Delayed Neurological Improvement After Full Endovascular Reperfusion in Acute Anterior Circulation Ischemic Stroke.

Background and Purpose: We aimed to determine the prevalence and predictors of delayed neurological improvement (DNI) after complete endovascular reperfusion in anterior circulation acute ischemic stroke (AIS). Methods: Retrospective analysis of an online multicenter prospective reperfusion registry of patients with consecutive anterior circulation AIS treated with endovascular thrombectomy (EVT) from January 2018 to June 2019 in tertiary stroke centers of the NORDICTUS (NORD-Spain Network for Research and Innovation in ICTUS) network. We included patients with AIS with a proximal occlusion in whom a modified Thrombolysis in Cerebral Infarction 3 reperfusion pattern was obtained. DNI was defined if, despite absence of early neurological improvement during the first 24 hours, patients achieved functional independence on day 90. Clinical and radiological variables obtained before EVT were analyzed as potential predictors of DNI. Results: Of 1565 patients with consecutive AIS treated with EVT, 1381 had proximal anterior circulation occlusions, 803 (58%) of whom achieved a modified Thrombolysis in Cerebral Infarction 3. Of these, 628 patients fulfilled all selection criteria and were included in the study. Mean age was 73.8 years, 323 (51.4%) were female, and median baseline National Institutes of Health Stroke Scale was 16. Absence of early neurological improvement was observed in 142 (22.6%) patients; 32 of these (22.5%) achieved good long-term outcome and constitute the DNI group. Predictors of DNI in multivariable-adjusted logistic regression were male sex (odds ratio, 6.4 [95% CI, 2.1­22.3] P=0.002), lower pre-EVT National Institutes of Health Stroke Scale score (odds ratio, 1.4 [95% CI, 1.2­1.5], P<0.001), and intravenous thrombolysis (odds ratio, 9.1 [95% CI, 2.7­30.90], P<0.001). Conclusions: One-quarter of patients with anterior circulation AIS who do not clinically improve within the first 24 hours after complete cerebral endovascular recanalization will achieve long-term functional independence, regardless of the poor early clinical course. Male sex, lower initial clinical severity, and use of intravenous thrombolysis before EVT predicted this clinical pattern.

Oral Anticoagulation and Risk of Symptomatic Hemorrhagic Transformation in Stroke Patients Treated With Mechanical Thrombectomy: Data From the Nordictus Registry.

Introduction: We aimed to evaluate if prior oral anticoagulation (OAC) and its type determines a greater risk of symptomatic hemorrhagic transformation in patients with acute ischemic stroke (AIS) subjected to mechanical thrombectomy. Materials and Methods: Consecutive patients with AIS included in the prospective reperfusion registry NORDICTUS, a network of tertiary stroke centers in Northern Spain, from January 2017 to December 2019 were included. Prior use of oral anticoagulants, baseline variables, and international normalized ratio (INR) on admission were recorded. Symptomatic intracranial hemorrhage (sICH) was the primary outcome measure. Secondary outcome was the relation between INR and sICH, and we evaluated mortality and functional outcome at 3 months by modified Rankin scale. We compared patients with and without previous OAC and also considered the type of oral anticoagulants. Results: About 1.455 AIS patients were included, of whom 274 (19%) were on OAC, 193 (70%) on vitamin K antagonists (VKA), and 81 (30%) on direct oral anticoagulants (DOACs). Anticoagulated patients were older and had more comorbidities. Eighty-one (5.6%) developed sICH, which was more frequent in the VKA group, but not in DOAC group. OAC with VKA emerged as a predictor of sICH in a multivariate regression model (OR, 1.89 [95% CI, 1.01-3.51], p = 0.04) and was not related to INR level on admission. Prior VKA use was not associated with worse outcome in the multivariate regression model nor with mortality at 3 months. Conclusions: OAC with VKA, but not with DOACs, was an independent predictor of sICH after mechanical thrombectomy. This excess risk was associated neither with INR value by the time thrombectomy was performed, nor with a worse functional outcome or mortality at 3 months.

Nutritional profile of multiple sclerosis.

INTRODUCTION: Background: multiple sclerosis (MS) is an inflammatory, neurodegenerative disease of the central nervous system. Weight loss and malnutrition are prevalent in advanced stages of MS. Objective: the aim of this study was to define the nutritional profile in moderate-advanced MS (especially by documenting malnutrition) and its evolution. Methods: a case-control study was designed; cross-sectional observational study was complemented by a 12-month prospective longitudinal observational study of MS patients. Nutritional status was evaluated by collecting clinical, anthropometric, dietary and analytical data. Results: one hundred and twenty-four patients with MS and 62 controls were recruited; 8% of the patients were malnourished or at risk of malnutrition. Only MS patients with advanced disability needed nutritional support. During the follow-up, five patients died and four of them received nutritional support. Conclusions: malnutrition was unusual in our sample of patients with moderate-advanced MS. The need for nutritional support is related to dysphagia in patients with advanced neurological disability. The nutritional status of patients with moderate-advanced MS is defined by a tendency to overweight and by the decrease in basal energy expenditure and handgrip strength test in relation to the loss of muscle mass. The deficient intake of polyunsaturated fatty acids, fiber and vitamin D is exacerbated in the evolution of the disease.

INTRODUCCIÓN: Introducción: la esclerosis múltiple (EM) es una enfermedad inflamatoria y neurodegenerativa del sistema nervioso central. La pérdida de peso y la malnutrición son frecuentes en fases avanzadas de la EM. Objetivo: el objetivo de este estudio fue definir el perfil nutricional de la EM en estadio moderado-avanzado (especialmente, documentando la malnutrición) y su evolución a 12 meses. Métodos: se realizó un estudio de casos-controles; el estudio observacional transversal se complementó con un estudio observacional longitudinal prospectivo a 12 meses de los pacientes con EM. El estado nutricional se evaluó mediante la recogida de datos clínicos, antropométricos, dietéticos y analíticos. Resultados: se incluyeron en el estudio 124 pacientes con EM y 62 controles. El 8% de los pacientes estaban desnutridos o en riesgo de desnutrición. Solo los pacientes con EM con discapacidad avanzada necesitaban soporte nutricional. Durante el seguimiento, cinco pacientes fallecieron y cuatro de ellos estaban recibiendo soporte nutricional. Conclusiones: la desnutrición es infrecuente en nuestra muestra de pacientes con EM moderada-avanzada. La necesidad de apoyo nutricional está relacionada con la disfagia en pacientes con discapacidad neurológica avanzada. El estado nutricional de los pacientes con EM moderada-avanzada se define por una tendencia al sobrepeso y por valores bajos en el gasto energético basal y en la dinamometría manual en relación con la pérdida de masa muscular. La ingesta deficiente de ácidos grasos poliinsaturados, fibra y vitamina D se acentúa en la evolución de la enfermedad.

[Cerebral hyperperfusion syndrome in carotid revascularisation surgery]. / Síndrome de hiperperfusión cerebral en la cirugía de revascularización carotídea.

INTRODUCTION: Cerebral hyperperfusion syndrome (CHS) is a serious complication of carotid revascularisation surgery associated with both carotid endarterectomy and carotid stenting. AIM: To review the literature published to date on CHS with the aim of updating the data available on its incidence, pathophysiology, clinical features, risk factors, diagnosis, management and treatment. DEVELOPMENT: Carotid revascularisation surgery entails a transient increase in cerebral blood flow, and if this increase is more than 100% of the pre-operative value, then hyperperfusion occurs. Two pathophysiological mechanisms are involved in increasing cerebral blood flow: alteration of the cerebrovascular autoregulation mechanisms and increased post-operative systolic arterial pressure. CHS consists in the clinical triad headache, convulsions and focal neurological deficit, associated with arterial hypertension and the absence of cerebral ischaemia. If left undiagnosed, as it progresses it will lead to brain oedema, brain or subarachnoid haemorrhage and, finally, death. The main risk factors for CHS are: diminished haemodynamic reserve, post-operative arterial hypertension and hyperperfusion, which remains for several hours after the carotid recanalisation. Diagnosis is based on clinical suspicion and complementary tests, such as trans-cranial Doppler ultrasonography or single-photon emission tomography, which confirm the suspected hyperperfusion. The keystone on which treatment is based is prevention by strict control of the arterial pressure with drugs such as labetalol and clonidine. CONCLUSIONS: CHS is a serious, under-diagnosed complication of carotid revascularisation that the specialist must be aware of so that treatment can be established at an early stage, thereby reducing its high morbidity and mortality rate.