Clinical Outcome of Patients With Large Vessel Occlusion and Low National Institutes of Health Stroke Scale Scores

Background and Purpose—

The treatment and prognosis of acute large vessel occlusion with mild symptoms have not been sufficiently studied. The present study aimed to investigate the clinical or radiological predictors of clinical outcome in patients with stroke with mild symptoms due to acute large vessel occlusion.

Methods—

Of 2420 patients with acute large vessel occlusion in the RESCUE-Japan Registry 2 (Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism-Japan Registry 2), a multicenter prospective registry in Japan, patients with modified Rankin Scale scores of 0 to 2 before onset and initial National Institutes of Health Stroke Scale (NIHSS) scores of 0 to 5 were examined in post hoc analysis. We examined the clinical and radiological characteristics associated with a favorable outcome (modified Rankin Scale score, 0–2 at 90 days) using multivariate analysis, as well as the factors associated with a favorable outcome in patients treated with endovascular therapy.

Results—

We analyzed 272 patients (median age, 73 years; median NIHSS score on admission, 3). Eighty-six (31.6%) patients were treated with intravenous recombinant tissue-type plasminogen activator, 54 (19.9%) underwent endovascular therapy, and 208 (76.5%) showed a favorable outcome. In multivariate analysis, age <75 years (odds ratio [OR], 2.42 [95% CI, 1.30–4.50]), initial NIHSS score 0 to 3 (OR, 3.08 [95% CI, 1.59–5.98]), intravenous recombinant tissue-type plasminogen activator (OR, 2. 86 [95% CI, 1.32–6.21]), and blood glucose level ≤140 mg/dL (OR, 2.37 [95% CI, 1.22–4.60]) were independently associated with a favorable outcome. However, endovascular therapy was not associated with a favorable outcome (OR, 1.65 [95% CI, 0.71–3.88]). Among 54 patients treated with endovascular therapy, good reperfusion status was more common in the favorable outcome group (88.6% versus 60.0%; P <0.05).

Conclusions—

Younger age, lower initial NIHSS score, intravenous recombinant tissue-type plasminogen activator, and absence of hyperglycemia were independently associated with a favorable outcome in patients with acute large vessel occlusion with low NIHSS scores.

Registration—

URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02419794.

Clinical Prediction Rules to Classify Types of Stroke at Prehospital Stage

Supplemental Digital Content is available in the text.

Background and Purpose—

Endovascular therapy is effective against acute cerebral large vessel occlusion (LVO). However, many patients do not receive such interventions because of the lack of timely identification of the type of stroke. If the types of stroke (any stroke, LVO, intracranial hemorrhage [ICH], and subarachnoid hemorrhage [SAH]) were to be predicted at the prehospital stage, better access to appropriate interventions would be possible. Japan Urgent Stroke Triage (JUST) score was clinical prediction rule to classify suspected patients of acute stroke into different types at the prehospital stage.

Methods—

We obtained information for signs and symptoms and medical history of consecutive suspected patients of acute stroke at prehospital stage from paramedics and final diagnosis from the receiving hospital. We constructed derivation cohort in the historical multicenter cohort study from June 2015 to March 2016 and validation cohort in the prospective multicenter cohort study from August 2016 to July 2017. The derivation and the validation cohorts included 1229 and 1007 patients, respectively. We constructed multivariate logistic regression models with 21 variables to develop clinical prediction rules, which distinguish between different types of stroke: any stroke, LVO, ICH, and SAH.

Results—

Among the 1229 patients (median age, 72 years; 55% men) in the derivation cohort, 533 stroke, 104 LVO, 169 ICH, and 57 SAH cases were observed. The developed rules showed that the areas under the receiver operating curves were 0.88 for any stroke, 0.92 for LVO, 0.84 for ICH, and 0.89 for SAH. The validation cohort of 1007 patients (median age, 75 years; 56% men) showed that the areas under the curves of any stroke, LVO, ICH, and SAH were 0.80, 0.85, 0.77, and 0.94, respectively.

Conclusions—

These clinical prediction rules can help paramedics classify the suspected patients of stroke into any stroke, LVO, ICH, and SAH groups with excellent accuracy.

Impact of Endovascular Therapy in Patients With Large Ischemic Core

Background and Purpose—

Endovascular therapy (EVT) is strongly recommended for acute cerebral large vessel occlusion with the Alberta Stroke Program Early CT Score (ASPECTS) ≥6 due to occlusion of the internal carotid artery or M1 segment of the middle cerebral artery. However, the effect of EVT for patients who have ischemic core with ASPECTS ≤5 (0–5) was not established. The purpose of this study was to elucidate the outcomes of EVT for patients with large ischemic core.

Methods—

Based on the data of The Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism Japan Registry 2, patients with internal carotid artery or M1 segment of the middle cerebral artery occlusion and pretreatment ASPECTS 0 to 5 on noncontrast CT or diffusion-weighted image were extracted, and the outcomes by EVT were analyzed. Primary end point was defined as a good functional outcome (modified Rankin Scale score of ≤2) after 90 days.

Result—

Among 2420 registered patients, 504 patients were with internal carotid artery or M1 segment of the middle cerebral artery occlusion and ASPECTS 0 to 5. Among these 504 patients, 172 (34.1 %) were treated with EVT (EVT group) and 332 (65.9 %) without (no-EVT group). In the no-EVT group, elderly patients, females, poor prestroke modified Rankin Scale, high National Institutes of Health Stroke Scale, low ASPECTS, and late admission were significantly more observed. Good functional outcomes were significantly more observed in the EVT group than in the no-EVT group (19.8 % versus 4.2 %; P <0.0001; adjusted odds ratio, 2.33; 95% CI, 1.10–4.94). The incidences of symptomatic intracranial hemorrhage within 72 hours did not significantly different between the EVT group and the no-EVT group (3.7 % versus 4.9%; P =0.55; adjusted odds ratio, 0.50; 95% CI, 0.14–1.73).

Conclusions—

Although outcomes in this group of patients were usually poor, the data suggested EVT may increase the likelihood of a good functional outcome.

Abstract TP244: The Clinical Prediction Rules to Classify Type of Stroke at Prehospital

Introduction: The effectiveness of endovascular thrombectomy for acute cerebral large vessel occlusion (LVO) was proved, but many patients did not received such interventions because capable operators were not placed at all hospitals. If the type of stroke [large vessel occlusion, subarachnoid hemorrhage (SAH), intracranial hemorrhage (ICH), other cerebral infarction (CI)] was predicted at prehospital, better access to appropriate interventions were capable. We, thus, developed the clinical prediction rules to classify the type of stroke who were suspected to suffer acute stroke at prehospital, and validated them.

Methods: We analyzed consecutive 1,229 patients who were suspected to suffer acute stroke from June, 2015 to March 2016. We obtained the history and physical signs at prehospital from paramedics and final diagnosis from hospital transferred. We constructed multivariate logistic regression models for 1) LVO, 2) SAH, 3) ICH, 4) CI, and developed the clinical prediction rules for each type. We prospectively validated the rules with another consecutive patients from August 2016 to July 2017 using mobile application.

Results: In the derivation cohort, 104 LVO, 57 SAH, 169 ICH, and 183 CI were observed. The area under the receiver operating curve (AUC) of the rules were 0.90 for LVO, 0.90 for SAH, 0.85 for ICH, and 0.65 for CI. The validation cohort of 932 patients showed the sensitivity and specificity of the rules were 0.53 and 0.95 for LVO, 0.73 and 0.96 for SAH, 0.52 and 0.85 for ICH, 0.63 and 0.70 for CI. The AUCs of LVO, SAH, ICH, and CI were 0.85, 0.96, 0.77, and 0.67, respectively.

Conclusions: The clinical prediction rule calculated by paramedics at prehospital can easily classify the patients who suspected to have stroke into LVO, SAH, ICH, and CI with excellent performance. By applying the rules, more patients would receive appropriate interventions without unnecessary delay. <!--EndFragment-->

Randomized Controlled Trial of Early Versus Delayed Statin Therapy in Patients With Acute Ischemic Stroke

Background and Purpose—

Several studies suggested that statins during hospitalization were associated with better disability outcomes in patients with acute ischemic stroke, but only 1 small randomized trial is available.

Methods—

We conducted a multicenter, open-label, randomized controlled trial in patients with acute ischemic strokes in 11 hospitals in Japan. Patients with acute ischemic stroke and dyslipidemia randomly received statins within 24 hours after admission in the early group or on the seventh day in the delayed group, in a 1:1 ratio. Statins were administered for 12 weeks. The primary outcome was patient disability assessed by modified Rankin Scale at 90 days.

Results—

A total of 257 patients were randomized and analyzed (early 131, delayed 126). At 90 days, modified Rankin Scale score distribution did not differ between groups ( P =0.68), and the adjusted common odds ratio of the early statin group was 0.84 (95% confidence interval, 0.53–1.3; P =0.46) compared with the delayed statin group. There were 3 deaths at 90 days (2 in the early group, 1 in the delayed group) because of malignancy. Ischemic stroke recurred in 9 patients (6.9%) in the early group and 5 patients (4.0%) in the delayed group. The safety profile was similar between groups.

Conclusions—

Our randomized trial involving patients with acute ischemic stroke and dyslipidemia did not show any superiority of early statin therapy within 24 hours of admission compared with delayed statin therapy 7 days after admission to alleviate the degree of disability at 90 days after onset.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT02549846.

Safety and Effectiveness of Drip, Ship, and Retrieve Paradigm for Acute Ischemic Stroke: a Single Center Experience

This study analyzed the efficacy and safety of the “drip, ship, and retrieve (DSR)” approach used to improve patient access to thrombectomy for acute stroke. Methods: The study participants were 45 patients who underwent thrombectomy following intravenous tissue plasminogen activator between September 2013 and August 2015. Patients were divided into two groups according to whether they were transferred from another hospital (DSR group; n = 33) or were brought in directly (Direct group; n = 12). The two groups were compared based on their baseline characteristics, time from stroke onset to reperfusion, outcome, and adverse events. Results: There were no significant differences in baseline characteristics. Time from onset until admission to our facility was significantly shorter in the Direct group (56.9 min) than in the DSR group (163.5 min) (P <0.0001). Conversely, time from arrival at the hospital to arterial puncture was significantly shorter in the DSR group (25.0 min) than in the Direct group (109.5 min) (P <0.0001). Time from onset to reperfusion did not differ significantly between the groups. There was no significant difference in patient outcomes, with a modified Rankin scale score of 0–2 (44.8% in DSR group versus 48.7% in Direct group). Moreover, there was no difference in the incidence of adverse events. Discussion: Despite the time required to transfer patients in the DSR group between hospitals, reducing the time from arrival until commencement of endovascular therapy meant that the time from onset to reperfusion was approximately equivalent to that of the Direct group. Conclusion: Time-saving measures need to be taken by both the transferring and receiving hospitals in DSR paradigm.

Use of the immunoperoxidase technique for estimation of susceptibility of herpes simplex virus to IDU

We applied the direct immunoperoxidase method to estimate the susceptibility to IDU of 17 strains of the virus which were isolated from the patients with active epithelial lesions of herpetic keratitis. All the strains were found to be sensitive below the IDU concentration of 5 micrograms/ml. The findings obtained by this method were in good agreement with those by the fluorescent antibody technique. The present method is specific and simple. It offers clear-cut interpretation and a permanent record of the results.

Enzymic determination of urinary free L-fucose

Conditions necessary for the precise measurement of free L-fucose in urine by an enzymic method using L-fucose dehydrogenase have been studied. The normal urinary levels of L-fucose were 16.4 /+- 9.1 micrograms/ml in children (22.2 /+- 6.5 micrograms/mg of creatinine) and 17.7 /+- 8.5 micrograms/ml in adults (16.6 /+- 5.7 micrograms/mg of creatinine). There was a close correlation between the concentration of free L-fucose and that of creatinine. A close correlation was also found between the concentration of free L-fucose and alpha-L-fucosidase activity. Thus, it was suggested that the free L-fucose in urine reflected the metabolism of L-fucose or L-fucose-containing glycoconjugates. In a preliminary screening test, several urine samples which showed high concentrations of free L-fucose, namely cases of "fucosuria" were found.

Isolation and characterization of L-fucose dehydrogenase from rabbit liver

L-Fucose dehydrogenase [EC 1.1.1.122] was isolated from a rabbit liver extract and purified about 390-fold with a yield of approximately 13%. The purification procedures included treatment with protamine, ammonium sulfate fractionation, treatment with acid, DE-32 celluose colum chromatography, gel filtration on Sephadex G-100, preparative polyacrylamide gel electrophoresis, and affinity chromatography on 5' AMP-Sepharose 4B. The last procedure, affinity chromatography on 5' AMP-Sephadex 4B, was useful for the removal of other dehydrogenases. The eznyme which was homogeneous, as shown by polyacrylamide gel electrophoresis, had a molecular weight of about 92,000. The optimum pH was at 10.0 and isoelectric point at 5.2. The enzyme accepted both L-fucose and D-arabinose as substrate, but was specific for NAD+ as coenzyme. Km values were 0.15 mM, 1.4 mM, and 0.7 mM for L-fucose, D-arabinose, and NAD+, respectively. A single enzyme catalyzed the oxidation of L-fucose and D-arabinose, which had the same configurations of hydroxyl groups from C-2 to C-4. The reaction products obtained with L-fucose as substrate were L-fucono-lactone and L-fuconic acid. The L-fucono-lactone was an immediate product of oxidation and was hydrolyzed to L-fuconic acid spontaneously. This reaction was irreversible. Therefore, it is likely that L-fucose dehydrogenase is involved in the initial step of the catabolic pathway of L-fucose in rabbit liver.