Neurologic Improvement in Acute Cerebral Ischemia

Abstract

BACKGROUNDAND PURPOSE: Investigations of rapid neurological improvement (RNI) in patients with acute cerebral ischemia (ACI) have focused upon RNI occurring after hospital arrival. However, with stroke routing decisions and interventions increasingly migrating to the prehospital setting, there is a need to delineate the frequency, magnitude, predictors, and clinical outcomes of ACI patients with ultra-early RNI (U-RNI) in the prehospital and early post-arrival period.METHODS:We analyzed prospectively collected data of the prehospital Field Administration of Stroke Therapy-Magnesium (FAST-MAG) randomized clinical trial.AnyU-RNI was defined as improvement by 2 or more points on the Los Angeles Motor Scale (LAMS) score between the prehospital and early post-Emergency Department (ED) arrival exams and classified asmoderate(2-3 point) ordramatic(4-5 point) improvement. Outcomes measures included excellent recovery [modified Rankin Scale (mRS) score 0-1] and death by 90 days.RESULTS:Among the 1,245 ACI patients, mean age was 70.9 years (standard deviation 13.2); 45% were women; median prehospital-LAMS was 4 [interquartile range (IQR) 3-5]; median last known well to ED-LAMS time was 59 minutes (IQR 46-80) and median prehospital-LAMS to ED-LAMS time was 33 minutes (IQR 28-39). Overall,anyU-RNI occurred in 31%,moderateU-RNI in 23%, anddramaticU-RNI in 8%.AnyU-RNI was associated with improved outcomes, including excellent recovery (mRS 0-1) at 90 days 65.1% (246/378) vs 35.4% (302/852), p<0.0001; decreased mortality by 90 days 3.7% (14/378) vs 16.4% (140/852), p<0.0001; decreased symptomatic intracranial hemorrhage 1.6% (6/384) vs 4.6% (40/861), p=0.0112 ; increased likelihood of being discharged home 56.8% (218/384) vs. 30.2% (260/861), p <0.0001.DISCUSSION:U-RNI occurs in nearly 1 in 3 ambulance-transported patients with ACI and is associated with excellent recovery and decreased mortality at 90 days. Accounting for U-RNI may be useful for routing decisions and future prehospital interventions.

Comparison of prehospital assessment by paramedics and in-hospital assessment by physicians in suspected stroke patients

“…Furthermore, symptoms might have altered between the assessments due to spontaneous improvement or worsening, which may explain some of the disparities. [16][17][18] However, we found no clear or clinically relevant trend in correlation after stratification for onset-to-ambulance-arrival time, the time interval between both assessments was relatively short (median 29 minutes) and patients with a final diagnosis of TIA were excluded. We therefore expect this effect to be limited.…”

“…Similarly, since spontaneous clinical improvement or deterioration might occur especially in the first few hours after onset, we also assessed Spearman's correlation after dividing the cohort in quartiles based upon the time between onset and ambulance arrival. [16][17][18] A Spearman's coefficient of 0-0.19 was regarded as very weak, 0.2-0.39 as weak, 0.40-0.59 as moderate, 0.6-0.79 as strong and 0.8-1 as very strong correlation. 19 Second, to identify more challenging items, we calculated the correlation, sensitivity and specificity of each prehospital item compared to its corresponding in-hospital item from the NIHSS.…”

Comparison of Prehospital Assessment by Paramedics and In-Hospital Assessment by Physicians in Suspected Stroke Patients: Results From 2 Prospective Cohort Studies

“…Furthermore, symptoms might have altered between the assessments due to spontaneous improvement or worsening, which may explain some of the disparities. 16–18 However, we found no clear or clinically relevant trend in correlation after stratification for onset-to-ambulance-arrival time, the time interval between both assessments was relatively short (median 29 minutes), and patients with a final diagnosis of transient ischemic attack were excluded. We, therefore, expect this effect to be limited.…”

“…Similarly, since spontaneous clinical improvement or deterioration might occur especially in the first few hours after onset, we also assessed Spearman correlation after dividing the cohort in quartiles based upon the time between onset and ambulance arrival. [16][17][18] A Spearman coefficient of 0 to 0.19 was regarded as very weak, 0.2 to 0.39 as weak, 0.40 to 0.59 as moderate, 0.6 to 0.79 as strong, and 0.8 to 1 as very strong correlation. 19 Second, to identify more challenging items, we calculated the correlation, sensitivity and specificity of each prehospital item compared with its corresponding in-hospital item from the NIHSS.…”

Optimization of nursing interventions for postoperative mental status recovery in patients with cerebral hemorrhage

“…Rehabilitation nursing care requires the nursing staff to pay constant attention to the patient's state of consciousness and communicate with the attending physician in a timely manner. Moreover, patients with postoperative cerebral hemorrhage often suffer from pressure injuries, and in the state of coma, nursing staff are required to turn the patient over and massage him/her regularly to avoid pressure injuries and to promote the recovery of consciousness[ 15 , 16 ]. In our study, we showed that the rehabilitative care provided to the patients resulted in a difference in the state of consciousness scores of the observation group compared to the control group on day 14, and that the state of consciousness scores of the observation group were significantly higher than those of the control group on day 21 ( P < 0.05).…”