Median National Institutes Of Health Stroke Scale Research Articles

Endovascular treatment of primary M3 occlusion stroke in clinical practice: analysis of the German Stroke Registry

BackgroundEndovascular treatment (ET) options for acute stroke due to distal middle cerebral artery occlusions are rapidly evolving, but data on outcome and safety are sparse. We therefore performed an analysis of patients undergoing ET for primary M3 occlusions in routine clinical practice in a nationwide registry.MethodsPatients enrolled between 01/20 and 12/21 in the prospective, multicenter German Stroke Registry-Endovascular Treatment (GSR-ET) were screened for mechanical thrombectomy performed for primary M3 occlusion. We analyzed neurological deficit as measured by the National Institute of Health Stroke Scale (NIHSS), symptomatic intracranial hemorrhage (sICH), thrombectomy technique, successful reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] score of 2b-3) and functional outcome as measured by the modified Rankin Scale (mRS) at discharge and 90 days.ResultsOut of 5574 patients, 11 patients (0.2%, median age 80 years, 54.5% female) underwent ET for primary M3 occlusion. All patients had pre-admission mRS ≤ 1, median NIHSS on admission was 8, and successful reperfusion was achieved in 6/11 patients (54.5%). While no vasospasm, dissection or perforation was reported, symptomatic intracranial hemorrhage occurred in 2 patients (18.2%). Favorable outcome (mRS ≤ 2) was achieved in 6/11 patients (54.5%) at 90-day follow-up.ConclusionsET for primary M3 occlusions is rarely performed. While technically feasible, the procedure’s potential benefits must be carefully weighed against its associated risks, including clinically relevant complications. Caution and further research is needed to optimize patient selection for this intervention.Trial RegistrationGSR-ET; ClinicalTrials.gov Identifier: NCT03356392; Trial Registration Date: 11/29/2017.

Impact of prior oral anticoagulation on admission stroke severity in patients with atrial fibrillation.

In patients with atrial fibrillation, oral anticoagulation therapy is indicated for both primary and secondary prevention of stroke/systemic embolism. Though direct oral anticoagulants with greater safety and efficacy than warfarin were introduced into clinical practice at the beginning of the last decade, even now not all patients with AF have adequate preventative anticoagulant treatment. The primary goal of this study was to evaluate the impact of prior use of oral anticoagulants on admission stroke severity in those with AF. Other aims were, inter alia, to assess the trend in atrial fibrillation prevalence in the years of the HISTORY trials 2012-2021 carried out in the Czech Republic and use of oral anticoagulants (OAC) in ischemic stroke (IS) patients. We analyzed consecutive ischemic stroke patients who had been enrolled in the HISTORY (Heart and Ischemic STrOke Relationship studY) study registered on ClinicalTrials.gov (identifier NCT01541163) in the year 2012 and carried out a yearly comparison (detailed in the text). In total, there were 1059 patients (55.9% males, mean age 71.7±12.8). There was no significant difference over the time period in rate of known (18.3 vs. 16.5%, P=0.442) or newly detected AF (17.0 vs. 16.0%, P=0.665), but sigificantly more patients with known AF were treated with oral anticoagulants before IS in the year 2021 (32.1 vs. 70.7%, P<0.0001), and direct oral anticoagulants (3.6 vs. 35.4%, P<0.0001). The number of patients with atrial fibrillation had not changed significantly over the years (26.2 vs. 31.3%). Patients on OAC had a lower median admission score on the National Institutes of Health Stroke Scale (NIHSS) than those not using an oral anticoagulant (6 vs. 16, P=0.0004) in 2021. There was no significant upward trend in atrial fibrillation in stroke patients admitted between 2012 and 2021, but patients with known AF were significantly more frequently treated with oral anticoagulants and direct oral anticoagulants (DOAC) in 2021. Patients on OAC had lower admission NIHSS scores than those not using any anticoagulent in the year 2021. The difference in the median admission NIHSS between the patients on OAC and those without OAC treatment was not significant in the year 2012 (6 vs. 12, P=0.066). This might be related to the fact that substantially fewer patients in 2012 were on DOACs, which are considered more effective than warfarin.

Pre-treatment radiological factors associated with poor functional outcome in an Asian cohort of large vessel occlusion acute ischemic stroke patients undergoing mechanical thrombectomy.

Endovascular thrombectomy (EVT) is the current standard of care for large vessel occlusion (LVO) acute ischemic stroke (AIS); however, up to two-thirds of EVT patients have poor functional outcomes despite successful reperfusion. Many radiological markers have been studied as predictive biomarkers for patient outcomes in AIS. This study seeks to determine which clinico-radiological factors are associated with outcomes of interest to aid selection of patients for EVT for LVO AIS. A retrospective study of patients who underwent EVT from 2016 to 2020 was performed. Data on various radiological variables, such as anatomical parameters, clot characteristics, collateral status, and infarct size, were collected alongside traditional demographic and clinical variables. Univariate and multivariate analysis was performed for the primary outcomes of functional independence at 3 months post-stroke (modified Rankin Scale 0-2) and secondary outcomes of in-hospital mortality and symptomatic intracranial hemorrhage. The study cohort comprised 325 consecutive patients with anterior circulation LVO AIS (54.5% male) with a median age of 68 years (interquartile range 57-76). The median NIHSS was 19. Age, hypertension, hyperlipidaemia, National Institutes of Health Stroke Scale (NIHSS), Alberta mCTA score, ASPECTS, clot length, thrombus HU and mTICI score and the angle between ICA and CCA were associated with functional outcomes at 3 months on univariate analysis. On multivariate analysis, age, Alberta mCTA collaterals and NIHSS were significantly associated with functional outcomes, while ASPECTS approached significance. Among the many proposed radiological markers for patients in the hyperacute setting undergoing EVT, the existing well-validated clinico-radiological measures remain strongly associated with functional status.

White matter integrity and functional connectivity of the default mode network in acute stroke are associated with cognitive outcome three months post-stroke

BackgroundKnowledge about factors that are associated with post-stroke cognitive outcome is important to identify patients with high risk for impairment. We therefore investigated the associations of white matter integrity and functional connectivity (FC) within the brain's default-mode network (DMN) in acute stroke patients with cognitive outcome three months post-stroke. MethodsPatients aged between 18 and 85 years with an acute symptomatic MRI-proven unilateral ischemic middle cerebral artery infarction, who had received reperfusion therapy, were invited to participate in this longitudinal study. All patients underwent brain MRI within 24–72 h after symptom onset, and participated in a neuropsychological assessment three months post-stroke. We performed hierarchical regression analyses to explore the incremental value of baseline white matter integrity and FC beyond demographic, clinical, and macrostructural information for cognitive outcome. ResultsThe study cohort comprised 34 patients (mean age: 64 ± 12 years, 35% female). The initial median National Institutes of Health Stroke Scale (NIHSS) score was 10, and significantly improved three months post-stroke to a median NIHSS = 1 (p < .001). Nonetheless, 50% of patients showed cognitive impairment three months post-stroke. FC of the non-lesioned anterior cingulate cortex of the affected hemisphere explained 15% of incremental variance for processing speed (p = .007), and fractional anisotropy of the non-lesioned cingulum of the affected hemisphere explained 13% of incremental variance for cognitive flexibility (p = .033). ConclusionsWhite matter integrity and functional MRI markers of the DMN in acute stroke explain incremental variance for post-stroke cognitive outcome beyond demographic, clinical, and macrostructural information.

Validation of a simple clinical tool for screening of acute lacunar stroke-A substudy of the WAKE-UP trial.

Lacunar stroke represents around a quarter of all ischemic strokes; however, their identification with computed tomography in the hyperacute setting is challenging. We aimed to validate a clinical score to identify lacunar stroke in the acute setting, independently, with data from the WAKE-UP trial using magnetic resonance imaging. We analyzed data from the WAKE-UP trial and extracted Oxfordshire Community Stroke Project (OCSP) classification. Lacunar score was defined by National Institutes of Health Stroke Scale (NIHSS) < 7 and OCSP lacunar syndrome. Assessment of lacunar infarct by two independent investigators was blinded to clinical data. We calculated sensitivity, specificity, negative and positive predictive value (NPV and PPV, respectively) of lacunar score. We included 503 patients in the analysis, mean (±SD) age 65.2 (±11.6) years, 325 (65%) males, median (IQR) NIHSS = 6 (4-9); 108 (22%) lacunar infarcts were identified on magnetic resonance (MR), patients fulfilling lacunar score criteria were 120 (24%), of which 47 (44%) had a lacunar infarct. Lacunar score was negative in 322 (82%) of patients without lacunar infarct. Patients with lacunar score had lower NIHSS (4 vs 7, p < 0.001), higher systolic (157 vs 151 mmHg, p = 0.001) and diastolic (86 vs 83 mmHg, p = 0.013) blood pressure and smaller infarct volume (2.4 vs 9.5 mL, p < 0.001). Performance of lacunar score was as follows: sensitivity 0.44; specificity 0.82; PPV 0.39; NPV 0.84; and accuracy 0.73. Assuming a prevalence of lacunar stroke of 13%, PPV lowered to 0.30 but NPV was 0.90. Lacunar score performed better for supratentorial lacunar infarcts. Lacunar score had a very good specificity and NPV for screening of lacunar stroke. Implementation of this simple tool into clinical practice may help hyperacute management and guide patient selection in clinical trials. Data supporting the results of this paper are available upon reasonable request to the corresponding author.

MMP-9 upregulation may predict hemorrhagic transformation after endovascular thrombectomy.

Hemorrhagic transformation (HT) is a serious complication after endovascular thrombectomy (EVT) for patients with acute ischemic stroke (AIS). We analyzed the plasma levels of MMP-9 before and after EVT and assessed the temporal changes of MMP-9 that may be associated with, and therefore predict, HT after EVT. We enrolled 30 AIS patients who received EVT, and 16 (53.3%) developed HT. The levels of MMP-9 in plasma collected from the arteries of AIS patients before and immediately after EVT were measured using ELISA. The percent change in MMP-9 after EVT (after/before) was calculated and compared between patients with and without HT. The median age of the AIS patients was 70 years, and 13 patients (43.3%) were men. The median National Institutes of Health Stroke Scale (NIHSS) scores of patients with HT were 18 on admission and 18 after EVT. The median NIHSS scores of patients without HT were 17 on admission and 11 after EVT. Patients with HT demonstrated significantly greater percentage increases in arterial MMP-9 levels after EVT. Patients with AIS who developed HT had significantly increased arterial MMP-9 levels after EVT, suggesting that the upregulation of MMP-9 following EVT could serve as a predictive biomarker for HT.

Relationship Between Hemorrhage Type and Development of Emotional and Behavioral Dyscontrol After Hemorrhagic Stroke.

Emotional and behavioral dyscontrol (EBD), a neuropsychiatric complication of stroke, leads to patient and caregiver distress and challenges to rehabilitation. Studies of neuropsychiatric sequelae in stroke are heavily weighted toward ischemic stroke. This study was designed to compare risk of EBD following intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) and to identify risk factors for EBD following hemorrhagic stroke. The authors conducted a prospective cohort study of patients hospitalized for nontraumatic hemorrhagic stroke between 2015 and 2021. Patients or legally authorized representatives completed the Quality of Life in Neurological Disorders (Neuro-QOL) EBD short-form inventory 3 months after hospitalization. Univariable and multivariable analyses identified risk factors for EBD after hemorrhagic stroke. The incidence of EBD was 21% (N=15 of 72 patients) at 3 months after hemorrhagic stroke. Patients with ICH were more likely to develop EBD; 93% of patients with EBD (N=14 of 15) had ICH compared with 56% of patients without EBD (N=32 of 57). The median Glasgow Coma Scale (GCS) score at hospital admission was lower among patients who developed EBD (13 vs. 15 among those without EBD). Similarly, admission scores on the National Institutes of Health Stroke Scale (NIHSS) and the Acute Physiology and Chronic Health Evaluation II (APACHE II) were higher among patients with EBD (median NIHSS score: 7 vs. 2; median APACHE II score: 17 vs. 11). Multivariable analyses identified hemorrhage type (ICH) and poor admission GCS score as predictors of EBD 3 months after hemorrhagic stroke. Patients with ICH and a low GCS score at admission are at increased risk of developing EBD 3 months after hemorrhagic stroke and may benefit from early intervention.

Combined intravenous and intra-arterial thrombolysis in hyperacute cerebral ischemia without significant corresponding vascular occlusion/stenosis: A Preliminary investigation

ObjectiveIn this study, we assessed the efficacy and safety of various thrombolytic treatment protocols in patients with hyperacute cerebral infarction. MethodsPatients diagnosed with acute ischemic stroke within 6 h of symptom onset and with brain computer tomography angiography confirming the absence of major vessel stenosis or occlusion were eligible for this study. The enrolled patients were subsequently randomized into two groups: all the groups received the standard intravenous thrombolysis treatment with rt-PA (0.9 mg/kg), and the experimental group underwent sequential intra-arterial thrombolysis treatment with alteplase (0.3 mg/kg, with a maximum dose of 22 mg), administered directly into the target vessel via a microcatheter. Both groups were closely monitored for changes in their National Institutes of Health Stroke Scale (NIHSS) score, modified Rankin scale score, hemorrhage rate, all-cause mortality rate, and the rate of favorable outcomes at 90 ± 7 days. ResultsNinety-four participants were enrolled in this study, with both the control and experimental groups initiating intravenous injection of rt-PA at a median time of 29 min. For the experimental group, the median time for arterial puncture was 123 min. Baseline data for both groups were similar (P > 0.05). Hemorrhagic transformation occurred in 24.47 % (23 patients), with a lower intracranial hemorrhage rate observed in the experimental group compared to the control group (15.2 % vs 33.3 %, P < 0.05). Asymptomatic hemorrhage rates were 8.7 % for the experimental group and 12.5 % for the control group, with no hemorrhage detected in other locations. Post-treatment median NIHSS scores were lower in the experimental group than in the control group (7 vs 9, P < 0.05), but short-term NIHSS scores were similar (P > 0.05). A higher proportion of patients in the experimental group achieved favorable outcomes compared to the control group (87.0 % vs 43.8 %, P < 0.05). ConclusionIn patients with acute ischemic stroke with an onset time of ≤6 h and no major intracranial vessel occlusion, combining rt-PA intravenous thrombolysis with intra-arterial thrombolysis via a microcatheter might yield superior functional outcomes.

The precision by the Face Arm Speech Time (FAST) algorithm in stroke capture, sex and age differences: a stroke registry study

BackgroundThe shift towards milder strokes and studies suggesting that stroke symptoms vary by age and sex may challenge the Face-Arm-Speech Time (FAST) coverage. We aimed to study the proportion of...

Portable cerebral blood flow monitor to detect large vessel occlusion in patients with suspected stroke

BackgroundEarly detection of large vessel occlusion (LVO) facilitates triage to an appropriate stroke center to reduce treatment times and improve outcomes. Prehospital stroke scales are not sufficiently sensitive, so we...

Clopidogrel Plus Aspirin vs Aspirin Alone in Patients With Acute Mild to Moderate Stroke

Dual antiplatelet therapy has been demonstrated to be superior to single antiplatelet in reducing recurrent stroke among patients with transient ischemic attack or minor stroke, but robust evidence for its effect in patients with mild to moderate ischemic stroke is lacking. To evaluate whether dual antiplatelet therapy is superior to single antiplatelet among patients with mild to moderate ischemic stroke. This was a multicenter, open-label, blinded end point, randomized clinical trial conducted at 66 hospitals in China from December 20, 2016, through August 9, 2022. The date of final follow-up was October 30, 2022. The analysis was reported on March 12, 2023. Of 3065 patients with ischemic stroke, 3000 patients with acute mild to moderate stroke within 48 hours of symptom onset were enrolled, after excluding 65 patients who did not meet eligibility criteria or had no randomization outcome. Within 48 hours after symptom onset, patients were randomly assigned to receive clopidogrel plus aspirin (n = 1541) or aspirin alone (n = 1459) in a 1:1 ratio. The primary end point was early neurologic deterioration at 7 days, defined as an increase of 2 or more points in National Institutes of Health Stroke Scale (NIHSS) score, but not as a result of cerebral hemorrhage, compared with baseline. The superiority of clopidogrel plus aspirin to aspirin alone was assessed based on a modified intention-to-treat population, which included all randomized participants with at least 1 efficacy evaluation regardless of treatment allocation. Bleeding events were safety end points. Of the 3000 randomized patients, 1942 (64.6%) were men, the mean (SD) age was 65.9 (10.6) years, median (IQR) NIHSS score at admission was 5 (4-6), and 1830 (61.0%) had a stroke of undetermined cause. A total of 2915 patients were included in the modified intention-to-treat analysis. Early neurologic deterioration occurred in 72 of 1502 (4.8%) in the dual antiplatelet therapy group vs 95 of 1413 (6.7%) in the aspirin alone group (risk difference -1.9%; 95% CI, -3.6 to -0.2; P = .03). Similar bleeding events were found between 2 groups. Among Chinese patients with acute mild to moderate ischemic stroke, clopidogrel plus aspirin was superior to aspirin alone with regard to reducing early neurologic deterioration at 7 days with similar safety profile. These findings indicate that dual antiplatelet therapy may be a superior choice to aspirin alone in treating patients with acute mild to moderate stroke. ClinicalTrials.gov Identifier: NCT02869009.

Impact of Frailty on Healthcare Outcomes after Cardioembolic Ischaemic Stroke Due to Atrial Fibrillation.

Stroke due to atrial fibrillation (AF) is more common in older adults. Frailty is associated with AF. As little is known about the impact of frailty on cardioembolic stroke, we examined its association with important healthcare outcomes including mortality and functional outcome in stroke with AF. Data were collected from patients presenting consecutively to a regional university hospital to assess pre-admission frailty using the Clinical Frailty Scale (CFS) and function with the Modified Rankin Scale (mRS). Stroke severity was assessed on the National Institute of Health Stroke Scale (NIHSS). In total, 113 patients presenting between August 2014 and July 2016 were identified with cardioembolic stroke, median age 80 years; 60% were male. Their median NIHSS score was 6. The median pre-admission CFS score was 3; 26.5% scored ≥5/9, indicating frailty. The median pre-admission mRS scores increased significantly from 1 to 3 at discharge (p < 0.001). Frailty was associated with worse mRS scores at discharge, odds ratio 1.5, (p = 0.03). While no patients with frailty were suitable to avail of early supported discharge, 10% of those without frailty were (p = 0.02). There was no significant difference in 30-day mortality. Frailty is prevalent among patients with cardioembolic stroke due to AF and was associated with poorer functional outcomes. Although the numbers were small, these data suggest that brief frailty assessments are useful to risk-stratify patients with acute cardioembolic stroke. Frailty status on admission with stroke due to AF can help identify those more likely to have poorer outcomes, to benefit from intervention, to require prolonged rehabilitation, and to avail of ESD.

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

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

Persistent headache attributed to past ischemic stroke: A prospective cohort study.

To assess the incidence, characteristics, and risk factors for developing persistent headache attributed to past ischemic stroke. Although the most recent International Classification of Headache Disorders has recognized the existence of persistent headache attributed to past ischemic stroke, there has been limited research in this area. This was a prospective cohort study. We initially assessed patients hospitalized with ischemic stroke admitted within 72 h of symptom onset. All patients underwent diffusion-weighted magnetic resonance imaging. These patients were re-interviewed by telephone 1 year after the stroke. Semi-structured questionnaires, the National Institutes of Health Stroke Scale (NIHSS), and six-item Headache Impact Test were used. A total of 119 participants answered the interview conducted 1 year after the stroke. The mean (standard deviation) age was 64 (13.1) years, 82/119 (68.9%) were female, and the median (interquartile range) NIHSS score was 2 (1.0-4.0). The incidence rate of persistent headache attributed to past ischemic stroke was 12/119 (10.1%; 95% confidence interval [CI] 5.3-17.0%). The most frequent pattern presented was a migraine-like pattern in seven of the 12 (58.3%) patients, which had a substantial/severe impact on five of the 12 (41.7%). For most patients this headache continued, although it began to improve. Previous migraine (odds ratio 7.1, 95% CI 1.06-50.0; p = 0.043) and headache intensity in the acute phase of stroke (odds ratio 1.75, 95% CI 1.13-2.7; p = 0.012) were associated with the occurrence of persistent headache attributed to past ischemic stroke. Persistent headache attributed to past ischemic stroke is a frequent complication after stroke. It often has a significant impact on patients' lives and presents a migraine-like pattern as its most frequent phenotype.

Stroke as the index presentation of traditional cardiovascular risk factors and Human Immunodeficiency Virus in a South African population

ObjectivesWe sought to identify what proportion of each cardiovascular risk factor and Human Immunodeficiency Virus (HIV) was first diagnosed at the time of stroke, compared to those that were diagnosed prior to the event, and to explore if this had any impact on the severity of stroke. MethodsAdult patients presenting with a new stroke to a quaternary hospital in Johannesburg between 2014 and 2017 were prospectively recruited. Patients were investigated for undiagnosed traditional cardiovascular risk factors (hypertension, diabetes mellitus, dyslipidaemia, atrial fibrillation, obesity and smoking), as well as HIV infection. Stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS). Results346 patients were included. Stroke was the index presentation for at least one risk factor in 199 (57.5 %) patients. Dyslipidaemia was newly diagnosed in 76.0 % of all dyslipidaemics (95 out of 125). Newly-diagnosed dyslipidaemia was associated with a more severe neurological deficit (Median NIHSS of 12 (8-16) vs 7 (4-12), p=0.0007) and younger age on presentation (53 (44-63) years vs 62 (51-71) years, p=0.02) as compared to previously-diagnosed dyslipidaemia. ConclusionsMore than half of patients had previously undiagnosed modifiable risk factors at the time of their stroke. Dyslipidaemia was undiagnosed in a very high proportion, and this was associated with a higher stroke severity and younger age of presentation.

Intensive care unit admission prediction tool for ischemic stroke patients receiving intravenous thrombolysis: A retrospective cohort study

Background: Some evidence suggests that given the limited healthcare resources, the majority of low- risk stroke patients may not require critical care monitoring. This study aimed to establish a predictive score for identifying post-intravenous thrombolysis (IVT) acute ischemic stroke patients who should be monitored in the intensive care unit (ICU). Methods: This was a retrospective cohort study of patients with acute ischemic stroke who underwent IVT at Songklanagarind Hospital, Thailand between January 2010 and December 2019. Baseline characteristics and clinical outcomes were recorded. Systolic blood pressure (SBP) was collected using the first recorded in the emergency department (ED) as well as the National Institutes of Health Stroke Scale (NIHSS). Results: Of the 171 patients with stroke, 73 (42.7%) needed ICU care. The median age was 67 years old. The median SBP and NIHSS were 160 mm Hg and 10, respectively. The predicting stroke ICU (PSU) score was developed, with the following points assigned: NIHSS score (1 point if &gt; 9), SBP (1 point if &gt; 170 mmHg), and infarct size greater than 1 lobe (2 points if present). The PSU score achieved an area under the ROC curve of 0.759 (95% confidence interval [CI] = 0.688–0.830). A PSU score ≥ 1 predicted the need for ICU care with a sensitivity of 91.78%. Conclusions: The PSU score, which is based on the NIHSS score, systolic blood pressure, and infarct size, predicts the need for ICU care after IVT in patients with stroke.

Initial Experience with the Solitaire X 3 mm Stent Retriever for the Treatment of Distal Medium Vessel Occlusions

Endovascular therapy (EVT) is the standard treatment for ischemic stroke caused by a large vessel occlusion (LVO). The effectiveness of EVT for distal medium vessel occlusions (MDVOs) is still uncertain, but newer, smaller devices show potential for EVT in MDVOs. The new Solitaire X 3 mm device offers a treatment option for MDVOs. Our study encompassed consecutive cases of primary and secondary MDVOs treated with the Solitaire X 3 mm stent-retriever as first-line EVT device between January and December 2022 at 12 European stroke centers. The primary endpoint was a first-pass near-complete or complete reperfusion, defined as a modified treatment in cerebral infarction (mTICI) score of 2c/3. Additionally, we examined reperfusion results, National Institutes of Health Stroke Scale (NIHSS) scores at 24 h and discharge, device malfunctions, complications and procedural technical parameters. Sixty-eight patients (38 women, mean age 72 ± 14 years) were included in our study. Median NIHSS at admission was 11 (IQR 6–16). In 53 (78%) cases, a primary combined approach was used as the frontline technique. Among all enrolled patients, first-pass mTICI 2c/3 was achieved in 22 (32%) and final mTICI 2c/3 in 46 (67.6%) patients after a median of 1.5 (IQR 1–2) passes. Final reperfusion mTICI 2b/3 was observed in 89.7% of our cases. We observed no device malfunctions. Median NIHSS at discharge was 2 (IQR 0–4), and no symptomatic intracranial hemorrhages were reported. Based on our analysis, the utilization of the Solitaire X 3 mm device appears to be both effective and safe for performing EVT in cases of MDVO stroke.

Useful treatment paradigms: Decompressive hemicraniectomy with hematoma evacuation in larger intracranial hemorrhage. Insights from a leading vietnamese hospital

Background and PurposeSpontaneous intracerebral hemorrhage (SICH) bears a poor prognosis, with a 30-day mortality rate of 35%–52%. The mass effects of hematoma and surrounding edema in larger supratentorial SICH lead to an increased intracranial pressure (ICP) and subsequent brain herniation. Multiple trials have failed to prove the superiority of surgical evacuation over conservative methods. However, surgery in a carefully selected set of patients is beneficial in reducing mortality and limiting disability. The aim of this study was to investigate the effectiveness of decompressive hemicraniectomy (DHC) with hematoma evacuation for treating patients with larger supratentorial SICH. MethodsThis was a retrospective study conducted at our hospital between December 2016 and April 2020. A total of 55 patients with large supratentorial SICH treated with DHC and hematoma evacuation during this period. Patient characteristics and clinical information were analyzed, including age, sex, Glasgow Coma Scale (GCS), stroke severity (e.g. National Institutes of Health Stroke Scale), computed tomography (CT) scan data (signs of herniation, side and size of hematoma, midline shift), the time interval between ictus and surgery, surgical characteristics, and time of ventilation. Outcome was assessed by modified Rankin Scale (mRS) at six months after surgery. ResultsFifty-five patients (82% males) were treated with DHC. The mean age was 55 years. The median NIHSS (National Institutes of Health Stroke Scale) score at admission was 26 (range 9–32). Approximately two-thirds of the patients (69.1%) had hematoma located within the basal ganglia, while 30.9% had lobar hematomas. The median midline shift was 10.9 mm (range 4–20 mm). Intraventricular extensions were observed in 23 patients on the pre-operative CT scan. At discharge, the median mRS score was 5 (range 4–6), and 5 patients (9.1%) died. Six months after surgery, 17 patients (31%) had favorable outcomes (mRS scores 0–3), while the remaining patients had poor outcomes (mRS scores 4–6). The mortality rate was 25.5% (n = 14 patients). In comparison to the poor outcome group, those with favorable outcomes had a significantly higher GCS score (mean, 9.5 [SD = 2.5] vs 8.0 [SD = 1.9]; p = 0.013). Conversely, those who had poor outcomes were more likely to be older (mean 57.2 [SD = 10.4] vs 49.7 [SD = 10.7]; p = 0.017) and had a larger hematoma volume (mean 95.8 [SD = 32] vs 71.6 [SD = 33.0]; p = 0.018). ConclusionsDecompressive hemicraniectomy with hematoma evacuation could be beneficial for a selected group of young patients with large SICH.

Abstract 215: A Sweet Indicator: HbA1C and Thrombectomy Outcomes in Hispanics

Introduction There is a higher prevalence of diabetes mellitus type 2 in Hispanics as compared to other ethnic groups in the United States. Diabetes is a risk factor for acute ischemic stroke and also a poor predictor of outcome for many interventional surgeries. We performed this retrospective cohort analysis to assess the impact of poorly controlled diabetes, defined as HbA1C of 9.0% or greater, on the functional and procedural outcomes of Hispanic patients with acute ischemic stroke undergoing mechanical thrombectomy. Methods We conducted a retrospective review of a prospectively maintained patient database at a large volume comprehensive stroke center. Patients included were of Hispanic origin presenting between 2012 and 2022 who underwent thrombectomy for acute ischemic stroke. Baseline patient demographics and clinical characteristics recorded include age, gender, HbA1C level, National Institutes of Health Stroke Scale (NIHSS) at admission, manual CT ASPECTS and stroke risk factors (hypertension, atrial fibrillation, coronary artery disease, congestive heart failure, LDL, smoking, history of stroke/TIAs). Patients were separated into two groups depending on the presence poorly controlled diabetes defined as an HbA1C of 9.0% or greater. Outcomes evaluated include modified Rankin scale at 3 months, symptomatic intracranial hemorrhage, mass effect, 90‐day mortality, and whether any stenting or angioplasty was required during mechanical thrombectomy. Results 495 patients met the inclusion criteria out of which 69 had HbA1c of 9% or greater. Patients with poorly controlled diabetes were significantly younger (median age 63 vs 72, p &lt;0.001), had a lower prevalence of atrial fibrillation (7.69% vs 29.8%, p &lt;0.001) and a higher median LDL level (95.5 vs 72, p&lt;0.001) compared to patients who did not have poorly controlled diabetes. Median NIHSS on admission was also lower in the poorly controlled diabetics group (13 vs 17, p = 0.02). There was a statistically significant lower rate of functional independence (mRS 0‐2) at 90 days in patients with poorly controlled diabetes (30.6% vs 45.3%, p=0.05) after adjusting for age, NIHSS, and atrial fibrillation. Patients with poorly controlled diabetes also were more likely to require angioplasty (31.3% vs. 20.5%; p = 0.048) and stenting (28.4% vs. 18.1%; p = 0.049) during mechanical thrombectomy. Conclusion High HbA1c levels upon admission may be used to predict poor functional outcomes of thrombectomy and may also be associated with a greater chance of patients requiring angioplasty and/or stenting during thrombectomy. This can assist the physician in deciding if thrombectomy should be done on a patient with poorly controlled diabetes.

Abstract 211: Comparing Early and Late Window 3mm Trevo Stent Retriever Performance in Medium Vessel Occlusion Thrombectomy

Introduction Endovascular thrombectomy has been shown to be beneficial for select patients with medium vessel occlusion ischemic strokes. Newer mechanical thrombectomy devices have designs to facilitate navigation of the medium and distal cerebrovasculature. In this single‐center study, we aim to compare the performance of 3mm Trevo NXT stent retrievers (Stryker, Kalamazoo, MI) for medium vessel occlusion mechanical thrombectomy for patients treated within either the early (&lt;6 hour) or late (&gt;6 hour) treatment window. Methods A retrospective review was conducted of acute ischemic stroke patients with medium vessel occlusions (i.e., M2‐M4, ACA, and PCA) who underwent thrombectomy over 5 years (2018‐2022) at a single comprehensive stroke center. Classification into early or late window was defined as time from last known well to groin puncture less than 6 hours or greater than 6 hours, respectively. Primary efficacy outcome included successful recanalization (modified thrombolysis in cerebral infarction [mTICI]&gt;=2B) using 3mm Trevo NXT on either first pass or rescue pass (i.e., after initial pass failure with another device). Primary safety outcome is rate of complications associated with the stent retriever. Primary clinical outcome was National Institutes of Health Stroke Scale (NIHSS) shift between admission and discharge. Results Of 81 patients with medium vessel occlusion ischemic strokes, 38 patients (44.7% female, median age of 73.5 years [IQR 66‐82], median initial NIHSS 13 [IQR 8‐23]) underwent thrombectomy with 3mm Trevo NXT. Stent retriever‐assisted aspiration (versus stent retriever only) was performed in 31/38 (81.6%) patients. Successful recanalization with stent retriever was achieved in 28/38 (73.7%) of patients. There was no significant difference in rate of recanalization between early and late window thrombectomy (16/22 [72.7%] early window vs. 12/16 [75%] late window, p=0.8752). The lack of significant difference in recanalization rate was consistent with stent retriever use during first pass (11/14 [78.6%] early window vs. 9/10 [90%] late window, p=0.6146) and as rescue (5/8 [62.5%] early window vs. 3/6 [50%] late window, p=0.6400). There was no significant difference in the rate of stent retriever complications between early and late windows (1/16 [6.3%] early vs. 0/22 [0%] late, p=0.4211). There was no significant difference in median NIHSS shift from admission to discharge ( ‐6 [IQR ‐16 ‐ 9] early window vs. ‐3 [IQR ‐5 ‐ 4] late window, p=0.3666). Conclusion In both early and late window medium vessel occlusion thrombectomy, the 3mm Trevo NXT as first line and rescue intervention performs comparably and adequately. Future multicenter studies will further characterize novel stent retriever performance in medium vessel occlusion thrombectomies.