The Kurashiki Prehospital Stroke Scale Is a Prehospital Scale That Can Predict Long-Term Outcome of Patients with Acute Cerebral Ischemia

Background and Purpose: Our aim was to confirm the clinical relationship between the Kurashiki Prehospital Stroke Scale (KPSS) scored by paramedics and favorable outcomes in patients with modified Rankin scale (mRS) scores of 0–1 assessed 3 months after symptom onset. Methods: We enrolled patients with acute stroke and transient ischemic attack showing symptoms on admission. Paramedics transferred patients to our hospital after estimating stroke severity using the KPSS. After categorizing patients into either the mRS 0–1 group (favorable outcome) or the mRS 2–6 group (no favorable outcome), we compared the background data between the two groups. We assessed KPSS scores predictive of a favorable outcome. Multivariate regression modeling was conducted to identify factors independently associated with a favorable outcome. Results: The study cohort comprised 147 patients with a premorbid status of mRS 0–1: 69 patients (47%) of them were in the mRS 0–1 group and 78 (53%) in the mRS 2–6 group at the follow-up 3 months after symptom onset. The median KPSS score was lower in the mRS 0–1 group than in the mRS 2–6 group (1 vs. 4, p Conclusion: KPSS score <3 apparently presents a reasonable cutoff for predicting a favorable outcome in patients with acute cerebral ischemia

Right-to-left shunts may be not uncommon cause of TIA in Japan.

BACKGROUND AND PURPOSE: Although 30% to 60% of transient ischemic attacks (TIAs) have embolic sources, the etiology of the remaining TIAs is unknown. Right-to-left shunt (RLS) is one of the most important etiologies of cryptogenic stroke. The aim of this study was to determine whether RLS is related to transient ischemic attack (TIA) of unknown etiology. METHODS: We performed transesophageal echocardiography (TEE) and/or transcranial Doppler (TCD) studies for consecutive TIA patients in order to detect RLS from April 2004 to December 2006. TIA patients were divided into three groups, as follows: 1) Cardioembolic TIA, with a patent cardioembolic source, 2) thrombotic TIA, with an atherothrombotic and/or lacunar mechanism, and 3) undetermined TIA, without identified cause of TIA. We compared the characteristics and presence of RLS among these three groups. RESULTS: We enrolled 124 TIA patients (age: 67+/-13 years old, 80 men). There were 13 patients with Cardioembolic TIA, 25 with Thrombotic TIA, and 86 with Undetermined TIA. TEE and/or TCD were able to detect RLS in 61 of the 124 (49%) patients. RLS was frequent in patients with Undetermined TIA compared with those in the other TIA groups (60% in the Undetermined TIA group, 28% in the Thrombotic TIA group, and 15% in the Cardioembolic TIA group; p<0.001). Smoking and previous history of TIA were frequent in the Thrombotic TIA group (p=0.030 and p=0.016, respectively). CONCLUSION: RLS may play an important role in the etiology of TIA of undetermined cause

Negative Fluid-Attenuated Inversion Recovery- Based Intravenous Thrombolysis Using Recombinant Tissue Plasminogen Activator in Acute Stroke Patients with Unknown Onset Time

Background: Approximately 25% of acute stroke patients were excluded from intravenous thrombolysis using recombinant tissue plasminogen activator (IV-tPA) because of unknown onset time. Recent studies have shown that patients with unknown onset time would be able to receive IV-tPA when showing no ischemia on fluid-attenuated inversion recovery (negative FLAIR). The present study evaluated the safety and feasibility of IV-tPA in patients with unknown onset time and negative FLAIR compared to those with standard IV-tPA. Methods: Stroke patients with unknown onset time were prospectively enrolled. Only patients with an occlusion of the internal carotid artery (ICA) and/or middle cerebral artery (M1 and M2) with a Diffusion-Weighted Imaging-Alberta Stroke Program Early CT Score (DWI-ASPECTS) ≥5 were analyzed. IV-tPA was performed within 3 h from the ‘first found abnormal time' if the patient showed negative FLAIR. Standard IV-tPA patients were extracted from our registry as controls after having been matched by age and occluded artery to the negative FLAIR (N-F) group. Results: Twenty patients in the N-F group and 60 in the control group were included. National Institutes of Health Stroke Scale (NIHSS) scores [median 18 (interquartile range 13-20) vs. 17 (12-20), p = 0.609] and DWI-ASPECTS [9 (7-9) vs. 8 (5-9), p = 0.213] were similar between the 2 groups. ICA occlusion was seen in 35%, M1 in 50%, and M2 in 15% in both groups. None of the N-F group and 1 (2%) of the control group experienced symptomatic intracerebral hemorrhage (p = 1.000). Recanalization within 1 h after IV-tPA was achieved in 6 (30%) patients in the N-F group and 24 (40%) in the control group (p = 0.595). Recanalization at 24 h after IV-tPA was seen in 13 (65%) patients in the N-F group and 43 (72%) in the control group (p = 0.584). At 7 days, 8 (40%) in the N-F group and 28 (47%) in the control group had a dramatic recovery (defined as a ≥10-point reduction in the total NIHSS score or a score of 0 or 1) (p = 0.796). At 3 months, a favorable outcome (modified Rankin scale score, 0-2) was seen in 47% in the N-F group and 33% in the control group (p = 0.365). Conclusion: IV-tPA in negative FLAIR patients with unknown onset time appears safe and feasible

Location of the Susceptibility Vessel Sign on T2*-Weighted MRI and Early Recanalization within 1 Hour after Tissue Plasminogen Activator Administration

Background: We have recently reported that the susceptibility vessel sign (SVS) at the proximal portion of the horizontal (M1) middle cerebral artery (MCA) on T2*-weighted MRI is a strong predictor for no early recanalization after intravenous recombinant tissue plasminogen activator (t-PA) therapy. However, it is unclear whether the presence of the SVS at other locations, such as distal M1, the vertical portion (M2) of the MCA, and distal branches (MCA distal), is a predictor for no early recanalization in acute ischemic stroke patients. Methods: The SVS was defined as a hypointense signal of the MCA on T2*-weighted MRI on admission. The locations of the SVS were classified as M1 proximal, M1 distal, and MCA distal. M1 proximal SVS was defined as an SVS at the origin of the M1. M1 distal SVS was any M1 SVS not including the origin of the M1. MCA distal SVS was an SVS further away from M1. Early recanalization was defined as a new appearance of at least one of the distal branches on MRA within 1 h after t-PA therapy. A good outcome at 3 months was defined as a modified Rankin Scale (mRS) score of 0-1. Results: Consecutive acute stroke patients admitted to our stroke center and treated with t-PA between October 2005 and October 2012 were enrolled. There were 158 patients [median age, 78 (71-84) years; 84 (53%) males; median National Institutes of Health Stroke Scale score, 16 (10-20)]. Internal carotid artery occlusion was seen in 18 (72%) of the 25 patients with M1 proximal SVS, in 3 (14%) of the 22 patients with M1 distal SVS, in 4 (9%) of the 44 patients with MCA distal SVS, and in 18 (27%) of the 67 patients with No SVS (p Conclusion: M1 proximal SVS on T2*-weighted MRI is a strong predictor for no early recanalization, and all patients with it had a poor outcome. However, M1 distal SVS and MCA distal SVS were not predictors for no early recanalization, and half of the patients had a poor outcome