Early Neurological Worsening Research Articles

Abstract 156: Cerebral Edema in Patients Presenting With Large Ischemic Core Undergoing Thrombectomy versus Medical Therapy: Secondary Analysis of SELECT 2 Trial

Background: Endovascular thrombectomy (EVT) improves long-term outcome in patients presenting with large ischemic core but is associated with early neurological worsening (ENW), potentially related to cerebral edema post-reperfusion. We investigated whether EVT increases edema development, and the relationship between edema and ENW in a secondary analysis of the SELECT2 trial. Methods: SELECT 2 tested the efficacy and safety of EVT versus medical therapy in patients with large ischemic core (ASPECTS 3-5 or core volume ≥50ml on CT Perfusion[CTP]/MR diffusion). Core volume was defined as the larger of the CTP-CBF relative cerebral blood flow <30% or the visible hypodensity on non-contrast CT. Cerebral edema was measured as the maximum midline shift (MLS) on 24h follow-up MRI or CT. ENW was defined as >=4 point worsening in NIHSS at 24h compared to baseline. Probabilistic index model was used in multivariable analyses to assess ≥1 point improvement on modified Rankin Scale at 90-days. Results: After exclusion of 10 patients with hemicraniectomy, the median MLS in 327 patients was 2.75mm (IQR 0-5.85) in EVT and 0mm (IQR 0-4.02) in control patients (p=0.005). EVT was independently associated with greater MLS (adjusted odds ratio, aOR 1.50, 95%CI 1.17-1.92, p=0.0012) after adjusting for age and core volume. There was no interaction between EVT and core volume on the association with MLS (p>0.79). Patient with ENW had greater MLS (5.05mm [IQR2.06-10.2] vs 0mm [IQR0-3.94, p<0.001]) MLS was associated with development of ENW (aOR 1.22, 95%CI 1.13-1.32, p<0.001), and lower likelihood of long-term functional improvement (adjusted generalized OR 0.96, 95%CI 0.92-0.97, p<0.001, adjusted for core volume, EVT, age and baseline NIHSS). Sensitivity analysis testing alternative definitions of core volume (CTP core volume only and Hypodensity on non-contrast only) showed concordant results. Conclusion: In patients presenting with large ischemic core, EVT was associated with increased cerebral edema at 24h which, in turn, was associated with ENW. Despite overall benefit of EVT, EVT-related edema is independently associated with neurological deterioration and long-term disability and is therefore a potential treatment target to improve EVT outcomes.

Middle Meningeal Artery Embolization versus Surgery in Patients with Chronic Subdural Hematoma-No More Fence Sitting?

Endovascular treatment of patients with chronic subdural hematoma using middle meningeal artery (MMA) embolization could become an alternative to surgical hematoma evacuation. The aim of the study was to compare methods and identify parameters to help determine the correct treatment modality. We retrospectively reviewed 142 cases conducted internally; 78 were treated surgically and 64 were treated using MMA embolization. We analyzed the treatment failure rate and complications, and using a binary logistic regression model, we identified treatment failure risk factors. We found a comparable treatment failure rate of 23.1% for the surgery group and 21.9% for the MMA embolization group. However, in the MMA embolization group, 11 cases showed treatment failure due to early neurological worsening with a need for concomitant surgery. We also found a recurrence of hematoma in 15.4% of cases in the surgery group and 6.3% of cases in the MMA embolization group. Both modalities have their advantages; however, correct identification is crucial for treatment success. According to our findings, hematomas with a maximal width of <18 mm, a midline shift of <5 mm, and no acute or subacute (hyperdense) hematoma could be treated with MMA embolization. Hematomas with a maximal width of >18 mm, a midline shift of >5 mm, and no membranous segmentation could have better outcomes after surgical treatment.

EFFICACY OF INTRAVENOUS TIROFIBAN THERAPY IN LACUNAR STROKE PATIENTS

Background: Lacunar ischemic infarcts are small-sized infarcts that develop as a result of occlusion of perforating arteries. Although its pathophysiology differs from other stroke types, there is no separate treatment option from non-cardioembolic strokes. Early neurological worsening in lacunar strokes is a common condition reported up to 41%. There is no effective treatment method to prevent or correct progression. Tirofiban is a reversible receptor antagonist of glycoprotein IIb/IIIa. There are cohort studies with small number of cases related to its use in ischemic stroke. We wanted to evaluate its effectiveness on the progression of lacunar stroke because it is a powerful antiplatelet agent. Objective: Tirofiban is a reversible receptor antagonist of glycoprotein IIb/IIIa. There are cohort studies with small number of cases related to its use in ischemic stroke. We wanted to evaluate its effectiveness on the progression of lacunar stroke because it is a powerful antiplatelet agent. Methods: The data of patients who were followed up in our clinic with the diagnosis of lacunar stroke between August 2020 and May 2022 and who received tirofiban treatment were evaluated retrospectively. Patients' ages, infarct localizations, NIHSS scores at admission, at the beginning and end of tirofiban treatment, and 3rd month mRS scores were recorded. Results: Fifteen patients, 11 male and 4 female, were included in the study. The mean age of the patients was 68.73±9.58 (range, 51-85). Tirofiban was started proactively in 2 patients, after progression in 13 patients. The NIHSS scores were 7.20±2.65 at the start of the infusion, and 4.80±3.93 after the infusion, and the decrease was statistically significant (P=0.010). Conclusion: These findings suggest that intravenous tirofiban therapy is a safe and effective treatment option to stop symptomatic fluctuations and shorten the duration of deficit in patients with progressive lacunar stroke.

D ‐Dimer Level After Endovascular Treatment Can Help Predict Outcome of Acute Ischemic Stroke

Background d ‐Dimer level is a marker of hypercoagulability, which is associated with thrombus formation and resolution. We investigated the value of d ‐dimer levels in predicting outcomes of acute ischemic stroke in patients who underwent endovascular treatment (EVT). Methods We analyzed data of patients who underwent only EVT from the SECRET (Selection Criteria in Endovascular Thrombectomy and Thrombolytic Therapy) registry. d ‐Dimer levels were routinely measured in 10 of 15 participating hospitals. Patients were grouped into tertiles (tertile 1, tertile 2, and tertile 3) according to d ‐dimer levels (lowest, moderate, and highest, respectively). We compared serial scores on the National Institutes of Health Stroke Scale at baseline, on day 1 of hospitalization, and at discharge; functional outcome 3 months after EVT; and rate of mortality within 6 months after EVT. Results In the 170 patients, the median d ‐dimer level was 477 ng/mL (interquartile range, 249–988 ng/mL). In tertile 3, the National Institutes of Health Stroke Scale score was higher at discharge than on day 1 of hospitalization. Poor outcome 3 months after EVT (modified Rankin Scale score, ≥3) was more common with high d ‐dimer levels (26.3% of tertile 1, 57.1% of tertile 2, and 76.4% of tertile 3; P &lt;0.001). Multivariable analysis showed that a high d ‐dimer level was independently associated with poor outcome 3 months after EVT (odds ratio [OR], 4.399 [95% CI, 1.594–12.135]). Kaplan–Meier survival analysis showed that a high d ‐dimer level was independently associated with death within 6 months after EVT (OR, 5.441 [95% CI, 1.560–18.978]; log‐rank test, P &lt;0.001). The d ‐dimer effect showed no heterogeneity across the subgroups for poor outcome 3 months after EVT or death within 6 months after EVT. The direction of effect was unfavorable for tertile 3 across all demographic strata. Conclusions High plasma d ‐dimer levels were predictive of early neurologic worsening, poor functional outcome 3 months after EVT, and death within 6 months after EVT. Registration URL: http://www.clinicaltrials.gov ; Unique identifier: NCT02964052.

Non-association of stroke risk with intracranial hemodynamic steal in patients with symptomatic internal carotid artery occlusions

ObjectivesParadoxical intracranial hemodynamic steal (IHS) is known in patients having persistent proximal arterial occlusions and is linked with early neurological worsening. However, stroke risk specific to symptomatic internal carotid artery occlusions (SICAO) having paradoxical IHS is unknown. Therefore, we aimed to investigate the association of paradoxical IHS in SICAO patients with stroke recurrence during a one-year follow-up. Materials and methodsWe prospectively enrolled adult patients having SICAO with a recent history of ischemic events. Steal magnitude (SM) to classify patients in IHS and non-IHS categories was evaluated by a breath-holding test using bilateral transcranial doppler (TCD). Patients were prescribed optimal medical therapy and followed up for one year for any ischemic stroke/TIA/cardiovascular death. Results36 SICAO patients, mean age of 56 years, were assessed using TCD at median 22.5 days (Interquartile range, IQR= 9-42), and 11 (30.6%) had paradoxical IHS with median SM 12% (IQR= 6%-18%). On follow-up, 7 (19.4%) patients had event recurrence and its association with IHS was non-significant (IHS vs non-IHS, 18.2% vs 20%; Log-rank statistics=0.006; P=0.940). On Cox regression analysis, event recurrence was independently associated with the presence of significant contralateral stenosis only (regression coefficient= 2.237; P= 0.012; 95% CI= 1.63-53.89). ConclusionsIHS prevalence among SICAO is high. However, paradoxical IHS was not associated with an increased risk of stroke in SICAO. Therefore, the presence of paradoxical IHS in SICAO may be considered a transit state and does not necessarily imply an increased risk of stroke.

Mechanical thrombectomy in minor stroke due to isolated M2 occlusion: a multicenter retrospective matched analysis

BackgroundThe purpose of this study was to evaluate the effectiveness of mechanical thrombectomy (MT) in patients with isolated M2 occlusion and minor symptoms and identify possible baseline predictors of clinical...

Progressive Lacunar Strokes: A Predictive Score

Background and PurposeProgressive lacunar syndromes (PLS) occur in up to 20-30% of patients with lacunar strokes, increasing the risk of long term dependency. Our aim is to develop a predictive score to identify patients at high risk of presenting PLS. MethodsWe derived a risk score for PLS in a cohort of consecutive patients (n=187) presenting with one of the five classic lacunar syndromes (LS) and absence of vascular occlusion, perfusion deficit or symptomatic stenosis. A risk score was developed using the coefficients from the logistic regression model, and receiver operating characteristic (ROC) analysis was conducted to assess the prognostic value of the risk score. Sensitivity, specificity and accuracy were estimated for each total point score. ResultsOut of 187 patients included in our sample, 52 (27.8%) presented PLS. Previous history of diabetes mellitus (1 point), diastolic blood pressure at admission (2 points), clinical deficits consistent with a pure motor syndrome (1 point) and asymptomatic intracranial atheromatosis or stenosis in non-symptomatic territory (1 point) were independent predictors for PLS. The estimated area under the ROC curve for this model was 0.77 (95% CI,0.68 - 0.84). ConclusionThis score could be a useful tool in routine clinical practice to predict the occurrence of PLS, allowing the identification of those patients with LS who are at high risk of long term dependency due to early neurological worsening, and who would benefit the most from an intensive treatment.

Acute Revascularization Induced Reversed Robin Hood Syndrome

Paradoxical intracranial hemodynamic steal (IHS) is a contradictory reduction of cerebral blood flow volume in the territory of the impaired perfusion area occurring spontaneously or in response to vasodilatory stimuli, which can be recorded and evaluated on transcranial doppler (TCD). IHS followed by early neurological worsening (change in National Institute of Health Stroke Scale [NIHSS]&gt; 2) in acute ischemic stroke patients has been described as reversed Robin Hood syndrome (RRHS). We describe two cases of RRHS following carotid artery stenting (CAS) in patients with contralateral carotid occlusion and its further management. Two patients with a history of anterior circulation strokes presented with recent complaints of dizziness and a sensation of being pulled back (patient 1), and episodic numbness of upper limbs (patient 2). On CT angiogram, both of the patients had severe extracranial internal carotid artery (ICA) stenosis on the symptomatic side associated with complete occlusion of the ICA on the contralateral side. In addition, both patients had impaired vasomotor reactivity (VMR) on TCD in the bilateral middle cerebral artery (MCA). Therefore, CAS on the symptomatic side was performed in both patients by femoral artery access without any periprocedural and postprocedural complications. However, on day 1 post CAS, complaints of transient upper limb tingling (patient 1) and limb shaking (patient 2) were reported corresponding to the completely occluded ICA, and TCD examinations confirmed RRHS in both patients. Patients were managed by decreasing the dose of antihypertensive medication to augment the blood pressure for 2 weeks. Normalization of the VMR on TCD was seen on follow-up, and both patients remain asymptomatic.

Serum ferritin level as a prognostic sign in cases of ischemic and hemorrhagic stroke: A prospective study

Humans require iron to function. In cerebral ischemia, free radicals that utilize iron cause more damage. In this study, serum ferritin levels were looked at as a potential indicator of early neurologic worsening in patients with stroke. In this study, the maximum number of patients was in the 18-90-year-old group. In total, 70 patients were admitted within 48 hours of a stroke. According to inclusion criteria, the study only included patients who were admitted within 48 hours of the onset of stroke. Of 70 patients, 34% were female and 65% were male.A total of 32 patients with ischemic stroke were admitted, of which 25 improved and 7 deteriorated. Patients in the age group 61-70 were most likely to suffer an ischemic stroke. The mean serum ferritin level for improved patients was 211.61, while that of deteriorated patients was 316.82.In all, 38 patients with haemorrhagic stroke were admitted, out of which 29 improved and 9 deteriorated. Patients aged 61-70 were more likely to experience haemorrhagic strokes. A mean serum ferritin level of 228.67 was found in improved patients, whereas 364.27 was found in deteriorated patients.The mean serum ferritin level in deteriorated patients is significantly higher than that of improved patients. Early neurologic deterioration is associated with high ferritin levels within 24 hours after stroke onset. In cerebral ischemia, increased body iron stores may enhance cytotoxic mechanisms contributing to stroke progression. More research is needed to identify the underlying causes and potential therapeutic implications of serum ferritin elevations. The reduction of serum ferritin levels can be achieved with medications like Deferoxamine.

Emergency department point-of-care biomarkers and day 90 functional outcome in spontaneous intracerebral hemorrhage: A single-center pilot study.

Spontaneous intracerebral hemorrhage (sICH) results in high morbidity and mortality rates, thus identifying strategies for timely prognosis and treatment is important. The present study aimed to analyze the relationship between emergency department point-of-care (POC) blood biomarkers and day 90 functional outcome (FO) in patients with acute (<8 h) sICH. On-site POC determinations, including complete blood count, glucose, cardiac troponin I, D-dimer and C-reactive protein, and derived inflammatory indexes were performed for a cohort of 35 patients. The primary endpoint was a favorable day 90 FO (modified Rankin Score ≤3). Secondary endpoints included early neurological worsening (ENW), day 7/discharge neurological impairment, day 90 independence assessment (Barthel Index <60), hematoma enlargement and perihematomal edema (PHE) growth. A favorable three-month FO was reported in 16 (46%) participants. Older age, previous history of ischemic stroke and initial imagistic parameters, including intraventricular hemorrhage, enlarged contralateral ventricle and cerebral atrophy, significantly predicted an unfavorable FO. The admission D-dimer similarly predicted day 90 FO and the independence status, along with ENW and a more severe day 7/discharge neurological status. The D-dimer also correlated with the initial neurological status and PHE. PHE growth correlated with granulocytes, systemic immune-inflammation index and glycemia. The results suggested that a lower admission D-dimer could indicate an improved day 90 FO of patients with sICH, while also anticipating the development of PHE growth and ENW.

FUNC SCORE IN PREDICTION INTRACEREBRAL HEMORRHAGE PATIENTS AT HUE CENTRAL HOSPITAL

Introduction: Intracerebral hemorrhage (ICH) remains a cause of significant morbidity and mortality and is associated with long-term disability. Early neurological worsening (ENW) is a major determinant of death in ICH. Besides predicting morbidity, prognosis functional independence is a crucial matter. In 2008, Natalia Sana Rost created FUNC score to predict the likelihood of functional independence. The aim of our study was to evaluate the ability of FUNC score to predict three outcomes of ICH: Early neurological worsening, 30-day morbidity, and 90-day functional independence. And compare to ICH grading scales. Methods: We prospectively characterized 123 consecutive patients with ICH at Hue Central Hospital. ICH and FUNC scores were calculated. Receiver operating characteristic (ROC) analysis, including area under the curve (AUC), was used to assess the ability of each score to predict ENW, 30-day morbidity, and 90-day functional independence. Results: Overall, thirty-day mortality rate was 31.7% (n=39), while 48 (39.0%) patients had good outcome at 90-days (mRS ≤ 2). Thirty-three patients (26.8%) had ENW then all of them died at 30-days after ICH. Intraventricular bleeding involved significantly worse outcomes including ENW, mortality at 30-days after ICH, and poor outcome at 90-days. Worse outcomes had significantly bigger mean hematoma volume in all three outcomes. Both scores were accurate predictors of study outcomes demonstrating excellent discrimination (AUC &gt; 0.80). And FUNC score, which had larger AUCs, predicted ENW, 30-day morbidity, and 90-day functional independence better than ICH score. Conclusions: FUNC scores are appropriate tools to predict ENW, with potential applications to clinical practice and research.

Elevated troponin levels are associated with early neurological worsening in ischemic stroke with atrial fibrillation

Serum cardiac troponin I (cTnI) is often elevated in patients with ischemic stroke, and is associated with their prognosis. Since cTnI is also closely related to atrial fibrillation (AF), cTnI may be a sensitive prognostic indicator in patients with AF-related stroke. This study aimed to evaluate the association between serum cTnI and early neurological deterioration (END) in patients with AF-related stroke. We included consecutive AF-related stroke patients between 2013 and 2015. END was defined as an increase ≥ 2 in the total NIHSS score or ≥ 1 in the motor NIHSS score within the first 72 h of admission. A total of 1,133 patients with AF-related stroke were evaluated. In multivariable analysis, cTnI [adjusted odds ratio (aOR) = 1.16, 95% confidence interval (CI) 1.00–1.34; P = 0.047] remained significant after adjusting for confounders. Initial NIHSS score (aOR = 1.03, 95% CI 1.00–1.06; P = 0.043) was also positively associated with END; meanwhile, the use of anticoagulants was negatively associated in both vitamin K antagonists (aOR = 0.35, 95% CI 0.23–0.54; P < 0.001) and new oral anticoagulants (aOR = 0.41, 95% CI 0.19–0.89; P = 0.024). In conclusion, higher serum cTnI was associated with END in patients with AF-related stroke.

Prognostic determinants in patients with non traumatic intracerebral hemorrhage: a real life report

ABSTRACT Background and aim: Nontraumatic intracerebral hemorrhage (ICH) remains a devastating disease for high in-hospital and long-term mortality and residual neurological disability. The aim of our study was to analyze the prognostic factors in patients managed for ICH in the real-life clinical practice. Materials and Methods: We retrospectively analyzed clinical and neuro-radiological data of consecutive patients admitted to our Hospital for ICH along 1 year. In-hospital mortality and 90-day modified Rankin scale (mRS) ≥4 were the study outcomes. Moreover, we compared patients admitted in Intensive Care Unit (ICU) with patients admitted in Stroke Unit (SU). Results: Ninety-eight patients with mean age ± SD 78 ± 12 years were enrolled. In-hospital and 90-day mortality were 36.7% and 41.8%, respectively. Patients who died had a significantly higher percentage of ICH volume >30 mL, irregular shape, lobar location, intraventricular hemorrhage (IVH), midline shift, hydrocephalus, hematoma enlargement, Glasgow Coma Scale (GCS) ≤9 at hospital admission, early neurological worsening (ENW), higher Hemphill ICH score, and underwent oro-tracheal intubation more frequently compared with patients who survived. Patients admitted to ICU were younger and significantly more critical compared with those who were admitted to SU. In-hospital mortality in patients admitted to ICU was 52.6% compared with 25% in patients admitted to SU (p < 0.01). Median mRS score at hospital discharge was 4 (IQR 3–5) and at 90 days was 4 (IQR 3–4). ENW, hematoma enlargement, Hemphill ICH score ≥3 and midline shift >10 mm were found independent risk factors for in-hospital mortality, while age was found as independent risk factor for 90-day mRS ≥4). Conclusion: In real life, prognosis of ICH is associated with clinical and radiological determinants. In our study ENW, hematoma enlargement, Hemphill ICH score ≥3 and midline shift >10 mm were associated with short-term mortality risk, while age with 90-day mRS ≥4.

Abstract WP372: Hydration Status and Clinical Outcomes in Acute Ischemic Stroke Patients Undergoing Mechanical Thrombectomy

Introduction: Impaired hydration measured by elevated blood urea nitrogen (BUN) to creatinine ratio has been associated with worsened outcome after acute ischemic stroke. Whether hydration status is relevant for patients with acute ischemic stroke treated with mechanical thrombectomy remains unknown. Materials and Methods: We conducted a retrospective review of consecutive acute ischemic stroke patients who underwent endovascular procedures for anterior circulation large artery occlusion at Johns Hopkins Comprehensive Stroke Centers between 2012 and 2017. A volume contracted state (VCS), was determined based on surrogate lab markers and defined as blood urea nitrogen (BUN) to creatinine ratio greater than 15. Endpoints were achievement of successful revascularization (TICI 2b or 3), early re-occlusion, and short term clinical outcomes including development of early neurological worsening and functional outcome at 3 months. Results: Of the 158 patients who underwent an endovascular procedure, 102 patients had a final diagnosis of anterior circulation large vessel occlusion and met the inclusion criteria for analysis. Volume contracted state was present in 62/102 (61%) of patients. Successful revascularization was achieved in 75/102 (74%) of the cohort. There was no relationship between VCS and successful revascularization, but there was a 1.13 increased adjusted odds (95% CI 1.01, 1.27) of re-occlusion within 24 hours for every point higher BUN/creatinine ratio in the subset of patients who underwent radiological testing for pre-procedure planning (n=57). There was no relationship between VCS and clinical outcomes including early neurological worsening and 3 month outcome. Conclusions: Patients with VCS and large vessel anterior circulation stroke may have a higher odds of early re-occlusion after mechanical thrombectomy than their non-VCS counterparts, but no differences in successful revascularization nor clinical outcomes were present in this cohort. These results may suggest an opportunity for the exploration of pre-procedure hydration to improve outcomes.

Endovascular and microsurgical treatment for spinal arteriovenous malformations. Our experience

Objective – to improve the treatment quality for patients with spinal arteriovenous malformations (AVM).Materials and methods. A retrospective analysis of endovascular and surgical treatment of patients was made. In SO «Scientific-practical Center of endovascular neuroradiology NAMS of Ukraine» since 2005 till 2018 were operated 55 patients (34 (61.8 %) men and 21 (38.2 %) women). The age of patients ranged from 11 to 62 years (middle age is 45.3 years). The classification proposed by Anson and Spetzler in 1992 was used in order to divide patients into experimental groups: type I, arteriovenous fistula (AVF); type II, glomus intramedullary AVM; type III, juvenile AVM; and type IV, perimedullary AVF. Patients with type I were 36 (65.5 %), with ІІ type – 10 (18.2 %), with ІIІ type – 5 (9.0 %), with IV type – 4 (7.3 %). For diagnostics were used MRI and spinal angiography. The Aminoff–Logue scale was used for assessment of the neurological deficiency severity. Early postoperative complications (CSF) leakage, wound infection, early postoperative worsening) were counted.Results. 12 (21.8 %) patients were treated using the microsurgical method and 43 (78.2 %) were treated endovascular. We used endovascular and microsurgical methods to treat patients with I type spinal AVM. Microsurgical intervention for 9 (33 %) patients was performed. Complete disconnection of fistula was achieved in 9 patients. Early postoperative complication (CSF leakage) was observed in 1 (11 %) case. Endovascular treatment was performed for 27 (67 %) patients. Total disconnection was achieved in 16 (59 %) cases, 17 patients (63 %) had early transient neurological worsening. Embolization is the first-line treatment for patients with type II AVM – 8 (80 %) patients. Complete obliteration of AVM was attained in 5 patients (62.5 %), 6 (75 %) patients suffered from early worsening of postoperative neurological symptoms. The microsurgical method was used in case of low risk of spinal cord injury in 2 patients (20 %), AVMs were excluded totally in 2 patients and in 1 patient neurological deterioration was stabilized. All patients with III type AVM were treated endovascular. AVM was obliterated complete in 1 patient (20 %). Three (60 %) patients had transient neurological deterioration. Endovascular method was used to treat 3 (75 %) patients with type IV AVM. Totally disconnection of AVM was achieved in 1 (33 %) patient. Super-selective catheterization of all conductive arteries was not possible. Neurological worsening was observed in 1 (33 %) patient.Conclusions. Angiography is the first-line diagnostic method which permits to find the most effective and safe way (endovascular or/and microsurgical treatment) to disconnect AVM from spinal cord bloodstream. Microsurgical intervention helps to achieve eye-controlled total arteriovenous disconnection. Microsurgical technique usage leads to good neurological results – neurological improvement the following day after surgery in all cases of AVM type I treatment. The structure of AVM determines effectiveness, radicality, method of treatment and the level of feeder artery catheterization. The main goal of embolization to achieve the safe catheterization level of the afferent. Multimodal treatment, which includes endovascular and microsurgical methods, is the most effective in case of AVM II and III types.

High risk of early neurological worsening of lacunar infarction.

We aimed to evaluate factors associated with neurological worsening among patients with lacunar or non-lacunar infarction admitted within 3hours and between 3 and 24hours after stroke onset. All patients admitted to Haukeland university hospital between 2006 and 2016 with acute cerebral infarction on MRI and admission within 24hours were included. Repeated National Institute of Health Stroke Scale (NIHSS) scoring was performed in all patients whenever possible. Neurological worsening during the hospital stay was defined as NIHSS score increase ≥3 compared to NIHSS score on admission. In patients with lacunar infarction admitted within 3hours of onset, neurological worsening was associated with low NIHSS score on admission, low body temperature, and leukoaraiosis, whereas only internal carotid artery stenosis or occlusion was associated with neurological worsening in non-lacunar infraction. For patients admitted 3-24hours after onset, neurological worsening was associated with low body temperature, high systolic blood pressure, and short time from onset to admission in patients with lacunar infarction, whereas high systolic blood pressure, high NIHSS score on admission, middle cerebral artery occlusion, and high blood glucose were associated with neurological worsening in patients with non-lacunar infarction (all P<0.05). Lacunar infarctions with minor neurological deficits within 3hours of stroke onset are at high risk of neurological worsening especially if concomitant low body temperature and leukoaraiosis.

Association of C-Reactive Protein Level and Short Term Clinical Outcome among Spontaneous Intracerebral Haemorrhage Patients

Background: C-reactive protein is a biomarker among the spontaneous intracerebral haemorrhage patients.Objective: The purpose of this present study was to see the association of CRP level with the short term clinical outcome among spontaneous intracerebral haemorrhage patients.Methodology: This prospective cohort study was conducted in the Department of Neurology at Dhaka Medical College and Hospital, Dhaka, Bangladesh from July 2012 to June 2014 for a period of two (02) years. Patients presented with first ever spontaneous intracerebral haemorrhage with the age group of more than or equal to 18 years with both sexes and hospital admission within 48 hours of onset were included for this study. Admission plasma CRP was measured and study population were divided into group I (plasma CRP≥6 mg/L) and group II (plasma CRP&lt;6 mg/L). The patients were observed daily till 1 week after admission with special attention to vital parameters and clinical outcome which were mortality, functional outcome and early neurological worsening. Finally findings were analyzed and clinical outcome were compared in patient with different level of admission plasma CRP.Result: Early neurological worsening at the end of first week was 37(38%) patients. Poor functional outcome (GOS 2-3) at the end of first week was found in 51(52%) patients. Overall mortality within that period was 16(17%) patients. Elevated CRP level was associated with higher proportion of GCS score &lt; 9 at day seven. Early neurological worsening and poor functional outcome (GOS2-3) was also found more in these patients.Conclusion: High admission plasma CRP level may be associated with higher proportions of poor short term outcome (GOS 2-3), early neurological worsening at the end of the first week after onset and mortality within this period in the patients with spontaneous intracerebral haemorrhage.Journal of National Institute of Neurosciences Bangladesh, 2017;3(2): 89-93

Safety of Dual Antiplatelet Therapy with Argatroban in Patients with Acute Ischemic Stroke

To prevent early neurological worsening or recurrence in stroke patients with intracranial arterial stenosis or branch atheromatous disease, aggressive antithrombotic therapy, such as dual antiplatelet therapy (DAPT) with or without anticoagulant therapy, is warranted. Such an aggressive antithrombotic therapy, however, may increase the bleeding risk. We studied the risks of DAPT with the anticoagulant argatroban in patients with acute ischemic stroke or transient ischemic attack (TIA). Between October 2011 and September 2015, 341 patients with stroke or TIA, who received DAPT with argatroban within 48 hours after onset, were retrospectively studied. The endpoint was any bleeding event during hospitalization or 30 days after admission. Median duration of DAPT was 12 days, and 66% of the patients received intravenous heparin (median duration, 5 days) following argatroban. No symptomatic intracerebral hemorrhages were observed, while severe, moderate, and mild extracranial hemorrhages occured in one (0.3%), three (0.9%), and four (1.2%) patients, respectively. In conclusion, DAPT with argatroban can be safely administered to patients with acute ischemic stroke or TIA. (Received July 24, 2017; Accepted January 15, 2018; Published May 1, 2018).

Abstract TP398: Hemodynamic Predictors of Early Neurological Worsening in Acute Ischemic Stroke

Introduction: Early neurological worsening is common in acute ischemic stroke (AIS) and associated with increased morbidity. Hypothesis: We tested the hypothesis that early hemodynamic factors are associated with early neurological worsening in AIS. Methods: Prospective, observational study of AIS patients with a NIHSS &gt; 3. Patients were enrolled in the emergency department as soon as AIS was suspected. Exclusion criteria were: time of onset &gt; 12 hours and hemorrhagic stroke. We performed baseline non-invasive, continuous hemodynamic monitoring and measured cerebral blood flow velocity with transcranial Doppler insonation of the middle cerebral arteries. We limited analysis to patients with confirmed stroke. Early neurological worsening was defined by any increase in the NIHSS over the first 24 hours. Results: We enrolled 77 patients, 57 of whom had AIS confirmed on imaging. The mean age was 67 ± 13 years, 53% were female and 78% were African American. The median NIHSS was 6 (IQR 4,8) and baseline SBP was 151 ± 35 mmHg. Fifteen (26%) patients had neurological worsening. Blood pressure, age, and presenting NIHSS were not predictive of neurological worsening. Low stroke volume index was associated with neurological worsening (OR 5.2, 95% CI 1.5 - 18.3). There was no significant difference in baseline MCA mean flow velocity (MFV) between patients with or without neurological worsening (42 vs 41 cm/sec, p=0.8). There was a trend towards higher MFV in patients with normal stroke volume vs. those with low stroke volume (43 ± 14 vs 37 ± 9 cm/sec, p=0.07). Conclusion: In this sample of low to moderate severity AIS patients, low stroke volume index was predictive of early neurological worsening, suggesting a hemodynamic effect on the ischemic penumbra.

Abstract WMP39: Clopidogrel Resistance Predicts Early Neurological Worsening In Patients With Acute Large Artery Atherosclerotic Stroke

Introduction: Although platelet reactivity on clopidogrel is related to outcomes in patients with acute coronary syndromes, few studies have investigated its relation to clinical outcomes in acute ischemic stroke. Hypothesis: This study evaluated the association between clopidogrel resistance and early neurological outcomes in patients diagnosed with acute large artery atherosclerotic stroke. Methods: 1067 consecutive patients with onset within 7 days and stroke classification of large artery atherosclerosis were included. Platelet reactivity on clopidogrel was assessed using VeryfyNow P2Y12 assay at least 72 hours after the time of first clopidogrel dosage. Optimal cutoff value of clopidogrel resistance was obtained by using receiver-operating characteristic curve. Early neurological deterioration was defined as an increment of motor NIHSS score ≥1 before P2Y12 assay. We assessed any hemorrhagic transformation on 5-day MRI. Results: A total of 235 patients who met inclusion criteria were analyzed. The median initial dose of clopidogrel was 300 mg, and their median P2Y12 % inhibition was 26.3. P2Y12 % inhibition &lt;29 was the significant discriminator of clopidogrel resistance with an AUC of 0.632 (95% CI 0.48-0.67; p=0.048). A multivariate analysis revealed that clopidogrel resistance is an independent risk factor even after adjustment for the variables that may affect the outcome (OR 2.75; 95% CI 1.11 to 6.83; p=0.029). Hemorrhagic transformation was not influenced by clopidogrel resistance (OR 0.60, 95% CI 0.14 to 2.540; P=0.484). Conclusion: In conclusion, high platelet reactivity with clopidogrel is an independent risk factor of early neurological worsening in acute large artery atherosclerotic stroke. Evaluation of ischemic stroke patients regarding antiplatelet resistance might be of clinical importance and alternative pharmacological strategies could be investigated in patients with high platelet reactivity.