Heads Up! A Novel Provocative Maneuver to Guide Acute Ischemic Stroke Management

Survivors don't want their stroke 'managed'! THEY WANT RECOVERY!  When the hell will you GET THERE? That requires EXACT protocols that deliver recovery!

Wasn't this proven over a decade ago?

• head of bed (4 posts to May 2012)

Heads Up! A Novel Provocative Maneuver to Guide Acute Ischemic Stroke Management

Latisha K. Ali,^a,* Julius K. Weng,^a,b Sidney Starkman,^a,b Jeffrey L. Saver,^a Doojin Kim,^a Bruce Ovbiagele,^f Brian H. Buck,^g Nerses Sanossian,^e Paul Vespa,^a,c Oh Young Bang,^h Reza Jahan,^a,d Gary R. Duckwiler,^a,d Fernando Viñuela,ⁱ and David S. Liebeskind^a

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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.

Key Words: Cerebral blood flow, Collaterals, Endovascular stroke therapy, Ischemic stroke

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Introduction

Spontaneous improvements or deterioration related to dynamic changes in cerebral perfusion can occur as part of the natural history of acute ischemic stroke. These may be associated with spontaneous thrombolysis, microembolism, reocclusion, thrombus propagation and fluctuations in the degree of collateral flow [1,2,3,4]. A common dilemma in acute ischemic stroke management is whether to pursue recanalization therapy in patients with large vessel occlusions but rapidly improving and/or mild neurologic symptoms (RIMS) [5]. The current guidelines for administering intravenous tissue plasminogen activator distinguish RIMS as a relative exclusion criterion to treatment [6]. However, data suggest that 25–29% of patients eligible for acute recanalization therapy who are excluded as a result of RIMS may be at risk for clinical deterioration with poor neurologic and functional outcomes [7,8,9].

Persisting large vessel occlusion identifies a subset of RIMS patients who are at high risk for subsequent neurologic deterioration [5,10]. These patients are exquisitely dependent on adequate collateral flow and hemodynamic stability to avert neurologic worsening. In some of these patients, collateral flow is sufficient during the first 3–8 h after onset which averts severe neurologic deficits. However, when collateral failure occurs subsequently, stroke progresses at a time period when advanced tissue injury in the infarct core precludes rescue recanalization therapy. Clinicians are in need of a test to distinguish those collateral-dependent patients who will sustain collateral flow indefinitely and do not require recanalization therapy from those who will experience delayed collateral failure and warrant immediate recanalization interventions while the treatment window is still open.

Diverse clinical and physiologic literature suggests that changes in upright versus supine head and body posture can modify the efficiency of collateral flow in patients with borderline collateral robustness [11,12,13,14]. The term ‘Heads Down’ has been associated with the practice of purposely lowering the head of the bed to increase cerebral blood flow in the ischemic hemisphere [11]. We tested the converse, a ‘Heads Up’ provocative maneuver with a 90-degree head of bed elevation for 30 min, to stress collaterals and guide early recanalization procedure decision-making in patients with large vessel occlusion or critical stenosis and rapidly improving or mild symptoms while in a supine position.

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