Weekday Versus Weekend Presentation in the Acute Management of Ischemic Stroke Through Telemedicine

A “weekend effect” resulting in higher mortality rates for patients with stroke admitted on weekends has been reported. We examine this phenomenon for patients with acute ischemic stroke (AIS) presenting to telestroke (TS) sites to determine its effect on stroke alert process times and outcomes. From October 2015 to June 2017, we reviewed patients with AIS receiving intravenous alteplase within our TS network. We compared patients presenting to TS sites on weekdays (Monday 07:00 to Friday 18:59) to those presenting on weekends (Friday 19:00 to Monday 06:59). We analyzed door-to-alert activation, alert activation-to-TS evaluation, door-to-imaging, and door-to-needle times. Rates of favorable outcome (modified Rankin Scale score ≤2) and death at 90 days were compared. We identified 89 (54 weekday and 35 weekend) patients (mean age: 71.8 ± 13.3 years, 47.2% women) during the study period. Median door-to-alert activation ( P = .01) and door-to-needle ( P = .004) times were significantly longer for patients presenting on weekends compared to weekdays. There were no significant differences in median door-to-imaging ( P = .1) and alert activation-to-TS evaluation ( P = .07) times. Rates of favorable outcome ( P = .19) and death ( P = .56) at 90 days did not differ. While there were no significant differences in outcomes, patients presenting on weekends had longer door-to-alert activation and door-to-needle times. Efforts to improve methods in efficiency of care on weekends should be considered.

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Abstract 268: Is There a Weekend Effect on Telestroke Code Time Metrics?

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.11.suppl_1.268 ◽

2018 ◽

Vol 11 (suppl_1) ◽

Author(s):

Ganesh Asaithambi ◽

Amy L Castle ◽

Emily H Marino ◽

Bridget M Ho ◽

Sandra K Hanson

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Scale Score ◽

Mortality Rates ◽

Weekend Effect ◽

Favorable Outcome ◽

Modified Rankin Scale ◽

Stroke Patients ◽

Code Process

Background: It has been suggested that there is a “weekend effect” resulting in higher mortality rates for stroke patients admitted on weekends. We examine this phenomenon for acute ischemic stroke (AIS) patients presenting to telestroke (TS) sites to determine its effect on stroke code process times and outcomes. Methods: From October 2015-June 2017, we reviewed consecutive AIS patients receiving IV alteplase within our TS network who then were transferred to our CSC. We compared patients presenting to TS sites on weekdays (Monday 0700 to Friday 1859) to patients presenting on weekends (Friday 1900 to Monday 0659). We analyzed door to code activation, code activation to TS evaluation, door to imaging, and door to needle times. Rates of favorable outcome (modified Rankin Scale score ≤2) and death at 90 days were compared. Results: We identified 89 (54 weekday, 35 weekend) patients (mean age 71.8±13.3 years, 47.2% women) during the study period. Median door to code activation (15 [5, 27] vs 8 [1, 17] mins, p=0.01) and door to needle (61 [49, 73] vs 47 [35, 59] mins, p=0.003) times were significantly longer for patients presenting on weekends compared to weekdays. There were no significant differences in median door to imaging (weekend 17 [7, 30] vs weekday 11 [6, 21], p=0.1) and code activation to TS evaluation (weekend 7 [6, 10] vs weekday 5 [4, 9], p=0.14) times. The rates of favorable outcome (weekend 50% vs weekday 66.7%, p=0.18) and death (weekend 8.3% vs weekday 4.8%, p=0.56) at 90 days were not significantly different. Conclusion: While there were no significant differences in outcomes, the “weekend effect” results in slower door to code activation and door to needle times. Efforts to improve methods in increasing efficiency of care on weekends should be considered.

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Predictors of Outcome, Complications, and Recanalization of the Solitaire Device

Neurosurgery ◽

10.1227/neu.0000000000000830 ◽

2015 ◽

Vol 77 (3) ◽

pp. 355-361 ◽

Cited By ~ 12

Author(s):

Badih Daou ◽

Nohra Chalouhi ◽

Robert M. Starke ◽

Richard Dalyai ◽

Kate Hentschel ◽

...

Keyword(s):

Ischemic Stroke ◽

Cerebral Infarction ◽

Acute Ischemic Stroke ◽

Scale Score ◽

Univariate Analysis ◽

Favorable Outcome ◽

Modified Rankin Scale ◽

Nihss Score ◽

Flow Restoration ◽

The Mean

Abstract BACKGROUND: The use of mechanical thrombectomy in the management of acute ischemic stroke is becoming increasingly popular. OBJECTIVE: To identify notable factors that affect outcome, revascularization, and complications in patients with acute ischemic stroke treated with the Solitaire Flow Restoration Revascularization device. METHODS: Eighty-nine patients treated with the Solitaire Flow Restoration Revascularization device (ev3/Covidien Vascular Therapies, Irvine, California) were retrospectively analyzed. Three endpoints were considered: revascularization (Thrombolysis In Cerebral Infarction), outcome (modified Rankin Scale score), and complications. Univariate analysis and multivariate logistic regression were conducted to determine significant predictors. RESULTS: The mean time from onset of symptoms to the start of intervention was 6.7 hours. The average procedure length was 58 minutes. The mean NIH Stroke Scale (NIHSS) score was 16 on arrival and 8 at discharge. Of the patients, 6.7% had a symptomatic intracerebral hemorrhage, 16.8% had fatal outcomes within 3 months post-intervention, and 81.4% had a successful recanalization. Thrombus location in the M1 segment of the middle cerebral artery was associated with successful recanalization (thrombolysis in cerebral infarction 2b/3) (P = .003). Of the patients, 56.6% had a favorable outcome (modified Rankin Scale score at 3 months: 0–2). In patients younger than 80 years of age, 66.7% had favorable outcome. Increasing age (P = .01) and NIHSS score (P = .002) were significant predictors of a poor outcome. On multivariate analysis, NIHSS score on admission (P = .05) was a predictor of complications. On univariate analysis, increasing NIHSS score from admission to 24 hours after the procedure (P = .05) and then to discharge (P = .04) was a predictor of complications. Thrombus location in the posterior circulation (P = .04) and increasing NIHSS score (P = .04) predicted mortality. CONCLUSION: The Solitaire device is safe and effective in achieving successful recanalization after acute ischemic stroke. Important factors to consider include age, NIHSS score, and location.

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Clinical Course of Acute Ischemic Stroke Due to Medium Vessel Occlusion With and Without Intravenous Alteplase Treatment

Stroke ◽

10.1161/strokeaha.120.030227 ◽

2020 ◽

Vol 51 (11) ◽

pp. 3232-3240 ◽

Cited By ~ 1

Author(s):

Johanna M. Ospel ◽

Bijoy K. Menon ◽

Andrew M. Demchuk ◽

Mohammed A. Almekhlafi ◽

Nima Kashani ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Functional Outcome ◽

Scale Score ◽

Odds Ratio ◽

Clinical Course ◽

Functional Independence ◽

Modified Rankin Scale ◽

Excellent Functional Outcome ◽

Intravenous Alteplase

Background and Purpose: Available data on the clinical course of patients with acute ischemic stroke due to medium vessel occlusion (MeVO) are mostly limited to those with M2 segment occlusions. Outcomes are generally better compared with more proximal occlusions, but many patients will still suffer from severe morbidity. We aimed to determine the clinical course of acute ischemic stroke due to MeVO with and without intravenous alteplase treatment. Methods: Patients with MeVO (M2/M3/A2/A3/P2/P3 occlusion) from the INTERRSeCT (The Identifying New Approaches to Optimize Thrombus Characterization for Predicting Early Recanalization and Reperfusion With IV Alteplase and Other Treatments Using Serial CT Angiography) and PRoveIT (Precise and Rapid Assessment of Collaterals Using Multi-Phase CTA in the Triage of Patients With Acute Ischemic Stroke for IA Therapy) studies were included. Baseline characteristics and clinical outcomes were summarized using descriptive statistics. The primary outcome was a modified Rankin Scale score of 0 to 1 at 90 days, describing excellent functional outcome. Secondary outcomes were the common odds ratio for a 1-point shift across the modified Rankin Scale and functional independence, defined as modified Rankin Scale score of 0 to 2. We compared outcomes between patients with versus without intravenous alteplase treatment and between patients who did and did not show recanalization on follow-up computed tomography angiography. Logistic regression was used to provide adjusted effect-size estimates. Results: Among 258 patients with MeVO, the median baseline National Institutes of Health Stroke Scale score was 7 (interquartile range: 5–12). A total of 72.1% (186/258) patients were treated with intravenous alteplase and in 41.8% (84/201), recanalization of the occlusion (revised arterial occlusive lesion score 2b/3) was seen on follow-up computed tomography angiography. Excellent functional outcome was achieved by 50.0% (129/258), and 67.4% (174/258) patients gained functional independence, while 8.9% (23/258) patients died within 90 days. Recanalization was observed in 21.4% (9/42) patients who were not treated with alteplase and 47.2% (75/159) patients treated with alteplase ( P =0.003). Early recanalization (adjusted odds ratio, 2.29 [95% CI, 1.23–4.28]) was significantly associated with excellent functional outcome, while intravenous alteplase was not (adjusted odds ratio, 1.70 [95% CI, 0.88–3.25]). Conclusions: One of every 2 patients with MeVO did not achieve excellent clinical outcome at 90 days with best medical management. Early recanalization was strongly associated with excellent outcome but occurred in <50% of patients despite intravenous alteplase treatment.

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Recanalization and Angiographic Reperfusion Are Both Associated with a Favorable Clinical Outcome in the IMS III Trial

Interventional Neurology ◽

10.1159/000446749 ◽

2016 ◽

Vol 5 (3-4) ◽

pp. 118-122 ◽

Cited By ~ 8

Author(s):

Marie L. Schmitz ◽

Sharon D. Yeatts ◽

Thomas A. Tomsick ◽

David S. Liebeskind ◽

Achala Vagal ◽

...

Keyword(s):

Ischemic Stroke ◽

Clinical Outcome ◽

Scale Score ◽

Predictive Accuracy ◽

Favorable Outcome ◽

Modified Rankin Scale ◽

Arterial Tree ◽

Stroke Treatment ◽

Optimal Thresholds ◽

Favorable Clinical Outcome

Background: Prompt revascularization is the main goal of acute ischemic stroke treatment. We examined which revascularization scale - reperfusion (modified Treatment in Cerebral Infarctions, mTICI) or recanalization (Arterial Occlusive Lesion, AOL) - better predicted the clinical outcome in ischemic stroke participants treated with endovascular therapy (EVT). Additionally, we determined the optimal thresholds for the predictive accuracy of each scale. Methods: We included participants from the Interventional Management of Stroke (IMS) III trial with complete occlusion in the internal carotid artery terminus or proximal middle cerebral artery (M1 or M2) who completed EVT within 7 h of symptom onset. The abilities of the AOL and mTICI scales to predict a favorable outcome (defined as a modified Rankin Scale score of 0-2 at 3 months) were compared by receiver operating characteristic analyses. The maximal sensitivity and specificity for each revascularization scale were established. Results: Among 240 participants who met the study inclusion criteria, 79 (33%) achieved a favorable outcome. Higher scores of mTICI and AOL increased the likelihood of a favorable outcome (2.7% with mTICI 0 vs. 83.3% with mTICI 3, and 3.0% with AOL 0 vs. 43% with AOL 3). The accuracy of mTICI reperfusion and AOL recanalization for a favorable outcome prediction was similar, with optimal thresholds of mTICI 2b/3 and AOL 3, respectively. Conclusion: Reperfusion (mTICI) and recanalization (AOL) predicted a favorable clinical outcome with comparable accuracy in ischemic stroke participants treated with EVT. Optimal revascularization goals to maximize clinical outcome (modified Rankin Scale score of 0-2) consisted of complete recanalization (AOL 3) and reperfusion of at least 50% of the arterial tree of the symptomatic artery (mTICI 2b/3) in the IMS III trial setting.

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Acute Ischemic Stroke: Acute Management and Selection for Endovascular Therapy

Seminars in Interventional Radiology ◽

10.1055/s-0040-1709152 ◽

2020 ◽

Vol 37 (02) ◽

pp. 109-118

Author(s):

Sabeen Dhand ◽

Paul O'Connor ◽

Charles Hughes ◽

Shao-Pow Lin

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Early Recognition ◽

Rapid Assessment ◽

Medical Emergency ◽

Acute Management ◽

Permanent Disability ◽

Prehospital Emergency ◽

Intravenous Alteplase

AbstractStroke is a medical emergency and expeditious treatment is critical to reducing permanent disability or death. Acute management of patients suffering from acute ischemic stroke (AIS) requires early recognition of symptoms, rapid assessment and stabilization (hyperacute workup), and appropriate selection of patients for reperfusion with intravenous alteplase and/or mechanical thrombectomy. Established stroke protocols which involve both prehospital emergency medical services and in-hospital multidisciplinary stroke teams have been shown to be crucial to reducing the long term, devastating effects of stroke.

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Adiposity and Outcome After Ischemic Stroke

Stroke ◽

10.1161/strokeaha.119.027900 ◽

2021 ◽

Vol 52 (1) ◽

pp. 144-151

Author(s):

Zuolu Liu ◽

Nerses Sanossian ◽

Sidney Starkman ◽

Gilda Avila-Rinek ◽

Marc Eckstein ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Scale Score ◽

Odds Ratio ◽

Functional Outcomes ◽

National Institutes Of Health ◽

Modified Rankin Scale ◽

Related Quality ◽

Severely Obese

Background and Purpose: A survival advantage among individuals with higher body mass index (BMI) has been observed for diverse acute illnesses, including stroke, and termed the obesity paradox. However, prior ischemic stroke studies have generally tested only for linear rather than nonlinear relations between body mass and outcome, and few studies have investigated poststroke functional outcomes in addition to mortality. Methods: We analyzed consecutive patients with acute ischemic stroke enrolled in a 60-center acute treatment trial, the NIH FAST-MAG acute stroke trial. Outcomes at 3 months analyzed were (1) death; (2) disability or death (modified Rankin Scale score, 2–6); and (3) low stroke-related quality of life (Stroke Impact Scale<median). Relations with BMI were analyzed univariately and in multivariate models adjusting for 14 additional prognostic variables. Results: Among 1033 patients with acute ischemic stroke, average age was 71 years (±13), 45.1% female, National Institutes of Health Stroke Scale 10.6 (±8.3), and BMI 27.5 (±5.6). In both unadjusted and adjusted analysis, increasing BMI was linearly associated with improved 3-month survival ( P =0.01) odds ratios in adjusted analysis for mortality declined across the BMI categories of underweight (odds ratio, 1.7 [CI, 0.6–4.9]), normal (odds ratio, 1), overweight (0.9 [CI, 0.5–1.4]), obese (0.5, [CI, 0.3–1.0]), and severely obese (0.4 [CI, 0.2–0.9]). In unadjusted analysis, increasing BMI showed a U-shaped relation to poststroke disability or death (modified Rankin Scale score, 2–6), with odds ratios of modified Rankin Scale score, 2 to 6 for underweight, overweight, and obese declined initially when compared with normal weight patients, but then increased again in severely obese patients, suggesting a U-shaped or J-shaped relation. After adjustment, including for baseline National Institutes of Health Stroke Scale, modified Rankin Scale score 2 to 6 was no longer related to adiposity. Conclusions: Mortality and functional outcomes after acute ischemic stroke have disparate relations with patients’ adiposity. Higher BMI is linearly associated with increased survival; and BMI has a U-shaped or J-shaped relation to disability and stroke-related quality of life. Potential mechanisms including nutritional reserve aiding survival during recovery and greater frequency of atherosclerotic than thromboembolic infarcts in individuals with higher BMI.

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Abstract WP32: Good Reperfusion Can Rescue Acute Ischemic Stroke Patients Treated With Endovascular Therapy Beyond 6 Hours After Onset.

Stroke ◽

10.1161/str.48.suppl_1.wp32 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

KENTARO SUZUKI ◽

Junya Aoki ◽

Yohei Takayama ◽

Arata Abe ◽

Satoshi Suda ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Onset Time ◽

Favorable Outcome ◽

Modified Rankin Scale ◽

Single Center ◽

Stroke Patients ◽

Tissue Plasminogen ◽

Improve Patient

Objective: Endovascular therapy (EVT) within 6 hours from ischemic stroke onset were recommended by 2015 AHA/ASA guideline. Effectiveness and factors for favorable outcome for EVT beyond 6 hours are unclear. We investigated whether onset to puncture time (O2P) beyond 6 hours is associated with outcome at 3 months and what is the favorable factors in patients treated with EVT beyond 6 hours. Methods: We performed a retrospective, single center analysis of patients with acute ischemic stroke who underwent EVT. The O2P, risk factors, reperfusion success rate and outcome at 3 month were assessed. First, all patients were classified into the two groups with EVT beyond 6 hours or not. Second, we compared any characteristics and favorable outcome between two groups. Finally, we investigated independent factors for favorable outcome in patients treated with EVT beyond 6 hours. Favorable outcome and good reperfusion were defined by modified Rankin scale ≤ 2 and thrombolysis in cerebral infarction (TICI) score ≥ 2B, respectively. Results: Of the 130 EVT cases, 124 cases with known onset time were enrolled (age; 75 [66-83] and 74 (60.5%) men). 98 (79%) were treated with EVT within 6 hours and 26 (21%) patients were beyond 6 hours. Absence of atrial fibrillation (11[42%] vs. 70[71%], p=0.01), high DWI-ASPECTS (9 [7-10] vs. 7 [6-9], p=0.01), no use of intravenous tissue plasminogen (1[4%] vs. 50[51%], p<0.01) and low achievement of good reperfusion (14[54%] vs. 77[79%], p=0.01) were more frequently observed in beyond 6 hours group than within 6 hours group. However, favorable outcome was not different between two groups (beyond 6 hours group ;10(38%) vs. within 6 hours group; 43(44%), p = 0.66). In beyond 6 hours group, good reperfusion (9[90%] vs. 5[31%], p=0.01) and presence of hyperlipidemia (7[70%] vs. 3[19], p=0.02) were associated with favorable outcome. On multivariate analysis, only good reperfusion (OR 45.6, 95%CI 3.7-2271.4, p<0.01) was the independent factor associated with favorable outcome. Conclusions: The frequency of favorable outcome in beyond 6 hours group was not lower than within 6 hours group. Good reperfusion can improve patient outcome in O2P within 6 hours as well as beyond 6 hours.

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Predicting Clinical Outcomes After Thrombolysis Using the iScore

Stroke ◽

10.1161/strokeaha.113.001343 ◽

2013 ◽

Vol 44 (10) ◽

pp. 2755-2759 ◽

Cited By ~ 20

Author(s):

Gustavo Saposnik ◽

Mathew J. Reeves ◽

S. Claiborne Johnston ◽

Philip M.W. Bath ◽

Bruce Ovbiagele

Keyword(s):

Ischemic Stroke ◽

Confidence Interval ◽

Acute Ischemic Stroke ◽

Clinical Outcomes ◽

Odds Ratio ◽

Primary Outcome ◽

Favorable Outcome ◽

Tissue Type ◽

Modified Rankin Scale ◽

Secondary Outcomes

Background and Purpose— The ischemic stroke risk score (iScore) is a validated tool developed to estimate the risk of death and functional outcomes early after an acute ischemic stroke. Our goal was to determine the ability of the iScore to estimate clinical outcomes after intravenous thrombolysis tissue-type plasminogen activator (tPA) in the Virtual International Stroke Trials Archive (VISTA). Methods— We applied the iScore ( www.sorcan.ca/iscore ) to patients with an acute ischemic stroke within the VISTA collaboration to examine the effect of tPA. We explored the association between the iScore (<200 and ≥200) and the primary outcome of favorable outcome at 3 months defined as a modified Rankin scale score of 0 to 2. Secondary outcomes included death at 3 months, catastrophic outcomes (modified Rankin scale, 4–6), and Barthel index >90 at 3 months. Results— Among 7140 patients with an acute ischemic stroke, 2732 (38.5%) received tPA and 711 (10%) had an iScore ≥200. Overall, tPA treatment was associated with a significant improvement in the primary outcome among patients with an iScore <200 (38.9% non-tPA versus 47.5% tPA; P <0.001) but was not associated with a favorable outcome among patients with an iScore ≥200 (5.5% non-tPA versus 7.6% tPA; P =0.45). In the multivariable analysis after adjusting for age, baseline National Institutes of Health Stroke Scale, and onset-to-treatment time, there was a significant interaction between tPA administration and iScore; tPA administration was associated with 47% higher odds of a favorable outcome at 3 months among patients with an iScore <200 (odds ratio, 1.47; 95% confidence interval, 1.30–1.67), whereas the association between tPA and favorable outcome among those with an iScore ≥200 remained nonsignificant (odds ratio, 0.80; 95% confidence interval, 0.45–1.42). A similar pattern of benefit with tPA among patients with an iScore <200, but not ≥200, was observed for secondary outcomes including death. Conclusions— The iScore is a useful and validated tool that helps clinicians estimate stroke outcomes. In stroke patients participating in VISTA, an iScore <200 was associated with better outcomes at 3 months after tPA.

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Middle Cerebral Artery M2 Thrombectomy in the STRATIS Registry

Stroke ◽

10.1161/strokeaha.120.033951 ◽

2021 ◽

Author(s):

Mouhammad A. Jumaa ◽

Alicia C. Castonguay ◽

Hisham Salahuddin ◽

Ashutosh P. Jadhav ◽

Kaustubh Limaye ◽

...

Keyword(s):

Ischemic Stroke ◽

Middle Cerebral Artery ◽

Acute Ischemic Stroke ◽

Functional Outcome ◽

Scale Score ◽

Cerebral Artery ◽

Mechanical Thrombectomy ◽

Modified Rankin Scale ◽

Good Functional Outcome ◽

First Choice

Background and Purpose: The safety and benefit of mechanical thrombectomy in the treatment of acute ischemic stroke patients with M2 segment middle cerebral artery occlusions remain uncertain. Here, we compare clinical and angiographic outcomes in M2 versus M1 occlusions in the STRATIS (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) Registry. Methods: The STRATIS Registry was a prospective, multicenter, nonrandomized, observational study of acute ischemic stroke large vessel occlusion patients treated with the Solitaire stent-retriever as the first-choice therapy within 8 hours from symptoms onset. Primary outcome was defined as functional disability at 3 months measured by dichotomized modified Rankin Scale. Secondary outcomes included reperfusion rates and rates of symptomatic intracranial hemorrhage. Results: A total of 984 patients were included, of which 538 (54.7%) had M1 and 170 (17.3%) had M2 occlusions. Baseline demographics were well balanced within the groups, with the exception of mean baseline National Institutes of Health Stroke Scale score which was significantly higher in the M1 population (17.3±5.5 versus 15.7±5.0, P ≤0.001). No difference was seen in mean puncture to revascularization times between the cohorts (46.0±27.8 versus 45.1±29.5 minutes, P =0.75). Rates of successful reperfusion (modified Thrombolysis in Cerebral Infarction≥2b) were similar between the groups (91% versus 95%, P =0.09). M2 patients had significantly increased rates of symptomatic ICH at 24 hours (4% versus 1%, P =0.01). Rates of good functional outcome (modified Rankin Scale score of 0–2; 58% versus 59%, P =0.83) and mortality (15% versus 14%, P =0.75) were similar between the 2 groups. There was no difference in the association of outcome and onset to groin puncture or onset to successful reperfusion in M1 and M2 occlusions. Conclusions: In the STRATIS Registry, M2 occlusions achieved similar rates of successful reperfusion, good functional outcome, and mortality, although increased rates of symptomatic ICH were demonstrated when compared with M1 occlusions. The time dependence of benefit was also similar between the 2 groups. Further studies are needed to understand the benefit of mechanical thrombectomy for M2 occlusions. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02239640.

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National Institutes of Health Stroke Scale Zero Strokes

Stroke ◽

10.1161/strokeaha.118.022517 ◽

2018 ◽

Vol 49 (12) ◽

pp. 3057-3059

Author(s):

Elissavet Eskioglou ◽

Mitra Huchmandzadeh Millotte ◽

Michael Amiguet ◽

Patrik Michel

Keyword(s):

Computed Tomography ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Scale Score ◽

Significant Proportion ◽

National Institutes Of Health ◽

Modified Rankin Scale ◽

Stroke Patients ◽

Recurrence Rates ◽

Long Term Outcome

Background and Purpose— We aimed to characterize acute ischemic stroke patients who have an immeasurable deficit on the admission National Institutes of Health Stroke Scale (NIHSS), and to evaluate their long-term outcome. Methods— We retrospectively compared all acute ischemic stroke patients with an admission NIHSS of 0 in the Acute Stroke Registry and Analysis of Lausanne from 2003 to 2013 with all other acute ischemic stroke patients. We compared demographics, clinical, radiological, and laboratory findings. Outcome was considered favorable at 3 months if the modified Rankin Scale score corrected for prestroke disability was ≤1. Stroke recurrences >12 months were also assessed. Results— Comparing 108 NIHSS zero (NIHSS=0) patients with the 2889 other strokes by multivariate analysis, NIHSS=0 had lower prestroke disability, longer onset-to-hospital delays and more lacunar and infratentorial strokes. NIHSS=0 patients were less likely to have early ischemic changes on acute computed tomography, had less arterial pathology and lower creatinine levels. They were more likely to have favorable modified Rankin Scale score after correction for prestroke modified Rankin Scale score (zero versus others: 83.2% versus 44.6%) and less likely to die (3.9% versus 13.3%) at 12 months. Stroke and transient ischemic attack recurrence rates were similar (11% versus 11.4%), however. Conclusions— Patients with NIHSS=0 strokes are characterized by lacunar and infrantentorial strokes, normal acute computed tomography, and less arterial pathology. However, a significant proportion face recurrent ischemic events and persistent handicap at 12 months. Therefore, NIHSS=0 stroke patients require aggressive secondary prevention and adequate follow-up.

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