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Stroke Severity Score based on Six Signs and Symptoms The 6S Score: A Simple Tool for Assessing Stroke Severity and In-hospital Mortality.

Juan Manual RACOSTA ; Federico DI GUGLIELMO ; Francisco Ricardo KLEIN ; Patricia Mariana RICCIO ; Francisco Munoz GIACOMELLI ; Maria Eugenia GONZALEZ TOLEDO ; Fatima PAGANI CASSARA ; Agustina TAMARGO ; Matias DELFITTO ; Luciano Alberto SPOSATO

Journal of Stroke.2014;16(3):178-183. doi:10.5853/jos.2014.16.3.178

BACKGROUND AND PURPOSE: Ascertaining stroke severity and predicting risk of in-hospital mortality is crucial to advise patients and families about medical decisions. We developed and tested the validity of a new stroke score, the 6S Score (Stroke Severity Score based on Six Signs and Symptoms), for quantifying ischemic stroke severity and predicting in-hospital mortality. METHODS: We prospectively assessed 210 consecutive acute ischemic stroke patients. The cohort was further divided into a derivation (n=120) and a validation (n=90) sample. From a total of 10 stroke signs and symptoms, we selected those with likelihood ratio's P<0.005. We tested the validity of the score for predicting in-hospital mortality by using receiver operating characteristic curves. We used a scatterplot and the Spearman's test to evaluate the correlation between the 6S Score and the National Institutes of Health Stroke Scale as a marker of stroke severity. We used principal component and exploratory factor analyses for assessing qualitative aspects of the 6S Score. RESULTS: The C statistic for in-hospital mortality was 0.82 for the 6S Score and 0.86 for the National Institutes of health Stroke Scale, respectively, with no significant differences between each other (P=0.79). The correlation between both scores was strong (Spearman's rho 0.68, P<0.001). The factor analyses showed a good balance between left/right hemispheres and anterior/posterior circulations. CONCLUSIONS: The 6S Score may constitute a tool for easily assessing stroke severity and predicting stroke mortality. Further research is needed for further assessing its external validity.
Cohort Studies ; Hospital Mortality* ; Humans ; Mortality ; National Institutes of Health (U.S.) ; Prospective Studies ; ROC Curve ; Stroke*

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Risk Factors and Etiologies of Ischemic Strokes in Young Patients: A Tertiary Hospital Study in North India.

Deepa DASH ; Ashu BHASHIN ; Awadh Kumar PANDIT ; Manjari TRIPATHI ; Rohit BHATIA ; Kameshwar PRASAD ; Madakasira Vasantha PADMA

Journal of Stroke.2014;16(3):173-177. doi:10.5853/jos.2014.16.3.173

BACKGROUND AND PURPOSE: Stroke in young adults has a special significance in developing countries, as it affects the most economically productive group of the society. We identified the risk factors and etiologies of young patients who suffered ischemic strokes and were admitted to a tertiary referral hospital in North India. METHODS: A retrospective review of case records from patients with ischemic stroke in the age range of 18-45 years was conducted from 2005 to 2010. Data regarding patients' clinical profiles, medical histories, diagnostic test results, and modified Rankin Scale scores at hospital discharge were examined. Stroke subtyping was conducted in accordance with the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria. RESULTS: Of the 2,634 patients admitted for ischemic stroke, 440 (16.7%) were in the 18-45 year age range and the majority (83.4%) were male. The most common risk factors were hypertension (34.4%) and dyslipidemia (26.5%). The most common subtype of stroke was undetermined (57%), followed by other determined causes (17.3%). Among the category of undetermined etiology, incomplete evaluation was the most common. Most of the patients demonstrated good functional outcomes. CONCLUSIONS: Young adults account for 16.7% of all stroke patients in North India. Risk factors are relatively prevalent, and a high proportion of the patients are categorized under undetermined and other determined causes. The results highlight the needs for aggressive management of traditional risk factors and extensive patient work-ups to identify stroke etiology in India.
Developing Countries ; Diagnostic Tests, Routine ; Dyslipidemias ; Humans ; Hypertension ; India* ; Male ; Retrospective Studies ; Risk Factors* ; Stroke* ; Tertiary Care Centers* ; Young Adult

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MRI-based Algorithm for Acute Ischemic Stroke Subtype Classification.

Youngchai KO ; Soojoo LEE ; Jong Won CHUNG ; Moon Ku HAN ; Jong Moo PARK ; Kyusik KANG ; Tai Hwan PARK ; Sang Soon PARK ; Yong Jin CHO ; Keun Sik HONG ; Kyung Bok LEE ; Jun LEE ; Dong Eog KIM ; Dae Hyun KIM ; Jae Kwan CHA ; Joon Tae KIM ; Jay Chol CHOI ; Dong Ick SHIN ; Ji Sung LEE ; Juneyoung LEE ; Kyung Ho YU ; Byung Chul LEE ; Hee Joon BAE

Journal of Stroke.2014;16(3):161-172. doi:10.5853/jos.2014.16.3.161

BACKGROUND AND PURPOSE: In order to improve inter-rater reliability and minimize diagnosis of undetermined etiology for stroke subtype classification, using a stroke registry, we developed and implemented a magnetic resonance imaging (MRI)-based algorithm for acute ischemic stroke subtype classification (MAGIC). METHODS: We enrolled patients who experienced an acute ischemic stroke, were hospitalized in the 14 participating centers within 7 days of onset, and had relevant lesions on MR-diffusion weighted imaging (DWI). MAGIC was designed to reflect recent advances in stroke imaging and thrombolytic therapy. The inter-rater reliability was compared with and without MAGIC to classify the Trial of Org 10172 in Acute Stroke Treatment (TOAST) of each stroke patient. MAGIC was then applied to all stroke patients hospitalized since July 2011, and information about stroke subtypes, other clinical characteristics, and stroke recurrence was collected via a web-based registry database. RESULTS: The overall intra-class correlation coefficient (ICC) value was 0.43 (95% CI, 0.31-0.57) for MAGIC and 0.28 (95% CI, 0.18-0.42) for TOAST. Large artery atherosclerosis (LAA) was the most common cause of acute ischemic stroke (38.3%), followed by cardioembolism (CE, 22.8%), undetermined cause (UD, 22.2%), and small-vessel occlusion (SVO, 14.6%). One-year stroke recurrence rates were the highest for two or more UDs (11.80%), followed by LAA (7.30%), CE (5.60%), and SVO (2.50%). CONCLUSIONS: Despite several limitations, this study shows that the MAGIC system is feasible and may be helpful to classify stroke subtype in the clinic.
Arteries ; Atherosclerosis ; Classification* ; Diagnosis ; Humans ; Magic ; Magnetic Resonance Imaging ; Recurrence ; Stroke* ; Thrombolytic Therapy

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Critical Care for Patients with Massive Ischemic Stroke.

Sang Beom JEON ; Younsuck KOH ; H Alex CHOI ; Kiwon LEE

Journal of Stroke.2014;16(3):146-160. doi:10.5853/jos.2014.16.3.146

Malignant cerebral edema following ischemic stroke is life threatening, as it can cause inadequate blood flow and perfusion leading to irreversible tissue hypoxia and metabolic crisis. Increased intracranial pressure and brain shift can cause herniation syndrome and finally brain death. Multiple randomized clinical trials have shown that preemptive decompressive hemicraniectomy effectively reduces mortality and morbidity in patients with malignant middle cerebral artery infarction. Another life-saving decompressive surgery is suboccipital craniectomy for patients with brainstem compression by edematous cerebellar infarction. In addition to decompressive surgery, cerebrospinal fluid drainage by ventriculostomy should be considered for patients with acute hydrocephalus following stroke. Medical treatment begins with sedation, analgesia, and general measures including ventilatory support, head elevation, maintaining a neutral neck position, and avoiding conditions associated with intracranial hypertension. Optimization of cerebral perfusion pressure and reduction of intracranial pressure should always be pursued simultaneously. Osmotherapy with mannitol is the standard treatment for intracranial hypertension, but hypertonic saline is also an effective alternative. Therapeutic hypothermia may also be considered for treatment of brain edema and intracranial hypertension, but its neuroprotective effects have not been demonstrated in stroke. Barbiturate coma therapy has been used to reduce metabolic demand, but has become less popular because of its systemic adverse effects. Furthermore, general medical care is critical because of the complex interactions between the brain and other organ systems. Some challenging aspects of critical care, including ventilator support, sedation and analgesia, and performing neurological examinations in the setting of a minimal stimulation protocol, are addressed in this review.
Analgesia ; Anoxia ; Brain ; Brain Death ; Brain Edema ; Brain Stem ; Cerebrospinal Fluid ; Coma ; Critical Care* ; Drainage ; Head ; Humans ; Hydrocephalus ; Hypothermia ; Infarction ; Infarction, Middle Cerebral Artery ; Intracranial Hypertension ; Intracranial Pressure ; Mannitol ; Mortality ; Neck ; Neurologic Examination ; Neuroprotective Agents ; Perfusion ; Stroke* ; Ventilators, Mechanical ; Ventriculostomy

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Magnetic Resonance Imaging in Acute Ischemic Stroke Treatment.

Bum Joon KIM ; Hyun Goo KANG ; Hye Jin KIM ; Sung Ho AHN ; Na Young KIM ; Steven WARACH ; Dong Wha KANG

Journal of Stroke.2014;16(3):131-145. doi:10.5853/jos.2014.16.3.131

Although intravenous administration of tissue plasminogen activator is the only proven treatment after acute ischemic stroke, there is always a concern of hemorrhagic risk after thrombolysis. Therefore, selection of patients with potential benefits in overcoming potential harms of thrombolysis is of great importance. Despite the practical issues in using magnetic resonance imaging (MRI) for acute stroke treatment, multimodal MRI can provide useful information for accurate diagnosis of stroke, evaluation of the risks and benefits of thrombolysis, and prediction of outcomes. For example, the high sensitivity and specificity of diffusion-weighted image (DWI) can help distinguish acute ischemic stroke from stroke-mimics. Additionally, the lesion mismatch between perfusion-weighted image (PWI) and DWI is thought to represent potential salvageable tissue by reperfusion therapy. However, the optimal threshold to discriminate between benign oligemic areas and the penumbra is still debatable. Signal changes of fluid-attenuated inversion recovery image within DWI lesions may be a surrogate marker for ischemic lesion age and might indicate risks of hemorrhage after thrombolysis. Clot sign on gradient echo image may reflect the nature of clot, and their location, length and morphology may provide predictive information on recanalization by reperfusion therapy. However, previous clinical trials which solely or mainly relied on perfusion-diffusion mismatch for patient selection, failed to show benefits of MRI-based thrombolysis. Therefore, understanding the clinical implication of various useful MRI findings and comprehensively incorporating those variables into therapeutic decision-making may be a more reasonable approach for expanding the indication of acute stroke thrombolysis.
Administration, Intravenous ; Biomarkers ; Combined Modality Therapy ; Diagnosis ; Hemorrhage ; Humans ; Magnetic Resonance Imaging* ; Patient Selection ; Reperfusion ; Risk Assessment ; Sensitivity and Specificity ; Stroke* ; Tissue Plasminogen Activator

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Isolated Vascular Vertigo.

Hyung LEE

Journal of Stroke.2014;16(3):124-130. doi:10.5853/jos.2014.16.3.124

Strokes in the distribution of the posterior circulation may present with vertigo, imbalance, and nystagmus. Although the vertigo due to a posterior circulation stroke is usually associated with other neurologic symptoms or signs, small infarcts involving the cerebellum or brainstem can develop vertigo without other localizing symptoms. Approximately 11% of the patients with an isolated cerebellar infarction present with isolated vertigo, nystagmus, and postural unsteadiness mimicking acute peripheral vestibular disorders. The head impulse test can differentiate acute isolated vertigo associated with cerebellar strokes (particularly within the territory of the posterior inferior cerebellar artery) from more benign disorders involving the inner ear. Acute audiovestibular loss may herald impending infarction in the territory of anterior inferior cerebellar artery. Appropriate bedside evaluation is superior to MRIs for detecting central vascular vertigo syndromes. This article reviews the keys to diagnosis of acute isolated vertigo syndrome due to posterior circulation strokes involving the brainstem and cerebellum.
Arteries ; Brain Stem ; Cerebellum ; Diagnosis ; Ear, Inner ; Head Impulse Test ; Humans ; Infarction ; Magnetic Resonance Imaging ; Neurologic Manifestations ; Stroke ; Vertigo*

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Stroke Genetics: A Review and Update.

Arne LINDGREN

Journal of Stroke.2014;16(3):114-123. doi:10.5853/jos.2014.16.3.114

Stroke genetics includes several topics of clinical interest, including (1) molecular genetic variations affecting risk of monogenic stroke syndromes; (2) molecular genetic variations affecting risk of common stroke syndromes, sometimes with specific effects on risk of specific main types of stroke or subtypes of ischemic and hemorrhagic stroke; (3) genetics of conditions associated with stroke risk e.g. white matter hyperintensities, atrial fibrillation and hypertension; (4) hereditary causes of familial aggregation of stroke; (5) epigenetic impact on protein expression during acute brain injury; (6) genetic influence on stroke recovery; and (7) pharmacogenetics. Genetic research methods include candidate gene studies; Genome Wide Association Studies; family studies; RNA and protein analyses; and advanced computer-aided analytical methods to detect statistically significant associations. Several methods that could improve our knowledge of stroke genetics are being developed e.g.: Exome content analysis; Next-generation sequencing; Whole genome sequencing; and Epigenetics. During 2012-2014, several Single Nucleotide Polymorphisms (SNPs) have been related to common ischemic stroke risk. Certain SNPs have been associated with risk of specific ischemic stroke subtypes such as large vessel disease and cardiac embolism, particular subtypes of intracerebral hemorrhage (ICH), especially lobar ICH, and with prognosis after ICH. Large international studies on stroke recovery and exome content are ongoing. Advanced mathematical models have been used to study how several SNPs can act together and increase stroke risk burden. Such efforts require large numbers of patients and controls, which is achieved by co-operation in large international consortia such as the International Stroke Genetics Consortium. This overview includes an introduction to genetics, stroke genetics in general, and different genetic variations that may influence stroke risk. It presents some of the latest reports on stroke genetics published in high impact journals. The role of pharmacogenetics, the current clinical situation, and future prospects will also be discussed.
Atrial Fibrillation ; Brain Injuries ; Cerebral Hemorrhage ; Embolism ; Epigenomics ; Exome ; Genetic Association Studies ; Genetic Research ; Genetic Variation ; Genetics* ; Genome ; Genome-Wide Association Study ; Humans ; Hypertension ; Models, Theoretical ; Molecular Biology ; Pharmacogenetics ; Polymorphism, Single Nucleotide ; Prognosis ; RNA ; Stroke*

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Research on Intracranial Atherosclerosis from the East and West: Why Are the Results Different?.

Jong S KIM ; David BONOVICH

Journal of Stroke.2014;16(3):105-113. doi:10.5853/jos.2014.16.3.105

Intracranial atherosclerosis (ICAS) is a major cause of stroke worldwide and is more common in Asians than Caucasians. The study results from the East and West are generally similar, but notable differences exist. For example, studies from the East have reported that ICAS is associated with young age, whereas ICAS seems to be associated with old age in the West. Studies from the East have strongly suggested that mild ICAS associated with branch occlusion is one of the main causes of single subcortical infarction, whereas this aspect has not been considered in stroke classification systems developed in the West. While clopidogrel is commonly used in patients with large artery disease in the West, cilostazol has been more extensively studied and commonly used in ICAS patients in the East. A randomized controlled study from the West reported negative results regarding the efficacy of stenting in ICAS patients due largely to a relatively high rate of periprocedural adverse events, whereas research papers from the East have reported a relatively lower rate of complications. Studies to narrow these East-West gaps should be performed, including risk factor studies using homogenous ethnic populations, studies investigating appropriate classification systems, drug trials in different ethnic populations, and rigorous high standard randomized controlled studies on the efficacy of stenting in Eastern populations.
Arteries ; Asian Continental Ancestry Group ; Cerebral Infarction ; Classification ; Humans ; Intracranial Arteriosclerosis* ; Risk Factors ; Stents ; Stroke

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Prolonged Ictal Aphasia Presenting as Clinical-Diffusion Mismatch in a Patient with Acute Ischemic Stroke.

Joo Yea JIN ; Yeon Jung KIM ; Sun U KWON

Journal of Stroke.2014;16(2):102-104.

No abstract available.
Aphasia* ; Humans ; Stroke*

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Can STOP Trial Velocity Criteria Be Applied to Iranian Children with Sickle Cell Disease?.

Reza BAVARSAD SHAHRIPOUR ; Martin M MORTAZAVI ; Kristian BARLINN ; Bijan KEIKHAEI ; Hadi MOUSAKHANI ; Mahmoud Reza AZARPAZHOOH ; Morteza OGHBAEE ; Seyed Aidin SAJEDI ; Jessica KEPPLINGER ; R Shane TUBBS ; Karen C ALBRIGHT ; Andrei V ALEXANDROV

Journal of Stroke.2014;16(2):97-101.

BACKGROUND AND PURPOSE: Sickle cell disease (SCD) is strongly linked to stroke across all haplotypes in the pediatric population. Transcranial Doppler (TCD) ultrasound is known to identify the highest risk group in African-Americans who need to receive and stay on blood transfusions, but it is unclear if the same flow velocity cut-offs can be applied to the Iranian population. We aimed to evaluate baseline TCD findings in Iranian children with SCD and no prior strokes. METHODS: Children with genetically confirmed SCD (Arabian haplotype, homozygote) and without SCD (controls) were prospectively recruited from pediatric outpatient clinic over a period of 9 months. We performed TCD in both groups to determine flow velocities in the middle cerebral (MCA) and terminal internal carotid arteries (TICA). RESULTS: Of 74 screened children, 60 met the inclusion/exclusion criteria (62% female; mean age 10+/-4 years). Baseline characteristics did not differ between the cases and controls, except hemoglobin (Hb) which was significantly lower in the SCD group (P<0.001). The right MCA TAMM (Time Averaged Maximum Mean) was significantly higher than in controls (125+5.52 cm/s vs. 92.5+1.63 cm/s, P<0.001). Left MCA did not show differences. The TICA TAMM was also different between cases and controls (P<0.05). CONCLUSIONS: Among Iranian children with asymptomatic SCD and without receiving recent transfusion TCD velocities are higher as compared to healthy controls but appear much lower than those observed in STOP (Stroke Prevention Trial in Sickle Cell Anemia) studies. We hypothesize that some children at high risk may be present with velocities lower than 170-200 cm/s thresholds. A prospective validation of ethnicity-specific prognostic criteria is warranted.
Ambulatory Care Facilities ; Anemia, Sickle Cell* ; Blood Transfusion ; Carotid Artery, Internal ; Child* ; Female ; Haplotypes ; Humans ; Prospective Studies ; Stroke ; Ultrasonography

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