Median mRS Research Articles

Endovascular treatment versus no endovascular treatment after 6–24 h in patients with ischaemic stroke and collateral flow on CT angiography (MR CLEAN-LATE) in the Netherlands: a multicentre, open-label, blinded-endpoint, randomised, controlled, phase 3 trial

Endovascular treatment for anterior circulation ischaemic stroke is effective and safe within a 6 h window. MR CLEAN-LATE aimed to assess efficacy and safety of endovascular treatment for patients treated in the late window (6-24 h from symptom onset or last seen well) selected on the basis of the presence of collateral flow on CT angiography (CTA). MR CLEAN-LATE was a multicentre, open-label, blinded-endpoint, randomised, controlled, phase 3 trial done in 18 stroke intervention centres in the Netherlands. Patients aged 18 years or older with ischaemic stroke, presenting in the late window with an anterior circulation large-vessel occlusion and collateral flow on CTA, and a neurological deficit score of at least 2 on the National Institutes of Health Stroke Scale were included. Patients who were eligible for late-window endovascular treatment were treated according to national guidelines (based on clinical and perfusion imaging criteria derived from the DAWN and DEFUSE-3 trials) and excluded from MR CLEAN-LATE enrolment. Patients were randomly assigned (1:1) to receive endovascular treatment or no endovascular treatment (control), in addition to best medical treatment. Randomisation was web based, with block sizes ranging from eight to 20, and stratified by centre. The primary outcome was the modified Rankin Scale (mRS) score at 90 days after randomisation. Safety outcomes included all-cause mortality at 90 days after randomisation and symptomatic intracranial haemorrhage. All randomly assigned patients who provided deferred consent or died before consent could be obtained comprised the modified intention-to-treat population, in which the primary and safety outcomes were assessed. Analyses were adjusted for predefined confounders. Treatment effect was estimated with ordinal logistic regression and reported as an adjusted common odds ratio (OR) with a 95% CI. This trial was registered with the ISRCTN, ISRCTN19922220. Between Feb 2, 2018, and Jan 27, 2022, 535 patients were randomly assigned, and 502 (94%) patients provided deferred consent or died before consent was obtained (255 in the endovascular treatment group and 247 in the control group; 261 [52%] females). The median mRS score at 90 days was lower in the endovascular treatment group than in the control group (3 [IQR 2-5] vs 4 [2-6]), and we observed a shift towards better outcomes on the mRS for the endovascular treatment group (adjusted common OR 1·67 [95% CI 1·20-2·32]). All-cause mortality did not differ significantly between groups (62 [24%] of 255 patients vs 74 [30%] of 247 patients; adjusted OR 0·72 [95% CI 0·44-1·18]). Symptomatic intracranial haemorrhage occurred more often in the endovascular treatment group than in the control group (17 [7%] vs four [2%]; adjusted OR 4·59 [95% CI 1·49-14·10]). In this study, endovascular treatment was efficacious and safe for patients with ischaemic stroke caused by an anterior circulation large-vessel occlusion who presented 6-24 h from onset or last seen well, and who were selected on the basis of the presence of collateral flow on CTA. Selection of patients for endovascular treatment in the late window could be primarily based on the presence of collateral flow. Collaboration for New Treatments of Acute Stroke consortium, Dutch Heart Foundation, Stryker, Medtronic, Cerenovus, Top Sector Life Sciences & Health, and the Netherlands Brain Foundation.

Efficacy of inhaled hydrogen on neurological outcome following brain ischaemia during post-cardiac arrest care (HYBRID II): a multi-centre, randomised, double-blind, placebo-controlled trial

Inhaled molecular hydrogen gas (H2) has been shown to improve outcomes in animal models of cardiac arrest (CA). H2 inhalation is safe and feasible in patients after CA. We investigated whether inhaled H2 would improve outcomes after out-of-hospital CA (OHCA). HYBRID II is a prospective, multicentre, randomised, double-blind, placebo-controlled trial performed at 15 hospitals in Japan, between February 1, 2017, and September 30, 2021. Patients aged 20-80 years with coma following cardiogenic OHCA were randomly assigned (1:1) using blinded gas cylinders to receive supplementary oxygen with 2% H2 or oxygen (control) for 18h. The primary outcome was the proportion of patients with a 90-day Cerebral Performance Category (CPC) of 1 or 2 assessed in a full-analysis set. Secondary outcomes included the 90-day score on a modified Rankin scale (mRS) and survival. HYBRID II was registered with the University Hospital Medical Information Network (registration number: UMIN000019820) and re-registered with the Japan Registry for Clinical Trials (registration number: jRCTs031180352). The trial was terminated prematurely because of the restrictions imposed on enrolment during the COVID-19 pandemic. Between February 1, 2017, and September 30, 2021, 429 patients were screened for eligibility, of whom 73 were randomly assigned to H2 (n=39) or control (n=34) groups. The primary outcome, i.e., a CPC of 1 or 2at 90 days, was achieved in 22 (56%) and 13 (39%) patients in the H2 and control groups (relative risk compared with the control group, 0.72; 95% CI, 0.46-1.13; P=0.15), respectively. Regarding the secondary outcomes, median mRS was 1 (IQR: 0-5) and 5 (1-6) in the H2 and control groups, respectively (P=0.01). An mRS score of 0 was achieved in 18 (46%) and 7 (21%) patients in the H2 and control groups, respectively (P=0.03). The 90-day survival rate was 85% (33/39) and 61% (20/33) in the H2 and control groups, respectively (P=0.02). The increase in participants with good neurological outcomes following post-OHCA H2 inhalation in a selected population of patients was not statistically significant. However, the secondary outcomes suggest that H2 inhalation may increase 90-day survival without neurological deficits. Taiyo Nippon Sanso Corporation. For the Japanese translation of the abstract see Supplementary Materials section.

No Difference in Sleep Desaturations Severity between Patients with Wake-Up and Non-Wake-Up Stroke: A PRESS Study Results.

Wake-up stroke (WUS) is a certain type of ischemic stroke in which a patient wakes up with a new neurological deficit due to cerebral ischemia. Sleep-disordered breathing is an independent risk factor for stroke, but the role of nocturnal oxygen desaturation in the pathophysiology of WUS is still insufficiently explored. According to several studies, patients with WUS have a significantly more severe sleep apnea syndrome and lower mean blood oxygen saturation. This study aimed to assess the severity of nocturnal desaturations in acute WUS and non-WUS patients using nocturnal pulse oximetry. The cohort of 225 consecutive patients with neuroimaging-verified acute cerebral ischemia was prospectively enrolled. For further analyses, 213 subjects with known WUS/non-WUS status were selected (111 males and 102 females, average age 70.4 ±12.9, median baseline NIHSS = 5, median baseline mRS = 3). Patients were divided into the WUS group (n = 45) and the non-WUS group (n = 168). Overnight pulse oximetry was performed within 7 days of the stroke onset and data of both of the studied groups were compared. We found oxygen desaturation index (ODI) in the WUS group was 14.5 vs. 16.6 (p = 0.728) in the non-WUS group, basal O2 saturation was 92.2% vs. 92.5% (p = 0.475), average low O2 saturation was 90.3% vs. 89.6% (p = 0.375), minimal O2 saturation was 79.5% vs. 80.6% (p = 0.563), and time with O2 saturation <90% (T90) was 4.4% vs. 4.7% (p = 0.729). In the studied sample, monitored respiratory parameters including ODI, basal O2 saturation, average low O2 saturation, minimal O2 saturation, and T90 did not significantly differ between groups of WUS and non-WUS patients.

Abstract NS2: Intracerebral Hemorrhage Patients Actively Involved In Post-acute Care With Nurse Navigators Experienced Reduced Readmission Rates And Better Outcomes

Objective: To evaluate whether the level of engagement of hemorrhagic patients with nurse navigators affected readmissions and outcomes. Methods: Retrospective multicenter study of hemorrhagic stroke patients from seven hospitals between January 2021 and April 2022. Patients who died or discharged to hospice were excluded. Navigators contacted patients at scheduled intervals to review care, medications, confirm appointments and provide education. Engagement was defined as a phone or virtual encounter with patient: low (&lt; 5 encounters) or high (≥ 5 encounters) during 90-day epoch. The primary outcome examined readmission within 90 days using a binomial logistic regression. Secondary outcomes included: attendance of neurology visit; new or worsening symptoms and 90 day modified Rankin Scale (mRS) analyzed with binomial logistic and ordinal regressions. Sensitivity analysis examined outcomes in patients discharged to inpatient rehabilitation or skilled nursing. Multivariable analyses were adjusted for potential confounding variables. Results: We enrolled 368 hemorrhagic stroke patients, of which, 281 were included; 217 (77.2%) intracerebral hemorrhage and 64 (22.8%) subarachnoid hemorrhage. There were 144 (51.2%) less engaged and 137 (48.8%) highly engaged patients. Highly engaged patients were less likely to be readmitted compared to less engaged patients (23% vs. 42%), adjusted odds ratio (aOR) = 0.49 [95%CI, 0.28 - 0.87], p= 0.02. There was no difference in engagement and attendance of appointments, aOR = 1.73 [95%CI, 0.96 - 3.11], p = 0.07 or new neurologic events, aOR = 0.52 [95%CI, 0.25 - 1.08], p = 0.08. Highly engaged patients had less disability at 90 days compared to less engaged patients, median mRS = 2 (IQR, 1 - 3) versus 3 (IQR, 2 - 5), aOR = 0.49 [95% CI, 0.30 - 0.81], p = 0.006. Highly engaged patients discharged to a health care facility were also less likely to be readmitted and had less disability at 90 days compared to less engaged patients, all p&lt; 0.05. Conclusions: Patients were found to have lower readmission rates and less disability at 90 days if they had a high level of engagement with the nurse navigators.

Abstract 59: Reduced Readmissions And Improved Outcomes In Hemorrhagic Stroke Patients Actively Involved In Post-acute Care With Nurse Navigators

Objective: To evaluate whether the level of engagement of hemorrhagic patients with nurse navigators affected readmissions and outcomes. Methods: Retrospective multicenter study of hemorrhagic stroke patients from seven hospitals between January 2021 and April 2022. Patients who died or discharged to hospice were excluded. Navigators contacted patients at scheduled intervals to review care, medications, confirm appointments and provide education. Engagement was defined as a phone or virtual encounter with patient: low (&lt; 5 encounters) or high (≥ 5 encounters) during 90-day epoch. The primary outcome examined readmission within 90 days using a binomial logistic regression. Secondary outcomes included: attendance of neurology visit; new or worsening symptoms and 90 day modified Rankin Scale (mRS) analyzed with binomial logistic and ordinal regressions. Sensitivity analysis examined outcomes in patients discharged to inpatient rehabilitation or skilled nursing. Multivariable analyses were adjusted for potential confounding variables. Results: We enrolled 368 hemorrhagic stroke patients, of which, 281 were included; 217 (77.2%) intracerebral hemorrhage and 64 (22.8%) subarachnoid hemorrhage. There were 144 (51.2%) less engaged and 137 (48.8%) highly engaged patients. Highly engaged patients were less likely to be readmitted compared to less engaged patients (23% vs. 42%), adjusted odds ratio (aOR) = 0.49 [95%CI, 0.28 - 0.87], p= 0.02. There was no difference in engagement and attendance of appointments, aOR = 1.73 [95%CI, 0.96 - 3.11], p = 0.07 or new neurologic events, aOR = 0.52 [95%CI, 0.25 - 1.08], p = 0.08. Highly engaged patients had less disability at 90 days compared to less engaged patients, median mRS = 2 (IQR, 1 - 3) versus 3 (IQR, 2 - 5), aOR = 0.49 [95% CI, 0.30 - 0.81], p = 0.006. Highly engaged patients discharged to a health care facility were also less likely to be readmitted and had less disability at 90 days compared to less engaged patients, all p&lt; 0.05. Conclusions: Patients were found to have lower readmission rates and less disability at 90 days if they had a high level of engagement with the nurse navigators.

Abstract WMP69: Recreational Drug Use And Ischemic Stroke: Demographics, Stroke Mechanism, And Outcomes

Introduction: Various recreational drugs have been linked to cerebrovascular events, especially in young adults, however, few studies have examined relationships between substance abuse (SA) and acute ischemic stroke (AIS) in detail. The objective of this study was to determine prevalence and stroke mechanism in a cohort of AIS patients with SA and the impact of SA on outcomes and recovery. Methods: A retrospective case-control study comparing adults hospitalized with AIS with positive urine drug screen (UDS, excluding cannabis and its related products) from January 2015 to December 2019 compared with matched AIS controls from Greater Chicago area. Logistic regression was used to compare demographics, mechanism of stroke, discharge outcomes as measured by modified Rankin Scale (mRS), and disposition outcomes. Results: Out of 3229 AIS patients, 141 (6.5%) has positive UDS (SA group) and were compared to 282 controls. Illicit drugs used were cocaine (69%), opiates (21%), and the rest were amphetamines, phencyclidine, ecstasy, or multiple substances. Demographically, there were no significant differences in age [56.0±10.0 years vs 55.9±10.5], or sex [men 63.1% vs 60.3%]. Controls had higher rates of traditional stroke risk factors [diabetes (DM), p=0.0001 and hyperlipidemia (HLD), p=0.004], and a higher incidence of large artery atherosclerosis as suspected stroke mechanism than the SU group (p = 0.001). SA group at discharge had higher levels of disability [median mRS 2 vs 3 (p = 0.001)] and worse discharge disposition, i.e. subacute rehab/long term care facility/hospice/death vs home or acute rehabilitation (OR 0.49, p =0.009, CI 0.29-0.84), even after correcting for age, sex, HTN, DM, coronary artery disease, and HLD in a multiple logistic regression (OR 0.43, p= 0.004, CI 0.24-0.76). Conclusion: In our cohort, patients with AIS and SA were more likely to have a stroke mechanism of large artery atherosclerosis and poorer outcomes with higher levels of disability and worse discharge disposition.

Abstract 61: Retrospective Safety Study Of Low Intensity Monitoring In Cases Of Acute Ischemic Stroke That Received Thrombolytic Therapy

Introduction: It is standard to observe acute ischemic stroke (AIS) patients under high intensity monitoring (HIM) for the first 24 hours after intravenous thrombolysis (IVT). However, HIM is resource intensive and may not be necessary for every AIS patient. This study evaluates the safety and efficacy of low-intensity monitoring (LIM) for a subset of low-risk AIS patients who received IVT. Methods: Data from patients discharged from 2 hospitals between April 2020-April 2022 admitted to LIM post-IVT were retrospectively abstracted from patient records. Patients under age 18, arrival NIHSS ≥17, presence of large vessel occlusion, need for endovascular therapy, uncontrolled high blood pressure or unstable neuro exam (change in NIHSS of 4 or more within the 1st hour) were excluded. Primary outcomes were transfer back to HIM, instances and treatment of high blood pressure (HBP), in-hospital stroke mortality, discharge disposition and 90-day mRS. Population characteristics of age, sex, race, medical history, transfers to hub prior to LIM admission, discharge mRS and door-to-needle times were also examined. Results: Among 173 patients who met inclusion criteria, 1 (.6%) patient was transferred back to HIM and no patients died from in-patient stroke-related causes. Most patients were discharged home (80.9%) with a median 90-day mRS score of 1 (IQR: 0, 2, Table 1). Conclusion: LIM can reduce resource intensity of stroke care and free up critical care beds, which can result in less cost for the hospital and the patient. We conclude that LIM is safe and effective and could be the standard of care for low-risk AIS patients treated with IVT.

Abstract WP8: A Comprehensive Analysis Of The Effect Of Intravenous Tirofiban In Combination With Endovascular Thrombectomy On Functional Outcomes In Patients With Large Vessel Occlusion Stroke: The RESCUE BT Trial

Background: In the RESCUE BT (Endovascular Treatment With versus Without Tirofiban for Stroke Patients with Large Vessel Occlusion) trial, enrollment in extended time window was based on non-contrast computed tomography. To assess whether tirofiban was safe and effective in the RESCUE BT trial according to advance imaging selection criteria based on current American Heart Association guidelines. Methods: This is a secondary analysis of a multicenter, double-blinded and randomized trial that was conducted at 55 centers in China and involved 950 participants with stroke with large vessel anterior circulation occlusion from October 2018 to October 2021. All randomized patients were screened according to the current guidelines and were followed up for 90 days from stroke onset. The primary outcome was the distribution of the 90-day modified Rankin scale (mRS) scores. Secondary outcomes included the rates of functional independence (mRS 0-2) and favorable outcome (mRS 0-3). Safety outcomes included the incidences of symptomatic intracranial hemorrhage (sICH) within 48 hours and 90-day mortality. Results: A total of 652 patients (319 in tirofiban group and 333 in placebo group) who met the current guidelines were included in this analysis, with median (IQR) age of 68 (58-75) years, 278 (42.6%) were women. The median 90-day mRS score was 3 (IQR, 1-4) in tirofiban group, and 3 (IQR, 1-4) in placebo group. The adjusted common odds ratio (OR) for a lower level of disability with tirofiban than placebo was 1.08 (95% confidence intervals [CI] 0.83-1.42). Incidence of sICH (10.1% vs 6.3%; adjusted OR 1.70 [95%CI 0.95-3.04]) was not different between groups. However, intravenous tirofiban might be associated with lower disability level (adjusted common OR 1.74 [95%CI 1.14-2.65]; P=0.01) in large artery atherosclerosis patients. Conclusions: There was no significant difference in severity of disability at 90 days with intravenous tirofiban compared with placebo among patients with large vessel anterior circulation occlusion undergoing endovascular therapy according to current guidelines. We observed potential benefits of tirofiban in large artery atherosclerosis patients, and further randomized controlled trials are warranted to validate the present results.

The DERIVO®2 Embolization Device in the treatment of ruptured and unruptured intracranial aneurysms: A multicenter analysis.

Flow diverters are an increasingly used treatment option for intracranial aneurysms. A recent addition to the European market is the DERIVO®2 Embolization Device (DED2), promising improved radiopacity. We aimed to assess the safety and efficacy of the DED2 regarding angiographic and clinical outcomes in ruptured and unruptured cerebral aneurysms. We performed a multicenter trial at six interventional centers. Data were prospectively collected and all patients treated with the DED2 were included. The primary endpoint was angiographic aneurysm occlusion at 6 months as assessed by the O'Kelly Marotta (OKM) grading scale with a favorable outcome definition of OKM C + D. Clinical outcome was evaluated according to the modified Rankin scale (mRS). Between August 2020 and July 2021, 37 patients were treated with the DED2 and were included in our analysis. Five patients presented with ruptured aneurysms. Median age was 60 years, 27 patients were female, and 10 male. Median mRS was 0 (range 0-4). Mean aneurysm size was 8.9 ± 7.1 mm with a mean neck size of 6.5 ± 6.1. The DED2 fully opened at deployment in all cases. Clinical follow-up was available for 30 patients (81%). Twenty-five (83%) had an mRS of 0 or 1. Three patients with ruptured aneurysms died during the follow-up period. No treatment-related major morbidity was observed. Follow-up imaging was available in 27 (90%) patients, with 23 patients (85%) showing satisfactory aneurysm occlusion OKM grade C-D. In this small cohort, the DED2 provided safe and effective treatment of ruptured and unruptured intracranial aneurysms.

521: CEREBRAL ISCHEMIA AND OUTCOMES WITH RAPID BLOOD PRESSURE LOWERING IN INTRACEREBRAL HEMORRHAGE

Introduction: Guidelines support acute systolic blood pressure (SBP) lowering in intracerebral hemorrhage (ICH) if SBP is between 150 and 220 mmHg to improve outcomes. Recommendations for SBP >220 mm Hg are less clear. A proposed risk is failure of cerebral autoregulation, leading to brain ischemia and poor outcomes. Methods: A single center, retrospective cohort study of adult ICH patients from July 2017 to 2021. Patients from outside of the hospital system, in-hospital ICH, pregnant, or a prisoner were excluded. The primary outcome was incidence of cerebral ischemia in patients with SBP >220 mmHg (high) vs. 150-219 mmHg (low), assessed through percent SBP lowering and evaluation of radiographic imaging during admission. Secondary outcomes included poor neurologic status with mRS of 4 to 6 at discharge. Results: Of the 393 patients included, median (IQR) premorbid mRS was 0 in both groups, median (IQR) NIHSS was high; 16 (8, 23) vs. low; 13 (5, 19), p < 0.01. The median (IQR) presenting SBP was high; 236 (225, 246) mmHg vs. low; 180 (166, 197) mmHg. SBP goal was achieved in the first 24 hours in high; 86% vs. low; 77%, p = 0.09. Median (IQR) change in SBP 12 hours after arrival was high; -98 (-112, -83) mmHg vs. low; -47 (-62, -25) mmHg (p < 0.01) with a percent change in 12 hour SBP of 41% vs. 25%, p < 0.01. Significance persisted at 18 and 24 hours after arrival. Both groups had a mean (SD) of 7 (4) radiographic images obtained during admission. The median (IQR) time to detection of ischemia was high; 2.8 (1.4, 5.7) days vs. low; 3.1 (1.2, 6.6) days, p = 0.6. Presence of ischemic insults did not differ in the regression model based on presenting SBP groups [HR 0.57 (0.25, 1.3) p = 0.81] or percent change in SBP > or < 25% at 24 hours [HR 0.83 (0.41, 1.69) p = 0.61]. Poor neurologic outcome at discharge was present in high; 82% vs. low; 69% of patients (p = 0.07). Higher admission ICH score (p < 0.01) and NIHSS (p < 0.01) was associated with a poor outcome in the regression model. Conclusions: These results suggest there was no difference in the development of ischemic changes based on presenting SBP or percent change in the SBP. Poor neurologic outcome was associated with higher NIHSS and ICH score on admission in the analysis. These results will need to be confirmed in a randomized study.

Prehospital Ultra-Early Neurological Deterioration in Intracerebral Hemorrhage: Definition, Prevalence, and Association with Outcomes

Introduction: The objective of this study was to define prehospital ultra-early neurological deterioration (UND) and to investigate the association with functional outcomes in patients with intracerebral hemorrhage (ICH). Methods: We conducted a prospective cohort study of consecutive acute ICH patients. The stroke severity at onset and hospital admission was assessed using the Chongqing Stroke Scale (CQSS), and prehospital UND was defined as a CQSS increase of ≥2 points between symptoms onset and admission. Early neurological deterioration (END) was defined as the increase of ≥4 points in NIHSS score within the first 24 h after admission. Poor outcome was defined as a modified Rankin Scale (mRS) of 4–6 at 3 months. Results: Prehospital UND occurred in 29 of 169 patients (17.2%). Patients with prehospital UND had a median admission NIHSS score of 17.0 as opposed to those without prehospital UND with a median NIHSS score of 8.5. There were three patterns of neurological deterioration: prehospital UND only in 21 of 169 patients (12.4%), END but without prehospital UND in 20 of 169 patients (11.8%), and continuous neurological deterioration in both phases in 8 patients (4.7%). Prehospital UND was associated with worse 3-month outcomes (median mRS score, 4.0 vs. 2.0, p = 0.002). After adjusting for age, time from onset to admission, END, and systolic blood pressure, prehospital UND was an independent predictor of poor outcome (odds ratio [OR] 3.27, 95% confidence interval [CI] 1.26–8.48, p = 0.015). Conclusion: Prehospital UND occurs in approximately 1 in 7 patients between symptom onset and admission and is associated with poor functional outcome in patients with ICH. Further research is needed to investigate the prehospital UND in the prehospital phase in the triage of patients with ICH.

Severe neuromuscular immune-related adverse events of immune checkpoint inhibitors at national cancer center in Korea

PurposeNeuromuscular immune-related adverse events (irAEs) associated with immune checkpoint inhibitors (ICIs) have been increasingly recognized as a consequence of expanding use of ICIs in advanced cancers. We aimed to evaluate the frequency, phenotypes, rescue treatment, and clinical outcomes of severe neuromuscular irAEs of ICIs at National Cancer Center (NCC), Korea.Materials and methodsConsecutive patients with newly developed severe neuromuscular irAEs (common terminology criteria for adverse events grade 3 or greater) after ICI treatment at NCC in Korea between December 2018 and April 2022 were included by searching neuromuscular diagnostic codes in electronic medical records and/or reviewing neurological consultation documentations.ResultsOf the 1,503 ICI-treated patients, nine (0.6%) experienced severe neuromuscular irAEs; five with pembrolizumab and four with atezolizumab. The patients included five women and four men; their median age at onset was 59 years. The irAEs included Guillain–Barre syndrome (n = 5) and myasthenia gravis (MG) crisis with myositis (n = 4), and developed after a median of one (range 1–5) ICI cycle. The median modified Rankin score (mRS) was 4 (range 3–5) at the nadir. ICIs were discontinued in all patients, and rescue immunotherapy included corticosteroids (n = 9), intravenous immunoglobulin (n = 7), and plasmapheresis (n = 2). Eight patients showed improvements, with a median mRS of 3 (range 1–4); however, one patient (who had MG crisis with myocarditis) died.ConclusionsIn this real-world monocentric study, ICI-induced neuromuscular irAEs were rare but potentially devastating; thus, physicians should remain vigilant to enable prompt recognition and management of irAEs.

The Effect of COVID-19 Vaccines on Stroke Outcomes: A Single-Center Study

One of the defining narratives of the COVID-19 pandemic has been the acceptance and distribution of vaccine. Compare the outcomes of COVID-19 positive vaccinated and unvaccinated stroke patients. This is a single-center retrospective study of COVID-19-vaccinated and unvaccinated stroke patients between April 2020 and March 2022. All patients presenting with stroke regardless of treatment modalities were included. NIHSS was used to assess stroke severity. The primary outcome was functional capacity of the patients at discharge. The study cohort comprised 203 COVID-19 positive stroke patients divided into 139 unvaccinated and 64 fully vaccinated patients. At discharge, the mRS score was significantly lower in the vaccinated cohort (3[1-4] vs 4[2-5], OR=0.508, p=0.011). At 3 months of follow-up, the median mRS score was comparable between both cohorts. Although vaccination did not show any significant difference in stroke patient outcomes on follow-up, vaccines were associated with lower rates of morbidity and mortality at discharge among stroke patients during the pandemic.

Pachymeningitis in Biopsy-Proven Sarcoidosis: Clinical Course, Radiographic Findings, Response to Treatment, and Long-Term Outcomes

Objective To study the clinicoradiographic features of pachymeningeal involvement in neurosarcoidosis and its evolution over time in response to treatment. Background Meningeal inflammation is one of the most common forms of neurosarcoidosis, occurring in 16-69% of affected patients. While the clinical and radiographic features of leptomeningitis in neurosarcoidosis are well known, those of pachymeningitis are far less clear. Design/Methods Patients with a diagnosis of neurosarcoidosis seen at Emory University [01/2011-8/2021] were included if pachymeningeal involvement was evident by MRI and the patient's sarcoidosis was pathologically confirmed (from a neural or extraneural site). Results 26/215 (12.1%) patients with neurosarcoidosis qualified for inclusion. Pathological confirmation came from neural tissue in 50%. Median age of onset was 43.5 years; most were male (16/26, 61.5%). Symptoms were primarily related to pachymeningitis in 20/26 (76.9%). Headache (19/26, 73.1%), visual dysfunction (12/26, 46.2%), and seizures (7/26, 26.9%) were the most common symptoms. All patients had cranial pachymeningitis; only a single patient undergoing spinal imaging (1/11, 9.1%) had spinal pachymeningitis. The falx cerebri (16/26, 61.5%) was the most commonly affected dural structure, but the anterior and middle cranial fossae and tentorium were frequently involved (12/26 each, 46.2%). The pachymeningeal lesions were unifocal (11/26, 42.3%) or multifocal (15/26, 57.7%) in distribution, nodular morphologically (23/25, 92.0%), and homogeneously enhancing (24/25, 96.0%). Symptomatic improvement occurred with steroids initially in 22/25 (88.0%). Ultimately, 23/26 (88.5%) required initiation of steroid-sparing immunosuppressants, including 8/26 (30.8%) eventually undergoing TNF inhibition. Pachymeningeal relapses occurred in 7/26 (26.9%). Median clinical follow-up was 48 months. Median mRS at last follow-up improved to 1.0 from 2.0 at presentation. Conclusions Sarcoid pachymeningitis often presents with headaches and visual dysfunction, usually affects the falx cerebri and anterior and middle cranial fossae, and tends to require steroid-sparing immunosuppressants. It has the potential to relapse, but the prospect for recovery is excellent.

Understanding Correlation of Electroclinical Findings With Functional and Neuropsychiatric Outcomes in Patients with LGI1-Encephalitis

Objective To evaluate the interplay between seizures, quality of life (QoL), and neuropsychiatric outcomes in patients with leucine-rich glioma-inactived 1 antibody encephalitis (LGI1-Ab-E). Background Patients with LGI1-Ab-E experience varied seizure semiologies, but their potential differing impact on long-term outcomes remains under-explored. Design/Methods We conducted a single-center retrospective cohort study of patients with antibody-confirmed LGI1-Ab-E with seizures. Patients were categorized as having faciobrachial dystonic seizures (FBDS) or non-faciobrachial dystonic seizures (non-FBDS). Patient Health Questionnaire-9 (PHQ-9), Neuro-QoL, Patient Reported Outcomes Measurement Information System (PROMIS), and modified Rankin Scale (mRS) were abstracted. Outcomes were compared using two-tailed independent sample t-tests for continuous variables and chi-square and Fisher's exact test for categorical variables. Change over time was evaluated using Wilcoxon signed-rank test. Results 21 patients (33% female, median 65 years) were included, 10 (47.6%) with FBDS and 11 (53.4%) with non-FBDS. Levetiracetam (66%), lacosamide (42.9%), and valproate (19.0%) were the most common anti-seizure medications; 19 (90.5%) underwent immunotherapy. In patients with at least one year of follow-up, all patients with FBDS (n = 7) and 75% with non-FBDS (n = 6) achieved seizure freedom (p = 0.48). From 8 months to 30 months post-diagnosis, PHQ-9 improved in the FBDS cohort (median 6, IQR 5.5—9.5 to median 2.5, IQR 2.0—4.5, p = 0.06), but remained stable in the non-FBDS cohort (median 5.5, IQR 2.3—9.3 to median 5, IQR 3.0 to 8.0, p = 0.75). Both groups had similar mRS baselines (median mRS 1 for both, p = 0.91) and experienced similar significant mRS worsening at median 23 months post-symptoms onset (median increase 1, p &lt; 0.001 over time). Neuro-QoL and PROMIS scores were similar between groups (for all, p &gt; .05). Conclusions Patients with LGI1-Ab-E who experience exclusively non-FBDS may be at higher risk of sustained depressive symptoms than those with FBDS. Regardless of seizure type, patients with LGI1-Ab-E are at risk for significantly worsening disability despite treatment and seizure freedom.

Melatonin supplementation may benefit patients with acute ischemic stroke not eligible for reperfusion therapies: Results of a pilot study

BackgroundWe explored the potential efficacy of melatonin in the treatment of patients with acute ischemic stroke. MethodsThis double-blind, placebo-controlled single-center clinical trial was conducted on 65 patients with acute ischemic stroke not eligible for reperfusion therapy. All patients received routine acute stroke management. Melatonin and placebo were administrated orally at a dose of 20 mg once daily for five days. The severity of neurological deficit and stroke-related functional disability was assessed on the National Institute of Health Stroke Scale (NIHSS) and modified Rankin Scale score (mRS), respectively, on days 5, 30, and 90 after treatment. ResultsAll patients completed the 5-day treatment period, and no serious adverse event was observed. While on day 5, the neurological status and stroke-related functional disability were comparable in both groups, on days 30 and 90, melatonin treatment resulted in a higher reduction in the median NIHSS and mRS score than placebo. Moreover, the overall changes in the NIHSS and mRS scores through a three-month follow-up assessment were significantly greater in the melatonin group than in the placebo group. The analysis of NIHSS scores distribution on day 90 showed a significant difference between the study groups in favor of the melatonin treatment. However, in relation to the functional independence criteria, defined as an mRS < 3, there were no significant differences between the groups at different study time points. ConclusionsAlthough preliminary, our findings support the hypothesis that early treatment with melatonin may be helpful in improving functional and neurological recovery following stroke. Trial registrationThe trial was registered at Clinicaltrials.gov (identifier code: IRCT20120215009014N378). Registration date: 2021-01-28.

Cognitive impairment after first-ever ischemic stroke

Background and aim Ischemic stroke has a good outcome because these patients usually have a good motor recovery. The aim of this work was to assess the prognostic value of the neurocognitive status to detect early cognitive dysfunction in stroke phases, evaluate outcome after first-ever ischemic stroke, and to choose proper preventive management of stroke cognitive dysfunction. Patients and methods Patients with ischemic stroke were prospectively evaluated using Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE) individually and in combination with National Institutes of Health Stroke Scale (NIHSS), either at the subacute stroke phase or within 2 weeks (baseline), and modified Rankin scale (mRS) scores, for functional outcome 3 and 6 months later. Results Cognitive impairment was diagnosed at baseline in 37.5% of patients with median NIHSS=4 and median mRS=2 (P&lt;0.001). Baseline NIHSS, MMSE, and MoCA can individually predict mRS scores at 3 and 6 months, and NIHSS is the strongest predictor. However, patients with more disability at baseline (NIHSS&gt;2), baseline MoCA, and MMSE had a moderately large significant predictive value to the baseline NIHSS for mRS scores at 3 and 6 months. Conclusion Screening of cognitive state at the subacute stroke phase can predict functional outcome independently and improve the predictive value of stroke severity scores. And it is important to evaluate what cognition is, and the brief cognitive test may facilitate assessment in the early phases.

Prognostic significance of age within the adolescent and young adult acute ischemic stroke population after mechanical thrombectomy: insights from STAR.

Although younger adults have been shown to have better functional outcomes after mechanical thrombectomy (MT) for acute ischemic stroke (AIS), the significance of this relationship in the adolescent and young adult (AYA) population is not well defined given its undefined rarity. Correspondingly, the goal of this study was to determine the prognostic significance of age in this specific demographic following MT for large-vessel occlusions. A prospectively maintained international multi-institutional database, STAR (Stroke Thrombectomy and Aneurysm Registry), was reviewed for all patients aged 12-18 (adolescent) and 19-25 (young adult) years. Parameters were compared using chi-square and t-test analyses, and associations were interrogated using regression analyses. Of 7192 patients in the registry, 41 (0.6%) satisfied all criteria, with a mean age of 19.7 ± 3.3 years. The majority were male (59%) and young adults (61%) versus adolescents (39%). The median prestroke modified Rankin Scale (mRS) score was 0 (range 0-2). Strokes were most common in the anterior circulation (88%), with the middle cerebral artery being the most common vessel (59%). The mean onset-to-groin puncture and groin puncture-to-reperfusion times were 327 ± 229 and 52 ± 42 minutes, respectively. The mean number of passes was 2.2 ± 1.2, with 61% of the cohort achieving successful reperfusion. There were only 3 (7%) cases of reocclusion. The median mRS score at 90 days was 2 (range 0-6). Between the adolescent and young adult subgroups, the median mRS score at last follow-up was statistically lower in the adolescent subgroup (1 vs 2, p = 0.03), and older age was significantly associated with a higher mRS at 90 days (coefficient 0.33, p < 0.01). Although rare, MT for AIS in the AYA demographic is both safe and effective. Even within this relatively young demographic, age remains significantly associated with improved functional outcomes. The implication of age-dependent stroke outcomes after MT within the AYA demographic needs greater validation to develop effective age-specific protocols for long-term care across both pediatric and adult centers.

Recanalization Treatments for Pediatric Acute Ischemic Stroke in France

There is to date limited evidence that revascularization strategies are associated with improved functional outcome in children with acute ischemic stroke (AIS). To report clinical outcomes and provide estimates of revascularization strategy safety and efficacy profiles of intravenous thrombolysis (IVT) and/or endovascular treatment (EVT) in children with AIS. The KidClot multicenter nationwide cohort study retrospectively collected data of children (neonates excluded) with AIS and recanalization treatment between January 1, 2015, and May 31, 2018. Data analysis was performed from January 1, 2015, to May 31, 2019. IVT and/or EVT. Primary outcome was day 90 favorable outcome (modified Rankin Scale [mRs] 0-2, with 0 indicating no symptoms and 6 indicating death). Secondary end points included 1-year favorable outcome (mRs, 0-2), mortality, and symptomatic intracerebral hemorrhage. Other measures included the Pediatric National Institutes of Health Stroke Scale (pedNIHSS), with pedNIHSS 0 indicating no symptoms, 1 to 4 corresponding to a minor stroke, 5 to 15 corresponding to a mild stroke, greater than 15 to 20: severe stroke, and the adult Alberta Stroke Program Early CT Score (ASPECTS), which provides segmental assessment of the vascular territory, with 1 point deducted from the initial score of 10 for every region involved (from 10 [no lesion] to 0 [maximum lesions]). Overall, 68 children were included in 30 centers (IVT [n = 44]; EVT [n = 40]; 44 boys [64.7%]; median [IQR] age, 11 [4-16] years; anterior circulation involvement, 57 [83.8%]). Median (IQR) pedNIHSS score at admission was 13 (7-19), higher in the EVT group at 16 (IQR, 10-20) vs 9 (6-17) in the IVT only group (P < .01). Median time from stroke onset to imaging was higher in the EVT group at 3 hours and 7 minutes (IQR, 2 hours and 3 minutes to 6 hours and 24 minutes) vs 2 hours and 39 minutes (IQR, 1 hour and 51 minutes to 4 hours and 13 minutes) (P = .04). Median admission ASPECTS score was 8 (IQR, 6-9). The main stroke etiologies were cardioembolic (21 [30.9%]) and focal cerebral arteriopathy (17 [25.0%]). Median (IQR) time from stroke onset to IVT was 3 hours and 30 minutes (IQR, 2 hours and 33 minutes to 4 hours and 28 minutes). In the EVT group, the rate of postprocedure successful reperfusion (≥modified Treatment in Cerebral Infarction 2b) was 80.0% (32 of 40). Persistent proximal arterial stenosis was more frequent in focal cerebral arteriopathy (P < .01). Death occurred in 3 patients (4.4%). Median pedNIHSS reduction at 24 hours was 4 (IQR, 0-9) points. Intracerebral hemorrhage occurred in 4 patients and symptomatic intracerebral hemorrhage occurred in 1 patient, all in the EVT group. The median mRS was 2 (IQR, 0-3) at day 90 and 1 (IQR, 0-2) at 1 year, which was not significantly different between EVT and IVT only groups, although different in initial severity. The findings of this cohort study suggest that use of EVT and/or IVT is safe in children with AIS.

Capsular Warning Syndrome: Features, Risk Profile, and Prognosis in a Large Prospective TIA Cohort

Introduction: Features and prognosis of capsular warning syndrome (CWS) have been poorly investigated prospectively. Aims: The study aimed to characterize CWS clinical features, risk profile, short- and long-term prognosis, among a large TIA cohort. Methods: Prospective cohort study of consecutive TIAs was conducted from August 1, 2010, to December 31, 2017. Demographic and clinical characteristics, risk profile, primary (stroke and composite outcome) and secondary (TIA recurrence, cerebral hemorrhage, new onset atrial fibrillation) outcomes were compared between CWS, lacunar (L), and nonlacunar (NL) TIAs. Results: 1,035 patients (33 CWS, 189 L-TIAs, 813 NL-TIAs) were enrolled. Newly diagnosed (ND) hypertension, hypercholesterolemia, cigarette smoking, and leukoaraiosis were independent risk factors of CWS (p < 0.05). CWS showed the highest stroke (30.3% vs. 0.5% and 1.5% for L-TIAs and NL-TIAs, respectively) and composite outcome risk at follow-up (p < 0.001), but better 3-month post-stroke prognosis (mRS 0–2 90.0% vs. 36.8%; p = 0.002). CWS-related stroke mostly occurred <48 h (80.0%) and had a small vessel occlusion etiology (100%), affecting more often the internal capsule (60.0%). Dual antiplatelet therapy (DAPT) versus single antiplatelet therapy was associated with lower 3-month cumulative stroke incidence (12.5% vs. 57.1%; p = 0.010). Intravenous thrombolysis (IVT) showed similar 3-month efficacy and safety in strokes after TIAs groups (median mRS 0, IQR 0–1; p = 0.323). Conclusions: CWS is associated with higher stroke risk and better functional prognosis than L- and NL-TIAs. CWS risk profile is consistent with severe small vessel disease, and ND hypertension could represent a major risk factor. DAPT and IVT seem effective and safe in preventing and treating stroke following CWS.