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Li H, Zhang JT, Zheng Y, Zhang DD, Cui XY, Zhao X, Zhang GW, Yang F, Fu Y, Fan XT, Jiang H, Shi JM, Wang B, Zhang R. Risk factors and prognosis of early neurological deterioration in patients with posterior circulation cerebral infarction. Clin Neurol Neurosurg 2023; 228:107673. [PMID: 36958072 DOI: 10.1016/j.clineuro.2023.107673] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 02/11/2023] [Accepted: 03/12/2023] [Indexed: 03/15/2023]
Abstract
BACKGROUND The incidence, risk factors, and pathogenesis of early neurological deterioration (END) in posterior circulation stroke are still unclear. In this study, we aimed to determine the risk factors and prognosis of END in patients with acute posterior circulation cerebral infarction. METHODS Acute posterior circulation ischemic stroke patients who had completed neuroimaging within 72 h of onset were selected from a prospective registry study Demographic characteristics, physiological data, medical history, laboratory data, in-hospital evaluation, neurological severity and TOAST classification, treatment, and the modified Rankin Scale (mRS) score of patients were assessed. Early neurological deterioration was defined as an increase of 2 points in the National Institutes of Health Stroke Scale score between the baseline and 72 h evaluation. Favorable and poor outcomes were defined as mRSs of 02 and≥ 3, respectively, at 3 months. The incidence and risk factors were evaluated by univariate and multivariate regression analysis (step-back method). RESULTS The analysis included 455 subjects with an acute posterior circulation non-cardiac ischemic stroke, 330 (72.53 %) of them male, with an average age of 63.12 ( ± 10.14) years and with 47 (10.33 %) having END. The results of univariate and multivariate logistic regression analysis showed that BATMAN scores ≥ 5 (OR: 0.1, 95 % CI: 0.02-0.53, P < 0.01), large artery atherosclerosis (OR: 11.55, 95 % CI: 4.18-31.93, P < 0.01), vascular stenosis > 50 % (OR: 2.44, 95 % CI: 1.1-5.42, P = 0.029), reperfusion therapy (OR: 4.21, 95 % CI: 1.66-10.64, P < 0.01), and the distribution of pontine lesions (OR: 5.66, 95 % CI: 2.39-13.44, P < 0.01) were significantly associated with END. Patients with END had a lower rate of favorable outcomes at discharge and long-term follow-up (P < 0.001), regardless of whether they received reperfusion therapy. CONCLUSION The lesion distribution of the pons, the progression of temporo-occipital lobe lesions, and large arterial atherosclerosis are independent risk factors of END that might predict a poor short- and long-term prognosis.
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Affiliation(s)
- Hui Li
- Chengde Medical University, Chengde, Hebei 067000, China; Department of Neurology, Chengde Central Hospital, Chengde, Hebei 067000, China
| | - Jiang-Tao Zhang
- Department of Neurology, Chengde Central Hospital, Chengde, Hebei 067000, China
| | - Yi Zheng
- Image center, Chengde Central Hospital, Chengde, China
| | - Ding-Ding Zhang
- Central laboratory, Peking Union Medical College Hospital, Beijing, China
| | - Xiu-Ying Cui
- Department of Neurology, Chengde Central Hospital, Chengde, Hebei 067000, China
| | - Xin Zhao
- Department of Neurology, Chengde Central Hospital, Chengde, Hebei 067000, China
| | - Guan-Wen Zhang
- Department of Neurology, Chengde Central Hospital, Chengde, Hebei 067000, China
| | - Fei Yang
- Chengde Medical University, Chengde, Hebei 067000, China; Department of Neurology, Chengde Central Hospital, Chengde, Hebei 067000, China
| | - Yu Fu
- Chengde Medical University, Chengde, Hebei 067000, China; Department of Neurology, Chengde Central Hospital, Chengde, Hebei 067000, China
| | - Xiao-Tian Fan
- Chengde Medical University, Chengde, Hebei 067000, China; Department of Neurology, Chengde Central Hospital, Chengde, Hebei 067000, China
| | - Hao Jiang
- Clinical blood laboratory, Chengde Central Hospital, Chengde, China
| | - Jian-Ming Shi
- Information center, Chengde Central Hospital, Chengde, China
| | - Bo Wang
- Department of Neurology, Bijie People's Hospital, Guizhou, China
| | - Ran Zhang
- Department of Neurology, Chengde Central Hospital, Chengde, Hebei 067000, China.
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Kim M, Park SY, Lee SE, Lee JS, Hong JM, Lee SJ. Significance of Vertigo, Imbalance, and Other Minor Symptoms in Hyperacute Treatment of Posterior Circulation Stroke. Front Neurol 2022; 13:845707. [PMID: 35651338 PMCID: PMC9150563 DOI: 10.3389/fneur.2022.845707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 04/25/2022] [Indexed: 12/01/2022] Open
Abstract
Background This study aimed to determine the clinical significance of acute vestibular syndrome (AVS)/acute imbalance syndrome (AIS) in posterior circulation stroke (PCS) and how it should be addressed in the thrombolysis code. Methods Our institution has recently changed its thrombolysis code from one that is generous to AVS/AIS to one that is exclusive. The subjects in this study were patients with PCS who presented before this transition (May 2016 to April 2018, period 1) and those who presented after (January 2019 to December 2020, period 2) with an onset-to-door time of 4.5 h. Hyperacute stroke treatment was compared between the two periods. The clinical significance of AVS/AIS was evaluated by dichotomizing the patients' clinical severity to minor or major deficits, then evaluating the significance of AVS/AIS in each group. Presenting symptoms of decreased mental alertness, hemiparesis, aphasia (anarthria), or hemianopsia were considered major PCS symptoms, and patients who did not present with these symptoms were considered minor PCS. Results In total, 114 patients presented in period 1 and 114 in period 2. Although the code activation rate was significantly lower in period 2 (72.8% vs. 59.7%), p = 0.04, there were no between-group differences in functional outcomes (mRS score at 3 months; 1 [0–3] vs. 0 [0–3], p = 0.18). In 77 patients with PCS and AVS/AIS, the difference in code activation rate was not significant according to changes in thrombolysis code. In minor PCS, AVS/AIS was associated with lower NIHSS scores, lower early neurological deterioration rates, and favorable outcomes. In major PCS, while AVS/AIS was not associated with outcomes, the majority of cases were prodromal AVS/AIS which simple vertigo and imbalance symptoms were followed by a major PCS symptom. Conclusions This study failed to show differences in outcome in patients with PCS according to how AVS/AIS is addressed in the stroke thrombolysis code. In patients with minor PCS, AVS/AIS was associated with a benign clinical course. Prompt identification of prodromal AVS/AIS is essential.
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Affiliation(s)
- Min Kim
- Department of Neurology, Ajou University Medical Center, Ajou University School of Medicine, Suwon, South Korea
| | - So Young Park
- Department of Neurology, Ajou University Medical Center, Ajou University School of Medicine, Suwon, South Korea
| | - Sung Eun Lee
- Department of Emergency Medicine, Ajou University Medical Center, Ajou University School of Medicine, Suwon, South Korea
| | - Jin Soo Lee
- Department of Neurology, Ajou University Medical Center, Ajou University School of Medicine, Suwon, South Korea
| | - Ji Man Hong
- Department of Neurology, Ajou University Medical Center, Ajou University School of Medicine, Suwon, South Korea
| | - Seong-Joon Lee
- Department of Neurology, Ajou University Medical Center, Ajou University School of Medicine, Suwon, South Korea
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Lee SJ, Hong JM, Kim JS, Lee JS. Endovascular Treatment for Posterior Circulation Stroke: Ways to Maximize Therapeutic Efficacy. J Stroke 2022; 24:207-223. [PMID: 35677976 PMCID: PMC9194547 DOI: 10.5853/jos.2022.00941] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 05/20/2022] [Indexed: 11/11/2022] Open
Abstract
The efficacy of endovascular treatment (EVT) in patients with posterior circulation stroke has not been proven. Two recent randomized controlled trials failed to show improved functional outcomes after EVT for posterior circulation stroke (PC-EVT). However, promising results for two additional randomized controlled trials have also been presented at a recent conference. Studies have shown that patients undergoing PC-EVT had a higher rate of futile recanalization than those undergoing EVT for anterior circulation stroke. These findings call for further identification of prognostic factors beyond recanalization. The significance of baseline clinical severity, infarct volume, collaterals, time metrics, core-penumbra mismatch, and methods to accurately measure these parameters are discussed. Furthermore, their interplay on EVT outcomes and the potential to individualize patient selection for PC-EVT are reviewed. We also discuss technical considerations for improving the treatment efficacy of PC-EVT.
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Affiliation(s)
- Seong-Joon Lee
- Department of Neurology, Ajou University School of Medicine, Suwon, Korea
| | - Ji Man Hong
- Department of Neurology, Ajou University School of Medicine, Suwon, Korea
| | - Jong S. Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Soo Lee
- Department of Neurology, Ajou University School of Medicine, Suwon, Korea
- Correspondence: Jin Soo Lee Department of Neurology, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon 16499, Korea Tel: +82-31-219-5175 Fax: +82-31-219-5178 E-mail:
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Koh S, Lee SE, Jung WS, Choi JW, Lee JS, Hong JM, Lee SJ. Predictors of Early Neurological Deterioration in Stroke Due to Vertebrobasilar Occlusion. Front Neurol 2021; 12:696042. [PMID: 34594293 PMCID: PMC8476904 DOI: 10.3389/fneur.2021.696042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 08/12/2021] [Indexed: 01/12/2023] Open
Abstract
Background and Aims: This study explores the predictors of early neurological deterioration (END) in patients with vertebrobasilar occlusion (VBO) in both primary endovascular therapy (EVT) and medical management (MM) groups. Methods: Patients diagnosed with VBO from 2010 to 2018 were included. Comparative and multivariate analyses were used to identify predictors of all-cause END in the EVT group, and END due to ischemia progression (END-IP) in the MM group. Results: In 174 patients with VBO, 43 had END. In the primary EVT group (N = 66), 17 all-cause END occurred. Distal basilar occlusion (odds ratio (OR), 14.5 [95% confidence interval (CI), 1.4-154.4]) and reperfusion failure (eTICI < 2b67 (OR, 5.0 [95% CI, 1.3-19.9]) were predictive of END in multivariable analysis. In the MM group (N=108), 17 END-IP occurred. Higher systolic blood pressure (SBP) at presentation (per 10 mmHg increase, OR, 1.5 [95% CI, 1.1-2.0]), stroke onset-to-door time <24 h (OR, 5.3 [95% CI, 1.1-2.0]), near-total occlusions (OR, 4.9 [95% CI, 1.2-19.6]), lower posterior circulation-Alberta Stroke Program Early CT scores (OR, 1.6 [95% CI, 1.0-2.5]), and lower BATMAN collateral scores (OR, 1.6 [95% CI, 1.1-2.2]) were predictive of END-IP. Conclusions: In patients with stroke due to VBO, potential predictors of END can be identified. In the primary EVT group, failure to achieve reperfusion and distal basilar occlusion were associated with all-cause END. In the MM group, higher SBP at presentation, onset-to-door time less than 24 h, incomplete occlusions, larger infarct cores, and poorer collaterals were associated with END-IP.
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Affiliation(s)
- Seungyon Koh
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
| | - Sung Eun Lee
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea.,Department of Emergency Medicine, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
| | - Woo Sang Jung
- Department of Radiology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
| | - Jin Wook Choi
- Department of Radiology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
| | - Jin Soo Lee
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
| | - Ji Man Hong
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
| | - Seong-Joon Lee
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
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Lee JS, Hwang YH, Sohn SI. Factors Contributing to an Efficacious Endovascular Treatment for Acute Ischemic Stroke in Asian Population. Neurointervention 2021; 16:91-110. [PMID: 33765729 PMCID: PMC8261106 DOI: 10.5469/neuroint.2020.00339] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 02/19/2021] [Indexed: 12/13/2022] Open
Abstract
Although randomized control trials about endovascular treatment (EVT) of emergent large vessel occlusion (LVO) have demonstrated the success of mechanical thrombectomy as the choice of treatment, a wide range of caveats remain unaddressed. Asian patients were rarely included in the trials, thereby raising the question of whether the treatment could be generalized. In addition, there remains a concern on the feasibility of the method with respect to its application against intracranial atherosclerosis (ICAS)-related LVO, frequently observed in the Asian population. It is important to include evidence on ICAS LVO from Asian countries in the future for a comprehensive understanding of LVO etiology. Besides the issues with EVT, prognostic concerns in diabetes patients, acute kidney injury following EVT, neuroprotective management against reperfusion injury, and other peri-EVT issues should be considered in clinical practice. In the current article, we present an in-depth review of the literature that revises information pertaining to such concerns.
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Affiliation(s)
- Jin Soo Lee
- Department of Neurology, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Yang-Ha Hwang
- Department of Neurology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University Dongsan Hospital, Kyemyung University School of Medicine, Daegu, Korea
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