Initial National Institutes Of Health Stroke Scale Score Research Articles

Association between Asymptomatic Cerebrovascular Stenosis and Early Neurological Deterioration in Single Subcortical Infarction Patients

Background: Patients with ischemic stroke may experience early neurological deterioration (END) during the acute phase. This study aimed to identify association between asymptomatic vascular stenosis and END in single subcortical infarction patients.Methods: The study included 562 patients admitted within 48 hours of symptom onset between January 2015 and August 2022. END was defined as a decrease of ≥1 point in the National Institutes of Health stroke scale (NIHSS) motor score or ≥2 points in the total NIHSS score within the first 48 hours after stroke onset. Clinical characteristics, including age, sex, smoking habits, underlying vascular risk factors, initial NIHSS score, trial of Org 10172 in acute stroke treatment classification, laboratory parameters, and presence of vascular stenosis or occlusion, were analyzed to identify predictors of END.Results: END occurred in 115 patients (20%) with single subcortical infarction. Age (odds ratio [OR], 1.0; <i>p</i>=0.011), female sex (OR, 1.7; <i>p</i>=0.042), location of cerebral infarction at corona radiata (OR, 3.0; <i>p</i>=0.023), systolic blood pressure (OR, 1.0; <i>p</i>=0.011) and presence of asymptomatic vascular stenosis (OR, 2.2; <i>p</i>=0.019) were independently associated with END in multivariable logistic regression.Conclusions: This study suggests that age, sex, location of cerebral infarction, systolic blood pressure and the presence of asymptomatic vascular stenosis are independent predictors of END.

Iodine-Based Dual-Energy Computed Tomography After Mechanical Thrombectomy Predicts Secondary Neurologic Decline from Cerebral Edema After Severe Stroke.

Patients with severe stroke are at high risk of secondary neurologic decline (ND) from the development of malignant cerebral edema (MCE). However, early infarcts are hard to diagnose on conventional head computed tomography (CT). We hypothesize that high-energy (190keV) virtual monochromatic imaging (VMI) from dual-energy CT (DECT) imaging enables earlier detection of ND from MCE. Consecutive patients with severe stroke with National Institute of Health Stroke Scale (NIHSS) scores > 15 and DECT within 10h of mechanical thrombectomy from May 2020 to March 2022 were included. We excluded patients with parenchymal hematoma type 2 transformation. Retrospective analysis of clinical and novel variables included the VMI Alberta Stroke Program Early CT Score (ASPECTS), total iodine content, and VMI infarct volume. The primary outcome was secondary ND, defined using a composite outcome variable of clinical worsening (increase in NIHSS score ≥ 4 or decrease in Glasgow Coma Scale score > 2) or malignant radiographical edema (midline shift ≥ 5mm at the level of the septum pellucidum). Fisher's exact test and Wilcoxon's test were used for univariate analysis. Logistic regression was used to develop prediction models for categorical outcomes. Eighty-four patients with severe stroke with a median age of 67.5 (interquartile range [IQR] 57-78) years and an NIHSS score of 22 (IQR 18-25) were included. Twenty-nine patients had ND. The VMI ASPECTS, total iodine content, and VMI infarct volume were associated with ND. The VMI ASPECTS, VMI infarct volume, and total iodine content were predictors of ND after adjusting for age, sex, initial NIHSS score, and tissue plasminogen activator administration, with areas under the receiver operating characteristic curve (AUROC) of 0.691 (95% confidence interval [CI] 0.572-0.810), 0.877 (95% CI 0.800-0.954), and 0.845 (95% CI 0.750-0.940). By including all three predictors, the model achieved an AUROC of 0.903 (95% CI 0.84-0.97) and was cross-validated by the leave one out method, with an AUROC of 0.827. The VMI ASPECTS and VMI infarct volume from DECT are superior to the conventional CT ASPECTS and are novel predictors for secondary ND due to MCE after severe stroke. Clinical trial registration ClinicalTrials.gov identifier: NCT04189471.

Futile recanalization after endovascular treatment in acute ischemic stroke with large ischemic core

BackgroundEndovascular therapy (EVT) is the treatment of choice for acute ischemic stroke (AIS) with large vessel occlusion. However, in many patients, successful EVT recanalization does not correspond to a clinical improvement, called futile recanalization (FR). We aimed to identify stroke risk factors and patient characteristics associated with FR in AIS with large core infarct (LCI).MethodsA total of 137 patients with AIS with LCI treated by EVT at a single stroke center were retrospectively included from January 2016 to June 2023. LCI was defined by Diffusion-Weighted Imaging-Alberta Stroke Program Early Computed Tomography Score (DWI-ASPECT) < 6. Patient age, sex, modified Rankin Scale (mRS), National Institutes of Health Stroke Scale (NIHSS), time to treatment, risk factors, and radiologic findings were collected, and potential associations with FR were analyzed. FR was defined as successful reperfusion with modified Thrombolysis in Cerebral Infarction (mTICI) ≥ 2b but without functional independence at 90 days (mRS ≥ 3). A multivariate logistic regression analysis was conducted on the clinical characteristics of patients, based on the presence or absence of FR, and the factors influencing FR.ResultsOf 137 patients, 120 showed successful recanalization (mTICI ≥ 2b). All patients were divided into FR (n = 80) and no FR (n = 40) groups. Older age (odds ratio [OR] 1.052, 95% confidence interval [CI] 1.002–1.105; p = 0.041), the higher the initial NIHSS score (OR 1.181, 95% CI 1.037–1.344; p = 0.012), and prior intravenous plasminogen activator (OR 0.310, 95% CI 0.118–0.813, p = 0.017) were independent influencing factors of FR.ConclusionsThe older age, the higher the initial NIHSS, and not receiving intravenous plasminogen activator were independently associated with FR in AIS with LCI. These factors could identify poor responders to EVT recanalization.

Prognostic Value of Optic Nerve Sheath Diameters after Acute Ischemic Stroke According to Slice Thickness on Computed Tomography.

The optic nerve sheath diameter (ONSD) can predict intracranial pressure and outcomes in neurological disease, but it remains unclear whether a small ONSD can be accurately measured on routine CT images with a slice thickness of approximately 4-5 mm. We measured the ONSD and ONSD/eyeball transverse diameter (ETD) ratio on routine-slice (4 mm) and thin-slice (0.6-0.75 mm) brain CT images from initial scans of acute ischemic stroke (AIS) patients. ONSD-related variables, National Institutes of Health Stroke Scale (NIHSS) scores, and age were compared between good (modified Rankin Scale [mRS] ≤ 2) and poor (mRS > 2) outcomes at discharge. Among 155 patients, 38 had poor outcomes. The thin-slice ONSD was different between outcome groups (p = 0.047), while the routine-slice ONSD showed no difference. The area under the curve (AUC) values for the ONSD and ONSD/ETD were 0.58 (95% CI, 0.49-0.66) and 0.58 (95% CI, 0.50-0.66) on the routine-slice CT, and 0.60 (95% CI, 0.52-0.68) and 0.62 (95% CI, 0.54-0.69) on the thin-slice CT. The thin-slice ONSD/ETD ratio correlated with initial NIHSS scores (r = 0.225, p = 0.005). After adjusting for NIHSS scores and age, ONSD-related variables were not associated with outcomes, and adding them to a model with NIHSS scores and age did not improve performance (all p-values > 0.05). Although ONSD measurements were not an independent outcome predictor, they correlated with stroke severity, and the thin-slice ONSD provided a slightly better prognostic performance than the routine-slice ONSD.

High glycated albumin is associated with early neurological deterioration in patients with acute ischemic stroke

BackgroundGlycated albumin (GA) is an indicator of glycemic variability over the past 2–4 weeks and has suitable characteristics for predicting the prognosis of ischemic stroke during the acute phase. This study evaluated the association between early neurological deterioration (END) and GA values in patients with acute ischemic stroke (AIS).MethodsWe assessed consecutive patients with AIS between 2022 and 2023 at two large medical centers in Korea. END was defined as an increase of ≥ 2 in the total National Institutes of Health Stroke Scale (NIHSS) score or ≥ 1 in the motor NIHSS score within the first 72 h of admission. We evaluated various glycemic parameters including fasting glucose (mg/dL), hemoglobin A1c (%), and GA (%).ResultsIn total, 531 patients with AIS were evaluated (median age: 69 years, male sex: 66.3%). In the multivariable logistic regression analysis, GA value was positively associated with END (adjusted odds ratio [aOR] = 3.24, 95% confidence interval [CI]: 1.10–9.50). Initial NIHSS score (aOR = 1.04, 95% CI: 1.01–1.08) and thrombolytic therapy (aOR = 2.06, 95% CI: 1.14–3.73) were also associated with END. In a comparison of the predictive power of glycemic parameters for END, GA showed a higher area under the curve value on the receiver operating characteristic curve than fasting glucose and hemoglobin A1c.ConclusionsHigh GA values were associated with END in patients with AIS. Furthermore, GA was a better predictor of END than fasting glucose or hemoglobin A1c.

Reperfusion Therapy for Trousseau Syndrome-Related Cerebral Infarction: A Case-Control Analysis of Efficacy and Prognosis.

To evaluate the efficacy and prognostic significance of reperfusion therapy in patients with Trousseau syndrome-related cerebral infarction. Descriptive study. Place and Duration of the Study: Department of Neurology, Zhongshan Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China, and The Second Affiliated Hospital of Xiamen Medical College, Xiamen, China, between January 2017 and December 2023. Patients with Trousseau-associated cerebral infarction who were treated at two hospitals were included in the study. Clinical outcomes, including early neurological deterioration, intracranial haemorrhage, in-hospital mortality, 90-day modified Rankin scale (mRS) score, 90-day mortality, initial and discharge National Institutes of Health Stroke Scale (NIHSS) score, and ΔNIHSS (difference between the initial and discharge NIHSS score), were compared between the reperfusion-treated group (n = 9) and the conventionally treated group (n = 23). Patients who received reperfusion therapy demonstrated significant neurological improvement at discharge, with a statistically significant difference in their ΔNIHSS scores compared to those of the conventionally treated group (p <0.001). No significant differences were observed in early neurological deterioration (11.10% vs. 13.00%, p = 1.000), intracranial haemorrhage (33.33% vs. 8.70%, p = 0.121), in-hospital mortality (22.20% vs. 26.10%, p = 1.000), 90-day mortality (55.60% vs. 87.00%, p = 0.076), or 90-day mRS score (p = 0.052) between the two groups. Despite the high mortality rate within 90 days, reperfusion therapy has the potential to improve the quality of life of surviving cancer patients with Trousseau-associated cerebral infarction. Trousseau syndrome-related cerebral infarction, Reperfusion therapy, Intravenous thrombolysis, Mechanical thrombectomy, Acute cerebral infarction.

Study of Biochemical Predictors of Early Neurological Deterioration in Ischemic Stroke in a Tertiary Care Hospital.

Background and objective Early neurological deterioration (END) following acute ischemic stroke (AIS) poses a significant clinical challenge, often leading to increased disability and mortality. This study aimed to investigate the association between specific biomarkers (lactate dehydrogenase (LDH), ferritin,erythrocyte sedimentation rate (ESR),C-reactive protein (CRP), homocysteine) and the occurrence of END in ischemic stroke patients in a tertiary care hospital. Materials and methods Across-sectional hospital-basedstudy was conducted at Dr. D. Y. Patil Medical College and Hospital, Pune, from July 2022 to April 2024. Patients aged 18 and above with confirmed ischemic stroke were included, while those with hemorrhagic stroke, intracranial tumors, mass effect with midline shift, or extensive cerebral edema were excluded. Upon admission, patients were assessed using the National Institutes of Health Stroke Scale (NIHSS) and monitored daily for seven days. Biomarkers, including LDH, ferritin, ESR, CRP, and homocysteine, were measured, and patients were categorized into those with END and without END. Statistical analysis was performed using IBM SPSS Statistics for Windows, Version 20 (Released 2011; IBM Corp., Armonk, New York). Results Out of 100 patients, 12% experienced END. The mean age of patients with END was 53.50 ± 11.20 years, compared to 53.62 ± 11.74 years in those without END (p = 0.790). Males constituted 91.7% of the END group and 73.9% of the non-END group (p = 0.284). A significant association was found between END and alcohol use (41.7% in END vs. 12.5% in non-END, p = 0.010) and tobacco use (41.7% in END vs. 11.4% in non-END, p = 0.010). The mean NIHSS scores were significantly higher in the END group on day 1 (11.58 ± 3.06 vs. 7.69 ± 3.98,p = 0.002) and on day 3 (13.92 ± 3.15 vs. 6.00 ± 3.65, p = 0.001). Biomarker analysis showed a significant difference in the mean vitamin B12 levels between END and non-END groups (93.17 ± 48.58 vs. 183.45 ± 349.33, p = 0.025). Conclusion Our study identified significant predictors of ENDin ischemic stroke patients, including alcohol and tobacco use, higher initial NIHSS scores, and elevated levels of LDH, ferritin, ESR, CRP, and homocysteine, along with low vitamin B12 levels. These findings highlight the importance of routine biochemical assessments and personalized treatment plans in managing AIS, emphasizing lifestyle changes and nutritional support to improve outcomes. Limitations include the single-center design, small sample size, and lack of long-term follow-up data. Future research should validate these findings in larger, multicenter studies and explore their long-term impact on stroke recovery.

CASE SERIES: EFFICACY OF THROMBOLYSIS USING INTRAVENOUS ALTEPLASE IN ACUTE ISCHEMIC STROKE WITH ONSET LESS THAN 6 HOURS (CODE STROKE)

Background: The gold standard therapy for acute ischemic stroke is timely reperfusion of ischemic brain tissue. Intravenous thrombolysis with tPA is the only proven medical therapy for acute ischemic stroke within 4.5 hours of symptom onset using intravenous alteplase at a dose of 0.9 mg per kilogram of body weight. Hemorrhagic transformation is one of the complications of thrombolytic therapy and East Asian population having a higher prevalence of cerebral hemorrhage. This study will examine several cases of ischemic stroke that were treated with thrombolysis using a standard dose (0.9 mg/kg) of intravenous alteplase in acute ischemic stroke with an onset of less than 6 hours in the Special Region of Yogyakarta, especially at the UGM Academic Hospital. Objective: To determine the efficacy of standard dose thrombolysis using intravenous alteplase (rTPA-recombinant tissue plasminogen activator) in acute ischemic stroke with an onset of less than 6 hours through activation of the Code Stroke. Methods: Descriptive research design using a case series, the hyperacute stroke patients with an onset of less than 6 hours who received intravenous alteplase which were then assessed by the National Institutes of Health Stroke Scale (NIHSS) score at initial admission, 24 hours post-alteplase and 30 days post -alteplase. The study took place and was conducted from May to October 2022 by administering intravenous alteplase at a dose of 0.9 mg/kg body weight in acute ischemic stroke patients at UGM RSA who are eligible for thrombolysis therapy with a maximum administration time of 6 hours after stroke onset with the maximum dose of alteplase is 50 mg. Results: The study sample was 8 patients with acute ischemic stroke who were treated between May to October 2022. There were 2 patients who died before completing the 3-month follow-up. One of the patients died within the second week of treatment from sepsis which may have occurred from a pre-existing pneumonia. Another patient died from ileus that occurred 1 month after tissue plasminogen activator (tPA). However, the patient with this ileus showed clinical improvement at the 24-hour post-tPA follow-up, i.e. the initial NIHSS score of 12 improved to an NIHSS score of 6. Conclusion: The modified Alteplase dose, which is 0.9 mg/kg body weight with a maximum dose of 50 mg, at the onset of stroke less than 6 hours can be an option to maximize thrombolytic therapy while still considering the efficiency of treatment costs.

Prognostic significance of serum cystatin C in acute brainstem infarctions patients

ObjectivesSome studies show that high circulating cystatin C (CysC) may predict cardiovascular events and death after ischemic stroke onset. However, the association between serum CysC and outcome in ischemic stroke patients remains contradictory. We sought to assess the association between a specific stroke subgroup, brainstem infarction (BSI) and serum CysC. Materials and methodsA total of 324 acute BSI patients were included in the study. Serum CysC was used to calculate estimated glomerular filtration rate (eGFRCysC) at baseline. Modified Rankin scale score ((mRS) ≥3) six months after acute BSI indicates poor functional outcome. Patients were categorized into two groups according to mRS and eGFRCysC. Logistic regression analyses were performed to determine independent risk factors. ResultsLower eGFRCysC was associated with hemoglobin A1c (HbA1c). This risk remained statistically significant after controlling for age, hypertension, initial National Institutes of Health Stroke Scale (NIHSS) score, HbA1c, fibrinogen and homocysteine. The serum eGFRCysC levels were significantly lower in the poor functional outcome group than the good functional outcome group (P<0.001). Multivariate logistic regression analyses showed that eGFRCysC level was significantly lower in the poor outcome group after adjusting for age, previous infarctions, initial NIHSS score, and HbA1c. ConclusionsLower eGFRCysC levels were strongly associated with poor functional outcome of acute BSI patients with a higher HbA1c level. Lower eGFRCysC may be a more helpful serologic biomarker for the prediction of prognosis in BSI.

Abstract WP38: Nurse-Driven Emergency Evaluation Improves Timely Acute Stroke Response

Background: Stroke is associated with high rates of death and disability; prompt and effective interventions are imperative. Depending on emergency department (ED) physicians to initiate stroke codes may delay critical time targets, especially for patients arriving by private vehicle (POV). This study examines existing stroke care protocols in the ED of a Comprehensive Stroke Center and evaluates a new nurse-driven acute stroke response protocol. Purpose: The primary goal of this initiative was to improve outcomes for patients arriving by POV, by reducing triage delays and accelerating time-sensitive acute stroke interventions. Methods: This retrospective study implemented a nurse-led stroke activation process, in lieu of the conventional physician-led method. Nurses received comprehensive training in intervention goals and identification of stroke symptoms and last known-well times. The nurse-led model targeted patients presenting to the ED with a minimum of 2 stroke symptoms within 6 hours of symptom onset—an assessment tool, incorporating the FAST algorithm (Face, Arm, Speech, Time) and key National Institutes of Health Stroke Scale (NIHSS) exam components, enhanced symptom specificity. Critical intervention times were evaluated for improvement. Results: ED POV arrival patients with acute stroke symptoms were studied from 11/7/21-7/31/23; the nurse-driven process was implemented on 11/7/22. Pre-intervention review included 247 patients with 216 patients in the post-intervention review. Median door-to-activation times fell from 17 to 10 minutes, door-to-CT from 24 to 19 minutes, and door-to-needle times from 49 to 43.5 minutes. Median NIHSS scores in tPA-treated patients were compared pre- and post-intervention. In the physician-led group, initial median NIHSS scores were 6, reducing to 1 at discharge. The nurse-led group showed an initial median NIHSS score of 5, also reducing to 1 at discharge. Conclusions: The nurse-driven method effectively shortened critical time metrics in the stroke code process, while maintaining optimal patient outcomes. A paradigm shift towards ED triage nurse-led stroke code activation for acute stroke may lead to higher quality acute stroke care.

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.

Predictive factors of poor outcome and mortality among anterior ischaemic stroke patients despite successful recanalisation in China: a secondary analysis of the CAPTURE trial

ObjectivesThis work aimed to analyse the risk factors for poor outcomes and mortality among patients with anterior large vessel occlusion (LVO) ischaemic stroke, despite successful recanalisation.Setting and participantsThis study conducted...

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.

Association between Rapid Ventricular Response and Stroke Outcomes in Atrial Fibrillation-Related Cardiac Embolic Stroke

Introduction: Patients with atrial fibrillation-related stroke (AF-stroke) are prone to developing rapid ventricular response (RVR). We investigated whether RVR is associated with initial stroke severity, early neurological deterioration (END) and poor outcome at 3 months. Methods: We reviewed patients who had AF-stroke between January 2017 and March 2022. RVR was defined as having heart rate >100 beats per minute on initial electrocardiogram. Neurological deficit was evaluated with National Institutes of Health Stroke Scale (NIHSS) score at admission. END was defined as increase of ≥2 in total NIHSS score or ≥1 in motor NIHSS score within first 72 h. Functional outcome was score on modified Rankin Scale at 3 months. Mediation analysis was performed to examine potential causal chain in which initial stroke severity may mediate relationship between RVR and functional outcome. Results: We studied 568 AF-stroke patients, among whom 86 (15.1%) had RVR. Patients with RVR had higher initial NIHSS score (p < 0.001) and poor outcome at 3 months (p = 0.004) than those without RVR. The presence of RVR [adjusted odds ratio (aOR) = 2.13; p = 0.013] was associated with initial stroke severity, but not with END and functional outcome. Otherwise, initial stroke severity [aOR = 1.27; p = <0.001] was significantly associated with functional outcome. Initial stroke severity as a mediator explained 58% of relationship between RVR and poor outcome at 3 months. Conclusion: In patients with AF-stroke, RVR was independently associated with initial stroke severity but not with END and functional outcome. Initial stroke severity mediated considerable proportion of association between RVR and functional outcome.

Temporalis and masseter muscle thickness as predictors of post-stroke dysphagia after endovascular thrombectomy

PurposePost-stroke dysphagia (PSD) is a common sequela of stroke. Given the association between dysphagia and sarcopenia, we aimed to investigate the association between PSD and temporal muscle thickness (TMT) and masseter muscle thickness (MMT) following endovascular thrombectomy (EVT) in patients with large-vessel occlusion (LVO). MethodsThis retrospective cohort study included hospitalized patients with LVO stroke who underwent EVT between January 1, 2018, and October 31, 2022. TMT and MMT were measured using brain computed tomography (CT) angiography. The correlation between relevant clinicodemographic factors and both TMT and MMT was examined. The relationship between each of two parameters (TMT and MMT) and PSD, which was defined as the retention of the nasogastric (NG) tube at 4 and 12 weeks, was evaluated in adjusted logistic regression models. ResultsAmong the 148 participants, the mean TMT and MMT was 5.9 ± 1.6 and 11.2 ± 2.3 mm, respectively. Lower age, male sex, higher body mass index (BMI), higher albumin levels, and a lower initial National Institute of Health Stroke Scale (NIHSS) score were associated with higher TMT and MMT (p < 0.05). In the logistic regression analysis adjusted for age, sex, BMI, serum albumin, and NIHSS score, lower TMT and MMT significantly correlated with PSD at weeks 4 and 12 (p < 0.001). ConclusionTMT and MMT are associated with age, sex, BMI, albumin, and the initial NIHSS score. Both TMT and MMT are independent indicators of post-EVT PSD in stroke patients and serve as reliable predictors of NG removal.

Association between Triglyceride-Glucose Index and Early Neurological Outcomes after Thrombolysis in Patients with Acute Ischemic Stroke.

The triglyceride-glucose (TyG) index is a novel biomarker of insulin resistance which might plausibly influence endogenous fibrinolysis and thus early neurological outcomes in patients with acute ischemic stroke (AIS) treated with intravenous thrombolysis using recombinant tissue-plasminogen activator. We included consecutive AIS patients within 4.5 h of symptom onset undergoing intravenous thrombolysis between January 2015 and June 2022 in this multi-center retrospective observational study. Our primary outcome was early neurological deterioration (END), defined as ≥2 (END2) or ≥ 4 (END4) National Institutes of Health Stroke Scale (NIHSS) score worsening compared to the initial NIHSS score within 24 h of intravenous thrombolysis. Our secondary outcome was early neurological improvement (ENI), defined as a lower NIHSS score at discharge. TyG index was calculated using the log scale of fasting triglyceride (mg/dL) × fasting glucose (mg/dL)/2. We evaluated the association of END and ENI with TyG index using a logistic regression model. A total of 676 patients with AIS were evaluated. The median age was 68 (Interquartile range, IQR (60-76) years old), and 432 (63.9%) were males. A total of 89 (13.2%) patients developed END2, 61 (9.0%) patients developed END4, and 492 (72.7%) experienced ENI. In multivariable logistic regression analysis, after adjustment for confounding factors, TyG index was significantly associated with increased risks of END2 (categorical variable, vs. lowest tertile, medium tertile odds ratio [OR] 1.05, 95% confidence interval, CI 0.54-2.02, highest tertile OR 2.94, 95%CI 1.64-5.27, overall p < 0.001) and END4 (categorical variable, vs. lowest tertile, medium tertile OR 1.21, 95%CI 0.54-2.74, highest tertile OR 3.80, 95%CI 1.85-7.79, overall p < 0.001), and a lower probability of ENI (categorical variable, vs. lowest tertile, medium tertile OR 1.00, 95%CI 0.63-1.58, highest tertile OR 0.59, 95%CI 0.38-0.93, overall p = 0.022). Increasing TyG index was associated with a higher risk of END and a lower probability of ENI in patients with acute ischemic stroke treated with intravenous thrombolysis.

Prevalence and Prognostic Factors of Cortical Laminar Necrosis in Acute Ischemic Stroke.

Cortical laminar necrosis (CLN) is a specific type of cortical infarction, and little is known about its frequency and outcomes. We aimed to investigate the prevalence and outcomes of CLN caused by brain infarction and its prognostic factors. This retrospective cohort study included patients with acute ischemic stroke (AIS) between 2019 and 2022 and for whom magnetic resonance images obtained at our center showed acute-stage CLN. Their medical records were collected and analyzed. An unfavorable outcome was defined as a modified Rankin Scale score of 3-6 at 90 days. Logistic regression was performed to identify independent predictors of an unfavorable outcome. Among 5548 consecutive patients with AIS, 151 patients (2.7%) were diagnosed with CLN, and 112 had CLN enrolled in the final analysis. At 90 days, 25 patients (22.3%) had an unfavorable outcome. Compared with the favorable group, poor outcome patients had higher rates of previous stroke (p = 0.012), higher National Institutes of Health Stroke Scale (NIHSS) scores at admission (p < 0.001), and were more likely to have early neurologic deterioration (END) (p = 0.014), diffuse ischemic lesions (p = 0.011), and lesions involving multiple lobes (p = 0.030). In multivariable analysis, the initial NIHSS score (OR, 1.258, (95% CI 1.090 - 1.453), p = 0.002) and END (OR, 5.695, [95% CI 1.410 - 23.007], p = 0.015) were independently associated with unfavorable outcome. CLN is a rare ischemic event but has a good prognosis in most cases. A higher initial NIHSS score and END may predict an unfavorable outcome.

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.

Intravenous thrombolysis for mild stroke: NIHSS 3–5 Versus NIHSS 0–2

Background and purposeStudies have shown that mild stroke patients with National Institutes of Health Stroke Scale (NIHSS) score 3–5 but not 0–2 may benefit from the intravenous thrombolysis when compared with antiplatelet therapy. We aimed to compare the safety and effectiveness of thrombolysis in mild stroke with NIHSS score of 0–2 vs. 3–5 and identify the predictors of an excellent functional outcome in a real world longitudinal registry. MethodsIn a prospective thrombolysis registry, we identified patients with acute ischemic stroke who presented within 4.5 hours of symptom onset and had initial NIHSS scores ≤ 5. Demographic data, medical history, pre–stroke medications, imaging data, and laboratory measures were collected. The outcome of interest was modified Rankin Scale score of 0 to 1 at discharge. Safety outcome was evaluated by syptomatic intracrerebral hemorrhage defined as any decline in neurologic status due to hemorrhage within 36 h. Multivariable regression models were performed to explore the safety and effectiveness in the alteplase–treated patients with admission NIHSS 0–2 vs. 3–5 and identify factors independently associated with an excellent functional outcome. ResultsOf a total of 236 eligible patients, those with an admission NIHSS score of 0–2 (n=80) had a better functional outcome at discharge compared with NIHSS 3–5 group (n=156) (81.3% vs. 48.7%, adjusted odds ratio [aOR] 0.40, 95% confidential interval [CI] 0.17 – 0.94, P=0.04) without increasing the rate of symptomatic intracerebral hemorrhage and mortality. Non–disabling stroke (Model 1: aOR 0.06, 95%CI 0.01–0.50, P=0.01; Model 2: aOR 0.06, 95% CI 0.01–0.48, P=0.01) and prior statin therapy (Model 1: aOR 3.46, 95% CI 1.02–11.70, P=0.046; Model 2: aOR 3.30, 95% CI 0.96–11.30, P=0.06) were independent predictors of excellent outcomes. ConclusionsAcute ischemic stroke patients with admission NIHSS 0–2 was associated with better functional outcomes at discharge compared with NIHSS 3–5 within the 4.5–hour time window. Minor stroke severity, non–disabling stroke and prior statin therapy were independent predictors for funcitonal outcomes at discharge. Further studies with large sample size are needed to confirm the findings.

XGBoost-Based Simple Three-Item Model Accurately Predicts Outcomes of Acute Ischemic Stroke

An all-inclusive and accurate prediction of outcomes for patients with acute ischemic stroke (AIS) is crucial for clinical decision-making. This study developed extreme gradient boosting (XGBoost)-based models using three simple factors-age, fasting glucose, and National Institutes of Health Stroke Scale (NIHSS) scores-to predict the three-month functional outcomes after AIS. We retrieved the medical records of 1848 patients diagnosed with AIS and managed at a single medical center between 2016 and 2020. We developed and validated the predictions and ranked the importance of each variable. The XGBoost model achieved notable performance, with an area under the curve of 0.8595. As predicted by the model, the patients with initial NIHSS score > 5, aged over 64 years, and fasting blood glucose > 86 mg/dL were associated with unfavorable prognoses. For patients receiving endovascular therapy, fasting glucose was the most important predictor. The NIHSS score at admission was the most significant predictor for those who received other treatments. Our proposed XGBoost model showed a reliable predictive power of AIS outcomes using readily available and simple predictors and also demonstrated the validity of the model for application in patients receiving different AIS treatments, providing clinical evidence for future optimization of AIS treatment strategies.