PT - JOURNAL ARTICLE AU - Clotilde Balucani AU - Steven R. Levine AU - Nerses Sanossian AU - Sidney Starkman AU - David Liebeskind AU - Jeffrey A. Gornbein AU - Kristina Shkirkova AU - Samuel Stratton AU - Marc Eckstein AU - Scott Hamilton AU - Robin Conwit AU - Latisha K. Sharma AU - Jeffrey L. Saver TI - Neurologic Improvement in Acute Cerebral Ischemia AID - 10.1212/WNL.0000000000201656 DP - 2023 Mar 07 TA - Neurology PG - e1038--e1047 VI - 100 IP - 10 4099 - http://n.neurology.org/content/100/10/e1038.short 4100 - http://n.neurology.org/content/100/10/e1038.full SO - Neurology2023 Mar 07; 100 AB - 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.ACI=acute cerebral ischemia; ASPECTS=Alberta Stroke Program Early CT Score; ED=emergency department; IV t-PA=IV tissue plasminogen activator; LAMS=Los Angeles Motor Scale; LKW=last known well; mRS=modified Rankin Scale; NIHSS=NIH Stroke Scale; ROC=receiver operator characteristic curve; SICH=symptomatic intracranial hemorrhage; U-RNI=ultra-early rapid neurologic improvement