3-month Modified Rankin Scale Research Articles

Can ischemic stroke patients with mTICI of 2b achieve similar outcomes compared to those with complete recanalization following endovascular therapy?

Endovascular therapy (EVT) has been used as a standard treatment method for patients with large vessel ischemic stroke within 24 h of the onset. The extent of recanalization after EVT can be assessed using the modified thrombolysis in cerebral infarction (mTICI) scale as an accepted angiographic grading system. In this study, we aimed to investigate whether patients with a mTICI grade of 2b achieve similar outcomes compared to those with complete recanalization (mTICI of 3) following EVT for acute ischemic stroke. A retrospective analysis was conducted on 196 consecutive patients who underwent EVT in a comprehensive stroke center. In the final study, 176 patients were included based on the inclusion criteria. The primary outcome was the 3-month modified Rankin Scale (mRS) of 0-2 considered as a favorable outcome, while excellent outcomes were defined as mRS scores of 0-1. Our data showed that 59.46% of patients in the mTICI 2b group achieved a favorable outcome, comparable to 58.99% observed in the mTICI 3 group (p = 0.959). Additionally, 54.05% (n = 37) of patients with mTICI 2b achieved an excellent outcome, compared to 51.80% (n = 139) in the mTICI 3 group (p = 0.807). The case fatality rates were also comparable between the groups, with 8.11% in the mTICI 2b group and 10.79% in the mTICI 3 group (p = 0.632). Overall, there were no statistically significant differences between the two groups in terms of 3-month favorable outcomes, excellent outcomes, or mortality. Similar 3-month outcomes can be achieved for ischemic stroke patients undergoing EVT with a mTICI grade of 2b compared to those with a mTICI grade of 3. These data can help clinicians in setting realistic expectations and making informed decisions during EVT procedures.

The early prognostic value of the 1–4-day BCM/PA trend after admission in neurocritical patients

The purpose of this study was to investigate early stage dynamic changes in relevant indicators in neurocritical patients to identify biomarkers that can predict a poor prognosis at an early stage (1–4 days after admission). This study retrospectively collected clinical data, inflammatory indicators, and nutritional indicators from 77 patients at the neurology intensive care unit. The 3-month modified Rankin scale score was used as the outcome indicator. A linear mixed model was used to analyze changes in inflammatory indicators and nutritional indicators in neurocritical patients over time from 1–4 days after admission. Logistic regression was used to determine the independent risk factors for a poor prognosis in neurocritical patients and to construct a predictive model. The predictive efficacy of the model was verified using leave-one-out cross-validation and decision curve analysis methods. The analysis results showed that 1–4 days after admission, the inflammatory indicators of white blood cell and absolute monocyte counts and the nutritional indicators of body cell mass(BCM), fat-free mass, body cell mass/phase angle (BCM/PA), intracellular water, extracellular water, and skeletal muscle index increased overall, while the nutritional indicators of albumin and visceral fat area decreased overall. The logistic multivariate regression model showed that the Charlson comorbidity index (CCI) (odds ratio (OR) = 2.526, 95% CI [1.202, 5.308]), hemoglobin (Hb)(on admission)-Hb(min) (OR = 1.049, 95% CI [1.015, 1.083), BCM(on admission) (OR = 0.794, 95% CI [0.662, 0.952]), and the change in BCM/PA 1–4 days after admission (OR = 1.157, 95% CI [1.070, 1.252]) were independent risk factors for a poor prognosis in neurocritical patients. The predictive analysis showed that the predictive power of Model 1 with BCM/PA (area under the curve (AUC) = 0.95, 95% CI (0.90, 0.99)) was 93%, 65%, 141%, and 133% higher than that of Model 2 without BCM/PA, the CCI, the APACHE II score, and the NRS2002 score (all P < 0.05), respectively. The CCI, Hb(on admission)-Hb(min), BCM(on admission), and an increase in BCM/PA 1–4 days after admission were independently associated with a poor prognosis in neurocritical patients. Of these variables, BCM/PA may be a valid indicator for early stage prediction of a poor prognosis in neurocritical patients.

Clinical outcome and cost effectiveness of acute ischemic stroke transfers for endovascular reperfusion therapy from geographically distant counties: Stroke transfer outcomes

ObjectivesEndovascular reperfusion therapy (EVT) for acute ischemic stroke (AIS) with large vessel occlusion (LVO) has resulted in increased patient transfers to comprehensive stroke centers (CSCs). Clinical outcomes including the financial impact of these transfers from geographically dispersed population are lacking. Hence, we studied outcomes and cost-effectiveness of stroke transfers from remote areas. Materials and methodsWe used a 3-year cohort of AIS patients transferred from geographically dispersed counties (<100 mi., 101-200 mi., and >200 mi.). A 3-month modified Rankin scale (mRS) score of 0-2 defined a favorable clinical outcome. Cost-effectiveness is studied by calculating the incremental cost effectiveness ratio, using hospital costs reimbursed data and utility-weighted (UW)-mRS. ResultsAmong 172 patients transferred for EVT, patients transferred from nearby counties were more likely to undergo intervention compared to other counties (56.9 % vs. 36.7 % vs. 49.2 % p = .11). Irrespective of proximity (in mi.) to CSC [21.5 (14-56.3)] vs. 185 (137-185) vs. 349 (325-355)], there was a similar delay (in min.) to arrival from all locations [321.5 (244-490), 366 (298-432), and 460 (385–554.5) respectively], but no statistically significant differences in favorable outcomes (18.0 %, 34.1 %, and 22.2 %, respectively, p = .41). Patients undergoing EVT had higher hospital costs reimbursed compared to non-EVT patients [$37,303 (25,745-40,658) vs. $14,008 (8,640-21,273) respectively, p < .001] and no statistically significant difference in UW-mRS [0.32 (0.06-0.56) vs. 0.06 (0-0.56), p = .30]. ConclusionsOur study identifies a need for targeted interventions to improve community awareness and optimize systems of care to improve outcomes and cost-effectiveness of EVT.

Neutrophil-to-albumin Ratio as a Prognostic Factor in Patients with Acute Ischemic Stroke.

Neutrophil-To-Albumin Ratio (NAR) is a novel inflammatory biomarker. However, the potential prognostic value of NAR in acute ischemic stroke (AIS) remains unclear. This study aimed to evaluate whether NAR levels correlated with the 3-month modified Rankin scale (mRS) in patients with AIS. AIS patients were included in this retrospective study. NAR was calculated as the ratio of absolute neutrophil count to serum albumin level. Logistic regression analyses were used to investigate the effect of NAR on 3-month mRS of AIS. The predictive values of NAR, albumin level, and neutrophil count were compared utilizing receiver operating characteristic (ROC) curves. Moreover, subgroup analyses and interaction tests were conducted to evaluate the consistency of NAR's effect on AIS prognosis. Of the 780 patients included, 403 (51.67%) had a poor clinical outcome (mRS 3-6) at 3 months. NAR was independently correlated to 3-month poor functional outcome after adjusting for confounders (Odds ratios (OR), 9.34; 95% confidence intervals (CI), 1.09 to 80.13; p =0.0417). Subgroup analysis showed a relative effect consistent with the overall population results, and no statistical interactions were found in the subgroups (all p for interaction > 0.05). The ROC curve showed that the prognosis-related cutoff value for NAR was 0.123, with corresponding specificity and sensitivity of 53.55% and 63.94%, respectively. When comparing the predictive power, NAR (0.590; 95%CI 0.549-0.630) exhibited the highest area under the curve (AUC) of ROC compared to neutrophils (0.584; 95%CI 0.543-0.624) and albumin (0.540; 95%CI 0.500-0.581). There is a positive relationship between NAR levels and 3-month poor functional outcomes in AIS patients, supporting the potential of NAR as a readily available and economic serum biomarker for the early identification of AIS prognosis. Further studies are required to validate the prognostic value and clinical utility of the NAR.

Predictive value of intracranial high-density areas in neurological function.

Intracranial high-density areas (HDAs) have attracted considerable attention for predicting clinical outcomes; however, whether HDAs predict worse neurological function and mental health remains controversial and unclear, which requires further investigation. To investigate the predictive value of intracranial HDAs for neurological function and mental health after endovascular treatment. In this prospective study, 96 patients with acute ischemic stroke (AIS) who accepted endovascular mechanical thrombectomy (EMT) were included. The enrolled patients underwent cranial computed tomography (CT) examination within 24 hours after EMT. Clinical data in terms of National Institutes of Health Stroke Scale (NIHSS), the 3-month modified Rankin Scale (mRS), self-rating depression scale (SDS), and self-rating anxiety scale (SAS) scores were collected and compared between patients with HDAs and non-HDAs and between patients with good and poor clinical prognosis. Compared to patients without HDAs, patients with HDAs presented severe neurological deficits (admission NIHSS score: 18 ± 3 vs 19 ± 4), were more likely to have post-stroke disabilities (mRS < 3: 35% vs 62%), and suffered more severe depression (SDS score: 58 ± 16 vs 64 ± 13) and anxiety disorder (SAS score: 52 ± 8 vs 59 ± 10). Compared to patients with a good prognosis, patients with a poor prognosis presented severe neurological deficits (admission NIHSS score: 17 ± 4 vs 20 ± 3), were more likely to have HDAs on CT images (64% vs 33%), and suffered more severe depression (SDS score: 55 ± 19 vs 65 ± 11) and anxiety (SAS score: 50 ± 8 vs 58 ± 12). Multivariate analysis revealed that HDAs were independent negative prognostic factors. In conclusion, HDAs on CT images predicted poor prognosis and severe depressive and anxiety symptoms in patients with AIS who underwent EMT.

Genetic Variation and Stroke Recovery: The STRONG Study.

Genetic association studies can reveal biology and treatment targets but have received limited attention for stroke recovery. STRONG (Stroke, Stress, Rehabilitation, and Genetics) was a prospective, longitudinal (1-year), genetic study in adults with stroke at 28 US stroke centers. The primary aim was to examine the association that candidate genetic variants have with (1) motor/functional outcomes and (2) stress-related outcomes. For motor/functional end points, 3 candidate gene variants (ApoE ε4, BDNF [brain-derived neurotrophic factor], and a dopamine polygenic score) were analyzed for associations with change in grip strength (3 months-baseline), function (3-month Stroke Impact Scale-Activities of Daily Living), mood (3-month Patient Health Questionnaire-8), and cognition (12-month telephone-Montreal Cognitive Assessment). For stress-related outcomes, 7 variants (serotonin transporter gene-linked promoter region, ACE [angiotensin-converting enzyme], oxytocin receptor, FKBP5 [FKBP prolyl isomerase 5], FAAH [fatty acid amide hydrolase], BDNF, and COMT [catechol-O-methyltransferase]) were assessed for associations with posttraumatic stress disorder ([PTSD]; PTSD Primary Care Scale) and depression (Patient Health Questionnaire-8) at 6 and 12 months; stress-related genes were examined as a function of poststroke stress level. Statistical models (linear, negative binomial, or Poisson regression) were based on response variable distribution; all included stroke severity, age, sex, and ancestry as covariates. Stroke subtype was explored secondarily. Data were Holm-Bonferroni corrected. A secondary replication analysis tested whether the rs1842681 polymorphism (identified in the GISCOME study [Genetics of Ischaemic Stroke Functional Outcome]) was related to 3-month modified Rankin Scale score in STRONG. The 763 enrollees were 63.1±14.9 (mean±SD) years of age, with a median initial National Institutes of Health Stroke Scale score of 4 (interquartile range, 2-9); outcome data were available in n=515 at 3 months, n=500 at 6 months, and n=489 at 12 months. At 1 year poststroke, the rs6265 (BDNF) variant was associated with poorer cognition (0.9-point lower telephone-Montreal Cognitive Assessment score, P=1×10-5). For stress-related outcomes, rs4291 (ACE) and rs324420 (FAAH) were risk factors linking increased poststroke stress with higher 1-year depression and PTSD symptoms (P<0.05), while rs4680 (COMT) linked poststroke stress with lower 1-year depression and PTSD. Findings were unchanged when considering stroke subtype. STRONG replicated GISCOME: rs1842681 was associated with lower 3-month modified Rankin Scale score (P=3.2×10-5). This study identified genetic associations with cognitive function, depression, and PTSD 1 year poststroke. Genetic susceptibility to PTSD and depressive symptoms varied according to the amount of poststroke stress, underscoring the critical role of lived experiences in recovery. Together, the results suggest that genetic association studies provide insights into the biology of stroke recovery in humans.

Association between blood urea nitrogen to creatinine ratio and 3-month outcome in patients with acute ischaemic stroke: a retrospective cohort study from a large healthcare system

ObjectivesThe blood urea nitrogen to creatinine (BUN/Cr) ratio is associated with early neurological deterioration in acute ischaemic stroke (AIS). However, the predictive value of the BUN/Cr ratio for the AIS...

Precranial artery calcification burden: a potential indicator of the clinical outcome of reperfusion in patients with acute large artery occlusion.

With mechanical thrombectomy (MT), we investigated the prognostic importance of aortic arch calcification (AoAC) and carotid sinus calcification (CaSC) for symptomatic intracerebral hemorrhage (sICH) and poor outcome in acute large artery occlusion (LAO). In this retrospective observational study, we calculated pre-cranial artery calcification burden (PACB) scores (burden score of AoAC and CaSC) using the AoAC grading scale score plus Woodcock visual score. The outcome measure was sICH per the European Cooperative Acute Stroke Study III definition. A 3-month modified Rankin scale score 3-6 was designated as poor outcome. Compared with patients who had PACB <3, those with PACB ≥3 showed substantially higher risks of sICH (odds ratio [OR] = 2.567, 95% confidence interval [CI] = 1.187-5.550) and poor outcome (OR = 4.777, 95% CI = 1.659-13.756). According to receiver operating characteristic (ROC) curves, adding PACB to the regression model enhanced the predictive value for poor outcome (area under the ROC curve [AUC]: 0.718 vs. 0.519, Z = 2.340) and in patients receiving MT (AUC: 0.714 vs. 0.584, Z = 2.021), independently. Factors related to PACB were consistent with common risk factors of systemic atherosclerosis. Low PACB scores indicated better prognosis. In patients with LAO following MT, PACB was useful in predicting sICH and poor clinical outcome.

Endovascular Versus Medical Therapy in Posterior Cerebral Artery Stroke: Role of Baseline NIHSS Score and Occlusion Site.

Acute ischemic stroke with isolated posterior cerebral artery occlusion (iPCAO) lacks management evidence from randomized trials. We aimed to evaluate whether the association between endovascular treatment (EVT) and outcomes in iPCAO acute ischemic stroke is modified by initial stroke severity (baseline National Institutes of Health Stroke Scale [NIHSS]) and arterial occlusion site. Based on the multicenter, retrospective, case-control study of consecutive iPCAO acute ischemic stroke patients (PLATO study [Posterior Cerebral Artery Occlusion Stroke]), we assessed the heterogeneity of EVT outcomes compared with medical management (MM) for iPCAO, according to baseline NIHSS score (≤6 versus >6) and occlusion site (P1 versus P2), using multivariable regression modeling with interaction terms. The primary outcome was the favorable shift of 3-month modified Rankin Scale (mRS). Secondary outcomes included excellent outcome (mRS score 0-1), functional independence (mRS score 0-2), symptomatic intracranial hemorrhage, and mortality. From 1344 patients assessed for eligibility, 1059 were included (median age, 74 years; 43.7% women; 41.3% had intravenous thrombolysis): 364 receiving EVT and 695 receiving MM. Baseline stroke severity did not modify the association of EVT with 3-month mRS distribution (Pinteraction=0.312) but did with functional independence (Pinteraction=0.010), with a similar trend on excellent outcome (Pinteraction=0.069). EVT was associated with more favorable outcomes than MM in patients with baseline NIHSS score >6 (mRS score 0-1, 30.6% versus 17.7%; adjusted odds ratio [aOR], 2.01 [95% CI, 1.22-3.31]; mRS score 0 to 2, 46.1% versus 31.9%; aOR, 1.64 [95% CI, 1.08-2.51]) but not in those with NIHSS score ≤6 (mRS score 0-1, 43.8% versus 46.3%; aOR, 0.90 [95% CI, 0.49-1.64]; mRS score 0-2, 65.3% versus 74.3%; aOR, 0.55 [95% CI, 0.30-1.0]). EVT was associated with more symptomatic intracranial hemorrhage regardless of baseline NIHSS score (Pinteraction=0.467), while the mortality increase was more pronounced in patients with NIHSS score ≤6 (Pinteraction=0.044; NIHSS score ≤6: aOR, 7.95 [95% CI, 3.11-20.28]; NIHSS score >6: aOR, 1.98 [95% CI, 1.08-3.65]). Arterial occlusion site did not modify the association of EVT with outcomes compared with MM. Baseline clinical stroke severity, rather than the occlusion site, may be an important modifier of the association between EVT and outcomes in iPCAO. Only severely affected patients with iPCAO (NIHSS score >6) had more favorable disability outcomes with EVT than MM, despite increased mortality and symptomatic intracranial hemorrhage.

Dynamic Evolution of Infarct Volumes at MRI in Ischemic Stroke Due to Large Vessel Occlusion.

The typical infarct volume trajectories in stroke patients, categorized as slow or fast progressors, remain largely unknown. This study aimed to reveal the characteristic spatiotemporal evolutions of infarct volumes caused by large vessel occlusion (LVO) and show that such growth charts help anticipate clinical outcomes. We conducted a secondary analysis from prospectively collected databases (FRAME, 2017-2019; ETIS, 2015-2022). We selected acute MRI data from anterior LVO stroke patients with witnessed onset, which were divided into training and independent validation datasets. In the training dataset, using Gaussian mixture analysis, we classified the patients into 3 growth groups based on their rate of infarct growth (diffusion volume/time-to-imaging). Subsequently, we extrapolated pseudo-longitudinal models of infarct growth for each group and generated sequential frequency maps to highlight the spatial distribution of infarct growth. We used these charts to attribute a growth group to the independent patients from the validation dataset. We compared their 3-month modified Rankin scale (mRS) with the predicted values based on a multivariable regression model from the training dataset that used growth group as an independent variable. We included 804 patients (median age 73.0 years [interquartile range 61.2-82.0 years]; 409 men). The training dataset revealed nonsupervised clustering into 11% (74/703) slow, 62% (437/703) intermediate, and 27% (192/703) fast progressors. Infarct volume evolutions were best fitted with a linear (r = 0.809; p < 0.001), cubic (r = 0.471; p < 0.001), and power (r = 0.63; p < 0.001) function for the slow, intermediate, and fast progressors, respectively. Notably, the deep nuclei and insular cortex were rapidly affected in the intermediate and fast groups with further cortical involvement in the fast group. The variable growth group significantly predicted the 3-month mRS (multivariate odds ratio 0.51; 95% CI 0.37-0.72, p < 0.0001) in the training dataset, yielding a mean area under the receiver operating characteristic curve of 0.78 (95% CI 0.66-0.88) in the independent validation dataset. We revealed spatiotemporal archetype dynamic evolutions following LVO stroke according to 3 growth phenotypes called slow, intermediate, and fast progressors, providing insight into anticipating clinical outcome. We expect this could help in designing neuroprotective trials aiming at modulating infarct growth before EVT.

The association of gender with functional outcome in thrombolysed stroke: A secondary analysis of INTRECIS study

Background and PurposeSex differences in acute ischemic stroke have been widely investigated, but the difference in acute ischemic stroke patients who received intravenous thrombolysis is not well understood. The current study was to investigate the issue based on a prospective cohort. MethodsFrom the Intravenous Thrombolysis Registry for Chinese Ischemic Stroke within 4.5h onset (INTRECIS) cohort, a total of 953 eligible patients with acute ischemic stroke were enrolled in final analysis. Based on 3-month modified Rankin scale score (mRS), patients were classified into good outcome group (mRS 0–1) and poor outcome group (mRS 2–6). Univariate and multivariate logistic regression analyses were used to identify predictive factors for clinical outcome in male or female patients. ResultsOf the 953 patients treated with intravenous thrombolysis, 314 (32.9 %) were women. At day 90, we found no significant gender differences in good outcome (72.5 % vs 65.6 %, adjusted p = 0.414). We got the same results after propensity score matching (69.5 % vs 63.4 %, adjusted p = 0.637). Furthermore, we found that initial National Institute of Health Stroke Scale (NIHSS) score (odd ratio [OR] 0.877; 95 % CI 0.847–0.909, p < 0.001) and serum creatinine (OR 0.993; 95 % CI 0.986–1.000, p = 0 0.043) were found to be independent risk factors for poor outcome in male patients, while initial NIHSS score (OR 0.879; 95 % CI 0.839–0.920, p < 0.001), age (OR 0.970; 95 % CI 0.946–0.995, p = 0.017), systolic blood pressure (OR 0.984; 95 % CI 0.972–0.996, p = 0.007) and small artery occlusion (OR 2.718; 95 % CI 1.065–6.936, p = 0.036) in female patients. ConclusionsIn this study, we found no gender difference in clinical outcome of thrombolysed stroke patients, but a difference in risk factors predicting outcome in male vs female patients was identified for the first time.

Safety and clinical outcomes of endovascular therapy versus medical management in late presentation of large ischemic stroke.

The benefit of endovascular therapy (EVT) among stroke patients with large ischemic core (ASPECTS 0-5) in the extended time window outside of trial settings remains unclear. We analyzed the effect of EVT among these stroke patients in real-world settings. The CT for Late Endovascular Reperfusion (CLEAR) study recruited patients from 66 centers in 10 countries between 01/2014 and 05/2022. The extended time-window was defined as 6-24 h from last-seen-well to treatment. The primary outcome was shift of the 3-month modified Rankin scale (mRS) score. Safety outcomes included symptomatic intracranial hemorrhage (sICH) and mortality. Outcomes were analyzed with ordinal and logistic regressions. Among 5098 screened patients, 2451 were included in the analysis (median age 73, 55% women). Of patients with ASPECTS 0-5 (n = 310), receiving EVT (n = 209/310) was associated with lower 3-month mRS when compared to medical management (median 4 IQR 3-6 vs 6 IQR 4-6; aOR 0.4, 95% CI 0.2-0.7). Patients undergoing EVT had higher sICH (11.2% vs 4.0%; aOR 4.1, 95% CI 1.2-18.8) and lower mortality (31.6% vs 58.4%, aOR 0.4; 95% CI 0.2-0.9) compared to medically managed patients. The relative benefit of EVT was comparable between patients with ASPECTS 0 and 5 and 6-10 in the extended time window (interaction aOR 0.9; 95% CI 0.5-1.7). In the extended time window, patients with ASPECTS 0-5 may have preserved relative treatment benefit of EVT compared to patients with ASPECTS 6-10. These findings are in line with recent trials showing benefit of EVT among real-world patients with large ischemic core in the extended time window. clinicaltrials.gov; Unique identifier: NCT04096248.

Risk factors and outcomes for refeeding syndrome in acute ischaemic stroke patients.

Patients with acute ischaemic stroke are more likely to develop refeeding syndrome due to increased need for nutritional support when suffering alterations of consciousness and impairment of swallowing. This study aimed to evaluate the incidence, risk factors and outcomes of refeeding syndrome in stroke patients. This was a retrospective observational study, using the prospective stroke database from hospital, included all consecutive acute ischaemic stroke patients who received enteral nutrition for more than 72 h from 1 January 2020 and 31 December 2022. Refeeding syndrome was defined as occurrence of new-onset hypophosphataemia within 72 h after enteral feeding. Multiple logistic regression analysis was conducted to evaluate risk factors and relationships between refeeding syndrome and stroke outcomes. 338 patients were included in the study. 50 patients (14.8%) developed refeeding syndrome. Higher scores on National Institutes of Health Stroke Scale and Nutritional Risk Screening 2002, albumin <30 g/L and BMI <18.5 kg/m2 were risk factors for refeeding syndrome. Moreover, refeeding syndrome was independently associated with a 3-month modified Rankin Scale score of >2 and 6-month mortality. Refeeding syndrome was common in stroke patients and higher baseline National Institutes of Health Stroke Scale, higher Nutritional Risk Screening 2002, albumin <30 g/L and BMI <18.5 kg/m2 were independent risk factors of refeeding syndrome. Occurrence of refeeding syndrome was significantly associated with higher 3-month modified Rankin Scale and 6-month mortality.

Effect of mean platelet volume and platelet count on the prognosis of branch atheromatous disease.

The purpose of this study was to investigate the predictive value of mean platelet volume (MPV) and platelet count (PC) in branch atheromatous disease (BAD). This retrospective study included 216 patients with BAD-stroke within 48h of symptom onset. These patients were divided into good and poor prognosis groups according to their 3-month modified Rankin scale scores after discharge. Multiple logistic regression analysis was used to evaluate independent predictors of poor prognosis in BAD-stroke patients. Receiver-operating characteristic (ROC) analysis was used to estimate the predictive value of MPV and PC on BAD-stroke. Our research showed that a higher MPV (aOR, 2.926; 95% CI, 2.040-4.196; p<.001) and PC (aOR, 1.013; 95% CI, 1.005-1.020; p=.001) were independently associated with poor prognosis after adjustment for confounders. The ROC analysis of MPV for predicting poor prognosis showed that the sensitivity and specificity were 74% and 84.9%, respectively, and that the AUC was.843 (95% CI,.776-.909, p<.001). The optimal cut-off value was 12.35. The incidence of early neurological deterioration (END) was 24.5% (53 of 163), and 66% of patients in the poor prognosis group had END (33 of 50). Multiple logistic regression analyses showed that elevated MPV and PC were associated with the occurrence of END (p<.05). Our results suggested that an elevated MPV and PC may be important in predicting a worse outcome in BAD-stroke patients. Our study also demonstrated an independent association of MPV and PC with END, which is presumably the main reason for the poor prognosis.

Impact of stent retriever size on clinical outcomes in the RECO registry

ObjectiveIn the RECO study, we investigated the impact of the operator's choice of stent retriever size on patients with internal carotid artery (ICA) occlusion. MethodsData from the RECO Registry, a prospective multicentre study, were utilized. Patients who underwent mechanical thrombectomy (MT) were divided according to the size of the stent into the RECO 4 × 20 group, the RECO 5 × 30 group and the RECO 6 × 30 group. The outcome measures assessed in the study were the 3-month modified Rankin Scale (mRS) score, occurrence of any intracranial haemorrhage (aICH), workflow timing, recanalization success rate, number of attempts, and all-cause mortality within a 3-month period. ResultsAnalysis was conducted on a total of 89 patients with ICA occlusion. RECO 4 × 20, 5 × 30, and 6 × 30 stent retrievers were used in 19 (21.3%), 52 (58.4%), and 18 (20.2%) patients, respectively. The demographic and baseline characteristics showed considerable similarity across the three groups. The puncture-to-recanalization time of the RECO 6 × 30 group [56.5 min (IQR, 41.5–80.8)] was significantly shorter than that of the RECO 4 × 20 group [110 min (IQR, 47–135)]. In 10 out of 18 patients (55.6%), the RECO 6 × 30 stent retriever achieved reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] score 2b-3) after the initial attempt, surpassing the rates of 31.6% in the RECO 4 × 20 group and 32.7% in the RECO 5 × 30 group. In the RECO 4 × 20 group, the median number of passes was 2 (IQR, 1–3); in the RECO 5 × 30 group, it was 2 (IQR, 1–3); and in the RECO 6 × 30 groups, it was 1 (IQR, 1–2.5). There were no statistically significant differences observed among the three groups concerning aICH or good outcomes (mRS score 0–2). ConclusionOur study demonstrated the practical implications of stent-retriever size selection in the context of the MT for ICA occlusion. The routine use of a RECO 6 × 30 stent retriever holds the potential for early revascularization in clinical practice. The significant reduction in the puncture-to-reperfusion time and the greater first-pass effect associated with this stent size underscore its efficiency in treating ICA occlusion.

Arterial transit artifact as a short-term prognostic indicator in acute ischemic stroke

BackgroundArterial transit artifact (ATA) observed on arterial spin labeling (ASL) was recently suggested to be associated with improved functional outcomes following acute ischemic stroke (AIS). AIS is a heterogeneous disease with diverse pathogenic mechanisms depending on the stroke subtype. This study aimed to investigate the association between ATA and 3-month functional outcomes in AIS patients according to etiology subtypes.MethodsConsecutive patients with AIS were included. All patients underwent ASL MRI with postlabeling delay (PLD) of 1.5 and 2.5 s. ATA was assessed from the ASL images of both PLDs. Stroke etiologic subtypes were determined according to the modified TOAST (Trial of ORG 10172 in Acute Stroke Treatment) classification. Short-term functional outcomes were evaluated using the 3-month modified Rankin scale (mRS). Log-binomial regression was applied to analyze the association between ATA and functional outcomes at 3 months after stroke.ResultsNinety-eight AIS patients (62.73 ± 13.05 years; 68 men) were finally included. ATA was detected in forty-six patients and most frequently seen in the large-artery atherosclerosis (LAA) subtype (35/46). The ATA group exhibited a lower percentage of patients with mRS > 2 compared to the group without ATA (36.5% vs. 19.6%; P < 0.001). ATA was independently associated with better 3-month clinical outcomes (adjusted risk ratio, 0.35[95% CI, 0.16—0.74]) in the multivariate log-binomial regression model. After stratification by TOAST subtypes, a significant association was found between ATA and better outcomes in the LAA subtype (adjusted risk ratio, 0.20[ 95% CI, 0.05—0.72]) but not in cardioembolism and small artery occlusion (SVO) subtype.ConclusionATA is associated with better outcomes at 3 months in patients with AIS, especially in the LAA subtype, but this association attenuated in the cardioembolism and SVO subtypes.

Abstract TMP87: Thrombus Age in Ischemic Stroke With Atrial Fibrillation

Background and purpose: Because the biochemical composition of thrombus changes after formation over time, thrombus maturation in the left atrium may affect clot compositions in ischemic stroke with atrial fibrillation (AF). We aimed to investigate the association of the age of retrieved thrombi with clinical features and outcomes after MT for ischemic stroke with AF. Methods: We retrospectively reviewed consecutive patients with ischemic stroke with known AF or AF diagnosed after stroke onset who underwent MT and whose retrieved thrombi were pathologically analyzed. Thrombi were classified as fresh (&lt;1 day) and older (1-5 days) based on the areas (≤20 % or &gt;20 %) of lytic features of granulocytes in the section. Components of thrombi were quantified using immunostaining. Outcomes included first pass effect (FPE, extended Thrombolysis in Cerebral Infarction [eTICI] 2c/3 after first pass) and favorable outcome (3-month modified Rankin Scale score of 0 to 2 or equal to premorbid mRS score). Results: Of 168 patients, 62 patients (37%) had older thrombi. The presence of older thrombi was independently associated with the higher CHADS 2 score (adjusted OR [aOR], 1.46; 95% confidence interval [CI], 1.07-1.99). Older thrombi had the higher proportion of fibrin, platelets, von Willebrand factor, and neutrophil extracellular traps than fresh thrombi. FPE was less frequently achieved in patients with older thrombi than those with fresh thrombi (21% versus 43%; aOR, 0.36; 95% CI, 0.17-0.77). Favorable outcomes were fewer in patients with older thrombi than those with fresh thrombi (40% versus 73%; aOR, 0.37; 95% CI, 0.16-0.85). Conclusions: In patients with ischemic stroke with AF, older thrombi was associated with cardiovascular risk factors and included abundant amounts of components associated with the thrombectomy resistance. Patients with older thrombi had poorer functional outcomes presumably due to concomitant risk factors and worse revascularization outcomes.

Clinical outcome of rural in-hospital-stroke patients after interhospital transfer for endovascular therapy within a telemedical stroke network in Germany: a registry-based observational study

ObjectivesLittle is known about in-hospital-stroke (IHS) patients with large vessel occlusion and subsequent transfer to referral centres for endovascular therapy (EVT). However, this subgroup is highly relevant given the substantial...

Detrimental effect of anemia after mechanical thrombectomy on functional outcome in patients with ischemic stroke.

Anemia can occur due to an aspiration maneuver of blood with thrombi during mechanical thrombectomy (MT) for stroke. However, the association between postoperative anemia and stroke outcomes is unknown. In a registry-based hospital cohort, consecutive patients with acute ischemic stroke who underwent MT were retrospectively recruited. Patients were divided into the following three groups according to their hemoglobin (Hb) concentrations within 24 h after MT; no anemia (Hb concentrations ≥13 g/dL for men and ≥ 12 g/dL for women), mild anemia (Hb concentrations of 11-13 g/dL and 10-12 g/dL, respectively), and moderate-to-severe anemia (Hb concentrations <11 g/dL and < 10 g/dL, respectively). A 3-month modified Rankin Scale score of 0-2 indicated a favorable outcome. Of 470 patients, 166 were classified into the no anemia group, 168 into the mild anemia group, and 136 into the moderate-to-severe anemia group. Patients in the moderate-to-severe anemia group were older and more commonly had congestive heart failure than those in the other groups. Patients in the moderate-to-severe anemia group also had more device passes than those in the other groups (p < 0.001). However, no difference was observed in the rate of final extended thrombolysis in cerebral infarction ≥2b reperfusion or intracranial hemorrhage among the groups. A favorable outcome was less frequently achieved in the moderate-to-severe anemia group than in the no anemia group (adjusted odds ratio, 0.46; 95% confidence interval, 0.26-0.81) independent of the baseline Hb concentration. A restricted cubic spline model with three knots showed that the adjusted odds ratio for a favorable outcome was lower in patients with lower Hb concentrations within 24 h after MT. Moderate-to-severe anemia within 24 h after MT is independently associated with a reduced likelihood of a favorable outcome. https://www.clinicaltrials.gov, NCT02251665.

Stroke unit and Neurocritical Care Unit for acute neurological diseases in the USL Toscana Centro: a pilot model of Santo Stefano Hospital in Prato

BackgroundAcute neurological diseases are leading causes of disability and death. The need for specialist neurocritical care skills for managing neurological emergencies has increased. Promising opportunities exist to improve outcomes in acute phases of neurological diseases, such as, for example, the concept of a stroke unit for stroke patients. A similar concept was introduced for a neurocritical care unit, which is associated with improved clinical outcomes compared with more traditional management. However, neurocritical care is often not recognized as a separate specialty. Significant progress in neurology has enabled better approaches for the critically ill neurologic patient, in particular those with stroke and hemorrhage, but also with epileptic seizures and epileptic status, traumatic brain injury (TBI), subdural/epidural hematoma, acute inflammatory polyradiculoneuritis, encephalitis, myasthenia gravis, acute myelitis, etc.Assessment of policy/guidelines options and implicationsExcept for cerebrovascular diseases, for other acute neurological diseases, there is no standardized model care service recognized. A good patient outcome can be obtained by the choice of neurology setting for acute patients including nursing and medical staff with specific training in neurocritical care. As we believe neurocritical care practices should be implemented, we suggest a pilot model on the basis of our experience. In this report, we show a model of the 2A setting of the Santo Stefano Hospital (Prato, USL Toscana Centro), where, as well as stroke units for cerebrovascular events, we have neurocritical care unit and acute-neurology experts for all acute neurological diseases.Actionable recommendations: our pilot experienceThe 2A setting of Stroke Unit/Neurocritical Care of the Santo Stefano Hospital includes 15 beds; 8 ± 2 beds are monitored by portable multi-parameter monitoring devices. Following acute treatment, diagnostic/etiologic work-up and automated monitoring of vital functions are performed in addition to adapted secondary prevention, early rehabilitation, and prevention of complications in all acute patients. We retrospectively assessed the diagnoses in the hospital discharge forms (HDF) of Stroke Unit/Neurocritical Care (2A) of 249 patients consecutively analyzed between 1 January 2022 and 30 June 2022. Out of the 249 patients affected by acute neurological diseases, 155 had cerebrovascular diseases (62.2%). In particular, 100 (64.5%) were diagnosed with ischemic stroke and 44 (28.4%) with hemorrhagic stroke. Thirty-two patients (12.8%) were hospitalized following a TBI. Sixteen patients (6.4%) had a new diagnosis of epilepsy and three (1.2%) of epileptic status. In our setting, the 3-month modified Rankin Scale (mRS) in the 36 stroke patients treated with recombinant-tissue plasminogen activator (r-TPA) was 0–2 (low disability) in 60% of cases. Additionally, 31% of 44 intracerebral haemorrhage (ICH) patients reported a moderate-severe degree of disability. Regarding TBI patients, the mRS ranged from 1 to 5, with significate difference between patients in Stroke Unit/Neurocritical Care (2A) in comparison with those in other departments (2–3 vs. 3–4, respectively). Globally, the setting discharge of the acute neurological patients were: rehabilitation (26%), intermediate care hospitals (44%), long-term care (5%), and home (25%). The 1-month mortality rate was 1.8%.DiscussionWe provide a brief description of the cases treated over a 6-month period to draw attention to the possibility of the existence of a ward dedicated exclusively and specifically to all acute neurological diseases. The sample of patients is very varied and interesting. More than 60% of patients had cerebrovascular diseases. The paucity of outcome data makes this report limited, but the diagnostic-therapeutic strategies, the presence of staff trained in specific neurocritical care, and the use of inpatient hospital-based registries are, in our opinion, strengths. Our pilot model of the setting of Stroke Unit/Neurocritical Care (2A) in the Santo Stefano Hospital (Prato, USL Toscana Centro) should be further implemented, also to verify systematically the associations with measurable outcome improvements in patients affected by strokes and other neurological acute diseases.