Management of covert brain infarction survey: A call to care for and trial this neglected population

BACKGROUND Covert brain infarction (CBI) is highly prevalent and linked with stroke risk factors, increased mortality, and morbidity. Evidence to guide management is sparse. We sought to gain information on current practice and attitudes toward CBI and to compare differences in management according to CBI phenotype. METHODS We conducted a web-based, structured, international survey from November 2021 to February 2022 among neurologists and neuroradiologists. The survey captured respondents' baseline characteristics, general approach toward CBI and included two case scenarios designed to evaluate management decisions taken upon incidental detection of an embolic-phenotype and a small-vessel-disease phenotype. RESULTS Of 627 respondents (38% vascular neurologists, 24% general neurologists, and 26% neuroradiologists), 362 (58%) had a partial, and 305 (49%) a complete response. Most respondents were university hospital senior faculty members experienced in stroke, mostly from Europe and Asia. Only 66 (18%) of respondents had established institutional written protocols to manage CBI. The majority indicated that they were uncertain regarding useful investigations and further management of CBI patients (median 67 on a slider 0-100, 95% CI 35-81). Almost all respondents (97%) indicated that they would assess vascular risk factors. Although most would investigate and treat similarly to ischemic stroke for both phenotypes, including initiating antithrombotic treatment, there was considerable diagnostic and therapeutic heterogeneity. Less than half of respondents (42%) would assess cognitive function or depression. CONCLUSIONS There is a high degree of uncertainty and heterogeneity regarding management of two common types of CBI, even among experienced stroke physicians. Respondents were more proactive regarding the diagnostic and therapeutic management than the minimum recommended by current expert opinions. More data are required to guide management of CBI; meantime, more consistent approaches to identification and consistent application of current knowledge, that also consider cognition and mood, would be promising first steps to improve consistency of care

The relationship between γ Cassiopeiae’s X-ray emission and its circumstellar environment

γ Cas is the prototypical classical Be star and is recently best known for its variable hard X-ray emission. To elucidate the reasons for this emission, we mounted a multiwavelength campaign in 2010 centered around four XMM-Newton observations. The observational techniques included long baseline optical interferometry (LBOI) from two instruments at CHARA, photometry carried out by an automated photometric telescope and Hα observations. Because γ Cas is also known to be in a binary, we measured radial velocities from the Hα line and redetermined its period as 203.55 ± 0.20 days and its eccentricity as near zero. The LBOI observations suggest that the star’s decretion disk was axisymmetric in 2010, has an system inclination angle near 45°, and a larger radius than previously reported. In addition, the Be star began an “outburst” at the beginning of our campaign, made visible by a brightening and reddening of the disk during our campaign and beyond. Our analyses of the new high resolution spectra disclosed many attributes also found from spectra obtained in 2001 (Chandra) and 2004 (XMM-Newton). As well as a dominant hot ( ≈ 14 keV) thermal component, the familiar attributes included: (i) a fluorescent feature of Fe K even stronger than observed at previous times; (ii) strong lines of N VII and Ne XI lines indicative of overabundances; and (iii) a subsolar Fe abundance from K-shell lines but a solar abundance from L-shell ions. We also found that two absorption columns are required to fit the continuum. While the first one maintained its historical average of 1 × 1021 cm-2, the second was very large and doubled to 7.4 × 1023 cm-2 during our X-ray observations. Although we found no clear relation between this column density and orbital phase, it correlates well with the disk brightening and reddening both in the 2010 and earlier observations. Thus, the inference from this study is that much (perhaps all?) of the X-ray emission from this source originates behind matter ejected by γ Cas into our line of sight

Transient ischemic attacks in patients with active and occult cancer.

BACKGROUND AND AIM Paraneoplastic coagulopathy can present as stroke and is associated with specific biomarker changes. Identifying paraneoplastic coagulopathy can help guide secondary prevention in stroke patients, and early cancer detection might improve outcomes. However, unlike ischemic stroke, it remains unclear whether paraneoplastic coagulopathy is associated with transient ischemic attacks (TIA). This study assessed the presence of cancer-related biomarkers in TIA patients and evaluated long-term mortality rates in patients with and without active cancer. METHODS Active cancer was retrospectively identified in consecutive TIA patients treated at a comprehensive stroke center between 2015 and 2019. An association between the presence of cancer and cancer-related biomarkers was assessed using multivariable logistic regression. Long-term mortality after TIA was analyzed using multivariable Cox regression. RESULTS Among 1436 TIA patients, 72 had active cancer (5%), of which 17 were occult (1.2%). Cancer-related TIA was associated with male gender (adjusted odds ratio [aOR] 2.29, 95% CI 1.12-4.68), history of smoking (aOR 2.77, 95% CI 1.34-5.7), elevated D-dimer (aOR 1.77, 95% CI 1.26-2.49), lactate dehydrogenase (aOR 1.003, 95% CI 1.00-1.005), lower leukocyte count (aOR 1.20, 95% CI 1.04-1.38), and lower hemoglobin (aOR 1.02, 95% CI 1.00-1.04). Long-term mortality was associated with both active cancer (adjusted hazard ratios [aHR] 2.47, 95% CI 1.58-3.88) and occult cancer (aHR 3.08, 95% CI 1.30-7.32). CONCLUSION Cancer-related TIA is not uncommon. Biomarkers known to be associated with cancer-related stroke also seem to be present in TIA patients. Early identification would enable targeted treatment strategies and could improve outcomes in this patient population

Development of a score for prediction of occult malignancy in stroke patients (occult-5 score).

BACKGROUND AND PURPOSE Malignancy associated acute ischemic stroke (AIS) requires specific diagnostic work-up, treatment and prevention to improve outcome. This study aimed to develop a biomarker-based score for prediction of occult malignancy in AIS patients. METHODS Single-center cross-sectional study including consecutive AIS patients treated between July 2017 and November 2018. Patients with active malignancy at presentation, or diagnosed within 1 year thereafter and patients free of malignancy, were included and malignancy associated biomarkers were assessed. LASSO analyses of logistic regression were performed to determine biomarkers predictive of active malignancy. Predictors were derived from a predictive model for active malignancy. A comparison between known and unknown (=occult) malignancies when the index stroke occurred was used to eliminate variables not associated with occult malignancy. A predictive score (OCCULT-5 score) for occult malignancy was developed based on the remaining variables. RESULTS From 1001 AIS patients, 61 (6%) presented an active malignancy. Thirty-nine (64%) were known and 22 (36%) occult. Five variables were included in the final OCCULT-5 score: age ≥ 77 years, embolic stroke of undetermined source, multi-territorial infarcts, D-dimer levels ≥ 820 µ/gL, and female sex. A score of ≥ 3 predicted an underlying occult malignancy with a sensitivity of 64%, specificity of 73%, positive likelihood ratio of 2.35 and a negative likelihood ratio of 0.50. CONCLUSIONS The OCCULT-5 score might be useful to identify patients with occult malignancy. It may thus contribute to a more effective and timely treatment and thus lead to a positive impact on overall outcome

Absence of Susceptibility Vessel Sign in Patients With Malignancy-Related Acute Ischemic Stroke Treated With Mechanical Thrombectomy.

Background and Purpose Clots rich in platelets and fibrin retrieved from patients with acute ischemic stroke (AIS) have been shown to be independently associated with the absence of the susceptibility vessel sign (SVS) on MRI and active malignancy. This study analyzed the association of SVS and the presence of active malignancy in patients with AIS who underwent mechanical thrombectomy (MT). Methods This single-center, retrospective, and cross-sectional study included consecutive patients with AIS with admission MRI treated with MT between January 2010 and December 2018. SVS status was evaluated on susceptibility-weighted imaging. Adjusted odds ratios (aORs) were calculated to determine the association between absent SVS and the presence of active or occult malignancy. The performance of predictive models incorporating and excluding SVS status was compared using areas under the receiver operating characteristics curve (auROC). Results Of 577 patients with AIS with assessable SVS status, 40 (6.9%) had a documented active malignancy and 72 (12.5%) showed no SVS. The absence of SVS was associated with active malignancy (aOR 4.85, 95% CI 1.94-12.11) or occult malignancy (aOR 11.42, 95% CI 2.36-55.20). The auROC of predictive models, including demographics and common malignancy biomarkers, was higher but not significant (0.85 vs. 0.81, p = 0.07) when SVS status was included. Conclusion Absence of SVS on admission MRI of patients with AIS undergoing MT is associated with malignancy, regardless of whether known or occult. Therefore, the SVS might be helpful in detecting paraneoplastic coagulation disorders and occult malignancy in patients with AIS

Baseline characteristics and outcome of stroke patients after endovascular therapy according to previous symptomatic vascular disease and sex

AimThe aim of this study was to investigate baseline characteristics and outcome of patients after endovascular therapy (EVT) for acute large vessel occlusion (LVO) in relation to their history of symptomatic vascular disease and sex.MethodsConsecutive EVT-eligible patients with LVO in the anterior circulation admitted to our stroke center between 04/2015 and 04/2020 were included in this observational cohort study. All patients were treated according to a standardized acute ischaemic stroke (AIS) protocol. Baseline characteristics and successful reperfusion, recurrent/progressive in-hospital ischaemic stroke, symptomatic in-hospital intracranial hemorrhage, death at discharge and at 3 months, and functional outcome at 3 months were analyzed according to previous symptomatic vascular disease and sex.Results995 patients with LVO in the anterior circulation (49.4% women, median age 76 years, median admission NIHSS score 14) were included. Patients with multiple vs. no previous vascular events showed higher mortality at discharge (20% vs. 9.3%, age/sex − adjustedOR = 1.43, p = 0.030) and less independency at 3 months (28.8% vs. 48.8%, age/sex − adjustedOR = 0.72, p = 0.020). All patients and men alone with one or multiple vs. patients and men with no previous vascular events showed more recurrent/progressive in-hospital ischaemic strokes (19.9% vs. 6.4% in all patients, age/sex − adjustedOR = 1.76, p = 0.028) (16.7% vs. 5.8% in men, age-adjustedOR = 2.20, p = 0.035). Men vs. women showed more in-hospital symptomatic intracranial hemorrhage among patients with one or multiple vs. no previous vascular events (23.7% vs. 6.6% in men and 15.4% vs. 5.5% in women, OR = 2.32, p = 0.035/age − adjustedOR = 2.36, p = 0.035).ConclusionsPrevious vascular events increased the risk of in-hospital complications and poorer outcome in the analyzed patients with EVT-eligible LVO-AIS. Our findings may support risk assessment in these stroke patients and could contribute to the design of future studies

SIGNAL GENERATION AND EVALUATION IN FLUORESCENCE-BASED ON-LINE FIBER OPTIC BIOSENSORS

The signal generation, size and transmission of pre-steady-state and steady-state signals in fluorescence based fiber optic biosensors for on-line use and their applicability in several flow sensor configurations are investigated. In contrast to the theory, the signal for dynamic column biosensorswith larger particles was foundto be onlyslightly higher than for a column sensorwith smaller particles. This is due to interparticle interactions, which reduce the areathat is accessible for mass transfer, on particles with a diameter below 100 pm. Additionally this system has shown that dynamic biosensors with hydrolases can not be used for the determination of the end-pointof hydrolytic processes, when the equilibrium of the substrate conversion remains below 100%. The flow of optical power in fluorescent fiber optic sensors is analyzed, multiplicative noise is identified as the dominantlimitation of sensor performance. Evanescent coupling is a promising concept for fast biosensors. The observed nonlinear relation between absorbance and concentration is explained as an optical effect, caused by multimode operation. The use of special fibers with increased surface area gives higher sensitivity, reduced nonlinearity