Abstract TP14: Predictors of Neurological Worsening Among Patients Presenting With Large Vessel Occlusions and Mild Symptoms

Abstract

Introduction: We aim to evaluate the predictors of poor neurological outcome among patients presenting with large vessel occlusion (LVO) and mild symptoms who did not undergo upfront thrombectomy. Methods: Single-center retrospective study of consecutive patients with NIHSS≤5 and LVO on CT/MR angiography within 24h from symptom onset and baseline modified rankin score (mRS)0-2 from Jan 2014-Dec 2017. Acute neurologic deterioration definition: change in NIHSS≥4 within 24h. Primary outcome: NIHSS shift ≥4 (discharge NIHSS minus admission NIHSS score). Results: Among 1156 patients with acute minor strokes, 134 (11%) met criteria. 78% underwent CTA/22% MRA, performed <4h of arrival in 83%. Median age was 64[53-71]years, 58% were male, and last-normal-to-hospital-arrival was 5[2- 8]h. Median baseline NIHSS 3[1- 4] and initial systolic blood pressure 161[137-177]mmHg. Median glucose was 114[100- 143]mg/dL, ejection fraction 55[52- 60]%, and NCCT ASPECTS 10[9-10]. Occlusion site was intracranial carotid in 10%, middle cerebral M1 30%, M2 26%, M3 9%, anterior cerebral 3%, extracranial carotid 11%, basilar 7%, and posterior cerebral 2%. RAPID CT perfusion was performed in 42%, with median core 0[0-5]cc, Tmax>4s 152[62-232]cc, Tmax>6s 57[25-108]cc, Tmax>10s 10[0-33]cc. Orthostatic challenge was performed in 28 (21%) with NIHSS worsening ≥1 in 46%. Twenty-four (18%) patients had acute neurological deterioration of NIHSS≥4 at a median of 2[1-16] hours from arrival. Median discharge NIHSS was 2[0- 4] and the NIHSS shift -1[-3- 0]. Etiology was cryptogenic in 24%, cardioembolic in 25%, and large vessel atherosclerosis in 26%. Parenchymal hematomas occurred in 7%. Overall, 22% had an unfavorable NIHSS shift ≥1, 15% NIHSS≥2, and 11% had NIHSS shift≥4. At discharge, only 62% were independent (22% mRS0, 27% mRS1, 12% mRS2). Multivariable regression indicated acute neurological deterioration (OR 7.9; 96%CI 1.4-41.9;p=0.01) and discharge mRS (OR 3.6; 96%CI 1.6-8.4;p=0.01) independently associated with NIHSS shift ≥4. Conclusion: Acute neurological worsening occurs early and predicts an NIHSS shift≥4 at discharge, which in turn is associated with worse discharge mRS. The optimal therapeutic window in LVO with mild NIHSS may be relatively narrow.