Acute Neurological Deterioration in Large Vessel Occlusions and Mild Symptoms Managed Medically

Abstract

Background and Purpose— It is unclear which factors predict acute neurological deterioration in patients with large vessel occlusion and mild symptoms. We aim to evaluate the frequency, timing, and potential predictors of acute neurological deterioration ≥4 National Institutes of Health Stroke Scale (NIHSS) points in medically managed patients with large vessel occlusion and mild presentation. Methods— Single-center retrospective study of patients with consecutive minor stroke (defined as NIHSS score of ≤5 on presentation) and large vessel occlusion from January 2014 to December 2017. Primary outcome was acute neurological deterioration ≥4 NIHSS points during the hospitalization. Secondary outcomes included ΔNIHSS (defined as discharge minus admission NIHSS score). Results— Among 1133 patients with acute minor strokes, 122 (10.6%) had visible occlusions on computed tomography angiography/magnetic resonance angiography. Twenty-four (19.7%) patients had ≥4 points deterioration on NIHSS at a median of 3.6 (1–16) hours from arrival. No clinical or radiological predictors of acute neurological deterioration ≥4 NIHSS points were observed on multivariable analysis. Rescue endovascular thrombectomy was performed more often in the ones with acute neurological deterioration ≥4 NIHSS points compared with patients with no deterioration (54% versus 0%; P <0.001). Acute neurological deterioration ≥4 NIHSS points was associated with ΔNIHSS ≥4 points (33% versus 4.9%; P <0.01) and a trend toward lower independence rates at discharge (50% versus 70%; P =0.06) compared with the group with no deterioration. In patients with any degree of neurological worsening, patients who underwent rescue thrombectomy were more likely to be independent at discharge (73% versus 38%; P =0.02) and to have a favorable ΔNIHSS (−2 [−3 to 0] versus 0 [−1 to 6]; P =0.05) compared with the ones not offered rescue thrombectomy. Conclusions— Acute neurological deterioration ≥4 NIHSS points was observed in a fifth of patients with large vessel occlusion and mild symptoms, occurred very early in the hospital course, impacted functional outcomes, and could not be predicted by any of the studied clinical and radiological variables. Rescue thrombectomy was associated with improved clinical outcomes at discharge in patients with neurological deterioration.

Perfusion and Diffusion Variables Predict Early Neurological Deterioration in Minor Stroke and Large Vessel Occlusion

“…25 Accordingly, optimal imaging variables predicting END in minor stroke and LVO remain unknown. Although a recent study failed to find radiological predictors of END in a similar patient population, patients with END tended to have larger Tmax >6 seconds lesion volumes, 34 which is in line with our findings. The current and earlier studies suggest that critical hypoperfusion lesions on magnetic resonance imaging would reliably reflect collateral status, 35,36 which is an important determinant of fluctuations of neurological status.…”

Patient Characteristics and Outcomes Associated with Decline in Stroke Volumes During the Early COVID-19 Pandemic

“…However, approximately 10% of patients with mild stroke symptoms have a large vessel occlusion. 17 Further research is needed to determine whether the decline in MT volumes was due to patients with large vessel occlusion and mild symptoms not seeking medical care, and if so, the associated morbidity.…”

More expansive horizons: a review of endovascular therapy for patients with low NIHSS scores

“…34 In a more recent study, 19.7% of medically managed patients with LVO-AIS experienced END at a median time of 3.6 hours from hospital arrival. 35 Some identified predictors of good outcome (mRS score ≤2) in patients with LVO-AIS and a low NIHSS score include lower NIHSS score (0-3), younger age, reperfusion therapy (IVT, EVT, or both), absence of hypertension, and absence of hyperglycemia. 9 32 36 Literature for the treatment of patients with LVO-AIS and a low NIHSS score with IVT has yielded conflicting results, probably related to variability in patient exclusion criteria.…”