Clinical Outcome of Isolated Cerebellar Stroke—A Prospective Observational Study

Background: The aim of this prospective study was to investigate clinical deficits of patients with isolated cerebellar stroke applying a dedicated clinical score, the modified International Cooperative Ataxia Rating Scale (MICARS) and identifying factors that influence recovery.Methods: Fifteen patients with acute isolated cerebellar stroke received a standard stroke MRI on the day of admission and were clinically assessed using the mRS, NIHSS and the modified International Cooperative Ataxia Rating Scale (MICARS) on day 1, 3, 7, 30, and 90. A generalized linear model for repeated measures was employed to analyze the effect of stroke lesion location, volume, days after stroke, patient age, and MICARS score at admission on the total MICARS score.Results: Median patient age was 54 years, lesion location in most cases was right (87%) and in the PICA territory (11/15). Median lesion volume was 3.2 ml. Median NIHSS was 1. The median MICARS decreased from on day 1 with 23–4 at day 90. The generalized linear model identified MICARS score at day 1, lesion location, days after admission and the interaction of the last two on the total MICARS score, whereas there was no significant effect of stroke volume or patient age.Conclusions: Isolated cerebellar stroke can present with low NIHSS while more specific scales like the MICARS indicate a severe deficit. Patient age at onset of stroke and lesion volume had no significant effect on recovery from cerebellar symptoms as opposed to severity of symptoms at admission and lesion location

Clinical characteristics and outcome of patients with lacunar infarcts and concurrent embolic ischemic lesions

Purpose: Lacunar infarcts are thought to result from occlusion of small penetrating arteries due to microatheroma and lipohyalinosis, pathognomonic for cerebral small vessel disease (CSVD). Concurrent embolic ischemic lesions indicate a different stroke mechanism. The purpose of this study was to examine the clinical characteristics and outcome of patients with lacunar infarcts and concurrent embolic infarcts on diffusion-weighted imaging (DWI). Methods: All patients screened for the WAKE-UP trial (ClinicalTrials.gov number, NCT01525290) were reviewed for acute lacunar infarcts and concurrent embolic lesions on baseline DWI. Clinical characteristics and outcome were compared between lacunar infarct patients with and without concurrent embolic lesions. Results: Of 244 patients with an acute lacunar infarct, 20 (8.2%) had concurrent acute embolic infarcts. Compared to patients with a lacunar infarct only, patients with concurrent embolic infarcts were older (mean age 69 years vs. 63 years; p = 0.031), more severely affected (median National Institutes of Health Stroke Scale [NIHSS] score 5 vs. 4; p = 0.046), and—among those randomized—had worse functional outcome at 90 days (median modified Rankin Scale [mRS] 3 vs. 1; p = 0.011). Conclusion: Approximately 8% of lacunar infarct patients show concurrent embolic lesions suggesting a stroke etiology other than CSVD. These patients are more severely affected and have a worse functional outcome illustrating the need for a thorough diagnostic work-up of possible embolic sources even in patients with an imaging-defined diagnosis of lacunar infarcts

Quantitative signal intensity in Fluid-Attenuated Inversion Recovery and treatment effect in the WAKE-UP trial

Background and Purpose: Relative signal intensity of acute ischemic stroke lesions in fluid-attenuated inversion recovery (fluid-attenuated inversion recovery relative signal intensity [FLAIR-rSI]) magnetic resonance imaging is associated with time elapsed since stroke onset with higher intensities signifying longer time intervals. In the randomized controlled WAKE-UP trial (Efficacy and Safety of MRI-Based Thrombolysis in Wake-Up Stroke Trial), intravenous alteplase was effective in patients with unknown onset stroke selected by visual assessment of diffusion weighted imaging fluid-attenuated inversion recovery mismatch, that is, in those with no marked fluid-attenuated inversion recovery hyperintensity in the region of the acute diffusion weighted imaging lesion. In this post hoc analysis, we investigated whether quantitatively measured FLAIR-rSI modifies treatment effect of intravenous alteplase. Methods: FLAIR-rSI of stroke lesions was measured relative to signal intensity in a mirrored region in the contralesional hemisphere. The relationship between FLAIR-rSI and treatment effect on functional outcome assessed by the modified Rankin Scale (mRS) after 90 days was analyzed by binary logistic regression using different end points, that is, favorable outcome defined as mRS score of 0 to 1, independent outcome defined as mRS score of 0 to 2, ordinal analysis of mRS scores (shift analysis). All models were adjusted for National Institutes of Health Stroke Scale at symptom onset and stroke lesion volume. Results: FLAIR-rSI was successfully quantified in stroke lesions in 433 patients (86% of 503 patients included in WAKE-UP). Mean FLAIR-rSI was 1.06 (SD, 0.09). Interaction of FLAIR-rSI and treatment effect was not significant for mRS score of 0 to 1 (P=0.169) and shift analysis (P=0.086) but reached significance for mRS score of 0 to 2 (P=0.004). We observed a smooth continuing trend of decreasing treatment effects in relation to clinical end points with increasing FLAIR-rSI. Conclusions: In patients in whom no marked parenchymal fluid-attenuated inversion recovery hyperintensity was detected by visual judgement in the WAKE-UP trial, higher FLAIR-rSI of diffusion weighted imaging lesions was associated with decreased treatment effects of intravenous thrombolysis. This parallels the known association of treatment effect and elapsing time of stroke onset

Post-Stroke Depression: Impact of Lesion Location and Methodological Limitations—A Topical Review

Post-stroke depression (PSD) affects approximately one-third of all stroke patients. It hinders rehabilitation and is associated with worse functional outcome and increased mortality. Since the identification of PSD is a significant clinical problem, clinicians and researchers have tried to identify predictors that indicate patients at risk of developing PSD. This also includes the research question whether there is an association between PSD and stroke lesion characteristics, e.g., lesion size and lesion location. Early studies addressing this question are largely limited by technical constraints and, thus, focused on simple lesion characteristics such as lesion side or proximity of the lesion to the frontal pole of the brain. More recent studies have addressed the impact of involvement of specific neuronal circuits in the stroke lesion. State-of-the-art methods of lesion symptom mapping to study PSD have only been applied to small patient samples. Overall, results are controversial and no clear pattern of stroke lesions associated with PSD has emerged, though there are findings suggesting that more frontal stroke lesions are associated with higher incidence of PSD. Available studies are hampered by methodological limitations, including drawbacks of lesion analysis methods, small sample size, and the issue of patient selection. These limitations together with differences in approaches to assess PSD and in methods of image analysis limit the comparability of results from different studies. To summarize, as of today no definite association between lesion location and PSD can be ascertained and the understanding of PSD rests incomplete. Further insights are expected from the use of modern lesion inference analysis methods in larger patient samples taking into account standardized assessment of possible confounding parameters, such as stroke treatment and reperfusion status

Table_1_Clinical Outcome of Isolated Cerebellar Stroke—A Prospective Observational Study.DOCX

<p>Background: The aim of this prospective study was to investigate clinical deficits of patients with isolated cerebellar stroke applying a dedicated clinical score, the modified International Cooperative Ataxia Rating Scale (MICARS) and identifying factors that influence recovery.</p><p>Methods: Fifteen patients with acute isolated cerebellar stroke received a standard stroke MRI on the day of admission and were clinically assessed using the mRS, NIHSS and the modified International Cooperative Ataxia Rating Scale (MICARS) on day 1, 3, 7, 30, and 90. A generalized linear model for repeated measures was employed to analyze the effect of stroke lesion location, volume, days after stroke, patient age, and MICARS score at admission on the total MICARS score.</p><p>Results: Median patient age was 54 years, lesion location in most cases was right (87%) and in the PICA territory (11/15). Median lesion volume was 3.2 ml. Median NIHSS was 1. The median MICARS decreased from on day 1 with 23–4 at day 90. The generalized linear model identified MICARS score at day 1, lesion location, days after admission and the interaction of the last two on the total MICARS score, whereas there was no significant effect of stroke volume or patient age.</p><p>Conclusions: Isolated cerebellar stroke can present with low NIHSS while more specific scales like the MICARS indicate a severe deficit. Patient age at onset of stroke and lesion volume had no significant effect on recovery from cerebellar symptoms as opposed to severity of symptoms at admission and lesion location.</p

Prevalence of Fractures and Diagnostic Accuracy of Emergency X-ray in Older Adults Sustaining a Low-Energy Fall: A Retrospective Study

Background: Plain radiography (XR) series are standard of care for detection of fall-related fractures in older patients with low-energy falls (LEF) in the emergency department (ED). We have investigated the prevalence of fractures and diagnostic accuracy of XR imaging in the ED. Methods: 2839 patients with LEF, who were presented to two urban level I trauma centers in 2016 and received XR and computed tomography (CT), were consecutively included in this retrospective cohort study. The primary endpoint was the prevalence of fractures of the vertebral column, rib cage, pelvic ring, and proximal long bones. Secondary endpoints were diagnostic accuracy of XR for fracture detection with CT as reference standard and cumulative radiation doses applied. Results: Median age was 82 years (range 65&ndash;105) with 64.1% female patients. Results revealed that 585/2839 (20.6%) patients sustained fractures and 452/2839 (15.9%) patients received subsequent XR and CT examinations of single body regions. Cross-tabulation analysis revealed sensitivity of XR of 49.7%, a positive likelihood ratio of 27.6, and negative likelihood ratio of 0.5. Conclusions: XR is of moderate diagnostic accuracy for ruling-out fractures of the spine, pelvic ring, and rib cage in older patients with LEF. Prospective validations are required to investigate the overall risk&ndash;benefit of direct CT imaging strategies, considering the trade-off between diagnostic safety, health care costs, and radiation exposure

Insular Cell Integrity Markers Linked to Weight Concern in Anorexia Nervosa—An MR-Spectroscopy Study

Objective: An insular involvement in the pathogenesis of anorexia nervosa (AN) has been suggested in many structural and functional neuroimaging studies. This magnetic resonance spectroscopy (MRS) study is the first to investigate metabolic signals in the anterior insular cortex in patients with AN and recovered individuals (REC). Method: The MR spectra of 32 adult women with AN, 21 REC subjects and 33 healthy controls (HC) were quantified for absolute N-acetylaspartate (NAA), glutamate + glutamine (Glx), total choline, myo-inositol, creatine concentrations (mM/L). After adjusting the metabolite concentrations for age and partial gray/white matter volume, group differences were tested using one-way multivariate analyses of variance (MANOVA). Post-hoc analyses of variance were applied to identify those metabolites that showed significant group effects. Correlations were tested for associations with psychometric measures (eating disorder examination), duration of illness, and body mass index. Results: The MANOVA exhibited a significant group effect. The NAA signal was reduced in the AN group compared to the HC group. The REC and the HC groups did not differ in metabolite concentrations. In the AN group, lower NAA and Glx signals were related to increased weight concern. Discussion: We interpret the decreased NAA availability in the anterior insula as a signal of impaired neuronal integrity or density. The association of weight concern, which is a core feature of AN, with decreased NAA and Glx indicates that disturbances of glutamatergic neurotransmission might be related to core psychopathology in AN. The absence of significant metabolic differences between the REC and HC subjects suggests that metabolic alterations in AN represent a state rather than a trait phenomenon

Clinical Characteristics and Outcome of Patients with Lacunar Infarcts and Concurrent Embolic Ischemic Lesions

PURPOSE: Lacunar infarcts are thought to result from occlusion of small penetrating arteries due to microatheroma and lipohyalinosis, pathognomonic for cerebral small vessel disease (CSVD). Concurrent embolic ischemic lesions indicate a different stroke mechanism. The purpose of this study was to examine the clinical characteristics and outcome of patients with lacunar infarcts and concurrent embolic infarcts on diffusion-weighted imaging (DWI). METHODS: All patients screened for the WAKE-UP trial (ClinicalTrials.gov number, NCT01525290) were reviewed for acute lacunar infarcts and concurrent embolic lesions on baseline DWI. Clinical characteristics and outcome were compared between lacunar infarct patients with and without concurrent embolic lesions. RESULTS: Of 244 patients with an acute lacunar infarct, 20 (8.2%) had concurrent acute embolic infarcts. Compared to patients with a lacunar infarct only, patients with concurrent embolic infarcts were older (mean age 69 years vs. 63 years; p = 0.031), more severely affected (median National Institutes of Health Stroke Scale [NIHSS] score 5 vs. 4; p = 0.046), and-among those randomized-had worse functional outcome at 90 days (median modified Rankin Scale [mRS] 3 vs. 1; p = 0.011). CONCLUSION: Approximately 8% of lacunar infarct patients show concurrent embolic lesions suggesting a stroke etiology other than CSVD. These patients are more severely affected and have a worse functional outcome illustrating the need for a thorough diagnostic work-up of possible embolic sources even in patients with an imaging-defined diagnosis of lacunar infarcts.status: publishe