Abstract TMP69: Poor Clinical Outcome Of Patients With Early Neurological Deterioration In Large Vessel Occlusion And Low NIHSS

Abstract

Introduction: Early neurological deterioration (END) in patients with large vessel occlusion (LVO) stroke with low NIHSS treated with medical management (MM) has been well described. However, the effect of END on 90-day disability outcomes relative to patients presenting with more severe stroke, remains undetermined. Methods: From our multi-center prospective registry across 4 comprehensive stroke centers, we identified patients with LVO (basilar, ICA, M1/2, or P1 identified on CTA or MRA) from January 2018 to June 2020. Low NIHSS was defined as 0-5, and END as a worsening of > 3 points. To determine the effect of END on outcomes, we used propensity score to match patients who presented with low NIHSS who suffered END by age and worsened NIHSS (i.e. subsequent, greater NIHSS) to patients who presented initially with LVO and comparable NIHSS. Results: Among 348 patients with LVO acute ischemic stroke, median age was 67 [IQR 59-76], 46.6% were female. 58 patients (17%) of the cohort had low NIHSS. Compared to the higher NIHSS group, low NIHSS group had less EVT performed (39.7% vs 78.3%, p=<0.001), greater ASPECTS (9 vs 8, p=0.001), fewer M1 occlusions (27.6% vs 51.7%, p<0.001), and lower prevalence of risk factors, such as hypertension, hyperlipidemia, and congestive heart failure (50.0% vs 71.4, p=0.001; 20.7% vs 36.9%, p=0.018; and 0.0% vs 9.3%, p=0.016, respectively). Overall 90-day disability outcomes (mRS 0-2) were better in the low NIHSS group (58.6% vs 44.8%, p=0.055) although it did not reach statistical significance. On the other hand, 41.4% of low NIHSS group did not achieve functional independence. Of 35 patients with initial MM in the low NIHSS group, 7 (20%) suffered END. The median increase in NIHSS was 7 (range 4-15), and only 1 patient achieved 90-day mRS 0-2. In a propensity matching analysis, LVO patients with initially low NIHSS patients followed by END had significantly worse outcomes than the patients who initially presented with comparable NIHSS (Coef=26, p=<0.001). Conclusions: In patients with low NIHSS and LVO, those treated initially with MM who suffer END have worse clinical outcomes when matched to patients with comparable NIHSS post-worsening. These finding suggest that the delaying EVT in this population may lead to worsened outcomes.