Hannah Roeder, MD, MPH
The presence of cortical signs, such as aphasia and neglect, on a stroke code examination prompts neurologists to investigate for the presence of a large vessel occlusion (LVO) and to determine if the patient may benefit from thrombectomy. Can the rescue or persistence of cortical signs following mechanical thrombectomy (MT) help us predict outcomes among stroke patients?
The authors performed a retrospective analysis of the stroke database at a single Comprehensive Stroke Center to assess the impact of neglect and aphasia on clinical outcomes for patients with right and left anterior LVO, respectively. They found that a significant majority of patients with right-sided LVOs presented with neglect (71%) and patients with left-sided LVOs presented with language impairment (93%). MT resulted in “rescue of neglect” (31%) and “rescue of language impairment” (23%) in a minority of cases but was an independent and better predictor of functional independence (mRS 0-2) and survival even after adjustment for NIHSS and infarct volume.
The study included thrombectomies from January 2015 to October 2018, so many of their cases pre-dated the publication of thrombectomy trials establishing the efficacy of extended window thrombectomy. Nonetheless, nearly half of the thrombectomies (42%) were treated in the 6- to 24-hour window, but only a minority (24%) of those thrombectomies used penumbral imaging to select patient eligibility for thrombectomy. One wonders if the rates of language and neglect rescue may be higher if patient selection utilized perfusion imaging. Additionally, the investigators did not have access to handedness data, which may have given insight into whether patients could have had right hemispheric language dominance. The authors did report that 17% of right-sided LVOs had initial language impairment within their cohort. The authors also point out that language deficits are often easier to identify on exam and are given more points in the NIHSS as compared to neglect. The authors controlled for confounders, but notably, the study was retrospective and differences between the rescue and persistence groups at baseline may have influenced the results.
This was a single-center study, and these findings should be replicated first across other institutions; however, if consistently demonstrated, the results suggest that rescue or persistence of cortical signs should be documented after thrombectomy and may help inform prognostication.