Purpose: To characterize and predict early post-stroke cognitive impairment by describing cognitive changes in stroke patients 4–8 weeks post-infarct, determining the relationship between cognitive ability and functional status at this early time point, and identifying the in-hospital risk factors associated with early dysfunction. Materials and Methods: Data were collected for 214 patients with ischemic stroke and 39 non-stroke controls. Montreal Cognitive Assessment (MoCA) exams were administered at post-hospitalization clinic visits approximately 4–8 weeks after infarct. MoCA scores were compared for patients with: no stroke, minor stroke [NIH Stroke Scale (NIHSS) < 5], and major stroke. Ordinal logistic regression was performed to assess the relationship between MoCA score and functional status [modified Rankin Scale score (mRS)] at follow-up. Predictors of MoCA < 26 and < 19 (cutoffs for mild and severe cognitive impairment, respectively) at follow-up were identified by multivariable logistic regression using variables available during hospitalization. Results: Post stroke cognitive impairment was common, with 66.8% of patients scoring < 26 on the MoCA and 22.9% < 19. The average total MoCA score at follow-up was 18.7 (SD 7.0) among major strokes, 23.6 (SD 4.8) among minor strokes, and 27.2 (SD 13.0) among non-strokes ( p = <0.0001). The follow-up MoCA score was associated with the follow-up mRS in adjusted analysis (OR 0.69; 95% C.I. 0.59–0.82). Among patients with no prior cognitive impairment ( N = 201), a lack of pre-stroke employment, admission NIHSS > 6, and left-sided infarct predicted a follow-up MoCA < 26 (c-statistic 0.75); while admission NIHSS > 6 and infarct volume > 17 cc predicted a MoCA < 19 (c-statistic 0.75) at follow-up. Conclusion: Many patients experience early post-stroke cognitive dysfunction that significantly impacts function during a critical time period for decision-making regarding return to work and future independence. Dysfunction measured at 4–8 weeks can be predicted during the inpatient hospitalization. These high-risk individuals should be identified for targeted rehabilitation and counseling to improve longer-term post-stroke outcomes.
We aim to investigate the benefit of patent foramen ovale (PFO) closure in older patients with embolic stroke of undetermined source (ESUS). Patients were carefully selected after an evaluation by a group of neurologists and cardiologists.
Significance Patients with small infarcts often demonstrate a poststroke acute dysexecutive syndrome resulting in failure to successfully re-integrate into society. The mechanism is poorly understood given that lesions are small and do not typically involve areas classically associated with cognitive decline. This knowledge gap makes designing treatment strategies difficult. We used MEG to evaluate changes in cerebral processing in individuals with small strokes. MEG showed a decrease in the amplitude of activation and temporal dispersion of activation peaks in areas responsible for visual word processing, along with an inability to modulate activity in response to task difficulty. These changes suggest disruption of network dynamics resulting in inefficient processing. Functional connectivity studies to isolate affected networks are the critical next step.
Hypertension is a common cause of intracerebral hemorrhage (ICH). The work up typically involves neuroimaging of the brain and blood vessels to determine etiology. However, extensive testing may be unnecessary for presumed hypertensive hemorrhages, and instead prolong hospital stay and increase costs. This study evaluates the predictive utility of hemorrhage location on the non-contrast head CT in determining hypertensive ICH. Patients presenting with non-traumatic ICH between March 2014 and June 2019 were prospectively enrolled. Hemorrhage etiology was determined based on previously defined criteria. Chi square and Student's t tests were used to determine the association between patient demographics, ICH severity, neuroimaging characteristics, and medical variables, with hypertensive etiology. Multivariable regression models and an ROC analysis determined utility of CT to accurately diagnose hypertensive ICH. Data on 380 patients with ICH were collected; 42% were determined to be hypertensive. Along with deep location on CT, black race, history of hypertension, renal disease, left ventricular hypertrophy, and higher admission blood pressure were significantly associated with hypertensive etiology, while atrial fibrillation and anticoagulation were associated with non-hypertensive etiologies. Deep location alone resulted in an area under the curve of 0.726. When history of hypertension was added, this improved to 0.771. Additional variables did not further improve the model's predictability. Hypertensive ICH is associated with several predictive factors. Using deep location and history of hypertension alone correctly identifies the majority of hypertensive ICH without additional work-up. This model may result in more efficient diagnostic testing without sacrificing patient care.
Cervical artery dissection (CeAD) accounts for 25% of ischemic strokes in young adults. This study evaluated the benefits and harms of intravenous thrombolysis (IVT) in patients presenting with spontaneous CeAD and acute ischemic stroke symptoms.
Introduction: Cervical artery dissection (CAD) accounts for nearly 2% of all ischemic strokes but up to 25% of ischemic strokes in young adults. Dissection is likely precipitated by the interplay between risk factors (migraine, low body mass index), environmental triggers (cervical trauma or infection), and genetic connective tissue abnormalities (e.g. Ehlers-Danlos or Marfan’s disease). In this study, we delineate the prevalence of triggers and risk factors in a multicenter cohort of cervical artery dissection. Methods: This is a post-hoc analysis of the Antithrombotic for Stroke Prevention in Cervical Artery Dissection Study (STOP-CAD). We recorded information using the admission data on risk factors (migraine), triggers (upper respiratory infection, COVID-19, and minor cervical injury), and whether the patient had a known connective tissue disorder (CTD). We determined the prevalence of risk factors, triggers, and presence of CTD in patients with cervical artery dissection as well as the interplay between these factors in the pathogenesis of CAD. Results: We identified 4023 patients with CAD, the mean age was 47 years and 45% were women. A history of migraines was present in 16.6% (668) patients. At least one environmental trigger was present in 26.3% of patients (1061 patients), with minor cervical injury being the most common (22.2%, 892 patients), then upper respiratory infections (6.2%, 251 patients), and COVID-19 (1.2%, 49 patients). Among cervical injury, the most common was chiropractic manipulation (5.7%, 228 patients). Only 2% (83 patients) were known to have a CTD with Fibromuscular Dysplasia being the most common (0.6%, 23 patients). Among the entire STOP-CAD cohort, only 5 patients (0.1%) had evidence of at least one trigger, risk factor, or a known connection tissue disease. On the other hand, 61% of patients (2441 patients) had none of the three recorded. Conclusion: In patients with CAD, the absence of any risk factor, trigger, or known CTD is common and should not lead to dismissing a dissection diagnosis in patients with symptoms concerning for CAD.
Introduction: Strokes affecting the posterior circulation (PCS) account for 20% of all ischemic strokes. In the emergency department, patients with PCS will often present with nonspecific symptoms such as dizziness, blurry vision, headache, nausea/vomiting, and altered mentation, leading to lower NIHSS scores. These also make PCS more prone to delayed recognition, missed diagnoses and delays in acute treatment. Recent studies indicate that PCS are half as likely to receive thrombolytic therapy and threefold less likely to receive intervention with mechanical thrombectomy compared to anterior circulation strokes (ACS). We aimed to create a protocol that identifies thrombolysis candidates for patients presenting with isolated dizziness. Methods: A code stroke activation protocol was implemented by the Rhode Island Hospital Stroke Committee in 08/2021. In addition to focal neurological symptoms typically associated with ACS, the protocol included objective criteria for a chief complaint of sustained isolated dizziness, including evidence of localizing examination findings and <24 hrs since last known well (LKW), or new balance issues and <4.5 hrs since LKW. A retrospective chart review was conducted for patients between 01/2021-06/2024 with a chief complaint of isolated dizziness. We compared the patients’ discharge diagnoses, decision for thrombolytic administration, door to activation times, and door to needle times. Results: In the years 2021 and 2022, there were 3 missed thrombolysis opportunities per year for patients presenting with isolated dizziness. From 01/2023-06/2024 there were 0 misses. The number of stroke mimics presenting with isolated dizziness who received thrombolysis was 11 in 2021, 16 in 2022, 9 in 2023, and 11 in 2024. The average door to needle time (in min) for patients with isolated dizziness and a diagnosis of acute ischemic stroke were 48.5 in 2021, 37.5 in 2022, 48 in 2023, and 62 in 2024. All delays in door to needle times were related to delayed activation, though all cases should have met criteria for the protocol. Conclusion: A simplified protocol is feasible to identify stroke patients with isolated dizziness eligible for thrombolysis. Use of the protocol reduced the number of missed PCS, however it also increased the number of stroke mimic patients who received thrombolysis for isolated dizziness. Continued education of the protocol is required to reduce the door to needle times in patients with isolated dizziness.
