Faculty Bibliography

BACKGROUND AND PURPOSE/OBJECTIVE:Early neurologic improvement (ENI) in patients treated with alteplase has been shown to correlate with functional outcome. However, the definition of ENI remains controversial and has varied across studies. We hypothesized that ENI defined as a percentage change in the National Institute of Health Stroke Scale (NIHSS) score (percent change NIHSS score) at 24-hours would better correlate with favorable outcomes at 3 months than ENI defined as the change in NIHSS score (delta NIHSS score) at 24 hours. METHODS:Retrospective analysis of prospectively collected single-center quality improvement data was performed of all acute ischemic stroke (AIS) patients treated with alteplase. We examined delta NIHSS score and percent change NIHSS score in unadjusted and adjusted logistic regression models as predictors of a favorable outcome at 3 months (defined as mRS 0-1). RESULTS:Among 586 patients who met the inclusion criteria, 194 (33.1%) had a favorable outcome at 3 months. In fully adjusted models, both delta NIHSS score (OR per point decrease 1.27; 95% confidence interval [CI] 1.19-1.36) and percent change NIHSS score (OR per 10 percent decrease 1.17; 95% CI 1.12-1.22) were associated with favorable functional outcome at 3 months. Receiver operating characteristic (ROC) curve comparison showed that the area under the ROC curve for percent change NIHSS score (.755) was greater than delta NIHSS score (.613) or admission NIHSS (.694). CONCLUSIONS:Percentage change in NIHSS score may be a better surrogate marker of ENI and functional outcome in AIS patients after receiving acute thrombolytic therapy. More studies are needed to confirm our findings.

BACKGROUND:There is limited data on predictors of symptomatic intracranial haemorrhage (sICH) in patients who underwent mechanical thrombectomy. In this study, we aim to determine those predictors with external validation. METHODS:and t tests to identify independent predictors of sICH with p<0.1. Significant variables were then combined in a multivariate logistic regression model to derive an sICH prediction score. This score was then validated using data from the Blood Pressure After Endovascular Treatment multicentre prospective registry. RESULTS:We identified 578 patients with acute ischaemic stroke who received thrombectomy, 19 had sICH (3.3%). Predictive factors of sICH were: thrombolysis in cerebral ischaemia (TICI) score, Alberta stroke program early CT score (ASPECTS), and glucose level, and from these predictors, we derived the weighted TICI-ASPECTS-glucose (TAG) score, which was associated with sICH in the derivation (OR per unit increase 1.98, 95% CI 1.48 to 2.66, p<0.001, area under curve ((AUC)=0.79) and validation (OR per unit increase 1.48, 95% CI 1.22 to 1.79, p<0.001, AUC=0.69) cohorts. CONCLUSION/CONCLUSIONS:High TAG scores are associated with sICH in patients receiving mechanical thrombectomy. Larger studies are needed to validate this scoring system and test strategies to reduce sICH risk and make thrombectomy safer in patients with elevated TAG scores.

Background: Stroke code activations are a valuable tool in providing prompt care to stroke patients who may be eligible for treatments such as tPA and endovascular interventions. However, stroke codes involve the immediate attention of many members of the healthcare team and significant hospital resources. The National Institutes of Health Stroke Scale (NIHSS) is commonly used to evaluate stroke severity; however, even patients with an NIHSS score of zero can have ongoing neurologic symptoms and disability. Confusion over the goals of stroke codes and the appropriate situations for their use may contribute to unnecessary activations.
Objective(s): The purpose of this analysis was to evaluate the frequency of stroke code activations in situations where activating a stroke code provides little potential benefit in terms of therapeutic options over a non-emergent neurology consult.
Method(s): We reviewed the records for all emergency department (ED) stroke code activations over the first five months of 2018, looking specifically at cases with an NIHSS score of zero. Within this pool, we identified cases where the patient was documented as being asymptomatic during initial ED evaluation as their symptoms had resolved (transient ischemic attack), as well as those who had been symptomatic for over 24 hours and were outside the therapeutic window. These patients were not eligible for emergent therapeutic intervention. Thus, these were cases in which a stroke code activation was avoidable.
Result(s): Of the 120 stroke codes with an NIHSS of zero, 39 (32.5%) involved patients whose symptoms had completely resolved prior to arrival. Another three cases involved patients who had been symptomatic for over 24 hours and were outside the therapeutic window. Thus, of the stroke code activations with an NIHSS of zero in this time period, 42 (35%) were avoidable as these patients would not have been considered candidates for emergent treatment.
Conclusion(s): Clarification and reinforcement of appropriate criteria for stroke code activation have the potential to reduce overutilization of resources in situations unlikely to affect acute therapeutic management. Addressing this would allow for a reduction in the burden on healthcare professionals and ED resources