outcomes

Ammad Mahmood, MBChB
@AMahmoodNeuro

Millán M, Ramos-Pachón A, Dorado L, Bustamante A, Hernández-Pérez M, Rodríg uez-Esparragoza L, Gomis M, Remollo S, Castaño C, Werner M, et al., and on behalf of the Cat-SCR Consortium. Predictors of Functional Outcome After Thrombectomy in Patients With Prestroke Disability in Clinical Practice. Stroke. 2021.

Major clinical trials generally exclude patients with pre-stroke disability, generally defined as pre-stroke modified Rankin scale (mRS) of ≥2 or 3. Accordingly, thrombectomy guidelines [1, 2] state the benefit of mechanical thrombectomy (MT) for patients with pre-stroke disability is less clear, particularly for those aged >80. Patients with pre-stroke disability are routinely considered for MT particularly when other clinical and radiological factors are favorable, such as early presentation or good ASPECTS score. In this registry-based study, patients with mRS of 2 or 3 who underwent MT in the Catalonia stroke network were examined to assess any association between pre-stroke disability and outcomes, as well as aiming to identify factors predictive of favorable outcome for patients with pre-stroke disability. A favorable outcome in this context was defined as a return to baseline mRS at 90 days.

Meghana Srinivas, MD
@SrinivasMeghana

Bres-Bullrich M, Fridman S, Sposato LA. Relative Effect of Stroke Severity and Age on Outcomes of Mechanical Thrombectomy in Acute Ischemic Stroke. Stroke. 2021;52:2846–2848.

In this article by Maria Bres-Bullrich et al., the authors discuss the utilization of prognostic tools in determining functional outcomes in patients with acute ischemic due to an anterior circulation large vessel occlusion (LVO) with or without mechanical thrombectomy (MT). Mechanical thrombectomy (MT) is the standard of care for patients presenting with anterior circulation LVO. However, not all patients who receive MT benefit in a similar way. Stroke severity and age, which are readily available, are strong determinants of outcomes in patients receiving MT in clinical trials, and they heavily influence the decision to perform MT. However, there is a possible discrepancy between observational studies and clinical trials, with the former showing older age group (≥80 years) is associated with lower likelihood of shift to better outcomes and higher rates of death. In real-world practice, the interplay between stroke severity and age, as well as the relative weight of each variable on outcomes, are poorly understood.

Kevin O’Connor, M.D.

Sundelin HEK, Tomson T, Zelano J, Söderling J, Bang P, Ludvigsson JF. Pediatric Ischemic Stroke and Epilepsy: A Nationwide Cohort Study. Stroke. 2021.

Post-stroke epilepsy is a well-known entity, particularly in adults. To explore post-stroke epilepsy in children, Sundelin et al. used the Swedish National Registers to identify 1220 children with ischemic stroke (including cerebral venous sinus thrombosis, which could not be differentiated in the Register) and 12155 comparators between 1969-2016; they excluded patients with previously known epilepsy.

Of the 1220 children with ischemic stroke, 219 (18%) developed post-stroke epilepsy compared to 91 comparators (0.7%). The epilepsy risk was highest in the six months following stroke (HR, 119.4 [95% CI, 48.0–297.4]) and remained elevated even at 20 years post-stroke (HR, 7.9 [95% CI, 3.3–19.0]). The cumulative incidence of post-stroke epilepsy increased with longer follow-up periods: 11.9% at 5 years (95% CI, 10.1%–14.0%), 21.6% (95% CI, 19.0%–24.6%), and 26.4% at 30 years (95% CI, 23.0%–30.1%).

Mona Al Banna, MB BCh, Msc(Res)
@DrMonaAlBanna

Martí-Fàbregas J, Guisado-Alonso D, Delgado-Mederos R, Martínez-Domeño A, Prats-Sánchez L, Guasch-Jiménez M, Cardona P, Núñez-Guillén A, Requena M, Rubiera M, et al. Impact of COVID-19 Infection on the Outcome of Patients With Ischemic Stroke. Stroke. 2021.

Various studies are showing that neurologic complications, including stroke, occur frequently in COVID-19 patients. In addition, the COVID-19 pandemic has compromised the delivery of well-established time-sensitive therapies and system delivery in stroke care. The authors of this study set out to determine whether patients with stroke and COVID-19 had worse functional outcomes compared to patients without COVID-19 and, if so, evaluate whether this was attributable to direct effects of the virus itself or due to logistical difficulties of providing care during a global pandemic.

The authors conduced a prospective multicentered cohort study of 19 hospitals in Catalonia, Spain, from mid-March to May 15, 2020. Patients were eligible if they had an acute ischemic stroke with a previous modified Rankin Scale (mRS) of 0-3. Patients were then classified according to their SARS-CoV-2 PCR status. The authors then collected various data variables, including demographic data, vascular risk factor profiles, pre-admission medications, NIHSS on admission and at 72 hours, imaging data, reperfusion therapies (and, if applicable, TICI scores), time metrics (e.g., door to needle, door to groin), stroke etiology and functional outcome at 3 months.  

Dixon Yang, MD

Romano JG, Gardner H, Campo-Bustillo I, Khan Y, Tai S, Riley N, Smith EE, Sacco RL, Khatri P, Alger HM, et al, on behalf of the MaRISS Investigators. Predictors of Outcomes in Patients With Mild Ischemic Stroke Symptoms: MaRISS. Stroke. 2021;52:1995–2004.

Acute ischemic stroke commonly presents with mild or improving symptoms,¹ often defined as minor stroke with NIHSS ≤ 5. Many of these patients are not treated with acute thrombolytic therapy due to exclusion from the landmark NINDS recombinant tissue-type plasminogen activator efficacy trials.² Despite perceived minor symptoms, many of those hospitalized may be unable to walk independently or return directly to home at discharge.³ Effects of thrombolysis and long-term outcomes in minor stroke are still not well understood. Thus, Romano and colleagues sought to describe multidimensional long-term outcomes in patients with mild ischemic stroke symptoms from MaRISS (Mild and Rapidly Improving Stroke Study).

This prospective observational study recruited sites who participated in Get With The Guidelines-Stroke, had more than 300 annual stroke discharges, and reflected regional and national representation of hospital centers. Eligible MaRISS participants presented within 4.5 hours from stroke symptoms onset, had a brain CT excluding non-ischemic causes, and initial NIHSS of 0-5. Those with pre-morbid disability of mRS ≥2 or with complete resolution of symptoms on initial evaluation were excluded. The primary outcome was an mRS score of 0-1 at 90 days post-event. Secondary outcomes included Barthel Index 95-100 versus <95, Stroke Impact Scale-16 (SIS-16) ≥88.2 versus <88.2, and European Quality of Life 5D-5L 1 versus <1 and its visual analogue scale ≥90 versus <90.