Latisha K Ali1, Julius K Weng1,2, Sidney Starkman1,2, Jeffrey L Saver1, Doojin Kim1, Bruce Ovbiagele3, Brian H Buck4, Nerses Sanossian5, Paul Vespa1,6, Oh Young Bang7, Reza Jahan1,8, Gary R Duckwiler1,8, Fernando Viñuela9, David S Liebeskind1. 1. Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, Calif., USA. 2. Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, Calif., USA. 3. Department of Neurology, Medical University of South Carolina, Charleston, S.C., USA. 4. Department of Neurology, University of Alberta, Edmonton, Alta., Canada, Rio de Janeiro, Brazil. 5. Department of Neurology, University of Southern California, Keck School of Medicine, Los Angeles, Calif, USA. 6. Department of Neurosurgery, UCLA Stroke Center, David Geffen School of Medicine at UCLA, Los Angeles, Calif., USA. 7. Department of Samsung Medical Center, Sungkyunkwan University, Seoul, South Korea, Rio de Janeiro, Brazil. 8. Department of Interventional Neuroradiology, UCLA Stroke Center, David Geffen School of Medicine at UCLA, Los Angeles, Calif., USA. 9. Department of Américas Medical City, Rio de Janeiro, Brazil.
Abstract
BACKGROUND: A common dilemma in acute ischemic stroke management is whether to pursue recanalization therapy in patients with large vessel occlusions but minimal neurologic deficits. We describe and report preliminary experience with a provocative maneuver, i.e. 90-degree elevation of the head of bed for 30 min, which stresses collaterals and facilitates decision-making. METHODS: A prospective cohort study of <7.5 h of acute anterior circulation territory ischemia patients with minimal deficits despite middle cerebral artery (MCA) or internal carotid artery (ICA) occlusive disease. RESULTS: Five patients met the study entry criteria. Their mean age was 78.4 years (range 65-93). All presented with substantial deficits (median NIHSS score 11, range 5-22), but improved while in supine position during initial imaging to normal or near-normal (NIHSS score 0-2). MRA showed persistent M1 MCA occlusions in 4, critical ICA stenosis or occlusion in 1, and substantial perfusion-diffusion mismatch in all. To evaluate the potential for eventual collateral failure, patients were placed in a head of bed upright posture. Mean arterial pressure and heart rate were unchanged. Two showed no neurologic worsening and were treated with supportive care with excellent final outcome. Three showed worsening, including recurrent hemiparesis and aphasia at the 6th, recurrent aphasia at the 23rd, and recurrent hemineglect at the 15th upright minute. These 3 underwent endovascular recanalization therapies with successful reperfusion and excellent final outcome. CONCLUSION: The 'Heads Up' test may be a useful, simple maneuver to assess the risk of collateral failure and guide the decision to pursue recanalization therapy in acute cerebral ischemia patients with minimal deficits despite persisting large cerebral artery occlusion.
BACKGROUND: A common dilemma in acute ischemic stroke management is whether to pursue recanalization therapy in patients with large vessel occlusions but minimal neurologic deficits. We describe and report preliminary experience with a provocative maneuver, i.e. 90-degree elevation of the head of bed for 30 min, which stresses collaterals and facilitates decision-making. METHODS: A prospective cohort study of <7.5 h of acute anterior circulation territory ischemiapatients with minimal deficits despite middle cerebral artery (MCA) or internal carotid artery (ICA) occlusive disease. RESULTS: Five patients met the study entry criteria. Their mean age was 78.4 years (range 65-93). All presented with substantial deficits (median NIHSS score 11, range 5-22), but improved while in supine position during initial imaging to normal or near-normal (NIHSS score 0-2). MRA showed persistent M1 MCA occlusions in 4, critical ICA stenosis or occlusion in 1, and substantial perfusion-diffusion mismatch in all. To evaluate the potential for eventual collateral failure, patients were placed in a head of bed upright posture. Mean arterial pressure and heart rate were unchanged. Two showed no neurologic worsening and were treated with supportive care with excellent final outcome. Three showed worsening, including recurrent hemiparesis and aphasia at the 6th, recurrent aphasia at the 23rd, and recurrent hemineglect at the 15th upright minute. These 3 underwent endovascular recanalization therapies with successful reperfusion and excellent final outcome. CONCLUSION: The 'Heads Up' test may be a useful, simple maneuver to assess the risk of collateral failure and guide the decision to pursue recanalization therapy in acute cerebral ischemiapatients with minimal deficits despite persisting large cerebral artery occlusion.
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