Scoring System to Predict Hospital Outcome After Subarachnoid Hemorrhage-Incorporating Systemic Response: The CRIG Score.

OBJECTIVES: Local and systemic proinflammatory and prothrombotic processes after aneurysmal subarachnoid hemorrhage (aSAH) precipitate delayed cerebral ischemia (DCI) and determine clinical outcome. Recent studies using admission and temporal trends of mean platelet volume to platelet count ratio (MPV:PLT) and neutrophil to lymphocyte ratio (NLR) have identified patients developing DCI. We examine if MPV:PLT and NLR along with admission clinical or radiological features can be used to develop a scoring system to predict DCI and in-hospital clinical outcome. MATERIALS AND METHODS: A 7-year retrospective cohort of aSAH patients admitted to a tertiary care medical center was used to study and identify clinical, radiological and laboratory parameters to predict DCI and clinical outcome (good: discharge to home or rehabilitation facility; poor: all other discharge destinations). Using regression analyses a scoring system (Clinical, Radiological, Inflammatory, dysGlycemia, CRIG) was developed. RESULTS: Of 271 patients, admission clinical grade (World Federation of Neurological Surgeons' scale), radiological grade (modified Fisher score), NLR and glycated hemoglobin were identified as contributors for CRIG score. CRIGDCI score threshold of 112 and CRIGdischarge 109, respectively predicted DCI and adverse clinical outcome in score development cohort. The same threshold predicted DCI and adverse clinical outcome with 78.1 and 100% sensitivity, 44.0 and 52.2% specificity, and 63.2 and 61.4% accuracy, respectively in the score validation cohort. CONCLUSIONS: CRIG is an easily calculable scoring system that incorporates systemic response of aSAH - thus, alluding to its multisystem nature. It can be used at the time of admission to predict DCI and clinical outcome.

Transcranial Doppler findings in reversible cerebral vasoconstriction syndrome.

BACKGROUND AND PURPOSE: Reversible cerebral vasoconstriction syndrome (RCVS) is a syndrome characterized by reversible segmental vasoconstriction of cerebral arteries. Digital subtraction and noninvasive angiograms are typically used to detect vasospasm; however, due to the dynamic nature of RCVS these tests are often negative initially and may need to be repeated multiple times. Transcranial Doppler (TCD) offers many advantages as it is a noninvasive and nonradiating modality. Studies investigating its diagnostic utility for capturing vasospasm and studying temporal evolution of RCVS are limited. METHODS: We conducted a retrospective analysis on all patients admitted with suspected RCVS from 2009 to 2014 to a single center at Jackson Memorial Hospital. RESULTS: We identified 9 patients (88.9% women, age 46.6 ± 13.5 years) who met diagnostic criteria for RCVS. All patients presented with headache, 5 developed nonaneurysmal subarachnoid hemorrhage, 5 developed ischemic stroke, and 1 developed posterior reversible encephalopathy syndrome. At initial TCD, 8 patients had increased flow velocities in at least one large intracranial artery and ultimately all patients had abnormal middle cerebral artery flow velocity over the course of RCVS. We found that the number of vessels with abnormal velocities increases gradually and peaks between 13 and 14 days after first symptom onset. Finally, mean flow velocity of affected vessels also increases around the same time frame and normalizes at 60 days. CONCLUSIONS: In this case series, we found TCD to be useful in detecting vasospasm and monitoring the temporal evolution of RCVS. TCD could be a helpful clinical tool to diagnose and monitor RCVS.

Intravenous tPA for Acute Ischemic Stroke in Patients with COVID-19.

BACKGROUND/PURPOSE: Coronavirus disease 2019 (COVID-19) is associated with increased risk of acute ischemic stroke (AIS), however, there is a paucity of data regarding outcomes after administration of intravenous tissue plasminogen activator (IV tPA) for stroke in patients with COVID-19. METHODS: We present a multicenter case series from 9 centers in the United States of patients with acute neurological deficits consistent with AIS and COVID-19 who were treated with IV tPA. RESULTS: We identified 13 patients (mean age 62 (±9.8) years, 9 (69.2%) male). All received IV tPA and 3 cases also underwent mechanical thrombectomy. All patients had systemic symptoms consistent with COVID-19 at the time of admission: fever (5 patients), cough (7 patients), and dyspnea (8 patients). The median admission NIH stroke scale (NIHSS) score was 14.5 (range 3-26) and most patients (61.5%) improved at follow up (median NIHSS score 7.5, range 0-25). No systemic or symptomatic intracranial hemorrhages were seen. Stroke mechanisms included cardioembolic (3 patients), large artery atherosclerosis (2 patients), small vessel disease (1 patient), embolic stroke of undetermined source (3 patients), and cryptogenic with incomplete investigation (1 patient). Three patients were determined to have transient ischemic attacks or aborted strokes. Two out of 12 (16.6%) patients had elevated fibrinogen levels on admission (mean 262.2 ± 87.5 mg/dl), and 7 out of 11 (63.6%) patients had an elevated D-dimer level (mean 4284.6 ±3368.9 ng/ml). CONCLUSIONS: IV tPA may be safe and efficacious in COVID-19, but larger studies are needed to validate these results.

Predicting Clinical Outcome After Mechanical Thrombectomy: The GADIS (Gender, Age, Diabetes Mellitus History, Infarct Volume, and Current Smoker [corrected]) Score.

OBJECTIVE: To investigate predictive factors and develop an outcome assessment tool to determine clinical outcome after endovascular mechanical thrombectomy (EMT) in patients presenting with large vessel occlusion (LVO). METHODS: A retrospective analysis was carried out of a prospective cohort of patients presenting with LVO who underwent EMT after adoption of an expanded time window of ≤24 hours. Final cerebral infarction volume (CIV) after EMT was estimated using magnetic resonance imaging segmentation software. Stepwise linear regression models were used to identify factors that determined clinical outcome and to develop a predictive scale. RESULTS: Ninety patients underwent EMT over 19 months (68 within 6 hours and 22 between 6 and 24 hours). Clinical outcome determined using modified Rankin Scale (mRS) score at discharge and 3 months was no different among these subcohorts. A threshold of 16.99 mL of CIV, using the Youden index, resulted in a sensitivity of 90.5% and specificity of 58.1% for predicting mRS score of 0-2. A regression model identified gender, age, diabetes mellitus status, CIV, and smoking status as outcome determinants, which were used to develop the GADIS (Gender, Age, Diabetes Mellitus History, Infarct Volume, and Sex) scoring system to predict good clinical outcome. Using the GADIS score, <6 predicted mRS score 0-2 at discharge with a sensitivity of 83.3% and specificity of 80.6%. CONCLUSIONS: The GADIS score for patients with LVO-related acute ischemic stroke includes CIV after EMT and helps in early short-term prognostication. It is not intended to predict preintervention patient selection or outcome prediction.

Stroke in the Young: a Global Update.

PURPOSE OF REVIEW: We aim to evaluate the epidemiology, racial and gender disparity, etiology, and treatment of stroke in the younger population. RECENT FINDINGS: The younger age group without vascular risk factors exhibits an increased prevalence of cardio-embolism in context of patent foramen ovale/atrial septal aneurysm strokes, from other determined etiology of non-atherosclerotic vasculopathy including dissection, inherited or acquired thrombophilia, and other unusual causes of stroke. Ethnic disparities also exist in certain populations. The prevalence of stroke in the young is increasing due to several factors. Since stroke is often disabling, this trend poses an enormous threat to socioeconomic stability especially in developing countries. In young patients with an absence of conventional vascular risk factors and negative preliminary stroke work-up, clinicians must consider less common causes of stroke in this population. There is prime opportunity for future investigations as there is currently a lack of evidence-based management guidelines for these uncommon etiologies based on research completed to date.

Dasatinib Reinitiation After Poststroke Thrombolysis Associated with Symptomatic Intracerebral Hemorrhage.

BACKGROUND: Dasatinib, a tyrosine kinase inhibitor commonly used in treatment of acute lymphoblastic leukemia and chronic myelogenous leukemia, is often associated with hemorrhagic complications. Safety of dasatinib after thrombolytic therapy in acute ischemic stroke is unknown. CASE DESCRIPTION: A 63-year-old man with multiple vascular risk factors and chronic myelogenous leukemia (in molecular remission) on dasatinib presented with signs and symptoms of right hemispheric stroke owing to acute intracranial internal carotid artery occlusion that was treated with intravenous thrombolysis and mechanical thrombectomy resulting in near-complete resolution of stroke symptoms. The patient developed clinical worsening (>24 hours of thrombolytic therapy) after receiving a second dose of dasatinib that was due to symptomatic intracerebral hemorrhage and necessitated decompressive hemicraniectomy. Routine coagulation profile was normal. The etiology of this hemorrhagic complication was likely secondary to primary platelet dysfunction due to dasatinib as reported in some recent in vitro and ex vivo studies. CONCLUSIONS: It is advisable to withhold dasatinib during the poststroke period owing to its associated risk of symptomatic intracerebral hemorrhage.