90-day mRS Score Research Articles

Does Symptom Onset to Primary Stroke Center Time Goals Affect Stroke Outcome?

Treating acute ischemic stroke (AIS) within 4.5hours and door-to-needle time of less than 60minutes may optimize recovery. It is unknown if onset to Primary Stroke Center (PSC) time goals affect outcome. The purpose of this study was to examine effects of symptom onset to PSC time goals on outcome. Analysis included prospectively collected data from the University of California San Diego Specialized Program of Treatment Research in Acute Stroke. All AIS patients treated with intravenous recombinant tissue plasminogen activator were included if treated within 270minutes, and 90-day modified Rankin Scale (mRS) score was known. Primary outcome of the 90-day mRS was analyzed using multivariable logistic regression. Good outcome was defined as a 90-day mRS score of 0-2. Variables assessed were time from onset to arrival, stroke code, neurologic exam, imaging, laboratories, treatment decision, and treatment (by quartiles). Two hundred ninety-one patients were included (49.8% female, mean age 70.6±16.1, median National Institutes of Health Stroke Scale 10, SD=8.5). Good outcome occurred in 45% of patients. Significant baseline differences included HTN (P ≤ .001), A fib (P ≤ .001), prestroke mRS (P<.001), and Hispanic ethnicity (P=.011). Comparing good with poor outcome groups: mean onset to arrival was 70.6min versus 62.5min (P=.129) and mean onset to treatment was 140.1min versus 134.9min (P=.118). Controlling for prespecified covariates, no PSC time goals were significant predictors of the 90-day outcome. In our Comprehensive Stroke Center (CSC), onset to PSC time goals were not significant predictors of the 90-day outcome. Expedited care processes in CSC may compensate for differences in outcome. These results should be validated in a larger cohort and in PSCs versus CSCs.

Blood Pressure Control for Spontaneous Intracerebral Hemorrhage

Blood Pressure Control for Spontaneous Intracerebral Hemorrhage

Abstract 100: Cellular Therapy for Acute Stroke: Assessing a Potential Treatment Effect

Introduction Cell therapy is an investigational modality to enhance recovery after stroke. We completed a Phase I clinical trial of 25 patients assessing the safety and feasibility of autologous bone marrow derived mononuclear cells (MNCs). Study participants underwent a bone marrow harvest and were intravenously administered autologous MNCs 24-72 hours after stroke onset. We report an ordinal analysis that compares 90-day outcomes of study patients with retrospectively generated controls. Methods We compared the study patients to a group of patients derived from our stroke registry who presented to our center during the same time period as the clinical trial. The control group was initially matched for age and NIHSS and was further refined based on other inclusion / exclusion criteria of the trial, generating a final set of 185 patients. Between the two groups, we compared demographics, clinical characteristics, baseline lab values, co-morbidities and adverse events. An ordinal logistic regression model, utilizing the full range of outcome scores, was fitted to compare 90-day mRS scores. Results: The bone marrow harvest and infusion of MNCs was completed successfully in all study patients without any definitive study related severe adverse event. Table 1 shows the balance of tested co-variates between the stem cell and control groups. After controlling for 24-48 hour NIHSS, t-PA, rehab, length of stay, cardiac disease, and PTT, the final model estimated a greater odds of having a higher mRS at 90 days in the control group compared with the study patients (OR: 3.25, 95% CI: 1.48 - 7.14). Our model did not violate the proportionality of odds assumption (likelihood-ratio, p=0.1). Figure 1 shows the proportion of patients for each level of discharge and day 90 mRS score. Conclusion: Intravenous infusion of autologous MNCs is safe in the setting of acute stroke. This analysis suggests that patients receiving MNCs may also be exhibiting a signal of enhanced functional recovery.

Importance of proper patient selection and endpoint selection in evaluation of new therapies in acute stroke: further analysis of the SENTIS trial

BackgroundThe magnitude of treatment effect in acute stroke depends on several factors, including time from symptom onset (TFSO) to treatment and severity of the initial insult.ObjectiveTo report further evaluation of...

Abstracts for Canadian Stroke Conference

Specogna, AV; Patten, SB; Hill, MD; University of Calgary, Calgary, AB Background: Previous studies have examined predictors of treatment costs after Spontaneous Intracerebral Hemorrhage (ICH) in various countries and healthcare systems. Currently however, there is no clear understanding of which factors are associated with cost in any Canadian setting and thus no way of understanding how to plan ICH healthcare spending. Methods: We used a retrospective case series study design and adjusted linear regression to investigate if an association existed between the total cost of ICH hospital care in a Canadian health centre and age (years), gender (female vs. male), Charlson Comorbidity Index (0 vs. ≥1), in-hospital mortality (alive vs. dead), and having surgery (no vs. yes). Economic, treatment, and patient data were obtained from administrative sources. Total inflation-adjusted hospital cost per discharge was estimated in Canadian Dollars and log transformed for all analyses. Results: Analyses were performed using 987 consecutive ICH discharges from 1999 to 2008. The total cost of ICH hospital care was highly variable (mean cost per discharge=$25,613.96±$36,116.33; min $446.81 to max $326,275.10). Older age (β=–0.0057; 95% CI: –0.0103 to –0.0011) and death in hospital (β=–0.4859; 95% CI: –0.6357 to –0.3342) were significantly associated with lower total hospital cost per discharge. Whereas Charlson Comorbidity Index of ≥1 (β=0.6489; 95% CI: 0.5063 to 0.7916) and having surgery (β=1.3552; 95% CI: 1.1893 to 1.5210) were significantly associated with higher total hospital cost per discharge. Gender was not significantly associated with cost (β=0.0727; 95% CI: –0.0679 to 0.2134). Conclusions: To our knowledge this is the first study to examine predictors of ICH treatment costs in Canada. In a Canadian health centre, ICH treatment costs were significantly associated with patient age, level of comorbidity, in-hospital mortality, and surgical treatment. This study provides evidence that it may be reasonable to consider …

Abstract 72: Refining The Pre-treatment Noncontrast CT ASPECTS Threshold For IAT Selection: Pooled Analysis Of The Penumbra Pivotal Study And PICS Registry

Background: Previous studies have demonstrated that the Alberta Stroke Program Early CT Score (ASPECTS) on pre-treatment noncontrast CT (NCCT) can be used to identify patients who will benefit from intra-arterial therapy (IAT). Specifically, an ASPECTS threshold of 7 has been identified as clinically important. We sought to test this threshold and further characterize the clinical impact of pre-treatment ASPECTS (pre-ASPECTS) in a large IAT cohort. Materials and methods: We identified anterior circulation acute ischemic stroke patients treated with the Penumbra Stroke System in the Pivotal Study and the Penumbra Imaging Collaborative Study (PICS). Inclusion criteria for this analysis were evaluable pre-treatment NCCT and available 90-day modified Rankin Scale (mRS) score. Expert readers graded ischemic change on NCCT using ASPECTS and blinded to all clinical information except stroke side. Results: Of 221 patients who fulfilled study criteria, the mean age was 66.0±15.1 years, and median NIHSS score was 16 (IQR 12-21). The cohort was 50.9% (112/220) female. There were 111 (50.2%) right-sided strokes. The target vessel occlusion involved the ICA in 21.9% (48/219), MCA in 77.6% (170/219) and ACA in 0.5% (1/219). The median ASPECTS was 7 (IQR 6-9). TIMI 2-3 reperfusion was achieved in 83% (181/218). Good outcome (mRS 0-2) was achieved in 77 (34.8%) patients at 90 days. Adjusting for age, NIHSS and reperfusion, pre-treatment ASPECTS was an independent predictor of good outcome (O.R. 1.47; 95%C.I.:1.23 to 1.76). Pre-ASPECTS &gt;7 predicted good outcome with a relative risk of 1.80 (95%C.I.:1.23 to 2.64). The proportion of good outcomes was exceedingly low among pre-ASPECTS 0-4 (2.8% [1/36]; Figure ). When trichotomizing pre-ASPECTS at 0-4 (n=36), 5-7 (n=76) and 8-10 (n=109), the median 90-day mRS scores were 6 (IQR 4-6), 3.5 (IQR 2-6) and 3 (IQR 1-4), respectively (p&lt;0.0001). In pairwise comparison, the only significant differences were between pre-ASPECTS 0-4 and the other groups. While there was no effect of reperfusion on outcome among pre-ASPECTS 0-4, TIMI 2-3 reperfusion (p=0.04) and earlier timing of reperfusion (none vs. &lt;300 minutes vs. ≥300 minutes; p=0.03) were associated with better outcomes among pre-ASPECTS 5-10. Conclusions: Pre-treatment NCCT ASPECTS is a critical determinant of outcome following IAT. Pre-ASPECTS 0-4 identifies a population of patients who are highly likely to have dismal outcomes and do not benefit from endovascular reperfusion.

Alberta Stroke Program Early CT Score (ASPECTS) in Patients With Wake-Up Stroke

One-quarter of ischemic strokes occur during sleep, and affected patients are excluded from thrombolytic therapy because of an unknown time of stroke onset. It has been suggested that early ischemic changes detected on computed tomography (CT) are similar in patients with acute stroke and patients who recently awoke with stroke. We compared head CT scans using the Alberta Stroke Program Early CT Score (ASPECTS) in patients who were likely to suffer their stroke during sleep (awoke group) and a control group of patients with stroke of known onset time. Patients were recruited from a prospectively collected acute stroke database. The awoke group was defined as all ischemic stroke patients who were "last seen normal" more than 4 hours ago, arrived between 4 a.m. and 10 a.m., and underwent head CT within 15 hours of the time last seen normal. The control group was randomly selected from patients who underwent head CT within 4 hours of stroke onset. The ASPECTS evaluations were performed by investigators blinded to patient group and time of onset. A modified Rankin Scale (mRS) score was available in 15 awoke patients and 46 control patients at 90 days after stroke. Twenty-eight awoke patients and 68 control patients had suitable imaging for the ASPECTS. Baseline demographic characteristics and risk factors were similar in the 2 groups. The dichotomized ASPECTS analysis (≤7 vs 8-10) showed no significant differences between the groups. ASPECTS was 8-10 in 89.3% the awoke group and 95.6% in the control group (P=.353). There was a trend toward higher 90-day mRS score (0-1) in the awoke group versus controls (73% vs 45%; P=.079). Initial ASPECTS was similar in patients with wake-up stroke and those with 4 hours of symptoms. This suggests that a subset of wake-up stroke patients might be suitable for thrombolytic therapy.

Normal Magnetic Resonance Perfusion-Weighted Imaging in Lacunar Infarcts Predicts a Low Risk of Early Deterioration

Background: Current clinical tools to identify lacunar infarct patients at risk of deterioration are inadequate, and imaging techniques to predict fluctuation and deterioration would be of value. We sought to determine the occurrence of MRI perfusion-weighted imaging (PWI) abnormalities in lacunes, and whether they help predict clinical and radiological outcome. Methods: Patients with lacunar stroke or TIA were selected from a prospective MR imaging study. MRI was performed within 24 h of the event and follow-up imaging completed at 30 or 90 days. Baseline perfusion maps were qualitatively assessed and infarct volumes measured. Early clinical deterioration (NIHSS worsening of ≥3 points within 72 h of event) and 90-day modified Rankin Scale score (mRS) were recorded. Results: Twenty-two patients were included. Fifteen (68.2%) had abnormal PWI at the site of the diffusion-weighted imaging lesion. Patients with abnormal PWI were more likely to have stroke than TIA as their index event (RR 2.2, 95% CI 0.9–5.2, p = 0.02). Early clinical deterioration occurred in 4 patients (18.2%), all of whom had abnormal PWI. PWI lesions were not associated with a higher 90-day NIHSS or mRS score, nor did they predict infarct volume growth. Conclusions: MR-PWI abnormalities are seen in two thirds of lacunar infarcts, and are associated with stroke rather than TIA. Normal PWI identifies patients at low risk of early clinical deterioration.

Baseline computed tomography changes and clinical outcome after thrombolysis with recombinant tissue plasminogen activator in acute ischemic stroke.

Intravenous recombinant tissue plasminogen activator (rt-PA) is the only therapy of proven value for patients with acute ischemic stroke (AIS). Controversy exists with regard to the prognostic significance of early computed tomography (CT) changes in patients receiving rt-PA for AIS. The authors retrospectively reviewed all cases of AIS who received intravenous rt-PA for AIS in University of South Alabama hospitals between January 1996 and May 1999. A neuroradiologist, blinded to clinical outcomes, reviewed all baseline CT scans for the presence of the following signs: hyperdense middle cerebral artery (HMCA), loss of gray-white differentiation (LGWD), insular ribbon sign (IRS), parenchymal hypodensity (PH), and sulcal effacement (SE). Modified Rankin Scale (mRS) score was recorded 90 days after thrombolysis, and clinical outcome was dichotomized as favorable (0-1) or unfavorable (2-6). The authors performed both univariate and multivariate analyses to investigate the relationship between early CT signs, baseline clinical variables, and functional outcome as measured by the 90-day mRS scores. Any one early CT finding was detected in 23(64%) patients. The frequency of specific findings were as follows: SE in 13 patients (36%), LGWD in 12 patients (33%), PH in 9 patients (25%), HMCA in 4 patients (11%), and IRS in 3 patients (8%) patients. There was no statistically significant association between the occurrence of these imaging findings and subsequent functional outcome after thrombolysis. The data suggest that the presence of subtle acute CT changes in AIS patients is not predictive of clinical outcome following administration of rt-PA as per National Institute of Neurological Disorders and Stroke protocol.