Steno-Occlusive Arterial Disease and Early Neurological Deterioration in Acute Ischemic Stroke

110

Background and Purpose-Early neurological deterioration (END) is a relatively common unfavorable course after anterior circulation ischemic stroke that can lead to worse clinical outcome. None of the END predictors identified so far is sufficiently reliable to be used in clinical practice and the mechanisms underlying END are not fully understood. We review the evidence from the literature for a role of hemodynamic and perfusion abnormalities, more specifically infarction of the oligemia, in END. Summary of Review-After an overview of the neuroimaging, including perfusion imaging, predictors of END, we review the putative mechanisms of END with a special focus on hemodynamic factors. The evidence relating perfusion abnormalities to END is addressed and potential hemodynamic mechanisms are suggested. Conclusions-Hemodynamic factors and perfusion abnormalities are likely to play a critical role in END. Infarction of the oligemic tissue surrounding the penumbra could be the putative culprit leading to END as a result of perfusion, but also physiological and biochemical abnormalities. Further studies addressing the role of the oligemia in END and developing measures to protect its progression to infarction are now needed. (Stroke. 2009;40:e443-e450.)

Section: Hemodynamic Mechanisms Cerebral Perfusion Pressuresupporting

confidence: 86%

“…5,7 The need for an internationally agreed definition has been previously highlighted 10 but not fulfilled so far. However, the National Institutes of Health Stroke Scale has been recently widely used to define END with deterioration Ն4 points during the first 48 3,11 or 72 12 hours being almost consistently used.…”

mentioning

confidence: 99%

Hemodynamic Factors and Perfusion Abnormalities in Early Neurological Deterioration

Alawneh

Moustafa

Baron

2009

110

“…16 Recent studies have shown a high recurrence risk in the first days after TIA or TIA and minor stroke. 17 However, few data are available concerning recurrence risk in patients with minor stroke, which generally includes early neurological deterioration, 18,19 a factor that may often reflect early recurrence. Moreover, no previous series to our knowledge specifically included patients in the first 6 hours from onset of symptoms.…”

Section: Discussionmentioning

confidence: 99%

High Risk of Early Neurological Recurrence in Symptomatic Carotid Stenosis

Ois

Cuadrado-Godia

Rodríguez-Campello

et al. 2009

Self Cite

129

Background and Purpose— Few data are available on very early stroke recurrence evaluated within the first hours after onset of symptoms and outcome for unselected patients with first-ever mild stroke or TIA and symptomatic carotid stenosis ≥50%. Methods— One hundred sixty-three patients with symptomatic carotid stenosis and initial mild stroke (121) or TIA (42) were evaluated within 6 hours from onset of symptoms in a single tertiary hospital. Neurological recurrence (NR) was defined as a clearly defined new neurological event (TIA or stroke) or an increase of 4 points in the initial NIHSS. The NR rate was determined at 72 hours, 7 days, and 14 days. Disability was defined as a score of 3 to 6 on the modified Rankin scale at 14 days. Results— Forty-five patients (27.6%) had NR, including 6 patients with 2 episodes in different time periods: 34 (20.9%) within the first 72 hours; 11 (6.7%) between 72 hours and 7 days; and 6 (3.7%) at 14 days. Only carotid stenosis ≥70% was associated with NR; diabetes was marginally associated. At 2 weeks, 19 patients (11.7%) had disability; 14 of them experienced NR in the first 72 hours. Conclusions— Patients with first-ever mild stroke or TIA and symptomatic carotid stenosis are at high risk for NR, especially within the first 72 hours. Our results suggest the necessity of testing pharmacological or interventional strategies for use during the hyperacute stroke phase in these patients.

“…13 Additional data on NIHSS were available for the validation cohort (VC) allowing assessment of early neurological deterioration, defined as an increase of NIHSS score of ≥4 in the first 72 hours after the stroke. 23 Successful reperfusion was assessed by thrombolysis in cerebral infarction scale and defined as thrombolysis in cerebral infarction 2b-3.…”

Section: Outcome Measuresmentioning

confidence: 99%

The Basilar Artery on Computed Tomography Angiography Prognostic Score for Basilar Artery Occlusion

Alemseged

Shah

Diomedi

et al. 2017

118

122

B asilar artery occlusion (BAO) comprises ≈1% of all strokes and is one of the most devastating neurological conditions associated with high risk of disability and mortality if recanalization does not occur. [1][2][3] Despite recent breakthroughs in the treatment of large vessel occlusion ischemic stroke, BAO patients were excluded from recent randomized controlled trials, 4-8 and the evidence for treatment is derived largely from small retrospective studies.9,10 The Australian Urokinase Stroke Trial is the only completed randomized trial, in which 16 patients were randomized, and a good outcome was observed in 4 of 8 patients who received intra-arterial urokinase compared with 1 of 8 patients in the control group, 11 with a significant association between successful recanalization and favorable outcome in pooled observational data.12 However, the largest prospective observational study in BAO patients showed similar outcomes Background and Purpose-Basilar artery occlusion is associated with high risk of disability and mortality. This study aimed to assess the prognostic value of a new radiological score: the Basilar Artery on Computed Tomography Angiography (BATMAN) score. Methods-A retrospective analysis of consecutive stroke patients with basilar artery occlusion diagnosed on computed tomographic angiography was performed. BATMAN score is a 10-point computed tomographic angiography-based grading system which incorporates thrombus burden and the presence of collaterals. Reliability was assessed with intraclass coefficient correlation. Good outcome was defined as modified Rankin Scale score of ≤3 at 3 months and successful reperfusion as thrombolysis in cerebral infarction 2b-3. BATMAN score was externally validated and compared with the Posterior Circulation Collateral score. Results-The derivation cohort included 83 patients with 41 in the validation cohort. In receiver operating characteristic (ROC) analysis, BATMAN score had an area under receiver operating characteristic curve of 0.81 (95% confidence interval [CI], 0.7-0.9) in derivation cohort and an area under receiver operating characteristic curve of 0.74 (95% CI, 0.6-0.9) in validation cohort. In logistic regression adjusted for age and clinical severity, BATMAN score of <7 was associated with poor outcome in derivation cohort (odds ratio, 5.5; 95% CI, 1.4-21; P=0.01), in validation cohort (odds ratio, 6.9; 95% CI, 1.4-33; P=0.01), and in endovascular patients, after adjustment for recanalization and time to treatment (odds ratio, 4.8; 95% CI, 1.2-18; P=0.01). BATMAN score of <7 was not associated with recanalization. Interrater agreement was substantial (intraclass coefficient correlation, 0.85; 95% CI, 0.8-0.9). BATMAN score had greater accuracy compared with Posterior Circulation Collateral score (P=0.04). Conclusions-The addition of collateral quality to clot burden in BATMAN score seems to improve prognostic accuracy in basilar artery occlusion patients.