Sex Differences in 90-Day Functional Outcomes for Acute Ischemic Stroke Patients With Obstructive Sleep Apnea.

Background Obstructive sleep apnea (OSA) is characterized by repeated episodes of either full or partial obstruction of the upper airway. OSA is an independent risk factor for acute ischemic stroke (AIS) and a contributor to other key risk factors. OSA may damage endothelial and brain tissues and worsen outcomes following AIS. We aimed to evaluate the impact of sex differences on 90-day functional outcomes following AIS in an OSA population, as measured by the modified Rankin Scale (mRS) score. Methodology We performed a retrospective study of patients with OSA and AIS from the Houston Methodist Hospital Outcomes-Based Prospective Endpoints in Stroke (HOPES) Registry from 2016 to 2022. Patients with charts that noted a diagnosis of OSA before AIS or within the 90 days following AIS were included. A multivariable logistic regression model was constructed adjusting for demographics, first admit National Institutes of Health Stroke Scale (NIHSS), and comorbidities on the binary outcome. The odds ratios (ORs) and 95% confidence intervals (CIs) were reported, providing likelihood estimates of a shift to higher mRS for a given comparison between females (reference category) and males. Statistical significance was defined as two-tailed p-values <0.05 for all tests. Results From the HOPES registry, 291 females and 449 males were found to have OSA. Males had a higher proportion of comorbid conditions such as atrial fibrillation (15% vs. 9%, p = 0.014) and intracranial hemorrhage compared to females (6% vs. 2%, p = 0.020). The multivariate logistic regression model showed that males were at two times higher risk for developing poor functional outcomes at 90 days (OR = 2.35, 95% CI = 1.06-5.19), p < 0.001). Conclusions Males were found to have two times higher risk for developing poor functional outcomes at 90 days. This may be due to more severe oxygen desaturation, increased susceptibility to oxidative stress, and greater frequency of full airway obstruction in males. Greater emphasis on early diagnosis and treatment of OSA may be necessary to reduce the disproportionate incidence of poor functional outcomes, particularly among apneic male stroke survivors.

Long-Term Disability Outcomes for Patients With Ischemic Stroke Presenting With Visual Deficits.

BACKGROUND: Ischemic strokes in both the anterior and posterior circulation can lead to visual deficits, which can affect functional ability. Thrombolytic therapies are often withheld to patients with visual deficits because of either being missed on initial evaluation or because of the misconception that their deficits are not as severe or as disabling. Alternatively, delays in patient arrival for emergent evaluation lead to missed opportunities for acute stroke treatment. This retrospective study aims to explore the differences in perceived long-term disability for patients with stroke who present with visual deficits vs those who do not as a manifestation of their acute stroke syndrome. In addition, we explore the differences in treatment effect with thrombolytics and further analyze if the region of ischemia causing the deficit leads to differences in disability outcomes. METHODS: We conducted a retrospective analysis of patients with visual deficits as evidenced by an abnormal score on NIHSS categories related to vision (gaze palsy, visual fields, or extinction/inattention). Patients with Acute Ischemic Stroke were reviewed from the Houston Methodist Hospital Outcomes-based Prospective Endpoints in Stroke (HOPES) Registry from 2016-2021 for visual deficits. In total, 155 patient charts with visual deficits and 155 patient charts without a documented visual deficit were reviewed for ischemic stroke location (anterior vs posterior circulation), NIHSS scores, and thrombolytic therapies. The outcome variable was categorized using mRS, as mRS between 0 and 3 while mRS 4 to 6 was considered as poor functional outcome at 90 days. The independent variable was the vision group. A multivariable logistic regression model was constructed adjusting for demographics and comorbidities on the binary outcome. RESULTS: Multivariable logistic model after adjusting for demographics and comorbidities showed that patients with acute ischemic stroke with vision defects were 4 times more likely to have poor functional outcomes at 90 days, with most of these patients (14% vs 6%; P < 0.05) suffering from severe disability compared with patients in the control group (i.e., patients with acute ischemic stroke without vision defects) (OR = 4.05; 95% CI [2.28-7.19]; P < 0.001). The application of thrombolytics and the location of ischemia (ACS vs PCS) did not result in a significant change in disability outcomes in patients with visual defects in this limited sample size. CONCLUSIONS: The results of this study indicated that a large population of patients with ischemic stroke experience visual deficits and are, therefore, at an increased likelihood of worse functional outcome. This reveals the necessity for rehabilitation techniques that specifically target visual deficits to speed up the recovery process of these patients. Further studies with larger sample size are needed to assess whether the location of ischemic event and the application of thrombolytic treatments plays a role in the disability outcomes of these patients.

Characteristics and Outcomes of Left Ventricular-Assist Device-Associated Cerebrovascular Events in Setting of Infectious Intracranial Aneurysms.

BACKGROUND AND PURPOSE: The study aims to identify the characteristics and neurological outcomes of the left ventricular-assist device (LVAD)-associated cerebrovascular events (CVE) and infections, particularly in the setting of infectious intracranial aneurysms (IIA). METHODS: A single-center retrospective review of patients having undergone LVAD implantation between 2011 and 2017 was conducted using institutional registries and screened for CVE. Patients with CVE were assessed for concurrent bacteremia; neurovascular imaging was then used to isolate patients with IIA. A review of comorbidities, imaging characteristics, and management were performed to determine predictors of neurological outcomes, as defined by the 90-day modified Rankin scale (mRS) scores. RESULTS: Of the 383 HeartMate II LVAD implantations performed, 43 all-cause stroke events were identified across 35 (9%) patients. The majority of the events were hemorrhagic CVE (n=28) with 21 events complicated by bacteremia. Of patients with hemorrhagic CVE and bacteremia, Staphylococcus aureus (n=10) and Pseudomonas aeruginosa (n= 8) infection were the most frequently associated organisms. Severe disability or death (90-day mRS > 4) was observed in 15 patients (63%). Seven patients had confirmed findings of IIA on diagnostic cerebral angiogram and were associated with distal middle cerebral artery (MCA) territory involvement (n=6; 86%) with concurrent Staphylococcus (n=5, 71%) and/or Pseudomonas (n=4, 57%) infections. Overall, a higher incidence of acute and chronic bacteremia was observed in the hemorrhagic CVE subgroup compared to the ischemic CVE subgroup (74% vs 36% & 71% vs 29%, respectively; p <0.05). Despite endovascular and/or surgical intervention in patients with IIA, four patients failed management and elected for comfort measures. CONCLUSION: Our results indicate that P. aeruginosa and S. aureus bacteremia are associated with a greater incidence of intracranial hemorrhage and worse neurological outcomes. Future management considerations may include pre-implantation cerebrovascular imaging to assess vascular pathology including prior aneurysms and intracranial atherosclerotic disease burden as a screen for higher-risk patients, as well as more aggressive antibiotic therapy at bacteremia onset.

Incidence, predictors, and outcomes of post-thrombectomy seizures in the extended time window.

Mechanical thrombectomy 6-24 h after the last time where a patient was known to be without signs or symptoms of a stroke is the standard of care for patients with a stroke due to large vessel occlusion. This is referred to as thrombectomy within an extended time window. There have been very few studies looking at patients who had seizures within the first week (early post-stroke seizures) following mechanical thrombectomy in this extended time window. Our study suggests that this group of patients does not have a higher incidence of early post stroke seizures. Our findings do reveal however, that patients who do have early post-stroke seizures may have a less favorable functional outcome at 90 days than those who did not develop early seizures. Hence, rapid identification and subsequent treatment of seizures in these patients is important.

Severe Cerebral Small Vessel Disease Burden Is Associated With Poor Outcomes After Endovascular Thrombectomy in Acute Ischemic Stroke With Large Vessel Occlusion.

Background Despite recent advancements in the treatment of acute ischemic stroke (AIS) with large vessel occlusion (LVO), infarct progression over time and functional outcomes remain variable. This variation in outcomes may be partially attributed to an underlying state of chronic cerebral hypoperfusion and ischemia affecting small cerebral perforating arterioles, venules, and capillaries of the brain; broadly termed cerebral small vessel disease (CSVD). We investigated the association between CSVD burden and the degree of disability following successful recanalization with endovascular thrombectomy (EVT) in patients with AIS presenting with LVO. Methodology We conducted a single center retrospective analysis of all patients presenting with AIS LVO between May 2016 and May 2019. Patients who were premorbidly independent and presented within six hours from the last known well (LKW) with a proximal anterior circulation occlusion confirmed on computed tomography (CT) angiography of the head or neck were treated with EVT. Patients presenting after six hours and up to 24 hours from LKW with a target ischemic core to perfusion mismatch profile on CT or magnetic resonance (MR) perfusion, or a clinical imaging mismatch on MR diffusion-weighted imaging, were also treated. Patients with successful revascularization, defined as a thrombolysis in cerebral infarction score 2b or 3, were included and evaluated for CSVD burden. The presence of CSVD was quantified using the Fazekas scale (0-3). All patients were further evaluated for disability at 90 days using the modified Rankin Scale (mRS, range 0-6). An mRS score of ≤2 was defined as a good functional outcome. Results Of the 190 patients evaluated, absent (Fazekas grade 0), mild (Fazekas grade 1), moderate (Fazekas grade 2), and severe (Fazekas grade 3) CSVD was present in 33 (17.4%), 84 (44.2%), 35 (18.4%), and 38 (20.0%) patients, respectively. Patients with severe CSVD (Fazekas grade 3) were found to be older, had a higher presenting National Institute of Health Stroke Scale (NIHSS), and had greater proportions of preexisting atrial fibrillation and dementia compared to patients with no CSVD (Fazekas grade 0). Using a multivariate ordinal logistic regression model to adjust for age, presenting NIHSS, thrombus location, LKW to groin puncture time, use of tissue plasminogen activator, ischemic infarct volume, development of a symptomatic intracerebral hemorrhage, and treatment with hemicraniectomy, patients with Fazekas grade 3 were significantly more likely to have poor 90-day functional outcomes compared to patients with Fazekas grade 0 (odds ratio 10.25, 95% confidence interval [3.3-31.84]). Conclusions Based on our analytical cohort of AIS LVO patients treated with EVT, we found that patients with severe CSVD burden had worse functional outcomes at 90 days and increased mortality. These results provide evidence that the burden of CSVD may be considered an independent risk factor of poor clinical outcome and a predictor of mortality in patients with AIS presenting with LVO, despite successful radiographic recanalization with EVT.

The HOPES Registry - Houston Methodist Hospital Outcomes-based Prospective Endpoints in Stroke.

BACKGROUND: We present a single institution registry with the novel feature of 90-day outcome assessments on all hospitalized acute stroke patients, inclusive of every patient with a primary discharge diagnosis of transient ischemic attack (TIA), acute ischemic stroke (AIS), nontraumatic subarachnoid hemorrhage (SAH), and intracerebral hemorrhage (ICH). METHODS: Patient data obtained in the HOPES registry include demographics, comorbid diagnoses, medications, health behaviors, laboratory values, imaging studies, vital signs, and outcome measures, most notably the modified Rankin Scale (mRS) at 90days. RESULTS: From May 2016 to December 31, 2017, 1607 patients were enrolled in the HOPES registry. 90-day outcome assessments were captured on 1555 patients (97%): 1096 AIS, 230 ICH, 110 SAH, and 119 TIA patients. Mortality rates and 90-day outcomes were most favorable for TIA patients. Mortality and 90-day disability scores were poorest for patients in the ICH group. CONCLUSIONS: The inclusion of 90-day outcomes data will allow HOPES to stand apart among stroke registries as a new standard for stroke outcomes research. The registry will provide the necessary comprehensive data that the field needs as we transition our focus of stroke research to poststroke recovery.