RT Journal Article
SR Electronic
T1 Neurologic Improvement in Acute Cerebral Ischemia
JF Neurology
JO Neurology
FD Lippincott Williams & Wilkins
SP e1038
OP e1047
DO 10.1212/WNL.0000000000201656
VO 100
IS 10
A1 Clotilde Balucani
A1 Steven R. Levine
A1 Nerses Sanossian
A1 Sidney Starkman
A1 David Liebeskind
A1 Jeffrey A. Gornbein
A1 Kristina Shkirkova
A1 Samuel Stratton
A1 Marc Eckstein
A1 Scott Hamilton
A1 Robin Conwit
A1 Latisha K. Sharma
A1 Jeffrey L. Saver
YR 2023
UL http://n.neurology.org/content/100/10/e1038.abstract
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