Baseline National Institutes Of Health Stroke Scale Score Research Articles

Procedural Predictors of Outcome in Patients Undergoing Endovascular Therapy for Acute Ischemic Stroke

To identify factors impacting outcome in patients undergoing interventions for acute ischemic stroke (AIS). This was a retrospective analysis of patients undergoing endovascular therapy for AIS secondary during a 30month period. Outcome was based on modified Rankin score at 3- to 6-month follow-up. Recanalization was defined as Thrombolysis in myocardial infarction score 2 to 3. Collaterals were graded based on pial circulation from the anterior cerebral artery either from an ipsilateral injection in cases of middle cerebral artery (MCA) occlusion or contralateral injection for internal carotid artery terminus (ICA) occlusion as follows: no collaterals (grade 0), some collaterals with retrograde opacification of the distal MCA territory (grade 1), and good collaterals with filling of the proximal MCA (M2) branches or retrograde opacification up to the occlusion site (grade 2). Occlusion site was divided into group 1 (ICA), group 2 (MCA with or without contiguous M2 involvement), and group 3 (isolated M2 or M3 branch occlusion). A total of 89 patients were studied. Median age and National Institutes of health stroke scale (NIHSS) score was 71 and 15years, respectively. Favorable outcome was seen in 49.4% of patients and mortality in 25.8% of patients. Younger age (P=0.006), lower baseline NIHSS score (P=0.001), successful recanalization (P<0.0001), collateral support (P=0.0008), distal occlusion (P=0.001), and shorter procedure duration (P=0.01) were associated with a favorable outcome. Factors affecting successful recanalization included younger age (P=0.01), lower baseline NIHSS score (P=0.05), collateral support (P=0.01), and shorter procedure duration (P=0.03). An ICA terminus occlusion (P<0.0001), lack of collaterals (P=0.0003), and unsuccessful recanalization (P=0.005) were significantly associated with mortality. Angiographic findings and preprocedure variables can help prognosticate procedure outcomes in patients undergoing endovascular therapy for AIS.

A higher body temperature is associated with haemorrhagic transformation in patients with acute stroke untreated with recombinant tissue-type plasminogen activator (rtPA)

Higher body temperature is a prognostic factor of poor outcome in acute stroke. Our aim was to study the relationship between body temperature, HT (haemorrhagic transformation) and biomarkers of BBB (blood-brain barrier) damage in patients with acute ischaemic stroke untreated with rtPA (recombinant tissue-type plasminogen activator). We studied 229 patients with ischaemic stroke <12 h from symptom onset. Body temperature was determined at admission and every 6 h during the first 3 days. HT was evaluated according to ECASS II (second European Co-operative Acute Stroke Study) criteria in a multimodal MRI (magnetic resonance imaging) at 72 h. We found that 55 patients (34.1%) showed HT. HT was associated with cardioembolic stroke (64.2% against 23.0%; P<0.0001), higher body temperature during the first 24 h (36.9°C compared with 36.5°C; P<0.0001), more severe stroke [NIHSS (National Institutes of Health Stroke Scale) score, 14 (9-20) against 10 (7-15); P=0.002], and greater DWI (diffusion-weighted imaging) lesion volume at admission (23.2 cc compared with 13.2 cc; P<0.0001). Plasma MMP-9 (matrix metalloproteinase 9) (187.3 ng/ml compared with 44.2 ng/ml; P<0.0001) and cFn (cellular fibronectin) levels (16.3 μg/ml compared with 7.1 μg/ml; P=0.001) were higher in patients with HT. Body temperature within the first 24 h was independently associated with HT {OR (odds ratio), 7.3 [95% CI (confidence interval), 2.4-22.6]; P<0.0001} after adjustment for cardioembolic stroke subtype, baseline NIHSS score and DWI lesion volume. This effect remained unchanged after controlling for MMP-9 and cFn. In conclusion, high body temperature within the first 24 h after ischaemic stroke is a risk factor for HT in patients untreated with rtPA. This effect is independent of some biological signatures of BBB damage.

Two-Hour Improvement of Patients in the National Institute of Neurological Disorders and Stroke Trials and Prediction of Final Outcome

Ongoing clinical trials are using early response to intravenous tissue-type plasminogen activator (tPA) to stratify patients into endovascular therapies. Little is known about the likelihood of early recovery and its correlation with final stroke outcome. We analyzed the National Institute of Neurological Disorders and Stroke tPA dataset for patients with early improvement (EI), a change of ≥4, or score 0 on the 2-hour National Institutes of Health Stroke Scale (NIHSS) to predict good 90-day outcome. We adjusted for multiple confounders and divided the patients by baseline NIHSS score 0 to 10, 11 to 20, >20, and stroke type to analyze if EI predicted good outcome across stroke severities and types. We analyzed different EI thresholds to identify the best level of NIHSS change to predict good 90-day outcome using a receiver-operator characteristic curve. In total, 183 of 624 (29.3%) patients had EI, 112 of 312 (35.9%) in the tPA group had EI, and 71 of 312 (22.7%) in the placebo group had EI (P<0.0001). Smokers (P=0.012) and patients treated in <90 minutes (P=0.008) were more likely to have EI; diabetic patients (P=0.023) were less likely to show EI. The baseline NIHSS (mean±SD) of patients with EI was 16.1±6.5 versus 14.3±7.4 (P=0.001). A 90-day modified Rankin Scale score of 0 to 1 was achieved in 68 of 112 (60.7%) tPA-treated patient with EI and 65 of 200 (32.5%) without (placebo groups 30 of 71 [42.3%] versus 53/241 [22.0%]). The adjusted odds ratio for good outcome was 1.71 (95% confidence interval [CI], 1.1-2.6; P=0.011) for tPA treatment and 7.69 (95% CI, 4.63-12.76; P<0.0001) for early improvement. EI predicted good outcome in patients with cardioembolic (13.6; 95% CI, 3.6-51.5) and small vessel (6.98; 95% CI, 2.86-17.03), but not large vessel stroke (1.82; 95% CI, 0.38-8.59). The receiver-operator characteristic curve showed that a threshold of 4 on the NIHSS for prediction of good outcome had a sensitivity of 84% and 36% specificity. Early improvement was more common in tPA-treated patients and was associated with good 90-day outcome. Whereas 32.5% of nonresponders after tPA had a good 90-day outcome, the use of EI to predict stroke outcome shows value.

Outcomes of intra-arterial thrombolytic treatment in acute ischemic stroke patients with a matched defect on diffusion and perfusion MR images

BackgroundFor acute ischemic stroke patients with matched defects on diffusion–perfusion imaging, the effects of reperfusion therapy remain poorly documented. The outcomes in a rare series of patients who had a...

Measured Neurological Improvements Correlate with Self-perceived Improvements After Stroke

Important advantages of neurologic impairment scales after stroke include measurements of within-subject changes over time starting at baseline. We compared percent improvement on the National Institutes of Health stroke scale (NIHSS) to stroke outcome that seems tangible to patients and caregivers: their perceived percent improvement. We prospectively measured improvement on the NIHSS between baseline and 3 to 6 months in consecutive patients with acute stroke presenting within 48 hours after onset. Unaware of the measured result, patients and caregivers were asked to estimate their perceived overall improvement since baseline assessment at the time of enrollment. We excluded patients with baseline NIHSS <3, clear improvement before screening, coma, brain herniation, or intraventricular hemorrhage. Of 40 enrolled patients, 9 died, 5 could not return for reevaluation, and the remaining 26 were reevaluated and analyzed. Median time from stroke onset to enrollment was 19.5 hours (range 2-45) and the median baseline NIHSS score was 8 (range 3-31). The measured improvements on the NIHSS ranged between 12.5% and 100% and correlated moderately (Spearman rank coefficient 0.54) and significantly (P = .005) with the patient- and caregiver-perceived percent improvement. Percent improvement on the NIHSS after stroke correlates moderately and significantly with patient and caregiver perceived overall improvement and appears to be a useful addition to the current functional outcome measures.

Rapid Neurological Recovery after Intravenous Tissue Plasminogen Activator in Stroke: Prognostic Factors and Outcome

Background: Treatment with tissue plasminogen activator (tPA) is associated with improved outcome in acute ischemic stroke. Of note, a proportion of patients demonstrate rapid and significant neurological recovery within 24 h. This has previously not been systematically studied. We aimed to examine its incidence, predictive factors and correlation with clinical outcomes. Methods: We included 161 patients with acute ischemic stroke who received intravenous tPA within 4.5 h. Patient demographics and clinical data were collected. Rapid neurological recovery was defined as an improvement of at least 50% within 24 h as measured by the National Institute of Health Stroke Scale (NIHSS) score, and long-term outcomes were assessed by 3-month modified Rankin Scale. The incidence of rapid neurological recovery and its correlation with outcomes were studied. The predictors of the phenomenon were examined by univariate analysis. Results: Rapid neurological recovery was present in 44 of the 161 patients (27.3%). This correlated with favorable outcomes at 3 months (p < 0.0005). Lower baseline NIHSS score (p = 0.006), mild (NIHSS score <12) versus severe stroke (NIHSS score ≧12; p = 0.002), normal serum glucose levels on admission (3.3–7.7 mmol/l; p = 0.009) and younger age (p = 0.043) predicted rapid neurological recovery. However, there was no association with time to treatment (p = 0.3). Conclusion: Rapid neurological recovery defines a rapid responder population and was demonstrated in a quarter of patients treated with intravenous tPA. It strongly predicts a good clinical outcome.

Characteristics and Outcome of Ischemic Stroke Patients Who Are Free of Symptoms at 24 Hours following Thrombolysis

Background: A part of ischemic stroke patients score 0 on the National Institutes of Health Stroke Scale (NIHSS) within 24 h following thrombolysis. Their clinical characteristics and long-term outcome are poorly studied. We report a single-center assessment of such patients. Methods: The cohort comprises 874 consecutive patients from the Helsinki Stroke Thrombolysis Registry, out of whom 113 scored 0 on 24-hour NIHSS. We analyzed their baseline demographic, clinical and radiological characteristics and 3-month outcome (modified Rankin Scale, mRS). Associations between the study parameters were tested by multivariate analysis. Results: Patients with a 24-hour NIHSS score = 0 (n = 113) were younger than the rest of the population (n = 761; median: 65.6 vs. 71.5 years; p < 0.001), their NIHSS score on admission was lower (median: 5 vs. 10; p < 0.001), as was their glucose level (median: 6.2 vs. 6.7 mmol/l; p = 0.02). The onset-to-treatment time was similar in both groups (median: 120 vs. 115 min; p = 0.89). Patients with a 24-hour NIHSS score = 0 more often achieved an excellent outcome (mRS scores: 0–1; 81 vs. 31%; p < 0.001) and had lower mortality (1.8 vs. 11.8%; p < 0.01). One third of these patients had a brain infarction visible on 24-hour imaging. Lower baseline NIHSS score and younger age were independently associated with 24-hour NIHSS score = 0, which, in turn, was independently associated with excellent 3-month outcome. Conclusions: Patients with an NIHSS score = 0 at 24 h following thrombolysis are younger, have milder symptoms and have a lower glucose level on admission. They achieve more often excellent outcome and lower mortality. Still, 8% of them required help in daily activities or were dead at 3 months (mRS scores: 3–6).

Predictors of Percutaneous Endoscopic Gastrostomy Tube Placement in Patients With Severe Dysphagia From an Acute-Subacute Hemispheric Infarction

This study investigated the influence of age, National Institutes of Health Stroke Scale (NIHSS) score, time from stroke onset, infarct location and volume in predicting placement of a percutaneous endoscopic gastrostomy (PEG) tube in patients with severe dysphagia from an acute-subacute hemispheric infarction. We performed a retrospective analysis of a hospital-based patient cohort to analyze the effect of the aforementioned variables on the decision of whether or not to place a PEG tube. Consecutive patients were identified using International Classification of Diseases, Ninth Revision (ICD-9) codes for acute ischemic stroke, Current Procedural Terminology (CPT)-4 codes for a formal swallowing evaluation by a speech pathologist, and procedure codes for PEG placement over a 5-year period from existing medical records at our institution. Only patients with severe dysphagia were enrolled. A total of 77 patients met inclusion criteria; 20 of them underwent PEG placement. The relationship between age (dichotomized; < and ≥75 years), time from stroke onset (days), NIHSS score, acute infarct lesion volume (dichotomized; < and ≥100 cc), and infarct location (ie, insula, anterior insula, periventricular white matter, inferior frontal gyrus, motor cortex, or bilateral hemispheres) with PEG tube placement were analyzed using logistic regression analysis. In univariate analysis, NIHSS score (P = .005), lesion volume (P = .022), and presence of bihemispheric infarction (P = .005) were found to be the main predictors of interest. After multivariate adjustment, only NIHSS score (odds ratio [OR], 1.15; 90% confidence interval [CI], 1.02-1.29; P = .04) and presence of bihemispheric infarcts (OR, 4.67; 90% CI, 1.58-13.75; P = .018) remained significant. Our data indicates that baseline NIHSS score and the presence of bihemispheric infarcts predict PEG placement during hospitalization from an acute-subacute hemispheric infarction in patients with severe dysphagia. These results require further validation in future studies.

Impact of nutritional status on long-term functional outcomes of post-acute stroke patients in Taiwan

Nutritional status is important in stroke care, but little is known regarding to the prognostic role of nutritional status on long-term functional outcomes among stroke survivors. The main purpose of this study was to evaluate to the prognostic role of nutritional status on long-term functional outcomes among stroke survivors. Data of acute stroke registry in Kaohsiung Veterans General Hospital were retrieved for analysis. Overall, 483 patients (mean age = 70.7 ± 10.3 years) with first-ever stroke were found. Among them, 95 patients (19.7%) were malnourished at admission, 310 (mean age = 70.4 ± 10.1 years, 63.5% males) survived for 6 months, and 244 (78.7%) had good functional outcomes. Subjects with poor functional outcomes were older (74.7 ± 8.9 vs. 69.0 ± 10.1 years, p < 0.001), more likely to be malnourished (56.2% vs. 26.6%, p < 0.001), to develop pneumonia upon admission (23.3% vs. 12.7%, p = 0.027), had a longer hospital stay (23.5 ± 13.9 vs. 12.5 ± 8.2 days, p < 0.001), had a higher National Institutes of Health Stroke Scale (NIHSS) score (12.9 ± 9.3 vs. 4.9 ± 4.3, p < 0.001), poorer stroke recovery (NIHSS improvement: 6.9% vs. 27.4%, p = 0.005), and poorer functional improvement (Barthel index = BI improvement in the first month: 31.4% vs. 138%, p < 0.001). Older age (odds ratio = OR) = 1.07, 95% confidence interval (CI = 1.03–1.11, p < 0.001), baseline NIHSS score (OR = 1.23, 95%CI = 1.15–1.31, p < 0.001) and malnutrition at acute stroke (OR = 2.57, 95%CI: 1.29–5.13, p < 0.001) were all independent risk factors for poorer functional outcomes. In conclusion, as a potentially modifiable factor, more attentions should be paid to malnutrition to promote quality of stroke care since the acute stage.

Reperfusion Therapy for Acute Stroke Improves Outcome by Decreasing Neuroinflammation

Inflammation is a major step in the ischemic cascade, and proinflammatory cytokines, adhesion molecules and chemokines have been related to brain injury after stroke. To investigate if tissue plasminogen activator (tPA) treatment decreases the deleterious neuroinflammatory response that follows ischemic stroke. Our target population was 80 patients with ischemic stroke involving the middle cerebral artery (MCA) territory. Among them, 41 received tPA within 3h of symptom onset according to National Institute of Neurological Disorders and Stroke recommendations and the remaining 39 were assessed prior to local approval of tPA. In all patients, blood samples were obtained at 12 and 24h after symptom onset. Serum determinations of interleukin (IL)-6, inter-cellular adhesion molecule 1 (ICAM-1), IL-8 and tumor necrosis factor-alpha (TNF-α) were obtained by ELISA. National Institutes of Health Stroke Scale (NIHSS) and transcranial Doppler recordings (proximal/distal occlusion, p.o/d.o) were obtained at baseline and follow-up. No differences were found between the two groups in baseline NIHSS scores (tPA = 17 and control = 17; p = 0.38) or MCA status (tPA: p.o = 65.8%, control: p.o = 55.3%; p = 0.41). We found a lower level of mean IL-6 and IL-8 in the tPA treatment group: IL-6 (14.06 vs. 37.88pg/ml, p = 0.001) and IL-8 (70.98 vs. 465pg/ml, p < 0.001). No significant changes appeared for ICAM-1 and TNF-α. This biological response was accompanied by a neurological improvement (24h NIHSS: tPA = 11 and control = 15; p = 0.024) and a mortality reduction (tPA = 9.75% vs. controls = 28.2%; p = 0.038). Patients who improved and those who recanalised had the lowest IL-6 levels (p < 0.005). tPA treatment reduces the severity of the inflammatory phenomena that follows stroke. These results may partially explain the efficacy of reperfusion therapy on stroke outcome.

Factors Predicting Outcome in Stroke Patients Treated With 0.6 mg/kg Alteplase: Evidence From the Japan Alteplase Clinical Trial (J-ACT)

The aim of the present study was to identify factors associated with functional outcome, mortality, and symptomatic intracranial hemorrhage (sICH) in patients from the Japan Alteplase Clinical Trial (J-ACT) data set with ischemic stroke treated with intravenous (IV) 0.6 mg/kg alteplase within 3 hours after onset. The patient sample comprised 103 patients from the J-ACT, a multicenter, single-dose, open-label cohort study conducted to verify the efficacy and safety of IV 0.6 mg/kg alteplase in treating acute hemispheric stroke. The effects of 21 patient baseline characteristics on a favorable outcome (as evaluated by modified Rankin scale [mRS] score of 0-1 after 3 months), death within 3 months, and incidence of sICH within 36 hours after the start of treatment were examined by univariate analysis and stepwise logistic regression analysis. The baseline characteristics associated with a favorable outcome in univariate analysis included age and National Institutes of Health Stroke Scale (NIHSS) score. The factors associated with death included age and the NIHSS score. No factors were significantly associated with sICH. In stepwise logistic regression analysis, age and NIHSS score significantly predicted both favorable outcome and death. No factors significantly predicted sICH. Age and baseline NIHSS score were independent predictors for both favorable outcome and death. Although these factors are consistent with those found to be predictors in studies on IV 0.9 mg/kg alteplase, there were no factors predicting outcomes specific for IV 0.6 mg/kg alteplase.

Dosing Errors Did Not Have a Major Impact on Outcome in the NINDS t-PA Stroke Study

Intravenous tissue plasminogen activator (IV t-PA) for acute stroke is dosed by weight, which is typically estimated, and requires a multistep infusion, which may lead to administration errors. We evaluated the impact of dosing errors on outcome in the National Institute of Neurological Disorders and Stroke (NINDS) t-PA Stroke Study. Using logistic regression, we investigated the relationship between actual weight-based dose (administered dose divided by actual weight, capped at 100 kg) and intracerebral hemorrhage (ICH) at 36 hours and likelihood of good recovery (modified Rankin score of 0 or 1) at 3 months. Estimated weight, actual weight, and total t-PA dose administered were available for 311 of 312 patients; 3 received only the bolus and were excluded. In multivariable logistic regression, there was no association between the risk of any ICH using actual dose as a continuous variable (P = .65), or when comparing the highest quintile of actual dose (>0.944 mg/kg) to the lower 4 quintiles (9.8% vs 10.9%; odds ratio [OR], 0.60; 95% confidence interval [CI], 0.22-1.61; P = .31), adjusting for age, baseline National Institutes of Health Stroke Scale (NIHSS) score, and changes on baseline computed tomography. Similarly, there was no association between likelihood of good outcome and actual dose as a continuous variable (P=.87), or when comparing the lowest quintile (<0.879 mg/kg) of actual dose to the 4 higher quintiles (44.3% vs 42.5%; OR, 1.08; 95% CI, 0.55-2.09; P = .83), adjusting for age, baseline NIHSS score, and time of onset to treatment. Our findings indicate that it is reasonable to estimate weight when administering IV t-PA for acute stroke, because dosing errors did not have a major impact on the risk of ICH or the likelihood of good outcome in the NINDS t-PA Stroke Study.

Combining Acute Diffusion-Weighted Imaging and Mean Transmit Time Lesion Volumes With National Institutes of Health Stroke Scale Score Improves the Prediction of Acute Stroke Outcome

The purpose of this study was to determine whether acute diffusion-weighted imaging (DWI) and mean transit time (MTT) lesion volumes and presenting National Institutes of Health Stroke Scale (NIHSS) can identify patients with acute ischemic stroke who will have a high probability of good and poor outcomes. Fifty-four patients with acute ischemic stroke who had MRI within 9 hours of symptom onset and 3-month follow-up with modified Rankin scale were evaluated. Acute DWI and MTT lesion volumes and baseline NIHSS scores were calculated. Clinical outcomes were considered good if the modified Rankin Scale was 0 to 2. The 33 of 54 (61%) patients with good outcomes had significantly smaller DWI lesion volumes (P=0.0001), smaller MTT lesion volumes (P<0.0001), and lower NIHSS scores (P<0.0001) compared with those with poor outcomes. Receiver operating characteristic curves for DWI, MTT, and NIHSS relative to poor outcome had areas under the curve of 0.889, 0.854, and 0.930, respectively, which were not significantly different. DWI and MTT lesion volumes predicted outcome better than mismatch volume or percentage mismatch. All patients with a DWI volume >72 mL (13 of 54) and an NIHSS score >20 (6 of 54) had poor outcomes. All patients with an MTT volume of <47 mL (16 of 54) and an NIHSS score <8 (17 of 54) had good outcomes. Combining clinical and imaging thresholds improved prognostic yield (70%) over clinical (43%) or imaging (54%) thresholds alone (P=0.01). Combining quantitative DWI and MTT with NIHSS predicts good and poor outcomes with high probability and is superior to NIHSS alone.

Carotid Duplex Ultrasonography Can Predict Outcome of Intravenous Alteplase Therapy for Hyperacute Stroke

We evaluated whether carotid duplex ultrasonography (US) can help predict the safety and efficacy of treating hyperacute stroke with intravenous (IV) tissue plasminogen activator (alteplase) therapy. Consecutive patients with stroke were assigned to the carotid artery occlusion (CO) group or the other (non-CO) group according to US findings before or immediately after receiving IV alteplase. Effectiveness and safety outcomes included early neurologic improvement, defined as a reduction in a National Institutes of Health Stroke Scale (NIHSS) score of ≥4 points within the initial 24 hours after stroke onset; completely independent routine activity, defined as a modified Rankin Scale score of ≤1 at day 90 after stroke onset; symptomatic intracranial hemorrhage (ICH) occurring within 36 hours after stroke onset; and any ICH. We enrolled 127 patients (27 in the CO group and 100 in the non-CO group) with a median baseline NIHSS score of 13 (range, 4-30). The CO group had a higher baseline NIHSS score (median, 18 vs 12; P=.005). After multivariate adjustment, the CO group was inversely associated with early improvement (odds ratio [OR]=0.26; 95% confidence interval [CI]=0.09-0.72) and independence at day 90 (OR=0.23; 95% CI=0.05-0.73) and positively associated with any ICH (OR=3.11; 95% CI=1.23-8.48). Our findings indicate that CO identified by US in the emergency clinical setting is an independent predictor of unfavorable outcome and ICH following IV alteplase therapy.

Intervencionismo neurovascular en la fase aguda del infarto cerebral

Background and purpose Endovascular therapies in acute ischaemic stroke may offer benefits to patients that are not eligible for standard use of intravenous tissue activator plasminogen (iv t-PA) or when this is not effective. Our aim is to present the initial experience in with endovascular techniques in the Community of Madrid. Methods We present data from our registry of acute ischaemic strokes treated with endovascular re-perfusion therapies in five University Hospitals in Madrid (Spain) during the period 2005-2009. We recorded demographic data, vascular risk factors, risk severity with the NIHSS (National Institute of Health Stroke Scale), endovascular techniques, complications and mortality rates. Functional outcome and neurological disability at 90 days was defined by the modified Rankin scale (mRs). Results A total of 41 patients were treated with endovascular therapies. Mean age was 58.6 ± 19.9, and 56.1% were males. Of those 22 patients had an anterior circulation stroke and 19 had a posterior circulation stroke. Baseline NIHSS score was: median, 17 [range, 2-34]; 7 patients had previously received iv t-PA. The following endovascular techniques were performed: mechanical disruption (26 patients), intra-arterial infusion of t-PA (26 patients), angioplasty and stenting (5 patients), mechanical use of MERCI device (3 patients). Partial or total re-canalization was achieved in 32 patients (78%). Only one patient had a symptomatic cerebral haemorrhage. Three months after stroke, 53.6% of the patients were independent (mRs ≤ 2) and overall mortality rate was 19.5%. Conclusions Acute ischaemic stroke is a potentially treatable medical emergency within the first hours after the onset of symptoms. Stroke endovascular procedures constitute an alternative for patients with iv t-PA exclusion criteria or when this is not effective.

Neurovascular intervention in the acute phase of cerebral infarction

Background and purpose Endovascular therapies in acute ischaemic stroke may offer benefits to patients that are not eligible for standard use of intravenous tissue activator plasminogen (iv t-PA) or when this is not effective. Our aim is to present the initial experience in with endovascular techniques in the Community of Madrid. Methods We present data from our registry of acute ischaemic strokes treated with endovascular re-perfusion therapies in five University Hospitals in Madrid (Spain) during the period 2005–2009. We recorded demographic data, vascular risk factors, risk severity with the NIHSS (National Institute of Health Stroke Scale), endovascular techniques, complications and mortality rates. Functional outcome and neurological disability at 90 days was defined by the modified Rankin scale (mRs). Results A total of 41 patients were treated with endovascular therapies. Mean age was 58.6 ± 19.9, and 56.1% were males. Of those 22 patients had an anterior circulation stroke and 19 had a posterior circulation stroke. Baseline NIHSS score was: median, 17 [range, 2–34]; 7 patients had previously received IV t-PA. The following endovascular techniques were performed: mechanical disruption (26 patients), intra-arterial infusion of t-PA (26 patients), angioplasty and stenting (5 patients), mechanical use of MERCI device (3 patients). Partial or total re-canalization was achieved in 32 patients (78%). Only one patient had a symptomatic cerebral haemorrhage. Three months after stroke, 53.6% of the patients were independent (mRs = 2) and overall mortality rate was 19.5%. Conclusions Acute ischaemic stroke is a potentially treatable medical emergency within the first hours after the onset of symptoms. Stroke endovascular procedures constitute an alternative for patients with IV t-PA exclusion criteria or when this is not effective.

Mechanical Clot Disruption Following Intravenous Recombinant Tissue Plasminogen Activator Administration in Non-Responders

The efficacy of selecting non-responders to intravenous recombinant tissue plasminogen activator (rt-PA) for mechanical clot disruption (MCD) was investigated based on cerebral angiography in the acute stage following rt-PA therapy. rt-PA therapy using 0.6 mg/kg was performed in eligible patients within 3 hours of onset. Patients who did not show recanalization on cerebral angiography 1 hour after rt-PA initiation immediately underwent MCD. Clinical outcome was evaluated by National Institutes of Health Stroke Scale (NIHSS) score at baseline, 24 hours, and 1 month, and by modified Rankin scale (mRS) score at 3 months. Eighteen patients were initially treated with intravenous rt-PA, with mean time from stroke onset to rt-PA therapy of 120 +/- 27 minutes. Eight of these patients underwent MCD. Seven of these eight patients had complete recanalization. Time to recanalization by percutaneous transluminal angioplasty from stroke onset was 258 +/- 59 minutes. Final recanalization was achieved in 16 of the 18 patients. Baseline NIHSS score improved significantly at 1 month (median from 22.5 to 4). Twelve of the 18 patients treated according to our protocol were classified as independent (mRS scores 0-2). No patients had symptomatic hemorrhage. MCD for non-responders determined by cerebral angiography at the end of intravenous rt-PA infusion can decrease the time to recanalization and improve recanalization rates, leading to good clinical outcome after acute stroke.

Symptomatic Delayed Reocclusion after Initial Successful Revascularization in Acute Ischemic Stroke

Endovascular stroke therapy is used for patients with ischemic stroke after failed intravenous thrombolysis or in patients not eligible for thrombolytics. With increasing experience, acute reocclusion has been described and likely worsens clinical outcomes. We assessed the rates and outcomes of delayed symptomatic reocclusion after endovascular therapy for acute ischemic stroke. Patients with acute ischemic stroke undergoing endovascular procedures at out institutions from January 2008 to August 2008 were reviewed. In all, 107 consecutive acute stroke interventions were performed. Four patients (3.5%) experienced delayed symptomatic reocclusion detectable by the National Institutes of Health Stroke Scale (NIHSS). The 4 patients (age 45-79 years) had baseline NIHSS score ranging from 8 to 24. Three had right middle cerebral artery occlusions and one had a left middle cerebral artery occlusion. Successful recanalization (thrombolysis in myocardial infarction score 2-3) occurred in all cases after initial treatment. All patients improved postprocedure (NIHSS score 5-10). Clinical deterioration (NIHSS score 14-22) occurred 12 to 18 hours postprocedure. Successful recanalization was achieved in each patient, with improvement in NIHSS score (range 6-13) but not to a lower level compared with after the initial intervention. Delayed symptomatic reocclusion after initial endovascular stroke therapy can lead to sudden clinical deterioration and impact outcomes. The entity may be missed as many patients present with large clinical deficits at presentation thus requiring careful assessments of patients treated via endovascular methods.

EEG Power Spectrum to Predict Prognosis after Hemicraniectomy for Space-Occupying Middle Cerebral Artery Infarction

Background: Early prediction of outcome after decompressive surgery for space-occupying middle cerebral artery (MCA) infarction is needed to guide further therapy. Here we applied spectral EEG analysis to determine the prognosis early after hemicraniectomy, while the patient is still treated in the intensive care unit. Methods: Continuous EEG monitoring following hemicraniectomy was performed in 10 patients with space-occupying MCA infarction. All patients were analgosedated and mechanically ventilated. The first 6 h of monitoring after surgery were evaluated by spectral analysis. Outcome measures included Glasgow Outcome Scale (GOS), Level of Consciousness Scale (LOC) and National Institute of Health Stroke Scale (NIHSS) at discharge. Outcome after 3 months was assessed by modified Rankin Scale. Results: Six patients displayed a peak at 5–10 Hz in the EEG power spectrum. All these patients had a GOS score of 3 and an LOC score ≧7 at discharge. In contrast, the 4 patients without faster EEG activity had a GOS of 2 and LOC ≤6. GOS (r = 1, p < 0.001), LOC (r = 0.89, p = 0.001) and NIHSS (r = –0.8; p < 0.01) at discharge significantly correlated with the presence of 5- to 10-Hz activity, but not with age, time to hemicraniectomy, duration of hospital stay or baseline NIHSS scores. Outcome after 3 months significantly correlated with age (r = 0.67; p < 0.05) and the presence of faster EEG activity (r = –0.76; p < 0.01). Conclusions: Spectral analysis in the subacute phase following hemicraniectomy may represent a parameter to predict early regain of consciousness and thus the capability and potential for further rehabilitation and favorable outcome.

Prediction of long-term outcome by percent improvement after the first day of thrombolytic treatment in stroke patients

Background We investigated a method for assessing early improvement and predictive factors of early and late outcomes in patients receiving thrombolytic therapy. Methods A total of 160 consecutive patients who received thrombolytic therapy were included in the study. Using National Institutes of Health Stroke Scale (NIHSS) scores, percent improvement [(baseline NIHSS score − 24-hour NIHSS score) / baseline NIHSS score × 100] was calculated and compared with delta (baseline NIHSS score − 24-hour NIHSS score) and with major neurological improvement (MNI, NIHSS score of 0–1 or ≥ 8 point improvement at 24 h) by receiver operating characteristic (ROC) curve analysis. Finally, we investigated the independent predictors of improvement at 24 h after the thrombolytic therapy and of favorable 3-month outcome (modified Rankin scale score 0–2). Results By pairwise comparison of ROC curves, percent improvement was stronger than delta ( p = 0.004) and MNI ( p < 0.001) in predicting long-term outcome. First day improvement (FDI), defined as greater than 20% improvement, was a strong predictor of favorable 3-month outcome (OR 12.55, 95% CI 5.41–29.10). Recanalization (OR 3.30, 95% CI 1.28–8.45), absence of carotid T occlusion (OR 0.09, 95% CI 0.02–0.42) and hemorrhagic transformation (OR 0.25, 95% CI 0.09–0.73) were independent predictors of FDI. Independent predictors of favorable 3-month outcome were FDI, current smoking, absence of carotid T occlusion and hemorrhagic transformation. Conclusions Percent improvement at 24 h after thrombolytic therapy is a useful surrogate marker for predicting the long-term outcome. Our findings highlight the importance of early stroke management.