Impact of High-Intensity Statin on Early Neurologic Deterioration in Patients with Single Small Subcortical Infarction.

BACKGROUNDS: One of the major hypotheses for early neurological deterioration (END) in single small subcortical infarction (SSSI) is the process of atherosclerosis. However, the association between statin therapy, especially high-intensity statin therapy, and its effectiveness in reducing the incidence of END during the acute phase of SSSI remains unclear. This study aimed to investigate the influence of high-intensity statin therapy compared to moderate-intensity statin therapy during the acute phase on the incidence of END in SSSI. METHODS: The records of 492 patients with SSSI who received statin therapy within 72 h of symptom onset from a prospective stroke registry were analyzed. The association between END and statin intensity was evaluated using multivariable regression analysis for adjusted odds ratio (aOR). RESULTS: Of the 492 patients with SSSI (mean age: 67.2 years, median NIHSS score on admission: 3), END occurred in 102 (20.7%). Older age (aOR, 1.02; 95% confidence interval (CI), 1.00-1.05; p = 0.017), and branch atheromatous lesion (aOR, 3.49; 95% CI 2.16-5.74; p < 0.001) were associated with END. Early high-intensity statin therapy was associated with a lower incidence of END than moderate-intensity statin therapy (aOR, 0.44; 95% CI, 0.25-0.77; p = 0.004). In addition, there was significantly lower incidence of END in early administration (≤24 h) of high-intensity statin group. CONCLUSIONS: We identified an association between the intensity of early statin therapy and END in patients with SSSI. Early administration of high-intensity statin (≤24 h) is associated with a reduced incidence of END in patients with SSSI.

Emergency Cervical Carotid Artery Stenting After Intravenous Thrombolysis in Patients With Hyperacute Ischemic Stroke.

BACKGROUND: Intravenous recombinant tissue plasminogen activator (IV rtPA) is the mainstay of treatment for acute ischemic stroke to recanalize thrombosed intracranial vessels within 4.5 hours. Emergency carotid artery stenting for the treatment of acute stroke due to steno-occlusion of the proximal internal carotid artery (ICA) can improve symptoms, prevent neurological deterioration, and reduce recurrent stroke risk. The feasibility and safety of the combination therapy of IV rtPA and urgent carotid artery stenting have not been established. METHODS: From November 2005 to October 2020, we retrospectively assessed patients who had undergone emergent carotid artery stenting after IV rtPA for hyperacute ischemic stroke due to steno-occlusive proximal ICA lesion. Hemorrhagic transformation, successful recanalization, modified Rankin Scale (mRS) score at 90 days, and stent patency at 3 and 12 months or longer were evaluated. Favorable outcome was defined as a 90-days mRS score of ≤ 2. RESULTS: Nineteen patients with hyperacute stroke had undergone emergent carotid artery stenting after IV rtPA therapy. Their median age was 70 (67.5-73.5) years (94.7% men). Among 15 patients with an additional intracranial occlusion after flow restoration in the proximal ICA, a modified TICI grade ≥ 2b was achieved in 11 patients (73.3%). Hemorrhagic transformation occurred in five patients (26.3%); mortality rate was 5.7%. Eleven patients (57.9%) had favorable outcomes at 90 days. Stent patients (94.1%) maintained stent patency for ≥ 12 months. CONCLUSION: We showed that emergent carotid artery stenting after IV rtPA therapy for hyperacute stroke caused by atherosclerotic proximal ICA steno-occlusion was feasible and safe.

Intracranial non-occlusive intraluminal thrombus may indicate underlying etiology of large vessel occlusion in patients undergoing endovascular therapy.

BACKGROUND: The underlying etiology of intracranial non-occlusive intraluminal thrombus (iNOT) remains unknown. This study aimed to investigate whether the presence of iNOT can indicate the underlying etiology of large vessel occlusion (LVO) in patients undergoing endovascular therapy (EVT). METHODS: Among patients who underwent EVT at three comprehensive stroke centers, we included those with intracranial LVO in the anterior circulation. The presence of iNOT was determined by pretreatment DSA. We investigated the association between iNOT and intracranial atherosclerotic stenosis (ICAS) related LVO. RESULTS: Of 546 patients, 44 (8.1%) had iNOT. Patients with iNOT were younger, had less hypertension, atrial fibrillation, and a history of antiplatelet use. In addition, the involvement of the M1 segment of the middle cerebral artery (MCA) was more frequent. However, they had a lower National Institutes of Health Stroke Scale (NIHSS) score on admission and longer onset to recanalization time compared with patients with no iNOT. In a logistic regression model adjusting for age, sex, atrial fibrillation, smoking, prior antiplatelet and anticoagulant use, intravenous tissue plasminogen activator, NIHSS on admission, number of technical trials, intraprocedural re-occlusion, and the location of LVO (p<0.10 in the univariate analysis), the presence of iNOT was significantly associated with ICAS related LVO (adjusted OR 3.04; 95% CI 1.33 to 6.90; p=0.007). CONCLUSIONS: The presence of iNOT may reflect an underlying ICAS related LVO in patients undergoing EVT.

Clinical Implications of Neurological Comorbidities and Complications in ICU Patients with COVID-19.

Clinical implications of neurological problems during intensive care unit (ICU) care for coronavirus disease 2019 (COVID-19) patients are unknown. This study aimed to describe the clinical implications of preexisting neurological comorbidities and new-onset neurological complications in ICU patients with COVID-19. ICU patients who were isolated and treated for COVID-19 between 19 February 2020 and 3 May 2020, from one tertiary hospital and one government-designated branch hospital were included. Clinical data including previous neurological disorders were extracted from electronic medical records. All neurological complications were evaluated by neurointensivists. Multiple logistic regression analysis was performed to investigate independent factors in ICU mortality. The median age of 52 ICU patients with COVID-19 was 73 years. Nineteen (36.5%) patients had preexisting neurological comorbidities, and new-onset neurological complications occurred in 23 (44.2%) during ICU admission. Patients with preexisting neurological comorbidities required tracheostomy more frequently and more ventilator and ICU days than those without. Patients with new-onset neurological complications experienced more medical complications and had higher ICU severity score and ICU mortality rates. New-onset neurological complications remained an independent factor for ICU mortality. Many COVID-19 patients in the ICU have preexisting neurological comorbidities, making them at a high risk of new-onset neurological complications.

Clinical prognosis of isolated anterior cerebral artery territory infarction: a retrospective study.

BACKGROUND: Isolated anterior cerebral artery territory (ACA) infarction is a rare phenomenon, and is known to have distinctive clinical features. Little is known regarding the clinical prognosis of isolated ACA territory infarction with associated factors, and its impact on dwelling and job status. We investigated the short- and long-term outcomes of anterior cerebral artery (ACA) territory infarction, and the associated factors involved in the development of the distinctive symptoms. METHODS: This retrospective study in a prospective cohort of acute ischaemic stroke patients included consecutively enrolled patients with isolated ACA territory infarction. We investigated the functional status using the modified Rankin scale (mRS) score at discharge, three months' post-discharge, and one-year post-discharge. We also investigated the occlusion site of the ACA (proximal vs. distal); presence of distinctive symptoms of ACA territory infarction including behaviour changes, indifference, aphasia, and urinary incontinence; and the effect of these symptoms on dwelling and job status one year after discharge. RESULTS: Between April 2014 and March 2019, 47 patients with isolated ACA territory infarction were included. Twenty-nine patients (61.7 %) had good outcomes (mRS ≤ 2) at discharge; however, the mRS score increased at three months (40; 85.1 %, p < 0.001) and one year (41; 87.2 %) post-discharge. Occlusion of the ACA proximal segment was independently associated with the development of distinctive symptoms (adjusted odds ratio, 17.68; 95 % confidence interval: 2.55-122.56, p < 0.05). Twenty-one (48.8 %) patients with good outcomes at one year experienced a change in dwelling status and job loss; 20 (95.2 %) of them had distinctive ACA territory symptoms with proximal ACA occlusion. CONCLUSIONS: Short- and long-term outcomes of isolated ACA territory infarction were favourable. However, proximal segment occlusion was associated with the development of distinctive symptoms, possibly related to future dwelling and job status.

Impact of statin pretreatment on the complications of carotid stenting in asymptomatic patients: observational study.

BACKGROUND: Carotid stenosis is a known risk factor for ischemic stroke, and carotid artery stenting is an effective preventive procedure. However, the stroke risk reduction for asymptomatic patients is small. Therefore, it is important to reduce the risk of complications, particularly in asymptomatic carotid stenosis. Statins are known to reduce the overall risk of periprocedural complications, although there is a lack of data focusing on asymptomatic patients. We aimed to investigate whether different doses of statin pretreatment can reduce periprocedural complications of carotid artery stenting (CAS) in patients with asymptomatic carotid artery stenosis. METHODS: Between July 2003 and June 2013, 276 consecutive patients received CAS for asymptomatic carotid stenosis. Periprocedural complications included the outcome of stroke, myocardial infarction, or death within 30 days of CAS. Statin pretreatment was categorized as no-statin (n = 87, 31.5%), standard-dose (< 40 mg, n = 139, 50.4%), and high-dose statin (≥40 mg, n = 50, 18.1%) according to the atorvastatin equivalent dose. The Cochran-Armitage (CA) trend test was performed to investigate the association of periprocedural complications with statin dose. RESULTS: The overall periprocedural complication rate was 3.3%. There was no significant difference in the risk of periprocedural complications between the three groups (no statin: n = 3 [3.4%]; standard-dose: n = 4 [2.9%]; high-dose n = 2 [4.0%] p = 0.923). The CA trend test did not demonstrate a trend in the proportion of periprocedural complications across increasing statin equivalent doses (p = 0.919). CONCLUSIONS: Statin pretreatment before CAS showed neither absolute nor dose-dependent effects against periprocedural complications in asymptomatic patients undergoing CAS.

The Length of an Infarcted Lesion Along the Perforating Artery Predicts Neurological Deterioration in Single Subcortical Infarction Without Any Relevant Artery Stenosis.

Objectives: This study aimed to assess image biomarkers of early neurological deterioration in single subcortical infarction (SSI) without any relevant artery stenosis. Methods: Between June 2005 and December 2009, consecutive patients with SSI within 24 h of symptom onset were enrolled. Magnetic resonance angiography of the brain and neck was obtained from all patients to confirm the absence of any stenosis of relevant arteries. We defined early neurological deterioration (END) as neurological worsening by ≥ 2 points based on the initial National Institutes of Health Stroke Scale score during the first week post admission or prior to hospital discharge. A multiple logistic regression analysis was used to evaluate the independent predictors of END in SSI. Results: A total of 205 patients (109 males; aged 63.9 ± 11.0 years, range 39-90 years) were enrolled, of whom 158 (77%) remained stable or improved, while 47 (23%) showed neurological worsening. There were significant differences in the maximum diameter of the largest area on an axial view and in the number of slices showing cerebral infarction on a transverse plane between patients with and without END. A adjusting for age, hypercholesterolemia, hemoglobin, NIHSS on admission and these magnetic resonance imaging characteristics, the occurrence of having three or more slices showing the cerebral infarction on a transverse plane was an independent predictor of END in SSI without relevant artery stenosis (1 vs. 3; OR 14.281; 95% CI 1.76-115.8; p = 0.013, 1 vs. 4; OR 14.04; 95% CI 1.65-119.57; p = 0.016). Conclusion: The longitudinal length of the infarcted lesion along the perforating artery predicts END in cases of acute SSI without any relevant artery stenosis.