Abstract 3329: Multimodal Predictors of Massive Ischemic Stroke Presentation and Favourable Outcome.

Abstract

Background: Severe stroke carries a high case fatality and disability rate. The aims of this study are to determine the characteristics of patients with initially severe (“massive”) ischemic stroke, and to identify acute and subacute predictors of favourable clinical outcome in such patients. Methodology: Using the Acute STroke Registry and Analysis of Lausanne (ASTRAL), we compared all patients with massive stroke defined as a NIHSS ≥ 20 on admission with all the other patients. In a multivariate analysis, associations with a demographic, clinical, pathophysiological, metabolic and neuroimaging factors and were determined. Furthermore, we analyzed predictors in the subgroup of massive stroke patients with favourable outcome (mRS ≤3 at three months). Results: Among 1’915 consecutive patients, 243 (12.7%) had massive stroke. It was significantly associated with cardio-embolic stroke mechanism (OR=1.74 / 95% CI 1.193 - 2.548), unknown stroke onset (OR=2.35 / 95% CI 1.143 - 4.831), more early ischemic findings on neuroimaging (mostly CT, OR=2.65 / 95% CI 1.795 - 3.924), arterial occlusions on acute imaging (OR=0.03 / 95% CI 0.0158 - 0.0862), less chronic radiological infarcts (OR=0.43 / 95% 0.258 - 0.719), lower haemoglobin concentration per g/l (OR=0.97 / 95% CI 0.965 - 0.987), and higher white cell count per 1000 cells/l (OR=1.05 / 95%CI 1.001 - 1.109). In the 68 (28%) patients with favourable outcome, this was predicted by lower age (OR=0.943 / 95% CI 0.917 - 0.971), previous cerebrovascular events (OR=3.00 / 95% CI 1.009 - 8.964), hypolipemic pre-treatement (OR= 3.82 / 95% CI 1.341 - 10.895), lower acute temperature (OR=0.427 / 95% CI 0.232 - 0.785), lower subacute glucose concentration (OR=0.739 / 95% CI 0.565 - 0.966), and spontaneous or treatment-induced recanalisation at 24 hours (OR= 4.51 / 95%CI 1.957 - 10.407). Conclusion: Massive stroke presentation is predicted by multiple clinical, radiological and metabolic variables, several of which are modifiable. Predictors in the 28% of patients with favourable outcome despite massive stroke include hypolipemic pretreatment, lower acute temperature, lower glucose levels at 24 hours and arterial recanalisation. Massive ischemic stroke is a serious, preventable and treatable condition.