Good mRS Score Research Articles

Endovascular coiling versus neurosurgical clipping in the management of aneurysmal subarachnoid haemorrhage in the elderly: a multicenter cohort study

The comparability of endovascular coiling over neurosurgical clipping has not been firmly established in elderly patients with aneurysmal subarachnoid haemorrhage (aSAH). Data were obtained from all patients with aSAH aged ≥60 across three tertiary hospitals in Singapore from 2014 to 2019. Outcome measures included modified Rankin Scale (mRS) score at 3 and at 6 months, and in-hospital mortality. Of the 134 patients analyzed, 84 (62.7%) underwent coiling and 50 (37.3%) underwent clipping. The endovascular group showed a higher incidence of good mRS score 0–2 at 3 months (OR = 2.45 [95%CI:1.16–5.20];p = 0.018), and a lower incidence of in-hospital mortality (OR = 0.31 [95%CI:0.10–0.91];p = 0.026). There were no significant difference between the two treatment groups in terms of good mRS score at 6 months (OR = 1.98 [95%CI:0.97–4.04];p = 0.060). There were no significant differences in the incidence of complications, such as aneurysm rebleed, delayed hydrocephalus, delayed ischemic neurological deficit and venous thromboembolism between the two treatment groups. However, fewer patients in the coiling group developed large infarcts requiring decompressive craniectomy (OR = 0.32 [95%CI:0.12–0.90];p = 0.025). Age, admission WFNS score I–III, and coiling were independent predictors of good functional outcomes at 3 months. Only age and admission WFNS score I–III remained significant predictors of good functional outcomes at 6 months. Endovascular coiling, compared with neurosurgical clipping, is associated with significantly better short term outcomes in carefully selected elderly patients with aSAH. Maximal intervention is recommended for aSAH in the young elderly age group and those with favorable WFNS scores.

Abstract TMP95: Context Matters: Geographic Decision-Making Could Improve Prehospital Stroke Triage

Introduction: Emergency medical services (EMS) play a key role in stroke outcomes, as triage decisions made under diagnostic uncertainty impact availability of time sensitive treatments. Quantifying both time varying effects and uncertainty allows for optimized algorithms to improve destination decisions for stroke patients. We developed a Bayesian model of neurological outcomes and an algorithm for hospital triage based on clinical trials data. Methods: We used data from Virtual International Stroke Trials Archive (VISTA), RACECAT, and FAST-MAG. To model prehospital diagnosis, we included patients with any stroke-like illness (ischemic/hemorrhagic stroke, and mimics). Primary outcome was 90-day modified Rankin scale (mRS). Due to variability in reported measures from each trial, model-based Bayesian imputation was used. Our model accepts time-from symptoms, location, and capability of all local hospitals as inputs. Results: We included 9048 participants with 8600 (95%) ischemic strokes, 1801 (20%) had large vessel occlusion, and 4064 (45%) had a 90-day mRS of 0-2 (good neurologic outcome). We evaluated the impact of our algorithm using 1,320 stroke events from RACECAT. The estimated median absolute difference in chance of good mRS score between bypass and non local hospital bypass was 2.3% (ranging from 0 to 7.4%) among 1,320 stroke events in the RACECAT data set; covariate-adjusted patient scenarios predicted a preference for local hospital bypass of -2.9% to 7.4%. Destination maps for Catalonia show important patterns of bypass optimality. Conclusion: We found that no uniform destination selection approach is likely to be optimal under all circumstances. This finding is important, because it suggests that a personalized approach considering diagnostic uncertainty, patient characteristics, and geospatial factors could outperform simpler approaches. Predicted time-to-treatment targets may be insufficient for appropriate system optimization.

Two weeks administration of tranexamic acid for acute intracerebral hemorrhage: A hospital-based pilot study.

A previous report suggested that functional status does not differ between patients who received tranexamic acid and those who received placebo within the early hours of intracerebral hemorrhage (ICH). Our pilot study tested the hypothesis that 2 weeks administration of tranexamic acid would contribute to functional improvement. Consecutive patients with ICH were administered 250 mg tranexamic acid 3 times a day continuously for 2 weeks. We also enrolled historical control consecutive patients. We collected clinical data that involved hematoma size, level of consciousness, and Modified Rankin Scale (mRS) scores. Univariate analysis showed that the mRS score on day 90 was better in the administration group (P = 0.0095). The mRS scores on the day of death or discharge suggested a favorable effect of the treatment (P = 0.0678). Multivariable logistic regression analysis also showed that the treatment was associated with good mRS scores on day 90 (odds ratio [OR] = 2.81, 95% confidence interval [CI]: 1.10-7.21, P = 0.0312). In contrast, ICH size was associated with poor mRS scores on day 90 (OR = 0.92, 95% CI: 0.88-0.97, P = 0.0005). After propensity score matching, there was no difference in the outcomes between the two groups. We did not detect mild and serious adverse events. The study could not show the significant effect of 2 weeks administration of tranexamic acid on functional outcomes of ICH patients after the matching; however, suggested that this treatment is at least safe and feasible. A larger and adequately powered trial is needed.

Safety and efficacy of tirofiban after early neurological deterioration in patients with branch atheromatous disease receiving alteplase

ObjectivesNo standard treatment exists for branch atheromatous disease (BAD), and patients' conditions often worsen after thrombolytic therapy. We evaluated the safety and effectiveness of tirofiban after early neurological deterioration (END) development in patients receiving intravenous alteplase.Materials and methodsBleeding incidence, National Institute of Health Stroke Scale (NIHSS) score, and modified Rankin scale (mRS) score were assessed for patients with BAD receiving alteplase within 4.5 h of stroke onset.ResultsAmong 193 patients, 119 (61.64%) did not experience exacerbation after thrombolytic treatment, 74 (38.34%) had END, 34 were treated with tirofiban after END, and 40 received standard treatment. On day 7 or at discharge, no cases of symptomatic cerebral hemorrhage were noted, and no patient died during the 90-day follow-up. Fifty-two of 74 patients (70.27%) had a good mRS score at 90 days. Among patients with END who received tirofiban, 27 (79.41%) had a good mRS score at 90 days, which was significantly better than that of the 18 cases that did not receive tirofiban after exacerbation (45%; P < 0.001). NIHSS scores were significantly lower 24 h, 48 h, and 7 days after tirofiban treatment in patients with exacerbation after thrombolytic therapy than in those without tirofiban treatment.ConclusionsPatients with BAD have elevated risks of END after thrombolytic therapy. Compared with conventional oral antiplatelet aggregation drugs, tirofiban rescue therapy resulted in significantly better NIHSS and mRS scores without increased symptomatic cerebral hemorrhage rates.

Predictors of poor outcome, surgical nuances and clinical outcome of microsurgical excision of brain arterio-venous malformations: A single center experience

BackgroundBrain arteriovenous malformations (bAVMs) are abnormal direct connections between arteries and veins forming a complex network of tangled vessels (nidus) leading to shunting of oxygenated blood directly into the veins without a true capillary bed. Digital Subtraction Angiography (DSA) is considered to be the gold standard to diagnose bAVMs. Microsurgical excision has better cure rates than embolization and/or radiosurgery. MethodsWe performed a retrospective review of 15 patients with bAVMs treated with craniotomy and microsurgical excision. At the final follow-up visit, the clinical outcome was measured using a postoperative modified Rankin Scale (mRS) score. Results13 (86.7 %) out of 15 patients had complete excision of the AVMs, while 2 patients (13.3 %) had partial obliteration with residual arterio-venous shunting. At the last follow up visit, 14 patients had Glasgow Coma Scale (GCS) between 13 and 15 and good mRS score (≤2). ConclusionFor low-grade bAVMs, microsurgical excision continues to offer the highest cure rate, outstanding clinical outcomes in both ruptured and unruptured AVMs, as well as optimal protection against haemorrhage; despite technological breakthroughs in endovascular and radiosurgical therapy.

Effect of Minimally Invasive Puncture Drainage and Conservative Treatment on Prognosis of Patients with Cerebral Hemorrhage.

The objective of this study was to explore the effect of minimally invasive puncture drainage under unsupervised learning algorithm and conservative treatment on the prognosis of patients with cerebral hemorrhage. Fifty patients with cerebral hemorrhage were selected as the research objects. The CT images of patients were segmented by unsupervised learning algorithm, and the application value of unsupervised learning algorithm on CT images of patients with cerebral hemorrhage was evaluated. According to the treatment wishes of the patients themselves and their authorizers, they were divided into 30 patients with cerebral hemorrhage in the minimally invasive group and 20 patients with cerebral hemorrhage in the conservative group. The incidence rate of complications of cerebral hemorrhage, the length of hospitalization of the two groups, hematoma volume at admission, 3 days and 7 days after operation, and the hematoma dissipation rate on the 3rd and 7th day after operation were used as the evaluation index of therapeutic effect. MRS and ADL scores were used as prognostic indicators. The results show that K-means clustering algorithm has high quality and short time for CT image segmentation. The overall incidence rate of complications in minimally invasive group was 10%, lower than that in conservative group (25%) (P < 0.05), and the length of hospitalization in minimally invasive group was longer than that in conservative group (P < 0.05). The hematoma volume of minimally invasive group was 16.5 ± 2.4 mL on the 3rd day after operation, and that of conservative group was 27.4 ± 1.8 mL. There was significant difference between the two groups (P < 0.05). In addition, CT showed that the hematoma reduction degree of minimally invasive group was higher than that of conservative group, and the hematoma dissipation rate was higher than that of conservative group on the 3rd and 7th day (P < 0.05). The good MRS score in minimally invasive group was 3.15 times that in conservative group, and the good ADL score was 1.6 times that in conservative group, and there was significant difference in the total score between the two groups (P < 0.05). Minimally invasive puncture drainage is better than conservative treatment in the clearance of hematoma, which is conducive to the recovery of neurological function and daily life of patients with cerebral hemorrhage and is of great help to the prognosis of patients.

P.005 Ovarian resection in anti-NMDAr encephalitis

Background: Anti-N-methyl-D-aspartate receptor encephalitis (NMDArE) is commonly associated with ovarian teratomas, surgical resection of which can lead to significant neurologic improvement. However, the necessity of aggressive resection at the time of diagnosis is unknown; specifically, whether unilateral or bilateral oophorectomy, versus lesionectomy and partial oophorectomy (ovariotomy), is required. Methods: Eleven patients with NMDArE who underwent ovarian resection between January 1st 2012 and December 31st 2020 were retrospectively identified. Primary outcome was good one-year functional status, defined as modified Rankin Scale (mRS) score of 0-1. Results: Median age at encephalitis onset was 24 years (19–38); median delay from symptom onset to surgery was 39 days (16–129). Six patients (54.5%) had good mRS scores, unrelated to surgical resection type. Conclusions: Added clinical benefit of aggressive ovarian resection techniques at one-year follow-up was not identified in our data. Further longitudinal studies are needed to determine the indications for different surgical techniques in patients with NMDArE. Ovarian resection approaches and associated functional outcomes in patients with NMDArE

Neuroimaging risk factors for participation restriction after acute ischemic stroke: 1-year follow-up study

The aim of the present study was to determine the neuroimaging predictors of poor participation after acute ischemic stroke. A total of 443 patients who had acute ischemic stroke were...

Functional Outcomes and Postoperative Cerebral Venous Sinus Thrombosis after Translabyrinthine Approach for Vestibular Schwannoma Resection: A Radiographic Demonstration of Anatomic Predictors.

Introduction While regarded as an effective surgical approach to vestibular schwannoma (VS) resection, the translabyrinthine (TL) approach is not without complications. It has been postulated that postoperative cerebral venous sinus thrombosis (pCVST) may occur as a result of injury and manipulation during surgery. Our objective was to identify radiologic, surgical, and patient-specific risk factors that may be associated with pCVST. Methods The Institutional Review Board (IRB) approval was obtained and the medical records of adult patients with VS who underwent TL craniectomy at University Hospitals Cleveland Medical Center between 2009 and 2019 were reviewed. Demographic data, radiographic measurements, and tumor characteristics were collected. Outcomes assessed included pCVST and the modified Rankin score (mRS). Results Sixty-one patients ultimately met inclusion criteria for the study. Ten patients demonstrated radiographic evidence of thrombus. Patients who developed pCVST demonstrated shorter internal auditory canal (IAC) to sinus distance (mean: 22.5 vs. 25.0 mm, p = 0.044) and significantly smaller petrous angles (mean: 26.3 vs. 32.7 degrees, p = 0.0045). Patients with good mRS scores (<3) appeared also to have higher mean petrous angles (32.5 vs. 26.8, p = 0.016). Koos' grading and tumor size, in our study, were not associated with thrombosis. Conclusion More acute petrous angle and shorter IAC to sinus distance are objective anatomic variables associated with pCVST in TL surgical approaches.

Abstract TP49: Acute Intracranial Stenting With Mechanical Thrombectomy Shows No Difference in Discharge Outcomes Compared With Mechanical Thrombectomy Alone

Background: Mechanical thrombectomy (MT) is a proven method of treating patients with acute ischemic stroke (AIS) from a large vessel occlusion. However, there has been controversy regarding the safety and efficacy of incorporating acute intracranial stenting in addition to standard MT especially after the WEAVE trial results which showed a significant increase in stroke and hemorrhage in patients receiving wingspan stenting within 7 days of index ischemic event. We compared the outcomes of all AIS patients treated with acute intracranial stenting + MT versus MT alone. Methods: Through the utilization of a prospectively collected endovascular database at a comprehensive stroke center between 2012-2019, variables such as demographics, co-morbid conditions, symptomatic intracerebral hemorrhage (ICH), mortality rate at discharge, and good/poor outcomes in regard to modified thrombolysis in cerebral infarction score (TICI) and modified Rankin Scale at discharge (mRS dc) were examined. The outcomes between patients receiving acute intracranial stenting + MT and patients that underwent MT alone were compared. Results: There were a total of 439 AIS patients who met criteria for the study (average age 70.38 ± 13.46 years; 45.6% were women). Analysis of 36 patients from the acute stenting + MT group (average age 66.72 ± 13.17 years; 30.6% were women), and 403 patients from the MT Alone group (average age 70.71 ± 13.45 years; 46.9% were women); see Table 1 for baseline characteristics and outcomes. Three patients (8.3%) in the acute stenting + MT group experienced ICH versus forty-four patients (10.9%) in the MT alone group (P=0.631); no significant increases were noted in length of stay (9.08 days vs 9.84 days; P=0.620) or good mRS scores at dc (P=0.636). Conclusion: Acute intracranial stenting in addition to MT was not associated with an increase in ICH rates, overall length of stay, or poor outcome upon discharge of patients. Prospective studies are recommended.

Thrombolytic treatment in stroke mimic, inevitable but fortunately safe: An observational study from Iran

Background: A number of patients with symptoms of acute cerebral ischemia may have other causes called stroke mimics (SM). The prevalence of SM can be as high as 31% in some reports, and these patients are potentially at the risk of intravenous thrombolysis (IVT) therapy and its complications. This study was designed to determine the prevalence of our center's SM (Firoozgar Hospital) among patients who received IVT, their baseline characteristics, final diagnoses, and outcomes. Methods: We reviewed the medical records of all patients who received IVT between June 2015 and May 2018. The following variables were collected: demographic characteristics, past medical history, onset-to-needle (OTN) time, door-to-needle (DTN) time, National Institutes of Health Stroke Scale (NIHSS) score at admission, brain imaging, and all paraclinic findings. Functional outcome at discharge based on modified Rankin Scale (mRS) was also assessed. Results: 10 out of 165 (6.0%) patients including 8 men and 4 women were finally diagnosed with SM. The median age and NIHSS score at presentation were 60 years and 7, respectively. Final diagnoses were seizure (n = 6), hemiplegic migraine (n = 2), conversion (n = 1), and alcohol intoxication (n = 1). All patients were discharged with a mRS score of 0 and 1 without experiencing any thrombolytic adverse effects. Conclusion: None of the patients with SM experienced any adverse effect of tissue plasminogen activator (tPA) including hemorrhage and all of them reached good mRS score. This shows that tPA is generally safe and the risk of treating patients with SM is very low and making a vital treatment decision may outweigh the risk of neglected cases in a time-sensitive setting.

Unmet Needs and Challenges in Clinical Research of Intracerebral Hemorrhage.

Unmet Needs and Challenges in Clinical Research of Intracerebral Hemorrhage.

Arterial Spin Labeling—Can Neurointerventionists Rely on This Novel Technique? A Case Series on Successful Use of Arterial Spin Labeling in Acute Stroke Imaging

AbstractPresence of ischemic penumbra is the principal factor that decides the need for mechanical thrombectomy in acute stroke patients with large vessel occlusion. Our objective was to evaluate the usefulness of arterial spin labeling (ASL) in detecting diffusion perfusion mismatch and directing patients into mechanical thrombectomy. We retrospectively studied all patients with acute nonhemorrhagic stroke in the anterior circulation, who had undergone stroke imaging with ASL followed by mechanical thrombectomy from July 2016 to November 2016. Area of diffusion perfusion mismatch was graded semiquantitatively into three grades: small, medium, and large. Mismatch was compared with 30-day modified Rankin scale (mRS) score. Interpretable PASL-perfusion images were obtained in all patients. Diffusion perfusion mismatches were present in all patients. Out of six patients with good mRS score, five patients had large diffusion perfusion mismatch. Two out of three patients with poor mRS were secondary to failed recanalization, in spite of large mismatch. One out of nine patients had poor outcome as well as a small area of mismatch. ASL is a rapid noninvasive imaging technique in acute stroke that has got the potential to detect ischemic penumbra.

PG2 for patients with acute spontaneous intracerebral hemorrhage: a double-blind, randomized, placebo-controlled study

PG2 is an infusible polysaccharide extracted from Astragalus membranaceus, which is a Chinese herb traditionally used for stroke treatment. We investigated the effect of PG2 on patients with spontaneous acute intracerebral hemorrhage (ICH). A total of 61 patients with acute spontaneous ICH were randomized to either the treatment group (TG, 30 patients), which received 3 doses of PG2 (500 mg, IV) per week for 2 weeks, or the control group (CG, 31 patients), which received PG2 placebo. At 84 days after PG2 administration, the percentage of patients with a good Glasgow outcome scale (GOS 4–5) score in the TG was similar to that in the CG (69.0% vs. 48.4%; p = 0.2). The percentage of good mRS scores (0–2) in the TG was similar to that in the CG (62.1% vs. 45.2%; p = 0.3). In addition, no significant differences were seen when comparing differences in the C-reactive protein, erythrocyte sedimentation rate, interleukin-6 (IL-6), IL-1β, tumor necrosis factor-α, and S100B levels between baseline and days 4, 7, and 14 after PG2 administration (all p > 0.05). The results are preliminary, necessitating a more thorough assessment.

Preoperative predictive factors for surgical and functional outcomes in chronic subdural hematoma.

Chronic subdural hematoma (CSDH) is a frequently encountered neurosurgical condition, especially in the elderly. We investigated predictive factors for surgical and functional outcomes after burr-hole drainage (BHD) surgery. All patients with CSDH treated by BHD between January 2012 and December 2014 were included in this study. All patients were classified by symptom, clinical grade, time, location, hematoma density, midline shift, and other characteristics. Pre- and postoperative CT evaluation was performed at 0, 3, and 6months. Clinical grades were classified as described in Markwalder et al. Surgical and clinical outcomes were evaluated with the brain expansion rate and modified Rankin Scale (mRS). Brain expansion rate was calculated as the ratio between post- and pre-operative hematoma thickness. Recurrence was defined as the occurrence of symptoms and hematoma on CT within 6months. This study included 130 patients over 2years. Among the variable parameters, young age (<75), iso-density of hematoma on CT, and short duration from symptom to surgery were correlated with good brain expansion. Patients with good brain expansion had fewer recurrences. In terms of mRS, young age, iso-density, and good clinical grade were correlated with good functional outcomes. Clinicians should be more aware of general conditions and medical problems, especially in elderly patients. Membranectomy should be considered in patients with a long duration of symptoms or hypo-dense hematomas to promote good brain expansion and good mRS scores.

Ischemic Event and Risk Factors of Embolic Stroke in Atherosclerotic Cerebral Aneurysm Patients Treated with a New Clipping Technique

We would like to know the exact rate of ischemic event and the risk factors associated with embolic stroke by treatment of atherosclerotic cerebral aneurysm with a new technique. This is a retrospective cohort study in patients diagnosed as unruptured atherosclerotic cerebral aneurysm who underwent microsurgical clipping between January 2012 and August 2014. All intraoperative video recordings were reviewed and chosen in patients who were identified as atherosclerotic lesion on the dome, neck, or parent artery of the aneurysm. The demographic, radiographic, operative, and postoperative data were collected. The primary end point was the incidence of cerebral infarction and the neurologic outcomes using the discharge modified Rankin Scale (mRS) score at postoperation time. A statistical analysis of the factors associated with embolic stroke was done by Fisher exact and Wilcoxon rank-sum tests. The individual surgical technique was demonstrated as an illustration for use as a guide. Among 103 atherosclerotic cerebral aneurysms, only 3 patients (2.9%) were associated with postoperative cerebral infarction and 1 of them had permanent neurologic deficit. A good mRS score (0-2) was found in 99% of patients and only 1% had a fair mRS score (3-4). A factor associated with ischemic outcome was duration of operation (P=.046). The differences in the atherosclerotic location showed no statistical significance. We found a very low incidence of embolic infarction after clipping of an atherosclerotic cerebral aneurysm with our new technique. Only duration of the operation time was a dependent risk factor for embolic infarction.

Prediction of two month modified Rankin Scale with an ordinal prediction model in patients with aneurysmal subarachnoid haemorrhage

BackgroundAneurysmal subarachnoid haemorrhage (aSAH) is a devastating event with a frequently disabling outcome. Our aim was to develop a prognostic model to predict an ordinal clinical outcome at two months in patients with aSAH.MethodsWe studied patients enrolled in the International Subarachnoid Aneurysm Trial (ISAT), a randomized multicentre trial to compare coiling and clipping in aSAH patients.Several models were explored to estimate a patient's outcome according to the modified Rankin Scale (mRS) at two months after aSAH. Our final model was validated internally with bootstrapping techniques.ResultsThe study population comprised of 2,128 patients of whom 159 patients died within 2 months (8%). Multivariable proportional odds analysis identified World Federation of Neurosurgical Societies (WFNS) grade as the most important predictor, followed by age, sex, lumen size of the aneurysm, Fisher grade, vasospasm on angiography, and treatment modality. The model discriminated moderately between those with poor and good mRS scores (c statistic = 0.65), with minor optimism according to bootstrap re-sampling (optimism corrected c statistic = 0.64).ConclusionWe presented a calibrated and internally validated ordinal prognostic model to predict two month mRS in aSAH patients who survived the early stage up till a treatment decision. Although generalizability of the model is limited due to the selected population in which it was developed, this model could eventually be used to support clinical decision making after external validation.Trial RegistrationInternational Standard Randomised Controlled Trial, Number ISRCTN49866681