Functional status at 30 and 90 days after mild ischaemic stroke.

BACKGROUND/OBJECTIVE: This study compares the global disability status of patients who had a mild ischaemic stroke at 30 and 90 days poststroke, as measured by the modified Rankin Scale (mRS), and identifies predictors of change in disability status between 30 and 90 days. METHODS: The study population included 1339 patients who had a ischaemic stroke enrolled in the Mild and Rapidly Improving Stroke Study with National Institutes of Health (NIH) stroke score 0-5 and mRS measurements at 30 and 90 days. Outcomes were (1) Improvement defined as having mRS >1 at 30 days and mRS 0-1 at 90 days OR mRS >2 at 30 days and mRS 0-2 at 90 days and (2) Worsening defined as an increase of ≥2 points or a worsening from mRS of 1 at 30 days to 2 at 90 days. Demographic and clinical characteristics at hospital arrival were abstracted from medical records, and regression models were used to identify predictors of functional improvement and decline from 30 to 90 days post-stroke. Significant predictors were mutually adjusted in multivariable models that also included age and stroke severity. RESULTS: Fifty-seven per cent of study participants had no change in mRS value from 30 to 90 days. Overall, there was moderate agreement in mRS between the two time points (weighted kappa=0.59 (95% CI 0.56 to 0.62)). However, worsening on the mRS was observed in 7.54% of the study population from 30 to 90 days, and 17.33% improved. Participants of older age (per year OR 1.02, 95% CI 1.00 to 1.03), greater stroke severity (per NIH Stroke Scale (NIHSS) point at admission OR 1.17, 95% CI 1.03 to 1.34), and those with no alteplase treatment (OR 1.72, 95% CI 1.11 to 2.69) were more likely to show functional decline after mutual adjustment. DISCUSSION: A quarter of all mild ischaemic stroke participants exhibited functional changes between 30 and 90 days, suggesting that the 30-day outcome may insufficiently represent long-term recovery in mild stroke and longer follow-up may be clinically necessary. TRIAL REGISTRATION NUMBER: NCT02072681.

Frequency and Prognostic Significance of Clinical Fluctuations Before Hospital Arrival in Stroke.

BACKGROUND AND PURPOSE: Clinical fluctuations in ischemic stroke symptoms are common, but fluctuations before hospital arrival have not been previously characterized. METHODS: A standardized qualitative assessment of fluctuations before hospital arrival was obtained in an observational study that enrolled patients with mild ischemic stroke symptoms (National Institutes of Health Stroke Scale [NIHSS] score of 0-5) present on arrival to hospital within 4.5 hours of onset, in a subset of 100 hospitals participating in the Get With The Guidelines-Stroke quality improvement program. The number of fluctuations, direction, and the overall improvement or worsening was recorded based on reports from the patient, family, or paramedics. Baseline NIHSS on arrival and at 72 hours (or discharge if before) and final diagnosis and stroke subtype were collected. Outcomes at 90 days included the modified Rankin Scale, Barthel Index, Stroke Impact Scale 16, and European Quality of Life. Prehospital fluctuations were examined in relation to hospital NIHSS change (admission to 72 hours or discharge) and 90-day outcomes. RESULTS: Among 1588 participants, prehospital fluctuations, consisting of improvement, worsening, or both were observed in 35.5%: 25.1% improved once, 5.3% worsened once, and 5.1% had more than 1 fluctuation. Those who improved were less likely and those who worsened were more likely to receive alteplase. Those who improved before hospital arrival had lower change in the hospital NIHSS than those who did not fluctuate. Better adjusted 90-day outcomes were noted in those with prehospital improvement compared to those without any fluctuations. CONCLUSIONS: Fluctuations in neurological symptoms and signs are common in the prehospital setting. Prehospital improvement was associated with better 90-day outcomes, controlling for admission NIHSS and alteplase treatment. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02072681.

Predictors of Outcomes in Patients With Mild Ischemic Stroke Symptoms: MaRISS.

Background and Purpose: Although most strokes present with mild symptoms, these have been poorly represented in clinical trials. The objective of this study is to describe multidimensional outcomes, identify predictors of worse outcomes, and explore the effect of thrombolysis in this population. Methods: This prospective observational study included patients with ischemic stroke or transient ischemic attack, a baseline National Institutes of Health Stroke Scale (NIHSS) score 0 to 5, presenting within 4.5 hours from symptom onset. The primary outcome was a 90-day modified Rankin Scale score of 0 to 1; secondary outcomes included good outcomes in the Barthel Index, Stroke Impact Scale-16, and European Quality of Life. Multivariable models were created to determine predictors of outcomes and the effect of alteplase. Results: A total of 1765 participants were included from 100 Get With The Guidelines-Stroke participating hospitals (age, 65±14; 42% women; final diagnosis of ischemic stroke, 90%; transient ischemic attack, 10%; 57% received alteplase). At 90 days, 37% were disabled and 25% not independent. Worse outcomes were noted for older individuals, women, non-Hispanic Blacks and Hispanics, Medicaid recipients, smokers, those with diabetes, atrial fibrillation, prior stroke, higher baseline NIHSS, visual field defects, and extremity weakness. Similar outcomes were noted for the alteplase-treated and untreated groups. Alteplase-treated patients were younger (64±13 versus 67±1.4) with higher NIHSS (2.9±1.4 versus 1.7±1.4). After adjusting for age, sex, race/ethnicity, and baseline NIHSS, we did not identify an effect of alteplase on the primary outcome but did find an association with Stroke Impact Scale-16 in the restricted sample of baseline NIHSS score 3­5. Few symptomatic intracerebral hemorrhages were recorded (<1%). Conclusions: A large proportion of stroke patients presenting with low NIHSS have a disabled outcome. Baseline predictors of worse outcomes are described. An effect of alteplase on outcomes was not identified in the overall cohort, but a suggestion of efficacy was noted in the NIHSS 3­5 subgroup. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02072681.

Patients with Low National Institutes of Health Stroke Scale Scores Have Longer Door-to-Needle Times: Analysis of a Telestroke Network.

BACKGROUND: The benefits of intravenous tissue-type plasminogen activator (IV-tPA) in acute ischemic stroke (AIS) are time dependent. Because emergency rooms quickly initiate a stroke alert with more severe symptoms, we hypothesized that patients with lower National Institutes of Health Stroke Scale (NIHSS) scores, indicating a less severe stroke, would have longer door-to-needle (DTN) times compared to patients with higher NIHSS scores. METHODS: Data obtained from the 19-hospital Providence Stroke Registry were used to identify AIS patients who received IV-tPA within 4.5 hours of last-known-well. NIHSS scores were obtained prior to tPA administration at the time of emergency department presentation and categorized as low-NIHSS (score = 0-5) or high-NIHSS (score = 6-42) strokes. Median DTN times were collected for both groups as the primary outcome variable. Linear mixed-effects regression models were used to assess the effect of NIHSS scores on DTN and its 2 components: door-to-CT (DCT) and CT-to-needle (CTN) times. RESULTS: We identified 692 AIS patients who received IV-tPA within 4.5 hours of last-known-well, with 198 patients presenting with low-NIHSS strokes and 494 patients with high-NIHSS strokes. In multivariable analysis, median DTN time was estimated to be 18% higher for low-NIHSS strokes than high-NIHSS strokes after adjusting for covariates (P < .001). Median DCT times were also higher for low-NIHSS (19 minutes) compared to high-NIHSS (11 minutes) strokes after adjusting for covariates (P < .001), whereas CTN times were unchanged (P = .055). CONCLUSION: In AIS patients receiving IV-tPA in a telestroke network, lower NIHSS scores were associated with longer DTN and DCT times.

Neurophysiological monitoring with brainstem evoked potentials can be a valuable tool for patients undergoing vertebrobasilar stenting and angioplasty-initial experience.

INTRODUCTION: Brainstem auditory evoked potentials (BAEPs) are routinely used during a variety of intracranial surgeries involving the posterior fossa and endovascular procedures including coiling of cerebral aneurysms. However, use of BAEPs has not been reported in vertebrobasilar stenting. METHODS: Six patients underwent stenting and angioplasty of the basilar artery (four) or the dominant vertebral artery (two) for symptomatic stenosis. All the patients received stenting and angioplasty with Wingspan stent and Gateway balloon, respectively. Continuous real time BAEPs were recorded in all patients, and somatosensory evoked potentials in five patients. RESULTS: All the patients had successful stenting and angioplasty in their target vessels. All the procedures were done under general anesthesia. In five patients, there were no significant changes in the BAEP responses during the predilation, stenting, and postdilation. There were no postprocedural neurological deficits in these patients. In one patient, there was a 1-ms increase of latency of wave V at the time of predilation angioplasty. No changes in the amplitude of wave V were noted. This patient had immediate postprocedure left hemiplegia, which improved to power of 3/5 in both upper and lower limbs at the time of discharge and to 4/5 at 3-month follow-up. Computed tomography scan did not show any evidence of hemorrhage. CONCLUSIONS: Brainstem auditory evoked potentials may be a valuable monitoring tool in patients undergoing stenting and angioplasty of vertebrobasilar system. Early signs of brainstem dysfunction can be identified to modify the procedure and reduce neurological deficits. Large studies are needed to validate the use of BAEP during this procedure.

What drives the increasing utilisation of hemicraniectomy in acute ischaemic stroke?

BACKGROUND: Survival after malignant middle cerebral artery infarcts is dismal. In 2007, a pooled analysis of randomised trials in Europe demonstrated a substantial survival benefit from decompressive hemicraniectomy, with a number needed to treat of 2 for survival. Our objective was to review factors driving the nationwide utilisation of this potentially lifesaving procedure in the USA. METHODS: Data from the Nationwide Inpatient Sample for 2001-2009 were reviewed. Hospitalisations with a discharge diagnosis of an acute ischaemic stroke were included. Hemicraniectomy utilisation was determined within this subset. Nationwide estimates of utilisation were calculated for each year. Trends across the years were estimated for various subgroups. RESULTS: From 2001 to 2009, there were an estimated 4 909 519 acute ischaemic stroke discharges. The estimated frequency of hemicraniectomy increased from 118 (0.02% of stroke discharges in 2001) to 804 (0.15% of stroke discharges in 2009) (trend p<0.001). The increased utilisation was greatest for younger subjects (age<45 years; trend p<0.001) and men (trend p<0.001). Urban teaching hospitals were responsible for the greatest increase in hemicraniectomy utilisation: from 0.05% of stroke discharges in 2001 to 0.28% in 2009. The increase was steady and sustained over the decade. In comparison, rural and urban non-teaching hospitals showed a much smaller improvement in utilisation. CONCLUSION: Utilisation of hemicraniectomy in the USA has increased significantly, in line with compelling results from European clinical trials. Early transfer of patients with malignant infarctions to urban teaching centres could potentially extend the survival benefit to a larger population.

Thrombolysis and outcome of young stroke patients over the last decade: insights from the Nationwide Inpatient Sample.

BACKGROUND: A recent study found a trend toward increasing hospitalizations for acute ischemic stroke (AIS) among young adults, raising concern for this subgroup. In the present study, we evaluated trends of use of thrombolysis and outcome among young adults (19-44 years of age) with AIS using a nationally representative administrative database. METHODS: Discharge data were obtained from Nationwide Inpatient Sample between 2001 and 2009. Hospitalizations with a discharge diagnosis of AIS for patients 19 to 44 years of age were included. Use of thrombolysis was determined within this subset. The Cochran-Armitage test was used for trend analysis. RESULTS: Thrombolysis in young patients with AIS increased from 354 (1.84%) in 2001 to 1,237 (4.97%) in 2009 (P < .0001). The highest increase was noted at urban teaching hospitals. There was a progressive decrease in mortality in young AIS patients, from 6.81% in 2001 to 5.43% in 2009 (trend P = .027) and significant increase in discharges to rehabilitation (3.42% in 2002 to 12.7% in 2009 [trend P < .0001]). Discharge to other facilities decreased significantly (29.1% in 2001 to 17.8% in 2009 [trend P < .0001]). The rate of intracranial hemorrhage (2.70% in 2001; 2.69% in 2009) did not show any significant change despite the increase in the use of thrombolysis (trend P = .39). CONCLUSIONS: The rate of thrombolysis among young patients with AIS increased significantly between 2001 and 2009. A decrease in deaths with increased rehabilitation placements of young patients with AIS was noted over the last decade, suggesting improving outcomes. The lower rate of use of thrombolysis in rural hospitals may be improved with the widespread use of telestroke.

Angioplasty and stenting for mechanical thrombectomy in acute ischemic stroke.

A large number of patients presenting with acute ischemic stroke have large artery intracranial occlusions, and timely recanalization of these occlusions often leads to improved neurologic outcome. Starting with the widespread use of IV tissue plasminogen activator, a wide variety of pharmacologic and mechanical methods have been introduced to improve vessel recanalization and clinical outcome of patients with acute ischemic stroke, which include endovascular therapies such as intra-arterial thrombolytics and mechanical thrombectomy devices. One of the potential therapies is angioplasty and stenting, and this has been evaluated in multiple case reports and small series published by various centers regarding its use in this setting. In this article, we review the current literature on stenting with and without angioplasty, used alone or as a part of multimodal therapy for recanalization for acute cerebrovascular occlusions.

Variability in carotid endarterectomy practice patterns within a metropolitan area.

BACKGROUND AND PURPOSE: Previous clinical studies have suggested that patients with carotid stenosis with high surgical risk features may fare better with carotid artery stenting or aggressive medical therapy. The extent to which carotid endarterectomy is still being performed in this group of patients is unclear. METHODS: A retrospective audit was performed among 4 hospitals over a 2-year period. The proportion of high surgical risk patients was compared and the in-hospital stroke, myocardial infarction, and death rates were compared among conventional and high surgical risk patients. RESULTS: Three hundred thirty-five carotid endarterectomy operations were performed (63% asymptomatic) with 37.9% being high surgical risk subjects. The stroke, myocardial infarction, and death rate was 4.6% in conventional risk subjects and 10.2% in high surgical risk patients (P<0.05). The only hospital with multidisciplinary carotid conferences had the lowest proportion of carotid endarterectomy operations in asymptomatic patients. CONCLUSIONS: A substantial proportion of carotid endarterectomy operations are performed in patients with high surgical risk features. These patients experienced a 2-fold increase in major in-hospital complications, raising doubts about whether they benefit from carotid surgery. The use of preintervention multidisciplinary conferences may improve patient safety.

The safety and efficacy of coiling multiple aneurysms in the same session.

OBJECTIVE: Multiple intracranial aneurysms are common. While sequential clipping of multiple aneurysms during a single open surgical procedure has been reported, the same is not true for endovascular coiling. We present our experience describing the safe coiling of multiple aneurysms in the same setting. METHODS: Retrospective review of our coiling log between 2006 and 2009 showed six cases in which multiple aneurysms were coiled in the same session. RESULTS: All patients were coiled using the same microcatheter. Distal aneurysms were coiled first. Good occlusion rates were achieved in all cases. There were no thromboembolic events or procedure-related rupture or mortality. CONCLUSION: In addition to safety and efficacy, cost savings are expected when coiling multiple aneurysms in the same procedure.

Safety and efficacy of intracranial stenting for acute ischemic stroke beyond 8 h of symptom onset.

OBJECTIVE: To report our experience with stent supported intracranial recanalization for acute ischemic stroke beyond 8 h of symptoms onset. Background Acute ischemic stroke (AIS) therapy is often limited to an 8 h window using mechanical means. However, recent reports have shown delayed recanalization beyond 8 h might be a viable option in a subset of patients. METHODS: A retrospective review was performed of our AIS database for patients who underwent stent supported intracranial recanalization beyond 8 h of symptom onset. Clinical and angiographic data were reviewed. Outcome was measured using modified Rankin Scale (mRS) scores at 30 and 90 days. RESULTS: 12 patients (11 men and one woman) underwent delayed stenting for AIS. Mean age was 49 years (range 37-73) and mean National Institutes of Health Stroke Scale was 17 (range 8-29, median 15). Mean time from stroke onset to intervention was 66.1 h (range 10-168 h, median 46 h). 10 patients presented with a Thrombolysis in Myocardial Infarction (TIMI) score of 0 and the remaining two had a TIMI of 1. Recanalized vessels included: left middle cerebral artery (n=6), basilar trunk (n=2), vertebrobasilar junction (n=3) and internal carotid artery (ICA)-T (n=1). Four patients had prior attempts of embolectomy/thrombolysis using mechanical and chemical means. Stents used included: six balloon mounted stents, five Wingspan and one Enterprise self-expanding intracranial stent. Recanalization, defined as a TIMI score of 2 or more, was achieved in 11 patients. Two patients (17%) had intracranial hemorrhage. Thirty day mRS of ≤3 was achieved in six patients (50%). Seven patients (58%) had a 90 day mRS of ≤2. CONCLUSION: Stent supported intracranial recanalization is a safe and feasible approach in a selective group of patients presenting with acute ischemic stroke beyond 8 h of symptom onset.

Stenting of acute and subacute intracranial vertebrobasilar arterial occlusive lesions.

BACKGROUND AND OBJECTIVE: The outcome of failed recanalization in patients with acutely symptomatic intracranial vertebrobasilar (VB) artery occlusive disease is poor. This paper reports the recanalization rate and safety of VB artery stenting in acutely symptomatic patients presenting >8 h after onset of symptoms. METHODS: A retrospective review of a prospectively maintained database of stent-supported endovascular treatment of intracranial circulation was carried out to identify patients with VB artery occlusive disease who were acutely revascularized >8 h after symptom onset. RESULTS: Of 12 patients (mean age 61 years), nine had acute stroke and three had recurrent transient ischemic attacks. The median time to intervention was 59 h (range 8-80). The median National Institute of Health Stroke Scale score was 11.5 (range 1-40). Angiography showed thrombolysis in myocardial infarction (TIMI) 0 flow in six patients and TIMI 1 flow in the other six. Stents were placed in the basilar artery in six and at the VB junction in the other six. Mechanical and/or intra-arterial thrombolysis was used in three patients before stenting. Nine patients had self-expanding stents and three had balloon-expandable stents. The recanalization rate was 100%. Procedure-related and 3-month mortality was zero. Two patients had asymptomatic intracranial hemorrhage. At 3-month follow-up a favorable outcome with a modified Rankin score ≤2 was achieved in eight. A follow-up angiogram in eight patients showed mild re-stenosis in three. CONCLUSION: Stent-supported VB artery revascularization can be a viable option with an acceptable safety profile in acute VB occlusion or unstable intracranial atherosclerotic arterial disease (ICAD) in carefully selected patients.

CT perfusion guided delayed recanalization with favorable outcome in pediatric stroke.

There are no approved treatment options for acute ischemic stroke in the pediatric population. A case is presented of a 16-year-old boy with acute left-sided weakness who was transferred to our institution on the third day after onset of symptoms and after deterioration in his condition. He had right internal carotid artery occlusion beyond the origin of the ophthalmic artery. CT perfusion study showed a large area of penumbra in the right middle cerebral artery distribution. Recanalization was achieved with self-expanding stent placement and mechanical thrombectomy. Post procedure CT perfusion study showed resolution of the penumbra. At the 3 month follow-up, his modified Rankin Scale score was 1 and at 1 year it was 0. A subset of pediatric patients with acute ischemic stroke secondary to large intracranial arterial occlusion may be potential candidates for this treatment approach.