Diagnosis and Management of Acute Ischemic Stroke

Journal Name	Impact Factor	CiteScore	Launched Year	First Decision (median)	APC
Journal of Clinical Medicine jcm	3.9	5.4	2012	17.9 Days	CHF 2600	Submit
Diagnostics diagnostics	3.6	3.6	2011	20.7 Days	CHF 2600	Submit
Journal of Personalized Medicine jpm	3.4	2.6	2011	17.8 Days	CHF 2600	Submit
Brain Sciences brainsci	3.3	3.9	2011	15.6 Days	CHF 2200	Submit
Journal of Vascular Diseases jvd	-	-	2022	25 Days	CHF 1000	Submit

12 pages, 793 KiB

Open AccessArticle

Impact of Direct Transport to Thrombectomy-Capable Center vs. Nearby/Distant Local Stroke Centers on Stroke Outcome in Patients Undergoing Thrombectomy: A Real-Life Study

by Cristina del Toro-Pérez, Laura Amaya-Pascasio, Antonio Arjona-Padillo and Patricia Martínez-Sánchez

J. Pers. Med. 2024, 14(4), 395; https://doi.org/10.3390/jpm14040395 - 08 Apr 2024

Viewed by 418

Abstract

Our aim was to compare the stroke outcomes of a direct transfer (DT) to a thrombectomy-capable center vs. initial care at two local stroke centers: a nearby hospital (NH, 36 km) and a distant hospital (DH, 113 km). Patients who underwent a mechanical [...] Read more.

Our aim was to compare the stroke outcomes of a direct transfer (DT) to a thrombectomy-capable center vs. initial care at two local stroke centers: a nearby hospital (NH, 36 km) and a distant hospital (DH, 113 km). Patients who underwent a mechanical thrombectomy were analyzed (February 2017–October 2021), and the outcome was considered favorable if the modified Rankin scale (mRS) score was ≤ 2 at three months. A total of 300 patients were included, 55 of which were transferred from the NH and 58 from the DH. There was a difference in the median (IQR) transfer time of 39 min between the hospitals (149 min for the NH vs. 188 min for the DH, p = 0.003). After adjusting for confounding variables, a secondary transfer from the DH, compared to a DT, was associated with a lower functional independence: mRS score ≤ 2 (OR = 0.37, 95% CI = 0.14–0.97, p = 0.043), without significant differences in the mortality between the groups. These differences were not observed in patients from the NH. Conclusions: A secondary transfer from a distant hospital was associated with a poorer functional outcome at 3 months. This unfavorable outcome was not observed among patients transferred from a nearby hospital. These findings highlight the importance of categorizing the suitability of one transfer model over another based on the proximity of hospitals to the thrombectomy center, but also in accordance with organizational and geographic characteristics that vary within each health region. Full article

(This article belongs to the Topic Diagnosis and Management of Acute Ischemic Stroke)

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25 pages, 1385 KiB

Open AccessReview

Deciphering Post-Stroke Sleep Disorders: Unveiling Neurological Mechanisms in the Realm of Brain Science

by Pinqiu Chen, Wenyan Wang, Weikang Ban, Kecan Zhang, Yanan Dai, Zhihong Yang and Yuyang You

Brain Sci. 2024, 14(4), 307; https://doi.org/10.3390/brainsci14040307 - 25 Mar 2024

Viewed by 928

Abstract

Sleep disorders are the most widespread mental disorders after stroke and hurt survivors’ functional prognosis, response to restoration, and quality of life. This review will address an overview of the progress of research on the biological mechanisms associated with stroke-complicating sleep disorders. Extensive [...] Read more.

Sleep disorders are the most widespread mental disorders after stroke and hurt survivors’ functional prognosis, response to restoration, and quality of life. This review will address an overview of the progress of research on the biological mechanisms associated with stroke-complicating sleep disorders. Extensive research has investigated the negative impact of stroke on sleep. However, a bidirectional association between sleep disorders and stroke exists; while stroke elevates the risk of sleep disorders, these disorders also independently contribute as a risk factor for stroke. This review aims to elucidate the mechanisms of stroke-induced sleep disorders. Possible influences were examined, including functional changes in brain regions, cerebrovascular hemodynamics, neurological deficits, sleep ion regulation, neurotransmitters, and inflammation. The results provide valuable insights into the mechanisms of stroke complicating sleep disorders. Full article

(This article belongs to the Topic Diagnosis and Management of Acute Ischemic Stroke)

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12 pages, 964 KiB

Open AccessArticle

Direct Exposure to Outdoor Air Pollution Worsens the Functional Status of Stroke Patients Treated with Mechanical Thrombectomy

by Anetta Lasek-Bal, Wiktor Rybicki, Sebastian Student, Przemysław Puz, Aleksandra Krzan and Aleksandra Derra

J. Clin. Med. 2024, 13(3), 746; https://doi.org/10.3390/jcm13030746 - 27 Jan 2024

Viewed by 592

Abstract

Background The effect of air pollutants on the functional status of stroke patients in short-term follow-up is unknown. The aim of this study was to evaluate the effect of air pollution occurring in the stroke period and during hospitalization on the functional status [...] Read more.

Background The effect of air pollutants on the functional status of stroke patients in short-term follow-up is unknown. The aim of this study was to evaluate the effect of air pollution occurring in the stroke period and during hospitalization on the functional status of patients undergoing mechanical thrombectomy (MT). Methods Our study included stroke patients for which the individual-level exposure to ambient levels of O₃, CO, SO₂, NO₂, PM2.5, and PM10 during the acute stroke period was assessed. The correlations between the air pollutants’ concentration and the patients’ functional state were analyzed. A total of 499 stroke patients (mean age: 70) were qualified. Results The CO concentration at day of stroke onset was found to be significant regarding the functional state of patients on the 10th day (OR 0.014 95% CI 0–0.908, p = 0.048). The parameters which increased the risk of death in the first 10 days were as follows: NIHSS (OR 1.27; 95% CI 1.15–1.42; p < 0.001), intracranial bleeding (OR 4.08; 95% CI 1.75–9.76; p = 0.001), and SO₂ concentration on day 2 (OR 1.21; 95% CI 1.02–1.47; p = 0.03). The parameters which increased the mortality rate within 90 days include age (OR 1.07; 95% CI 1.02–1.13; p = 0.005) and NIHSS (OR 1.37; 95% CI 1.19–1.63; p < 0.001). Conclusions Exposure to air pollution with CO and SO₂ during the acute stroke phase has adverse effects on the patients’ functional status. A combination of parameters, such as neurological state, hemorrhagic transformation, and SO₂ exposure, is unfavorable in terms of the risk of death during a hospitalization due to stroke. The risk of a worsened functional status of patients in the first month of stroke rises along with the increase in particulate matter concentrations within the first days of stroke. Full article

(This article belongs to the Topic Diagnosis and Management of Acute Ischemic Stroke)

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12 pages, 1054 KiB

Open AccessArticle

Prolonged Secondary Stroke Prevention with Edoxaban: A Long-Term Follow-Up of the SATES Study

by Irene Scala, Simone Bellavia, Pier Andrea Rizzo, Jacopo Di Giovanni, Mauro Monforte, Roberta Morosetti, Giacomo Della Marca, Fabio Pilato, Aldobrando Broccolini, Paolo Profice and Giovanni Frisullo

Brain Sci. 2023, 13(11), 1541; https://doi.org/10.3390/brainsci13111541 - 02 Nov 2023

Cited by 1 | Viewed by 1386

Abstract

Background: Little evidence is available on the long-term efficacy and safety of edoxaban, mainly due to the recent release date. The primary objective of the study was to evaluate the safety of edoxaban, defined by the incidence of major bleedings. We then aimed [...] Read more.

Background: Little evidence is available on the long-term efficacy and safety of edoxaban, mainly due to the recent release date. The primary objective of the study was to evaluate the safety of edoxaban, defined by the incidence of major bleedings. We then aimed to evaluate the incidence of thromboembolic events and the persistence of edoxaban therapy in the long-term. Methods: In this observational cohort study, we included ischemic stroke patients enrolled in a previous study to evaluate the safety and efficacy of long-term edoxaban treatment. Data were collected by a trained investigator through a structured telephone interview. Results: Sixty-three subjects (median age 81.0 (73.5–88.0) years, 38.1% male) were included in the study, with a mean follow-up of 4.4 ± 0.7 years (range: 3.2–5.5 years). Only one patient (1.6%, 0.4%/year) presented a major extracranial bleeding, and none had cerebral hemorrhage. Six thromboembolic events occurred in five patients (7.9%): three recurrent strokes, two transient ischemic attacks, and one myocardial infarction (2.2%/year). Over a follow-up period of more than three years, 13 patients discontinued edoxaban (20.6%). Conclusions: Edoxaban seems to be effective and safe in the long-term. The persistence rate of edoxaban therapy is optimal after more than three years of treatment. Full article

(This article belongs to the Topic Diagnosis and Management of Acute Ischemic Stroke)

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12 pages, 2661 KiB

Open AccessArticle

Leucine Reduced Blood–Brain Barrier Disruption and Infarct Size in Early Cerebral Ischemia-Reperfusion

by Oak Z. Chi, Xia Liu, Jedrick Magsino and Harvey R. Weiss

Brain Sci. 2023, 13(10), 1372; https://doi.org/10.3390/brainsci13101372 - 26 Sep 2023

Cited by 1 | Viewed by 988

Abstract

A disruption of the blood–brain barrier (BBB) is a crucial pathophysiological change that can impact the outcome of a stroke. Ribosomal protein S6 (S6) and protein kinase B (Akt) play significant roles in early cerebral ischemia-reperfusion injury. Studies have suggested that branched-chain amino [...] Read more.

A disruption of the blood–brain barrier (BBB) is a crucial pathophysiological change that can impact the outcome of a stroke. Ribosomal protein S6 (S6) and protein kinase B (Akt) play significant roles in early cerebral ischemia-reperfusion injury. Studies have suggested that branched-chain amino acids (BCAAs) may have neuroprotective properties for spinal cord or brain injuries. Therefore, we conducted research to investigate if leucine, one of the BCAAs, could offer neuroprotection and alter BBB disruption, along with its effects on the phosphorylation of S6 and Akt during the early phase of cerebral ischemia-reperfusion, specifically within the thrombolytic therapy time window. In rats, ten min after left middle cerebral artery occlusion (MCAO), 5 µL of 20 mM L-leucine or normal saline was injected into the left lateral ventricle. After two hours of reperfusion following one hour of MCAO, we determined the transfer coefficient (K_i) of ¹⁴C-α-aminoisobutyric acid to assess the BBB disruption, infarct size, and phosphorylation of S6 and Akt. Ischemia-reperfusion increased the K_i (+143%, p < 0.001) and the intra-cerebroventricular injection of leucine lowered the K_i in the ischemic-reperfused cortex (−34%, p < 0.001). Leucine reduced the percentage of cortical infarct (−42%, p < 0.0001) out of the total cortical area. Ischemia-reperfusion alone significantly increased the phosphorylation of both S6 and Akt (p < 0.05). However, the administration of leucine had no further effect on the phosphorylation of S6 or Akt in the ischemic-reperfused cortex. This study suggests that an acute increase in leucine levels in the brain during early ischemia-reperfusion within a few hours of stroke may offer neuroprotection, possibly due to reduced BBB disruption being one of the major contributing factors. Leucine did not further increase the already elevated phosphorylation of S6 or Akt by ischemia-reperfusion under the current experimental conditions. Our data warrant further studies on the effects of leucine on neuronal survival and its mechanisms in the later stages of cerebral ischemia-reperfusion. Full article

(This article belongs to the Topic Diagnosis and Management of Acute Ischemic Stroke)

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10 pages, 14052 KiB

Open AccessArticle

Hemorrhagic Transformation Assessment Based on Dual Energy CT of Immediately and Twenty-Four Hours after Endovascular Thrombectomy for Acute Ischemic Stroke

by Tianyu Wang, Weili Ding, Qing Chen and Zhongxiang Ding

Diagnostics 2023, 13(15), 2493; https://doi.org/10.3390/diagnostics13152493 - 27 Jul 2023

Cited by 2 | Viewed by 759

Abstract

Background: Dual-energy CT (DECT) shows good performance in differentiating hemorrhage from contrast staining (CS). However, no guidelines have standardized the post-endovascular thrombectomy (EVT) examination time. We evaluated the value of performing DECT immediately and 24 h post-EVT in the diagnosis and prediction of [...] Read more.

Background: Dual-energy CT (DECT) shows good performance in differentiating hemorrhage from contrast staining (CS). However, no guidelines have standardized the post-endovascular thrombectomy (EVT) examination time. We evaluated the value of performing DECT immediately and 24 h post-EVT in the diagnosis and prediction of hemorrhagic transformation (HT). Methods: Two readers evaluated simulated conventional CT (sCCT) images compared with a second reading with DECT, establishing the diagnosis of HT immediately and 24 h post-EVT. Another reader’s diagnosis 2–7 days post-EVT using non-contrast CT was identified as the final diagnostic criteria. Results: DECT performed immediately and 24 h post-EVT changed 22.4% (52/232) and 12.5% (29/232) of sCCT-based HT diagnoses, respectively (χ² = 10.7, p < 0.05). The sensitivity, negative predictive value (NPV), and accuracy of DECT performed immediately post-EVT for predicting the final diagnosis of HT were 33.6%, 58.9%, and 65.9%, respectively, whereas those for DECT performed 24 h post-EVT were 82.4%, 84.3%, and 90.9%, respectively (χ² = 58.0, χ² = 42.9, χ² = 13.6; p < 0.05). The specificity and positive predictive value were both 100.0%. Delayed HT occurred in 50.0% (78/156) and 42.2% (19/45) of patients with CS diagnosed immediately and 24 h post-EVT, respectively. Conclusions: DECT performed immediately post-EVT changed a greater proportion of real-time HT diagnoses, whereas that performed 24 h post-EVT had higher sensitivity, NPV, and accuracy in predicting the final diagnosis of HT. A substantial proportion of patients with CS diagnosed at these two post-EVT timepoints subsequently developed delayed HT. Full article

(This article belongs to the Topic Diagnosis and Management of Acute Ischemic Stroke)

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11 pages, 744 KiB

Open AccessArticle

Impact of High-Intensity Statin on Early Neurologic Deterioration in Patients with Single Small Subcortical Infarction

by Seong Hwa Jang, Hyungjong Park, Jeong-Ho Hong, Joonsang Yoo, Hyung Lee, Hyun Ah Kim and Sung-Il Sohn

J. Clin. Med. 2023, 12(9), 3260; https://doi.org/10.3390/jcm12093260 - 03 May 2023

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Abstract

Backgrounds: One of the major hypotheses for early neurological deterioration (END) in single small subcortical infarction (SSSI) is the process of atherosclerosis. However, the association between statin therapy, especially high-intensity statin therapy, and its effectiveness in reducing the incidence of END during the [...] Read more.

Backgrounds: One of the major hypotheses for early neurological deterioration (END) in single small subcortical infarction (SSSI) is the process of atherosclerosis. However, the association between statin therapy, especially high-intensity statin therapy, and its effectiveness in reducing the incidence of END during the acute phase of SSSI remains unclear. This study aimed to investigate the influence of high-intensity statin therapy compared to moderate-intensity statin therapy during the acute phase on the incidence of END in SSSI. Methods: The records of 492 patients with SSSI who received statin therapy within 72 h of symptom onset from a prospective stroke registry were analyzed. The association between END and statin intensity was evaluated using multivariable regression analysis for adjusted odds ratio (aOR). Results: Of the 492 patients with SSSI (mean age: 67.2 years, median NIHSS score on admission: 3), END occurred in 102 (20.7%). Older age (aOR, 1.02; 95% confidence interval (CI), 1.00–1.05; p = 0.017), and branch atheromatous lesion (aOR, 3.49; 95% CI 2.16–5.74; p < 0.001) were associated with END. Early high-intensity statin therapy was associated with a lower incidence of END than moderate-intensity statin therapy (aOR, 0.44; 95% CI, 0.25–0.77; p = 0.004). In addition, there was significantly lower incidence of END in early administration (≤24 h) of high-intensity statin group. Conclusions: We identified an association between the intensity of early statin therapy and END in patients with SSSI. Early administration of high-intensity statin (≤24 h) is associated with a reduced incidence of END in patients with SSSI. Full article

(This article belongs to the Topic Diagnosis and Management of Acute Ischemic Stroke)

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10 pages, 986 KiB

Open AccessArticle

Stroke in Young Adults in Spain: Epidemiology and Risk Factors by Age

by Laura Amaya Pascasio, Marina Blanco Ruiz, Rodrigo Milán Pinilla, Juan Manuel García Torrecillas, Antonio Arjona Padillo, Cristina Del Toro Pérez and Patricia Martínez-Sánchez

J. Pers. Med. 2023, 13(5), 768; https://doi.org/10.3390/jpm13050768 - 29 Apr 2023

Cited by 1 | Viewed by 1594

Abstract

Introduction: Recent research has highlighted an increased incidence of ischemic stroke (IS) in young adults, along with a higher percentage of vascular risk factors at younger ages. This study aimed to estimate the in-hospital incidence of IS and associated comorbidities by sex and [...] Read more.

Introduction: Recent research has highlighted an increased incidence of ischemic stroke (IS) in young adults, along with a higher percentage of vascular risk factors at younger ages. This study aimed to estimate the in-hospital incidence of IS and associated comorbidities by sex and age group in Spain. Methods: A retrospective analysis of the Spain Nationwide Inpatient Sample database from 2016 to 2019 was conducted, which included adult patients with IS. In-hospital incidence and mortality rates were estimated, and a descriptive analysis of the main comorbidities was performed, stratified by sex and age groups. Results: A total of 186,487 patients were included, with a median age of 77 (IQR 66–85) years and 53.3% were male. Of these, 9162 (5%) were aged between 18 and 50 years. The estimated incidence of IS in adults younger than 50 years ranged from 11.9 to 13.5 per 100,000 inhabitants during the study period, with a higher incidence in men. The overall in-hospital mortality was 12.6%. Young adults with IS had a higher prevalence of most vascular risk factors compared to the general Spanish population, with a specific distribution according to sex and age. Conclusions: This study provides estimates of the incidence of IS and the prevalence of vascular risk factors and comorbidities associated with IS in Spain, stratified by sex and age, using a national registry of hospital admissions. These findings should be considered in terms of both primary and secondary prevention strategies. Full article

(This article belongs to the Topic Diagnosis and Management of Acute Ischemic Stroke)

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13 pages, 2199 KiB

Open AccessSystematic Review

Incidence of Stress-Induced Hyperglycemia in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

by Haofuzi Zhang, Kangyi Yue, Zijian Jiang, Xiuquan Wu, Xin Li, Peng Luo and Xiaofan Jiang

Brain Sci. 2023, 13(4), 556; https://doi.org/10.3390/brainsci13040556 - 26 Mar 2023

Cited by 1 | Viewed by 1528

Abstract

The aim of this study was to systematically evaluate the incidence of stress-induced hyperglycemia (SIH) in acute ischemic stroke (AIS). Studies that reported SIH incidence in AIS and examined risk factors for SIH and non-SIH patients were systematically searched in PubMed, Embase, Cochrane [...] Read more.

The aim of this study was to systematically evaluate the incidence of stress-induced hyperglycemia (SIH) in acute ischemic stroke (AIS). Studies that reported SIH incidence in AIS and examined risk factors for SIH and non-SIH patients were systematically searched in PubMed, Embase, Cochrane Library, and Web of Science from the inception of each database to December 2021. Article screening and data extraction were performed by two independent reviewers according to the inclusion and exclusion criteria. The quality of the included studies was assessed using the Newcastle–Ottawa Scale (NOS), and meta-analysis was performed using Stata. A total of 13 studies involving 4552 patients (977 in the SIH group and 3575 in the non-SIH group) were included. Meta-analysis showed that the incidence of SIH was 24% (95% CI: 21–27%) in the total population, 33% (14–52%) in North America, 25% (20–29%) in Europe, and 21% (12–29%) in Asia. Subgroup analysis by year of publication revealed that the pooled incidence of SIH was 27% (22–32%) in studies published before 2010 and 19% (14–24%) in those published after 2010. SIH is relatively common in AIS and poses a serious public health problem. Therefore, more emphasis should be placed on the prevention and control of SIH in AIS. Full article

(This article belongs to the Topic Diagnosis and Management of Acute Ischemic Stroke)

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13 pages, 831 KiB

Open AccessArticle

Collateral Circulation and BNP in Predicting Outcome of Acute Ischemic Stroke Patients with Atherosclerotic versus Cardioembolic Cerebral Large-Vessel Occlusion Who Underwent Endovascular Treatment

by Ruoyao Cao, Yao Lu, Peng Qi, Yanyan Wang, Hailong Hu, Yun Jiang, Min Chen and Juan Chen

Brain Sci. 2023, 13(4), 539; https://doi.org/10.3390/brainsci13040539 - 24 Mar 2023

Cited by 4 | Viewed by 1405

Abstract

Purpose: The aim of this study was to verify the value of collateral circulation and B-type natriuretic peptide (BNP) in predicting clinical outcomes of patients with acute ischemic stroke (AIS) and their biomarker value for stroke subtypes before endovascular treatment (EVT). Patients and [...] Read more.

Purpose: The aim of this study was to verify the value of collateral circulation and B-type natriuretic peptide (BNP) in predicting clinical outcomes of patients with acute ischemic stroke (AIS) and their biomarker value for stroke subtypes before endovascular treatment (EVT). Patients and Methods: In this retrospective study, 182 patients who underwent EVT for unilateral anterior circulation large-vessel occlusion between March 2016 and January 2022 were analyzed. The modified collateral circulation scoring system on four-dimensional computed tomography angiography (4D CTA-CS) was used to assess collateral status, and stroke subtypes were determined according to the TOAST classification criteria. Patients were divided into good (mRS ≤ 2) and poor outcome (mRS > 2) groups based on their modified Rankin Scale (mRS) score at 3 months. Results: 4D CTA-CS was an independent predictor of the clinical outcome for all AIS patients (odds ratio = 0.253; 95% CI, 0.147–0.437; p < 0.001), CE stroke patients (odds ratio = 0.513; 95% CI, 0.280–0.939; p = 0.030), and LAA stroke patients (odds ratio = 0.148; 95% CI, 0.049–0.447; p = 0.001). The BNP was a biomarker for clinical outcome prediction in CE (odds ratio = 1.004; 95% CI, 1.001–1.008; p = 0.005) but not in LAA patients. Combined with BNP, 4D CTA-CS improved predictive values for clinical outcomes (p < 0.05). Conclusion: Collateral status and BNP could be used as independent predictors of clinical outcomes in AIS patients and could determine stroke subtypes (CE stroke or LAA stroke). In addition, the model of 4D CTA-CS combined with BNP was the most effective in predicting clinical outcomes compared with collateral status or BNP alone. Full article

(This article belongs to the Topic Diagnosis and Management of Acute Ischemic Stroke)

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12 pages, 552 KiB

Open AccessArticle

Direct Mechanical Thrombectomy vs. Bridging Therapy in Stroke Patients in A “Stroke Belt” Region of Southern Europe

by Cristina del Toro-Pérez, Laura Amaya-Pascasio, Eva Guevara-Sánchez, María Luisa Ruiz-Franco, Antonio Arjona-Padillo and Patricia Martínez-Sánchez

J. Pers. Med. 2023, 13(3), 440; https://doi.org/10.3390/jpm13030440 - 28 Feb 2023

Cited by 1 | Viewed by 1269

Abstract

The aim of this 4-year observational study is to analyze the outcomes of stroke patients treated with direct mechanical thrombectomy (dMT) compared to bridging therapy (BT) (intravenous thrombolysis [IVT] + BT) based on 3-month outcomes, in real clinical practice in the "Stroke Belt" [...] Read more.

The aim of this 4-year observational study is to analyze the outcomes of stroke patients treated with direct mechanical thrombectomy (dMT) compared to bridging therapy (BT) (intravenous thrombolysis [IVT] + BT) based on 3-month outcomes, in real clinical practice in the "Stroke Belt" of Southern Europe. In total, 300 patients were included (41.3% dMT and 58.6% BT). The frequency of direct referral to the stroke center was similar in the dMT and BT group, whereas the time from onset to groin was longer in the BT group (median 210 [IQR 160–303] vs. 399 [IQR 225–675], p = 0.001). Successful recanalization (TICI 2b-3) and hemorrhagic transformation were similar in both groups. The BT group more frequently showed excellent outcomes at 3 months (32.4% vs. 15.4%, p = 0.004). Multivariate analysis showed that BT was independently associated with excellent outcomes (OR 2.7. 95% CI,1.2–5.9, p = 0.02) and lower mortality (OR 0.36. 95% CI 0.16–0.82, p = 015). Conclusions: Compared with dMT, BT was associated with excellent functional outcomes and lower 3-month mortality in this real-world clinical practice study conducted in a region belonging to the “Stroke Belt” of Southern Europe. Given the disparity of results on the benefit of BT in the current evidence, it is of vital importance to analyze the convenience of its use in each health area. Full article

(This article belongs to the Topic Diagnosis and Management of Acute Ischemic Stroke)

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12 pages, 1643 KiB

Open AccessArticle

Long-Term Lower Limb Motor Function Correlates with Middle Cerebellar Peduncle Structural Integrity in Sub-Acute Stroke: A ROI-Based MRI Cohort Study

by Daming Wang, Lingyan Wang, Dazhi Guo, Shuyi Pan, Lin Mao, Yifan Zhao, Liliang Zou, Ying Zhao, Aiqun Shi and Zuobing Chen

Brain Sci. 2023, 13(3), 412; https://doi.org/10.3390/brainsci13030412 - 27 Feb 2023

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Abstract

Crossed cerebellar diaschisis (CCD) has been widely investigated in patients with supratentorial stroke. However, the role of CCD in lower limb recovery after stroke is still unknown. In this study, using a region-of-interest-based analysis of diffusion tensor imaging (DTI), a total of 44 [...] Read more.

Crossed cerebellar diaschisis (CCD) has been widely investigated in patients with supratentorial stroke. However, the role of CCD in lower limb recovery after stroke is still unknown. In this study, using a region-of-interest-based analysis of diffusion tensor imaging (DTI), a total of 44 cases of stroke within 3 months onset were enrolled for assessment of the cerebral peduncle (CP) and middle cerebellar peduncles (MCP) in CCD. Compared with the control group, the fractional anisotropy ratio (rFA) and laterality index (LI) of the CP and MCP in the stroke group significantly decreased. The rFA of the MCP (unaffected side/affected side) showed a more significant correlation with 1-year paresis grading (PG), lower extremity PG, upper extremity PG, National Institutes of Health Stroke Scale (NIHSS), and functional independence measure (FIM) motor item score, in comparison to the rFA of the CP (affected side/unaffected side) (r = −0.698 vs. r = −0.541, r = −0.651 vs. r = −0.386, r = −0.642 vs. r = −0.565, r = −0.519 vs. r = −0.403, and r = 0.487 vs. r = 0.435, respectively). Furthermore, the LI of the CP had a more significant association with 1-year Brunel Balance Assessment (BBA), upper extremity PG, and Modified Rankin Scale (mRS) as compared to the LI of the MCP (r = 0.573 vs. r = 0.452; r = −0.554 vs. r = −0.528; and r = −0.494 vs. r = −0.344, respectively). We set the cutoff point for the MCP rFA at 0.925 (sensitivity: 79% and specificity: 100%) for predicting lower extremity motor function prognosis and found the receiver operating characteristic (ROC) curve of MCP rFA was larger than that of CP rFA (0.893 vs. 0.737). These results reveal that the MCP may play a significant role in the recovery of walking ability after stroke. Full article

(This article belongs to the Topic Diagnosis and Management of Acute Ischemic Stroke)

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11 pages, 2672 KiB

Open AccessArticle

Actigraphic Sensors Describe Stroke Severity in the Acute Phase: Implementing Multi-Parametric Monitoring in Stroke Unit

by Giuseppe Reale, Chiara Iacovelli, Marco Rabuffetti, Paolo Manganotti, Lucio Marinelli, Simona Sacco, Giovanni Furlanis, Miloš Ajčević, Aurelia Zauli, Marco Moci, Silvia Giovannini, Simona Crosetti, Matteo Grazzini, Stefano Filippo Castiglia, Matteo Podestà, Paolo Calabresi, Maurizio Ferrarin and Pietro Caliandro

J. Clin. Med. 2023, 12(3), 1178; https://doi.org/10.3390/jcm12031178 - 02 Feb 2023

Cited by 1 | Viewed by 1339

Abstract

Actigraphy is a tool used to describe limb motor activity. Some actigraphic parameters, namely Motor Activity (MA) and Asymmetry Index (AR), correlate with stroke severity. However, a long-lasting actigraphic monitoring was never performed previously. We hypothesized that MA and AR can describe different [...] Read more.

Actigraphy is a tool used to describe limb motor activity. Some actigraphic parameters, namely Motor Activity (MA) and Asymmetry Index (AR), correlate with stroke severity. However, a long-lasting actigraphic monitoring was never performed previously. We hypothesized that MA and AR can describe different clinical conditions during the evolution of the acute phase of stroke. We conducted a multicenter study and enrolled 69 stroke patients. NIHSS was assessed every hour and upper limbs’ motor activity was continuously recorded. We calculated MA and AR in the first hour after admission, after a significant clinical change (NIHSS ± 4) or at discharge. In a control group of 17 subjects, we calculated MA and AR normative values. We defined the best model to predict clinical status with multiple linear regression and identified actigraphic cut-off values to discriminate minor from major stroke (NIHSS ≥ 5) and NIHSS 5–9 from NIHSS ≥ 10. The AR cut-off value to discriminate between minor and major stroke (namely NIHSS ≥ 5) is 27% (sensitivity = 83%, specificity = 76% (AUC 0.86 p < 0.001), PPV = 89%, NPV = 42%). However, the combination of AR and MA of the non-paretic arm is the best model to predict NIHSS score (R²: 0.482, F: 54.13), discriminating minor from major stroke (sensitivity = 89%, specificity = 82%, PPV = 92%, NPV = 75%). The AR cut-off value of 53% identifies very severe stroke patients (NIHSS ≥ 10) (sensitivity = 82%, specificity = 74% (AUC 0.86 p < 0.001), PPV = 73%, NPV = 82%). Actigraphic parameters can reliably describe the overall severity of stroke patients with motor symptoms, supporting the addition of a wearable actigraphic system to the multi-parametric monitoring in stroke units. Full article

(This article belongs to the Topic Diagnosis and Management of Acute Ischemic Stroke)

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10 pages, 3281 KiB

Open AccessArticle

Quantitative Susceptibility Mapping as a Biomarker to Assess Middle Cerebral Artery Thrombus Composition in Acute Ischemic Stroke

by Shanhua Han, Yifan Lv, Ke Gao, Qiuyue Quan, Haitao Lu, Huazheng Liang, Ying Zhu, Linglei Meng and Yu Luo

J. Vasc. Dis. 2023, 2(1), 112-121; https://doi.org/10.3390/jvd2010009 - 01 Feb 2023

Viewed by 1502

Abstract

Objective: To compare the quantitative susceptibility mapping (QSM) susceptibility values and pathology composition with different types of thrombi in the middle cerebral artery (MCA), and assess the value of susceptibility weight imaging in thrombus component diagnosis in stroke. Materials and methods: This study [...] Read more.

Objective: To compare the quantitative susceptibility mapping (QSM) susceptibility values and pathology composition with different types of thrombi in the middle cerebral artery (MCA), and assess the value of susceptibility weight imaging in thrombus component diagnosis in stroke. Materials and methods: This study included 15 patients (73.47 ± 10.7 years; 6 males and 9 females) who underwent magnetic resonance imaging before mechanical thrombectomy due to acute middle cerebral artery occlusion between January 2017 and December 2019. All patients had the susceptibility vessel sign (SVS) on SWI (susceptibility weighted imaging), and the thrombus susceptibility was measured by signal processing in nuclear magnetic resonance SPIN software. The retrieved thrombi underwent histopathologic analysis, and the correlation between thrombus susceptibility and the pathologic composition was analyzed by two independent Kolmogorov–Smirnov tests. The location and length of thrombi were evaluated on both SWI and DSA, and the correlation was explored using two independent samples Wilcoxon rank test. The correlations between susceptibility and the infarct core volumes (ADC < 620 mm²/s volume map), hypoperfusion volumes (Tmax > 6 s volume map), 90-day modified Rankin scale (mRS), and the National Institutes of Health Stroke Scale (NIHSS) at admission were analyzed by Spearman’s correlation analysis. Results: Among the 15 retrieved thrombi, the mean thrombus susceptibility of RBC-dominant and fibrin-dominant thrombi were 209.88 ± 11.32 and 155.70 ± 28.20 (ppb), respectively (p = 0.037). The average distance of the proximal end of the thrombi to the midline was 24.67 ± 8.43 mm and 24.62 ± 8.44 mm, as measured by SWI and DSA (digital subtraction angiography), respectively (p < 0.001). The correlation between thrombus susceptibility was weakly negatively correlated with ADC < 620 mm²/s volume map (r = 0.356, p = 0.193) and poorly correlated with Tmax > 6 s volume map (r = 0.252, p = 0.365), 90-day mRS (r = 0.182, p = 0.517), and NIHSS at admission (r = 0.262, p = 0.345). Conclusions: The measurements of the Quantitative susceptibility value of thrombi may help predict the composition of thrombi in patients with acute middle cerebral artery occlusion. QSM provides a more accurate method to evaluate the thrombi. Full article

(This article belongs to the Topic Diagnosis and Management of Acute Ischemic Stroke)

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10 pages, 651 KiB

Open AccessArticle

Evaluation of High Intracranial Plaque Prevalence in Type 2 Diabetes Using Vessel Wall Imaging on 7 T Magnetic Resonance Imaging

by Masaharu Shozushima, Futoshi Mori, Satoshi Yashiro, Yusuke Todate, Tomoyasu Oda, Kan Nagasawa, Yutaka Hasegawa, Noriko Takebe, Makoto Sasaki and Yasushi Ishigaki

Brain Sci. 2023, 13(2), 217; https://doi.org/10.3390/brainsci13020217 - 28 Jan 2023

Cited by 1 | Viewed by 1335

Abstract

Background: While type 2 diabetes (T2D) is a major risk for ischemic stroke, the associated vessel wall characteristics remain essentially unknown. This study aimed to clarify intracranial vascular changes on three-dimensional vessel wall imaging (3D-VWI) using fast spin echo by employing 7Tesla (7T) [...] Read more.

Background: While type 2 diabetes (T2D) is a major risk for ischemic stroke, the associated vessel wall characteristics remain essentially unknown. This study aimed to clarify intracranial vascular changes on three-dimensional vessel wall imaging (3D-VWI) using fast spin echo by employing 7Tesla (7T) magnetic resonance imaging (MRI) in T2D patients without advanced atherosclerosis as compared to healthy controls. Methods: In 48 T2D patients and 35 healthy controls, the prevalence of cerebral small vessel diseases and intracranial plaques were evaluated by 3D-VWI with 7T MRI. Results: The prevalence rate of lacunar infarction was significantly higher in T2D than in controls (n = 8 in T2D vs. n = 0 in control, p = 0.011). The mean number of intracranial plaques in both anterior and posterior circulation of each subject was significantly larger in T2D than in controls (2.23 in T2D vs. 0.94 in control, p < 0.01). In T2D patients, gender was associated with the presence of intracranial plaques. Conclusion: This is the first study to demonstrate the high prevalence of intracranial plaque in T2D patients with neither confirmed atherosclerotic disease nor symptoms by performing intracranial 3D-VWI employing 7TMRI. Investigation of intracranial VWI with 7T MRI is expected to provide novel insights allowing early intensive risk management for prevention of ischemic stroke in T2D patients. Full article

(This article belongs to the Topic Diagnosis and Management of Acute Ischemic Stroke)

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10 pages, 274 KiB

Open AccessBrief Report

Assessing the Efficacy of Mechanical Thrombectomy in Patients with an NIHSS < 6 Presenting with Proximal Middle Cerebral Artery Vessel Occlusion as Compared to Best Medical Management

by Vivek Srikar Yedavalli, Omar Hamam, Julie Gudenkauf, Richard Wang, Rafael Llinas, Elisabeth Breese Marsh, Justin Caplan, Kambiz Nael and Victor Urrutia

Brain Sci. 2023, 13(2), 214; https://doi.org/10.3390/brainsci13020214 - 27 Jan 2023

Viewed by 1353

Abstract

Background and Purpose: Minor acute ischemic stroke (AIS) patients—defined by an NIHSS score < 6—presenting with proximal middle cerebral artery large vessel occlusions (MCA-LVO) is a subgroup for which treatment is still debated. Although these patients present with minor symptoms initially, studies have [...] Read more.

Background and Purpose: Minor acute ischemic stroke (AIS) patients—defined by an NIHSS score < 6—presenting with proximal middle cerebral artery large vessel occlusions (MCA-LVO) is a subgroup for which treatment is still debated. Although these patients present with minor symptoms initially, studies have shown that several patients afflicted with MCA-LVO in this subgroup experience cognitive and functional decline. Although mechanical thrombectomy (MT) is the standard of care for patients with an NIHSS score of 6 or higher, treatment in the minor stroke subgroup is still being explored. The purpose of this preliminary study is to report our center’s experience in evaluating the potential benefit of mechanical thrombectomy (MT) in minor stroke patients when compared to medical management (MM). Methods: We performed a retrospective study with two comprehensive stroke centers within our hospital enterprise of consecutive patients presenting with minor AIS secondary to MCA-LVO (defined as M1 or proximal M2 segments of MCA). We subsequently evaluated patients who received MT versus those who received MM. Results: Between January 2017 and July 2021, we identified 46 AIS patients (11 treated with MT and 35 treated with MM) who presented with an NIHSS score < 6 secondary to MCA-LVO (47.8% 22/46 female, mean age 62.3 years, range 49–75 years). MT was associated with a significantly lower mRS at 90 days (median: 1.0 [IQR 0.0–2.0] versus 3.0 [IQR 1.0–4.0], p = <0.001), a favorable NIHSS shift (−4.0 [IQR −10.0–−2.0] versus 0.0 [IQR −2.0–1.0], p = 0.002), favorable NIHSS shift dichotomization (5/11, 45.5% versus 3/35, 8.6%, p = 0.003) and favorable mRS dichotomization (7/11, 63.6% versus 14/35, 40.0%, p = 0.024). Conclusions: In our center’s preliminary experience, for AIS patients presenting with an NIHSS score < 6 secondary to MCA-LVO, MT may be associated with improved clinical outcomes when compared to MM only. Full article

(This article belongs to the Topic Diagnosis and Management of Acute Ischemic Stroke)

8 pages, 235 KiB

Open AccessArticle

The Impact of Prior Antithrombotic Use on Blood Viscosity in Cardioembolic Stroke with Non-Valvular Atrial Fibrillation

by Yo-Han Jung, Sang-Won Han and Joong-Hyun Park

J. Clin. Med. 2023, 12(3), 887; https://doi.org/10.3390/jcm12030887 - 22 Jan 2023

Viewed by 1320

Abstract

Although clinical studies have demonstrated that prior use of antiplatelets was associated with decreased blood viscosity (BV) in patients with acute ischemic stroke, the impact of previous anticoagulant use on blood viscosity in cardioembolic stroke with non-valvular AF (NVAF) has not yet been [...] Read more.

Although clinical studies have demonstrated that prior use of antiplatelets was associated with decreased blood viscosity (BV) in patients with acute ischemic stroke, the impact of previous anticoagulant use on blood viscosity in cardioembolic stroke with non-valvular AF (NVAF) has not yet been clearly studied. This single-center retrospective observational study aimed to determine the impact of prior antithrombotic (antiplatelet and anticoagulant) use on BV in patients with cardioembolic stroke (CES) due to NVAF. Patients with CES and NVAF were analyzed with the following inclusion criteria: (1) patients over 20 years of age admitted within five days of stroke onset; (2) ischemic stroke presumably due to an NVAF-derived embolus; (3) compatible cortical/subcortical lesion on brain computed tomography or magnetic resonance imaging; (4) hemoglobin level of 10–18 mg/dL; and (5) receiving antiplatelets within five days or anticoagulants within two days if previously medicated. From the screening of 195 patients (22% of the total stroke population during the study period) who had experienced ischemic stroke with AF, 160 were included for the final analysis. Eighty-nine patients (56%) were taking antithrombotics (antiplatelet, 57%; warfarin, 13%; NOACs, 30%) regularly. Compared to patients without previous antithrombotic use, those with previous antithrombotic use (antiplatelets, warfarin, and NOACs) were significantly associated with decreased systolic BV (SBV) and diastolic BV (DBV) (p < 0.036). In multiple linear regression analysis, hematocrit (Hct) level and prior antithrombotic use were significantly associated with decreased SBV and DBV. Hct was positively correlated with increased SBV and DBV. In Hct-adjusted partial correlation analysis, prior uses of any antithrombotic agents were associated with decreased SBV (r < −0.270, p < 0.015) and DBV (r < −0.183, p < 0.044). In conclusion, this study showed that prior antithrombotic use (antiplatelets, VKAs, and NOACs) was associated with decreased SBV and DBV in patients presenting with acute CES secondary to NVAF. Our results indicated that previous use of NOACs may be a useful hemorheological parameter in patients with acute CES due to NVAF. Accumulation of clinical data from a large number of patients with the risk of stroke occurrence, initial stroke severity, and functional outcome is necessary to assess the usefulness of BV. Full article

(This article belongs to the Topic Diagnosis and Management of Acute Ischemic Stroke)

16 pages, 2201 KiB

Open AccessArticle

Prediction of Functional Outcome in Stroke Patients with Proximal Middle Cerebral Artery Occlusions Using Machine Learning Models

by Burak B. Ozkara, Mert Karabacak, Omar Hamam, Richard Wang, Apoorva Kotha, Neda Khalili, Meisam Hoseinyazdi, Melissa M. Chen, Max Wintermark and Vivek S. Yedavalli

J. Clin. Med. 2023, 12(3), 839; https://doi.org/10.3390/jcm12030839 - 20 Jan 2023

Cited by 6 | Viewed by 1946

Abstract

At present, clinicians are expected to manage a large volume of complex clinical, laboratory, and imaging data, necessitating sophisticated analytic approaches. Machine learning-based models can use this vast amount of data to create forecasting models. We aimed to predict short- and medium-term functional [...] Read more.

At present, clinicians are expected to manage a large volume of complex clinical, laboratory, and imaging data, necessitating sophisticated analytic approaches. Machine learning-based models can use this vast amount of data to create forecasting models. We aimed to predict short- and medium-term functional outcomes in acute ischemic stroke (AIS) patients with proximal middle cerebral artery (MCA) occlusions using machine learning models with clinical, laboratory, and quantitative imaging data as inputs. Included were consecutive AIS patients with MCA M1 and proximal M2 occlusions. The XGBoost, LightGBM, CatBoost, and Random Forest were used to predict the outcome. Minimum redundancy maximum relevancy was used for selecting features. The primary outcomes were the National Institutes of Health Stroke Scale (NIHSS) shift and the modified Rankin Score (mRS) at 90 days. The algorithm with the highest area under the receiver operating characteristic curve (AUROC) for predicting the favorable and unfavorable outcome groups at 90 days was LightGBM. Random Forest had the highest AUROC when predicting the favorable and unfavorable groups based on the NIHSS shift. Using clinical, laboratory, and imaging parameters in conjunction with machine learning, we accurately predicted the functional outcome of AIS patients with proximal MCA occlusions. Full article

(This article belongs to the Topic Diagnosis and Management of Acute Ischemic Stroke)

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23 pages, 4934 KiB

Open AccessReview

Predictive Value of CT Perfusion in Hemorrhagic Transformation after Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

by Jie Xu, Fangyu Dai, Binda Wang, Yiming Wang, Jiaqian Li, Lulan Pan, Jingjing Liu, Haipeng Liu and Songbin He

Brain Sci. 2023, 13(1), 156; https://doi.org/10.3390/brainsci13010156 - 16 Jan 2023

Cited by 6 | Viewed by 2550

Abstract

Background: Existing studies indicate that some computed tomography perfusion (CTP) parameters may predict hemorrhagic transformation (HT) after acute ischemic stroke (AIS), but there is an inconsistency in the conclusions alongside a lack of comprehensive comparison. Objective: To comprehensively evaluate the predictive value of [...] Read more.

Background: Existing studies indicate that some computed tomography perfusion (CTP) parameters may predict hemorrhagic transformation (HT) after acute ischemic stroke (AIS), but there is an inconsistency in the conclusions alongside a lack of comprehensive comparison. Objective: To comprehensively evaluate the predictive value of CTP parameters in HT after AIS. Data sources: A systematical literature review of existing studies was conducted up to 1st October 2022 in six mainstream databases that included original data on the CTP parameters of HT and non-HT groups or on the diagnostic performance of relative cerebral blood flow (rCBF), relative permeability-surface area product (rPS), or relative cerebral blood volume (rCBV) in patients with AIS that completed CTP within 24 h of onset. Data Synthesis: Eighteen observational studies were included. HT and non-HT groups had statistically significant differences in CBF, CBV, PS, rCBF, rCBV, and rPS (p < 0.05 for all). The hierarchical summary receiver operating characteristic (HSROC) revealed that rCBF (area under the curve (AUC) = 0.9), rPS (AUC = 0.89), and rCBV (AUC = 0.85) had moderate diagnostic performances in predicting HT. The pooled sensitivity and specificity of rCBF were 0.85 (95% CI, 0.75–0.91) and 0.83 (95% CI, 0.63–0.94), respectively. Conclusions: rCBF, rPS, and rCBV had moderate diagnostic performances in predicting HT, and rCBF had the best pooled sensitivity and specificity. Full article

(This article belongs to the Topic Diagnosis and Management of Acute Ischemic Stroke)

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16 pages, 1337 KiB

Open AccessReview

Imaging and Hemodynamic Characteristics of Vulnerable Carotid Plaques and Artificial Intelligence Applications in Plaque Classification and Segmentation

by Na Han, Yurong Ma, Yan Li, Yu Zheng, Chuang Wu, Tiejun Gan, Min Li, Laiyang Ma and Jing Zhang

Brain Sci. 2023, 13(1), 143; https://doi.org/10.3390/brainsci13010143 - 13 Jan 2023

Cited by 6 | Viewed by 2609

Abstract

Stroke is a massive public health problem. The rupture of vulnerable carotid atherosclerotic plaques is the most common cause of acute ischemic stroke (AIS) across the world. Currently, vessel wall high-resolution magnetic resonance imaging (VW-HRMRI) is the most appropriate and cost-effective imaging technique [...] Read more.

Stroke is a massive public health problem. The rupture of vulnerable carotid atherosclerotic plaques is the most common cause of acute ischemic stroke (AIS) across the world. Currently, vessel wall high-resolution magnetic resonance imaging (VW-HRMRI) is the most appropriate and cost-effective imaging technique to characterize carotid plaque vulnerability and plays an important role in promoting early diagnosis and guiding aggressive clinical therapy to reduce the risk of plaque rupture and AIS. In recent years, great progress has been made in imaging research on vulnerable carotid plaques. This review summarizes developments in the imaging and hemodynamic characteristics of vulnerable carotid plaques on the basis of VW-HRMRI and four-dimensional (4D) flow MRI, and it discusses the relationship between these characteristics and ischemic stroke. In addition, the applications of artificial intelligence in plaque classification and segmentation are reviewed. Full article

(This article belongs to the Topic Diagnosis and Management of Acute Ischemic Stroke)

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9 pages, 794 KiB

Open AccessCase Report

The Role of Folate Deficiency as a Potential Risk Factor for Nontraumatic Anterior Spinal Artery Syndrome in an Adolescent Girl

by Chun-Chieh Hu, Yung-Yu Yang, G. W. Gant Luxton, Yu-Pang Lin, Kuo-Sheng Hung and Chih-Fen Hu

Brain Sci. 2022, 12(11), 1470; https://doi.org/10.3390/brainsci12111470 - 29 Oct 2022

Viewed by 1628

Abstract

Nontraumatic anterior spinal artery syndrome (ASAS) is an extremely rare clinical condition in pediatric populations with a mostly unknown underlying etiology. Here we discuss the case of a previously healthy 14-year-old girl presenting with sudden onset acute flaccid paralysis to the emergency department. [...] Read more.

Nontraumatic anterior spinal artery syndrome (ASAS) is an extremely rare clinical condition in pediatric populations with a mostly unknown underlying etiology. Here we discuss the case of a previously healthy 14-year-old girl presenting with sudden onset acute flaccid paralysis to the emergency department. A spinal STIR/DWI MRI revealed hyperintensities extending from cervical vertebrae C3-6, consistent with the diagnosis of ASAS. In order to determine any precipitating causes of ASAS, we also extensively investigated established potential risk factors for ASAS in our patient and noticed that she had a marked folate deficiency requiring folic acid supplementation to prevent future episodes of ASAS as well as to repair the patient’s injured spinal cord. Interestingly, the patient did not display elevated levels of homocysteine nor did she possess the three pathogenic MTHFR mutations characteristic of ASAS. Although her folate deficiency did not cause responsive hyperhomocysteinemia, and she did not have pathogenic MTHFR mutations that impair the function of methylenetetrahydrofolate reductase in folate cycle, we suggest that isolated folate deficiency may play a role in adolescent cases of ASAS that, once identified, would require prompt identification and early intervention to improve the prognosis of these patients. Full article

(This article belongs to the Topic Diagnosis and Management of Acute Ischemic Stroke)

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