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

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 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. Disclosure: Dr. Silverman has nothing to disclose. Dr. Wang has nothing to disclose. Dr. Kodali has nothing to disclose. Dr. Strander has nothing to disclose. Dr. Kimmel has nothing to disclose. Dr. Nguyen has nothing to disclose. Dr. Peshwe has nothing to disclose. Dr. Matouk has nothing to disclose. Dr. Sheth has received royalty, license fees, or contractual rights payments from Alva Health. Dr. Sheth holds stock and/or stock options in Alva Health which sponsored research in which Dr. Sheth was involved as an investigator. Dr. Sheth has received research support from Hyperfine, Novartis, Biogen, Bard, Zoll. Dr. Marshall has nothing to disclose. Dr. Tan has nothing to disclose. Dr. Petersen has nothing to disclose.