Large vessel occlusion stroke presenting with coma: Not uncommon and poor prognostic sign
Michael Young1, Amine Mohamed Marc Awad2, Alexander Andreev3, Anna Bonkhoff4, Markus Schirmer2, James Rabinov2, Christopher Stapleton5, Aneesh Singhal5, Natalia Rost5, Aman Patel2, Robert Regenhardt5
1Massachusetts General Hospital, Brigham, Harvard, 2MGH, 3BIDMC, 4Massachusetts General Hospital, Harvard Medical School, 5Massachusetts General Hospital
Objective:
To characterize the incidence and features of coma as a presentation of large vessel occlusion (LVO) stroke. 
Background:

Coma is an unresponsive state characterized by impaired arousal and awareness. The epidemiology and pathophysiology of coma in stroke has been underexplored.

 

Design/Methods:

Individuals who presented with LVO were identified from 07/2018 to 12/2020. Coma was defined as an unresponsive state of impaired arousal and awareness, operationalized as a score of 3 on NIHSS item 1a.

Results:

28/638 (4.4%) patients with LVO stroke were identified as presenting with coma. Median age was 65 (IQR 48-78); 57% were female. Median NIHSS was 32 (IQR 29-34). Occlusion locations included basilar (10), vertebral (2), P1 posterior cerebral (2), internal carotid (4), M1 (6), and M2 middle cerebral arteries (4). In all 14 patients with anterior LVO, the acute LVO was unilateral. Of these 14, 6 had evidence of acute or chronic stroke involving the contralateral hemisphere; 1 experienced seizure; 1 experienced cardiac arrest; and 1 had chronic occlusion of the contralateral ICA. Overall, 20/28 died during admission. Of those who died, 9 presented with anterior LVO and 11 with posterior LVO. Eight patients were treated with EVT. For those untreated, reasons included established infarct with ASPECTS <6 (11), delayed presentation (2), pre-stroke disability (3), and absence of intracranial proximal occlusion on repeat imaging (2).  

 

Conclusions:
It is not uncommon for patients with LVO stroke to present with coma, and 65% of patients not treated with EVT had delayed presentations or large established infarcts, 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. Further study of these patients may shed light on the pathophysiology of coma. Efforts to improve early diagnosis and care are crucial given poor outcomes. 
10.1212/WNL.0000000000204288