Predictors of poor outcome despite recanalization: a multiple regression analysis of the NASA registry

BackgroundMechanical thrombectomy with stent-retrievers results in higher recanalization rates compared with previous devices. Despite successful recanalization rates (Thrombolysis in Cerebral Infarction (TICI) score ≥2b) of 70–83%, good outcomes by 90-day modified Rankin Scale (mRS) score ≤2 are achieved in only 40–55% of patients. We evaluated predictors of poor outcomes (mRS >2) despite successful recanalization (TICI ≥2b) in the North American Solitaire Stent Retriever Acute Stroke (NASA) registry.MethodsLogistic regression was used to evaluate baseline characteristics and recanalization outcomes for association with 90-day mRS score of 0–2 (good outcome) vs 3–6 (poor outcome). Univariate tests were carried out for all factors. A multivariable model was developed based on backwards selection from the factors with at least marginal significance (p≤0.10) on univariate analysis with the retention criterion set at p≤0.05. The model was refit to minimize the number of cases excluded because of missing covariate values; the c-statistic was a measure of predictive power.ResultsOf 354 patients, 256 (72.3%) were recanalized successfully. Based on 234 recanalized patients evaluated for 90-day mRS score, 116 (49.6%) had poor outcomes. Univariate analysis identified an increased risk of poor outcome for age ≥80 years, occlusion site of internal carotid artery (ICA)/basilar artery, National Institute of Health Stroke Scale (NIHSS) score ≥18, history of diabetes mellitus, TICI 2b, use of rescue therapy, not using a balloon-guided catheter or intravenous tissue plasminogen activator (IV t-PA), and >30 min to recanalization (p≤0.05). In multivariable analysis, age ≥80 years, occlusion site ICA/basilar, initial NIHSS score ≥18, diabetes, absence of IV t-PA, ≥3 passes, and use of rescue therapy were significant independent predictors of poor 90-day outcome in a model with good predictive power (c-index=0.80).ConclusionsAge, occlusion site, high NIHSS, diabetes, no IV t-PA, ≥3 passes, and use of rescue therapy are associated with poor 90-day outcome despite successful recanalization.

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Abstract 10: Predictors of Poor Outcome in Acute Ischemic Stroke Patients after Successful Recanalization

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.7.suppl_1.10 ◽

2014 ◽

Vol 7 (suppl_1) ◽

Author(s):

Amy K Starosciak ◽

Italo Linfante ◽

Gail Walker ◽

Osama O Zaidat ◽

Alicia C Castonguay ◽

...

Keyword(s):

Ischemic Stroke ◽

Cerebral Infarction ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Predictive Power ◽

Rescue Therapy ◽

Univariate Analysis ◽

Stroke Patients ◽

Good Outcome ◽

Poor Outcome

Background: Recanalization of the occluded artery is a powerful predictor of good outcome in acute ischemic stroke secondary to large artery occlusions. Mechanical thrombectomy with stent-trievers results in higher recanalization rates and better outcomes compared to previous devices. However, despite successful recanalization rates (Treatment in Cerebral Infarction, TICI, score ≥ 2b) between 70 and 90%, good clinical outcomes assessed by modified Rankin Scale (mRS) ≤ 2 is present in 40-50% of patients . We aimed to evaluate predictors of poor outcomes (mRS > 2) despite successful recanalization (TICI ≥ 2b) in the acute stroke patients treated with the Solitaire device of the North American Solitaire Stent Retriever Acute Stroke (NASA) registry. Methods: The NASA registry is a multicenter, non-sponsored, physician-conducted, post-marketing registry on the use of SOLITAIRE FR device in 354 acute, large vessel, ischemic stroke patients. Logistic regression was used to evaluate patient characteristics and treatment parameters for association with 90-day mRS score of 0-2 (good outcome) versus 3-6 (poor outcome) within patients who were recanalized successfully (Thrombolysis in Cerebral Infarction or TICI score 2b-3). Univariate tests were followed by development of a multivariable model based on stepwise selection with entry and retention criteria of p < 0.05 from the set of factors with at least marginal significance (p ≤ 0.10) on univariate analysis. The c-statistic was calculated as a measure of predictive power. Results: Out of 354 patients, 256 (72.3%) were successfully recanalized (TICI ≥ 2b). Based on 90-day mRS score for 234 of these patients, there were 116 (49.6%) with mRS > 2. Univariate analysis identified increased risk of mRS > 2 for each of the following: age ≥ 80 years (upper quartile of data), occlusion site other than M1/M2, NIH Stroke Scale (NIHSS) score ≥ 18 (median), history of diabetes mellitus (DM), TICI = 2b, use of rescue therapy, not using a balloon-guided catheter (BGC) or intravenous tissue plasminogen activator (IV t-PA), and time to recanalization > 30 minutes (all p ≤ 0.05). Three or more passes was marginally significant (p=0.097). In multivariable analysis, age ≥ 80 years, site other than M1/M2, initial NIHSS ≥18, DM, absence of IV t-PA, use of rescue therapy and three or more passes were significant independent predictors of poor 90-day outcome in a model with good predictive power (c-index = 0.80). Conclusions: Age, occlusion site, high NIHSS, diabetes, not receiving IV t-PA, use of rescue therapy and three or more passes, were associated with poor 90-day outcome despite successful recanalization.

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An evaluation of the SAFIRE grading scale as a predictor of long-term outcomes for patients in the Barrow Ruptured Aneurysm Trial

Journal of Neurosurgery ◽

10.3171/2020.7.jns193431 ◽

2021 ◽

pp. 1-5

Author(s):

Joshua S. Catapano ◽

Mohamed A. Labib ◽

Fabio A. Frisoli ◽

Megan S. Cadigan ◽

Jacob F. Baranoski ◽

...

Keyword(s):

Univariate Analysis ◽

Ruptured Aneurysm ◽

Poor Outcome ◽

Increased Risk ◽

Grade Ii ◽

Grading Scale ◽

Poor Outcomes ◽

Grade Iii

OBJECTIVEThe SAFIRE grading scale is a novel, computable scale that predicts the outcome of aneurysmal subarachnoid hemorrhage (aSAH) patients in acute follow-up. However, this scale also may have prognostic significance in long-term follow-up and help guide further management.METHODSThe records of all patients enrolled in the Barrow Ruptured Aneurysm Trial (BRAT) were retrospectively reviewed, and the patients were assigned SAFIRE grades. Outcomes at 1 year and 6 years post-aSAH were analyzed for each SAFIRE grade level, with a poor outcome defined as a modified Rankin Scale score > 2. Univariate analysis was performed for patients with a high SAFIRE grade (IV or V) for odds of poor outcome at the 1- and 6-year follow-ups.RESULTSA total of 405 patients with confirmed aSAH enrolled in the BRAT were analyzed; 357 patients had 1-year follow-up, and 333 patients had 6-year follow-up data available. Generally, as the SAFIRE grade increased, so did the proportion of patients with poor outcomes. At the 1-year follow-up, 18% (17/93) of grade I patients, 22% (20/92) of grade II patients, 32% (26/80) of grade III patients, 43% (38/88) of grade IV patients, and 75% (3/4) of grade V patients were found to have poor outcomes. At the 6-year follow-up, 29% (23/79) of grade I patients, 24% (21/89) of grade II patients, 38% (29/77) of grade III patients, 60% (50/84) of grade IV patients, and 100% (4/4) of grade V patients were found to have poor outcomes. Univariate analysis showed that a SAFIRE grade of IV or V was associated with a significantly increased risk of a poor outcome at both the 1-year (OR 2.5, 95% CI 1.5–4.2; p < 0.001) and 6-year (OR 3.7, 95% CI 2.2–6.2; p < 0.001) follow-ups.CONCLUSIONSHigh SAFIRE grades are associated with an increased risk of a poor recovery at late follow-up.

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Abstract 9: Predictors of Poor Outcome in Patients Not Thrombolysed Due to Mild or Resolving Symptoms ("Too Good To Treat")

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.7.suppl_1.9 ◽

2014 ◽

Vol 7 (suppl_1) ◽

Author(s):

Syed F Ali ◽

Urooba Faheem ◽

Aneesh B Singhal ◽

Anand Viswanathan ◽

Scott B Silverman ◽

...

Keyword(s):

Atrial Fibrillation ◽

Univariate Analysis ◽

Multivariable Analysis ◽

Time Frame ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Factors Associated ◽

Poor Outcome ◽

Poor Outcomes ◽

Iv Tpa

Introduction: A common reason for exclusion of patients with acute ischemic stroke presenting within the time frame for IV tPA is that they are “too good to treat” due to rapidly improving or mild symptoms. Several studies have reported poor outcomes in this group which motivated us to evaluate patient factors associated with poor outcomes. Methods: Using our institutional GWTG database, we analyzed 2,745 consecutive stroke admissions (01/2009 - 07/2013). Univariate and multivariable analysis were carried out to determine factors associated with poor outcome, defined as not being discharged home. Results: Of the total 2,745 patients, 306 (11.1%) presented within the window for IV tPA but did not receive the treatment due to symptoms too mild or rapidly improving as judged by the treating team. Of these 306, 64.1% were discharged home, 26.5% to IRF, 7.2% to SNF and 2.9% expired/hospice. Patients with poor outcome were older, more frequently Hispanic and presented with more vascular risk factors such as hypertension, diabetes, CAD, PAD and atrial fibrillation than good outcome patients. They also had higher median initial NIHSS. Patients in both groups had similar adherence to early antithrombotics, dysphagia screening and DVT prophylaxis. Poor outcome patients had higher rates of in-hospital complications and a longer hospital length of stay (Table 1). On univariate analysis, factors associated with poor outcome included age [OR 1.50 (1.30 - 1.70), p<0.0001], ethnicity [4.15 (1.25 - 13.81), p=0.020], diabetes mellitus [1.91 (1.11 - 3.29), p=0.019], atrial fibrillation [1.82 (1.02 - 3.25), p=0.042], PAD [9.02 (1.04 - 78.20), p=0.046], NIHSS [1.16 per point (1.06 - 1.27), p=0.001], in-hospital pneumonia (all cases had poor outcome) or UTI [7.04 (1.92 - 25.81), p=0.003]. In multivariable analysis, only age [1.50 (1.30 - 1.70), p<0.0001], ethnicity [6.61 (1.83 - 23.85), p=0.004], NIHSS [1.14 per point (1.04 - 1.26), p=0.007] and UTI [7.30 (1.72 - 31.00), p=0.007] remained significant. Conclusion: A substantial percentage of patients deemed “too good” for IV tPA were unable to be discharged home. Factors such as advanced age and higher NIHSS should be considered in tPA decision-making to optimize outcomes. Large, multi-center prospective studies are underway to study the predictors of poor outcomes in this group.

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Abstract WMP6: Delayed Device Access to the Occluded Target Vessel Predicts Worse Recanalization Rates and Poor Outcomes in Endovascular Therapy for Acute Stroke

Stroke ◽

10.1161/str.44.suppl_1.awmp6 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Marc Ribo ◽

Brian Jankowitz ◽

Syed Zaidi ◽

Mouhammad Jumaa ◽

Jennifer Oakley ◽

...

Keyword(s):

Acute Stroke ◽

Infarct Volume ◽

Univariate Analysis ◽

Favorable Outcome ◽

Anterior Circulation ◽

Poor Outcome ◽

Improved Outcomes ◽

Poor Outcomes ◽

Left Hemisphere Stroke ◽

The Impact

During embolectomy for acute stroke, transfemoral access to occluded vessel may be technically difficult. We aim to study the impact of difficult catheter access to target artery. Methods: Single center review of anterior circulation stroke patients enrolled in prospective trials/registries (MR Rescue, MERCI, DEFUSE) requiring recording of time from groin puncture to first device deployment(Tdep). Patients were divided according to Tdep quartiles (Q): patients in Q4 were considered as difficult access. We recorded recanalization (TICI≥2a), complete recanalization (TICI≥2b), infarct volume(24h DWI), day 5 NIHSS, and favorable outcome (3 months mRS≤2). Results: We included 196 patients, mean age 66±14, median NIHSS 16(IQR:12-21). Overall outcomes were: median Tdep 52 min (36-77), recanalization 89.1%, complete recanalization 59.4%, favorable outcome 43.8%. We observed a positive correlation between Tdep and day 5 NIHSS (r=0.27; p=0.01) or 3 months mRS (r=0.26; p<0.01). Patients with difficult access (Q4: Tdep>77 min) had similar baseline NIHSS (16 Vs 17 p=0.58), time from symptom to procedure start (433 Vs 371min; p=0.28) and occlusion location (ICA/M1/M2: 46.7/42.2/11.1% Vs 39.1/54.3/6.5%; p=0.31). However, patients in Q4 had: longer IA procedures (153 vs 112 min;p<0.01), lower complete recanalization (41% Vs 66%;p<0.01), larger infarcts (87 Vs 53cc; p<0.01), higher day 5 NIHSS (15 Vs 9;p<0.01), and less favorable outcome (29.2% Vs 49%; p=0.02). After adjusting by age and time to reperfusion, a regression model identified admission NIHSS (OR% 1.12: 95%CI 1.02-1.21; p<0.01), age (OR% 1.03: 95%CI 1.01-1.06; p=0.01) and Tdep (OR% 1.02 95%CI 1.01-1.03; p=0.01) as independent predictors of poor outcome. In univariate analysis age>69, male gender and left hemisphere stroke were associated with difficult access. The combined presence of the 3 factors increased by 3.5 fold the likelihood of difficult access (OR:3.55 95%CI 1.5-8.6: p<0.01) Conclusion: Delayed device access to target occluded artery independently predicts poor outcome. Identification of difficult access using clinical scores or imaging may lead to alternative strategies; brachial, radial or cervical approaches that could result in shortened procedural times and improved outcomes

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Cut-off Values of the Respiratory Muscle Power and Peak Cough Flow in Post-Stroke Dysphagia

Medicina ◽

10.3390/medicina56120635 ◽

2020 ◽

Vol 56 (12) ◽

pp. 635

Author(s):

Yeon Jae Han ◽

Jungjae Lee ◽

Dong Gyun Sohn ◽

Geun-Young Park ◽

Youngkook Kim ◽

...

Keyword(s):

Receiver Operating Characteristic Curve ◽

Receiver Operating Characteristic ◽

Operating Characteristic ◽

Characteristic Curve ◽

Univariate Analysis ◽

Multivariable Analysis ◽

Post Stroke ◽

Increased Risk ◽

Operating Characteristic Curve ◽

Receiver Operating

Background and objectives: This study aimed to determine the cut-off values of the following three respiratory pressure meters; the voluntary peak cough flow (PCF), maximal expiratory pressure (MEP) and maximal inspiratory pressure (MIP); associated with post-stroke dysphagia and assess which of these parameters show good diagnostic properties associated with post-stroke dysphagia. Materials and Methods: Retrospective analysis of a prospectively maintained database. Records of patients with first-ever diagnosed dysphagia attributable to cerebrovascular disease, who had performed spirometry measurements for the PCF, MIP and MEP. Results: From a total of 237 stroke patients, 163 patients were diagnosed with dysphagia. Those with dysphagia had significantly lower PCF values than those without dysphagia (116.3 ± 75.3 vs. 219.4 ± 91.8 L/min, p < 0.001). In addition, the former group also had lower MIP (30.5 ± 24.7 vs. 41.6 ± 25.7 cmH2O, p = 0.0002) and MEP (41.0 ± 27.9 vs. 62.8 ± 32.3 cmH2O, p < 0.001) values than the latter group. The receiver operating characteristic curve analysis showed that the PCF cut-off value of 151 L/min (area under the receiver operating characteristic curve [AUC] 0.81; sensitivity 72%; specificity 78.8%) was associated with post-stroke dysphagia. The optimum MEP and MIP cut-off were 38 cmH2O (AUC 0.70, sensitivity 58%; specificity 77.7%) and 20 cmH2O (AUC 0.65, sensitivity 49%; specificity 84%). PCF showed the highest AUC results. Results from the univariate analysis indicated that PCF values of ≤151 L/min increased risk of dysphagia by 9.51-fold (4.96–18.23). Multivariable analysis showed that after controlling of other clinical factor, the PCFs at this cut-off value still showed increased risk of by 4.19 (2.02–83.69) but this was not observed with the MIPs or MEPs. Conclusions: Our study has provided cut-off values that are associated with increased risk of dysphagia. Among the three parameters, PCF showed increased association with post-stroke dysphagia.

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Downregulation of the Ubiquitin-E3 Ligase RNF123 Promotes Upregulation of the NF-κB1 Target SerpinE1 in Aggressive Glioblastoma Tumors

Cancers ◽

10.3390/cancers12051081 ◽

2020 ◽

Vol 12 (5) ◽

pp. 1081 ◽

Cited By ~ 3

Author(s):

Xiaowen Wang ◽

Matias Bustos ◽

Xiaoqing Zhang ◽

Romela Ramos ◽

Cong Tan ◽

...

Keyword(s):

Cell Lines ◽

Multivariable Analysis ◽

E3 Ligase ◽

Isocitrate Dehydrogenase 1 ◽

Poor Overall Survival ◽

Downstream Target ◽

Ubiquitin E3 Ligase ◽

Increased Risk ◽

Poor Outcomes

This study examined the role of the ubiquitin E3-ligase RNF123 in modulating downstream NF-κB1 targets in glioblastoma (GB) tumor progression. Our findings revealed an oncogenic pathway (miR-155-5p-RNF123-NF-κB1-p50-SerpinE1) that may represent a new therapeutic target pathway for GB patients with isocitrate dehydrogenase 1 and 2 (IDH) WT (wild type). Mechanistically, we demonstrated that RNF123 is downregulated in IDH WT GB patients and leads to the reduction of p50 levels. RNA-sequencing, reverse-phase protein arrays, and in vitro functional assays on IDH WT GB cell lines with RNF123 overexpression showed that SerpinE1 was a downstream target that is negatively regulated by RNF123. SERPINE1 knockdown reduced the proliferation and invasion of IDH WT GB cell lines. Both SerpinE1 and miR-155-5p overexpression negatively modulated RNF123 expression. In clinical translational analysis, RNF123, SerpinE1, and miR-155-5p were all associated with poor outcomes in GB patients. Multivariable analysis in IDH WT GB patients showed that concurrent low RNF123 and high SerpinE1 was an independent prognostic factor in predicting poor overall survival (p < 0.001, hazard ratio (HR) = 2.93, 95% confidence interval (CI) 1.7–5.05), and an increased risk of recurrence (p < 0.001, relative risk (RR) = 3.56, 95% CI 1.61–7.83).

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Thrombectomy versus medical management for large vessel occlusion strokes with minimal symptoms: an analysis from STOPStroke and GESTOR cohorts

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2017-013243 ◽

2017 ◽

Vol 10 (4) ◽

pp. 325-329 ◽

Cited By ~ 37

Author(s):

Diogo C Haussen ◽

Fabricio O Lima ◽

Mehdi Bouslama ◽

Jonathan A Grossberg ◽

Gisele S Silva ◽

...

Keyword(s):

Endovascular Therapy ◽

Medical Management ◽

Multivariable Analysis ◽

Large Vessel ◽

Secondary Outcome ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Nihss Score ◽

Intravenous Tissue Plasminogen Activator

IntroductionIt remains unclear whether patients presenting with large vessel occlusion strokes and mild symptoms benefit from thrombectomy.ObjectiveTo compare outcomes of endovascular therapy versus medical management in patients with large vessel occlusion strokes and National Institute of Health Stroke Scale (NIHSS) score ≤5.MethodsThis was a retrospective analysis combining two large prospectively collected datasets including patients with (1) admission NIHSS score ≤5, (2) premorbid modified Rankin Scale (mRS) score 0–2, and (3) middle cerebral-M1/M2, intracranial carotid, anterior cerebral or basilar artery occlusions. Groups receiving (1) endovascular treatment and (2) medical management were compared. The primary and secondary outcome measures were NIHSS shift (discharge NIHSS minus admission NIHSS) and the rates of mRS 0–2 at discharge and 3–6 months, respectively. Univariate, multivariate, and matched analyses were performed.ResultsEighty-eight patients received medical management and 30 thrombectomy. Multivariable analysis indicated thrombectomy was the only predictor of favorable NIHSS shift (β −3.7, 95% CI −6.0 to −1.5, p=0.02), as well as independence at discharge (β −21.995% CI −41.4to −20.8, p<0.01) and 3–6-month follow-up (β −21.1, 95% CI −39.1 to −19.7, p<0.01). A matched analysis (based on age, baseline NIHSS and intravenous tissue plasminogen activator use) produced 26 pairs. Endovascular therapy was statistically associated with lower NIHSS at discharge (p=0.04), favorable NIHSS shift (p=0.03), and increased independence rates at discharge (p=0.03) and 3–6-month follow-up (p=0.04).ConclusionIn patients presenting with minimal stroke symptoms (NIHSS score ≤5) and large vessel occlusion strokes, mechanical thrombectomy appears to be associated with a favorable shift of NIHSS at discharge, as well as higher rates of independence at discharge and long-term follow-up. Confirmatory prospective studies are warranted.

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Evaluation of Different Scoring Systems in Predicting the Severity of Acute Pancreatitis

Journal of Evidence Based Medicine and Healthcare ◽

10.18410/jebmh/2020/537 ◽

2020 ◽

Vol 7 (45) ◽

pp. 2604-2610

Author(s):

Rohan J. Harsoda ◽

Sharma Vipin Jaishree ◽

Krishna Prasad G.V

Keyword(s):

Acute Pancreatitis ◽

Scoring System ◽

Scoring Systems ◽

Apache Ii ◽

Prediction Of Outcome ◽

Poor Outcome ◽

Increased Risk ◽

Highly Sensitive ◽

Poor Outcomes ◽

Ranson Score

BACKGROUND Accurate prediction of the severity of acute pancreatitis will help in identifying patients at increased risk for morbidity and mortality. We wanted to evaluate the different scoring systems in predicting the severity of acute pancreatitis. METHODS This cross-sectional study was undertaken in the Department of Surgery at a zonal hospital between April 2013 and December 2014. RESULTS 40 patients were selected and enrolled in the study as per the selection criteria. 20 (50 %) patients had fair outcome and 20 (50 %) had a poor outcome. Accuracy of different scoring systems in predicting patient outcome ranged from 45 % (48-hr APACHE II) to 62.5 % (Goris MOF at baseline and 48 hr). Baseline Goris MOF was 70 % sensitive and 55 % specific in prediction of poor outcome. It had an accuracy of 62.5 % in prediction of outcome. 48-hr Goris MOF was 80 % sensitive and 45 % specific in predicting the outcome. Baseline APACHE II scores were below the cut-off level in all the patients. 48-hr APACHE II scores were 5 % sensitive and 100% specific for prediction of outcome. Ranson score > 3 was 25 % sensitive and 90 % specific in the prediction of outcome. Balthazar score > 6 was 65 % sensitive and 55 % specific in prediction of outcome. Ranson score was found to have a limited sensitivity for different outcomes (ranging from 21.1 % to 50 %) but was found to have a high specificity (83.8 % to 90 %). CONCLUSIONS Goris scoring system (at 48 hrs) was found to be highly sensitive to different poor outcomes as well as duration of hospital stay. It also correlated with Balthazar scoring system, which was also highly sensitive to different poor outcomes studied. KEYWORDS Acute Pancreatitis, Prediction, Scoring System, APACHE II, Goris MOF, Ranson’s Score, Balthazar Score

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Abstract W MP33: Baseline Clinical and Infarct Characteristics as Predictors of Poor Outcomes in Patients Not Thrombolysed Due to Mild or Resolving Symptoms ("Too Good To Treat")

Stroke ◽

10.1161/str.46.suppl_1.wmp33 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Syed F Ali ◽

Khawja A Siddiqui ◽

Abigail S Cohen ◽

Hakan Ay ◽

Aneesh B Singhal ◽

...

Keyword(s):

Multivariable Analysis ◽

Stroke Subtype ◽

Anterior Circulation ◽

Poor Outcome ◽

Imaging Characteristics ◽

Hospice Patients ◽

Poor Outcomes ◽

Posterior Anterior ◽

Iv Tpa ◽

Hemispheric Infarction

Introduction: A common reason for non-treatment of time eligible patients with IV tPA is mild symptoms in patients that are “too good to treat (TGTT)”. Several studies have reported poor outcomes in this group. We sought to identify patient and imaging characteristics associated with poor outcomes in this group. Methods: Using our institutional GWTG database, we analyzed 2,745 consecutive stroke admissions (01/2009 - 07/2013). Univariate and multivariable analysis were carried out to determine factors associated with the poor outcome of not being discharged home. Results: Of the total 2,745 patients, 306 (11.1%) presented within the window for IV tPA but did not receive the treatment due to symptoms too mild or rapidly improving. Of these, imaging characteristics were available in 238 patients. Among TGTT stroke patients, 62.6% were discharged home, 26.9% to IRF, 8.4% to SNF and 2.1% death/hospice. Patients with poor outcome were older, more often Hispanic, with more vascular risk factors, and higher NIHSS. Infarcts in both hemispheres, and in posterior+/- anterior circulation were more common with poor outcome. On multivariable analysis, increasing age, Hispanic ethnicity, higher NIHSS and bihemispheric stroke were associated with poor outcome, with a trend toward small vessel stroke subtype. Conclusion: A substantial percentage of patients deemed “too good” for IV tPA are still unable to be discharged home. Factors such as advanced age, higher NIHSS, bi-hemispheric infarction should be considered in tPA decision-making in potential TGTT patients. Large, multi-center prospective studies are needed to better identify potential biomarkers of poor outcomes in this group.

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122 Significance of Fluctuations in Serum Sodium Levels Following Aneurysmal Subarachnoid Hemorrhage: An Exploratory Analysis

Neurosurgery ◽

10.1093/neuros/nyx417.122 ◽

2017 ◽

Vol 64 (CN_suppl_1) ◽

pp. 227-227

Author(s):

Matt E Eagles ◽

Michael K Tso ◽

R Loch Macdonald

Keyword(s):

Subarachnoid Hemorrhage ◽

Serum Sodium ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Statistical Significance ◽

Univariate Analysis ◽

Delayed Cerebral Ischemia ◽

Exploratory Analysis ◽

Base Line ◽

Poor Outcome ◽

Increased Risk

Abstract INTRODUCTION Changes in serum sodium levels are common following aneurysmal subarachnoid hemorrhage (aSAH), and may be linked to increased morbidity. In this exploratory analysis we assessed whether fluctuations in serum sodium levels after aSAH have an association with clinical outcomes and/or delayed cerebral ischemia (DCI). METHODS We performed a retrospective analysis of data from CONSCIOUS-1 (n = 413), a randomized controlled trial of clazosentan treatment in patients with aSAH. Patient serum sodium levels were checked daily during the hospital stay up to day 14. Mean-per-day fluctuations in serum sodium were calculated by summing the absolute deviation of serum sodium at day 2–14 from day 1 base-line divided by the total number of days with lab values. Logistic regression and LOWESS smoothing curves were used to determine association between serum sodium deviation and poor outcome at 3 months (defined as modified Rankin Scale, mRS> 2) or DCI. RESULTS >Mean-per-day deviation of serum sodium from baseline was associated with poor outcome on univariate analysis (P = 0.028), and maintained statistical significance after correcting for age and World Federation of Neurological Surgeons (WFNS) grade (P = 0.044). A LOWESS smoothing curve showed an increased risk of DCI for patients with greater deviations from their baseline sodium values. Multivariate regression, including WFNS and Fisher Scale grades, demonstrated absolute variation in sodium values to be associated with DCI (P = 0.045). CONCLUSION In this study, greater deviations in serum sodium values independently predicted poor outcome and the development of DCI.

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