge than the non-high-risk group [median: 4 (range=2-5) vs. 3 (range=1-4); p=0.02]. Patients in the high-risk group were categorized according to OAC treatment before stroke onset: No OAC (n=148), warfarin (n=46), and DOAC (n=20). The numbers of patients with National Institutes of Health Stroke Scale score (NIHSS) ≥8 on admission in these groups were 104 (70%), 30 (65%), and 8 (40%) (p=0.03), respectively. Multivariate analysis confirmed that DOAC therapy had a lower odds ratio (OR) for severe stroke (NIHSS ≥8) on admission (OR relative to no OAC=0.22, 95% confidence interval=0.08-0.62; p=0.005) and poor functional outcome (mRS ≥4) at discharge (OR=0.31, 95% confidence interval=0.11-0.90; p=0.03). CONCLUSION: Very elderly patients with CES at high bleeding risk have unfavorable functional outcomes. DOAC administration may be associated with reduced stroke severity.

High brain natriuretic peptide level is associated with severe stroke in patients taking oral anticoagulants: A sub-analysis of the PASTA registry study.

BACKGROUND: Brain natriuretic peptides (BNP) are an important diagnostic and prognostic marker in patients with heart failure. However, the relationship between BNP levels and stroke severity in patients with atrial fibrillation (AF) remains unelucidated. In this study, we aimed to investigate the association between stroke severity at admission and BNP levels. METHODS: In this prospective observational study, we used data from 513 patients with AF and acute ischemic stroke treated with oral anticoagulants (OAC) registered in the Multicenter Prospective Analysis of Stroke Patients Taking Oral Anticoagulants study. The patients were divided into two groups: high-BNP (≥200 pg/mL) and low-BNP level (<200 pg/mL) groups. We compared the clinical characteristics between the two groups and determined the effect of BNP levels on stroke severity on admission. RESULTS: Among the 513 enrolled patients, 248 (females, n = 30; median age, 82 years) and 265 (females, n = 76; median age, 71 years) were assigned to the high- and low-BNP level groups, respectively. The high-BNP level group had a higher proportion of patients with severe stroke (National Institutes of Health Stroke Scale score, ≥10) on admission (49.2% vs. 32.8%, p = 0.002) and major vessel occlusion (57.5% vs. 39.2%, p < 0.0001) than that had by the low-BNP level group. Multivariate analysis showed that high BNP level was independently associated with severe stroke on admission (odds ratio 1.07, 95% confidence interval 1.00-1.15; p = 0.0478). CONCLUSIONS: High BNP level compared with low BNP level was associated with severe stroke and major vessel occlusion, even before OAC treatment.

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.

Scaling behaviours of deep learning and linear algorithms for the prediction of stroke severity.

Deep learning has allowed for remarkable progress in many medical scenarios. Deep learning prediction models often require 105-107 examples. It is currently unknown whether deep learning can also enhance predictions of symptoms post-stroke in real-world samples of stroke patients that are often several magnitudes smaller. Such stroke outcome predictions however could be particularly instrumental in guiding acute clinical and rehabilitation care decisions. We here compared the capacities of classically used linear and novel deep learning algorithms in their prediction of stroke severity. Our analyses relied on a total of 1430 patients assembled from the MRI-Genetics Interface Exploration collaboration and a Massachusetts General Hospital-based study. The outcome of interest was National Institutes of Health Stroke Scale-based stroke severity in the acute phase after ischaemic stroke onset, which we predict by means of MRI-derived lesion location. We automatically derived lesion segmentations from diffusion-weighted clinical MRI scans, performed spatial normalization and included a principal component analysis step, retaining 95% of the variance of the original data. We then repeatedly separated a train, validation and test set to investigate the effects of sample size; we subsampled the train set to 100, 300 and 900 and trained the algorithms to predict the stroke severity score for each sample size with regularized linear regression and an eight-layered neural network. We selected hyperparameters on the validation set. We evaluated model performance based on the explained variance (R2) in the test set. While linear regression performed significantly better for a sample size of 100 patients, deep learning started to significantly outperform linear regression when trained on 900 patients. Average prediction performance improved by ∼20% when increasing the sample size 9× [maximum for 100 patients: 0.279 ± 0.005 (R2, 95% confidence interval), 900 patients: 0.337 ± 0.006]. In summary, for sample sizes of 900 patients, deep learning showed a higher prediction performance than typically employed linear methods. These findings suggest the existence of non-linear relationships between lesion location and stroke severity that can be utilized for an improved prediction performance for larger sample sizes.

Baseline neurologic deficit and efficacy of remote ischemic conditioning after acute ischemic stroke: A post hoc analysis of RICAMIS.

RICAMIS (ClinicalTrials.gov Identifier: NCT03740971) trial has demonstrated efficacy of remote ischemic conditioning (RIC) in acute ischemic stroke, but whether baseline NIHSS score can affect outcomes in stroke remains unclear. We conducted a post hoc analysis of RICAMIS to investigate the issue. Patients included in RICAMIS were divided into three groups based on baseline NIHSS score. The primary outcome was excellent functional outcome at 90 days, defined as mRS score of 0-1. Compared with patients receiving usual care, we investigated association of RIC effect with outcomes in each group and interaction between RIC effect and stroke severity. Among 1776 patients, 1255 were assigned into NIHSS score 6-8 group, 402 into NIHSS score 9-12 group, and 119 into NIHSS score 13-16 group. A higher proportion of primary outcome was found associated with RIC in NIHSS score 9-12 group (adjusted risk difference [RD], 14.6 â€‹%; 95 â€‹% CI, 5.0 â€‹%-24.2 â€‹%; P â€‹= â€‹0.003), but no significant association was found in NIHSS score 6-8 group (adjusted RD, 2.3 â€‹%; 95 â€‹% CI, -2.5 â€‹%-7.2 â€‹%; P â€‹= â€‹0.34), or in NIHSS score 13-16 group (adjusted RD, 9.7 â€‹%; 95 â€‹% CI, -7.5 â€‹%-26.9 â€‹%; P â€‹= â€‹0.27). There was a significant interaction between RIC effect and stroke severity when analysis was performed between NIHSS score 6-8 and 9-12 groups (P â€‹= â€‹0.04), but not between NIHSS score 9-12 and 13-16 groups (P â€‹= â€‹0.57). Current study firstly reported patients with NIHSS score 9-12 may get more benefit from RIC after stroke with respect to excellent functional outcome at 90 days.

Association between Rapid Ventricular Response and Stroke Outcomes in Atrial Fibrillation-Related Cardiac Embolic Stroke.

INTRODUCTION: Patients with atrial fibrillation-related stroke (AF-stroke) are prone to developing rapid ventricular response (RVR). We investigated whether RVR is associated with initial stroke severity, early neurological deterioration (END) and poor outcome at 3 months. METHODS: We reviewed patients who had AF-stroke between January 2017 and March 2022. RVR was defined as having heart rate >100 beats per minute on initial electrocardiogram. Neurological deficit was evaluated with National Institutes of Health Stroke Scale (NIHSS) score at admission. END was defined as increase of ≥2 in total NIHSS score or ≥1 in motor NIHSS score within first 72 h. Functional outcome was score on modified Rankin Scale at 3 months. Mediation analysis was performed to examine potential causal chain in which initial stroke severity may mediate relationship between RVR and functional outcome. RESULTS: We studied 568 AF-stroke patients, among whom 86 (15.1%) had RVR. Patients with RVR had higher initial NIHSS score (p < 0.001) and poor outcome at 3 months (p = 0.004) than those without RVR. The presence of RVR [adjusted odds ratio (aOR) = 2.13; p = 0.013] was associated with initial stroke severity, but not with END and functional outcome. Otherwise, initial stroke severity [aOR = 1.27; p = <0.001] was significantly associated with functional outcome. Initial stroke severity as a mediator explained 58% of relationship between RVR and poor outcome at 3 months. CONCLUSION: In patients with AF-stroke, RVR was independently associated with initial stroke severity but not with END and functional outcome. Initial stroke severity mediated considerable proportion of association between RVR and functional outcome.

Effects of preceding antiplatelet agents on severity of ischemic stroke in patients with a history of stroke.

INTRODUCTION: Antiplatelet agents are effective for secondary prevention of ischemic stroke and can reduce the severity of first-ever ischemic stroke. However, it is uncertain if prophylactic antiplatelet therapy reduces the severity of recurrent ischemic stroke. The aim of this study was to determine the effect of preceding antiplatelet treatment on the severity of thrombotic stroke (TS) in patients with a prior history of stroke. METHODS: From a prospective hospital registry of 1338 consecutive patients with acute ischemic stroke, we identified patients with a prior history of stroke who were admitted for cardioembolic stroke (CE); TS including large-artery atherosclerosis, small vessel occlusion, and branch atheromatous disease; or other cause or cryptogenic stroke (OCS). Cases in each subtype were categorized based on preceding medication: antiplatelet agents (AP) and none (N). Severity of stroke (National Institutes of Health Stroke Scale: NIHSS) on admission was compared between AP and N cases. RESULTS: The total cohort of 252 patients included 83 with CE, 102 with TS, and 67 with OCS. After excluding those with prior anticoagulants, the median NIHSS on admission was lower in AP cases than in N cases (3 vs. 5, p = 0.002). In multivariate analysis, preceding AP treatment was independently associated with minor stroke (NIHSS ≤4) on admission in CE group (OR 8.48, 95% CI 1.71-62.9, p = 0.008) and TS group (OR 4.24, 95% CI 1.44-13.4, p = 0.009). CONCLUSION: Preceding antiplatelet treatment in patients with a prior history of stroke may reduce the severity of subsequent thrombotic and cardiogenic stroke.

RELATIONSHIP OF MEAN PLATELET VOLUME TO SEVERITY AND SHORT-TERM OUTCOME OF ACUTE ISCHEMIC STROKE.

Introduction: Despite the considerable number of clinical studies conducted, questions on the importance of the determinants of outcome after ischaemic stroke still exits. Methodology: Eighty consenting acute ischaemic stroke patients presenting to the emergency unit of Federal Teaching Hospital Gombe, along with 80 age and sex-matched controls were recruited. All the subjects were examined after relevant clinical history and stroke severity was determined using the NIHSS score. A brain imaging computed tomography or magnetic resonance imaging (CT/MRI) was performed for each patient and the stroke outcome of each patient was documented at the end of 30 days. MPV was assayed using the Sysmex KX-21N automated haematology analyser. Result: The mean age of patients 59.74±14.44 years was similar to the mean age of controls 59.80±14.08 years; P=0.947. The gender distribution between the two groups was also similar (p=0.436). Systemic hypertension was the most common modifiable risk factor for stroke accounting for 58.8%. The MPV of stroke patients 10.51 ± 0.88fl was significantly higher than that of controls 9.86±0.88fl p=0.0001 with a reference interval of 9.10-10.62fl using controls. Patients with MPV ≥10.62fl were categorized as high MPV range. The majority of patients in the high MPV category had significantly severe stroke with NIHSS score >16 p=0.001. No significant relationship was observed between the high MPV category and functional outcome based on mRS category p=0.101, The effect of MPV in the prediction of mortality remained significant (OR: 4.58, P= 0.012) in the multivariate regression model after controlling for other factors associated with mortality in acute ischemic stroke. A significant relationship was observed between MPV and infarct volume on the ROC curve and the area under the curve was 0.684 and an MPV value of 9.85fl was determined at 90% sensitivity and specificity of 50%. Conclusion: The study shows that MPV is associated with stroke severity and can be used as a marker to predict mortality in acute ischaemic stroke.

Fibrosis-4 index is closely associated with clinical outcomes in acute cardioembolic stroke patients with nonvalvular atrial fibrillation.

Liver cirrhosis is a confirmed risk factor for poor prognosis of stroke; however, the contribution of clinically inapparent liver fibrosis to cardioembolic stroke (CES) and its outcomes are poorly understood. This study aimed to investigate the associations between liver fibrosis-measured by the Fibrosis-4 (FIB-4) score-and stroke severity and short-term clinical outcomes of patients with acute CES due to nonvalvular atrial fibrillation (NVAF). A total of 522 patients were followed for a median of 90 days. We calculated the FIB-4 score and defined liver fibrosis as follows: likely advanced fibrosis (FIB-4 > 3.25), indeterminate advanced fibrosis (FIB-4, 1.45-3.25), and unlikely advanced fibrosis (FIB-4 < 1.45). Logistic regression analysis and Cox regression analysis were used to investigate the relations between the FIB-4 score and stroke severity, major disability at discharge, and all-cause mortality. Among these 522 acute CES patients with NVAF, the mean FIB-4 score (2.28) on admission reflected intermediate fibrosis, whereas liver enzymes were largely normal. In multivariate regression analysis, patients with advanced liver fibrosis were more likely to have a higher risk of severe stroke (OR = 2.21, 95% CI 1.04-3.54), major disability at discharge (OR = 4.59, 95% CI 1.88-11.18), and all-cause mortality (HR = 1.25, 95% CI 1.10-1.56) than their counterparts. Regarding sex, these associations were stronger in males but not significant in females. In patients with acute CES due to NVAF, advanced liver fibrosis is associated with severe stroke, major disability, and all-cause death. Our findings indicate that early screening and management of liver fibrosis may decrease stroke severity and risk of death in patients with NVAF, especially for male patients. Consequently, FIB-4 > 3.25 of male patients should receive ultrasound elastography to further determine the degree of liver fibrosis.