Abstract
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
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
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
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.
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Funding
This study was funded by NIH BRAIN Initiative (F32MH123001), NIH Director’s Office (DP2HD101400) and American Academy of Neurology, Palatucci Advocacy Award.
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This study was compliant with the Health Insurance Portability and Accountability Act (HIPAA) and was reviewed and approved by the local institutional review board (IRB), Protocol Number: 2014P002789. The data that support the findings of this study will be made available from the corresponding author upon reasonable request and pending approval of local institutional review board.
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Young, M.J., Awad, A., Andreev, A. et al. Characterizing coma in large vessel occlusion stroke. J Neurol 271, 2658–2661 (2024). https://doi.org/10.1007/s00415-024-12199-2
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DOI: https://doi.org/10.1007/s00415-024-12199-2