Associations of Neutrophil-Lymphocyte Ratios with Reperfusion and Functional Outcomes in Ischemic Stroke after Endovascular Therapy.

OBJECTIVES: Treatment of ischemic stroke with endovascular thrombectomy (EVT) leads to improved outcomes compared to IV tPA. The neutrophil-lymphocyte ratio (NLR), a marker of inflammation, has been proposed to predict outcomes in ischemic stroke patients and may be used to identify patients at risk for poor outcomes after EVT. MATERIALS AND METHODS: This was a retrospective study of adult ischemic stroke patients undergoing EVT between 1/1/2018 and 12/31/2020. Outcomes were successful reperfusion (TICI score ≥2B), favorable discharge NIHSS (≤4), favorable discharge and 3-month mRS (≤2), and symptomatic intracranial hemorrhage (sICH). The primary exposure was NLR, measured pre- and post-EVT. Other variables collected included demographics and timing of stroke onset, arrival, groin puncture, tPA, and recanalization. RESULTS: A total of 592 patients were included. The most common vessel involved was the middle cerebral artery (73%). Lower admission NLR was associated with favorable discharge NIHSS and favorable discharge and 3-month mRS (all P < 0.01). NLRs measured after EVT were associated with all the primary outcomes. Improvements in NLR after EVT were associated with favorable discharge (P = 0.02) and 3-month mRS (P = 0.02) and lower incidence of sICH (P = 0.01). CONCLUSIONS: Because of the long-term functional deficits that can persist after ischemic stroke, it is vital to identify patients with higher probability for these outcomes. The results from this study showed that favorable NLR measures, as well as favorable trends in NLR over time, are associated with improved outcomes, indicating that NLR is a useful marker to identify patients at risk for poor functional outcomes.

Spontaneous thrombosis with a conservative approach to posterior spinal artery pseudoaneurysm management: A case series.

In this study, we address the rarity and management challenges associated with ruptured spinal artery pseudoaneurysms, which comprise < 1% of subarachnoid hemorrhage cases. With our limited understanding of their natural history, the prevailing consensus leans towards surgical clipping, contrasting with the typically benign symptoms of sudden back pain and lower extremity weakness. Despite reported low morbidity and mortality, fatal re-ruptures underscore the need for effective management strategies. In this context, we present the largest case series to date, featuring five patients with spinal subarachnoid hemorrhage from isolated posterior spinal artery pseudoaneurysms. All cases achieved spontaneous thrombosis and resolution through conservative management, challenging the prevailing surgical emphasis. The patients, aged 58-81, exhibited varied symptoms, including back pain, paresthesia, confusion, and seizures, with hypertension as a common comorbidity. The results of these cases lead us to tender a "hybrid" management strategy, combining conservative measures with short-term follow-up angiograms, fostering a paradigm shift and warranting further investigation into individualized patient care within larger clinical cohorts.

Decreased timing to vasospasm prophylaxis improves outcomes among patients with aneurysmal subarachnoid hemorrhage (aSAH) on prehospital CCBs, ARBs, or ACE-inhibitors.

INTRODUCTION: Aneurysmal subarachnoid hemorrhage (aSAH) patients are given calcium channel blockers (CCBs) to prevent brain vessel vasospasm. We hypothesized that preinjury antihypertensive use may protect against vasospasm. It remains unclear whether the timing of in-hospital CCB initiation affects the vasospasm risk in this population. METHODS: This retrospective cohort study included aSAH patients (≥18 y/o) at a Comprehensive Stroke Center (1/18-11/21). Patients taking prehospital antihypertensives [CCBs, Angiotensin-converting enzyme (ACE) inhibitors or Angiotensin II receptor blockers (ARBs)] were compared to those who were not. Results were stratified by patients receiving vasospasm prophylaxis ('in-hospital CCBs') ≤1.2 h of arrival vs. >1.2 h from arrival. Outcomes included vasospasm, hospital length of stay (LOS), and mortality. RESULTS: Of 251 patients, 18% were taking prehospital antihypertensives. Patients were comparable in baseline characteristics. There was no difference in the rate of vasospasm when compared by prehospital antihypertensive use. For those on prehospital antihypertensives, the time to in-hospital CCBs was significantly longer for patients who developed vasospasm than for those who did not (1.2 vs. 4.9 h, respectively, p = 0.02). For those on prehospital antihypertensives, receipt of in-hospital CCBs within 1.2 h of arrival was associated with a significantly lower vasospasm rate (6% vs. 39%, p = 0.03) and LOS (14 vs. 20 d, p = 0.01) when compared to receiving in-hospital CCBs > 1.2 h of arrival, respectively. The mortality rate (50% vs. 26%, p = 0.06) was statistically similar between groups, respectively. These results were not observed among patients who were not on prehospital antihypertensives. The timing to in-hospital CCB initiation had no effect on vasospasm (p = 0.23), death (p = 0.08), or LOS (p = 0.31) for patients not on prehospital antihypertensives. CONCLUSIONS: Enhancing the efficiency of in-hospital CCB initiation for patients on prehospital antihypertensives may decrease the occurrence of vasospasm and lead to a shorter LOS.

Pilot study examining anti-factor Xa levels for heparin monitoring and outcomes in patients with cerebral venous thrombosis.

Objective: There are no studies to date that examine the association between anti-factor-Xa (AFXa)-based heparin monitoring and clinical outcomes in the setting of cerebral venous thrombosis (CVT). Methods: This pilot study included adults aged ≥18 admitted with CVT between 1 January 2018 and 1 January 2021, who were treated with unfractionated heparin (UFH) and were monitored via AFXa-based nomogram within 24 h of arrival. Comparisons were made between patients with AFXa levels within the target therapeutic range (0.25-0.5 IU/mL) and patients whose levels were not within the therapeutic range within 24 h of arrival; the time (hours) from arrival to reach the therapeutic range was also examined. Outcomes were length of stay (LOS) in the hospital, major (actionable) bleeding events, and discharge home (vs. higher acuity location). Continuous data are reported in the form of the median (interquartile range). Results: Among 45 patients, treatment with UFH was initiated 2 (1-11) h after arrival, and the majority (84%) of UFH infusions did not need dose adjustment. AFXa assays were conducted every 6 (5.5-7) h. Thirty patients (67%) fell within the therapeutic range. Outcomes were similar for patients with levels within the therapeutic range vs. not: major bleeding events, 10% vs. 0% (p = 0.54); discharge home, 77% vs. 80% (p = 1.0); LOS, 5 days in each group (p = 0.95). There was also no association between outcomes and time to reach the therapeutic range. Conclusion: Our findings demonstrate the practicability of monitoring UFH based on AFXa values in this population of patients with CVT, but reaching target AFXa levels within 24 h of arrival may not necessarily be prognostic.

Blood glucose monitoring (BGM) still matters for many: Associations of BGM frequency and glycemic control in youth with type 1 diabetes.

AIMS: This study aimed to compare three approaches of blood glucose monitoring (BGM) frequency attainment and to examine their associations with glycemic control in youth with type 1 diabetes (T1D). METHODS: Cross-sectional data was derived from the baseline assessment in three clinical trials. Clinical and demographic characteristics of youth with T1D was obtained by chart review. BGM frequency was assessed by parent-youth interview, chart review, and meter downloads. To examine the relationship between A1c and frequency of BGM we performed analysis of variance. RESULTS: In youth with T1D (N = 385, 50% female, age 13.6 ± 2.5 years, 74% pump users), the 3 methods of assessing BGM frequency were significantly correlated. Frequency by self-report (6.4 ± 2.3 times/day) was significantly higher than both meter download (5.6 ± 2.4 times/day, p < 0.0001) and clinician report (5.7 ± 2.4 times/day, p < 0.0001). For all methods, more frequent BGM was associated with lower A1c and lower mean glucose (p < 0.0001). For each additional daily blood glucose check, there was a 0.2% decrease in A1c (p < 0.0001). CONCLUSION: BGM remains a potent predictor of glycemic control, warranting continued targeting in clinical efforts to improve glycemic management in youth with T1D.