Initial National Institutes Of Health Stroke Scale Score Research Articles

A Measure of Neural Function Provides Unique Insights into Behavioral Deficits in Acute Stroke.

Clinical and neuroimaging measures incompletely explain behavioral deficits in the acute stroke setting. We hypothesized that electroencephalography (EEG)-based measures of neural function would significantly improve prediction of acute stroke deficits. Patients with acute stroke (n=50) seen in the emergency department of a university hospital from 2017 to 2018 underwent standard evaluation followed by a 3-minute recording of EEG at rest using a wireless, 17-electrode, dry-lead system. Artifacts in EEG recordings were removed offline and then spectral power was calculated for each lead pair. A primary EEG metric was DTABR, which is calculated as a ratio of spectral power: [(Delta*Theta)/(Alpha*Beta)]. Bivariate analyses and least absolute shrinkage and selection operator (LASSO) regression identified clinical and neuroimaging measures that best predicted initial National Institutes of Health Stroke Scale (NIHSS) score. Multivariable linear regression was then performed before versus after adding EEG findings to these measures, using initial NIHSS score as the dependent measure. Age, diabetes status, and infarct volume were the best predictors of initial NIHSS score in bivariate analyses, confirmed using LASSO regression. Combined in a multivariate model, these 3 explained initial NIHSS score (adjusted r2=0.47). Adding any of several different EEG measures to this clinical model significantly improved prediction; the greatest amount of additional variance was explained by adding contralesional DTABR (adjusted r2=0.60, P<0.001). EEG measures of neural function significantly add to clinical and neuroimaging for explaining initial NIHSS score in the acute stroke emergency department setting. A dry-lead EEG system can be rapidly and easily implemented. EEG contains information that may be useful early after stroke.

National Institutes of Health Stroke Scale (NIHSS) scoring inconsistencies between neurologists and emergency room nurses.

Little is known about the consistency of initial NIHSS scores between neurologists and RNs in clinical practice. A cohort study of patients with a code stroke was conducted at an urban academic Primary Stroke Center in the Midwest between January 1, 2018, and December 31, 2019 to determine consistency in National Institutes of Health Stroke Scale Scores (NIHSS) between neurologists and registered nurses (RNs). Among the 438 patients included in this study 65.3% (n = 286) of neurologist-RN NIHSS scoring pairs had congruent scores. One-in-three, (34.7%, n = 152) of neurologist-RN NIHSS scoring pairs had a clinically meaningful scoring difference of two points or greater. Higher NIHSS (p ≤ 0.01) and aphasia (p ≤ 0.01) were each associated with incongruent scoring between neurologist and emergency room RN pairs. One-in-three initial NIHSS assessed by both a neurologist and RN had a clinically meaningful score difference between providers. More severe stroke, as indicated by a higher NIHSS was associated with scoring inconsistency between neurologist-RN pairs. Subjective scoring measures, especially those involving a patient having aphasia, was associated with greater score incongruency. Score differences may be attributed to differences in NIHSS training requirements between neurologists and RNs.

Lymphocyte-to-Monocyte Ratio Is Independently Associated with Progressive Infarction in Patients with Acute Ischemic Stroke.

From April 2017 to December 2020, we retrospectively recruited 477 patients with acute ischemic stroke (within 48 hours after onset). Progressive infarction was defined as an increase of ≥1 point in motor power or ≥2 points on the total National Institutes of Health Stroke Scale (NIHSS) within 7 days after admission and extension of the original infarction were further confirmed by diffusion-weighted imaging. Demographic characteristics, clinical information, and neuroimaging characteristics were evaluated after admission. All blood draws and initial imaging were completed within 24 hours of admission. PI occurred in 147 (30.8%) patients. Univariate analysis comparing the two groups revealed that hypertension, initial NIHSS score, discharge NIHSS score, modified Rankin scale score at 90 days, monocyte level, creatinine level, fasting glucose level, LMR, monocyte-to-high-density lipoprotein ratio (MHR), and lesion location were significantly different (P < 0.05). Multivariate logistic regression analysis showed that the odds ratio of PI increased as the quartile of LMR increased, with the lowest quartile as the reference value. Subgroup analyses showed that a high LMR was an independent predictor of PI only in large artery atherosclerosis (LAA) patients. The receiver operating characteristic (ROC) curve was drawn to estimate the predictive value of LMR for PI. For all cases, the area under the curve was 0.583 (95% CI 0.526-0.641), and the best predictive cutoff value was 3.506, with a sensitivity of 53.1% and a specificity of 63.9%. In patients with LAA, the area under the curve was 0.585 (95% CI 0.505-0.665), and the best predictive cutoff value was 3.944, with a sensitivity of 48.7% and a specificity of 72.8%. LMR was an independent predictor for progressive infarction in patients with acute ischemic stroke, especially in LAA cerebral infarction patients.

Occlusion type and posterior communicating artery patency may predict favorable outcome after endovascular thrombectomy in selective basilar top occlusion.

The top of the basilar artery is a five-branched junction, consisting of two superior cerebellar arteries (SCAs), two posterior cerebellar arteries (PCAs), and the basilar artery itself. This study aimed to investigate prognostic factors in patients with selective acute basilar top occlusion managed with mechanical thrombectomy, focusing on occlusion type and posterior communicating artery (PCoA) patency. Eligible patients who underwent endovascular treatment (EVT) for acute basilar top occlusion were reviewed. Patterns of basilar top occlusion were categorized as types I-III according to whether the SCA and PCA were visible on angiography. The PCoA was categorized as hypoplastic or non-visible (type I), normal patency but non-visible PCA through PCoA flow (type II), and fetal type (type III). Good outcomes were observed in 50% (21/42) and mortality in 11.9% (5/42) of the cases at 90 days. Patients with good outcomes showed lower baseline National Institutes of Health Stroke Scale (NIHSS) score (P = 0.001) and a higher proportion of type III basilar top occlusion (P = 0.004) and type III PCoA (P = 0.001). Multivariable logistic analysis showed that baseline NIHSS score [odds ratio (OR), 0.84; 95% confidence interval (CI), 0.73-0.97; P = 0.017) and type III PCoA (OR, 21.54, 95% CI, 1.33-347.97; P = 0.031) were independent predictors of good functional outcomes. A low initial NIHSS score and good PCoA patency were independent predictors of favorable clinical outcomes after EVT in patients with acute basilar top occlusion. Furthermore, the favorable outcome group showed a high proportion of type III basilar top occlusions.

Impact of Patency of the Carotid Terminus and Middle Cerebral Artery on Early Clinical Outcomes in Patients with Acute Internal Carotid Artery Occlusion and Mild Symptoms

Introduction: Both collateral flow via the internal carotid artery (ICA) terminus (ICT) and initial mild symptoms might be associated with favorable outcomes in patients with acute ICA occlusion (ICAO). This study aimed to address the association between early clinical outcomes and patency of the ICT and middle cerebral artery (MCA) in patients with acute ICAO with mild symptoms. Methods: Of 1,214 consecutive patients with acute ischemic stroke or transient ischemic attack due to large vessel occlusion, patients with ipsilateral ICAO and initial National Institutes of Health Stroke Scale (NIHSS) score ≤5 were retrospectively enrolled. We examined the associations between clinical factors including patency of the ICT and MCA and recurrence of stroke or early neurological deterioration (REND). Significant early neurological deterioration was defined as increment in NIHSS score ≥1 during hospital stay. Results: Thirteen of the 35 patients who were finally enrolled had REND (37%), and median modified Rankin scale (mRS) score at discharge was 1 (interquartile range, 0–4). Initial NIHSS score (4 vs. 1, p < 0.001) and rates of diabetes mellitus (61.5% vs. 13.6%, p = 0.007), intravenous thrombolysis (IVT) (30.9% vs. 0%, p = 0.014), and mechanical thrombectomy (MT) (23.1% vs. 0%, p = 0.044) were significantly higher in patients with REND rather than in those without. The rate of patent ICT and MCA was comparable between groups. Except for 1 patient who underwent MT promptly after IVT immediately after REND, 3 patients initially treated with IVT deteriorated after the procedure. One patient without patent ICT and MCA did not meet the indications for MT. In 2 other patients with patent ICT and MCA, MT was not initially performed, but was eventually performed because of REND due to thrombus migration, and both were discharged with an mRS score of 5. Conclusion: The overall clinical outcomes of patients with acute ICAO with mild symptoms were not depending on the patency of the ICT and MCA, but initial treatment with IVT alone might risk unfavorable outcomes due to thrombus migration in patients with patent ICT and MCA.

Association between rehabilitation after reperfusion treatment and in-hospital mortality: Results from a national registry study.

BackgroundThere is no effective regimen to reduce the mortality of patients treated with intravenous thrombolysis or endovascular therapy (EVT). Therefore, we aimed to examine whether sequential therapy by rehabilitation could effectively reduce the in-hospital mortality of patients treated with reperfusion therapy.MethodsThis prospective registry study included patients with ischemic stroke who were treated by intravenous thrombolysis or endovascular therapy at Stroke Center Work Plan in China between 1 October 2018 and 31 July 2020. The patients were divided into 2 groups: those with (IRT+) or without (IRT–) inpatient rehabilitation therapy (IRT). The primary outcome was all-cause in-hospital mortality. We used Cox proportional hazards models and conducted a propensity score matching analysis to calculate hazard ratios (HRs) for mortality in the thrombolysis-only and EVT groups.ResultsOf the 189,519 patients in the thrombolysis-only group, 35.7% were women, and the median (interquartile range, IQR) age, onset-to-needle time, and follow-up time were 66 (57–74) years, 165 (119–220) min, and 9 (5–12) days, respectively. Among the 45,211 patients in the EVT group, 35.9% were women, and the median (interquartile range, IQR) age, onset-to-puncture time, and follow-up time were 66 (56–74) years, 297 (205–420) min, and 11 (6–16) days, respectively. In the thrombolysis-only group with a median (IQR) initial National Institutes of Health Stroke Scale (NIHSS) score of 6 (3–11), 105,244 patients (55.5%) treated with IRT had significantly lower all-cause in-hospital mortality [0.6 vs. 2.3%; adjusted HR 0.18 (95% confidence interval (CI) 0.16–0.2)] than those without IRT. In the EVT group with a median (IQR) initial NIHSS score of 15 (10–20), 31,098 patients (68.8%) treated with IRT also had significantly lower all-cause in-hospital mortality [2 vs. 12.1%; adjusted HR, 0.13 (95% CI 0.12–0.15)]. IRT remained significantly associated with reduced in-hospital mortality in sensitivity, subgroup, and propensity score matching analyses among both the thrombolysis-only and EVT groups.ConclusionAmong the patients with ischemic stroke treated with intravenous thrombolysis or endovascular therapy, sequential therapy by rehabilitation was associated with lower all-cause in-hospital mortality. These findings suggest the necessity of promoting inpatient rehabilitation therapy after reperfusion in patients with ischemic stroke.

Assessment and prediction of affective disorders in patients after cerebral stroke using modern measurement scales

Objective — to analyze the results of scale‑based assessments of post‑stroke depression (PSD) and post‑stroke anxiety disorders (PSAD) in different phases of cerebral stroke (CS) as well as to determine independent predictors of PSD at discharge from the Stroke Center (StC), and to evaluate the characteristics of the respective predictive models. Methods and subjects. Two hundred patients, including 92 (46.0 %) women and 108 (54.0 %) men with the median age of 65.6 years (IQR 58.2 — 75.1) were enrolled. The health status of all patients was assessed after hospitalization using the National Institutes of Health Stroke Scale (NIHSS), Barthel Index, Modified Rankin Scale, Mini‑Mental State Examination (MMSE), and Montreal Cognitive Assessment (MoCA). 172 (86.0 %) patients were diagnosed with ischemic stroke (IS), 28 (14.0 %) — intracerebral hemorrhage. Among patients with IS, 58 (33.7 %) had an atherothrombotic subtype, 85 (49.4 %) had a cardioembolic subtype, 16 (9.3 %) had a lacunar subtype, 13 (7.6 %) had another or unknown subtype. The PSD and PSAD were assessed using the Hospital Anxiety and Depression Scale (HADS) and the Patient Health Questionnaire (PHQ‑9) before discharge from the Stroke Center. The impact of factors was assessed by odds ratio (OR) and its 95 % confidence interval (95 % CI). The method of constructing and analyzing logistic regression models was used to determine independent predictors of PSD at discharge. Results. The baseline NIHSS score ranged from 1 to 29. The mRS scores upon admission were from 1 to 5, and the BI scores from 0 to 100. Forty‑one (20.5 %) patients were admitted in the hyperacute period, 55 (27.5 %) in the acute period, 68 (34.0 %) in the early subacute period, 13 (6.5 %) in the late subacute period, and 23 (11.5 %) in the chronic phase of stroke. The HADS‑D score ranged from 0 to 18, and the HADS‑A score from 0 to 15. PHQ‑9 scores ranged from 0 to 21. Based on the HADS score, 19 (9.5 %) of the patients had clinically significant PSD and 16 (8.0 %) of the participants had clinically significant PSAD. According to the total HADS score, 22 (11.0 %) of the patients had clinically significant affective disorders. With PHQ‑9 showed that clinically significant PSD was detected in 45 (22.5 %) patients. The HADS and PHQ‑9 scores had a strong positive significant correlation, but neither of them correlated with the age or sex of the patients, the subtype or severity of CS. However, univariate analysis showed that the risk of clinically significant PSD at discharge (according to HADS‑D) was significantly directly related to age and atrial fibrillation in addition to inverse relationship with the BI, MMSE and MoCA scores, LA subtype of IS and ICH. The risk of moderate to severe PSD (according to PHQ‑9) had a statistically significant direct corelation with the initial NIHSS score, as well as an inverse corelation with the baseline BI, MMSE, and MoCA scores. In multivariate analysis, 4 features were independently associated with PSD (HADS‑D &gt; 10) at discharge: initial MMSE score (OR 0.93; 95 % CI 0.88 — 0.98, on average, for each additional point, p = 0.006), arterial hypertension (OR 8.5; 95 % CI 0.9 — 76.3; p = 0.057) or obesity (OR 0.23; 95 % CI 0.05 — 1.14; p = 0.072) as well as hospitalization after 30 days from CS onset. The predictive model based on these 4 variables had excellent sensitivity (94.7 %) and satisfactory specificity (73.3 %) and could assess the risk of developing PSD with good accuracy (AUC = 0.847). Furthermore, three factors were independent predictors of moderate or severe PSD (PHQ‑9 &gt; 9) at discharge: age (OR 1.04; 95 % CI 1.00 — 1.08, on average, for each additional year, p = 0.028), the baseline MoCA score (OR 0.94; 95 % CI 0.91 — 0.98, on average, with an increase in the score for each additional point, p = 0.005) and UN subtype of IS. The prognostic model based on the latter 3 variables had satisfactory sensitivity (65.1 %) and specificity (75.5 %), but good accuracy of PSD prediction (AUC = 0.735). Conclusions. The HADS and PHQ‑9 scores in CS patients varied widely, and indicated high prevalence of clinically significant PSD and PSAD. HADS and PHQ‑9 scores correlated with each other, but not with age, sex, subtype, or severity of stroke. Elderly patients with significant cognitive impairment on admission were at a higher risk of affective disorders. The prognostic models allow accurate PSD prediction, which can contribute to the timely detection and initiation of PSD treatment in patients at risk.

An Initial High National Institutes of Health Stroke Scale Score and Any Intracranial Hemorrhage Are Independent Factors for a Poor Outcome in Nonagenarians Treated with Thrombectomy for Acute Large Vessel Occlusion: The Tokyo/Tama-REgistry of Acute Endovascular Thrombectomy (TREAT) Study

Mechanical thrombectomy (MT) is effective in acute ischemic stroke patients ≥80years old with large vessel occlusion (LVO). However, data for patients ≥90years old remain very limited, and factors influencing functional outcomes are unclear. This study aimed to investigate factors influencing functional outcomes in patients ≥90years old treated with MT for acute LVO. This retrospective observational study used prospectively collected data from the Tokyo/tama-REgistry of Acute endovascular Thrombectomy (TREAT) study. Inclusion criteria were as follows: 1) patients ≥90years old treated with MT for LVO and 2) prestroke modified Rankin Scale (mRS) score, 0-3. The functional outcome was defined based on the mRS score at 90days after the procedure: good functional outcome, mRS score 0-3 and poor functional outcome, mRS score 4-6. Data were analyzed for 104 patients ≥90years old. The good functional outcome was observed in 25 patients (24.0%), and the poor functional outcome was observed in the remaining 79 patients. Significant differences were identified in initial National Institutes of Health Stroke Scale (NIHSS) score, modified Thrombolysis in Cerebral Infarction grade 2b-3, modified Thrombolysis in Cerebral Infarction grade 3, and any intracranial hemorrhage and hemorrhagic infarction in univariate analyses. Multivariable analysis confirmed the initial NIHSS score (odds ratio, 1.08; 95% confidence interval, 1.01-1.17; P=0.045) and any intracranial hemorrhage (odds ratio, 11.6; 95% confidence interval, 1.43-95.0; P= 0.022) as independent factors for the functional outcome. An initial high NIHSS score and any intracranial hemorrhage are independent factors for the poor functional outcome in acute ischemic stroke patients ≥90years old treated with MT.

Early Response to Endovascular Thrombectomy after Stroke: Early, Late, and Very Late Time Windows

Background and Purpose: Endovascular thrombectomy (EVT) has benefits in selected patients 6–24 h after stroke onset. However, the response to EVT >24 h after stroke onset is still unclear. We compared the early response to EVT in patients with different time windows. Methods: Patients who underwent EVT in an emergency setting were enrolled and categorized according to when EVT was performed: within 6 (early), 6–24 (late), and >24 h (very late) after stroke onset. Early neurological improvement (ENI) and deterioration (END) were defined as improvement and worsening, respectively, of National Institutes of Health Stroke Scale (NIHSS) score by ≥4 points after EVT. The three groups’ clinical characteristics and response to EVT were compared. We also investigated factors associated with ENI and END. Results: During study period, 274 patients underwent EVT (109 early, 104 late, and 61 very late). Patients who underwent EVT very late were younger (p = 0.007), had smaller ischemic cores, and had lower initial NIHSS scores (8 ± 5) than those who underwent EVT early (14 ± 6) and late (13 ± 7; p < 0.001). Stroke mechanisms also differed according to the time window (p < 0.001): cardioembolism was more common after early EVT, whereas large-artery atherosclerosis was more prevalent among patients who underwent EVT very late. ENI was significantly more common after early (60.6%) and late EVT (51.0%) than after very late EVT (29.5%; p = 0.001); however, rates of END did not differ (11.0%, 13.5%, and 4.9%, respectively). ENI was independently associated with male, higher NIHSS score, and early and late EVT. END was associated with failure of recanalization. Conclusions: ENI was more observed and associated with early and late EVT. Highly selected patients receiving very late EVT may not benefit from ENI but may still have a chance to prevent END. The occurrence of END was associated not with time window but with failure of recanalization.

Etiology-Related Outcome of Endovascular Therapy in Posterior Circulation Stroke Compared to Anterior Circulation Stroke.

Background and Purpose We investigated the impact of stroke etiology on the endovascular treatment (EVT) procedure and clinical outcome of posterior circulation stroke (PCS) patients with EVT compared to anterior circulation stroke (ACS) patients. Methods We retrospectively analyzed ischemic stroke patients who underwent EVT between January 2012 and December 2020. Enrolled ACS and PCS patients were compared according to etiologies (intracranial arterial steno-occlusion [ICAS-O], artery-to-artery embolic occlusion [AT-O], and cardioembolic occlusion [CA-O]). EVT procedure and favorable clinical outcomes at 3 months (modified Rankin Scale 0–2) were compared between the ACS and PCS groups for each etiology. Results We included 419 patients (ACS, 346; PCS, 73) including 88 ICAS-O (ACS, 67; PCS, 21), 66 AT-O (ACS, 50; PCS, 16), and 265 CA-O (ACS, 229; PCS, 36) patients in the study. The onset-to-recanalization time was longer in the PCS group than in the ACS group (median 628.0 minutes vs. 421.0 minutes, P=0.01). In CA-O patients, the door-to-puncture time was longer, whereas the puncture-to-recanalization time was shorter in the PCS group than in the ACS group. The proportions of successful recanalization and favorable clinical outcomes were similar between the ACS and PCS groups for all three etiologies. Low baseline National Institutes of Health Stroke Scale (NIHSS) scores and absence of intracerebral hemorrhage at follow-up imaging were associated with favorable clinical outcomes in both groups, whereas successful recanalization (odds ratio, 11.74; 95% confidence interval, 2.60 to 52.94; P=0.001) was only associated in the ACS group. Conclusions The proportions of successful recanalization and favorable clinical outcomes were similar among all three etiologies between PCS and ACS patients who underwent EVT. Initial baseline NIHSS score and absence of hemorrhagic transformation were related to favorable outcomes in the PCS and ACS groups, whereas successful recanalization was related to favorable outcomes only in the ACS group.

Predictors of unfavorable outcome at 90 days in basilar artery occlusion patients.

BACKGROUNDIn a previous study, basilar artery occlusion (BAO) was shown to lead to death or disability in 80% of the patients. The treatment for BAO patients in the acute stage includes thrombolysis and intra-arterial thrombectomy, but not all patients benefit from these treatments. Thus, understanding the predictors of outcome before initiating these treatments is of special interest.AIMTo determine the predictors related to the 90-d clinical outcome in patients with BAO in an Asian population. METHODSWe performed a retrospective case review of patients admitted to a tertiary stroke center between 2015 and 2019. We used the international classification of diseases-10 criteria to identify cases of posterior circulation stroke. A neurologist reviewed every case, and patients fulfilling the criteria defined in the Basilar Artery International Cooperation Study were included. We then analyzed the patients’ characteristics and factors related to the 90-d outcome. RESULTSWe identified a total of 99 patients as real BAO cases. Of these patients, 33 (33.3%) had a favorable outcome at 90 d (modified Rankin Scale: 0–3). Moreover, 72 patients received intra-arterial thrombectomy, while 13 patients received intravenous tissue-type plasminogen activator treatment. We observed a favorable outcome in 33.3% of the cases and an unfavorable outcome in 66.7% of the cases. We found that the initial National Institutes of Health Stroke Scale (NIHSS) score and several BAO symptoms, including impaired consciousness, tetraparesis, and pupillary abnormalities, were significantly associated with an unfavorable outcome (P < 0.05), while cerebellar symptoms were associated with a favorable outcome (P < 0.05). In the receiver operating characteristic (ROC) analysis, the areas under the ROC curve of initial NIHSS score, impaired consciousness, tetraparesis, cerebellar symptoms, and pupillary abnormalities were 0.836, 0.644, 0.727, 0.614, and 0.614, respectively. Initial NIHSS score showed a higher AUROC (0.836) compared to BAO symptoms.CONCLUSIONThe most important predictor of an unfavorable outcome was the initial NIHSS score. BAO symptoms, including tetraparesis, impaired consciousness, and pupillary abnormality were also related to an unfavorable outcome.

Poor clinical outcome despite successful basilar occlusion recanalization in the early time window: incidence and predictors

BackgroundEndovascular treatment (EVT) for basilar artery occlusions (BAO) is associated with a higher rate of futile recanalization compared with anterior circulation procedures. We aimed to identify the incidence and predictors...

Clinical and Functional Outcomes of Patients Receiving Cerebral Reperfusion Therapy: A Stroke Databank Study in Brazil.

ObjectivesCerebral reperfusion therapy is recommended for the treatment of acute ischemic stroke. However, the outcomes of patients receiving this therapy in middle- and low-income countries should be better defined. This study aimed to evaluate the clinical and functional outcomes of cerebral reperfusion therapy in patients with ischemic stroke.Materials and MethodsThis retrospective study included patients with ischemic stroke treated with cerebral reperfusion therapy, including intravenous thrombolysis (IVT), mechanical thrombectomy (MT), and IVT with MT. The primary outcomes were death and disability, assessed using the modified Rankin scale (mRS), and stroke severity, assessed using the National Institutes of Health Stroke Scale (NIHSS), after intervention and 90 days after ictus. The association between the type of treatment and the primary outcome was assessed using binary logistic regression after adjusting for confounding variables. Furthermore, receiver operating characteristic (ROC) curves were generated to identify the cutoff point of the NIHSS score that could best discriminate the mRS score in all types of treatments.ResultsPatients (n = 291) underwent IVT only (n = 241), MT (n = 21), or IVT with MT (n = 29). In the IVT with MT group, the incidence of death within 90 days increased by five times (OR, 5.192; 95% CI, 2.069–13.027; p = 0.000), prevalence of disability increased by three times (OR, 3.530; 95% CI, 1.376–9.055; p = 0.009) and NIHSS score increased after IVT (from 14.4 ± 6.85 to 17.8 ± 6.36; p = 0.045). There was no significant difference between the initial NIHSS score and that after MT (p = 0.989). Patients' NIHSS score that increased or decreased by 2.5 points had a sensitivity of 0.74 and specificity of 0.65, indicating severe disability or death in these patients.ConclusionAltogether, a 2.5-point variation in NIHSS score after reperfusion is an indicator of worse outcomes. In our particular context, patients receiving the combination of IVT and MT had inferior results, which probably reflects challenges to optimize MT in LMIC.

Rapid Identification of Patients Eligible for Direct Emergent Computed Tomography Angiography during Acute Ischemic Stroke: The DARE-PACE Assessment.

Background: We investigated the clinical signs to establish a method for rapid identification of patients with the National Institute of Health Stroke Scale (NIHSS) score ≥ 8 eligible for direct brain CTA study; Methods: We retrospectively enrolled 2895 in patients with acute ischemic stroke (AIS). Four items in the NIHSS were selected as the main clinical signs of stroke; Results: A total of 922 (31.8%) patients had an initial NIHSS score of ≥8. The average door-to-CT time and door-to-CTA time were 13.4 ± 1.8 and 75.5 ± 44.5 min, respectively. Among 658 patients who had the priority signs, namely dense hemiplegia (D), aphasia with right arm drop (AR), and eyeball forced deviation (E), 634 patients (96.4%) with an NIHSS score ≥ 8 were identified. By using a classification and regression tree analysis, 153 patients with an NIHSS ≥ 8 were identified among 175 patients (87.4%) who had the secondary signs, namely hemiparesis with limb falls (P), aphasia (A), drowsy or worse consciousness (C), and eyeball limitation (E). The sensitivity, specificity, and accuracy were 85.4%, 97.7%, and 95.3%, respectively. Conclusions: The DARE-PACE assessment involving a checkbox list provides excellent accuracy for rapid identification of AIS patients with an NIHSS score ≥ 8 for direct CTA study to reduce the time delay for endovascular thrombectomy.

Comparison of Clinical Features, Immune-Inflammatory Markers, and Outcomes Between Patients with Acute In-Hospital and Out-of-Hospital Ischemic Stroke.

PurposeWe investigated the differences of clinical features, four immune-inflammatory markers, namely neutrophil counts, platelet-to-lymphocyte ratio, neutrophil-to-lymphocyte ratio (NLR), and systemic immune-inflammation index (SII), as well as outcomes between patients with in-hospital ischemic stroke (IHIS) and out-of-hospital ischemic stroke (OHIS).Patients and MethodsWe retrospectively enrolled 72 patients with IHIS and 3330 patients with OHIS.ResultsIHIS accounted for 2% of all patients with ischemic stroke and occurred more often in cardiology and orthopedic surgery wards. Infection, cardiac disease, and pulmonary disorder were the most common causes of hospitalization. Compared with those with OHIS, patients with IHIS had higher levels of immune-inflammatory markers, initial National Institute of Health Stroke Scale (NIHSS) scores, longer hospital stays, higher rates of heart disease, large-artery atherosclerosis or cardioembolism, received more intravenous thrombolysis (IVT) or endovascular thrombectomies (EVTs), more complications, unfavorable outcomes, and mortality. Every immune-inflammatory marker exhibited positive correlations with initial NIHSS scores and discharge modified Rankin Scale scores among patients with OHIS. NLR and SII were higher among patients with a fatal outcome in both groups. Among patients receiving IVT, most of treatment time intervals were shorter for those with IHIS than those with OHIS. Significant factors for mortality were NLR >5.5, atrial fibrillation, and complications, with a C-statistic of 0.897 in those with IHIS; in those with OHIS, these factors were an initial NIHSS score of >10, NLR >6.0, atrial fibrillation, prior stroke, cancer history, and complications with a C-statistic of 0.902. The results were similar after replacing the NLR with SII.ConclusionPatients with IHIS had more complicated clinical features, higher levels of immune-inflammatory markers, and higher rates of mortality than patients with OHIS. The most significant predictor for mortality among those with OHIS was NIHSS score >10, and the predictors among patients with IHIS were NLR >5.5 and SII >2120.

Abstract WP80: Stroke Outcomes Among English And Spanish Speaking Mexican Americans

Introduction: We examined if language preference was associated with differences in neurological, functional, and cognitive stroke outcomes among Mexican Americans (MAs). Methods: Ischemic or hemorrhagic stroke patients identified from the Brain Attack Surveillance in Corpus Christi (BASIC) Project (2009-2018). Poststroke outcomes at 90 days included neurological [National Institutes of Health Stroke Scale (NIHSS) range 0-44, higher worse], functional [activities of daily living/instrumental activities of daily living (ADL/iADL) range 1-4, higher worse], and cognitive [modified Mini-Mental State Examination (3MSE) range 0-100, lower worse]. Language was determined by which language participant preferred to complete outcome interview in. Differences in stroke outcomes by language were analyzed by weighted Tobit regression. Weights (baseline and outcome interview participation) were created by logistic regression to account for attrition. Age, education, initial NIHSS score, smoking status, BMI, insurance status, sex, and comorbidities were included in weighted Tobit regression models. Results: Of 1,096 patients, 1,001 preferred English and 95 Spanish. Spanish speakers were older (72 versus 66 years; p &lt; 0.01), received less education (p &lt; 0.01), and had higher prevalence of atrial fibrillation (p = 0.02) than English speakers. No other significant differences in baseline demographics or clinical factors were found. In fully adjusted models (Table 1) Spanish speakers had significantly better neurological and functional but worse cognitive outcomes compared with English speakers. Conclusion: This population-based study found better neurologic and functional stroke outcomes among Spanish speaking versus English speaking MAs. The difference in the cognitive outcome may be explained, at least in part, to lack of cultural equivalence of the test instrument. These data suggest further research into the resilience observed among Spanish speakers.

Post-stroke Hyperglycemia in Non-diabetic Ischemic Stroke is Related With Worse Functional Outcome: A Cohort Study.

ObjectiveTo investigate long-term and serial functional outcomes in ischemic stroke patients without diabetes with post-stroke hyperglycemia.MethodsThe Korean Stroke Cohort for Functioning and Rehabilitation (KOSCO) is a large, multi-center, prospective cohort study of stroke patients admitted to participating hospitals in nine areas of Korea. From KOSCO, ischemic stroke patients without diabetes were recruited and divided into two groups: patients without diabetes without (n=779) and with post-stroke hyperglycemia (n=223). Post-stroke hyperglycemia was defined as a glucose level >8 mmol/L. Functional assessments were performed 7 days and 3, 6, and 12 months after stroke onset.ResultsThere were no significant differences in baseline characteristics between the groups, except in the age of onset and smoking. Analysis of the linear correlation between the initial National Institutes of Health Stroke Scale (NIHSS) score and glucose level showed no significant difference. Among our functional assessments, NIHSS, Fugl-Meyer Assessment (affected side), Functional Ambulatory Category, modified Rankin Scale, and Korean Mini-Mental State Examination (K-MMSE) showed statistically significant improvements in each group. All functional improvements except K-MMSE were significantly higher in patients without post-stroke hyperglycemia at 7 days and 3, 6, and 12 months.ConclusionThe glucose level of ischemic stroke patients without diabetes had no significant correlation with the initial NIHSS score. The long-term effects of stress hyperglycemia showed worse functional outcomes in ischemic stroke patients without diabetes with post-stroke hyperglycemia.

Clinical-Diffusion Mismatch Is Associated with Early Neurological Improvement after Late-Window Endovascular Treatment

Background: Clinical-diffusion mismatch (CDM) and perfusion-diffusion mismatch (PDM) are used to select patients for endovascular thrombectomy (EVT) in the late-window period. As CDM well reflects true penumbra, we hypothesized that patients with CDM and PDM would respond better to EVT than those with PDM only at the late-window period. Methods: Acute ischemic stroke patients who received EVT 6–24 h after stroke onset were included. PDM (perfusion-/diffusion-weighted image (DWI) lesion volume >1.8) was used to select candidates for EVT in this time-period in our center. CDM was defined according to the DAWN trial criteria. Response to EVT was compared between patients with and without CDM. Early neurological improvement (ENI) was defined as improvement >4 points on National Institutes of Health Stroke Scale (NIHSS) score 1 day after EVT. Multivariable analysis was performed to investigate independent factors associated with ENI. The correlation between DWI lesion volume and NIHSS score was investigated in those with and without CDM. Results: Among 94 patients enrolled, all patients had PDM and 44 (46.3%) had CDM. Forty-eight patients (51.1%) showed ENI. The prevalence of hypertension, initial NIHSS score, improvement in NIHSS score after EVT, and prevalence of ENI were greater in patients with CDM than those without. ENI was independently associated with onset-to-door time (odds ratio [95% confidence interval]: 0.998 [0.997–1.000]; p = 0.042), complete recanalization (23.912 [2.238–255.489]; p = 0.009), initial NIHSS score (1.180 [1.012–1.377]; p = 0.034), and the presence of CDM (5.160 [1.448–18.386]; p = 0.011). The correlation between DWI lesion volume and initial NIHSS score was strong in patients without CDM (r = 0.731) but only moderate in patients with CDM (r = 0.355). Conclusion: Patients with both CDM and PDM had a better response to late-window EVT than those with PDM only.

Large Vessel Occlusion Prediction in the Emergency Department with National Institutes of Health Stroke Scale Components: A Machine Learning Approach

ObjectiveTo determine the feasibility of using a machine learning algorithm to screen for large vessel occlusions (LVO) in the Emergency Department (ED). Materials and methodsA retrospective cohort of consecutive ED stroke alerts at a large comprehensive stroke center was analyzed. The primary outcome was diagnosis of LVO at discharge. Components of the National Institutes of Health Stroke Scale (NIHSS) were used in various clinical methods and machine learning algorithms to predict LVO, and the results were compared with the baseline method (aggregate NIHSS score with threshold of 6). The Area-Under-Curve (AUC) was used to measure the overall performance of the models. Bootstrapping (n = 1000) was applied for the statistical analysis. ResultsOf 1133 total patients, 67 were diagnosed with LVO. A Gaussian Process (GP) algorithm significantly outperformed other methods including the baseline methods. AUC score for the GP algorithm was 0.874 ± 0.025, compared with the simple aggregate NIHSS score, which had an AUC score of 0.819 ± 0.024. A dual-stage GP algorithm is proposed, which offers flexible threshold settings for different patient populations, and achieved an overall sensitivity of 0.903 and specificity of 0.626, in which sensitivity of 0.99 was achieved for high-risk patients (defined as initial NIHSS score > 6). ConclusionMachine learning using a Gaussian Process algorithm outperformed a clinical cutoff using the aggregate NIHSS score for LVO diagnosis. Future studies would be beneficial in exploring prospective interventions developed using machine learning in screening for LVOs in the emergent setting.

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&lt;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.