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Abstract Details

Novel Ischemic Stroke Treatment Protocol for Salvageable Penumbra in Acute Small Vessel Disease
Cerebrovascular Disease and Interventional Neurology
S6 - Cerebrovascular Disease: Diagnosis, Prediction, and Population Health (5:18 PM-5:30 PM)
In SVD-related AIS, no specific acute treatment exists. 

We propose an acute treatment protocol for patients with fluctuating exam secondary to salvageable micropenumbra in high risk small vessel disease (SVD)-related acute ischemic stroke (AIS).

Inclusion criteria included acute SVD-related stroke with NIHSS fluctuation ≥ 2 previously described as a sensitive indicator of neurological deterioration in SVD ischemic stroke. Patients with large vessel atheroma secondarily causing stroke were excluded. Treatment protocol consisted of albumin IV, eptifibatide IV, magnesium sulfate IV, cilostazol PO, normoglycemia, normothermia, aggressive fluid resuscitation, and targeted blood pressure parameters in neurocritical care setting. Protocol was prospectively initiated August 2020 at onset of exam fluctuation and continued until plateau NIHSS was reached. Retrospective data for subjects from June 2016 to July 2020 was collected for historical controls. Primary outcomes measures included safety and early efficacy end points. Efficacy was measured by change from maximum NIHSS to plateau NIHSS (NIHSSdiff). Wilcoxon rank-sum test was used to evaluate significance difference of NIHSSdiff in both groups. Social Science Statistics was used for data analysis.

From January 2017 - May 2021, out of 7,146 AIS patients, 30 met selection criteria. From August 2020 to May 2021, consecutive subjects received treatment protocol (n=15, baseline NIHSS 4.93, 95% CI [3.3572, 6.5028]). They were compared with historical controls (n=15, baseline NIHSS 5.87, 95% CI [2.9407, 8.7993]). There was no significant difference in baseline characteristics (p=1; U=112 at p<0.05; z-score 0). In the SVD group, no subjects had adverse events leading to early termination. Early efficacy as suggested by NIHSSdiff between groups was statistically significant (p=0.00228; U=38.5; z-score 3.04864; 80% power at p<0.05). 

To our knowledge, this is the first systematic demonstration of safety and early efficacy of multimodal intervention for acute SVD-related ischemic stroke. Larger randomized trials using concurrent controls are required to corroborate our findings.

Farah Fourcand (Cleveland Clinic Indian River)
Dr. Fourcand has nothing to disclose.
Hemal Patel (Northshore University Hospital, Northwell Health) Dr. Patel has nothing to disclose.
Sean Scarpiello (Hackensack Meridian Health- JFK Medical Center) Dr. Scarpiello has nothing to disclose.
Muhammad Nagy (JFK Neuroscience institute (Neurology Department)) Dr. Nagy has nothing to disclose.
Siddhart Mehta Dr. Mehta has nothing to disclose.
Haralabos Zacharatos Dr. Zacharatos has nothing to disclose.
Jawad Kirmani (RWJBarnabas Medical) Dr. Kirmani has nothing to disclose.