All Acute Ischemic Stroke Research Articles

Age and Stroke Severity Matter Most for Clinical Outcome in Acute Arteriosclerotic Tandem Lesions.

Background: Tandem lesions (TLs) cause up to 15-30% of all acute ischemic strokes (AISs). Endovascular treatment (EVT) is regarded as the first-line treatment; however, uncertainties remain with respect to the treatment and predictive outcome parameters. Here, we aimed to identify the clinical and demographic factors associated with functional short- and long-term outcomes in AIS patients with arteriosclerotic TLs undergoing EVT. Methods: This was a retrospective, mono-centric cohort study of 116 consecutive AIS patients with arteriosclerotic TLs who were endovascularly treated at a stroke center, with analysis of the relevant demographic, procedural, and imaging data. Results: A total of 116 patients were included in this study, with a median age of 72 years (IQR 63-80), 31% of whom were female (n = 36). The median NIHSS on admission was 14 (IQR 7-19), with a median ASPECT score of 9 (IQR 8-10) and median NASCET score of 99% (IQR 88-100%). A total of 52% of the patients received intravenous thrombolysis. In 77% (n = 89) of the patients, an antegrade EVT approach was used, with a good recanalization (mTICI2b3) achieved in 83% of patients (n = 96). Symptomatic intracerebral hemorrhage occurred in 12.7% (n = 15) of patients. A favorable outcome (mRS0-2) and mortality at 3 months were obtained for 40% (n = 47) and 28% of patients (n = 32), respectively. Age and NIHSS on admission were strongly associated with outcome parameters. Diabetes mellitus and previous neurological disorders were independently associated with long-term mortality (median 11 months, IQR 0-42). Conclusions: Younger age, lower stroke severity, and good recanalization were found to be independently associated with a favorable outcome. In contrast, older age, higher stroke severity, previous neurological disorders, and diabetes were correlated with mortality. The endovascular treatment of acute arteriosclerotic tandem lesions is feasible and relatively safe.

Diagnostic accuracy of CT angiography and CT perfusion imaging for detecting distal medium vessel occlusions: Protocol for a systematic review and meta-analysis.

Distal medium vessel occlusions (DMVOs) represent 25-40% of all acute ischemic strokes (AIS). DMVO clinical syndromes are heterogenous, but as eloquent brain regions are frequently involved, they are often disabling. Since current intravenous fibrinolytic therapies may fail to recanalize up to two-thirds of DMVOs, endovascular treatment is progressively being considered in this setting. Nevertheless, the optimal imaging method for diagnosis remains to be defined. Stroke centers that use computed tomography as a routine stroke imaging approach rely on either isolated computed tomography angiography (CTA) or combined perfusion (CTP) studies. Despite a simplified non-CTP-dependent approach seeming reasonable for large vessel occlusion AIS diagnosis, CTP may still hold advantages for DMVOs workup. Therefore, this systematic review aims to compare the diagnostic performance of CTA and CTP in detecting DMVOs. We will perform a systematic search in PubMed, EMBASE, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials. In addition, grey literature and ClinicalTrials.gov will be scanned. We will include any type of study that presents data on the diagnostic accuracy of CTA and/or CTP for detecting DMVOs. Two authors will independently review retrieved studies, and any discrepancies will be resolved by consensus or with a third reviewer. Reviewers will extract the data and assess the risk of bias in the selected studies. Data will be combined in a quantitative meta-analysis following the guidelines provided by the Cochrane Handbook for Systematic Reviews of Interventions. We will assess cumulative evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. This will be the first systematic review and meta-analysis that compares two different imaging approaches for detecting DMVOs. This study may help to define optimal acute ischemic stroke imaging work-up. PROSPERO registration: CRD42022344006.

Efficacy Outcomes of Tenecteplase versus Alteplase in Patients with Ischemic Stroke in Therapeutic Window: Experience from a Single Institution

Background and Aim: The World Health Organization estimated that 15 million people throughout the world suffer stroke every year. Only 5%–10% of all acute ischemic stroke (AIS) patients presenting to emergency departments (EDs) are eligible for and receive thrombolytic therapy. This study was conducted to assess and compare the efficacy and safety profile of thrombolysis with tenecteplase (TNK) with that of alteplase among patients with AIS who were eligible for thrombolysis. Materials and Methods: This was a hospital-based prospective observational study. All the patients who presented with AIS within the time window period of ≤4.5 h to ED of Sher-i-Kashmir Institute of Medical Sciences, Soura, from September 2018 to March 2021, were screened for eligibility of thrombolysis by TNK. A total of 76 patients were enrolled; among which 42 were thrombolysed with TNK and 34 patients were thrombolysed with alteplase. These data were compared with departmental data of patients thrombolysed by alteplase during July 2015–July 2017. Inclusion and exclusion criteria used in the study were as per the American Heart Association/American Stroke Association guidelines for thrombolysis. Efficacy and safety were assessed and compared of the two drugs. Results: After 24 h of thrombolysis, early neurological improvement occurred in 62% of TNK patients compared to only 35% of patients from alteplase group, which was significant statistically (P < 0.05). An excellent functional outcome, defined as the Modified Rankin Scale (mRS) of 0–1 at 3 months of discharge, was seen in 67.6% of TNK and 48.5% of alteplase group. A poor recovery, defined as the mRS of 4–6 at 3 months of follow-up, was seen in 16% and 21% in TNK and alteplase group patients, respectively. Conclusion: TNK appears to be characterized by a better safety and efficacy profile than alteplase; however, further multicenter studies and randomized controlled trials are required to confirm our preliminary findings.

Endovascular treatment of distal medium vessel occlusions using microcatheter aspiration thrombectomy.

Recent studies suggest that endovascular treatment (EVT) in distal medium vessel occlusion (DMVO) stroke is beneficial even beyond middle cerebral artery (MCA) - M2 segment. However, data about aspiration thrombectomy of DMVOs is scarce since common state-of-the-art aspiration catheters are usually too large for small distal intracranial arteries. We report our initial experiences using the microcatheter aspiration thrombectomy (MAT) technique as frontline therapy for acute DMVOs in the MCA territory. We retrospectively analyzed all acute ischemic stroke (AIS) patients that underwent MAT of a primary or secondary DMVO in the M3 or M4 segment between January 2019 and October 2021. Recanalization rates, procedural safety and outcome data were recorded. MAT of acute M3 and M4 occlusions was performed in 19 patients with AIS. Six had isolated DMVO strokes, 13 had secondary DMVOs during EVT of a proximal large vessel occlusion. Successful revascularization to DMVO TICI ≥ 2b was achieved in 58% (11/19) with a single pass in all of them. The median National Institutes of Health Strokes Scale (NIHSS) score at admission and discharge was 12 and 3, respectively. 68% (13/19) of the patients had a good clinical outcome at discharge (modified Rankin Scale 0-2). No symptomatic complications related to MAT occurred. MAT of DMVOs in the MCA territory is technically feasible and effective. Compared to stent retriever-based thrombectomy in DMVOs the hemorrhagic complication rate appears notably lower. Further studies are needed to validate the benefit of mechanical thrombectomy in the distal intracranial vasculature.

Mini review

The impact of stroke, currently the second leading cause of death worldwide, continues to worsen, and even those that survive can have persistent neurological deficits. A potentially significant implication may be due to hyperglycemia, found in one-third of all acute ischemic stroke (AIS) patients. However, prior studies reported conflicting information about the impact of hyperglycemia on poststroke prognosis, likely due to different measurements of stress-induced hyperglycemia. The glucose-to-glycated hemoglobin ratio is an index of stress-induced hyperglycemia after AIS that better quantifies acute changes in blood glucose, as opposed to absolute variations in glucose levels. Moderate blood glucose reductions might counteract the negative effects of hyperglycemia and glycemic control medications can also play a role in neuroprotection. The liver is the main organ that functions to maintain energy and glucose metabolism and the effects of AIS can reach far peripheral organs, including the liver. In this review, we highlighted the mechanism responsible for acute poststroke hyperglycemia, a hepatic inflammatory pathway that results in hepatic gluconeogenesis and reduced hepatic insulin sensitivity. Hepatitis cascades lead to hepatic gluconeogenesis, and targeted therapy with antihyperglycemic drugs has the potential to improve stroke prognosis and recovery.

In-Hospital Acute Ischemic Stroke is Associated with Worse Outcome: Experience of a Single Center in Santiago Chile

ObjectivesIn-hospital acute ischemic stroke (HIS) accounts for 2–17% of all acute ischemic strokes (AIS) seen in hospital and they have worse prognosis. In this study we aimed to identify the frequency of HIS and their characteristics in our center. Materials and MethodsRetrospective analysis of a prospective register of patients with AIS seen at Clínica Alemana de Santiago, between January 2017 and January 2019. HIS and community onset ischemic strokes patients (CIS) were compared, univariate analysis was performed, covariates with p < 0.25 were selected for multivariate analysis. Differences between, proportion of strokes treated with thrombolytic therapy, door to needle time were compared between HIS and CIS patients, as also mortality rates at 90 days. ResultsDuring the study period 369 patients with AIS were seen; of these 20 (5.4%, 95 CI%, 3.5–8.2) corresponded to HIS. In univariate analysis, HIS compared to patients arriving form the community to the emergency room, suffered more frequently from, heart failure (p = 0.04), and active malignancies (p < 0.001). HIS patients had longer times from symptom onset to non-contrast brain tomography (540 ±150 minutes); they were also less frequently treated with intravenous thrombolysis compared to community AIS: 15% versus 30% respectively (p = 0.08). Mortality rates at 90 days were higher in HIS: 30 versus 5% (p = 0.001). ConclusionsIn this cohort, HIS patients suffered delays in their neuroimaging studies and received less intravenous thrombolysis; this underscores the need for a standardized approach to the recognition and management of inhospital acute ischemic stroke.

Abstract P585: Age- and Sex-Specific Temporal Trends in the Incidence of Pediatric Stroke in New York State From 2006-2016

Objectives: 1. To estimate sex- and race-specific incidence of pediatric stroke by age group 2. To describe trends in pediatric stroke incidence in New York(NY) from 2006 to 2016 Methods: International Classification of Disease codes were used to retrospectively to identify all acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), and cerebral venous thrombosis (CVT) admissions in pediatric patients (0-19 years old [yo]) in the 2006-2016 NY State Inpatients Database (SID; total N=4,083). Incident counts were combined with annual US Census data to compute age- and sex-specific incidence. Joinpoint regression was used to evaluate trends in incidence over time. Results: Across the study period, 52% of all pediatric strokes were AIS, 23% ICH, 11% SAH, and 14% CVT. Total stroke incidence/100,000 population was 47.8 and the age-standardized incidence in &gt;=1yo was 4.8. Incidence differed by age (1-4yo: 4.4, 5-9yo: 3.6, 10-14yo: 4.5, and 15-19yo: 6.7), but not by sex. Age-standardized incidence of strokes in &gt;=1yo also differed by race (Blacks 5.9, Whites 4.0, Hispanics 3.3, Asians/Pacific Islanders 3.1). While there was no change in overall stroke, AIS, or SAH incidence, ICH (annualized percentage change [APC] 4.3%, 95%CI 1.7-6.9) and CVT (APC 4.1, 95%CI 1.22-6.25%) increased over time. When stratified by age, overall stroke incidence increased over time in 15-19 yo (APC 1.3%, 95%CI 0.27-2.35, p=0.019), but not in other age groups. Conclusion: We observed increasing incidence in pediatric ICH, CVT, and overall stroke in 15-19 yo in the state of NY. Pediatric stroke incidence in NY is disproportionately higher in blacks compared to other races. Further investigation is warranted to determine the association of these changes with risk factors, lifestyle and systems of care.

Circular RNA FUNDC1 improves prediction of stroke associated infection in acute ischemic stroke patients with high risk.

Identifying those patients who were at high risk of stroke associated infection (SAI) for preventive antibiotic therapy was imperative for patients’ benefits, thus improving prediction of SAI was critical for all acute ischemic stroke (AIS) patients. Circular RNA FUNDC1 (circFUNDC1) has been reported to be the diagnosis and prognosis biomarker of AIS. Therefore, the present study aimed to figure out whether circFUNDC1 could be the potential predictor of SAI that could help to guide preventive treatment. In total, 68 patients were included in the study, 26 of which had infection and 42 without. Copy number of circFUNDC1 in plasma were quantified by quantitative real-time polymerase chain reaction (qPCR). Platelet spike-in experiment and correlation analysis were conducted to explore possible origins of circFUNDC1 in plasma. A significantly elevated level of circFUNDC1 was found in SAI patients compared with not infected AIS patients (P=0.0258). Receiver operating characteristic (ROC) curves demonstrated the prediction significance of circFUNDC1, with the area under the curve (AUC) at 0.6612 and sensitivity, specificity at 69.23%, 61.90% respectively in predicting SAI. Then, when adding circFUNDC1 in the risk model, the AUC increased from 0.7971 in model A to 0.8038 in model B. Additionally, positive correlation was observed between circFUNDC1 level and neutrophils counts. WBC and neutrophil ratios were significantly elevated in SAI patients compared with non-SAI patients. Therefore, circFUNDC1 could be used to construct a risk model for the prediction of SAI that is beneficial for AIS patients’ preventive treatment.

1143 Wake-up Stroke In Hispanic Veterans: Clinical Characteristics

Abstract Introduction Wake-up stroke (WUS) is a stroke that occurs during sleep and accounts for 14-29.6% of all acute ischemic stroke (AIS) cases. The use of intravenous alteplase, the therapeutic standard, requires identifying time of stroke onset. Recent studies suggest that obstructive sleep apnea (OSA) is an independent risk factor for WUS. This study aims to describe a population of Puerto Rican Veterans with WUS and to evaluate clinical differences between patients WUS and non-WUS (NWUS). Methods The study was a cross-sectional analysis of all patient records with AIS from April 2018 to July 2019. One hundred forty records were reviewed. Patients who woke up with new AIS symptoms were labeled as WUS. Study variables included demographics, comorbidities, medications, sleep disorders, prior stroke, administration of alteplase and the National Institute of Health Stroke Scale (NIHSS). Results Among 140 participants predominantly male (98.6%), 27.1% had WUS. The mean age was 75 (range 21-89). NIHSS mean was 5.9. Comorbidities for WUS vs NWUS were as follows: overweight or obese (60% vs 62.6% p=0.667), hypertension (100% vs 95.1% p=0.323), hyperlipidemia (95% vs 93% p=0.999), diabetes mellitus (55.3% vs 67% p=0.212), atrial fibrillation (26.3% vs 24.5% p=0.826), anxiety (36.8% vs 33.3% p=0.697), depression (55.3% vs 51.0% p=0.652), non-smokers (89.% vs 89%), smokers (10.5% vs 11.1%), and prior stroke (34.2% vs 35.3% p=0.905). Insomnia was observed in 42% vs 40% (p= 0.838) and 24% vs 23% (p=0.955) had OSA. Conclusion There were no significant differences in clinical characteristics between patients with WUS and NWUS in this sample of Puerto Rican Veterans. OSA was less prevalent than previously reported. Lack of recognition of OSA as a risk factor for stroke and under-diagnosis of OSA might explain the study results. Support

Abstract TMP8: Nationwide Analysis of Endovascular Thrombectomy Provider Specialization

Introduction: Endovascular thrombectomy (ET) has the greatest benefit of all acute ischemic stroke (AIS) therapies. However, ET trials were performed in centers with rigorous protocols, expert procedural skill, and cerebrovascular specialists. Systems of care are evolving to meet LVO clinical demand nationwide, and real-world data are needed regarding case volumes and provider specialty to better evaluate expertise, quality, and capacity. Methods: Using de-identified 100% inpatient Medicare data from 2016-2017 for individuals aged &gt; 65 years in the US, we utilized validated International Classification of Diseases, 10 th Revision, Clinical Modification codes to identify admission with AIS and treatment with ET. We identified proceduralist specialty by linking the ET proceduralist National Provider Identifier (NPI) to the provider specialty listed in the NPI database, grouping specialty into: radiology, neurology, neurosurgery, other surgical, and internal medicine. We calculated the number of proceduralists and hospitals who performed ET, the ET team specialty composition by hospital, and the number of proceduralists who perform ET at multiple hospitals. Results: Among 13,311 AIS patients treated with ET, 2,754 different proceduralists treated at 641 hospitals. The median number of proceduralists per hospital was 4. 11.7% (n=322) of proceduralists performed ET at multiple hospitals. The ET team included a neurology- or neurosurgery-trained proceduralist at 64.9% (n=407) of hospitals that performed ET, and included both in 25.6% (n=160) of teams. At 175 hospitals that performed &lt;5 ET cases, surgery- and internal medicine-trained proceduralists treated 26.9% and 12.8% of total cases, respectively, but only 1.9% and 2.4% at the 151 hospitals that performed &gt;30 ET. As hospital case volume increased, there was a progressive increase in the proportion of cases performed by neurosurgeons and neurologists. Conclusion: Nationally, 65% of ET teams include a neurology- or neurosurgery-trained proceduralist, more often in higher volume hospitals. A minority of LVO stroke is treated by proceduralists who perform ET at multiple hospitals. A better understanding of the impact of ET team structure on access to care and outcomes is essential.

Abstract WP382: Cardiac Troponin Assessment in Acute Ischemic Stroke Patients Presenting Within 4.5 Hours From Last Known Well

Introduction: American Heart Association guidelines recommend obtaining baseline troponin in all acute ischemic stroke (AIS) patients to detect an acute coronary syndrome (ACS). Yet, data regarding the prevalence and diagnostic yield of troponin elevation in patients presenting within the time window for thrombolysis is limited. We sought to determine the diagnostic yield of cTnI in detecting ACS when assessed before or after 4.5h from last known well (LKW). Methods: We retrospectively analyzed 526 consecutive patients admitted for AIS or transient ischemic attack, who presented within 4.5h and had cardiac troponin I (cTnI) obtained within 48h from LKW. Results: The median time from LKW to cTnI measurement was 3.8h (IQR 1.5h-7.9h). 58% patients (n=306) had cTnI obtained ≤ 4.5h from LKW. After adjustment, factors independently relating to an elevated cTnI were the time to cTnI assessment (p&lt;0.001), patient age (p=0.012), history of congestive heart failure (p&lt;0.001), and a history of stroke/TIA (p=0.049). Patients who had a cTnI obtained within 4.5 hours from LKW, had significantly more often a normal (≤0.04 ng/mL) than elevated (&gt;0.04 ng/mL) cTnI levels (61.9% vs. 44.7%; p=0.001). The sensitivity, specificity, and overall accuracy of an elevated cTnI assessed within 48h from LKW for ACS was 63.6%, 80.2%, and 79.5%, respectively. After stratification by the time to cTnI assessment within 4.5 h versus beyond 4.5h, the sensitivity of an elevated cTnI for ACS was markedly reduced to 42.9% whereas the specificity remained high at 84%. The optimal threshold to assess cTnI for detecting an ACS was 320 min in all included patients (sensitivity = 0.54, specificity = 0.67, Youden’s J = 0.203) and 340 minutes in patients with ACS (sensitivity 0.79, specificity 0.88, Youden’s J 0.661). Conclusions: Among patients presenting within the time window for rtPA treatment, the sensitivity of cTnI obtained within 4.5 hours from LKW to detect ACS is low. Our data suggests that cTnI routine assessment of cTnI in AIS subjects without cardiac symptoms should not be done within the first 6 hours from LKW.

Abstract WP109: Redefining Early Neurological Improvement After Intravenous Tissue Plasminogen Activator Treatment of Stroke

Background and Purpose: Early neurologic improvement (ENI) in patients treated with alteplase has been shown to correlate with functional outcome. However, the definition of ENI remains controversial and has varied across studies. Current definitions take into account the absolute difference between the admission and 24-hour NIHSS but this difference is usually not reported as a function of the baseline NIHSS. We hypothesized that ENI defined as a percentage change in NIHSS (percent change NIHSS) at 24-hours would better correlate with favorable outcomes at 3 months than ENI defined as the change in NIHSS (delta NIHSS) at 24 hours. Methods: Retrospective analysis of prospectively collected single center quality improvement data was performed of all acute ischemic stroke (AIS) patients treated with alteplase. Delta NIHSS was defined as the difference in admission and 24-hour NIHSS. Percent change NIHSS was defined as delta NIHSS divided by the admission NIHSS. We examined delta NIHSS and percent change NIHSS in unadjusted and adjusted logistic regression models as predictors of a favorable outcome at 3 months (defined as mRS 0-1). Results: Among 586 patients with AIS treated with alteplase with admission NIHSS, 24-hour NIHSS, and 3-month mRS available, 194 (33.1%) had a favorable outcome at 3 months. The mean age was 65 years and 59% were men. In fully adjusted models, both delta NIHSS (OR per point decrease 1.27; 95% CI, 1.19– 1.36) and percent change NIHSS (OR per 10 percent decrease 1.17; 95% CI, 1.12-1.22) were associated with favorable functional outcome at 3 months. Receiver operating characteristic (ROC) curve comparison showed that the area under the ROC curve for percent change NIHSS (0.755) was greater than delta NIHSS (0.613) or admission NIHSS (0.694). Conclusion: Percentage change in NIHSS may be a better surrogate marker of ENI and functional outcome in AIS patients after receiving acute thrombolytic therapy. More studies are needed to confirm our findings.

Redefining Early Neurological Improvement After Reperfusion Therapy in Stroke

Background and Purpose: Early neurologic improvement (ENI) in patients treated with alteplase has been shown to correlate with functional outcome. However, the definition of ENI remains controversial and has varied across studies. We hypothesized that ENI defined as a percentage change in the National Institute of Health Stroke Scale (NIHSS) score (percent change NIHSS score) at 24-hours would better correlate with favorable outcomes at 3 months than ENI defined as the change in NIHSS score (delta NIHSS score) at 24 hours. Methods: Retrospective analysis of prospectively collected single-center quality improvement data was performed of all acute ischemic stroke (AIS) patients treated with alteplase. We examined delta NIHSS score and percent change NIHSS score in unadjusted and adjusted logistic regression models as predictors of a favorable outcome at 3 months (defined as mRS 0-1). Results: Among 586 patients who met the inclusion criteria, 194 (33.1%) had a favorable outcome at 3 months. In fully adjusted models, both delta NIHSS score (OR per point decrease 1.27; 95% confidence interval [CI] 1.19-1.36) and percent change NIHSS score (OR per 10 percent decrease 1.17; 95% CI 1.12-1.22) were associated with favorable functional outcome at 3 months. Receiver operating characteristic (ROC) curve comparison showed that the area under the ROC curve for percent change NIHSS score (.755) was greater than delta NIHSS score (.613) or admission NIHSS (.694). Conclusions: Percentage change in NIHSS score may be a better surrogate marker of ENI and functional outcome in AIS patients after receiving acute thrombolytic therapy. More studies are needed to confirm our findings.

Overview of Evidence on Emergency Carotid Stenting in Acute Ischemic Stroke due to Tandem Occlusions: A Systematic Review and Meta-Analysis

Introduction - The combination of cervical internal carotid artery (ICA) occlusion with synchronous intracranial thrombus represents 10-20% of all acute ischemic strokes (AIS), and such tandem occlusions are strongly associated with poor outcome.

Temporal Trends in the Use of Acute Recanalization Therapies for Ischemic Stroke in Patients with Cancer

Objective: We sought to characterize the US nationwide temporal trends in recanalization therapy utilization for ischemic stroke among patients with and without cancer. Methods: We identified all acute ischemic stroke (AIS) hospitalizations in the National Inpatient Sample from January 1, 1998 to September 30, 2015. The primary exposure was solid or hematologic cancer. The primary outcome was use of intravenous thrombolysis. The secondary outcome was use of endovascular therapy (EVT). Results: Among 9,508,804 AIS hospitalizations, 503,510 (5.3%) involved cancer patients. Intravenous thrombolysis use among ischemic stroke patients with cancer increased from .01% (95% confidence interval [CI], .00%-.02%) in 1998 to 4.91% (95% CI, 4.33%-5.48%) in 2015, whereas intravenous thrombolysis use among ischemic stroke patients without cancer increased from .02% (95% CI, .01%-.02%) in 1998 to 7.22% (95% CI, 6.98%-7.45%) in 2015. The demographic- and comorbidity-adjusted odds ratio/year of receiving intravenous thrombolysis was similar in patients with cancer (1.21; 95% CI, 1.20-1.23) versus those without (1.20; 95% CI, 1.19-1.21). EVT use among ischemic stroke patients with cancer increased from .05% (95% CI, .02%-.07%) in 2006 to 1.90% (95% CI, 1.49%-2.31%) in 2015, whereas EVT use among ischemic stroke patients without cancer increased from .09% (95% CI, .00%-.18%) in 2006 to 1.88% (95% CI, 1.68%-2.09%) in 2015. Conclusions: Among 9.5 million AIS hospitalizations, patients with cancer received intravenous thrombolysis about two thirds as often as patients without cancer. This difference persisted over time despite increased utilization in both groups. EVT utilization was similar between cancer and non–cancer AIS patients.

Abstract WP71: Multicenter ALADIN: Automated Large Artery Occlusion Detection in Stroke Imaging Using Artificial Intelligence

Introduction: Large vessel occlusion (LVO) may account for up to 40% of all acute ischemic strokes (AIS) and may be associated with worse patient prognosis, being responsible for 60% of dependency and more than 90% of mortality after AIS. Therefore, accurate and rapid identification of LVO and notification of specialists is critical to maximizing the benefit of proven reperfusion therapies. Recent advances in artificial intelligence technology have facilitated the development of automated LVO detection on computed tomography angiography (CTA) imaging. This study evaluated the performance of the Viz LVO algorithm in AIS patients treated at four comprehensive stroke centers. Methods: We performed a multicenter retrospective analysis of 800 CTAs from 750 AIS patients admitted to three comprehensive stroke centers between 2014 and 2018. All studies were analyzed by the latest version of Viz LVO algorithm (version 4.1.2) and the performance was compared to expert neurointerventionalists’ reports. Algorithm run-time and notification time through the Viz platform times were also recorded for each CTA. Results: The Viz LVO algorithm demonstrated 92% sensitivity, 90% specificity in the analysis of 750 CTAs. The mean and maximum run time of the algorithm were 3 minutes and 6 minutes, respectively. Furthermore, mean time to notification was 6 minutes, with a maximum time to notification of 9 minutes. Conclusions: This multicenter retrospective study demonstrates fast and accurate performance of the Viz LVO algorithm in the detection and notification of LVOs on CTAs from three comprehensive stroke centers. Using artificial intelligence, this algorithm may permit early and accurate identification of LVO stroke patients and timely notification to emergency teams, enabling quick decision-making for reperfusion therapies or transfer to specialized centers if needed. Additional studies are required to demonstrate impact on the stroke workflow that result in improved patient outcomes, operational efficiencies, and cost reductions.

Abstract TP182: Physical Therapy/Occupational Therapy Evaluation Within the First 24-Hours for Patients Who Have Received Intravenous Alteplase

Background: Designated Stroke Centers are required by The Joint Commission to evaluate all acute ischemic stroke (AIS) patients for rehabilitation prior to discharge. Timing of this evaluation is controversial. Purpose: To evaluate the feasibility and safety of having a Physical Therapist (PT) or Occupational Therapist (OT) evaluate AIS patients within 24 hours of alteplase administration. Methods: Based on a comprehensive literature review, various committee discussions and agreement, the PT/OT team initiated evaluations within 24-hours for AIS patients treated with alteplase. The target post-alteplase evaluation time was 12-hours. Medical stability was determined by the physician as evidenced by an initial request for PT/OT evaluation. Prior to the evaluation, the therapist performed a thorough chart review. Patients with unstable vital signs, a fluctuating neurological assessment, and/or inability to participate in therapies were excluded. During the therapy evaluation, reassessment was ongoing. If any adverse change was observed, the evaluation was immediately stopped, the patient placed back in bed, and the primary nurse and/or physician notified. Results: A baseline review of data was performed. In 2016, 77 patients received alteplase, none of whom were evaluated within 24-hours following alteplase administration. Evaluations within 24 hours post-alteplase began in mid-March 2017 and continued through July 2018. A total of 103 patients received alteplase during this period, of whom 11 patients met initial exclusion criteria. Of these, 83% (76/92) were seen within the initial 24-hour timeframe. All patients reviewed and evaluated by the team were in the Intensive Care Unit. No mobility-associated complication or adverse neurologic change occurred during therapy evaluations or because of mobilization within the initial 24-hours. Conclusion: PT/OT neurological evaluations within 24-hours of alteplase administration did not result in adverse events or complications. Although difficult to quantify, therapy staff determined this change in practice was beneficial to patients as it allowed for earlier mobilization and initiation of the rehabilitation plan.

Abstract TP345: Early Mobilization Following Recombinant Tissue Plasminogen Activator Administration and/or Mechanical Thrombectomy Reduces Length of Stay

Background: Nearly 800,000 strokes occur each year in the United States and are a leading cause of disability. They result in an annual financial burden of roughly $34 billion, which includes hospitalization and rehabilitation thereafter. Despite this cost, data regarding appropriate timing of mobilization follow administration of intravenous recombinant tissue plasminogen activator (rt-PA) is lacking. As value-based payment models drive systems to reduce length of stay (LOS) and cost of care, early mobilization following rt-PA provides a means to achieve those ends in addition to potentially improving outcomes. Methods: We conducted a retrospective case-control study including all acute ischemic stroke (AIS) patients admitted to a tertiary academic hospital stroke service from November 2017 to July 2018 who received IV rt-PA locally or by drip and ship, and/or underwent mechanical thrombectomy. The control group includes AIS patients from November 2017 to April 1, 2018. Per protocol, controls (Group 1) were maintained on bedrest for 24 hours after receiving IV rt-PA. Beginning April 2, 2018, a total of 88 (Group 2) patients were managed with early mobility protocols stratifying patients for early mobilization based on NIHSS score, presence of severe aphasia, whether they underwent thrombectomy, and their clinical stability. Results: Among Group 1 (n=109), the mean time from rt-PA bolus to PT/OT assessment was 38 hours 55 minutes, and the average LOS was six days. With delays removed (PT/OT unable to assess due to intubation/sedation), mean time from bolus to assessment was 33 hours 25 minutes (n=101) and average LOS was five days. Following implementation of early mobility protocols in Group 2 (n=81 treated with IV rt-PA), patients had a mean time from bolus to PT/OT assessment of 22 hours 29 minutes, with an average LOS of 4.42 days. With delays removed, mean time from bolus to assessment was 18 hours 10 minutes, with an average LOS of 3.66 days. No adverse events were seen related to early mobilization in Group 2. Conclusions: These data suggest that early mobilization following IV thrombolysis is safe and results in decreased time to PT/OT evaluation with subsequent reduction in length of stay. Further study is needed to evaluate for potential impacts on outcome.

Duplex ultrasound for the diagnosis of symptomatic carotid stenosis: real value in clinical practice

Background: Atherosclerotic plaque leading to internal carotid stenosis greater than 50%, accounts for about 10 to 15% of all acute ischemic stroke (AIS) causes. Stenosis identification and severity is frequently estimated by Duplex ultrasound (DUS) assessment. Symptomatic carotid disease is defined as focal neurologic symptoms with sudden onset and related to the appropriate carotid artery cerebral distribution. It includes established acute ischemic stroke, one or more transient ischemic attacks characterized by focal neurologic dysfunction or transient monocular blindness, in the preceding 6 months of the carotid stenosis identification. Revascularization should be considered in symptomatic patients with a carotid artery stenosis of 50–69% and recommended in symptomatic patients with a stenosis of 70–99%. In our clinical practice it is seen frequently the indiscriminate use of DUS in the etiological study for AIS. Therefore, we consider the possibility of such an exam being excessively performed, since most patients may have no indication for DUS assessment. Objectives: (1) estimation of symptomatic carotid artery disease prevalence in hospitalized patients with the diagnosis of AIS and ≥ 50% carotid stenosis; (2) determination of carotid artery revascularization in this subgroup of patients; (3) evaluation of the centre clinical practice and to determine a real estimative of the therapeutic impact associated with DUS in patients with AIS. Methods: Retrospective observational cohort study of patients admitted with established AIS within the year of 2017 and followed for an additional 12 month period. Inclusion criteria: a definite diagnosis of AIS (based in symptoms within 24 hours’ period and/or image in CT scan suggestive of AIS), date of hospitalization within the mentioned timeframe and patients who underwent carotid DUS within the first 6 months after the event. No hemorrhagic stroke or transient ischemic attacks were considered in this study. Results: Of the 198 stroke patients, 144 (72%) underwent Doppler ultrasound. The average age was 78 years, 50% were male and 23.6% had previous stroke. From the total 144 included patients, only 18 (12.5%) had stenosis ≥50%, and 9 (6.25%) had ipsilateral lesions to the carotid stenosis. The remaining had lesions contralateral to the stenosis or lacunar strokes. Considering this, 6.25% of patients were assumed to have symptomatic carotid disease. None underwent surgical intervention for various reasons (e.g. high risk procedure, contraindications, high degree disability and/or multiple comorbidities). Conclusions: The present study reinforces the idea that etiological study of AIS is essential, and DUS appears as a first line exam. However, we emphasize that DUS should only be performed in patients with non-disabling AIS (mRS score 0–2) who are candidates for vascular intervention.

A population-based study for 30-d hospital readmissions after acute ischemic stroke

Objective: To determine post-stroke 30-d readmission rate, its predictors, its impact on mortality and to identify potentially preventable causes of post-stroke 30-d readmission in a population-based study. Patients and methods: We identified all acute ischemic strokes (AIS) using the International Classification of Diseases 9th revision codes (433.x1, 434.xx and 436) via the Rochester Epidemiology Project (REP) between January 2007 and December 2011. Acute stroke care in Olmsted County is provided by two medical centers, Saint Marys Hospital and Olmsted Medical Center Hospital. All readmissions to these two hospitals were accounted for this study. Thirty-day readmission data was abstracted through manual chart review. The REP linkage database was used to identify the status (living/dead) of all patients at last follow up. Results: Forty-one (7.6%, 95% CI 5.7%–10.2%) of total 537 AIS patients were readmitted 30-d post-stroke. In a multivariable logistic regression model, discharge to nursing home following index stroke (OR: 0.29, 95% CI 0.08–0.84) was an independent negative predictor of unplanned 30-d readmission. In a subgroup of patients with dementia, being married at time of index stroke was found to be a negative predictor of readmission (OR: 0.10, 95% CI 0.005–0.58). Only 2.8% of the patients had potentially preventable readmissions. Hospital readmission had no significant impact on patient's short-term (three months) or long-term (one or two years) mortality (p > 0.05). Conclusion: Post-stroke 30-d readmission rate is low in AIS patients from Olmsted County. Further research is needed in regarding discharge checklists, protocols and stroke transitional programs to reduce potentially preventable readmissions.