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Acute insular infarction: Early outcomes of minor stroke with proximal artery occlusion.

ABSTRACT: BACKGROUND AND PURPOSE:We hypothesized that admission insular infarcts could be associated with early neurological deterioration (END) in acute minor stroke with large vessel occlusion. METHODS:Using acute and follow-up diffusion-weighted imaging (DWI), we assessed insular involvement including the percent insular ribbon infarction (PIRI) scores and follow-up lesion patterns in acute minor stroke (NIHSS ?5) with MCA/ICA occlusion. Follow-up lesion patterns were classified as swelling, new lesions, or infarct growth. END was defined as any increase in the NIHSS score. RESULTS:Among 166 patients (age: 66±12 y, 60.8% male), 82 (49.4%) had insular lesions on baseline DWI, and 64 (38.6%) had PIRI scores ?2. On follow-up DWI, infarct growths, new lesions, and swelling were observed in 34.9%, 69.9%, and 29.5% of patients. Infarct growths were significantly more frequent in patients with insular infarcts (43.9%), especially those with a PIRI score of 2 (54.8%), than in patients without insular infarcts (p = 0.02). While END was not significantly different in patients with and without insular lesions, insular lesions were independently associated with infarct growths (OR 2.18, 95% CI 1.12-4.26, p = 0.02) and END due to infarct growth (OR 2.54, 95% CI 1.12-5.76, p = 0.03), particularly in those with PIRI scores ?2. CONCLUSION:In acute minor stroke with MCA/ICA occlusion, insular lesions on admission DWI, especially in patients with PIRI scores ?2, were more likely to exhibit infarct growth and END due to infarct growth. This finding may help identify patients with higher risks of clinical worsening following acute minor stroke with large vessel occlusion.

SUBMITTER: Min SH

PROVIDER: S-EPMC7065779 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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Acute insular infarction: Early outcomes of minor stroke with proximal artery occlusion.

Min Seung-Hyun SH Kim Joon-Tae JT Kang Kyung-Wook KW Choi Min-Ji MJ Yoon Hana H Shinohara Yuki Y Lev Michael H MH Saver Jeffrey L JL Cho Ki-Hyun KH

PloS one 20200311 3

<h4>Background and purpose</h4>We hypothesized that admission insular infarcts could be associated with early neurological deterioration (END) in acute minor stroke with large vessel occlusion.<h4>Methods</h4>Using acute and follow-up diffusion-weighted imaging (DWI), we assessed insular involvement including the percent insular ribbon infarction (PIRI) scores and follow-up lesion patterns in acute minor stroke (NIHSS ≤5) with MCA/ICA occlusion. Follow-up lesion patterns were classified as swell ...[more]

PMID: 32160209

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Project description:Background and purposeProximal middle cerebral artery (MCA) occlusions impede blood flow to the noncollateralized lenticulostriate artery territory. Previous work has shown that this almost inevitably leads to infarction of the dependent gray matter territories in the striate even if perfusion is restored by mechanical thrombectomy. Purpose of this analysis was to evaluate potential sparing of neighboring fiber tracts, ie, the internal capsule.MethodsAn observational single-center study of patients with proximal MCA occlusions treated with mechanical thrombectomy and receiving postinterventional high-resolution diffusion-weighted imaging was conducted. Patients were classified according to internal capsule ischemia (IC+ versus IC-) at the postero-superior level of the MCA lenticulostriate artery territory (corticospinal tract correlate). Associations of IC+ versus IC- with baseline variables as well as its clinical impact were evaluated using multivariable logistic or linear regression analyses adjusting for potential confounders.ResultsOf 92 included patients with proximal MCA territory infarctions, 45 (48.9%) had an IC+ pattern. Longer time from symptom-onset to groin-puncture (adjusted odds ratio, 2.12 [95% CI, 1.19-3.76] per hour), female sex and more severe strokes were associated with IC+. Patients with IC+ had lower rates of substantial neurological improvement and functional independence (adjusted odds ratio, 0.26 [95% CI, 0.09-0.81] and adjusted odds ratio, 0.25 [95% CI, 0.07-0.86]) after adjustment for confounders. These associations remained unchanged when confining analyses to patients without ischemia in the corona radiata or the motor cortex and here, IC+ was associated with higher National Institutes of Health Stroke Scale motor item scores (β, +2.8 [95% CI, 1.5 to 4.1]) without a significant increase in nonmotor items (β, +0.8 [95% CI, -0.2 to 1.9).ConclusionsRapid mechanical thrombectomy with successful reperfusion of the lenticulostriate arteries often protects the internal capsule from subsequent ischemia despite early basal ganglia damage. Salvage of this eloquent white matter tract within the MCA lenticulostriate artery territory seems strongly time-dependent, which has clinical and pathophysiological implications.

Project description:BackgroundThis study aimed to investigate the association between the hyperdense basilar artery sign (HBAS) on non-enhanced computed tomography (CT) and clinical outcomes in patients with acute basilar artery occlusion (BAO) who underwent endovascular treatment (EVT).MethodsEligible patients who underwent EVT due to acute BAO between January 2014 and May 2019 were divided into two groups based on HBAS. HBAS was assessed by two neuroradiologists using five grades on nonenhanced CT. The primary outcome was a favorable functional outcome (defined as a modified Rankin Scale [mRS] of 0-3) at 90 days. Secondary outcomes included successful recanalization and mortality within 90 days.ResultsAmong 829 patients with BAO as assessed with CT angiography, magnetic resonance angiography, or digital subtraction angiography, 643 patients were treated with EVT. Of these, 51.32% (330/643) had HBAS. Patients with HBAS were older and had more severe neurological deficits and a higher frequency of atrial fibrillation than those without HBAS. There was no significant difference in favorable outcome (adjusted odds ratio [aOR]: 1.354, 95% confidence interval [CI]: 0.906-2.024; p = 0.14), successful recanalization (aOR: 0.926, 95% CI: 0.616--1.393; p = 0.71), and mortality (aOR: 1.193, 95% CI: 0.839-1.695; p = 0.33) between patients with or without HBAS. Subgroup analysis showed that the HBAS predicted a favorable outcome in patients aged <60 years (aOR: 2.574, 95% CI: 1.234-5.368; p = 0.01) and patients with vertebral artery-V4 segment occlusion (aOR: 3.738, 95% CI: 1.212-11.530; p = 0.02). In patients with HBAS, the baseline National Institutes of Health Stroke Scale (NIHSS) score, posterior circulation-Acute Stroke Prognosis Early Computed Tomography Score (pc-ASPECTS), and stent retriever were associated with successful recanalization.ConclusionsOur study did not find a significant association between HBAS and favorable outcomes and successful recanalization in patients with BAO who underwent EVT. Moreover, large prospective studies are warranted to further investigate this relationship.

Project description:PurposeBeyond intravenous thrombolysis, evidence is lacking on acute treatment of minor stroke caused by large artery occlusion. To identify candidates for additional endovascular therapy, we aimed to determine the frequency of non-haemorrhagic early neurological deterioration in patients with intravenous thrombolysis-treated minor stroke caused by occlusion of large proximal and distal cerebral arteries. Secondary aims were to establish risk factors for non-haemorrhagic early neurological deterioration and report three-month outcomes in patients with and without non-haemorrhagic early neurological deterioration.MethodWe analysed data from the SITS International Stroke Thrombolysis Register on 2553 patients with intravenous thrombolysis-treated minor stroke (NIH Stroke Scale scores 0-5) and available arterial occlusion data. Non-haemorrhagic early neurological deterioration was defined as an increase in NIH Stroke Scale score ≥4 at 24 h, without parenchymal hematoma on follow-up imaging within 22-36 h.FindingsThe highest frequency of non-haemorrhagic early neurological deterioration was seen in 30% of patients with terminal internal carotid artery or tandem occlusions (internal carotid artery + middle cerebral artery) (adjusted odds ratio: 10.3 (95% CI 4.3-24.9), p < 0.001) and 17% in extracranial carotid occlusions (adjusted odds ratio 4.3 (2.5-7.7), p < 0.001) versus 3.1% in those with no occlusion. Proximal middle cerebral artery-M1 occlusions had non-haemorrhagic early neurological deterioration in 9% (adjusted odds ratio 2.1 (0.97-4.4), p = 0.06). Among patients with any occlusion and non-haemorrhagic early neurological deterioration, 77% were dead or dependent at three months.ConclusionsPatients with minor stroke caused by internal carotid artery occlusion, with or without tandem middle cerebral artery involvement, are at high risk of disabling deterioration, despite intravenous thrombolysis treatment. Acute vessel imaging contributes usefully even in minor stroke to identify and consider endovascular treatment, or intensive monitoring at a comprehensive stroke centre, for patients at high risk of neurological deterioration.

Project description:ImportanceEndovascular therapy (EVT) has been reported to be safe and effective in improving clinical outcomes among patients with acute basilar artery occlusion (ABAO). The benefits associated with EVT remain uncertain for patients with ABAO with severe symptoms (ie, National Institutes of Health Stroke Scale [NIHSS] score ≥ 21).ObjectivesTo assess the outcomes associated with EVT and identify factors associated with outcomes among patients with ABAO and severe symptoms.Design, setting, and participantsThis prospective, nationwide cohort study was conducted using data from January 2014 to May 2019 in China from the Endovascular Treatment for Acute Basilar Artery Occlusion Study Registry (BASILAR). Included patients had ABAO and underwent EVT or standard medical treatment (SMT) alone in routine clinical practice. Patients were dichotomized into severe symptoms (ie, NIHSS score ≥ 21) and minor to moderate symptoms (NIHSS score < 21) groups. Patients were followed up for 90 days. Data were analyzed from December 2020 through June 2021.ExposuresEVT with SMT vs SMT alone.Main outcomes and measuresThe primary outcome was improvement in modified Rankin Scale (mRS) score at 90 days, defined as a decrease by 1 grade in mRS score. Secondary outcomes included favorable functional outcome (ie, mRS score, 0-3) and mortality.ResultsAmong 542 patients with ABAO and severe symptoms (median [IQR] age, 65 [57-74] years; 147 [27.1%] women), 431 patients (79.5%) received EVT and 111 patients (20.5%) received SMT. Compared with SMT, EVT was associated with increased odds of improved mRS score (adjusted common odds ratio [OR], 3.44 [95% CI, 2.05-5.78]; P < .001), with increased odds of a favorable functional outcome (ie, mRS score, 0-3; adjusted OR, 4.52 [95% CI, 1.64-12.43]; P = .004) and decreased odds of mortality (adjusted OR, 0.27 [95% CI, 0.15-0.50]; P < .001). Among patients receiving EVT, baseline NIHSS score was associated with decreased odds of a favorable functional outcome (adjusted OR per 1-point increase in score, 0.90 [95% CI, 0.85-0.95]; P < .001) and increased odds of mortality (adjusted OR per 1-point increase in score, 1.13 [95% CI, 1.07-1.19]; P < .001), while posterior circulation Acute Stroke Prognosis Early Computed Tomography Score (pc-ASPECTS) was associated with increased odds of a favorable functional outcome (adjusted OR per 1-point increase in score, 1.71 [95% CI, 1.41-2.07]; P < .001) and decreased odds of mortality (adjusted OR per 1-point increase in score, 0.74 [95% CI, 0.64-0.85]; P < .001). Different occlusion sites, compared with distal basilar artery, were associated with decreased odds of favorable functional outcome (eg, middle basilar artery: adjusted OR vs distal basilar artery, 0.36 [95% CI, 0.17-0.80]; P = .01).Conclusions and relevanceThis study found that EVT was associated with increased odds of functional favorable outcomes among patients with ABAO and severe symptoms. Baseline NIHSS score, pc-ASPECTS, and occlusion site were independent factors associated with clinical outcomes.

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Acute insular infarction: Early outcomes of minor stroke with proximal artery occlusion.

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Acute insular infarction: Early outcomes of minor stroke with proximal artery occlusion.

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