Difference In mRS Scores Research Articles

No difference in 6-month functional outcome between early and late decompressive craniectomies following acute ischaemic stroke in a national neurosurgical centre: a single-centre retrospective case-cohort study.

Decompressive craniectomies (DCs) are recommended for the treatment of raised intracranial pressure after acute ischaemic stroke. Some studies have demonstrated improved outcomes with early decompressive craniectomy (< 48h from onset) in patients with malignant cerebral oedema following middle cerebral artery infarction. Limited data is available on suboccipital decompressive craniectomy after cerebellar infarction. Our primary objective was to determine whether the timing of DCs influenced functional outcomes at 6months. Our secondary objectives were to analyse whether age, gender, the territory of stroke, or preceding thrombectomy impacts functional outcome post-DC. We conducted a retrospective study of patients admitted between January 2014 and December 2020 who had DCs post-acute ischaemic stroke. Data was collected from ICU electronic records, individual patient charts, and the stroke database. Twenty-six patients had early DC (19 anterior/7 posterior) and 21 patients had late DC (17 anterior/4 posterior). There was no difference in the modified Rankin Scale (mRS) score of the two groups at 90 (p = 0.318) and 180 (p = 0.333) days post early vs late DC. Overall outcomes were poor, with 5 out of 46 patients (10.9%) having a mRS score ≤ 3 at 6months. There was no difference in mRS scores between the patients who had hemicraniectomies for anterior circulation stroke (n = 35) and suboccipital DC for posterior circulation stroke (n = 11) (p = 0.594). In this single-centre retrospective study, we found no significant difference in functional outcomes between patients who had early or late DC after ischaemic stroke.

Abstract WP211: Mechanical Thrombectomy in Patients With Mild Thrombocytopenia is Safe and Effective; a Systematic Review and Meta-Analysis

Background: MT is a effective treatment for AIS patients with LVO, but MT on TP patients is risky due to lack of data and potential hemorrhage. Methods: Our review followed the PRISMA guidelines for systematic review and meta-analysis. We defined thrombocytopenia as platelet count ≤150х109/L, with further sub-classification into two groups: 1) Mild TP (Platelet count 100,000 - 149,000x109/L); 2) Moderate/severe TP (platelet count &lt;100х109/L). A favorable outcome was 90-day functional independence (mRS) ≤ 2). Unfavorable outcomes were mortality at 90 days and (sICH). Results: Compared to patients with normal platelets, patients with TP had no significant difference in outcomes (mRS &gt;2) at 90 days (RR 0.80 [95% CI: 0.69 - 0.94] p = 0.006). Further analysis based on sub-groups, the difference in mRS score was not statistically significant in patients with mild TP group (RR 0.84 [95% CI: 0.70 - 1.00] p = 0.05) and moderate/severe TP group (RR 0.71 [95% CI: 0.48 - 1.06] p = 0.09) when compared to patients with normal platelets. However Mortality was found to be higher in the TP group (RR 1.95 [95% CI: 1.62 - 2.36] p &lt; 0.00001), with similar trends of increased mortality in the mild and severe TP group (RR 1.88 [ 95% CI: 1.34 - 2.63] p = 0.0002 and RR 2.07 [95% CI: 1.46 - 2.92] p &lt; 0.0001). There was an overall slight increase in the incidence of sICH in the TP group (Relative Risk [RR] 2.47 [95% CI: 1.51 - 4.05], p = 0.0003) compared to patients with normal platelet counts, however subgroup demonstrated no significant higher risk in the mild thrombocytopenia group (RR 2.34 [95% CI: 1.24 - 4.40], p = 0.008) Conclusions: Mechanical thrombectomy for LVO in patients with mild thrombocytopenia is safe and does not increase the risk of sICH or worse outcomes. However, caution is advised in cases of moderate to severe thrombocytopenia, as there is a slightly higher risk of sICH and mortality. Nonetheless, we recommend thrombectomy for LVO patients with thrombocytopenia.

Abstract 246: Effect of platelet count on outcome in ischemic stroke patients with LVO undergoing MT;a meta‐analysis

Introduction Large randomized clinical trials have established the superiority of Mechanical Thrombectomy (MT) for the treatment of Large Vessel occlusion (LVO) in patients with Acute Ischemic stroke (AIS) in terms of revascularization rates and clinical outcomes as compared to IV‐tPA alone.(1, 2, 3) However, Data regarding outcomes of mechanical thrombectomy in patients with low platelets is limited and shows conflicting results. (4, 5, 6, 7, 8) Methods This meta‐analysis was performed according to the preferred reporting items for systematic review and meta‐analysis (PRISMA) guidelines.(9) We defined thrombocytopenia as platelet count &lt; 150,000 /μL. We further classified these patients into two groups: 1) Mild thrombocytopenia (Platelet count 100,000 – 149,000 /μL) and 2) Moderate to severe thrombocytopenia (Platelet count &lt;100,000 /μL). The favourable outcome was 90‐day functional independence, designated as an Modified Rankin Score (MRS) ≤ 2 at 90 days. Unfavorable outcomes were 1) Symptomatic Intracranial hemorrhage (sICH) and 2) Mortality at 90 days. Results All studies were determined to be of good/high quality (Newcastle Ottawa scale).(10) Compared to patients with normal platelets, Patients with low platelets (&lt; 150,000 /μL) had a statistically significant worse outcome (mRS &gt;2 )at 90 days (RR 0.80 [95% CI: 0.69 ‐ 0.94] p = 0.006). However, on analysis based on different platelet cutoff values, the difference in mRS score was not statistically significant in patients with Mild low platelets (100,000 – 149,000 /μL) (RR 0.84 [95% CI: 0.70 ‐ 1.00] p = 0.05) and moderate/severely low platelets (&lt; 100,000 /μL) (RR 0.71 [95% CI: 0.48 ‐ 1.06] p = 0.09) when compared to patients with normal platelets. Similarly, Mortality was significantly increased in patients in the low platelet group (RR 1.95 [95% CI: 1.62 ‐ 2.36] p &lt; 0.00001). Mortality was also significantly increased in the mild low platelet subgroup (RR 1.88 [ 95% CI: 1.34 ‐ 2.63] p = 0.0002) and moderate/severe low platelet subgroup (RR 2.07 [95% CI: 1.46 ‐ 2.92] p &lt; 0.0001) when compared to patients with normal platelets. Furthermore, sICH events were significantly increased in patients in the low platelet group (RR 2.47 [95% CI: 1.51 ‐ 4.05] p = 0.0003). Similarly, on analysis based on different platelet cutoff values, sICH was also significantly increased in the mild low platelet subgroup (RR 2.34 [ 95% CI: 1.24 ‐ 4.40] p = 0.008) and moderate/severe low platelet subgroup (RR 4.13 [95% CI: 2.00 ‐ 8.50] p = 0.0001). Conclusion Our meta‐analysis revealed that compared to individuals with normal platelet count, those with platelet count (&lt; 150,000 /μL) had worse functional outcomes (MRS ≤ 2) , higher mortality rates, and a greater incidence of sICH. However, on analysis based on different platelet cutoffs, difference in MRS score was insignificant while the mortality rates and sICH incidence remained significantly higher. This may be attributed to smaller number of studies in the “cut‐off” groups leading to decreased power. Nevertheless, our findings suggest that MT for LVO in patients with low platelets leads to worse outcomes, however these risk were not significant in group with mild thrombocytopenia. Hence, Clinicians should carefully monitor for these risks while performing procedure or post procedure care.

Pediatric anti-NMDAR encephalitis with demyelination on brain MRI: A single center study

ObjectiveTo explore the clinical characteristics, immunotherapy response, and prognosis of pediatric anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis associated with demyelination on brain magnetic resonance (MRI). MethodsWe retrospectively reviewed the medical records of children diagnosed with anti-NMDAR encephalitis in our hospital between January 2016 and December 2021. All children with evidence of demyelination on brain MRI were included. ResultsA total of 183 anti-NMDAR encephalitis children were included; 8.7 % (16/183) of them had demyelination on brain MRI. Nine were positive for myelin oligodendrocyte glycoprotein (MOG)-IgG, while two were positive for both MOG-IgG and glial fibrillary acidic protein (GFAP)-IgG. Four patients had a history of acquired demyelinating syndromes and encephalitis, respectively, while nine (56.3 %) had atypical symptoms of anti-NMDAR encephalitis. All children had supratentorial demyelination on brain MRI; four of them had additional infratentorial lesions. All children received first-line immunotherapy; four were administered repeated first-line immunotherapy and/or rituximab because of poor initial response. During the follow-up, 37.5 % (6/16) of the children relapsed, but all responded well to immunotherapy. There were no significant differences in mRS score before immunotherapy, response to first-line immunotherapy, and long-term prognosis between anti-NMDAR encephalitis children with and without demyelination. However, patients with demyelination were more likely to have a history of acquired demyelinating syndromes or unexplained cortical encephalitis and to relapse. ConclusionPediatric anti-NMDAR encephalitis can co-occur with demyelination and has a high rate of MOG-IgG positivity. A history of acquired demyelinating syndromes or unexplained cortical encephalitis and atypical symptoms may indicate demyelination in children with anti-NMDAR encephalitis. Pediatric anti-NMDAR encephalitis with demyelination is more likely to relapse and needs a closer follow-up. However, it remains unknown whether more intensive immunotherapy is required in these patients.

Bridging therapy improves functional outcomes and reduces 90-day mortality compared with direct endovascular thrombectomy in patients with acute posterior ischemic stroke: a systematic review and meta-analysis.

It remains unclear whether bridging therapy can achieve better neurologic outcomes than direct endovascular thrombectomy (EVT) in patients with posterior ischemic stroke. We systematically searched PubMed, EMBASE, and Cochrane databases with posterior artery occlusion treated with bridging therapy vs. EVT. Efficacy was assessed based on functional independence at 90days and successful recanalization, whereas safety was assessed by mortality, rate of symptomatic intracranial hemorrhage (sICH), and occurrence of any hemorrhage. All data were analyzed with Review Manager software v5.3 and the risk of bias was determined using the Methodological Index for Non-randomized Studies. We included 17 studies with a total of 3278 patients (1211 in the bridging therapy group and 2067 in the EVT group). Patients in the bridging group had a better functional outcome at 90days, as evidenced by a higher proportion with a Modified Rankin Scale (mRS) score of 0-2 compared with the EVT group (odds ratio (OR) = 1.83, 95% confidence interval (CI): 1.54-2.19, P < 0.01), while no difference in mRS score of 0-3 (OR = 1.18, 95% CI: 0.96-1.45, P = 0.11). Patients in the bridging therapy group also had lower 90-day mortality rate (OR = 0.75, 95% CI: 0.59-0.95, P = 0.02). There were no significant differences between groups in rates of successful recanalization (OR = 0.96, 95% CI: 0.74-1.25, P = 0.77), sICH (OR = 1.27, 95% CI: 0.86-1.89, P = 0.24), and hemorrhage (OR = 1.22, 95% CI: 0.60-2.50, P = 0.58). Among patients with posterior ischemic stroke, bridging therapy may be superior to EVT in achieving a good functional outcome and lowering the mortality without increasing the risks of hemorrhage.

Associations of Serum Neurofilament Light Chain with Outcomes in Children with Autoimmune Encephalitis (P4-5.009)

<h3>Objective:</h3> To examine associations between serum neurofilament light chain (sNfL) levels at disease onset with markers of clinical severity in children with autoimmune encephalitis (AE). <h3>Background:</h3> Despite significant advances in the diagnosis and treatment of AE, little is known about markers of disease severity and their associations with outcomes. sNfL, a marker of axonal destruction, may fill this gap. <h3>Design/Methods:</h3> This is a longitudinal prospective case-control study of children presenting to a single tertiary center with AE (n=48) vs. an age-matched healthy control population (HC) (n=88). Clinical data and modified Rankin Scale (mRS) scores were collected using a standard CRF at baseline and at follow-up, up to one year. sNfL levels in stored samples were measured by Single Molecule Array Immunoassay (SIMOA). Volumetric analyses of key anatomic structures of brain MRIs were performed using FreeSurfer. Diffusion weighted MRI was assessed for restricted diffusion. Following standard diagnostic criteria, children were classified into those with no biological marker (antibody or genetic) and those with. We further dichotomized children into high vs. low sNFL levels. Descriptive statistics, group differences, and correlational analyses were performed using JASP version 0.16.3. <h3>Results:</h3> Baseline sNfL levels were significantly higher in patients with AE (no Ab), AE (MOG), and ANEC vs. HCs (log₂ sNfL=4.3 AE(no Ab), 2.9 AE(NMDA), 5.6 AE(MOG), 6.3(ANEC), 2.4(HC), <i>p</i>&lt;0.001). AE patients in the high sNfL group were more likely to be admitted to the ICU (<i>p</i>=0.02) and had significantly higher mRS scores at nadir (<i>p</i>=0.04), compared to patients in the low sNfL group. However, there was no significant difference in mRS scores at follow-up between groups. Baseline sNfL correlated significantly with baseline restricted diffusion (r_s(43)=0.45, <i>p</i>=0.002) and thalamic volumes (r_s(31)=0.45, <i>p</i>=0.009). <h3>Conclusions:</h3> Baseline sNfL levels may serve as a marker of disease severity in patients with AE. Future studies are needed to evaluate their associations with long-term outcomes. <b>Disclosure:</b> Ms. Da Silva has nothing to disclose. Ms. Yea has nothing to disclose. Dr. AlYanbuaawy has nothing to disclose. Dr. Matt has nothing to disclose. Dr. Longoni has nothing to disclose. Helen Branson has nothing to disclose. Logi Vidarsson has nothing to disclose. An immediate family member of Dr. Ertl-Wagner has received personal compensation for serving as an employee of Siemens Healthineers. Dr. Yeh has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Roche. Dr. Yeh has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for PRIME. Dr. Yeh has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Novartis. Dr. Yeh has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Elsevier. The institution of Dr. Yeh has received research support from Biogen. The institution of Dr. Yeh has received research support from Stem Cell Network. The institution of Dr. Yeh has received research support from CIHR. The institution of Dr. Yeh has received research support from Ontario Institute for Regenerative Medicine. The institution of Dr. Yeh has received research support from National MS Society. The institution of Dr. Yeh has received research support from NIH. The institution of Dr. Yeh has received research support from SickKids Foundation. The institution of Dr. Yeh has received research support from CMSC. The institution of Dr. Yeh has received research support from MSSC.

Abstract TP188: Ischemic Stroke While Bathing: Stroke Subtype And Association With Cerebral Small Vessel Disease

Background and Purpose: Ischemic stroke developed while bathing (ISB) occasionally causes fatal accident. Factors associated with ISB remain unclear. We aimed to estimate the clinical characteristics of ISB, especially the subtype of stroke and the association between cerebral small vessel disease (CSVD) markers. Methods: Consecutive patients with ischemic stroke ≤48 h from onset who underwent MRI during the hospitalization were included. We divided patients into ISB and non-ISB group to analyze differences in clinical characteristics, especially the stroke subtype based on TOAST classification and the association between CSVD markers. The CSVD markers were evaluated by MRI and defined as old lacunes, white matter hyperintensities scale (separately scored by periventricular hyperintensity [PVH] and deep and subcortical white matter hyperintensity), the number of cerebral microbleeds (CMBs) categorized as lobar, deep, and infratentorial lesions, and the scale of enlarged perivascular space in the basal ganglia and centrum semiovale. Results: We screened 2,112 consecutive patients with ischemic stroke including 1,517 patients (1,070 [71%] male, median age 69 years). Of these patients, 52 (3%) were included in ISB group. In univariable analysis, ISB group showed higher frequency of large-artery atherosclerosis ( p = 0.004), lower frequency of cardioembolism ( p = 0.008), smaller number of cerebral microbleeds in deep lesions ( p = 0.025) and lower grade of PVH ( p = 0.023). ISB group showed a lower NIHSS score on admission ( p = 0.002). However, there was no difference in mRS score at 3 months from the onset. In the multivariable analysis (Figure), large-artery atherosclerosis (OR 2.46, 95% CI 1.21-5.01, p = 0.013) and CMBs in deep lesions (OR 0.75, 95% CI 0.58-0.98, p = 0.038) showed independently associated with ISB. Conclusions: ISB showed higher frequency of large-artery atherosclerosis, however, had a less association with the presence of CMBs in deep lesions.

Prognostic Role of Chronic Rhinosinusitis in Acute Ischemic Stroke Patients Undergoing Mechanical Thrombectomy.

Background: The aim of the study was to assess the relevance of chronic rhinosinusitis (CRS) CT features to the efficacy of mechanical thrombectomy (MT) in patients with acute ischemic stroke. Methods: This study included 311 patients qualified for MT in whom the CRS features were assessed based on a CT scan, according to the Lund-Mackay (L-M) score. Clinical, inflammatory parameters, patients neurological (NIHSS) and functional status (mRS), and recanalisation efficacy (TICI) were compared between patients with mild lesions (L-M score 0–3 points)-group 1, and patients with more severe lesions (L–M score 4–24)-group 2. Results: There was a significant difference in the NIHSS on day seven after stroke onset-10 points in group 1 and 14 points in group 2, p = 0.02. NIHSS ≤ 6 points on day seven was found in 41.9% of patients in group 1, and in 27.5% in group 2, p = 0.042. There were no significant differences in mRS score and in the TICI score. L-M score, lipid abnormalities and CRP were factors associated with NIHSS ≥ 7 points on day 7. Conclusions: The CT features of CRS may be used as a prognostic tool for early prognosis assessment in stroke patients.

Effects of Anterior Borderzone Angle Grading on Predicting the 90-Day Prognosis After Recanalization of Acute Middle Cerebral Artery Occlusion.

Objective: This work explores collateral circulation metrics, such as the anterior borderzone angle grading (ABZA-grading), as a predictor of the prognosis in patients with acute middle cerebral artery occlusion (MCAO) following endovascular treatment (EVT).Methods: Clinical data from 108 patients with acute MCAO, treated by EVT, were retrospectively analyzed. In patients with MCAO, ABZA is the angle between the median line of the sagittal sinus and the borderzone of the pial arterioles of ACA and MCA, and the ABZA/23.0° was rounded to obtain the corresponding collateral circulation score (ABZA-grading). In parallel, the primary outcome was defined as the 90-day clinical outcome by modified ranking scale score (mRS). Univariate analysis and logistic regression were used to analyze the independent predictors of the 90-day clinical outcome (mRS). Receiver operating characteristic curve (ROC) analysis was used to judge the predictive value of ABZA.Results: Univariate analysis and logistic regression analysis showed that ABZA-grading > 2 and age were independent predictors of the 90-day clinical outcome after EVT in patients with acute MCAO. The ROC analysis showed that ABZA alone could predict a favorable 90-day clinical outcome with an area under the curve (AUC) of 0.868. Using an ABZA of >57.8° (the corresponding ABZA-grading of >2) as the cut-off value, the predictive sensitivity and specificity were 75.7 and 88.7%, respectively. Contingency table analysis showed a statistical difference in mRS score between ABZA-grading subgroups, and ABZA-grading between stroke caused by large artery atherosclerosis (LAA) and cardiogenic embolism (CE).Conclusion: The ABZA-grading is an easy and objective assessment of collateral circulation that is independently associated with short-time clinical outcome after EVT in patients with acute MCAO. Therefore, it may guide selection of patients with acute ischemic stroke (AIS) suitable for EVT. The ABZA-grading of collateral circulation can be a supplemental metric to help differentiate stroke by LAA and CE.

Non-immunogenic recombinant staphylokinase versus alteplase for patients with acute ischaemic stroke 4·5 h after symptom onset in Russia (FRIDA): a randomised, open label, multicentre, parallel-group, non-inferiority trial

Non-immunogenic staphylokinase is modified recombinant staphylokinase with low immunogenicity, high thrombolytic activity, and selectivity to fibrin. We aimed to assess the safety and efficacy of a single intravenous bolus of non-immunogenic staphylokinase compared with alteplase in patients with acute ischaemic stroke within 4·5 h after symptom onset. We did a randomised, open-label, multicentre, parallel-group, non-inferiority trial in 18 clinical sites in Russia. We included patients aged 18 years and older with a diagnosis of acute ischaemic stroke (up to 25 points on the National Institutes of Health Stroke Scale). The study drug had to be administered within 4·5 h after the onset of symptoms. Patients were randomly assigned to receive either non-immunogenic staphylokinase (10 mg) or alteplase (0·9 mg/kg, maximum 90 mg), both administered intravenously. The randomisation sequence was created by an independent biostatistician using computer-generated random numbers. 84 blocks (block size of four) of opaque sealed envelopes were numbered sequentially from 1 to 336 and were opened in numerical order. Patients were unaware of their assigned treatment and were assessed by the study investigators who were also unaware of the treatment assignment on all trial days. Emergency department staff, who administered the assigned drug and opened the envelopes, were not masked to treatment. The primary efficacy endpoint was a favourable outcome, defined as a modified Rankin scale (mRS) score of 0-1 on day 90. The margin of non-inferiority was established as 16% for the difference in mRS score of 0-1 on day 90. Non-inferiority was tested using Welch's t-test for the primary outcome only. Endpoints were analysed in the per-protocol population, which comprised all randomly assigned patients who completed treatment without any protocol violations; this population was identical to the intention-to-treat population. This trial is completed and registered at ClinicalTrials.gov, NCT03151993. Of 385 patients recruited from March 18, 2017, to March 23, 2019, 336 (87%) were included in the trial. 168 (50%) patients were randomly assigned to receive non-immunogenic staphylokinase and 168 (50%) to receive alteplase. The median duration of follow-up was 89 days (IQR 89-89). 84 (50%) of 168 patients in the non-immunogenic staphylokinase group had a favourable outcome at day 90 compared with 68 (40%) of 168 patients in the alteplase group (odds ratio [OR] 1·47, 95% CI 0·93 to 2·32; p=0·10). The difference in the rate of favourable outcome at day 90 was 9·5% (95% CI -1·7 to 20·7) and the lower limit did not cross the margin of non-inferiority (pnon-inferiority <0·0001). Symptomatic intracranial haemorrhage occurred in five (3%) patients in the non-immunogenic staphylokinase group and in 13 (8%) patients in the alteplase group (p=0·087). On day 90, 17 (10%) patients in the non-immunogenic staphylokinase group and 24 (14%) patients in the alteplase group had died (p=0·32). 22 (13%) patients in the non-immunogenic staphylokinase group had serious adverse events, compared with 37 (22%) patients in the alteplase group (p=0·044). Non-immunogenic staphylokinase was non-inferior to alteplase for patients with acute ischaemic stroke. Mortality, symptomatic intracranial haemorrhage, and serious adverse events did not differ significantly between groups. Future studies are needed to continue to assess the safety and efficacy of non-immunogenic staphylokinase in patients with acute ischaemic stroke within the 4·5 h time window, and to assess the drug in patients with acute ischaemic stroke outside this time window with reperfusion CT or magnetic resonance angiography followed by thrombectomy if necessary. The Russian Academy of Sciences.

Remote ischemic conditioning combined with intravenous thrombolysis for acute ischemic stroke.

ObjectiveThe objective of this study was to investigate the safety and efficacy of remote ischemic conditioning (RIC) combined with intravenous thrombolysis (IVT) in the treatment of acute ischemic stroke (AIS).MethodsPatients with AIS who underwent IVT were enrolled and 1:1 randomized to the RIC group and sham‐RIC group in this study. RIC (or sham‐RIC) was performed twice within 6–24 h of IVT. The subjects in the two groups were followed up for 90 days. The safety outcome included the ratio of hemorrhagic transformation (HT), adverse events during the follow‐up, blood pressure within the first 24 h after IVT, and laboratory tests 24 h after IVT. The efficacy outcome included the modified Rankin Scale (mRS) score, National Institute of Health Stroke Scale (NIHSS) score during the follow‐up, and level of high‐sensitivity C‐reactive protein (hs‐CRP) tested 24 h after IVT.ResultsForty‐nine patients (24 in the RIC group and 25 in the sham‐RIC group) were recruited. No significant difference was observed in the ratio of HT, adverse events, blood pressure, coagulation function or liver function between groups. In addition, there was no significant difference in mRS score and NIHSS score during the follow‐up between groups. However, patients in the RIC group exhibited a significant lower level of hs‐CRP compared with the control group (P = 0.048).InterpretationRIC combined with IVT is safe in the treatment of AIS. The neuroprotective and anti‐inflammatory effects of this therapy warrant further study on a larger scale.

Abstract WP26: Use of Balloon-guide Catheter Bridges the Difference in Technical Outcomes Between Adapt and Stent Retriever Thrombectomy for Ischemic Stroke - Insights From STAR Collaboration

Introduction: Recently completed randomized controlled trials comparing aspiration thrombectomy (ADAPT) to stent retriever thrombectomy (SRT) demonstrated similar clinical outcomes, but faster thrombectomy procedure time in the ADAPT group. This study evaluates the difference in technical outcomes between ADAPT and SRT combined with balloon-guide catheters (BGC). Methods: Patients undergoing thrombectomy for acute ischemic stroke at 12 comprehensive stroke centers in the US and Europe between 01/2013 and 12/2018 were reviewed. Data was collected retrospectively from patient charts, procedure notes, and patient follow-up in neurology clinics. Clinical endpoint was the modified Rankin score (mRS) at 90-days, and technical outcomes were procedure time, total attempts, and mTICI scores. Results: The study included 2,016 patients (mean age 69±15) who underwent stroke thrombectomy using ADAPT (46%), SRT (46%), or SRT+BGC (8%). Similar baseline characteristics were observed between the three groups, and no significant difference in mRS scores at 90-days between the three groups in univariate and multivariate analyses. Thrombectomy performed using SRT+BGC required significantly shorter procedure time compared to SRT (35 vs 61 min, p&lt;0.001) that was comparable to ADAPT (36 min, p&gt;0.1). However, use of SRT+BGC required significantly lower number of aspiration attempts compared to ADAPT (median 1 vs. 2, p&lt;0.05). On multivariate linear regression, use of SRT+BGC independent predicted a significant reduction in procedure time compared to SRT (coefficient=-30.6, p&lt;0.001), and significantly lower number of attempts compared to ADAPT (coefficient=-0.4, p=0.01). SRT+BGC was an independent predictor of higher mortality compared to ADAPT (OR=2.4, p&lt;0.01), despite comparable rates of favorable outcomes (mRS 0-2) between the two groups. Use of SRT+BGC was not an independent predictor of symptomatic hemorrhage or complications compared to SRT or ADAPT. Conclusions: This study shows that although ADAPT allows for faster procedure time compared to SRT, the use of BGC in SRT allows for a comparable procedure time to ADAPT with similar overall rates of favorable outcome, complications and hemorrhage. Mortality was higher with the use of BGC compared to ADAPT.

Abstract TP107: Midline Shift Predicts Functional Outcomes in Porcine Ischemic Stroke Model

In this study, we sought to identify acute MRI parameters which are predictive of long-term functional outcomes as well as assess the effects of a neural stem cell extracellular vesicle (NSC EV) therapeutic in a large animal model of ischemic stroke. In this randomized study, stroke was induced through a permanent right-sided middle cerebral artery occlusion (MCAO) on 16 male landrace pigs, which were divided into either treatment or control group. NSC EVs or PBS was administered at 2, 14, and 24 hours, and MRI was conducted at day 1 and 84 post-stroke. Data on 65 gait and 25 behavior parameters were collected pre-stroke and at multiple timepoints over 84 days following MCAO. Of all 15 measured MRI parameters, axial and coronal midline shift (MLS), at day 1 post stroke, had the highest total number of significant correlations (52 parameters at p&lt;0.05) to acute and chronic functional measurements in control animals such as step time in the left front limb (p=0.0322) and cycle time in the right hind limb (p=0.0011) respectively. This suggests MLS is the best overall predictor of specific functional deficits at both acute and chronic timepoints, which to our knowledge has never been shown in an animal model. Additionally, the parameters found to be correlated to MLS in control animals were not correlated in NSC EV-treated animals, suggesting NSC EV treatment disrupts this natural correlation between degree of MLS and functional outcomes. NSC EVs and control pigs were binned into either high or low MLS groups and their survival and recovery was assessed by the modified Rankin Scale (mRS). While there was a significant difference in mRS scores of control animals with high and low MLS at day 6 post-MCAO (p=0.0008), there was not in NSC EV-treated animals (p=0.6754). Further, there was a significant difference in survival of control animals with high and low axial MLS (p=0.0401), but not in the NSC EV group (p=0.4142). Additionally, mRNA expression of GFAP was significantly correlated with increasing MLS in non-treated but not NSC EV-treated animals. These findings show although NSC EV treatment does not significantly alter the degree of MLS 1-day post-MCAO, it does alter gene expression, increase survival, and improve functional recovery following large MLS alterations.

Does Drain Position and Duration Influence Outcomes in Patients Undergoing Burr-Hole Evacuation of Chronic Subdural Hematoma? Lessons from a UK Multicenter Prospective Cohort Study.

BackgroundDrain insertion following chronic subdural hematoma (CSDH) evacuation improves patient outcomes.ObjectiveTo examine whether this is influenced by variation in drain location, positioning or duration of placement.MethodsWe performed a subgroup analysis of a previously reported multicenter, prospective cohort study of CSDH patients performed between May 2013 and January 2014. Data were analyzed relating drain location (subdural or subgaleal), position (through a frontal or parietal burr hole), and duration of insertion, to outcomes in patients aged >16 yr undergoing burr-hole drainage of primary CSDH. Primary outcomes comprised modified Rankin scale (mRS) at discharge and symptomatic recurrence requiring redrainage within 60 d.ResultsA total of 577 patients were analyzed. The recurrence rate of 6.7% (12/160) in the frontal subdural drain group was comparable to 8.8% (30/343) in the parietal subdural drain group. Only 44/577 (7.6%) patients underwent subgaleal drain insertion. Recurrence rates were comparable between subdural (7.7%; 41/533) and subgaleal (9.1%; 4/44) groups (P = .95). We found no significant differences in discharge mRS between these groups. Recurrence rates were comparable between patients with postoperative drainage for 1 or 2 d, 6.4% and 8.4%, respectively (P = .44). There was no significant difference in mRS scores between these 2 groups (P = .56).CONCLUSIONDrain insertion after CSDH drainage is important, but position (subgaleal or subdural) and duration did not appear to influence recurrence rate or clinical outcomes. Similarly, drain location did not influence recurrence rate nor outcomes where both parietal and frontal burr holes were made. Further prospective cohort studies or randomized controlled trials could provide further clarification.

Clinical Study on Minimally Invasive Liquefaction and Drainage of Hypertensive Putaminal Hemorrhage through Frontal Approach

Background Hypertensive intracerebral hemorrhage is one of the most common cerebrovascular diseases with high mortality and high disability rate. The aim of this study was to observe the curative effect of minimally invasive liquefaction and drainage of hypertensive putaminal hemorrhage (HPH) through frontal approach. Methods This study retrospectively reviewed the clinical data of 66 HPH patients who underwent surgery from January 2012 to January 2017 including 35 males and 31 females, aged 51 to 82 years, with an average age of 61.6 ± 7.32 years. All patients were treated in the first people's hospital of Kunshan. They were divided into two groups: puncture thrombolysis and drainage therapy (PTDT) group and conventional craniotomy (CC) group. Result The pulmonary infection rate in PTDT group was 13.8%, significantly lower than that of 27.7% in CC group ( p < 0.05). One year after onset, the modified Rankin scale (mRS) score of surviving patients was evaluated. The mRS score of the PTDT group with 30 to 60 mL of preoperative bleeding was 1.91 ± 0.82, which was significantly better than that of the CC group (2.21 ± 0.83) ( p < 0.05). There was no significant difference in mRS score between PTDT group (2.59 ± 0.62) and CC group (2.88 ± 0.87) with preoperative bleeding > 60 mL ( p > 0.05). In patients with Glasgow coma scale (GCS) 5 to 8 scores, the mRS of PTDT and CC groups were 2.73 ± 0.72 and 2.94 ± 0.96, respectively ( p > 0.05). In patients with GCS 9 to 13 scores, the mRS score of PTDT group was 1.83 ± 0.69, which was significantly better than that of CC group (2.06 ± 0.74) ( p < 0.05). Conclusion HPH can be treated effectively through PTDT. PTDT group has lower lung infection rate than CC group. And it can significantly improve the prognosis of patients with preoperative bleeding volume of 30 to 60 mL and preoperative GCS score of 9 to 13.

Predictors and clinical features of transient neurological events after combined bypass revascularization for moyamoya disease

ObjectiveTransient neurological events (TNEs) are frequently observed after revascularization surgery for moyamoya disease (MMD). However, clinical features and pathophysiology of TNEs in MMD are still unclear. This study was aimed to clarify the incidence and time course of TNEs and to determine the independent predictors of TNEs in MMD. Patients and methodsA total of 195 hemispheres in 171 consecutive patients with MMD who had undergone combined direct and indirect bypass surgery were analyzed. Preoperative clinical characteristics and radiographic features were recorded. The incidence and clinical feature of postoperative TNEs were evaluated. Multivariate logistic regression analyses were performed to identify the risk factors for postoperative TNEs. Outcomes were compared between patients who had TNEs with those without TNEs at the time of discharge. ResultsPostoperative TNEs were detected in 40 (20.5%) of 195 operated hemispheres, including 17 (42.5%) aphasia, 9 numbness of the extremities (22.5%), 6 seizures (15%), 5 motor weakness (12.5%), 4 dysarthria (10%) and 6 others (15%). The incidence of TNEs was significantly higher in adult patients than in pediatric ones. Multivariate analysis revealed that female, left-sided surgery and the presence of the edematous lesion was an independent predictor of TNEs after surgery in MMD (OR, 3.0; 95% CI, 1.1–8.2; P = 0.03, OR, 2.9; 95% CI, 1.2–7.0; P = 0.02 and OR, 17.4; 95% CI, 5.7–53.0; P < 0.01, respectively). DSA stage (OR 0.05, 95% CI 0.0–0.5, p = 0.005; OR 0.08, 95% CI 0.0–0.4, p = 0.008), PCA involvement (OR 2.75, 95% CI 1.0–7.4, p = 0.046), left-sided surgery (OR 2.73, 95% CI 1.2–6.5, p = 0.022) and edematous lesion (OR 21.2, 95% CI 7.6–59.7, <0.001) were significantly associated with TNE severity. Compared with patients without postoperative TNEs, no significant differences in mRS score between the two groups were detected. ConclusionsFemale, left-sided surgery and edematous lesion were independent risk factors for postoperative TNEs; the left-sided surgery and edematous lesion were also independently associated with the severity of TNE. Although patients with postoperative TNEs had worse neurological status during the perioperative period, postoperative TNEs had no associations with worse mRS score at the time of discharge.

The efficacy and safety of Batroxobin in combination with anticoagulation on cerebral venous sinus thrombosis.

Cerebral venous sinus thrombosis (CVST) is an uncommon subtype of stroke with highly variable clinical presentation. Although anticoagulation with heparin and/or warfarin remains the standard treatment for CVST, treatment failure is still common. This study aims to evaluate the safety and efficacy of Batroxobin in combination with anticoagulation on CVST control. In this retrospective study, a total of 61 CVST patients were enrolled and divided into Batroxobin (n = 23) and control (n = 38) groups. In addition to the same standard anticoagulation in control, patients in the treatment group received Batroxobin 5BU intravenous infusion (10BU for the first time) every other day, for a total of three infusions. A higher recanalization rate was found in Batroxobin group (adjusted OR [95% CI] of 2.5 [1.1-5.0], p = 0.028) compared to the control group, especially in patients with high levels of fibrinogen (adjusted OR [95% CI] of 4.7 [1.4-16.7], p = 0.015). Statistically significant differences between the two groups were seen regarding the levels of thrombin time, fibrinogen and D-dimer at each cut-off time point (all p < 0.01). Compared with baseline, NIHSS scores at discharge showed significant improvement in the Batroxobin group [0(0, 4.25)-5(2, 11), p = 0.036]. No significant difference in mRS scores was found between the two groups at discharge or at 6-month outpatient follow-up (all p > 0.05). Additionally, Batroxobin did not increase the risk of intracranial hemorrhage. We conclude that Batroxobin is a potentially safe and effective adjunct therapeutic agent promoting CVST recanalization especially in patients with high level of fibrinogen.

Is bridging therapy still required in stroke due to carotid artery terminus occlusions?

IntroductionStudies comparing endovascular stroke treatment using mechanical thrombectomy (MT) with or without prior IV tissue plasminogen activator (tPa) have included only 30% of internal carotid artery terminus occlusions (ICA-O), a...

STROKE OUTCOMES IN NON-DIABETIC, DENOVO DIABETIC AND DIABETIC INDIAN PATIENTS MEASURED BY MODIFIED RANKIN SCALE: AN OBSERVATIONAL STUDY

Objective: Hyperglycemia is a known risk factor which adversely impacts the outcomes in stroke patients compared to patients with normal blood glucose levels. Patients suffering from an acute stroke who are previously nonhyperglycemic may show elevated blood glucose levels. The present study was designed to measure the outcomes in denovo diabetic and diabetic stroke patients compared to nondiabetics.Methods: A prospective observational study over a period of 6 mo, in which 103 patients were divided into three cohorts based on their blood glucose levels (nondiabetic, denovo diabetic and diabetics). The modified Rankin scale (mRS) score was calculated at in-hospital admission and discharge in these three cohorts. The initial and final scores were correlated and mean differences with respect to outcomes between all the three cohorts was calculated.Results: The mean mRS at the time of hospital admission in diabetics and nondiabetics was 3.6±0.81 and 3.3±0.78 which decreased to 2.8±0.95 and 2.9±0.83 respectively at the time of discharge. The mean mRS score in denovo diabetic stroke patients during in-hospital admission was 4±0.81 which was calculated as 3.7±0.85 at the time of discharge. The mean difference in mRS score in diabetics vs non-diabetics was found to be 0.73±0.8 (p =&lt;0.001). The mean difference in mRS score of denovo diabetics vs non-diabetics and denovo diabetics vs diabetics was 0.30±0.63 and 0.38±0.61 respectively (p = 0.1).Conclusion: Results of these observational study in Indian patients, highlights the need for controlling hyperglycemia in stroke patients to improve outcomes and to prevent mortality arising out of acute stroke attacks.

Cervicocranial Arterial Dissection: An Analysis of the Clinical Features, Prognosis, and Treatment Efficacy

Clinical features and therapeutic strategies of cervicocranial arterial dissection (CCAD) are still unclear. A retrospective review was conducted on 71 CCAD patients. Diagnosed by DSA and outcome evaluation was through mRS scores follow-up 12 months. All patients were allocated into three groups according to clinical situation: 1) subarachnoid hemorrhage (SAH), 2) ischemic symptoms and 3) mass effect. CCAD with anterior circulation arterial dissection (ACAD) had higher ischemia than that with posterior circulation arterial dissection (PCAD) (p=0.023). The non-aneurysmal dissection (NAD) patients were susceptible to ischemia (p=0.00) and patients with aneurismal dissection (AD) were more susceptible to SAH (p=0.001); The outcome of patients with SAH was significantly worse than patients with other manifestations (p=0.012). Following up one year, the outcome of CCAD involving posterior inferior cerebellar artery (PICA) was significantly worse than the other area (p=0.035). There was no statistically significant difference in mRS scores between endovascular treatment and conservative treatment (p=0.052) at one year follow-up. Patients suffering from SAH that received endovascular treatment experienced improved outcomes than patients with conservative treatment (p=0.033). The patients in the ACAD, NAD and extracranial CCAD groups were more likely to suffer from ischemia, while patients in the AD group were susceptible to SAH. CCAD with SAH or involving PICA had poor prognoses. The therapeutic efficacy of conservative treatment is nearly equal to endovascular treatment in CCAD patients follow up 12 months; however, endovascular treatment may decrease the risk of mortality for the patient with SAH.