Academic Stroke Center Research Articles

Managing Recurrent Ischemic Cerebrovascular Events in Patients with Atrial Fibrillation Compliant with Oral Anticoagulant Therapy (P6-5.001)

<h3>Objective:</h3> To evaluate if oral anticoagulant therapy change (OAC change) or adding antiplatelet therapy to anticoagulation (AC+AP) in patients with nonvalvular atrial fibrillation (AF) and acute ischemic stroke (AIS) or transient ischemic attack (TIA) despite OAC compliance, is associated with lower risk of recurrent cerebrovascular events compared to patients that continued the same anticoagulant regimen. <h3>Background:</h3> Patients with AF still have an appreciable risk of AIS or TIA despite compliance with OAC. Yet little is known about the best management options in this population. <h3>Design/Methods:</h3> We reviewed all consecutive patients with AF on OAC that presented with AIS/TIA to our tertiary academic stroke center between 2011–2021. Baseline characteristics, type of index event, antithrombotic therapy before and after index event, subsequent recurrent AIS/TIA or major bleeding events were extracted. Fisher’s exact or Log-rank tests and logistic regression models were used to compare outcomes between OAC unchange vs OAC change, and AC+AP vs AC only groups. <h3>Results:</h3> 185 patients (mean age 78.3 ± 12 years) were included. 61% were males and 79 (42.7%) had AIS at index event. 17 (9%) had OAC change and 100 (79%) received AP+AC. 39 (21.15%) had recurrent AIS/TIA, and 28 (15.1%) had major bleeding following the index event. No significant difference was observed between OAC unchange versus OAC change groups regarding recurrent AIS/TIA (HR = 0.607, 95% CI: 0.229–1.609, p = 0.316) or major bleeding events (OR = 1.541, 95% CI: 0.391–10.299, p = 0.586). Additionally, no significant difference was observed between AC+AP versus AC groups regarding recurrent AIS/TIA (HR= 0.863, 95% CI: 0.430–1.732, p = 0.679) or major bleeding events (OR= 0.894, 95% CI: 0.377–2.135, p = 0.798). <h3>Conclusions:</h3> In patients with AF and acute ischemic cerebrovascular events despite OAC compliance, changing anticoagulant or adding antiplatelet agent may not decrease risk of future cerebrovascular events. <b>Disclosure:</b> Dr. Harahsheh has nothing to disclose. Mr. Elshaigi has nothing to disclose. Dr. Alhayek has nothing to disclose. Vanesa Vanderhye has nothing to disclose. Dr. O’Carroll has nothing to disclose. Dr. Dumitrascu has nothing to disclose.

Acute Ischemic Stroke Large Vessel Occlusion treated with Mechanical Thrombectomy in the Pediatric Populatio (P8-5.015)

<h3>Objective:</h3> We sought to assess the safety and efficacy of mechanical thrombectomy performed in children at our institution for acute ischemic stroke (AIS) due to large vessel occlusion (LVO). <h3>Background:</h3> AIS due to large vessel occlusion (LVO) is relatively rare in the pediatric population, and evidence supporting thrombectomy in children is limited. The use of thrombectomy in the pediatric population is extrapolated from data in the adult stroke literature. <h3>Design/Methods:</h3> We performed a retrospective chart review of pediatric patients (age &lt; 18 years) with AIS due to LVO who underwent thrombectomy at our comprehensive academic stroke center from January 2019 to June 2022. <h3>Results:</h3> We identified 4 cases of pediatric AIS with LVO treated with thrombectomy. The mean age was 12 years old (range, 9–17), 3 were males. The mean National Institutes of Health Stroke Scale was 16 (range, 10 to 28). One patient received partial thrombolysis (aborted with 20% of dose received). Prior to thrombectomy, 1 patient had CT brain perfusion which showed MCA mismatch favorable for thrombectomy, whereas the remaining 3 patients had MRI brain showing acute infarct in the territory of LVO. LVO sites included M1 occlusion (2), carotid T occlusion (1), and M2 occlusion (1). All 4 patients had successful revascularization including 3 patients with thrombolysis in cerebral infarction (TICI) 3 and 1 patient with TICI 2b. There were no symptomatic hemorrhages. The mean time from last known normal to groin puncture was 5.7 hours (range, 2.9 to 9.2). The clinical outcomes included 2 patients with modified rankin scores (mRS) 1 and 2 patients with mRS 3. <h3>Conclusions:</h3> In our case series of pediatric AIS cases with LVO, thrombectomy was feasible and associated with successful revascularization. There were no safety concerns. The majority of cases were diagnosed by MRI brain, highlighting the difficulty in diagnosis of LVO in the pediatric population. <b>Disclosure:</b> Mrs. Glenn has nothing to disclose. Dr. Lee has nothing to disclose. Shahid Nimjee has nothing to disclose. The institution of Dr. Lo has received research support from NIH. Dr. Lo has received publishing royalties from a publication relating to health care. Mrs. Forrest has nothing to disclose. Randheer Yadav has stock in Quest Recovery Center LLC. Patrick Youssef has nothing to disclose.

Abstract Number ‐ 27: VARIANCE: Variability of Assessed BP Readings In Acute Neuro‐intervention Cases and its Effect on outcomes

Introduction Blood pressure variability (BPV) following endovascular thrombectomy (EVT) in acute ischemic strokes is associated with poor functional outcomes both in the short and long term. Patient variables which may predict high BPV must be examined to improve outcomes. The purpose of this study is to analyze the affect of BPV on outcomes in patients with good recanalization with EVT and examine potential predictors of BPV. Methods We conducted a retrospective analysis of prospectively collected data from an IRB approved Stroke Registry of two academic Comprehensive Stroke Centers in Southern California between 2017 and 2022. Patients were included if they had 1) anterior circulation ischemic stroke due to large vessel occlusions (LVO) and 2) successful EVT with TICI 2b‐3. All BPs were recorded as immediate pre‐op SBP and DBP (one minute prior to procedure start time), immediate post‐op SBP and DBP (at time of recanalization), and 24 hours post revascularization. Variables examined include age, sex, Hispanic ethnicity, initial NIHSS, history of HTN, current antihypertensive use, symptom onset to groin puncture time, door to groin puncture time, and symptomatic ICH (sICH). Outcome was assessed via hospital discharge disposition and modified Rankin Scale at 90 days. Good short‐term outcome was disposition to home or rehab. Good long‐term outcome was mRS of 0–2. BPV was defined by the average real variability (ARV) calculated as the absolute value of the average of the differences between consecutive BP measurements divided by the number of measurements. A correlation matrix was used to identify both continuous and categorical variables with a significant correlation with ARV (p≤0.10). A stepwise logistic regression model for good versus poor outcome was created by including all significant variable from the correlation matrix. A significance level of p≤0.05 was included for all non‐correlational analysis. Results We identified 253 patients (mean age 70±14 years, 51.4% female). 49% were white, 6.3% asian, 5.5% black, 1.6% native Hawaiian pacific islander, and 37.5% are unspecified. 30.4% were Hispanic. The median NIHSS was 17±8. Mean BMI was 27±8. Mean symptom onset to groin puncture time was 478±326 mins. Mean door to groin puncture time was 86±110 mins. 34.8% of patients received tPA (100% of those eligible as our population included patients in the extended window who qualified per DAWN/DEFUSE‐3). 57.2% had cardioembolic etiology. 4.7% had sICH. 58.9% of patients had a good discharge disposition. ARVAB as defined as the average SBP variability as an absolute value was 30.6±25.6. ARVAB was associated with sex, home antihypertensive use, and immediate pre‐op and post‐op SBPs. ARVAB was not associated with age, initial NIHSS, Hispanic ethnicity, HTN, rate of sICH, or short or long term outcome. Conclusions There was a significant correlation with female sex and home use of antihypertensives and higher BPV. These variables can potentially be used as predictors of BPV. BPV was not correlated with discharge disposition or 90 day mRS in our population. While our study did not show a positive correlation between BPV and outcome, our ARVAB was lower than prior populations likely due to more accurate BP monitoring and control.

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 ‐ 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 ‐ 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 Number ‐ 164: Clot Density as a Predictor for Successful Mechanical Thrombectomy

Introduction Switching mechanical thrombectomy techniques (ADAPT, SR or combination) mid procedure has the potential to prolong time to recanalization as well as increase associated healthcare costs. The basis of selecting the frontline technique still relies heavily on the operators’ preference. Conflicting results indicating the varying performance of techniques relative to clot composition have been reported. Clot composition can be estimated based on clot density calculated in Hounsfield Units (HU) on pre‐intervention CT. Identifying how various clot composites behave can aid in the decision making for selecting a frontline technique.Our objective is to determine if clot density as measured by Hounsfield units can predict successful recanalization with ADAPT and the need for rescue stentriever when using ADAPT as the first line technique. Methods Retrospective review of all patients undergoing mechanical thrombectomy with first pass ADAPT at a single urban tertiary care academic stroke center. Clot HU values were calculated on pre‐intervention scans. We evaluated the number of passes, the use of rescue SR, the post intervention TICI grade and mRS on final follow up. Results There were 167 patients that underwent MT with ADAPT as the frontline approach. 122 were excluded for inability to calculate HU on pre‐ intervention scans, most often due to contamination with contrast media. 45 patients were included in the final analysis. 18/45 (40%) required SR rescue due to incomplete recanalization with first pass ADAPT. HU were dichotomized around the mean to “high” and “low”. Higher HU value was associated higher likelihood of SR use and higher final mRS scores, these however did not reach statistical significance. There was no difference in the total number of passes or the final TICI grade. AUC and ROC did not show a correlation between HU value and the use of SR or a higher number of passes need to achieve TICI ≥ 2b recanalization. Conclusions In our patient cohort, HU value was not able to predetermine the success rate of MT using ADAPT. There was no correlation between HU value and functional outcomes of patients. Reliability of clot HU value in determining MT success with ADAPT could not be established. Other factors should be considered when selecting frontline technique in mechanical thrombectomy.

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 TP144: VARIANCE-S: Variability Of Assessed Bp Readings In Acute Neuro-intervention Cases And Its Effect On Outcomes Pertaining To Sex Differences

Introduction: Sex differences exist in thrombolytic stroke treatment and outcome and likely in endovascular thrombectomy (EVT). Previous analysis has shown a significant correlation of blood pressure variability (BPV) and sex. The purpose of this study was to assess sex differences in a sample of patients with good recanalization post-with EVT and examine the impact of BPV. Methods: We conducted a retrospective analysis of prospectively collected data from an IRB approved Stroke Registry of two academic Comprehensive Stroke Centers in Southern California between 2017 and 2022. Patients were included if they had 1) anterior circulation ischemic stroke due to large vessel occlusions (LVO) and 2) underwent successful EVT defined as a TICI 2b or 3 result. Male and female subjects were compared for age, sex, Hispanic ethnicity, initial NIHSS, history of HTN, current antihypertensive use, symptom onset to groin puncture time, door to groin puncture time, and symptomatic ICH (sICH), BPV, onset to groin, and door to groin . Good outcome was defined as mRS 0-2. Chi squared a t-test were used as appropriate. Results: We included 131 females and 124 males. There was a significant difference between males and females in: 1) history of a fib (76% v 64%, p=0.42); 2) atrial fibrillation during admission (36% v 50%, p=0.01); 3) age (male 67 v female 73 years, p&lt;0.001); 4) post-EVT SBP (137mmHg v 144mmHg, p-0.02). There was a significant difference in onset to groin (p=0.41), but no significant difference in door to groin (p=0.59). When adjusting for time of onset, there was no significant difference in thrombolysis prior to EVT between groups. There was no significant difference in sICH (6 male v 4% female, p=0.50), 90 day mRS (p=0.81); or discharge disposition (p=0.56). BPV was significantly correlated with sex but not significant for any interaction effect with the variables assessed. Conclusion: This study found no significant sex differences in outcome in this sample. The systems of care provided by an academic, CSC ensure that all patients’ care is expedited and provides the best opportunity for a good outcome in both sexes. Studies of sex differences in EVT treatment and outcome in multiple stroke care settings are vital to reduce disparities in care.

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.

Abstract 33: Risk Scores And Brain Mri Markers In Distinguishing Ischemic Stroke And Intracerebral Hemorrhage Risk Among Atrial Fibrillation Patients: The Neuro-Afib Study

Background: Recent studies cast doubt on the accuracy of the most-commonly used risk scores (CHA 2 DS 2 -VASC and HAS-BLED) in differentiating the risk of acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH) among patients with fibrillation (AF). Because of the importance of AIS/ICH risk determination for choice of proper preventive approaches, we aimed to compare the value of these risk scores and brain MRI markers to differentiate the occurrence of AIS and ICH in a large cohort of AF-related strokes. Methods: The Neuro-AFib study is a multicenter effort to elucidate the causes and consequences of AIS and ICH in AF patients. Demographics, CHA 2 DS 2 -VASC and HAS-BLED scores, and ischemic/hemorrhagic brain MRI markers were compared between AF patients admitted with AIS and ICH to 15 academic stroke centers in the US between 1/2018-12/2019. Results: Of 5694 stroke admissions with AF, 4826 (84.8%) had AIS and 868 (15.2%) ICH. Mean age was similar between groups (75.9±11.5 vs 76.6±11.9, p=0.1), more ICH patients were male (57% vs 50%). Pre-index event CHA 2 DS 2 -VASC (4.14±1.6 vs 4.22±1.6) and HAS-BLED (2.71±1.09 vs 2.68±1.13) were similar between groups [both p&gt;0.2]. Cerebral microbleeds (CMB, 56% vs 33.5%), cortical superficial siderosis (cSS, 15% vs 9.4%), and moderate-to-severe leukoaraiosis (41% vs 33.4%) were more commonly found among ICH patients compared to AIS (all p&lt;0.001). Chronic lacunar infarcts (43.5% vs 39.5%, p=0.03) and chronic non-lacunar infarcts (29% vs 18%, p&lt;0.001) were more commonly found in AIS. In a multivariable logistic regression model that included all variables above, male sex, presence of CMBs, cSS, moderate-to-severe leukoaraiosis were associated with ICH, chronic non-lacunar infarcts with AIS (all p&lt;0.005), while CHA 2 DS 2 -VASC (p=0.9) and HAS-BLED (p=0.9) were not related to the stroke type. Conclusions: Data from our multicenter study confirm the lack of specificity of CHA 2 DS 2 -VASC and HAS-BLED to categorize the risk of AIS vs ICH in AF patients. The chronic MRI findings (CMB, cSS, moderate-to-severe leukoaraiosis, chronic infarcts) should be incorporated into risk scores, and their predictive value for AIS and ICH should be investigated in prospective studies to select optimal stroke prevention methods in AF patients.

National Institutes of Health Stroke Scale (NIHSS) scoring inconsistencies between neurologists and emergency room nurses.

Little is known about the consistency of initial NIHSS scores between neurologists and RNs in clinical practice. A cohort study of patients with a code stroke was conducted at an urban academic Primary Stroke Center in the Midwest between January 1, 2018, and December 31, 2019 to determine consistency in National Institutes of Health Stroke Scale Scores (NIHSS) between neurologists and registered nurses (RNs). Among the 438 patients included in this study 65.3% (n = 286) of neurologist-RN NIHSS scoring pairs had congruent scores. One-in-three, (34.7%, n = 152) of neurologist-RN NIHSS scoring pairs had a clinically meaningful scoring difference of two points or greater. Higher NIHSS (p ≤ 0.01) and aphasia (p ≤ 0.01) were each associated with incongruent scoring between neurologist and emergency room RN pairs. One-in-three initial NIHSS assessed by both a neurologist and RN had a clinically meaningful score difference between providers. More severe stroke, as indicated by a higher NIHSS was associated with scoring inconsistency between neurologist-RN pairs. Subjective scoring measures, especially those involving a patient having aphasia, was associated with greater score incongruency. Score differences may be attributed to differences in NIHSS training requirements between neurologists and RNs.

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.

Multivariable Prediction Model for Futile Recanalization Therapies in Patients With Acute Ischemic Stroke.

Background and ObjectivesVery poor outcome despite IV thrombolysis (IVT) and mechanical thrombectomy (MT) occurs in approximately 1 of 4 patients with ischemic stroke and is associated with a high logistic and economic burden. We aimed to develop and validate a multivariable prognostic model to identify futile recanalization therapies (FRTs) in patients undergoing those therapies.MethodsPatients from a prospectively collected observational registry of a single academic stroke center treated with MT and/or IVT were included. The data set was split into a training (N = 1,808, 80%) and internal validation (N = 453, 20%) cohort. We used gradient boosted decision tree machine learning models after k-nearest neighbor imputation of 32 variables available at admission to predict FRT defined as modified Rankin scale 5–6 at 3 months. We report feature importance, ability for discrimination, calibration, and decision curve analysis.ResultsA total of 2,261 patients with a median (interquartile range) age of 75 years (64–83 years), 46% female, median NIH Stroke Scale 9 (4–17), 34% IVT alone, 41% MT alone, and 25% bridging were included. Overall, 539 (24%) had FRT, more often in MT alone (34%) as compared with IVT alone (11%). Feature importance identified clinical variables (stroke severity, age, active cancer, prestroke disability), laboratory values (glucose, C-reactive protein, creatinine), imaging biomarkers (white matter hyperintensities), and onset-to-admission time as the most important predictors. The final model was discriminatory for predicting 3-month FRT (area under the curve 0.87, 95% CI 0.87–0.88) and had good calibration (Brier 0.12, 0.11–0.12). Overall performance was moderate (F1-score 0.63 ± 0.004), and decision curve analyses suggested higher mean net benefit at lower thresholds of treatment (up to 0.8).ConclusionsThis FRT prediction model can help inform shared decision making and identify the most relevant features in the emergency setting. Although it might be particularly useful in low resource healthcare settings, incorporation of further multifaceted variables is necessary to further increase the predictive performance.

Performance of Automated RAPID Intracranial Hemorrhage Detection in Real-World Practice: A Single-Institution Experience.

Intracranial hemorrhage (ICH) is a common finding in patients presenting to the emergency department with acute neurological symptoms. Noncontrast head computed tomography (NCCT) is the primary modality for assessment and detection of ICH in the acute setting. RAPID ICH software aims to automatically detect ICH on NCCT and was previously shown to have high accuracy when applied to a curated test data set. Here, we measured the test performance characteristics of RAPID ICH software in detecting ICH on NCCT performed in patients undergoing emergency stroke evaluation at a tertiary academic comprehensive stroke center. This retrospective study assessed consecutive patients over a 6-month period who presented with acute neurological symptoms suspicious for stroke and underwent NCCT with RAPID ICH postprocessing. RAPID ICH detection was compared with the interpretation of a reference standard comprising a board-certified or board-eligible neuroradiologist, or in cases of discrepancy, adjudicated by a consensus panel of 3 neuroradiologists. Accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of RAPID ICH for ICH detection were determined. Three hundred seven NCCT scans were included in the study. RAPID ICH correctly identified 34 of 37 cases with ICH and 228 of 270 without ICH. RAPID ICH had a sensitivity of 91.9% (78.1%-98.3%), specificity of 84.4% (79.6%-88.6%), NPV of 98.7% (96.3%-99.6%), PPV of 44.7% (37.6%-52.1%), and overall accuracy of 85.3% (80.9%-89.1%). In a real-world scenario, RAPID ICH software demonstrated high NPV but low PPV for the presence of ICH when evaluating possible stroke patients.

Incidence of post-stroke depression symptoms and potential risk factors in adults with aphasia in a comprehensive stroke center

ABSTRACT Introduction Depression may be a frequent sequela after stroke, however, its incidence has rarely been reported. The likelihood of post-stroke depression (PSD) may relate to individual factors including the presence of aphasia, which also complicates PSD diagnosis. The current study’s purpose was to investigate the incidence of PSD symptoms in adults with aphasia, compare it to the incidence of PSD symptoms in adults without aphasia, and to identify potential risk factors for developing PSD in adults with aphasia. Method Incidence proportions and relative risk were calculated using data compiled from 970 patient records at an urban tertiary care academic institution and comprehensive stroke center throughout the year of 2019. Focusing exclusively on adults with aphasia, the selected variables of age, gender, race, and aphasia severity were used to conduct logistic regression analyses to explore potential risk factors contributing to the development of PSD. Results Adults with aphasia were 7.408 times more likely to exhibit PSD symptoms than adults without aphasia. Logistic regression controlling for the presence of aphasia showed a significant relationship between aphasia severity and post-stroke depression symptoms. Adults with aphasia were 2.06 times more likely to experience post-stroke depression symptoms with every 1-point increase in aphasia severity. Conclusions These findings align with earlier evidence identifying aphasia as a risk factor for experiencing PSD symptoms and also suggest aphasia severity is proportionate to the risk. This highlights the need for early identification of PSD symptoms in persons with aphasia in order to provide timely interventions.

Small vessel disease and collaterals in ischemic stroke patients treated with thrombectomy.

To determine the influence of the cerebral small vessel disease (SVD) burden on collateral recruitment in patients treated with mechanical thrombectomy (MT) for anterior circulation acute ischemic stroke (AIS). Patients with AIS due to large vessel occlusion (LVO) from the Thrombectomie des Artères Cérébrales (THRACE) trial and prospective cohorts from 2 academic comprehensive stroke centers treated with MT were pooled and retrospectively analyzed. Collaterals' adequacy was assessed using the American Society of Interventional and Therapeutic Radiology/Society of Interventional Radiology (ASITN/SIR) score on initial digital subtraction angiography and dichotomized as good (3,4) versus poor (0-2) collaterals. The SVD burden was rated with the global SVD score on MRI. Multivariable logistic regression analyses were used to determine relationships between SVD and ASITN/SIR scores. A total of 312 participants were included (53.2% males, mean age 67.8 ± 14.9years). Two hundred and seven patients had poor collaterals (66.4%), and 133 (42.6%) presented with any SVD signature. In multivariable analysis, patients demonstrated worse leptomeningeal collaterality with increasing SVD burden before and after adjustment for SVD risk factors (adjusted odds ratio [aOR] 0.69; 95%CI [0.52-0.89] and aOR 0.66; 95%CI [0.5-0.88], respectively). Using individual SVD markers, poor collaterals were significantly associated with the presence of lacunes (aOR 0.40, 95% CI [0.20-0.79]). Our study provides evidence that in patients with AIS due to LVO treated with MT, the burden of SVD assessed by pre-treatment MRI is associated with poorer recruitment of leptomeningeal collaterals.

Pre-treatment lesional volume in older stroke patients treated with endovascular treatment.

Recent studies in the general stroke population treated with endovascular treatment (EVT) reported that higher pre-treatment lesional volumes were independently associated with poor neurological outcome and functional dependence after stroke. However, it has been not evaluated in older patients. We test the association between the pre-treatment lesional volume on diffusion-weighted magnetic resonance imaging and relevant outcome measures in older adults with stroke treated with EVT. We included consecutive older adults with stroke (⩾80 years old) treated with EVT in two academic comprehensive stroke centers. The association between pre-treatment lesional volume and relevant outcome measures (poor outcome (modified Rankin scale 4-6), 3-month mortality and symptomatic intracerebral hemorrhage (sICH)) was evaluated using univariate and multivariable models. Five hundred seventy-nine patients were included (mean age: 85.6 ± 4.1, median lesional volume was 10 ml; interquartile range: 3-30 ml). Pre-treatment lesional volume was associated with poor functional outcome (adjusted odds ratio (aOR): 1.87, 95% confidence interval (CI): 1.60-2.20, for +1 logarithmic increase of lesional volume), 3-month mortality (aOR: 1.50, CI: 1.28-1.76), and sICH (aOR: 1.67, CI: 1.27-2.20). A threshold lesional volume >35 ml predicted 90% of patients with poor functional outcome and a cut-off >51 ml predicted 90% of patients dead at 3 months. Pre-treatment lesional volume might contribute, in association with other relevant clinical features, to the selection of older stroke patients who will benefit from EVT.