Acute and Critical Care

Original Articles

Neurology
Clinical variable-based decision-support model for rapid differentiation of hemorrhagic and ischemic stroke at emergency department presentation in South Korea: Jae-Woo Kim, Jin-Heon Jeong, Moon-Ku Han, Sang-Hoon Han, Ka Hyun Kim, Seung Park, Dong-Ick Shin, Kyu Sun Yum; Received October 21, 2025 Accepted February 10, 2026 Published online February 27, 2026; DOI: https://doi.org/10.4266/acc.004925 [Epub ahead of print]

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Abstract PDF Supplementary Material: Background
Prompt differentiation between ischemic stroke (IS) and hemorrhagic stroke (HS) is critical because their treatment strategies fundamentally differ. While neuroimaging is essential, clinical decision-making often begins before imaging is completed, and conventional clinical scores have shown inconsistent performance. The objective of this study was therefore to develop and externally validate a machine-learning model that supports HS vs. IS subtype suspicion at emergency department (ED) presentation using only clinical variables.
Methods
We conducted a retrospective multicenter cohort study of 2,998 adult patients with a final diagnosis of acute IS or HS treated at three comprehensive stroke centers (July 2020–January 2024). Patients from hospitals A and B comprised the development/internal validation cohort (n=2,418), while patients from hospital C served as an independent external validation cohort (n=580). An extreme gradient boosting (XGBoost) algorithm was trained using four-fold cross-validation, and feature contributions were assessed using Shapley additive explanation (SHAP) values.
Results
Internal validation showed an area under the receiver operating characteristic curve (AUROC) of 0.937 (95% CI, 0.922–0.950) with a sensitivity 0.828, specificity of 0.932, and accuracy of 0.905. Independent external validation yielded an AUROC of 0.841 (95% CI, 0.792–0.883) with a sensitivity 0.758, specificity of 0.789, and accuracy of 0.783. SHAP analysis identified headache and higher National Institutes of Health Stroke Scale item 1a (level of consciousness) as factors increasing the model output toward HS, whereas atrial fibrillation shifted predictions toward IS.
Conclusions
A clinical variable-only model can support early HS vs. IS subtype suspicion at ED presentation among patients managed in an acute-stroke pathway without requiring laboratory tests. Performance decreased on independent external validation, suggesting potential site-related differences and the need for prospective evaluation and calibration. Stroke mimics were not included and should be addressed in future studies.

Neurology
Effectiveness of intravenous thrombolysis in patients with large-vessel occlusion receiving endovascular treatment in South Korea: Min Kim, Ji Sung Lee, Seong-Joon Lee, So Young Park, Jungyun Seo, Ji Man Hong, Hee-Kwon Park, Jae-Kwan Cha, Jeffrey L. Saver, Jin Soo Lee; Acute Crit Care. 2025;40(2):282-292. Published online April 11, 2025; DOI: https://doi.org/10.4266/acc.004248

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2 Web of Science
2 Crossref

Background
The effectiveness of intravenous tissue plasminogen activator (IV tPA) in patients with large-vessel occlusion (LVO) receiving endovascular treatment (EVT) for acute ischemic stroke (AIS) has been questioned. We investigated IV tPA effectiveness in real-world AIS patients, including those with intracranial LVO receiving EVT.
Methods
We identified patients with AIS who presented to hospital with National Institutes of Health Stroke Scale ≥4 within 8 hours of symptom onset from the institutional stroke registry. The association of IV tPA use with effectiveness and safety outcomes was analyzed in overall enrolled AIS patients; LVO patients; and patients treated with EVT. The effect of IV tPA was assessed using multiple logistic regression.
Results
Among the 654 patients meeting study entry criteria, 238 (36.4%) received IV tPA and 416 (63.6%) did not. Multiple logistic regression analysis and shift analysis revealed IV tPA was associated with improved outcomes in overall enrolled AIS population, LVO, and EVT-treated subgroups. Among EVT-treated patients, IV tPA was associated with higher likelihood of ambulatory or better outcome (modified Rankin Scale 0–3) with odds ratio of 1.95 (P=0.03).
Conclusions
In this real-world study, IV tPA use was associated with improved outcomes for patients with AIS, including among LVO patients treated and not treated with EVT, in the contemporary mechanical thrombectomy era.

Citations

Citations to this article as recorded by

SMART-M24: A Prognostic Nomogram for Long-Term Mortality in Acute Ischemic Stroke Beyond 24 H from Symptom Onset
Soo-Hyun Park, Ji Sung Lee, Tae Jung Kim, Mi Sun Oh, Ji-Woo Kim, Kyungbok Lee, Kyung-Ho Yu, Byung-Chul Lee, Byung-Woo Yoon, Sang-Bae Ko
Translational Stroke Research.2025; 16(6): 1975. CrossRef
Knowledge and experience of local emergency care staff on stroke recognition and acute care in the United Arab Emirates
Mohammed Alkuwaiti, Azhar Talal, Emad Masuadi, Ghada Albluwi, Abdulla Alkuwaiti, David Olukolade Alao
International Journal of Emergency Medicine.2025;[Epub] CrossRef

Anesthesiology
Anesthesiological management in endovascular mechanical thrombectomy: a propensity score-matched retrospective analysis in Italy: Antonio Romanelli, Aniello Iovino, Antonella Langone, Rosa Napoletano, Giulia Frauenfelder, Flora Minichino, Liliana D’Ambrosio, Miriam Caterino, Raffaele Tortora, Renato Gammaldi, Paolo Barone, Renato Saponiero, Daniele Giuseppe Romano; Acute Crit Care. 2025;40(2):252-263. Published online April 11, 2025; DOI: https://doi.org/10.4266/acc.003000

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Abstract PDF: Background
Endovascular mechanical thrombectomy (EMT) can be performed with general anesthesia (GA) or using non-GA techniques. Several meta-analyses on the topic have reported discordant main outcomes. The aim of this retrospective single-center study was to analyze the relationship between clinical outcomes and anesthesiological management (GA vs. non-GA) in patients who underwent EMT for acute anterior ischemic stroke (AIS).
Methods
We performed a propensity score-matched (PSM) analysis of patients who underwent EMT for acute AIS from January 2018 to December 2021. For PSM, we chose covariates influencing clinical decisions about anesthesiological management. Comparisons between groups were performed with the chi-square test for categorical variables and Student t-test or the Mann-Whitney U-test for continuous variables as appropriate. The relationships between anesthesiological management and clinical outcomes were analyzed using logistic regression, and results are reported as odds ratios with 95% confidence intervals. A two-sided P-value <0.05 was considered statistically significant.
Results
From 194 observations (78 in the GA group, 116 in the non-GA group), after PSM, we obtained 70 data pairs. Both anesthesiological approaches resulted in similar rates of in-hospital mortality, 90-day functional independence, full recanalization, procedural complications, and intracerebral hemorrhage (ICH). Performing EMT with GA was unrelated to the in-hospital and 90-day death rates, 90-day functional independence, full recanalization rate, procedural complications, and ICH (P>0.05).
Conclusions
Anesthesiological management did not influence clinical outcomes of EMT for acute AIS. Physiological stability during EMT may impact outcomes more significantly than anesthesiological management. Further studies on this topic are needed.

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