Abstract 149: Patterns, Determinants and Outcomes of Ultra-early Neurological Deterioration (U-END) in Intracranial Hemorrhage

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Kristina Shkirkova ◽  
Gregory Wong ◽  
Julius Weng ◽  
Jeffrey L Saver ◽  
Sidney Starkman ◽  
...  
Keyword(s):  
Clinical Trials ◽  
Glasgow Coma Scale ◽  
Intracranial Hemorrhage ◽  
Neurological Deterioration ◽  
Stroke Therapy ◽  
Phase 3 ◽  
Lowering Therapy ◽  
Higher Ed ◽  
Early Neurological Deterioration ◽  
History Of

Background: The patterns and outcomes of deterioration during prehospital transport and the first phase of ED care are important for planning for design of prehospital intracranial hemorrhage (ICH) treatment trials. Methods: Patients were enrolled in the NIH Phase 3 Field Administration of Stroke Therapy - Magnesium (FAST-MAG) prehospital trial within 2h of last known well (LKW). Deterioration was defined as worsening by ≥2 on the Glasgow Coma Scale (GCS), performed serially by paramedics in the field, upon ED arrival, and after the early ED course Results: Among 213 patients with ICH, age was 65.4 (±13.4), 33.3% female. Times from LKW to GCS assessments were: paramedic, 23 mins (IQR 14-39); ED arrival, 57 mins (IQR 45-75); and after early ED course, 89 mins (IQR 65-107). Overall, 38.5% experienced neurological deterioration, including 12.7% in prehospital phase only, 12.2% in early ED phase only, and 10.3% in both. Granular patterns of deficit progression were: Prehospital Sustained - prehospital deterioration, then stable early ED phase, 6.1% (13); Dippers - prehospital deterioration, then early ED improvement, 6.6% (14); Delayed - stable prehospital, then ED deterioration, 12.2% (26); and Continuous - prehospital deterioration, then further deterioration in ED, 10.3% (22) (Figure). ICH patients who experienced any U-END had lower prehospital GCS scores, 15 (IQR 12-15) vs 15 (IQR 15-15), p<0.001, greater prehospital focal weakness, LAMS 4.4 vs 3.9, p<0.001, history of hypertension, 87.4% vs 74.9%, p<0.001, higher ED SBP, 186 vs 174, p<0.001, and larger ICH volume, 45.8 vs 21.8 cm 3 , p<0.001. U-END was associated with higher dependence or death (mRS 3-6) at 90d, 90.1% vs 61.6%, p<0.001. Conclusions: Ultra-early neurological deterioration occurs in more than one-third of EMS-transported ICH patients, is associated with elevated BP, and leads to unfavorable outcome. Clinical trials testing prehospital initiation of BP-lowering therapy for ICH are desirable.

Abstract TP233: Patterns, Determinants and Outcomes of Ultra-Early Neurological Deterioration (U-END) in Acute Ischemic Stroke

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Kristina Shkirkova ◽  
Gregory Wong ◽  
Julius Weng ◽  
Jeffrey L Saver ◽  
Sidney Starkman ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Cerebral Ischemia ◽  
Management Strategies ◽  
Neurological Deterioration ◽  
Effective Management ◽  
Stroke Therapy ◽  
Phase 3 ◽  
Prehospital Treatment ◽  
Acute Cerebral Ischemia ◽  
Early Neurological Deterioration

Background: The patterns and outcomes of deterioration during prehospital transport and the first phase of ED care are important for planning for diversion of acute cerebral ischemia (ACI) patients to designated stroke centers and design of prehospital treatment trials. Methods: We analyzed patients enrolled in the NIH Phase 3 Field Administration of Stroke Therapy - Magnesium (FAST-MAG) trial within 2h of last known well (LKW). Deterioration was defined as worsening by ≥2 on the Glasgow Coma Scale (GCS), performed serially by paramedics in the field, upon ED arrival, and after the early ED course. Results: Among 713 acute cerebral ischemia patients, age was 65.4 (±13.4), 45% female. Times from LKW to GCS assessments were: paramedic, 25 mins (IQR 15-46); ED arrival, 60 mins (IQR 48-82); and after early ED course, 83 mins (IQR 60-106). Overall, 16.3% experienced neurological deterioration, including 9.0% in prehospital phase only, 7.3% in early ED phase only, and none in both phases. Granular patterns of deficit progression were: Prehospital Sustained - prehospital deterioration, then stable early ED phase, 2.2% (16); Dippers - prehospital deterioration, then early ED improvement, 6.7% (48); Delayed - stable prehospital, then ED deterioration, 3.0% (22); and Peakers - prehospital improvement, then early ED deterioration, 4.2% (30) (Figure). Ischemic stroke patients who experienced any U-END had higher age, 73.2 vs 69.8, p<0.01; lower prehospital GCS scores, 14 (IQR 11-15) vs 15 (IQR 14-15), p<0.001; and greater prehospital focal weakness, LAMS 4.2 vs 3.6, p<0.001. U-END was associated with higher rates of disability or death (mRS 2-6) at 90 days, 77.8% vs 53.8%, p<0.001. Conclusions: Ultra-early neurological deterioration occurs in one-sixth of EMS-transported acute cerebral ischemia patients, and is associated with less favorable outcome. Early identification and effective management strategies are needed to reduce its occurrence.

Blood Pressure After Endovascular Thrombectomy and Outcomes in Patients With Acute Ischemic Stroke: An Individual Patient Data Meta-analysis

Neurology ◽  
2021 ◽  
pp. 10.1212/WNL.0000000000013049
Author(s):  
Aristeidis H Katsanos ◽  
Konark Malhotra ◽  
Niaz Ahmed ◽  
Georgios Seitidis ◽  
Eva A. Mistry ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Intracranial Hemorrhage ◽  
Individual Patient Data ◽  
Patient Data ◽  
Neurological Deterioration ◽  
Endovascular Thrombectomy ◽  
Early Neurological Deterioration ◽  
Symptomatic Intracranial Hemorrhage

Objective:To explore the association between blood pressure (BP) levels after endovascular thrombectomy (EVT) and the clinical outcomes of acute ischemic stroke (AIS) patients with large vessel occlusion (LVO).Methods:A study was eligible if it enrolled AIS patients older than 18 years, with an LVO treated with either successful or unsuccessful EVT, and provided either individual or mean 24-hour systolic BP values after the end of the EVT procedure. Individual patient data from all studies were analyzed using a generalized linear mixed-effects model.Results:A total of 5874 patients (mean age: 69±14 years, 50% women, median NIHSS on admission: 16) from 7 published studies were included. Increasing mean systolic BP levels per 10 mm Hg during the first 24 hours after the end of the EVT were associated with a lower odds of functional improvement (unadjusted common OR=0.82, 95%CI:0.80-0.85; adjusted common OR=0.88, 95%CI:0.84-0.93) and modified Ranking Scale score≤2 (unadjusted OR=0.82, 95%CI:0.79-0.85; adjusted OR=0.87, 95%CI:0.82-0.93), and a higher odds of all-cause mortality (unadjusted OR=1.18, 95%CI:1.13-1.24; adjusted OR=1.15, 95%CI:1.06-1.23) at 3 months. Higher 24-hour mean systolic BP levels were also associated with an increased likelihood of early neurological deterioration (unadjusted OR=1.14, 95%CI:1.07-1.21; adjusted OR=1.14, 95%CI:1.03-1.24) and a higher odds of symptomatic intracranial hemorrhage (unadjusted OR=1.20, 95%CI:1.09-1.29; adjusted OR=1.20, 95%CI:1.03-1.38) after EVT.Conclusion:Increased mean systolic BP levels in the first 24 hours after EVT are independently associated with a higher odds of symptomatic intracranial hemorrhage, early neurological deterioration, three-month mortality, and worse three-month functional outcomes.

scholarly journals Effect of Argatroban Combined With Dual Antiplatelet Therapy on Early Neurological Deterioration in Acute Minor Posterior Circulation Ischemic Stroke

2020 ◽  
Vol 26 ◽  
pp. 107602962090413 ◽  
Author(s):  
Ling-Shan Zhou ◽  
Xiao-Qiu Li ◽  
Zhong-He Zhou ◽  
Hui-Sheng Chen
Keyword(s):  
Ischemic Stroke ◽  
Antiplatelet Therapy ◽  
Intracranial Hemorrhage ◽  
Dual Antiplatelet Therapy ◽  
Posterior Circulation ◽  
Neurological Deterioration ◽  
Nihss Score ◽  
Safety Outcome ◽  
Early Neurological Deterioration ◽  
Symptomatic Intracranial Hemorrhage

There is a lack of studies on anticoagulant plus antiplatelet therapy for acute ischemic stroke. The present study made a pilot effort to investigate the efficacy and safety of argatroban plus dual antiplatelet therapy (DAPT) in patients with acute posterior circulation ischemic stroke (PCIS). We retrospectively collected patients diagnosed with acute PCIS according to inclusion/exclusion criteria. According to treatment drugs, patients were divided into an argatroban plus DAPT group and a DAPT group. The primary efficacy end point was the proportion of early neurological deterioration (END). The primary safety outcome was symptomatic intracranial hemorrhage. All outcomes were compared between the 2 groups before and after propensity score matching (PSM). A total of 502 patients were enrolled in the study, including 35 patients with argatroban plus DAPT and 467 patients with DAPT. There was a higher National Institutes of Health Stroke Scale (NIHSS) score in the argatroban plus DAPT group than the DAPT group before PSM (3 vs 2, P = .017). Compared with the DAPT group, the argatroban plus DAPT group had no END (before PSM: 0% vs 6.2%, P = .250; after PSM: 0% vs 5.9%, P = .298). Argatroban plus DAPT yielded a significant decrease in the NIHSS score from baseline to 7 days after hospitalization, compared with that of the DAPT group before PSM ( P = .032), but not after PSM ( P = .369). No symptomatic intracranial hemorrhage was found in any patient. A short-term combination of argatroban with DAPT appears safe in acute minor PCIS.

Hypercoagulation on Thromboelastography Predicts Early Neurological Deterioration in Patients with Acute Ischemic Stroke

2018 ◽  
Vol 46 (3-4) ◽  
pp. 123-129 ◽  
Author(s):  
Zhu Shi ◽  
Wei C. Zheng ◽  
Xiao L. Fu ◽  
Xue W. Fang ◽  
Pei S. Xia ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
High Sensitivity ◽  
Roc Curves ◽  
Neurological Deterioration ◽  
Nihss Score ◽  
Lower Tertile ◽  
Reactive Protein ◽  
Early Neurological Deterioration ◽  
History Of

Background: Thromboelastography (TEG) provides an integrated measurement of blood coagulation function and has been reported to be a useful tool for predicting clinical outcomes in patients with cardiovascular diseases. We aimed to investigate the application of TEG on admission for predicting early neurological deterioration (END) in patients with acute ischemic stroke and its potential correlation with the evolution of ischemic lesions. Methods: Among patients consecutively admitted between January 1, 2016, and September 31, 2017, those presenting with mild and moderate acute ischemic stroke (National Institutes of Health Stroke Scale [NIHSS] score ≤14) within 24 h of stroke onset were identified and included in this study. TEG was performed on the first day of admission. END was defined as an increase of ≥1 on subitems of the NIHSS or the emergence of new symptoms within 72 h of admission. Demographics, lab test results, and TEG values were compared according to whether END occurred. A multiple logistic regression model was then developed to investigate the predictive power of TEG for END. Receiver operating characteristic (ROC) curves were then plotted to evaluate the optimal cutoff values. Results: Of the 246 eligible patients (mean age 65.3 ± 12.9 years, 73.6% male), END was identified in 72 (29.3%) patients. Patients with END corresponded to a higher proportion of females, a more prevalent history of diabetes mellitus (DM), higher baseline NIHSS scores, higher serum high-sensitivity C-reactive protein (hsCRP) levels, and significantly shorter R on TEG (4.0 ± 1.0 vs. 4.7 ± 1.2 min, p < 0.001). In further comparisons stratified by R tertiles, significant trends were found between shorter R and being female and older and being more likely to exhibit diffusion weighted imaging progression on follow-up MRI. After adjusting for female sex, baseline NIHSS score, DM, and hsCRP, the lower tertile of R (R ≤3.8 min) was strongly associated with END (OR 3.556, 95% CI 1.165–10.856, p < 0.001). ROC analysis demonstrated that R ≤3.45 min had the best predictive value for END with 87.9% sensitivity and 40.3% specificity. Conclusion: Decreased R time on admission TEG is associated with END within 3 days in patients with acute ischemic stroke.

scholarly journals Associated factors of early neurological deterioration in isolated acute lacunar infarction in basal ganglia

2019 ◽  
Vol 7 (2) ◽  
pp. 63-69
Author(s):  
Honghao Man ◽  
Yuhua Bi ◽  
Yongpeng Yu ◽  
Shengwu Wang ◽  
Zhenming Zhao ◽  
...  
Keyword(s):  
White Matter ◽  
Basal Ganglia ◽  
Cerebral Infarction ◽  
Age Of Onset ◽  
Neurological Deterioration ◽  
Lacunar Infarction ◽  
Cerebral White Matter ◽  
Lesion Location ◽  
Early Neurological Deterioration ◽  
History Of

Objective:To investigate, in basal ganglia, the factors associated with early neurological deterioration (END) of isolated acute lacunar infarction.Methods:167 patients, in the retrospective group, with isolated acute lacunar infarction in basal ganglia, were defined by magnetic resonance imaging (MRI). The National Institutes of Health Stroke Scale (NIHSS) defined early neurological deterioration as increases of ≥ 2 within 72 hours following admission. Baseline variables predicting END were investigated with multivariate logistic regression analysis.Results:In the study, END occurred in 42 (25.15%) patients. Lesions located in posterior limb of internal capsule were independent risk factors for END (P < 0.01). Associated with END were the age of onset, history of cerebral infarction, history of diabetes, systolic blood pressure at admission and lesions of cerebral white matter. This presented significant differences (P < 0.05). With or without diabetes and different lesion location at varying layers and inter-layers, single-factor and multi-factor analysis revealed no effect on the association between positive ENT and age, history of stroke, white matter. Previous history of stroke, pathological changes of white matter, and age of onset, correlates with END which showed significant difference (P < 0.05).Conclusions:There is a close relationship between the lesion location and other related factors, such as lesions of cerebral white matter, history of cerebral infarction, history of diabetes and age, etc. and END in patients with isolated acute lacunar infarction in basal ganglia. Protective factors of END included age ≥ 65, high systolic pressure, stroke history, cerebral white matter lesions in our study.

Efficacy of Certolizumab Pegol for Psoriasis of the Head and Neck in Two Phase 3 Clinical Trials: CIMPASI-1 and CIMPASI-2

2019 ◽  
Vol 3 ◽  
pp. S40
Author(s):  
P Van de Kerkhof ◽  
A Pinter ◽  
M Boehnlein ◽  
S Kavanagh ◽  
J.J. Crowley
Keyword(s):  
Clinical Trials ◽  
Head And Neck ◽  
Certolizumab Pegol ◽  
Phase 3 ◽  
Two Phase

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