Predictors of Outcome following Stroke due to Isolated M2 Occlusions

Background: Factors influencing outcome after cerebral artery occlusion are not completely understood. Although it is well accepted that the site of arterial occlusion critically influences outcome, the majority of studies investigating this issue has focused on proximal large artery occlusion. To gain a better understanding of factors influencing outcome after distal large artery occlusion, we sought to assess predictors of outcome following isolated M2 middle cerebral artery occlusion infarcts. Methods: We retrospectively analyzed patients with isolated acute M2 occlusion admitted to a single academic center from January 2010 to August 2012. Baseline clinical, laboratory imaging, and outcome data were assessed from a prospectively collected database. Factors associated with a modified Rankin Scale (mRS) score ≤2 in univariable analyses (p Results: 90 patients with isolated M2 occlusion were included in the final analyses. Of these, 69% had a good 90-day outcome which was associated with age 28 ml (OR 11.874, 95% CI 2.630-53.604, p = 0.001), age >80 years (OR 4.953, 95% CI 1.087-22.563, p = 0.039), need for intubation (OR 7.788, 95% CI 1.072-56.604), and history of congestive heart failure (OR 5.819, 95% CI 1.140-29.695) were independent predictors of 90-day mortality (20% of all included patients). Conclusion: While the majority of patients with isolated M2 occlusion stroke has a good 90-day outcome, a substantial proportion of subjects dies by 90 days, as identified by a unique subset of predictors. The knowledge gained from our study may lead to an improvement in the prognostic accuracy, clinical management, and resource utilization in this patient population

Leukoaraiosis predicts a poor 90-day outcome after endovascular stroke therapy

BACKGROUND AND PURPOSE: Leukoaraiosis is a common finding among patients with ischemic stroke and has been associated with poor stroke outcomes. Our aim was to ascertain whether the severity of pre-existing leukoaraiosis is associated with outcome in patients with acute ischemic stroke who are treated with endovascular stroke therapy. MATERIALS AND METHODS: We retrospectively analyzed data from 129 consecutive, prospectively enrolled patients with stroke undergoing endovascular stroke therapy at a single tertiary care center between January 2006 and August 2013. Leukoaraiosis was assessed as supratentorial white matter hypoattenuation on admission head CT and graded as 0-2 (absent-to-moderate) versus 3-4 (severe) according to the van Swieten scale. We dichotomized the 90-day mRS into good (0-2 or return to baseline) versus poor (3-6) as the primary study outcome. Incremental multivariable logistic regression analyses were performed to identify independent predictors of a poor 90-day outcome. RESULTS: In all multivariable models, severe leukoaraiosis was independently (P \u3c .05) associated with a poor outcome at 90 days (fully adjusted model: OR, 6.37; 95% CI, 1.83-12.18; P = .004). The independent association between leukoaraiosis and a poor outcome remained when the analysis was restricted to patients who were alive at discharge (n = 87, P \u3c .05). Last, among patients who were alive at discharge, those with severe leukoaraiosis had significantly less frequent improvement on the mRS from discharge to 90 days compared with patients with absent-to-moderate leukoaraiosis (P = .034). CONCLUSIONS: The severity of pre-existing leukoaraiosis is independently associated with 90-day functional outcome in patients with stroke who underwent endovascular stroke therapy. These results highlight the need to further explore leukoaraiosis as a promising surrogate marker for poor outcome after endovascular stroke therapy to improve risk assessment, patient selection, and early prognostic accuracy

Atrial fibrillation is associated with anterior predominant white matter lesions in patients presenting with embolic stroke

OBJECTIVE: High white matter hyperintensity (WMH) burden is commonly found on brain MRI among patients with atrial fibrillation (AF). However, whether the link between AF and WMH extends beyond a common vascular risk factor profile is uncertain. We sought to determine whether AF relates to a distinct WMH lesion pattern which may suggest specific underlying pathophysiological relationships. METHODS: We retrospectively analysed a cohort of consecutive patients presenting with embolic stroke at an academic hospital and tertiary referral centre between March 2010 and March 2014. In total, 234 patients (53% female, 74% anterior circulation infarction) fulfilled the inclusion criteria and were included in the analyses. WMH lesion distribution was classified according to previously defined categories. Multivariable logistic regression analysis was performed to determine variables associated with AF within 90 days of index hospital discharge. RESULTS: Among included patients, 114 had AF (49%). After adjustment for the CHA2DS2-VASc score (congestive heart failure, hypertension, age \u3e /=75 years (doubled), diabetes mellitus, prior stroke/TIA (doubled), vascular disease, age 65-74 years, sex category (female)) score, WMH lesion burden as assessed on the Fazekas scale, embolic stroke pattern, infarct distribution and pertinent interaction terms, AF was significantly associated with presence of anterior subcortical WMH patches (OR 3.647, 95% CI 1.681 to 7.911, p=0.001). CONCLUSIONS: AF is associated with specific WMH lesion pattern among patients with embolic stroke aetiology. This suggests that the link between AF and brain injury extends beyond thromboembolic complications to include a cardiovasculopathy that affects the brain and can be detected and characterised by WMH

12 versus 24 h bed rest after acute ischemic stroke thrombolysis: a preliminary experience

BACKGROUND: The practice of \u3e /=24 h of bed rest after acute ischemic stroke thrombolysis is common among hospitals, but its value compared to shorter periods of bed rest is unknown. METHODS: Consecutive adult patients with a diagnosis of ischemic stroke who had received intravenous thrombolysis treatment from 1/1/2010 until 4/13/2016, identified from the local ischemic stroke registry, were included. Standard practice bed rest for \u3e /=24 h, the protocol prior to 1/27/2014, was retrospectively compared with standard practice bed rest for \u3e /=12 h, the protocol after that date. The primary outcome was favorable discharge location (defined as home, home with services, or acute rehabilitation). Secondary outcome measures included incidence of pneumonia, NIHSS at discharge, and length of stay. RESULTS: 392 patients were identified (203 in the \u3e /=24 h group, 189 in the \u3e /=12 h group). There was no significant difference in favorable discharge outcome in the \u3e /=24 h bed rest protocol compared with the \u3e /=12 h bed rest protocol in multivariable logistic regression analysis (76.2% vs. 70.9%, adjusted OR 1.20 CI 0.71-2.03). Compared with the \u3e /=24 h bed rest group, pneumonia rates (8.3% versus 1.6%, adjusted OR 0.12 CI 0.03-0.55), median discharge NIHSS (3 versus 2, adjusted p = .034), and mean length of stay (5.4 versus 3.5 days, adjusted p = .006) were lower in the \u3e /=12 h bed rest group. CONCLUSION: Compared with \u3e /=24 h bed rest, \u3e /=12 h bed rest after acute ischemic stroke reperfusion therapy appeared to be similar. A non-inferiority randomized trial is needed to verify these findings

Impact of Leukoaraiosis Severity on the Association of Time to Successful Reperfusion with 90-Day Functional Outcome After Large Vessel Occlusion Stroke

The chance for a favorable outcome after mechanical thrombectomy (MT) for large vessel occlusion stroke decreases with the symptom onset-to-reperfusion time (OTR). Patients with severe leukoaraiosis are at increased risk for a poor outcome after MT. However, whether leukoaraiosis modulates to the association between OTR and 90-day functional outcome is uncertain. We retrospectively analyzed 144 consecutive patients with successful (TICI \u3e /= 2b/3) MT for anterior circulation large vessel occlusion within 24 h form OTR between January 2012 to November 2016. Leukoaraiosis was dichotomized to absent-to-mild (van Swieten scale score 0-2) versus moderate-to-severe (3-4) as assessed on admission head CT. Multiple linear, logistic, and ordinal regression analyses were used to determine the association between leukoaraiosis, OTR, and 90-day modified Rankin Scale (mRS) score, after adjustment for pertinent covariates. Leukoaraiosis was independently associated with the OTR on multivariable linear regression (p = 0.003). The association between OTR and 90-day outcome depended on the degree of pre-existing leukoaraiosis burden as shown by a significant leukoaraiosis-by-OTR interaction on multivariable logistic regression (OR 0.76, 95% CI 0.58-0.98, p = 0.037) and multivariable ordinal regression (OR 0.87, 95% CI 0.78-0.97, p = 0.011). Pre-existing leukoaraiosis is associated with the 90-day functional outcome after successful reperfusion and impacts the association between the OTR and 90-day mRS among patients undergoing MT. Patients with high leukoaraiosis burden need to present earlier than patients with low leukoaraiosis burden for a similar favorable outcome. Pending confirmation, these results may have important implications for optimizing patient selection for acute stroke therapies

Effect of general anaesthesia on functional outcome in patients with anterior circulation ischaemic stroke having endovascular thrombectomy versus standard care: a meta-analysis of individual patient data

Background: General anaesthesia (GA) during endovascular thrombectomy has been associated with worse patient outcomes in observational studies compared with patients treated without GA. We assessed functional outcome in ischaemic stroke patients with large vessel anterior circulation occlusion undergoing endovascular thrombectomy under GA, versus thrombectomy not under GA (with or without sedation) versus standard care (ie, no thrombectomy), stratified by the use of GA versus standard care. Methods: For this meta-analysis, patient-level data were pooled from all patients included in randomised trials in PuMed published between Jan 1, 2010, and May 31, 2017, that compared endovascular thrombectomy predominantly done with stent retrievers with standard care in anterior circulation ischaemic stroke patients (HERMES Collaboration). The primary outcome was functional outcome assessed by ordinal analysis of the modified Rankin scale (mRS) at 90 days in the GA and non-GA subgroups of patients treated with endovascular therapy versus those patients treated with standard care, adjusted for baseline prognostic variables. To account for between-trial variance we used mixed-effects modelling with a random effect for trials incorporated in all models. Bias was assessed using the Cochrane method. The meta-analysis was prospectively designed, but not registered. Findings: Seven trials were identified by our search; of 1764 patients included in these trials, 871 were allocated to endovascular thrombectomy and 893 were assigned standard care. After exclusion of 74 patients (72 did not undergo the procedure and two had missing data on anaesthetic strategy), 236 (30%) of 797 patients who had endovascular procedures were treated under GA. At baseline, patients receiving GA were younger and had a shorter delay between stroke onset and randomisation but they had similar pre-treatment clinical severity compared with patients who did not have GA. Endovascular thrombectomy improved functional outcome at 3 months both in patients who had GA (adjusted common odds ratio (cOR) 1·52, 95% CI 1·09–2·11, p=0·014) and in those who did not have GA (adjusted cOR 2·33, 95% CI 1·75–3·10, p<0·0001) versus standard care. However, outcomes were significantly better for patients who did not receive GA versus those who received GA (covariate-adjusted cOR 1·53, 95% CI 1·14–2·04, p=0·0044). The risk of bias and variability between studies was assessed to be low. Interpretation: Worse outcomes after endovascular thrombectomy were associated with GA, after adjustment for baseline prognostic variables. These data support avoidance of GA whenever possible. The procedure did, however, remain effective versus standard care in patients treated under GA, indicating that treatment should not be withheld in those who require anaesthesia for medical reasons