Post Stroke Depression

Depression is the most common neuropsychiatric disorder affecting over one third of all stroke patients. The presence of depression after a stroke greatly affects the ability of patients to participate in rehabilitation and can even affect their long-term mortality. Poststroke depression is a well-documented and studied aspect of stroke management because of the implications it has on morbidity, mortality and recovery. Despite post stroke depression being a well-studied phenomenon, it remains underdiagnosed. The development of poststroke depression is multifactorial and has been evaluated from the cellular, genetic, and environmental perspective. Using numerous studies this chapter will review facets of post stroke depression such as epidemiology, etiology and treatment, while evaluating how this phenomena effects patient recovery and rehabilitation

Abstract Number ‐ 161: Comparing Stroke Thrombectomy Outcomes In Younger V/S Older Population

Introduction Large vessel occlusion (LVO) is estimated to account for up to 39% of all ischemic strokes with 62% of them resulting in post‐ischemic stroke dependency and 96% of all post‐ischemic stroke mortality. Advanced imaging modalities and efficient stroke systems of care have resulted in faster reperfusion times. There is however limited data on the outcomes of thrombectomy as a function of age. We present a retrospective analysis on thrombectomy in younger (age 18–49 years) versus older (age >50 years) patients. Methods Retrospective single center study with population being identified using our procedural database and “SlicerDicer” tool on EPIC from 2017–2021. Patients who underwent mechanical thrombectomy were divided into 2 groups based on age. Younger group consists of patients between the ages 18–49 while older group is 50 and over. Primary outcome of the study was to identify good clinical outcome as defined by mRS of 0–2 in both groups. Secondary outcomes included rate of favorable reperfusion defined by TICI 2b‐3, symptomatic ICH and mortality rate. Results > We have identified 48 patients between the age of 18–49 and 436 over the age of 50. > We found that median groin puncture to repercussion time was lower in younger population (32 v/s 69 mins; p = 0.0044) > The median groin puncture to first pass time was lower in younger population (22 v/s 43; p = 0.056), but it failed to show statistical significance. > Younger compared to older patients had better clinical outcomes (mRS 0–2) at 77.1% v/s 32.3% (p The older group required more passes to achieve recanalization (4 or more passes: 4.3% v/s 16.2%; p = 0.035) > Mortality rate was significantly less in the younger population (8.3% v/s 22.1%; p = 0.026) Conclusions Younger patients had better clinical outcomes than their older counterparts after mechanical thrombectomy in our analysis. Other than younger age, higher rates of favorable repercussion, earlier recanalization, and less passes to recanalization were seen in association with better observed outcomes

Abstract Number ‐ 200: Aneurysmal versus “Benign” Perimesencephalic Subarachnoid Hemorrhage

Introduction Perimesencephalic subarachnoid hemorrhage (PMSAH) is characterized by bleeding centered in the basal cisterns anterior to the midbrain and pons without intraparenchymal or overt intraventricular extension. The term “benign” is often attached, because typically no source of bleeding is identified on high‐resolution vascular imaging, and recovery if often uncomplicated. Rarely, however, PMSAH can be secondary to ruptured vertebrobasilar aneurysms, and outcomes of these patients is underreported. Methods Retrospective analysis of patients with PMSAH to determine the rate of underlying ruptured aneurysm or vascular abnormality, associated complications, and outcomes. Age, sex, vascular risk factors, presenting symptoms, Hunt and Hess grade, modified Fisher grade, rate of underlying ruptured aneurysm, vasospasm, re‐bleed, hydrocephalus, and modified Rankin scale (mRS) were collected. Primary outcome was good functional status at discharge (mRS 0–2), reported as odds ratio (OR) with 95% confidence interval (CI). Results A total of 74 patients with PMSAH between 2007 and 2022 were identified. Mean age was 55.5± 10 years, and 60% were male. Hypertension and smoking were reported in 57% and 35% of patients, respectively. The most common presenting symptom was thunderclap headache in 89% of patients. Median (IQR) ofHunt and Hess grade was 2 (1‐2), and modified Fisher grade was 3 (1‐3). An underlying ruptured aneurysm was found in 3 patients (4%); two of which were in the vertebrobasilar system and one in the posterior communicating artery. Most common complications in this cohort was vasospasm in 28%, followed by hydrocephalus in 11%. Among patients with aneurysmal bleed, vasospasm and hydrocephalus occurred in 66% of patients each, compared to 8.5% and 27%, respectively in patients with non‐aneurysmal PMSAH. Re‐bleeding occurred only in one patient (1.3%); which occurred in a patient with non‐aneurysmal source of hemorrhage. A total of 88% of patients in our cohort had a favorable functional outcome (mRS 0–2) at discharge. An underlying ruptured aneurysm and acute hydrocephalus were associated with poor functional status(OR = 18.3, [1.5–228], P < 0.024), and OR = 25.8, [4.5–149], P < 0.001), respectively. However, vasospasm was noted to be asymptomatic in most cases (90%) and was not associated with unfavorable outcomes (OR = 0.75, [0.14–3.9], P < 0.73). Conclusions “Benign” PMSAH pattern was associated with a ruptured aneurysm in 4% of patients in our cohort.An underlying aneurysm and acute hydrocephalus were associated with poor outcomes. However, vasospasm was incidental and was not associated with unfavorable outcomes in patients with PMSAH

Admission hyperglycemia and outcomes in large vessel occlusion strokes treated with mechanical thrombectomy

Background and purpose: Higher admission serum glucose levels have been associated with poor outcomes in patients with acute ischemic stroke (AIS) treated with IV thrombolysis. We sought to evaluate the association of admission serum glucose with early outcomes of patients with emergent large vessel occlusion (ELVO) treated with mechanical thrombectomy (MT). Methods: Consecutive AIS patients due to ELVO treated with MT in three tertiary stroke centers were evaluated. The following outcomes were documented using standard definitions: symptomatic intracranial hemorrhage (sICH), complete reperfusion, mortality, functional independence (modified Rankin Scale (mRS) score of 0–2), and functional improvement (shift in mRS score) at 3 months. The association of admission serum glucose and admission hyperglycemia (>140 mg/dL) with outcomes was evaluated using univariable and multivariable binary and ordinal logistic regression models. Results: 231 AIS patients with ELVO (mean age 62±14 years, 51% men, median admission National Institute of Health Stroke Scale score 16 points (IQR 12–21), median admission serum glucose 125 mg/dL (IQR 104–162)) were treated with MT. Admission hyperglycemia was associated with a lower likelihood of functional improvement (common OR 0.53; 95% CI 0.31 to 0.97; p=0.027) and higher odds of 3 month mortality (OR 2.76; 95% CI 1.40 to 5.44; p=0.004) in multivariable analyses adjusting for potential confounders. A 10 mg/dL increase in admission blood glucose was associated with a higher likelihood of sICH (OR 1.07; 95% CI 1.01 to 1.13; p=0.033) and 3 month mortality (OR 1.07; 95% CI 1.02 to 1.12; p=0.004) in multivariable models. There was no association between admission serum glucose or hyperglycemia and complete reperfusion. Conclusions: Higher admission serum glucose and admission hyperglycemia are independent predictors of adverse outcomes in ELVO patients treated with MT

Hemicraniectomy for malignant middle cerebral artery syndrome: A review of functional outcomes in two high-volume stroke centers

Background and Purpose: Despite recent landmark randomized controlled trials showing significant benefits for hemicraniectomy (HCT) compared with medical therapy (MT) in patients with malignant middle cerebral artery infarction (MMCAI), HCT rates have not substantially increased in the United States. We sought to evaluate early outcomes in patients with MMCAI who were treated with HCT (cases) in comparison to patients treated with MT due to the perception of procedural futility by families (controls). Methods: We retrospectively evaluated consecutive patients with acute MMCAI treated in 2 tertiary care centers during a 7-year period. Pretreatment National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) at 3 months were documented. Functional independence (FI) and survival without severe disability (SWSD) were defined as mRS of 0-2 and 0-4, respectively. Results: A total of 66 patients (37 cases and 29 controls) fulfilled the study inclusion criteria (mean age 59 ± 15 years, 52% men, median admission NIHSS score: 19 points [interquartile range {IQR}: 16-22]). Cases were younger (51 ± 11 versus 68 ± 13 years; P < .001) and tended to have lower median admission NIHSS than controls (18 [IQR:16-20] versus 20 [IQR:18-23]; P = .072). The rates of FI and SWSD at 3 months were higher in cases than controls (16% versus 0% [P = .031] and 62% versus 0% [P < .001]), while 3-month mortality was lower (24% versus 77%; P < .001). Multivariable Cox regression analyses adjusting for potential confounders identified HCT as the most important predictor of lower risk of 3-month mortality (hazard ratio: .02, 95% confidence interval: .01-0.10; P < .001). Conclusions: HCT is a critical and effective therapy for patients with MMCAI but cannot provide a guarantee of functional recovery

Admission Neutrophil to Lymphocyte Ratio for Predicting Outcome in Subarachnoid Hemorrhage

Purpose: We sought to evaluate the relationship between admission neutrophil-to-lymphocyte ratio (NLR) and functional outcome in aneurysmal subarachnoid hemorrhage (aSAH) patients. Material and methods: Consecutive patients with aSAH were treated at two tertiary stroke centers during a five-year period. Functional outcome was defined as discharge modified Rankin score dichotomized at scores 0-2 (good) vs. 3-6 (poor). Results: 474 aSAH patients were evaluated with a mean NLR 8.6 (SD 8.3). In multivariable logistic regression analysis, poor functional outcome was independently associated with higher NLR, older age, poorer clinical status on admission, prehospital statin use, and vasospasm. Increasing NLR analyzed as a continuous variable was independently associated with higher odds of poor functional outcome (OR 1.03, 95%CI 1.001.07, p=0.05) after adjustment for potential confounders. When dichotomized using ROC curve analysis, a threshold NLR value of greater than 6.48 was independently associated with higher odds of poor functional outcome (OR 1.71, 95%CI 1.07-2.74, p=0.03) after adjustment for potential confounders. Conclusions: Higher admission NLR is an independent predictor for poor functional outcome at discharge in aSAH patients. The evaluation of anti-inflammatory targets in the future may allow for improved functional outcome after aSAH

Microbleed prevalence and burden in anticoagulant-associated intracerebral bleed

10.1002/acn3.50834ANNALS OF CLINICAL AND TRANSLATIONAL NEUROLOGY6

Comparative safety and efficacy of combined IVT and MT with direct MT in large vessel occlusion.

OBJECTIVE: In this multicenter study, we sought to evaluate comparative safety and efficacy of combined IV thrombolysis (IVT) and mechanical thrombectomy (MT) vs direct MT in emergent large vessel occlusion (ELVO) patients. METHODS: Consecutive ELVO patients treated with MT at 6 high-volume endovascular centers were evaluated. Standard safety and efficacy outcomes (successful reperfusion [modified Thrombolysis in Cerebral Infarction IIb/III], functional independence [FI] [modified Rankin Scale (mRS) score of 0-2 at 3 months], favorable functional outcome [mRS of 0-1 at 3 months], functional improvement [mRS shift by 1-point decrease in mRS score]) were compared between patients who underwent combined IVT and MT vs MT alone. Additional propensity score-matched analyses were performed. RESULTS: A total of 292 and 277 patients were treated with combination therapy and direct MT, respectively. The combination therapy group had greater functional improvement ( CONCLUSIONS: This observational study provides preliminary evidence that IVT pretreatment may improve outcomes in ELVO patients treated with MT. The question of the potential effect of IVT on ELVO patients treated with MT should be addressed with a randomized controlled trial. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that for stroke patients with emergent large vessel occlusion, combined IVT and MT is superior to direct MT in improving functional outcomes

Alarming downtrend in mechanical thrombectomy rates in African American patients during the COVID-19 pandemic-Insights from STAR

BackgroundThe coronavirus disease (COVID-19) pandemic has affected stroke care globally. In this study, we aim to evaluate the impact of the current pandemic on racial disparities among stroke patients receiving mechanical thrombectomy (MT).MethodsWe used the prospectively collected data in the Stroke Thrombectomy and Aneurysm Registry from 12 thrombectomy-capable stroke centers in the US and Europe. We included acute stroke patients who underwent MT between January 2017 and May 2020. We compared baseline features, vascular risk factors, location of occlusion, procedural metrics, complications, and discharge outcomes between patients presenting before (before February 2020) and those who presented during the pandemic (February to May 2020).ResultsWe identified 2083 stroke patients: of those 235 (11.3%) underwent MT during the COVID-19 pandemic. Compared with pre-pandemic, stroke patients who received MT during the pandemic had longer procedure duration (44 vs 38 min, P=0.006), longer length of hospitalization (6 vs 4 days, P<0.001), and higher in-hospital mortality (18.7% vs 11%, P<0.001). Importantly, there was a lower number of African American patients undergoing MT during the COVID-19 pandemic (609 (32.9%) vs 56 (23.8%); P=0.004).ConclusionThe COVID-19 pandemic has affected the care process for stroke patients receiving MT globally. There is a significant decline in the number of African American patients receiving MT, which mandates further investigation

Optimization of risk stratification for anticoagulation-associated intracerebral hemorrhage: net risk estimation

BACKGROUND: Every anticoagulation decision has in inherent risk of hemorrhage; intracerebral hemorrhage (ICH) is the most devastating hemorrhagic complication. We examined whether combining ischemic and hemorrhagic stroke risk in individual patients might provide a meaningful paradigm for risk stratification. METHODS: We enrolled consecutive patients with anticoagulation-associated ICH in 15 tertiary centers in the USA, Europe and Asia between 2015 and 2017. Each patient was assigned baseline ischemic stroke and hemorrhage risk based on their CHA RESULTS: We enrolled 357 patients [59% men, median age 76 (68-82) years]. 31% used non-vitamin K antagonist (NOAC). 191 (53.5%) patients had a favorable indication for anticoagulation prior to their ICH; 166 (46.5%) unfavorable. Those with unfavorable indication were younger [72 (66-80) vs 78 (73-84) years, p = 0.001], with lower CHA CONCLUSIONS: In this anticoagulation-associated ICH cohort, baseline hemorrhagic risk exceeded ischemic risk in approximately 50%, highlighting the importance of careful consideration of risk/benefit ratio prior to anticoagulation decisions. The remaining 50% suffered an ICH despite excess baseline ischemic risk, stressing the need for biomarkers to allow more precise estimation of hemorrhagic complication risk