Late lesion growth following endovascular therapy: is 24 hours too early to assess acute infarct size including the effects of secondary injury?

Introduction Stroke lesion volume on MRI or CT provides objective evidence of tissue injury as a consequence of ischemic stroke. Measurement of "final" lesion volume at 24hr following endovascular therapy (post-EVT) has been used in multiple studies as a surrogate for clinical outcome. However, despite successful recanalization, a significant proportion of patients do not experience favorable clinical outcome. The goals of this study were to quantify lesion growth during the first week after treatment, identify early predictors, and explore the association with clinical outcome. Methods This is a prospective study of stroke patients at two centers who met the following criteria: i) anterior large vessel occlusion (LVO) acute ischemic stroke, ii) attempted EVT, and iii) had 3T MRI post-EVT at 24hr and 5-day. We defined "Early" and "Late" lesion growth as ≥10mL lesion growth between baseline and 24hr DWI, and between 24hr DWI and 5-day FLAIR, respectively. Complete reperfusion was defined as >90% reduction of the volume of tissue with perfusion delay (Tmax>6sec) between pre-EVT and 24hr post-EVT. Favorable clinical outcome was defined as modified Rankin scale (mRS) of 0-2 at 30 or 90 days. Results One hundred twelve patients met study criteria with median age 67 years, 56% female, median admit NIHSS 19, 54% received IV or IA thrombolysis, 66% with M1 occlusion, and median baseline DWI volume 21.2mL. Successful recanalization was achieved in 87% and 68% had complete reperfusion, with an overall favorable clinical outcome rate of 53%. Nearly two thirds (65%) of the patients did not have Late lesion growth with a median volume change of -0.3mL between 24hr and 5-days and an associated high rate of favorable clinical outcome (64%). However, ~1/3 of patients (35%) did have significant Late lesion growth despite successful recanalization (87%: 46% mTICI 2b/ 41% mTICI 3). Late lesion growth patients had a 27.4mL change in Late lesion volume and 30.1mL change in Early lesion volume. These patients had an increased hemorrhagic transformation rate of 68% with only 1 in 3 patients having favorable clinical outcome. Late lesion growth was independently associated with incomplete reperfusion, hemorrhagic transformation, and unfavorable outcome. Conclusion Approximately 1 out of 3 patients had Late lesion growth following EVT, with a favorable clinical outcome occurring in only 1 out of 3 of these patients. Most patients with no Early lesion growth had no Late lesion growth. Identification of patients with Late lesion growth could be critical to guide clinical management and inform prognosis post-EVT. Additionally, it can serve as an imaging biomarker for the development of adjunctive therapies to mitigate reperfusion injury.

Trends in age and sex-specific prevalence of cancer and cancer subtypes in acute ischemic stroke from 2007-2019.

OBJECTIVE: To describe age and sex-specific prevalence of cancer in acute ischemic stroke (AIS) hospitalizations in the United States over the last decade. METHODS: We conducted a retrospective serial cross-sectional study using all primary AIS discharges (weighted n=5,748,358) with and without cancer in the 2007-2019 National Inpatient Sample. Admissions with primary central nervous system cancers were excluded. Joinpoint regression was used to compute the average annualized percentage change (AAPC) in cancer prevalence over time. RESULTS: Across the study period, 12.7% of AIS admissions had previous/active cancer, while 4.4% had active cancer. Of these, 18.8% were hematologic cancers, 47.2% were solid cancers without metastasis and 34.0% were metastatic cancers of any type. Age-adjusted active cancer prevalence differed by sex (males:4.8%; females:4.0%) and increased with age up to age 70-79 years (30-39 years 1.4%; 70-79 years:5.7%). Amongst cancer admissions, lung (18.7%) and prostate (17.8%) were the most common solid cancers in men, while lung (19.6%) and breast (13.7%) were the most prevalent in women. Active cancer prevalence increased over time (AAPC 1.7%, p<0.05) but the pace of increase was significantly faster in women (AAPC 2.8%) compared to men (AAPC 1.1%) (p-comparison =0.003). Fastest pace of increased prevalence was seen for genitourinary cancers in women and for gastrointestinal cancers in both sexes. Genitourinary cancers in men declined over time (AAPC -2.5%, p<0.05). Lung cancer prevalence increased in women (AAPC 1.8%, p<0.05) but remained constant in men. Prevalence of head/neck, skin/bone, gastrointestinal, hematological and metastatic cancers increased over time at similar pace in both sexes. CONCLUSION: Prevalence of cancer in AIS admissions increased in the US over the last decade but the pace of this increase was faster in women compared to men. Gastrointestinal cancers in both sexes and genitourinary cancers in women are increasing at the fastest pace. Additional studies are needed to determine whether this increase is from co-occurrence or causation of AIS by cancer.

African Americans and Women Have Lower Functional Gains During Acute Inpatient Rehabilitation After Hemorrhagic Stroke.

OBJECTIVE: Intracerebral hemorrhage can lead to significant long-term disability. While research in stroke rehabilitation has focused primarily on ischemic strokes, identifying factors that impact recovery in patients with intracerebral hemorrhage is necessary. Our purpose is to identify factors, including racial and sex disparities, associated with functional outcomes in intracerebral hemorrhage patients after inpatient rehabilitation. DESIGN: This was a retrospective analysis of consecutive patients with intracerebral hemorrhage admitted to an inpatient rehabilitation facility at an academic tertiary facility in the Southeastern United States from 2016 to 2019. Clinical characteristics, demographics, admission, and discharge Functional Independence Measure scores were collected. RESULTS: We evaluated 59 patients (54.4 ± 14.1 yrs, 39% females, 48.2% African American) with a median intracerebral hemorrhage volume of 13.4 (4.2-33.0) and a mean (SD) Functional Independence Measure efficiency of 1.8 ± 1.3. In multiple regression, being female was negatively associated with Functional Independence Measure efficiency (ß = -1.13, P = 0.0037) when adjusting for race and intracerebral hemorrhage score. The Functional Independence Measure efficiency was lower in African Americans (ß = -0.97, P = 0.0119) when adjusting for sex and intracerebral hemorrhage volume. CONCLUSIONS: The results of our study indicate that Functional Independence Measure efficiency was worse for African Americans and female patients with intracerebral hemorrhage. Future research should consider these racial and sex disparities and focus on providing targeted rehabilitation therapy.

Emerging Neurology of COVID-19.

The virus, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is responsible for the current pandemic known as coronavirus disease 2019 (COVID-19) with severe respiratory illness as the predominant manifestation. Neurologic complications from COVID-19 were reported in the early stages of the pandemic and are now increasingly recognized. These include various symptoms like headache and anosmia as well as neurologic complications of severe COVID-19 like encephalopathy, seizures, and stroke. There are few reports of direct involvement of the central nervous system with SARS-CoV-2 causing meningoencephalitis. There is concern for higher incidence and severity of COVID-19 in patients with chronic neurologic conditions. Here, we review the emerging literature along with our anecdotal experience in regard to these neurologic manifestations in patients with COVID-19 and detail the putative pathophysiologic mechanisms for the same.

De Novo Status Epilepticus in patients with COVID-19.

Neurological complications are increasingly recognized with SARS-CoV-2, the causative pathogen for COVID-19. We present a single-center retrospective case series reporting the EEG and outcome of de novo status epilepticus (SE) in two African-American women with laboratory-confirmed SARS-CoV-2 virus. SE was the initial presentation in one asymptomatic individual. Patient 2 had COVID-19 pneumonia, and fluctuating mental status that raised the suspicion of subclinical SE. The patient with older age and higher comorbidities failed to recover from the viral illness that has no definitive treatment.

Management of bleeding gastric varices: a single session of histoacryl injection may be sufficient.

OBJECTIVE: Gastric variceal bleeding is one of the most feared complications of portal hypertension and hence merits investigation for its optimal therapy. We aimed to evaluate the efficacy and long-term outcome(s) of patients treated with a single session of histoacryl sclerotherapy for active gastric variceal bleeding. METHODS: The medical records of patients who presented with active gastric variceal bleeding between 1998 and 2011 in a tertiary care setting were evaluated retrospectively and the eventual outcome(s) (initial hemostasis, rebleeding, and mortality rate) was assessed at least 1 year after the index bleed. RESULTS: Ninety-seven patients were included. The mean age of the patients was 51.0 ± 12.5 years; 62% were men. Hepatitis C was the most common etiology, found in 63 (65%) patients. The majority of the patients were classified as Child-Pugh grade B and C: 44 (46%) and 29 (31%) patients, respectively. A total of 40 (41%) patients were IGV1, 35 (36%) patients were GOV 2, 20 (21%) patients were GOV 1, and 2 (2%) patients were IGV2. A single session of histoacryl was successful in controlling bleeding in 83 (86%) patients. Seven (7%) patients died during the hospital stay. Rebleeding was observed in 24 (27%) patients during the 1-year follow-up, of whom 12 (50%) were managed successfully with repeated histoacryl injection. The overall mortality rate at 6 weeks, 6 months, and 1 year was 14 (14%), 19 (20%) and 26 (27%) patients, respectively. Child-Pugh classification was a significant prognostic factor of survival (P<0.001). CONCLUSION: A single session of histoacryl sclerotherapy is effective in the majority of patients with active gastric variceal bleeding. Rebleeding was observed in one-fourth of patients, half of whom were controlled successfully by repeated histoacryl sclerotherapy.