Mechanical Thrombectomy in Wake-Up Strokes: A Case Series Using Alberta Stroke Program Early CT Score (ASPECTS) for Patient Selection.

BACKGROUND: There is lack of published studies on mechanical thrombectomy with stent retrievers for wake-up stroke (WUS). OBJECTIVE: To report the outcomes of WUS patients with large vessel occlusions, selected for intervention based on Alberta Stroke Program Early CT Score (ASPECTS) and treated with stent retrievers or primary aspiration thrombectomy. METHODS: Data were collected retrospectively for each consecutive WUS patient undergoing mechanical thrombectomy with a stent retriever or primary aspiration catheter between February 2015 and September 2016. ASPECTS ≥ 6 was used as the primary imaging criterion for offering thrombectomy in these WUS patients. Main outcomes were the in-hospital improvement in the National Institutes of Health Stroke Scale (NIHSS) and the occurrence of symptomatic hemorrhage. RESULTS: Twelve patients were included in this study; 11 were treated with stent retrievers and 1 was treated with primary aspiration thrombectomy alone. Successful recanalization was achieved in 100% of the patients (33% thrombolysis in cerebral infarction [TICI] 2B and 67% TICI 3). Every patient experienced a reduction in the NIHSS during hospitalization, with a mean NIHSS decrease of 11.1 ± 5.1 points. There was a trend for a larger reduction in the NIHSS in patients with TICI 3 compared to TICI 2B recanalization. There was no symptomatic intracranial hemorrhage in our cohort. CONCLUSIONS: For patients with WUS, careful selection of patients using ASPECTS may allow for safe interventions, with low risk of clinical deterioration, and no-periprocedural mortality. All our patients demonstrated a reduction in their NIHSS after the thrombectomy and clinical improvement.

Emergency Department Length of Stay and Outcome after Ischemic Stroke.

BACKGROUND: Emergency department length of stay (ED-LOS) has been associated with worse outcomes after various medical conditions. However, there is a relative paucity of data for ischemic stroke patients. We sought to determine whether a longer ED-LOS is associated with a poor 90-day outcome after ischemic stroke. METHODS: This study is a retrospective analysis of a single-center cohort of consecutive ischemic stroke patients (n = 325). Multivariable linear and logistic regression models were constructed to determine factors independently associated with ED-LOS as well as a poor 90-day outcome (modified Rankin Scale [mRS] score >2), respectively. RESULTS: The median ED-LOS in the cohort was 5.8 hours. For patients admitted to the inpatient stroke ward (n = 160) versus the neuroscience intensive care unit (NICU; n = 165), the median ED-LOS was 8.2 hours versus 3.7 hours, respectively. On multivariable linear regression, NICU admission (P <.001), endovascular stroke therapy (P = .001), and thrombolysis (P = .021) were inversely associated with the ED-LOS. Evening shift presentation was associated with a longer ED-LOS (P = .048). On multivariable logistic regression, a greater admission National Institutes of Health Stroke Scale score (P <.001), worse preadmission mRS score (P = .001), hemorrhagic conversion (P = .041), and a shorter ED-LOS (P = .016) were associated with a poor 90-day outcome. Early initiation of statin therapy (P = .049), endovascular stroke therapy (P = .041), NICU admission (P = .029), and evening shift presentation (P = .035) were associated with a good 90-day outcome. CONCLUSIONS: In contrast to prior studies, a shorter ED-LOS was associated with a worse 90-day functional outcome, possibly reflecting prioritized admission of more severely affected patients who are at high risk of a poor functional outcome.

Clinical impact of leukoaraiosis burden and chronological age on neurological deficit recovery and 90-day outcome after minor ischemic stroke.

BACKGROUND AND AIMS: Ischemic stroke remains a leading cause of disability, particularly among the elderly, but this association has not been consistently noted among patients with minor stroke. We sought to determine the association of chronological age and leukoaraiosis, which is considered a marker of biological age, with the degree of neurological deficit recovery and 90-day disability after minor ischemic stroke. METHODS: We retrospectively analyzed 185 patients with a minor ischemic stroke (National Institutes of Health Stroke Scale [NIHSS] score ≤ 5). Leukoaraiosis severity was graded according to the van Swieten scale. NIHSS was assessed at baseline, discharge, and 90-days. Multivariable linear and ordinal logistic regression analyses were constructed to identify independent predictors of the degree of NIHSS-improvement (ΔNIHSS) and 90-day outcome as assessed by the modified Rankin Scale (mRS). RESULTS: Patients with severe leukoaraiosis had attenuated ΔNIHSS at 90 days as compared to patients with none-to-mild leukoaraiosis (p=0.028). After adjustment, leukoaraiosis severity (p<0.001) but not chronological age (p=0.771) was independently associated with the ΔNIHSS by day 90. Severe leukoaraiosis (p=0.003, OR 3.1, 95%-CI 1.5-6.4), older age (p=0.001, OR 1.0 95%-CI 1.0-1.1), and admission NIHSS (p<0.001, OR 1.5, 95%-CI 1.2-1.8) were independent predictors of the 90-day mRS. CONCLUSION: Leukoaraiosis is a more sensitive predictor for neurological deficit recovery after ischemic stroke than chronological age. Further study is required to establish the specific contribution of leukoaraiosis to functional outcome after minor ischemic stroke beyond its impact on recovery mechanisms.

Incidence and outcome of procedural distal emboli using the Penumbra thrombectomy for acute stroke.

BACKGROUND: The Penumbra system is effective for recanalization of the primary arterial occlusion (PAO) in acute stroke. However, clinical outcomes are not as promising. The authors hypothesized that the formation of procedural distal emboli (PDE) during mechanical thrombectomy may lead to poorer patient outcomes. DESIGN/METHODS: A retrospective review of patients with acute ischemic stroke treated with the Penumbra system was undertaken. Patients' outcome was evaluated by comparing discharge National Institute of Health stroke scale and modified Rankin score (mRS) of patients with and without PDE. RESULTS: Out of 20 patients reviewed, recanalization of PAO was 100%. Six patients (30%) were confirmed to have PDE, of which two died (33.3%) and one (16.7%) had mRS of 2 or less. Of the 14 patients without PDE, three died (21.4%) and six (42.9%) had mRS of 2 or less. In the patient group who survived, mean National Institute of Health stroke scale decrease was only 2.3 in patients with PDE versus a decrease of 10.6 in patients without PDE. CONCLUSIONS: In spite of PAO recanalization, distal emboli formed subsequent to Penumbra thrombectomy may contribute to poorer clinical outcome in acute stroke patients.