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Background and Purpose— We sought to investigate the direct costs of acute hospitalization for patients with first-ever ischemic stroke in Taiwan. Methods— Data were prospectively collected from 360 first-ever ischemic stroke patients. Hospital charges were used for analysis. Multiple linear regression analysis was used to identify the main factors influencing costs. Results— Mean age was 64.9 years (median, 67.0 years), and 58% were male. Mean National Institutes of Health Stroke Scale (NIHSS) score at admission was 9.4 (median, 6.0). Mean initial score of modified Barthel Index was 10.7 (median, 12.0). Median length of stay was 7 days (range, 1 to 122 days). In-hospital mortality was 8%. Overall, median cost per patient was 26 326 New Taiwan dollars (NTD) (original currency) or $841; median cost per day was 3777 NTD or $121. Median costs for patients with initial NIHSS score 0 to 6, 7 to 15, and 16 to 38 were 20 365 NTD ($650), 31 954 NTD ($1020), and 62 653 NTD ($2000), respectively. Daily component (physician and ward charges) accounted for approximately 38% of total costs. Initial NIHSS score, small-vessel occlusion, admission to intensive care unit, sex, and smoking had significant impacts on costs. Conclusions— Apart from providing cost estimates, we note that stroke severity strongly affects costs.

The advent of new MRI techniques such as perfusion- (PWI) and diffusion- (DWI) weighted imaging in the early 1990s has added another dimension to diagnostic imaging in stroke [98, 195, 224, 236, 237, 372]. During the last few years a growing body of evidence has accumulated, documenting the usefulness of this method in the clinical setting of acute ischemic stroke. Several investigators found a significant correlation of DWI and PWI changes with follow-up imaging as well as with neurological outcome [18, 205, 322, 344, 371, 373]. Some authors concluded that different infarct patterns can be identified by means of DWI and PWI in hyperacute stroke, which may allow a more rational selection of therapeutic strategies based on the presence or absence of a tissue at risk. Nevertheless, substantial doubts remain regarding the feasibility and practicality as well as the validity of stroke MRI in the clinical setting [268, 397].

The presence of a thrombus on initial arteriography is directly related to the baseline NIHSS score. Magnetic resonance angiography (MRA) offers a noninvasive and rapid assessment of large cerebral vessel patency. We aimed at evaluating (1) the baseline NIHSS score as a tool for predicting the likelihood of an occluded artery on MRA and (2) the course of stroke within the first week according to the presence of a cerebral arterial occlusion. Patients were enrolled in this prospective study according to the following criteria: (1) acute cerebral ischemia with a neurological deficit lasting >1 h, and (2) brain MRI performed within 24 h of stroke onset. The NIHSS score assessment was performed on admission and at day 1 and day 7. The MRI protocol included: (1) T2-weighted Turbo spin echo, (2) echo-planar imaging isotropic diffusion, (3) T2*-gradient echo sequence, and (4) time of flight MRA (3D TOF Turbo MRA). The presence of a symptomatic cerebral arterial occlusion on MRA was systematically screened. Fifty-four patients were studied. Median age was 60 years. Mean time from stroke onset to NIHSS assessment was 170 ± 95 min. The mean baseline NIHSS score was 13.5 ± 7.3. The mean time from stroke onset to MRI was 384 ± 171 min. MRA was readable in 50 cases. An arterial occlusion was detected in 23 patients (46%). The median baseline NIHSS score was significantly higher in the group of patients with occlusion than in the group of patients without occlusion (18 vs. 7, p = 0.01). The predictive probability to demonstrate an arterial occlusion was related to the baseline NIHSS score. None of the patients with an NIHSS score of 1–6 (11 patients) had visible occlusion, whereas 9 (43%) out of 21 patients with an NIHSS score of 7–15 and 14 (78% ) out of 18 patients with an NIHSS score above 16 had an arterial occlusion. For an increase by one point in the NIHSS score, the odds ratio for the presence of occlusion was 1.28 (95% CI: 1.11–1.46). The course of the stroke as assessed by follow-up NIHSS score was significantly more severe if an occlusion was detected. Median day 0, day 1 and day 7 NIHSS score were, respectively, 18, 16 and 13 in patients who had an occlusion versus 7, 4 and 0 in patients who had no visible occlusion (p < 0.01). A direct relation between the baseline NIHSS score and the likelihood of the presence of an occlusion on initial MRA is demonstrated. The presence of a cerebral arterial occlusion on MRA is significantly linked to a poor neurological outcome.

Background: Ischemic stroke comprises 85% of all stroke cases. Stroke is the third major cause of mortality worldwide and an important cause of long term disability contributing to major economic burden in most of the countries. Since inflammatory response is a key factor for ischemic damage of neurons, the markers of inflammation are supposed to have some predictive value in outcome of the ischemic stroke patients. Objective: The purpose of this study was to estimate the biochemical markers of inflammation and atherosclerosis (CRP and TNFα) in acute ischemic stroke patients and compare them with controls. Also to correlate these parameters with stroke severity, short term outcome after 7 days and long term outcome at 6 months using modified Rankin scale and Barthel Index. Method and Material: The present study was conducted on 45 acute ischemic stroke patients and 80 age and sex matched. The biochemical markers of inflammation and atherosclerosis (CRP and TNFα) in acute ischemic stroke patients were estimated and compared with controls. These parameters were analyzed for correlation with stroke severity (NIHSS), short term outcome after 7 days and long term outcome at 6 months using modified Rankin scale, Barthel Index and DWI MRI volume of infarct. The first blood sample was taken within 72 hours of onset of stroke and second sample was taken 7 days following the first sampling Results: Broadly the results showed that CRP and TNF α levels on the day of admission were higher in the experimental group as compared to controls. Difference was statistically significant. After 7 days, the levels of serum CRP and TNF α were high when compared to controls, however, the difference between day 1 and day 7 were not found to be statistically significant. When the biochemical parameters were correlated with the severity of stroke in NIHSS score, it was found that CRP on the day of admission and around 7th day correlated significantly with the severity of stroke assessed on both occasions. Correlating with the DWI MRI, volume of infarct, it was found that CRP on the day of admission as well as after 7 days correlated with the volume of infarct, therefore CRP levels correlate with the extent of tissue damage following ischemia. TNFα level did not correlate with the volume of infarct. CRP levels around 7th day also correlated with short term and long term outcome of patients assessed by modified Rankin scale and Barthel Index. Conclusion: Measuring CRP around one week following the stroke has the greatest prognostic value.

I read the article by Saposnik et al.1 with interest. Without a control group with a positive Stroke Prognostication using Age and NIHSS (SPAN)–100, it is difficult to know whether giving tissue plasminogen activator (tPA) is of benefit. Studies have shown that the elderly benefit from tPA, so that leaves the severity of the stroke as measured by the NIHSS Score as the main determinant of a good outcome.

Purpose The Penumbra MAX System (5MAX, 4MAX, and 3MAX) refers to a new generation of reperfusion catheters with a larger, tapered lumen and new material composition in the distal end designed to enhance aspiration efficiency with improve trackability. Results from a retrospective multicentre study with the Penumbra System 5 MAX, 4MAX and 3MAX reperfusion catheters in acute stroke patients with large vessel occlusion are reported. Methods A retrospective case-review of 22 consecutive acute ischaemic stroke cases from July 2012 through March 2013 treated by the Penumbra System (5 MAX, 4MAX and 3MAX) was performed. The case experience from three institutions was collected in the initial months after the device was released. Results are reported from cases which involved occlusions in the ICA (n=6), proximal MCA M1 (n=10), distal MCA M2 (n=3) and vertebrobasilar arteries (n=3). Results Prior to intervention, all patients presented with TICI 0 or 1. Successful revascularisation was primarily achieved in 86.3% (Tici 2b & Tici 3 ) using the Penumbra System with 5 MAX, 4MAX and 3MAX reperfusion catheters. Mean age was 71.45 ± 14.4 years; median baseline NIHSS score was 20.5 ± 3.96. In 1 patient, embolisation of new territory was found and treated by IA rtPA. One case of intracerebral haemorrhage (ICH) was noted with haemorrhage in a previously unaffected region, possibly secondary to IV rtPA treatment. Conclusion Early clinical experience suggests that the 5 MAX, 4MAX and 3MAX appear to have improved aspiration efficiency and tracking. Follow-up data and additional cases are critical in confirming these initial results. Disclosures J. Farkas: None. K. Arcot: None. R. Kumar: None. J. Delbrune: None. N. Papamitsakis: None. Y. Margulis: None. D. Walzman: None. S. Dash: None. K. Levin: None. S. Azhar: None.

Introduction/Purpose The new material composition and larger, tapered lumen in the distal end of the novel Penumbra MAX System reperfusion catheters are designed to enhance aspiration efficiency with improved trackability. Reported herein are results from a retrospective multicentre study with the Penumbra System 5MAX, 4MAX and 3MAX reperfusion catheters in the treatment of acute ischaemic stroke secondary to large vessel occlusion. Materials and Methods A retrospective case-review of 19 consecutive acute ischaemic stroke cases treated with the Penumbra System either as a standalone device or in combination: 5MAX (n=8), 4MAX (n=6) and 3MAX (n=8), from July 2012 through December 2012 was undertaken. Clinical experience at 3 institutions was collected and reported in the first six months after device release. Occlusions were located in the MCA M1and M2 (n=11), ICA and ICA/MCA (n=6), and vertebrobasilar arteries (n=2). Results Eighteen of 19 cases (94.7%) were successfully recanalised to TICI 2 and 3 using the Penumbra MAX System. Complete revascularisation to TICI 3 was achieved in 16 of 19 (84%). The mean patient age was 70.3 ± 13.9 years; the median NIHSS score at presentation was 19 (15 to 29). All patients presented with TICI scores of 0 or 1. At discharge, the median NIHSS score was 14 (1 to 29). One death due to cardiac arrest occurred at 15 days post-procedure. In one patient, stroke in a new territory was observed and treated with IA rtPA. One ICH was found in a previously unaffected region, possibly secondary to IV rtPA therapy. Conclusion Early multicentre experience indicates that the 5MAX, 4MAX and 3MAX reperfusion catheters have enhanced aspiration efficiency and trackability. Follow-up studies will be required to verify these findings. Disclosures J. Farkas: None. K. Arcot: None. D. Walzman: None. R. Kumar: None. J. Delbrune: None. N. Papamitsakis: None. Y. Margulis: None. S. Dash: None. K. Levin: None. S. Azhar: None.

Background and purpose Presence of aphasia or severe neurological deficits is considered an indication for pre-procedural intubation (PPI) for endovascular treatment (ET) of acute ischaemic stroke (AIS) patients although a critical analysis has not been performed. To compare outcomes in AIS patients undergoing ET with or without PPI in two groups of patients: those with presence of aphasia; and those with admission NIHSS score of ≥20. Methods All endovascular treated AIS patients were identified through a database maintained from two comprehensive stroke centres over an 8 year period. The rate of intra-procedural intubation in patients without PPI was ascertained. The rates of poor functional outcome at discharge (modified Rankin score [mRS] of ≥3) and intracerebral haemorrhage (ICH) were compared between those who did or did not undergo PPI in the two study groups. Results In the first analysis, 60 (50%) of 120 patients with aphasia underwent procedure without PPI; 6 of 60 patients required intra-procedural intubation. The odds of any ICH [OR 6.3, 95% CI 1.6–24.0] and in-hospital mortality [OR 9.3, 95% CI 2.7–31.0] were significantly higher among those who underwent PPI after adjusting for potential confounders. In the second analysis, 36 (39%) of 93 patients with NIHSS score ≥20 underwent ET without PPI; 6 of 57 patients required intra-procedural intubation. The risk of any ICH (OR 7.6, 95% CI 0.9–67.8) and in-hospital mortality [OR 5.0, 95% CI 0.9–27.5] were higher among patients who underwent PPI, after adjusting for potential confounders. The rates of good outcome at discharge were significantly lower among those patients with aphasia [OR 0.1, 95% CI 0.04–0.2, p= Conclusions Despite the risk of intra-procedural intubation among patients with either aphasia or admission NIHSS score ≥20 who undergo ET without PPI, the rates of poor outcomes, ICH, and death are prominently lower than those with PPI. Disclosures A. Hassan: None. M. Adil: None. W. Tekle: None. A. Qureshi: None.

Background There is currently an intense interest in defining predictive profiles from MRI based diffusion/perfusion information for acute ischemic stroke patients. Perfusion/diffusion ratio (mismatch ratio) and penumbra volumes are factors used to select patients for thrombolysis. The current literature considers a mismatch ratio of 1.2 as the minimum for thrombolysis. There is much debate, however, as to how mismatch ratios and penumbra volumes affect patient outcome. Methods 31 acute ischemic stroke patients were selected at random and had their presenting acute stroke-protocol MRI processed through OLEA Medical9s PerfScape, which calculated the penumbral volume and mismatch ratio, using a Tmax of 4 s. A mismatch ratio of 1.2–4.5 with a penumbra volume >80 cc was labeled as a Favorable Profile (FP). NIHSS scores were collected both at stroke presentation and at time of discharge. An improvement of NIHSS ≥4 at time of discharge was considered a good outcome. Results Eight patients were found to have a FP with a mismatch ratio between 1.2 and 4.5 and a penumbra volume >80 cc. Twenty-three patients did not have an FP. Of the eight patients with an FP, all 8 had an improvement of ≥4 in their NIHSS score. Of the 23 patients who did not have an FP, 7 had an improvement of ≥4 in their NIHSS score, while 16 had no improvement or an improvement of Conclusion This small study demonstrates that our definition of a favorable MRI perfusion profile in ischemic stroke patients (mismatch ratio of 1.2–4.5 and a penumbra volume >80 cc) was associated with a good outcome at discharge, for all patients as well as an endovascularly treated homogeneous subset. Furthermore, the clinical application of this upper limit of 4.5 for the mismatch ratio warrants further investigation. Competing interests None.

Objective: To assess the safety and feasibility of combining IV rt-PA with IV abciximab within a 24 hour period for treatment of worsening lacunar syndromes. Background Lacunar strokes are often preceded by "warning syndromes" and are a major cause of progressive motor deficit. Some controversy exists about the correct management of Fluctuating Lacunar Syndromes (FLS). We present our experience using IV abciximab within 24 hours of IV rt-PA thrombolysis for FLS. Design/Methods: We retrospectively identified all patients who received IV rt-PA followed by IV abciximab within a 24hr period. We excluded all patients who received IA rt-PA, mechanical thromboembolectomy, and a longer time period between rt-PA and abciximab. We identified the NIHSS score at four different times: at presentation, after IV rt-PA, before IV abciximab, and at discharge; we also reviewed imaging reports for any evidence of hemorrhagic conversion. Results: 18 patients received IV rt-PA followed by IV abciximab within 24 hours. All four NIHSS scores were recorded in 12 patients; the remaining 6 patients only had documentation of deterioration after IV rt-PA, without specific score mentioned. The overall mean admission score was 9, and the mean improvement post-TPA was a decrease of 4 (in the 12 patients). For those 12 patients, the mean deterioration post-TPA was an increase of 4, indicating a return to pre-thrombolytic stroke severity. After IV abciximab, the mean score at discharge (for all patients) was 3, for an overall improvement of 6, from admission to discharge. No hemorrhagic conversions were identified, either after IV rt-PA or after IV abciximab. Conclusions: No therapeutic options currently exist for lacunar stroke patients who deteriorate after thrombolysis with IV rt-PA. Our results suggest that abciximab may be beneficial and safe for this population. Larger randomized trials will need to be conducted to prove safety and efficacy. Disclosure: Dr. Nair has nothing to disclose. Dr. McNeil has nothing to disclose. Dr. Wang has nothing to disclose. Dr. Jahnel has received personal compensation for activities with Genetech as a Consultant. Dr. Stapel has nothing to disclose. Dr. Stapel has nothing to disclose. Dr. Stapel has nothing to disclose. Dr. Stapel has nothing to disclose. Dr. Hodges has nothing to disclose. Dr. Beck has nothing to disclose. Dr. Alanis has nothing to disclose. Dr. Talkad has received personal compensation for activities with Genentech, Inc. as a speaker. Dr. Wang has received personal compensation for activities with Sanofi-Aventis Pharmaceuticals, Inc. and Boehringer Ingelheim Pharmaceuticals, Inc.

Abstact Stroke unit has been believed as the best institutional care for stroke patients. Recent researches in 1990s indicated that stroke units can produce increasing survival rate and improving the functional state of the patients which can reduce the need for institutional care after stroke. In Indonesia, stroke unit is still new. Because stroke unit has educational role beside its clinical importance, the research about stroke unit especially in its value in managing stroke patients in Indonesia is needed. This study was evaluated the effectiveness of stroke unit care in managing stroke patients especially in improving the functional state of the patients in compared with conventional care of stroke corner in general neurology ward. This study indicated that both stroke unit (SU) and stroke corner in general neurology ward (SC) shows reduction in NIHSS score. In Stoke Unit, the reduction of NIHSS was 17.35 to 5.31 while in Neurology ward from 13.83 to 8.87.Using independent t-test, the reduction of NIHSS in stroke unit is more significance compared with stroke corner in general neurology ward (p=0,000). (Med J Indones 2006; 15:30-3) Keywords: Stroke Unit, General Neurology Ward, NIHSS

Background and Purpose The National Institutes of Health Stroke Scale (NIHSS) score is known to be effective in predicting the likelihood of recovery after stroke. However, the baseline NIHSS score predicts long-term outcomes rather crudely because early changes in stroke scores may influence the stroke outcomes. Therefore, a precise prognostic algorithm or a cutoff point for predicting long-term outcomes based on data from serial NIHSS scores is needed. Methods We serially assessed 437 patients with acute symptomatic ischemic stroke within the middle cerebral artery territory who presented with nonlacunar stroke and were followed-up for at least 6 months after symptom onset. The NIHSS score was serially checked at 0, 1, 3, 7, and 14 days after admission. In all patients, the Barthel index (BI) and the modified Rankin Scale (mRS) score were checked, with a poor outcome defined as any of the following endpoints: death, modified mRS score of >3, or BI of

To the Editor: The excellent article by Grotta and Alexandrov1 not only provides objective evidence in a small number of patients that intravenous tissue plasminogen activator (tPA) improves cerebral perfusion but also provides important data about the National Institutes of Health Stroke Scale (NIHSS) rating system. If the NIHSS score data from their article are plotted against the corresponding single-photon emission computed tomography (SPECT)-graded scale score, a relationship becomes apparent, as shown in the Figure⇓. If one omits the …

Background Edaravone is widely used to treat acute ischemic stroke (AIS) within 24 hours of onset. We aimed to evaluate current edaravone treatment practices and the efficacy and safety of edaravone used with recombinant tissue plasminogen activator (tPA) in AIS patients within 4.5 hours of onset. The results were compared with those of the Safe Implementation of Treatments in Stroke-International Stroke Thrombolysis Registry (SITS-ISTR) study. Methods PROTECT4.5 was a prospective observational study conducted from April 2010 to March 2013 in Japan. The primary end points were favorable outcomes (modified Rankin Scale score [mRS] 0-1) at 3 months after onset and incidence of symptomatic intracranial hemorrhage (sICH) within 36 hours of treatment. For comparison with SITS-ISTR, patients were categorized based on the time from onset to treatment (within 3 hours of and 3-4.5 hours after onset) and baseline National Institutes of Health Stroke Scale score (NIHSS). Results Among the 11,384 registered patients, 11,126 and 8274 patients were included in the safety and efficacy analysis populations, respectively. The proportions of patients with mRS 0-1 receiving edaravone alone and edaravone + tPA were 51.3% (95% confidence interval, 49.7%-52.8%) and 39.0% (37.6%-40.5%), respectively. The incidence of sICH within 36 hours after tPA treatment (edaravone + tPA group) was 1.6% (1.3%-2.0%). When compared with the SITS-ISTR results, those treated with edaravone + tPA appeared to show better outcomes in patients with NIHSS score ≥16. Conclusions The efficacy and safety of edaravone combined with tPA and administered within 4.5 hours of AIS onset were demonstrated with numerically lower incidence of sICH and better outcomes.