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Li H, Zhang JT, Zheng Y, Zhang DD, Cui XY, Zhao X, Zhang GW, Yang F, Fu Y, Fan XT, Jiang H, Shi JM, Wang B, Zhang R. Risk factors and prognosis of early neurological deterioration in patients with posterior circulation cerebral infarction. Clin Neurol Neurosurg 2023; 228:107673. [PMID: 36958072 DOI: 10.1016/j.clineuro.2023.107673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 02/11/2023] [Accepted: 03/12/2023] [Indexed: 03/15/2023]
Abstract
BACKGROUND The incidence, risk factors, and pathogenesis of early neurological deterioration (END) in posterior circulation stroke are still unclear. In this study, we aimed to determine the risk factors and prognosis of END in patients with acute posterior circulation cerebral infarction. METHODS Acute posterior circulation ischemic stroke patients who had completed neuroimaging within 72 h of onset were selected from a prospective registry study Demographic characteristics, physiological data, medical history, laboratory data, in-hospital evaluation, neurological severity and TOAST classification, treatment, and the modified Rankin Scale (mRS) score of patients were assessed. Early neurological deterioration was defined as an increase of 2 points in the National Institutes of Health Stroke Scale score between the baseline and 72 h evaluation. Favorable and poor outcomes were defined as mRSs of 02 and≥ 3, respectively, at 3 months. The incidence and risk factors were evaluated by univariate and multivariate regression analysis (step-back method). RESULTS The analysis included 455 subjects with an acute posterior circulation non-cardiac ischemic stroke, 330 (72.53 %) of them male, with an average age of 63.12 ( ± 10.14) years and with 47 (10.33 %) having END. The results of univariate and multivariate logistic regression analysis showed that BATMAN scores ≥ 5 (OR: 0.1, 95 % CI: 0.02-0.53, P < 0.01), large artery atherosclerosis (OR: 11.55, 95 % CI: 4.18-31.93, P < 0.01), vascular stenosis > 50 % (OR: 2.44, 95 % CI: 1.1-5.42, P = 0.029), reperfusion therapy (OR: 4.21, 95 % CI: 1.66-10.64, P < 0.01), and the distribution of pontine lesions (OR: 5.66, 95 % CI: 2.39-13.44, P < 0.01) were significantly associated with END. Patients with END had a lower rate of favorable outcomes at discharge and long-term follow-up (P < 0.001), regardless of whether they received reperfusion therapy. CONCLUSION The lesion distribution of the pons, the progression of temporo-occipital lobe lesions, and large arterial atherosclerosis are independent risk factors of END that might predict a poor short- and long-term prognosis.
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Affiliation(s)
- Hui Li
- Chengde Medical University, Chengde, Hebei 067000, China; Department of Neurology, Chengde Central Hospital, Chengde, Hebei 067000, China
| | - Jiang-Tao Zhang
- Department of Neurology, Chengde Central Hospital, Chengde, Hebei 067000, China
| | - Yi Zheng
- Image center, Chengde Central Hospital, Chengde, China
| | - Ding-Ding Zhang
- Central laboratory, Peking Union Medical College Hospital, Beijing, China
| | - Xiu-Ying Cui
- Department of Neurology, Chengde Central Hospital, Chengde, Hebei 067000, China
| | - Xin Zhao
- Department of Neurology, Chengde Central Hospital, Chengde, Hebei 067000, China
| | - Guan-Wen Zhang
- Department of Neurology, Chengde Central Hospital, Chengde, Hebei 067000, China
| | - Fei Yang
- Chengde Medical University, Chengde, Hebei 067000, China; Department of Neurology, Chengde Central Hospital, Chengde, Hebei 067000, China
| | - Yu Fu
- Chengde Medical University, Chengde, Hebei 067000, China; Department of Neurology, Chengde Central Hospital, Chengde, Hebei 067000, China
| | - Xiao-Tian Fan
- Chengde Medical University, Chengde, Hebei 067000, China; Department of Neurology, Chengde Central Hospital, Chengde, Hebei 067000, China
| | - Hao Jiang
- Clinical blood laboratory, Chengde Central Hospital, Chengde, China
| | - Jian-Ming Shi
- Information center, Chengde Central Hospital, Chengde, China
| | - Bo Wang
- Department of Neurology, Bijie People's Hospital, Guizhou, China
| | - Ran Zhang
- Department of Neurology, Chengde Central Hospital, Chengde, Hebei 067000, China.
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Endovascular Treatment of Basilar Artery Occlusion: What Can We Learn from the Results? MEDICINA (KAUNAS, LITHUANIA) 2022; 59:medicina59010096. [PMID: 36676720 PMCID: PMC9866638 DOI: 10.3390/medicina59010096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 12/27/2022] [Accepted: 12/28/2022] [Indexed: 01/03/2023]
Abstract
Background and Objectives: Current guidelines lack specific endovascular treatment (EVT) recommendations for posterior circulation stroke (PCS). The results of earlier studies are controversial. We aimed to compare early hospital outcomes of stroke caused by large-vessel occlusion (LVO) treated with EVT or bridging therapy (BT) in anterior circulation stroke (ACS) versus PCS (middle cerebral artery occlusion (MCAO) and basilar artery occlusion (BAO), and establish the risk factors for poor outcome. Materials and Methods: we analyzed the data of 279 subjects treated with EVT due to LVO-caused stroke in a comprehensive stroke centre in 2015−2021. The primary outcome was hospital mortality, secondary outcomes were National Institutes of Health Stroke Scale (NIHSS) after 24 h, early neurological deterioration, futile recanalization (FR), the ambulatory outcome at discharge, and complications. Results: BAO presented with higher baseline NIHSS scores (19 vs. 14, p < 0.001), and longer door-to-puncture time (93 vs. 82 min, p = 0.034), compared to MCAO. Hospital mortality and the percentage of FR were the same in BAO and almost two times higher than in MCAO (20.0% vs. 10.3%, p = 0.048), other outcomes did not differ. In BAO, unsuccessful recanalization was the only significant predictor of the lethal outcome, though there were trends for PAD and RF predicting lethal outcome. A trend for higher risk of symptomatic intracranial hemorrhage (sICH) was observed in the BAO group when BT was applied. Nevertheless, neither BT nor sICH predicted lethal outcomes in the BAO group. Conclusions: Compared to the modern gold standard of EVT in the ACS, early outcomes in BAO remain poor, there is a substantial amount of FR. Nevertheless, unsuccessful recanalization remains the strongest predictor of lethal outcomes. BT in PCS might pose a higher risk for sICH, but not the lethal outcome, although this finding requires further investigation in larger trials.
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Kim M, Park SY, Lee SE, Lee JS, Hong JM, Lee SJ. Significance of Vertigo, Imbalance, and Other Minor Symptoms in Hyperacute Treatment of Posterior Circulation Stroke. Front Neurol 2022; 13:845707. [PMID: 35651338 PMCID: PMC9150563 DOI: 10.3389/fneur.2022.845707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 04/25/2022] [Indexed: 12/01/2022] Open
Abstract
Background This study aimed to determine the clinical significance of acute vestibular syndrome (AVS)/acute imbalance syndrome (AIS) in posterior circulation stroke (PCS) and how it should be addressed in the thrombolysis code. Methods Our institution has recently changed its thrombolysis code from one that is generous to AVS/AIS to one that is exclusive. The subjects in this study were patients with PCS who presented before this transition (May 2016 to April 2018, period 1) and those who presented after (January 2019 to December 2020, period 2) with an onset-to-door time of 4.5 h. Hyperacute stroke treatment was compared between the two periods. The clinical significance of AVS/AIS was evaluated by dichotomizing the patients' clinical severity to minor or major deficits, then evaluating the significance of AVS/AIS in each group. Presenting symptoms of decreased mental alertness, hemiparesis, aphasia (anarthria), or hemianopsia were considered major PCS symptoms, and patients who did not present with these symptoms were considered minor PCS. Results In total, 114 patients presented in period 1 and 114 in period 2. Although the code activation rate was significantly lower in period 2 (72.8% vs. 59.7%), p = 0.04, there were no between-group differences in functional outcomes (mRS score at 3 months; 1 [0–3] vs. 0 [0–3], p = 0.18). In 77 patients with PCS and AVS/AIS, the difference in code activation rate was not significant according to changes in thrombolysis code. In minor PCS, AVS/AIS was associated with lower NIHSS scores, lower early neurological deterioration rates, and favorable outcomes. In major PCS, while AVS/AIS was not associated with outcomes, the majority of cases were prodromal AVS/AIS which simple vertigo and imbalance symptoms were followed by a major PCS symptom. Conclusions This study failed to show differences in outcome in patients with PCS according to how AVS/AIS is addressed in the stroke thrombolysis code. In patients with minor PCS, AVS/AIS was associated with a benign clinical course. Prompt identification of prodromal AVS/AIS is essential.
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Affiliation(s)
- Min Kim
- Department of Neurology, Ajou University Medical Center, Ajou University School of Medicine, Suwon, South Korea
| | - So Young Park
- Department of Neurology, Ajou University Medical Center, Ajou University School of Medicine, Suwon, South Korea
| | - Sung Eun Lee
- Department of Emergency Medicine, Ajou University Medical Center, Ajou University School of Medicine, Suwon, South Korea
| | - Jin Soo Lee
- Department of Neurology, Ajou University Medical Center, Ajou University School of Medicine, Suwon, South Korea
| | - Ji Man Hong
- Department of Neurology, Ajou University Medical Center, Ajou University School of Medicine, Suwon, South Korea
| | - Seong-Joon Lee
- Department of Neurology, Ajou University Medical Center, Ajou University School of Medicine, Suwon, South Korea
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Lee SJ, Hong JM, Kim JS, Lee JS. Endovascular Treatment for Posterior Circulation Stroke: Ways to Maximize Therapeutic Efficacy. J Stroke 2022; 24:207-223. [PMID: 35677976 PMCID: PMC9194547 DOI: 10.5853/jos.2022.00941] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 05/20/2022] [Indexed: 11/11/2022] Open
Abstract
The efficacy of endovascular treatment (EVT) in patients with posterior circulation stroke has not been proven. Two recent randomized controlled trials failed to show improved functional outcomes after EVT for posterior circulation stroke (PC-EVT). However, promising results for two additional randomized controlled trials have also been presented at a recent conference. Studies have shown that patients undergoing PC-EVT had a higher rate of futile recanalization than those undergoing EVT for anterior circulation stroke. These findings call for further identification of prognostic factors beyond recanalization. The significance of baseline clinical severity, infarct volume, collaterals, time metrics, core-penumbra mismatch, and methods to accurately measure these parameters are discussed. Furthermore, their interplay on EVT outcomes and the potential to individualize patient selection for PC-EVT are reviewed. We also discuss technical considerations for improving the treatment efficacy of PC-EVT.
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Affiliation(s)
- Seong-Joon Lee
- Department of Neurology, Ajou University School of Medicine, Suwon, Korea
| | - Ji Man Hong
- Department of Neurology, Ajou University School of Medicine, Suwon, Korea
| | - Jong S. Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Soo Lee
- Department of Neurology, Ajou University School of Medicine, Suwon, Korea
- Correspondence: Jin Soo Lee Department of Neurology, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon 16499, Korea Tel: +82-31-219-5175 Fax: +82-31-219-5178 E-mail:
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