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Objective To investigate the effect of electromyography (EMG)-driven robotic therapy on the recovery of the hand in a stroke case lasting 9 years. Case An 18-year-old patient with hemiparesis due to the ischemic lesion was admitted to our clinic with hand impairment. Fifteen sessions (5 weeks x 3 times) of robotic rehabilitation were applied with the Hand of Hope. Average EMG (mV) of flexor digitorum superficialis (FDS) muscle, average force (N) and the rate of force development (RFD)(N/s) were also assessed before and after the treatment following the 5th and 10th sessions and at the end of treatment. Also, Fugl-Meyer Assessment of Upper Extremity Scale (FMU-UE), Motor Activity Log (MAL), Canadian Occupational Performance Score (COPM) and Visual Analog Scale (VAS) were used for assessment before and after the treatment. Results The average EMG measured from FDS increased from 0.093-0.133 mV. The average force and average RFD increased from 45.6-97.7 and from 135.6-172.6 respectively. While affected and/or unaffected side force ratio increased dramatically from 54%-82%, the FMA-UE score increased from 56-59. The MAL quality of use score increased from 3.93-4.13. Performance and satisfaction scores of COPM changed from 5.25-7.25 and 4.5-8.25 respectively. VAS score for fatigue changed from 6 to 4. Discussion The improvement achieved 9 years later with 15 sessions of rehabilitation suggests that improvement may be possible for chronic stroke patients.

Background and purpose Gadolinium leakage in ocular structures (GLOS) on fluid attenuated inversion recovery images (FLAIR) is a novel imaging marker in acute ischemic stroke and other neurological disorders. Methods In patients with transient neurovascular symptoms who underwent repeated MRI with intravenous contrast agent administration, the presence of acute ischemic lesions on diffusion-weighted images (DWI) as well as the frequency and pattern of blood-brain barrier and blood-retina barrier impairment as demonstrated by the hyperintense acute reperfusion marker (HARM) and GLOS respectively on postcontrast FLAIR were evaluated. Results Overall 28 patients with transient neurovascular symptoms (median age 70.5 years; 18 (64.3%) male) were included. Follow-up MRI was performed within 35 (IQR 21–47) hours after the initial MRI. On DWI, acute ischemic lesions were observed in 22 (78.6%). On contrast-enhanced FLAIR, GLOS was observed in 12 (42.9%) patients: in 1 (3.6%) only in the anterior chamber, and in 11 (39.3%) in the anterior chamber and vitreous body. HARM was observed in 3 (10.7%) patients. In one patient without ischemic lesion on DWI or HARM on FLAIR, GLOS was observed in the anterior chamber and vitreous body. Presence of GLOS was associated with higher age (p = 0.04) and detection of HARM (p = 0.03). Conclusions In patients with transient neurovascular symptoms, GLOS is a frequent finding and associated with HARM on contrast-enhanced FLAIR. As GLOS was observed in one patient without an ischemic lesion or HARM, it might be useful as an additional imaging marker.

Presentamos un paciente con un síndrome opercular con síntomas y signos pseudobulbares bilaterales; la mayoría de casos presentan afectación de ambos hemisferios cerebrales, nuestro paciente tuvo afectación unilateral. Caso Clínico: Varón de 65 años, diestro, con antecedente de Hipertensión arterial, con un tiempo de enfermedad de un año y un mes de evolución, caracterizado por presentar en forma súbita monoparesia en miembro superior derecho, asimetría facial, anartria con compromiso pseudobulbar bilateral. En Resonancia Magnética se evidenció lesión isquémica del área opercular izquierda. Discusión: El síndrome opercular o biopercular conocido también como síndrome de Foix-Chavany-Marie, es una entidad poco frecuente caracterizada por la afectación del área opercular cerebral bilateral, que compromete la vía cortico-bulbar/protuberancial, es importante la presencia de la disociación motora automática-voluntaria y cuya etiología más frecuente en adultos es isquémica, como en nuestro caso. Se desconoce el motivo por el que una sola lesión puede producir afectación bilateral pseudobulbar, se postula una predominancia del haz cortico protuberancial/bulbar del hemisferio dominante. En los casos publicados el pronóstico no es favorable desde el punto de vista del lenguaje, pero en nuestro paciente hubo mejoría de la anartria, la deglución, masticación y fuerza muscular; recibió terapia física con buena evolución.

PURPOSE: Amide proton transfer-weighted (APTw) MRI provides a non-invasive pH-sensitive image, complementing perfusion and diffusion imaging for refined stratification of ischemic tissue. Although the commonly used magnetization transfer (MT) asymmetry (MTR(asym)) calculation reasonably corrects the direct RF saturation effect, it is susceptible to the concomitant semisolid macromolecular MT contribution. Therefore, this study aimed to compare the performance of MTR(asym) and magnetization transfer and relaxation-normalized APT (MRAPT) analyses under two representative experimental conditions. METHODS: Multiparametric MRI scans were performed in a rodent model of acute stroke, including relaxation, diffusion, and Z-spectral images under two representative RF levels of 0.75 and 1.5 μT. Both MTR(asym) and MRAPT values in the ischemic diffusion lesion and the contralateral normal areas were compared using correlation and Bland-Altman tests. In addition, the acidic lesion volumes were compared. RESULTS: MRAPT measurements from the diffusion lesion under the two conditions were highly correlated (R(2)=0.97) vs. MTR(asym) measures (R(2)=0.58). The pH lesion sizes determined from MRAPT analysis were in good agreement (178 ± 43 mm(3) vs. 186 ± 55 mm(3) for B(1) of 0.75 and 1.5 μT, respectively). CONCLUSIONS: The study demonstrated that MRAPT analysis could be generalized to moderately different RF amplitudes, providing a more consistent depiction of acidic lesions than the MTR(asym) analysis.

Background Variants of the Circle of Willis (vCoW) may impede correct identification of ischemic lesion patterns and stroke etiology. We assessed reclassifications of ischemic lesion patterns due to vCoW. Methods We analyzed vCoW in patients with acute ischemic stroke from the 1000+ study using time-of-flight magnetic resonance angiography (TOF MRA) of intracranial arteries. We assessed A1 segment agenesis or hypoplasia in the anterior circulation and fetal posterior cerebral artery in the posterior circulation. Stroke patterns were classified as one or more-than-one territory stroke pattern. We examined associations between vCoW and stroke patterns and the frequency of reclassifications of stroke patterns due to vCoW. Results Of 1000 patients, 991 had evaluable magnetic resonance angiography. At least one vCoW was present in 37.1%. VCoW were more common in the posterior than in the anterior circulation (33.3% vs. 6.7%). Of 238 patients initially thought to have a more-than-one territory stroke pattern, 20 (8.4%) had to be reclassified to a one territory stroke pattern after considering vCoW. All these patients had fetal posterior cerebral artery and six (30%) additionally had carotid artery disease. Of 753 patients initially presumed to have a one-territory stroke pattern, four (0.5%) were reclassified as having more-than-one territory pattern. Conclusions VCoW are present in about one in three stroke patients and more common in the posterior circulation. Reclassifications of stroke lesion patterns due to vCoW occurred predominantly in the posterior circulation with fetal posterior cerebral artery mimicking multiple territory stroke pattern. Considering vCoW in these cases may uncover symptomatic carotid disease.

Background and Purpose: Ischemic lesion volume can increase even 24 hours after onset of an acute ischemic stroke. In this study, we investigated the association of lesion evolution with functional outcome and the influence of successful recanalization on this association. Methods: We included patients from the MR CLEAN trial (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) who received good quality noncontrast CT images 24 hours and 1 week after stroke onset. The ischemic lesion delineations included infarct, edema, and hemorrhagic transformation. Lesion evolution was defined as the difference between the volumes measured on the 1-week and 24-hour noncontrast CTs. The association of lesion evolution with functional outcome was evaluated using unadjusted and adjusted logistic regression. Adjustments were made for baseline, clinical, and imaging parameters that were associated P Results: Of the 226 patients who were included, 69 (31%) patients achieved the favorable functional outcome. Median lesion evolution was 22 (interquartile range, 10–45) mL. Lesion evolution was significantly inversely correlated with favourable functional outcome: unadjusted odds ratio, 0.76 (95% CI, 0.66–0.86; per 10 mL of lesion evolution; P P =0.03). There was no significant interaction of successful recanalization on the association of lesion evolution and favorable functional outcome (odds ratio, 1.01 [95% CI, 0.77–1.36]; P =0.94). Conclusions: In our population, subacute ischemic lesion evolution is associated with unfavorable functional outcome. This study suggests that even 24 hours after onset of stroke, deterioration of the brain continues, which has a negative effect on functional outcome. This finding may warrant additional treatment in the subacute phase.

Ischemic stroke is the most common form of brain stroke. It is associated with functional changes of various blood and bone marrow cell populations, altered release of various cytokines, chemokines, etc. There are conflicting data about serum and plasma TNFα levels in acute ischemic stroke.We have examined 21 patients with a diagnosis of ischemic stroke treated at the hospital. The severity of ischemic stroke was evaluated by neurologists, in accordance with NIHSS criteria at admission and at discharge. In the patients with ischemic stroke, we have found a significantly increased serum concentration of tumor necrosis factor-α (p < 0.001), as compared with healthy individuals. The highest concentrations of this marker were recorded on days 1 and 3 of the disease, being significant at p < 0.001 and p= 0.003, respectively, then decreasing by day 14, however, not reaching, the levels of control group. It should be noted that, among patients with ischemic stroke, there is a significantly (p < 0.001) increased proportion of individuals with high serum concentrations (>10 pg/ml) of this cytokine, i.e., 76.2±9.3% on day 1 of the disease.To statistically evaluate the individual differences of the patients’ dynamics, they were divided into subgroups, depending on the level of TNFα on the 1st day of hospitalization, using a discriminant analysis with estimation of a classification matrix. The correlation analysis showed numerous strongly positive correlations between TNFα levels on the 1st and 3rd days, as well as between similar indexes on the 1st and 14th days. A correlation between TNFα concentrations on the 3rd and 14th day was also found (r = 0.711; p < 0.01). Also, positive correlation in various periods of observation was established between the absolute levels of cytokine and differences in their concentration changes. The level of tumor necrosis factor-alpha on the first and third day of hospitalization did positively correlate (respectively, r = 0.503, p < 0.01; r = 0.411, p < 0.01) with the volume of the ischemic lesion according neuroimaging methods research. The volume of the ischemic focus was positively correlated with the difference in the concentration of TNFα on days 1-3 and 1-14 (respectively, r = 0.425, p < 0.01; r = 0.507, p < 0.01).The results of our study show a necessity for measuring TNFα levels at admission, in order to plan treatment in these groups of patients, especially in cases of increase or insufficient decrease in TNFα recorded on the 3rd day of therapy.

Transcutaneous oxygen tension measurement (TcPO2) is widely applied for the evaluation of chronic limb-threatening ischemia (CLTI). Nevertheless, studies that focused on the clinical value of TcPO2 have shown varying results. We identified factors that potentially play a role in TcPO2 measurement variation such as probe placement, probe temperature, and the use of a reference probe. In this review of the current literature, we assessed the application of these factors. A systematic search was conducted. Parameters that were assessed were probe placement, probe temperature, and mentioning and/or use of a reference probe. In total, 36 articles were eligible for analysis. In 24 (67%) studies, probes were placed on specific anatomical locations. Seven (19%) studies placed probes, regardless of the location of the ulcer, adjacent to an ischemic lesion or ulcer (perilesion). Selected temperature setting of the probe differed; in 18 (50%), a default probe temperature of 44°C was selected, and in 13 (36%), a different temperature was selected. In 31 (84%) studies, the use of a reference probe was not reported. Transcutaneous oxygen tension measurement is applied diversely in patients with CLTI. Homogeneity in TcPO2 protocols is warranted for reliable clinical application and to compare future TcPO2 research.

Background: Since the advent of magnetic resonance imaging technology, cerebral microbleeds can be diagnosed in vivo. However, the underlying mechanism of cerebral microbleed formation is not fully understood. Objectives: This study aimed to identify the factors associated with cerebral microbleeds after carotid artery stenting (CAS). Method: We retrospectively examined 125 patients who underwent CAS for carotid stenosis. Cerebral microbleeds were investigated using T2*-weighted gradient-echo (GRE) imaging before and after CAS. We analyzed the possible association of new microbleeds with the following risk factors: the number of baseline microbleeds and ischemic cerebral lesions, the occurrence of cerebral hyperperfusion syndrome, and new ischemic cerebral lesions after CAS. Results: Baseline cerebral microbleeds were detected in 53 patients (42.4%). New cerebral microbleeds after CAS were observed in 13 of 125 patients (10.4%) and were exclusively associated with new ischemic lesions but not with other risk factors. No patient showed a merged image of a new cerebral microbleed on GRE imaging or a new ischemic lesion on diffusion-weighted imaging. Lobar and deep microbleeds were noted in 12/13 (92.3%) and 1 patient (7.7%), respectively. Of 12 patients with new microbleeds, 10 (76.9%) and 2 (15.4%) had a new microbleed in the ipsilateral and contralateral hemispheres, respectively. Conclusions: We found that new cerebral microbleeds developed after CAS and that these might be associated with new ischemic lesions, mostly in the territory of the treated carotid artery. We speculate that these microbleeds result from the deoxygenation of hemoglobin in the embolus or, alternatively, small hemorrhagic transformation of ischemic lesions.

Infarct growth from the early ischemic core to the total infarct lesion volume (LV) is often used as an outcome variable of treatment effects, but can be overestimated due to vasogenic edema. The purpose of this study was (1) to assess two components of early lesion growth by distinguishing between water uptake and true net infarct growth and (2) to investigate potential treatment effects on edema-corrected net lesion growth. Sixty-two M1-MCA-stroke patients with acute multimodal and follow-up CT (FCT) were included. Ischemic lesion growth was calculated by subtracting the initial CTP-derived ischemic core volume from the LV in the FCT. To determine edema-corrected net lesion growth, net water uptake of the ischemic lesion on FCT was quantified and subtracted from the volume of uncorrected lesion growth. The mean lesion growth without edema correction was 20.4 mL (95% CI: 8.2–32.5 mL). The mean net lesion growth after edema correction was 7.3 mL (95% CI: −2.1–16.7 mL; p

The risk of cerebral embolism after CAS in patients with carotid IPH is still controversial. This study was to further investigate the relationship between IPH and new ipsilateral ischemic lesion (NIIL) after CAS, and to perform a volumetric analysis of IPH for predicting the risk of NIIL following CAS. One hundred and seventeen patients with carotid stenosis undergoing CAS were prospectively enrolled. Preprocedural multi-contrast carotid MRI was performed. NIIL was evaluated by brain DWI before and after CAS. IPH volume, wall volume at the plaque (WVplaque) and relative IPH volume were calculated. Associations between IPH and postprocedural NIIL were studied. NIILs were shown in 52 patients. IPH were identified in 53 patients. NIILs were found more frequently in IPH-positive (33/53, 62.3%) than in IPH-negative patients (19/64, 29.7%, p

We studied the role of Sirtuin 3 (SIRT3) in microglial cell migration in ischemic stroke. We used a middle cerebral artery occlusion (MCAO) model of focal ischemia. We then applied lentivirus-packaged SIRT3 overexpression and knock down in microglial N9 cells to investigate the underlying mechanism driving microglial cell migration. More microglial cells appeared in the ischemic lesion side after MCAO. The levels of SIRT3 were increased in macrophages, the main source of microglia, after ischemia. CX3CR1 levels were increased with SIRT3 overexpression. SIRT3 promoted microglial N9 cells migration by upregulating CX3CR1 in both normal and glucose deprived culture media. These effects were G protein-dependent. Our study for the first time shows that SIRT3 promotes microglia migration by upregulating CX3CR1.

Background and ObjectivesIn acute stroke, early ischemic lesion hypodensity on CT is considered the imaging hallmark of brain infarction, representing a state of irreversible tissue damage with a continual increase of net water uptake. This dogma, however, is challenged by rare cases of apparently reversed early lesion hypodensity after complete reperfusion. The purpose of this study was to investigate the occurrence of reversible ischemic edema after endovascular treatment.MethodsOne hundred eighty-four patients with acute ischemic anterior circulation stroke were included after consecutive screening. Ischemic brain edema was determined with quantitative lesion net water uptake (NWU) in admission CT and follow-up CT based on CT densitometry, and ΔNWU was calculated as the difference. The association of edema progression to imaging and clinical parameters was investigated. Clinical outcome was assessed with the modified Rankin Scale (mRS) scores at day 90.ResultsOf 184 patients, 27 (14.7%) showed edema arrest and 3 (1.6%) exhibited significant edema reversibility. Higher degree of recanalization (odds ratio [OR] 2.96, 95% confidence interval [CI] 1.46–6.01, p < 0.01) and shorter time from imaging to recanalization (OR per hour 0.32, 95% CI 0.18–0.54, p < 0.0001) were significantly associated with edema arrest or reversibility. Clinical outcome was significantly better in patients without edema progression (median mRS score 2 vs 5, p = 0.004).DiscussionAlthough rare, lesion hypodensity considered to be representative of early infarct in acute stroke CT may be reversible after complete recanalization. Arrest of edema progression of acute brain infarct lesions may occur after successful rapid vessel recanalization, resulting in improved functional outcome. Future research is needed to investigate conditions in which early revascularization may halt or even reverse vasogenic edema of ischemic tissue.

Background: High on-treatment platelet reactivity or its equivalent—resistance to the antiplatelet agent—significantly reduces the efficacy of the therapy, contributing to a negative impact on stroke course. Previous studies demonstrated that aspirin resistance is associated with a larger size of acute ischemic infarct. Due to the increasing use of clopidogrel in the secondary prevention of stroke, we aimed to assess the impact of clopidogrel resistance on the size and extent of ischemic lesions, both acute and chronic. Methods: This prospective, single-center and observational study involved 74 ischemic stroke subjects, treated with 75 mg of clopidogrel. We used impedance aggregometry to determine platelet reactivity 6–12 h after a dose of clopidogrel as a first assessment and 48 h later as the second measurement. A favorable dynamics of platelet reactivity over time was the decrease in the minimum value equal to the median in the entire study. The volume of acute ischemic infarct was estimated within 48 h after onset in diffusion-weighted imaging and fluid-attenuated inversion recovery sequences of magnetic resonance and the severity of chronic vascular lesions by Fazekas scale. Results: Subjects with mild severity of chronic vascular lesions (Fazekas 1) exhibited a significant decrease of platelet reactivity over time (p = 0.035). Dynamics of platelet reactivity over time differed between subjects with large, moderate, mild and insignificant size of acute ischemic lesion (Kruskall-Wallis H = 3.2576, p = 0.048). In multivariate regression models, we reported unfavorable dynamics of platelet reactivity alone and combined with a high initial value of platelet reactivity as independent predictors of higher risk of a significant ischemic infarct volume (OR 7.16 95%CI 1.69-30.31, p = 0.008 and 26.49 95%CI 1.88-372.4, p = 0.015, respectively). Conclusions: We emphasized that unfavorable dynamics of platelet reactivity over time during clopidogrel therapy in acute phase of stroke affect the volume of acute infarct and the severity of chronic vascular lesions.

There is growing research interest on identification of CT Perfusion (CTP) parameters that predict the outcome in acute ischemic stroke patients. The aim of this study is to produce the model, based on core-penumbra related parameters assessed by CTP processing and commonly used clinical prediction factors, to predict the final infarct volume in thrombolysis-treated anterior circulation wake-up stroke (WUS) patients. The study was conducted on 51 consecutive wake-up ischemic stroke patients. The model for the predictive estimation of final ischemic volume was determined by using the Least Absolute Shrinkage and Selection Operator (LASSO) regularized least-squares regression. The results showed that CTP core volume and CTP total ischemic volume at admission, together with ASPECT score predict the final infarct lesion volume. In particular, the identified model presented 5-fold cross-validation root mean square error RMSE of 8.1 ml and the coefficient of determination (R2=0.94) on our dataset. The results should be confirmed in a lager study. In conclusion, in this study we preliminarily identified a predictive model to estimate final ischemic lesion volume in thrombolysis treated wake-up stroke patients.

В исследовании изучалась динамика объема ишемического очага и объемов полушарий мозга у животных с локальной ишемией в течении 2 месяцев после ишемии при помощи ручной сегментации. Были выявлены значимые различия между объемами полушарий на 1, 3, 14, 21, 30, 42 день исследования (p Ischemic lesion volume and the brain hemisphere volume long-term changes were evaluated during 2 month after focal ischemia in rats using manual segmentation,. Significant differences were identified between hemisphere volumes on the 1st, 3rd, 14th, 21st, 30th, 42nd day after ischemia (p

The effect of age on lesion pathophysiology in the context of thrombectomy has been poorly investigated. We aimed to investigate the impact of age on ischemic lesion water homeostasis measured with net water uptake (NWU) within a multicenter cohort of patients receiving thrombectomy for anterior circulation large vessel occlusion (LVO) stroke. Lesion-NWU was quantified in multimodal CT on admission and 24 h for calculating Δ-NWU as their difference. The impact of age and procedural parameters on Δ-NWU was analyzed. Multivariable regression analysis was performed to identify significant predictors for Δ-NWU. Two hundred and four patients with anterior circulation stroke were included in the retrospective analysis. Comparison of younger and elderly patients showed no significant differences in NWU on admission but significantly higher Δ-NWU ( p = 0.005) on follow-up CT in younger patients. In multivariable regression analysis, higher age was independently associated with lowered Δ-NWU (95% confidence interval: −0.59 to −0.16, p

Calcifying uremic arteriolopathy (CUA), also called calciphylaxis, refers to the calcification of the walls of the arteries of medium and small caliber, causing ischemic skin lesions. Diagnosis should be made if ischemic lesion develops in a patient with chronic renal failure (CRF), and it is confirmed based on clinical, radiological, and histological criteria. Generalized CUA characterized by ischemia of the penis (IP) along with other localizations of cutaneous ischemia is exceptional, and the morbidity and high mortality rate associated with this entity most often warrant multidisciplinary and conservative management.

Background The postoperative course after surgery for primary brain tumours can be difficult to predict. We examined the time course of postoperative neurological deficits and analysed possible predisposing factors. Method Hundred adults with a radiological suspicion of low- or high-grade glioma were prospectively included and the postoperative course analysed. Possible predictors of postoperative neurological deterioration were evaluated. Results New postoperative neurologic deficits occurred in 37% of the patients, and in 4%, there were worsening of a preoperative deficit. In 78%, the deficits occurred directly after surgery. The probable cause of deterioration was EEG-verified seizures in 7, ischemic lesion in 5 and both in 1, resection of eloquent tissue in 6, resection close to eloquent tissue including SMA in 11 and postoperative haematoma in 1 patient. Seizures were the main cause of delayed neurological deterioration. Two-thirds of patients with postoperative deterioration showed complete regression of the deficits, and in 6% of all patients, there was a slight disturbance of the function after 3 months. Remaining deficits were found in 6% and only in patients with preoperative neurological deficits and high-grade tumours with mainly eloquent locations. Eloquent tumour location was a predictor of postoperative neurological deterioration and preoperative neurological deficits of remaining deficits. Conclusions Postoperative neurological deficits occurred in 41% and remained in 6% of patients. Remaining deficits were found in patients with preoperative neurological deficits and high-grade tumours with mainly eloquent locations. Eloquent tumour location was a predictor of neurological deterioration and preoperative neurological deficits of remaining deficits.