From the Emory University/Grady Memorial Hospital- Marcus Stroke and Neuroscience Center, Atlanta, GA.
Stroke. 2020 May;51(5):1428-1434. doi: 10.1161/STROKEAHA.119.027011. Epub 2020 Apr 16.
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%; <0.001). Acute neurological deterioration ≥4 NIHSS points was associated with ΔNIHSS ≥4 points (33% versus 4.9%; <0.01) and a trend toward lower independence rates at discharge (50% versus 70%; =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%; =0.02) and to have a favorable ΔNIHSS (-2 [-3 to 0] versus 0 [-1 to 6]; =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.
背景与目的- 目前尚不清楚哪些因素可预测大血管闭塞且症状轻微的患者发生急性神经功能恶化。本研究旨在评估经药物治疗的大血管闭塞且表现为轻度卒中的患者中，神经功能恶化≥4 分国立卫生研究院卒中量表（NIHSS）评分的频率、时间和潜在预测因素。
方法- 这是一项单中心回顾性研究，纳入了 2014 年 1 月至 2017 年 12 月连续收治的小卒中（定义为入院时 NIHSS 评分≤5 分）且存在大血管闭塞的患者。主要结局为住院期间发生的急性神经功能恶化≥4 分 NIHSS 评分。次要结局包括 NIHSS 差值（定义为出院时 NIHSS 评分减去入院时 NIHSS 评分）。
结果- 在 1133 例急性小卒中患者中，122 例（10.6%）CT 血管造影/磁共振血管造影可见血管闭塞。24 例（19.7%）患者在入院后 3.6（1-16）小时内 NIHSS 评分恶化≥4 分。多变量分析未发现急性神经功能恶化≥4 分 NIHSS 评分的预测因素。与无神经功能恶化的患者相比，神经功能恶化≥4 分 NIHSS 评分的患者更常接受急性血管内血栓切除术（54%与 0%；<0.001）。与无神经功能恶化的患者相比，神经功能恶化≥4 分 NIHSS 评分的患者 NIHSS 差值≥4 分（33%与 4.9%；<0.01）和出院时独立性较低（50%与 70%；=0.06）的发生率更高。在任何程度的神经功能恶化的患者中，接受血管内血栓切除术的患者出院时更可能独立（73%与 38%；=0.02），且 NIHSS 差值更有利（-2 [-3 至 0]与 0 [-1 至 6]；=0.05）。
结论- 大血管闭塞且症状轻微的患者中有五分之一发生了神经功能恶化≥4 分 NIHSS 评分，这种恶化发生在住院的早期，影响了功能结局，且无法通过任何研究中的临床和影像学变量进行预测。在发生神经功能恶化的患者中，血管内血栓切除术与出院时的临床结局改善相关。
