Acute Ischemic Stroke Admissions Research Articles

National Institutes of Health Stroke Scale Reporting in Medicare Claims Data: Reporting in the First 3 Years.

Since 2016, hospitals have been able to document International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes for the National Institutes of Health Stroke Scale (NIHSS). As of 2023, the Centers for Medicare & Medicaid Services uses NIHSS as a risk adjustment variable. We assessed associations between patient- and hospital-level variables and contemporary NIHSS reporting. We performed a retrospective cross-sectional analysis of 2019 acute ischemic stroke admissions using deidentified, national 100% inpatient Medicare Fee-For-Service data sets. We identified index acute ischemic stroke admissions using the ICD-10-CM code I63.x and abstracted demographic information, medical comorbidities, hospital characteristics, and NIHSS. We linked Medicare and Mount Sinai Health System (New York, NY) registry data from 2016 to 2019. We calculated NIHSS documentation at the patient and hospital levels, predictors of documentation, change over time, and concordance with local data. There were 231 383 index acute ischemic stroke admissions in 2019. NIHSS was documented in 44.4% of admissions and by 66.5% of hospitals. Hospitals that documented ≥1 NIHSS were more commonly teaching hospitals (39.0% versus 5.5%; standardized mean difference score, 0.88), stroke certified (37.2% versus 8.0%; standardized mean difference score, 0.75), higher volume (mean, 80.8 [SD, 92.6] versus 6.33 [SD, 14.1]; standardized mean difference score, 1.12), and had intensive care unit availability (84.9% versus 23.2%; standardized mean difference score, 1.57). Adjusted odds of documentation were lower for patients with inpatient mortality (odds ratio, 0.64 [95% CI, 0.61-0.68]; P<0.0001), in nonmetropolitan areas (odds ratio, 0.49 [95% CI, 0.40-0.61]; P<0.0001), and male sex (odds ratio, 0.95 [95% CI, 0.93-0.97]; P<0.0001). NIHSS was documented for 52.9% of Medicare cases versus 93.1% of registry cases, and 74.7% of Medicare NIHSS scores equaled registry admission NIHSS. Missing ICD-10-CM NIHSS data remain widespread 3 years after the introduction of the ICD-10-CM NIHSS code, and there are systematic differences in reporting at the patient and hospital levels. These findings support continued assessment of NIHSS reporting and caution in its application to risk adjustment models.

Age-Specific Association of Co-Morbidity With Home-Time After Acute Stroke.

To examine the association of co-morbidity with home-time after acute stroke and whether the association is influenced by age. We conducted a province-wide study using linked administrative databases to identify all admissions for first acute ischemic stroke or intracerebral hemorrhage between 2007 and 2018 in Alberta, Canada. We used ischemic stroke-weighted Charlson Co-morbidity Index of 3 or more to identify those with severe co-morbidity. We used zero-inflated negative binomial models to determine the association of severe co-morbidity with 90-day and 1-year home-time, and logistic models for achieving ≥ 80 out of 90 days of home-time, assessing for effect modification by age and adjusting for sex, stroke type, comprehensive stroke center care, hypertension, atrial fibrillation, year of study, and separately adjusting for estimated stroke severity. We also evaluated individual co-morbidities. Among 28,672 patients in our final cohort, severe co-morbidity was present in 27.7% and was associated with lower home-time, with a greater number of days lost at younger age (-13 days at age < 60 compared to -7 days at age 80+ years for 90-day home-time; -69 days at age < 60 compared to -51 days at age 80+ years for 1-year home-time). The reduction in probability of achieving ≥ 80 days of home-time was also greater at younger age (-22.7% at age < 60 years compared to -9.0% at age 80+ years). Results were attenuated but remained significant after adjusting for estimated stroke severity and excluding those who died. Myocardial infarction, diabetes, and cancer/metastases had a greater association with lower home-time at younger age, and those with dementia had the greatest reduction in home time. Severe co-morbidity in acute stroke is associated with lower home-time, more strongly at younger age.

Abstract 93: Upgrading to Endovascular Therapy-Performing Hospital Increases Acute Ischemic Stroke Admissions

Introduction: Given the impact of endovascular therapy (EVT) on clinical outcomes and the use of pre-hospital bypass protocols to route acute ischemic stroke (AIS) patients to EVT-performing hospitals (EPHs), there is substantial interest in upgrading stroke center certification to become EPHs. Here, we assess trends in patient volumes of AIS admissions at three hospitals after upgrade, in comparison to one long-standing EPH and six non-EPHs within the same urban area. Methods: From our prospectively collected, multi-institutional registry, we identified consecutive AIS admissions at ten hospitals in the Houston metropolitan area from November 2017 through March 2022. One hospital had been an EPH throughout the study period (Group A: EPH 0), three transitioned to EPHs in November 2017 (Group B: EPH 1, EPH 2, EPH 3), and six were non-EPHs (Group C). Primary outcomes were trends in volume of total AIS admissions over time determined by linear regression. Secondary outcomes included trends in volumes of tPA usage, LVO admissions, and mechanical thrombectomy (MT) determined by linear regression. Results: Among 13,099 patients with AIS presenting to ten hospitals, median age was 67 [IQR 57-78], 45% were female, median NIHSS was 4 [IQR 1-11], 17.5% were given tPA, 22% had LVO, and 9.5% underwent mechanical thrombectomy. Centers that became EPH in 2017 experienced an overall increase in AIS admissions (p=0.0007) at rates of 8 per year for EPH 1 (p=0.005), 5 per year for EPH 2 (p&lt;0.001) and 4 per year for EPH 3 (p=0.11). AIS admissions did not change significantly at the original EPH (p=0.13) nor at three of the non-EPHs (p=0.24, 0.39, 0.82), and volumes decreased at the other three non-EPHs (p=0.009, 0.02, 0.09). Changes in LVO volumes did not reach significance for any group. Volumes of tPA use and MT increased for group B (p&lt;0.005) but did not change significantly for group A (p&gt;0.18), and tPA use decreased for group C (p=0.03). Conclusions: In this observational cohort study, upgrading to EPH status resulted in increasing AIS admissions over time, as well as increases in tPA use and MT. Volumes at the previously established EPH did not change significantly over the study period, while AIS admissions decreased slightly at the non-EPHs in the surrounding area.

Abstract 5: National Institutes of Health Stroke Scale Reporting in Administrative Claims Data: Incomplete and Biased Reporting in the First Three Years

Background: Since 2016, hospitals have been able to document International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes for National Institutes of Health Stroke Scale (NIHSS). As of 2023, Center for Medicare &amp; Medicaid Services uses NIHSS as a risk adjustment variable. We assessed associations between patient- and hospital-level variables and contemporary NIHSS reporting using Medicare datasets. Methods: Retrospective cross-sectional analysis of acute ischemic stroke (AIS) admissions from October 1, 2016-December 31, 2019 using de-identified, national 100% inpatient Medicare datasets. Index AIS admissions were identified using the ICD-10-CM code of I63.x. Demographic information, medical comorbidities, hospital characteristics, and NIHSS were abstracted. Medicare and Mount Sinai Health System registry data were linked using a matching algorithm. We calculated documentation of NIHSS at the patient and hospital level, predictors of NIHSS documentation, change over time, and concordance with local registry data. Results: There were 770104 index AIS admissions. NIHSS was documented in 40.1% of AIS admissions and by 62.5% of hospitals. Hospitals documenting ≥1 NIHSS were more commonly teaching hospitals, in metropolitan areas, stroke certified, higher-volume, and had ICU availability. Adjusted odds of documentation were lower for patients of black race compared to white and with inpatient mortality, increasing Charlson comorbidity score, discharge home, and treatment in non-metropolitan areas. NIHSS was documented for 52.9% of Medicare cases even though it was documented in 93.1% of registry cases, and 74.7% of Medicare NIHSS scores equaled registry admission NIHSS. Conclusions: Hospitals face financial implications for risk-standardized mortality rate adjustment, and administrative data play an increasingly important in stroke health services and outcomes research. Yet, missing ICD-10-CM NIHSS data remains widespread three years after introduction of the ICD-10-CM NIHSS code, and there are systematic differences in reporting at the patient and hospital levels.

Abstract WMP86: Mechanical Thrombectomy Frequency and Outcomes in Acute Ischemic Stroke With Mild Deficits in the Unites States

Background: More than half of patients with acute ischemic stroke have minor neurological deficits; however, the frequency and outcomes of reperfusion therapy in regular practice hasn't been well-delineated. Methods: Analysis of US National Inpatient Sample of hospitalizations with acute ischemic stroke and mild deficits (National Institutes of Health Stroke Scale [NIHSS] score 0-5) from October 1, 2016 to December 31, 2020. Patient and hospital-level characteristics associated with use and outcome of reperfusion therapies were analyzed. Primary outcomes included excellent discharge disposition (discharge to home without assistance); poor discharge disposition (discharge to facility or death) and in-hospital mortality. Results: Among 1,013,055 acute ischemic stroke admissions with recorded NIHSS during the 4-year study period, 601,645 (59.4%) had mild strokes (46.6% women; median age, 69 [interquartile range (IR), 59-79] years; median NIHSS score of 2 [IR, 1-3]). Among 70,765 hospitalizations with MT and documented NIHSS, mild deficits accounted for 8,900 (12.6%) of MT procedures (47% women; median age, 67 [IR, 57-77] years; median NIHSS score of 3 [IR, 2-4]). There was a gradual increase in the proportion of MTs performed among mild strokes during study period (10% to 13.5%, p&lt;0.01). Favorable discharge outcome occurred in 65.8% of all mild strokes and in 56.9% of strokes with mild deficits following MT. In multivariable analysis among stroke patients with minor deficits with thrombectomy, favorable outcome was associated with younger age (OR, 0.96 [95% CI, 0.95-0.97], P&lt;0.001), male sex (OR, 0.77 [95% CI, 0.62-0.95], P&lt;0.001), lower NIHSS score (OR, 0.85 [95% CI, 0.80-0.90], P&lt;0.001), history of atrial fibrillation (OR, 1.27 [95% CI, 1.01-1.60], P&lt;0.001), and absence of diabetes (OR, 0.77 [95% CI, 0.60-0.98], P&lt;0.001). Conclusions: In conclusion, we observed a recent trend of gradual increase in the use of MT in mild strokes in US. Favorable discharge outcomes were achieved in a significant proportion of mild strokes following MT. Further research and clinical trials should aim to refine patient selection criteria and treatment protocols to optimize the use of MT in mild strokes.

Abstract 97: Acute Ischemic Stroke Despite Anticoagulant Use: The Neuro-AFib Study

Background: Acute ischemic stroke (AIS) admissions in patients with atrial fibrillation (AF) using anticoagulants (AIS-despite-AC) are commonly seen in stroke units but data on their frequency, causes, and outcomes are scarce. Methods: The Neuro-AFib study is a multicenter effort geared toward elucidating the causes and consequences of strokes in a contemporary AF cohort. Detailed clinical, laboratory and multimodal imaging data from known AF patients consecutively admitted to 20 stroke centers with an IS between 1/2018-12/2019 were used to define characteristics of AIS-despite-AC and compared to AIS-off-AC. Results: Out of 4456 patients with known AF prior to the AIS, 2051 (46%) were using anticoagulants. Patients who had AIS-despite-AC were younger (76.8 + 11 vs 77.8 + 12, p=0.007), had higher mean CHA 2 DS 2 -VASc scores (4.57 + 1.7 vs 4.21 + 1.7, p&lt;0.001), and they were more likely to have permanent AF (23.5% vs 19.6%, p=0.002) and a past-history of stroke/TIA (36% vs 25%, p&lt;0.001) when compared to non-AC group. Chronic embolic (non-lacunar) infarcts on imaging were more common among AIS-despite-AC (34.5% vs 26.7%, p&lt;0.001). Acute large vessel occlusion (LVO) was common among AIS-despite-AC (48%). The pattern of the acute infarcts (numbers, embolic features) was not different. The calculated acute infarct volume was large (34ml) and mean NIHSS was 10.4 for AIS-despite-AC. Intravenous thrombolysis was used much less commonly for AIS-despite-AC (10.5% vs 32.1%, p&lt;0.001). Symptomatic carotid disease was suspected in 2.4%, a hypercoagulable condition in 5.7%, whereas acute lacunar infarct was found in 6.5% of all patients. Death or significant disability (mRS 3-5) at hospital discharge were common in AIS on vs off AC (70.6% vs 75.2%, p&lt;0.001). Conclusions: Based on a large multicenter cohort, AF patients who have AIS-despite-AC have higher AF load and risk scores, most don't have a concurrent etiology and they are more likely to have recurrent embolic events. The stroke severity, common presence of LVO, infarct size, and poor outcomes are alarming features, and most patients are unable to receive thrombolysis because of AC use. Overall, detection of AF patients at risk of AIS-despite-AC and development of specific preventive modalities should be priorities.

Provider Care Segregation and Hospital-Region Racial Disparities in the United States for Acute Ischemic Stroke and Endovascular Therapy Outcomes.

Reasons for racial disparities in the use and outcomes of endovascular treatment (ET) are not known. We examined patterns in care segregation for acute ischemic stroke (AIS) in the United States, and outcomes of segregation of care after ET. We used deidentified Medicare data sets to identify AIS admissions between January 1, 2016 and December 31, 2019, using validated International Classification of Diseases, Tenth Revision (ICD-10) codes. For AIS, we calculated (1) the proportion of White patients at the hospital, (2) the proportional difference in the proportion of White patients between hospital patients and the county, and (3) provider care segregation by the dissimilarity index for ET cases. Using unadjusted and adjusted multilevel logistic models, we examined associations between measures of segregation and outcomes of discharge home, inpatient mortality, and 30-day mortality. The mean proportional difference in the proportion of White patients comparing hospitalized patients with AIS to the county race distribution was 0.015 (SD, 0.219) at the hospital level. For ET, the mean proportional difference in the proportion of White patients comparing patients receiving ET to the county race distribution was much higher, at 0.146 (SD, 0.374). The dissimilarity index for ET providers was high, with a mean of 0.48 (SD, 0.29) across all hospitals. Black patients with AIS (compared with White patients) had reduced odds of discharge home, inpatient mortality, and 30-day mortality. In this national study with contemporary data in the endovascular era of AIS treatment, we found substantial evidence for segregation of care in the United States, not for only AIS in general but also especially for ET.

Plateauing atrial fibrillation burden in acute ischemic stroke admissions in the United States from 2010 to 2020.

Utilization of oral anticoagulants for acute ischemic stroke (AIS) prevention in patients with atrial fibrillation (AF) increased in the United States over the last decade. Whether this increase has been accompanied by any change in AF prevalence in AIS at the population level remains unknown. The aim of this study is to evaluate trends in AF prevalence in AIS hospitalizations in various age, sex, and racial subgroups over the last decade. We used data contained in the 2010-2020 National Inpatient Sample to conduct a serial cross-sectional study. Primary AIS hospitalizations with and without comorbid AF were identified using International Classification of Diseases Codes. Joinpoint regression was used to compute annualized percentage change (APC) in prevalence and to identify points of change in prevalence over time. Of 5,190,148 weighted primary AIS hospitalizations over the study period, 25.1% had comorbid AF. The age- and sex-standardized prevalence of AF in AIS hospitalizations increased across the entire study period 2010-2020 (average APC: 1.3%, 95% confidence interval (CI): 0.8-1.7%). Joinpoint regression showed that prevalence increased in the period 2010-2015 (APC: 2.8%, 95% CI: 1.9-3.9%) but remained stable in the period 2015-2020 (APC: -0.3%, 95% CI: -1.0 to 1.9%). Upon stratification by age and sex, prevalence increased in all age/sex groups from 2010 to 2015 and continued to increase throughout the entire study period in hospitalizations in men 18-39 years (APC: 4.0%, 95% CI: 0.2-7.9%), men 40-59 years (APC: 3.4%, 95% CI: 1.9-4.9%) and women 40-59 years (APC: 4.4%, 95% CI: 2.0-6.8%). In contrast, prevalence declined in hospitalizations in women 60-79 (APC: -1.0%, 95% CI: -0.5 to -1.5%) and women ⩾ 80 years over the period 2015-2020 but plateaued in hospitalizations in similar-aged men over the same period. AF prevalence in AIS hospitalizations in the United States increased over the period 2010-2015, then plateaued over the period 2015-2020 due to declining prevalence in hospitalizations in women ⩾ 60 years and plateauing prevalence in hospitalizations in men ⩾ 60 years.

Abstract 17538: The Weekend Effect on In-Hospital Outcomes of Elderly Patients With Acute Ischemic Stroke and Concurrent COVID-19 Infection: A Nationwide Multicenter Study

Background: Acute ischemic stroke (AIS) and COVID-19 are individually associated with poor outcomes. The impact of the pandemic on the US healthcare system, including staff shortages and disparities, may have delayed timely interventions and adherence to guidelines. We investigated the Weekend Effect on outcomes in elderly patients with AIS and COVID-19 to better understand its relationship during the challenging pandemic period. Methods: Using ICD-10-CM codes, we analyzed AIS and COVID-19 hospitalizations among the elderly (&gt;65 years) from the 2020 National Inpatient Sample. Weekday and weekend admissions were compared for baseline characteristics, comorbidities, and outcomes. The multivariable analysis was adjusted for confounding variables. A two-tailed p&lt;0.05 was considered significant. Results: Of 14,070 total AIS and concurrent COVID-19 admissions among the elderly, 10,425 were on weekdays, and 3645 were on weekends. While both cohorts exhibited comparable age distributions, the weekend admissions had a higher percentage of females (47.1% vs. 45.2%) and whites (59.5% vs. 58.1%). They had a higher prevalence of hypertension (82.2% vs. 78.6%), hyperlipidemia (52.9% vs. 50.1%), chronic pulmonary disease (19.1% vs. 17%), obesity (15% vs. 13.6%), depression (10.2% vs. 8.2%). Additionally, all-cause mortality (33.5% vs. 32.5%) and cardiogenic shock (1.9% vs. 1.7%) were slightly higher among weekend admissions. Upon adjusting for confounding factors, the overall mortality rate among weekend admissions showed no significant association, aOR-1.15 [95%CI:0.42-0.96; p-0.169]. Conclusion: Although there is a higher prevalence of comorbidities and overall mortality among weekend admissions, no significant association between the Weekend Effect and poor in-hospital outcomes in elderly COVID-19 patients with AIS was noted. However, ensuring adequate staffing and resource availability during weekends may enhance the quality of care provided.

Influence of Activated Protein C Resistance on Short-Term Hospital Outcomes Following Admission for Acute Ischemic Stroke in the United States

Introduction: Activated protein C (APC) plays a crucial role in breaking down factor Va and VIIIa, preventing excessive blood clotting. APC resistance occurs when protein C is unable to degrade these factors, leading to a higher risk of thrombosis. This condition can be either hereditary or acquired, with the most common cause being the factor V Leiden mutation. While previous studies have indicated that APC resistance increases the likelihood of acute ischemic stroke (AIS), their specific outcomes have not been extensively studied. Our research aims to bridge this gap via a national study. Methods: We used hospital records via the National Inpatient Sample (NIS) for our study. It consists of de-identified in-patient data, released on an annual basis by HCUP, AHRQ, and collaborating hospitals. Patients admitted with a primary diagnosis of AIS were recruited. We excluded all hospitalizations of ages &amp;lt;18 years. The impact of APCR status on outcomes and in-hospital complications such as acute kidney injury (AKI), myocardial infarction (MI), thrombolysis, mechanical thrombectomy (MT), vasopressor use, seizures, unfavorable discharge (discharge to another center such as short-term hospital, skilled nursing facility, intermediate care facility, and another type of facility) was studied using multivariable regression analysis, while adjusting for the impact of several potential patient and hospital characteristics. Results: Our selection criteria identified 2631890 admissions for AIS between 2016-2020, including 5910 (0.2%) patients also reporting a diagnosis of APCR (Table 1). In addition, APCR patients were younger (mean age 60.1 vs. 70.1 years, p&amp;lt;0.01) with a lower mean Charlson Comorbidity Index (CCI) score (3.50 vs. 3.87, p&amp;lt;0.01), and showed higher odds of a history of prior stroke (19.3% vs. 15.4%, aOR 1.482, 95% CI 1.387-1.584, p&amp;lt;0.01). While both groups were primarily covered by Medicare (65.0% in non-APCR group and 47.3% in APCR patients), a higher proportion of patients with APCR were also covered by private insurance (33.0% vs 19%, p&amp;lt;0.01). The APCR group also showed a higher prevalence of Whites (85.9% vs. 68.2%, p&amp;lt;0.01). Most cases in both cohorts were treated in Urban teaching centers. While higher prevalences of smoking(43.2% vs. 39.8%, p&amp;lt;0.01), obesity (20.3% vs. 14.5%, p&amp;lt;0.01), and drug abuse (4.4% vs. 2.8%, p&amp;lt;0.01) were seen in APCR patients, they also expressed fewer cases of cirrhosis (0.3% vs. 0.7%, p&amp;lt;0.01), diabetes (30.6% vs 39.2%, p&amp;lt;0.01), hypertension (51.9% vs 58.2%, p&amp;lt;0.01), chronic kidney disease (13.7% vs 18.3%, p&amp;lt;0.01), atrial fibrillation (18.8% vs 24.9%, p&amp;lt;0.01), and lipid disorder (53.8% vs 60.3%, p&amp;lt;0.01). After careful adjustments of confounders, APCR patients showed a higher use of mechanical thrombectomy (aOR 1.523, 95% CI 1.374-1.689, p&amp;lt;0.01) and vasopressor use (aOR 1.877, 95% CI 1.435-2.455, p&amp;lt;0.01) and also reported higher odds of seizures (aOR 1.413, 95% CI 1.265-1.578, p&amp;lt;0.01) and unfavorable discharge (aOR 1.065, 95% CI 1.006-1.128, p=0.03). However, lower odds of acute kidney injury (aOR 0.87, 95% CI 0.794-0.952, p&amp;lt;0.01) and death(aOR 0.708, 95% CI 0.597-0.838, p&amp;lt;0.01) were noted. No differences in events of MI (aOR 1.161, 95% CI 0.994-1.358, p=0.06) and thrombolysis (aOR 0.94, 95% CI 0.863-1.024, p=0.159) use were seen between the two groups. Conclusion: The study reported higher short-term outcomes, including increased use of mechanical thrombectomy and vasopressors and higher odds of seizures and unfavorable discharge in APCR patients with acute stroke. However, no similar increased odds of in-patient death, acute kidney injury, thrombolysis, and myocardial infarction were noted. While the impact of APCR on stroke recurrence has been highly debated in prior studies, our analysis provides a novel update showing an increased risk of subsequent stroke in patients with a history of stroke. Encouraging more extensive studies in a clinical setting, with larger groups of people and more extended observation periods, can provide a clearer understanding of the situation and thus improve their long-term outcomes.

Association between three-territory sign and prognosis of acute ischemic stroke patients with malignancy.

Multiple cerebral infarcts are usually secondary to cardiogenic embolism, particularly through atrial fibrillation (AF). The three-territory sign (TTS) is an imaging marker that reflects multiple cerebral lesions involving three vascular territories measured by diffusion-weighted imaging (DWI), and the most common etiology is an underlying malignancy. Recent studies have shown that TTS is six times more frequently observed in acute ischemic stroke (AIS) patients with malignancy than in those with AF-related AIS. However, the relevance of TTS to the prognosis of IS patients with malignancy remains unclear. Over a 5-year period (May 2016 to 31 June 2021), AIS admissions with DWI were identified from the First Affiliated Hospital of Xi'an Jiaotong University. Patients were divided into two groups according to whether they had malignancy or AF, resulting in a total of 80 patients with known malignancy (malignancy group) and 92 patients with AF (AF group). All DWI images were reviewed to determine the territory lesion count. Demographic, clinical, and laboratory data, together with radiographic examination data and modified Rankin Scale (mRS) score within a year, were collected. The main outcome was the association between TTS and the prognosis of AIS patients with malignancy, analyzed by a multivariate logistic regression model. A total of 172 patients met the selection criteria, including 17 (21.3%) patients in the malignancy group and 8 (8.7%) patients in the AF group with TTS. Age and sex distributions were similar for AIS patients of malignancy and AF. The TTS was 2.4 times more likely to be observed in AIS patients with malignancy compared to AF-related IS patients. The univariate analysis showed that hypertension (OR = 1.137, 95%CI: 1.002-1.291), D-dimer (OR = 1.328, 95%CI: 1.022-1.726), fibrin degradation product (OR = 1.117, 95%CI: 1.010-1.236), and lactate dehydrogenase (LDH; OR = 1.007, 95%CI: 1.000-1.015) were the risk factors for the high mortality rate. Multivariate analysis showed that TTS was the independent risk factor for mortality in AIS patients with malignancy (adjusted OR: 6.866, 95% CI: 1.371-34.395). TTS was more frequently observed in AIS patients with malignancy than AF-related AIS and substantially related to high poor outcome (mRS > 2) in AIS patients with malignancy, indicating diagnostic and prognostic value in malignancy-associated hypercoagulation stroke.

Clinicopathologic Analysis of COVID‐19 Associated Thrombi in the Setting of Large Vessel Occlusion: A Prospective Case–Control Study

Background Acute ischemic stroke secondary to large vessel occlusion is among the most serious complications associated with COVID‐19 infection resulting in worse morbidity and mortality. We sought to study the association between COVID‐19 infection and large vessel occlusion thrombus pathology to better define the etiopathogenesis of this atypical cause of stroke. Methods Thrombi were collected during mechanical thrombectomy and stained using hematoxylin and eosin. Blinded analysis of pathology was prospectively performed by a board‐certified neuropathologist. Red blood cell, fibrin, and white blood cell predominance was ascertained. Concomitant peripheral blood counts and clinical and imaging data were collected and analyzed. All samples underwent performance of reverse transcription polymerase chain reaction for SARS‐CoV2. Results Between January 2020 and February 2022, a total of 952 acute ischemic stroke admissions were seen at the University Medical Center of El Paso, TX. Of these, 195 patients (20.5%) had large vessel occlusions and underwent mechanical thrombectomy and 53 patients had thrombus collected and analyzed. Seven patients (3.6%) tested positive for SARS‐CoV2. COVID‐19 positive patients were more likely to be younger (mean 57.4 years; P =0.07), male (85.7%; P =0.03), and have red blood cell predominant thrombi (85.7%; P =0.03). There was a statistically significant association between peripheral neutrophil count and white blood cell lysis in the overall cohort ( P =0.015), who did not differ according to COVID‐19 status. Conclusion Thrombi retrieved from patients who were COVID‐19 positive and had stroke demonstrated red blood cell predominance. This finding requires further investigation using appropriate immunohistochemical techniques in a larger cohort of patients.

Patterns and outcomes of weekend admission for acute ischemic stroke

Background and objectivesThe “weekend effect” describes worse care delivery during off-hours or weekends and has been demonstrated in multiple sub-specialties. Off-hours care for acute ischemic stroke (AIS) has been associated with poorer outcomes. However, there is less data about the “weekend effect” on endovascular thrombectomy (ET) outcomes. MethodsWe used Medicare 100% sample datasets and included all AIS admissions from 2018-2019, using validated International Classification of Diseases, 10th Revision, Clinical Modification codes to identify AIS and comorbidities. Medicare provides the date of admission for all hospitalizations, and the day of the week was determined and assigned to weekend (Saturday or Sunday) or weekday (Monday through Friday). We defined 3 major outcomes: inpatient mortality, discharge home (vs. other destination), and 30-day mortality. ResultsAmong 471427 AIS admissions,13.0% and 12.9% of all AIS admissions occurred on a Saturday and Sunday, respectively, less than the expected 14.3% occurring on any given day (p-value <0.0001). AIS admissions on a weekend were less likely to receive IV thrombolysis (13.6% on Saturday and 12.9% on Sunday) and ET (13.1% on Saturday and 13.2% on Sunday), p-value <0.0001. Among all AIS admissions, weekend admission was associated with worse outcomes, including higher odds of inpatient mortality (adjusted OR 1.04 [95% CI 1.01-1.08, p<0.0001]), lower odds of discharge home (0.94 [0.93-0.96, p<0.0001]), and higher odds of 30-day mortality (1.06 [1.04-1.08, p<0.0001]). However, among AIS patients treated with ET, there was no association of weekend admission with outcomes. ConclusionsIn this national and contemporary dataset, we observed that the proportion of thrombolysis and ET cases was less over the weekend, and outcomes (inpatient mortality, 30-day mortality and odds of discharge home) were worse overall. We did not observe this association among AIS patients undergoing ET on a weekend vs. weekday.

Neuron-specific enolase in hypertension patients with acute ischemic stroke and its value forecasting long-term functional outcomes

BackgroundNeuron Specific Enolase (NSE), a neuro-biochemical protein marker, may correlate with the prognosis of stroke patients. Moreover, hypertension is the most common comorbidities in patients with acute ischemic stroke (AIS), and the relationship between NSE levels and long-term functional outcomes in such an increasingly large population is unclear. The aim of the study was to investigate the relationships mentioned above and optimize the prediction models.MethodsFrom 2018 to 2020, 1086 admissions for AIS were grouped as hypertension and non-hypertension, while hypertension group was randomly divided into development and validation cohorts for internal validation. The severity of the stroke was staged by National Institutes of Health Stroke Scale (NIHSS) score. Stroke prognosis after 1 year of follow up was documented by modified Rankin Scale (mRS) score.ResultsAnalysis revealed the following findings:(i) Serum NSE levels increased greatly in hypertension subjects with poor functional outcomes(p = 0.046). However, there was no association in non-hypertension individuals(p = 0.386). (ii) In addition to the conventional factors (age and NIHSS score), NSE (OR:1.241, 95% CI: 1.025–1.502) and prothrombin time were significantly related to the incidence of unfavorable outcomes. (iii)Based on the above four indicators, a novel nomogram was established to predict the prognosis of stoke in hypertension patients with the c-index values of 0.8851.ConclusionsOverall, high baseline NSE is associated with poor 1-year AIS outcomes in hypertension patients, suggesting NSE may be a potential prognostic and therapeutic target for stroke in hypertension patients.

Direct Oral Anticoagulant Failures in Atrial Fibrillation With Stroke: Retrospective Admission Analysis and Novel Classification System.

Breakthrough acute ischemic stroke (AIS) in patients with known, nonvalvular Atrial Fibrillation (AF), on Direct Oral Anticoagulants (DOAC), is an ongoing clinical conundrum. Switching anticoagulants was shown to be ineffective in preventing recurrent AIS. Systematic, patient-level chart review of so-called "DOAC failures" may offer insight into this phenomenon. We conducted an IRB-approved, 6-year, retrospective study of AIS admissions, already prescribed DOAC for known AF. We sought plausible, alternative reasons for the AIS using a novel classification schema, CLAMP: C for Compliance concerns, L for Lacunes (small-vessel disease), A for Arteriopathy (atherosclerosis, web, or vasculitis), M for Malignancy, and P for Patent Foramen Ovale (PFO). These categories were labeled as DOAC "Pseudo-failures." Conversely, absence of CLAMP variables were labeled as DOAC "Crypto-failures" conceivably from AF itself ("atriopathy") or pharmacokinetic/pharmacogenomic dysfunction (ie, altered DOAC absorption, clearance, metabolism, or genetic polymorphisms). Forward logistic regression analysis was performed on prespecified DOAC subgroups. Of 4890 AIS admissions, 606 had AF, and 87 were previously prescribed DOAC (14.4% overall DOAC failure rate, 2.4% annualized over 6 years). Pseudo-failures comprised 77%: Compliance concerns (48.9%), Lacunes (5.7%), Arteriopathy (17.0%), Malignancy (26.1%), and PFO (2.3%). Crypto-failures comprised 23%, had lower CHADSVASc scores (AOR = .65, P = .013), and occurred more with rivaroxaban (41%) than apixaban (16%) or dabigatran (5.6%). In AIS patients with known AF, DOAC Pseudo-failures, with identified alternate etiologies, are 3 times more likely than DOAC Crypto-failures. The CLAMP schema represents a novel approach to diagnostic classification and therapeutic adjustments in patients already prescribed DOAC for AF.

Relationships among hospital acute ischemic stroke volumes, hospital characteristics, and outcomes in the US

Background and ObjectivesPrior research on volume-based patient outcomes related to acute ischemic stroke (AIS) have demonstrated contradictory results and fail to reflect recent advances in stroke care. We sought to examine contemporary relationships between hospital AIS volumes and outcomes. MethodsWe used complete Medicare datasets in a retrospective cohort study using validated International Classification of Diseases Tenth Revision codes to identify patients admitted with AIS from January 1, 2016 through December 31, 2019. AIS volume was calculated as the total number of AIS admissions per hospital during the study period. We examined several hospital characteristics by AIS volume quartile. We performed adjusted logistic regressions testing associations of AIS volume quartiles with: inpatient mortality, receipt of tissue plasminogen activator (tPA) and endovascular therapy (ET), discharge home, and 30-day outpatient visit. We adjusted for sex, age, Charlson comorbidity score, teaching hospital status, MDI, hospital urban-rural designation, stroke certification status and ICU and neurologist availability at the hospital. ResultsThere were 952400 AIS admissions among 5084 US hospitals; AIS 4-year volume quartiles were: 1st: 1-8 AIS admissions; 2nd: 9-44; 3rd: 45-237; 4th: 238+. Highest quartile hospitals more often were stroke-certified (49.1% vs 8.7% in lowest quartile, p<0.0001), with ICU bed availability (19.8% vs 4.1%, p<0.0001) and with neurologist expertise (91.1% vs 3%, p<0.0001). In the highest AIS quartile (compared to the lowest quartile), there was lower inpatient mortality (odds ratio [OR] 0.71 [95%CI 0.57-0.87, p<0.0001]), lower 30-day mortality (0.55 [0.49-0.62], p<0.0001), greater receipt of tPA (6.60 [3.19-13.65], p<0.0001) and ET (16.43 [10.64-25.37], p<0.0001, and greater likelihood of discharge home (1.38 [1.22-1.56], p<0.0001). However, when the highest quartile hospitals were examined separately, higher volumes were associated with higher mortality despite higher rates of tPA and ET receipt. ConclusionsHigh AIS-volume hospitals have greater utilization of acute stroke interventions, stroke certification and availability of neurologist and ICU care. These features likely play a role in the better outcomes observed at such centers, including inpatient and 30-day mortality and discharge home. However, the highest volume centers had higher mortality despite greater receipt of interventions. Further research is needed to better understand volume-outcome relationships in AIS to improve care at lower volume centers.

Changes in the care of acute cerebrovascular and cardiovascular conditions during the first year of the covid-19 pandemic in 746 hospitals in the USA: retrospective analysis

ObjectiveTo measure the impact of the covid-19 pandemic on admissions to hospital and interventions for acute ischemic stroke and acute myocardial infarction.DesignA retrospective analysis.Setting746 qualifying hospitals in the USA from...

Race and sex disparities in acute outcomes of patients with acute ischemic stroke and diabetes mellitus. A national inpatient sample study

BackgroundDiabetes Mellitus (DM) disproportionately affects racial minority groups and is a well-established risk factor for ischemic stroke and worse stroke outcomes. Whether racial disparities exist in acute outcomes of patients presenting with Acute Ischemic Stroke (AIS) and comorbid DM, including potential differences in the administration of evidence-based reperfusion therapy, remains unclear. We aimed to assess whether racial and sex differences exist in the acute outcomes and treatment of patients with DM presenting with AIS. MethodsJanuary 2016-December 2018 AIS admissions with diabetes were extracted from the US National Inpatient Sample (NIS). Multivariable logistic regressions assessed the association between race, sex, and differences in in-hospital outcomes (mortality, hospitalisation >4 days, routine discharge, and stroke severity). Further models assessed the relationship between race, sex, and receipt of thrombolysis and thrombectomy. All models were adjusted for relevant confounders, including comorbidities and stroke severity. Results92,404 records representative of 462,020 admissions were extracted. Median (IQR) age was 72 (61−79), with 49 % women, 64 % White, 23 % African American, and 10 % Hispanic patients. African Americans had lower odds of in-hospital mortality compared to Whites (adjusted odds ratio; 99 % confidence interval=0.72;0.61–0.86), but were more likely to have prolonged hospitalisation (1.46;1.39–1.54), be discharged to locations other than home (0.78;0.74–0.82) and have moderate/severe stroke (1.17;1.08–1.27). Additionally, African American (0.76;0.62–0.93) and Hispanic patients (0.66;0.50–0.89) had lower odds of receiving thrombectomy. Compared to men, women had increased odds of in-hospital mortality (1.15;1.01–1.32). ConclusionsRacial and sex disparities exist in both evidence-based reperfusion therapy and in-hospital outcomes amongst patients with AIS and diabetes. Further measures are needed to address these disparities and reduce the excess risk of adverse outcomes among women and African American patients.

Relationships among Hospital Acute Ischemic Stroke Volumes, Hospital Characteristics, and Outcomes in the US (P14-5.025)

<h3>Objective:</h3> We sought to examine contemporary relationships between hospital acute ischemic stroke (AIS) volumes and outcomes. <h3>Background:</h3> Prior research on AIS volume-based patient outcomes demonstrated contradictory results and failed to reflect recent advances in stroke care. <h3>Design/Methods:</h3> We used complete Medicare datasets in a retrospective cohort study employing validated International Classification of Diseases Tenth Revision codes to identify patients admitted with AIS from January 1, 2016 through December 31, 2019. AIS volume was calculated as the total number of AIS admissions per hospital during the study period. We examined hospital characteristics by AIS volume quartile. We performed adjusted logistic regression testing associations of AIS volume with: inpatient mortality, receipt of tissue plasminogen activator (tPA) and endovascular therapy (ET), discharge home and 30-day outpatient visit. We adjusted for sex, age, Charlson comorbidity score, teaching hospital status, socioeconomic status, hospital urban-rural designation, stroke certification status, and ICU and neurologist availability at the hospital. <h3>Results:</h3> There were 952400 AIS admissions among 5084 US hospitals; AIS 4-year volume quartiles were: 1st: 1–8 AIS admissions; 2nd: 9–44; 3rd: 45–237; 4th: 238+. Highest quartile hospitals more often were stroke-certified (49.1% vs 8.7% in lowest quartile, p&lt;0.0001), with ICU bed availability (19.8% vs 4.1%, p&lt;0.0001) and with neurologist expertise (91.1% vs 3%, p&lt;0.0001). For every ten-unit increase in volume, there were higher odds of receiving tPA (OR 1.009, 95% CI 1.008–1.01, p&lt;0.0001) and ET (1.041, 1.037–1.046, p&lt;0.0001), but also higher inpatient mortality (1.004, 1.003–1.005, p&lt;0.0001) and 30-day mortality (1.001, 1.001–1.002, p&lt;0.0001). <h3>Conclusions:</h3> High AIS-volume hospitals have greater utilization of acute stroke interventions, stroke certification and availability of neurologist and ICU care. Despite these advantages, higher AIS volumes were associated with increased inpatient and 30-day mortality. Further research is needed to better understand volume-outcome relationships in AIS to provide effective stroke care and accurately risk-adjust hospital outcomes. <b>Disclosure:</b> Dr. McCarthy has nothing to disclose. Dr. Daniel has nothing to disclose. Dr. Santos has nothing to disclose. Dr. Dhamoon has received personal compensation in the range of $10,000-$49,999 for serving as an Expert Witness for Faegre Baker Daniels LLP. Dr. Dhamoon has received personal compensation in the range of $10,000-$49,999 for serving as an Expert Witness for Wellstar Health System Inc. Dr. Dhamoon has received personal compensation in the range of $10,000-$49,999 for serving as an Expert Witness for Fabiani Cohen &amp; Hall, LLP. Dr. Dhamoon has received personal compensation in the range of $5,000-$9,999 for serving as an Expert Witness for Kramer, Dillof, Livingston &amp; Moore. Dr. Dhamoon has received personal compensation in the range of $500-$4,999 for serving as an Expert Witness for Robins Kaplan. Dr. Dhamoon has received personal compensation in the range of $5,000-$9,999 for serving as an Expert Witness for Parker Waichman LLP. Dr. Dhamoon has received personal compensation in the range of $500-$4,999 for serving as an Expert Witness for Heidell, Pittoni, Murphy &amp; Bach, LLP.

Outcomes of Multiple Sclerosis Patients following Admission for Acute Ischemic Stroke in the United States (P14-5.004)

<h3>Objective:</h3> To understand the characteristics of Multiple Sclerosis (MS) patients admitted for Acute Ischemic Stroke (AIS) and any differences in outcomes. <h3>Background:</h3> While MS can influence various pathways in the body, there is a lack of research on the impact the disease has on outcomes following an AIS. <h3>Design/Methods:</h3> The 2019 National Inpatient Sample (NIS) was queried to explore the characteristics and outcomes of MS patients admitted for AIS. <h3>Results:</h3> Our study found 2100 (0.4%) AIS patients who also had a diagnosis of MS. More MS patients were females (70.2%), while non-MS patients were more likely to be males (50.8%) (p&lt;0.05). Both groups comprised a higher proportion of patients classified as White (75.4% among MS cases and 67.9% among non-MS cases, p&lt;0.05). MS patients also had a lower prevalence of old myocardial infarct (6.4% vs. 7.5%), but it was not statistically significant (p=0.066). We also found that MS patients were less likely to be diabetic (34.4% vs. 39.3%), hypertensive (77.4% vs. 86.1%), and hyperlipidemia (55.7% vs. 60.8%) compared to non-MS cases of AIS. However, more MS patients with AIS had a smoking history (44.5% vs. 40.1%) and cannabis use (2.4% vs. 1.6%). Finally, we also found that the MS cases were younger, with a mean age of 62.89 years vs. 69.97 years, had a shorter stay of 4.91 days vs. 5.04 days, and a lower mean hospital charge ($67,201 vs. $71,186). During their stay, 1.9% of MS patients admitted with AIS died (vs. 3.7% in non-MS cases). After adjusting for multiple confounders, the adjusted odds ratio of death among MS patients with AIS compared to non-MS patients was 0.555 (95% confidence interval 0.405–0.760, p&lt;0.05). <h3>Conclusions:</h3> MS patients admitted with AIS have a lower mortality risk than non-MS cases. This can be related to the differences seen in age and multiple comorbidities. <b>Disclosure:</b> Dr. Sanikommu has nothing to disclose. Dr. Sombans has nothing to disclose. Dr. Ramphul has nothing to disclose. Dr. Verma has nothing to disclose. Dr. Ramphul has nothing to disclose. Dr. Jairam Das Lohana has nothing to disclose. Dr. Meena has nothing to disclose. Dr. Kumari has nothing to disclose. Dr. Gonzalez Mejias has nothing to disclose. Dr. Kumar has nothing to disclose. Dr. Arti has nothing to disclose.