Abstract Details

Title Cerebral Autoregulation-guided Parameters for Predicting Midline Shift After Large-vessel Occlusion Ischemic Stroke

Topic Neuro Trauma, Critical Care, and Sports Neurology

Presentation(s) S61 - Neurocritical Care: Cerebrovascular Disease (1:12 PM-1:24 PM)

Poster/Presentation
Number 002

Objective To use autoregulation neuromonitoring to predict midline shift after ischemic stroke.

Background Identification of patients likely to develop midline shift (MLS) after large-vessel occlusion (LVO) stroke is essential for appropriate triage and patient disposition. Studies have identified clinical and radiographic predictors of MLS, but with limited predictive accuracy. Using an innovative assessment of cerebral autoregulation, we sought to develop a translatable and accurate predictive model for MLS.

Design/Methods We prospectively enrolled 73 patients with LVO stroke. Beat-by-beat cerebral blood flow (transcranial Doppler) and arterial pressure (arterial catheter or finger photoplethysmography) were recorded within 24 hours of the stroke, and a 24-hour brain MRI was obtained to determine infarct volume and MLS. Autoregulatory function was quantified from pressure-flow relation via projection pursuit regression (PPR), allowing for characterization of 5 hemodynamic markers: falling slope, rising slope, autoregulatory range, as well as lower and upper limits of autoregulation. We assessed the predictive relation of autoregulatory capacity and radiological and clinical variables to MLS using recursive classification tree models.

Results

PPR successfully quantified autoregulatory function in 50/73 (68.5%) patients within 24 hours of LVO ischemic stroke (age 63.9±13.6, 66% female, NIHSS 15.8±6.7). Of these 50 patients, most (78%) underwent endovascular therapy. Thirteen (26%) experienced 24-hour MLS; in these patients, infarct volumes were larger (140.2 vs. 48.6 mL, P<0.001), and ipsilateral (but not contralateral) falling slopes were steeper (1.1 vs. 0.7 cm·s^-1·mmHg^-1, P=0.001). Among all clinical, demographic, and hemodynamic variables, only two (infarct volume and ipsilateral falling slope) significantly contributed to the prediction of MLS (with a sensitivity of 95%, specificity of 95%, and an accuracy of 94%).

Conclusions We were able to predict MLS with high accuracy, sensitivity, and specificity. This predictive model of MLS wields translatable potential for triaging level of care in patients suffering from LVO ischemic stroke.

Authors/Disclosures
PRESENTER	No disclosure on file
Anson Wang, MD (Massachusetts General Hospital)	Dr. Wang has nothing to disclose.
Sreeja Kodali	Ms. Kodali has nothing to disclose.
Sumita M. Strander	Ms. Strander has nothing to disclose.
Alexandra Kimmel	No disclosure on file
Cindy Khanh P. Nguyen (Yale University)	Miss Nguyen has nothing to disclose.
Krithika Umesh Peshwe, MD (West Virginia University School of Medicine)	Dr. Peshwe has nothing to disclose.
Charles Matouk	Charles Matouk has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Silk Road Medical. Charles Matouk has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Microvention. Charles Matouk has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Navigantis.
Kevin N. Sheth, MD, FAAN (Yale UniversityDivision of Neuro and Critical Care)	Dr. Sheth has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Ceribell. Dr. Sheth has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Zoll. Dr. Sheth has received personal compensation in the range of $10,000-$49,999 for serving on a Scientific Advisory or Data Safety Monitoring board for NControl. Dr. Sheth has received stock or an ownership interest from Astrocyte. Dr. Sheth has received stock or an ownership interest from Alva. The institution of Dr. Sheth has received research support from Biogen. The institution of Dr. Sheth has received research support from Novartis. The institution of Dr. Sheth has received research support from Bard. The institution of Dr. Sheth has received research support from Hyperfine. Dr. Sheth has received intellectual property interests from a discovery or technology relating to health care.
Randolph S. Marshall, MD, FAAN (Columbia University)	The institution of Dr. Marshall has received research support from NIH. Dr. Marshall has received publishing royalties from a publication relating to health care.
	No disclosure on file
Nils Petersen, MD (Yale University)	The institution of Dr. Petersen has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Silkroad Medical. Dr. Petersen has received research support from NIH.

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