Impact of the pandemic and concomitant COVID-19 on the management and outcomes of middle cerebral artery strokes: a nationwide registry-based study.

OBJECTIVES: To investigate the impact of the COVID-19 pandemic as well as concomitant COVID-19 itself on stroke care, focusing on middle cerebral artery (MCA) territory infarctions. DESIGN: Registry-based study. SETTING: We used the National Inpatient Sample (NIS) database, which covers a wide range of hospitals within the USA. PARTICIPANTS: The NIS was queried for patients with MCA strokes between 2016 and 2020. In total, 35 231 patients were included. OUTCOME MEASURES: Outcome measures were postprocedural complications, length of stays (LOSs), in-hospital mortality and non-routine discharge. Propensity score matching using all available baseline variables was performed to reduce confounders when comparing patients with and without concomitant COVID-19. RESULTS: Mechanical thrombectomy (MT) was performed in 48.4%, intravenous thrombolysis (IVT) in 38.2%, and both MT and IVT (MT+IVT) in 13.4% of patients. A gradual increase in the use of MT and an opposite decrease in the use of IVT (p<0.001) was detected during the study period. Overall, 25.0% of all patients were admitted for MCA strokes during the pandemic period (2020), of these 209 (2.4%) were concomitantly diagnosed with COVID-19. Patients with MCA strokes and concomitant COVID-19 were significantly younger (64.9 vs 70.0; p<0.001), had significantly worse NIH Stroke Severity scores, and worse outcomes in terms of LOS (12.3 vs 8.2; p<0.001), in-hospital mortality (26.3% vs 9.8%; p<0.001) and non-routine discharge (84.2% vs 76.9%; p=0.013), as compared with those without COVID-19. After matching, only in-hospital mortality rates remained significantly higher in patients with COVID-19 (26.7% vs 8.5%; p<0.001). Additionally, patients with COVID-19 had higher rates of thromboembolic (12.3% vs 7.6%; p=0.035) and respiratory (11.3% vs 6.6%; p=0.029) complications. CONCLUSIONS: Among patients with MCA stroke, those with concomitant COVID-19 were significantly younger and had higher stroke severity scores. They were more likely to experience thromboembolic and respiratory complications and in-hospital mortality compared with matched controls.

Malignant Middle Cerebral Artery Infarction during Early versus Late Endovascular Treatment in Acute Ischemic Stroke.

INTRODUCTION: Endovascular treatment (EVT) performed in the early time window has been shown to decrease the incidence of malignant middle cerebral artery infarction (MMI). However, the incidence of MMI in patients undergoing EVT during the late time window is unclear. This study aimed to investigate the prevalence of MMI in patients undergoing late EVT and compare it with that in patients undergoing early EVT. METHODS: We retrospectively analyzed consecutive patients with anterior large vessel occlusion stroke who underwent EVT at Xuanwu Hospital between January 2013 and June 2021. Eligible patients were divided into early EVT (within 6 h) and late EVT (6-24 h) groups according to the time from their stroke onset to puncture and compared. The occurrence of MMI post-EVT was the primary outcome. RESULTS: A total of 605 patients were recruited, of whom 300 (50.4%) underwent EVT within 6 h and 305 (49.6%) underwent EVT within 6-24 h. A total of 119 patients (19.7%) developed MMI. 68 patients (22.7%) in the early EVT group and 51 patients (16.7 %) in the late EVT group developed MMI (p = 0.066). After adjusting for covariate variables, late EVT was independently associated with a lower incidence of MMI (odds ratio, 0.404; 95% confidence interval, 0.242-0.675; p = 0.001). CONCLUSION: MMI is not an uncommon phenomenon in the modern thrombectomy era. Compared with the early time window, patients selected by stricter radiological criteria to undergo EVT in the late time window are independently associated with a lower incidence of MMI.

In vitro fertilization exacerbates stroke size and neurological disability in wildtype mice.

BACKGROUND AND PURPOSE: Assisted reproductive technologies (ART) induce premature vascular aging in human offspring. The related alterations are well-established risk factors for stroke and predictors of adverse stroke outcome. However, given the young age of the human ART population there is no information on the incidence and outcome of cerebrovascular complications in humans. In mice, ART alters the cardiovascular phenotype similarly to humans, thereby offering the possibility to study this problem. METHODS: We investigated the morphological and clinical outcome after ischemia/reperfusion brain injury induced by transient (45 min) middle cerebral artery occlusion in ART and control mice. RESULTS: We found that stroke volumes were almost 3-fold larger in ART than in control mice (P < 0.001). In line with these morphological differences, neurological performance assessed by the Bederson and RotaRod tests 24 and 48 h after artery occlusion was significantly worse in ART compared with control mice. Plasma levels of TNF-alpha, were also significantly increased in ART vs. control mice after stroke (P < 0.05). As potential underlying mechanisms, we identified increased blood-brain barrier permeability evidenced by increased IgG extravasation associated with decreased tight junctional protein claudin-5 and occludin expression, increased oxidative stress and decreased NO-bioactivity in ART compared with control mice. CONCLUSIONS: In wildtype mice, ART predisposes to significantly worse morphological and functional stroke outcomes, related at least in part to altered blood-brain barrier permeability. These findings demonstrate that ART, by inducing premature vascular aging, not only is a likely risk factor for stroke-occurrence, but also a mediator of adverse stroke-outcome. TRANSLATIONAL PERSPECTIVE: This study highlights that ART not only is a likely risk factor for stroke-occurrence, but also a mediator of adverse stroke-outcome. The findings should raise awareness in the ever-growing human ART population in whom these techniques cause similar alterations of the cardiovascular phenotype and encourage early preventive and diagnostic efforts.

Cerebral large artery stenosis and occlusion in POEMS syndrome.

BACKGROUND: This study aimed to investigate the frequency and risk factors for cerebral artery stenosis and occlusion in patients with polyneuropathy, organomegaly, endocrinopathy, M-protein, and skin changes (POEMS) syndrome. METHODS: We reviewed results of magnetic resonance angiography (MRA) or computed tomography angiography (CTA) in 61 patients with POEMS syndrome seen between 2010 and 2017. Stenosis or occlusion was assessed in the initial MRA/CTA. Multivariate analysis was used to identify risk factors for artery stenosis/occlusion. In an autopsy case, pathologic examination was conducted of the occluded middle cerebral arteries. RESULTS: Stenosis (> 50 %) or occlusion of the major cerebral arteries was found in 29 (47.5 %) patients on the initial MRA/CTA. The internal carotid artery was involved most frequently (32.8 %), followed by the anterior (21.3 %) and middle (16.4 %) cerebral arteries. The basilar (1.3 %) and vertebral (3.6 %) arteries were rarely affected. Cerebral infarction developed in eight (13.1 %) patients. The serum vascular endothelial growth factor (VEGF) level was an independent predictor for stenosis/occlusion (odds ratio, 1.228; 95 % confidence interval, 1.042-1.447; P = 0.014). An autopsy study showed occluded middle cerebral arteries by fibrous and myxomatous thickening of intima with splitting of the internal elastic lamina. Follow-up MRA in 23 patients showed improved, worsened, and unchanged stenosis in 20.7 %, 8.7 %, and 69.6 %, respectively. CONCLUSIONS: Cerebral large-vessel stenosis or occlusion is frequently seen in approximately half of patients with POEMS syndrome. Vasculopathy was related to serum VEGF levels and thereby disease activity. Assessment of cerebral vessels is recommended in these patients to improve management.

Seizures after decompressive hemicraniectomy for large middle cerebral artery territory infarcts: Incidence, associated factors, and impact on long-term outcomes.

BACKGROUND AND PURPOSE: Decompressive hemicraniectomy (DH) reduces mortality of large middle cerebral artery (MCA) territory infarcts. Survivors are at high risk of poststroke seizures (PSSs). This study aims to describe the incidence of PSSs, to identify associated factors, and to assess their impact on long-term outcomes. METHODS: We included consecutive patients who underwent DH for large MCA infarcts from May 2005 to December 2019 at Lille University Hospital. Patients were followed up at 3 months, 1 year, and 3 years. We analysed (i) the incidence and associated factors of early onset PSSs (EPSSs) with logistic regression models; (ii) the incidence and associated factors of late onset PSSs (LPSSs) in survivors at 7 days with a univariate Cox proportional hazard regression model for interval-censored data; and (iii) the impact of PSSs (EPSSs and LPSSs) on mortality with univariate and multivariate Cox proportional hazard regression models and modified Rankin Scale at 1 and 3 years, with univariate and adjusted multivariate ordinal logistic regression analyses. RESULTS: Of 248 patients (150 men, 60.5%; mean age = 50.4 ± 9.6 years), 106 (42.7%) presented PSSs (six inaugural seizures, 22 EPSSs, 78 LPSSs) during follow-up. The PSS cumulative incidence was 12.3% at 7 days, 24.9% at 3 months, 49.8% at 1 years, and 54.8% at 3 years. No predictor was significantly associated with either EPSSs or LPSSs. PSSs did not significantly impact mortality and long-term functional outcome. CONCLUSIONS: The incidence of PSSs after DH is high, reaching more than 50% 3 years after stroke, but PSSs did not influence long-term mortality or functional outcome.

The association between white matter changes and development of malignant middle cerebral artery infarction: A case-control study.

ABSTRACT: Disrupted blood-brain barrier (BBB) in patients with ischemic stroke plays a critical role in malignant middle cerebral artery infarction (MMI) development.Cerebral white matter changes (WMC), particularly in the deep subcortical area or in severe one, may be also underlain by disrupted BBB. It is unclear whether the presence of WMC with potential premorbid disruption of BBB makes patients susceptible to MMI. Therefore, this study aimed to clarify any putative relationship between the MMI and WMC in terms of their severity and locations.In this case-control study, patients with infarction in the middle cerebral artery territory were retrospectively reviewed. Brain magnetic resonance images were analyzed according to Fazekas scale, and identified WMC were divided into periventricular WMC (PV-WMC) and deep subcortical WMC (deep-WMC). Patients were scored as having WMC, PV-WMC, deep-WMC, severe PV-WMC, and severe deep-WMC according to the severity and locations. Patients were defined as having MMI if either a progressive conscious disturbance or signs of uncal herniation was recorded in combination with a midline shift >5 mm identified on the follow-up computed tomography.Among 297 patients admitted between July 2009 and February 2015, 92 patients were eligible for final analysis. Compared to patients without MMI, patients with MMI had a higher score of National Institutes of Health Stroke Scale, a larger infarct volume, and an increasingly greater proportion of severe PV-WMC, deep-WMC, and severe deep-WMC, respectively. After adjustment for sex, age, infarct volume, and history of hypertension, severe deep-WMC (odds ratio [OR] = 6.362, 95% confidence interval [CI] = 1.444-28.023, P = .0144) and severe PV-WMC (odds ratio = 5.608, 95% confidence interval = 1.107-28.399, P = .0372) were significantly associated with MMI development.MMI and WMC are significantly associated such that MMI development is more likely when PV-WMC or deep-WMC is more severe. We hypothesize that Fazekas scale-defined severe deep-WMC and PV-WMC may be considered as clinically approachable predictors of MMI development. These findings support that the WMC with potential premorbid disrupted BBB may make patients susceptible to MMI, and further prospective study should be conducted to clarify this hypothesis.

Prevalence and outcome of young stroke patients with middle cerebral artery stenosis.

BACKGROUND: Etiologies of acute ischemic stroke in young adults are heterogeneous. Middle cerebral artery (MCA) stenosis is a common finding in Asians which may be an important cause of stroke in young adults. However, studies of stroke in young Asian populations are rare. Our study was to investigate the prevalence and outcome of young stroke patients with MCA stenosis in Chinese populations. METHODS: Young patients with MCA territory infarction between January 2013 and September 2018 were retrospectively recruited. Subjects were defined as stenosis group (MCA stenosis ≥50%) and no-stenosis group (MCA stenosis<50% or no stenosis) by their MCA stenosis. For patients in stenosis group, they were categorized as uni-MCA stenosis subgroup and multiple stenosis subgroup. Demographic data, risk factors, imaging feature and complications were compared between groups. Prevalence of MCA stenosis and risk factor score (score ≥ 2 or 3) in different age groups were investigated. Modified Rankin Scale (mRS) was used for evaluating functional outcome at discharge (unfavorable outcome: 3-6). Binary logistic regression was performed to determine independent risk factors of unfavorable outcome. RESULTS: Two hundred forty-nine young stroke patients were included in our study and 110 (44.2%) patients were defined as stenosis group. 55 (50%) patients were categorized as uni-MCA stenosis subgroup and 55 (50%) were multiple stenosis subgroup. The most common traditional vascular risk factors included hypertension, hyperlipemia, smoking, hyperhomocysteinemia and alcohol consumption. Prevalence of risk factor score ≥ 2 or 3 increased with age, but not incidence of MCA stenosis. By TOAST classification, the most common etiologies were large-artery atherosclerosis (41.0%) and small vessel disease (33.7%). Compared with no-stenosis group, patients in stenosis group were more likely to have large territorial infarct, develop complications and have unfavorable outcome. No significant difference was found between patients in uni-MCA stenosis and multiple stenosis subgroups except history of stroke/TIA, risk factor score ≥ 3 and silent infarct. By logistic regression, hypertension (OR = 3.561; 95%CI, 1.494 to 8.492; p = 0.004), NIHSS scores at admission (OR = 1.438; 95%CI, 1.276 to 1.620; p = 0,000) and infarct size (p = 0.015) independently predicted unfavorable outcome. CONCLUSIONS: Forty-four point two percent young Chinese adults with MCA territory infarction had MCA stenosis. Prevalence of MCA stenosis did not increase with age. Patients with MCA stenosis had worse clinical outcome, however, only hypertension, NIHSS scores at admission and infarct size were independent predictors.

Association between Low-Density Lipoprotein Cholesterol Levels and Proximal Single Subcortical Infarction in Comparison with Distal Single Subcortical Infarction.

PURPOSE: Single subcortical infarction (SSI) in the middle cerebral artery (MCA) territory can be classified into proximal SSI (pSSI) and distal SSI (dSSI) based on the heterogeneous pathogenesis. It is hypothesized that pSSI is more relevant with atherosclerosis, as low-density lipoprotein cholesterol (LDL-C) is the major atherogenic lipoprotein, we conducted the present study to investigate the association between LDL-C levels and pSSI in comparison with dSSI. PATIENTS AND METHODS: This study is a subset of the Chinese Intracranial Atherosclerosis study. A total of 380 with SSI in the MCA territory classified as small artery occlusion stroke were enrolled in this study. 3.0-T magnetic resonance imaging (MRI) was performed to categorize the participants into two groups, pSSI (extending to the basal surface of MCA) and dSSI (not extending to the basal surface of MCA). RESULTS: Out of the 380 enrolled participants (273 men and 107 women), the proportion of pSSI and dSSI were 53.2% (202/380) versus 46.8% (178/380) based on MRI. The results of univariate and multivariate logistic regression were both at the borderline level of statistical significance. Further stratified analyses revealed that age is an interaction factor (P = 0.03), the association between LDL-C levels and the pSSI in participants aged over 65 had a significant positive relation (OR: 1.56; 95%CI: 1.14-2.12). CONCLUSION: LDL-C level is an independent risk factor for pSSI in patients aged over 65. Our result is in accordance with the hypothesis that pSSI is more relevant with atherosclerosis, thus appropriate treatment should be applied differently to pSSI and dSSI.

Long-term follow-up of patients undergoing decompressive hemicraniectomy for malignant stroke: Quality of life and caregiver's burden in a real-world setting.

BACKGROUND AND PURPOSE: Decompressive hemicraniectomy is a life-saving procedure for the treatment of space-occupying middle cerebral artery infarctions (malignant stroke); however, patients may survive severely disabled. Comprehensive data on long-term sequelae outside randomized controlled trials are scarce. METHODS: We retrospectively evaluated the survival rates, quality of life, ability to perform activities of daily living, and caregiver burden of 61 patients (aged from 37 to 83) who had previously undergone decompressive hemicraniectomy for malignant stroke between 2012 and 2017. RESULTS: The mortality rate was higher among patients older than 60 years than among younger patients (71.0 % vs 36.7 %, p = 0.007; odds ratio 4.222, 95 % confidence interval 1.443-12.355). The mean survival time was 37.9 ± 6.0 months for 19 survivors of the younger group and 22.6 ± 5.7 months for 9 survivors of the older group. Among the 28 surviving patients, 22 (78.6 %) were interviewed, and we found that age was a determining factor for functional outcome (Barthel indices of 65.7 ± 10.6 for younger patients vs 48.0 ± 9.3 for older patients, p < 0.001), but not for quality of life. The caregiver burden was significantly correlated (R = -0.53, p < 0.01) with the severity of disability and age (R = 0.544, p = 0.011) of the patients. CONCLUSION: Our findings show that the degree of impairment, as well as caregiver burden, is higher in patients older than 60 years than in younger patients.

Fifteen-Year Institutional Retrospective Case Series of Decompressive Craniectomy for Malignant Middle Cerebral Artery Infarction.

OBJECTIVE: In the present study, we updated our previously reported case series of patients who had undergone decompressive craniectomy for malignant middle cerebral artery infarction (mMCAI) (2005-2020). To the best of our knowledge, the present case series constitutes the largest reported series from a UK neurosurgical unit of decompressive craniectomy for mMCAI. METHODS: We extracted data regarding the clinical discriminators, surgical timescales, and functional outcomes of patients. RESULTS: A total of 67 patients had undergone decompressive craniectomy. The 30-day mortality was 17.9% (n = 12). Of the 67 patients, 31 were male (46.3%) and 36 were female (53.7%). Their mean age was 45 years (range, 16-64 years). The mean age of the survivors was 43 years (range, 16-62 years) compared with 50 years (range, 38-64 years) for those who had died. The median ictal and preoperative Glasgow coma scale score was 14 (range, 7-15) and 8 (range, 3-15), respectively. The corresponding motor scores were 6 and 5. The mean interval from ictus to neurosurgical unit admission was 18.25 hours (range, 0.5-66 hours) and from admission to decompressive craniotomy was 7.30 hours (range, 0.5-46 hours). Of the 67 patients, 63% had undergone "early" craniectomy (<48 hours from mMCAI evolution), with 89% of these patients having undergone craniectomy <24 hours after neurosurgical unit admission. The mean maximum anteroposterior craniectomy diameter was 13.01 cm (range, 10.29-15.56 cm), and mean surface area was 94.38 cm2 (range, 74.75-132.32 cm2). Overall, 46% of patients had had a modified Rankin scale score of <3 (range, 0-6) from discharge to 12 months postoperatively. The median neurosurgical unit length of stay was 15 days (range, 6 hours to 365 days). CONCLUSIONS: The findings from the present update have confirmed that local practice has remained consistent with current evidence. However, patient selection might be optimized if diffusion-weighted magnetic resonance imaging and computed tomography perfusion were used at the original middle cerebral artery infarct admission.

Clinical and Imaging Determinants of Collateral Status in Patients With Acute Ischemic Stroke in MR CLEAN Trial and Registry.

Background and Purpose- Collateral circulation status at baseline is associated with functional outcome after ischemic stroke and effect of endovascular treatment. We aimed to identify clinical and imaging determinants that are associated with collateral grade on baseline computed tomography angiography in patients with acute ischemic stroke due to an anterior circulation large vessel occlusion. Methods- Patients included in the MR CLEAN trial (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands; n=500) and MR CLEAN Registry (n=1488) were studied. Collateral status on baseline computed tomography angiography was scored from 0 (absent) to 3 (good). Multivariable ordinal logistic regression analyses were used to test the association of selected determinants with collateral status. Results- In total, 1988 patients were analyzed. Distribution of the collateral status was as follows: absent (7%, n=123), poor (32%, n=596), moderate (39%, n=735), and good (23%, n=422). Associations for a poor collateral status in a multivariable model existed for age (adjusted common odds ratio, 0.92 per 10 years [95% CI, 0.886-0.98]), male (adjusted common odds ratio, 0.64 [95% CI, 0.53-0.76]), blood glucose level (adjusted common odds ratio, 0.97 [95% CI, 0.95-1.00]), and occlusion of the intracranial segment of the internal carotid artery with occlusion of the terminus (adjusted common odds ratio 0.50 [95% CI, 0.41-0.61]). In contrast to previous studies, we did not find an association between cardiovascular risk factors and collateral status. Conclusions- Older age, male sex, high glucose levels, and intracranial internal carotid artery with occlusion of the terminus occlusions are associated with poor computed tomography angiography collateral grades in patients with acute ischemic stroke eligible for endovascular treatment.

Craniectomía descompresiva en el infarto maligno de arteria cerebral media: percepción familiar, resultados y factores pronósticos / Decompressive craniectomy in malignant middle cerebral artery infarction: family perception, outcome and prognostic factors

OBJETIVO: El pronóstico en los infartos malignos de un hemisferio siembra dudas entre los neurocirujanos a la hora de indicar una hemicraniectomía descompresiva. ¿Qué resultados a corto y medio plazo se obtienen? ¿Están las familias satisfechas con la cirugía una vez el enfermo se encuentra en su domicilio? En el presente trabajo analizamos nuestra experiencia en esta materia en los últimos 13 años. MATERIAL Y MÉTODOS: Incluimos en nuestra revisión a 21 pacientes intervenidos entre 2004 y 2017 siguiendo la vía clínica de nuestro centro para el ictus. Se entrevistó a los familiares vía telefónica. Se midió el resultado funcional al alta, 3 meses, un año y actual con la escala modificada de Rankin (mRS). RESULTADOS: La edad demostró estar directamente relacionada con la mRS (r = 0,56; p = 0,035) y en el 37,5% se obtuvo un buen resultado (mRS ≤ 3). El 78,9% de los familiares entrevistados repetirían la decisión quirúrgica tomada. CONCLUSIONES: Aportamos un grupo de 21 pacientes intervenidos mediante craniectomía descompresiva por infarto maligno donde los mejores resultados funcionales se han dado entre los < 60 años. Las graves secuelas neurológicas en pacientes con infarto maligno intervenidos mediante hemicraniectomía descompresiva fueron toleradas y aceptadas por la mayoría de familias a favor de su supervivencia. No debemos dejar que esta satisfacción familiar camufle el pronóstico, teniendo que contextualizarla dentro de la situación real ambulatoria de los pacientes

OBJECTIVE: The prognosis of one hemisphere malignant infarction creates doubt among neurosurgeons about decompressive hemicraniectomy indication. What results are achieved in the short to medium term? Are families satisfied with the surgery once the patient is at home? In the present study, we analyze our experience in this matter during the last thirteen years. MATERIAL AND METHODS: In our review, twenty-one patients were included from 2004 to 2017, according to the protocol for the management of ischaemic stroke that is implemented in our institution. The relatives were interviewed by telephone. The functional outcome at discharge, 3 months, 1 year, and at present was measured using the modified Rankin scale (mRS). RESULTS: Patient age was shown to be directly related to the mRS (r = 0.56; p = 0.035) and 37.5% achieved a good outcome (mRS ≤ 3); 78.9% of the interviewed relatives would repeat the surgical decision. CONCLUSIONS: We present a 21 patients group where the best outcome was achieved in patients ≤ 60 years old. The severe neurological sequelae in patients with malignant infarction subjected to decompressive hemicraniectomy are tolerated and accepted by most families to the benefit of survival. We must not let this family satisfaction hide the prognosis, having to contextualize it within the real ambulatory situation of the patients

Large Vessel Occlusion in Acute Ischemic Stroke Patients: A Dual-Center Estimate Based on a Broad Definition of Occlusion Site.

BACKGROUND: Accurate assessment of the frequency of large vessel occlusion (LVO) is important to determine needs for neurointerventionists and thrombectomy-capable stroke facilities. Current estimates vary from 13% to 52%, depending on acute ischemic stroke (AIS) definition and methods for AIS and LVO determination. We sought to estimate LVO prevalence among confirmed and suspected AIS patients at 2 comprehensive US stroke centers using a broad occlusion site definition: internal carotid artery (ICA), first and second segments of the middle cerebral artery (MCA M1,M2), the anterior cerebral artery, vertebral artery, basilar artery, or the proximal posterior cerebral artery. METHODS: We analyzed prospectively maintained stroke databases of patients presenting to the centers between January and December 2017. ICD-10 coding was used to determine the number of patients discharged with an AIS diagnosis. Computed tomography angiography (CTA) or magnetic resonance angiography (MRA) was reviewed to determine LVO presence and site. Percentages of patients with LVO among the confirmed AIS population were reported. RESULTS: Among 2245 patients with an AIS discharge diagnosis, 418 (18.6%:95% confidence interval [CI] 17.3%-20.0%) had LVO documented on CTA or MRA. Most common occlusion site was M1 (n=139 [33.3%]), followed by M2 (n=114 [27.3%]), ICA (n=69[16.5%]), and tandem ICA-MCA lesions (n=44 [10.5%]). Presentation National Institutes of Health Stroke Scale scores were significantly different for different occlusion sites (P=.02). CONCLUSIONS: The LVO prevalence in our large series of consecutive AIS patients was 18.6% (95% CI 17.3%-20.0%). Despite the use of a broad definition, this estimate is less than that reported in most previous studies.

Predictors of malignant cerebral edema in cerebral artery infarction: A meta-analysis.

Malignant cerebral edema (MCE) is a life-threatening complication of acute cerebral stroke. To date, the focus has been on symptomatic treatment, rather than on prevention. Therefore, to identify high-risk patients and explore potential therapeutic approaches, we investigated the possible predictors of MCE. Specifically, we performed a meta-analysis to identify the potential predictors of MCE in patients with acute cerebral infarction. We searched the MEDLINE, Embase, Cochrane, China National Knowledge Infrastructure, Wanfang Data, and VIP databases from their inception to July 2018 for cohort and case control studies on the predictors of MCE in patients with cerebral infarction. Forty-seven eligible studies containing a total of 45,826 patients were included. Our results suggest that the risk of MCE is higher in case of severe clinical symptoms and large infarct volumes. Additionally, male sex, older age, and a history of stroke and smoking were protective factors against MCE in cerebral infarction patients. Furthermore, thrombolytic therapy and recanalization substantially decreased the risk of MCE in patients with acute stroke. Higher admission temperature (in the subgroup with admission ≤12 h after onset), higher admission blood pressure, and admission leukocytes were also MCE predictors. Our findings facilitate the early prediction of MCE and may contribute to potential therapeutic approaches.

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.

Outcome in Survivors of Middle Cerebral Artery Territory Ischemic Stroke: Can it be predicted?

BACKGROUND: Stroke is the fourth leading cause of disability worldwide. The present study was designed to assess functional disability in middle cerebral artery (MCA) territory ischemic stroke patients by applying standard scales for stroke severity, cognitive impairment, disability, dependency and depression. We also wanted to study whether baseline assessment predicts outcome at 1 month. METHODOLOGY: After institutional ethics committee approval, patients were enrolled from the inpatients of the Department of Medicine at Topiwala National Medical College and BYL Nair Charitable Hospital, Mumbai from July 2014 to December 2015. Various clinical parameters were recorded on admission. On day 5(±1) the National Institutes of health Stroke Scale (NIHSS), Mini Mental state examination (MMSE) were administered. On 1 month follow up, these were repeated along with Modified Rankin scale, Barthel's index (BI) and Hospital Anxiety and Depression Scale (HADS). Presence of certain risk factors for stroke were reviewed at 1 month. RESULTS: 75 patients were enrolled. There was a delay in reaching the hospital and therefore imaging, in a greater majority. Only 4% could be imaged within the first 3 hours. Mean NIHSS score at day-5 was 9 and at day-30 was 6. Thus it had significantly reduced over 1 month. The MMSE remain unchanged at day 5 and at day 30. Lower baseline MMSE scores correlated with poorer outcomes on NIHSS, BI and mRS at 1 month. Both BI and mRS at 1 month indicated that about 60% of the cases had poor outcome. Amongst 48 of the non-aphasic MCA strokes, 11(22.92%) had depression. An NIHSS score of 6 or above on day 5, predicted poor outcome at 1 month. Presence of aphasia, dominant lobe affection and female sex were associated with a higher disability at 1 month. Around 30% cases had at least 1 risk factor uncontrolled at 1 month follow-up. CONCLUSIONS: Our findings show that disability assessment late in the first week after onset of stroke using NIHSS accurately forecast outcome at one month after onset of stroke. The MMSE too is not expected to change at 1 month. Those with aphasia are expected to have greater disability. Based on or study we recommend that stroke patients should be assessed with NIHSS and MMSE before discharge, to explain the prognosis of the patient. Also more intense counselling on controlling blood pressure and diabetes as well as abstinence from smoking should be undertaken routinely.

Endovascular therapy for middle cerebral artery M2 segment occlusion: subanalyses of RESCUE-Japan Registry 2.

OBJECTIVE: To compare the efficacy of endovascular therapy (EVT) with that of medical treatment in 'real-world 'patients with M2 occlusion. METHODS: This was a post hoc analysis of the Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism Japan Registry 2. Among 2420 patients in the registry, we evaluated patients with isolated M2 occlusion and those with functional independence before the stroke. Multivariable logistic regression analysis was used to evaluate and compare clinical outcomes between EVT and medical treatment. Additional propensity score-matched (PSM) analyses were performed. We performed subgroup analyses of the primary outcome (modified Rankin Scale score 0-2 at 90 days) using forest plots of treatment effects. RESULTS: Overall, 372 patients with M2 occlusion (n=184 EVT; n=188, medical treatment) were evaluated. The EVT group had a higher baseline National Institutes of Health Stroke Scale score (median (IQR), 15 [9-19] vs 10 [5-16]) and earlier onset to hospital door time (110 [50-258] vs 150 [60-343] min) than the medical treatment group. After adjustment, EVT was significantly associated with higher odds of primary outcome (adjusted OR=2.09; 95% CI 1.26 to 3.47) and lower odds of mortality at 90 days (adjusted OR= 0.27; 95% CI 0.08 to 0.93). After PSM analyses (184 patients were 1:1 matched with each group), EVT was effective and safe relative to medical treatment. Effects favoring EVT were present in several subgroups of interest. CONCLUSION: In patients with M2 occlusion, our registry suggests that EVT is effective and safe.

Determining factors of better leptomeningeal collaterals: a study of 857 consecutive acute ischemic stroke patients.

BACKGROUND: In acute ischemic stroke (AIS) collaterals correlate with infarct size, recanalization rate and clinical outcome. We aimed to identify factors associated with better collateral status in a large series of AIS patients with middle cerebral artery (MCA) occlusion. METHODS: In the Acute STroke Registry and Analysis of Lausanne (ASTRAL) from 2003 to 2016, we identified all consecutive AIS with proximal MCA occlusion on CT-angiography performed < 24 h. Collaterals were scored from 0 (absent) to 3 (≥ 100%) and related to multiple demographic, clinical, metabolic and radiological variables in a multivariate regression analysis (MVA). RESULTS: The 857 included patients had a median age of 72.3 years, 48.4% were female and median admission NIHSS was 16. Better collaterals were associated with younger age (OR 0.99; 95% CI 0.98-1.00), hemineglect (OR 1.35; 95% CI 1.03-1.76), absence of visual field defects (OR 0.64; 95% CI 0.46-0.90), eye deviation (OR 0.58; 95% CI 0.43-0.79) and decreased vigilance (OR 0.62; 95% CI 0.44-0.88). Better collaterals were also associated with dyslipidemia (OR 1.57; 95% CI 1.16-2.13), no previous statin use (OR 0.69; 95% CI 0.50-0.95), and lower creatinine levels (OR 0.99; 95% CI 0.99-1.00). On neuroimaging, better collaterals related to higher ASPECTS score (OR 1.27; 95% CI 1.20-1.35) and higher clot burden score (OR 1.09; 95% CI 1.03-1.14). CONCLUSIONS: Younger age, dyslipidemia and lower creatinine levels were predictors of better collaterals in AIS patients from proximal MCA occlusions. Greater degree of collaterals related to lower stroke severity on admission. On neuroimaging, better collaterals were independently associated with minor early ischemic changes and lower clot burden. These data may add knowledge on pathophysiology of collaterals development and may help to identify patients with better collaterals for late or aggressive recanalization treatments.

Early Prediction of Malignant Brain Edema After Ischemic Stroke.

Background and Purpose- Malignant brain edema after ischemic stroke has high mortality but limited treatment. Therefore, early prediction is important, and we systematically reviewed predictors and predictive models to identify reliable markers for the development of malignant edema. Methods- We searched Medline and Embase from inception to March 2018 and included studies assessing predictors or predictive models for malignant brain edema after ischemic stroke. Study quality was assessed by a 17-item tool. Odds ratios, mean differences, or standardized mean differences were pooled in random-effects modeling. Predictive models were descriptively analyzed. Results- We included 38 studies (3278 patients) with 24 clinical factors, 7 domains of imaging markers, 13 serum biomarkers, and 4 models. Generally, the included studies were small and showed potential publication bias. Malignant edema was associated with younger age (n=2075; mean difference, -4.42; 95% CI, -6.63 to -2.22), higher admission National Institutes of Health Stroke Scale scores (n=807, median 17-20 versus 5.5-15), and parenchymal hypoattenuation >50% of the middle cerebral artery territory on initial computed tomography (n=420; odds ratio, 5.33; 95% CI, 2.93-9.68). Revascularization (n=1600, odds ratio, 0.37; 95% CI, 0.24-0.57) were associated with a lower risk for malignant edema. Four predictive models all showed an overall C statistic >0.70, with a risk of overfitting. Conclusions- Younger age, higher National Institutes of Health Stroke Scale, and larger parenchymal hypoattenuation on computed tomography are reliable early predictors for malignant edema. Revascularization reduces the risk of malignant edema. Future studies with robust design are needed to explore optimal cutoff age and National Institutes of Health Stroke Scale scores and to validate and improve existing models.

Quantitative Lesion Water Uptake in Acute Stroke Computed Tomography Is a Predictor of Malignant Infarction.

Background and Purpose- Early selection of patients with acute middle cerebral artery infarction at risk for malignant edema is critical to initiate timely decompressive surgery. Net water uptake (NWU) per brain volume is a quantitative imaging biomarker of space-occupying ischemic edema which can be measured in computed tomography. We hypothesize that NWU in early infarct lesions can predict development of malignant edema. The aim was to compare NWU in acute brain infarct against other common predictors of malignant edema. Methods- After consecutive screening of single-center registry data, 153 patients with acute proximal middle cerebral artery occlusion fulfilled the inclusion criteria. A total of 29 (18.2%) patients developed malignant edema defined as end point in follow-up imaging leading to decompressive surgery and death as a direct implication of mass effect. Early infarct lesion volume and NWU were quantified in multimodal admission computed tomography; time from symptom onset to admission imaging was recorded. Results- Mean time from onset to admission imaging was equivalent between patients with and without malignant infarcts (mean±SD: 3.3±1.4 hours and 3.3±1.7 hours, respectively). Edematous tissue expansion by NWU within infarct lesions occurred across all patients in this cohort (NWU: 9.1%±6.8%; median, 7.9%; interquartile range, 8.8%; range, 0.1%-35.6%); 7.0% (±5.2) in nonmalignant and 18.0% (±5.7) in malignant infarcts. Based on univariate receiver operating characteristic curve analysis, NWU >12.7% or an edema rate >3.7% NWU/h identified malignant infarcts with high discriminative power (area under curve, 0.93±0.02). In multivariate binary logistic regression, the probability of malignant infarct was significantly associated with early infarct volume and NWU. Conclusions- Computed tomography-based quantitative NWU in early infarct lesions is an important surrogate marker for developing malignant edema. Besides volume of early infarct, the measurements of lesion water uptake may further support identifying patients at risk for malignant infarction.