The Types of Neurological Deficits Might Not Justify Withholding Treatment in Patients With Low Total National Institutes of Health Stroke Scale Scores

Object Stereotactic radiosurgery (SRS) is an established treatment modality for brain arteriovenous malformations (AVMs) in children, but the optimal treatment parameters and associated treatment-related complications are not fully understood. The authors present their single-institution experience of using SRS, at a relatively low marginal dose, to treat AVMs in children for nearly 20 years; they report angiographic outcomes, posttreatment hemorrhage rates, adverse treatment-related events, and functional outcomes. Methods The authors conducted a retrospective review of 2 cohorts of children (18 years of age or younger) with AVMs treated from 1991 to 1998 and from 2000 to 2010. Results A total of 80 patients with follow-up data after SRS were identified. Mean age at SRS was 12.7 years, and 56% of patients had hemorrhage at the time of presentation. Median target volume was 3.1 cm3 (range 0.09–62.3 cm3), and median prescription marginal dose used was 17.5 Gy (range 12–20 Gy). Angiograms acquired 3 years after treatment were available for 47% of patients; AVM obliteration was achieved in 52% of patients who received a dose of 18–20 Gy and in 16% who received less than 18 Gy. At 5 years after SRS, the cumulative incidence of hemorrhage was 25% (95% CI 16%–37%). No permanent neurological deficits occurred in patients who did not experience posttreatment hemorrhage. Overall, good functional outcomes (modified Rankin Scale Scores 0–2) were observed for 78% of patients; for 66% of patients, functional status improved or remained the same as before treatment. Conclusions A low marginal dose minimizes SRS-related neurological deficits but leads to low rates of obliteration and high rates of hemorrhage. To maximize AVM obliteration and minimize posttreatment hemorrhage, the authors recommend a prescription marginal dose of 18 Gy or more. In addition, SRS-related symptoms such as headache and seizures should be considered when discussing risks and benefits of SRS for treating AVMs in children.

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Mechanical thrombectomy beyond the circle of Willis: efficacy and safety of different techniques for M2 occlusions

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2021-017425 ◽

2021 ◽

pp. neurintsurg-2021-017425

Author(s):

Leonardo Renieri ◽

Iacopo Valente ◽

Adam A Dmytriw ◽

Ajit S Puri ◽

Jasmeet Singh ◽

...

Keyword(s):

Ischemic Stroke ◽

Clinical Outcome ◽

Mechanical Thrombectomy ◽

Circle Of Willis ◽

Stent Retriever ◽

National Institutes Of Health ◽

Neurological Deficits ◽

Stent Retrievers ◽

Subarachnoid Hemorrhages ◽

Combined Technique

BackgroundM2 segment occlusions represent approximately one-third of non-lacunar ischemic stroke and can lead to permanent neurological deficits. Various techniques are available for mechanical thrombectomy beyond the circle of Willis, but data evaluating their effectiveness and safety are lacking.MethodsA retrospective review of patients with ischemic stroke undergoing mechanical thrombectomy for M2 occlusions from 13 centers in North American and Europe was performed. Tandem or multiple-territory occlusions were excluded. The primary outcome was 90-day modified Rankin Scale and reperfusion rates across stent-retriever, direct aspiration and combined techniques.ResultsThere were 465 patients (mean age 71.48±14.03 years, 53.1% female) with M2 occlusions who underwent mechanical thrombectomy. Stent-retriever alone was used in 133 (28.6%), direct aspiration alone in 93 (20.0%) and the combined technique in 239 (51.4%) patients. Successful reperfusion was achieved with the combined technique in 198 (82.2%; OR 2.6 (1.1–6.9)), with stent-retriever alone in 112 (84.2%; OR 9.2 (1.9–44.6)) and with direct aspiration alone in 62 (66.7%; referencecategory). Intraprocedural subarachnoid hemorrhages (iSAH) were 36 (7.7%) and were more likely to occur in patients treated with the stent-retrievers (OR 5.0 (1.1–24.3)) and combined technique (OR 4.6 (1.1–20.9)). Good clinical outcome was achieved in 260 (61.8%) patients, while 59 (14.0%) patients died. Older age, higher baseline NIHSS (National Institutes of Health Stroke Scale), parenchymal hemorrhage and iSAH were associated with poor outcome while successful recanalization and higher baseline ASPECTS (Alberta Stroke Program Early CT Score) were associated with good outcome. No differences were found among the three techniques in terms of clinical outcome.ConclusionStent-retrievers and a combined approach for M2 occlusions seem more effective than direct aspiration, but with higher rates of iSAH. This leads to no detectable difference in clinical outcome at 3 months.

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Underdosed Direct Oral Anticoagulants in Atrial Fibrillation Patients Reduce Stroke Severity and Improve Outcome

Cerebrovascular Diseases ◽

10.1159/000520857 ◽

2021 ◽

pp. 1-8

Author(s):

Masaki Naganuma ◽

Yuichiro Inatomi ◽

Toshiro Yonehara ◽

Makoto Nakajima ◽

Mitsuharu Ueda

Keyword(s):

Atrial Fibrillation ◽

Functional Outcomes ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

National Institutes Of Health ◽

Stroke Severity ◽

Anticoagulant Drugs ◽

Scale Scores ◽

Anticoagulant Drug ◽

Ischemic Attack

Background and Purpose: Anticoagulant drugs, including vitamin K antagonist (VKA) and direct oral anticoagulants (DOACs), can reduce stroke severity and are associated with good functional outcomes. Some patients are prescribed lower-than-recommended doses of DOACs; whether these have similar effects has not been clarified. Methods: We retrospectively evaluated 1,139 consecutive ischemic stroke and transient ischemic attack patients with atrial fibrillation. Patients were divided into 5 groups according to their preceding anticoagulant drug therapies: no anticoagulant therapy (ACn), undercontrolling VKA doses (VKAuc), recommended, controlling VKA doses (VKArec), prescribed underdoses of DOAC (DOACud), and recommended doses of DOAC (DOACrec). We investigated the associations between these anticoagulant drug therapies and patients’ initial stroke severity and 3-month outcomes. Results: Median National Institutes of Health Stroke Scale scores at admission were as follows: ACn: 16, VKAuc: 15, VKArec: 9, DOACud: 5, and DOACrec: 7. When the ACn group was used as a reference, regression analysis showed that VKArec (odds ratio [OR] 1.49, 95% confidence interval [CI] 1.01–2.21), DOACud (OR 2.84, 95% CI: 1.47–5.66), and DOACrec (OR 1.83, 95% CI: 1.23–2.74) were associated with milder stroke severity, while VKAuc was not. Median 3-month modified Rankin Scale scores were 2 in the DOACud and DOACrec groups and 4 in all other groups. After adjusting for confounding factors, DOACud (OR 3.14, 95% CI: 1.50–6.57) and DOACrec (OR 1.67, 95% CI: 1.05–2.64) were associated with good 3-month outcomes while VKAuc and VKArec were not. Conclusions: In patients with atrial fibrillation, recommended doses and underdoses of DOACs reduced stroke severity on admission and were associated with good 3-month outcomes.

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Stent Reconstruction of Carotid Tonsillar Loop Dissection Using Telescoping Peripheral Stents

Interventional Neurology ◽

10.1159/000486457 ◽

2018 ◽

Vol 7 (3-4) ◽

pp. 189-195 ◽

Cited By ~ 1

Author(s):

Benjamin M. Zussman ◽

Bradley A. Gross ◽

William J. Ares ◽

Cynthia L. Kenmuir ◽

Gregory M. Weiner ◽

...

Keyword(s):

Internal Carotid ◽

Treatment Options ◽

National Institutes Of Health ◽

Modified Rankin Scale ◽

Endovascular Techniques ◽

Aspiration Thrombectomy ◽

Patient Demographics ◽

Clinical Presentations ◽

Scale Scores

Background: Endovascular treatment options for internal carotid artery (ICA) dissection with tandem intracranial occlusion are evolving. We report 2 cases of stent reconstruction of carotid loop dissections. Methods: Two patients with symptomatic ICA dissections of true 360° tonsillar loops and tandem intracranial occlusions were treated with manual aspiration thrombectomy (MAT) and telescoping Zilver self-expanding peripheral stents. Patient demographics, clinical presentations, endovascular techniques, and clinical outcomes were reviewed. Results: In both cases, MAT achieved modified Treatment in Cerebral Ischemia scale 2B reperfusion, and complete endovascular reconstruction of the dissected extracranial loop was performed. Both patients had improved pre- to postintervention National Institutes of Health Stroke Scale scores (16 to 0 and 14 to 0), and both had modified Rankin scale scores of 1 at 3-month follow-up. Conclusions: Stent reconstruction of complex cerebrovascular anatomy is increasingly feasible with advancements in stent technology and catheter support system design. This technique may be of use to neuroendovascular surgeons who encounter variant ICA anatomy.

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Is the Association of National Institutes of Health Stroke Scale Scores and Acute Magnetic Resonance Imaging Stroke Volume Equal for Patients With Right- and Left-Hemisphere Ischemic Stroke?

Stroke ◽

10.1161/01.str.0000013069.24300.1d ◽

2002 ◽

Vol 33 (4) ◽

pp. 954-958 ◽

Cited By ~ 95

Author(s):

John N. Fink ◽

Magdy H. Selim ◽

Sandeep Kumar ◽

Brian Silver ◽

Italo Linfante ◽

...

Keyword(s):

Magnetic Resonance Imaging ◽

Ischemic Stroke ◽

Magnetic Resonance ◽

Stroke Volume ◽

Left Hemisphere ◽

National Institutes Of Health ◽

Resonance Imaging ◽

Scale Scores

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Treatment and Outcome in Stroke Patients With Acute M2 Occlusion and Minor Neurological Deficits

Stroke ◽

10.1161/strokeaha.120.031672 ◽

2021 ◽

Author(s):

Tomas Dobrocky ◽

Eike I. Piechowiak ◽

Bastian Volbers ◽

Nedelina Slavova ◽

Johannes Kaesmacher ◽

...

Keyword(s):

Middle Cerebral Artery ◽

Scale Score ◽

Cerebral Artery ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

National Institutes Of Health ◽

Neurological Deficits ◽

Minor Stroke ◽

Modified Rankin Scale ◽

Stroke Patients

Background and Purpose: Treatment in stroke patients with M2 segment occlusion of the middle cerebral artery presenting with mild neurological deficits is a matter of debate. The main purpose was to compare the outcome in patients with a minor stroke and a M2 occlusion. Methods: Consecutive intravenous thrombolysis (IVT) eligible patients admitted to the Bernese stroke center between January 2005 and January 2020 with acute occlusion of the M2 segment and National Institutes of Health Stroke Scale score ≤5 were included. Outcome was compared between IVT only versus endovascular therapy (EVT) including intra-arterial thrombolysis and mechanical thrombectomy (MT; ±IVT) and between IVT only versus MT only. Results: Among 169 patients (38.5% women, median age 70.2 years), 84 (49.7%) received IVT only and 85 (50.3%) EVT (±IVT), the latter including 39 (45.9%) treated with MT only. Groups were similar in sex, age, vascular risk factors, event cause, or preevent independency. Compared with IVT only, there was no difference in favorable outcome (modified Rankin Scale score, 0−2) for EVT (adjusted odds ratio, 0.96; adjusted P =0.935) or for MT only (adjusted odds ratio, 1.12; adjusted P =0.547) groups. Considering only patients treated after 2015, there was a significantly better 3-month modified Rankin Scale shift (adjusted P =0.032) in the EVT compared with the IVT only group. Conclusions: Our study demonstrates similar effectiveness of IVT only versus EVT (±IVT), and of IVT only versus MT only in patients with peripheral middle cerebral artery occlusions and minor neurological deficits and indicates a possible benefit of EVT considering only patients treated after 2015. There is an unmet need for randomized controlled trials in this stroke field, including imaging parameters, and more sophisticated evaluation of National Institutes of Health Stroke Scale score subitems, neurocognition, and quality of life neglected by the standard outcome scales such as modified Rankin Scale and National Institutes of Health Stroke Scale score.

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CORRECTION OF NEUROLOGICAL DEFICIENCY IN PATIENTS WITH ACUTE ISCHEMIC STROKE BY APPLICATION OF DIFFERENT QUALITATIVE COMPOSITION OF INFUSION SOLUTIONS

Wiadomości Lekarskie ◽

10.36740/wlek201904107 ◽

2019 ◽

Vol 72 (4) ◽

pp. 543-547 ◽

Cited By ~ 1

Author(s):

Andrii I. Semenenko ◽

Bogdan O. Kondratsky ◽

Galyna I. Hrebtiy ◽

Svitlana L. Malyk ◽

Mykola G. Hinhuliak ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Treatment Efficacy ◽

National Institutes Of Health ◽

Neurological Deficits ◽

Infusion Therapy ◽

Control Group ◽

Qualitative Composition ◽

Four Score ◽

Neurological State

Introduction: Infusion therapy is an important component in the treatment of patients with acute ischemic stroke (AIS). The aim: Compare the dynamics of changes neurological deficiency in the application of solutions: 0.9% NaCl, HES 130, HAES-LX-5% and mannitol 15% in patients with AIS. Materials and methods: The study included 100 patients with AIS. As the investigated solutions were used: isosmolar 0.9% NaCl, hyperosmolar mannitol 15%, colloid-isoosmolar HES 130, colloid-hyperosmolar HAES-LX-5%. The control group received only 0.9% NaCl compared: 0.9% NaCl+HES 130, 0.9% NaCl+HAES-LX-5%, 0.9% NaCl+mannitol 15%. The evaluation of treatment efficacy (magnitude of neurological deficiency) was performed daily for 7 days using the Glasgow Coma Scale (GCS), Full Outline of UnResponsiveness (FOUR) Score, National Institutes of Health Stroke Scale (NIHSS) and BIS-index. Results: The conducted research showed that the application of 0.9% NaCl and mannitol did not have a significant effect on the dynamics of neurological deficits according to the GCS, FOUR and NIHSS scales for 7 days of observation (p>0.05). The use of HES 130 contributed to a statistically significant improvement in the parameters of the GCS (p<0,05), which is confirmed by significant changes in the BIS-index (p<0,05) during a seven-day infusion therapy. The most significant positive changes were observed in the group with HAES-LX-5%, which was marked by an improvement in the neurological state during 7 days treatment acoording to the GCS, FOUR and BIS index (p<0.05). Conclusions: The intergroup analysis of the neurological deficiency confirmed the worst result of treatment in the group with mannitol (p<0,05) and the best result with HAES-LX-5% (p<0,05).

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Acute Ischemic Stroke in Patients With COVID-19

Stroke ◽

10.1161/strokeaha.121.034301 ◽

2021 ◽

Vol 52 (5) ◽

pp. 1826-1829

Author(s):

Pratyaksh K. Srivastava ◽

Shuaiqi Zhang ◽

Ying Xian ◽

Hanzhang Xu ◽

Christine Rutan ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Odds Ratio ◽

Adverse Outcomes ◽

National Institutes Of Health ◽

Stroke Severity ◽

Younger Age ◽

Increased Risk ◽

Scale Scores ◽

Get With The Guidelines

Background and Purpose: Studies suggest an increased risk of adverse outcomes among patients with acute ischemic stroke (AIS) and coronavirus disease 2019 (COVID-19). Methods: Using Get With The Guidelines–Stroke, we identified 41 971 patients (AIS/COVID-19: 1143; AIS/no COVID-19: 40 828) with AIS hospitalized between February 4, 2020 and June 29, 2020, from 458 Get With The Guidelines–Stroke hospitals with at least one COVID-19 case and evaluated clinical characteristics, treatment patterns, and outcomes. Results: Compared with patients with AIS/no COVID-19, those with AIS/COVID-19 were younger, more likely to be non-Hispanic Black, Hispanic, or Asian, more likely to present with higher National Institutes of Health Stroke Scale scores, and had greater proportions of large vessel occlusions. Rates of thrombolysis and thrombectomy were similar between the groups. Door to computed tomography (median 55 [18–207] versus 35 [14–99] minutes, P <0.001), door to needle (59 [40–82] versus 46 [33–64] minutes, P <0.001), and door to endovascular therapy (114 [74–169] versus 90 [54–133] minutes, P =0.002) times were longer in the AIS/COVID-19 cohort. In adjusted models, patients with AIS/COVID-19 had decreased odds of discharge with modified Rankin Scale score of ≤2 (odds ratio, 0.65 [95% CI, 0.52–0.81], P <0.001) and increased odds of in-hospital mortality (odds ratio, 4.34 [95% CI, 3.48–5.40], P <0.001). ConclusionS: This analysis demonstrates younger age, greater stroke severity, longer times to evaluation and treatment, and worse morbidity and mortality in patients with AIS/COVID-19 compared with those with AIS/no COVID-19.

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Abstract T P72: Baseline Variables Have Little Influence on Early Change in Neurological Status (ΔNIHSS) After Acute Ischemic Stroke: Basis For a Genetic Study

Stroke ◽

10.1161/str.46.suppl_1.tp72 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Laura Heitsch ◽

Carlos Cruchaga ◽

Naim Khoury ◽

Rebecca Weisenhan ◽

Ford L Andria ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Neurological Status ◽

Neurological Recovery ◽

Neurological Deficits ◽

Dramatic Improvement ◽

Scale Scores ◽

Multivariable Regression ◽

Jewish Hospital ◽

The Difference

Introduction: Neurological deficits can be highly unstable within the first 24 hours after acute ischemic stroke (AIS), with some patients showing dramatic improvement while others rapidly deteriorate. We are interested in genetic influences on early neurological recovery/deterioration. Here, we characterize NIHSS changes within the first 24 hours after stoke onset (ΔNIHSS) in a large cohort to determine baseline clinical variables that influence this outcome measure. Methods: AIS patients presenting to two sites (Barnes-Jewish Hospital, St Louis and Vall D’Hebron Hospital Barcelona) between 2008-2013 were prospectively enrolled. Baseline NIHSS was collected within 6 hours and again at 24 hours after symptom onset. ΔNIHSS was calculated as the difference in these stroke scale scores. Demographics, baseline comorbidities and medications, as well as acute treatment variables were recorded for each subject. Stepwise multivariable regression (SAS) was used to determine variables that significantly influence ΔNIHSS. Results: There were 954 patients enrolled (St Louis = 433, Barcelona = 521). Table 1 demonstrates the frequencies and means (SD) of the baseline variables. ΔNIHSS follows a normal distribution (figure). All baseline variables listed in table 1 were analyzed for influence on ΔNIHSS. Only baseline NIHSS (R2 = 0.0597, p<0.0001), baseline glucose (R2 = 0.0176, p=<0.0001,) and age (R2 = 0.0106, p=0.0011) independently influenced ΔNIHSS, accounting for only 8.79% of the variance. Conclusion: Baseline variables (NIHSS, glucose and age) modestly influence early neurological recovery/deterioration. However, 91% of ΔNIHSS variability remains unexplained, suggesting that other factors such as genetics, could play an important role in early outcomes following AIS. A GWAS of ΔNIHSS is currently underway.

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