Higher National Institutes Of Health Stroke Scale Score Research Articles

Favorable prognosis in posterior circulation ischemic stroke: Insights from a nationwide stroke databank

IntroductionClinical trials have historically underrepresented patients with posterior circulation ischemic stroke (PCIS). This study aimed to comprehensively assess the clinical characteristics and outcomes of PCIS patients compared to those with anterior circulation ischemic stroke (ACIS). MethodsA retrospective analysis was conducted using data from the Japan Stroke Data Bank, encompassing 20 years across 130 stroke centers. The study focused on patients diagnosed with PCIS or ACIS. ResultsAmong 37,069 patients reviewed, 7425 had PCIS, whereas 29,644 had ACIS. PCIS patients were younger and had a lower female representation than ACIS patients. Notably, PCIS patients had more favorable outcomes: 71% achieved a modified Rankin Scale of 0–2 or showed no deterioration at discharge (17 days at the median after admission), compared to 60% for ACIS patients (p < 0.001). Factors associated with an unfavorable outcome in the PCIS subgroup were older age, female sex (assigned at birth), history of hypertension, and higher National Institute of Health Stroke Scale (NIHSS) scores at admission. In both sexes, older age and higher NIHSS scores were negatively associated with favorable outcomes. ConclusionsPCIS patients demonstrated a more favorable prognosis than ACIS patients. Factors like older age, female sex, and higher NIHSS scores at admission were identified as independent predictors of unfavorable outcomes in PCIS patients. Older age and higher NIHSS scores at admission were common independent negative factors for a favorable outcome regardless of sex.

Risk factors and characteristics analysis of cognitive impairment in patients with cerebral infarction during recovery period

Objective To analyze the risk factors and characteristics of cognitive impairment in patients with cerebral infarction during the recovery period. Methods This retrospective case-control study included 183 patients with cerebral infarction in the recovery period. According to the MMSE score, they were divided into a cognitive impairment group of 79 cases and a cognitive normal group of 104 cases. Collect clinical data from all patients, including age, gender, body mass index, laboratory test results, past medical history, National Institute of Health Stroke Scale (NIHSS) score, modified Barthel index, Oxfordshire Community Stroke Project (OCSP) classification, and number of infarcted lesions. Multiple logistic regression analysis was used to identify risk factors related to cognitive impairment in patients with cerebral infarction. Result There were significant differences (p < 0.05) between the cognitive impairment group and the cognitive normal group in terms of age, body mass index, low-density lipoprotein level, NIHSS score, modified Barthel index, and number of infarcted lesions. Multivariate logistic regression analysis showed that age ≥ 65 years, stroke, carotid artery plaques, NIHSS score ≥ 5, anterior circulation infarction type, and multiple infarcted lesions were important risk factors for cognitive impairment. Conclusion Elderly age, presence of carotid artery plaques, high NIHSS score, multiple infarct lesions, and specific infarct types are important risk factors for cognitive dysfunction in patients during the recovery period of cerebral infarction.

Initial stroke severity and discharge outcome in patients with muscle mass deficit.

This study aimed to investigate the association between muscle mass deficit and the initial severity of ischemic stroke. The impact of muscle mass deficit on the discharge outcome was also evaluated. This retrospective study included 660 patients with acute ischemic stroke who underwent bioelectrical impedance analyses. We compared the National Institute of Health Stroke Scale (NIHSS) score, occurrence of moderate stroke (NIHSSS ≥ 5) at admission, and unfavorable functional outcome (modified Rankin Scale score ≥ 2) at discharge between patients with and without muscle mass deficit using Poisson and logistic regression analyses. The mean age of the study patients was 65.6 ± 13.0, and 63.3% were males. Muscle mass deficit was present in 24.4% of patients. Muscle mass deficit was significantly and independently associated with NIHSS score or moderate stroke (all p < 0.05). This association was noted regardless of patient characteristics. Among the respective NIHSS items, muscle mass deficit was significantly associated with facial palsy, motor function of the arm or leg, limb ataxia, and dysarthria. Muscle mass deficit also led to unfavorable functional outcome, which was mediated by the initial NIHSS score. In conclusion, muscle mass deficit is associated with higher NIHSS score and unfavorable functional outcome in patients with acute ischemic stroke.

The effect of asymptomatic intracranial hemorrhage after mechanical thrombectomy on clinical outcome

Background and objectiveWhether asymptomatic intracranial hemorrhage (ICH) affects the clinical outcomes in patients with acute large vessel occlusion treated with mechanical thrombectomy (MT) remains unclear. This study aimed to address this uncertainty. MethodsWe retrospectively analyzed patients with acute ischemic stroke and internal carotid or middle cerebral (M1 segment) artery occlusion treated with MT between April 2011 and March 2021 at a single center. All patients had a premorbid modified Rankin scale (mRS) score ≤ 2 and an anterior circulation occlusion and underwent magnetic resonance imaging at admission. Asymptomatic ICH was defined as ICH without symptomatic ICH defined by the SITS-MOST criteria. A favorable outcome was defined as an mRS score ≤ 2 at 90 days after stroke onset. ResultsOur study included 349 patients; 62% were men, the median age was 76 [67–83] years, and the median National Institutes of Health Stroke Scale (NIHSS) score was 15 [8–21]. As determined via computed tomography, 103 (30%) patients had ICH (20 symptomatic and 83 asymptomatic). The favorable outcome rate was significantly lower for asymptomatic vs. no ICH (30% vs. 67%, p < 0.01). In a multivariate regression analysis, a high NIHSS score (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.02–1.10; p < 0.01) and low Alberta Stroke Program Early CT Score (OR, 0.78; 95% CI, 0.65–0.92; p < 0.01) were independent risk factors for ICH. ConclusionsAsymptomatic ICH is associated with poor clinical outcome at 90 days after stroke onset.

An Observational Study of Glycemic Status in New Onset Acute Stroke and Their Clinical Outcome in a Tertiary Care Teaching Hospital

Abstract Objective The study was aimed to test the blood glucose level in acute stroke patients to find out any correlation with types and prognosis of different glycaemic groups. Method It was a prospective observational study of patients admitted to hospital in Nizamabad due to an acute ischemic or hemorrhagic stroke (&lt;24Hrs after the onset). Clinical parameters including history and clinical examination findings were recorded. CT scan of brain, blood glucose level, HbA1c, and other laboratory tests were taken in all the patients. 2D echocardiography (2D-ECHO) and X-Ray chest picture were also performed. According to glycaemia, the patients were classified into four groups such as Nondiabetic/euglycemic, known Diabetics on glycemic control therapy with or without glycemic control, Newly detected diabetics, and Stress hyperglycemia patients. On the day 1 and 15 National Institutes of Health Stroke Scale (NIHSS) was calculated to evaluate the severity of stroke and its outcome. Good prognosis was considered when NIHSS 5, moderate prognosis when NIHSS was 6–15, and poor prognosis when NIHSS was 16–20. Patients with NIHSS 20 died within 3 days of admission. Results Finally, 158 patients with acute stroke were included. Hemorrhagic stroke was seen in 43 (27.2%) and ischaemic stroke in 115 (72.8%) patients. Maximum cases were found in 51–60 years age group (37.9%) followed by 41–50 (20.3%) and 61–70 years age group (20.3%). Majority of study subjects were males, 65.8 % (n=104). Maximum cases were Euglycemics (44.3%), followed by stress hyperglycemic (27.8%), known diabetes (15.9%), and newly diagnosed diabetes (12%) presenting with acute stroke. Higher NIHSS score was found in stress hyperglycemic patients (19.4%) followed by known diabetics (17.3%), newly detected diabetics (16.3%), and euglycemics (9.5%). Maximum proportion (81.8%) of ischaemic stroke cases were found with stress hyperglycemia compared to other glycemic conditions but in hemorrhagic stroke maximum proportion (47.3%) were newly diagnosed diabetics. Maximum proportion of large size of lesion (47.4%) was found in newly diagnosed diabetes followed by stress hyperglycemia (45.55). Medium size of the lesions was found more in newly diagnosed diabetes (52.6%) followed by known diabetes cases (52%). Good outcome was found in 51 cases (32.2%), moderate outcome in 34 (21.5%), and poor outcome was in 30 (18.9%). 43 patients with NIHSS score &gt;20 died within 3 days of admission (27.2%). Maximum proportion of death cases in ischemic group those belongs to newly diagnosed diabetes cases (8/9=88.8%). Higher deaths were found in blood sugar &lt;110 mg/dl and blood sugar &gt;199 mg/dl with an incidence rates of 41.2% and 53.4%. Conclusion Hyperglycaemia in non-diabetic patients after acute stroke is a stress response reflecting more severe neurological damage. Elevated HbA1c presenting stroke glycaemia status has a significant trend in increasing the risk of cause mortality. The management of hyperglycaemia in patients with diabetes and non-diabetes is an important aspect of the emergency management of stroke.

Repeated intravenous thrombolysis in recurrent ischemic stroke within 3 months: a systematic review

BackgroundRepeated intravenous thrombolysis (RIVT) within 3 months is an off-guideline therapy, however, may be an effective and safe way to treat early recurrent ischemic stroke. This study was conducted to assess the potential influencing factors on the efficacy and safety of RIVT in recurrent ischemic stroke within 3 months and to explore the strategy of RIVT within 3 months.MethodsPubMed, Cochrane Library, Embase, China National Knowledge Infrastructure, and Wanfang Database were searched for cases of RIVT in recurrent ischemic stroke within 3 months up to February 1, 2023. Clinical characteristics were compared and analyzed between the good-outcome and poor-outcome groups and between the symptomatic intracranial hemorrhage (sICH) and non-sICH groups respectively.ResultsA total of 16 studies including 24 cases of RIVT within 3 months were retrospectively analyzed in the present study. The patients’ ages ranged from 42 to 87 years (median 73.5 years) and the intervals between thrombolysis were from 0.25 to 90 days (median 9.5 days). Comparing the clinical characteristics between the good-outcome group and the poor-outcome group, no statistically significant differences were found (P > 0.05), but the differences in baseline National Institutes of Health stroke scale (NIHSS) score of the recurrent stroke (P = 0.056) and good outcome after the previous IVT (P = 0.054) nearly reached statistical significance. Comparing the data between the non-sICH group and the sICH group, statistically significant differences were found in terms of the proportion of cardiogenic embolism (P = 0.036), baseline NIHSS score in the recurrent stroke (P = 0.007) and the interval between thrombolysis (P = 0.041), but no significant difference was found by regression analysis.ConclusionIn patients with recurrent ischemic stroke within 3 months, those with a good outcome after the previous IVT and a low baseline NIHSS score in the recurrent stroke may be considered for RIVT, whereas those with a high baseline NIHSS score, a short interval between thrombolysis, and cardiogenic embolism may suffer a higher risk of sICH. Due to sample size and publication bias, more studies with larger sample sizes and more rigorous designs are needed to confirm this conclusion.

Association between arterial tortuosity and early neurological deterioration in lenticulostriate artery infarction

Early neurological deterioration (END) in lenticulostriate artery (LSA) infarction is associated with perforating artery hypoperfusion. As middle cerebral artery (MCA) tortuosity may alter hemodynamics, we investigated the association between MCA tortuosity and END in LSA infarction. We reviewed patients with acute LSA infarction without significant MCA stenosis. END was defined as an increase of ≥ 2 or ≥ 1 in the National Institutes of Health Stroke Scale (NIHSS) total or motor score, respectively, within first 72 h. The MCA tortuosity index (actual /straight length) was measured. Stroke mechanisms were categorized as branch atheromatous disease (BAD; lesions > 10 mm and 4 axial slices) and lipohyalinotic degeneration (LD; lesion smaller than BAD). Factors associated with END in LD and BAD were investigated. END occurred in 104/390 (26.7%) patients. A high MCA tortuosity index (adjusted odds ratio, aOR 10.63, 95% confidence interval [2.57–44.08], p = 0.001) was independently associated with END. In patients with BAD, high initial NIHSS score (aOR 1.40 [1.03–1.89], p = 0.031) and presence of parental artery disease (stenosis < 50%; aOR 10.38 [1.85–58.08], p = 0.008) were associated with END. In patients with LD, high MCA tortuosity (aOR 41.78 [7.37–237.04], p < 0.001) was associated with END. The mechanism causing END in patients with LD and BAD may differ.

Outcomes and poor prognostic factors in endovascular thrombectomy for octo‐ and nonagenarians with large vessel occlusion: A real‐world experience

AbstractEndovascular thrombectomy (EVT) is the preferred treatment for eligible patients with acute large vessel occlusions (LVOs). However, its role in very elderly patients remains uncertain. This study retrospectively analysed EVT outcomes, including successful reperfusion, change in National Institutes of Health Stroke Scale (NIHSS) score at 24 h after EVT, inpatient haemorrhagic transformation and favourable functional outcomes and mortality at 90 days after EVT in patients aged over 80 years. The primary outcome of the study was risk factors significantly associated with poorer functional outcomes at 90 days after EVT. The secondary outcomes were risk factors associated with higher NIHSS scores at 24 h after EVT and higher mortality rates at 90 days after EVT. Among the 73 octo‐ and nonagenarians, successful reperfusion was achieved in 86.3%, and up to 35.6% maintained functional independence at 90 days. Poorer outcomes were associated with internal carotid artery occlusion; risk factors such as hypertension, diabetes mellitus and atrial fibrillation; higher admission NIHSS score; longer time between symptom onset and successful reperfusion and unsuccessful reperfusion. EVT is both safe and effective in our elderly population, with over one‐third of very elderly patients achieving satisfactory functional outcomes after EVT. Therefore, age alone should not be the sole criterion for excluding very elderly LVO patients from EVT. Instead, each patient should undergo individual assessment based on their premorbid condition, clinical presentation and LVO characteristics before making a treatment decision.

Relationship between Kidney Dysfunction, Stroke Severity, and Outcomes in a Nigerian Tertiary Hospital: A Prospective Study.

Stroke is a common neurologic disease associated with fatal outcomes. Kidney dysfunction may be an important predictor of stroke severity and outcome. To determine the relationship between kidney dysfunction at admission and stroke severity and 30-day outcome. This was a prospective study that involved 150 stroke patients. Stroke severity at admission was assessed using the National Institutes of Health Stroke Scale (NIHSS). Renal dysfunction was assessed by the presence of albuminuria and or reduced glomerular filtration rate (GFR) at admission. Neurological outcome was assessed using mortality, modified Rankin Scale (mRS), and Glasgow Outcome Scale (GCS). The mean age of the study participants was 61.0 ± 13.2 years. Renal dysfunction was present in 66% of the participants while the case fatality rate of stroke was 26%. Poor neurological outcome at 30 days was found in 44.1% of survivors. Those with albuminuria had lower GCS (P = 0.041), lower GFR (P = 0.004), higher mRS score on day 14 (P = 0.041) and day 30 (P = 0.032), and higher NIHSS score (P = 0.034). Independent predictors of 30-day mortality were albuminuria (Adjusted Odd Ratio (AOR) 3.60, 95%CI: 1.07-12.17) and increasing NIHSS score (AOR = 1.15, 95%CI: 1.04-1.28). Lower GCS (P < 0.001), elevated white blood cells (P = 0.003), serum creatinine (P = 0.048), and NIHSS score (P < 0.001) were associated with poor neurological outcome. NIHSS score was the only significant predictor of neurologic outcome (AOR: 1.25; CI: 1.11-1.41; P ≤ 0.001). Kidney dysfunction was associated with stroke severity and mortality. However, it was not an independent predictor of neurological outcome.

Association between GABRG2 Gene Single Nucleotide Polymorphisms and Susceptibility to Ischemic Stroke in a Chinese Population.

Current evidence suggests that Gamma-aminobutyric acid (GABA) receptors are associated with the occurrence and progression of cerebrovascular diseases. The present study investigated the association between single nucleotide polymorphisms (SNPs) in the Gamma-aminobutyric acid type A receptor gamma2 subunit (GABRG2) gene and ischemic stroke (IS). A total of 120 healthy volunteers and 187 patients with IS were recruited. Patients underwent complete neurological assessment and classification with the National Institute of Health Stroke Scale (NIHSS) and the Trial of ORG 10172 in Acute Stroke Treatment (TOAST). Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) was used to analyze SNP sites in 4 different regions (rs211037, rs418210, rs211035, and rs424740) of the GABRG2 gene. SHEsis online platform was used to assess SNP allele and genotype frequencies. Multivariate logistic regression analysis was performed to identify the risk factors for IS. Univariate analysis showed that the T allele and TT genotype distribution for rs211037 were significantly more frequent in the IS group compared to controls (pallele = 0.01, odds ratio (OR) = 1.673, 95% confidence intervals (CI), 1.119-2.500, pgenotype = 0.03). Furthermore, multivariate logistic regression analysis revealed the TT genotype for rs211037 was an independent risk factor for IS (p = 0.017, OR = 1.925, 95% CI, 1.122-3.303). Age was also found to be an independent risk factor, and the older the age, the higher the risk of IS (p = 0.001, OR = 1.047, 95% CI, 1.020-1.073). Finally, subgroup analysis revealed that patients with the rs211037 TT genotype were associated with a higher NIHSS score (p = 0.03), and that large-artery atherosclerosis (LAA) subtype was predominant in patients with the rs211037 TT genotype (p = 0.042). These findings suggest the rs211037 polymorphism in the GABRG2 gene is an independent risk factor for IS in the Chinese population. GABRG2 could thus be a potential biomarker to assess the risk of IS.

Follow-Up Diffusion-Weighted Image Reveals Delayed Appearance of Ischemic Lesions in Suspected Transient Ischemic Attack.

In patients suspected of transient ischemic attack (TIA), it is not uncommon to find no lesion on the diffusion-weighted image (DWI) on admission but a delayed appearance on the follow-up DWI. Enrolled patients met the following criteria: (1) MRI performed within 24 hours of onset and seven days after admission; (2) National Institutes of Health Stroke Scale (NIHSS) score ≦4 on admission; (3) pre-stroke modified Rankin scale (mRS) score of 0-1. Patients were divided as follows: no lesion on the first DWI and a new lesion on the second DWI (delayed-specified ischemic stroke; DSIS); and no lesion on either the first or second DWI (well-screened TIA; WSTIA). We compared both groups regarding the clinical background and the outcome at three months. We identified 144 cases (male 70%; median age 64 years; DSIS, n=34) between October 2012 and March 2019. DSIS was older (71 vs. 60 years, p=0.006) and had a higher NIHSS score on admission (1 vs. 0, p=0.041), a higher rate of large vessel occlusion (LVO) (17% vs. 2%, p=0.008),and symptom duration over one hour (82% vs. 64%, p=0.041). A favorable outcome mRS score of 0-1 at three months was less frequent in DSIS (85% vs. 96%, p=0.004). Age/10 (OR 1.62, 95%CI 1.17-2.24; p=0.004) and LVO (OR 10.84, 95%CI 1.87-63.06; p=0.008) were independent factors for DSIS. In suspected TIA with age or LVO but no lesion in the initial DWI, the second DWI should be considered to identify the delayed appearance of an ischemic stroke.

Prognostic utility of sTREM-1 in predicting early neurological deterioration in patients with acute ischemic stroke treated without reperfusion therapy

ObjectiveSerum triggering receptor expressed on myeloid cells type 1 (sTREM-1) is a new type of immunoglobulin superfamily receptor related to inflammation that aggravates brain injury. This study aimed to assess the clinical value of sTREM-1 in predicting early neurological deterioration in patients with acute ischemic stroke (AIS) treated without reperfusion therapy. MethodsThis prospective cohort study enrolled 315 patients with acute ischemic stroke admitted to the Affiliated Taizhou People's Hospital of Nanjing Medical University between October 2020 and October 2022. The study excluded patients treated with reperfusion therapy. sTREM-1 levels were evaluated within 24 h of the acute ischemic stroke. Early neurological deterioration (END) was defined as an increase in the National Institutes of Health Stroke Scale (NIHSS) score ≥ 4 points within three days after admission. Multivariable analyses were used to investigate the relationship between sTREM-1 levels and END. ResultsA total of 81 (25.7 %) patients had early neurological deterioration. Patients in the END group had a higher NIHSS score at admission (P =0.007), CRP levels (P =0.011), white blood cell count (P =0.002), fasting blood glucose levels (P =0.028), and sTREM-1 levels (P <0.001). After adjusting for confounders, higher sTREM-1 levels were significantly associated with an increased risk of early neurological deterioration (OR, 1.98; 95 % CI, 1.17-3.38, P=0.012). Moreover, sTREM-1 levels efficiently differentiated END (area under the curve: 0.779; 95 % CI: 0.731-0.822). Furthermore, the results showed significant differences between the high sTREM-1 group and the low sTREM-1 group in NIHSS scores (P=0.019), C-reactive protein (P=0.018), white blood cell count (P=0.013), and the incidence of early neurological deterioration (P<0.001). According to the multivariate logistic regression model, we discovered that the high sTREM-1 group was a significant independent predictor of early neurological deterioration incidence (OR, 4.19; 95 % CI, 1.46-9.84; P= 0.003). ConclusionsTREM-1 could be a potential biomarker for predicting early neurological deterioration in AIS patients not treated with reperfusion therapy.

Elevated SIRT2 of serum exosomes is positively correlated with diagnosis of acute ischemic stroke patients

BackgroundSilent Information Regulator 2 (SIRT2) protein inhibition has been shown to play a neuroprotective role in acute ischemic stroke (AIS) in mice. However, its role in AIS patients has not been fully understood. In this study, we aimed to analyze SIRT2 protein expression in serum exosomes of AIS and non-AIS patients, and evaluate its potential role in diagnosis and prognosis of AIS.MethodsSerum exosomes from 75 non-AIS subjects and 75 AIS patients were isolated. The SIRT2 protein levels in exosomes were analyzed using enzyme linked immunosorbent assay (ELISA). The National Institutes of Health Stroke Scale (NIHSS) was used to evaluate the severity of the disease. The modified Rankin Scale (mRS) was employed to assess the functional outcomes of the patients at 3-months following stroke onset.ResultsThe SIRT2 protein concentration of serum exosomes were higher in AIS patients than non-AIS patients (p < 0.001). Furthermore, the receiver operative characteristic curve (ROC) demonstrated that higher serum exosome SIRT2 could differentiate AIS patients from non-AIS patients with a sensitivity of 81.3% and a specificity of 75.3%. The area under the curve was 0.838 (95% CI: 0.775, 0.902). Additionally, higher SIRT2 concentration of serum exosomes were associated with NIHSS ≥ 4 (p < 0.001) and mRS ≥ 3 (p = 0.025) in AIS patients. The ROC analysis showed SIRT2 could discriminate stroke with NIHSS ≥ 4 from mild stroke (NIHSS < 4) with a sensitivity of 75.0% and a specificity of 69.6%. The area under the curve was 0.771 (95% CI: 0.661,0.881). Similarly, the test showed SIRT2 could differentiate between AIS patients with mRS ≥ 3 from those with mRS < 3 with a sensitivity of 78.3% and a specificity of 51.9%. The area under the curve was 0.663 (95% CI: 0.531,0.796). The logistic regression analysis revealed that SIRT2 concentration in serum exosomes can independently predict the diagnosis of AIS (odd ratio = 1.394, 95%CI 1.231–1.577, p < 0.001) and higher NIHSS scores (≥ 4) (odd ratio = 1.258, 95%CI 1.084–1.460, p = 0.002). However, it could not independently predict the prognosis of AIS (odd ratio = 1.065, 95%CI 0.983–1.154, p = 0.125).ConclusionThe elevation of SIRT2 in serum exosomes may be a valuable biomarker of AIS, which may be a potential diagnostic tool to facilitate decision making for AIS patients.

Door-in-Door-out Times for Interhospital Transfer of Patients With Stroke

Treatments for time-sensitive acute stroke are not available at every hospital, often requiring interhospital transfer. Current guidelines recommend hospitals achieve a door-in-door-out time of no more than 120 minutes at the transferring emergency department (ED). To evaluate door-in-door-out times for acute stroke transfers in the American Heart Association Get With The Guidelines-Stroke registry and to identify patient and hospital factors associated with door-in-door-out times. US registry-based, retrospective study of patients with ischemic or hemorrhagic stroke from January 2019 through December 2021 who were transferred from the ED at registry-affiliated hospitals to other acute care hospitals. Patient- and hospital-level characteristics. The primary outcome was the door-in-door-out time (time of transfer out minus time of arrival to the transferring ED) as a continuous variable and a categorical variable (≤120 minutes, >120 minutes). Generalized estimating equation (GEE) regression models were used to identify patient and hospital-level characteristics associated with door-in-door-out time overall and in subgroups of patients with hemorrhagic stroke, acute ischemic stroke eligible for endovascular therapy, and acute ischemic stroke transferred for reasons other than endovascular therapy. Among 108 913 patients (mean [SD] age, 66.7 [15.2] years; 71.7% non-Hispanic White; 50.6% male) transferred from 1925 hospitals, 67 235 had acute ischemic stroke and 41 678 had hemorrhagic stroke. Overall, the median door-in-door-out time was 174 minutes (IQR, 116-276 minutes): 29 741 patients (27.3%) had a door-in-door-out time of 120 minutes or less. The factors significantly associated with longer median times were age 80 years or older (vs 18-59 years; 14.9 minutes, 95% CI, 12.3 to 17.5 minutes), female sex (5.2 minutes; 95% CI, 3.6 to 6.9 minutes), non-Hispanic Black vs non-Hispanic White (8.2 minutes, 95% CI, 5.7 to 10.8 minutes), and Hispanic ethnicity vs non-Hispanic White (5.4 minutes, 95% CI, 1.8 to 9.0 minutes). The following were significantly associated with shorter median door-in-door-out time: emergency medical services prenotification (-20.1 minutes; 95% CI, -22.1 to -18.1 minutes), National Institutes of Health Stroke Scale (NIHSS) score exceeding 12 vs a score of 0 to 1 (-66.7 minutes; 95% CI, -68.7 to -64.7 minutes), and patients with acute ischemic stroke eligible for endovascular therapy vs the hemorrhagic stroke subgroup (-16.8 minutes; 95% CI, -21.0 to -12.7 minutes). Among patients with acute ischemic stroke eligible for endovascular therapy, female sex, Black race, and Hispanic ethnicity were associated with a significantly higher door-in-door-out time, whereas emergency medical services prenotification, intravenous thrombolysis, and a higher NIHSS score were associated with significantly lower door-in-door-out times. In this US registry-based study of interhospital transfer for acute stroke, the median door-in-door-out time was 174 minutes, which is longer than current recommendations for acute stroke transfer. Disparities and modifiable health system factors associated with longer door-in-door-out times are suitable targets for quality improvement initiatives.

Analysis of factors associated with futile recanalization after endovascular treatment for acute ischemic stroke with large vessels occlusion in anterior intracranial circulation

Objective: To analyze the related factors of futile recanalization (FR) after emergency endovascular treatment of large artery occlusion in anterior circulation. Methods: Three studies on endovascular treatment of acute anterior circulation large vessels occlusion stroke were selected, and their data were merged for retrospective analysis. Patients were divided into the FR group and favorable prognosis group according to the functional prognosis. Risk factor analysis was conducted using multivariate logistic regression. Results: A total of 1 581 patients were finally included, with 858 (48.9%) patients in favorable prognosis group and 926 (51.91%) patients in FR group. Among them, there were 939 males and 642 females, with a mean age of (65±12) years. Multivariate logistic regression analysis showed that National Institute of Health Stroke Scale (NIHSS) score (OR=1.089,95%CI:1.066-1.113), puncture to recanalization time (OR=0.756, 95%CI:0.586-0.971), age (OR=1.04,95%CI:1.029-1.051), serum glucose (OR=1.101,95%CI:1.062-1.143), systolic blood pressure (OR=1.005,95%CI:1.001-1.010), passes≥3(OR=1.941,95%CI:1.294-2.941)Alberta stroke program early CT (ASPECT) score (OR=0.919,95%CI:0.847-0.996), occlusion site (M1 segment of middle cerebral artery, OR=0.744,95%CI:0.565-0.980) and collateral circulation [(2 points, OR=0.757, 95%CI:0.581-0.985); (3-4 points, adjusted OR=0.640, 95%CI: 0.472-0.866)] were independent factors of FR. Conclusion: The incidence of FR in patients with large artery occlusion in anterior circulation who achieve satisfied reperfusion after endovascular treatment is high. Higher NIHSS score, longer puncture to recanalization time, older age, higher serum glucose and systolic blood pressure are risk factors, while lower ASPECTS, occlusion in cerebral middle M1 segment, better collateral circulation are protective factors.

Frequency of Hyponatremia and Its Impact on Prognosis in Ischemic Stroke.

Background Hyponatremia, often encountered in hospitalized patients, is associated with adverse outcomes in ischemic stroke patients. In this study, we investigated the frequency of hyponatremia and its impact on prognosis and clinical outcomes in ischemic stroke patients from a tertiary care hospital. Methodology A total of 289 patients admitted to the hospital with ischemic stroke from September 2022 to February 2023 were considered in this cross-sectional study. Serum sodium level was measured on admission, and hyponatremia was defined as sodium less than 135 mmol/L. The primary outcome of the study was assessed by the National Institutes of Health Stroke Scale (NIHSS) score on admission and discharge and inpatient mortality. Data were analyzed using SPSS version 20 (IBM Corp., Armonk, NY, USA), and multivariate logistic regressions were conducted using variables identified as having a relationship with hyponatremia. Results Our study shows that among 289 patients with ischemic stroke, the mean age was 61 ± 8.53 years. Hyponatremia was observed in 101 (35%) patients, and all baseline characteristics and risk factors for stroke were similar between patients with and without hyponatremia. The patients with hyponatremia had higher NIHSS scores on admission (p = 0.041) and at discharge (p = 0.039). In the resultant multivariate analysis, hyponatremia was an independent predictor of mortality rates during the hospital stay. The cumulative incidence rates of in-hospital mortality for hyponatremia and normal sodium level were 16.8% and 10.1%, respectively. Conclusions Hyponatremia is prevalent in ischemic stroke and is independently associated with in-hospital mortality and worse NIHSS scores at admission and discharge.

The relationship between neurological function trajectory, assessed by repeated NIHSS measurement, and long-term cardiovascular events, recurrent stroke, and mortality after ischemic stroke.

Clinically significant changes in neurological deficits frequently occur after stroke onset, reflecting further neurological injury or neurological improvement. However, the National Institutes of Health Stroke Scale (NIHSS) score is only evaluated once in most studies, usually at stroke onset. Utilizing repeated measures of NIHSS scores to identify different trajectories of neurological function may be more informative and provide more useful predictive information. We determined the association of neurological function trajectories with long-term clinical outcomes after ischemic stroke. A total of 4025 participants with ischemic stroke from the China Antihypertensive Trial in Acute Ischemic Stroke were included. Patients were recruited from 26 hospitals across China between August 2009 and May 2013. A group-based trajectory model was used to identify distinct neurological function trajectories, as measured by NIHSS at admission, 14 days or hospital discharge, and 3 months. Study outcomes were cardiovascular events, recurrent stroke, and all-cause mortality during 3-24 months after ischemic stroke onset. Cox proportional hazards models were used to examine the associations of neurological function trajectories with outcomes. We identified three distinct subgroups of NIHSS trajectories: persistent severe (persistent high NIHSS scores during the 3-month follow-up), moderate (NIHSS scores started at around 5 and gradually reduced), and mild (NIHSS scores always below 2). The three trajectory groups had different clinical profiles and different risk of stroke outcomes at 24-month follow-up. Compared to the mild trajectory group, patients in the persistent severe trajectory group had a higher risk of cardiovascular events (multivariable-adjusted hazard ratios (95% confidence intervals) = 1.77 (1.10-2.86)), recurrent stroke (1.82 (1.10-3.00)), and all-cause mortality (5.64 (3.37-9.43)). Those with moderate trajectory had an intermediate risk: 1.45 (1.03-2.04) for cardiovascular events and 1.52 (1.06-2.19) for recurrent stroke. Longitudinal neurological function trajectories derived from repeated NIHSS measurements during the first 3 months after stroke provide additional predictive information and are associated with long-term clinical outcomes. The trajectories characterized by persistent severe and moderate neurological impairment were associated with increased risk of subsequent cardiovascular events.

Predictors for clinical and functional outcomes in stroke patients with first-pass complete recanalization after thrombectomy.

The aim was to identify baseline clinical and radiological/procedural predictors and 24-h radiological predictors for clinical and functional outcomes in stroke patients obtaining complete recanalization in one pass of mechanical thrombectomy (MT) in an optimal baseline and procedural setting. A retrospective analysis was conducted of prospectively collected data from 924 stroke patients with anterior large vessel occlusion, Alberta Stroke Program Early Computed Tomography (ASPECT) score ≥6 and pre-stroke modified Rankin Scale score 0, who started MT ≤6 h from symptom onset and obtained first-pass complete recanalization. A first logistic regression model was performed to identify baseline clinical predictors and a second model to identify baseline radiological/procedural predictors. A third model including baseline clinical and radiological/procedural predictors was performed, and a fourth model including independent baseline predictors from the third model plus 24-h radiological variables (hemorrhagic transformation [HT] and cerebral edema [CED]). In the fourth model, higher National Institutes of Health Stroke Scale (NIHSS) score (odds ratio [OR] 1.089) and higher ASPECT score (OR 1.292) were predictors of early neurological improvement (ENI) (NIHSS score ≤4 points from baseline or NIHSS score of 0 at 24 h), whereas older age (OR 0.973), longer procedure time (OR 0.990), HT (OR 0.272) and CED (OR 0.569) were inversely associated with ENI. Older age (OR 0.970), diabetes mellitus (OR 0.456), higher NIHSS score (OR 0.886), general anesthesia (OR 0.454), longer onset-to-groin time (OR 0.996), HT (OR 0.340) and CED (OR 0.361) were inversely associated with 3-month excellent functional outcome (mRS score 0-1), whereas higher ASPECT score (OR 1.294) was a predictor of excellent outcome. Higher NIHSS score was a predictor of ENI but inversely associated with 3-month excellent outcome. Older age, HT and CED were inversely associated with both good outcomes.

Incidence, temporal profile and neuroanatomic correlates of poststroke epilepsy.

The relationship between ischemic stroke site and occurrence of poststroke epilepsy (PSE) is incompletely understood. This study intended to evaluate incidence and temporal profiles of seizures and to correlate ischemic lesion sites with PSE using voxel-based lesion symptom mapping (VLSM). Patients with imaging-confirmed first-ever ischemic stroke without prior history of epilepsy were prospectively included. Demographic data, cardiovascular risk factors, and National Institute of Health Stroke Scale (NIHSS) scores were assessed. Data on seizures and modified Rankin scale scores were determined within a 90-day period after stroke onset. Ischemic lesion sites were correlated voxel wise with occurrence of PSE using nonparametric permutation test. Age- and sex-matched patients with first-ever ischemic strokes without PSE after 90days served as controls for the VLSM analysis. The stroke database contained 809 patients (mean age: 68.4±14.2years) with first-ever imaging-confirmed ischemic strokes without history of epilep. Incidence of PSE after 90-day follow-up was 2.8%. Five additional patients were admitted to the emergency department with a seizure after 90-day follow-up. Fifty percent of the seizures occurred in the acute phase after stroke. PSE patients had higher NIHSS scores and infarct volumes compared to controls without PSE (p<.05). PSE patients had infarcts predominantly involving the cerebral cortex. The hemisphere-specific VLSM analysis shows associations between PSE and damaged voxels in the left-hemispheric temporo-occipital transition zone. The data indicate that PSE occurs in a small proportion of patients with rather large ischemic strokes predominantly involving the cerebral cortex. Especially patients with ischemic lesions in the temporo-occipital cortex are vulnerable to develop PSE.

Very early neurological deterioration after thrombolysis (P11-5.021)

<h3>Objective:</h3> To clarify the associated factors and outcomes of very early neurological deterioration (VEND) after thrombolysis. <h3>Background:</h3> Early neurological deterioration (END) within 24 hours after thrombolysis for acute ischemic stroke was associated with high mortality and disability. However, no prior studies focused on END within 1 hour after thrombolysis. <h3>Design/Methods:</h3> We retrospectively analyzed patients receiving intravenous thrombolysis for acute ischemic stroke at the National Taiwan University Hospital from January 2018 to December 2021. Relevant clinical and radiographical findings were reviewed. VEND was defined as a ≥ 4-point increase in the National Institutes of Health Stroke Scale (NIHSS) score within 1 hour after thrombolysis compared with initial score. A Modified Rankin Scale (mRS) score 0–2 at 3 months was defined as good functional outcome. <h3>Results:</h3> In the total of 347 patients (mean age 69.6 ± 13.7 years, 57% male) who received thrombolysis for acute ischemic stroke, 29 (8.4%) patients had VEND. Compared with non-VEND group, VEND group had higher NIHSS scores at 1 hour (19.2 ± 7.3 vs. 9.0 ± 7.1, <i>p</i> &lt; 0.001) and 24 hours (14.1 ± 9.8 vs. 7.3 ± 7.5, <i>p</i> = 0.001), more likely to receive endovascular thrombectomy (EVT) (59% vs. 25%, <i>p</i> &lt; 0.001), and less likely to achieve good functional outcome (24% vs. 58%, <i>p</i> &lt; 0.001). VEND was inversely associated with good functional outcome after adjustment of other significant variables (adjusted odds ratio = 0.24, <i>p</i> = 0.006). In patients with initial NIHSS score ≤ 6 who were initially not regarded as candidates for EVT, VEND was significantly associated with intracranial atherosclerotic disease (ICAD), undergoing EVT after deterioration, and less likely to have good functional outcome. <h3>Conclusions:</h3> VEND was a negative predictor for good functional outcome after thrombolysis, which was especially important for patients with initial low NIHSS score and associated with ICAD. <b>Disclosure:</b> Dr. Shen has nothing to disclose. Dr. Yeh has nothing to disclose. Sung-Chun Tang has nothing to disclose. Dr. Jeng has nothing to disclose.