Combination of blood biomarkers and stroke scales improves identification of large vessel occlusions

Background and Purpose. Acute ischemic stroke caused by large vessel occlusions (LVO) is a major contributor to stroke deaths and disabilities; however, identification for emergency treatment is challenging. Aims. To evaluate the diagnostic accuracy of a panel of biomarkers for LVO prediction. Methods. 170 patients with suspected stroke were recruited retrospectively at one hospital. We analysed the plasma levels of D-dimer, OPN, OPG, GFAP, vWF, and ADAMTS13 in LVO vs non-LVO. Diagnostic performance was estimated by using blood biomarkers alone or in combination with NIHSS-derived stroke severity scales. Results. Our patient cohort comprised 20% stroke mimics, 11% transient ischemic attack, 11% hemorrhagic stroke, 15% LVO ischemic stroke, 28% non-LVO ischemic stroke, and 15% ischemic stroke with unknown LVO status. Multivariable analysis found that the optimal set of blood biomarkers for LVO prediction was D-dimer (OR 15.4, 95% CI 4.9 to 57.6; p-value<0.001) and GFAP (OR 0.83, 95% CI 0.90 to 0.99; p-value=0.03). The combination of D-dimer and GFAP with stroke scales significantly improved LVO prediction, compared to the stroke scales alone (p-value<0.001). The combination of biomarkers with constructed FAST-ED or EMSA scales achieved an AUC of 95% (95% CI 91-100%) or 93% (CI 95% 89-97%), a sensitivity of 91% (95% CI 71-98%) or 86 (95% CI 66-97%), and a specificity of 95% (95% CI 89-98%) or 94% (95% CI 88-98%), for LVO prediction, respectively. Conclusions. The combination of D-dimer, GFAP, and stroke scales could provide a simple and highly accurate tool for identifying LVO patients.

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A Novel Combination of Blood Biomarkers and Clinical Stroke Scales Facilitates Detection of Large Vessel Occlusion Ischemic Strokes

Diagnostics ◽

10.3390/diagnostics11071137 ◽

2021 ◽

Vol 11 (7) ◽

pp. 1137

Author(s):

Edoardo Gaude ◽

Barbara Nogueira ◽

Marcos Ladreda Mochales ◽

Sheila Graham ◽

Sarah Smith ◽

...

Keyword(s):

Multivariable Analysis ◽

Large Vessel ◽

P Value ◽

Stroke Severity ◽

Blood Biomarkers ◽

Protein Biomarkers ◽

Vessel Occlusion ◽

Suspected Stroke ◽

D Dimer ◽

Independent Cohort

Acute ischemic stroke caused by large vessel occlusions (LVOs) is a major contributor to stroke deaths and disabilities; however, identification for emergency treatment is challenging. We recruited two separate cohorts of suspected stroke patients and screened a panel of blood-derived protein biomarkers for LVO detection. Diagnostic performance was estimated by using blood biomarkers in combination with NIHSS-derived stroke severity scales. Multivariable analysis demonstrated that D-dimer (OR 16, 95% CI 5–60; p-value < 0.001) and GFAP (OR 0.002, 95% CI 0–0.68; p-value < 0.05) comprised the optimal panel for LVO detection. Combinations of D-dimer and GFAP with a number of stroke severity scales increased the number of true positives, while reducing false positives due to hemorrhage, as compared to stroke scales alone (p-value < 0.001). A combination of the biomarkers with FAST-ED resulted in the highest accuracy at 95% (95% CI: 87–99%), with sensitivity of 91% (95% CI: 72–99%), and specificity of 96% (95% CI: 90–99%). Diagnostic accuracy was confirmed in an independent cohort, in which accuracy was again shown to be 95% (95% CI: 87–99%), with a sensitivity of 82% (95% CI: 57–96%), and specificity of 98% (95% CI: 92–100%). Accordingly, the combination of D-dimer and GFAP with stroke scales may provide a simple and highly accurate tool for identifying LVO patients, with a potential impact on time to treatment.

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Abstract WP13: Stroke Severity and Revascularization are the Strongest Predictors of Outcome in Large Vessel Occlusion Strokes: Post-Hoc Analysis of the TREVO 2 Trial

Stroke ◽

10.1161/str.44.suppl_1.awp13 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Helmi L Lutsep ◽

Raul G Nogueira ◽

Rishi Gupta ◽

Tudor G Jovin ◽

Gregory W Albers ◽

...

Keyword(s):

Ischemic Stroke ◽

Left Hemisphere ◽

Symptom Onset ◽

Univariate Analysis ◽

Large Vessel ◽

P Value ◽

Stroke Severity ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Good Outcome

Introduction.: The Trevo Retriever showed higher recanalization rates and better outcomes than the Merci Retriever in patients with ischemic stroke due to large vessel occlusion (LVO) in TREVO 2. Hypothesis.: We assessed the hypothesis that except for device-related variables, predictors of good outcome would be similar in TREVO 2 and single arm Merci Retriever studies. Methods.: The study evaluated predictors of good outcome, modified Rankin Scale (mRS) 0-2 at 90 days, in TREVO 2 including those with ischemic stroke due to LVO aged 18-85 years with a National Institutes of Health Stroke Scale Score (NIHSS) 8-29 and a first device treatment pass within 8 hours of symptom onset. A secondary analysis investigated mortality predictors. Variables included baseline characteristics of age, sex, NIHSS, IV tPA use, occlusion side, most proximal occlusion site, stroke etiology, body mass index, systolic blood pressure (BP), diastolic BP, glucose; history including hypertension, diabetes, dyslipidemia, smoking, congestive heart failure (CHF), atrial fibrillation, previous coronary or cerebral ischemia; and procedural characteristics of time from symptom onset to arterial puncture, time to TICI ≥2 or end of procedure, device allocation, intubation status, rescue therapy usage and post device revascularization success TICI ≥ 2 per core lab. Variables were assessed with univariate analysis for association with mRS 0-2 and mortality and those with a p-value of <0.15 were eligible for the multivariate model. Results.: TREVO 2 data were available for 168 patients. Variables significant on multivariate analysis for an association with good outcome were baseline NIHSS (OR 0.76, 95% CI 0.67, 0.86), post device revascularization success per core lab (OR 117.6, 95% CI 8.40, 1645), diabetes (OR 0.12, 95% CI 0.03, 0.41), intubation (OR 0.11, 95% CI 0.03, 0.41) and left hemisphere involvement (OR 5.11, 95% CI 1.77, 14.71). Predictors of mortality included baseline NIHSS and left hemisphere involvement but also age and CHF. Conclusions.: While age did not appear as a predictor of good outcome and diabetes was negatively associated with it for the first time in a Merci analysis, predictors of favorable outcome in TREVO 2 were similar to those previously reported for the Merci Retriever.

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Abstract T P291: Impact of Diastolic Dysfunction for Predicting Mortality in Ischemic Stroke and Transient Ischemic Attack Patients

Stroke ◽

10.1161/str.45.suppl_1.tp291 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Yohei Tateishi ◽

Akira Tsujino ◽

Jumpei Hamabe ◽

Osamu Tasaki ◽

Nobutaka Horie ◽

...

Keyword(s):

Ischemic Stroke ◽

Diastolic Dysfunction ◽

Transient Ischemic Attack ◽

Univariate Analysis ◽

Stroke Severity ◽

Lesion Volume ◽

Nihss Score ◽

Ischemic Attack ◽

D Dimer

Background: The aim of this study is to identify whether diastolic dysfunction predicts 90-day mortality and develop and validate a risk score model using information available at hospital presentation in ischemic stroke or transient ischemic attack (TIA) patients Methods: Consecutive ischemic stroke or TIA patients within 48 hours of onset were enrolled. Diastolic filling pressure was estimated as the ratio of early transmitral flow velocity (E) to mitral annular velocity (e’) on transthoracic echocardiography performed within 24 hours of presentation. Plasma brain natriuretic peptide (BNP) and D-dimer were measured on admission. We calculated initial diffusion weighted imaging (DWI) lesion volume. Stroke severity was assessed by the National Institute of Health Stroke Scale (NIHSS) score. Mortality was evaluated at 90-day follow-up. Univariate and multivariate analyses were conducted to identify predictors of 90-day mortality. Results: A total of 265 patients with ischemic stroke or TIA were enrolled. Of these, nineteen (7%) patients deceased at 90-day follow-up. At univariate analysis, higher age (p=0.002), atrial fibrillation (p<0.001), use of antiplatelet agent (p=0.005) and anticoagulant agent (p=0.017), cardioembolic infarction (p<0.001), higher NIHSS score (p<0.001), larger DWI lesion volume (p=0.002), internal carotid artery occlusion (p<0.001), higher E/e’ (p<0.001), PT-INR level (p=0.004), BNP level (p<0.001) and D-dimer level (p<0.001) and lower albumin level (p=0.002) were associated with death. Multivariable predictors of 90-day mortality included higher E/e’ (Odds ratio [OR]=1.176; 95% confidence interval [CI], 1.051 to 1.317), NIHSS score (OR=1.180; 95% CI, 1.067- 1.306) and D-dimer level (OR=1.137; 95% CI, 1.009 to 1.281). The END score (1 point each for E/e’ of >= 18.5, NIHSS score of >= 17 and D-dimer level of >= 2.0) stratified patients with a predicted probability of death rate from 0% to 77.8%. The c statistic was 0.947. Conclusions: Diastolic dysfunction could be one of the most important predictors of 90-day mortality of acute ischemic stroke and TIA. The END score may assist clinicians in estimating stroke mortality at hospital presentation.

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D-Dimer as Predictor of Large Vessel Occlusion in Acute Ischemic Stroke

Stroke ◽

10.1161/strokeaha.120.031657 ◽

2021 ◽

Author(s):

Anna Ramos-Pachón ◽

Elena López-Cancio ◽

Alejandro Bustamante ◽

Natàlia Pérez de la Ossa ◽

Mònica Millán ◽

...

Keyword(s):

Logistic Regression ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Independent Predictor ◽

Large Vessel ◽

Stroke Severity ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Predictive Values ◽

D Dimer

Background and Purpose: Improving prehospital triage of large vessel occlusion (LVO) would reduce time to reperfusion therapies. We aimed to study early predictors of LVO in acute ischemic stroke to identify candidates for endovascular treatment. Methods: The Stroke-Chip was a prospective observational study conducted at 6 Stroke Centers in Catalonia. Blood samples were obtained in the first 6 hours from symptom onset of consecutive patients. Stroke severity was evaluated with National Institutes of Health Stroke Scale (NIHSS) and LVO was assessed. Independent association of multiple blood biomarkers with LVO was evaluated using logistic regression models adjusted by covariates. Sensitivity, specificity, and predictive values were assessed for NIHSS and the combination of NIHSS and selected serum biomarkers levels. Results: One thousand three hundred eight suspected strokes were enrolled for a 17-month period. LVO was not assessed in 131 patients. One thousand one hundred seventy-seven patients were selected for analysis (mean age 69.3 years, 56% men, median baseline NIHSS of 6, and median time to blood collection 2.5 hours). LVO was detected in 262 patients. LVO patients were older, had higher baseline NIHSS, history of atrial fibrillation, and lower time from stroke onset to admission. After logistic regression analysis, D-dimer remained an independent predictor of LVO (odds ratio, 1.59 [1.31–1.92]). Specificity and positive predictive value to exclude or detect LVO were higher when using combined D-dimer levels and NIHSS score assessment rather than NIHSS alone. Conclusions: Early D-dimer levels are an independent predictor of LVO and may be useful to better optimize prehospital patient transport to the appropriate stroke center.

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Outcome after Stroke upon Awakening

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/s0317167100004029 ◽

2005 ◽

Vol 32 (2) ◽

pp. 232-236 ◽

Cited By ~ 48

Author(s):

Janel O. Nadeau ◽

Jiming Fang ◽

Moira K. Kapral ◽

Frank L. Silver ◽

Michael D. Hill

Keyword(s):

Ischemic Stroke ◽

Subarachnoid Hemorrhage ◽

Stroke Severity ◽

Linear Modeling ◽

Stroke Impact Scale ◽

Impact Scale ◽

Level Of Consciousness ◽

Using Data ◽

Poor Outcomes ◽

Ischemic Attack

ABSTRACT:Background:An estimated 20-25% of all strokes occur during sleep and these patients wake up with their deficits. This study evaluated outcomes among patients who woke up with stroke compared to those who were awake at stroke onset.Methods:Using data from the Registry of the Canadian Stroke Network Phases 1 and 2, we compared demographics, clinical data and six-month outcomes between patients with stroke-on-awakening versus stroke-while-awake. Strokes of all types (ischemic stroke, transient ischemic attack, intracerebral hemorrhage and subarachnoid hemorrhage) were included. Standard descriptive statistics, multivariable logistic regression and general linear modeling were applied to the data to compare variables.Results:Among 2,585 stroke patients, 349 (13.5%) woke up with stroke and 2,236 (86.5%) did not. Patients with stroke-on-awakening were more likely to have higher blood pressure and to suffer ischemic stroke, but stroke severity, measured by level of consciousness, did not differ. Mortality both at discharge and at six-month follow-up did not differ between the two cohorts. However, patients with stroke-on-awakening were less likely to return home, and their median Stroke Impact Scale-16 scores were 7.0 points lower compared to those with stroke-while-awake.Conclusions:There are minor demographic and clinical differences between patients with stroke-on-awakening and stroke-while-awake. Functional outcomes are slightly worse among patients with stroke-on-awakening, an effect which was driven by poor outcomes among patients with subarachnoid hemorrhage.

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Abstract P685: Primary Care Utilization for Primary Prevention Continues to Be Lacking in Patients With Stroke

Stroke ◽

10.1161/str.52.suppl_1.p685 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Alexander J Senetar ◽

Daniel A Bonnin ◽

Hannah E Branstetter ◽

Alexis N Simpkins ◽

Keyword(s):

Primary Care ◽

Regression Analysis ◽

Primary Prevention ◽

Hemoglobin A1c ◽

Care Utilization ◽

P Value ◽

Stroke Severity ◽

Institutional Review ◽

And Gender ◽

Ischemic Attack

Introduction: Primary care plays an essential role in stroke prevention. Yet still, for many stroke patients, a relationship with a primary care provider (PCP) is not established until after stroke. Our goal was to determine if lack of PCP and the consequential differences in management affects stroke severity. Methods: Data was obtained from our Institutional Review Board approved stroke admission database from 2017 to November 2019 of all stroke subtypes (ischemic stroke, transient ischemic attack, subarachnoid and intracerebral hemorrhages). Non-parametric Mann Whitney t-test and regression analysis was used to identify significant differences in medications, stroke risk factors and stroke severity. Results: A total of 559 patients were included, median age 67 (interquartile range (IQR) 58-76), 49% woman, 32% established care with a PCP, 36% on medications for diabetes mellitus (DM), 42% hyperlipidemia, 66% anti-hypertensives, 39% anti-platelet agents, and 10% anticoagulation. More patients with PCP were taking anti-hypertensive medications (80% versus (vs) 60%, p value < 0.0001), DM medications (56% vs 30%, p value < 0.0001), anti-platelet agents (46% vs 35%, p value = 0.0149), and medications for hyperlipidemia (49% vs 39%, p value = 0.0426). Admission NIHSS was lower in patients with a PCP median 6 (IQR 3-11) vs median 9 (IQR 4 -15), p value= 0.0016, and median hemoglobin A1c was higher in patients with a PCP 8 (IQR 5.7- 9.3) vs patients without a PCP prior to their stroke 6 (IQR 5.4 - 8.5), p value= 0.0002. Admitting systolic blood pressure was similar 155 (137-177) vs 152 (134-171). After correcting for age and gender, regression analysis demonstrated a significant association between whether a patient had PCP and antihypertensive medication use (odds ratio (OR) 2.413, 95% confidence interval 1.511 - 3.914) and hemoglobin A1c (OR 1.122, 95% CI 1.037 - 1.215). Also, patients with a PCP were more likely to have a lower NIHSS on admission (OR 0.9679, 95% CI 0.9423 - 0.9930). Conclusions: These result show that patients not followed by a PCP prior to stroke are less likely to be on medications for primary prevention of stroke, contributing to an increased stroke severity on admission. More research is needed to identify barriers to patients establishing care with PCP.

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Association of Level and Increase in D‐Dimer With All‐Cause Death and Poor Functional Outcome After Ischemic Stroke or Transient Ischemic Attack

Journal of the American Heart Association ◽

10.1161/jaha.120.018600 ◽

2021 ◽

Author(s):

Huiqing Hou ◽

Xianglong Xiang ◽

Yuesong Pan ◽

Hao Li ◽

Xia Meng ◽

...

Keyword(s):

Ischemic Stroke ◽

Functional Outcome ◽

Transient Ischemic Attack ◽

Cox Regression ◽

Poor Functional Outcome ◽

Stroke Registry ◽

Poor Outcomes ◽

Ischemic Attack ◽

High Level ◽

D Dimer

Background D‐dimer is involved in poor outcomes of stroke as a coagulation biomarker. We aimed to investigate the associations of the level and increase in D‐dimer between baseline and 90 days with all‐cause death or poor functional outcome in patients after ischemic stroke or transient ischemic attack. Methods and Results We collected data from the CNSRIII (Third China National Stroke Registry) study. The present substudy included 10 518 patients within 7 days (baseline) of ischemic stroke or transient ischemic attack and 6268 patients at 90 days. Poor functional outcome at 1 year was assessed on the basis of the modified Rankin Scale (≥3). Multivariable Cox regression or logistic regression was used to assess the association of D‐dimer levels with all‐cause death or poor functional outcome. D‐dimer levels at 90 days were lower than those at baseline (1.4 µg/mL versus 1.7 µg/mL; P <0.001). Higher baseline D‐dimer level was associated with all‐cause death (adjusted hazard ratio [HR], 1.77; 95% CI, 1.25–2.52; P =0.001) and poor functional outcome (adjusted odds ratio [OR], 1.49; 95% CI, 1.23–1.80; P <0.001) during 1‐year follow‐up. Higher D‐dimer level at 90 days was also associated with poor outcomes independently. Furthermore, an increase in D‐dimer levels between baseline and 90 days was associated with all‐cause death (since 90 days to 1 year after index event) (adjusted HR, 1.99; 95% CI, 1.12–3.53; P =0.019) but not with poor functional outcome (adjusted OR, 1.08; 95% CI, 0.82–1.41). Conclusions Our study shows that high level and an increase in D‐dimer between baseline and 90 days are associated with poor outcomes in patients after ischemic stroke or transient ischemic attack.

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Association of Iron Deficiency Anemia with Stroke Severity in patients with Acute Ischemic Stroke

10.53350/pjmhs2115113004 ◽

2021 ◽

Vol 15 (11) ◽

pp. 3004-3006

Author(s):

Rabia Rathore ◽

Nasir Farooq Butt ◽

Adil Iqbal ◽

Hina Latif ◽

Mariam Azeem ◽

...

Keyword(s):

Ischemic Stroke ◽

Iron Deficiency ◽

Acute Ischemic Stroke ◽

Iron Deficiency Anemia ◽

Descriptive Study ◽

World Health ◽

Deficiency Anemia ◽

P Value ◽

Stroke Severity ◽

Cross Sectional

Aim: To study the relationship of Iron Deficiency anemia (IDA) with severity of acute ischemic stroke. Study Design: A cross-sectional descriptive study. Place & Duration of Study: Department of Medicine, Mayo Hospital, Lahore from March 2020 to February 2021 Methods: A descriptive study of cross-sectional type was done on 200 individuals who had acute ischemic stroke (AIS) and were hospitalized at Mayo Hospital Lahore. Consecutive non-probability convenience sampling method was used to gather the data. Severity of stroke was assessed at the time of admission using the National Institute of Health Stroke Scale, (NIHSS) at the same time blood complete examination along with peripheral blood film was done to diagnose anemia in these patients. Iron studies were done to diagnose iron deficiency anemia (IDA). P-value less than 0.05 was taken as significant. Results: About 200individuals presenting with AIS were enrolled in the research work. Anemia according to World Health Organization was seen in 80(40%) and was not present in 120(60%) patients. Among the subjects who had anemia, 16(20%) had a minor AIS, 23(28.75%) had a moderately severe AIS, and 41(51.25%) reported with a severe AIS, according to NIHSS criteria. A notable relationship was found to exist between anemia and stroke severity, (P-value 0.000). Conclusion: Anemia was a commonly found in individuals with acute stroke due to ischemia and had direct relation with severity of stroke. Keywords: Iron deficiency Anemia, severity, ischemic stroke.

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Abstract 3314: The Role of Bridging with Intravenous Thrombolysis in Endovascular Therapy of Acute Ischemic Stroke.

Stroke ◽

10.1161/str.43.suppl_1.a3314 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Omar Kass-Hout ◽

Tareq Kass-Hout ◽

Maxim Mokin ◽

David Orion ◽

Shadi Jahshan ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Combined Therapy ◽

Large Vessel ◽

P Value ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Nihss Score

Background: Large vessel occlusions with a high clot burden are less likely to improve with the FDA-approved IV strategy. Endovascular therapy within the first 3 h of stroke symptom onset provides an effective alternative treatment in patients with large vessel occlusion. It is not clear if combination of IV thrombolysis and endovascular approach is superior to endovascular treatment alone. Methods: We retrospectively reviewed all cases of acute ischemic stroke with large vessel occlusion treated within the first 3 h stroke onset during the 2005-2010 period. First group received endovascular therapy within the first 3 h of stroke onset. Second group consisted of patients who received IV thrombolysis within the first 3 h followed by endovascular therapy. We compared the following outcomes: revascularization rates, NIHSS score at discharge, mRS at discharge and 3months, symptomatic hemorrhage rates and mortality. Results: Among 104 patients identified, 42 received combined therapy, and 62 received endovascular therapy only. The two groups had similar demographic (age and sex distribution) and vascular risk factors distribution, as well as NIHSS score on admission (14.8±4.7 and 16.0±5.3; p=0.23). We found no difference in TIMI recanalization rates (Thrombolysis in Myocardial Infarction scale score of 2 or 3) following combined or endovascular therapy alone (83.3% and 79.0%; p=0.59). A preferred outcome, defined as a mRS of 2 or less at 90 days also did not differ between the combined therapy group and the endovascular only group (37.5% and 34.5%; p=0.76). There was no difference in mortality rate (22.5% and 31.0%; p=0.36) and the rate of symptomatic intracranial hemorrhage (9.5% and 8.1%; p=0.73). There was a significant difference in mean time from symptom onset to endovascular treatment between the combined group (227±88 min) and endovascular only group (125±40 min; p<0.0001).Patients with good TIMI recanalization rate of 2 or 3 showed a trend of having a better mRS at 90 days in both bridging (16.67% vs. 41.18%, p-value: 0.3813) and endovascular groups (25% vs. 34.78%, p-value: 0.7326).When analyzing the correlation of mRS at 90 days with the site of occlusion, patients in the bridging group showed a trend of a better outcome when the site of occlusion was ICA (33.3% vs 30%) and MCA (66.67% vs. 27.59%) and worse outcome when the site of occlusion was in the posterior circulation (26.32% vs. 50%), however, these results were not statistically significant (p-values: 0.1735& 0.5366). Conclusion: Combining IV thrombolysis and endovascular therapy achieves similar rates of clinical outcomes, revascularization rates, complications and mortality rates, when compared with endovascular treatment alone. The combined therapy, however, significantly delays initiation of endovascular treatment. A randomized prospective trial comparing both treatment strategies in acute ischemic stroke is warranted

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Abstract 3183: Prognosis of Mild Ischemic Stroke with Large Vessel Occlusion

Stroke ◽

10.1161/str.43.suppl_1.a3183 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Esteban Cheng-Ching ◽

Russell Cerejo ◽

Ken Uchino ◽

Muhammad S Hussain ◽

Gabor Toth

Keyword(s):

Ischemic Stroke ◽

Endovascular Therapy ◽

Time Window ◽

Optimal Treatment ◽

Large Vessel ◽

Stroke Severity ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Nihss Score ◽

Mild Stroke

Background and purpose Large vessel occlusion (LVO) in acute ischemic stroke has been reported to be an independent predictor of unfavorable clinical outcome. However, the prognosis and optimal treatment of patients with only mild neurologic deficits due to LVO are not known. Methods We performed a retrospective chart review from a database of stroke patients admitted to our large academic medical center between July 1, 2010 and June 30 , 2011. Inclusion criteria were acute stroke or TIA, presentation within 9 hours from symptom onset, large vessel occlusion as a culprit of ischemic symptoms, and mild stroke severity with initial NIH Stroke Scale (NIHSS) score <8. Results We identified 59 patients with mild ischemic stroke or TIA, who were evaluated within 9 hours from onset. Of these, 13 (22%) had culprit large vessel occlusions. Five were female, 1 had diabetes, 12 had hypertension, 7 had hyperlipidemia, 2 had atrial fibrillation and 7 were smokers. The median NIHSS score was 5. The location of arterial occlusions were 5 in M1 segment of the middle cerebral artery (MCA), 6 in M2 segment of MCA, 1 each in posterior cerebral and vertebral arteries. Two patients received acute therapy, 1 with intravenous thrombolysis and 1 with endovascular therapy. Reasons for withholding thrombolytic therapy were time window in 8, mild stroke severity in 2, and atypical presentations in 2. Reasons for withholding acute endovascular therapy were mild stroke severity in 7, imaging finding in 2, technical considerations in 2, and lack of consent in 1. From hospital admission to discharge, 10 (77%) patients had symptom improvement, 2 had worsening, and one was unchanged. At 30 days, 5 (38%) had good outcome with a modified Rankin Scale (mRS) of 0-1. Three (23%) had mRS of 2, one (8%) patient had mRS of 3. Outcomes for 4 patients were unknown. Conclusions A significant proportion of patients presenting with mild ischemic symptoms has large vessel occlusion. Acute treatment in this population is frequently withheld due to mild severity or thrombolytic time window. Despite mild symptoms at presentation, some patients are left with moderate disability. Optimal treatment options for this population should be further evaluated in a larger group of patients.

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