Lower National Institutes Of Health Stroke Scale Score Research Articles

Predictors of futile recanalization in ischemic stroke patients with low baseline NIHSS.

There is yet no randomized controlled evidence that mechanical thrombectomy (MT) is superior to best medical treatment in patients with large vessel occlusion but minor stroke symptoms (National Institutes of Health Stroke Scale (NIHSS) <6). Prior studies of patients with admission NIHSS scores ≥6 observed unfavorable functional outcomes despite successful recanalization, commonly termed as futile recanalization (FR), in up to 50% of cases. The aim of this study is to determine the prevalence of FR in patients with minor stroke and identify associated patient-specific risk factors. Our multicenter cohort study screened all patients prospectively enrolled in the German Stroke Registry Endovascular Treatment from 2015 to 2021 (n = 13,082). Included were patients who underwent MT for anterior circulation vessel occlusion with a baseline NIHSS score of <6 and successful recanalization (modified Thrombolysis in Cerebral Infarction (mTICI) scores of 2b-3). FR was defined by modified Rankin Scale (mRS) scores of 2-6 at 90 days. Multivariable logistic regression analysis was conducted to explore factors associated with FR. A total of 674 patients met the inclusion criteria. FR occurred in 268 (40%) patients. Multivariable logistic regression analysis indicates that higher age (adjusted odds ratio (aOR) = 1.04 (95% confidence interval (CI) = 1.02-1.06)), pre-stroke mRS 1 (aOR = 2.70 (95% CI = 1.51-4.84)), transfer from admission hospital to comprehensive stroke center (aOR = 1.67 (95% CI = 1.08-2.56)), longer time from symptom onset/last seen well to admission (aOR = 1.02 (95% CI = 1.00-1.04)), MT under general anesthesia (aOR = 1.78 (95% CI = 1.13-2.82)), higher NIHSS after 24 h (aOR = 1.09 (95% CI = 1.05-1.14)), and symptomatic intracranial hemorrhage (aOR = 16.88 (95% CI = 2.03-140.14)) increased the odds of FR. There was no significant difference in primary outcome between achieving mTICI score of 2b or 3. Unfavorable functional outcomes despite successful vessel recanalization were frequent in acute ischemic stroke patients with low NIHSS scores on admission. We provide patient-specific risk factors that indicate an increased risk of FR and should be considered when treating patients with minor stroke. The data that support the findings of our study are available on reasonable request after approval of the German Stroke Registry (GSR) steering committee.

Lower admission stroke severity is associated with good collateral status in distal medium vessel occlusion stroke.

Distal medium vessel occlusions (DMVOs) are a significant contributor to acute ischemic stroke (AIS), with collateral status (CS) playing a pivotal role in modulating ischemic damage progression. We aimed to explore baseline characteristics associated with CS in AIS-DMVO. This retrospective analysis of a prospectively collected database enrolled 130 AIS-DMVO patients from two comprehensive stroke centers. Baseline characteristics, including patient demographics, admission National Institutes of Health Stroke Scale (NIHSS) score, admission Los Angeles Motor Scale (LAMS) score, and co-morbidities, including hypertension, hyperlipidemia, diabetes, coronary artery disease, atrial fibrillation, and history of transient ischemic attack or stroke, were collected. The analysis was dichotomized to good CS, reflected by hypoperfusion index ratio (HIR) <.3, versus poor CS, reflected by HIR ≥.3. Good CS was observed in 34% of the patients. As to the occluded location, 43.8% occurred in proximal M2, 16.9% in mid M2, 35.4% in more distal middle cerebral artery, and 3.8% in distal anterior cerebral artery. In multivariate logistic analysis, a lower NIHSS score and a lower LAMS score were both independently associated with a good CS (odds ratio [OR]: 0.88, 95% confidence interval [CI]: 0.82-0.95, p<.001 and OR: 0.77, 95% CI: 0.62-0.96, p=.018, respectively). Patients with poor CS were more likely to manifest as moderate to severe stroke (29.1% vs. 4.5%, p<.001), while patients with good CS had a significantly higher chance of having a minor stroke clinically (40.9% vs. 12.8%, p<.001). CS remains an important determinant in the severity of AIS-DMVO. Collateral enhancement strategies may be a worthwhile pursuit in AIS-DMVO patients with more severe initial stroke presentation, which can be swiftly identified by the concise LAMS and serves as a proxy for underlying poor CS.

HYPERDENSE BASILAR ARTERY SIGN IN ISCHEMIC STROKE PATIENT WITH COVID-19: A CASE REPORT

Background: Coronavirus disease 2019 (COVID-19) can cause coagulopathy, leading to thromboembolism disease such as ischemic stroke. Ischemic stroke due to basilar artery occlusion (BAO) is rare condition, which is hard to diagnose and has high mortality especially if accompanied by COVID-19. Objective: To evaluate the presence of infarction in the basilar area in COVID-19 patients and prevent complications that arise due to misdiagnosis Methods: 41 year old male patient came to the emergency unit with left-side weakness, slurred speech, vertigo, and nausea 7 hours before admission. He also had mild fever, cough, and fatigue a week before admission. Patient had full consciousness, blood pressure 180/100, left hemiparesis (motoric 3/5), dysarthria, dysphagia. His National Institutes of Health Stroke Scale (NIHSS) score was 7. Results: From laboratory examination, neutrophil lymphocyte ratio (NLR) was increased to 3.60, he tested positive for SARS-CoV-2 rapid antigen and Polymerase Chain Reaction (PCR) with cycle threshold (CT) value 28.66, and D-dimer was increased to 4000 ng/mL. Bronchovascular markings increased on chest X-ray and hyperdense bacillary artery sign found on head CT-scan suggesting vertebrobasilar infarct. Acute stroke ischemic due to large vessel occlusion in COVID-19 found more often in young men with mild symptoms or asymptomatic COVID-19. Prodromal symptoms and stroke onset in BAO can be atypical and variable. Hyperdense bacillary artery sign on head CT scan was a specific sign and can support the diagnosis of BAO. Concussion: Patient’s condition got better progressively and was allowed to discharge from hospital after 6 days. BAO patients with younger age, lower NIHSS scores, early diagnosis, and prompt treatment had better prognosis.

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

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

Efficacy and safety of thrombectomy for acute ischaemic stroke in patients with pre-stroke mRS scores of 2-3: Real-world evaluation from an open-label, prospective, multicentre, observational study.

This study assessed the efficacy and safety of thrombectomy for acute ischaemic stroke in a population with pre-stroke modified Rankin scale (mRS) scores of 2-3 using real-world data. Our sample set included 2313 consecutive patients enrolled in the Kanagawa Registry of Intravenous and Endovascular Treatment of Acute Ischemic Stroke registry between January 2018 and June 2020 in 40 stroke centres in Kanagawa Prefecture, Japan. Patients treated with intravenous tissue plasminogen activator (t-PA), thrombectomy, or both were included. Patients with pre-stroke mRS scores of 4-5 and those treated only with intra-arterial thrombolysis were excluded. The primary outcome of this study was an mRS score of 0-3 at 90 days after onset to assess the efficacy of thrombectomy for pre-stroke disabled individuals. We performed multivariate logistic regression analyses to investigate independent factors for a 90-day mRS score of 0-3. We also performed nearest-neighbour within-calliper matching between thrombectomy and t-PA only. After excluding patients meeting the exclusion criteria, we analysed data of 2136 consecutive patients, of which 315 (14.7%) had pre-stroke disabilities (mRS score 2-3). A 90-day mRS score of 0-3 was achieved by 33.3% of patients with pre-stroke mRS scores of 2-3. According to multivariate analysis, the National Institutes of Health Stroke Scale (NIHSS) score was an independent factor. Furthermore, after propensity-score matching, thrombectomy showed considerable superiority for achieving a 90-day mRS score of 0-3. Intravenous t-PA and especially thrombectomy were safe and effective for the population with pre-stroke disabilities, particularly for patients with low NIHSS scores.

The predictors of prognosis in endovascular treatment of basilar artery occlusion

Background &amp; Objective: Data about outcomes of endovascular treatment (EVT) in basilar artery occlusion (BAO) are limited. The aim of this study is to evaluate the predictors of functional outcome and to investigate the benefit of bridging intravenous thrombolysis (IVT) and the impact of first-pass effect (FPE) on prognosis. Methods: A total of 57 consecutive BAO patients who received EVT at our tertiary stroke center between January 2018 and March 2021 were retrospectively analyzed. The primary outcome was to evaluate excellent prognosis (mRS 0-1) and mortality (mRS 6) at day 90. The secondary outcome was to define the benefit of bridging IVT and the impact of FPE on prognosis. The safety outcome was symptomatic intracranial hemorrhage (sICH). National Institutes of Health Stroke Scale (NIHSS) at admission and at 24 hours, collateral scores, successful recanalization, asymptomatic ICH, embolization, malignant infarction and decompression were also evaluated. Results: The mean age of the patients was 64.1 ± 14.5 years. Male-to-female ratio was 1.7. Hypertension (HT) was the most common risk factor. Bridging IVT was performed in nine patients (15.8%). The FPE rate was 56.1%. NIHSS scores at admission and at 24 hours were found to be statistically significant predictors of prognosis (P=0.023 and P&lt;0.001, respectively). Bridging IVT, FPE, successful recanalization and collateral status did not significantly predict outcome. Conclusion: Lower NIHSS scores at admission and at 24 hours were significantly associated with excellent prognosis. NIHSS scores at admission and at 24 hours were significantly higher in mortality group. sICH did not predict mortality.

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.

Influencing factors of early dramatic recovery of neurological function after intravenous thrombolysis in patients with branch atheromatous disease.

Intravenous thrombolysis can significantly improve the neurological function of patients with acute ischemic stroke. However, the expected early dramatic recovery (EDR) of neurological function after thrombolysis is not achieved in some patients with branch atheromatous disease (BAD). Here we evaluated the factors associated with EDR after thrombolysis in BAD patients. We conducted a retrospective study on 580 consecutive BAD patients. All patients met the diagnostic criteria of BAD and received intravenous recombinant tissue-type plasminogen activator (rt-PA). EDR was defined when the improvement of National Institutes of Health Stroke Scale (NIHSS) score was >8 points within 2 or 24 hours after rt-PA, or the total NIHSS score was 0 or 1. The factors associated with EDR were analyzed with multivariate logistic regression analysis. Among 580 patients, the incidence of EDR was 35.2% (204 cases). Compared with patients without EDR, patients with EDR had lower incidence of diabetes (15.7% vs 29.3%, P < .001), lower NIHSS scores at 2 and 24 hours after rt-PA (P < .001), less cerebral hemorrhage (0% vs 5.3%, P = .001), and shorter onset to treatment time (OTT) (P < .001). Multivariate logistic regression analysis in propensity score-matched cohort showed that EDR was associated with OTT (adjusted OR = 0.994; 95% CI, 0.989-0.999) and NIHSS score after rt-PA (adjusted OR = 0.768; 95% CI, 0.663-0.890). Notably, diabetes (adjusted OR = 0.477, 95% CI, 0.234-0.972) was an independent factor related to EDR of neurological function in BAD patients. In the subgroup analysis, a lower incidence of diabetes (adjusted OR = 0.205, 95% CI: 0.059-0.714, P = .013) and a lower NIHSS score after thrombolysis in patients with paramedian pontine infarction (adjusted OR = 0.809, 95% CI: 0.656-0.997, P = .047) were significantly associated with EDR. Diabetes is not conducive to EDR of neurological function in patients with BAD, especially in patients with paramedian pontine infraction. Low NIHSS score and short OTT after thrombolysis may be closely related to EDR after intravenous thrombolysis.

Analysis of Advanced Imaging Utilization in Low National Institutes of Health Stroke Scale Score and Rate of Large Vessel Occlusion Detection in Large Telestroke Database (S24.009)

<h3>Objective:</h3> Analyze the rate of large vessel occlusion (LVO) detection in low National Institutes of Health Stroke Scale (NIHSS) score patients in a large multicenter database. <h3>Background:</h3> The benefits of mechanical thrombectomy in low NIHSS score (&lt;6) is unclear and undergoing investigation. Currently, great variation exists in practice patterns of computed tomography angiography (CTA) for patients with low NIHSS. Current guidelines do not address low NIHSS largely owing to a paucity of data. Better understanding of the rate of LVO associated with low NIHSS could help guide clinical practice and pave the way for expanding guideline recommendations. <h3>Design/Methods:</h3> Acute stroke consultations seen in the emergency department in 227 facilities (27 states) from July 1, 2021 to December 31, 2021 were extracted from the TeleCare™ database. The encounters seen within 24 hours of last known normal were reviewed for CTA performed, LVO detected, and NIHSS score. Multivariate analysis was performed to determine the odds ratio (OR) for CTA performed, and LVO found at each NIHSS score of 0–5 with reference of ≥6. <h3>Results:</h3> 23,166 acute stroke encounters were included and 10,507 had CTA performed. There were lesser odds for CTA being performed among patients with an NIHSS of: 0 (OR=0.14, [0.13,0.15]); 1 (OR=0.16, [0.15,0.18]); 2 (OR=0.27, [0.24,0.3]); 3 (OR=0.33, [0.3,0.37]); 4 (OR=0.49, [0.43,0.55]); and 5 (OR=0.71, [0.61,0.82]). In addition, there were lesser odds of an LVO detected among patients with an NIHSS of: 0 (OR=0.1, [0.07,0.13]); 1 (OR=0.09, [0.06,0.12]); 2 (OR=0.16, [0.12,0.22]); 3 (OR=0.14, [0.1,0.2]); 4 (OR=0.24, [0.18,0.32]), and 5 (OR=0.27, [0.2,0.37]). <h3>Conclusions:</h3> Analysis of our large telemedicine database demonstrated a significant number of LVOs detected with NIHSS &lt;6, supporting lowering the minimum NIHSS score for emergent CTA. The cutoff of ≥4 may be optimal threshold for LVO capture. We suggest a rational approach to CTA performance to include patients with NIHSS ≥4 or cortical symptoms. <b>Disclosure:</b> Dr. Sevilis has stock in Moderna. Dr. Fowler has nothing to disclose. Dr. Avila has nothing to disclose. Ms. Boyd has nothing to disclose. Mr. Collins has nothing to disclose. Dr. Gao has nothing to disclose. Dr. Heath has received personal compensation in the range of $0-$499 for serving as a Epidemiologic analysis consultant with Neuroscience Innovation Foundation . Dr. Devlin has received personal compensation for serving as an employee of Neuroscience Innovation Foundation. Dr. Devlin has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Nova Signal. Dr. Devlin has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Viz.ai. Dr. Devlin has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Medtronic. Dr. Devlin has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Medtronic. Dr. Devlin has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Viz,ai. Dr. Devlin has received personal compensation in the range of $5,000-$9,999 for serving as an officer or member of the Board of Directors for Neuroscience Innovation Foundation. Dr. Devlin has stock in Nova Signal. Dr. Devlin has stock in Viz.ai. The institution of Dr. Devlin has received research support from Viz.ai. Dr. Devlin has received research support from Nova Signal. Dr. Devlin has received intellectual property interests from a discovery or technology relating to health care.

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.

Validity of Early Outcomes as Indicators for Comparing Hospitals on Quality of Stroke Care.

Background Insight into outcome variation between hospitals could help to improve quality of care. We aimed to assess the validity of early outcomes as quality indicators for acute ischemic stroke care for patients treated with endovascular therapy (EVT). Methods and Results We used data from the MR CLEAN (Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands)Registry, a large multicenter prospective cohort study including 3279 patients with acute ischemic stroke undergoing EVT. Random effect linear and proportional odds regression were used to analyze the effect of case mix on between-hospital differences in 2 early outcomes: the National Institutes of Health Stroke Scale (NIHSS) score at 24 to 48 hours and the expanded thrombolysis in cerebral infarction score. Between-hospital variation in outcomes was assessed using the variance of random hospital effects (tau2). In addition, we estimated the correlation between hospitals' EVT-patient volume and (case-mix-adjusted) outcomes. Both early outcomes and case-mix characteristics varied significantly across hospitals. Between-hospital variation in the expanded thrombolysis in cerebral infarction score was not influenced by case-mix adjustment (tau 2=0.17 in both models). In contrast, for the NIHSS score at 24 to 48 hours, case-mix adjustment led to a decrease in variation between hospitals (tau 2 decreases from 0.19 to 0.17). Hospitals' EVT-patient volume was strongly correlated with higher expanded thrombolysis in cerebral infarction scores (r=0.48) and weakly with lower NIHSS score at 24 to 48 hours (r=0.15). Conclusions Between-hospital variation in NIHSS score at 24 to 48 hours is significantly influenced by case-mix but not by patient volume. In contrast, between-hospital variation in expanded thrombolysis in cerebral infarction score is strongly influenced by EVT-patient volume but not by case-mix. Both outcomes may be suitable for comparing hospitals on quality of care, provided that adequate adjustment for case-mix is applied for NIHSS score.

Predictive value of computed tomography perfusion for acute ischemic stroke patients with ASPECTS < 6 in an early time window

ObjectiveThe standard for computed tomography perfusion (CTP) assessment has not been well established in early acute ischemic stroke (AIS). We aimed to examine the prognostic factors for good outcomes in patients who received CTP, with an Alberta Stroke Program Early CT Score (ASPECTS) < 6 after endovascular thrombectomy (EVT) in the early time window (0–6 h). MethodsWe retrospectively reviewed 59 patients who met the criteria from October 2019 to April 2021. Based on the modified Rankin Score (mRS) at 90 days, the patients were divided into a good outcome group (mRS 0–2) and a poor outcome group (mRS 3–6). Baseline and procedural characteristics were collected for unilateral and multivariate regression analyses to explore the influencing factors for good outcomes. ResultsOf the 59 patients included, good outcomes were observed in 21 (35.6%). Multivariate logistic regression analysis showed that smaller ischemic core volume (odds ratio [OR]: 0.950; 95% CI: 0.908–0.994; P = 0.026), lower National Institutes of Health Stroke Scale (NIHSS) score (OR: 0.750; 95% CI: 0.593–0.949; P = 0.017) and shorter stroke onset to reperfusion time (ORT) (OR: 0.981; 95% CI: 0.966–0.996; P = 0.016) were independent predictors for good outcomes at 90 days. ConclusionSmaller ischemic core volume based on CTP, lower NIHSS score and shorter ORT were significant independent predictors of good outcomes in patients with ASPECTS < 6 in the early time window after EVT.

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.

A low score on the National Institutes of Health Stroke Scale with eye movement disorder may indicate a good candidate for acute mechanical thrombectomy for posterior circulation large vessel occlusion: illustrative cases.

Basilar artery occlusion (BAO) accounts for 1% of all strokes, and its natural prognosis is extremely poor. There is no consensus on the treatment strategy for mild BAO. Between August 2015 and May 2021, 429 patients received mechanical thrombectomy (MT) in the authors' hospital. Three patients had a BAO with a National Institutes of Health Stroke Scale (NIHSS) score of ≤6 and showed eye movement disorder as the main symptom. MT immediately improved ocular symptoms in all three cases, and the patients were discharged with a modified Rankin Scale ≤2. Lesions responsible for the eye movement disorder are distributed from the midbrain to the pontine tegmentum. These lesions are supplied by the arteries of the interpeduncular fossa, which is impaired by BAO. Symptoms due to problems with the arteries of the interpeduncular fossa can be rapidly improved by MT, and it is useful for preventing neurological deterioration in mild cases. BAO with a low NIHSS score in the presence of eye movement disorder as the main symptom may be a good indication for MT.

Clinical Evidence of Acetyl-L-Carnitine Efficacy in the Treatment of Acute Ischemic Stroke: A Pilot Clinical Trial.

Background This study was undertaken to evaluate the influence of oral Acetyl-L-carnitine (ALC) in patients with acute ischemic stroke. Methods Sixty-nine cases with acute ischemic stroke with the onset of symptoms less than 24 hours not candidates for reperfusion therapy were randomly assigned to either the ALC group (1000 mg three times per day for three consecutive days) or the matching placebo group. The study outcomes based on intention-to-treat criteria included the change in the modified Rankin Scale (mRS) and National Institutes of Health Stroke Scale (NIHSS) score from baseline to day 90, as well as the change in serum levels of the inflammatory and oxidative stress biomarkers over the 3-day treatment protocol. Results The NIHSS score and mRS score on day 90 were improved by 5.82 and 0.94 scores, respectively, in the ALC-treated group compared to 2.83 and 0.11 scores, respectively, in the placebo-treated group, which demonstrated the superiority of ALC relative to placebo. By using the multivariable analysis after adjusting for other variables in the model, compared to the group treated with placebo, patients in the ALC group had lower NIHSS score (β: -2.40, 95% CI: -0.69, -4.10 (p = 0.007)) and mRS score (β: -1.18, 95% CI: -0.52, -1.84 (p = 0.001)) 90 days after the intervention. The percentage of patients with a favourable functional outcome at day 90, defined as mRS scores of 0 or 1, was significantly higher in the ALC group in comparison to the placebo group (52.9% versus 28.6%). Further, over the 3-day treatment protocol, in the patients receiving ALC, the serum levels of proinflammatory biomarkers, including soluble intercellular adhesion molecule-1 (sICAM-1), interleukin 6 (IL-6), tumor necrosis factor-alpha (TNF-α), and neuron-specific enolase (NSE), showed a significant decrease, while the serum levels of antioxidant biomarkers, including glutathione peroxidase (GPx), superoxide dismutase (SOD), and total antioxidant capacity (TAC), as well as the total L-carnitine's level showed a significant increase compared to those in patients receiving placebo indicating significant alteration. Conclusions Although preliminary, these results suggested that ALC administration during the acute phase of ischemic stroke might be helpful in improving functional and neurological outcomes that are probably linked to its anti-inflammatory and antioxidant properties. Trial Registration. This trial is registered with IRCT20150629022965N17 at Iranian Registry of Clinical Trials (registration date: 25/07/2018).

Impact of Medical Community Model on Intravenous Alteplase Door-to-Needle Times and Prognosis of Patients With Acute Ischemic Stroke.

ObjectiveIn this study, we retrospectively analyzed 795 AIS patients who received intravenous alteplase for thrombolytic therapy in one third-class hospital or three second-class hospitals in Dongyang City and sought to evaluate the effects of the medical community model on intravenous alteplase door-to-needle time (DNT) and prognosis of patients with acute ischemic stroke.MethodsAccording to whether the medical community model is established or not, 303 AIS patients (204 cases from the third-class hospital and 99 cases from three second-class hospitals) were assigned to control group unavailable to the medical community model and 492 AIS patients (297 cases from the third-class hospital, and 195 cases from three second-class hospitals) into observational group available to the medical community model.ResultsA higher thrombolysis rate, a shorter DNT, more patients with DNT ≤ 60 min and DNT ≤ 45 min, a shorter ONT, lower National Institutes of Health Stroke Scale (NIHSS) scores at 24 h, 7 d, 14 d, and modified Rankin scale (mRS) scores at 3 months after thrombolytic therapy, a shorter length of hospital stay, and less hospitalization expense were found in the observational group than the control group. Subgroup analysis based on different-class hospitals revealed that the medical community model could reduce the DNT and ONT to increase the thrombolysis rate of AIS patients, especially in low-class hospitals. After the establishment of the medical community model, the AIS patients whether from the third-class hospital or three second-class hospitals exhibited lower NIHSS scores at 24 h, 7 d, 14 d after thrombolytic therapy (p < 0.05). After a 90-day follow-up for mRS scores, a significant difference was only noted in the mRS scores of AIS patients from the third-class hospital after establishing the medical community model (p < 0.05). It was also found that the medical community model led to reduced length of hospital stay and hospitalization expenses for AIS patients, especially for the second-class hospitals.ConclusionThe data suggest that the medical community model could significantly reduce intravenous alteplase DNT and improve the prognosis of patients with AIS.

Arterial spin labeling signal ratio between the lesion and contralateral sides for evaluation of acute middle cerebral artery infarct.

The purpose of our study was to differentiate arterial transit artifact from post-recanalization luxury perfusion on arterial spin labeling (ASL) image, and obtain the relationship between ASL signal intensity and clinical outcomes in patients with acute ischemic stroke.Thirty-five subjects with an acute middle cerebral artery (MCA) infarct were enrolled (18 with recanalized and 17 with non-recanalized MCAs). ASL images were obtained using pseudo-continuous ASL technique with 1600 ms (millisecond) of post-label delay within 3 days from symptom onset. Signal intensities on color ASL images were classified as high, intermediate, and poor grade visually. The ratio of maximum ASL signal between the ischemic area and contralateral side was calculated and compared between patients with and without MCA recanalization. Among patients with non-recanalized MCA, ASL signal ratios were compared between patients with and without hyperintense vessel sign on fluid attenuated inversion recovery (FLAIR). Also, correlation between the ASL signal ratio and National Institutes of Health Stroke Scale (NIHSS) score was evaluated.High or intermediate grade on color ASL images were more frequently found in patients with recanalized MCA (P < .01). Patients with non-recanalized MCA had higher ASL signal ratio in overall ASL signal grade (P = .010) and intermediate grade (P = .011). Among patients with non-recanalized MCA, those with hyperintense vessel sign on FLAIR had higher ASL signal ratios (P = .049). ASL signal ratio was negatively correlated with both initial (P = .023) and final (P = .003) NIHSS scores.The ASL signal ratio could help to differentiate between the pial collaterals and post-recanalization luxury perfusion. A higher ASL ratio was related with the hyperintense vessel sign on FLAIR and lower NIHSS score.

Computed Tomography Perfusion Deficit as an Indicator for Reperfusion in Large-vessel Occlusions with Low National Institutes of Health Stroke Scale Scores in Acute Ischaemic Stroke: A Retrospective Review

Background: Endovascular thrombectomy (EVT) has proven to be successful in acute ischaemic stroke (AIS) with a National Institutes of Health Stroke Scale (NIHSS) score of &gt;8, but remains controversial in AIS with an NIHSS score of &lt;8. This study evaluated computed tomography (CT) perfusion indicators for EVT in large-vessel occlusion (LVO) ischaemic strokes with low NIHSS scores. Methods: We retrospectively reviewed data from 49 patients with AIS, LVO and an NIHSS score of &lt;8 who received medical therapy (n=27), or rescue (n=10) or urgent (n=12) thrombectomy. Therapy decision was made from clinical course and perfusion imaging. The urgent group underwent EVT in &lt;6 hours. The rescue group underwent EVT in &gt;6 hours due to increasing NIHSS scores; this included patients who presented after 6 hours and underwent urgent EVT. Modified Rankin scores were obtained at 3 months to assess outcomes. Results: More patients in the urgent group (91.7%) had a discharge NIHSS improvement (&gt;1) compared with the rescue (50.0%) and medical (51.9%) groups (p=0.02). The urgent group displayed thrombolysis in cerebral infarction (TICI) scores of 2b/3 in 100% of patients, whereas the rescue group displayed TICI scores of 2b/3 in 80% and 1/2a in 20% (p=0.076). The perfusion core (cerebral blood flow [CBF] &lt;30%) was not different between the groups (2.1 cm3, 1.0 cm3 and 9.2 cm3, for urgent, rescue and medical groups, respectively). The perfusion penumbra (time to max [Tmax] &gt;6 s) and mismatch (Tmax minus CBF) were significantly larger for the urgent and rescue groups. Penumbra volume was 80.1 cm3, 107.5 cm3 versus 50.6 cm3 (p=0.011), and mismatch was 78.0 cm3, 106.5 cm3 versus 41.5 cm3 (p=0.002) for urgent and rescue thrombectomy versus medical therapy, respectively. Conclusion: The biggest driver of urgent reperfusion was a larger penumbra seen on CT perfusion, which appeared to show better outcomes in NIHSS scores at discharge without any difference in 3-month outcomes graded by modified Rankin scores. Our data suggest that larger perfusion deficits on CT imaging may serve as a tool for patient selection for EVT in LVO with an NIHSS score of &lt;8 and should be investigated further.

Sodium ozagrel and atorvastatin for type 2 diabetes patients with lacunar cerebral infarction.

BACKGROUNDThe main pathological factor of cerebral infarction is atherosclerosis, which is the pathological process of chronic inflammatory diseases such as vascular smooth muscle hyperplasia, inflammatory cell infiltration, extracellular matrix increase, and thrombosis. At present, the focus of clinical treatment is anti-platelet aggregation and improving blood status, and current research is limited to improving symptoms only.AIMTo observe the effect of sodium ozagrel and atorvastatin on type 2 diabetes patients with lacunar cerebral infarction.METHODSEighty-two patients with type 2 diabetes and lacunar cerebral infarction admitted to our hospital from January 2018 to February 2020 were equally categorized into two groups according to their treatment method. The control group was administered atorvastatin, and the observation group was administered sodium ozagrel combined with atorvastatin. The National Institutes of Health stroke scale (NIHSS) score, activities of daily living (ADL) score, blood glucose, lipid levels, inflammatory factors, high-mobility group box 1 (HMGB1) levels, paraoxonase-1 (PON-1) levels, erythrocyte sedimentation rate (ESR), and macrophage migration inhibitory factor (MIF) levels were recorded before and after treatment. The total effective rate and adverse reaction rate of the two groups were analyzed. RESULTSThe total effective rate of the observation group (94.00%) was significantly higher than that of the control group (80.00%) (χ2 = 3.998; P = 0.046). The blood glucose indexes, total cholesterol levels, triglyceride levels, low-density lipoprotein cholesterol levels, high-sensitivity C-reactive protein levels, interleukin-1β levels, tumor necrosis factor-α levels, HMGB1 Levels, ESR, MIF levels, platelet aggregation rates, and plasma viscosity of the two groups decreased after treatment; however, high-density lipoprotein cholesterol and PON-1 Levels increased after treatment. After treatment, the blood glucose indexes; blood lipid indexes; inflammatory factors; HMGB1, PON-1, and MIF levels; ESR; platelet aggregation rate; and plasma viscosity of the observation group were better than those of the control group (P < 0.05). After treatment, all patients in the observation group had higher ADL scores and lower NIHSS scores than those in the control group (P < 0.05).CONCLUSIONSodium ozagrel with atorvastatin can reduce inflammatory reactions; regulate ESR and HMGB1, PON-1, and MIF levels; control blood glucose and lipid indexes; and alleviate nerve injury without increasing adverse effects of atorvastatin alone.

Persistent challenges in endovascular treatment decision-making for acute ischaemic stroke.

Although endovascular treatment (EVT) is the gold standard for treating acute stroke patients with large vessel occlusion (LVO), multiple challenges in decision-making for specific conditions persist. Recent evidence on a selection of patient subgroups will be discussed in this narrative review. Two randomized controlled trials (RCTs) have been published in EVT of basilar artery occlusion (BAO). Large single arm studies showed promising results in Patients with low Alberta stroke program early CT score (ASPECTS) and more distal vessel occlusions. Recent data confirm patients with low National Institutes of Health Stroke Scale (NIHSS) despite LVO to represent a heterogeneous and challenging patient group. The current evidence does not justify withholding EVT from BAO patients as none of the RCTs showed any signal of superiority of BMT alone vs. EVT. Patients with low ASPECTS, more distal vessel occlusions and patients with low NIHSS scores should be included into RCTs if possible. Without participation in a RCT, patients should be selected for EVT based on age, severity and type of neurological impairment, time since symptom onset, location of the ischaemic lesion and perhaps also results of advanced imaging.