Independent Predictors Of Good Outcome Research Articles

Clinical outcome of generalized myasthenia gravis in Hong Kong Chinese

BackgroundMyasthenia gravis (MG) is an organ-specific autoimmune disease characterized by autoantibody-mediated impairment of skeletal muscle neuromuscular transmission. MG causes significant morbidity and even mortality. We studied the long-term clinical outcome of generalized MG (gMG) patients. MethodsRecords of Chinese gMG patients managed in Queen Mary Hospital from 1997 to 2012 were reviewed. Clinical, serological and radiological characteristics were studied for independent predictors of good long-term clinical outcome. ResultsA total of 123 Chinese gMG patients were studied. Their mean onset age was 44.8years (range 7–83years), 87 (70.7%) were female, and median follow-up duration was 114months (interquartile range 67–188months). Thymoma were detected in 45 patients (36.6%). Acetylcholine receptor autoantibodies were detected in 99 patients (87.6%). Ninety-three patients (75.6%) received immunosuppressant therapy (corticosteroid 75.6%, azathioprine 58.5%, mycophenolate mofetil 5.7%, cyclosporin 5.7%) and 77 (62.6%) received thymectomy. Thirty-five (28.5%) patients experienced MG crisis and two died. Ninety-six (78.0%) patients had good outcome defined by Myasthenia Gravis Foundation of America (MGFA) post-intervention status (PIS) of complete stable remission (CSR), pharmacological remission (PR) or minimal manifestation (MM) at latest follow-up, whereas 24 patients (19.5%) had intermediate outcome defined by MGFA PIS of Improved (I); 3 patients (2.4%) had poor prognosis defined by MGFA PIS of unchanged (U), worse (W), exacerbation (E) or died of MG (D). Azathioprine therapy was the only independent predictor of good outcome (OR 3.57, 95% CI 1.05–12.10, p=0.042). Conclusion78.0% of gMG patients had good long-term clinical outcome. Azathioprine therapy independently predicted good clinical outcome.

Predictors of Outcome Following Cerebral Aqueductoplasty: An Individual Participant Data Meta-analysis.

The evidence supporting the efficacy and safety of cerebral aqueductoplasty (CA) is limited to small surgical series. To perform an individual participant data meta-analysis to determine the efficacy and safety of CA and to determine the effect of patient's age, etiology, surgical approach, and use of stent on success. Electronic databases (MEDLINE, EMBASE, and CINAHL) were searched with no language or date restrictions to identify cohort studies of consecutive participants undergoing CA (without concomitant endoscopic third ventriculostomy or cerebrospinal fluid [CSF] shunt) that reported outcome. Outcome was defined as the time elapsed from the index operation until a second procedure was performed for CSF diversion. Of 146 citations, 14 articles reporting on 137 participants were eligible. One hundred three participants (75%) did not require a second CSF diversion procedure. The mean duration until repeat CSF diversion procedure was 121.6 months (95% confidence interval [CI], 102.2-141.0). In multivariate analysis, older age at surgery (hazard ratio [HR], 0.43; 95% CI, 0.21-0.88; P = .020), congenital etiology (HR, 0.18; 95% CI, 0.04-0.85; P = .030), and use of stent (HR, 0.30; 95% CI, 0.13-0.70; P = .006) were independent predictors of good outcome. Morbidity, mainly ophthalmoparesis and hemorrhage, was experienced in 22% of participants. Small retrospective cohort studies are inherently prone to biases, some of which are overcome through the use of individual participant data. The best available evidence suggests that CA is an effective procedure with a moderate morbidity profile. Older age at surgery, congenital etiology, and use of stent predict a good outcome with respect to delaying the requirement for a second CSF diversion procedure.

Impact of Precision Medicine in Diverse Cancers: A Meta-Analysis of Phase II Clinical Trials.

The impact of a personalized cancer treatment strategy (ie, matching patients with drugs based on specific biomarkers) is still a matter of debate. We reviewed phase II single-agent studies (570 studies; 32,149 patients) published between January 1, 2010, and December 31, 2012 (PubMed search). Response rate (RR), progression-free survival (PFS), and overall survival (OS) were compared for arms that used a personalized strategy versus those that did not. Multivariable analysis (both weighted multiple linear regression and random effects meta-regression) demonstrated that the personalized approach, compared with a nonpersonalized approach, consistently and independently correlated with higher median RR (31% v 10.5%, respectively; P < .001) and prolonged median PFS (5.9 v 2.7 months, respectively; P < .001) and OS (13.7 v 8.9 months, respectively; P < .001). Nonpersonalized targeted arms had poorer outcomes compared with either personalized targeted therapy or cytotoxics, with median RR of 4%, 30%, and 11.9%, respectively; median PFS of 2.6, 6.9, and 3.3 months, respectively (all P < .001); and median OS of 8.7, 15.9, and 9.4 months, respectively (all P < .05). Personalized arms using a genomic biomarker had higher median RR and prolonged median PFS and OS (all P ≤ .05) compared with personalized arms using a protein biomarker. A personalized strategy was associated with a lower treatment-related death rate than a nonpersonalized strategy (median, 1.5% v 2.3%, respectively; P < .001). Comprehensive analysis of phase II, single-agent arms revealed that, across malignancies, a personalized strategy was an independent predictor of better outcomes and fewer toxic deaths. In addition, nonpersonalized targeted therapies were associated with significantly poorer outcomes than cytotoxic agents, which in turn were worse than personalized targeted therapy.

Differences Between Vascular Structural Abnormality and Hypertensive Intracerebral Hemorrhage

How the clinical characteristics and prognosis of various types of vascular structural abnormality-related intracerebral hemorrhage (ICH) differ from those of hypertensive ICH is poorly understood. This lack of understanding poses a problem for differential diagnosis and prognosis. Patients diagnosed with ICH between January 2012 and February 2014 at 50 tertiary and secondary hospitals in China were enrolled into this prospective cohort study. Patients were classified as having vascular structural abnormality-related ICH or hypertensive ICH, and data on the demographics and clinical characteristics of each group were compared. Multivariate logistic regression was used to explore associations while controlling for other risk factors for good outcome and mortality. Data for 281 patients showed that vascular structural abnormality-related ICH usually occurred in lobar areas and affected patients who were younger and had higher Glasgow Coma Scale (GCS) scores than those with hypertensive ICH. Mortality and good outcome at 3 months after ICH were significantly better among patients with vascular structural abnormality-related ICH (3.4% and 77.2%) than among patients with hypertensive ICH (15.2% and 49.9%, both P < .001). Multivariate logistic regression identified the following independent predictors of mortality: lower GCS score, old age, presence of intraventricular hemorrhage, larger hematoma volume, and surgery treatment. The regression also identified several independent predictors of good outcome at 3 months: ICH etiology due to vascular structural abnormality, higher GCS score, younger age, and smaller hematoma volume. Patients with vascular structural abnormality-related ICH are more likely to experience better clinical outcomes than those with hypertensive ICH. GCS score, age, hematoma volume, and ICH etiology are independent predictors of ICH outcome.

A Cohort Study of Decompressive Craniectomy for Malignant Middle Cerebral Artery Infarction: A Real-World Experience in Clinical Practice.

Decompressive hemicraniectomy with malignant middle cerebral artery (MCA) infarction is effective but remains underutilized. The aim of this study was to observe the utilization of this intervention in mainland China.We included patients with malignant MCA infarction who admitted in West China Hospital between December 2007 to March 2011. The outcomes were death and favorable outcome (mRS < 4) at 1 month and 1 year. The multivariate logistic regression model was used to identify the independent predictors for outcomes.Ten percent (219/2174) of patients with acute ischemic stroke had malignant MCA infarction and 31.1% (68/219) patients meet the criteria that ≤60 years of age and the timing to hospital <48 hours after stroke onset. Of them, 18 patients (26.5%) underwent to decompressive hemicraniectomy. In total, 31 patients (14.2%) underwent the decompressive surgery. The average age was 53 ± 12 years; median NIHSS score was 21. The case fatality rate of patients in surgery group was significantly lower than those of in nonsurgery group at 1 month and 1 year follow-ups (32.3% and 38.7% vs. 51.1% and 61.2%, respectively, P < 0.05). Patients in surgery group had a higher proportion of good outcome at 1 year follow-up (32.2% vs. 13.3%, P = 0.006). After adjusting for confounders including age, sex, NIHSS score, and GCS score on admission, decompressive hemicraniectomy was an independent predictor of good outcome for 1 year (OR = 3.44, 95% CI, 1.27–9.31).This study shows better outcomes in the surgical group, which are consistent with findings in previous prospective randomized trials. However, this beneficial intervention remains underutilized in clinical settings.

Abstract 128: Pittsburgh Outcomes After Stroke Thrombectomy Vertebrobasilar (POST VB) Score Predicts Outcomes After Endovascular Therapy for Basilar Artery Occlusions

Background: Basilar artery occlusion (BAO) is associated with high rates of morbidity and mortality. Endovascular therapy offers improved outcomes, but the road to recovery is often protracted necessitating aggressive supportive care. We sought to develop a prognostic score incorporating these factors to predict outcomes after endovascular therapy for BAO. Methods: The derivation cohort was obtained from a previously utilized prospectively maintained database of patients with BAO treated endovascularly at our institution prior to June 2012 (N=59). Logistic regression was performed to identify any independent predictors of good outcome (90-day mRS, 0-2). Factors were weighted based on β-coefficients to derive the Pittsburgh Outcomes After Stroke Thrombectomy Vertebrobasilar (POST VB) score. The POST VB score was then validated in a similar cohort of patients with BAO treated endovascularly at our institution after June 2012 (N=30). Results: In the derivation cohort, independent predictors (P&lt;0.1) of good outcome included final brainstem infarct volume (in cm3, β =-1.067, P&lt;0.01) (but not infarct in other locations within the posterior circulation) and age (years, β=-0.114 P=0.011). The POSTVB score was calculated as age+10хfinal infarct volume. The Hosmer Lemeshow test of the model demonstrated a good fit (p=0.92). A POST VB &lt;75 was associated with an 80% chance of good outcome compared with 0% with a score ≥125. POSTVB accurately predicted good outcomes in the derivation (AUC=0.89) and validation cohorts (AUC=0.88). Predictive accuracy was very similar across all groups. Conclusions: The POST VB score appears to accurately predict of outcome following endovascular therapy for acute stroke due to BAO and thus may aid in guiding post-interventional care. Our results await validation from larger prospectively acquired datasets.

Abstract W P10: Lower Intraprocedural Mean Arterial Pressure Predicts Good Outcome and Lower Mortality in Patients Undergoing Endovascular Therapy for Acute Ischemic Stroke

Introduction: Several factors influence the outcome of patients who undergo intra-arterial therapy (IAT) for acute ischemic stroke (AIS). The influence of intra-procedural hemodynamics on functional outcome and mortality has not been studied. There is no data to guide intraprocedural blood pressure (BP) management and it is unknown whether systolic, diastolic, or mean arterial pressure (MAP) is important for determining outcomes. Methods: Retrospective study of patents that underwent IAT for anterior circulation AIS between 1/08- 12/12 was conducted. Detailed intra-procedural hemodynamics, demographics, NIH stroke scale score, IV tPA use, thrombus location, recanalization grade, intracranial hemorrhage were collected. Outcomes measured were in-hospital mortality and 30-day good outcome defined as modified Rankin Scale score of 0-2. Successful recanalization was defined as TICI 2b-3 and ICH was classified into parenchymal hematoma (PH1+2) and hemorrhagic infarction (HI 1+ 2). Results: The cohort in the analysis consisted of 190 patients (56% females, mean age 67 + 15 years). Thirty-six (19%) patients died in-hospital, and 25 (17%) achieved an mRS 0-2. Intra-procedural maximum systolic BP (SBP) and maximum MAP were significantly lower in the good outcome group (Table 1). In multivariable logistic regression analysis, maximum MAP was an independent predictor of good outcomes along with baseline CT ASPECTS score, and successful recanalization. Maximum MAP was also an independent predictor of mortality along with age and presence of PH 1+2 ICH. Conclusions: Maximum intraprocedural MAP was an independent predictor of good outcome and mortality in in patients undergoing IAT for AIS. This results may have implications for intraprocedural BP management.

Abstract W P22: Examining the Effects of Intra-Arterial Therapy in Acute Posterior Circulation Occlusions

Background: Recent trials have failed to show benefit of intra-arterial therapy (IAT) in acute ischemic stroke (AIS) patients. Patients with posterior circulation occlusions, however, were vastly underrepresented (only 4 patients in IMS3, MR-RESCUE and SYNTHESIS combined). IAT is often pursued, due to the inherent poor outcome associated with brainstem infarction. We sought to evaluate potential benefit with IAT in this population. Methods: A US multicenter retrospective cohort of 106 patients with AIS and LAO in the vertebrobasilar distribution presenting 01/05-3/14 within 12 hours from stroke onset was examined. Patients were divided into two groups (IAT vs No IAT). Logistic regression with good and poor (discharge mRS 0-2 and 4-6) outcome was performed. Univariate and multivariate analyses evaluated independent predictors of good outcome after IAT. Results: Patients in the IAT group (n=57) had more severe strokes (NIHSS 24 vs 12) than the medical management group (n=49); otherwise the two groups were comparable (Table 1). IAT was not associated with improved odds of good outcome (OR 0.76, 95%CI 0.27-2.14, p=0.60), even after adjusting for admission NIHSS, recanalization, and time to IAT start (OR 1.35, 95%CI 0.39-4.68, p=0.63). The subgroup with basilar occlusions also did not benefit from IAT. Stroke severity predicted treatment with IAT; each additional point in NIHSS was associated with 5% increased chances of IAT (P 0.07). There were more deaths in the IAT group (Figure 1); 73% of these, however, were associated with care withdrawal decisions. Conclusion: While vascular neurologists intervene more often on severe posterior circulation strokes, our results suggest poor outcome was not averted, even after adjusting for stroke severity. While our results are affected by the inherited limitations of a retrospective cohort and selection bias of a non- randomized design, it addressed an underrepresented stroke population. RCTs are needed to validate these results.

Abstract W P18: Evaluating Clot Burden and the Vascular Basis of Pial Collaterals with a Bimodal Angiographic Score

Treatment decision for endovascular recanalization in acute ischemic stroke is based on validated outcome predictors such as age, initial infarct size, collaterals and clot burden. The CTA-based Clot Burden Score (CBS) only considers occlusions of the A1-segment of the anterior cerebral artery (ACA), but patency of the ipsilateral A2-segment is mandatory for collateral formation in a typical middle cerebral artery (MCA) occlusion. Secondly, CTA often cannot differentiate between an extra- or intra-cranial internal carotid artery (ICA) occlusion due to non-contrasting of the whole ICA in both. Thirdly, a 4-vessel angiogram, necessary to grasp the vascular basis of all pial collaterals, is often not done during acute recanalization therapy for reasons of time. To bypass these inadequacies, we propose a combined CTA/DSA score (ALITA) to assess pre-therapeutic thrombus load. We hypothesized a good outcome prediction of this score. We evaluated the ALITA score in a retrospective study including consecutive patients of the years 2010-12, who received endovascular therapy for acute stroke in the ICA-territory. Final outcome was measured with the modified Rankin Scale score (mRS) at 90 days. Reperfusion (mTICI), collaterals (CT-CS), clot burden (CBS), and the ALITA score were independently assessed. ALITA evaluates patency of the ACA and MCA in CTA and of the ICA in DSA. Data-driven ordinal regression analysis modeled outcome prediction of all scores. Of 99 patients 60% had a good reperfusion (mTICI 2b/3) and 29% had a good outcome (mRS 0-2), mortality was 23%. Age and reperfusion were independent predictors of good outcome (p&lt;.001). CT-CS (p&lt;.01), CBS (p&lt;.01) and ALITA (p&lt;.05) were significant predictors, but showed interaction regarding outcome. In the considered model CBS was a stronger predictor than ALITA. Although ALITA assesses all vessels of the anterior circulation contributing to collaterals the score was statistically different from CT-CS. This is consistent with results that describe pial collaterals as genetically determined. In conclusion, the combined CTA/DSA clot burden score better depicts the vascular basis of pial collaterals and predicts outcome in acute stroke patients.

Abstract T MP1: The Pittsburgh Collateral Ratio: A Novel Method to Assess Collateral Circulation Status in Acute Mca Occlusions

Introduction: Collateral status is a robust predictor of recanalization and clinical outcome in acute ischemic stroke and numerous collateral grades exist to evaluate it (many of which are qualitative or semi-quantitative) being CT angiography (CTA)-based collateral grading the most frequently used. We attempt to quantitatively assess collateral grade based on a comparison between contrast filling proximal and distal to a medial cerebral artery (MCA) occlusion. Material and methods: We retrospectively reviewed the data of patients with M1 MCA occlusions referred to our center between January 15, 2006 and January 15, 2014. The Pittsburgh Collateral Ratio (PCR) was determined by calculating the mean Hounsfield Units (HU) in regions of interest (ROI) in the MCA, both pre and post-thrombus at the time of maximal opacification of the vessel (PCR = HU post-thrombus/ HU pre-thrombus). Ipsilateral (iPCR) and contralateral (cPCR) ratios were calculated. Two independent reviewers (CA and WD) graded pre-treatment CTA collateral status as good (the entire MCA reconstitutes with contrast) and poor (partial or no reconstitution of the distal MCA). PCR was compared to CTA collateral status and associated with good outcome (mRS 0-2 at 3 months) by logistic regression analysis. Results: Fifty one patients were included (mean age 65±3 yrs, median initial NIHSS 17 [IQR 14-21]). Strong correlation between PCR and CTA collateral grade was observed (iPCR: Pearson’s R=-0.796, p&lt;0.001, cPCR: Pearson’s R=-0.64, p&lt;0.001). iPCR was highly predictive of good collateral status (AUC 0.89, p&lt;0.001) and iPCR ≥ 0.6 had a 100% sensitivity and 64% specificity for good collateral status. In multivariate analysis after controlling for age, NIHSS and ivTPA, iPCR was an independent predictor of good outcome (p=0.02). Conclusions: The PCR is a simple and accurate method to evaluate collateral circulation status in MCA occlusion patients and further validation of this score in larger cohorts is warranted.

Abstract W P38: Collateral Circulation Status Correlates With Aspects Decay During Inter-facility Transfer After Anterior Acute Ischemic Stroke Patients

Introduction: The collateral circulation plays an important role in the dynamic process of cerebral ischemia. The aim of this study is to determine if collateral status correlates with the early ischemic changes measured by the rate of Alberta Stroke Program Early CT Scores (ASPECTS) decay in emergently transferred acute ischemic stroke patients with anterior large vessel conclusions. Material and methods: We retrospectively analyzed the data of patients referred to our comprehensive stroke center from 7 outside hospitals between January 15, 2006 and January 15, 2014. Collateral status was assessed using an initial CT angiography obtained before treatment, and graded as "Good" (the entire medial cerebral artery reconstitutes with contrast) or "Poor" (partial or no reconstitution of the distal medial cerebral artery), by two independent reviewers (CA and WD). ASPECTS decay was calculated in the following ways: 1. Absolute ASPECTS decay: (A1-A2)/T, 2. Relative ASPECTS decay: [(A1-A2)/A1]/T 3. Net ASPECTS difference: (A1-A2) and 4. Relative ASPECTS difference: (A1-A2)/A1; where A1= ASPECTS 1st CT, A2= ASPECTS 2nd CT, T= hours between 2 CT scans. Results: After reviewing 701 medical records from transferred patients, 51 patients with mean age 65±3 yrs and median initial NIHSS of 17 (IQR 14-21) were selected. In the multivariate analysis, good collateral status was independently associated with lower rates of ASPECTS decay measured by the relative rate of ASPECTS decay (0.04+/-0.01 score/h; p&lt;0.05), the net ASPECTS difference (1.10+/-0.17 score/h, p&lt;0.05) and the relative ASPECTS difference (0.12+/-0.02 score, p&lt;0.05). The relative ASPECTS difference was most strongly associated with collateral status, and an independent predictor of good outcome (p=0.047) and final infarct volume (p=0.001) after controlling for age and NIHSS in a multivariate analysis. Conclusions: Good collateral circulation status is associated with lower rates of ASPECTS decay in transferred patients, which also tend to have smaller final infarct volumes and better clinical outcome after 3 months. The analysis of the collateral circulation gives us a better understanding of the pathophysiology in acute ischemic stroke.

Abstract T P10: Therapeutic Time Window for Endovascular Therapy of Acute Ischemic Stroke Depends on THRIVE Score: A Retrospective Single-center Study

Background and purpose: The outcome after endovascular therapy in acute ischemic stroke is associated with onset-to-reperfusion time (ORT). The Totaled Health Risks in Vascular Events (THRIVE) score is also an important pre-thrapeutic predictor of outcome. We hypothesized that the therapeutic time window is narrower in patients with the higher THRIVE score. Methods: We retrospectively studied consecutive 109 ischemic stroke patients with successful reperfusion after endovascular therapy between October 2005 and March 2014 at a single institute (Kobe City Medical Center General Hospital). Inclusion criteria was as follows: National Institutes of Health Stroke Scale (NIHSS) score ≥8, stroke symptom duration ≤8 h, premorbid modified Rankin Scale (mRS) score ≤2, and thrombolysis myocardial infarction score 2-3. We analyzed the relationships of ORT, THRIVE score, and THRIVE+ORT score with good outcome (mRS ≤2 at 3 months). The THRIVE+ORT score was defined as the sum of the THRIVE score and ORT (h). Results: Median ORT was 5.5 h (IQR; 4.4-7.1 h), median THRIVE score was 5 (IQR; 4-6), and median THRIVE+ORT score was 10.8 (IQR; 9.2-12.5). Good outcome rates for patients with ORT ≤4 h, &gt;4 and ≤6 h, &gt;6 and ≤8 h, and &gt;8h were 50.0%, 45.8%, 37.0%, and 21.4%, respectively (p=0.3), those with THRIVE score ≤3, &gt;3 and ≤5, &gt;5 and ≤7, and &gt;7 were 57.1%, 51.4%, 28.3%, and 20.0%, respectively (p9 and ≤11, &gt;11 and ≤13, and &gt;13 were 64.0%, 44.1%, 34.4%, and 16.7%, respectively (p&lt;0.05). Multivariate logistic regression analysis revealed that THRIVE+ORT score was an independent predictor of good outcome after adjusted for THRIVE score (odds ratio [OR], 1.367; 95% confidence interval [CI], 1.082-1.728) or after adjusted for ORT (OR, 1.517: 95% CI, 1.160-1.983). Conclusion: Our study showed that THRIVE+ORT score was associated with outcome that was independent from THRIVE score or ORT. This is the first report to suggest that patients with the higher THRIVE score require the shorter ORT for good outcome.

Abstract T P8: Outcomes of Endovascular Treatment Using Solitaire Devices in Acute Ischemic Stroke With Favorable Penumbral Imaging Pattern

Introduction: Through emerging of novel devices and elaborated patient selection, endovascular treatment against acute ischemic stroke is gaining popularity. We investigated factors influencing outcomes after endovascular treatment in highly applicable patients. Methods: We enrolled consecutive 72 patients with favorable penumbral pattern, who underwent endovascular treatment with Solitaire from 2010 through 2013 in three hospitals of Korea. Inclusion criteria were these: the NIHSS and age were between 6 and 29, and 18 and 85, respectively, and endovascular procedures could begin within 8 h from onset. A favorable penumbral pattern was defined as a mismatch ratio ≥ 1.43 between hypoperfusion by Tmax &gt; 6 s and infarction core by DWI which should be &lt; 90 mL. The good outcome was defined as mRS ≤ 2 at 3 Mo. The recanalization was evaluated by TICI grading and successful recanalization was defined as grade 2b or 3. Results: Among 72 patients, 44 (61%) underwent combined treatment with intravenous (IV) and endovascular treatments, and 28 (39%) were treated by endovascular thrombectomy only. The overall recanalization rate was 82%, and the proportion of good outcome was 55.6%. Younger age and recanalization were associated with good outcome, but onset to treatment time and the combined IV thrombolysis was not related to good outcome. After propensity score matching to balance possible confounders between combined and endovascular-only treatment groups, combined treatment did not have beneficial effects than endovascular-only (OR, 0.8; 95% CI, 0.1-2.6). The successful recanalization after endovascular treatment was an independent predictor for good outcome (adjusted OR, 6.8; 95% CI, 1.3-34.5), after controlling age, sex, stroke severity, onset to treatment time, the combined IV therapy, and risk factors. Conclusion: In patients with discrete diffusion-perfusion mismatch, the recanalization after thrombectomy is the most important predictor for good outcomes.

Assessment of intracranial collaterals on CT angiography in anterior circulation acute ischemic stroke.

Intracranial collaterals influence the prognosis of patients treated with intravenous tissue plasminogen activator in acute anterior circulation ischemic stroke. We compared the methods of scoring collaterals on pre-tPA brain CT angiography for predicting functional outcomes in acute anterior circulation ischemic stroke. Two hundred consecutive patients with acute anterior circulation ischemic stroke treated with IV-tPA during 2010-2012 were included. Two independent neuroradiologists evaluated intracranial collaterals by using the Miteff system, Maas system, the modified Tan scale, and the Alberta Stroke Program Early CT Score 20-point methodology. Good and extremely poor outcomes at 3 months were defined by modified Rankin Scale scores of 0-1 and 5-6 points, respectively. Factors associated with good outcome on univariable analysis were younger age, female sex, hypertension, diabetes mellitus, atrial fibrillation, small infarct core (ASPECTS ≥8), vessel recanalization, lower pre-tPA NIHSS scores, and good collaterals according to Tan methodology, ASPECTS methodology, and Miteff methodology. On multivariable logistic regression, only lower NIHSS scores (OR, 1.186 per point; 95% CI, 1.079-1.302; P = .001), recanalization (OR, 5.599; 95% CI, 1.560-20.010; P = .008), and good collaterals by the Miteff method (OR, 3.341; 95% CI, 1.203-5.099; P = .014) were independent predictors of good outcome. Poor collaterals by the Miteff system (OR, 2.592; 95% CI, 1.113-6.038; P = .027), Maas system (OR, 2.580; 95% CI, 1.075-6.187; P = .034), and ASPECTS method ≤5 points (OR, 2.685; 95% CI, 1.156-6.237; P = .022) were independent predictors of extremely poor outcomes. Only the Miteff scoring system for intracranial collaterals is reliable for predicting favorable outcome in thrombolyzed acute anterior circulation ischemic stroke. However, poor outcomes can be predicted by most of the existing methods of scoring intracranial collaterals.

Pittsburgh outcomes after stroke thrombectomy score predicts outcomes after endovascular therapy for anterior circulation large vessel occlusions.

Prognostication tools that predict good outcome in patients with anterior circulation large vessel occlusions after endovascular therapy are lacking. We aim to develop a tool that incorporates clinical and imaging data to predict outcomes after endovascular therapy. In a derivation cohort of anterior circulation large vessel occlusion stroke patients treated with endovascular therapy within 8 hours from time last seen well (n=247), we performed logistic regression to identify independent predictors of good outcome (90-day modified Rankin Scale, 0-2). Factors were weighted based on β-coefficients to derive the Pittsburgh Outcomes After Stroke Thrombectomy (POST) score. POST was validated in an institutional endovascular database (University of Pittsburgh Medical Center, n=393) and the Diffusion-Weighted Imaging Evaluation for Understanding Stroke Evolution Study-2 (DEFUSE-2) data set (n=105), as well as in patients treated beyond 8 hours (n=194) and in octogenarians (n=111). In the derivation cohort, independent predictors (P<0.1) of good outcome included 24- to 72-hour final infarct volume (in cm(3), P<0.001), age (years, P<0.001), and parenchymal hematoma types 1 and 2 (H, P=0.01). POST was calculated as age+0.5×final infarct volume+15×H. Patients with POST score <60 had a 91% chance of good outcome compared with 4% with POST score ≥120. POST accurately predicted good outcomes in the derivation (area under the curve [AUC]=0.85) and validation cohorts (University of Pittsburgh Medical Center, AUC=0.81; DEFUSE-2, AUC=0.86), as well as in patients treated beyond 8 hours (AUC, 0.85) and octogenarians (AUC=0.76). POST had better predictive accuracy for good and poor outcome than the ischemic stroke predictive risk score (iSCORE). POST score is a validated predictor of outcome in patients with anterior circulation large vessel occlusions after endovascular therapy.

Arterial Blood Gas Tensions After Resuscitation From Out-of-Hospital Cardiac Arrest

Optimal oxygen and carbon dioxide levels during postcardiac arrest care are currently undefined and observational studies have suggested harm from hyperoxia exposure. We aimed to assess whether mean and time-weighted oxygen and carbon dioxide levels during the first 24 hours of postcardiac arrest care correlate with 12-month neurologic outcome. Prospective observational cohort study. Twenty-one ICUs in Finland. Out-of-hospital cardiac arrest patients treated in ICUs in Finland between March 2010 and February 2011. None. Arterial blood PaO2 and PaCO2 during the first 24 hours from admission were divided into predefined categories from the lowest to the highest. Proportions of time spent in different categories and the mean PaO2 and PaCO2 values during the first 24 hours were included in separate multivariable regression models along with resuscitation factors. The cerebral performance category at 12 months was used as primary endpoint. A total of 409 patients with arterial blood gases analyzed at least once and with a complete set of resuscitation data were included. The average amount of PaO2 and PaCO2 measurements was eight per patient. The mean 24 hours PaCO2 level was an independent predictor of good outcome (odds ratio, 1.054; 95% CI, 1.006-1.104; p = 0.027) but the mean PaO2 value was not (odds ratio, 1.006; 95% CI, 0.998-1.014; p = 0.149). With multivariate regression analysis, time spent in the PaCO2 band higher than 45 mm Hg was associated with good outcome (odds ratio, 1.015; 95% CI, 1.002-1.029; p = 0.024, for each percentage point increase in time) but time spent in different oxygen categories were not. In this multicenter study, hypercapnia was associated with good 12-month outcome in patients resuscitated from out-of-hospital cardiac arrest. We were unable to verify any harm from hyperoxia exposure. Further trials should focus on whether moderate hypercapnia during postcardiac arrest care improves outcome.

Early dermatologic adverse events predict better outcome in HCC patients treated with sorafenib

There are no clinical data/markers to predict improved survival in patients with hepatocellular carcinoma treated with sorafenib. Majority of sorafenib adverse events appear within the first 60 days of treatment and studies correlating them with outcome are needed. We prospectively studied 147 hepatocellular carcinoma patients (97% cirrhotic, 82% Child-Pugh A, BCLC-B 77, BCLC-C 69) treated with sorafenib. Follow-up included monthly clinical and laboratory monitoring and tumor staging at week 4 and every 8 weeks. After a median follow up of 11.6 months (treatment duration 6.7 months), time to progression and overall survival were 5.1 and 12.7 months. All but one patient presented at least one adverse event (median time to appearance 56 days). Time dependent covariate analysis (HR [95% CI]) identified baseline performance status (2.86 [1.75 to 4.55], p<0.001), BCLC (1.69 [1.18 to 2.50], p = 0.005), and dermatologic adverse event requiring dose adjustment within the first 60 days (0.58 [0.36 to 0.92], p = 0.022) as independent predictors of better outcome. Other early adverse events did not have an impact in outcome. The predictive value of dermatologic adverse events for survival was confirmed by the landmark analysis (p = 0.0270). Development of dermatologic adverse events within 60 days of sorafenib initiation is associated with better survival. Therefore, this should not to be taken as a negative event and discourage treatment maintenance. Likewise, second line clinical trials should be designed and/or evaluated considering this information to avoid significant bias.

Outcomes of a Contemporary Cohort of 536 Consecutive Patients With Acute Ischemic Stroke Treated With Endovascular Therapy

We sought to assess outcomes after endovascular treatment/therapy of acute ischemic stroke, overall and by subgroups, and looked for predictors of outcome. We used data from a mandatory, population-based registry that includes external monitoring of completeness, which assesses reperfusion therapies for consecutive patients with acute ischemic stroke since 2011. We described outcomes overall and by subgroups (age ≤ or >80 years; onset-to-groin puncture ≤ or >6 hours; anterior or posterior strokes; previous IV recombinant tissue-type plasminogen activator or isolated endovascular treatment/therapy; revascularization or no revascularization), and determined independent predictors of good outcome (modified Rankin Scale score ≤2) and mortality at 3 months by multivariate modeling. We analyzed 536 patients, of whom 285 received previous IV recombinant tissue-type plasminogen activator. Overall, revascularization (modified Thrombolysis In Cerebral Infarction scores, 2b and 3) occurred in 73.9%, 5.6% developed symptomatic intracerebral hemorrhages, 43.3% achieved good functional outcome, and 22.2% were dead at 90 days. Adjusted comparisons by subgroups systematically favored revascularization (lower proportion of symptomatic intracerebral hemorrhages and death rates and higher proportion of good outcome). Multivariate analyses confirmed the independent protective effect of revascularization. Additionally, age >80 years, stroke severity, hypertension (deleterious), atrial fibrillation, and onset-to-groin puncture ≤6 hours (protective) also predicted good outcome, whereas lack of previous disability and anterior circulation strokes (protective) as well as and hypertension (deleterious) independently predicted mortality. This study reinforces the role of revascularization and time to treatment to achieve enhanced functional outcomes and identifies other clinical features that independently predict good/fatal outcome after endovascular treatment/therapy.

Endovascular treatment for M2 occlusions in the era of stentrievers: a descriptive multicenter experience

BackgroundPatients with M2 middle cerebral artery (MCA) occlusions are not always considered for endovascular treatment.ObjectiveTo study outcomes in patients with M2 occlusion treated with endovascular procedures in the era of...

Abstract 144: The Pittsburgh Outcomes After Stroke Thrombectomy (POST) Score Predicts Good Outcomes After Endovascular Therapy for Anterior Circulation Large Vessel Occlusions

Background: Independent predictors of good outcome following large vessel occlusions (LVO) include age, infarct volume, NIHSS at presentation and revascularization status. The aim of this study was to develop an easy-to-use tool to predict good outcome following endovascular treatment for LVO. Methods: In a derivation cohort of patients with anterior circulation LVO treated with endovascular therapy at Grady Memorial Hospital (GMH, n=247), we performed logistic regression to identify independent predictors of good outcome (mRS 0-2 at 90 days). Factors were weighted based on B-coefficients to generate a score (POST) that predicts good outcome. The derivation cohort was divided in risk group quartiles and correlation analysis between predicted and observed rates of good outcomes was performed. POST was also validated in two cohorts derived from the University of Pittsburgh Medical Center (UPMC, n=380) and the DEFUSE 2 database (n=105). Results: In the derivation cohort (mean age 66±1 yrs, median NIHSS 18), independent predictors (p&lt;0.2) of good outcome included final infarct volume (FIV; OR 0.97, 0.96-0.98), age (OR 0.96, 0.94-0.98), NIHSS at presentation (OR 0.93, 0.88-0.98) and PH1/PH2 hemorrhage (H; OR 0.3, 0.06-1.6, p=0.15). POST was defined as Age + 0.5 X FIV + 15 X H. Patients in the lowest POST quartile (&lt;60) had a 91% chance of good outcome as compared to 3% in the highest POST quartile (≥120). There was a strong correlation between predicted and observed rates of good outcomes in the 4 groups (R=0.99, p&lt;.001). POST performed well in predicting good outcomes in the derivation (AUC=0.85), as well as the UPMC (AUC=0.81) and DEFUSE 2 (AUC=0.86) validation cohorts. Discussion: The POST score is a validated tool to predict good clinical outcomes following endovascular therapy in patients with acute large vessel occlusions. This tool can guide families and physicians in clinical decision making following endovascular therapy.