Abstract only Introduction Large vessel occlusion (LVO) is estimated to account for up to 39% of all ischemic strokes with 62% of them resulting in post‐ischemic stroke dependency and 96% of all ...post‐ischemic stroke mortality. Advanced imaging modalities and efficient stroke systems of care have resulted in faster reperfusion times. There is however limited data on the outcomes of thrombectomy as a function of age. We present a retrospective analysis on thrombectomy in younger (age 18–49 years) versus older (age >50 years) patients. Methods Retrospective single center study with population being identified using our procedural database and “SlicerDicer” tool on EPIC from 2017–2021. Patients who underwent mechanical thrombectomy were divided into 2 groups based on age. Younger group consists of patients between the ages 18–49 while older group is 50 and over. Primary outcome of the study was to identify good clinical outcome as defined by mRS of 0–2 in both groups. Secondary outcomes included rate of favorable reperfusion defined by TICI 2b‐3, symptomatic ICH and mortality rate. Results > We have identified 48 patients between the age of 18–49 and 436 over the age of 50. > We found that median groin puncture to repercussion time was lower in younger population (32 v/s 69 mins; p = 0.0044) > The median groin puncture to first pass time was lower in younger population (22 v/s 43; p = 0.056), but it failed to show statistical significance. > Younger compared to older patients had better clinical outcomes (mRS 0–2) at 77.1% v/s 32.3% (p< 0.0001) and higher rates of favorable repercussion (TICI 2b‐3) at 93.7% v/s 72.9% (p = 0.0016) > The older group required more passes to achieve recanalization (4 or more passes: 4.3% v/s 16.2%; p = 0.035) > Mortality rate was significantly less in the younger population (8.3% v/s 22.1%; p = 0.026) Conclusions Younger patients had better clinical outcomes than their older counterparts after mechanical thrombectomy in our analysis. Other than younger age, higher rates of favorable repercussion, earlier recanalization, and less passes to recanalization were seen in association with better observed outcomes.
The outcomes of administration of Perampanel (PER) which is a β-amino-3-(5-methyl-3-oxo-1,2-oxazol-4-yl)propionic acid (AMPA) receptor antagonist for the treatment of refractory status epilepticus ...(RSE) and Super-refractory (SRSE) were previously reported in small cohort studies and case reports. We report efficacy and side effect results of an observational cohort of 75 patients treated with PER for RSE and SRSE.
This was a single-center, retrospective, observational study of patients with RSE admitted to the neurocritical care unit between April 2017 and September 2019 who received treatment with PER. The primary outcome was the occurrence of a definite response to PER, which was defined as clear resolution of the ictal pattern and/or seizures within 72 h of delivery of PER which was the last administered antiseizure medication (ASM). Secondary outcomes included the percentage of patients other response types (partial responder or non-responder), as well as the rate of adverse effects.
A total 75 patients were included in our analysis. PER was initiated as the median sixth ASM at a median initial dose of 12 mg. For the primary outcome, 31 (41.3%; 95% confidence interval 31.0%–53.0%) patients were classified as a definite responder. Seven patients (9.3%) experienced an adverse effect that was attributed to PER, with the most common being sedation in four patients.
In our retrospective cohort of RSE, we observed a definite response rate of 41.3% within 72 h of PER initiation. PER was well tolerated with few documented adverse effects. Further prospective studies are needed to confirm the role of PER in treating patients with RSE.
•Refractory (RSE) and super-refractory (SRSE) status epilepticus represent a challenging condition with significant morbidity and mortality.•Perampanel is a new option for RSE and SRSE given it's unique mechanism of action.•We observed a 41.3% definite response rate in our cohort when PER was used in RSE and SRSE .•7 patients (9.3%) experienced an adverse effect.•Our results reinforce the need for further trials evaluating the role of PER in RSE and SRSE.
Abstract only Introduction Perimesencephalic subarachnoid hemorrhage (PMSAH) is characterized by bleeding centered in the basal cisterns anterior to the midbrain and pons without intraparenchymal or ...overt intraventricular extension. The term “benign” is often attached, because typically no source of bleeding is identified on high‐resolution vascular imaging, and recovery if often uncomplicated. Rarely, however, PMSAH can be secondary to ruptured vertebrobasilar aneurysms, and outcomes of these patients is underreported. Methods Retrospective analysis of patients with PMSAH to determine the rate of underlying ruptured aneurysm or vascular abnormality, associated complications, and outcomes. Age, sex, vascular risk factors, presenting symptoms, Hunt and Hess grade, modified Fisher grade, rate of underlying ruptured aneurysm, vasospasm, re‐bleed, hydrocephalus, and modified Rankin scale (mRS) were collected. Primary outcome was good functional status at discharge (mRS 0–2), reported as odds ratio (OR) with 95% confidence interval (CI). Results A total of 74 patients with PMSAH between 2007 and 2022 were identified. Mean age was 55.5± 10 years, and 60% were male. Hypertension and smoking were reported in 57% and 35% of patients, respectively. The most common presenting symptom was thunderclap headache in 89% of patients. Median (IQR) ofHunt and Hess grade was 2 (1‐2), and modified Fisher grade was 3 (1‐3). An underlying ruptured aneurysm was found in 3 patients (4%); two of which were in the vertebrobasilar system and one in the posterior communicating artery. Most common complications in this cohort was vasospasm in 28%, followed by hydrocephalus in 11%. Among patients with aneurysmal bleed, vasospasm and hydrocephalus occurred in 66% of patients each, compared to 8.5% and 27%, respectively in patients with non‐aneurysmal PMSAH. Re‐bleeding occurred only in one patient (1.3%); which occurred in a patient with non‐aneurysmal source of hemorrhage. A total of 88% of patients in our cohort had a favorable functional outcome (mRS 0–2) at discharge. An underlying ruptured aneurysm and acute hydrocephalus were associated with poor functional status(OR = 18.3, 1.5–228, P < 0.024), and OR = 25.8, 4.5–149, P < 0.001), respectively. However, vasospasm was noted to be asymptomatic in most cases (90%) and was not associated with unfavorable outcomes (OR = 0.75, 0.14–3.9, P < 0.73). Conclusions “Benign” PMSAH pattern was associated with a ruptured aneurysm in 4% of patients in our cohort.An underlying aneurysm and acute hydrocephalus were associated with poor outcomes. However, vasospasm was incidental and was not associated with unfavorable outcomes in patients with PMSAH.
Background
Every anticoagulation decision has in inherent risk of hemorrhage; intracerebral hemorrhage (ICH) is the most devastating hemorrhagic complication. We examined whether combining ischemic ...and hemorrhagic stroke risk in individual patients might provide a meaningful paradigm for risk stratification.
Methods
We enrolled consecutive patients with anticoagulation-associated ICH in 15 tertiary centers in the USA, Europe and Asia between 2015 and 2017. Each patient was assigned baseline ischemic stroke and hemorrhage risk based on their CHA
2
DS
2
-VASc and HAS-BLED scores. We computed a net risk by subtracting hemorrhagic from ischemic risk. If the sum was positive the patient was assigned a “Favorable” indication for anticoagulation; if negative, “Unfavorable”.
Results
We enrolled 357 patients 59% men, median age 76 (68–82) years. 31% used non-vitamin K antagonist (NOAC). 191 (53.5%) patients had a favorable indication for anticoagulation prior to their ICH; 166 (46.5%) unfavorable. Those with unfavorable indication were younger 72 (66–80) vs 78 (73–84) years,
p
= 0.001, with lower CHA
2
DS
2
-VASc score 3(3–4) vs 5(4–6),
p
< 0.001. Those with favorable indication had a significantly higher prevalence of most cardiovascular risk factors and were more likely to use a NOAC (35% vs 25%,
p
= 0.045). Both groups had similar prevalence of hypertension and chronic kidney disease.
Conclusions
In this anticoagulation-associated ICH cohort, baseline hemorrhagic risk exceeded ischemic risk in approximately 50%, highlighting the importance of careful consideration of risk/benefit ratio prior to anticoagulation decisions. The remaining 50% suffered an ICH despite excess baseline ischemic risk, stressing the need for biomarkers to allow more precise estimation of hemorrhagic complication risk.
Background The rate of underlying ruptured aneurysms, complications, and their relevance to outcomes in “benign” perimesencephalic subarachnoid hemorrhage are not well known and underreported. ...Methods Retrospective analysis of patients with perimesencephalic subarachnoid hemorrhage from a large tertiary care center (2007–2022). Results Eighty‐one patients were included with mean age of 55.5 ± 10.3 years. An underlying ruptured aneurysm was diagnosed in 5 patients (6.2%); 3 (60%) had negative computed tomography angiography and they were detected only in digital subtraction angiography (2 on initial digital subtraction angiography and 1 on follow‐up digital subtraction angiography). The most common complication was vasospasm in 25/81 patients (31%), and the majority 21/25 (84%) were asymptomatic. Symptomatic vasospasm occurred at a significantly higher rate among patients with underlying aneurysm (40% versus 2.6%; P = 0.01). Hydrocephalus occurred in 10% of patients, all within 1 day, but at a higher rate in the aneurysmal group (40% versus 8%; P = 0.07). A total of 88% of patients had modified Rankin scale score 0–2 at discharge, but at a significantly higher rate in nonaneurysmal patients (91% versus 40%; P = 0.01). An underlying aneurysm, hydrocephalus, and symptomatic vasospasm were associated with poor functional status (odds ratio OR = 14.7 2.1–104; P = 0.007, OR = 22.6 4.2–123.5; P <0.001, OR = 8.6 1.06–69.88; P = 0.04), respectively. Conclusion “Benign” perimesencephalic subarachnoid hemorrhage pattern was associated with a ruptured aneurysm in 6.2% of patients, and 3.7% were detected only on cerebral angiogram. Underlying aneurysm, symptomatic vasospasm, and hydrocephalus were associated with lower rates of good clinical outcome. All hydrocephalus cases were symptomatic and occurred very early. Asymptomatic vasospasm alone was not associated with poor outcomes. Our findings suggest that patients with nonaneurysmal perimesencephalic subarachnoid hemorrhage without hydrocephalus can safely be managed with less strict monitoring and a shorter hospital stay.
Background
Magnesium (Mg) has potential hemostatic properties. We sought to investigate the potential association of serum Mg levels (at baseline and at 48 hours) with outcomes in patients with acute ...spontaneous intracerebral hemorrhage (ICH).
Methods and Results
We reviewed data on all patients with spontaneous ICH with available Mg levels at baseline, over a 5‐year period. Clinical and radiological outcome measures included initial hematoma volume, admission National Institutes of Health Stroke Scale and ICH scores, in‐hospital mortality, favorable functional outcome (modified Rankin Scale scores, 0–1), and functional independence (modified Rankin Scale scores, 0–2) at discharge. Our study population consisted of 299 patients with ICH (mean age, 61±13 years; mean admission serum Mg, 1.8±0.3 mg/dL). Increasing admission Mg levels strongly correlated with lower admission National Institutes of Health Stroke Scale score (Spearman's r, −0.141; P=0.015), lower ICH score (Spearman's r, −0.153; P=0.009), and lower initial hematoma volume (Spearman's r, −0.153; P=0.012). Higher admission Mg levels were documented in patients with favorable functional outcome (1.9±0.3 versus 1.8±0.3 mg/dL; P=0.025) and functional independence (1.9±0.3 versus 1.8±0.3 mg/dL; P=0.022) at discharge. No association between serum Mg levels at 48 hours and any of the outcome variables was detected. In multiple linear regression analyses, a 0.1‐mg/dL increase in admission serum Mg was independently and negatively associated with the cubed root of hematoma volume at admission (regression coefficient, −0.020; 95% confidence interval, −0.040 to −0.000; P=0.049) and admission ICH score (regression coefficient, −0.053; 95% confidence interval, −0.102 to −0.005; P=0.032).
Conclusions
Higher admission Mg levels were independently related to lower admission hematoma volume and lower admission ICH score in patients with acute spontaneous ICH.
Nearly 380,000 U.S. service members between 2000 and 2017 were, and at least 300,000 athletes annually are, diagnosed with concussion. It is imperative to establish a gold-standard diagnostic test to ...quickly and accurately diagnose concussion. In this non-randomized, prospective study, we examined the reliability and validity of a novel neurocognitive assessment tool, the Defense Automated Neurobehavioral Assessment (DANA), designed to be a more sensitive, yet efficient, measure of concussion symptomatology. In this study, the DANA Brief version was compared to an established measure of concussion screening, the Military Acute Concussion Evaluation (MACE), in a group of non-concussed service members. DANA Brief subtests demonstrated low to moderate reliability, as measured by intra-class correlation coefficient (ICC; values range: 0.28–0.58), which is comparable to other computerized neurocognitive tests that are widely-implemented to diagnose concussion. Statistically significant associations were found between learning and memory components of the DANA Brief and the diagnostic MACE cognitive test score (DANA Brief subtests: CDD:
R
2
= 0.05,
p
= 0.023; CDS:
R
2
= 0.10,
p
= 0.010). However, a more robust relationship was found between DANA Brief components involving attention and working memory, including immediate memory, and the MACE cognitive test score (DANA Brief subtests: GNG:
R
2
= 0.08,
p
= 0.003; PRO:
R
2
= 0.08,
p
= 0.002). These results provide evidence that the DANA Rapid version, a 5-min assessment self-administered on a hand-held portable device, based on the DANA Brief version, may serve as a clinically useful and improved neurocognitive concussion screen to minimize the time between injury and diagnosis in settings where professional medical evaluation may be unavailable or delayed. The DANA's portability, durability, shorter test time and lack of need for a medical professional to diagnose concussion overcome these critical limitations of the MACE.
ABSTRACT No eligibility screening logs were kept in recent mechanical thrombectomy (MT) RCTs establishing safety and efficacy of endovascular reperfusion therapies for acute ischemic stroke (AIS). We ...sought to evaluate the potential eligibility for MT among consecutive AIS patients in a prospective international multicenter study. We prospectively evaluated consecutive AIS patients admitted in four tertiary-care stroke centers during a twelve-month period. Potential eligibility for MT was evaluated using inclusion criteria from MR CLEAN & REVASCAT. Our study population consisted of 1464 AIS patients (mean age 67 ± 14 years, 56% men, median admission NIHSS-score:5,IQR:3–10). A total of 123 (8%, 95%CI:7%–10%) and 82 (6%, 95%CI:5%–7%) patients fulfilled the inclusion criteria for MR CLEAN&REVASCAT respectively. No evidence of heterogeneity ( p > 0.100) was found in the eligibility for MT across the participating centers. Absence of proximal intracranial occlusion (69%) and hospital arrival outside the eligible time window (38% for MR CLEAN & 35% for REVASCAT) were the two most common reasons for ineligibility for MT. Our everyday clinical practice experience suggests that approximately one out of thirteen to seventeen consecutive AIS may be eligible for MT if inclusion criteria for MR CLEAN and REVASCAT are strictly adhered to.
Prior studies suggest an association between Vitamin K antagonists (VKA) and cerebral microbleeds (CMBs); less is known about nonvitamin K oral anticoagulants (NOACs). In this observational study we ...describe CMB profiles in a multicenter cohort of 89 anticoagulation‐related intracerebral hemorrhage (ICH) patients. CMB prevalence was 51% (52% in VKA‐ICH, 48% in NOAC‐ICH). NOAC‐ICH patients had lower median CMB count 2(IQR:1–3) vs. 7(4–11); P < 0.001; ≥5 CMBs were less prevalent in NOAC‐ICH (4% vs. 31%, P = 0.006). This inverse association between NOAC exposure and high CMB count persisted in multivariable logistic regression models adjusting for potential confounders (OR 0.10, 95%CI: 0.01–0.83; P = 0.034).
There are limited data evaluating the effect of post mechanical thrombectomy (MT) blood pressure (BP) levels on early outcomes of patients with large vessel occlusions (LVO). We sought to investigate ...the association of BP course following MT with early outcomes in LVO.
Consecutive patients with LVO treated with MT during a 3-year period were evaluated. Hourly systolic BP (SBP) and diastolic BP (DBP) values were recorded for 24 hours following MT and maximum SBP and DBP levels were identified. LVO patients with complete reperfusion following MT were stratified in 3 groups based on post-MT achieved BP goals: <140/90 mm Hg (intensive), <160/90 mm Hg (moderate), and <220/110 mm Hg or <180/105 mm Hg when pretreated with IV thrombolysis (permissive hypertension). Three-month functional independence was defined as modified Rankin Scale score of 0-2.
A total of 217 acute ischemic stroke patients with LVO were prospectively evaluated. A 10 mm Hg increment in maximum SBP documented during the first 24 hours post MT was independently (
= 0.001) associated with a lower likelihood of 3-month functional independence (odds ratio OR 0.70; 95% confidence interval CI 0.56-0.87) and a higher odds of 3-month mortality (OR 1.49; 95% CI 1.18-1.88) after adjusting for potential confounders. In addition, achieving a BP goal of <160/90 mm Hg during the first 24 hours following MT was independently associated with a lower likelihood of 3-month mortality (OR 0.08; 95% CI 0.01-0.54;
= 0.010) in comparison to permissive hypertension.
High maximum SBP levels following MT are independently associated with increased likelihood of 3-month mortality and functional dependence in LVO patients. Moderate BP control is also related to lower odds of 3-month mortality in comparison to permissive hypertension.
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