Background: and Purpose Cardioembolic sources account for 20%–30% of acute ischemic strokes (AIS), often with high morbidity. Conventional imaging confirms etiology retrospectively but lacks insight into the dynamic behavior of embolic transport. We aimed to predict stroke laterality by integrating patient-specific computational fluid dynamics (CFD) simulations with robust Bayesian logistic regression modeling. Methods: Eight patients (median age 77.5 years; 2 females) with anterior circulation AIS of confirmed cardiac origin underwent high-resolution computed tomography angiography. Vascular geometries were segmented to generate CFD models simulating physiologic pulsatile flow. In each cardiac cycle, 1,000 massless particles were released at the aortic inlet. Two features were derived: x1 (long-term embolic bias over 10 seconds) and x2 (short-term embolic bias during the first cardiac cycle). These were used as predictors in a robust Bayesian logistic regression model. Results: The right internal carotid artery (ICA) received more embolic particles (mean 34/s) than the left ICA (mean 28/s). Patients with right-sided strokes had higher x1 (median 0.27 vs. -0.44) and lower x2 (median -0.82 vs. 0.56) than those with left-sided strokes. The model yielded posterior mean coefficients of 1.51 (95% credible interval [CrI]: -0.46 to 4.11) for x1 and -1.96 (95% CrI: -4.88 to 0.20) for x2, achieving complete separation of stroke patients by laterality in this pilot cohort. Conclusions The combination of CFD-based embolic modeling and Bayesian analysis accurately predicted stroke laterality in cardioembolic AIS, exposing distinct patient-specific embolic transport dynamics.

Background: and Purpose Speedy decision-making is important for optimal outcomes from endovascular thrombectomy (EVT) for acute ischemic stroke (AIS). Figural decision aids facilitate rapid review of treatment benefits and harms, but have not yet been developed for late-presenting patients selected for EVT based on multimodal computed tomography or magnetic resonance imaging. Methods: For combined pooled study-level randomized trial (DAWN and DEFUSE 3) data, as well as each trial singly, 100 person-icon arrays (Kuiper-Marshall personographs) were generated showing beneficial and adverse effects of EVT for patients with AIS and large vessel occlusion using automated (algorithmic) and expert-guided joint outcome table specification. Results: Among imaging-selected patients 6 to 24 hours from last known well, for the full 7-category modified Rankin Scale (mRS), EVT had number needed to treat to benefit 1.9 (interquartile range [IQR], 1.9 to 2.1) and number needed to harm 40.0 (IQR, 29.2 to 58.3). Visual displays of treatment effects among 100 patients showed that, with EVT: 52 patients have better disability outcome, including 32 more achieving functional independence (mRS 0 to 2); three patients have worse disability outcome, including one more experiencing severe disability or death (mRS 5 to 6), mediated by symptomatic intracranial hemorrhage and infarct in new territory. Similar features were present in person-icon figures based on a 6-level mRS (levels 5 and 6 combined) rather than 7-level mRS, and based on the DAWN trial alone and DEFUSE 3 trial alone. Conclusions Personograph visual decision aids are now available to rapidly educate patients, family, and healthcare providers regarding benefits and risks of EVT for late-presenting, imaging-selected AIS patients.

A 34-year-old male was brought to the hospital with a chest gunshot wound. Pulseless upon arrival, blood pressure was absent for 10 minutes. A thoracotomy resulted in return of spontaneous circulation. On hospital day 5, with brainstem reflexes present, he was unresponsive to call or pain, exhibited generalized hyperreflexia and bilateral Babinskys. Median nerve somatosensory evoked potentials (mSSEPs) and brainstem auditory evoked potentials were obtained. International Federation of Clinical Neurophysiology recommendations for mSSEPs and brainstem auditory evoked potentials were followed. Despite absence of the N20 responses from cortical mSSEPs no withdrawal from care was agreed upon. After awaking on day 7, mSSEPs were repeated and present. The patient survived and was discharged with minor deficits. Bilateral absence of N20 responses from mSSEPs performed beyond 48 hours after resuscitation from cardiac arrest is highly associated with bad neurological outcomes. However, variation due to hypothermia, noisy signals, medications, and brain hypo-perfusion must be taken into account.
Adult ; Blood Pressure ; Brain ; Brain Stem ; Critical Care Outcomes ; Evoked Potentials, Auditory, Brain Stem ; Evoked Potentials, Somatosensory ; Heart Arrest ; Humans ; Hypothermia ; Male ; Median Nerve ; Nervous System Diseases ; Neurophysiology ; Prognosis ; Reflex ; Reflex, Abnormal ; Resuscitation ; Thoracotomy ; Thorax ; Wounds, Gunshot