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Original Investigation |

Prognosis of Untreated Strokes Due to Anterior Circulation Proximal Intracranial Arterial Occlusions Detected by Use of Computed Tomography Angiography

Fabricio O. Lima, MD, MPH1; Karen L. Furie, MD, MPH2; Gisele S. Silva, MD, PhD3; Michael H. Lev, MD4; Érica C. S. Camargo, MD, PhD5; Aneesh B. Singhal, MD6; Gordon J. Harris, PhD4; Elkan F. Halpern, PhD4; Walter J. Koroshetz, MD7; Wade S. Smith, MD8; Raul G. Nogueira, MD9
[+] Author Affiliations
1Neurovascular Service, Department of Neurology, Campinas State University, Campinas, São Paulo, Brazil
2Department of Neurology, Brown University, Providence, Rhode Island
3Neurovascular Service, Department of Neurology, Federal University of São Paulo, São Paulo, Brazil
4Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
5Department of Neurology, Boston Medical Center, Boston University, Boston, Massachusetts
6Stroke Service, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
7National Institutes of Neurological Disorders and Stroke, Bethesda, Maryland
8Neurovascular Service, Department of Neurology, University of California, San Francisco
9Neuroendovascular and Neurocritical Care Services, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia
JAMA Neurol. 2014;71(2):151-157. doi:10.1001/jamaneurol.2013.5007.
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Importance  Limited data exist regarding the natural history of proximal intracranial arterial occlusions.

Objective  To investigate the outcomes of patients who had an acute ischemic stroke attributed to an anterior circulation proximal intracranial arterial occlusion.

Design, Setting, and Participants  A prospective cohort study at 2 university-based hospitals from 2003 to 2005 in which nonenhanced computed tomography scans and computed tomography angiograms were obtained at admission of all adult patients suspected of having an ischemic stroke in the first 24 hours of symptom onset.

Exposure  Anterior circulation proximal intracranial arterial occlusion.

Main Outcomes and Measures  Frequency of good outcome (defined as a modified Rankin Scale score of ≤2) and mortality at 6 months.

Results  A total of 126 patients with a unilateral complete occlusion of the intracranial internal carotid artery (ICA; 26 patients: median National Institutes of Health Stroke Scale [NIHSS] score, 11 [interquartile range, 5-17]), of the M1 segment of the middle cerebral artery (MCA; 52 patients: median NIHSS score, 13 [interquartile range, 6-16]), or of the M2 segment of the MCA (48 patients: median NIHSS score, 7 [interquartile range, 4-15]) were included. Of these 3 groups of patients, 10 (38.5%), 20 (38.5%), and 26 (54.2%) with ICA, MCA-M1, and MCA-M2 occlusions, respectively, achieved a modified Rankin Scale score of 2 or less, and 6 (23.1%), 12 (23.1%), and 10 (20.8%) were dead at 6 months. Worse outcomes were seen in patients with a baseline NIHSS score of 10 or higher, with a modified Rankin Scale score of 2 or less achieved in only 7.1% (1 of 14), 23.5% (8 of 34), and 22.7% (5 of 22) of patients and mortality rates of 35.7% (5 of 14), 32.4% (11 of 34), and 40.9% (9 of 22) among patients with ICA, MCA-M1, and MCA-M2 occlusions, respectively. Age (odds ratio, 0.94 [95% CI, 0.91-0.98]), NIHSS score (odds ratio, 0.73 [95% CI, 0.64-0.83]), and strength of leptomeningeal collaterals (odds ratio, 2.37 [95% CI, 1.08-5.20]) were independently associated with outcome, whereas the level of proximal intracranial arterial occlusion (ICA vs MCA-M1 vs MCA-M2) was not.

Conclusions and Relevance  The natural history of proximal intracranial arterial occlusion is variable, with poor outcomes overall. Stroke severity and collateral flow appear to be more important than the level of proximal intracranial arterial occlusion in determining outcomes. Our results provide useful data for proper patient selection and sample size calculations in the design of new clinical trials aimed at recanalization therapies.

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