Rate Of Neurological Deterioration Research Articles

P.108 Rate and clinical utility of early postoperative CT head in adult craniotomy

Background: Postoperative cranial neurosurgical imaging practices are highly variable. We evaluated the rate and utility of early postoperative computed tomography (EPCT, defined as a CT head scan within 24h of surgery) in consecutive adult craniotomies. Methods: We retrospectively reviewed consecutive adult craniotomies at the University of Alberta Hospital over a 45-day period (17/09/2022 to 01/11/2022). Electronic medical records were reviewed to extract data on the rate, timing, and utility of EPCT as well as the rate of neurologic deterioration and repeat surgical intervention. Results: A total of 56 patients (27 female; 55.5 ± 2.1 yrs, range: 19-84 years) were identified. All patients underwent EPCT, including 10/56 (17.9%) on POD0 and 46/56 (82.1%) on POD1. Surgical complications (bleeding, extensive pneumocephalus, edema, ischemia) were identified in 8/56 (14.3%) of the EPCT, of which 6 (10.7%) were reported to have neurologic deterioration and 2 (3.6%) underwent further surgical intervention (hematoma evacuation). Clinical and radiological postoperative changes were highly related (p=5.16e-06), and the rate of EPCT being adverse without neurologic deficit, managed surgically, was 1/56 (1.8%). Conclusions: EPCT is routine practice. Given the low rate (1.8%) of repeat surgical intervention in the absence of neurologic deficit despite abnormal EPCT, omitting EPCT in neurologically intact patients may be warranted.

Focal compression of the cervical spinal cord alone does not indicate high risk of neurological deterioration in patients with a diagnosis of mild degenerative cervical myelopathy

Degenerative Cervical Myelopathy (DCM) is the functional derangement of the spinal cord resulting from vertebral column spondylotic degeneration. Typical neurological symptoms of DCM include gait imbalance, hand/arm numbness, and upper extremity dexterity loss. Greater spinal cord compression is believed to lead to a higher rate of neurological deterioration, although clinical experience suggests a more complex mechanism involving spinal canal diameter (SCD). In this study, we utilized machine learning clustering to understand the relationship between SCD and different patterns of cord compression (i.e. compression at one disc level, two disc levels, etc.) to identify patient groups at risk of neurological deterioration. 124 MRI scans from 51 non-operative DCM patients were assessed through manual scoring of cord compression and SCD measurements. Dimensionality reduction techniques and k-means clustering established patient groups that were then defined with their unique risk criteria. We found that the compression pattern is unimportant at SCD extremes (≤14.5 mm or > 15.75 mm). Otherwise, severe spinal cord compression at two disc levels increases deterioration likelihood. Notably, if SCD is normal and cord compression is not severe at multiple levels, deterioration likelihood is relatively reduced, even if the spinal cord is experiencing compression. We elucidated five patient groups with their associated risks of deterioration, according to both SCD range and cord compression pattern. Overall, SCD and focal cord compression alone do not reliably predict an increased risk of neurological deterioration. Instead, the specific combination of narrow SCD with multi-level focal cord compression increases the likelihood of neurological deterioration in mild DCM patients.

Evaluation of Post-thrombolytic Events to Determine Appropriate ICU Monitoring Duration for Patients with Ischemic Stroke.

Standard treatment for eligible patients presenting with acute ischemic stroke (AIS) is thrombolysis with tissue plasminogen activators alteplase or tenecteplase. Current guidelines recommend monitoring patients in an intensive care unit (ICU) for 24h after thrombolytic therapy. However, recent studies have questioned the need for prolonged ICU monitoring. This retrospective cohort study aims to identify potential candidates for early transition to a lower level of care by assessing risk factors for neurological deterioration, symptomatic intracranial hemorrhage (sICH), or need for ICU intervention within 24h post-thrombolysis. This retrospective cohort study included adult patients 18years and older with AIS who received thrombolysis. Patients were excluded if they were transferred to another facility, if they were transitioned to comfort care or hospice care within 24h, or if they lacked imaging and National Institutes of Health Stroke Scale (NIHSS) score data. The primary end point was incidence of sICH between 0-12 and 12-24h. Secondary end points included the need for ICU intervention and rates of neurological deterioration. The analysis included 204 patients who received the full dose of alteplase. Among them, ten patients (4.9%) developed sICH, with the majority (n = 7) occurring within 12h post-thrombolysis. Sixty-two patients required ICU interventions within 12h compared with four patients after 12h. Twenty-four patients had neurological deterioration within 12h, and seven patients had neurological deterioration after 12h. Multivariable analysis identified mechanical thrombectomy and increased blood pressure at presentation as predictors of ICU need beyond 12h post-thrombolysis. Our study demonstrates that sICH, neurological deterioration, and need for ICU intervention rarely occur beyond 12h after thrombolytic administration. Patients presenting with blood pressures < 140/90mm Hg, NIHSS scores < 10, and not undergoing mechanical thrombectomy may be best candidates for early de-escalation. Larger prospective studies are needed to more fully evaluate the safety, feasibility, and financial impact of early transition out of the ICU.

Abstract 27: A Novel Adjuvant Strategy After Endovascular Therapy: Arterial Glyceryl Trinitrate in Acute Ischemic Stroke for Neuroprotection (AGAIN)

Introduction: Although mechanical thrombectomy (MT) demonstrates robust clinical efficacy in acute ischemic stroke (AIS), not all stroke patients benefit from successful reperfusion. The protective effect of NO donors has been shown to prevent ischemia-reperfusion injury through reduction of reactive oxygen species formation in cardiovascular studies. Glyceryl Trinitrate (GTN), a Food and Drug Administration-approved vasodilator, is one of the widely used exogenous NO donors used in the clinic and has been trialed for neuroprotection in AIS without successful clinical translation. The recent advances in MT for AIS have paved the way for promising new opportunities to supplementary neuroprotective therapies to patients after reperfusion. This study evaluated the safety, feasibility, and preliminary efficacy of intra-arterial administration of GTN after MT for neuroprotection. Methods: This is a prospective randomized controlled study (ID: ChiCTR2100045254). Eligible patients were randomized to receive 800μg GTN or same volume of normal saline through the catheter after recanalization. The primary outcome was symptomatic intracranial hemorrhage (sICH), while secondary outcomes included mortality, functional outcome, infarction volume, complications, and blood nitrate index (NOx). Results: A total of 40 patients were enrolled and randomized with no participants being lost to follow-up. There was no significant difference in the proportion of sICH between GTN and control groups. No significant difference was observed in mortality or rates of neurological deterioration and other complications. Favorable trends for both functional independence (mRS 0-2, 75.0% vs. 65.0%) at 90 days and reduction in final infarct volume (33.2 vs. 38.9 ml) have been observed in GTN group, although they did not reach the significant levels. Moreover, the concentration of blood NO X was increased (p&lt;0.05) at 2 hours after GTN administration (26.2 vs 18.0 μmol/l). Conclusion: The AGAIN study suggests intra-arterial administration of GTN post MT is safe and feasible in AIS patient. The discernible positive trends may be due to the raised NO X levels, which potentially highlight the mechanistic reinforcement for these observed benefits.

Cilostazol addition to aspirin may worsen the short-term outcome in patients with large artery disease: ADS subanalysis

Our previous acute dual study (ADS) reported that dual antiplatelet therapy (DAPT) using cilostazol and aspirin did not reduce the rate of neurological deterioration in non-cardioembolic stroke patients. In this post-hoc analysis, we investigated whether the impact of dual antiplatelet therapy (DAPT) may depend on neurological severity, as represented by large artery disease. Neurological deterioration was defined as neurological progression with an increment of the National Institutes of Health Stroke Scale (NIHSS) score of ≥2. NIHSS score subgroups were divided into that of 0-1, 2-4, 5-10, and >10. Among 1014 patients, 203 (20%) had the large artery disease, and 811 (80%) did not. In the total cohort, the rate of neurological deterioration was 10.8% in the DAPT group and 8.3% in the aspirin group (P=0.197). When we focused on the large artery disease group, DAPT group had a higher rate of neurological deterioration as 18.3% compared to 8.2% in the aspirin group (P=0.036). Among patients with NIHSS score of 0-1 and 2-4, the rates of neurological deterioration were not different between the two group (both, P=1.000). However, when NIHSS score elevated to 5-10, 45% in the DAPT group and 9.1% in the aspirin group deteriorated (P=0.013). Among the patients with NIHSS score of >10, 60% in the DAPT group and none (0%) in the aspirin group had the neurological deterioration (P=0.045). DAPT with aspirin and cilostazol was associated with higher rate of neurological deterioration when patients have large artery disease and not mild neurological deficits.

Nuance and profound impact: Evaluating the effects of the unmet full coma scale in patients with mild subdural hemorrhage

IntroductionPatients with subdural hemorrhage (SDH) and a Glasgow Coma Scale (GCS) score of 13–15 are typically categorized as having mild traumatic brain injury. We hypothesize that patients without a maximum GCS score – specifically, patients with GCS scores of 13 and 14 – may exhibit poorer neurological outcomes. MethodBetween January 1, 2019, and December 31, 2020, SDH patients with GCS scores ranging from 13 to 15 were retrospectively studied. We compared outcomes between patients with a maximum GCS score of 15 and those with scores of either 13 or 14. Independent factors associated with neurological deterioration among patients with a GCS score of 15 were evaluated using multivariate logistic regression (MLR) analysis. ResultsDuring the study period, 470 patients with SDH and GCS scores between 13 and 15 were examined. Compared to patients with a maximum GCS score (N = 375), those in the GCS 13–14 group (N = 95) showed significantly higher rates of neurological deterioration (33.7% vs. 10.4%, p value <0.001) and neurosurgical interventions (26.3% vs. 16.3%, p value <0.024). Moreover, the GCS 13–14 group had a significantly poorer prognosis than patients with a GCS score of 15 [mortality rate: 7.4% vs. 2.4%, p value <0.017; rate of impaired consciousness at discharge: 21.1% vs. 4.0%, p value <0.001; and rate of neurological disability at discharge: 29.5% vs. 6.9%, p value <0.001]. The MLR analysis revealed that SDH thickness (odds ratio = 1.127, p value = 0.006) was an independent risk factor for neurological disability at discharge in patients with a GCS score of 15. ConclusionAmong SDH patients with mild TBI, those with GCS scores of 13–14 exhibited poorer neurological outcomes than those with a maximum GCS score. The thickness of the SDH is positively associated with neurological disability in SDH patients with a maximum GCS score.

Arterial Glyceryl Trinitrate in Acute Ischemic Stroke After Thrombectomy for Neuroprotection (AGAIN): A Pilot Randomized Controlled Trial

Although endovascular therapy demonstrates robust clinical efficacy in acute ischemic stroke (AIS), not all stroke patients benefit from successful reperfusion. This study aimed to evaluate the safety, feasibility, and preliminary efficacy of intra-arterial administration of glyceryl trinitrate (GTN) after endovascular recanalization for neuroprotection. This is a prospective randomized controlled study. Eligible patients were randomized to receive 800 μg GTN or the same volume of normal saline through the catheter after recanalization. The primary outcome was symptomatic intracranial hemorrhage (ICH), while secondary outcomes included mortality, functional outcome, infarction volume, complications, and blood nitrate index (NOx). A total of 40 patients were enrolled and randomized with no participants being lost to follow-up. There was no significant difference in the proportion of sICH between GTN and control groups. Additionally, no significant difference was observed in mortality or rates of neurological deterioration and other complications. Favorable trends, while non-significant, were noted in both outcome and imaging for functional independence at 90 days and reduction in final infarct volume (75.0% vs 65.0%; 33.2 vs 38.9 ml) for the GTN group. Moreover, the concentration of blood NOx in the GTN group was significantly higher than in the control group at 2 h after GTN administration (26.2 vs 18.0 μmol/l, p < 0.05). The AGAIN study suggests intra-arterial administration of GTN post-endovascular therapy is safe and feasible and GTN successfully raised NOx levels over controls at 2 h. A multi-center randomized controlled trial with a larger sample size is warranted to determine GTN neoadjuvant efficacy.

Development and Validation of a Predictive Model for Failure of Medical Management in Spinal Epidural Abscesses.

The optimal management of spinal epidural abscesses (SEA) secondary to primary spinal infections has demonstrated large variability in the literature. Although some literature suggests a high rate of neurological deterioration, others suggest failure of medical management is uncommon. To develop a predictive model to evaluate the likelihood of failure of medical therapy in the setting of SEA. A retrospective review was conducted of all patients presenting with SEA from primary spinal infections. Patients presenting with MRI evidence of SEA without neurological deficits were included. Failure of medical management was defined as requiring surgical intervention over 72 hours after the initiation of antibiotics. A machine learning method (Risk-Calibrated Supersparse Linear Integer Model) was used to create a risk stratification score to identify patients at high risk for requiring surgical intervention. In total, 159 patients were identified as presenting with MRI findings of SEA without evidence of neurological deficit. Of these patients, 50 required delayed surgery compared with 109 whose infection were successfully treated with surgical intervention. The Spinal Epidural Abscess Predictive Score was created using a machine learning model with an area under the curve of 0.8043 with calibration error of 14.7%. Factors included active malignancy, spondylodiscitis, organism identification, blood cultures, and sex. The probability of failure of medical management ranged from <5% for a score of 2 or less and >95% for a score of 7 or more. The Spinal Epidural Abscess Predictive Score model is a quick and accurate tool to assist in clinical decision-making in SEA.

Surgical Timing in Patients With Infective Endocarditis and With Intracranial Hemorrhage: A Systematic Review and Meta-Analysis.

BackgroundIntracranial hemorrhage (ICH) is one of the main causes for lack of surgery in patients with infective endocarditis (IE), despite the presence of surgical indications. We aimed to evaluate the impact of early surgery in patients with IE and with ICH on postoperative neurological deterioration and all‐cause mortality and to elucidate the risk of 30‐day mortality in patients who were denied surgery.Methods and ResultsThree libraries (MEDLINE, EMBASE, and Cochrane Library) were assessed. The primary outcome was all‐cause mortality, and the secondary outcome was neurological deterioration. Inverse variance method and random model were performed. We identified 16 studies including 355 patients. Nine studies examined the impact of surgical timing (early versus late) and were included in the meta‐analysis. Only one study examined the fate of patients with IE and with ICH who were treated conservatively despite having an indication for cardiac surgery, showing higher mortality rates than those who underwent surgery (11.8% versus 2.5%). We found no significant association between early surgery, regardless of its definition, and a higher mortality (odds ratio [OR], 1.69; 95% CI, 0.95–3.02). Early surgery was associated with higher risk for neurological deterioration (OR, 2.00; 95% CI, 1.10–3.65).ConclusionsCardiac surgery for IE within 30 days of ICH was not associated with higher mortality, but with an increased rate of neurological deterioration. The 30‐day mortality in patients with IE and with ICH who were denied surgery has not yet been sufficiently investigated. This patient group should be analyzed in future studies in more detail.

Abstract WMP73: Surgical Timing In Infective Endocarditis Patients With Intracranial Hemorrhage -a Systematic Review And Meta-analysis

Background and Purpose: Cardiac surgery is indicated in more than half of patients with infective endocarditis (IE); however, it is performed in only 60% of the indicated cases. Majority of patients with surgical indications who were denied surgery due to certain reasons die within 30 days. Intracranial hemorrhage (ICH) is one of the main causes for denial of surgery despite the presence of surgical indications. We aimed to evaluate the impact of early surgery (within 30 days) in IE-patients with ICH on postoperative outcome and to elucidate the risk of 30-day mortality in patients for whom surgery was denied. Methods: Three libraries (MEDLINE, EMBASE and Cochrane Library) were assessed for studies evaluating the postoperative outcome in early vs. late surgery in IE-patients with preoperative ICH. The primary outcome was all-cause mortality, and the secondary outcome was neurological deterioration. Inverse variance method and random model were performed. Results: We identified 16 studies including 355 patients. Nine studies examined the impact of surgical timing (early vs. late) and were included in the meta-analyses. Only one study examined the fate of IE-patients with ICH who were treated conservatively despite of having an indication for cardiac surgery, showing higher mortality rates than those who were operated (11.8 % vs. 2.5 %). We found no significant association between early surgery, regardless of its definition, and a higher mortality (relative risk [RR]= 1.46; 95% confidence interval [CI]: 0.98-2.17). However, early surgery was associated with higher risk for neurological deterioration (RR= 1.97; 95% CI: 1.15-3.38). Conclusions: Cardiac surgery for IE within 30 days of ICH was not associated with higher mortality, but with increased rate of neurological deterioration. Thirty-day mortality in IE-patients with ICH for whom surgery was denied has not yet been sufficiently investigated. This patient group should be analysed in future studies in more detail.

Predicting Neurological Deterioration after Moderate Traumatic Brain Injury: Development and Validation of a Prediction Model Based on Data Collected on Admission.

Moderate traumatic brain injury (mTBI) is a heterogeneous entity that is poorly defined in the literature. Patients with mTBI have a high rate of neurological deterioration (ND), which is usually accompanied by poor prognosis and no definitive methods to predict. The purpose of this study is to develop and validate a prediction model that estimates the ND risk in patients with mTBI using data collected on admission. Data for 479 patients with mTBI collected retrospectively in our department were analyzed by logistic regression models. Bivariable logistic regression identified variables with a p < 0.05. Multi-variable logistic regression modeling with backward stepwise elimination was used to determine reduced parameters and establish a prediction model. The discrimination efficacy, calibration efficacy, and clinical utility of the prediction model were evaluated. The prediction model was validated using data for 176 patients collected from another hospital. Eight independent prognostic factors were identified: hypertension, Marshall scale (types III and IV), subdural hemorrhage (SDH), location of contusion (frontal and temporal contusions), Injury Severity Score >13, D-dimer level >11.4 mg/L, Glasgow Coma Scale score ≤10, and platelet count ≤152 × 109/L. A prediction model was established and was shown as a nomogram. Using bootstrapping, internal validation showed that the C-statistic of the prediction model was 0.881 (95% confidence interval [CI]: 0.849-0.909). The results of external validation showed that the nomogram could predict ND with an area under the curve of 0.827 (95% CI: 0.763-0.880). The present model, based on simple parameters collected on admission, can predict the risk of ND in patients with mTBI accurately. The high discriminative ability indicates the potential of this model for classifying patients with mTBI according to ND risk.

Brain Tumor Rehabilitation: Symptoms, Complications, and Treatment Strategy.

Brain tumors are receiving increasing attention in cancer rehabilitation due to their high rate of neurological deterioration. Motor dysfunction, cognitive deterioration, and emotional problems are commonly present in patients with brain tumors. Other medical complications, such as seizures, headache, and dysphagia are also common. An individualized multidisciplinary rehabilitation intervention is necessary to treat functional impairment due to the tumor itself and/or treatment-related dysfunction. Herein, we discuss rehabilitation treatment strategies in relation to the neurological and functional complications that commonly occur in patients with brain tumors.

Risk factors associated with post-operative neurological deterioration in patients with thoracic disc disorders with myelopathy.

Post-operative neurological deterioration (ND) is a severe complication. However, limited literature exists on the ND in thoracic disc disorders with myelopathy (TDM). This study describes the risk factors of neurological deterioration in TDM with instrumentation and fusion. A single-centre review of TDM with instrumentation and fusion during 2006-2019 was performed. Post-operative neurological deterioration was defined as the deterioration of pre-existing neurological function or the appearance of new neurological symptoms. Patients were then grouped into two groups depending on neurological deterioration (ND group) or not (non-ND group). Demographics, radiographic parameters, and surgical characteristics were compared between the two groups. A total of 257 cases were included, and neurological deterioration occurred in 16 (6.23%) cases. Multivariate analysis revealed spinal canal occupancy ratio > 75%, U-shaped compressed spinal cord in axial MRI, calcified herniated disc, anterior approach, and intra-operative blood loss > 1500 mL were associated with ND. Ten patients (62.5%) had complete neurological recovery within six months, and four patients (25%) had progressive neurological function improvement and equal or better than pre-operation within nine months. The rate of neurological deterioration is 6.23%, and a higher spinal canal occupancy ratio, U-shaped compressed spinal cord, calcified herniated disc, anterior approach, and massive intra-operative blood loss were associated with neurological deterioration. Long-term outcomes of neurological deterioration are favourable, and 62.5% of patients experienced complete neurological recovery within six months. Patients with TMD who undergo surgery should be properly informed of the potential risks of neurological deterioration, despite its usually transient nature in most patients.

Abstract P661: Atheromatous Disease of the Parent Artery is Common in Patients With Lacunar Infarcts

Background: Perforator disease caused by parent artery atheromatous disease is one of the mechanisms implicated in the pathogenesis of lacunar infarcts, but there is limited data on its prevalence. We sought to determine the prevalence of parent vessel atheromatous disease in patients with lacunar infarcts. Methods: This is a retrospective study of consecutive patients with lacunar strokes admitted to NYU Langone Medical Center and Brown University from 2017-2019. Lacunar infarct was defined as subcortical infarct &lt;1.5cm on CT or &lt;2cm on diffusion-weighted imaging without significant stenosis (&gt;50%) in the parent vessel and no cardioembolic source. Non-invasive imaging (CTA or MRA) was reviewed by a neuroradiologist or a vascular neurologist to determine the presence or absence of stenosis (&lt; 50%) or luminal irregularity without stenosis in the stem artery segment at the location of the perforator corresponding to the infarct. Patients were divided into two groups: luminal irregularity/stenosis vs. none. We compared clinical and radiographic characteristics and rates of neurological deterioration between the two groups. Results: Among 208 patients with lacunar infarcts (mean age 68.9±11.9 years, 40.9% women, 61.1% White, 13.9% Black, and 12.5% Hispanic), 42 (20.2%) had luminal stenosis and 90 (43.3%) had luminal irregularity without stenosis. Baseline characteristics and prevalence of risk factors were similar between the two groups. Patients with luminal irregularity/stenosis had longer median infarct diameter (10.6 mm vs 8.7 mm, p=0.007). Other imaging variables such as the presence of prior lacunar infarcts and white matter disease burden assessed by Fazekas Score were not significantly different between the two groups. The rate of any neurological deterioration after admission was similar between the two groups (22.7% vs. 15.8%, p=0.283). Conclusion: In this multi-ethnic population, nearly two-thirds of patients with a lacunar infarct were found to have luminal irregularity or stenosis in the parent artery corresponding to the infarct, implying a potential atherosclerotic mechanism. Future studies are needed using advanced imaging of the stem artery to define plaque characteristics which may help determine the underlying mechanism.

Abstract P401: Subocclusive and Occlusive Intracranial Thrombi in Acute Ischemic Stroke

Background: Non-occlusive thrombus in an intracranial artery in acute ischemic stroke is an uncommon occurrence. We compared the clinical course and outcome of intracranial subocclusive to occlusive thrombi. Methods: We conducted a review of patients who presented with acute ischemic stroke and received CT angiogram at a single comprehensive stroke center from January 2018 to December 2019. Patients with intracranial subocclusive thrombus were compared to a control group with complete occlusion matched for occlusion location. Subocclusive thrombus was reviewed by two raters on CT angiography, disagreement resolved by consensus. Patient and stroke characteristics and the clinical course were analyzed. Neurological deterioration was defined as an increase in NIH Stroke Scale (NIHSS) score &gt; 4 compared from baseline to 48 hours. Good outcome at discharge was defined as modified Rankin Score of ≤2. Results: Among 1151 acute ischemic strokes, there were 896 patients with CT angiograms. Sixteen out of 896 (1.8%) patients had intracranial subocclusive thrombus. Thirty-two with comparable intracranial occlusions were identified. In the subocclusive group, 3 of 16 (19%) of received acute endovascular intervention, compared to 13 of 32 (41%) in the occluded group. Sex, median age or time from last known well to hospital arrival did not differ between the two groups. The subocclusive thrombus group had less severe strokes, with median NIHSS score at arrival 3 compared to 8.5 in the occlusion group (p&lt;0.01) and median NIHSS at discharge 1 compared to 5.5 in the occlusive group (p&lt;0.01). Frequency of neurological deterioration in hospital did not differ between the subocclusive and occluded groups at 48 hours (15% vs 15% p=1.00). The subocclusive group was associated with a good outcome at discharge, OR 0.5.71, 95% confidence interval 1.41-23.1. Conclusion: Intracranial subocclusive thrombus in acute ischemic stroke has a more mild presentation compared to complete intracranial occlusion without a high rate of neurological deterioration.

Cilostazol Addition to Aspirin could not Reduce the Neurological Deterioration in TOAST Subtypes: ADS Post-Hoc Analysis

BackgroundOur previous trial acute dual study (ADS) reported that dual antiplatelet therapy (DAPT) using cilostazol and aspirin did not reduce the rate of short-term neurological worsening in non-cardioembolic stroke patients. Present post-hoc analysis investigated whether the impact of combined cilostazol and aspirin differed among stroke subtypes and factors associated with neurological deterioration and/or stroke recurrence. MethodsUsing the ADS registry, the rate of neurological deterioration, defined as clinical worsening and/or recurrent stroke, including transient ischemic attack was calculated. Stroke subtypes included large-artery atherosclerosis (LAA), small vessel occlusion (SVO), other determined etiology (Others), and undetermined etiology of stroke (Undetermined). ResultsData of 1022 patients were analyzed. Deterioration was seen in 104 (10%) patients, and the rates were not markedly different between patients treated with DAPT vs. aspirin in any stroke subtypes: LAA, 19% vs. 11%, (p=0.192); SVO, 10% vs. 10% (p=1.000); Others, 6% vs. 6% (p=1.000); Undetermined, 11% vs. 8% (p=0.590). Diabetes mellitus was the independent factor associated with deterioration (odds ratio 4.360, 95% confidence interval 1.139–16.691, p=0.032) in the LAA group. Age (1.030 [1.004–1.057], p=0.026), systolic blood pressure (1.012 [1.003–1.022], p=0.010), and infarct size (2.550 [1.488–4.371], p=0.001) were associated with deterioration in SVO group, and intracranial stenosis/occlusion was associated with it in the Undetermined group (3.744 [1.138–12.318], p=0.030). ConclusionsCombined cilostazol and aspirin did not reduce the rate of short-term neurological deterioration in any clinical stroke subtype. The characteristics of patients whose condition deteriorates in the acute period may differ based on the stroke subtypes.

Outcomes of Intensive Systolic Blood Pressure Reduction in Patients With Intracerebral Hemorrhage and Excessively High Initial Systolic Blood Pressure

The safety and efficacy of intensive systolic blood pressure reduction in patients with intracerebral hemorrhage who present with systolic blood pressure greater than 220 mm Hg appears to be unknown. To evaluate the differential outcomes of intensive (goal, 110-139 mm Hg) vs standard (goal, 140-179 mm Hg) systolic blood pressure reduction in patients with intracerebral hemorrhage and initial systolic blood pressure of 220 mm Hg or more vs less than 220 mm Hg. This post hoc analysis of the Antihypertensive Treatment of Acute Cerebral Hemorrhage-II trial was performed in November 2019 on data from the multicenter randomized clinical trial, which was conducted between May 2011 to September 2015. Patients with intracerebral hemorrhage and initial systolic blood pressure of 180 mm Hg or more, randomized within 4.5 hours after symptom onset, were included. Intravenous nicardipine infusion titrated to goals. Neurological deterioration and hematoma expansion within 24 hours and death or severe disability at 90 days, plus kidney adverse events and serious adverse events until day 7 or hospital discharge. A total of 8532 patients were screened, and 999 individuals (mean [SD] age, 62.0 [13.1] years; 620 men [62.0%]) underwent randomization and had an initial SBP value. Among 228 participants with initial systolic blood pressures of 220 mm Hg or more, the rate of neurological deterioration within 24 hours was higher in those who underwent intensive (vs standard) systolic blood pressure reduction (15.5% vs 6.8%; relative risk, 2.28 [95% CI, 1.03-5.07]; P = .04). The rate of death and severe disability (39.0% vs 38.4%; relative risk, 1.02 [95% CI, 0.73-1.78]; P = .92) was not significantly different between the 2 groups. There was a significantly higher rate of kidney adverse events in participants randomized to intensive systolic blood pressure reduction (13.6% vs 4.2%; relative risk, 3.22 [95% CI, 1.21-8.56]; P = .01), but no difference was observed in the rate of kidney serious adverse events. The higher rate of neurological deterioration within 24 hours associated with intensive treatment in patients with intracerebral hemorrhage and initial systolic blood pressure of 220 mm Hg or more, without any benefit in reducing hematoma expansion at 24 hours or death or severe disability at 90 days, warrants caution against generalization of recommendations for intensive systolic blood pressure reduction.

Blood Pressure-Attained Analysis of ATACH 2 Trial.

We compared the rates of death or disability, defined by modified Rankin Scale score of 4 to 6, at 3 months in patients with intracerebral hemorrhage according to post-treatment systolic blood pressure (SBP)-attained status. We divided 1000 subjects with SBP ≥180 mm Hg who were randomized within 4.5 hours of symptom onset as follows: SBP <140 mm Hg achieved or not achieved within 2 hours; subjects in whom SBP <140 mm Hg was achieved within 2 hours were further divided: SBP <140 mm Hg for 21 to 22 hours (reduced and maintained) or SBP was ≥140 mm Hg for at least 2 hours during the period between 2 and 24 hours (reduced but not maintained). Compared with subjects without reduction of SBP <140 mm Hg within 2 hours, subjects with reduction and maintenance of SBP <140 mm Hg within 2 hours had a similar rate of death or disability (relative risk of 0.98; 95% confidence interval, 0.74-1.29). The rates of neurological deterioration within 24 hours were significantly higher in reduced and maintained group (10.4%; relative risk, 1.98; 95% confidence interval, 1.08-3.62) and in reduced but not maintained group (11.5%; relative risk, 2.08; 95% confidence interval, 1.15-3.75) compared with reference group. The rates of cardiac-related adverse events within 7 days were higher among subjects with reduction and maintenance of SBP <140 mmHg compared to subjects without reduction (11.2% versus 6.4%). No decline in death or disability but higher rates of neurological deterioration and cardiac-related adverse events were observed among intracerebral hemorrhage subjects with reduction with and without maintenance of intensive SBP goals. URL: https://www.clinicaltrials.gov. Unique identifier: NCT01176565.

Predictive factors for neurological deterioration after surgical decompression for thoracic ossified yellow ligament.

To investigate the rate and predictive factors of post-operative neurological deterioration in ossified yellow ligament (OYL) surgery. A retrospective review was conducted for all patients with thoracic OYL causing myelopathy requiring surgical decompression from January 1998 to December 2012. Clinical parameters under study included clinical presentation, distribution of OYL, pre-operative walking score, pre- and post-operative neurological status, status of intra-operative neurophysiological monitoring, and modified Japanese Orthopaedic Association (mJOA) score. Any complications were also recorded. All outcomes were measured at post-operative 1week and at 2years. A total of 26 patients were included in this study. Most patients (92.3%) had Frankel grade D pre-operatively. The rate of neurological deterioration was 15.4% and was correlated with thepresence of dural tear, extra-dural hematoma and spinal cord injury. Pre-operative walking score was prognostic of patients' walking ability in the post-operative period. Intra-operative monitoring of Somatosensory Evoked Potentials (SSEP) was found to be useful for monitoringspinal cord injury in OYL surgery, with a positive predictive value of 100% and anegative predictive value of 92.3%. The false negative rate of a SSEP signal drop was only 7.7% CONCLUSIONS: This is the first study exploring risk factors for post-operative neurological deterioration after surgery for thoracic OYL. The rate of neurological deficit is not small and prognostic factors for poor outcome include poor pre-operative walking score, presence of intra-operative dural tear, extra-dural hematoma and spinal cord injury, and intra-operative drop of SSEP signal.

Abstract 210: Is Endovascular Treatment Beneficial in Acute Ischemic Stroke Patients With M2 Segment Middle Cerebral Artery Occlusion?

Background: The benefit of endovascular treatment in acute ischemic stroke patients with occlusion of distal middle cerebral artery (M2 segment) is unclear. Methods: We analyzed data from subjects with occlusion of M2 segment of middle cerebral artery confirmed with computed tomographic (CT) angiogram who were randomized to either intravenous (IV) recombinant tissue plasminogen activator (rt-PA) alone or in combination with endovascular treatment. We compared the rates of neurological deterioration within 24 hours; symptomatic intracranial hemorrhage (ICH) within 30 hours; good quality of life (defined by EQ-5D index score of ≥0.6) and functional independence (defined by modified Rankin scale of 0-2) at 3 months among subjects who underwent endovascular treatment with subjects who received IV rt-PA alone. Results: Of these 51 subjects (mean age ±SD; 68.3±11.8 years) with M2 segment occlusion, 34 and 17 subjects received IV rt-PA followed by endovascular treatment and IV rt-PA alone, respectively. There was a non-significantly lower rate of neurological deterioration (14.7% versus 25.0%) and symptomatic intracranial hemorrhages (5.9% versus 17.6%) among subjects who received IV rt-PA followed by endovascular treatment. At 3 months, the rates of independent functional outcome (52.9% versus 41.2%, odds ratio [OR] 1.6; 95 % confidence interval [CI] 0.5-5.2; P = 0.46) and good quality of life (50.0% vs 35.3% OR 1.9; 95% CI 0.5-7.2; p=0.37) were non-significantly higher among subjects with M2 segment occlusion who received IV rt-PA followed by endovascular treatment. The rate of death within 3 months was significantly lower among those who received IV rt-PA followed by endovascular treatment (5.9% vs 35.3%; OR 0.2; 95% CI 0.1-0.9; p=0.048). Conclusions: A randomized clinical trial should be considered based on the significant reduction in mortality and non-significant increase in functional independence and good quality of life following endovascular treatment in among acute ischemic stroke patients with M2 segment occlusion.