RESUMO
Background and Objectives: Large hemispheric infarctions (LHIs) are associated with significant morbidity and mortality, with limited data on therapeutic anticoagulation (AC) management. We provide a descriptive analysis of the type of therapeutic AC used, the timing of introduction, rate of of radiographic vs symptomatic hemorrhagic transformation (HT), and patient outcomes. Methods: This was a retrospective review of patients with acute ischemic stroke admitted to the Neurosciences intensive care unit at a tertiary care center from January 2012 to December 2018. Inclusion criteria included admission imaging with stroke size ≥ two-thirds of the middle cerebral artery territory, ± other vascular territory, and need for therapeutic AC. HT categories included hemorrhagic infarction types 1 and 2 and parenchymal hematoma types 1 and 2. The primary outcome included HT with and without an associated clinical change. Secondary outcomes included disposition at discharge and modified Rankin Scale (mRS) score at discharge and at follow-up when available. Results: A total of 2,317 patients were screened, 380 met the inclusion criteria for LHI, and 105 received AC. The mean age was 64 years (SD 16.8), and 50% (n = 53) were female. The mean admission NIH Stroke Scale score was 20 (SD 5.9). The mean poststroke timing to initiation of AC was 17 days (SD 10.1) (median 14 [interquartile range 10-19 days]). Indications for AC included atrial fibrillation (51%), cardiac thrombus (19%), venous thromboembolism (19%), and other (10%). Heparin was most commonly used in the very early (≤7 days) group (n = 11, 79%), whereas vitamin K antagonists without a bridge were the most commonly used among the entire cohort (n = 54, 51%). Radiographic HT was seen in 68 patients (65%) before AC initiation. After initiation of AC, 70 patients had repeat imaging, with 6 cases (6%) of worsening radiographic HT and 4 cases (4%) of symptomatic deterioration, of which 3 required reversal of AC. At discharge, 7 patients (7%) had a good outcome (mRS score 0-2). Discussion: Although radiographic HT is common among patients with LHI, it does not always portend symptomatic clinical deterioration. Further research regarding AC timing and safety is necessary.
RESUMO
BACKGROUND: Large hemispheric infarctions (LHI) are associated with significant morbidity and mortality. Leukocytosis has been observed to directly correlate with stroke severity but has not been specifically described in the LHI population. We hypothesized that patients with LHI and leukocytosis on admission have worse clinical outcomes. METHODS: Retrospective study of patients admitted to the neurosciences intensive care unit at a tertiary care center with the diagnosis of acute ischemic stroke from Jan 2012 to Dec 2018. Inclusion criteria included admission imaging with stroke size greater than two-thirds of the middle cerebral artery territory, with or without other vascular territory involvement. Patients were excluded if antibiotics were started on admission for presumed infection. White blood cell count was recorded at admission, along with Modified Rankin Scale on admission and discharge, need for mechanical ventilation, tracheostomy, and discharge disposition. Logistic regression was used for association measures. RESULTS: Of the 2,318 patients that were screened, 360 met inclusion criteria. Mean age was 64, median was 63; 51.7% were female. Mean and median NIHSS were 21. Leukocytosis on admission was seen in 139 patients (38.6%), and it was associated with need for mechanical ventilation (p<0.0001, OR 2.54, [1.64-3.95]) and mortality during hospitalization (p<0.0003, OR 2.66, [1.56-4.55]). Results persisted after correction for age and sex in a logistic regression model. CONCLUSIONS: Leukocytosis on admission in patients with LHI significantly correlated with mortality and need for mechanical ventilation. There was a trend towards association with poor outcome at discharge, although not statistically significant. Further research may identify how leukocytosis and other SIRS markers may be used to prognosticate outcomes in this challenging patient population.
