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There is an increased risk of stroke and other neurological complications in human immunodeficiency virus (HIV) infected patients with no large population-based studies in the literature. We aim to evaluate the prevalence of stroke, HIV-associated neurological complications, and identify risk factors associated with poor outcomes of stroke among HIV admissions in the United States. In the nationwide inpatient sample with adult HIV hospitalizations, patients with primary cerebrovascular disease (CeVDs) and HIV-associated neurological complications were identified by ICD-9-CM codes. We performed a retrospective study with weighted analysis to evaluate the prevalence of stroke and neurological complications and outcomes of stroke among HIV patients. We included 1,559,351 HIV admissions from 2003 to 2014, of which 22470 (1.4%) patients had CeVDs (transient ischemic attack [TIA]: 3240 [0.2%], acute ischemic stroke [AIS]: 14895 [0.93%], and hemorrhagic stroke [HS]: 4334 [0.27%]), 7781 (0.49%) had neurosyphilis, 29,925 (1.87%) meningitis, 39,190 (2.45%) cytomegalovirus encephalitis, 4699 (0.29%) toxoplasmosis, 9964 (0.62%) progressive multifocal leukoencephalopathy, and 142,910 (8.94%) epilepsy. There is increased overall prevalence trend for CeVDs (TIA: 0.17%-0.24%; AIS: 0.62%-1.29%; HS: 0.26%-0.31%; pTrend < .0001) from 2003 to 2014. Among HIV admissions, variables associated with AIS were neurosyphilis (odds ratio: 4.38; 95% confidence interval: 3.21-5.97), meningitis (4.87 [4.10-5.79]), and central nervous system tuberculosis (6.72 [3.85-11.71]). Toxoplasmosis [4.27 [2.34-7.76]), meningitis (2.91 [2.09-4.06)], and cytomegalovirus encephalitis (1.62 [1.11-2.37]) were associated with higher odds of HS compared to patients without HS. There was an increasing trend of CeVDs over time among HIV hospitalizations. HIV-associated neurological complications were associated with the risk of stroke, together with increased mortality, morbidity, disability, and discharge to long-term care facilities. Further research would clarify stroke risk factors in HIV patients to mitigate adverse outcomes., (© 2021 Wiley Periodicals LLC.)

Background: Artificial intelligence (AI) has influenced all aspects of human life and neurology is no exception to this growing trend. The aim of this paper is to guide medical practitioners on the relevant aspects of artificial intelligence, i.e., machine learning, and deep learning, to review the development of technological advancement equipped with AI, and to elucidate how machine learning can revolutionize the management of neurological diseases. This review focuses on unsupervised aspects of machine learning, and how these aspects could be applied to precision neurology to improve patient outcomes. We have mentioned various forms of available AI, prior research, outcomes, benefits and limitations of AI, effective accessibility and future of AI, keeping the current burden of neurological disorders in mind., Discussion: The smart device system to monitor tremors and to recognize its phenotypes for better outcomes of deep brain stimulation, applications evaluating fine motor functions, AI integrated electroencephalogram learning to diagnose epilepsy and psychological non-epileptic seizure, predict outcome of seizure surgeries, recognize patterns of autonomic instability to prevent sudden unexpected death in epilepsy (SUDEP), identify the pattern of complex algorithm in neuroimaging classifying cognitive impairment, differentiating and classifying concussion phenotypes, smartwatches monitoring atrial fibrillation to prevent strokes, and prediction of prognosis in dementia are unique examples of experimental utilizations of AI in the field of neurology. Though there are obvious limitations of AI, the general consensus among several nationwide studies is that this new technology has the ability to improve the prognosis of neurological disorders and as a result should become a staple in the medical community., Conclusion: AI not only helps to analyze medical data in disease prevention, diagnosis, patient monitoring, and development of new protocols, but can also assist clinicians in dealing with voluminous data in a more accurate and efficient manner.

Background: Pediatric stroke is a debilitating disease. There are several risk factors predisposing children to this life-threatening disease. Although, published literature estimates a relatively high incidence of pediatric stroke, treatment guidelines on intravenous tissue plasminogen activator and endovascular thrombectomy utilization remain a dilemma. There is a lack of large population-based studies and clinical trials evaluating the efficacy and safety outcomes associated with these treatments in this unique population., Aim: We sought to determine the prevalence of risk factors, concurrent utilization of intravenous tissue plasminogen activator and endovascular thrombectomy, and associated outcomes in pediatric stroke hospitalizations., Methods: We performed a retrospective analysis of the Nationwide Inpatient Sample data (2003-2014) in pediatric (1-21 years of age) acute ischemic stroke hospitalizations using ICD-9-CM codes. The multivariable survey logistic regression model was weighted to account for sampling strategy, evaluate predictors of hemorrhagic conversion, and treatment outcomes (mortality, morbidity, and discharge disposition) amongst pediatric stroke hospitalizations., Results: In this analysis, 9109 patients between 1 and 21 years of age were admitted during 2003-2014 for acute ischemic stroke. Of these 9109 patients, 119 (1.30%) received endovascular thrombectomy alone, 256 (2.82%) intravenous recombinant tissue plasminogen activator, and 69 (0.75%) both endovascular thrombectomy and intravenous recombinant tissue plasminogen activator. We found overall high prevalence of conditions like epilepsy (19.59%), atrial septal defect (11.76%), sickle cell disease (8.63%), and moyamoya disease (5.41%) in pediatric acute ischemic stroke patients. Unadjusted analysis showed high prevalence of all-cause in-hospital mortality in combined endovascular thrombectomy and intravenous recombinant tissue plasminogen activator utilization group, and higher prevalence of hemorrhagic conversion and morbidity in endovascular thrombectomy utilization group compared to other groups ( p  < 0.0001). Multivariate adjusted analysis showed that children with endovascular thrombectomy utilization (aOR: 19.19; 95% CI: 2.50-147.29, p  = 0.005), intravenous recombinant tissue plasminogen activator utilization (aOR: 8.85; 95% CI: 1.92-40.76, p  = 0.005), and both (endovascular thrombectomy and intravenous recombinant tissue plasminogen activator) utilization (aOR: 7.55; 95% CI: 1.16-49.31, p  = 0.035) had higher odds of hemorrhagic conversion compared to no-treatment group., Conclusion: We found various risk factors associated with pediatric stroke. The early identification can be useful to formulate preventive strategies and influence the incidence of pediatric stroke. Our study results showed that use of intravenous recombinant tissue plasminogen activator and endovascular thrombectomy increase risk of mortality and hemorrhagic conversion, but we suggest to have more clinical studies to evaluate the idea candidates for utilization of intravenous recombinant tissue plasminogen activator and endovascular thrombectomy based on risk: benefit ratio.

Introduction: Cranial irradiation is used both prophylactically and for the treatment of brain tumors. There are various complications associated with it. The rare complication of stroke-like migraine attacks after radiation therapy (SMART) syndrome usually occurs several years after radiation therapy but is a reversible phenomenon. It usually presents with headaches, seizures, or other focal neurological deficits concerning stroke or recurrence of the underlying disease., Objectives: We aim to present two cases of SMART syndrome highlighting the typical presentation, imaging findings, and differential diagnosis. We also conducted the literature review since the early recognition of this rare delayed onset complication is crucial, given its self-limited course and to avoid misinterpretations of the cases., Conclusion: Our extensive review favors MRI, CT, and prolonged EEG monitoring to rule out other differentials and showed that initiation of corticosteroid therapy and antiepileptic treatment were helpful in the resolution of symptoms and prevent recurrences. Therefore, future studies should be focused on early identification and management guidelines for SMART syndrome.

Background/purpose: Racial/ethnic and sex disparity may occur in stroke throughout the continuum of care. Endovascular therapy (EVT) became standard of care in 2015 for eligible patients with acute ischemic stroke (AIS). We evaluated for racial and sex differences in t-PA and EVT utilization and outcomes in 2016 in the National Inpatient Sample., Methods: Treatment rates for t-PA, EVT, and t-PA+EVT and outcomes including home discharge, in-hospital mortality and prolonged length of stay (pLOS) were evaluated by sex and race. Multivariate survey-logistic regression was performed to evaluate outcomes., Results: The study had 468,630 patients - 49.3% men, 50.7% women; 69.3% whites, and 30.7% non-whites. There was no difference in treatment utilization by sex, women vs men for t-PA (7.65% vs 7.76%; aOR:1.02; 95% CI:0.97-1.07), EVT (1.74% vs 1.67%; aOR:1.09; 95% CI:0.99-1.20) and t-PA+EVT (0.57% vs 0.57%; aOR:1.01; 95% CI:0.85-1.21); and by race, non-white vs white for t-PA (7.62% vs 7.74%; aOR:0.98; 95% CI:0.93-1.05), EVT (1.62% vs 1.74%; aOR:0.91; 95% CI:0.78-1.07), and t-PA+EVT(0.59% vs 0.56%; aOR:1.05; 95% CI:0.84-1.30). Compared to men, women treated with t-PA had less home discharge (37.2% vs 46.3%; aOR:0.81; 95% CI:0.72-0.90), more in-hospital mortality (5.7% vs 3.9%; aOR:1.37; 95% CI:1.06-1.77) and less pLOS (8.3% vs 9.6%; aOR:0.82; 95% CI:0.69-0.98); women treated with EVT had less home discharge (15.8% vs 23.7%; aOR:0.69; 95% CI:0.52-0.91). Compared to whites, non-whites treated with t-PA had lower odds of home discharge (42.1% vs 41.6%; aOR:0.79; 95% CI:0.69-0.90), less in-hospital mortality (3.7% vs 5.3%; aOR:0.65; 95% CI:0.49-0.87), and higher pLOS (11.4% vs 7.9%; aOR:1.3; 95% CI:1.07-1.56); non-whites treated with EVT had less home discharge (18%vs 20.2%; aOR:0.70; 95% CI:0.51-0.97) and higher pLOS (35.1% vs 24%; aOR:1.52; 95% CI:1.16-1.99)., Conclusion: Sex and racial disparity exists for outcomes of t-PA and EVT despite no difference in utilization rates., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: Pneumonia is the most common complication after stroke, but our knowledge on risk factors and predictors of stroke-associated pneumonia (SAP) is limited. We sought to evaluate the predictors and outcomes of SAP among acute ischemic stroke (AIS) hospitalizations., Methods: This is a cross-sectional study of the Nationwide Inpatient Sample database from the year 2003 to 2014. We identified adult hospitalizations with AIS using International Classification of Diseases, ninth revision, clinical modification (ICD-9-CM) codes. The SAP was identified by the presence of a secondary diagnosis of hospital-acquired pneumonia and ventilator-associated pneumonia. Multivariable survey logistic regression models were utilized to evaluate the predictors of SAP., Results: Overall, 4,224,924 AIS hospitalizations were identified, of which 149,169 (3.53%) had SAP. The prevalence of SAP decreased from 3.72% in 2003 to 3.17% in 2014 (P<0.0001). Mortality [17.12% vs. 4.77%; adjusted odds ratio (aOR): 1.71; P<0.0001] and morbidity (22.53% vs. 3.28%; aOR: 1.86; P<0.0001) were markedly elevated in SAP group compare to non-SAP group. The significant risk factors of pneumonia among AIS hospitalization were nasogastric tube (aOR: 1.21; P=0.0179), noninvasive mechanical ventilation (aOR: 1.65; P<0.0001), invasive mechanical ventilation (aOR: 4.09; P<0.0001), length of stay between 1 to 2 weeks (aOR: 1.99; P<0.0001), >2 weeks (aOR: 3.90; P<0.0001), hemorrhagic conversion (aOR: 1.17; P=0.0002), and epilepsy (aOR: 1.09; P=0.0009). Other concurrent comorbidities which increased the risk of SAP among AIS patients were acquired immune deficiency syndrome (aOR: 1.88; P<0.0001), alcohol abuse (aOR: 1.60; P=0.0006), deficiency anemia (aOR: 1.26; P<0.0001), heart failure (aOR: 1.62; P<0.0001), pulmonary disease (aOR: 1.73; P<0.0001), diabetes (aOR: 1.29; P=0.0288), electrolyte disorders (aOR: 1.50; P<0.0001), paralysis (aOR: 1.22; P<0.0001), pulmonary circulation disorders (aOR: 1.22; P<0.0001), renal failure (aOR: 1.12; P<0.0001), coagulopathy (aOR: 1.13; P=0.0006), and weight loss (aOR: 1.39; P<0.0001)., Conclusion: Our data underline the considerable epidemiological and prognostic impact of SAP in patients with AIS leading to higher mortality, morbidity, length of stay, and hospital cost despite advancements in care.

Stroke is a leading cause of death and disability, and novel treatments need to be found, particularly drugs with neuroprotective and restorative effects. Lately, there has been an increased interest in the relationship between opioids and ischemic stroke. To further appreciate this association between opioids and stroke, we conducted a systematic review to investigate anti-opioid medication's effectiveness in treating ischemic stroke. We used PubMed advanced-strategy and Google Scholar searches and only included full-text clinical trials on humans and written in the English language. After applying the inclusion/exclusion criteria, seven clinical trials were reviewed. Only one of the naloxone and nalmefene clinical trials showed statistically favorable results. Overall, the nalmefene clinical trials used more updated measures (NIHSS, GOS) to evaluate recovery and functional status in ischemic stroke patients than the naloxone clinical trials. There was less bias in the nalmefene clinical trials. Animal and in vitro studies have showed promising results. Additional research should be conducted with new clinical trials of both drugs with larger samples in patients less than 70 years old and moderate to severe infarcts. [ABSTRACT FROM AUTHOR]

U.S. demographics is shifting towards older population. Older stroke patients likely receive less tissue-plasminogen activator (t-PA) and mechanical thrombectomy (MT) compared to younger patients. The objective of this study is to evaluate extent of difference in utilization of t-PA and MT and outcomes of stroke between three age groups −18–45 (young adults), 46–80 (middle/old), and > 80 (oldest old) years. It is a retrospective cross-sectional observational study. Primary outcomes were rates of stroke intervention and effect of age on stroke intervention. Secondary outcomes were in-hospital mortality, discharge to home, and prolonged length of stay. Multivariate survey-logistic regression was performed to evaluate outcomes. Among 487,105 patients in the study 4.8% were young adults, 66.6% middle/old, and 28.6% oldest old. Compared to young adults, middle/old received 19% (OR = 0.81; 95%CI = 0.72–0.91) less t-PA alone; and 33% (OR = 0.67; 95%CI = 0.53–0.83) less MT alone; oldest old received 25% less t-PA alone (OR = 0.75; 95%CI = 0.66–0.86) and 51% (OR = 0.49; 95%CI = 0.38–0.63) less MT alone. Compared to young adults, in-hospital mortality was three-fold higher among middle/old (OR = 3.5; 95%CI = 1.3–9.6), and seven-fold higher among oldest old (OR = 7.5; 95%CI = 2.8–20.5) for t-PA alone; discharge to home reduced by 40% in middle/old (OR = 0.6; 95%CI = 0.4–0.7) and by 80% in oldest old (OR = 0.2; 95%CI = 0.1–0.2) for t-PA alone and similarly for MT alone. Oldest old receive one-fourth less t-PA and half less MT compared to young adults. Oldest old patients who received t-PA alone or MT alone had remarkably worse outcomes for in-hospital mortality and discharge to home than young adults did. • Patients with ischemic stroke aged >80 years receive one-fourth less t-PA and half less MT compared to young adults 18–45 years age. • In-hospital mortality is higher by seven-fold in patients >80 years compared to young adults who receive t-PA alone. • Discharge to home is reduced by 80% in patients >80 years compared to young adults who receive t-PA alone and MT alone. [ABSTRACT FROM AUTHOR]