Early Neurological Deterioration after Recanalization Treatment in Patients with Acute Ischemic Stroke: A Retrospective Study

Detection of early neurological deterioration using a quantitative electroencephalography system in patients with large vessel occlusion stroke after endovascular treatment

BACKGROUND

Early neurological deterioration (END) is a serious complication in patients with large vessel occlusion (LVO) stroke. However, modalities to monitor neurological function after endovascular treatment (EVT) are lacking. This study aimed to evaluate the diagnostic accuracy of a quantitative electroencephalography (qEEG) system for detecting END.

METHODS

In this prospective, nested case-control study, we included 47 patients with anterior circulation LVO stroke and 34 healthy adults from different clinical centers in Tianjin, China, from May 2023 to January 2024. Patients with stroke underwent EEG at admission and after EVT. The diagnostic accuracy of qEEG features for END was evaluated by receiver operating characteristic curve analysis, and the feasibility was evaluated by the percentage of artifact-free data and device-related adverse events.

RESULTS

14 patients with stroke had END (29.8%, 95% CI 16.2% to 43.4%), with most developed within 12 hours of recanalization (n=11). qEEG features showed significant correlations with National Institutes of Health Stroke Scale score and infarct volume. After matching, 13 patients with END and 26 controls were included in the diagnostic analysis. Relative alpha power demonstrated the highest diagnostic accuracy for the affected and unaffected hemispheres. The optimal electrode positions were FC3/4 in the unaffected hemisphere, and F7/8 and C3/4 in the affected hemisphere. No device-related adverse events were reported.

CONCLUSION

The qEEG system exhibits a high diagnostic accuracy for END and may be a promising tool for monitoring neurological function. The identification of optimal electrode positions may enhance device convenience.

CLINICAL TRIAL REGISTRATION

ChiCTR 2300070829.

Systolic blood pressure and early neurological deterioration in minor stroke: A post hoc analysis of ARAMIS trial

BACKGROUND

Systolic blood pressure (SBP) was a predictor of early neurological deterioration (END) in stroke. We performed a secondary analysis of ARAMIS trial to investigate whether baseline SBP affects the effect of dual antiplatelet versus intravenous alteplase on END.

METHODS

This post hoc analysis included patients in the as-treated analysis set. According to SBP at admission, patients were divided into SBP ≥140 mmHg and SBP <140 mmHg subgroups. In each subgroup, patients were further classified into dual antiplatelet and intravenous alteplase treatment groups based on study drug actually received. Primary outcome was END, defined as an increase of ≥2 in the NIHSS score from baseline within 24 h. We investigated effect of dual antiplatelet vs intravenous alteplase on END in SBP subgroups and their interaction effect with subgroups.

RESULTS

A total of 723 patients from as-treated analysis set were included: 344 were assigned into dual antiplatelet group and 379 into intravenous alteplase group. For primary outcome, there was more treatment effect of dual antiplatelet in SBP ≥140 mmHg subgroup (adjusted RD, -5.2%; 95% CI, -8.2% to -2.3%; p < 0.001) and no effect in SBP <140 mmHg subgroup (adjusted RD, -0.1%; 95% CI, -8.0% to 7.7%; p = 0.97), but no significant interaction between subgroups was found (adjusted p = 0.20).

CONCLUSIONS

Among patients with minor nondisabling acute ischemic stroke, dual antiplatelet may be better than alteplase with respect to preventing END within 24 h when baseline SBP ≥140 mmHg.

Therapeutic potential of Angelica sinensis in addressing organ fibrosis: A comprehensive review

Fibrosis-related diseases (FRD) include conditions like myocardial fibrosis, pulmonary fibrosis, hepatic fibrosis, renal fibrosis, and others. The impact of fibrosis can be severe, causing organ dysfunction, reduced functionality, and even organ failure, leading to significant health issues. Currently, there is a lack of effective modern anti-fibrosis drugs in clinical practice. However, Chinese medicine has a certain beneficial effect on the treatment of such diseases. Angelica sinensis, with its considerable medicinal value, has garnered attention for its anti-fibrosis properties in recent investigations. In the past few years, there has been a growing number of experimental inquiries into the impact of angelica polysaccharide (ASP), angelica water extract, angelica injection, and angelica compound preparation on fibrosis-associated ailments, piquing the interest of researchers. This paper aims to consolidate recent advances in the study of Angelica sinensis for the treatment of fibrosis-related disorders, offering insights for prospective investigations. Literature retrieval included core electronic databases, including Baidu Literature, CNKI, Google-Scholar, PubMed, and Web of Science. The applied search utilized specified keywords to extract relevant information on the pharmacological and phytochemical attributes of plants. The investigation revealed that Angelica sinensis has the potential to impede the advancement of fibrotic diseases by modulating inflammation, oxidative stress, immune responses, and metabolism. ASP, Angelica sinensis extract, Angelica sinensis injection, and Angelica sinensis compound preparation were extensively examined and discussed. These constituents demonstrated significant anti-fibrosis activity. In essence, this review seeks to gain a profound understanding of the role of Angelica sinensis in treating fiber-related diseases. Organ fibrosis manifests in nearly all tissues and organs, posing a critical challenge to global public health due to its widespread occurrence, challenging early diagnosis, and unfavorable prognosis. Despite its prevalence, therapeutic options are limited, and their efficacy is constrained. Over the past few years, numerous studies have explored the protective effects of traditional Chinese medicine on organ fibrosis, with Angelica sinensis standing out as a multifunctional natural remedy. This paper provides a review of organ fibrosis pathogenesis and summarizes the recent two decades' progress in treating fibrosis in various organs such as the liver, lung, kidney, and heart. The review highlights the modulation of relevant signaling pathways through multiple targets and channels by the effective components of Angelica sinensis, whether used as a single medicine or in compound prescriptions.

Safety and efficacy of tirofiban in preventing neurological deterioration in acute ischemic stroke (TREND): Protocol for an investigator-initiated, multicenter, prospective, randomized, open-label, masked endpoint trial

INTRODUCTION

Antithrombotic therapy prevents adverse ischemic events following acute ischemic stroke (AIS). Intravenous tirofiban provides desirable antiplatelet effects, especially in patients who are vulnerable to neurological deterioration (ND).

AIM

The aim of the study was to test the hypothesis that intravenous administration of tirofiban, initiated within 24 h of ictus and continued for consecutive 72 h, would be more effective than aspirin in reducing the risk of ND within 72 h of enrollment among patients with potentially atherothrombotic ischemic stroke.

METHODS

The Safety and Efficacy of Tirofiban in Preventing Neurological Deterioration in Acute Ischemic Stroke (TREND) trial is an investigator-initiated, multicenter, prospective, randomized, open-label, masked endpoint study. Its eligibility criteria included AIS secondary to potential atherosclerosis, a National Institutes of Health Stroke Scale (NIHSS) score ranging from 4 to 20 points, ineligibility for recanalization therapy, and administration within 24 h postsymptom onset. Randomization was performed at a 1:1 ratio to allocate 420 patients into two groups to receive an intravenous tirofiban bridge to oral antiplatelet drugs or direct oral antiplatelet drugs.

OUTCOMES

The primary outcome is the proportion of patients with a ≥4-point increase in NIHSS score within 72 h of intervention compared to the score at enrollment. The key secondary outcomes include changes in NIHSS score, modified Rankin scale (mRS) score at 90 days, and dichotomized mRS scores (0-2 vs. 3-6 and 0-1 vs. 2-6) at 90 days. The safety variables are symptomatic intracerebral hemorrhage, any intracerebral hemorrhage, and systemic hemorrhage within 72 h after randomization and 90-day mortality.

CONCLUSIONS

The TREND trial may identify the suitability of intravenous tirofiban as a routine clinical strategy to prevent ND in patients with AIS within 24 h of the onset of symptoms.

TRIAL REGISTRATION

http://www.clinicaltrials.gov (identifier: NCT04491695).

Early neurological deterioration in patients with acute ischemic stroke is linked to unfavorable cerebral venous outflow

INTRODUCTION

Early neurological deterioration (END) is associated with poor outcomes in patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO). Causes of END after mechanical thrombectomy (MT) include unsuccessful recanalization and reperfusion hemorrhages. However, little is known about END excluding the aforementioned causes. We aimed to investigate factors associated with unexplained END (ENDunexplained) with regard to the cerebral collateral status.

PATIENTS AND METHODS

Multicenter retrospective study of AIS-LVO patients with successful MT (mTICI 2b-3). On admission CT angiography (CTA), pial arterial collaterals and venous outflow (VO) were assessed using the modified Tan-Scale and the Cortical Vein Opacification Score (COVES), respectively. ENDunexplained was defined as an increase in NIHSS score of ⩾ 4 within the first 24 hours after MT without parenchymal hemorrhage on follow-up imaging. Multivariable regression analyses were performed to examine factors of ENDunexplained and unfavorable functional outcome (modified Rankin Scale score 3-6).

RESULTS

A total of 620 patients met the inclusion criteria. ENDunexplained occurred in 10% of patients. While there was no significant difference in pial arterial collaterals, patients with ENDunexplained exhibited more often unfavorable VO (81% vs. 53%; P < 0.001). Unfavorable VO (aOR [95% CI]; 2.56 [1.02-6.40]; P = 0.045) was an independent predictor of ENDunexplained. ENDunexplained was independently associated with unfavorable functional outcomes at 90 days (aOR [95% CI]; 6.25 [2.06-18.94]; P = 0.001).

DISCUSSION AND CONCLUSION

Unfavorable VO on admission CTA was associated with ENDunexplained. ENDunexplained was independently linked to unfavorable functional outcomes at 90 days. Identifying AIS-LVO patients at risk of ENDunexplained may help to select patients for intensified monitoring and guide to optimal treatment regimes.

Hemodynamic predictors of early neurological deterioration and clinical outcome after endovascular treatment in large artery occlusion

Objective

Half of the patients with acute large artery occlusion (LAO) have poor outcomes after endovascular treatment (EVT). Early complications such as cerebral edema and symptomatic intracranial hemorrhage (sICH) can lead to early neurological deterioration (END), which correlates with hemodynamics. This study aimed to identify the hemodynamic predictors of END and outcomes in LAO patients after EVT.

Methods

A total of 76 patients with anterior circulation LAO who underwent EVT and received transcranial Doppler (TCD) monitoring were included. Bilateral middle cerebral artery (MCA) blood flow velocities (BFVs) were measured repeatedly within 1 week. Mean flow velocities (MFV) and MFV index (ipsilateral MFV/contralateral MFV) were calculated. The primary outcome was the incidence of END within 72 h. The secondary outcome was the functional outcome at 90 days-a good outcome was defined as a modified Rankin scale (mRS) score of 0-2, while a poor outcome was defined as an mRS score of 3-6.

Results

A total of 13 patients (17.1 %) experienced END within 72 h, including 5 (38.5 %) with cerebral edema, 5 (38.5 %) with sICH, and 3 (23.0 %) with infarct progression. Multivariable logistic regression analysis showed that a higher 24 h MFV index was independently associated with END (aOR 10.5; 95 % CI 2.28-48.30, p = 0.003) and a poor 90-day outcome (aOR 5.10; 95 % CI 1.38-18.78, p = 0.014). The area under the receiver operating characteristic (ROC) curve (AUC) of the 24 h MFV index for predicting END was 0.807 (95 % CI 0.700-0.915, p = 0.0005), the sensitivity was 84.6 %, and the specificity was 66.7 %. At the 1-week TCD follow-up, patients who had poor 90-day outcomes showed significantly higher 1-week iMFV [73.5 (58.4-99.0) vs. 57.7 (45.3-76.3), p = 0.004] and MFV index [1.24 (0.98-1.57) vs.1.0 (0.87-1.15) p = 0.007]. A persistent high MFV index (PHMI) was independently associated with a poor outcome (aOR 7.77, 95 % CI 1.81-33.3, p = 0.006).

Conclusion

TCD monitoring within 24 h after EVT in LAO patients can help predict END, while dynamic follow-up within 1 week is valuable in predicting clinical outcomes.

Application of a nomogram model for the prediction of 90-day poor outcomes following mechanical thrombectomy in patients with acute anterior circulation large-vessel occlusion

Background

The past decade has witnessed advancements in mechanical thrombectomy (MT) for acute large-vessel occlusions (LVOs). However, only approximately half of the patients with LVO undergoing MT show the best/independent 90-day favorable outcome. This study aimed to develop a nomogram for predicting 90-day poor outcomes in patients with LVO treated with MT.

Methods

A total of 187 patients who received MT were retrospectively analyzed. Factors associated with 90-day poor outcomes (defined as mRS of 4-6) were determined by univariate and multivariate logistic regression analyzes. One best-fit nomogram was established to predict the risk of a 90-day poor outcome, and a concordance index was utilized to evaluate the performance of the model. Additionally, 145 patients from a single stroke center were retrospectively recruited as the validation cohort to test the newly established nomogram.

Results

The overall incidence of 90-day poor outcomes was 45.16%, affecting 84 of 186 patients in the training set. Moreover, five variables, namely, age (odds ratio [OR]: 1.049, 95% CI [1.016-1.083]; p = 0.003), glucose level (OR: 1.163, 95% CI [1.038-1.303]; p = 0.009), baseline National Institute of Health Stroke Scale (NIHSS) score (OR: 1.066, 95% CI [0.995-1.142]; p = 0.069), unsuccessful recanalization (defined as a TICI grade of 0 to 2a) (OR: 3.730, 95% CI [1.688-8.245]; p = 0.001), and early neurological deterioration (END, defined as an increase of ≥4 points between the baseline NIHSS score and the NIHSS score at 24 h after MT) (OR: 3.383, 95% CI [1.411-8.106]; p = 0.006), were included in the nomogram to predict the potential risk of poor outcomes at 90 days following MT in LVO patients, with a C-index of 0.763 (0.693-0.832) in the training set and 0.804 (0.719-0.889) in the validation set.

Conclusion

The proposed nomogram provided clinical evidence for the effective control of these risk factors before or during the process of MT surgery in LVO patients.

Prediction of early neurological deterioration in acute ischemic stroke patients treated with intravenous thrombolysis

A proportion of acute ischemic stroke (AIS) patients suffer from early neurological deterioration (END) within 24 hours following intravenous thrombolysis (IVT), which greatly increases the risk of poor prognosis of these patients. Therefore, we aimed to explore the predictors of early neurological deterioration of ischemic origin (ENDi) in AIS patients after IVT and develop a nomogram prediction model. This study collected 244 AIS patients with post-thrombolysis ENDi as the derivation cohort and 155 patients as the validation cohort. To establish a nomogram prediction model, risk factors were identified by multivariate logistic regression analysis. The results showed that neutrophil to lymphocyte ratio (NLR) (OR 2.616, 95% CI 1.640-4.175, P < 0.001), mean platelet volume (MPV) (OR 3.334, 95% CI 1.351-8.299, P = 0.009), body mass index (BMI) (OR 1.979, 95% CI 1.285-3.048, P = 0.002) and atrial fibrillation (AF) (OR 8.012, 95% CI 1.341-47.873, P = 0.023) were significantly associated with ENDi. The area under the curve of the prediction model constructed from the above four factors was 0.981 (95% CI 0.961-1.000) and the calibration curve was close to the ideal diagonal line. Therefore, this nomogram prediction model exhibited good discrimination and calibration power and might be a reliable and easy-to-use tool to predict post-thrombolysis ENDi in AIS patients.

Prominent Vessel Signs After Endovascular Thrombectomy Corelates with Unexplained Neurological Deterioration and is a More Reliable Imaging Predictor of Prognosis in Anterior Large Vessel Occlusion Stroke

OBJECTIVE

Fifty percent of patients who undergo endovascular thrombectomy (EVT) for large-vessel occlusion exhibit unfavorable outcomes. The primary factor is attributed to persistent brain impairment even after successful EVT. The prominent vessel sign (PVS) on magnetic resonance susceptibility-weighted imaging reflects the territory of dysmetabolism and may facilitate an expeditious assessment for prognostication. We aimed to examine the relationship between PVS after EVT and the occurrence of early neurological deterioration (END) and 3-month outcomes.

METHODS

Patients who underwent EVT and multimodal magnetic resonance imaging were included. END was defined as an increase of ≥2 in the National Institutes of Health Stroke Scale within 72 hours after EVT. Symptomatic intracranial hemorrhage, malignant edema, and surgical complications were defined as definite END, whereas the other symptoms were categorized as unexplained END (ux-END). The PVS-Alberta Stroke Program Early CT Score (ASPECTS) score was used to evaluate the asymmetric cerebral venous signal on the susceptibility-weighted imaging sequences semiquantitatively.

RESULTS

A total of 116 eligible patients were included, 18 (15.5%) of whom presented with ux-END. The 72 hour National Institutes of Health Stroke Scale was strongly correlated with diffusion-weighted imaging infarct volume and PVS-ASPECTS and was significantly higher in the ux-END group (16 ± 6 vs. 5 ± 4, P = 0.001). The PVS-ASPECTS score was significantly associated with poor outcomes (odds ratio 2.551, 95% confidence interval (CI) 1.722-3.780, P＜0.001), and PVS-ASPECTS (area under the curve 0.884, 95% CI 0.815-0.953, P < 0.001) was superior to diffusion-weighted imaging infarct volume (area under the cure 0.720, 95% CI 0.620-0.820, P = 0.001) in predicting 3-month poor outcome. At the optimal cut-off of 2, the PVS-ASPECT predicted poor outcomes with a sensitivity of 89.7% and a specificity of 78.2%.

CONCLUSIONS

PVS 72 hours after EVT correlated with ux-END. The PVS-ASPECTS is a more reliable predictor of stroke prognosis and provides valuable information regarding post-EVT management.

Nomogram model of functional outcome for endovascular treatment in patients with acute basilar artery occlusion

Background and purpose

The efficacy and safety of endovascular treatment (EVT) in acute basilar artery occlusion (ABAO) has been confirmed by four randomized clinical trials. Nevertheless, the predictors of a 90-day favorable outcome after EVT have not been elucidated. We attempted to establish a nomogram for the prediction of a 90-day favorable outcome in ABAO patients with EVT.

Methods

Clinical data of ABAO patients with EVT were obtained from two nationwide clinical trial registries in China. Factors associated with a 90-day favorable outcome were screened by multivariable step-wise regression on the basis of univariable analysis. A nomogram was established to predict 90-day favorable outcome after EVT.

Results

The proportion of ABAO patients with a favorable outcome was 41.53% (157/378). Seven variables, including baseline National Institutes of Health Stroke Scale (NIHSS) <20 [odds ratio (OR): 8.330; P-value < 0.0001], posterior circulation Alberta Stroke Program Early CT (pc-ASPECT) score ≥7 (OR: 1.948; P-value = 0.0296), Pons-Midbrain Index (PMI) score < 2 (OR: 2.108; P-value = 0.0128), Posterior Circulation Collateral Score (PC-CS) ≥5 (OR: 3.288; P-value < 0.0001), local anesthesia (OR: 0.389; P-value = 0.0017), time from onset to recanalization (OTR) <330 min (OR: 2.594; P-value = 0.0013), and no occurrence of early neurological deterioration (END; OR: 0.039; P-value < 0.0001) were included into the nomogram, with C-index values of 0.8730 and 0.8857 in the training and the internal validation set, respectively.

Conclusions

The proposed nomogram provided a reliable prognostic scale, which can be employed in clinical settings for the selection and clinical management of ABAO patients.

Registration

https://www.clinicaltrials.gov, identifier: NCT03370939.

CNS-LAND score: predicting early neurological deterioration after intravenous thrombolysis based on systemic responses and injury

Importance

Early neurological deterioration (END) is a critical complication in acute ischemic stroke (AIS) patients receiving intravenous thrombolysis (IVT), with a need for reliable prediction tools to guide clinical interventions.

Objective

This study aimed to develop and validate a rating scale, utilizing clinical variables and multisystem laboratory evaluation, to predict END after IVT.

Design setting and participants

The Clinical Trial of Revascularization Treatment for Acute Ischemic Stroke (TRAIS) cohort enrolled consecutive AIS patients from 14 stroke centers in China (Jan 2018 to Jun 2022).

Outcomes

END defined as NIHSS score increase >4 points or death within 24 h of stroke onset.

Results

1,213 patients (751 in the derivation cohort, 462 in the validation cohort) were included. The CNS-LAND score, a 9-point scale comprising seven variables (CK-MB, NIHSS score, systolic blood pressure, LDH, ALT, neutrophil, and D-dimer), demonstrated excellent differentiation of END (derivation cohort C statistic: 0.862; 95% CI: 0.796-0.928) and successful external validation (validation cohort C statistic: 0.851; 95% CI: 0.814-0.882). Risk stratification showed END risks of 2.1% vs. 29.5% (derivation cohort) and 2.6% vs. 31.2% (validation cohort) for scores 0-3 and 4-9, respectively.

Conclusion

CNS-LAND score is a reliable predictor of END risk in AIS patients receiving IVT.

A nomogram predicts early neurological deterioration after mechanical thrombectomy in patients with ischemic stroke

Introduction

Early neurological deterioration (END) is common in acute ischemic stroke and is directly associated with poor outcome after stroke. Our aim is to develop and validate a nomogram to predict the risk of END after mechanical thrombectomy (MT) in acute ischemic stroke patients with anterior circulation large-vessel occlusion.

Methods

We conducted a real-world, multi-center study in patients with stroke treated with mechanical thrombectomy. END was defined as a worsening by 2 or more NIHSS points within 72-hour after stroke onset compared to admission. Multivariable logistic regression was used to determine the independent predictors of END, and the discrimination of the scale was assessed using the C-index. Calibration curves were constructed to evaluate the calibration of the nomogram, and decision curves were used to describe the benefits of using the nomogram.

Results

A total of 1007 patients were included in our study. Multivariate logistic regression analysis found age, admission systolic blood pressure, initial NIHSS scores, history of hyperlipemia, and location of occlusion were independent predictors of END. We developed a nomogram that included these 6 factors, and it revealed a prognostic accuracy with a C-index of 0.678 in the derivation group and 0.650 in the validation group. The calibration curves showed that the nomogram provided a good fit to the data, and the decision curves demonstrated a large net benefit.

Discussion

Our study established and validated a nomogram to stratify the risk of END before mechanical embolectomy and identify high-risk patients, who should be more cautious when making clinical decisions.

Predictors and outcome of early neurological deterioration after endovascular thrombectomy: a secondary analysis of the DIRECT-MT trial

BACKGROUND

There is uncertainty regarding the predictors of early neurological deterioration (END) after endovascular thrombectomy in patients with acute ischemic stroke (AIS). Limited studies have focused on the effect of END on functional outcome. Our aim was to determine the predictors of END after endovascular thrombectomy in AIS and its effect on functional outcome at 90 days.

METHODS

This is a secondary analysis of the DIRECT-MT trial. Patients who failed to complete endovascular thrombectomy were additionally excluded. END was defined as ≥4-point increase in National Institutes of Health Stroke Scale score between admission and 24 hours after endovascular thrombectomy. Multivariable logistic regression was used to identify predictors for END and its effect on the modified Rankin Scale (mRS) score at 90 days.

RESULTS

Of 591 patients enrolled, 111 (18.8%) had postoperative END, which was associated with higher ordinal mRS score at 90 days (adjusted common OR (aOR) 6.968, 95% CI 4.444 to 10.926). Non-modifiable factors included baseline Alberta Stroke Program Early CT Score (aOR 0.883, 95% CI 0.790 to 0.987), systolic blood pressure (aOR 1.017, 95% CI 1.006 to 1.028), glucose level (aOR 1.178, 95% CI 1.090 to 1.273), collateral status (aOR 0.238, 95% CI 0.093 to 0.608), occlusion site (aOR 0.496, 95% CI 0.290 to 0.851) and the presence of an anterior communicating artery (aOR 0.323, 95% CI 0.148 to 0.707). Admission-to-groin puncture time (aOR 1.010, 95% CI 1.003 to 1.017), general anesthesia (aOR 2.299, 95% CI 1.193 to 4.444), number of passes (aOR 1.561, 95% CI 1.243 to 1.961) and contrast extravasation (aOR 6.096, 95% CI 1.543 to 24.088) were modifiable predictors for END.

CONCLUSIONS

Postoperative END is associated with adverse functional outcome. Several non-modifiable and modifiable factors can predict END and support future treatment decision-making to improve the potential utility of endovascular thrombectomy.

TRIAL REGISTRATION NUMBER

DIRECT-MT ClinicalTrials.gov NCT03469206.

Association of triglyceride-glucose index with early neurological deterioration events in patients with acute ischemic stroke

BACKGROUND

The Triglyceride and Glucose (TyG) index has been found to have a strong correlation with the recurrence of acute ischemic stroke (AIS) and poor patient outcomes. Nevertheless, the relationship between the TyG index and early neurological deterioration (END) has not been fully explored. Therefore, the present study aims to investigate the potential association between the TyG index and END.

METHODS

A retrospective analysis of 2129 patients diagnosed with AIS between January 2019 and December 2022 at the Second Affiliated Hospital of Harbin Medical University. Patients were divided into END and non-END groups based on changes in National Institutes of Health Stroke Scale scores within 7 days of admission, and the differences in the indicators between the two groups were examined using univariate analysis. The patients were then divided into three groups based on the tertile of the TyG index (T1: TyG index < 8.662; T2: 8.662 ≤ TyG index < 9.401; T3: TyG index ≥ 9.401), and logistic regression analysis was used to examine the association between the TyG index and END. Finally, the predictive ability of the TyG index was evaluated using the receiver operating characteristic (ROC) curve.

RESULTS

A total of 724 patients experienced END. The results of the analysis showed that the TyG index was significantly higher in the END group compared to the non-END group. Furthermore, the TyG index was found to be an independent risk factor for the development of END (OR, 1.561; 95% 1.166-2.090, P = 0.003). After adjusting for confounders, the risk of END was 3.953 (95% CI 2.793-5.595; P < 0.001) and 5.906 (95% CI 3.676-9.488; P < 0.001) times higher in the T2 and T3 groups, respectively, in contrast to the T1 group. The area under the ROC curve of the TyG index was 0.711 (0.688-0.733), indicating an excellent predictive indicator.

CONCLUSIONS

Our study uncovered that higher TyG index levels were associated with END development in AIS patients.

Risk factors and prognosis of early neurological deterioration in patients with posterior circulation cerebral infarction

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.

Early neurological deterioration as a predictor of outcomes after endovascular thrombectomy for stroke: A systematic review and meta-analysis

BACKGROUND

Early neurological deterioration (END) is a potential predictor for 90-day outcomes following mechanical thrombectomy for acute ischemic stroke (AIS). We performed a systematic review and meta-analysis to better understand whether END can be used as a surrogate for long-term outcomes.

METHODS

Following the PRISMA guidelines, a systematic literature review of the English language literature was conducted using PubMed, MEDLINE, and Embase. END definition was cataloged for each included study. Outcomes of interest included 90-day modified Rankin Scale (mRS) 0-2, symptomatic intracranial hemorrhage (sICH), mortality, and thrombolysis in cerebral infarction (TICI) 2b-3. We calculated pooled odds ratios (ORs) and their corresponding 95% confidence intervals (CI) for all definitions of END.

RESULTS

We included seven studies with 2992 patients in our analysis. There was a significant, inverse association with END and mRS 0-2 rates (OR = 0.15; 95% CI = 0.08-0.29; P-value< 0.001). Moreover, END was a significant predictor of increased odds for reported sICH rates (OR = 16.37; 95% CI = 7.66-34.99; P-value< 0.001). Furthermore, there was a significant association between END and increase in mortality rates (OR = 6.79; 95% CI = 2.62-17.62; P-value< 0.001). There was no significant association between END and rates of TICI 2b-3 (OR = 0.53; 95% CI = 0.27-1.05; p = 0.069).

CONCLUSIONS

Broadly defined, END holds value as a potential predictor of rates of mRS 0-2 at 90 days and is associated with higher rates of mortality and sICH, but had no correlation with TICI 2b-3.

Neutrophil-to-Lymphocyte Ratio Predicts Early Neurological Deterioration after Endovascular Treatment in Patients with Ischemic Stroke

The worsening of neurological status that occurs early after acute ischemic stroke (AIS) remains a serious issue, and the inflammatory response plays a key role in stroke pathobiology. Recently, endovascular treatment (EVT) has revolutionized the management and outcome of patients with AIS due to either extracranial carotid disease or intracranial disease. The neutrophil-to-lymphocyte ratio (NLR) represents an easily available inflammatory biomarker. The aim of the study was to assess the relationship between the NLR at admission and the occurrence of early neurological deterioration (END) in patients with AIS who underwent EVT. Patients with AIS and proximal arterial occlusion in the anterior circulation undergoing EVT were retrospectively identified. Absolute neutrophil count (ANC) and absolute lymphocyte count (ALC) were collected from admission blood work to calculate the NLR. The study outcome was END defined as an increase in at least 4 points in NIHSS score or death between baseline and 24 h after the ischemic event. Patients included were 211, and END occurred in 30 (14.2%). Patients with older age (OR = 1.07, 95% CI: 1.02−1.13), higher serum glucose (OR = 1.01, 95% CI: 1.01−1.02), and higher NLR (OR = 1.011, 95% CI: 1.04−1.18) had an increased risk of END. The best predictive cut-off value of NLR was 6.4, and END occurred in 24.1% and 3.9% of the patients with NLR ≥ 6.4 and <6.4, respectively (p < 0.001). In patients with AIS undergoing EVT, higher NLR values predicted a higher risk of END. Biomarkers able to identify inflammatory mechanisms might identify novel treatment targets and enhance proof-of-concept trials of immunomodulation in stroke.

Meta-Analysis of Predictive Role of Early Neurological Deterioration after Intravenous Thrombolysis

With the popularization of intravenous thrombolysis, more and more people use intravenous thrombolysis to treat related diseases, but problems also arise. There are still a considerable number of patients with early disease after thrombolytic therapy not only not significantly improving, but also progressing, that is, early neurological deterioration (END). In view of this problem, the prediction of END after intravenous thrombolysis becomes very important. With the development of medical technology, research on the prediction of END after intravenous thrombolysis has gradually been carried out. Effective prediction is of great significance for the prevention and treatment of END after intravenous thrombolysis. This article aimed to carry out a meta-analysis of the predictive role of END after intravenous thrombolysis. Through an informed analysis of all studies of this type in this field, this article determines a method for predicting END after intravenous thrombolysis. The actual effect of its role is revealed in this paper, and its purpose is to promote the development of this field. This article addresses the same type of study on the predictive role of neurological deterioration after intravenous thrombolysis. The article performs test and meta-analysis of its role by conditionally searching for literature studies. It is explained using the relevant theoretical formulas. The analysis results show that the prediction of END after intravenous thrombolysis in this paper can effectively help make a preliminary judgment on the possible later neurological deterioration. Although there is an error between the predicted curve and the actual curve, the difference between the two is between 1% and 5%. It can basically effectively predict the occurrence of END. Therefore, the prediction of END after intravenous thrombolysis has a very large preventive effect on the END after intravenous thrombolysis.

Predictors of early neurologic deterioration (END) following stroke thrombectomy

BACKGROUND

Early neurologic deterioration (END) following ischemic stroke is a serious event and is associated with poor outcomes. However, the incidence and predictors of END after stroke thrombectomy for emergent large vessel occlusion are largely unknown.

METHODS

The baseline characteristics of patients enrolled in the COMPASS trial (NCT02466893) were analyzed. The primary outcome was worsening of ≥4 National Institutes of Health Stroke Scale (NIHSS) points 24 hours post thrombectomy (4+ END₂₄) and the secondary outcome was deterioration of ≥2 points (2+ END₂₄).

RESULTS

Among 270 patients, 27 (10%) developed 4+ END₂₄ and 42 (16%) had 2+ END₂₄. Those with 4+ END₂₄ were older (76.4±12.9 vs 70.9±12.9 years; p=0.04), had a higher prevalence of hypertension (96% vs 69%; p=0.003), diabetes (41% vs 27%; p=0.13) and higher pretreatment systolic blood pressure (SBP) (170.4±32.6 vs 157.6±28.1 mmHg; p=0.03). More 4+ END₂₄ patients had failed reperfusion: Thrombolysis in Cerebral Infarction ≤2a (26% vs 8%; p=0.003). In unadjusted analysis, older patients and those with hypertension, diabetes, elevated SBP and failed reperfusion had higher odds of 4+ END₂₄. In adjusted analysis, age increase by 5 years led to an increase in 4+ END₂₄ of 28%, diabetes increased odds of 2.6 and failed reperfusion increased odds of 4.5. In the multivariable analysis for the secondary outcome, age (OR 1.33; 95% CI 1.109 to 1.593), diabetes (OR 2.7; 95% CI 1.247 to 5.764) and failed reperfusion (OR 7.2; 95% CI 0.055 to 0.349) were also significant predictors of 2+ END₂₄.

CONCLUSIONS

Older patients with acute ischemic stroke who have a history of diabetes or hypertension, with elevated pretreatment SBP and failed reperfusion are at a higher risk of END following stroke thrombectomy for emergent large vessel occlusion.

Hyperoxia-Induced ΔR1: MRI Biomarker of Histological Infarction in Acute Cerebral Stroke

OBJECTIVE

To evaluate whether hyperoxia-induced ΔR₁ (hyperO₂ΔR₁) can accurately identify histological infarction in an acute cerebral stroke model.

MATERIALS AND METHODS

In 18 rats, MRI parameters, including hyperO₂ΔR₁, apparent diffusion coefficient (ADC), cerebral blood flow and volume, and ¹⁸F-fluorodeoxyglucose uptake on PET were measured 2.5, 4.5, and 6.5 hours after a 60-minutes occlusion of the right middle cerebral artery. Histological examination of the brain was performed immediately following the imaging studies. MRI and PET images were co-registered with digitized histological images. The ipsilateral hemisphere was divided into histological infarct (histological cell death), non-infarct ischemic (no cell death but ADC decrease), and non-ischemic (no cell death or ADC decrease) areas for comparisons of imaging parameters. The levels of hyperO₂ΔR₁ and ADC were measured voxel-wise from the infarct core to the non-ischemic region. The correlation between areas of hyperO₂ΔR₁-derived infarction and histological cell death was evaluated.

RESULTS

HyperO₂ΔR₁ increased only in the infarct area (p ≤ 0.046) compared to the other areas. ADC decreased stepwise from non-ischemic to infarct areas (p = 0.002 at all time points). The other parameters did not show consistent differences among the three areas across the three time points. HyperO₂ΔR₁ sharply declined from the core to the border of the infarct areas, whereas there was no change within the non-infarct areas. A hyperO₂ΔR₁ value of 0.04 s^-1 was considered the criterion to identify histological infarction. ADC increased gradually from the infarct core to the periphery, without a pronounced difference at the border between the infarct and non-infarct areas. Areas of hyperO₂ΔR₁ higher than 0.04 s^-1 on MRI were strongly positively correlated with histological cell death (r = 0.862; p < 0.001).

CONCLUSION

HyperO₂ΔR₁ may be used as an accurate and early (2.5 hours after onset) indicator of histological infarction in acute stroke.

Relationship Between Body Temperature and Early Neurological Deterioration after Endovascular Thrombectomy for Acute Ischemic Stroke with Large Vessel Occlusion

BACKGROUND

Early neurological deterioration (END) after endovascular thrombectomy (EVT) is strongly associated with poor prognosis in patients with large vessel occlusion. The relationship between body temperature and END after EVT is unknown, which we aimed to investigate in this study.

METHODS

END was defined as an increase of four or more points on the National Institutes of Health Stroke Scale score compared with the baseline assessment within 24 h. Logistic regression and restricted cubic spline models were used to assess the relationship between body temperature and END.

RESULTS

Among 7741 consecutive patients with ischemic stroke, 406 patients with large vessel occlusion who underwent EVT were enrolled. In total, 88 (21.7%) patients developed END. Logistic regression showed that the maximum body temperature within 24 h (odds ratio [OR] = 1.97 per °C, 95% confidence interval [CI] 1.17-3.32, p = 0.010) was independently associated with END. This association was nonlinear and J shaped (p for nonlinearity = 0.010), and the risk of END increased when the maximum body temperature within 24 h was lower or higher than 37.0 °C. Fever burden is also independently associated with END (OR = 1.06 per °C  × hour, 95% CI 1.01-1.11, p = 0.012). In addition, the timing of fever onset was independently associated with END, and the highest risk of END was associated with fever onset within 6 h after EVT (OR = 3.92, 95% CI 1.25-12.27, p = 0.019).

CONCLUSIONS

In summary, there is a J-shaped association between the maximum body temperature within 24 h after EVT and END. Moreover, the risk of END differed according to the timing of fever onset.

Unexplained early neurological deterioration after endovascular treatment for acute large vessel occlusion: incidence, predictors, and clinical impact: Data from ANGEL-ACT registry

BACKGROUND

Early neurological deterioration (END) may occur in some patients with acute large vessel occlusion (LVO) undergoing endovascular treatment (EVT). Despite several clear causes of END, such as symptomatic intracranial hemorrhage, failure of recanalization, and intraprocedure complications, a particular END, termed unexplained END (END_unexplained), exists. We aimed to investigate the incidence, independent predictors, and clinical impact of END_unexplained after EVT in patients with acute LVO.

METHODS

Subjects were selected from the ANGEL-ACT registry. END_unexplained was defined as ≥4-point increase in the National Institutes of Health Stroke Scale (NIHSS) score between baseline and 24 hours after EVT, without the causes listed above. Logistic regression analyses were performed to determine the independent predictors of END_unexplained, as well as the association between END_unexplained and 90-day outcomes assessed by modified Rankin Scale (mRS) score.

RESULTS

Among the 1557 enrolled patients, the incidence of END_unexplained was 4.3% (67/1557). Admission NIHSS ≤8 (OR=6.88, 95% CI 3.86 to 12.26, p<0.001), general anesthesia (OR=3.15, 95% CI 1.81 to 5.48, p<0.001), admission neutrophil to lymphocyte ratio >5 (OR=2.82, 95% CI 1.61 to 4.94, p<0.001), and number of EVT attempts >3 (OR=2.11, 95% CI 1.14 to 3.89, p=0.018) were associated independently with a high risk of END_unexplained. Furthermore, patients with END_unexplained were associated with a shift toward worse 90-day outcomes (mRS 5 vs 3, common OR=5.24, 95% CI 3.22 to 8.52, p<0.001).

CONCLUSIONS

END_unexplained associated with poor 90day outcomes occurred in 4.3% of patients with acute LVO undergoing EVT. Several independent predictors of END_unexplained were identified in this study, which should be considered in daily practice to improve acute LVO management.

CLINICAL TRIAL REGISTRATION

http://wwwclinicaltrialsgov NCT03370939.

Predicting prognosis in patients with stroke treated with intravenous alteplase through the 24-h trajectory of blood pressure changes

Blood pressure (BP) monitored within 24 h from the beginning of intravenous thrombolysis (IVT) with alteplase, is one of the important factors affecting the prognosis of patients with acute ischemic stroke (AIS). This study aimed to explore longitudinal BP trajectory patterns and determine their association with stroke prognosis after thrombolysis. From November 2018 to September 2019, a total of 391 patients were enrolled consecutively during the study period, and 353 patients were ultimately analyzed. Five systolic (SBP) and four diastolic blood pressure (DBP) trajectory subgroups were identified. The regression analysis showed that when compared with the rapidly moderate stable group, the continuous fluctuation‐very high level SBP group (odds ratio [OR]: 2.743, 95% confidence interval [CI]: 1.008–7.467) was associated with early neurological deterioration (END). Both the rapid drop‐high level SBP (OR: 0.448, 95% CI: 0.219–0.919) and DBP groups (OR: 0.399, 95% CI: 0.219–0.727) were associated with early neurological improvement (ENI). Moreover, there was a U‐shaped correlation between the OR value of SBP trajectory group and favorable outcome (the modified Rankin Scale [mRS] score 0–2) at 3 months: the slow drop‐low level SBP group represent a well‐established unfavorable outcome risk factor (OR:5.239, 95% CI: 1.271–21.595), and extremely high SBP—the continuous fluctuation‐very high level SBP group, are equally associated with elevated unfavorable outcome risk (OR:3.797, 95% CI: 1.486–9.697). The continuous fluctuation‐very high level DBP group was statistically significant in mRS (OR: 3.387, CI: 1.185–9.683). The BP trajectory groups show varying clinical features and risk of neurological dysfunction. The findings may help identify potential candidates for clinical BP monitoring, control, and specialized care.

Course of Early Neurologic Symptom Severity after Endovascular Treatment of Anterior Circulation Large Vessel Occlusion Stroke: Association with Baseline Multiparametric CT Imaging and Clinical Parameters

Background: Neurologic symptom severity and deterioration at 24 hours (h) predict long-term outcomes in patients with acute large vessel occlusion (LVO) stroke of the anterior circulation. We aimed to examine the association of baseline multiparametric CT imaging and clinical factors with the course of neurologic symptom severity in the first 24 h after endovascular treatment (EVT). Methods: Patients with LVO stroke of the anterior circulation were selected from a prospectively acquired consecutive cohort of patients who underwent multiparametric CT, including non-contrast CT, CT angiography and CT perfusion before EVT. The symptom severity was assessed on admission and after 24 h using the 42-point National Institutes of Health Stroke Scale (NIHSS). Clinical and imaging data were compared between patients with and without early neurological deterioration (END). END was defined as an increase in ≥4 points, and a significant clinical improvement as a decrease in ≥4 points, compared to NIHSS on admission. Multivariate regression analyses were used to determine independent associations of imaging and clinical parameters with NIHSS score increase or decrease in the first 24 h. Results: A total of 211 patients were included, of whom 38 (18.0%) had an END. END was significantly associated with occlusion of the internal carotid artery (odds ratio (OR), 4.25; 95% CI, 1.90–9.47) and the carotid T (OR, 6.34; 95% CI, 2.56–15.71), clot burden score (OR, 0.79; 95% CI, 0.68–0.92) and total ischemic volume (OR, 1.01; 95% CI, 1.00–1.01). In a comprehensive multivariate analysis model including periprocedural parameters and complications after EVT, carotid T occlusion remained independently associated with END, next to reperfusion status and intracranial hemorrhage. Favorable reperfusion status and small ischemic core volume were associated with clinical improvement after 24 h. Conclusions: The use of imaging parameters as a surrogate for early NIHSS progression in an acute LVO stroke after EVT reached limited performance with only carotid T occlusion as an independent predictor of END. Reperfusion status and early complications in terms of intracranial hemorrhage are critical factors that influence patient outcome in the acute stroke phase after EVT.

Time Course and Clinical Relevance of Neurological Deterioration After Endovascular Recanalization Therapy for Anterior Circulation Large Vessel Occlusion Stroke

Neurological deterioration (ND) is a devastating complication for patients with ischemic stroke after endovascular recanalization therapy (EVT). We aimed to investigate the time course and clinical relevance of ND after EVT. Consecutive patients with acute ischemic stroke who underwent EVT for large arterial occlusions of the anterior cerebral circulation were enrolled. The National Institutes of Health Stroke Scale (NIHSS) scores were assessed before EVT, at the end of EVT, at 24 h (d1), on day 3 (d3), on day 15 (d15), at discharge and anytime when ND was indicated. ND was defined as an increase of ≥ 4 points in the NIHSS score and was divided into acute ND (AD, within 24 h), subacute ND (SD, d1–d3), and delayed ND (DD, d3–d15 or discharge). Using multivariable logistic regression analysis, we explored predictors and outcomes of ND at different time periods. As a result, of 343 patients, 129 (37.6%) experienced ND, including 90 (26.2%) with AD, 27 (7.9%) with SD and 12 (3.5%) with DD. Multivariable logistic regression analysis revealed that history of hypertension, cardioembolic stroke, lower Alberta Stroke Program Early Computed Tomography Score (ASPECTS), and poor collaterals were significantly associated with an increased risk of AD; history of hypertension, lower ASPECTS, poor collaterals, and unsuccessful recanalization, with SD; and high admission NIHSS score, with DD. In addition, patients who experienced AD (OR = 10.22, P < 0.001), SD (OR = 15.89, P = 0.004), or DD (OR = 8.31, P = 0.015) were more likely to have poor outcomes. ND was a strong predictor of poor stroke outcomes. Management of related risk factors at different ND time periods might improve the prognosis of EVT.

Neurological Instability in Ischemic Stroke: Relation with Outcome, Latency Time, and Molecular Markers

The National Institutes of Health Stroke Scale (NIHSS) is commonly used to evaluate stroke neurological deficits and to predict the patient’s outcome. Neurological instability (NI), defined as the variation of the NIHSS in the first 48 h, is a simple clinical metric that reflects dynamic changes in the area of the brain affected by the ischemia. We hypothesize that NI may represent areas of cerebral instability known as penumbra, which could expand or reduce brain injury and its associated neurological sequels. In this work, our aim was to analyze the association of NI with the functional outcome at 3 months and to study clinical biomarkers associated to NI as surrogate biomarkers of ischemic and inflammatory penumbrae in ischemic stroke (IS) patients. We included 663 IS patients in a retrospective observational study. Neutral NI was defined as a variation in the NI scale between − 5 and 5% (37.1%). Positive NI is attributed to patients with an improvement of > 5% NI after 48 h (48.9%), while negative NI is assigned to patients values lower than − 5% (14.0%). Poor outcome was assigned to patients with mRS ≥ 3 at 3 months. We observed an inverse association of poor outcome with positive NI (OR, 0.35; 95%CI, 0.18–0.67; p = 0.002) and a direct association with negative NI (OR, 6.30; 95%CI, 2.12–18.65; p = 0.001). Negative NI showed a higher association with poor outcome than most clinical markers. Regarding good functional outcome, positive NI was the marker with the higher association (19.31; CI 95%, 9.03–41.28; p < 0.0001) and with the highest percentage of identified patients with good functional outcome (17.6%). Patients with negative NI have higher glutamate levels compared with patients with neutral and positive NI (p < 0.0001). IL6 levels are significantly lower in patients with positive NI compared with neutral NI (p < 0.0001), while patients with negative NI showed the highest IL6 values (p < 0.0001). High glutamate levels were associated with negative NI at short latency times, decreasing at higher latency times. An opposite trend was observed for inflammation, and IL6 levels were similar in patients with positive and negative NI in the first 6 h and then higher in patients with negative NI. These results support NI as a prognosis factor in IS and the hypothesis of the existence of a delayed inflammatory penumbra, opening up the possibility of extending the therapeutic window for IS.

Trans-cranial Doppler predicts early neurologic deterioration in anterior circulation ischemic stroke after successful endovascular treatment

Background

Early neurologic deterioration (END) may occur in patients with anterior circulation ischemic stroke (ACIS) after receiving endovascular treatment (EVT). Hemodynamic insufficiency, re-occlusion, and post-re-canalization hyper-perfusion are likely to play a critical role in END. We hypothesized that hemodynamic changes can predict END in patients with ACIS post-successful EVT using trans-cranial Doppler (TCD).

Methods

We utilized a prospectively maintained database of ACIS patients treated with EVT between September 2016 and June 2018 in the Xuanwu Hospital, Capital Medical University. TCD parameters including peak systolic velocity (PSV), bilateral mean flow velocity (MFV), and pulse index (PI) were determined via the middle cerebral arteries within 72 h post-EVT. A logistic regression model was applied to detect independent predictors for END.

Results

Totally, 112 EVT patients were included in this study and 80/112 patients experienced successful re-canalization with <50% residual stenosis, while 17/80 (21.3%) patients suffered END, for which vasogenic cerebral edema (11/17) was considered as a leading role and followed by symptomatic intra-cranial hemorrhage (4/17) and ischemia progression (2/17). For the 80 patients, the PSV (median: 127 cm/s vs. 116 cm/s, P = 0.039), the ratio of ipsilateral-MFV/contra-lateral-MFV (iMFV/cMFV) (median: 1.29 vs. 1.02, P = 0.036) and iMFV/mean blood pressure (MBP) (median: 0.97 vs. 0.79, P = 0.008) in END patients were higher than those of non-END. Using the receiver-operating characteristic curve to obtain cut-off values for PSV, PI, iMFV/cMFV, and iMFV/MBP for END, we found that PI ≥0.85 (odds ratio: 11.03, 95% confidence interval: 1.92–63.46, P = 0.007) and iMFV/MBP ≥0.84 (odds ratio: 9.20, 95% confidence interval: 2.07–40.84, P = 0.004) were independent predictors of END in a multivariate logistic regression model, with a sensitivity of 82.4% and 76.5% and a specificity of 42.9% and 66.7%, respectively, and had the positive predictive values of 29.0% and 38.2%, and negative predictive values of 90.0% and 91.3%, with an area under the receiver-operating characteristic curve of 0.57 and 0.71, respectively.

Conclusion

TCD examination of EVT patients may be used as a real-time tool to detect END predictors, such as the higher PI and iMFV/MBP, allowing for better post-thrombectomy management in ACIS patients.

Temporally distinct myeloid cell responses mediate damage and repair after cerebrovascular injury

Cerebrovascular injuries can cause severe edema and inflammation that adversely affect human health. Here, we observed that recanalization after successful endovascular thrombectomy for acute large vessel occlusion was associated with cerebral edema and poor clinical outcomes in patients who experienced hemorrhagic transformation. To understand this process, we developed a cerebrovascular injury model using transcranial ultrasound that enabled spatiotemporal evaluation of resident and peripheral myeloid cells. We discovered that injurious and reparative responses diverged based on time and cellular origin. Resident microglia initially stabilized damaged vessels in a purinergic receptor-dependent manner, which was followed by an influx of myelomonocytic cells that caused severe edema. Prolonged blockade of myeloid cell recruitment with anti-adhesion molecule therapy prevented severe edema but also promoted neuronal destruction and fibrosis by interfering with vascular repair subsequently orchestrated by proinflammatory monocytes and proangiogenic repair-associated microglia (RAM). These data demonstrate how temporally distinct myeloid cell responses can contain, exacerbate and ultimately repair a cerebrovascular injury.

Predictive Model of Early Neurological Deterioration in Patients with Acute Ischemic Stroke: A Retrospective Cohort Study

OBJECTIVE

This study aimed to develop a predictive model of early neurological deterioration (END) in patients with acute ischemic stroke (AIS).

METHODS

The present retrospective cohort study considered patients with AIS who were admitted to a tertiary hospital in Shenzhen, China between January 2014 and December 2018. An increase of 2 points or more on the National Institute of Health Stroke Scale (NIHSS) within 7 days indicated END. We selected baseline clinical, laboratory, and neuroimaging variables to construct predictive models through multivariate logistic regression. The receiver operating characteristic curve and calibration plots were calculated.

RESULTS

A total of 391 patients with AIS were enrolled in the study. END was observed in 64 (16.4%) cases. A prediction model developed from the initial NIHSS score, middle cerebral artery stenosis, and carotid stenosis of≥ 50% showed good discriminative ability: area under the receiver operating characteristic curve, 0.870 (95%CI, 0.813-0.911); threshold, -1.570; specificity, 84.40%; sensitivity, 75.00%; positive predictive value, 48.48%; and a negative predictive value, 94.52%.

CONCLUSION

Our predictive model developed from the initial NIHSS score, middle cerebral artery stenosis, and carotid stenosis of ≥ 50% could identify patients with AIS who were at risk of developing END. The model requires validation by larger studies performed at other institutions.

Early Neurological Deterioration Despite Recanalization in Basilar Artery Occlusion Treated by Endovascular Therapy

Background: We aim to identify the risk factors of early neurological deterioration (END) despite successful recanalization and explore the association of END with 90-day outcomes in acute basilar artery occlusion (BAO) treated by endovascular therapy (EVT).

Methods: A prospectively registered consecutive cohort of BAO patients with successful recanalization by EVT in a tertiary stroke center during a 6-year period was reviewed. END was defined as an National Institutes of Health Stroke Scale (NIHSS) score increase ≥4 points, or death, from baseline to 24 h after EVT. Multivariate logistic regression analysis was used to identify the risk factors of END. The 90-day outcomes between END and non-END groups were compared by Pearson's χ² test.

Results: END was observed in 21 of 148 patients included in this study. Multivariate logistic regression analysis showed that patients with progressive or fluctuating symptoms had a higher risk of END than those with symptoms of acute attack (OR 5.52, 95% CI 1.73–17.63), and NIHSS score and puncture-to-recanalization time (PTR), as continuous variables, were also significantly associated with END. Using a generalized additive model with spline smoothing function, we observed a linear relationship between PTR (increased by 1 h) and END (OR 2.57, 95% CI 1.45–4.57), and a non-linear relationship between NIHSS score and END. Only when the NIHSS score was ≥23 points was it related to END (OR 0.7, 95% CI 0.6–0.9). In addition, patients with END had a lower proportion of 90-day favorable outcome (19.0 vs. 59.1%, p < 0.01) and higher mortality (33.3 vs. 13.4%, p = 0.048) than those with non-END.

Conclusion: Mode of stroke onset, NIHSS score, and PTR may help to identify BAO patients with a higher risk of END after EVT. Moreover, END may affect the 90-day outcomes of these patients.

Predictors of Unexplained Early Neurological Deterioration After Endovascular Treatment for Acute Ischemic Stroke

BACKGROUND AND PURPOSE

Although the efficacy of endovascular treatment (EVT) in patients with anterior circulation ischemic stroke (AIS) is well documented, early neurological deterioration after EVT remains a serious issue associated with poor outcome. Besides obvious causes, such as lack of reperfusion, procedural complications, or parenchymal hemorrhage, early neurological deterioration may remain unexplained (UnEND). Our aim was to investigate predictors of UnEND after EVT in patients with AIS.

METHODS

Patients who underwent EVT for AIS, with an initial National Institutes of Health Stroke Scale score >5, Alberta Stroke Program Early CT Score ≥6, and included in a multicenter prospective observational registry were analyzed. Predictors of UnEND, defined as ≥4-point increase in the National Institutes of Health Stroke Scale score between baseline and day 1 after EVT, were determined via center-adjusted analyses.

RESULTS

Among the 1925 included in the analysis, 128 UnEND (6.6%) were recorded. In multivariate analysis, predictors of UnEND were diabetes mellitus (odds ratio [OR], 2.17 [95% CI, 1.32-3.56]), prestroke modified Rankin Scale score ≥2 (OR, 2.22 [95% CI, 1.09-4.55]), general anesthesia (OR, 2.55 [95% CI, 1.51-4.30]), admission systolic blood pressure (OR, 1.10 [95% CI, 1.01-1.20]), age (OR, 1.38 [95% CI, 1.14-1.67]), number of passes (OR, 1.16 [95% CI, 1.04-1.28]), direct admission or not to a comprehensive stroke center (OR, 0.49 [95% CI, 0.30-0.81]), and initial National Institutes of Health Stroke Scale score (OR, 0.65 [95% CI, 0.52-0.81]).

CONCLUSIONS

Severely impaired AIS patients with nonmodifiable factors are more likely to develop UnEND. Some modifiable predictors of UnEND such as the number of EVT passes could be the object of improvement in AIS management.

The Incidence and Associated Factors of Early Neurological Deterioration After Thrombolysis

Background and purpose:

Early neurological deterioration (END) after stroke onset may predict severe outcomes. Estimated rates of END after intravenous thrombolysis among small patient samples have been reported up to 29.8%. We studied the incidence and factors associated with END among patients following intravenous thrombolysis.

Methods:

We analyzed SITS-International Stroke Thrombolysis registry patients with known outcomes enrolled in 2010 to 2017. END was defined as an increase in National Institutes of Health Stroke Scale score ≥4 or death within 24 hours from baseline National Institutes of Health Stroke Scale. We determined the incidence of END and used logistic regression models to inspect its associated factors. We adjusted for variables found significant in univariate analyses ( P <0.05). Main outcomes were incidence of END, associated predictors of END, ordinal day-90 mRS, and day-90 mortality.

Results:

We excluded 53 539 patients and included 50 726 patients. The incidence of END was 3415/50 726 (6.7% [95% CI, 6.5%–7.0%]). Factors independently associated with END on multivariate analysis were intracerebral hemorrhage (OR, 3.23 [95% CI, 2.96–3.54], P <0.001), large vessel disease (LVD) with carotid stenosis (OR, 2.97 [95% CI, 2.45–3.61], P <0.001), other LVD (OR, 2.41 [95% CI, 2.03–2.88], P <0.001), and ischemic stroke versus transient ischemic attack (TIA)/stroke mimics (OR, 16.14 [95% CI, 3.99–65.3], P <0.001). END was associated with worse outcome on ordinal mRS: adjusted OR 2.48 (95% CI, 2.39–2.57, P <0.001) by day-90 compared with no END. The adjusted OR for day-90 mortality was 9.70 (95% CI, 8.36–11.26, P <0.001).

Conclusions:

The routinely observed rate of END reflected by real-world data is low, but END greatly increases risk of disability and mortality. Readily identifiable factors predict END and may help with understanding causal mechanisms to assist prevention of END.

Association of Blood Pressure With Outcomes in Acute Stroke Thrombectomy

Limited data exist evaluating the effect of blood pressure (BP) on clinical outcomes among patients with acute ischemic stroke with large vessel occlusion treated with mechanical thrombectomy (MT). We sought to evaluate the association of BP levels on clinical outcomes among patients with acute ischemic stroke with large vessel occlusion treated with MT. Studies were identified that reported the association of systolic BP (SBP) or diastolic BP levels before, during, or after MT on the outcomes of patients with acute ischemic stroke treated with MT. Unadjusted and adjusted analyses of studies reporting odds ratios (OR_adj) per 10 mm Hg BP increment were performed. Our analysis included 25 studies comprising 6474 patients. Higher pre-MT mean SBP (P=0.008) and post-MT maximum SBP (P=0.009) levels were observed in patients who died within 3 months. Patients with 3-month functional independence were noted to have lower pre-MT (P<0.001) and post-MT maximum SBP levels (P<0.001). In adjusted analyses, increasing post-MT maximum SBP and diastolic BP levels were associated with 3-month mortality (OR_adj, 1.19 [95% CI,1.00-1.43]; I²=78%, P value for Cochran Q test: 0.001) and symptomatic intracranial hemorrhage (OR_adj, 1.65 [95% CI, 1.11-2.44]; I²=0%, P value for Cochran Q test: 0.80), respectively. Increasing pre- and post-MT mean SBP levels were associated with lower odds of 3-month functional independence (OR_adj, 0.86 [95% CI, 0.77-0.96]; I²=18%, P value for Cochran Q test: 0.30) and (OR_adj, 0.80 [95% CI, 0.72-0.89]; I²=0%, P value for Cochran Q test: 0.51), respectively. In conclusion, elevated BP levels before and after MT are associated with adverse outcomes among patients with acute ischemic stroke with large vessel occlusion.

Association between neurological deterioration and outcomes in patients with stroke

Background

Neurological deterioration (ND) shortly after stroke is common in Chinese patients. We aimed to determine the effects of ND during hospitalization on stroke prognosis.

Methods

We retrospectively reviewed files from the stroke registry of the Department of Neurology of Tianjin Huanhu Hospital between October 1, 2008, and December 31, 2015. The inclusion criteria were: age ≥18 years, diagnosis of acute ischemic stroke, and first-ever ischemic stroke occurring within 7 days prior to admission. ND was defined as an increase in the National Institutes of Health Stroke Scale (NIHSS) score by ≥4 points during hospitalization. Early neurological deterioration (END) was defined as an increase in the NIHSS score by ≥4 points between the baseline and 48-hour evaluations. Late neurological deterioration (LND) was defined as an increase in the NIHSS score by ≥4 points between the 48-hour and discharge evaluations. Multivariate regression was used to evaluate the relationship between early and late ND and short- and long-term outcomes. Primary and secondary outcomes based on the modified Rankin scale (mRS) were evaluated at 3 months and 1 year. Favorable and poor outcomes were defined as mRS scores of 0-2 and ≥3, respectively.

Results

A total of 9,650 patients were included. ND occurred in 293 patients (3.0%) during hospitalization. Among them, 192 (65.5%) were in the END group, and 101 (34.5%) were in the LND group. After adjusting for age, gender, and NIHSS scores, END was a significant independent predictor of poor outcome at both 3 months (primary outcome OR 8.069, secondary outcome OR 8.194) and 1 year (primary outcome OR 7.895, secondary outcome OR 5.679). The same pattern was seen in the LND group (3 months primary outcome OR 7.608, secondary outcome OR 6.349, 1-year primary outcome OR 10.793, secondary outcome OR 5.245).

Conclusions

ND during hospitalization, regardless of whether it occurs in the early or late period after stroke, is an independent predictor of poor prognosis.

Clinical Variables and Genetic Risk Factors Associated with the Acute Outcome of Ischemic Stroke: A Systematic Review

Stroke is a complex disease and one of the main causes of morbidity and mortality among the adult population. A huge variety of factors is known to influence patient outcome, including demographic variables, comorbidities or genetics. In this review, we expound what is known about the influence of clinical variables and related genetic risk factors on ischemic stroke outcome, focusing on acute and subacute outcome (within 24 to 48 hours after stroke and until day 10, respectively), as they are the first indicators of stroke damage. We searched the PubMed data base for articles that investigated the interaction between clinical variables or genetic factors and acute or subacute stroke outcome. A total of 61 studies were finally included in this review. Regarding the data collected, the variables consistently associated with acute stroke outcome are: glucose levels, blood pressure, presence of atrial fibrillation, prior statin treatment, stroke severity, type of acute treatment performed, severe neurological complications, leukocyte levels, and genetic risk factors. Further research and international efforts are required in this field, which should include genome-wide association studies.

Contrast Extravasation After Endovascular Treatment in Posterior Circulation Stroke

OBJECTIVE

Endovascular treatment (EVT) is a promising clinical technology. However, some patients with posterior circulation stroke might not experience neurological function recovery after EVT. We reviewed the recent experience with EVT to clarify the clinical and radiographic factors that contribute to optimal neurological outcomes.

METHODS

We analyzed the data from 108 consecutive patients with acute posterior circulation stroke who had undergone EVT from January 2016 to December 2018. A favorable outcome was defined as a modified Rankin scale score of 0-3 at 3 months. We evaluated the association and predictive value of the clinical and radiographic factors that contribute to good neurological outcomes.

RESULTS

Of the 108 included patients, 43 had a favorable clinical outcome at day 90. Univariate analysis revealed a significant association between the 90-day favorable outcome and the baseline values of systolic blood pressure, time of stroke onset, contrast extravasation, symptomatic intracranial hemorrhage, general anesthesia, Alberta stroke program early computed tomography score for the posterior circulation, and the National Institutes of Health stroke scale (NIHSS) score. Contrast extravasation (odds ratio [OR], 5.094; 95% confidence interval [CI], 1.22-21.261), symptomatic intracranial hemorrhage (OR, 11.24; 95% CI, 1.309-96.517), general anesthesia (OR, 5.094; 95% CI, 1.22-21.26), and baseline NIHSS score (OR, 1.087; 95% CI, 1.023-1.309) were found to be independent predictors of a favorable outcome at day 90. Contrast extravasation alone predicted for unfavorable clinical outcomes and mortality with high specificity.

CONCLUSION

In the present retrospective case series, contrast extravasation, symptomatic intracranial hemorrhage, the use of general anesthesia, and baseline NIHSS score were related to a favorable prognosis for patients with posterior circulation stroke after EVT. Contrast extravasation was an independent and strong predictor of unfavorable clinical outcomes.