Academic Comprehensive Stroke Center Research Articles

High prevalence of intracranial arterial stenosis among acute ischemic stroke patients in a Brazilian center: a transcranial color-coded duplex sonography study.

There is limited data available regarding the prevalence of intracranial arterial stenosis (ICAS) among acute ischemic stroke (AIS) patients in Brazil and Latin America. The present study sought to investigate the frequency and predictors of ICAS among patients with AIS or transient ischemic attack (TIA) in a Brazilian center, with transcranial color-coded duplex sonography (TCCS) technique. Consecutive AIS and TIA patients, admitted to an academic public comprehensive stroke center in Brazil from February to December 2014, evaluated by TCCS were prospectively selected. Vascular narrowings > 50% were considered as ICAS, based on ultrasound criteria previously defined in the literature. We assessed 170 consecutive patients with AIS or TIA, of whom 27 (15.9%) were excluded due to an inadequate transtemporal acoustic bone window. We confirmed ICAS in 55 patients (38.5%). The most common location was the proximal segment of the middle cerebral artery (28.2%), followed by the vertebral (15.4%), posterior cerebral (13.6%), terminal internal carotid (9.1%) and basilar (8.2%) arteries. On multivariate models adjusting for potential confounders, systolic blood pressure (OR: 1.03, 95%CI: 1.01-1.04; p = 0.008) was independently associated with ICAS. We found significant ICAS in approximately ⅓ of patients admitted with symptoms of AIS or TIA in a public tertiary academic stroke center in Brazil. The TCCS is an accessible and noninvasive technique that can be used to investigate the presence of moderate and severe ICAS, especially in patients who cannot be exposed to more invasive exams, such as the use of intravenous contrast agents.

Abstract TP117: Improving Thrombolysis Door-to-Needle Time With a Multi-Pronged Approach

Introduction: Reducing door-to-needle (DTN) times lead to improved patient outcomes in acute ischemic stroke. We sought to use innovative methods to continuously reduce the DTN time, with the specific goal of consistently achieving a median DTN time < 30 minutes. Methods: At an academic Comprehensive Stroke Center, we implemented these strategies to reduce the DTN time: 1) Addition of a virtual DTN timer in the Electronic Medical Record (EMR) to display elapsed time since arrival.2) Creation of a multidisciplinary Thrombolysis Focus Group to analyze data and improve processes. Additional monthly quality improvement meetings were held to discuss all thrombolysis cases with times over our median. 3) Reduction of EMR barriers to recognize metric exclusion criteria and document accordingly. 4) Review of each thrombolysis case with direct provider feedback and an opportunity to appropriately document and clarify delays. 5) Addition of Specialized Neurovascular APPs responding to every Code Stroke with Neurology resident physicians.6) Creation of a “Golden Needle” award to recognize providers who achieved the fastest DTN time in the year. Results: The median DTN time steadily decreased over 3 academic years. The median DTN time was 40 minutes in 2020, 39 in 2021, 38 in 2022 and 36 in year-to-date 2023. Additionally, the percentage of thrombolysis cases meeting the institutional goal of < 30 minutes improved from 21.5% in 2020, to 31.9% in 2021, to 59.6% in 2022, to 88.6% in year-to-date 2023 (figure). Conclusion: Novel multifaceted measures surrounding acute stroke thrombolysis can positively impact both the door-to-needle time and percent of cases within the institutional DTN time goal. Figure: Percentage of Thrombolysis Cases with DTN < 30 Minutes

Abstract TP66: Decreased Order to Administration Times Following Transition to Tenecteplase for Acute Ischemic Stroke

Introduction: Alteplase was the first approved tissue plasminogen activator and standard of care for acute ischemic stroke (AIS). The utilization of Tenecteplase as a thrombolytic agent in AIS has offered many organizations several advantages over Alteplase, including ease of preparation and administration. Both thrombolytic agents require a Physician's order and reconstitution by a certified Pharmacist or Registered Nurse prior to administration. Our academic comprehensive stroke center transitioned from Alteplase to Tenecteplase as standard thrombolysis for acute ischemic stroke in November 2022. Treatment times were monitored to explore the benefits of a single bolus administration. Methods: A retrospective chart review was conducted at a single academic comprehensive stroke center. Patients were included if they received thrombolytic therapy in the Emergency Department for a diagnosis of AIS. Patients prior to November 2022 received Alteplase, and those after November 2022 received Tenecteplase. We evaluated the time frame for the medication bolus order for Alteplase and Tenecteplase to the administration time. Results: Of 140 patients screened, 108 were included in the study, with 51 in the alteplase group and 57 in the Tenecteplase group. Mean order to administration times were 10.9 minutes in the alteplase group and 7.37 minutes in the Tenecteplase group, with statistical significance (P=0.0052). There was no significant difference in mean door-to-needle time (59.27 Alteplase vs 53.09 Tenecteplase, P= 0.1803). Conclusions: In a single CSC, the transition from Alteplase to Tenecteplase reduced the order to administration time by 3.53 minutes. The decreased administration time highlights one of Tenecteplase’s potential advantages. Further review is necessary to evaluate additional stroke metrics and clinical outcomes.

Abstract WP110: DEVIATING: Determining Variability in Antiplatelet Timing in Stroke by Gender

Background: Antiplatelet administration within 48 hours of acute stroke presentation is standardized as it reduces mortality and recurrent ischemic stroke rate. Gender disparities have been noted in acute stroke care, including IV tPA and thrombectomy. Limited data exists for gender disparities in antiplatelet administration by day 2 of hospitalization. Methods: In an IRB-approved analysis, we retrospectively assessed patients admitted with acute ischemic strokes from the prospectively collected UC San Diego Stroke Registry from 2013 to 2023. We reviewed baseline demographics, whether an antiplatelet agent was initiated by hospital day 2, and choice of antiplatelet agent. We grouped patients based on their gender identification: male versus female. Patients who transitioned to comfort care, had an embolic source, were treated with a therapeutic dose of anticoagulation, had hemorrhagic conversion of infarct, or had a contraindication to antiplatelet use were excluded. Chi-squared, Kruskal-Wallis and Fisher tests were utilized. Results: 471 patients were included in this analysis (179 female, 292 male). We found no significant differences in medical history except diabetes (60 female, 69 male, p = 0.03). We found a significant difference in age (female 69.3 years, male 64.3 years, p < 0.01). We found a significant difference in patient race (p = 0.01). There was no significant difference in antiplatelet administration by hospital day 2 (171 female, 287 male, p = 0.14) or choice of antiplatelet (aspirin p = 0.29, clopidogrel p = 0.12, ticagrelor p = 0.67, dual antiplatelet p = 0.22). Conclusions: These findings suggest equality of care in antiplatelet administration for acute ischemic stroke between genders, which is reassuring. This data was collected at an academic comprehensive stroke center. Further studies should be completing including patients who were treated at various levels of stroke centers.

Abstract WP60: On vs. Off-Hours Arrival to Groin Time: Identifying Gaps in a Comprehensive Stroke Center

Introduction: Timeliness of treatment for patients with acute ischemic stroke (AIS) directly correlates with outcomes. The most current AHA guidelines standard of care for patients having a large vessel occlusion (LVO) stroke is endovascular mechanical thrombectomy (MT). Earlier treatment is associated with better outcomes at 90 days. Parallel processing is paramount when executing an expedited transition from the emergency department (ED) to the MT suite. At a large academic comprehensive stroke center (CSC), as we receive a high volume of direct ED cases, we examined whether there was a difference in daytime vs. off-hour LVO cases. Methods: The MT database maintained by the CSC was queried for all cases from July 2022- July 2023. Inclusion criteria included all AIS with LVO and receiving MT that were transported by EMS directly to the CSC ED. Data was further stratified by time of day and day of the week. Cases were designated as day if they arrived Monday through Friday between 7am-5pm. Cases were considered night/weekend if they arrived 5pm-7am or anytime Saturday or Sunday. Times between groups were compared with t-test. Results: There were a total of 37 cases in the day group and 43 cases in the night/weekend group. Patients arriving during the day had a median arrival-to-groin time of 89 minutes and a mean of 93 minutes. The night/weekend group had a median of 116 minutes and a mean of 125 minutes, and the difference was statistically significant (p=0.0009). Upon further analysis, mean ED arrival to suite time was significantly longer for night/weekends, 105 vs. 76 minutes, p=0.008, but mean suite to groin puncture time was not significantly different, 18 vs. 16 minutes, p=0.24. Conclusion: There is a statistically significant difference in arrival to suite/groin times between the day and night/weekend groups, therefore putting patients with LVO arriving off hours at higher risk for poor outcomes. Historically some cardiac cath labs have utilized nursing bridge teams to help with parallel processing, and we theorize that using such a team to facilitate preparation of the patient and suite, we can reduce treatment times for off-hour’s ED MT cases and potentially improve outcomes.

Abstract WMP30: Real World Experience With Tenecteplase on a Mobile Stroke Unit

Background: Tenecteplase (TNK) administered on a mobile stroke unit (MSU) has demonstrated superior rates of early reperfusion compared to alteplase. Current guidelines include TNK as a second-tier option for large vessel occlusions as TNK has many benefits, including rapid IV administration and ease of dosing. The objective of this study was to describe real world utilization of TNK on a MSU. Methods: This was a retrospective observational study of patients receiving TNK as compared to alteplase between February 2021 and April 2023 at a large academic comprehensive stroke center. Baseline demographics, GCS, NIHSS, as well as time of initial imaging were collected. Primary endpoint was time from MSU door to thrombolytic administration. Secondary endpoints included: MSU door to imaging interpretation, dispatch to thrombolytic administration, and provider decision time to thrombolytic administration. Safety endpoints included symptomatic ICH within 24 hours. Results: During the studied time period 40 patients received alteplase and 32 patients received TNK on the MSU. The median age was 65.7 years and median NIHSS score was 9. There was no difference in time from MSU door to thrombolytic administration (15 vs 17.5, p=0.30). There was also no difference in time from MSU door to imaging interpretation, dispatch to thrombolytic administration, or provider decision time to thrombolytic administration. No hemorrhagic conversion occurred. Conclusion: This is the largest series to date describing real-world utilization of TNK administration in a MSU. There were no significant differences in time to therapy in any of the time points evaluated. This data is promising for the treatment of ischemic stroke in which time to administration of thrombolytic therapy is paramount and TNK is administered as a rapid IV injection as compared to alteplase infusion.

Abstract 214: Predictors of Mechanical Thrombectomy Success and Failure: A Preliminary Analysis

Introduction Mechanical thrombectomy (MT) is now the standard of care in treatment of large vessel occlusion (LVO) in acute ischemic stroke (AIS). However, a significant minority of patients do not achieve successful recanalization. Previous case series’ have reported failed recanalization at a rate of approximately 12% (1). In the present study, we investigated clinical and procedural characteristics predictive of MT success and failure. Methods We conducted a retrospective analysis of MT patients with LVO presenting to our academic comprehensive stroke center from 2015‐2020. Recanalization failure was defined as TICI 0‐2a and success as TICI 2b‐3. We compared all 49 consecutive failure cases to a random selection of 85 successful MT cases. Demographic, clinical, procedural, and outcome data were compared between the two groups. Results In this cohort, there was no statistically significant difference in sex, pre‐stroke modified Rankin score (mRS), admission National Institutes of Health Stroke Scale (NIHSS), door‐to‐groin time, thrombolytic use, or site of occlusion between the two groups. In the success group, patients were older (76 vs 61, p=0.003), and had a higher average number of atherosclerotic risk factors (p=0.002). There was a higher proportion of embolic stroke of undetermined source (ESUS) in the success group compared with the failure group (8.5% vs 0%, p=0.039). A higher proportion of failure cases were due to large artery atherosclerosis (30.6% vs 19.5%, p=0.12) and cardioembolism (55.1% vs 67.1%, p=0.27), though neither of these differences were statistically significant. Stent‐retrieval alone (SR) was a more common first pass technique in failed than in successful MT (14.3% vs 0%, p=0.001). Conclusion This study investigated clinical and procedural factors associated with successful and failed recanalization in MT. In this cohort, stent‐retrieval alone as a first pass technique was more commonly associated with failed MT. Stroke etiology was associated with rates of failure, with a significantly higher proportion of ESUS in successful cases and a trend toward a higher proportion of large vessel atherosclerosis and cardioembolism in failed MT.

Abstract 053: Reduced‐Dose Ticagrelor Versus Full‐Dose Ticagrelor Versus Clopidogrel In Acute Stroke Management: A Retrospective Cohort Study

Introduction Ticagrelor use has become more prominent in acute ischemic stroke management in the presence of clopidogrel resistance(1‐2). This study compares the effectiveness of aspirin plus ticagrelor at different doses versus clopidogrel in reducing the risk of recurrent stroke and other thrombotic events without increasing the risk of bleeding. Methods We performed a retrospective chart review of patients diagnosed with acute ischemic stroke at a large academic comprehensive stroke center from September 1, 2020, to July 1, 2022. A total of 3 separate groups, low‐dose ticagrelor (45 mg or 60 mg twice a day), full‐dose ticagrelor (90 mg twice a day) and clopidogrel (75 mg daily) were created. We compared baseline characteristics and completed a one‐way ANOVA to analyze for outcome measures such as in‐hospital mortality, 90‐day mortality, favorable functional outcome defined as modified Rankin Score (mRS) of 0‐2, at 90 days, symptomatic intracranial hemorrhage (sICH) and asymptomatic hemorrhage (aICH) between groups. All data was analyzed via IBM SPSS v28.0. Results A total of 445 patients were included in our study. The mean age was 66.1 ± 12.8 years and the majority of patients were female (52.9%). The most common ethnicity was African American (82.9%). Sixty patients were discharged on low‐dose ticagrelor, 39 on full dose ticagrelor and 351 on clopidogrel. A total of 162/433 (36.0%) had a presumed stroke etiology of intracranial atherosclerotic disease (ICAD). Only 24 patients received intravenous thrombolytics (5.3%) and 47 had stent placement (10.4%). Out of 445 patients, 288 were on aspirin 81 mg at time of discharge. Of that group, 228 were on both aspirin and clopidogrel, 60 were on aspirin and low‐dose ticagrelor and 39 were on aspirin and full‐dose ticagrelor. There was no statistical significance for new or recurrent ischemic stroke between groups (low‐dose vs full‐dose vs clopidogrel) determined by one‐way ANOVA (10.0% vs. 17.9% vs. 7.8%, F(2,103) = 0.01, p=0.99). Symptomatic ICH was also similar between the groups (3.3% vs. 2.6% vs. 1.1%, F(2,101) = 0.68, p=0.51). There was no significance for favorable functional outcomes and mortality as well (26.7% vs. 23.1% vs. 24.2%, F(2,173) = 0.62, p=0.54; 80.0% vs. 79.5% vs. 81.5%, F(2,150) = 1.5, p=0.22). Conclusion These findings suggest that a lower dose of ticagrelor may be a safe and effective alternative to full dose ticagrelor or clopidogrel for the prevention of recurrent ischemic stroke without increasing hemorrhagic complications. Larger randomized trials are necessary to further evaluate these findings.

Underlying intracranial atherosclerotic disease is associated with worse outcomes in acute large vessel occlusion undergoing endovascular thrombectomy

BackgroundData on large vessel occlusion (LVO) management due to intracranial atherosclerotic disease (ICAD) are scarce. ObjectiveTo compare clinical outcomes between patients with ICAD and those without ICAD following mechanical thrombectomy (MT). MethodsWe performed a retrospective analysis of consecutive patients who underwent MT for LVO in a large academic comprehensive stroke center, and compared in-hospital mortality, 90-day mortality, favorable functional outcome at 90 days, and symptomatic intracranial hemorrhage (ICH) using chi-squared tests and multivariate logistic regression analyses. We defined ICAD as observable plaque at occlusion site post-thrombectomy. ResultsAmong 215 patients (mean age 67.1 ± 16.0 years; 60.5% female; 83.6% Black, median NIHSS score 16), ICAD was present in 38 patients (17.7%). Diabetes and dyslipidemia were more common in those with ICAD (57.9% vs. 38.4%, p = 0.027 and 29.0% vs. 14.7%, p = 0.035, respectively). Substantial reperfusion (TICI ≥2b) was achieved less often (84.2% vs. 94.4%, p = 0.031) but symptomatic ICH was also less common in ICAD patients (0% vs. 9.0%, p = 0.081). In-hospital and 90-day mortality were more common (36.8% vs. 15.8%, p = 0.003 and 52.6% vs. 26.6%, p = 0.002, respectively) and favorable functional outcome (mRS 0-2) at 90 days was less common (7.9% vs. 33.9%, p = 0.001) in ICAD patients. After adjusting for prognostic variables, ICAD was independently associated with in-hospital mortality (OR=4.1, 95% CI 1.7-9.7), 90-day mortality (OR=3.7, 95% CI 1.6-8.6), and poor functional outcome at 90 days (OR=5.5, 95% CI 1.6-19.4). ConclusionSymptomatic ICAD in a predominantly African American cohort is associated with increased odds of mortality and poor functional outcome at 90 days in patients with LVO undergoing MT.

Outcomes of recurrent stroke in patients with atrial fibrillation according to presumed etiology.

Atrial fibrillation (AF) is a potent risk factor for stroke. The presence of competing etiologies can modify disease outcomes and demand different treatment strategies. The primary purpose of the study was to examine the differences in outcomes for patients with AF admitted with a recurrent stroke, stratified according to the presumed etiology of the stroke. We analyzed AF patients admitted for a recurrent ischemic stroke in an academic comprehensive stroke center. Recurrent strokes were categorized as "Cardioembolic", meaning AF without any competing mechanism, versus "Undetermined" etiology due to competing mechanisms. We used logistic regression to test the association between recurrent stroke etiology and favorable outcome (discharge home), after accounting for important covariates. We included 230 patients, with a mean age 76.9 (SD ± 11.3), 52.2% male, median National Institute of Health Stroke Scale (NIHSS) score of 7 (IQR 2-16). Patients with cardioembolic stroke (65.2%) had higher median NIHSS 8.5 (3-18) versus 3 (1-8) and were more likely to be treated with reperfusion therapies. The favorable outcome was reached by 64 patients (27.8%), and in-hospital mortality was 15.2% overall. After adjustment, there was no difference in outcome between patients with cardioembolic versus undetermined stroke etiology (odds ratio for discharge home: 1.41; 95% CI: 0.65-3.15). In this single-center sample of AF patients with history of stroke, there was no difference in discharge outcomes between those with cardioembolic and those with undetermined stroke etiology. This question warrants examination in larger samples to better understand the importance of the stroke mechanism and secondary prophylaxis.

Real World Experience with Viz.ai Automated Large Vessel Occlusion in CT Angiogram (P8-5.010)

<h3>Objective:</h3> To determine the accuracy of Viz.AI LVO at our large academic comprehensive stroke center. <h3>Background:</h3> Viz.AI LVO is an artificial-intelligence platform which analyzes brain computed tomography angiography (CTA) images in patients with suspected acute ischemic stroke (AIS) and sends an automated alert for suspected large vessel occlusions (LVO). Viz.AI reports high sensitivity and specificity (96.3% and 93.8%); we report our experience with Viz.AI LVO detection. <h3>Design/Methods:</h3> We performed a retrospective review of suspected stroke patients who had CTA ordered as a stroke code from September 2020–May 2021. Data was collected on sex, age, Viz.AI LVO alert, and CTA radiologist review (considered gold standard). True negative was defined as Viz negative, Radiology negative, False positive as Viz positive, Radiology negative, false negative as Viz negative, Radiology positive, and true positive as Viz positive, Radiology positive. LVO was defined as occlusion of the intracranial carotid (ICAT) or MCA (M1 or M2). Data collected included performance of Viz.AI LVO alert, sensitivity, specificity, positive predictive value, and negative predictive value. <h3>Results:</h3> Among 980 consecutive suspected AIS patients with CTA analyzed by Viz.AI, the mean age was 64.2 years (range 19–99) and 531 (54.3%) were female. Viz LVO autodetection alerted for 161 patients (16.4%). Radiologist review reported 85 patients (8.7%) with LVO as follows: 33 (38.8%) M2, 36 (42.4%) M1, and 16 (18.8%) ICAT. The following were adjudicated: 805 true negatives, 90 false positives, 14 false negatives, and 71 true positives. Sensitivity was 83.5%, specificity 89.9%, PPV 44.1%, and NPV 98.3%. All 14 false negatives were M2 occlusions. The median time to alert (TTA) was 11 min (range 6–656). <h3>Conclusions:</h3> In our series of AIS patients evaluated with CTA at an academic CSC, Viz.AI automated LVO detection performed well with a sensitivity of 83.5%, specificity of 89.9%, and a median TTA of 11 minutes. <b>Disclosure:</b> Dr. Mannix has nothing to disclose. Ms. Penhos has nothing to disclose. Shahid Nimjee has nothing to disclose. Mohammad Taimur Shujaat has nothing to disclose. Ms. Hammond-Heaton has nothing to disclose. Dr. Vitellas has nothing to disclose. Dr. Lee has nothing to disclose.

Abstract Number ‐ 206: Evaluation of Disparities in Endovascular Treatment Times for Hispanics versus Non‐Hispanics

Introduction Endovascular therapy (EVT) within 24 hours from last known well (LKW) improves functional outcomes in acute ischemic stroke (AIS) with large vessel occlusion (LVO). Studies are limited in examining ethnic disparities in acute EVT revascularization times. The goal of this study is to evaluate disparities in EVT revascularization time metrics in Hispanic versus Non‐Hispanic ethnicity. Methods We retrospectively examined prospectively collected data from an IRB‐approved stroke registry at a certified, academic Comprehensive Stroke Center (CSC). The sample included AIS patients with acute large vessel occlusion (LVO) within 24 hours of LKW who underwent EVT between 1/1/2013 and 6/30/2022. Patients receiving IV rt‐PA prior to EVT were also included. Patients were excluded if the angiogram was diagnostic only or patient had comfort care measures initiated by Day 2. Categorical variables were analyzed via Chi‐squared, correlations, or frequencies as appropriate. We utilized a student’s t‐test to assess for between group differences following EVT for the CSC time metrics (in minutes): LKW‐to‐hospital arrival, LKW‐to‐groin puncture (GP), hospital arrival‐to‐GP, hospital arrival‐to‐revascularization, and GP‐to‐revascularization. Groups were defined as either Hispanic or Non‐Hispanic based on registry data capture. Analysis was adjusted for baseline NIHSS, baseline blood glucose, and age. A p‐value less than 0.05 was significant. Results A total of 411 patients at the CSC had an acute LVO and underwent emergent EVT. Thrombolysis was initiated prior to EVT in 67.5% of patients (n = 262). A total of 90 patients (21.9%) were transferred emergently from a CSC telemedicine site and had EVT. The mean age of the overall sample was 70 years ± 14, 47.2% of patients were female (n = 194), and the median initial NIHSS was 17 ± 8. The rate of Hispanic ethnicity in this sample was 29.4% (n = 121). There were no significant differences in baseline characteristics between Hispanic and Non‐Hispanic patients. In this study, there were no significant difference between Hispanics versus Non‐Hispanics for all EVT time metrics including: 1) LKW‐to‐hospital arrival (356 vs 370 minutes, 95% Confidence Interval [CI]: ‐62 to 89; p = 0.72); 2) LKW‐to‐GP (434 vs 475 minutes, 95% CI: ‐41 to 143; p = 0.327); 3) hospital arrival‐to‐GP (82 vs 103 minutes, 95% CI: ‐10 to 52; p = 0.185); 4) hospital arrival‐to‐revascularization (119 vs 138 minutes, 95% CI: ‐11 to 49; p = 0.221); or 5) GP‐to‐revascularization (37 vs 40 minutes, 95% CI: ‐1 to 8; p = 0.149). Conclusions In this study at a large, academic, certified Comprehensive Stroke Center with a considerable Hispanic population, there were no significant difference in EVT time metrics for Hispanic versus Non‐Hispanic patients. These results support the use of protocols, pathways, and stroke‐specific education utilized within the CSC framework to reduce treatment disparities and stroke burden across the diversity of AIS patients. Further studies must examine for disparities across ethnicities and race in time metrics at stroke centers located in various areas of the country to identify treatment disparities and implement plans to reduce those disparities with input from both healthcare teams and members of those groups.

Abstract Number ‐ 265: Reduced‐dose ticagrelor versus full‐dose ticagrelor in patients with stroke: A retrospective cohort study

Introduction There has been an increase in use of ticagrelor in patients with ischemic stroke, particularly in the setting of clopidogrel resistance. Our study aims to retrospectively determine if aspirin plus ticagrelor at a reduced dose is effective in reducing the risk of recurrent stroke and/or other thrombotic events, without increasing the risk of bleeding. Methods In a prospectively maintained database, we performed a retrospective analysis of consecutive patients with acute ischemic stroke in a large academic comprehensive stroke center between September 1, 2020 to July 1, 2022. We compared in‐hospital mortality, 90‐day mortality, favorable functional outcome, defined as a modified Rankin Scale (mRS) score of 0 to 2, at 90 days, symptomatic intracranial hemorrhage (sICH), and asymptomatic intracranial hemorrhage (ICH), between patients on reduced‐dose ticagrelor versus those on full‐dose ticagrelor, in unadjusted and adjusted logistic regression models. Results We included 567 patients in our study. The mean age of these patients was 67.0 ± 15.0 years. Females represented 59.5% of the patients, and the majority of the patients were Black (80.0%). Intracranial atherosclerotic disease was the presumed stroke etiology in 96 patients (17.0%). Out of 567 patients, 432 were on a combination of both ticagrelor and aspirin. A total of 62 patients were on a reduced dose of ticagrelor (45 mg or 60 mg twice daily). The remaining 505 patients were on 90 mg twice daily dosing. New or recurrent ischemic stroke was similar across both groups (10.2% vs. 12.0%, p = 0.08). Symptomatic ICH was also found to be similar across both groups (8.2% vs. 9.3%, p = 0.06). Mortality or favorable functional outcome at 90 days also did not differ between the two groups (25.3% vs. 24.7%, p = 0.007; 28.2% vs. 27.3%, p = 0.006). Conclusions A lower dose of ticagrelor (45 or 60 mg twice daily) appears to be a safe and effective regimen in reducing risk of ischemic strokes without increasing hemorrhagic complications when compared to full‐dose ticagrelor at 90 mg twice daily. Further randomized trials are necessary to inform this recommendation.

Abstract Number ‐ 163: Underlying ICAD is associated with worse outcomes in acute large vessel occlusion undergoing endovascular thrombectomy

Introduction Acute large vessel occlusion (LVO) can be secondary to thromboembolism or intracranial atherosclerotic disease (ICAD). Data on LVO management due to underlying ICAD are scarce. We hypothesized that patients with ICAD have worse clinical outcomes following mechanical thrombectomy (MT) than those without ICAD. Methods We performed a retrospective analysis of consecutive patients who underwent MT for LVO in a large academic comprehensive stroke center between January 14, 2018 and October 24, 2021. Presence of ICAD at LVO site was determined by the interventionalist. We compared in‐hospital mortality, 90‐day mortality, and 90‐day modified Rankin Scale (mRS) scores between those with and without ICAD, in unadjusted and adjusting logistic regression models. Results Among 215 patients (mean age 67.1±16.0 years; 60.5% female; 80.5% Black, median NIHSS score 16), ICAD was present in 38 patients (17.7%). Diabetes and dyslipidemia were more common in those with ICAD (57.9% vs. 38.4%, p = 0.027 and 29.0% vs. 14.7%, p = 0.035, respectively). Substantial reperfusion (TICI ≥ 2b) was achieved less often (84.2% vs. 94.4%, p = 0.031) but symptomatic ICH was also less common in ICAD patients (0% vs. 9.0%, p = 0.054). In‐hospital and 90‐day mortality were more common (36.8% vs. 15.8%, p = 0.003 and 52.6% vs. 26.6%, p = 0.002, respectively) and favorable functional outcome (mRS 0–2) at 90 days was less common (7.9% vs. 33.9%, p = 0.001) in ICAD patients. After adjusting for prognostic variables, ICAD was independently associated with in‐hospital mortality (OR = 4.1, 95% CI 1.7‐9.7), 90‐day mortality (OR = 3.7, 95% CI 1.6‐8.6), and poor functional outcome at 90 days (OR = 5.5, 95% CI 1.6‐19.4). Conclusions Symptomatic ICAD in a predominantly African American cohort is associated with increased odds of mortality and poor functional outcome at 90 days in patients with LVO undergoing MT. Further research is warranted to understand factors associated with worse outcomes and investigate alternative interventional approaches and medical management in this high‐risk population.

Abstract HUP15: Investigating Racial Disparities In Acute Stroke Management At An Academic Comprehensive Stroke Center

Introduction: In the U.S. racial disparities in age of diagnosis and outcome of ischemic stroke remain despite advances in preventive, acute and chronic management. Social determinants of health, implicit bias and lack of diversity in healthcare which are resultant of systems of oppression have been identified as root causes. It is currently understood that primordial factors such as relatively higher risk of vascular disease, limited access and low stroke literacy contribute to these discrepancies. The role of delivery of care in the acute stroke setting has, however, not yet been investigated. Objectives: In this retrospective study we sought to elucidate if significant delays in acute stroke care exist in non-white (NW) compared to white (W) patients at Wake Forest Baptist. Methods: Data from EPIC of patients hospitalized from January 2018 to December 2019 were pulled via the Comprehensive Stroke Center and Get with the Guidelines databases. Standard descriptive statistical analyses were used. Results: We found that time to activation of acute stroke protocol, time to IV thrombolytic administration (NW 42.5 min, W 44.0 min, p= 0.82) and proportion of Individuals with a 90-day modified Rankin Scale score of 0 to 3 (NW 71.4%, W 60.0%, p= 0.24) were comparable. Interestingly and though not statistically significant, we did find that white patients underwent EVT sooner (NW 98 min, W 88 min, p= 0.54) and were more likely to achieve near-complete reperfusion when compared to their non-white counterparts (NW 80.0%, W 92.3%, p= 0.30). Discussion: Within our institution there are no differences in outcome between races of the patients who receive standard acute stroke care, suggesting that the protocolization of this emergent clinical practice may potentially play a role in mitigating racial disparities.

Abstract WP89: Listen: Language Impact On Stroke Time To Evaluation And Intervention

Introduction: Previous reports raised concerns that time dependent treatments in acute ischemic stroke (AIS) might be delayed on non-English speaking patients. Here we report an analysis of patients after AIS stratified by primary language who were admitted to two large comprehensive stroke centers in California. The purpose of this analysis was to examine the impact of primary language on treatment times, frequency and causes of not using thrombolysis. Methods: We included all patients admitted between 12/2019-4/2022 who presented to a Comprehensive Stroke Center (CSC) using the electronic medical record (EMR). Language preference was identified as English (ES) or Non-English (NES). We compared comorbidities, demographics, baseline NIHSS, stroke time metrics [stroke onset to arrival (LTD), arrival to CT (DTC), arrival to tPA (DTN)], frequency of tPA administration and exclusion for last known normal (LKN) &gt; 4.5 hours between ES and NES. We utilized Chi-squared, t-test, ANOVA as appropriate and a p value of &lt;0.05 was significant. Results: We identified 1815 patients, ES n=1489, NES n=326. There was no significant difference in the mean age between groups (ES 67±16; NES 66±16, p=0.93). There was no significant difference in mean LTD between groups (NES 99.3±58.9 minutes (min); ES 83.6±52 min). There was no significant difference in mean DTC between groups (NES 13.2±8.5 min; ES 12±10.2 min). There was no significant difference in mean DTN between groups (NES 54.4±23.3 min; ES 53.8±27.9 min). There was a significant difference in ambulance arrival (p=0.001), HTN (p=0.01), DM (p=0.001), drug/alcohol use (p=.001), and smoking (p=.001). There was no significant difference in LKW to door (p=.12), DTC (p=.44), DTN (p=0.88). Conclusion: Primary language did not affect acute stroke time metrics at this academic CSC. This is likely due to the 24/7 availability of interpreter services at this CSC. Further studies must assess the impact of language preference on stroke time metrics and outcome in a heterogenous sample of healthcare settings. Communicating in patients’ preferred language is vital to rapid care and patient engagement in the acute stroke setting.

Abstract TP135: Underlying Intracranial Atherosclerotic Disease Is Associated With Worse Outcomes In Acute Large Vessel Occlusion Undergoing Endovascular Thrombectomy

Introduction: Acute large vessel occlusion (LVO) can be secondary to thromboembolism or intracranial atherosclerotic disease (ICAD). Data on LVO management due to underlying ICAD are scarce. We hypothesized that patients with ICAD have worse clinical outcomes following mechanical thrombectomy (MT) than those without ICAD. Methods: We performed a retrospective analysis of consecutive patients who underwent MT for LVO in a large academic comprehensive stroke center between January 14, 2018 and October 24, 2021. Presence of ICAD at LVO site was determined by the interventionalist. We compared in-hospital mortality, 90-day mortality, and 90-day modified Rankin Scale (mRS) scores between those with and without ICAD, in unadjusted and adjusting logistic regression models. Results: Among 215 patients (mean age 67.1±16.0 years; 60.5% female; 80.5% Black, median NIHSS score 16), ICAD was present in 38 patients (17.7%). Diabetes and dyslipidemia were more common in those with ICAD (57.9% vs. 38.4%, p=0.027 and 29.0% vs. 14.7%, p=0.035, respectively). Substantial reperfusion (TICI ≥2b) was achieved less often (84.2% vs. 94.4%, p=0.031) but symptomatic ICH was also less common in ICAD patients (0% vs. 9.0%, p=0.054). In-hospital and 90-day mortality were more common (36.8% vs. 15.8%, p=0.003 and 52.6% vs. 26.6%, p=0.002, respectively) and favorable functional outcome (mRS 0-2) at 90 days was less common (7.9% vs. 33.9%, p=0.001) in ICAD patients. After adjusting for prognostic variables, ICAD was independently associated with in-hospital mortality (OR=4.1, 95% CI 1.7-9.7), 90-day mortality (OR=3.7, 95% CI 1.6-8.6), and poor functional outcome at 90 days (OR=5.5, 95% CI 1.6-19.4). Conclusions: Symptomatic ICAD in a predominantly African American cohort is associated with increased odds of mortality and poor functional outcome at 90 days in patients with LVO undergoing MT. Further research is warranted to understand factors associated with worse outcomes and investigate alternative interventional approaches and medical management in this high-risk population.

Abstract 96: Independent Adjudication Of Get With The Guidelines Thrombectomy Imaging And Angiography Data Reveals Major Discrepancies

Introduction: The Get with the Guidelines - Stroke (GWTG-Stroke) registry has been collecting endovascular thrombectomy (EVT) data on acute stroke interventions since 2015. The key variables associated with EVT, solely based on local site documentation, have never been independently adjudicated. We conducted a detailed analysis of single center EVT data as entered in the GWTG-Stroke registry. Methods: Consecutive EVT cases entered into both GWTG-Stroke and an independent research database at a large academic comprehensive stroke center were sampled from 2020-2022. For each case, the following EMR and PACS imaging variables related to EVT efficacy and safety outcomes were compared between GWTG-Stroke and core lab independent readings, including: site of target occlusion (STO), first-pass time (FPT), time mTICI &gt;=2b50 first documented (reperfusion time), final mTICI score (0, 1, 2a, 2b50, 3; FTICI), presence of post-intervention hemorrhagic transformation (HT), and subtype/extent of HT. Results: The GWTG-Stroke registry EVT-imaging data variables document only 6/30 (20%) of the common data elements (CDEs) recommended by NINDS and 6/34 (18%) recommended by the FDA. Of the 80 cases sampled, 29 (36%) had discrepancies between GWTG-Stroke recorded data and independent core lab findings. In 4 cases (5%), reperfusion time was incorrect. In another 4 cases (5%), FTICI was incorrect, even when using the gross 2b50/3 categories. In 1 case (1.3%) STO was incorrect. In 2 cases (2.5%) patient data was not reported to GWTG-Stroke. In 21 cases (26%), HT was documented as not present, when in fact it was. Of those, 3 cases (4%) were PH2, while 18 cases (23%) were IPH of PH1 or less, SAH or SDH. Conclusions: Detailed analysis of the GWTG-Stroke registry on EVT for acute ischemic stroke reveal major discrepancies in numerous variables. In addition, the majority of variables recommended by NINDS and FDA for routine collection in thrombectomy procedures are not captured in GWTG-Stroke. Even the minority of recommended thrombectomy CDEs currently captured in GWTG-Stroke further contain subject level discrepancies in imaging and angiography outcomes when centrally adjudicated.

In-hospital predictors of post-stroke depression for targeted initiation of Selective Serotonin Reuptake Inhibitors (SSRIs)

BackgroundAlthough SSRIs are no longer widely prescribed for post-stroke motor recovery, fluoxetine demonstrated beneficial effects on post-stroke depression (PSD). Given the potential side effects of SSRIs, targeted initiation among individuals at highest risk for PSD warrants consideration. While previous studies have identified stroke severity and psychiatric history as factors associated with PSD, its predictability remains unknown. In this study, we investigate inpatient predictive factors to better identify individuals who might derive the most benefit from targeted initiation of SSRIs.MethodsWe performed a retrospective analysis of a prospectively-collected registry of adult patients presenting with acute ischemic stroke to a tertiary referral urban academic comprehensive stroke center between 2016–2020. Patients were seen 4–6 weeks post-discharge and administered the PHQ-9 (Patient Health Questionnaire-9) to screen for PSD (PHQ-9 ≥ 5). Demographics, history of depression, stroke severity, and inpatient PHQ-9 scores were abstracted. Logistic regression was used to determine factors associated with PSD and an ROC analysis determined the predictability of PSD in the inpatient setting.ResultsThree hundred seven individuals were administered the PHQ-9 at follow-up (mean age 65.5 years, 52% female). History of depression (OR = 4.11, 95% CI: 1.65–10.26) and inpatient PHQ-9 score (OR = 1.17, 95% CI: 1.06–1.30) were significantly associated with PSD. Stroke severity, marital status, living alone, employment, and outpatient therapy were not associated with PSD. The ROC curve using a positive inpatient PHQ-9 achieved an area under the curve (AUC) of 0.65 (95% CI: 0.60–0.70), while the AUC was 0.72 (95% CI: 0.66–0.77) after adding history of depression.ConclusionsHistory of depression and a positive inpatient PHQ-9 appear to be most strongly predictive of long-term PSD. Initiating SSRIs only in those individuals at highest risk for PSD may help reduce the burden of stroke recovery in this targeted population while minimizing adverse side effects.

Biomarker of early neurological deterioration in minor stroke and proximal large vessel occlusion: A pilot study.

Plasma neurofilament light chain (pNFL) represents one of the scaffolding proteins of central nervous system axonal injury. The aim of this study was to evaluate pNFL as a predictive biomarker for early neurological deterioration (END) in medically managed patients with large vessel occlusion (LVO) and mild presentation (NIHSS < 6). This retrospective study was developed from a prospectively collected stroke database, which was conducted at a large academic comprehensive stroke center in western China. Patients who first presented with acute ischemic stroke (AIS) within 24 h of symptom onset were continuously included. Stroke severity was analyzed at admission using the NIHSS score. The pNFL drawn on admission was analyzed with a novel ultrasensitive single-molecule array. Thirty-nine consecutive patients were included in the analysis, and 19 (48.72%) patients experienced END. Patients who experienced END had significantly higher pNFL levels (mean, 65.20 vs. 48.28 pg/mL; P < 0.001) and larger infarct volume (mean, 15.46 vs. 9.56 mL; P < 0.001). pNFL was valuable for the prediction of END (OR, 1.170; 95% CI, 1.049-1.306; P = 0.005), even after adjusted for age and sex (OR, 1.178; 95% CI, 1.038-1.323; P = 0.006), blood sampling time, baseline NIHSS, TOAST classification, and infarct volume (OR, 1.168; 95% CI, 1.034-1.320; P = 0.012). The area under the ROC curve was 85.0% (95% CI, 0.731-0.970; P < 0.001). The sensitivity was 73.7%, and the specificity was 80%. END in minor stroke with LVO was distinguishable from those without END following the determination of pNFL in the blood samples within 24 h of onset. The pNFL is a promising biomarker of END in minor stroke with LVO. ChiCTR1800020330.