Characterizing coma in large vessel occlusion stroke.

Coma Consciousness LVO Neuroethics Stroke Thrombectomy

Journal

Journal of neurology
ISSN: 1432-1459
Titre abrégé: J Neurol
Pays: Germany
ID NLM: 0423161

Informations de publication

Date de publication:
16 Feb 2024
Historique:
received: 30 11 2023
accepted: 14 01 2024
revised: 07 01 2024
medline: 17 2 2024
pubmed: 17 2 2024
entrez: 17 2 2024
Statut: aheadofprint

Résumé

Coma is an unresponsive state of disordered consciousness characterized by impaired arousal and awareness. The epidemiology and pathophysiology of coma in ischemic stroke has been underexplored. We sought to characterize the incidence and clinical features of coma as a presentation of large vessel occlusion (LVO) stroke. Individuals who presented with LVO were retrospectively identified from July 2018 to December 2020. Coma was defined as an unresponsive state of impaired arousal and awareness, operationalized as a score of 3 on NIHSS item 1a. 28/637 (4.4%) patients with LVO stroke were identified as presenting with coma. The median NIHSS was 32 (IQR 29-34) for those with coma versus 11 (5-18) for those without (p < 0.0001). In coma, occlusion locations included basilar (13), vertebral (2), internal carotid (5), and middle cerebral (9) arteries. 8/28 were treated with endovascular thrombectomy (EVT), and 20/28 died during the admission. 65% of patients not treated with EVT had delayed presentations or large established infarcts. In models accounting for pre-stroke mRS, basilar occlusion location, intravenous thrombolysis, and EVT, coma independently increased the odds of transitioning to comfort care during admission (aOR 6.75; 95% CI 2.87,15.84; p < 0.001) and decreased the odds of 90-day mRS 0-2 (aOR 0.12; 95% CI 0.03,0.55; p = 0.007). It is not uncommon for patients with LVO to present with coma, and delayed recognition of LVO can lead to poor outcomes, emphasizing the need for maintaining a high index of suspicion. While more commonly thought to result from posterior LVO, coma in our cohort was similarly likely to result from anterior LVO. Efforts to improve early diagnosis and care of patients with LVO presenting with coma are crucial.

Sections du résumé

BACKGROUND BACKGROUND
Coma is an unresponsive state of disordered consciousness characterized by impaired arousal and awareness. The epidemiology and pathophysiology of coma in ischemic stroke has been underexplored. We sought to characterize the incidence and clinical features of coma as a presentation of large vessel occlusion (LVO) stroke.
METHODS METHODS
Individuals who presented with LVO were retrospectively identified from July 2018 to December 2020. Coma was defined as an unresponsive state of impaired arousal and awareness, operationalized as a score of 3 on NIHSS item 1a.
RESULTS RESULTS
28/637 (4.4%) patients with LVO stroke were identified as presenting with coma. The median NIHSS was 32 (IQR 29-34) for those with coma versus 11 (5-18) for those without (p < 0.0001). In coma, occlusion locations included basilar (13), vertebral (2), internal carotid (5), and middle cerebral (9) arteries. 8/28 were treated with endovascular thrombectomy (EVT), and 20/28 died during the admission. 65% of patients not treated with EVT had delayed presentations or large established infarcts. In models accounting for pre-stroke mRS, basilar occlusion location, intravenous thrombolysis, and EVT, coma independently increased the odds of transitioning to comfort care during admission (aOR 6.75; 95% CI 2.87,15.84; p < 0.001) and decreased the odds of 90-day mRS 0-2 (aOR 0.12; 95% CI 0.03,0.55; p = 0.007).
CONCLUSIONS CONCLUSIONS
It is not uncommon for patients with LVO to present with coma, and delayed recognition of LVO can lead to poor outcomes, emphasizing the need for maintaining a high index of suspicion. While more commonly thought to result from posterior LVO, coma in our cohort was similarly likely to result from anterior LVO. Efforts to improve early diagnosis and care of patients with LVO presenting with coma are crucial.

Identifiants

DOI: 10.1007/s00415-024-12199-2 PMID: 38366071
pubmed: 38366071
doi: 10.1007/s00415-024-12199-2
pii: 10.1007/s00415-024-12199-2
doi:

Types de publication

Journal Article

Langues

eng

Sous-ensembles de citation

IM

Subventions

Organisme : NIH BRAIN Initiative
ID : F32MH123001
Organisme : NIH Director's Office
ID : DP2HD101400
Organisme : American Academy of Neurology
ID : Palatucci Advocacy Award

Informations de copyright

© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.

Références

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Auteurs

Michael J Young (MJ)

Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA. michael.young@mgh.harvard.edu.
ORCID: 0000-0001-6661-0811

Amine Awad (A)

Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA.

Alexander Andreev (A)

Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA.

Anna K Bonkhoff (AK)

Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA.

Markus D Schirmer (MD)

Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA.

Adam A Dmytriw (AA)

Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, USA.
Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, USA.

Justin E Vranic (JE)

Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, USA.
Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, USA.

James D Rabinov (JD)

Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, USA.
Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, USA.

Omer Doron (O)

Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, USA.

Christopher J Stapleton (CJ)

Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, USA.

Alvin S Das (AS)

Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA.
Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA.

Brian L Edlow (BL)

Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA.

Aneesh B Singhal (AB)

Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA.

Natalia S Rost (NS)

Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA.

Aman B Patel (AB)

Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, USA.

Robert W Regenhardt (RW)

Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA.
Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, USA.

Classifications MeSH