Treatment Challenges in Acute Minor Ischemic Stroke

Emergent endovascular treatment versus medical treatment for acute large vessel occlusions with nondisabling symptoms

OBJECTIVES

The aim of this study is to analyze the effectiveness and safety of medical treatment (MT) versus endovascular treatment (EVT) in acute large vessel occlusion patients with mild nondisabling stroke symptoms.

METHODS

This study is a multicenter observational study in which data from patients at three stroke centers were prospectively obtained and retrospectively analyzed. Patients were included if they arrived for treatment within 6 h of stroke onset or last known well time and had a baseline National Institutes of Health Stroke Scale (NIHSS) score of ≤5. Primary outcome was modified Rankin Scale (mRS) score 0-2 at 90 days. Secondary outcomes included symptomatic intracranial hemorrhage (sICH), discharge NIHSS score, 90-day all-cause mortality and length of stay. Clinical outcomes were compared through a multivariable logistic regression after adjusting for age, treatment type admission and discharge NIHSS score, admission Alberta Stroke Program Early CT (ASPECT) score and length of stay.

RESULTS

Of the 82 patients included in the study, 42 were in the EVT group and 40 were in the MT group. The groups were similar in age (MT:66, EVT:64 age; p = .62), gender (MT:55%, EVT:54.8%; male) admission NIHSS score (MT:2, EVT:3 points; p = .26), ASPECT score (MT:10, EVT:9; p = .15). While discharge NIHSS score was found to be statistically significant between the groups (MT:1, EVT:2; p = .04). There was no difference between the two groups in terms of 90-day mRS scores (MT:1, EVT:1, p = .86) and mortality rates (MT:4, EVT:4; p = .94). In unadjusted analysis, sICH rates were similar between the MT and EVT groups (MT 5%, EVT 7.1%, p = .52). Neurological intensive care unit length of stay (MT:5 days, EVT:2 days p < .001), inpatient clinic length of stay (MT:3, EVT:2 days p = .041), and total length of stay (MT:9 days, EVT:4 days p < .001) were significantly longer in the MT group.

CONCLUSIONS

Our multicenter study demonstrated that MT with blood pressure augmentation and anticoagulation at hyperacute stage is an alternative option for emergency large vessel occlusion patients with nondisabling mild stroke symptoms.

Association between Systemic Immune-Inflammation Index and Systemic Inflammation Response Index and Outcomes of Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

Systemic immune-inflammation index (SII) and systemic inflammation response index (SIRS) are being increasingly used to predict outcomes of various diseases. However, its utility for acute ischemic stroke (AIS) has not been established. Through this first systematic review and meta-analysis, we aimed to collate data on the prognostic ability of SII and SIRI for predicting functional outcomes and mortality after AIS. PubMed, CENTRAL, Scopus, Embase, and Web of Science were searched up to January 5, 2023, for studies reporting the association between SII or SIRI and outcomes of AIS. Adjusted data were pooled in a random-effects model. Meta-regression was conducted for variable cut-offs. Twelve studies were included. Pooled analysis of data showed that high SII was associated with poor functional outcomes after AIS (OR: 2.35 95% CI: 1.77, 3.10 I2 = 44% P < 0.00001). Meta-regression showed an increasing effect size with a higher cut-off of SII. Similarly, the meta-analysis demonstrated that AIS patients with high SIRI were at an increased risk of poor functional outcomes (OR: 1.69 95% CI: 1.08, 2.65 I2 = 78% P = 0.02). No association was noted with different cut-offs on meta-regression. Data on mortality were scarce but were suggestive of a higher risk of mortality with high SII and SIRI. SII and SIRI can be used to predict poor functional outcomes in AIS patients. Data on mortality are scarce to derive strong conclusions. Limited number of studies and variable cut-offs are important limitations that need to be overcome by future studies.

Advances in mechanical thrombectomy for acute ischaemic stroke

Mechanical thrombectomy is a ground breaking treatment for acute ischaemic stroke caused by occlusion of a large vessel. Its efficacy over intravenous thrombolysis has been proven in multiple trials with a lower number needed to treat than percutaneous coronary intervention for acute myocardial infarction. However, access to this key treatment modality remains limited with a considerable postcode lottery across the UK and many parts of the world. The evidence base for mechanical thrombectomy dates back to 2015. Since then, there have been important advances in establishing and widening the criteria for treatment. This narrative review aims to summarise the current evidence base and latest advances for physicians and academics with an interest in recanalisation treatments for acute ischaemic stroke.

NIHSS is deficient in acute stroke presenting with cortical deafness; clinical skills remain the backbone: a case report

Background

National institutes of health stroke scale (NIHSS) is used, since its appearance in analysis of stroke in any national or international single center or multicenter study. It is also the golden standard assessment scale for stroke patients whether by emergency medical services on the way to hospital or by emergency room staff and by neurologists whether juniors or senior consultants. Yet, it is not capable of identifying all stroke cases. Along the current case report a relatively rare case of cortical deafness is presented highlighting its rarity and its vascular mechanism as well as how defective is NIHSS in recognizing it.

Case presentation

72-year-old female patient presented with sudden episodic less than 60 min duration of bilateral deafness; initial imaging showed right hemispheric encephalomalacia of old stroke. Patient was initially managed as psychogenic case especially that her NIHSS was zero. On returning again to emergency room she was administered thrombolysis and regained full hearing power. Follow-up imaging revealed a new ischemic stroke along her left auditory cortex explaining her cortical deafness.

Conclusion

Cortical deafness might be missed especially that NIHSS does not detect it. NIHSS role as the only golden standard scale for diagnosing and following up stroke cases ought to be revised.

Quality metrics in the management of acute stroke in Greece during the first 5 years of Registry of Stroke Care Quality (RES-Q) implementation

Introduction

Establishment of a prospective stroke registry may promote the documentation and improvement of acute stroke care. We present the status of stroke management in Greece using the Registry of Stroke Care Quality (RES-Q) dataset.

Methods

Consecutive patients with acute stroke were prospectively registered in RES-Q registry by contributing sites in Greece during the years 2017-2021. Demographic and baseline characteristics, acute management, and clinical outcomes at discharge were recorded. Stroke quality metrics, with a specific interest in the association between acute reperfusion therapies and functional recovery in ischemic stroke patients are presented.

Results

A total of 3590 acute stroke patients were treated in 20 Greek sites (61% men, median age 64 years; median baseline NIHSS 4; 74% ischemic stroke). Acute reperfusion therapies were administered in almost 20% of acute ischemic stroke patients, with a door to needle and door to groin puncture times of 40 and 64 min, respectively. After adjustment for contributing sites, the rates of acute reperfusion therapies were higher during the time epoch 2020-2021 compared to 2017-2019 (adjusted OR 1.31; 95% CI 1.04-1.64; p < 0.022; Cochran-Mantel-Haenszel test). After propensity-score-matching, acute reperfusion therapies administration was independently associated with higher odds of reduced disability (one point reduction across all mRS scores) at hospital discharge (common OR 1.93; 95% CI 1.45-2.58; p < 0.001).

Conclusions

Implementation and maintenance of a nationwide stroke registry in Greece may guide the stroke management planning, so that prompt patient transportation, acute reperfusion therapies, and stroke unit hospitalization become more widely accessible, improving the functional outcomes of stroke patients.