Letter by Scutelnic et al Regarding Article, “Acute Neurological Deterioration in Large Vessel Occlusions and Mild Symptoms Managed Medically”

Abstract

HomeStrokeVol. 51, No. 10Letter by Scutelnic et al Regarding Article, “Acute Neurological Deterioration in Large Vessel Occlusions and Mild Symptoms Managed Medically” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessLetterPDF/EPUBLetter by Scutelnic et al Regarding Article, “Acute Neurological Deterioration in Large Vessel Occlusions and Mild Symptoms Managed Medically” Adrian Scutelnic, MD Simon Jung, MD Mirjam R. HeldnerMD, MSc Adrian ScutelnicAdrian Scutelnic Search for more papers by this author , Simon JungSimon Jung Search for more papers by this author , and Mirjam R. HeldnerMirjam R. Heldner https://orcid.org/0000-0002-3594-2159 Search for more papers by this author Originally published28 Sep 2020https://doi.org/10.1161/STROKEAHA.120.030856Stroke. 2020;51:e287–e288To the Editor:We thank the authors for their important work. Saleem et al1 retrospectively studied frequency, time point, and predictors of in-hospital secondary neurological deterioration (SND) in patients with admission National Institutes of Health Stroke Scale (NIHSS) score ≤5 despite large vessel occlusion managed medically (conservatively +/- with intravenous thrombolysis) initially. In-hospital SND of ≥4 NIHSS score points occurred in a fifth of patients, at a median of 3.6 (1–16) hours after admission, impacted outcome, and was not predictable in multivariate analysis. After SND, rescue reperfusion therapy improved outcome.To date, we have published 2 studies on related topics.2,3 Based thereon and in Saleem et al’s1 study, we performed the current analysis containing patients managed conservatively (+/- with rescue reperfusion therapy finally) from January 2004 until December 2019. In our prospective single tertiary care center cohort of patients with large vessel occlusion in the anterior circulation and low NIHSS score, there have been included 110 (47.6%) conservatively treated patients with occlusion of the internal carotid artery and/or M1 segment of the middle cerebral artery and without coexisting chronic vessel occlusion. Any in-hospital SND occurred at a median of 13.6 (0.8–23) hours, with an increase of the NIHSS score ≥1 in 58 (52.7%) and ≥4 in 36 (32.7%) of patients. The latter was not predictable in multivariate analysis which nearly included the same variables as in Saleem et al’s1 study. Thirty-one (28.2%) patients were finally treated with rescue reperfusion therapy: 24 (77.4%) with endovascular therapy, 6 (19.4%) with bridging therapy, and 1 (3.2%) with intravenous thrombolysis. Rescue reperfusion therapy was only performed in patients with in-hospital SND, in 51.7%/58% of patients with an increase of the NIHSS score ≥1/4. In patients with SND of NIHSS score ≥1/4 versus with no deterioration, median NIHSS score change from admission to discharge was 4 (−4 to 39)/6 (−3 to 39) versus −1 (−4 to 37) each P<0.0001, there was a reduced chance of 3 months independence (modified Rankin Scale, 0–2; 45.8%/28.6% versus 81.8%, odds ratio 0.19/0.09; each P<0.0001) and of survival (83.1%/80% versus 97.7%, odds ratio 0.11/0.9; each P<0.02). In patients with any in-hospital SND, patients treated with versus without rescue reperfusion therapy showed equal median NIHSS score change from admission to discharge: 4 (−4 to 39) versus 4 (−3 to 39); P=0.775, 2 symptomatic intracranial hemorrhages (6.5% versus 0%; P=0.494) and equal 3 months independence (50% versus 41.4%; P=0.506) and survival (83.3% versus 82.8%; P=0.953).Overall, compared to Saleem et al’s data, any in-hospital SND was more frequent in our analysis, also negatively impacted outcome and also was not predictable. Outcome after in-hospital SND was similar with versus without rescue reperfusion therapy. We have not included patients with vessel occlusions of a more distal or posterior circulation location and only those managed conservatively initially, without intravenous thrombolysis, which surely helps explain our less favorable outcome results. Also, at our center, we tend to have a rather low threshold in performing primary reperfusion therapy in this specific patient group. Likely, this caused an unfavorable selection bias for some patients left for potential rescue reperfusion therapy if SND occured.Anyway, repeatedly, rates of in-hospital SND have been shown to be around 40% in conservatively treated patients with large vessel occlusion, despite low NIHSS score. Evidence is increasing that primary reperfusion therapy probably is superior to conservative therapy or rescue reperfusion therapy in this specific patient group. However, it remains unclear yet, whether rescue reperfusion therapy is inferior, superior or equal to continued conservative therapy after SND.1–4 As suggested before, total NIHSS score and modified Rankin Scale might not show sufficient sensitivity in assessment of patients with large vessel occlusion and low NIHSS score, and there is an unmet need for multicenter randomized controlled trials addressing best therapy.3DisclosuresDr Heldner received a grant from Bangerter Foundation on the topic of best therapy in patients with large vessel occlusion and low National Institutes of Stroke Scale score.FootnotesThis manuscript was sent to Marc Fisher, Senior Consulting Editor, for editorial decision and final disposition.For Disclosures, see page e287.