Initial NIH Stroke Scale Score Research Articles

Abstract T P70: Outcome of Japanese Minor Stroke Patients Treated Without Intravenous Recombinant Tissue Plasminogen Activator Within 4.5 Hours After the Symptom Onset ~Fukuoka Stroke Registry~

Background & Purpose: Patients with minor stroke with the initial NIH stroke scale score of 4 or less were often treated without recombinant tissue plasminogen activator (rt-PA) even when they are admitted within 4.5 hours after the symptom onset. We investigated the outcome of minor stroke within 4.5 hours after the symptom onset without intravenous recombinant tissue plasminogen activator therapy. Methods: Among consecutive 6246 acute ischemic stroke patients who were admitted to the 7 stroke centers, 963 patients with admission within 4.5 hours after the symptom onset, ischemic lesions on diffusion-weighted image, NIH stroke scale of 4 or less, and prior modified Rankin scale (mRS) of 0 or 1 were included in the present study. Thirty-four (3.5%) of the 963 patients were treated with intravenous rt-PA. In other 926 patients, we observed a neurological deterioration (a NIHSS score worsening of ≥2-point) and stroke recurrence during the first 3 weeks. A good outcome (3 months) at was defined as mRS of 0 or 1. Results: Stroke recurrence and neurological deterioration occurred in 3.7% and 9.2% of 926 patients during the first 3 weeks. A good outcome 3 months after admission was observed in 82.3%. Atrial fibrillation and diabetes mellitus were less frequent in patients with than without a good outcome. The initial NIH stroke scale score, LDL-cholesterol, glucose, HbA1c, d-dimer, and CRP values were lower, and the initial HDL-cholesterol and estimated GFR values were higher in patients with than without a good outcome. On multivariate analysis, age (OR 0.94, 95%CI 0.92~0.97), the initial NIH stroke scale score (OR 0.60, 95%CI 0.48~0.74), LDL-cholesterol (OR 0.99, 95%CI 0.98~1.00), and D-dimer (OR 0.92, 95%CI 0.85~0.99) were negatively associated with a good outcome. With regard to the ROC curve analysis, the most accurate cut-off value for predicting a good outcome was 74 years in age, 2 in NIH stroke scale score, 137mg/ml in LDL-cholesterol, and 0.80μg/ml in D-dimer. Conclusions: In minor stroke patients treated without rt-PA, age of 75 years or more, NIH stroke scale score of 3 or more, LDL-cholesterol of 138mg/ml or more, or D-dimer of 0.80μg/ml or more could be negative predictor for a good outcome. In such patients, treatment with rt-PA may be considered.

Factors associated with unfavorable outcome in minor ischemic stroke

The purpose of this study was to elucidate the factors that correlate with unfavorable outcomes and to develop a simple validated model for assessing risk of unfavorable outcomes in patients with minor ischemic stroke. The derivation cohort included 1,313 patients hospitalized within 72 hours after onset with an initial NIH Stroke Scale score of 0 to 3 enrolled in a prospective, multicenter, observational study. Unfavorable outcome was defined as dependency (modified Rankin Scale score of 3-5) or death at 90 days. The predictive values of factors related to unfavorable outcome were evaluated. External validation was performed in 879 patients from a single-center stroke registry. In the derivation cohort, a total of 203 patients (15%) had unfavorable outcomes. On multivariable analysis, women (odds ratio [OR] 1.95, 95% confidence interval [CI] 1.30-2.94), age ≥72 years (OR 2.80, 95% CI 1.83-4.36), intra/extracranial vascular occlusive lesion (OR 2.80, 95% CI 1.82-4.28), leg weakness (OR 1.72, 95% CI 1.06-2.82), and extinction/inattention (OR 5.55, 95% CI 1.30-21.71) were independently associated with unfavorable outcome. Patients having both a vascular lesion and either leg weakness or extinction/inattention showed 4.63 (95% CI 2.23-9.33) times the risk of unfavorable outcome compared with those having neither. In the validation cohort, the risk was similar, at 3.77 (95% CI 1.64-8.37). Intra- and extracranial vascular imaging, NIH Stroke Scale items such as leg weakness and extinction/inattention, and their combination, as well as female sex and advanced age, may be useful for predicting unfavorable outcomes in patients with minor stroke.

Lower NIH Stroke Scale Scores Are Required to Accurately Predict a Good Prognosis in Posterior Circulation Stroke

Background: The NIH stroke scale (NIHSS) is an indispensable tool that aids in the determination of acute stroke prognosis and decision making. Patients with posterior circulation (PC) strokes often present with lower NIHSS scores, which may result in the withholding of thrombolytic treatment from these patients. However, whether these lower initial NIHSS scores predict better long-term prognoses is uncertain. We aimed to assess the utility of the NIHSS at presentation for predicting the functional outcome at 3 months in anterior circulation (AC) versus PC strokes. Methods: This was a retrospective analysis of a large prospectively collected database of adults with acute ischemic stroke. Univariate and multivariate analyses were conducted to identify factors associated with outcome. Additional analyses were performed to determine the receiver operating characteristic (ROC) curves for NIHSS scores and outcomes in AC and PC infarctions. Both the optimal cutoffs for maximal diagnostic accuracy and the cutoffs to obtain >80% sensitivity for poor outcomes were determined in AC and PC strokes. Results: The analysis included 1,197 patients with AC stroke and 372 with PC stroke. The median initial NIHSS score for patients with AC strokes was 7 and for PC strokes it was 2. The majority (71%) of PC stroke patients had baseline NIHSS scores ≤4, and 15% of these ‘minor' stroke patients had a poor outcome at 3 months. ROC analysis identified that the optimal NIHSS cutoff for outcome prediction after infarction in the AC was 8 and for infarction in the PC it was 4. To achieve >80% sensitivity for detecting patients with a subsequent poor outcome, the NIHSS cutoff for infarctions in the AC was 4 and for infarctions in the PC it was 2. Conclusion: The NIHSS cutoff that most accurately predicts outcomes is 4 points higher in AC compared to PC infarctions. There is potential for poor outcomes in patients with PC strokes and low NIHSS scores, suggesting that thrombolytic treatment should not be withheld from these patients based solely on the NIHSS.

Abstract T P98: Effect of Atrial Fibrillation and/or Large Artery Atherosclerosis on Stroke Recurrence and Long-term Outcome in Japanese Minor Stroke ~Fukuoka Strok Registry~

Background & Purpose: Atrial fibrillation (AF) and large artery atherosclerosis (LAA) can be associated with a bad outcome even in minor stroke. We investigated stroke recurrence and outcome in Japanese minor stroke patients with AF and/or LAA. Subjects & Methods: Among the consecutive 6246 stroke patients who were admitted to the 7 stroke centers within 7 days after the onset, 3725 patients with acute ischemic stroke with the initial NIH stroke scale score of 7 or less and prior modified Rankin scale (mRS) of 0 or 1 were included in the present study. In accordance with AF and intracranial or extracranial LAA (stenosis of 50% or more in diameter), they were classified into 4 subgroups: patients without both AF and LAA (Group A, n=2154), patients with only AF (Group B, n=475), patients with only LAA (Group C, n=937), and patients with both AF and LAA (Group D, n=159). We observed stroke recurrence and outcome during one year. Results: On the multivariate analysis, age (OR, 0.94; 95%CI 0.93~0.95), initial NIH stroke scale score (OR, 0.70; 95%CI, 0.67~0.74), chronic kidney disease (OR, 0.72; 95%CI, 0.55~0.95), initial HbA1c value (OR 0.87, 95%CI 0.79~0.95), and LAA (OR 0.70, 95%CI 0.55~0.88) had a negative association with a good outcome. Acute stroke recurrences within 3 weeks after the onset were observed in 2.0%, 2.5%, 6.1%, and 9.4% in Group A-D patients respectively (p<0.0001). Stroke recurrences during 1 year were observed 7.0%, 10.7%, 11.6%, and 13.8% in Group A-D patients respectively (p<0.0001). A good outcome (mRS of 0-1) 1 year after the onset was observed in 77.0%, 6.4%, 67.9%, and 65.8% in Group A-D patients respectively (p<0.0001). With regard to the Kaplan-Meier method, there was a significant difference in stroke recurrence among the 4 subgroups, and stroke recurrences were most frequent in Group D (p<0.0001, Log-rank test). Conclusions: In Japanese minor stroke, age, NIH stroke scale score, chronic kidney disease, HbA1c, and LAA were significant predictors for the long-term outcome. In patients with both AF and LAA, stroke recurrences were most frequent, especially in the acute phase, and a long-term good outcome was least frequent consequently.

Abstract 163: Carotid Stenosis and Stroke Recurrence in Minor Stroke Patients With Atrial Fibrillation

Background & Purpose: Both atrial fibrillation (AF) and carotid stenosis (CS) can be associated with acute stroke recurrence and consequent bad outcome even in minor stroke. We investigated stroke recurrence and outcome in Japanese minor stroke patients with AF and/or CS. Subjects & Methods: Among the consecutive 6246 stroke patients who were admitted to the 7 stroke centers within 7 days after the onset, 634 patients with acute ischemic stroke with AF, the initial NIH stroke scale score of 7 or less, and prior modified Rankin scale (mRS) of 0 or 1 were included in the present study. We observed an acute stroke recurrence during 3 weeks. Results: Acute stroke recurrence was observed in 27 (4.3%) patients. Major cerebral artery stenosis of 50% or more in diameter was observed in 159 (25.1%) patients, and among them 43 (6.8%) had carotid stenosis. Any major artery stenosis was more frequent in patients with than without stroke recurrence (55.6% vs 23.7%, p=0.0002). Carotid stenosis was more frequent in patients with than without stroke recurrence (25.9% vs 5.9%, p<0.0001). The initial NIHSS score was not different between patients with and without an acute stroke recurrence. Dyslipidemia, diabetes mellitus, and history of brain hemorrhage were more frequent, and HDL cholesterol and estimated GFR values were lower, and HbA1c, fasting glucose, BUN, and D-dimer values were higher, intima-media thickness 0f the common carotid artery was thicker in patients with than without an acute stroke recurrence. On the multivariate analysis, carotid stenosis (OR 4.93, 95%CI 1.60~15.2) and D-dimer value (OR 1.13, 95%CI 1.00~1.28) had a positive association with an acute stroke recurrence. Among 43 patients with both AF and CS, 7 had an acute stroke recurrence. With regard to the acute antithrombotic treatment, 5 patients were treated with only anticoagulant agents and other 2 patients were treated with both anticoagulant and antiplatelet agents. Conclusions: Carotid stenosis was a significant predictor for an acute stroke recurrence in patients with atrial fibrillation. Optimal antithrombotic treatment in the acute phase in stroke patients with both AF and CS should be investigated.

Abstract TP288: Introduction of a 24/7 Acute Care Nurse Practitioner-Based Stroke Code Team Improved Compliance with Time Targets

Introduction: An on-site stroke team improves access to IV tPA and speeds assessment of acute stroke patients. The impact of an acute care nurse practitioner (ACNP)-based team to provide 24/7 on-site stroke coverage was studied at a Primary Stroke Center that previously lacked on-site coverage around-the-clock. Hypothesis: We hypothesized that the introduction of 24/7 on-site coverage by an ACNP-based acute stroke team would improve compliance with time targets for rapid assessment of stroke patients. Methods: A single Primary Stroke Center in Honolulu, HI prospectively collected data on acute stroke code activations for the Get With the Guidelines - Stroke clinical database over a 33-month period. We retrospectively analyzed data for consecutive periods of 19 months before and 14 months after introduction of a 24/7 on-site acute stroke code team that included an ACNP as first responder. Data included patient characteristics, target times, and tPA utilization. Results: During the 19-month period prior to ACNP coverage, 200 acute stroke code activations occurred. The mean age of patients was 67.6 years, 51.5% were male, and the mean initial NIH stroke scale score was 15.3 +/- 5.1. Acute ischemic stroke was diagnosed in 47% of acute stroke code activations and 36.2% of those were treated with IV tPA. During the 14-month period after ACNP coverage began, the number of stroke code activations increased to 276. The mean age of patients was 67.5 years, 44.6% were male, and the mean initial NIH stroke scale score was 12.4 +/- 7.2. Acute ischemic stroke was diagnosed in 53.3% of acute stroke code activations and 33.3% of those were treated with IV tPA. After the intervention, door-to-CT-completion time improved from 45.2 +/- 30.1 to 37.8 +/- 20/8 minutes (p=0.192), door-to-lab-result time improved from 42.2 +/- 11.4 to 34.0 +/- 12.4 minutes (p=0.003), and door-to-needle time improved from 60.8 +/- 30.2 to 55.1 +/- 24.3 minutes (p=0.367). After the intervention, compliance with the 60-minute target door-to-needle time improved from 62.1% to 72.3% (p=0.247). Conclusions: Introduction of 24/7 on-site ACNP coverage as first responder for acute stroke code activations resulted in modest improvement of compliance with target times for assessment of acute stroke patients.

Abstract WP215: Stroke Without Ischemic Lesions On The Initial Diffusion Weighted Image ~Fukuoka Stroke Registry~

Background & Purpose: Diffusion weighted image (DWI) is indispensable in the early diagnosis of acute ischemic stroke. However, DWI cannot always detect an acute ischemic lesion. We investigated the clinical features and outcome of stroke patients without an ischemic lesion on the initial DWI. Subjects & Methods: Among the consecutive 3062 patients with sudden neurological deficits who were admitted to the 7 stroke centers in Fukuoka prefecture Japan within 24 hours after the symptom onset, 1731 patients with neurological deficits duration of 24 hours or more and pre-stroke modified Rankin scale (mRS) of 0 or 1 were included in the present study. All patients underwent MRI studies including DWI. We investigated clinical features, a neurological deterioration (a NIHSS score worsening of ≥1-point), and stroke recurrence. Results: Among 1731 patients, 102 (5.9%) had no ischemic lesions on DWI (DWI-negative Group), and other 1629 had ischemic lesions on DWI (DWI-positive Group). Atrial fibrillation (16.7% vs 29.2%, p=0.0064) and intracranial or extracranial cerebral artery stenosis of ≥50% in diameter (16.7% vs 36.3%, p<0.0001) were less frequent, and the initial NIH stroke scale score was lower (3.2±2.8 vs 5.8±5.9, p<0.0001) in the DWI-negative than the DWI-positive Group. Analysis on 285 patients who underwent transesophageal echocardiography (TEE), there was no significant differences in the frequency of complicated aortic arch lesions or patent foramen ovale between both groups. Stroke recurrence during the hospital days was relatively less frequent in the DWI-negative than the DWI-positive Group (2.9% vs 4.2%), however, stroke recurrence during 3 months after the onset was relatively more frequent in the DWI-negative than the DWI-positive Group (7.8% vs 6.2%). A good outcome (modified Rankin scale of 0 or 1) on 3 months after the onset was more frequent in the DWI-negative than the DWI-positive Group (73.1% vs 57.7%, p=0.0035). Conclusions: Although a good outcome was more frequent in the DWI-negative than the DWI-positive Group, a stroke recurrence was not rare in the DWI-negative Group. Evaluations for the etiology of stroke, such as TEE, were required even in the stroke patients without ischemic lesions on the initial DWI.

Abstract WP188: Cardiac Diastolic Dysfunction Is Associated With Poor Functional Outcome In Ischemic Stroke Patients

Background and Purpose: Some studies reported that cardiac diastolic dysfunction was related to poor prognosis in heart failure, however, its relationship with acute stroke has not yet been clear. We assessed the hypothesis that cardiac diastolic dysfunction may affect the outcome in acute ischemic stroke patients. Methods: Among 938 consecutive acute stroke patients admitted to Steel Memorial Yawata Hospital, Kitakyushu, Japan within 7 days after the symptom onset from January 2008 to March 2012, 460 patients with ischemic lesions on the initial diffusion-weighted image, prior modified Rankin scale (mRS) of 0 or 1, and available E/E’ values (one of the parameters of cardiac diastolic function in transthoracic echocardiography) evaluated after admission were included into the final statistical analysis. Patients were divided into quartiles according to E/E’ values; Q1 (less than 10), Q2 (10-13), Q3 (14-15), Q4 (more than 15). A NIH stroke scale score worsening of ≥1-point during the first 21 hospital days was defined as an acute neurological deterioration. A modified Rankin scale (mRS) of 2 or more was defined as a poor outcome. We also observed stroke recurrence or any death during one year from the onset. Results: Age (p<0.0001), frequency of female (p<0.0001), initial NIH stroke scale score (p=0.0184), and frequency of diabetes mellitus (p=0.0304), hypertension (p=0.0344), and severe valvular heart diseases (p=0.0008) showed a stepwise increase in Q1-Q4 in order. A poor outcome 3 months after the onset was observed in 15%, 27%, 24%, and 49% in the Q1-4 patients respectively. A stroke recurrence or any death occurred in 6%, 11%, 11%, and 17% in the Q1-4 patients respectively. On the multivariate logistic regression analysis, the worst E/E’ grade (Q4) was independently associated with a poor outcome 3 months after the onset (Odds Ratio 2.7; 95% CI 1.01-7.14; p=0.0463) and stroke recurrence or any death (Odds Ratio 5.2; 95% CI 1.59-18.9; p=0.0058), however, it was not associated with an acute neurological deterioration and a poor outcome on the discharge. Conclusions: Severe cardiac diastolic dysfunction might be associated with a poor outcome and long-term stroke recurrence in ischemic stroke patients.

Early Neurological Deterioration within 24 Hours after Intravenous rt-PA Therapy for Stroke Patients: The Stroke Acute Management with Urgent Risk Factor Assessment and Improvement rt-PA Registry

Background: The initial 24 h after thrombolysis are critical for patients’ conditions, and continuous neurological assessment and blood pressure measurement are required during this time. The goal of this study was to identify the clinical factors associated with early neurological deterioration (END) within 24 h of stroke patients receiving intravenous recombinant tissue plasminogen activator (rt-PA) therapy and to clarify the effect of END on 3-month outcomes. Methods: A retrospective, multicenter, observational study was conducted in 10 stroke centers in Japan. A total of 566 consecutive stroke patients [211 women, 72 ± 12 years old, the median initial NIH Stroke Scale (NIHSS) score of 13] treated with intravenous rt-PA (0.6 mg/kg alteplase) was studied. END was defined as a 4-point or greater increase in the NIHSS score at 24 h from the NIHSS score just before thrombolysis. Results: END was present in 56 patients (9.9%, 18 women, 72 ± 10 years old) and was independently associated with higher blood glucose [odds ratio (OR) 1.17, 95% confidence intervals (CI) 1.07–1.28 per 1 mmol/l increase, p < 0.001], lower initial NIHSS score (OR 0.92, 95% CI 0.87–0.97 per 1-point increase, p = 0.002), and internal carotid artery (ICA) occlusion (OR 5.36, 95% CI 2.60–11.09, p < 0.001) on multivariate analysis. Symptomatic intracranial hemorrhage within the initial 36 h from thrombolysis was more common in patients with END than in the other patients (per NINDS/Cochrane protocol, OR 10.75, 95% CI 4.33–26.85, p < 0.001, and per SITS-MOST protocol, OR 12.90, 95% CI 2.76–67.41, p = 0.002). At 3 months, no patients with END had a modified Rankin Scale (mRS) score of 0–1. END was independently associated with death and dependency (mRS 3–6, OR 20.44, 95% CI 6.96–76.93, p < 0.001), as well as death (OR 19.43, 95% CI 7.75–51.44, p < 0.001), at 3 months. Conclusions: Hyperglycemia, lower baseline NIHSS score, and ICA occlusion were independently associated with END after rt-PA therapy. END was independently associated with poor 3-month stroke outcome after rt-PA therapy.

Abstract 3681: Early Anticoagulation Is Not Associated With Hemorrhagic Transformation Of Ischemic Stroke In Patients With Atrial Fibrillation

Purpose: Hemorrhagic transformation (HT) is a common and potentially devastating complication of ischemic stroke, however its prevalence, predictors, and outcome remain unclear. Early anticoagulation is thought to be a risk factor for HT which raises the clinical question when to (re)start anticoagulation in ischemic stroke patients who have a compelling indication, such as atrial fibrillation. We conducted a prospective cohort study to address this question and to identify association of hemorrhagic transformation with outcome measures in patients with atrial fibrillation in the setting of acute ischemic stroke. Materials and Methods: We performed a prospective study which enrolled consecutive patients admitted with acute ischemic stroke presenting to a single center over a three-year period. As part of the observational study, baseline clinical data and stroke characteristics as well as 3 month functional outcome were collected. For this sub-study, we restricted the analysis to subjects diagnosed with atrial fibrillation. CT and MRI scans were reviewed by experienced readers, blinded to clinical data, to assess for hemorrhagic transformation (using ECASS 2 criteria), microbleeds and infarct volumes in both admission and follow-up scans. Clinical and outcome data were analyzed for association with hemorrhagic transformation. Results: Of 94 patients, 63 had a history of atrial fibrillation (67.0%) and 31 had newly discovered atrial fibrillation (33.0%). We identified HT in 3 of 94 baseline scans (3.2%) and 22 of 48 follow-up scans (45.8%) obtained a median of 3 days post-stroke. In-hospital initiation of either anti-platelet (n = 36; OR 0.34 [95% CI 0.10-1.16], p-value = 0.09) or anticoagulation with unfractionated intravenous heparin or low molecular weight heparin (n = 72; OR 0.25 [95% CI 0.06-1.15], p-value = 0.08) was not associated with HT. Initial NIH Stroke Scale (NIHSS) score (median 13.0 [IQR 15.0] vs. 7.0 [IQR 10.0], p-value = 0.029) and baseline infarct volume (median 17 [IQR 42.03] vs. 5 [IQR 10.95], p-value = 0.011) were significantly higher in patients with HT compared to those without. Hemorrhagic transformation was associated with a significantly higher 48-hour median NIHSS score (20 [IQR 3.0] vs. 2 [IQR 3.25], p-value = 0.007) and larger final infarct volume (81.40 [IQR 82.75] vs. 9.95 [IQR 19.73], p-value &lt; 0.001). Finally, we found a trend towards poorer 3-month modified Rankin Scale scores in subjects with HT (OR 11.25 [95% CI 0.97-130.22], p-value = 0.05). Conclusion: In patients with atrial fibrillation, initial NIHSS score and baseline infarct volume are associated with hemorrhagic transformation in acute ischemic stroke. Early initiation of antithrombotic therapy was not associated with hemorrhagic transformation. Patients with hemorrhagic transformation were found to have a poorer short and long term outcome and larger final infarct volumes.

Abstract 3362: Neurological Deterioration And Stroke Recurrence In The Acute Phase Of Japanese Minor Stroke ∼ Fukuoka Stroke Registry ∼

Background &amp; Purpose: A neurological deterioration in the acute phase can be associated with a bad outcome even in the minor stroke. We investigated the predictive factors for an acute neurological deterioration in minor stroke. Subjects &amp; Methods: Among the consecutive 3062 stroke patients who were admitted to the 7 stroke centers in Fukuoka prefecture Japan within 7 days after the onset, 2113 patients with acute ischemic stroke with the initial NIH stroke scale score of 7 or less and preclinical modified Rankin scale of 0 or 1 were included in the present study. We observed a neurological deterioration (a NIH stroke scale score worsening of ≥1-point), stroke recurrence, or any death during the first 21 hospital days. Results: A neurological deterioration with or without stroke recurrence was observed in 338 (16%) patients. Baseline NIH stroke scale score was not different between patients with and without a neurological deterioration. With regard to the TOAST classification, a neurological deterioration was most frequent in Large-artery atherosclerosis (18.3%), followed by Others (18.2%), Cardioembolism (15.6%), and Small-vessel occlusion (12.2%) in order. In accordance with the site of ischemic lesions, a neurological deterioration was most frequent in patients with both cortex or cerebellar lesions and deep perforating artery lesions (20.2%). A preexisting warfarin use was less frequent (6.8% vs 10%, p=0.0624), diabetes mellitus (42% vs 32%, p=0.0007) and a stenosis of ≥50% in the major brain artery (35% vs 28%, p=0.0133) were more frequent, and the initial values of low density lipoprotein (LDL) cholesterol (122.1±36.5 vs 116.6±34.7 mg/dl, p=0.0100), blood glucose (144.9±66.5 vs 138.9±60.1 mg/dl, p=0.0969), and HbA1c (6.05±1.42 vs 5.91±1.23, p=0.0801) were higher in patients with than without a neurological deterioration. Maximum intima-media thickness of the common carotid artery was relatively thicker in patients with than without a neurological deterioration (1.87±1.55 vs 1.69±0.97 mm, p=0.0624). On multivariate analysis, a stenosis of ≥50% in the major brain artery (OR, 1.40; 95%CI 1.07∼1.85), ischemic lesions including deep perforating artery area (OR, 1.47; 95%CI, 1.10∼1.96), LDL cholesterol (OR, 1.00; 95%CI, 1.00∼1.01), and diabetes mellitus (OR 1.70, 95%CI 1.21∼2.39) had a positive association, and preexisting warfarin use (OR 0.61, 95%CI 0.39∼0.98) had a negative association with a neurological deterioration. Conclusions: The major brain artery stenotic lesion, the site of ischemic lesions, LDL cholesterol, and diabetes mellitus were significant predictor for a neurological deterioration in the acute phase of minor stroke. A preexisting warfarin use might decrease the risk of a neurological deterioration.

Abstract 3984: Neurological Deterioration And Stroke Recurrence In The Acute Phase Of Ischemic Stroke In The Deep Perforating Artery Territory ∼ Fukuoka Stroke Registry ∼

Background &amp; Purpose: A neurological deterioration in the acute phase can be associated with a bad outcome even in the minor stroke. We investigated the predictive factors for an acute neurological deterioration or stroke recurrence in the deep perforating artery territory stroke. Subjects &amp;Methods: Among the consecutive 3062 stroke patients who were admitted to the 7 stroke centers in Fukuoka prefecture Japan within 7 days after the onset, 1141 patients with infarcts supplied by deep perforating artery with the initial NIH stroke scale score of 7 or less and preclinical modified Rankin scale of 0 or 1 were included in the present study. We observed a neurological deterioration (a NIH stroke scale score worsening of ≥1-point), stroke recurrence, or any death during the first 21 hospital days. Results: A neurological deterioration with or without stroke recurrence was observed in 196 (17.2%) patients. Baseline NIH stroke scale score was not different between patients with and without a neurological deterioration (2.7±1.9 vs 2.7±1.7). With regard to the TOAST classification, a neurological deterioration was most frequent in Large-artery atherosclerosis (27.8%), and was least frequent in Small-vessel occlusion (12.3%). The site of ischemic lesions was not associated with a neurological deterioration. A preexisting warfarin use was less frequent (7% vs 11%, p=0.0472), dyslipidemia (62% vs 53%, p=0.0182) and a stenosis of ≥50% in the major brain artery (26% vs 16%, p=0.0009) were more frequent, the values of low density lipoprotein (LDL) cholesterol was higher (124.6±36.3 vs 119.4±33.8 mg/dl, p=0.0495) and high density lipoprotein (HDL) was lower (50.7±14.1 vs 53.8±14.4 mg/dl, p=0.0056) in patients with than without a neurological deterioration. Diabetes mellitus was relatively more frequent in patients with than without a neurological deterioration (43% vs 36%, p=0.0669). On multivariate analysis, a stenosis of ≥50% in the major brain artery (OR, 2.44; 95%CI 1.44∼4.17) had a positive association with a neurological deterioration. Initial HDL values (OR, 0.99; 95%CI, 0.97∼1.00) and preexisting warfarin use (OR, 0.38; 95%CI, 0.13∼1.11) tended to be negatively associated with a neurological deterioration. Conclusions: The major brain artery stenotic lesion was a significant predictor for an acute neurological deterioration or stroke recurrence in the deep perforating artery territory stroke. A preexisting warfarin use and high HDL value might decrease the risk of a neurological deterioration.

Is asymptomatic hemorrhagic transformation really innocuous?

Asymptomatic hemorrhagic transformation (HT) is not associated with immediate deterioration of patients with acute ischemic stroke. However, it is unclear whether it is clinically innocuous with respect to long-term outcome. The aim of this study was to determine the impact of asymptomatic HT on 3-month outcome. A consecutive series of 1,618 patients, hospitalized between January 2004 and August 2007 for ischemic stroke within 7 days from symptom onset were identified in a prospective stroke registry database. Those who had no evidence of acute cerebral ischemia on diffusion-weighted MRI, who did not undergo T2-weighted gradient echo MRI, whose modified Rankin Scale (mRS) score at 3 months after stroke onset was not available, or who had symptomatic HT were excluded. The odds ratio (OR) of asymptomatic HT was calculated for the full distribution of mRS score and adjusted for variables with p < 0.25 with respect to their associations with asymptomatic HT or functional outcome. Of 1,412 patients eligible for the study, 100 (7.1%) had asymptomatic HT. Patients who experienced asymptomatic HT were more likely to have cardioembolic stroke, to receive thrombolytic therapy, to receive anticoagulation with heparin, and to have a higher initial NIH Stroke Scale score. The crude and adjusted ORs of asymptomatic HT for an increment of mRS score at 3 months were 2.94 (95% confidence interval 2.05-4.24) and 1.90 (1.27-2.82), respectively. Our study shows that the odds of a worse outcome are increased by a factor of 2 in patients with asymptomatic HT compared with those without HT after acute ischemic stroke.

Different meaning of vessel signs in acute cerebral infarction

A 64-year-old man presented with left-sided weakness with an initial NIH Stroke Scale score of 11. Brain CT imaging showed a hyperdense artery sign of right middle cerebral artery (MCA) occlusion (figure 1, A …

Early Hospital Arrival Improves Outcome at Discharge in Ischemic but Not Hemorrhagic Stroke: A Prospective Multicenter Study

Background: Our purpose was to determine whether the onset-to-arrival time affects the outcome of stroke patients. Methods: We carried out a prospective multicenter study involving 1,817 patients with ischemic stroke and 1,226 with intracerebral hemorrhage who presented to hospitals within 24 h of symptom onset. The primary outcome was independent activity of daily living corresponding to a modified Rankin Scale (mRS) score ≤2 at discharge approximately 3 weeks after stroke. Results: In ischemic stroke patients, the initial NIH Stroke Scale (NIHSS) score decreased as the onset-to-arrival time increased: 9 (median) in the earliest tertile group (<3 h), 5 in the second tertile group (3–8 h) and 4 in the latest tertile group (≥8 h, p < 0.001). The median mRS scores at discharge in these groups were 3, 2 and 2, respectively (p < 0.001). After adjustment for underlying features and the initial NIHSS score, the independent activity of daily living at discharge was 1.73 times more common in patients in the earliest group than in the latest group (95% CI = 1.24–2.42, p = 0.001). A similar tendency was shown in the subanalysis for large-artery atherosclerosis and cardioembolic stroke. In intracerebral hemorrhage patients, both the initial NIHSS score and the mRS score at discharge decreased as the onset-to-arrival time increased. After multivariate adjustment, the independent activity of daily living was 2.33 times (p < 0.001) and 1.69 times (p = 0.006) less common in patients in the earliest (<1.2 h) and second tertile groups (1.2–3.5 h), respectively, than in the latest tertile group (≥3.5 h). Conclusions: Early hospital arrival improved the clinical outcome in ischemic stroke patients but not in patients with intracerebral hemorrhage.

Distal hyperintense vessels on FLAIR

Hyperintense vessels (HV) on fluid-attenuated inversion recovery imaging are frequently observed in acute ischemic stroke patients. However, the exact mechanism and clinical implications of this sign have not yet been clearly defined. The features of HV and its relevance to other imaging factors are presented here. Prominence and location of HV were documented in 52 consecutive patients with middle cerebral artery (MCA) territory infarction, before treatment with IV recombinant tissue plasminogen activator. Pretreatment ischemic lesion volume, perfusion lesion volume, and vessel occlusion were determined in addition to recanalization status and ischemic lesion volume on follow-up imaging. NIH Stroke Scale (NIHSS) was used as a measure of clinical severity. HV distal to arterial occlusion was observed in 73% of patients; more frequent in proximal than distal MCA occlusion patients. Among the 38 patients with proximal MCA occlusion, initial perfusion lesion volume was comparable among patients with different grade distal HV. However, patients with more prominent distal HV had smaller initial, 24-hour, and subacute ischemic lesion volumes and lower initial NIHSS scores. The presence of distal hyperintense vessels before thrombolytic treatment is associated with large diffusion-perfusion mismatch and smaller subacute ischemic lesion volumes in patients with proximal middle cerebral artery occlusion. DWI = diffusion-weighted imaging; FLAIR = fluid-attenuated inversion recovery; GRE = gradient recalled echo; HV = hyperintense vessels; MCA = middle cerebral artery; MRA = magnetic resonance angiography; MTT = mean transit time; NIHSS = NIH Stroke Scale; PWI = perfusion-weighted imaging; rt-PA = recombinant tissue plasminogen activator; TE = echo time; TI = inversion time; TIMI = thrombolysis in myocardial infarction; TR = repetition time.

Is IV tissue plasminogen activator beneficial in patients with hyperdense artery sign?

To evaluate the effect of IV recombinant tissue plasminogen activator (rt-PA) in patients with hyperdense artery sign (HAS) on initial CT scan. The authors determined the differential effect of IV rt-PA (0.9 mg/kg) in patients with HAS by testing the interaction of rt-PA and HAS in a logistic regression model after adjusting for age, sex, initial NIH Stroke Scale score (NIHSSS), time to randomization, systolic blood pressure, serum glucose, body temperature, and rt-PA in 616 patients treated within 3 hours of symptom onset. Outcomes evaluated included intracranial hemorrhage, modified Rankin scale (mRS) 0-1, Barthel Index (BI) of > or = 95, Glasgow Outcome Scale (GOS) of 0-1, NIHSSS 0-1, and death at 90 days. HAS was detected on the initial CT scan in 91 (15%) of the 616 patients by an independent neuroradiologist. Significantly lower rates of mRS 0-1, BI > or = 95, GOS of 0-1, or NIHSSS 0-1 at 90 days were observed among patients with HAS. IV rt-PA significantly increased the rates of mRS 0-1, BI > or = 95, GOS of 0-1, or NIHSSS 0-1 at 90 days after adjusting for potential confounders without any significant modifying effect (interaction) of HAS. Among the 91 patients with HAS, rt-PA use demonstrated a trend or significance for increased adjusted rates of favorable outcomes by mRS (p = 0.04), BI (p = 0.1), GOS (p = 0.03), and NIHSSS (p = 0.01). Although hyperdense artery sign is associated with poor outcome, IV recombinant tissue plasminogen activator may be beneficial in this subgroup of patients with ischemic stroke.

Acute seizures after intracerebral hemorrhage: a factor in progressive midline shift and outcome.

To determine whether early seizures that occur frequently after intracerebral hemorrhage (ICH) lead to increased brain edema as manifested by increased midline shift. A total of 109 patients with ischemic stroke (n = 46) and intraparenchymal hemorrhage (n = 63) prospectively underwent continuous EEG monitoring after admission. The incidence, timing, and factors associated with seizures were defined. Serial CT brain imaging was conducted at admission, 24 hours, and 48 to 72 hours after hemorrhage and assessed for hemorrhage volume and midline shift. Outcome at time of discharge was assessed using the Glasgow Outcome Scale score. Electrographic seizures occurred in 18 of 63 (28%) patients with ICH, compared with 3 of 46 (6%) patients with ischemic stroke (OR = 5.7, 95% CI 1.4 to 26.5, p < 0.004) during the initial 72 hours after admission. Seizures were most often focal with secondary generalization. Seizures were more common in lobar hemorrhages but occurred in 21% of subcortical hemorrhages. Posthemorrhagic seizures were associated with neurologic worsening on the NIH Stroke Scale (14.8 vs 18.6, p < 0.05) and with an increase in midline shift (+ 2.7 mm vs -2.4 mm, p < 0.03). There was a trend toward increased poor outcome (p < 0.06) in patients with posthemorrhagic seizures. On multivariate analysis, age and initial NIH Stroke Scale score were independent predictors of outcome. Seizures occur commonly after ICH and may be nonconvulsive. Seizures are independently associated with increased midline shift after intraparenchymal hemorrhage.

Utility of perfusion-weighted CT imaging in acute middle cerebral artery stroke treated with intra-arterial thrombolysis: prediction of final infarct volume and clinical outcome.

The goal of this study was to evaluate the utility of perfusion-weighted CT (PWCT) in predicting final infarct volume and clinical outcome in patients with acute middle cerebral artery (MCA) stroke. Twenty-two consecutive patients with MCA stem occlusion who underwent intra-arterial thrombolysis within 6 hours of stroke onset had noncontrast CT and CT angiography with whole-brain PWCT imaging before treatment. Infarct volumes were computed from the initial PWCT and follow-up scans; clinical outcome was measured with the modified Rankin scale. Initial PWCT lesion volumes correlated significantly with final infarct volume (P=0.0002) and clinical outcome (P=0.01). For the 10 patients with complete recanalization, the relationship between initial and final lesion volume was especially strong (R(2)=0.94, P<0.0001, slope of regression line=0.92). For those without complete recanalization, there was progression of lesion volume on follow-up imaging (R(2)=0.50, P=0.01, slope of regression line=1.61). All patients with either initial PWCT lesion volumes >100 mL or no recanalization had poor outcomes (Rankin scores, 4 to 6). Mean admission NIH Stroke Scale scores and mean lesion volumes in the poor outcome group were significantly different compared with the good or fair outcome (Rankin scores, 0 to 3) group (21+/-4 versus 17+/-5, P=0.05, and 106+/-79 versus 29+/-37 mL, P=0.01). Patients with initial volumes <100 mL and partial or complete recanalization all had good (Rankin scores, 0 to 2) or fair (Rankin score, 3) outcomes. Lesion volumes on admission PWCT images approximate final infarct volume for patients with early complete recanalization of MCA stem occlusion. For those without complete recanalization, there is subsequent enlargement of lesion volume on follow-up. Initial PWCT lesion volumes also have predictive value; volumes >100 mL are associated with a poor clinical outcome. In these highly selected patients, initial PWCT lesion volume was a stronger predictor of clinical outcome than was initial NIH Stroke Scale score.

Progression in acute stroke: value of the initial NIH stroke scale score on patient stratification in future trials.

The objective was to determine the occurrence of neurological changes during the first 48 hours after acute stroke as it relates to initial stroke severity. The National Institutes of Health Stroke Scale (NIHSS) was performed serially for the first 48 hours on 127 consecutive ischemic stroke patients (129 strokes) admitted to the neuroscience intensive care unit. Incidence of stroke progression (a >/=3-point increase on the NIHSS) was recorded and analysis performed to determine its association with initial stroke severity and other demographic and physiological variables. Deficit resolution by 48 hours, defined as an NIHSS score of 0 or 1, measured the frequency of functional recovery predicted by the initial deficit. Overall progression was noted in 31% of events (40/129). Applying Bayes' solution to the observed frequency of worsening, the greatest likelihood of predicting future patient progression occurs with stratification at NIHSS scores of </=7 and >7. Patients with an initial NIHSS of </=7 experienced a 14.8% (13/88) worsening rate versus a those with a score of >7 with a 65.9% (27/41) worsening rate (P<0.000005). Forty-five percent (40/88) of those with an initial score of </=7 were functionally normal at 48 hours, whereas only 2.4% (1/41) of those with scores of >7 returned to a normal examination within this period (chi2, P<0.000005). This study suggests that the early clinical course of the neurological deficit after acute stroke is dependent on the initial stroke severity and that a dichotomy in early outcome exists surrounding an initial NIHSS score of 7. These findings may have significant implications for the design and patient stratification in treatment protocols with respect to primary clinical outcome.