Background and purpose
Better understanding the incidence, predictors and mechanisms of early neurological deterioration (END) following intravenous thrombolysis (IVT) for acute stroke with mild ...symptoms and isolated internal carotid artery occlusion (iICAo) may inform therapeutic decisions.
Methods
From a multicenter retrospective database, we extracted all patients with both National Institutes of Health Stroke Scale (NIHSS) score <6 and iICAo (i.e. not involving the Willis circle) on admission imaging, intended for IVT alone. END was defined as ≥4 NIHSS points increase within 24 h. END and no‐END patients were compared for (i) pre‐treatment clinical and imaging variables and (ii) occurrence of intracranial occlusion, carotid recanalization and parenchymal hemorrhage on follow‐up imaging.
Results
Seventy‐four patients were included, amongst whom 22 (30%) patients experienced END. Amongst pre‐treatment variables, suprabulbar carotid occlusion was the only admission predictor of END following stepwise variable selection (odds ratio = 4.0, 95% confidence interval: 1.3–12.2; P = 0.015). On follow‐up imaging, there was no instance of parenchymal hemorrhage, but an intracranial occlusion was now present in 76% vs. 0% of END and no‐END patients, respectively (P < 0.001), and there was a trend toward higher carotid recanalization rate in END patients (29% vs. 9%, P = 0.07). As compared to no‐END, END was strongly associated with a poor 3‐month outcome.
Conclusions
Early neurological deterioration is a frequent and highly deleterious event after IVT for minor stroke with iICAo, and is of thromboembolic origin in three out of four patients. The strong association with iICAo site—largely a function of underlying stroke etiology—may point to a different response of the thrombus to IVT. These findings suggest END may be preventable in this setting.
In this multicentre observational study including 74 patients with isolated internal carotid artery occlusion (i.e. without associated intracranial occlusion) with minor baseline symptoms (NIHSS score <6) and treated with IV‐thrombolysis, Early Neurological Deterioration (END) within 24hrs occurred in 30% of patients and was strongly associated with poor 3‐month outcome. The predominant END mechanism was thrombo‐embolic, as evidenced by a new intracranial occlusion in 3 out of 4 END cases. Supra‐bulbar carotid occlusion site –largely a function of underlying stroke etiology– was the only predictor of END, which may point to a different response of the thrombus to IV‐thrombolysis.
Devic's neuromyelitis optica (NMO) associates optic neuritis and myelitis without any other neurological signs. Many patients with NMO may be diagnosed as having multiple sclerosis (MS), optic ...neuritis and myelitis being the inaugural symptom in 20% and 5% of MS cases, respectively. The aim of our study was to compare a new NMO cohort with recent studies and to try to determine the place of NMO in the spectrum of MS. We retrospectively studied 13 patients with a complete diagnostic workup for NMO. We compared our data with the most recent studies on NMO and with the criteria proposed by Wingerchuck et al. Neurology 53 (1999) 1107. We also determined whether these patients fulfilled the diagnostic criteria for MS. Thirteen patients (10 women and three men, with a mean age of 37.4 years) were included in the study. We found similar results to previously published data, except for an association with vasculitis in 38% of our cases. All but three of the patients fulfilled the clinical criteria for MS and two patients fulfilled both clinical and MRI criteria for MS. However, if we applied more restrictive criteria concerning spinal cord and brain MRI and CSF, none of our NMO patients fulfilled the MS diagnostic criteria. NMO might therefore be differentiated from MS by the application of more stringent criteria. Furthermore, all NMO patients should be investigated for vasculitis, even those with no history of systemic disease.
To determine the 3-year outcome in 287 young adults (15 to 45 years old) consecutively admitted between 1992 and 1996 for an ischemic stroke.
Follow-up was obtained with clinical examinations or ...telephone interviews, and data were recorded about risk factors, associated disorders, causes of stroke, and current treatments. Functional outcomes were classified with the modified Rankin Scale (mRS). Endpoints were stroke recurrence, myocardial infarction, epileptic seizures, and death.
After a mean follow-up of 3 years, no patient was lost to follow-up; 25.4% of the follow-up visits were performed by telephone interview. The authors found 1) an annual mortality rate of 4.5% during the first year and then of 1.6%; 2) an annual stroke recurrence rate of 1.4% during the first year and then of 1.0%; 3) a 0.2% annual rate of myocardial infarct; 4) epileptic seizures occurring in 6.6% of patients, during the first year in most patients; 5) independence (mRS = 0 to 2) in 94.0% of patients; 6) 4.2% of patients lost their job after stroke despite an mRS score of < or =1; 7) 7.0% of patients reported divorce; and 8) only 22.2% of smokers gave up smoking.
Although young patients who experience ischemic strokes have a low risk of stroke recurrence and myocardial infarction, some patients do not regain independence.
Hospitals admitting acute strokes should offer access to mechanical thrombectomy (MT), but local organisations are still based on facilities available before MT was proven effective. MT rates and ...outcomes at population levels are needed to adapt organisations. We evaluated rates of MT and outcomes in inhabitants from the North-of-France (NoF) area.
We prospectively evaluated rates of MT and outcomes of patients at 3 months, good outcomes being defined as a modified Rankin scale (mRS) 0 to 2 or like the pre-stroke mRS.
During the study period (2016–2017), 666 patients underwent MT (454, 68.1% associated with intravenous thrombolysis IVT). Besides, 1595 other patients received IVT alone. The rate of MT was 81 (95% confidence interval CI 72–90) per million inhabitants-year, ranging from 36 to 108 between districts. The rate of IVT was 249 (95% CI 234–264) per million inhabitants-year, ranging from 155 to 268. After 3 months, 279 (41.9%) patients who underwent MT had good outcomes, and 167 (25.1%) had died. Patients living outside the district of Lille where the only MT centre is, were less likely to have good outcomes at 3 months, after adjustment on age, sex, baseline severity, and delay.
The rate of MT is one of the highest reported up to now, even in low-rate districts, but outcomes were significantly worse in patients living outside the district of Lille, and this is not only explained by the delay.
Many clinical trials are currently being conducted to evaluate the ability of neuroprotectors and thrombolytic agents to improve survival and functional outcome after ischemic stroke. Such trials ...require early predictors of survival and disability for ethical and methodological reasons. The aim of the study was to determine which variables, of those easily assessable during the first 24 hours after stroke onset, would be predictors of 8-day mortality rate and 3-month clinical outcome.
One hundred fifty-two consecutive patients with an acute ischemic event were evaluated within 24 hours after symptom onset. We determined (1) the 8-day mortality rate and (2) the 3-month functional outcome (Glasgow Outcome Scale). The following potential predictors of outcome were tested by means of a stepwise logistic regression analysis: age, sex, body mass index, atrial fibrillation, previous stroke, existence of headache, Orgogozo score, level of consciousness, swallowing disturbances, hemianopia, pulse rate, mean blood pressure, hematocrit, glycemia, and computed tomographic scan data (cerebral atrophy score, hyperdense middle cerebral artery sign, number of silent infarcts, leukoaraiosis score).
The multivariate analysis revealed that the 8-day mortality rate depended only on the level of consciousness at admission (P = .0001); death or dependence at month 3 (scores 3 to 5 on the Glasgow Outcome Scale) depended on the severity of the clinical deficits (P = .0001), previous stroke (P = .0018), and age (P = .0237).
In future drug trials, the distribution of patients between "active treatment" and "placebo" groups should be balanced regarding the severity of clinical deficits, history of stroke, and age.
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