• acute ischemic stroke
• carotid ultrasonography
• emergency medicine
• risk scoring model
• transient ischemic attack

• 111TMUH-NE-04 Taipei Medical University Hospital
• TMU111-AE1-B07 Taipei Medical University

• Transient ischemic attack
• intracranial arterial stenosis
• minor ischemic stroke
• recurrence
• risk stratification

• Humans
• Constriction, Pathologic/diagnostic imaging
• Stroke/etiology
• Stroke/complications
• Ischemic Attack, Transient/complications
• Risk Factors
• Risk Assessment
• Recurrence

• Machine learning
• Readmission
• SHAP
• Stroke

• Cerebral small vascular disease
• Infarction number
• Ischaemic stroke
• Recurrent stroke
• TIA

• Brain Ischemia/complications
• Cerebral Infarction/complications
• Cerebral Infarction/diagnostic imaging
• Cerebral Infarction/epidemiology
• Cerebral Small Vessel Diseases/complications
• Cerebral Small Vessel Diseases/diagnostic imaging
• Humans
• Ischemic Attack, Transient/complications
• Ischemic Attack, Transient/epidemiology
• Ischemic Stroke
• Platelet Aggregation Inhibitors/therapeutic use
• Stroke/complications
• Stroke/diagnostic imaging
• Stroke/epidemiology

• 81825007 the National Natural Science Foundation of China
• BJJWZYJH01201910025030 Beijing Outstanding Young Scientist Program
• 010 Youth Beijing Scholar Program
• 2018A12 Beijing Talent Project - Class A: Innovation and Development
• 2017YFC1307900 National Key R&D Program of China
• 2017YFC1307905 National Key R&D Program of China
• the National Natural Science Foundation of China
• Beijing Talent Project - Class A: Innovation and Development
• National Key R&D Program of China

• Acute ischemic stroke
• Improvement
• NIHSS
• Neurological improvement
• Prognosis
• Propensity score matching analysis
• Short-term outcome
• Survivors

• Mortality
• Stroke
• TIA

Introduction

Cerebrovascular accident (CVA), also termed as stroke, is the third leading cause of mortality and the most common cause of disability globally. The National Institutes of Health Stroke Scale (NIHSS) is a valid assessment tool utilized to determine the severity of the stroke and can be used to prioritize patients to design treatment plans, rehabilitation, and better clinical outcomes. The primary objective of this study was to determine the validity of the NIHSS to predict mortality among patients presenting with symptoms of a stroke.

Material and methods

This was a descriptive case-series conducted over a period of six months between September 2019 and February 2020 at a tertiary care hospital in Nawabshah, Pakistan. The sample population included 141 patients admitted within 24 hours of the onset of symptoms of a stroke. A neurological examination of the patients was performed. On admission, stroke severity was evaluated with the NIHSS. After an initial clinical evaluation, patients underwent a non-enhanced computed tomography (CT) scan of the brain. The score of NIHSS and mortality at 72 hours were recorded on the pre-defined proforma by the investigators. All statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 23.0 (Armonk, NY: IBM Corp).

Results

The mean age of the participants was 52.37±8.61 years. 68.1% of patients were hypertensive, 29.1% were diabetic, and 36.9% of patients were found with hyperlipidemia. The mortality rate was 41.1%. The mean NIHSS score was 16.68±6.72 points. The findings of this study demonstrated that the score of 14.9% cases was good (0-6 points), the score of 29.1% cases was moderate (7-15 points), and the score of 56% cases was poor (≥16 points). There was a significant association of NIHSS score with mortality (p<0.001).

Conclusions

Baseline NIHSS score has a profound association with mortality after acute stroke. It can help clinicians decide whether to provide thrombolytic treatment, rehabilitation or a combination of both in these patients and decrease the mortality rate. However, more studies are needed to potentiate these conclusions.

• health stroke scale system
• humans
• mortality
• national institutes of health stroke scale
• stroke
• validity

Large vessel occlusions (LVOs), variably defined as blockages of the proximal intracranial anterior and posterior circulation, account for approximately 24% to 46% of acute ischemic strokes. Commonly refractory to intravenous tissue plasminogen activator (tPA), LVOs place large cerebral territories at ischemic risk and cause high rates of morbidity and mortality without further treatment. Over the past few years, an abundance of high-quality data has demonstrated the efficacy of endovascular thrombectomy for improving clinical outcomes in patients with LVOs, transforming the treatment algorithm for affected patients. In this review, we discuss the epidemiology, pathophysiology, natural history, and clinical presentation of LVOs as a framework for understanding the recent clinical strides of the endovascular era.

• Endovascular thrombectomy
• Large vessel occlusion
• Stroke

• abcd² score
• cerebral infarction
• magnetic resonance angiography
• magnetic resonance diffusion weighted imaging
• transient ischemic attack

• China/epidemiology
• Diffusion Magnetic Resonance Imaging
• Female
• Humans
• Incidence
• Ischemic Attack, Transient/complications
• Ischemic Attack, Transient/diagnostic imaging
• Magnetic Resonance Angiography
• Male
• Middle Aged
• Predictive Value of Tests
• Risk Assessment
• Risk Factors
• Stroke/diagnostic imaging
• Stroke/epidemiology
• Stroke/etiology

Introduction: Recurrent stroke has a higher rate of death and disability. A number of risk scores have been developed to predict short-term and long-term risk of stroke following an initial episode of stroke or transient ischemic attack (TIA) with limited clinical utilities. In this paper, we review different risk score models and discuss their validity and clinical utilities.

Methods: The PubMed bibliographic database was searched for original research articles on the various risk scores for risk of stroke following an initial episode of stroke or TIA. The validation of the models was evaluated by examining the internal and external validation process as well as statistical methodology, the study power, as well as the accuracy and metrics such as sensitivity and specificity.

Results: Different risk score models have been derived from different study populations. Validation studies for these risk scores have produced conflicting results. Currently, ABCD² score with diffusion weighted imaging (DWI) and Recurrence Risk Estimator at 90 days (RRE-90) are the two acceptable models for short-term risk prediction whereas Essen Stroke Risk Score (ESRS) and Stroke Prognosis Instrument-II (SPI-II) can be useful for prediction of long-term risk.

Conclusion: The clinical risk scores that currently exist for predicting short-term and long-term risk of recurrent cerebral ischemia are limited in their performance and clinical utilities. There is a need for a better predictive tool which can overcome the limitations of current predictive models. Application of machine learning methods in combination with electronic health records may provide platform for development of new-generation predictive tools.

• clinical risk scores
• ischemic stroke
• predicting recurrence
• predictive modeling
• recurrent stroke risk

• cognition
• drug abuse
• health disparities
• homeless people
• infarct or infarction

• Adult
• Age Factors
• Alcoholism/epidemiology
• Attention
• Brain Infarction/epidemiology
• Brain Infarction/psychology
• British Columbia/epidemiology
• Cigarette Smoking/epidemiology
• Cognition
• Decision Making
• Diabetes Mellitus/epidemiology
• Dyslipidemias/epidemiology
• Female
• HIV Infections/epidemiology
• Hepatitis B/epidemiology
• Hepatitis C/epidemiology
• Ill-Housed Persons
• Housing
• Humans
• Hypertension/epidemiology
• Indigenous Peoples
• Inhibition, Psychological
• Intelligence Tests
• Magnetic Resonance Imaging
• Male
• Marijuana Abuse/epidemiology
• Memory
• Middle Aged
• Multivariate Analysis
• Overweight/epidemiology
• Poverty
• Prevalence
• Prospective Studies
• Risk Factors
• Stroke, Lacunar/epidemiology
• Stroke, Lacunar/psychology
• Substance Abuse, Intravenous/epidemiology
• Substance-Related Disorders/epidemiology
• Undiagnosed Diseases/epidemiology
• Verbal Learning
• White People
• Young Adult

• DWI-negative transient ischemic attack
• DWI-positive transient ischemic attack
• composite outcome
• follow-up study
• transient ischemic attack mimics

Endothelial progenitor cells (EPCs) play an important role in ischemic stroke. However, there are few studies on the relationship between EPC and nondisabling ischemic cerebrovascular events. Our aim was to investigate the association of EPCs and SDF-1 (serum stromal cell-derived factor-1) with NICE (nondisabling ischemic cerebrovascular events).

TIA (transient ischemic attack) and minor stroke patients (153 in total) who had an onset of symptoms within 1 day were consecutively collected. 83 of the patients were categorized into the HR-NICE (high-risk nondisabling ischemic cerebrovascular event) group, and 70 of the patients were in the NHR-NICE (non-high-risk nondisabling ischemic cerebrovascular events) group. Adopted FCM (flow cytometry) was used to measure EPCs, taking double-positive CD34/KDR as EPCs. ELISA was used to measure the concentrations of serum SDF-1 and VEGF (vascular endothelial growth factor). By the sequence of admission time, 15 patients were selected separately from the HR-NICE group and NHR-NICE group, and another 15 healthy volunteers were chosen as the NC (Normal Control) group. The MTT method was used to measure the proliferation of EPCs of peripheral blood in all groups, and the Boyden chamber was used to measure the migration of EPCs.

Compared with the NHR-NICE group, the HR-NICE group was older and contained more patients with hypertension and diabetes. Triglyceride, total cholesterol, and low-density lipoprotein in the HR-NICE group were also higher. For factors such as smoking, BMI (body mass index), and HCY (homocysteine), there were no significant differences (P > 0.05). Circulating EPCs, SDF-1, and VEGF in the NHR-NICE group were all higher. According to the multifactor regression analysis, age, hypertension, diabetes, total cholesterol, EPCs, and SDF-1 are independent risk factors for HR-NICE. For EPCs of 48-h isolated cultures, proliferation and migration were observed to be weakened compared with those of the NC group (P < 0.05). EPCs in HR-NICE group had lower proliferation and migration than those in NHR-NICE group (P < 0.01).

For TIA and minor stroke patients, circulating EPCs and serum SDF-1 concentrations can be used to prognose HR-NICE. Factors that lead to high-risk NICE might be relevant to the decrease in proliferation and migration of circulating EPCs.

• Endothelial progenitor cells
• Nondisabling ischemic cerebrovascular events
• Stromal cell-derived factor-1
• TIA;minor stroke

• Arterial spin labeling
• Cerebral blood flow
• Perfusion
• Resting-state fMRI
• Time-shift analysis
• Transient ischemic attack

Transient ischemic attack (TIA) and minor stroke have high risks of recurrence and deterioration into severe ischemic strokes. Risk stratification of TIA and minor stroke is essential for early effective treatment. Traditional tools have only moderate predictive value, likely due to their inclusion of the limited number of stroke risk factors. Our review follows Hans Selye’s fundamental work on stress theory and the progressive shift of the autonomic nervous system (ANS) from adaptation to disease when stress becomes chronic. We will first show that traditional risk factors and acute triggers of ischemic stroke are chronic and acute stress factors or “stressors,” respectively. Our first review shows solid evidence of the relationship between chronic stress and stroke occurrence. The stress response is tightly regulated by the ANS whose function can be assessed with heart rate variability (HRV). Our second review demonstrates that stress-related risk factors of ischemic stroke are correlated with ANS dysfunction and impaired HRV. Our conclusions support the idea that HRV parameters may represent the combined effects of all body stressors that are risk factors for ischemic stroke and, thus, may be of important predictive value for the risk of subsequent ischemic events after TIA or minor stroke.

• autonomic nervous system
• heart rate variability
• ischemic stroke
• prediction
• stress
• transient ischemic attack

• brain infarction
• cerebral circulation
• cerebral cortex
• magnetic resonance imaging
• transient ischemic attack

• Aged
• Denmark
• Diffusion Magnetic Resonance Imaging
• Female
• Gray Matter/diagnostic imaging
• Gray Matter/pathology
• Humans
• Ischemic Attack, Transient/diagnostic imaging
• Kaplan-Meier Estimate
• Logistic Models
• Male
• Middle Aged
• Multivariate Analysis
• Prospective Studies
• ROC Curve
• Tertiary Care Centers
• Time Factors

Diffusion tensor imaging may aid brain ischemia assessment but is more time consuming than conventional diffusion-weighted imaging (DWI). We compared 3-gradient direction DWI (3DWI) and 20-gradient direction DWI (20DWI) standard vendor protocols in a hospital-based prospective cohort of patients with transient ischemic attack (TIA) for lesion detection, lesion brightness, predictability of persisting infarction, and final infarct size.

We performed 3T-magnetic resonance imaging including diffusion and T2-fluid attenuated inversion recovery (FLAIR) within 72 h and 8 weeks after ictus. Qualitative lesion brightness was assessed by visual inspection. We measured lesion area and brightness with manual regions of interest and compared with homologous normal tissue.

117 patients with clinical TIA showed 78 DWI lesions. 2 lesions showed only on 3DWI. No lesions were uniquely 20DWI positive. 3DWI was visually brightest for 34 lesions. 12 lesions were brightest on 20DWI. The median 3DWI lesion area was larger for lesions equally bright, or brightest on 20DWI [median (IQR) 39 (18–95) versus 18 (10–34) mm², P = 0.007]. 3DWI showed highest measured relative lesion signal intensity [median (IQR) 0.77 (0.48–1.17) versus 0.58 (0.34–0.81), P = 0.0006]. 3DWI relative lesion signal intensity was not correlated to absolute signal intensity, but 20DWI performed less well for low-contrast lesions. 3DWI lesion size was an independent predictor of persistent infarction. 3-gradient direction apparent diffusion coefficient areas were closest to 8-week FLAIR infarct size.

3DWI detected more lesions and had higher relative lesion SI than 20DWI. 20DWI appeared blurred and did not add information.

http://www.clinicaltrials.gov. Unique Identifier NCT01531946.

• diffusion tensor imaging
• diffusion-weighted imaging
• infarction
• magnetic resonance imaging
• transient ischemic attack

• TIA
• anticoagulants
• antiplatelet therapy
• arterial revascularization
• stroke risk stratification
• transient ischemic attack

Transient ischemic attack (TIA) increases the risk for a subsequent stroke. Typical symptoms include motor weakness, gait disturbance, and loss of coordination. The association between the presence of motor impairments during a TIA and the chances of a subsequent stroke has not been examined. In the current meta-analysis, we examine whether the odds of a stroke are greater in TIA individuals who experience motor impairments as compared with those who do not experience motor impairments.

We conducted a systematic search of electronic databases as well as manual searches of the reference lists of retrieved articles. The meta-analysis included studies that reported an odds ratio relating motor impairments to a subsequent stroke, or the number of individuals with or without motor impairments who experienced a subsequent stroke. We examined these studies using rigorous meta-analysis techniques including random effects model, forest and funnel plots, I², publication bias, and fail-safe analysis.

Twenty-four studies with 15,129 participants from North America, Australia, Asia, and Europe qualified for inclusion. An odds ratio of 2.11 (95% CI, 1.67–2.65, p = 0.000) suggested that the chances of a subsequent stroke are increased by twofolds in individuals who experience motor impairments during a TIA compared with those individuals who have no motor impairments.

The presence of motor impairments during TIA is a significantly high-risk clinical characteristic for a subsequent stroke. The current evidence for motor impairments following TIA relies exclusively on the clinical reports of unilateral motor weakness. A comprehensive examination of motor impairments in TIA will enhance TIA prognosis and restoration of residual motor impairments.

• meta-analysis
• motor impairments
• odds ratio
• stroke
• transient ischemic attack

• Mean platelet volume
• Neutrophil to lymphocyte ratio
• Platelet to lymphocyte ratio
• Red blood cell distribution width

• NIHSSS
• occlusion
• stroke
• transcranial Doppler

• MRI
• TIA
• perfusion MRI
• stroke
• transient ischemic attack

• atrial fibrillation
• cardiac embolic events
• silent strokes
• stroke risk

• remote ischemic preconditioning
• octogenarian
• nonagenarians
• intracranial arterial stenosis
• stroke
• recurrence

• Aged, 80 and over
• Arm/blood supply
• Blood Pressure
• Female
• Heart Rate
• Humans
• Inflammation/blood
• Ischemic Preconditioning/adverse effects
• Ischemic Preconditioning/methods
• Male
• Muscles/pathology
• Prospective Studies
• Skin/pathology
• Stroke/prevention & control
• Stroke/therapy
• Treatment Outcome

The risk of a subsequent stroke following a minor stroke is high. However, there are no effective rating scales to predict recurrent stroke following a minor one. Therefore, we assessed the risk factors associated with recurrent ischemic stroke or transient ischemic attack (TIA) within one year of minor stroke onset in order to identify possible risk factors.

Eight hundred and sixty-three non-cardioembolic ischemic stroke patients in the Chinese IntraCranial AtheroSclerosis Study that presented with minor stroke, defined as an admission National Institutes of Health stroke scale (NIHSS) score of ≤3, were consecutively enrolled in our study. Clinical information and imaging features upon admission, and any recurrent ischemic stroke or TIA within one year was recorded. Cox regression was used to identify risk factors associated with recurrent ischemic stroke or TIA within the year following stroke onset.

A total of 50 patients (6.1%) experienced recurrent ischemic stroke or TIA within one year of minor stroke onset. Multivariate Cox regression model identified lower admission NIHSS score (HR, 1.75; 95% CI, 1.32 to 2.33; P<0.0001), history of coronary heart disease (HR, 2.62; 95% CI, 1.17 to 5.86; P = 0.02), severe stenosis or occlusion of large cerebral artery (HR, 4.68; 95% CI, 1.87 to 11.7; P = 0.001), and multiple acute cerebral infarcts (HR, 2.61; 95% CI, 1.01 to 6.80; P = 0.05) as independent risk factors for recurrent ischemic stroke or TIA within one year.

Some minor stroke patients are at higher risk for recurrent ischemic stroke or TIA. Urgent and intensified therapy may be reasonable in these patients.

• Aged
• Brain Ischemia/complications
• Brain Ischemia/pathology
• Female
• Humans
• Magnetic Resonance Imaging
• Male
• Middle Aged
• Mortality
• Population Surveillance
• Prognosis
• Recurrence
• Risk Factors
• Stroke/epidemiology
• Stroke/etiology
• Stroke/pathology
• Time Factors

• Infarct volume
• Ischemic stroke
• MRI
• Recanalization
• Sub-acute

• Carotid stenosis
• Chinese ethnicity
• Lacunar infarct
• Prognosis
• Stroke
• Transient ischemic attack

Magnetic resonance (MR) diffusion-weighted imaging (DWI) is sensitive to small acute ischemic lesions and might help diagnose transient ischemic attack (TIA). Reclassification of patients with TIA and a DWI lesion as “stroke” is under consideration. We assessed DWI positivity in TIA and implications for reclassification as stroke.

We searched multiple sources, without language restriction, from January 1995 to July 2012. We used PRISMA guidelines, and included studies that provided data on patients presenting with suspected TIA who underwent MR DWI and reported the proportion with an acute DWI lesion. We performed univariate random effects meta-analysis to determine DWI positive rates and influencing factors.

We included 47 papers and 9,078 patients (range = 18–1,693). Diagnosis was by a stroke specialist in 26 of 47 studies (55%); all studies excluded TIA mimics. The pooled proportion of TIA patients with an acute DWI lesion was 34.3% (95% confidence interval [CI] = 30.5–38.4, range = 9–67%; I² = 89.3%). Larger studies (n > 200) had lower DWI-positive rates (29%; 95% CI = 23.2–34.6) than smaller (n < 50) studies (40.1%; 95% CI = 33.5–46.6%; p = 0.035), but no other testable factors, including clinician speciality and time to scanning, reduced or explained the 7-fold DWI-positive variation.

The commonest DWI finding in patients with definite TIA is a negative scan. Available data do not explain why ⅔ of patients with definite specialist-confirmed TIA have negative DWI findings. Until these factors are better understood, reclassifying DWI-positive TIAs as strokes is likely to increase variance in estimates of global stroke and TIA burden of disease. ANN NEUROL 2014;75:67–76

In spite of a documented reduction in incidence in high-income countries over the last decades, stroke is still a leading cause of death and disability worldwide. With the ageing of the population stroke-related economic burden is expected to increase, because of residual disability and its complications, such as cognitive impairment, high risk of falls and fractures, depression and epilepsy. Furthermore, because of the substantial rate of early and long-term vascular recurrences after the first event, secondary prevention after cerebral ischaemia is a crucial issue. This is even more important after minor stroke and transient ischaemic attack (TIA), in order to reduce the risk of potentially more severe and disabling events. To accomplish this aim, acute long-term medical and surgical treatments as well as lifestyle modifications are strongly recommended. However, apart from the well-established indications to thrombolysis, studies in acute phase after a first stroke or TIA are scarce and evidence is lacking. More trials are available for long-term secondary prevention with different classes of drugs, including antithrombotic medications for ischaemic events of arterial and cardiac origin, especially related to atrial fibrillation (antiplatelets and anticoagulants, respectively), lipid lowering agents (mainly statins), blood pressure lowering drugs, surgical and endovascular revascularization procedures.

• Stroke
• Transient ischaemic attack
• Secondary prevention
• Antiplatelets
• Anticoagulants
• Medical stroke treatment
• Carotid stenosis

• cerebrovascular occlusion
• ischemic attack, transient
• magnetic resonance imaging
• perfusion

• Aged
• Aged, 80 and over
• Cerebral Infarction/etiology
• Cerebral Infarction/pathology
• Cohort Studies
• Diffusion Magnetic Resonance Imaging/instrumentation
• Diffusion Magnetic Resonance Imaging/methods
• Female
• Humans
• Ischemic Attack, Transient/complications
• Ischemic Attack, Transient/diagnosis
• Male
• Middle Aged
• Perfusion Imaging
• Predictive Value of Tests
• Prospective Studies
• Risk
• Sensitivity and Specificity
• Stroke/complications
• Stroke/diagnosis

• MOP-118096 Canadian Institutes of Health Research
• MOP-89937 Canadian Institutes of Health Research

• Aged
• Comorbidity
• Constriction, Pathologic/diagnosis
• Constriction, Pathologic/epidemiology
• Female
• France/epidemiology
• Humans
• Incidence
• Intracranial Arterial Diseases/diagnosis
• Intracranial Arterial Diseases/epidemiology
• Ischemic Attack, Transient/diagnosis
• Ischemic Attack, Transient/epidemiology
• Magnetic Resonance Angiography/statistics & numerical data
• Middle Aged
• Prognosis
• Recurrence
• Risk Factors

• TIA hotline
• health services research
• population-based
• stroke prevention
• transient ischaemic attack
• triaging