Higher Initial National Institute Of Health Stroke Scale Research Articles

Abstract 14012: Association Between Direct Oral Anticoagulant Concentration Upon Acute Stroke and Stroke Outcomes

Introduction: Ischemic stroke (IS) or intracranial hemorrhage (ICH) has been reported during direct oral anticoagulant (DOAC) therapy. However, data regarding the DOAC level upon acute stroke is lacking. Hypothesis: The DOAC level upon acute IS or ICH may be associated with stroke outcomes. Methods: Patients aged ≥ 20 years, under DOAC therapy and developed acute ischemic or hemorrhagic stroke were enrolled. The DOAC level upon hospital arrival was measured with ultra-high-performance liquid chromatography with tandem mass spectrometry. The primary outcome was the composite outcomes included IS, ICH, major bleeding or death at 3 months. The secondary outcome included modified Rankin Scale (mRS) 0 to 3 at 3 months. Results: During 2018 to 2022, a total of 105 patients who developed IS and 26 patients who developed ICH during DOAC therapy were enrolled. Among the IS cohort, 45 (42.9%) had DOAC level<50 ng/mL. The initial National Institutes of Health Stroke Scale (NIHSS) was similar between patients with DOAC level <or≥50 ng/mL. The primary outcome occurred in 13 and 9 patients with DOAC level<or≥ 50 ng/mL. After adjustment, factors associated with composite outcomes at 3 months included reduced creatinine clearance (HR=0.96 [0.93, 0.995]), higher initial NIHSS (HR=1.08 [1.01, 1.15]) and DOAC level<50 ng/mL (HR=5.63 [1.47, 21.65]). To predict mRS 0 to 3 at 3 months, initial NIHSS, and DOAC level<50 ng/mL displayed inverse association (OR=0.82 [0.75, 0.90] and 0.19 [0.05, 0.78]). Among the ICH cohort, 19 patients (73.1%) has DOAC level<50 ng/mL. Compared to patients with DOAC level≥50 ng/mL, their initial hematoma size was smaller. The primary outcome occurred in 0 and 5 patients with DOAC level <or≥ 50 ng/mL. The proportion of patients with hematoma expansion and having mRS 0 to 3 points were similar between patients with DOAC level<or≥50 ng/mL (40.0% versus 43.8%, p=1.00 for hematoma expansion; 85.7% versus 52.6%, p=0.19 for mRS 0 to 3 points). Conclusion: Among patients who develop IS during DOAC therapy, low DOAC level, along with higher initial NIHSS and worse renal function, predicts worse clinical outcomes.

Neurological and medical complications in cerebral stroke patients before hospitalization and during admission to the clinic «oberig» stroke center

Objective ‒ to determine the rate of medical and neurological complications in patients with cerebral stroke (CS) before hospitalization and during in-patient treatment at the Stroke Center (SC), as well as to establish independent predictors for new medical complications at the SC, and to develop an appropriate prognostic model. Materials and methods. The study enrolled 539 patients, 309 (57.3 %) were men and 230 (42.7 %) were women. The age of patients ranged from 20.4 to 95.6 (66.0 [57.9; 75.1]) years. 438 (81.3 %) patients were diagnosed with ischemic stroke (177 (40.4%) ‒ atherothrombotic subtype, 200 (45.7 %) ‒ cardioembolic, 30 (6.9 %) – lacunar, 32 (7.0 %) ‒ stroke of other established or undetermined etiology), 101 (18.7 %) ‒ intracerebral hemorrhage. 109 (20.2%) of the study participants were hospitalized in the hyperacute period, 113 (21.0 %) ‒ in the acute, 199 (36.9 %) ‒ in the early subacute, 36 (6.7 %) ‒ in the late subacute, 82 (15.2%) ‒ in the remote (chronic) period of CS. All patients were evaluated upon admission using the National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin Scale (mRS). The method of construction and analysis of logistic regression models was used to quantify the degree of influence of factor features on the risk of complications. The analysis was performed using the package MedCalc v. 19.1. Results. The total NIHSS score on admission ranged from 0 to 39 (11 [6; 18]). Among the studied patients, 119 (22.1 %) had mild, 218 (40.5 %) – moderate, 114 (21.2 %) – severe, 88 (16.3 %) – very severe CS. Asesed with mRS upon admission, 11 (2.0 %) patients have 0 point, 34 (6.3 %) – 1 point, 58 (10.8 %) – 2 point, 65 (12.1 %) – 3 point,136 (25.2 %) – 4 point, and 235 (43.6 %) – 5 point. Neurological or medical complications before hospitalization occurred in 303 (56.2 %) patients, including 111 (20.6 %) patients with neurological complications and 192 (35.6 %) patients with medical ones. More than one complication was recorded in 52 (9.6 %) persons. The incidence of new neurological and medical complications during the SC stay was significantly lower (p<0.001) than before hospitalization. The independent predictors of new medical complications were CE subtype of IS (OR 2.08; 95 % CI 1.11–3.92), medical complications before admission (OR 2.58; 95 % CI 1.51–4.42), higher initial NIHSS score (OR 1.11; 95 % CI 1.06–1.16 for each additional point), and higher initial mRS (OR 1.62; 95 % CI 1.07–2.48, for each additional point). The predictive model based on the selected set of features has good sensitivity (86.4 %) and moderate specificity (68.4 %). The area under the operating characteristics curve AUC = 0.85 (95 % CI 0.82–0.88), indicates a strong relationship between this set of factorial factors and the risk of medical complications during in-patient treatment at the SC. Conclusions. Before SC admission, complications, mainly medical, occurred in the majo-rity of the patients. A higher rate of medical complications associated with severe CS, greater dependency, older age, and a longer period from CS onset to SC admission. The incidence of complications at the SC was significantly lower than before the admission, which suggests the benefits of care at a Comprehensive Stroke Unit.

Abstract P493: Outcomes in Young Adults With Acute Ischemic Stroke Undergoing Endovascular Thrombectomy: A Multi-Centre Experience

Introduction: Endovascular thrombectomy(EVT) is considered standard of care for anterior circulation acute ischemic stroke(AIS) with large vessel occlusion(LVO). Young AIS-LVO patients have distinctly different underlying stroke mechanisms and etiologies. Methods: In this multicenter cohort study conducted from August 2014 to January 2020, we investigated the safety and effectiveness of EVT in young AIS-LVO patients aged≤50 years and evaluated associations between demographics, stroke etiology, neuroimaging factors and clinical outcomes, including functional outcomes, in-hospital mortality and symptomatic intracranial haemorrhage(sICH) in univariable and multivariable regression models. Results: 275 AIS-LVO patients from 10 tertiary centers in Germany, Sweden, Singapore and Taiwan were included. The more common TOAST subtypes included cardioembolism (82/275, 29.8%) and stroke of undetermined etiology (85/275, 30.9%). Arterial dissection was the most prevalent stroke etiology (42/195, 21.5%) and had the highest rate of good functional outcomes (29/42, 69.0%). Successful reperfusion was achieved in 85.1% (234/275). Excellent and good functional outcomes were achieved in 48.0% (132/275) and 66.0% (182/275) respectively. sICH occurred in 6.5% (18/275). National Institute of Health Stroke Scale (NIHSS) at presentation was inversely related with good functional outcomes (aOR0.92, 95% CI 0.88- 0.96 per point increase, p<0.001). Successful reperfusion (aOR3.22, 95% CI 1.44-7.21, p=0.005), higher ASPECTS (aOR1.21, 95% CI 1.01-1.44, p=0.036) and bridging intravenous thrombolysis (aOR2.37, 95% CI 1.29-4.34, p=0.005) independently predicted good functional outcomes. Higher initial NIHSS (aOR1.08, 95% 1.02-1.14, p=0.007) and lower ASPECTS (aOR0.73, 95% 0.58-0.93, p=0.012) were associated with sICH. Successful reperfusion was inversely associated with in-hospital mortality (aOR0.14, 95% CI 0.03-0.57, p=0.006). Hypertension strongly predicted in-hospital mortality (aOR4.59, 95% CI 1.10-19.13, p=0.036). Conclusion: While differences in functional outcomes exist across varying stroke aetiologies, high rates of successful reperfusion and good outcomes are generally achieved in young AIS-LVO patients undergoing EVT.

Abstract 82: Diastolic Dysfunction Revealed by Transesophageal Echocardiography Predicts New Atrial Fibrillation During Hospitalization for Acute Ischemic Stroke

Background: Transesophageal echocardiography (TEE) is often performed to explore an embolic source in ischemic stroke patients without atrial fibrillation (AF). The aim of this study was to elucidate the relationship between the ratio of transmitral flow velocity (E) and mitral annular velocity (e’) measured by using TEE (E/e’ TEE) and prediction of new AF during hospitalization. Method: We prospectively enrolled 170 patients with acute ischemic stroke without known atrial fibrillation at admission. Transthoracic echocardiography was performed to assess left atrial diameter, ejection fraction, and E/e’. A subset of patients underwent TEE to explore an embolic source. We obtained the e’ at the lateral wall located near the left atrial appendage by using TEE. Baseline characteristics, stroke features, initial National Institutes of Health Stroke Scale (NIHSS) score, plasma and serum biomarkers included brain natriuretic protein (BNP), and imaging findings were recorded. We investigated factors to predict new documented AF by multivariate logistic regression analysis. To elucidate the cut off value of factors for predicting new AF, the area under the curve of the receiver operating characteristic curve was evaluated. Results: AF was detected in 14 patients (8%). In univariate analysis, older age (median, 75 years vs. 71 years; p=0.022), higher initial NIHSS score (median, 8 vs. 3; p=0.017), elevated plasma BNP level (median, 183 pg/mL vs. 36 pg/mL; p<0.001), larger left atrial diameter (median, 38 mm vs. 35 mm; p=0.024) and higher E/e’ TEE (median, 22.4 vs. 14.4; p=0.004) were positively associated with new documented AF. In multivariate analysis, E/e’ TEE was an independent predictor of newly diagnosed AF during hospitalization (Odds ratio, 1.680; 95% confidence interval, 1.174 to 3.420; p<0.001). The cut off value of E/e’ TEE for predicting new AF was 21.5 with the sensitivity of 80 % and the specificity of 98 %. Conclusions: Diastolic dysfunction evaluated by TEE may be a good predictor of newly diagnosed AF.

Conjugate Eye Deviation on CT Associated With Worse Outcomes Despite IV Thrombolysis.

Rapid stroke management has significant implications in patient outcomes. Ipsilateral computed tomography conjugate eye deviation (CT-CED) has been associated with worse outcomes but has never been evaluated as predictive of vascular occlusion. To test the hypothesis that CT-CED is a marker for vascular occlusion, we evaluated patients treated with intravenous tissue plasminogen activator (IV tPA). We performed a retrospective analysis of patients with acute ischemic stroke treated with IV tPA at a large tertiary care hospital over an 18-month period. A waiver of informed consent was granted. Two examiners evaluated baseline brain CTs blinded to the location of infarct to assess the presence of CT-CED and follow-up imaging for the location of infarct and the presence of intracranial large vessel occlusion. Demographics, initial National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scales (mRSs), and hospital length of stay (LOS) were collected. Among 104 patients treated with IV tPA, 36 had CT-CED. Inter-rater reliability for CT-CED was excellent (κ = 0.97; 95% confidence interval: 0.98-1.0). The CT-CED group was older (69.8 vs 64 years; P = .038), had higher initial NIHSS (14.6 vs 11; P = .01), worse mRS (3.2 vs 2.4; P = .03), and longer LOS (8.4 vs 6.4; P = .05) compared with those without CT-CED. A vascular occlusion in the territory of the infarct was seen in 58% of patients with CT-CED versus 32% without CT-CED (P < .01). Atrial fibrillation (AF) was diagnosed in 61% patients with CT-CED versus 22% without (P < .01). The CT-CED is associated with higher initial NIHSS, large vessel occlusion, and AF. Prospective studies are needed to ascertain whether CT-CED may be utilized part of a screen for endovascular therapy.

Abstract 2261: Presence of Large Deep White Matter Lesion May Predict Futile Recanalization in Endovascular Therapy for Acute Ischemic Stroke

Background: A subset of stroke patients treated with endovascular recanalization therapy suffers poor outcome despite good arterial recanalization. The aim of this study is to identify whether large ischemic lesion in deep white matter (DWM) on diffusion weighted imaging (DWI) prior to therapy predicts futile recanalization. Method: Consecutive acute stroke patients with anterior circulation ischemia whose artery had been recanalized at Thrombolysis in Myocardial Infarct (TIMI) flow grade 2 or 3 following endovascular therapy were included. All patients underwent CT and MRI before endovascular therapy. We defined large DWI - DWM lesion if DWI showed the hyperintense lesion in the DWM which mostly extended between anterior and posterior horn of the lateral ventricle. We identified Alberta Stroke Program Early CT Scores (ASPECTS) of CT and DWI, and volumes measured on initial DWI and mean transit time of perfusion weighted images. We assessed the prevalence of TIMI grade 3 recanalization and parenchymal hemorrhage type 2, and final ischemic lesion volume after endovascular therapy. Stroke severity was assessed by the National Institutes of Health Stroke Scale (NIHSS) score. Futile recanalization was defined as a 30-day modified Rankin Scale score 3 to 6 despite recanalization at TIMI grade 2 or 3. Univariate and multivariate regression analyses were performed to identify predictors of futile recanalization. Results: Partial or complete recanalization (TIMI grade 2 or 3) was observed in 35 of 46 patients (76 %). Of the 35 patients, futile recanalization was observed in 20 patients (57 %). Patients with futile recanalization had older age (median, 74 versus 58 years old, p = 0.053), higher initial NIHSS score (median, 17 versus 9, p = 0.042), pre-treatment large DWI - DWM lesion (45 versus 9 %, p = 0.022), and larger final ischemic lesion volume (median, 37 versus 9 ml, p = 0.003). ASPECTS of CT (median, 9 versus 9, p = 0.527) and DWI (median, 8 versus 8, p = 0.943) and initial ischemic lesion volumes on DWI (median, 21 versus 14 ml, p = 0.230) and on mean transit time (median, 189 versus 192 ml, p = 0.976) did not demonstrate statistically significance between patients with and without futile recanalization. There were also no significant differences between the outcome groups in times from stroke onset to imaging or endovascular therapy. Logistic regression analysis demonstrated that large DWI - DWM lesion was an independent predictor of futile recanalization (OR 10.40, 95 % CI 1.03 to 105.21, p = 0.047). Conclusion: Patients who have large pre-treatment DWI - DWM lesion may be poor candidates for endovascular therapy.

Population pharmacokinetic and pharmacodynamic model of CP-101,606 following a 72-hour infusion in acute ischemic stroke patients

CP-101,606 (CP) is an N-methyl-D-aspartate NR2B subunit selective receptor antagonist. Pathologic overactivation of NMDA receptors is implicated in the neurodegeneration following stroke. A 72-hr infusion of CP or placebo was started within 8 hours of onset of symptoms. NONMEM was used for pharmacokinetic-pharmacodynamic modeling. A linear one-compartment mixture model describing fast and slow metabolizers with allometrically scaled clearance and volume described pharmacokinetics. Disease progression for stroke recovery (National Institute of Health Stroke Scale (NIHSS)) was modeled with an Emax function for recovering subjects and a linear function for subjects that worsened. The results suggested higher initial NIHSS, larger lesion volumes and older age negatively impacted rate and extent of recovery. Exposure to CP resulted in faster rate of recovery and larger maximum recovery in a concentration dependent manner. The statistical significance of including the effect of CP on the rate of recovery was somewhat low but reduced inter-patient variability in the disease progression model. Clinical Pharmacology & Therapeutics (2004) 75, P97–P97; doi: 10.1016/j.clpt.2003.11.370