Association of Serum Biomarkers with Post-Thrombolytic Early Neurological Improvement in Stroke: A Comprehensive Protein Microarray Analysis From INTRECIS Study

Objective Early neurological improvement (ENI) after intravenous thrombolysis is associated with favorable outcome, but associated serum biomarkers were not fully determined. We aimed to investigate the issue in a prospective cohort. Methods In INTRECIS study, five centers were designed to consecutively collect the blood sample from enrolled patients. Enrolled patients with ENI and without ENI were matched by propensity score matching with the ratio of 1:1. Preset 49 biomarkers were measured by protein microarray analysis. Enrichment of Gene Ontology and pathway, and protein-protein interaction network were analyzed in the identified biomarkers. Results Of 358 patients, 19 occurred ENI, who were assigned as ENI group, while 19 matched patients without ENI were assigned as Non ENI group. A total of 9 biomarkers were found different, among which levels of chemokine (C-C motif) ligand (CCL)-23, chemokine (C-X-C motif) ligand (CXCL)-12, insulin-like growth factor binding protein (IGFBP)-6, interleukin (IL)-5, lymphatic vessel endothelial hyaluronan receptor (LYVE)-1, plasminogen activator inhibitor (PAI)-1, platelet-derived growth factor (PDGF)-AA, suppression of tumorigenicity (ST)-2, and tumor necrosis factor (TNF)-α were higher in ENI group, compared with those in Non ENI group. Interpretation: Our finding indicated that pretreatment serum CCL-23, CXCL-12, IGFBP-6, IL-5, LYVE-1, PAI-1, PDGF-AA, ST-2, and TNF-α levels were associated with post-thrombolytic ENI in ischemic stroke. The role of these biomarkers warrant further investigation. Registration-URL : https://www.clinicaltrials.gov; Unique identifier: NCT02854592.

Mechanical Thrombectomy Beyond 2b Reperfusion: Should We Pursue a Higher Reperfusion Grade after Achievement of 2b?

Background Extended thrombolysis in cerebral infarction (eTICI) 2c/3 reperfusion after mechanical thrombectomy (MT) is associated with better stroke outcomes than eTICI 2b. Whether additional MT attempt after achieving eTICI 2b (beyond 2b attempt) leads to better outcomes is unknown. Methods Consecutive patients with acute anterior circulation stroke who achieved eTICI 2b during MT were divided into 2 groups: those who further tried MT (beyond‐2b group) and those without (nonbeyond‐2b group). The patients who directly achieved eTICI 2c/3 without experiencing 2b (direct‐2c/3 group) were also studied. The outcomes included the reperfusion status, favorable outcome (3‐month modified Rankin scale score of 0–2), neurological improvement (a ≥10‐point decrease of the National Institutes of Health Stroke Scale score from baseline or the score of 0) at 24 hours and symptomatic intracranial hemorrhage. Results Of 308 patients, 50 were in the beyond‐2b group, 87 in the nonbeyond‐2b group, and the remaining 171 in the direct‐2c/3 group. Perfusion of middle cerebral artery branches supplying the primary motor cortex was worse in the beyond‐2b than the nonbeyond‐2b group at the time of eTICI 2b ( P =0.007). Favorable outcome was similarly common (48% for each, P =0.40). Neurological improvement was more frequent (52% versus 37%; P =0.04) and symptomatic intracranial hemorrhage tended to be more common (6% versus 1%, P =0.11) in the beyond‐2b than the nonbeyond‐2b group. Eighteen patients (36%) in the beyond‐2b group finally achieved eTICI 2c/3; 10 of these (56%) and 14 of the remaining 32 (44%) had favorable outcome ( P =0.83). The former rate was similar to that in the direct‐2c/3 group (58%; P =0.99). Conclusions Patients undergoing additional MT attempt after achieving eTICI 2b had numerically but not significantly more symptomatic intracranial hemorrhage and showed a similar level of functional outcome at 3 months than those who did not. When eTICI 2c/3 was finally achieved by additional attempts, functional outcome was similar with that of patients who directly achieved eTICI 2c/3 without experiencing 2b. Clinical Trial Registration Information URL: https://www.clinicaltrials.gov . Unique identifier: NCT02251665.

Spontaneous Recovery of Penetrating Cervical Spinal Cord Injury with Physiotherapeutic Treatment: Case Report and Review of the Literature

Stab wounds to the cervical spine are less common than injuries from road accidents, sports injuries, and falls. The presence of vital, vascular, neural, respiratory, and digestive structures in the neck region mean that this kind of spinal injury is generally critical, and its management is a challenge. We report a unique case of a previously healthy 17-year-old adolescent admitted for quadriplegia secondary to a stab wound to the cervical spine at the C4C5 level. There was no surgical indication. The patient underwent physiotherapy. He showed spontaneous neurological improvement two weeks later and was able to sit on his own and to walk about three months of physical rehabilitation.

The Degree of Plasma Oxidized Low-Density Lipoprotein Level Decrease Is Related to Clinical Outcomes for Patients with Acute Ischemic Stroke

Objective. To investigate the relationship between the decrease of plasma oxidized low-density lipoprotein (oxLDL) levels and clinical outcomes in patients with acute atherosclerosis-related ischemic stroke. Methods. We recruited acute ischemic stroke patients within 3 days of onset consecutively. Plasma oxLDL levels were measured on the second day after admission and before discharge (10-14 days after stroke onset). Initial stroke severity was assessed by the National Institutes of Health Stroke Scale (NIHSS) scores, and infarct volume was measured using diffusion-weighted imaging (DWI) by the ITK-SNAP software. Clinical outcomes were evaluated by DWI volumes in the acute phase, neurological improvement at discharge, and favorable functional prognosis at 90 days. Logistic regression was performed to evaluate the association between oxLDL level decrease and clinical outcomes. Results. 207 patients were enrolled in this study. Compared with the mild decrease of the oxLDL level group, patients with a significant decrease of the oxLDL level group were more likely to have a higher ratio of neurological improvement at discharge (55.07% vs. 14.49%, p < 0.01 ) and favorable functional prognosis at 90 days (91.30% vs. 55.07%, p < 0.01 ). In multivariable logistic regression, the degree of oxLDL level decrease was related to neurological improvement at discharge and favorable functional prognosis at 90 days ( p < 0.01 ). Patients with significant decrease were more likely to have neurological improvement at discharge ( OR = 7.92 , 95% CI, 3.14-19.98, and p < 0.01 ) and favorable functional prognosis at 90 days ( OR = 7.46 , 95% CI, 2.40-23.23, and p < 0.01 ) compared to patients with mild decrease of oxLDL level. The DWI volumes in patients with different oxLDL level decrease groups had no statistical difference ( p = 0.41 ), and the Spearman’s rho between oxLDL level decrease and DWI infarct volumes was -0.03, but no statistical difference ( p = 0.72 ). Conclusions. The degree of oxLDL level decrease is related to neurological improvement at discharge and favorable functional prognosis at 90 days for patients with acute atherosclerosis-related ischemic stroke, but not with infarct volume in the acute phase.

Association of Multiple Passes during Mechanical Thrombectomy with Incomplete Reperfusion and Lesion Growth

<b><i>Introduction:</i></b> Despite complete recanalization by mechanical thrombectomy, abnormal perfusion can be detected on MRI obtained post-endovascular therapy (EVT). The presence of residual perfusion abnormalities post-EVT may be associated with blood-brain barrier breakdown in response to mechanical disruption of the endothelium from multiple-pass thrombectomy. We hypothesize that multiple-pass versus single-pass thrombectomy is associated with a higher rate of residual hypoperfusion and increased lesion growth at 24 h. <b><i>Materials and Methods:</i></b> For this analysis, we included patients presenting to one of two stroke centers between January 2015 and February 2018 with an acute ischemic stroke within 12 h from symptom onset if they had a large vessel occlusion of the anterior circulation documented on magnetic resonance angiography or CTA, baseline MRI pre-EVT with imaging evidence of hypoperfusion, underwent EVT, and had a post-EVT MRI with qualitatively interpretable perfusion-weighted imaging data at 24 h. MRI <i>T</i>_max maps using a time delay threshold of &#x3e;6 s were used to quantitate hypoperfusion volumes. Residual hypoperfusion at 24 h was solely defined as <i>T</i>_max volume &#x3e;10 mL with &#x3e;6 s delay. Complete recanalization was defined as modified treatment in cerebral infarction visualized on angiography at EVT completion. Hyperintense acute reperfusion injury marker was assessed on post-EVT pre-contrast fluid-attenuated inversion recovery at 24 h. Major early neurological improvement was defined as a reduction of the admission National Institutes of Health Stroke Scale by ≥8 points or a score of 0–1 at 24 h. Good functional outcome was defined as 0–2 on the modified Rankin Scale on day 30 or 90. <b><i>Results:</i></b> Fifty-five patients were included with median age 67 years, 58% female, 45% Black/African American, 36% White/Caucasian, median admission National Institutes of Health Stroke Scale 19, large vessel occlusion locations: 71% M1, 14.5% iICA, 14.5% M2, 69% treated with intravenous recombinant tissue plasminogen activator. Of these, 58% had multiple-pass thrombectomy, 39% had residual perfusion abnormalities at 24 h, and 64% had severe hyperintense acute reperfusion injury marker at 24 h. After adjusting for complete recanalization, only multiple-pass thrombectomy (odds ratio, 4.3 95% CI, 1.07–17.2; <i>p</i> = 0.04) was an independent predictor of residual hypoperfusion at 24 h. Patients with residual hypoperfusion had larger lesion growth on diffusion-weighted imaging (59 mL vs. 8 mL, <i>p</i> &#x3c; 0.001), lower rate of major early neurological improvement (24% vs. 70%, <i>p</i> = 0.002) at 24 h, and worse long-term outcome based on the modified Rankin Scale at 30 or 90 days, 5 versus 2 (<i>p</i> &#x3c; 0.001). <b><i>Conclusions:</i></b> Our findings suggest that incomplete reperfusion on post-EVT MRI is present even in some patients with successful recanalization at the time of EVT and is associated with multiple-pass thrombectomy, lesion growth, and worse outcome. Future studies are needed to investigate whether patients with residual hypoperfusion may benefit from immediate adjunctive therapy to limit lesion growth and improve clinical outcome.

THE INFLUENCE OF THE PREHOSPITAL PAUSE ON THE OUTCOMES OF EMERGENCY DECOMPRESSIVE-STABILIZING SURGERIES IN PATIENTS WITH TUMOR AND INFECTIOUS SPINE DISEASE

Resume. Purpose. To assess the relationship between the duration of pathological symptoms developed due to tumor or infectious destruction of the spine, and the medium-term (3 months after surgery) and long-term (1-year) outcomes of operations performed according to urgent indications. Study design: two-center cohort retrospective; level of evidence IIC [1]. Material and methods. 84 patients with tumor (group 1, n = 43) and infectious (group 2, n = 41) lesions of the spine underwent decompression and stabilization operations according to urgent indications in the period from 2016 to 2018. Neurological status (evaluation method -Frankel scale), pain intensity (evaluation method - visual analogue scale, VAS) and functional independence of patients (evaluation method - Karnofsky scale) were assessed before intervention, 3 months and 1 year after surgery. Statistical relationship between treatment outcomes and duration of the prehospital delay has been studied. Results. Only 11 out of 84 patients (13.1%), operated on for urgent indications, were hospitalized in the first 72 hours from the onset of vertebral syndrome; 6 (7.1%) of them had neurological disorders. At the time of surgery, 23 patients in each group had neurological disorders (53.5% and 56.1%, respectively), while the average duration of the prehospital period in both groups (Me) was 14.0 days. In patients without neurological disorders, the duration of the prehospital pause for the group of tumor lesions was 22.5 (14.0; 40; 0), for infectious - 14.5 (6.3; 30.0) days (data format - Me (Q25; Q75). After decompression and stabilization operations, positive neurological dynamics observed in patients with tumor lesions both in plegia and paresis (types B - D according to Frankel), while in infectious destruction - only in patients with mild paresis. An inverse correlation dependence of high strength between the duration of neurological disorders and the possibility of their improvement by 3 months after surgery was revealed in both groups (rs1 = -0.793 and rs2 = -0.828; p 0.001), as well as there was no connection between such outcomes and the duration of the hospital period (the urgency of the operation) (rs1 = -0.257; p = 0.283 and rs2 = -0.218; p = 0.330). When hospitalized for more than 14 days from the onset of pathological symptoms, the possibility of neurological improvement after surgery ceases to be statistically significant (p1 = 0.083, p2 = 0.157 for both groups, respectively), while the likelihood of a decrease in pain syndrome and functional dependence on others remains independent of the duration of the prehospital period. Conclusion. In case of tumor and infectious destruction of the vertebrae, urgent decompression and stabilization operations lead to a significant reduction in pain syndrome and an improvement in the functional independence of patients 3 and 12 months after the operation, regardless of the duration of the prehospital period. The duration of prehospital period of more than 2 weeks is critical for a reliable prognosis of improvement in neurological disorders after urgent surgeries in patients with neoplastic and infectious lesions of the spine.

726 Outcomes of ischaemic stroke in patients with atrial fibrillation

Aims Atrial fibrillation (AF) increases the risk of ischaemic strokes (IS) and is associated with a more severe neurological impairment. We sought to investigate whether AF also impacts the neurological recovery and whether patients with AF have a different response to the treatment. Methods and results Data of patients admitted to the Stroke Unit of our institution from January to December 2020 were retrieved from the local database. The stroke severity was calculated by mean of the National Institute of Health Stroke Scale (NIHSS) at hospital admission (NIHSSad), at 24 h (NIHSS24) and at discharge (NIHSSdis). The functional capacity was assessed by the modified Rankin score (mRS). As for the neurological recovery, this was assessed by the delta NIHSS at 24 h (Δ24 = NIHSS24−NIHSSad) and at discharge (Δdis = NIHSSdis−NIHSSad). Out of 545 patients with IS 64 had known history of AF or were admitted with AF. Patients with AF had higher NIHSSad (13.9 ± 7 vs. 8.5 ± 7; P &lt; 0.001) and NIHSS24 (9.6 ± 8 vs. 6.4 ± 7; P = 0.007) than patients without, however the neurological improvement was greater (Δdis −7.4 ± 9 vs. −3.4 ± 6; P = 0.002), indeed the NIHSSdis was similar (4.2 ± 5 vs. 4.2 ± 6; P = 0.98). Patients with AF also had a more impaired mRS before the ischaemic event and at discharge (2.4 ± 1.9 vs. 1.6 ± 1.7, P = 0.02; 1.2 ± 1.2 vs. 0.4 ± 0.9, P &lt; 0.001). Among AF patients with CHADVASC ≥ 3, 34% of them were taking antiplatelet therapy, 31% anticoagulants, and 35% didn’t take any therapy. Of interest, no differences in the NIHSSad nor in the NIHSSdis were found between them and neither in the Δdis. As for the treatment of AF patients, no differences in the neurological recovery were observed between those treated with intravenous thrombolysis and those not treated at all (Δdis 2.8 ± 5 vs. 2.8 ± 8, P = 1), whereas the Δdis was significantly higher in patients treated with mechanical thrombectomy (−11.7 ± 7, P = 0.007). Conclusions Patients with AF experience more severe stroke, however the neurological recovery is greater than in patients without the arrhythmia. The treatment with antiplatelets or anticoagulants before the event does not reduce the severity of the stroke and does not influence the improvement of the NIHSS at discharge. The mechanical thrombectomy is more effective in reducing the neurological impairment.

SEVERE CERVICAL MYELOPATHY: APPROACHES AND POSTOPERATIVE EVALUATION

ABSTRACT Objectives: To evaluate and compare the clinical evolution of surgical approaches used in patients with severe cervical myelopathy. Methods: Retrospective observational study in which 19 patients with myelopathy who underwent surgery were evaluated. Neurological assessments using the Frankel scale were conducted both preoperatively and one year following surgery, and the modified Japanese Orthopedic Association (JOA), Nurick, and Visual Analog Scale for pain (VAS) questionnaires were applied 1 year after the surgical procedure. Results: 89% of the participants were male and the average age was 63.9 years. No patient had postoperative neurological worsening, 12 patients (63.16%) had mild pain, and seven (36.84%) had moderate pain. The group with degenerative disease showed neurological improvement after surgery and the exclusively anterior approach was used in 84% of the cases, the exclusively posterior approach in 10% of the cases, and the dual approach in 6% of the cases. Conclusion: Surgical treatment has good results for inhibiting the unfavorable natural evolution of myelopathy within 1 year following surgery and promotes neurological improvement in degenerative cases, making it possible to use the anterior access route in most cases. Level of evidence III; Retrospective Study.

A multicenter cohort study of early complications after cranioplasty: results of the German Cranial Reconstruction Registry

OBJECTIVE Cranioplasty (CP) is a crucial procedure after decompressive craniectomy and has a significant impact on neurological improvement. Although CP is considered a standard neurosurgical procedure, inconsistent data on surgery-related complications after CP are available. To address this topic, the authors analyzed 502 patients in a prospective multicenter database (German Cranial Reconstruction Registry) with regard to early surgery-related complications. METHODS Early complications within 30 days, medical history, mortality rates, and neurological outcome at discharge according to the modified Rankin Scale (mRS) were evaluated. The primary endpoint was death or surgical revision within the first 30 days after CP. Independent factors for the occurrence of complications with or without surgical revision were identified using a logistic regression model. RESULTS Traumatic brain injury (TBI) and ischemic stroke were the most common underlying diagnoses that required CP. In 230 patients (45.8%), an autologous bone flap was utilized for CP; the most common engineered materials were titanium (80 patients [15.9%]), polyetheretherketone (57 [11.4%]), and polymethylmethacrylate (57 [11.4%]). Surgical revision was necessary in 45 patients (9.0%), and the overall mortality rate was 0.8% (4 patients). The cause of death was related to ischemia in 2 patients, diffuse intraparenchymal hemorrhage in 1 patient, and cardiac complications in 1 patient. The most frequent causes of surgical revision were epidural hematoma (40.0% of all revisions), new hydrocephalus (22.0%), and subdural hematoma (13.3%). Preoperatively increased mRS score (OR 1.46, 95% CI 1.08–1.97, p = 0.014) and American Society of Anesthesiologists Physical Status Classification System score (OR 2.89, 95% CI 1.42–5.89, p = 0.003) were independent predictors of surgical revision. Ischemic stroke, as the underlying diagnosis, was associated with a minor rate of revisions compared with TBI (OR 0.18, 95% CI 0.06–0.57, p = 0.004). CONCLUSIONS The authors have presented class II evidence–based data on surgery-related complications after CP and have identified specific preexisting risk factors. These results may provide additional guidance for optimized treatment of these patients.

Ischemic Stroke in a Child after a Probable Scorpion Sting

Scorpion stings are common emergencies in the tropics. Species-specific antivenom therapies are available. However, fatalities resulting from scorpion stings remain a public health concern in many settings. Children residing in rural towns and peri-urban areas represent the most vulnerable populations. Delays in the diagnosis of scorpion stings often occur as a result of the non-specific clinical presentations, which then lead to life-threatening complications. We report a 2-year-old Venezuelan boy presenting with acute pancreatitis and pulmonary edema without an identifiable cause 48 hours after his initial symptoms. We administered antivenom therapy when an undetected scorpion sting was suspected. Despite some initial clinical improvement with respect to his acute pancreatitis, pulmonary edema, and coagulation abnormalities, our patient experienced an ischemic stroke. Fortunately, our patient did demonstrate some neurological improvement. Although acute pancreatitis and pulmonary edema are known end-organ damage manifestations of the sting of Tityus in the Americas, our particular case illustrates the risk of ischemic stroke.