Lower NIHSS Score Research Articles

Urinary AD7c-NTP is Associated With Cognitive Recovery After Ischemic Stroke.

Urinary Alzheimer-associated neuronal thread protein (AD7c-NTP) is regarded as a biomarker for β-amyloid protein deposition in Alzheimer disease (AD). The value of AD7c-NTP in predicting post-stroke cognitive recovery was worth exploring. In total, 224 patients with first-ever stroke were enrolled in this retrospective study. Cognitive assessment was evaluated by Mini-Mental State Examination (MMSE), and cognitive improvement was defined as MMSE scores ≥27 or 4-score elevation at 3-month follow-up after stroke. The AD7c-NTP level was 0.68±0.40ng/mL in the 135 patients with cognitive improvement, while the AD7c-NTP level was 1.49±0.99ng/mL in the 89 patients without improvement ( P <0.001). Those displaying better cognitive recovery also had younger ages, higher MMSE scores, and lower NIHSS scores on admission. In multivariable logistic regression analysis, AD7c-NTP concentration (OR=9.14, 95% CI: 4.52-18.49, P <0.001), age (OR=1.04, 95% CI: 1.01-1.08, P =0.012), and NIHSS score on admission (OR=1.17, 95% CI: 1.07-1.28, P <0.001) remained the independent risk factors affecting cognitive recovery. The area under the receiver operating characteristics curve for AD7c-NTP in predicting unfavorable cognitive function was 0.80 (sensitivity: 0.73 and specificity: 0.84). Urinary AD7c-NTP is a valuable biomarker associated with post-stroke cognitive recovery. It might be adopted to discriminate coexisting AD pathology from vascular cognitive impairment.

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=13082). 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] score of 2b-3). FR was defined by a modified Rankin Scale (mRS) score 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: 1.04 [95% confidence interval: 1.02-1.06]), pre-stroke mRS 1 (aOR: 2.70 [1.51-4.84]), transfer from admission hospital to comprehensive stroke center (aOR: 1.67 [1.08-2.56]), longer time from symptom onset/last seen well to admission (aOR: 1.02 [1.00-1.04]), MT under general anesthesia (aOR: 1.78 [1.13-2.82]), higher NIHSS after 24 hours (aOR: 1.09 [1.05-1.14]), and symptomatic intracranial hemorrhage (aOR: 16.88 [2.03-140.14]) increased the odds of FR. There was no significant difference in primary outcome between achieving mTICI 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 GSR steering committee.

Clinical effect of external ventricular drainage under intracranial pressure monitoring in the treatment of aneurysmal subarachnoid hemorrhage patients and investigation of the mechanism of miR-146a-5p/STC1 axis in inhibiting early brain injury in aneurys.

Aneurismal subarachnoid hemorrhage (aSAH) is a common disease in the neural system, with high death rate. Our study aimed to explore the clinical effect of external ventricular drainage under intracranial pressure monitoring in the treatment of patients with aSAH and investigate the role along with mechanism of miR-146a-5p in aSAH. Ninety-six aSAH patients were allocated into control group (CG) and study group (SG). The CG was released by lumbar puncture. The SG underwent external ventricular drainage based on intracranial pressure monitoring. The prognosis, daily living ability, neurological function, S100β and NSE (neuron-specific enolase) levels and incidence of complications were monitored. Besides, a rat model of SAH was built to assess the neurobehavioral function, blood-brain barrier permeability, brain water content, neuronal apoptosis as well as inflammation. SAH cell model stimulated by oxyhemoglobin, and cell apoptosis as well as inflammation were measured. Luciferase reporter assay was implemented to explore the interaction between miR-146a-5p and STC1. Results showed higher GOS and BI scores but lower NIHSS scores, S100β and NSE levels and complication rates in SG compared with CG. Additionally, miR-146a-5p presented down-regulation in brain tissues of SAH rat model, and overexpressed miR-146a-5p reduced brain injury along with neuroinflammation in SAH rat model. Oxyhemoglobin-induced nerve cell apoptosis along with inflammation after SAH, and overexpressed miR-146a-5p repressed oxyhemoglobin-induced nerve cell apoptosis along with inflammation. STC1 is the target mRNA of miR-146a-5p, and overexpressed miR-146a-5p represses oxyhemoglobin-induced nerve cell apoptosis along with inflammation via regulating STC1 expression. In conclusion, external ventricular drainage under intracranial pressure monitoring could promote prognosis, promote daily living ability, improve neurological function, reduce S100β protein and NSE levels, and reduce the incidence of complications in patients with aSAH. Meanwhile, miR-146a-5p inhibited early brain injury and neuroinflammation in aSAH via regulating STC1 expression.

Observation of Efficacy of rt-PA Thrombolysis Combined with Solitaire AB Stent Mechanical Thrombectomy in Patients with Acute Ischemic Stroke: A Retrospective Analysis

Objective: To observe and analyze the efficacy of recombinant tissue-plasminogen activator (rt-PA) thrombolysis combined with Solitaire AB stent mechanical thrombectomy in patients with acute ischemic stroke. Methods: Clinical efficacy, neurological function, oxidative stress response, adverse reactions, and quality of life were compared between the two groups. Results: Lower NIHSS scores were observed among patients who received treatment within 2 hours after stroke onset when compared with those in a timeframe of 2-6 hours, suggesting better neurological function recovery of the patients with early intervention and thus emphasizing the importance of early treatment for patients with stroke onset. Clinical efficacy in the combination group was significantly higher than in the control group (P < 0.05). After treatment, Paraoxonase-1 (PON-1) levels were higher, while lipoprotein-associated phospholipase A2 (Lp-PLA2) and Serum Amyloid A (SAA) levels were lower in the combination group compared to the control group (P < 0.05). The incidence of adverse reactions was significantly lower in the combination group (P < 0.05). At discharge, we observed significantly more patients with good recovery in the combination group when compared to the control group (P < 0.05), suggesting better quality of life of the patients, while this statistical significance was no longer observable at 90 days after discharge (P > 0.05). Conclusion: For acute ischemic stroke patients, rt-PA thrombolysis combined with Solitaire AB stent mechanical thrombectomy treatment is effective. It promotes neurological function recovery, improves vascular stenosis, reduces inflammation and adverse reactions, and enhances quality of life, showing promising clinical applications.

Endovascular Thrombectomy for Stroke in Patients with Low NIHSS Scores and Outside the Thrombolysis Window: A Nationwide Inpatient Sample Analysis 2016–2019 (P1-5.016)

Endovascular Thrombectomy for Stroke in Patients with Low NIHSS Scores and Outside the Thrombolysis Window: A Nationwide Inpatient Sample Analysis 2016–2019 (P1-5.016)

Early neurological changes following endovascular therapy for acute stroke due to intracranial atherosclerotic disease

BackgroundEndovascular therapy (EVT) reduces functional disability in patients with acute large vessel occlusion (LVO). However, the early neurological change after EVT may be limited in patients with intracranial atherosclerotic disease (ICAD). MethodsWe analyzed the Japanese Registry of NeuroEndovascular Therapy (JR-NET) 4 which was a retrospective, nationwide, multicenter registry of patients with LVO between 2015 and 2019. We compared the early neurological change, efficacy and safety of EVT for acute LVO in ICAD and other etiologies. The primary outcome was NIHSS improvement ≥10 points, and secondary outcome were NIHSS worsening ≥4 points 7 days after EVT, effective reperfusion rate, 30-day functional outcomes, and safety outcomes. ResultsAmong the 6710 enrolled patients, 610 (9.1%) had ICAD. The ICAD group was younger (mean 72.0 vs. 75.8 years) and predominantly male (63.4% vs. 56.0%), had lower NIHSS scores before EVT (median 16 vs. 18), and underwent percutaneous transluminal angioplasty and stenting more frequently (43.0% vs. 4.4%, 12.3% vs. 4.4%). In the ICAD group, NIHSS improvement was significantly lower (adjusted odds ratio (aOR) [95% confidence interval (95%CI)] 0.52 [0.41–0.65]), NIHSS worsening was significantly higher (aOR [95%CI] 1.76 [1.31–2.34]), and effective reperfusion was significantly lower (aOR [95%CI] 0.47 [0.36–0.60]). Fewer patients with ICAD had modified Rankin scale 0–2 at 30 days (aOR [95%CI] 0.60 [0.47–0.77]). The risk of acute reocclusion was more prominent in the ICAD group (aOR [95%CI] 4.03 [1.98–8.21]). ConclusionsImprovement in neurological severity after EVT was lower in patients with LVO and ICAD.

Abstract WP178: Evaluation of Low NIHSS Subitems Association With LVO Detection in Large Telestroke Database

Background: The benefits of mechanical thrombectomy in low NIHSS score (&lt;6) is unclear and undergoing investigation. Current acute stroke guidelines do not address the utilization of computed tomography angiography (CTA) in low NIHSS largely due to a paucity of data leading to great variation in clinical practice. Understanding the predictive value of NIHSS subitems for LVO may help guide imaging selection. Methods: 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 by TeleSpecialists TM database. The encounters with CTA performed were reviewed for LVO detected, and NIHSS score with individual subitems. Logistic regression analysis was performed on the NIHSS subitems in total and at NIHSS cutoff points of ≤6, ≤4, and ≤2. Results: A total of 12,668 patients had complete NIHSS subitems available with 1,459 (11.5%) having an LVO and 11,209 without an LVO were extracted. There is a significant difference in the ORs for each subitem. The ORs for patients with NIHSS ≤6 subitems: Level of Consciousness 1.11 (p=0.626), Consciousness Questions 1.36 (p&lt;0.001), Consciousness Commands 1.94 (p&lt;0.001), Best Gaze 1.61 (p=0.061), Visual Field 1.65 (p&lt;0.001), Facial palsy 1.71 (p &lt;0.001), Motor Arm-left 1.43 (p &lt;0.001), Motor arm-right 1.03 (p=0.840), Motor leg-left 0.97 (p=0.758), Motor leg-right 0.83 (p=0.103), Limb ataxia 1.09 (p=0.545), Sensory 0.67 (p=0.001), Language 1.92 (p&lt;0.001), Dysarthria 1.81 (p&lt;0.001), and Neglect 5.78 (p&lt;0.001). Trends in subitems with each lower cutoff were increased odds of LVO with Consciousness Commands, Visual Fields, Language, and Neglect, and lower odds of LVO with Sensation. Conclusions: This analysis shows the limitations of the NIHSS subitems to predict LVO. Despite the trend of lower odds of LVO for Sensation, even with the NIHSS cutoff of ≤2 there would have been 7 LVOs missed. There are 6 subitems showing statistical significance at an NIHSS cutoff of ≤2 which suggests that an NIHSS cutoff, even with these identified subpoints, is not a good CTA candidate selection tool for the detection of all LVOs.

Effects of Solitaire AB stent thrombectomy with tirofiban and butylphthalide on neurological function and inflammatory factors in acute cerebral infarction patients

Background Acute cerebral infarction profoundly affects patients’ neurological function and quality of life. This study explores the impact of Solitaire AB stent thrombectomy, combined with tirofiban and butylphthalide, on neurological function and inflammatory factors in patients with acute cerebral infarction. Methods Seventy-three eligible patients treated between 2021 and 2023 were divided into a control group (Solitaire AB stent thrombectomy) and a treatment group (Solitaire AB stent thrombectomy with tirofiban and butylphthalide). Postoperative neurological function scores and inflammatory factor levels were analyzed. Results The treatment group demonstrated a higher clinical effective rate, lower National Institutes of Health Stroke Scale scores at one day and seven days and higher Mini-Mental State Examination and Montreal Cognitive Assessment scores post-treatment. Inflammatory factor levels (Neuron Specific Enolase (NSE), S100-β, TNF-α and IL-6) were lower in the treatment group. No significant differences in adverse outcomes were observed. Conclusion Solitaire AB stent thrombectomy with tirofiban and butylphthalide shows superior efficacy, improving neurological function and inflammatory factors without increasing adverse outcomes. This offers valuable insights for clinical treatment of acute cerebral infarction.

Efficacy of neuroendoscopic and small-bone-window craniotomy microsurgery for hypertensive cerebral hemorrhage: a meta-analysis of Chinese RCT studies.

To compare the clinical efficacy of neuroendoscopy and small-bone-window craniotomy microsurgery in the treatment of supratentorial hypertensive intracerebral hemorrhage. A search was conducted for Chinese randomized controlled trials on neuroendoscopy and small-bone-window craniotomy microsurgery treatment of hypertensive intracerebral hemorrhage published before February 1, 2024, in PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure, Wanfang Data, and China Science and Technology Journal Database. Meta-analysis was performed using Review Manager 5.4 software. We included 9 randomized controlled trials, with 391 cases in the neuroendoscopy group and 403 cases in the craniotomy group. The meta-analysis results showed that compared to the small-bone-window craniotomy group, the neuroendoscopy group had a higher rate of hematoma clearance (95% CI [6.65, 18.52], p < 0.00001), less intraoperative bleeding (95% CI [-294.83, -284.75], p < 0.00001), shorter operation time (95% CI [-138.65, -63.04], p < 0.00001), fewer days in the ICU (95% CI [-8.56, -4.04], p < 0.00001), lower rate of postoperative complications (95% CI [0.15, 0.50], p < 0.0001), lower NIHSS score at 3 months postoperatively (95% CI [-6.82, -5.36], p < 0.00001), and higher ADL score (95% CI [16.5, 20.07], p < 0.00001). All comparison results were statistically significant. Compared with small-bone-window craniotomy microsurgery, neuroendoscopic surgery for episodic hypertensive cerebral hemorrhage resulted in a higher rate of hematoma clearance, less intraoperative bleeding, shorter operative time, fewer days in the ICU, a lower rate of postoperative complications and a lower 3-month postoperative NIHSS score, and a higher ADL score.

Abstract 142: Safety and Efficacy of PCSK9 inhibitor injection in Pathients immediately before mechanical thrombectomy

Introduction Statins are lipid‐lowering agents and have beneficial effects in patients with acute ischemic stroke, including in the hyperacute period around mechanical thrombectomy.Evolucumab, a PCSK9 inhibitor, is a fast‐acting drug that lowers serum LDL with beneficial effects during chronic stroke period. During an hyperacute ischemic stroke, the brain can be vulnerable, especially around reperfusion therapy. However, the clinical effect of PCSK9 inhibitor injection around mechanical thrombectomy is still unknown. Here we showed the efficacy and safety of PCSK9 inhibitor injection immediately prior to mechanical thrombectomy for these patients. Methods The subjects were stroke patients who underwent mechanical thrombectomy at Inha University Hospital from April 2019 to March 2023. Clinical profiles between the evolucumab group and the non‐user group were analyzed. Results Of the 263 patients enrolled, 112 (42.6%) were male and the mean age was 69.1 years. Of these, 42 patients received a single dose of a PCSK9 inhibitor immediately prior to intervention and additional injections were not made due to insurance issues. Evolukumab injection was determined according to physician preference. There were no significant differences between the two groups in age, gender ratio, major risk factors, stroke etiology, or prior statin treatment. Evolucumab group had a higher stent recovery rate than the non‐user group (70.7 vs 53.4%, p = 0.04). However, there were no significant difference in TICI grade, or symptomatic hemorrhage. Compared with non‐user group, Evolucumab group had the lower NIHSS score on discharge (12.41 vs 8.83, p=0.03) and seemed to have the lower in‐hopital mortality(12.2 vs 2.4% p=0.06) Mean LDL‐C levels at admission and 3 months after stroke did not differ between the two groups. Cardiovascular and other adverse events within 3 months were similar in both groups. Conclusion Evolocumab added to conventional high‐intensity statin therapy was well tolerated and appeared to be associated with lower in‐hospital mortality and lower NIHSS scores at discharge without additional side effects. Further large randomized clinical trials might be needed to investigate the beneficial effects of PCSK9i during hyperacute stroke period.

The machine learning methods to analyze the using strategy of antiplatelet drugs in ischaemic stroke patients with gastrointestinal haemorrhage

BackgroundFor ischaemic stroke patients with gastrointestinal haemorrhage, stopping antiplatelet drugs or reducing the dose of antiplatelet drugs was a conventional clinical therapy method. But not a study to prove which way was better. And the machinery learning methods could help to obtain which way more suit for some patients.MethodsData from consecutive ischaemic stroke patients with gastrointestinal haemorrhage were prospectively collected. The outcome was a recurrent stroke rate, haemorrhage events, mortality and favourable functional outcome (FFO). We analysed the data using conventional logistic regression methods and a supervised machine learning model. We used unsupervised machine learning to group and analyse data characters. ResultsThe patients of stopping antiplatelet drugs had a lower rate of bleeding events (p = 0.125), mortality (p = 0.008), rate of recurrence of stroke (p = 0.161) and distribution of severe patients (mRS 3–6) (p = 0.056). For Logistic regression, stopping antiplatelet drugs (OR = 2.826, p = 0.030) was related to lower mortality. The stopping antiplatelet drugs in the supervised machine learning model related to mortality (AUC = 0.95) and FFO (AUC = 0.82). For group by unsupervised machine learning, the patients of better prognosis had more male (p < 0.001), younger (p < 0.001), had lower NIHSS score (p < 0.001); and had a higher value of serum lipid level (p < 0.001).ConclusionsFor ischemic stroke patients with gastrointestinal haemorrhage, stopping antiplatelet drugs had a better prognosis. Patients who were younger, male, with lesser NIHSS scores at admission, with the fewest history of a medical, higher value of diastolic blood pressure, platelet, blood lipid and lower INR could have a better prognosis.

The Good Clinical Outcome for Patients with Acute Ischemic Stroke Treated with Mechanical Thrombectomy—Does Time Still Matter?

The primary target was an investigation of the factors predicting a good clinical outcome of patients with acute ischemic stroke after treatment with mechanical thrombectomy. Additionally, we compared the treatment results in known and unknown symptom onset time groups. We retrospectively analyzed the data from 2012 to 2020 and divided 240 patients into the known and unknown symptom onset time groups. We looked for the variables predicting a good clinical outcome (NIHSS 0–4 at discharge) in both groups. In both groups, there was no statistically significant difference in good clinical outcomes (43% in the known symptom onset time group vs. 33.3% in the unknown symptom onset time group, p = 0.203). Factors predicting a good clinical outcome in both groups were lower NIHSS scores at admission, the presentation of pial arterial collaterals on admission CT angiography, and bridging intravenous thrombolysis. In the known symptom onset time group, lower age was also a factor predicting good outcome. Our clinical results of treatment by using mechanical thrombectomy were comparable in the known and unknown symptom onset time groups.

Frequency, characteristics, and predictors of headache attributed to acute ischemic stroke

ObjectivesAlthough headache is a common symptom in acute ischemic stroke, the clinical and radiological factors associated with its occurrence are controversial. This work aimed to determine the frequency, characteristics, and predictors of headache occurrence among patients with acute ischemic stroke. MethodsThis cross-sectional study was conducted on 303 patients with acute ischemic stroke. The patients were submitted to detailed history taking, clinical and radiological assessment. A detailed analysis of headache was performed for the patients who experienced headache temporally related to stroke onset. ResultsDiagnosis of headache attributed to the ischemic stroke was established in 129 (42.6%) patients; sentinel headache in 17.2% of patients, and headache at stroke onset in 25.4% of patients. The headache group had a significantly younger age (P=0.017), lower NIHSS score (P=0.042), higher frequency of pre-existing headache disorders (P=0.001), substance use disorder (P=0.021), and fever (P=0.036), and lower frequency of chronic hypertension (P=0.013) and small vessel disease (P=0.004) than non-headache group. Infarction involving posterior circulation was more frequent in headache than in non-headache groups (P=0.003). The presence of migraine, tension-type headache, other types of headache, fever and posterior circulation stroke increased the odds of headache by 27.4 (95%CI=8.0–94.4), 7.6 (95%CI=3.93–14.6), 26.2 (95%CI=8.0–85.8), 3.75 (95%CI=1.22–11.6) and 3.15 (95%CI=1.65–6.0) times, respectively, whereas, the presence of small vessel disease decreased the odds of headache by 0.51 (95%CI=0.279–0.95) times. ConclusionPre-existing headache disorder, fever, and posterior circulation stroke were associated with headache occurrence in acute ischemic stroke patients.

Predictors of congruency between clinical and radiographic Oxfordshire Community Stroke Project Classification subtypes

BackgroundThe Oxfordshire Community Stroke Project (OCSP) classification has been widely used to assess ischemic stroke patients based on clinical characteristics alone. However, the correlation between the clinical presentation evaluated using OCSP and imaging findings is yet to be determined. Our study aimed to describe the baseline characteristics of the OCSP subtypes of patients admitted with ischemic stroke and evaluate the predictors of the relationship between clinical and neuroimaging findings. MethodsPatients with a confirmed diagnosis of ischemic stroke admitted to a comprehensive stroke center in Brazil between February 2015 and October 2017 were eligible for the study. All participants underwent computed tomography (CT) at admission and follow-up neuroimaging within seven days, per the institutional protocol. Trained staff classified patients according to the OCSP at hospital admission. The radiographic OCSP classification was retrospectively assessed based on the last follow-up neuroimaging by investigators unaware of the clinical classification. ResultsThe overall agreement rates ranged from 65.5% to 88.7%. Lower NIHSS scores, absent hyperdense MCA sign, higher ASPECTS, and absent brainstem symptoms were related to a higher risk of misclassification. Treatment with intravenous tPA was associated with reclassification in patients with total anterior circulation syndrome. For predicting radiographic posterior circulation involvement, vertigo (OR 2.9, 95% CI 1.7–5.1, p < 0.001) and brainstem symptoms (OR 35, 95% CI 20.5–60.2, p < 0.001) were directly associated with correct classification, but motor and higher cerebral function were not correlated. ConclusionThe clinical OCSP classification presented good congruency rates with the neuroimaging findings. However, patients with lacunar syndromes are often misclassified when radiological criteria are considered.

Safety and Efficacy of ApTOLL in Patients With Ischemic Stroke Undergoing Endovascular Treatment

ApTOLL is a TLR4 antagonist with proven preclinical neuroprotective effect and a safe profile in healthy volunteers. To assess the safety and efficacy of ApTOLL in combination with endovascular treatment (EVT) for patients with ischemic stroke. This phase 1b/2a, double-blind, randomized, placebo-controlled study was conducted at 15 sites in Spain and France from 2020 to 2022. Participants included patients aged 18 to 90 years who had ischemic stroke due to large vessel occlusion and were seen within 6 hours after stroke onset; other criteria were an Alberta Stroke Program Early CT Score of 6 to 10, estimated infarct core volume on baseline computed tomography perfusion of 5 to 70 mL, and the intention to undergo EVT. During the study period, 4174 patients underwent EVT. In phase 1b, 0.025, 0.05, 0.1, or 0.2 mg/kg of ApTOLL or placebo; in phase 2a, 0.05 or 0.2 mg/kg of ApTOLL or placebo; and in both phases, treatment with EVT and intravenous thrombolysis if indicated. The primary end point was the safety of ApTOLL based on death, symptomatic intracranial hemorrhage (sICH), malignant stroke, and recurrent stroke. Secondary efficacy end points included final infarct volume (via MRI at 72 hours), NIHSS score at 72 hours, and disability at 90 days (modified Rankin Scale [mRS] score). In phase Ib, 32 patients were allocated evenly to the 4 dose groups. After phase 1b was completed with no safety concerns, 2 doses were selected for phase 2a; these 119 patients were randomized to receive ApTOLL, 0.05 mg/kg (n = 36); ApTOLL, 0.2 mg/kg (n = 36), or placebo (n = 47) in a 1:1:√2 ratio. The pooled population of 139 patients had a mean (SD) age of 70 (12) years, 81 patients (58%) were male, and 58 (42%) were female. The primary end point occurred in 16 of 55 patients (29%) receiving placebo (10 deaths [18.2%], 4 sICH [7.3%], 4 malignant strokes [7.3%], and 2 recurrent strokes [3.6%]); in 15 of 42 patients (36%) receiving ApTOLL, 0.05 mg/kg (11 deaths [26.2%], 3 sICH [7.2%], 2 malignant strokes [4.8%], and 2 recurrent strokes [4.8%]); and in 6 of 42 patients (14%) receiving ApTOLL, 0.2 mg/kg (2 deaths [4.8%], 2 sICH [4.8%], and 3 recurrent strokes [7.1%]). ApTOLL, 0.2 mg/kg, was associated with lower NIHSS score at 72 hours (mean difference log-transformed vs placebo, -45%; 95% CI, -67% to -10%), smaller final infarct volume (mean difference log-transformed vs placebo, -42%; 95% CI, -66% to 1%), and lower degrees of disability at 90 days (common odds ratio for a better outcome vs placebo, 2.44; 95% CI, 1.76 to 5.00). In acute ischemic stroke, 0.2 mg/kg of ApTOLL administered within 6 hours of onset in combination with EVT was safe and associated with a potential meaningful clinical effect, reducing mortality and disability at 90 days compared with placebo. These preliminary findings await confirmation from larger pivotal trials. ClinicalTrials.gov Identifier: NCT04734548.

Diagnostic accuracy of telestroke consultation: a Louisiana based tele-network experience.

Telestroke has grown significantly since its implementation. Despite growing utilization, there is a paucity of data regarding the diagnostic accuracy of telestroke to distinguish between stroke and its mimics. We aimed to evaluate diagnostic accuracy of telestroke consultations and explore the characteristics of misdiagnosed patients with a focus on stroke mimics. We conducted a retrospective study of all the consultations in our Ochsner Health's TeleStroke program seen between April 2015 and April 2016. Consultations were classified into one of three diagnostic categories: stroke/transient ischemic attack, mimic, and uncertain. Initial telestroke diagnosis was compared with the final diagnosis post review of all emergency department and hospital data. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+) and negative likelihood ratio (LR-) for diagnosis of stroke/TIA versus mimic were calculated. Area under receiver-operating characteristic curve (AUC) analysis to predict true stroke was performed. Bivariate analysis based on the diagnostic categories examined association with sex, age, NIHSS, stroke risk factors, tPA given, bleeding after tPA, symptom onset to last known normal, symptom onset to consult, timing in the day, and consult duration. Logistic regression was performed as indicated by bivariate analysis. Eight hundred and seventy-four telestroke evaluations were included in our analysis. Accurate diagnosis through teleneurological consultation was seen in 85% of which 532 were strokes (true positives) and 170 were mimics (true negatives). Sensitivity, specificity, PPV, NPV were 97.8, 82.5, 93.7 and 93.4%, respectively. LR+ and LR- were 5.6 and 0.03. AUC (95% CI) was 0.9016 (0.8749-0.9283). Stroke mimics were more common with younger age and female gender and in those with less vascular risk factors. LR revealed OR (95% CI) of misdiagnosis for female gender of 1.9 (1.3-2.9). Lower age and lower NIHSS score were other predictors of misdiagnosis. We report high diagnostic accuracy of the Ochsner Telestroke Program in discriminating stroke/TIA and stroke mimics, with slight tendency towards over diagnosis of stroke. Female gender, younger age and lower NIHSS score were associated with misdiagnosis.

Clinical and radiological predictive factors of silent AF in ESUS stroke

A quarter of cerebral infarctions remain without etiology (ESUS: embolic stroke of unknown source) with a risk of recurrence under anti-platelet therapy greater than 4% per year. In this population, the challenge is the detection of subclinical atrial fibrillation (AF), the incidence of which could reach 25%. The efficacy of the probabilistic anticoagulation strategy has not been demonstrated in this population making it necessary to identify ESUS patients at high risk of subclinical AF. The aim of this study is to determine clinical and radiological predictive factors of silent AF in ESUS stroke. Monocentric descriptive and analytical historical cohort study conducted at the Neurology Department between January 2016 and December 2020. Three hundred Esus patients were included. In our study 42/300 (14%) patients had at least one episode of AF (> 30 s). In univariate analysis, the variables significantly associated with slower AF in ESUS-type stroke were age greater than or equal to 60 years (P = 0.004, OR = 3.76), female gender (P = 0.045, OR = 1.94), coronary artery disease (P = 0.008, OR = 3.43), previous stroke (P = 0.007, OR = 2.67), stroke of different territory or age (P = 0.031, OR = 2.65), stroke on awakening (P < 10−3, OR = 5.95), higher NIHSS score on admission (P = 0.023, OR = 1.08), lower NIHSS score on discharge (P = 0.031, OR = 0.89), older cerebellar stroke (P < 10−3, OR = 14.16). In multivariate analysis, higher NIHSS score at admission (P = 0.023, OR = 1.08), and lower NIHSS score (P = 0.031, OR = 0.89) at discharge appeared as independent predictors of the occurrence of a subclinical AF episode. In this cohort of ESUS patients, several factors appeared to be predictive of subclinical AF. The subgroup of ESUS patients with these factors appeared to benefit from probabilistic anticoagulation in preventing recurrent cerebral infarction. A therapeutic trial should confirm this hypothesis.

Underlying causes of cryptogenic stroke and TIA in The Nordic Atrial Fibrillation and Stroke (NOR-FIB) Study – the importance of comprehensive clinical evaluation

BackgroundCryptogenic stroke is a heterogeneous condition, with a wide spectrum of possible underlying causes for which the optimal secondary prevention may differ substantially. Attempting a correct etiological diagnosis to reduce the stroke recurrence should be the fundamental goal of modern stroke management.MethodsProspective observational international multicenter study of cryptogenic stroke and cryptogenic transient ischemic attack (TIA) patients clinically monitored for 12 months to assign the underlying etiology. For atrial fibrillation (AF) detection continuous cardiac rhythm monitoring with insertable cardiac monitor (Reveal LINQ, Medtronic) was performed. The 12-month follow-up data for 250 of 259 initially included NOR-FIB patients were available for analysis.ResultsAfter 12 months follow-up probable stroke causes were revealed in 43% patients, while 57% still remained cryptogenic. AF and atrial flutter was most prevalent (29%). In 14% patients other possible causes were revealed (small vessel disease, large-artery atherosclerosis, hypercoagulable states, other cardioembolism). Patients remaining cryptogenic were younger (p < 0.001), had lower CHA2DS2-VASc score (p < 0.001) on admission, and lower NIHSS score (p = 0.031) and mRS (p = 0.016) at discharge. Smoking was more prevalent in patients that were still cryptogenic (p = 0.014), while dyslipidaemia was less prevalent (p = 0.044). Stroke recurrence rate was higher in the cryptogenic group compared to the group where the etiology was revealed, 7.7% vs. 2.8%, (p = 0.091).ConclusionCryptogenic stroke often indicates the inability to identify the cause in the acute phase and should be considered as a working diagnosis until efforts of diagnostic work up succeed in identifying a specific underlying etiology. Timeframe of 6-12-month follow-up may be considered as optimal.Trial registrationClinicalTrials.gov Identifier NCT02937077, EudraCT 2018-002298-23.

The controlling nutritional status score and risk factors associated with malnutrition in patients with acute ischemic stroke.

Malnutrition is an independent risk factor for poor outcomes in patients who suffered an acute ischemic stroke (AIS). The controlling nutritional status (CONUT) score can provide information for nutritional management in AIS patients. However, the risk factors associated with the CONUT score have not been established to date. Therefore, in this study, we aimed to investigate the CONUT score of patients with AIS and explore the potential risk factors associated with it. We conducted a retrospective review of the data from consecutive AIS patients who were recruited in the CIRCLE study. Within 2 days of admission, we gathered the CONUT score, the Nutritional Risk Screening 2002, the Modified Rankin Scale, the National Institutes of Health Neurological Deficit Score (NIHSS), and demographic data from medical records. We used chi-squared tests to examine admission, and a logistic regression analysis was performed to explore the risk factors associated with CONUT in patients with AIS. A total of 231 patients with AIS participated in the study, with a mean age of 62.32 ± 13.0 years and a mean NIHSS of 6.77 ± 3.8. Of these patients, 41(17.7%) had hyperlipidemia. In terms of nutritional assessment, 137(59.3%) patients with AIS had high CONUT scores, 86(37.2%) patients with AIS had low or high BMI, and 117(50.6%) patients with AIS had NRS-2002 scores below 3. The chi-squared tests showed that age, NIHSS, body mass index (BMI), and hyperlipidemia were associated with the CONUT score (P < 0.05). The logistic regression analysis showed that low NIHSS scores (OR = 0.055 95% CI: 0.003-0.893), younger age (OR = 0.159 95% CI: 0.054-0.469), and hyperlipidemia (OR = 0.303 95% CI: 0.141-0.648) were independently associated with lower CONUT scores (P < 0.05), whereas BMI was not found to be independently associated with the CONUT. More than half of the patients with AIS were at risk of malnutrition, with age and neurological deficits being identified as risk factors for nutritional control. Hyperlipidemia was found to be a protective factor of the CONUT, while NRS-2002 and BMI did not affect the nutritional control in patients with AIS.

Abstract Number ‐ 53: Endovascular therapy versus medical management for mild strokes due to medium and distal vessel occlusions

Introduction Distal and medium vessel occlusion (DMVO) strokes account for 25–40% of all acute ischemic strokes1 and are associated with long‐term disability in as many as 77% of patients2. Approximately one third of DMVO stroke patients have a low National Institute of Stroke Scale (NIHSS) (≤6)3. Multiple randomized controlled trials showed superiority of endovascular therapy (EVT) over best medical management (BMT) in patients presenting with proximal LVO involving the anterior circulation and NIHSS of &gt;64. The efficacy and safety of EVT for DMVO patients is uncertain, especially in patients with low NIHSS. A better understanding of this issue is important because many patients with DMVO and low NIHSS scores suffer disabling deficits while procedural risk are increased due to the target vessels’ small caliber, tortuosity, and thinner walls. We conducted a retrospective single center study to compare clinical and safety outcomes of DMVO patients with NIHSS ≤ 6 that were treated with EVT versus BMT. Methods We retrospectively analyzed consecutive patients with acute mild (NIHSS ≤ 6) DMVO stroke that presented between January 2018 and December 2021. We defined DMVO stroke as stroke caused by an occlusion of the M2‐4 segments of the MCA, A2‐3 segments of the ACA, P1‐2 segments of the PCA. Outcomes of interest were the NIHSS at day one and at discharge, the change in NIHSS from admission to discharge (ΔNIHSS) and the mRS at 90‐days. Safety outcomes were clinical deterioration, defined as an increase in the NIHSS by 4 or more points and the occurrence of symptomatic intracranial hemorrhage (sICH), defined as any type of ICH causing an increase in the NIHSS by 4 or more points. Results Overall, we included 80 subjects that fulfilled our study criteria. Of these, 41 were treated with BMT and 39 were selected to undergo EVT. Clinical characteristics of subjects selected for BMT versus EVT were overall similar except for more frequent diabetes (p = 0.035) and antiplatelet use (p = 0.045) as well as less frequent anticoagulation (p = 0.019) in the BMT group. Moreover, subjects selected for EVT had a lower pre‐stroke mRS (p = 0.025) and a lower ASPECT score on the admission head CT (p = 0.044). Overall, there was no statistical difference between NIHSS at day 1 (p = 0.654), NIHSS at discharge (p = 0.244), and ΔNIHSS from Day 0 to Day 1 (p = 0.08). There was further no difference in the discharge (p = 0.895) and 3‐month (p = 0.957) mRS between groups. Regarding safety outcomes, there was no difference in the number of all types of ICHs combined between the two groups (p = 0.229) and there was no difference in the number of patients who had clinical deterioration (p = 0.258). Conclusions Our analysis shows that in patients who present with mild DMVO strokes, early and 3‐month clinical outcomes were comparable between EVT and BMT groups. Moreover, risk of intracranial hemorrhage, clinical deterioration, and death were similar between groups. Nevertheless, given the low number of subjects, our analysis did not reach statistical significance and further large‐scale studies are required to clarify efficacy and safety of EVT versus BMT in DMVO patients with low clinical deficit severity