Frontiers in stroke最新文献

Background: Stroke-related impairments present in wide-ranging combinations, including cognitive and upper extremity (UE) sensorimotor deficits, complicating an understanding of their relationship with the anatomy of injury. Here, we hypothesized that deficits in UE sensorimotor function, mood, and cognition would be associated with distinct patterns of neural injury, and we explored whether complex outcome measures that make both cognitive and motor demands are more vulnerable to injury-related disconnection after stroke.

Methods: Subject testing included elementary sensorimotor behaviors (shoulder and finger strength [SAFE], Fugl-Meyer Assessment [FMUE], and wrist proprioception [WPST]), complex behaviors that require substantial motor and cognitive control (Box and Blocks Test [BBT] and Trail Making Test-A [TMT-A]), cognition (Montreal Cognitive Assessment [MoCA]), and mood (Geriatric Depression Scale). Infarcts were outlined on clinical scans and used to compute lesion volume, injury to the corticospinal tract (CST) as well as thalamocortical sensory tract, and measures of structural network disconnection. Associations between lesions and behavior were examined using three methods: [1] voxel-lesion-symptom mapping (VLSM) to identify lesioned voxels associated with behavioral deficits; [2] correlation, to identify bivariate relationships between neuroimaging and behavioral measures; and [3] LASSO regression to identify the most behaviorally relevant variables among neuroimaging and clinical measures.

Results: Stroke patients (n = 55, mean age 69.2, 42% females) had lesion volumes ranging from 0.1 to 354.9 (mean 30.9) ml and averaged 10.4 ± 4.9 days post-stroke. Deficits in all three elementary UE sensorimotor behaviors (SAFE, WPST, FMUE) correlated with extent of injury to CST not disconnection measures, with VLSM largely consistent, while deficits in complex motor and cognitive behaviors (BBT and TMT-A) were related to widespread structural disconnection between brain networks. LASSO models that consider all neuroimaging and clinical measures revealed complex patterns of disconnections across behaviors.

Conclusion: These findings indicate that elementary UE sensorimotor behaviors are related to the integrity of regional sensorimotor system structures, but that more complex motor and cognitive behaviors are more related to intact structural connectivity between multiple brain networks.

Introduction: Undetected atrial fibrillation (AF) increases the risk of recurrent ischaemic stroke, but current prediction scores do not incorporate heart rate variability (HRV) measures readily available from 24-h Holter ECGs.

Methods: In 697 patients with non-AF ischaemic stroke or non-AF high-risk transient ischaemic attack (TIA) from the STROKE-CARD Registry (NCT04582825), we assessed eight time-domain HRV parameters for predicting incident AF within 1 year. ROC analyses, logistic regression, and the Youden index were used to identify optimal cut-offs and compare HRV performance with Brown-ESUS AF and AS5F scores.

Results: New-onset AF was detected in 28 patients (4.0%). PNN50, rMSSD, and SDSD showed the best discrimination (AUC = 0.711, 0.766, and 0.775), outperforming both clinical scores (AUC ≤ 0.612). Optimal cut-offs were 5.5% (PNN50), 48.5 ms (rMSSD), and 43.5 ms (SDSD). Dichotomized analyses confirmed strong associations with AF (ORs 5.34-7.70, all p < 0.001), and adding HRV parameters significantly improved prediction beyond existing scores.

Conclusions: PNN50, rMSSD, and SDSD from routine Holter ECGs enhance AF risk prediction after non-cardioembolic stroke or high-risk TIA and may support targeted monitoring strategies.

Background: Delirium is a frequent complication of acute ischemic stroke associated with poor outcome. The complex interplay with post-stroke infections remains to be elucidated. Our study aimed to investigate whether post-stroke delirium (PSD) was a predictor of prolonged hospital stay, poor functional outcome, and mortality after acute ischemic stroke, independent of the development of post-stroke pneumonia (PSP) and post-stroke urinary tract infections (PSU).

Methods: In a previously published dataset of 514 patients with acute ischemic stroke, 201 patients (39%) developed delirium within the first week after stroke onset using a chart review method based on the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition criteria. Fifteen percent developed PSP and 22% PSU, using the modified criteria of the US Centers for Disease Control and Prevention. Logistic regression analyses were used to identify predictors of prolonged hospital stay (>median 9 days), poor functional outcome (modified Rankin Scale >2), and mortality at 3 months after stroke onset.

Results: Multiple logistic regression analysis showed that PSD was a predictor of prolonged hospital stay [odds ratio (OR): 4.085, 95% confidence interval (CI): 2.445-6.824] and poor functional outcome [OR: 3.362, 95% CI: 1.851-6.107) at 3 months after stroke onset, even after adjustment for age, premorbid disability, National Institutes of Health Stroke Scale on admission, PSP, and PSU. PSD was no predictor of mortality after stroke.

Conclusion: PSD is a predictor of prolonged hospital stay and poor functional outcome at 3 months after ischemic stroke, independent of PSP and PSU.

Background/objective: Most pediatric stroke survivors suffer long-term impairments. To minimize injury, it is essential to quickly restore perfusion to viable brain tissue. Minimizing the time to stroke diagnosis requires recognition of a possible stroke by prehospital and emergency healthcare personnel, and rapid neuroimaging. While CT suffices for diagnosing hemorrhagic stroke, MRI is necessary to diagnose acute ischemic stroke (IS), contributing to significant diagnostic delays and potentially missed opportunities for intervention.

Methods: We conducted a retrospective study of children 1-14 years old with acute neurological symptoms presenting by Emergency Medical Services (EMS) to the study institution from 1/2019-6/2023. We described patient characteristics and neuroimaging studies, then evaluated predictors of MRI acquisition and actionable findings, including stroke. To assess the generalizability of these data we analyzed a secondary retrospective cohort of all children admitted during this period with out-of-hospital strokes regardless of presentation modality [EMS, emergency department (ED) walk-in, and transfer].

Results: Among 3,888 pediatric patients with acute neurological symptoms presenting via EMS, 695 (17.9%) had neuroimaging: CT only in 570 patients (14.7%); CT and MRI in 125 (3.2%). Median (IQR) times from EMS activation to neuroimaging were 2.29 (1.56, 3.21) hours for CT and 26.8 (16.3, 43.8) hours for MRI. An EMS primary impression of "stroke" was rare (n = 13) but strongly predictive of imaging acquisition: all had CT and 11 had MRI. Thirty-one of the 125 patients with MRI had actionable MRIs, including nine acute strokes. During the study period another 14 stroke patients presented as ED walk-ins. Median time from ED arrival to CT was 0.92 (0.47, 1.08) hours for EMS patients with hemorrhagic stroke and 5.69 (1.50, 9.76) hours for walk-ins; for MRI, median time was 4.15 (3.00, 5.31) hours for EMS patients with ischemic stroke and 10.2 (1.99, 36.3) hours for walk-ins.

Conclusion: Among children with acute neurological symptoms selected for neuroimaging, CT was the most common modality while MRIs were performed with a substantial time delay. While EMS providers rarely suspected stroke, their diagnosis impacted imaging decisions in the ED, suggesting a need to raise awareness among prehospital providers. To measure quality improvement in pediatric stroke, new pediatric-specific metrics like "door to diagnosis" time, should be further explored.

Introduction: Although stroke is recognized as a chronic condition, estimates of different long-term outcomes after stroke are lacking in Africa. This study aimed to explore the profile, trajectory and determinants of long-term outcomes up to 4 years in a cohort of African stroke survivors.

Method: The data analyzed were collected in a longitudinal study of stroke survivors who were prospectively recruited into the CogFAST-Nigeria Study from two specialist hospitals in Nigeria. Subjects with subarachnoid hemorrhage, co-morbid psychiatric or neurologic illness, or any systemic disease that could impair cognition were excluded from the study. Cognition was assessed using the Vascular Neuropsychological Battery, depression with the Geriatric Depression Scale-short form, and functional performance with the Barthel Index. Weibull survival model, generalized estimating equation and linear mixed models were used to identify the predictors of mortality, cognitive impairment, functional performance, and caregiver burden respectively.

Result: Of the 253 stroke survivors that were recruited into the study, 157 (59.7%) were males while the overall mean age was 60.2 ± 9.8 years.The proportions of those with cognitive impairment were 126/251 (50.2%) at 3 months after stroke, 69/160 (43.1%), and 12/36 (33.3%) at 1^st and 4^th year respectively, while the proportion of those with depression was 39.3% at 3 months post-stroke, 35.2%, and 36.1% at year 1 and 4 respectively. Cumulative Mortality increased from 13.8% (95% CI = 10.08-18.63) at 9 months post-stroke to 45.3% (95% CI = 39.42-51.6) at 4 years follow-up. The only factor associated with mortality after adjusting for ethnicity was working as an artisan (aHR = 2.22; 95% CI = 1.77-4.02). History of previous stroke increased the likelihood of functional dependency (OR = 2.17; 95% CI = 1.19-3.95). Meanwhile, higher education (OR = 0.05; 95% CI = 0.02-0.16) protected against cognitive impairment while previous stroke (OR = 2.17; 95% CI = 1.19-3.95;) and higher caregiver burden (OR = 1.02; 95% CI = 1.01-1.02) were associated with increased risk.

Conclusion: Improving stroke treatment and rehabilitation is crucial, especially for those with prior stroke, as it strongly predicts poor functional and cognitive outcomes.

Introduction: Cerebral sinovenous thrombosis (CSVT) in neonates with acute kidney injury (AKI) is a rare neurologic condition with potential serious consequences. Rapid diagnosis is key to good outcomes. This study aims to identify challenges in acute care and to evaluate outcomes of these patients in a resource-limited setting.

Materials and methods: This retrospective cohort study included term neonates with AKI and CSVT admitted at a tertiary center in Western India (January 2021-January 2023). Clinical profile, timing of consult with healthcare providers, diagnosis, neuroimaging, management strategies, and outcomes at discharge and at age 2 years were analyzed.

Results: A total of 31 neonates (19 male) with mean age 18.5 ± 6.6 days at diagnosis were included. Dehydration was the most common risk factor in 80.6%, while seizures were the most common clinical presentation (80.6% patients). Almost 84% of patients had thrombosis in multiple sinuses. Venous infarcts were identified in 20 (64.5%) patients, with concomitant hemorrhage in 13 (42%). Only 10 patients received anticoagulation therapy. Median time from symptom onset to consult in first healthcare facility was 48 h [interquartile range (IQR): 44-72 h]. Eighteen patients (58.06%) were subsequently referred to a second facility after a median stay of 48 h (IQR: 28-72 h). At the secondary or tertiary referral center, diagnostic neuroimaging was performed after a median of 48 h (IQR: 36-108 h). Anticoagulation was initiated within a median of 2 h (IQR: 2-2.75 h) following the diagnosis of CSVT. Although all patients survived, 32% had neurologic sequelae at discharge which persisted at the 2-year follow-up. Complete vessel recanalization on follow-up neuroimaging was achieved in all anticoagulated patients, compared with 66.7% of those who were not anticoagulated. However, statistical analysis showed no significant association between anticoagulation therapy and either clinical outcome or vessel recanalization.

Conclusion: Neonatal CSVT associated with AKI can lead to persistent neurologic deficits at 2 years. Timely diagnosis and management remain a significant challenge in resource-limited settings due to delays both before and during hospitalization. Although anticoagulation treatment was not associated with outcomes in our cohort, further research is needed to develop acute care guidelines, applicable across diverse clinical settings, particularly in resource-limited situations.

Objectives: Stroke remains a leading cause of death and disability worldwide. While functional outcome predictors are well established in acute rehabilitation settings, less is known in community hospitals, which typically manage stroke patients with moderate or isolated impairments. This study aimed to identify predictors of short-term functional improvement in stroke survivors admitted to community hospitals in Singapore.

Design: Prospective cohort study.

Setting and participants: The study included 216 stroke survivors admitted to Outram and Sengkang Community Hospitals for inpatient rehabilitation.

Methods: Functional status was measured using the Modified Barthel Index (MBI) on admission and discharge. Data on depressive symptoms (PHQ-2), resilience (CD-RISC-10), comorbidities, stroke severity (NIHSS), time to rehabilitation initiation, and sociodemographics were collected. Logistic regression identified predictors of significant functional improvement, defined as at least a one-level increase in MBI.

Results: Participants' mean age was 71.20 years; most were male (59.30%), Chinese (82.00%), unemployed (58.80%), and living with family (86.50%). Functional improvement was more likely among those who were premorbidly independent (65.70%), had mild depressive symptoms (PHQ-2 ≤ 2; 63.70%), experienced mild strokes (NIHSS ≤ 4; 43.10%), or started rehabilitation within 1 day of onset (33.80%). Older age (p = 0.02) and shorter time to rehabilitation (p = 0.03) independently predicted functional improvement.

Conclusion and implications: Older age and early rehabilitation were significantly associated with greater short-term functional gains in community hospital stroke survivors, underscoring the importance of timely rehabilitation to optimize recovery after stroke, even for older adults.

Atrial fibrillation (AF) is the most common cardiac arrhythmia and a major cause of ischemic stroke. Between 91% and 100% of cardiogenic thrombi are in the left atrial appendage (LAA), and the morphology of the LAA is closely associated with the formation of LAA thrombus (LAAT). This review provides a detailed discussion of the anatomy of the LAA, the epidemiology, and the diagnosis of LAAT. It focuses on analyzing the role of LAA morphology in blood stasis, morphological abnormality, and hypercoagulable states. Accurate evaluation of the morphology of the LAA can assist with risk stratification in patients with AF. The commonly used LAA morphological evaluation indicators must be more comprehensive and objective. Recently, new imaging protocols allow for LA morphological remodeling and fibrosis assessment, which has been demonstrated to correlate with assessing the individual's risks of thromboembolic events and practical imaging of patients with LAAT.

Background: Apolipoprotein E (ApoE) and monocyte chemoattractant protein-1 (MCP-1) are inflammatory markers associated with premature atherosclerosis, which leads to increased cardiovascular disease risk among people with HIV (PWH). We aimed to evaluate the association between the plasma levels of these inflammatory markers and ischemic stroke in young PWH.

Methods: We conducted a prospective case-control study at the University Teaching Hospital in Lusaka, Zambia, between March 2022 and October 2024, comparing young PWH with non-cardioembolic ischemic stroke (cases) to age- and sex-matched PWH without a history of stroke (controls). Standardized data collection instruments were used to collect information on other known risk factors for stroke, including demographic, clinical, laboratory, and imaging parameters. ELISA was done to measure ApoE and MCP-1 levels in the plasma of individuals in both the case and control groups.

Results: We analyzed results for 50 cases and 50 controls. Compared to controls, cases were more likely to have (1) traditional stroke risk factors such as hypertension (42 vs. 2%, p = 0.001); (2) more poorly controlled HIV, including lower CD4 counts [259 (165-520) cells/μl vs. 452 (380-553) cells/μl, p = 0.030)] and higher viral loads [0 (0-4,217) copies/ml vs. 0 (0-1,578) copies/ml, p = 0.007]; (3) markers of atherosclerotic disease, including increased pulse wave velocity (PWV) [10.89 (9.99-12.15) m/s vs. 9.01 (7.989.67) m/s, p < 0.001] and carotid intima-media thickness (cIMT) [0.79 (0.70-0.99) mm vs. 0.63 (0.57-0.67) mm, p < 0.001]. Cases had lower plasma ApoE levels [1.20 (0.78-1.41) ng/ml vs. 1.55 (1.23-1.81) ng/ml, p = 0.001], but not statistically different MCP-1 plasma levels [622 (417-886) pg/ml vs. 594 (394-1,024) pg/ml, p = 0.772] compared to controls. Lower ApoE levels (aOR 0.13, 95% CI 0.03-0.68, p = 0.015), abnormal cIMT ≥0.70 mm (aOR 2.72, 95% CI 1.08-6.85, p = 0.033), and alcohol use (aOR 1,078, 95% CI 4-267,933, p = 0.013) were independently associated with ischemic stroke in multivariable analysis.

Conclusion: The results suggest that lower plasma ApoE levels are independently associated with non-cardioembolic ischemic stroke in young PWH. Additional studies with larger sample sizes are needed to further explore the contribution of these inflammatory markers in young-onset HIV-associated stroke.