Acute Ischemic Stroke Presenting Research Articles

Comparing Outcomes of Thrombectomy Versus Intravenous Thrombolysis Based on Middle Cerebral Artery M2 Occlusion Features.

Current evidence provides limited support for the superiority of endovascular thrombectomy (EVT) in patients with M2 segment middle cerebral artery occlusion. We aim to investigate whether imaging features of M2 segment occlusion impact the effectiveness of EVT. We conducted a retrospective cohort study from January 2017 to January 2022, drawing data from the CASE II registry (Computer-Based Online Database of Acute Stroke Patients for Stroke Management Quality Evaluation), which specifically documented patients with acute ischemic stroke presenting with M2 segment occlusion undergoing reperfusion therapy. Patients were stratified into the intravenous thrombolysis (IVT) group (IVT alone) and EVT group (IVT plus EVT or EVT alone). The primary outcome was a modified Rankin Scale score 0 to 2 at 90 days. Secondary outcomes included additional thresholds and distribution of modified Rankin Scale scores, 24-hour recanalization, early neurological deterioration, and relevant complications during hospitalization. Safety outcomes encompassed intracranial hemorrhagic events at 24 hours and mortality at 90 days. Binary logistic regression analyses with propensity score matching were used. Subgroup analyses were performed based on the anatomic site of occlusion, including right versus left, proximal versus distal, dominant/co-dominant versus nondominant, single versus double/triple branch(es), and anterior versus central/posterior branch. Among 734 patients (43.3% were females; median age, 73 years) with M2 segment occlusion, 342 (46.6%) were in the EVT group. Propensity score matching analysis revealed no statistical difference in the primary outcome (odds ratio, 0.860 [95% CI, 0.611-1.209]; P=0.385) between the EVT group and IVT group. However, EVT was associated with a higher incidence of subarachnoid hemorrhage (odds ratio, 6.655 [95% CI, 1.487-29.788]; P=0.004) and pneumonia (odds ratio, 2.015 [95% CI, 1.364-2.977]; P<0.001). Subgroup analyses indicated that patients in the IVT group achieved better outcomes when presenting with right, distal, or nondominant branch occlusion (Pall interaction<0.05). Our study showed similar efficiency of EVT versus IVT alone in acute M2 segment middle cerebral artery occlusion. This suggested that only specific patient subpopulations might have a potentially higher benefit of EVT over IVT alone. URL: https://clinicaltrials.gov; Unique identifier: NCT04487340.

Racial Disparities in Blood Pressure at Time of Acute Ischemic Stroke Presentation: APopulation Study.

Hypertension is a stroke risk factor with known disparities in prevalence and management between Black and White patients. We sought to identify if racial differences in presenting blood pressure (BP) during acute ischemic stroke exist. Adults with acute ischemic stroke presenting to an emergency department within 24 hours of last known normal during study epochs 2005, 2010, and 2015 within the Greater Cincinnati/Northern Kentucky Stroke Study were included. Demographics, histories, arrival BP, National Institutes of Health Stroke Scale score, and time from last known normal were collected. Multivariable linear regression was used to determine differences in mean BP between Black and White patients, adjusting for age, sex, National Institutes of Health Stroke Scale score, history of hypertension, hyperlipidemia, smoking, stroke, body mass index, and study epoch. Of 4048 patients, 853 Black and 3195 White patients were included. In adjusted analysis, Black patients had higher presenting systolic BP (161 mm Hg [95% CI, 159-164] versus 158 mm Hg [95% CI, 157-159], P<0.01), diastolic BP (86 mm Hg [95% CI, 85-88] versus 83 mm Hg [95% CI, 82-84], P<0.01), and mean arterial pressure (111 mm Hg [95% CI, 110-113] versus 108 mm Hg [95% CI, 107-109], P<0.01) compared with White patients. In adjusted subanalysis of patients <4.5 hours from last known normal, diastolic BP (88 mm Hg [95% CI, 86-90] versus 83 mm Hg [95% CI, 82-84], P<0.01) and mean arterial pressure (112 mm Hg [95% CI, 110-114] versus 108 mm Hg [95% CI, 107-109], P<0.01) were also higher in Black patients. This population-based study suggests differences in presenting BP between Black and White patients during acute ischemic stroke. Further study is needed to determine whether these differences influence clinical decision-making, outcome, or clinical trial eligibility.

Frequency of Hypomagnesemia and Its Relationship With Severity Among Patients of Acute Ischemic Stroke Presenting to a Tertiary Care Hospital.

Objective The objective of this study was to assess the prevalence of hypomagnesemia and its association with the severity of acute ischemic stroke (AIS) in patients presenting at a tertiary care hospital. Methodology A total of 100 patients with AIS were included in the study. Demographic data, including age, gender, and severity of stroke, were collected. Serum magnesium levels were measured at admission, and the severity of stroke was classified as mild, moderate, or severe based on clinical criteria. The presence of hypomagnesemia was defined as a serum magnesium level below 1.8 mg/dL determined within 72 hours of onset of stroke. Statistical analysis was performed to assess the association between hypomagnesemia, stroke severity, age, and gender. Results The mean age of the patients with standard deviation was 65.45 ± 11.8 years, with the majority (38, 38%) aged 60-74 years. There were 53 (53%) male and 47 (47%) female patients. Hypomagnesemia was found in 35 (35%) patients, with an average magnesium level of 1.93 mg/dL and a standard deviation of 0.37 at admission. There was no statistically significant difference in the distribution of stroke severity (P = 0.779; P = 0.406) or hypomagnesemia (P = 0.287; P = 0.591) based on gender or age group, respectively. Stratification based on stroke severity showed that 16 (39%) patients with mild stroke, 10 (31.3%) with moderate stroke, and 9 (33.3%) with severe stroke had hypomagnesemia. The correlation between stroke severity and hypomagnesemia was weak (r = 0.099). Further, among hypomagnesemia patients, the majority were females aged 60-74 years. Conclusions This study found a weak positive relationship between the severity of AIS and the presence of hypomagnesemia. However, no statistically significant association was observed between gender or age group and stroke severity or hypomagnesemia. These findings suggest that further research is needed to understand the role of hypomagnesemia in AIS and its potential implications for patient management.

316 Acute Ischemic Stroke Presentation Labs and Imaging Can Be Used to Model Thrombus Proteomic Composition

INTRODUCTION: The literature points to a strong relationship between the composition of acute ischemic stroke thrombi and their susceptibility to thrombolytic or endovascular treatment. Composition can be determined by molecular studies of the clot itself, but there is tremendous utility in being able to predict clot composition solely on data available at patient presentation. METHODS: Quantitative proteomes were generated using mass spectrometry of thromboembolic material retrieved by thrombectomy from 59 stroke patients. Of the 2,790 total identified proteins, marker proteins were selected to identify broad groups of thrombus components: RBCs (12 proteins), platelets (9 proteins), histones (23 proteins) and neutrophils (13 proteins). Dimensional reduction of marker proteins was done by principal component (PC) analysis for each group. A broad survey of demographic, lab, and radiographic data was gathered by retrospective chart review. Regression analysis was used to identify the combination of the four variables on chart review that most strongly associated with the PCs for each thrombus component group. RESULTS: After dimensional reduction, a significant amount of the variance in marker protein abundance for each group was represented by the first PC for each group (R2 &gt; 0.94 for all). It was possible to generate linear models representing the PC associated with RBCs (R2 = 0.37, p = 0.02), platelets (R2 = 0.40, p = 0.0004), histones (R2 = 0.52 and p = 0.001), and neutrophils (R2 = 0.81, p = 1E-12) using combinations of four data points at presentation. CONCLUSIONS: This preliminary work suggests that the abundance of clot components may be predicted by modeling patient data available at presentation, which has the potential to drive future choice of therapy. Next steps include refining and validating the models on a prospectively maintained stroke database at our home institution.

Sex Differences in Prehospital Identification of Large Vessel Occlusion in Patients With Suspected Stroke.

Differences in clinical presentation of acute ischemic stroke between men and women may affect prehospital identification of anterior circulation large vessel occlusion (aLVO). We assessed sex differences in diagnostic performance of 8 prehospital scales to detect aLVO. We analyzed pooled individual patient data from 2 prospective cohort studies (LPSS [Leiden Prehospital Stroke Study] and PRESTO [Prehospital Triage of Patients With Suspected Stroke Study]) conducted in the Netherlands between 2018 and 2019, including consecutive patients ≥18 years suspected of acute stroke who presented within 6 hours after symptom onset. Ambulance paramedics assessed clinical items from 8 prehospital aLVO detection scales: Los Angeles Motor Scale, Rapid Arterial Occlusion Evaluation, Cincinnati Stroke Triage Assessment Tool, Cincinnati Prehospital Stroke Scale, Prehospital Acute Stroke Severity, gaze-face-arm-speech-time, Conveniently Grasped Field Assessment Stroke Triage, and Face-Arm-Speech-Time Plus Severe Arm or Leg Motor Deficit. We assessed the diagnostic performance of these scales for identifying aLVO at prespecified cut points for men and women. Of 2358 patients with suspected stroke (median age, 73 years; 47% women), 231 (10%) had aLVO (100/1114 [9%] women and 131/1244 [11%] men). The area under the curve of the scales ranged from 0.70 (95% CI, 0.65-0.75) to 0.77 (95% CI, 0.73-0.82) in women versus 0.69 (95% CI, 0.64-0.73) to 0.75 (95% CI, 0.71-0.79) in men. Positive predictive values ranged from 0.23 (95% CI, 0.20-0.27) to 0.29 (95% CI, 0.26-0.31) in women versus 0.29 (95% CI, 0.24-0.33) to 0.37 (95% CI, 0.32-0.43) in men. Negative predictive values were similar (0.95 [95% CI, 0.94-0.96] to 0.98 [95% CI, 0.97-0.98] in women versus 0.94 [95% CI, 0.93-0.95] to 0.96 [95% CI, 0.94-0.97] in men). Sensitivity of the scales was slightly higher in women than in men (0.53 [95% CI, 0.43-0.63] to 0.76 [95% CI, 0.68-0.84] versus 0.49 [95% CI, 0.40-0.57] to 0.63 [95% CI, 0.55-0.73]), whereas specificity was lower (0.79 [95% CI, 0.76-0.81] to 0.87 [95% CI, 0.84-0.89] versus 0.82 [95% CI, 0.79-0.84] to 0.90 [95% CI, 0.88-0.91]). Rapid arterial occlusion evaluation showed the highest positive predictive values in both sexes (0.29 in women and 0.37 in men), reflecting the different event rates. aLVO scales show similar diagnostic performance in both sexes. The rapid arterial occlusion evaluation scale may help optimize prehospital transport decision-making in men as well as in women with suspected stroke.

CHinese Acute Tissue-Based Imaging Selection for Lysis In Stroke Tenecteplase II (CHABLIS-T II): rationale and design

Background and purposeTenecteplase (TNK) has demonstrated non-inferiority to alteplase in patients who had an acute ischaemic stroke presenting within 4.5 hours from symptom onset. The trial is aimed to explore...

Abstract TP44: Door In-Door Out Times: A Comprehensive Stroke Center Review

Expeditious transfer of patients with acute ischemic stroke (AIS) and LVO presenting to a primary stroke center (PSC) and within the window for mechanical thrombectomy (MT) is vital to optimize their functional outcome. Door-in-door-out (DIDO) represents the time of patient arrival to the PSC to the time of discharge from the PSC for transfer to a comprehensive stroke center (CSC). The goal for this metric is 90 minutes. At a large urban academic and CSC with a high volume of patient transfers, we examined our DIDO metrics to identify trends and opportunities for improvement. Methods: The CSC MT database was queried to analyze DIDO times. Inclusion criteria included AIS cases with LVO transferred to the CSC for MT from fiscal year 2022-2023. Hospitals transferring less than 5 cases during that timeframe, inpatient cases, and unavailable times were excluded. Hospital DIDO times and their components (i.e. each step in the process) were grouped into quartiles and analyzed. A survey to PSC stakeholders was sent to identify themes for possible barriers. Results: Among 8 hospitals, the top quartile with the fastest DIDO times had a mean of 132 minutes and median of 122 (N = 22 patients). The hospitals with the longest DIDO had a mean of 205 and a median of 193 (N=17). The components of DIDO times that separated the fastest from the slowest were PSC arrival to 1 st call to CSC and 1 st call of PSC to acceptance at CSC . The PSCs with the highest DIDOs took double the time in these components (40 vs 81, 22 vs 53 minutes). Distance from the CSC does not appear to be a factor in DIDO times, with the fastest being 13 to 68 miles away vs. 11 to 30 miles for the slowest. In the survey results, 81% of participants had CSC bed availability as the top barrier, whereas 69% reported delays in transport time to PSC. Conclusion: DIDO times from PSCs continues to be an opportunity for process improvement. Only 5% in our sample met the DIDO metric goal of 90 minutes. Two areas of potential improvement include decreasing PSC time to 1 st call and improving time of CSC acceptance. PSCs believe that a “ready” bed at the CSC would decrease DIDO times, but there are additional opportunities among the components.

Endovascular thrombectomy is cost-saving in patients with acute ischemic stroke with large infarct.

Endovascular thrombectomy (EVT) is the standard of care for acute large vessel occlusion stroke. Recently, the ANGEL-ASPECT and SELECT 2 trials showed improved outcomes in patients with acute ischemic Stroke presenting with large infarcts. The cost-effectiveness of EVT for this subpopulation of stroke patients has only been calculated using data from the previously published RESCUE-Japan LIMIT trial. It is, therefore, limited in its generalizability to an international population. With this study we primarily simulated patient-level costs to analyze the economic potential of EVT for patients with large ischemic stroke from a public health payer perspective based on the recently published data and secondarily identified determinants of cost-effectiveness. Costs and outcome of patients treated with EVT or only with the best medical care based on the recent prospective clinical trials ANGEL-ASPECT, SELECT2 and RESCUE-Japan LIMIT. A A Markov model was developed using treamtment outcomes derived from the most recent available literature. Deterministic and probabilistic sensitivity analyses addressed uncertainty. Endovascular treatment resulted in an incremental gain of 1.32 QALYs per procedure with cost savings of $17,318 per patient. Lifetime costs resulted to be most sensitive to the costs of the endovascular procedure. EVT is a cost-saving (i.e., dominant) strategy for patients presenting with large ischemic cores defined by inclusion criteria of the recently published ANGEL-ASPECT, SELECT2, and RESCUE-Japan LIMIT trials in comparison to best medical care in our simulation. Prospective data of individual patients need to be collected to validate these results.

Acute ischaemic larger artery stroke presenting as a subcortical lesion with grey matter sparing: a case report

Large artery infarctions classically involve both white matter and grey matter in the distribution of the occluded artery. Rarely, large artery infarctions can present as isolated white matter lesions. We describe a 38-year-old, right-hand dominant woman, who presented with sudden onset right face-arm-leg weakness together with expressive aphasia. Neuroimaging demonstrated changes restricted to the white matter in the distribution of the left middle cerebral artery territory. Vascular imaging of her head and neck vessels showed irregular narrowing of the intracranial portions of the left internal carotid artery. Vasculitis was suspected due to these findings on imaging, and she was initially treated with steroids. However, due to the negative vasculitis work-up and an inadequate response, the steroids were discontinued, and she was treated with antiplatelets and statins. Early stroke rehabilitation commenced while inward.Large artery ischaemic strokes can rarely present as white matter lesions when there is adequate collateral circulation, which leads to the sparing of the grey matter.

Sex differences in acute ischemic stroke presentation are a matter of infarct location

IntroductionRecognition of stroke by Emergency Medical Services (EMS) is critical to initiate rapid emergency department treatment. Most prehospital stroke screening tools rely heavily on presentation with the classic symptoms of facial droop, speech changes, unilateral weakness. However, women may be less likely to present with classic symptoms and may also have different distributions of stroke by anatomical location. This study seeks to determine the association between biological sex, presentation with classic symptoms, and the location of the infarcted tissue. MethodsThis is a retrospective cohort study. Data from electronic health records were extracted for patients with acute ischemic stroke who presented via EMS to a single Comprehensive Stroke Center between January 1, 2018 and December 31, 2020. We used descriptive statistics characterize the cohort. Multivariable logistic regression identified factors associated with classic symptom presentation (facial droop, speech changes, and/or unilateral weakness). Biological sex, location of the infarct, stroke etiology, age and the interaction between sex and infarct location were assessed as covariates. ResultsThere were 364 (58.6%) males and 257 (41.1%) females with an acute ischemic stroke included in this study. EMS documented one or more classic symptoms in 125 (72.3%) males and 161 (67.9%) females. There were no baseline differences in infarct location or presentation with classic symptoms as documented by EMS comparing males and females. Multivariate logistic regression found no association between biological sex and presentation with classic symptoms (Odds Ratio 1.08; 95% CI 0.58 to 1.55) after controlling for age, stroke location, etiology of stroke or the interaction between sex and infarct location. Presence of an anterior circulation infarct compared to posterior circulation infarct was positively associated with a classic presentation to EMS (Odds Ratio 3.41; 95% CI 2.15 to 5.41). ConclusionsThis study found no difference in the frequency of patient presentation with classic stroke symptoms based on biological sex alone, nor a significant different in distribution of infarcts between males and females. Infarct location (i.e., involving the anterior circulation) was associated with a classic presentation. This suggests that the likelihood of presenting with classic stroke symptoms is not influenced by sex, but rather the location of the infarct.

Simultaneous Cardiocerebral Infarction Associated with Postcoital Activity

BackgroundCardiocerebral infarction (CCI) is a rare and life-threatening presentation of simultaneous acute myocardial infarction and acute ischemic stroke that requires prompt recognition and proper treatment. CCI is time sensitive and carries a high mortality rate. There is no standardized treatment algorithm that addresses both conditions simultaneously. Case ReportWe present a 29-year-old man with simultaneous myocardial infarction and thrombotic stroke after coital activity. He presented to the Emergency Department with left-sided extremity weakness and numbness and radicular left-sided chest pain. He suffered a cardiac arrest during his evaluation and required emergent percutaneous coronary intervention with stent placement. He was resuscitated successfully and had an uncomplicated clinical course, with improved neurologic recovery prior to discharge. Why Should an Emergency Physician Be Aware of This?CCI is a rare condition that typically occurs in elderly patients with risk factors for cardiovascular disease. Management is challenging due to the time-sensitive nature of diagnosis and treatment of each condition. Treatment is not standardized, unlike individual evidence-based algorithms for thrombotic stroke and acute myocardial infarction. Risks and benefits for each treatment plan should be weighed and therapy should be directed toward the most immediate life-threatening process. This case would add to the literature surrounding this condition and help guide emergency physicians toward the most optimal treatment strategies for this patient population. This case also raises awareness of the existence of this condition and its potential presence in young, otherwise healthy patients.

Changes of migraine aura with advancing age of patients

AimGiven the similar presentation of migraine aura and acute ischemic stroke, advancing patient age might change the characteristics of migraine with aura (MA) and be clinically important. Clinical data, however, are limited. Experimental studies indicate a decrease in the magnitude of cortical spreading depression (CSD), the pathophysiological correlate of migraine aura, with advancing age. Our study aimed to assess the influence of age on the clinical features of MA.MethodsThree hundred and forty-three patients were interviewed using a structured questionnaire. The questions covered the headache characteristics and symptom types including the characteristics of the C-criterion, as defined by the International Classification of Headache Disorders 3rd Edition. The association of age with MA characteristics was assessed.ResultsThe median age was 29 (IQR 28–52) and 235 of the 343 patients were women (69%). Individual symptoms of the C-criterion such as gradual aura spreading over longer than 5 min (P < 0.001), two or more aura symptoms occurring in succession (P = 0.005), duration of at least one MA symptom for longer than 60 min (P = 0.004), and associated headache (P = 0.01) were more frequent in younger patients. The number of symptoms (P = 0.003) including the C-characteristics decreased with increasing age (P < 0.027). Patients with sensory (P < 0.001), motor (P = 0.04) and speech disturbance (P = 0.02) were younger, and older patients with headache had less photophobia (P = 0.04) and phonophobia (P = 0.03). Sensitivity analyses yielded similar results.ConclusionThe frequency of typical characteristics of migraine aura and migraine headache including photophobia and phonophobia decreases with advancing patient age. This might have potentially difficult implications for the diagnosis of MA in the elderly.

Dual Antiplatelet Therapy vs Alteplase for Patients With Minor Nondisabling Acute Ischemic Stroke

Intravenous thrombolysis is increasingly used in patients with minor stroke, but its benefit in patients with minor nondisabling stroke is unknown. To investigate whether dual antiplatelet therapy (DAPT) is noninferior to intravenous thrombolysis among patients with minor nondisabling acute ischemic stroke. This multicenter, open-label, blinded end point, noninferiority randomized clinical trial included 760 patients with acute minor nondisabling stroke (National Institutes of Health Stroke Scale [NIHSS] score ≤5, with ≤1 point on the NIHSS in several key single-item scores; scale range, 0-42). The trial was conducted at 38 hospitals in China from October 2018 through April 2022. The final follow-up was on July 18, 2022. Eligible patients were randomized within 4.5 hours of symptom onset to the DAPT group (n = 393), who received 300 mg of clopidogrel on the first day followed by 75 mg daily for 12 (±2) days, 100 mg of aspirin on the first day followed by 100 mg daily for 12 (±2) days, and guideline-based antiplatelet treatment until 90 days, or the alteplase group (n = 367), who received intravenous alteplase (0.9 mg/kg; maximum dose, 90 mg) followed by guideline-based antiplatelet treatment beginning 24 hours after receipt of alteplase. The primary end point was excellent functional outcome, defined as a modified Rankin Scale score of 0 or 1 (range, 0-6), at 90 days. The noninferiority of DAPT to alteplase was defined on the basis of a lower boundary of the 1-sided 97.5% CI of the risk difference greater than or equal to -4.5% (noninferiority margin) based on a full analysis set, which included all randomized participants with at least 1 efficacy evaluation, regardless of treatment group. The 90-day end points were assessed in a blinded manner. A safety end point was symptomatic intracerebral hemorrhage up to 90 days. Among 760 eligible randomized patients (median [IQR] age, 64 [57-71] years; 223 [31.0%] women; median [IQR] NIHSS score, 2 [1-3]), 719 (94.6%) completed the trial. At 90 days, 93.8% of patients (346/369) in the DAPT group and 91.4% (320/350) in the alteplase group had an excellent functional outcome (risk difference, 2.3% [95% CI, -1.5% to 6.2%]; crude relative risk, 1.38 [95% CI, 0.81-2.32]). The unadjusted lower limit of the 1-sided 97.5% CI was -1.5%, which is larger than the -4.5% noninferiority margin (P for noninferiority <.001). Symptomatic intracerebral hemorrhage at 90 days occurred in 1 of 371 participants (0.3%) in the DAPT group and 3 of 351 (0.9%) in the alteplase group. Among patients with minor nondisabling acute ischemic stroke presenting within 4.5 hours of symptom onset, DAPT was noninferior to intravenous alteplase with regard to excellent functional outcome at 90 days. ClinicalTrials.gov Identifier: NCT03661411.

Thrombectomy vs. medical management for large vessel occlusion strokes with minimal symptoms.

Patients with acute ischemic stroke (AIS) presenting mild symptoms with a low National Institutes of Health Stroke Scale (NIHSS) score ≤8 and also found to have an intracranial large vessel occlusion (LVO) undergo endovascular thrombolysis (ET) or medical management alone. The current study aimed to evaluate the safety and effectiveness of medical management vs. ET therapy among patients with mild AIS symptoms (NIHSS score ≤8) accompanied by LVO. The present meta-analysis included articles involving mild AIS, LVO, thrombectomy/ET and medical management alone published in full-text form (from 1980 to 2022). Collected variables included: First author name, covered study period, publication year, the total number of patients and age, number of males, presence of diabetes mellitus, hypertension, atrial fibrillation, prior ischemic stroke, location, NIHSS of admission, modified Rankin scale, bleeding, morbidity and mortality. After the initial search and applying all exclusion and inclusion criteria, eight articles were left in the final article pool. The total number of patients who underwent ET was 569, compared with 1097 with medical management for LVO strokes with minimal symptoms. The findings of the present meta-analysis study point out that ET management may be associated with a high risk of bleeding and mortality in patients with LVO presenting with mild symptoms (NIHSS score ≤8).

Outcomes of mechanical thrombectomy at a single-centre tertiary level public healthcare hospital in South Africa.

Mechanical thrombectomy (MT) is standard of care for acute ischaemic stroke from large vessel occlusion following randomised controlled trials performed largely in high-income countries. Limited data exists on its effectiveness in the setting of low-and-middle-income countries. We aimed to evaluate the safety and efficacy of MT in a tertiary level public hospital in Cape Town, South Africa. Patients with acute ischaemic stroke presenting consecutively to Groote Schuur Hospital between 1 January 2018 to 1 January 2022 with proximal intracranial occlusion in the anterior circulation treated with MT within 6 h from onset using computed tomography (CT) and CT angiography imaging-based protocols were evaluated. Demographic, clinical, radiological and procedural data were obtained from the stroke unit database. Recanalisation was evaluated post-procedure by modified Treatment in Cerebral Infarction score (mTICI). Functional independence (modified Rankin scores 0-2) and mortality at 90 days were also assessed. Thrombectomies were performed in 84 patients during the study period. The median age was 56 years (interquartile range, IQR) and 51% of participants were female. Median National Institute of Health Stroke Score was 18 and median baseline Alberta Stroke Programme Early CT score was 8. Bridging thrombolysis was given to 65% of participants. Median time from symptom onset to reperfusion was 339 min (IQR). Successful recanalisation (mTICI 2b/3) was obtained in 62%. At 90 days, 34% of participants gained functional independence and mortality was 34%. This study demonstrated similar rates of recanalisation and functional independence to that seen in trials in high-income countries using basic imaging despite a higher mortality and longer median time to reperfusion. This data supports the effectiveness of MT in a tertiary level public hospital in South Africa despite the challenges of providing emergent stroke care in a resource-constrained setting.

March 2023 Stroke Highlights.

March 2023 Stroke Highlights.

Abstract TP77: Point Of Care Inr And R-tpa Decision Making In Acute Ischemic Stroke

Introduction: IV r-tPA is the standard of care treatment in acute ischemic stroke presenting within 4.5 hours of last known well. Exclusion criteria for administering IV r-tPA include conditions that predispose to bleeding, including an INR of ≥ 1.7 . Point of care (POC) INR testing is significantly faster than laboratory derived INR results and can expedite IV r-tPA administration. However, POC INR testing is less accurate than laboratory-based testing with an acceptable variance range of +/- 0.4, which may lead to improper r-tPA exclusion or inclusion. Objectives: We demonstrate the utility of a protocolized approach to POC INR testing in acute ischemic stroke, in which known or suspected warfarin use requires a lab INR result to determine if r-tPA is contraindicated when POC INR is between 1.3-2.1. This approach prevents IV r-tPA from being inappropriately administered or withheld. Methods: We stratified a subset of real world paired POC and laboratory INR results (n=892) for stroke code patients at our institution from January 1st through July 4 th , 2022 by known or suspected warfarin status and calculated a positive predictive value for POC INR &gt; 1.7. Results: Fifty-four of 892 paired POC and laboratory INR results represented patients with known or suspected warfarin use. Twenty-five (46%) had a POC INR within 1.3-2.1 warranting a lab INR verification prior to safe administration of r-tPA. Thirteen of which had a POC INR &lt; 1.7 but a lab INR of ≥ 1.7. In 5.25% of cases where the POC INR &gt; 1.7 the laboratory INR was &lt; 1.7. The positive predictive value for POC INR &gt;= 1.7 among patients with known or suspected warfarin status is 88.2%. Conclusions: POC INR testing rapidly screens for coagulopathy in IV tPA eligible stroke patients, but due to inherent inaccuracy may inadvertently rule patients in or out for IV r-tPA treatment. Our institution has instituted a policy of requiring laboratory verified INR results when the POC INR is within +/- 0.4 of the laboratory based INR tPA cutoff. In our 892 patient sample, this policy would prevent 13 patients from inadvertently receiving IV tPA due to an inaccurate POC INR. Up to five percent of patients excluded from r-tPA based on POC INR may in-fact be treatment candidates.

Abstract WMP50: Lesion-symptom Mapping For Post-stroke Depression

Background: Post-stroke depression poses an important challenge for patients and delays reintegration to societal roles. Earlier identification of patients at higher risk for depression based on clinical imaging would allow a tailored treatment approach. Methods: We conducted machine-learning based lesion-symptom mapping (LSM) using a retrospective cohort of 477 patients with first-ever acute ischemic stroke (AIS) presenting to a large cerebrovascular center from 2013-2019 with mild motor impairment defined by mRS 0-2. Patient Health Questionnaire (PHQ-9) depression scale was collected within 60 days of index stroke. The location and volume of AIS lesions on brain MRI were analyzed using a machine-learning based algorithm coupled with the FreeSurfer parcellation package. LSM after random field theory-based multiple comparison correction was conducted to examine the association of AIS location and volume with PHQ-9 scale, adjusting for patient age, sex and NIHSS. Results: AIS in the right temporal, parietal, occipital lobes and the right basal ganglia were associated with depressive symptoms (Figure A). Sensitivity analysis excluding those with significant sleep disturbance (n=24) demonstrated that strokes in the right frontal and parietal lobes were associated with severe depression measured by PHQ-9&gt;10 (Figure B). Conclusions: This hypothesis generating study was suggestive of a neuroanatomic basis for the development of post-stroke depression. Further studies in a larger dataset are needed to confirm these associations. The methods will help to predict those patients at higher risk for post-stroke depression, allowing for earlier intervention and recovery.

COVID-19 independently predicts poor outcomes in Acute Ischemic Stroke- Insights from a multicenter study from Pakistan and United Arab Emirates

BackgroundIschemic stroke associated with coronavirus 2019 (COVID-19) has been well recognized by now. Few studies have compared COVID related versus unrelated strokes. We intend to report on a large group of Asian patients from two countries and compare COVID with non-COVID strokes admitted during the same time period. MethodsConsecutive cases of acute ischemic stroke either presenting or developing, between March 2020 and December 2021 in four tertiary care hospitals (1 in Dubai, UAE and 3 in Karachi, Pakistan) and testing positive for COVID-19 were included in the study. Patients admitted with ischemic stroke during the same time period and who tested negative for COVID-19 were also randomly selected from the four hospitals. All data was collected from the medical records of the patients and recorded on a standard questionnaire before it was entered in SPSS version 21 for analysis. ResultsThere were 139 COVID positive and 271 COVID negative patients with acute ischemic stroke included in the current study. There were significantly more males (80.6% vs 64.9%, p=0.001) and more large vessel strokes in the COVID positive group (41% vs 21.8%, p<0.001). Being COVID positive was an independent predictor of poor outcome at discharge, defined as a modified Rankin score of 3-6 (OR 3.87, 95% CI 2.21-6.77) after adjusting for country, age, sex, vascular comorbid conditions and stroke subtype. ConclusionsIn this largest series of patients with COVID related strokes from Asia, COVID-19 was an independent predictor of poor outcomes at discharge after adjusting for other variables.

Acute ischemic stroke for alteplase or medical care alone or intervention with/without alteplase in Palestine (AIS-AMI Palestine)

Background: Stroke is the most common cause of permanent disability and the third most common cause of death in Palestine. We aimed to examine patterns of stroke presentation, causes, management and outcomes at the largest public Mistry of health hospitals in Palestine. Methods: Comprehensive data from all patients with acute ischemic stroke who were admitted to al-Shifa hospital between November 2021 and July 2022 and treated with alteplase alone or endovascular intervention with or without alteplase were prospectively collected and compare with acute ischemic stroke patients who were treated with medical care alone at Palestine medical complex hospital at 2018. Acute ischemic stroke presentation patterns, in-hospital evaluation and management, mortality, and morbidity were evaluated. Results: Medical care alone group: 138 patients with acute ischemic stroke, mean age was 65 ± 14 years and 49% were women. Most of the patients received antiplatelet therapy (98%), although none received thrombolysis. Only 17% received physical therapy evaluation. In-hospital mortality was 13%, and a modified ranking score of 0 -2 was in 44 patients (32%). Endovascular intervention with/without alteplase group: 56 patients with acute ischemic stroke. The mean age was 61 ± 12 years and 41% were women. All patients received brain computed tomography scans, although few received other investigations such as carotid Doppler (13%). Most patients with ischemic stroke received antiplatelet therapy (99%), although 39 patients (70%) received thrombolysis. Only 61% received physical therapy evaluation. In-hospital mortality was 7%. The modified ranking score 0 - 2: 32 patients (57%). Conclusion: This study conducted in Palestine showed that among patients with acute ischemic stroke, functional outcomes according to modified ranking score 0 - 2 were better by endovascular therapy with/without alteplase than with medical care alone.