A nomogram predicts early neurological deterioration after mechanical thrombectomy in patients with ischemic stroke

IntroductionEarly neurological deterioration (END) is common in acute ischemic stroke and is directly associated with poor outcome after stroke. Our aim is to develop and validate a nomogram to predict the risk of END after mechanical thrombectomy (MT) in acute ischemic stroke patients with anterior circulation large-vessel occlusion.MethodsWe conducted a real-world, multi-center study in patients with stroke treated with mechanical thrombectomy. END was defined as a worsening by 2 or more NIHSS points within 72-hour after stroke onset compared to admission. Multivariable logistic regression was used to determine the independent predictors of END, and the discrimination of the scale was assessed using the C-index. Calibration curves were constructed to evaluate the calibration of the nomogram, and decision curves were used to describe the benefits of using the nomogram.ResultsA total of 1007 patients were included in our study. Multivariate logistic regression analysis found age, admission systolic blood pressure, initial NIHSS scores, history of hyperlipemia, and location of occlusion were independent predictors of END. We developed a nomogram that included these 6 factors, and it revealed a prognostic accuracy with a C-index of 0.678 in the derivation group and 0.650 in the validation group. The calibration curves showed that the nomogram provided a good fit to the data, and the decision curves demonstrated a large net benefit.DiscussionOur study established and validated a nomogram to stratify the risk of END before mechanical embolectomy and identify high-risk patients, who should be more cautious when making clinical decisions

Recurrent stroke in a reproductive age women with patent foramen ovale

Abstract Background Patent foramen ovale (PFO) is a known cause of ischemic stroke in young adults and combined oral contraceptives (COCs) are widely used by women of reproductive age. If young women with PFO are taking COCs, they may be subjected to a synergistic increase in the occurrence of stroke, though reports of ischemic stroke in this population are rare. We report a woman of reproductive age who was taking COC suffered repetitive ischemic strokes before a patent foramen ovale (PFO) was detected and closed, which may raise concerns in this field. Case presentation A 31-year-old woman presented to the emergency department with sudden-onset right upper- and lower-limb weakness and dysarthria for 1 hour, whose only risk factor of stroke was oral contraceptive use. On admission, she was alert with left gaze deviation, dysarthria, and right-sided hemiplegia. Her symptoms improved after receiving the revascularization therapy. About 24 hours later, her left eye experienced sudden painless vision loss. Then the PFO with a substantial right-to-left shunt was detected and then she received a trans-catheter closure of the defect. Over 3 months of follow-up, there were no signs of stroke, but visual loss persisted. Conclusion This case of disabling stroke raises concerns regarding optimal management in primary and secondary prevention of stroke in young women on COCs with additional risk factors of stroke

Pre-stroke warfarin enhancement of collateralization in acute ischemic stroke: a retrospective study

Abstract Background Warfarin therapies not only are used to prevent stroke in patients with high risk of cardioembolism such as patients with atrial fibrillation (AF) and rheumatic heart disease (RHD), but also was associated with lower stroke severity and more favorable functional outcomes in patients with acute ischemic stroke due to middle cerebral artery occlusion. It was speculated that pre-stroke warfarin may promote collateralization and result in reduced stroke severity. This study aimed to investigate the association between pre-stroke warfarin use and leptomeningeal collaterals in patients with acute ischemic stroke due to occlusion of the middle cerebral artery. Methods We enrolled consecutive acute ischemic stroke patients (occlusion of the middle cerebral artery within 24 h) with known history of AF and/or RHD at the neurology department of the West China Hospital from May 2011 to April 2017. Computed tomography angiography (CTA) before treatment was used to detect the thrombus. Regional leptomeningeal collateral (rLMC) score based on CTA images was used to assess collateral circulation. Prior use of warfarin was recorded. Univariate and multivariate analyses were performed to detect the association of prior warfarin use with the collateral circulation. Results A total of 120 patients were included; 29 (24.2%) were taking warfarin before stroke. The international normalized ratio (INR) in patients with prior warfarin use was 1.53 ± 1.00, compared with 1.02 ± 0.09 in patients without prior warfarin use (P < 0.001). Prior oral warfarin therapy was inversely associated with poor rLMC (OR = 0.07, 95%CI 0.01–0.44, P = 0.005). There were no associations between prior warfarin use and initial stroke severity or functional outcomes at 3 months. Conclusion Warfarin use seems improve collateralization in patients with acute stroke. However, clinical controlled studies should be used to verify this claim

Anti-alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor encephalitis developed after ovarian cancer cytoreduction surgery: a case report and literature review

Abstract Background Anti-alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR) encephalitis, a rare subtype of autoimmune encephalitis (AE), is often found associated with tumors such as thymoma, lung cancer, ovarian tumors, and breast cancer, and the tumors were generally detected during the screening process after the encephalitis initiated. The tumor is considered a trigger of AE, but the mechanism remains unclear. Case Presentation A 53-year-old woman presented short-term memory loss two days after the primary cytoreduction for high-grade serous ovarian cancer (HGSOC, FIGO stage IC3). Cell-based assay found AMPAR CluA2 IgG positive in both serum (1:3.2) and cerebrospinal fluid (1:32). Moreover, mild AMPAR GluA1 and strong GluA2 expressions were also found positive in the paraffin sections of ovarian tumor tissue, indicating the ovarian cytoreduction surgery might stimulate the release of receptor antigens into the circulation system. The patient’s condition deteriorated within two weeks, developing consciousness and autonomic dysfunction, leading to ICU admission. With oral steroids, intravenous immunoglobulin, plasmapheresis, and rituximab treatment, the patient’s consciousness markedly improved after three months. Conclusion We presented the first case of anti-AMPAR encephalitis developed right after the primary cytoreduction of a patient with HGSOC and retrieved paraneoplastic anti-AMPAR encephalitis cases (n = 66). Gynecologists should pay attention to patients who develop cognitive dysfunction or psychiatric symptoms shortly after the ovarian tumor resection and always include AE in the differentiation diagnosis

Comparison of the Flexible Parametric Survival Model and Cox Model in Estimating Markov Transition Probabilities using Real-World Data

Background and Objective: Markov micro-simulation models are being increasingly used in health economic evaluations. An important feature of the Markov micro-simulation model is its ability to consider transition probabilities of heterogeneous subgroups with different risk profiles. A survival analysis is generally performed to accurately estimate the transition probabilities associated with the risk profiles. This study aimed to apply a flexible parametric survival model (FPSM) to estimate individual transition probabilities. Materials and Methods: The data were obtained from a cohort study investigating ischemic stroke outcomes in Western China. In total, 585 subjects were included in the analysis. To explore the goodness of fit of the FPSM, we compared the estimated hazard ratios and baseline cumulative hazards, both of which are necessary to the calculate individual transition probabilities, and the Markov micro-simulation models constructed using the FPSM and Cox model to determine the validity of the two Markov micro-simulation models and cost-effectiveness results. Results: The flexible parametric proportional hazards model produced hazard ratio and baseline cumulative hazard estimates that were similar to those obtained using the Cox proportional hazards model. The simulated cumulative incidence of recurrent ischemic stroke and 5-years cost-effectiveness of Incremental cost-effectiveness Ratios (ICERs) were also similar using the two approaches. A discrepancy in the results was evident between the 5-years cost-effectiveness and the 10-years cost-effectiveness of ICERs, which were approximately 0.9 million (China Yuan) and 0.5 million (China Yuan), respectively. Conclusions: The flexible parametric survival model represents a good approach for estimating individual transition probabilities for a Markov micro-simulation model

Additional file 1 of Anti-alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor encephalitis developed after ovarian cancer cytoreduction surgery: a case report and literature review

Supplementary Material

Elevated CRP at admission predicts post-stroke cognitive impairment in Han Chinese patients with intracranial arterial stenosis

<p>Elevated C-reactive protein (CRP) levels have been associated with cognitive deficits in certain patient populations, but whether this is also true of ischemic stroke patients is controversial. This study aims to examine the possible association between CRP concentration and post-stroke cognitive impairment (PSCI) in Han Chinese patients and to determine whether this association depends on intracranial arterial stenosis (ICAS).</p> <p>Patients with mild or moderate stroke admitted to a large regional medical center in Western China were consecutively enrolled in our study. Serum levels of CRP and ICAS severity were assessed at admission and cognitive status was assessed 6 months after stroke using the Six-Item Screener.</p> <p>Of the 1116 patients included in our study, no association was observed between CRP levels at admission and cognitive performance at 6 months. However, among the subgroup of 311 patients with ICAS, a significant association did exist, and it persisted even after adjusting for potential confounders (OR 1.038, 95% CI 1.015–1.061). We did not find the same association in the subgroup of the patients without ICAS.</p> <p>To our knowledge, this is the first study to explore the effects of CRP on PSCI in Han Chinese with ICAS. Our findings indicate that higher CRP levels at admission are associated with subsequent cognitive decline in Han Chinese patients with ICAS following ischemic stroke. Further studies in other ethnic groups are needed to validate the use of CRP to predict dementia in ICAS patients.</p