Loeffler’s endocarditis: A rare cause of stroke resulting in person in the barrel syndrome (P3-10.001)

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Aterosclerosis Carotidea: Una Causa Frecuente Pero Prevenible de Ictus Isquémico

La aterosclerosis carotidea (AC) es responsable del 10-20% de todos los ictus isquémicos y se caracteriza por ser una causa prevenible de ictus mediante el control de factores de riesgo, manejo médico intensivo, y, en casos de AC severa, mediante la revascularización carotidea. Estudios originales en la década de 1990 mostraron un beneficio significativo de la revascularización por endarterectomia en pacientes con AC sintomática y estenosis severa (>70%), mientras que el beneficio en pacientes con estenosis moderada (50-69%) y en aquellos con AC asintomática fue más modesto. La identificación de factores de riesgo no tradicionales que puedan ayudar a la detección temprana y prevención primaria de AC, la eficacia de la terapia médica intensiva para disminuir el riesgo de ictus en pacientes con AC asintomática, y el desarrollo de nuevas técnicas quirúrgicas de revascularización con menor riesgo de complicaciones perioperatorias, son áreas de investigación activa en el manejo de pacientes de AC. El objetivo de nuestro artículo es resumir los conocimientos actuales de la AC y brindar un enfoque práctico para el diagnóstico y tratamiento de AC. Palabras clave: aterosclerosis carotidea, endarterectomía, estenosis carotídea, Ictus isquémic

Abstract WP153: Abnormal Cerebral Blood Flow Determined By Transcranial Doppler In Patients With Anterior Circulation Large-vessel Occlusion Stroke And Successful Endovascular Recanalization

Background: Almost half of large-vessel occlusion (LVO) stroke patients have unfavorable outcomes despite successful endovascular revascularization. We aim to characterize post-revascularization cerebral blood flow (CBF) determined by transcranial Doppler (TCD) and explore whether abnormal CBF associates with in-hospital outcomes in this population. Methods: We analyzed 105 stroke patients with anterior circulation LVO who had successful endovascular revascularization (Thrombolysis in Cerebral Infarction 2b-3) and CBF assessment by TCD within 48 hours of recanalization. TCD parameters recorded at the ipsilateral middle cerebral artery included mean flow velocity, peak systolic velocity, pulsatility index (PI), and resistance index (RI). CBF was classified according to the Thrombolysis in Brain Ischemia (TIBI) score into dampened flow (score of 3), stenotic flow (score of 4), and normal flow (score of 5). We explored unadjusted associations between post-revascularization CBF and hospitalization outcomes including reduced disability at discharge (modified Rankin Score [mRS] 0-2), home disposition, and in-hospital mortality. Results: Table 1 summarizes study population characteristics. Overall, 62 (59.1%) individuals had normal CBF, 29 (27.6%) had stenotic flow, and 14 (13.3%) had dampened flow. Patients with abnormal CBF showed a trend towards lower likelihood of mRS 0-2 at discharge (32.1% vs. 44.2%; p=0.20) and home disposition (28.1% vs. 46.6%; p=0.08). TCD parameters were not associated with disability at discharge or home disposition. However, in-hospital mortality was significantly associated with elevated PI (1.3 ± 0.4 vs. 1.1 ± 0.5; p<0.01) and RI (0.7 ± 0.1 vs. 0.6 ± 0.1; p<0.01). Conclusion: A noteworthy fraction of anterior circulation LVO stroke patients had TCD-defined abnormal CBF despite successful revascularization. Abnormal CBF and increased vascular resistance may relate to unfavorable outcomes in this population

Avoiding mistakes while writing scientific manuscripts in health sciences

INTRODUCTION: This article is part of a special series designed to help authors in the process of scientific writing. OBJECTIVE: To address common mistakes that researchers commit while writing a manuscript, in order to understand and optimize the process of writing a new research paper. METHODS: The authors made a nonsystematic search in the current literature (PubMed) to retrieve papers that address the most frequent mistakes found by editors, peer reviewers, journals and authors. RESULTS: According to the search results, key findings about the most common mistakes for each section of a manuscript were described (introduction section, methods section, results section, discussion section, conclusion section, references, title and abstract). CONCLUSION: There is a great amount of avoidable mistakes in each section of a scientific manuscript. Overall, among the most common mistakes are missing data, incomplete sections, excessive report of current literature or reporting data in an inadequate section.</p

Abstract TP97: Feasibility and Reliability of Patient-Reported Scores to Assess Long-Term Functional Outcomes in Stroke: A Sub-Group Analysis of the MaRISS Trial

Abstract only Obtaining delayed functional outcomes such as the modified Ranking score (mRS) after stroke is challenging in clinical practice, often resulting in missing data. Self-reported outcomes are an alternative to functional outcome collection, but their reliability and accuracy are not well-established Methods: In this subgroup analysis of the Mild and Rapidly Improving Stroke Study (MaRISS), we aimed to test the feasibility and reliability of the MaRISS Patient Reported Outcome (PRO) survey tool for obtaining delayed functional outcomes in low (0-5) National Institute of Health Stroke Scale ischemic stroke, particularly the modified Rankin Score (mRS), by assessing its inter-rater reliability with a score calculated by a clinician through a structured telephone interview. Other scores were compared as secondary outcomes. 125 surveys were distributed between January 2017 and July 2018. The tool consisted of an online survey aiming to collect information regarding the patient's functional status 90 days after stroke including the mRS (utilizing the mRS 9-Q version), Stroke Impact Scale-16 (SIS), Barthel Index (BI), European Quality of Life-5D-5L (EQ-Index). All participants also completed these scales administered by trained personnel through a structured telephone interview. Cohen's weighted kappa coefficients (κ) with 95% confidence intervals (CI) were calculated to assess the reliability of the PRO Tool Results: Of 125 surveys sent, 55/125 (46.4%) participants opened and started the survey but only 44/125 (36.8%) completed it entirely (mean age 62±12.5, 54.6% female, white 79.6%, NIHSS 2.3±1.8, ischemic stroke 84%, 16% TIA). 52 subjects completed both the online mRS 9-Q PRO and the telephone version (Table). The weighted kappa for the comparison of PRO mRS and the clinician-performed mRS was moderate [κ 0.53, SE 0.10; 95% CI (0.3-0.7)] as well as for the SIS (κ 0.43, SE 0.09) and EQ-Index (κ 0.40, SE 0.10) scores, whereas for BI was fair (κ 0.32, SE 0.15) Discussion: Engaging participants after hospital discharge remains difficult. Although participant completion rates for self-reported outcomes were low, the MaRISS PRO Tool showed moderate reliability. These findings should be confirmed in larger samples with a focus on improving participant engagemen

Impact of Covid-19 on Stroke Code Activations, Process Metrics, and Diagnostic Error

Background and Purpose: In a comprehensive stroke center, we analyzed the stroke code activations (SCA), assessed the impact of Covid-19, and the measures taken by the local government to lessen the spread of the disease. Methods: We retrospectively reviewed SCA and classified them into 2 groups: pre-pandemic activations (February 15 to March 10) and Covid-19 pandemic activations (March II to April 30). The primary outcome was the ratio of true positive diagnoses of stroke relative to the total number of SCA in the 2 time periods. Results: Among the 212 SCA, 83 (39.2%) were from the pre-pandemic period, whereas 129 (60.8%) were from the pandemic period, 147 (69.3%) in the Emergency Department (ED) versus 65 (30.7%) in the inpatient service. In the ED cohort, a rapid decrease in the number of SCA at the beginning of the pandemic was followed by a gradual increase to pre-pandemic levels and a significant increase in the number of true positive strokes over time (44.2% vs 61.1%, p = 0.037). An increase in door-to-CT time (p = 0.001) and an increase in the rate of diagnostic error in patients admitted from the ED (p = 0.016) were also seen. The in-hospital cohort had a sustained decrease in the number of SCA following the pandemic declaration, with no difference in the rate of true positive stroke. Conclusions: We observed a rapid decline and slow recovery in ED SCA with a shift toward increased true positive cases following the Covid-19 pandemic. Also, delays in obtaining CT and diagnostic error was increased, however, no difference in early clinical outcomes were seen between groups

Transcranial Doppler After Successful Endovascular Revascularization and Hospitalization Outcomes

Background Almost half of large‐vessel occlusion strokes have unfavorable outcomes despite successful endovascular therapy. We aim to investigate whether postrevascularization cerebral hemodynamics, determined by transcranial Doppler (TCD), associate with hospitalization outcomes in this population. Methods The current observational cohort study analyzed 155 patients with successfully revascularized anterior circulation large‐vessel occlusion stroke (mean age, 68.3±15.4 years; 55% women) who had TCD within 48 hours from endovascular therapy. TCD parameters (mean flow velocity, peak systolic velocity, and pulsatility index) were recorded at the ipsilateral middle cerebral artery, and blood flow signals were categorized using the Thrombolysis in Brain Ischemia grades into normal (grade 5), stenotic (grade 4), or dampened (grade ≤3). Hospitalization outcomes comprised favorable discharge modified Rankin Scale score (0–2), favorable discharge destination (home or acute inpatient rehabilitation), and in‐hospital mortality. Logistic regression models adjusted for age, initial National Institutes of Health Stroke Scale score, and Alberta Stroke Program Early CT [Computed Tomography] Score were fit to determine TCD findings in association with study outcomes. Results Abnormal TCD‐derived blood flow was found in 54 (35%) cases, including 35 (23%) with Thrombolysis in Brain Ischemia grade 4 and 19 (12%) with Thrombolysis in Brain Ischemia grade ≤3. Overall, 31% had favorable discharge modified Rankin Scale score, 65% had favorable destination, and 14% died. Thrombolysis in Brain Ischemia grade ≤3 was associated with lower likelihood of both favorable discharge modified Rankin Scale score (adjusted odds ratio [OR], 0.09 [95% CI, 0.01–0.81]) and favorable destination (adjusted OR, 0.22 [95% CI, 0.07–0.71]). Mean flow velocity and peak systolic velocity were not associated with study outcomes. Conversely, increased pulsatility index was inversely associated with favorable destination (adjusted OR, 0.34 [95% CI, 0.13–0.87]). Conclusions TCD after successful endovascular therapy identified abnormal blood flow in one‐third of cases. Dampened flow and markers of increased microvascular resistance were associated with unfavorable hospitalization outcomes. TCD could provide valuable prognostic information in this population and identify potential therapeutic targets

Abstract WMP84: The Impact of Pre-Morbid Antidepressant Exposure on the Risk of Intracerebral Hemorrhage: The Florida Stroke Registry

Abstract only Antidepressants (AD), particularly selective serotonin reuptake inhibitors (SSRIs), are amongst the most frequently prescribed medications. Concerns have been raised regarding their potential increased risk of bleeding complications including intracerebral hemorrhage (ICH) as they are known to affect platelet function. In the large Florida Stroke Registry (FSR), we sought to determine if pre-morbid use of AD impacted the risk of ICH Methods: Data collected from Jan 2010-Jun 2023 in FSR, GWTG statewide stroke registry comprised of 170 hospitals in the state of Florida was used to identify ischemic (IS) and hemorrhagic stroke cases with and without prior use of AD. Multivariate regression with generalized estimating equations, were used to determine whether premorbid-AD use was associated with an increased risk of ICH vs. ischemic stroke Results: A total of 219,558 stroke cases were identified (mean age 70.26±14.45; 52% male), among those 14% had pre-morbid AD use (age 72.13±13.23, 39% male). Patients on pre-morbid AD (vs no AD) were more likely White (75% vs. 62%) female (61% vs. 46%), with higher rates of vascular risk factors [(HTN (83%), DM (40%), HLD (61%), prior TIA (39%)]. The percentage of ICH was 11% and 14% amongst AD users and non-AD users respectively. In a multivariate model adjusting by multiple covariates, prior use of AD was not associated with an increased likelihood of presenting with ICH as opposed to IS (OR=0.72, 0.42-1.21). In the sensitivity analysis of subgroups of patients with data regarding the class of AD (SSRIs, Non-SSRIs) (n=657) or prior antiplatelet or anticoagulant therapies (n=740) premorbid SSRI use (vs no AD use) was not associated with increase ICH risk (OR=1.39, 95%CI 0.81-2.38 and OR=0.84, 0.64-1.10) Discussion In this large registry-based study we did not find an association between prior use of AD and increased risk of ICH as opposed to IS. Additionally, our findings were consistent among stroke patients with prior use of either antiplatelet or anticoagulants. These findings challenge the prevailing literature notion that AD, particularly SSRIs are linked to an increased risk of hemorrhages of all type. However, clinicians should consider individual patient's presentation, comorbidities and preferences when prescribing A

SSRI and Motor Recovery in Stroke: Reestablishment of Inhibitory Neural Network Tonus

Selective serotonin reuptake inhibitors (SSRIs) are currently widely used in the field of the neuromodulation not only because of their anti-depressive effects but also due to their ability to promote plasticity and enhance motor recovery in patients with stroke. Recent studies showed that fluoxetine promotes motor recovery after stroke through its effects on the serotonergic system enhancing motor outputs and facilitating long term potentiation, key factors in motor neural plasticity. However, little is known in regards of the exact mechanisms underlying these effects and several aspects of it remain poorly understood. In this manuscript, we discuss evidence supporting the hypothesis that SSRIs, and in particular fluoxetine, modulate inhibitory pathways, and that this modulation enhances reorganization and reestablishment of excitatory-inhibitory control; these effects play a key role in learning induced plasticity in neural circuits involved in the promotion of motor recovery after stroke. This discussion aims to provide important insights and rationale for the development of novel strategies for stroke motor rehabilitation