Neurologic Improvement in Acute Cerebral Ischemia (original) (raw)

Abstract

Background and Objectives

Investigations of rapid neurologic improvement (RNI) in patients with acute cerebral ischemia (ACI) have focused on RNI occurring after hospital arrival. However, with stroke routing decisions and interventions increasingly migrating to the prehospital setting, there is a need to delineate the frequency, magnitude, predictors, and clinical outcomes of patients with ACI with ultra-early RNI (U-RNI) in the prehospital and early postarrival period.

Methods

We analyzed prospectively collected data of the prehospital Field Administration of Stroke Therapy–Magnesium (FAST-MAG) randomized clinical trial. Any U-RNI was defined as improvement by 2 or more points on the Los Angeles Motor Scale (LAMS) score between the prehospital and early post–emergency department (ED) arrival examinations and classified as moderate (2–3 point) or dramatic (4–5 point) improvement. Outcome measures included excellent recovery (modified Rankin Scale [mRS] score 0–1) and death by 90 days.

Results

Among the 1,245 patients with ACI, the mean age was 70.9 years (SD 13.2); 45% were women; the median prehospital LAMS was 4 (interquartile range [IQR] 3–5); the median last known well to ED-LAMS time was 59 minutes (IQR 46–80 minutes), and the median prehospital LAMS to ED-LAMS time was 33 minutes (IQR 28–39 minutes). Overall, any U-RNI occurred in 31%, moderate U-RNI in 23%, and dramatic U-RNI in 8%. Any U-RNI was associated with improved outcomes, including excellent recovery (mRS score 0–1) at 90 days 65.1% (246/378) vs 35.4% (302/852), p < 0.0001; decreased mortality by 90 days 3.7% (14/378) vs 16.4% (140/852), p < 0.0001; decreased symptomatic intracranial hemorrhage 1.6% (6/384) vs 4.6% (40/861), p = 0.0112; and increased likelihood of being discharged home 56.8% (218/384) vs 30.2% (260/861), p < 0.0001.

Discussion

U-RNI occurs in nearly 1 in 3 ambulance-transported patients with ACI and is associated with excellent recovery and decreased mortality at 90 days. Accounting for U-RNI may be useful for routing decisions and future prehospital interventions.

Trial Registration Information

Get full access to this article

View all available purchase options and get full access to this article.

References

Nedeltchev K, Schwegler B, Haefeli T, et al. Outcome of stroke with mild or rapidly improving symptoms. Stroke 2007;38(9):2531-2535.

Balucani C, Bianchi R, Ramkishun C, et al. Rapidly improving stroke symptoms: a pilot, prospective study. J Stroke Cerebrovasc Dis. 2015;24(6):1211-1216.

Balucani C, Levine SR, Khoury JC, Khatri P, Saver JL, Broderick JP. Acute ischemic stroke with very early clinical improvement: a national Institute of neurological disorders and stroke recombinant tissue plasminogen activator stroke trials exploratory analysis. J Stroke Cerebrovasc Dis. 2016;25(4):894-901.

Hougaard KD, Hjort N, Zeidler D, et al. Remote ischemic perconditioning as an adjunct therapy to thrombolysis in patients with acute ischemic stroke: a randomized trial. Stroke 2014;45(1):159-167.

RIGHT-2 Investigators. Prehospital transdermal glyceryl trinitrate in patients with ultra-acute presumed stroke (RIGHT-2): an ambulance-based, randomised, sham-controlled, blinded, phase 3 trial. Lancet 2019;393(10175):1009-1020.

Saver JL, Starkman S, Eckstein M, et al. FAST-MAG Investigators and Coordinators. Prehospital use of magnesium sulfate as neuroprotection in acute stroke. N Engl J Med. 2015;372(6):528-536.

Noorian AR, Sanossian N, Shkirkova K, et al. FAST-MAG trial investigators and coordinators. Los Angeles motor scale to identify large vessel occlusion: prehospital validation and comparison with other screens. Stroke 2018;49(3):565-572.

Nguyen TTM, van den Wijngaard IR, Bosch J, et al. Comparison of prehospital scales for predicting large anterior vessel occlusion in the ambulance setting. JAMA Neurol. 2021;78(2):157-164.

Saver JL, Starkman S, Eckstein M, et al. Methodology of the field administration of stroke therapy - magnesium (FAST-MAG) phase 3 trial: Part 2 - prehospital study methods. Int J Stroke 2014;9(2):220-225.

Saver JL, Starkman S, Eckstein M, et al. Methodology of the field administration of stroke therapy - magnesium (FAST-MAG) phase 3 trial: Part 1 - rationale and general methods. Int J Stroke 2014;9(2):215-219.

Llanes JN, Kidwell CS, Starkman S, Leary MC, Eckstein M, Saver JL. The Los Angeles Motor Scale (LAMS): a new measure to characterize stroke severity in the field. Prehosp Emerg Care 2004;8(1):46-50.

Kim JT, Chung PW, Starkman S, et al. Field validation of the Los Angeles motor scale as a tool for paramedic assessment of stroke severity. Stroke 2017;48(2):298-306.

Brandler ES, Sharma M, Sinert RH, Levine SR. Prehospital stroke scales in urban environments: a systematic review. Neurology 2014;82(24):2241-2249.

Kidwell CS, Starkman S, Eckstein M, Weems K, Saver JL. Identifying stroke in the field. Prospective validation of the Los Angeles prehospital stroke screen (LAPSS). Stroke 2000;31(1):71-76.

Easton JD, Saver JL, Albers GW, et al. Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American heart association/American stroke association stroke council; council on cardiovascular surgery and anesthesia; council on cardiovascular radiology and intervention; council on cardiovascular nursing; and the interdisciplinary council on peripheral vascular disease. The American academy of neurology affirms the value of this statement as an educational tool for neurologists. Stroke 2009;40(6):2276-2293.

Romano JG, Gardener H, Smith EE, et al. MaRISS investigators. Frequency and prognostic significance of clinical fluctuations before hospital arrival in stroke. Stroke 2022;53(2):482-487.

Saver JL, Altman H. Relationship between neurologic deficit severity and final functional outcome shifts and strengthens during first hours after onset. Stroke 2012;43(6):1537-1541.

Shkirkova K, Saver JL, Starkman S, et al. Frequency, predictors, and outcomes of prehospital and early postarrival neurological deterioration in acute stroke: exploratory analysis of the FAST-MAG randomized clinical trial. JAMA Neurol. 2018;75(11):1364-1374.

Pérez de la Ossa N, Carrera D, Gorchs M, et al. Design and validation of a prehospital stroke scale to predict large arterial occlusion: the rapid arterial occlusion evaluation scale. Stroke 2014;45(1):87-91.

Nazliel B, Starkman S, Liebeskind DS, et al. A brief prehospital stroke severity scale identifies ischemic stroke patients harboring persisting large arterial occlusions. Stroke 2008;39(8):2264-2267.

Behnke S, Schlechtriemen T, Binder A, et al. Effects of state-wide implementation of the Los Angeles Motor Scale for triage of stroke patients in clinical practice. Neurol Res Pract. 2021;3(1):31.

Zakhari S. Alcohol and the cardiovascular system: molecular mechanisms for beneficial and harmful action. Alcohol Health Res World 1997;21(1):21-29.

Stettler GR, Moore EE, Nunns GR, et al. Do not drink and lyse: alcohol intoxication increases fibrinolysis shutdown in injured patients. Eur J Trauma Emerg Surg. 2021;47(6):1827-1835.

Kotila M, Waltimo O, Niemi ML, Laaksonen R, Lempinen M. The profile of recovery from stroke and factors influencing outcome. Stroke 1984;15(6):1039-1344.