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 1st and 4th 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.
Background: High-intensity gait training (HIGT) has emerged as a promising intervention to improve walking outcomes post-stroke. This quality improvement project aimed to increase the intensity of gait training for patients post-stroke in inpatient rehabilitation and evaluate HIGT's effects on functional mobility and discharge outcomes.
Methods: Eighty-four patients post-stroke admitted to inpatient rehabilitation (2019-2021) were divided into HIGT (n = 32) and standard of care (SoC; n = 52) groups. Baseline characteristics were compared using t-tests or χ2 tests. Linear mixed-effects models evaluated changes in Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) (total and item-level) and secondary outcomes (6-min walk test (6 MWT), 10-Meter Walk Test (10 MWT), berg balance scale (BBS), Functional Gait Assessment, Five Times Sit to Stand Test, and Activities-Specific Balance Confidence Scale). Logistic regression examined predictors of discharge destination.
Results: Groups were similar at baseline except for length of stay, which was longer for HIGT (16.6 vs. 11.1 days; p < 0.01). IRF-PAI Mobility improved significantly across all patients (p < 0.001), with a significant time × group interaction (p = 0.035) favoring HIGT. Item-level differences favored HIGT for "Chair/Bed-to-Chair Transfer" (p = 0.007), "Sit to Stand" (p = 0.005), and "Walk 10 Feet" (p = 0.008). Secondary outcomes improved within groups (p < 0.05) but did not differ significantly between groups. HIGT participants were more likely to discharge home (adjusted OR = 8.0, 95% CI [2.26-39.1], p = 0.003).
Conclusion: Patients receiving HIGT demonstrated greater functional mobility gains and were more likely to discharge home than those receiving standard care. HIGT may enhance post-stroke recovery and support independent living. Further research should assess fidelity, long-term outcomes, and broader implementation.
Background: Stroke remains the second leading cause of disability and death worldwide, with hypertension as its principal risk factor. Evidence from high-income countries indicates that blood pressure variability (BPV) is an independent predictor of outcomes during the acute phase, but data from African populations are limited despite the rising burden of cardiovascular disease. Understanding BPV patterns in this context is crucial for designing interventions to improve stroke outcomes.
Objectives: To determine 24-h BPV patterns in acute stroke patients and assess their impact on 30-day functional outcomes.
Methods: This multicenter prospective cohort study enrolled adults with acute stroke presenting within 72 h of symptom onset at two tertiary hospitals in Dar es Salaam. BPV patterns were measured using 24-h ambulatory monitoring, and demographic, clinical, and stroke subtype data were collected. Functional outcomes were evaluated using the modified Rankin Scale (mRS) and Barthel Index at admission, day 7, and day 30. Associations were examined using logistic regression.
Results: Of 52 patients enrolled, 48 (92.3%) completed follow-up. Most were male (n = 31; 64.6%), middle-aged (47-60 years, n = 19; 39.6%), and hypertensive (n = 43; 91.5%). Hemorrhagic strokes (n = 27; 56.3%) demonstrated higher systolic and diastolic BP variability than ischemic strokes, though differences were not statistically significant. Impaired nocturnal dipping (day/night systolic BP ratio) was linked to poor outcomes in univariate analysis (p = 0.019) but lost significance in multivariate testing (p = 0.16). Functional outcomes improved significantly by day 30: the Barthel Index increased, and mRS scores decreased. NIHSS score at day 7 emerged as the strongest independent predictor of poor outcome (mRS: p = 0.027, OR = 3.04, 95% CI: 1.13-8.15). Higher education level was also associated with better functional outcomes (p = 0.03).
Conclusion: In this Tanzanian cohort, reduced nocturnal dipping and elevated morning pressures were the most frequent BPV patterns, especially in hemorrhagic strokes, though not independently associated with outcomes at 30 days. Neurological severity at day 7 (NIHSS) was the strongest predictor of recovery, and lower education levels negatively influenced outcomes. The Barthel Index was more sensitive than the mRS in detecting functional gains.
Background: Etiologic subtyping of ischemic stroke is crucial for determining its treatment, prognosis, and prevention. However, data on the widely utilized TOAST and ASCOD criteria remain scarce in the East African region.
Aims: The study aimed to compare the performance of the TOAST and ASCOD systems in subtyping ischemic stroke among stroke patients at a tertiary hospital in Tanzania.
Methods: This was an institutional cross-sectional study. All adults (≥18 years) admitted with a diagnosis of stroke over a six-year period were selected from the registry, and their clinical details reviewed retrospectively. One hundred and thirty (130) patients with first- or second-time acute stroke (as defined by the World Health Organization) were included. Acute stroke was confirmed as ischemic by magnetic resonance imaging. For each index stroke, TOAST and ASCOD criteria were applied. The discordance and level of agreement between the approaches were assessed using McNemar's test χ2 (P-value) and Cohen's kappa coefficient (κ), respectively. The value of κ was interpreted as moderate (0.41-0.6), good (0.61-0.8), very good (0.81-0.9), or excellent (0.91-1.0). Statistical significance was set at P < 0.05.
Results: There was no significant discordance between TOAST and the grade 1 level of evidence of ASCOD (ASCOD1) in assigning stroke to all subtypes, except for undetermined etiology χ2 (P = 0.023). Agreement between these systems was good to very good (κ = 0.601 to 0.843, P < 0.01) across the subtypes. TOAST and ASCOD1 failed to determine a definitive etiology in 34.6% and 48.5% of strokes, respectively. On comparing TOAST vs. combined grade of evidence 1 and 2 of ASCOD (ASCOD1,2), there was a discordance in allocation of strokes to the cardioembolic subtype χ2 (P < 0.001), and agreement was moderate (κ = 0.471, P = 0.001). However, the agreement across other identified subtypes was good to very good (κ = 0.601 to 0.875, P ≤ 0.001).
Conclusion: There was a good to very good agreement between TOAST and ASCOD1 in etiologic subtyping of ischemic stroke. Further research is warranted to evaluate their consistency across diverse local settings and to explore factors influencing their performance.
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