Neurologic Improvement in Acute Cerebral Ischemia: Frequency, Magnitude, Predictors, and Clinical Outcomes - PubMed (original) (raw)

Randomized Controlled Trial

. 2023 Mar 7;100(10):e1038-e1047.

doi: 10.1212/WNL.0000000000201656. Epub 2022 Dec 7.

Steven R Levine 2, Nerses Sanossian 2, Sidney Starkman 2, David Liebeskind 2, Jeffrey A Gornbein 2, Kristina Shkirkova 2, Samuel Stratton 2, Marc Eckstein 2, Scott Hamilton 2, Robin Conwit 2, Latisha K Sharma 2, Jeffrey L Saver 2

Affiliations

Randomized Controlled Trial

Neurologic Improvement in Acute Cerebral Ischemia: Frequency, Magnitude, Predictors, and Clinical Outcomes

Clotilde Balucani et al. Neurology. 2023.

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: clinicaltrials.gov. Unique identifier: NCT00059332.

© 2022 American Academy of Neurology.

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Figures

Figure 1

Figure 1. Frequency of Changes of Different Magnitudes in Los Angeles Motor Scale Score From Prehospital to Emergency Department

Bar chart shows the frequency of all changes (improvement, neutral, and worsening). Dramatic ultra-rapid neurologic improvement (U-RNI) patient bars are dark blue, moderate U-RNI patient bars are light blue, and no U-RNI patient bars are light gray. As the delta score is measured by subtracting the emergency department Los Angeles Motor Scale (LAMS) from the prehospital LAMS, negative values indicate improvement, and positive values indicate worsening.

Figure 2

Figure 2. Correlation of Los Angeles Motor Scale Score Change From Prehospital to Emergency Department With NIH Stroke Scale Score at Hospital Admission

Scatterplot of the Los Angeles Motor Scale score LAMS change (emergency department LAMS–prehospital LAMS) vs NIH Stroke Scale score at admission. The LAMS change ranges from a 5-point improvement (decrease) to a 9-point worsening (increase); the scatter plot illustrates the positive correlation: Spearman correlation = 0.647, p < 0.001; red line connects medians.

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