Baseline Stroke Severity Research Articles

Impact of slice thickness on clinical utility of automated Alberta Stroke Program Early Computed Tomography Scores.

The clinical utility of electronically derived ASPECTS (e-ASPECTS) to quantify signs of acute ischemic infarction could be demonstrated in multiple studies. Here, we aim to clinically validate the impact of CT slice thickness (ST) on the performance of e-ASPECTS software. A consecutive series of n = 258 patients (06/2016 and 01/2019) with middle cerebral artery occlusion and subsequent treatment with mechanical thrombectomy was analyzed. The e-ASPECTS score and acute infarct volumes were calculated from baseline non-contrast CT with a software using 1-mm slice thickness (ST) (defined as ground truth) and axial reconstructions with 2-10-mm ST and correlated with baseline stroke severity (NIHSS) as well as clinical outcome (mRS) using logistic regressions. In comparison with the ground truth, significant differences were seen in e-ASPECTS scores with ST > 6mm (p ≤ 0.031) and infarct volumes with ST > 4mm (p ≤ 0.001). There was a significant correlation of lower e-ASPECTS and higher acute infarct volumes with increasing baseline NIHSS values for all ST (p ≤ 0.001, respectively), with values derived from 1mm yielding the highest correlation for both parameters (rho, - 0.38 and 0.31, respectively). Similarly, lower e-ASPECTS and higher acute infarct volumes from all ST were significantly associated with poor outcome after 90days (p ≤ 0.05, respectively) with values derived from 1-mm ST yielding the highest effects for both parameters (OR, 0.69 [95% CI 0.50-0.88] and 1.27 [95% CI 1.10-1.50], respectively). The e-ASPECTS software generates robust values for e-ASPECTS and acute infarct volumes when using ST ≤ 4mm with ST = 1mm yielding the best performance for predicting baseline stroke severity and clinical outcome after 90days. • Clinical utility of automatically derived ASPECTS from computed tomography scans was shown in patients with acute ischemic stroke and treatment with mechanical thrombectomy. • Thin slices (= 1mm) had the highest clinical utility in comparison with thicker slices (2-10mm) by having the strongest correlation with baseline stroke severity and independent effects on clinical outcome after 90days. • Automatically calculated acute infarct volumes possess clinical utility beyond ASPECTS and should be considered in future studies.

Abstract TP190: Elderly Stroke Patients Seen by Telemedicine and Retained at Spoke Community Hospitals Have Lower Early Mortality and Discharge to Hospice Than Those Presenting to a University Hub Hospital

Introduction: Age remains one of the most important non-modifiable risk factors leading to poor outcomes after acute ischemic stroke (AIS). Telemedicine (TM) increases care access for elderly AIS patients especially in rural areas, yet their outcomes after initial TM consultation in the emergency department (ED) are unknown. We compared discharge disposition between elderly AIS patients who presented to and were retained at spoke community hospitals (SCHs) in our TM network versus those who presented directly to the TM hub (DTH). Methods: From both our network’s hub and TM stroke registries, we identified AIS patients ≥80 years old who presented to the ED (9/2015 - 12/2018). We compared incidence of discharge disposition to hospice or expiration (HE) as well as demographic and clinical characteristics between the SCH and DTH patients. Patients transferred after TM evaluation or who did not present directly to the hub ED were excluded. Results: Of 716 patients seen by TM, 532 were admitted to SCHs and 64 (12%) went on to HE. Out of 388 patients presenting DTH, 111 (29%) went on to HE. DTH patients were more likely to go on to HE (OR 2.93; 95% CI 2.08 - 4.12) compared to those presenting to and retained at SCHs (Figure 1a). This difference persisted when adjusting for baseline characteristics, stroke severity, and acute treatment (OR 3.01; 95% CI 1.01 - 8.96) (Figure 1b). In both study groups, increased age and severe stroke were highly associated with HE in the multivariate analysis. DTH patients with dementia had a higher odds of HE upon discharge (p=0.009) while those who received endovascular therapy had a lower odds (p=0.014). High premorbid mRS did not confer significantly higher odds of HE in either group. Conclusions: Elderly patients seen over TM and admitted to SCHs have lower early mortality and discharge disposition to hospice compared to those who present DTH. Further study is needed to elucidate whether disparities in palliative care utilization account for this difference.

Deriving a Passive Surveillance Stroke Severity Indicator From Routinely Collected Administrative Data: The PaSSV Indicator.

Adjusting for stroke severity is crucial for stroke outcomes research. However, this information is not available in administrative healthcare data. We aimed to derive an indicator of baseline stroke severity using these data. We identified patients with stroke enrolled in a population-based registry in Ontario, Canada, and used the Canadian Neurological Scale (CNS), documented in the registry, as a measure of stroke severity. We derived an estimated CNS from a linear regression model in which we regressed the observed CNS on predictor variables: age, sex, arrival by ambulance, interhospital transfer, mechanical ventilation, and an emergency department triage score. The effect of stroke severity on the estimated hazard ratios for 30-day mortality was determined in 3 Cox-proportional hazards models with (1) no CNS, (2) observed CNS, and (3) estimated CNS, all adjusted for age, sex, Charlson index, and stroke type. We assessed model discrimination using C statistics. To assess for construct validity, we repeated these analyses in a subset of patients with documented National Institute of Health Stroke Scale and in a cohort of patients with stroke external to the registry. We derived the estimated stroke severity in 41 481 patients (48.7% female, median age of 75 years [interquartile range, 64- 83]). The magnitude of the association between stroke severity and mortality was similar for the observed and estimated CNS. The discriminative ability of the Cox-proportional hazards models to predict mortality was highest when the observed CNS was included (C statistic, 0.82 [95% CI, 0.81-0.82]), moderate with estimated CNS (0.76 [0.75-0.76]), and lowest without CNS (0.69 [0.69-0.70]. Our findings were replicated with the National Institute of Health Stroke Scale and in the external cohort. We derived an estimated measure of stroke severity using administrative data. This can be applied for risk adjustment in population-based stroke outcomes research and in assessments of health system performance.

Premorbid instrumental activities of daily living predicts discharge home following stroke.

Background and purposeStroke survivors who remain dependent require multiple healthcare resources, including rehabilitation and nursing care. The effect of premorbid instrumental ADL (IADL) on the discharge destination, which has not been studied previously in detail, is analyzed.Materials and methodsBetween April and September 2015, 40 stroke patients admitted to hospital were enrolled prospectively in the present study. The ADL (Barthel index) and IADL (Frenchay activities index: FAI) scores in their premorbid status were recorded. Baseline demographic data, stroke severity (NIHSS) and type of stroke, and whether they lived with family were also recorded. Simple univariate regression was performed between the two discharge destination groups (Home or Not Home). Significant factors were then included in multivariate logistic regression in order to determine the adjusted odds ratio for the discharge destination. A P value <.05 was taken as significant.Results25 patients (64.1%) returned home. According to univariate analysis, NIHSS on admission and premorbid FAI were significantly associated with the discharge destination. Multivariate analysis found that NIHSS (OR, 0.71; 95% CI0.56–0.92; p = .008) and premorbid FAI (OR, 1.17; 95% CI1.03–1.33; p = .01) were independent predictors of the discharge destination.ConclusionsSeverity of stroke upon admission and premorbid IADL are associated with discharge destination following stroke.

Circulating levels of vascular endothelial growth factor and post-stroke long-term functional outcome.

Vascular endothelial growth factor (VEGF) acts in angiogenesis and neuroprotection, although the beneficial effects on experimental ischemic stroke (IS) have not been replicated in clinical studies. We investigated serum VEGF (s-VEGF) in the acute stage (baseline) and 3months post-stroke in relation to stroke severity and functional outcome. The s-VEGF and serum high-sensitivity C-reactive protein (hs-CRP) concentrations were measured in patients enrolled in the Sahlgrenska Academy Study on Ischemic Stroke (SAHLSIS) at the acute time-point (median 4days, N=492, 36% female; mean age, 57years) and at 3months post-stroke (N=469). Baseline stroke severity was classified according to the National Institutes of Health Stroke Scale (NIHSS), and functional outcomes (3months and 2years) were evaluated using the modified Rankin Scale (mRS), dichotomized into good (mRS 0-2), and poor (mRS 3-6) outcomes. Multivariable logistic regression analyses were adjusted for covariates. The baseline s-VEGF did not correlate with stroke severity but correlated moderately with hs-CRP (r=.17, P<.001). The baseline s-VEGF was 39.8% higher in total anterior cerebral infarctions than in lacunar cerebral infarctions. In binary logistic regression analysis, associations with 3-month functional outcome were non-significant. However, an association between the 3-month s-VEGF and poor 2-year outcome withstood adjustments for age, sex, cardiovascular covariates, and stroke severity (per 10-fold increase in s-VEGF, odds ratio [OR], 2.56, 95% confidence interval [CI] 1.12-5.82) or hs-CRP (OR 2.53, CI 1.15-5.55). High 3-month s-VEGF is independently associated with poor 2-year functional outcome but not with 3-month outcome.

Pioglitazone and PPAR-\u03b3 modulating treatment in hypertensive and type 2 diabetic patients after ischemic stroke: a national cohort study

Background and aimPeroxisome proliferator-activated receptor-γ (PPAR-γ) modulating treatment may have cardiovascular benefits in type 2 diabetes mellitus (T2DM) patients after ischemic stroke (IS). However, whether there are additional benefits from intensive PPAR-γ modulating treatments in Asian patients with T2DM and hypertension (HTN) after IS remains unknown.MethodsBetween 2001 and 2013, patients admitted due to IS were identified from the National Health Insurance Research Database of Taiwan. Patients with T2DM and HTN using angiotensin receptor blockers were further included. Eligible patients were divided into two groups: (1) pioglitazone and (2) non-pioglitazone oral anti-diabetic agent groups. Propensity score matching (1:2) was used to balance the distribution of baseline characteristics, stroke severity and medications. The primary outcome was recurrent IS. Subgroup analysis for recurrent IS in pioglitazone and/or telmisartan users, the trend of IS risks across different PPAR-γ intensity treatments, and dose-dependent outcomes across different pioglitazone possession ratios were further studied. Statistical significance was set at p < 0.05 and p < 0.1 for clinical outcomes and interaction of subgroup analyses, respectively.ResultsThere were 3190 and 32,645 patients in the pioglitazone and non-pioglitazone groups. Patients of the pioglitazone group had a lower risk of recurrent IS (subdistribution hazard ratio, 0.91; 95% confidence interval 0.84–0.99). Pioglitazone was also associated with reduced recurrent IS in patients who also used telmisartan (p for interaction = 0.071). A graded correlation was found a borderline significant trend between the intensity of PPAR-γ therapy and following IS (p = 0.076). The dose-dependent outcome also showed that a borderline significant trend that higher pioglitazone possession ratio was associated with a lower risk of recurrent IS (p = 0.068).ConclusionsThe current study suggests that the use of pioglitazone in type 2 diabetic and hypertensive IS patients is associated with fewer recurrent IS events in an Asian population. Concurrent telmisartan use or a higher pioglitazone possession ratio may have a trend of increased pleiotropic effects, which could possibly be related to higher PPAR-γ effects. Future studies are warranted to confirm or refute the clinical effects and the possible mechanism of more intensive PPAR-γ-modulating treatments.

The frequency and impact of admission hyperglycemia on short term outcome of acute stroke patients admitted to Tikur Anbessa\xa0Specialized hospital, Addis Ababa, Ethiopia: a cross-sectional study

BackgroundAdmission hyperglycemia (HG) has been associated with worse outcomes among acute stroke patients. A better understanding and awareness of the potentially adverse influence of hyperglycemia on the clinical outcome of acute stroke patients would help to provide guidance for acute stroke management and prevention of its adverse outcomes. We aimed to assess the frequency of admission hyperglycemia and its impact on short term (30-days) morbidity and mortality outcomes of stroke in adult Ethiopian patients in an urban setting.MethodsA prospective, cross-sectional study was conducted among acute stroke patients admitted to Tikur Anbessa Specialized Hospital (TASH), within 72 h of symptom onset, from July to December 2016. Socio-demographic data, neuroimaging findings and capillary blood glucose values were obtained on admission. Hyperglycemia was defined as > 140 mg/dl. National Institute of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) were used to assess the baseline stroke severity and the 30-days post-stroke outcome, respectively.ResultsA total of 103 first-ever acute stroke patients were included (mean age = 55.5 + 15.3 years, 64.1% male and 65% under the age of 65 years) and 51 (49.5%) were hyperglycemic at time of admission. The median admission NIHSS score was worse in the hyperglycemic patients 14 (IQR 10–19) compared to normoglycemic patients 11 (IQR 8–15). Among stroke survivors, patients with hyperglycemia were 3.83 times (95% CI, 1.99–6.19) more likely to be functionally impaired (mRS = 3–5) at 30-days compared to normoglycemic patients (P = 0.041).Older age (≥ 65 years) (P = 0.017) and stroke severity (NIHSS > 14) (P = 0.006) at admission were both significantly associated with poor functional recovery at 30-day. Among patients who died at 30-day, two-third (66.7%) were hyperglycemic but they failed to show any significant association.ConclusionsHyperglycemia is prevalent among Ethiopian stroke patients at the time of presentation and it is associated with significantly poor functional recovery at 30th-day of follow up. This finding provides a rationale for achieving normal blood glucose in the course of acute stroke management which could have a favorable impact on the neurological outcome and quality of life for patients.

Temporal trends in intracerebral hemorrhage: Evidence from the Austrian Stroke Unit Registry.

BackgroundTo assess changes in frequency, severity, complications, therapy and outcome of intracerebral hemorrhage in patients treated in stroke units in Austria, we evaluated data from the Austrian Stroke Unit Registry between 2008 and 2016.Methods and findingsData of 6707 cases of ICH covering a time span of 9 years and including information on age, risk factors, pre-stroke modified Rankin Score (mRS), baseline stroke severity (NIHSS), complications, therapy, functional outcome, and mortality were extracted from the Austrian Stroke Unit Registry. A multivariate regularized logistic regression model and linear models for temporal dependence were computed for analyzing statistical inference and time trends. Bonferroni correction was applied to correct for multiple testing.Between 2008 and 2016, the proportion of ICH admissions to stroke units in Austria declined, with a shift among patients towards older age (>70 years, p = 0.04) and lower admission NIHSS scores. While no significant time trends in risk factors, pre-stroke mRS and medical complications were observed, therapeutic interventions declined significantly (p<0.001). Three-month mortality increased over the years independently (p = 0.003).ConclusionsDespite declining incidence and clinical severity of ICH we observed a clear increase in three-month mortality. This effect seems to be independent of predictors including age, admission NIHSS, pre-morbid MRS, or medical complications. The observations from this large retrospective database cohort study underline an urgent call for action in the therapy of ICH.

Influence of Pre-Existing Mild Cognitive Impairment and Dementia on Post-Stroke Mortality. The Dijon Stroke Registry

Objective: We assessed the association between pre-stroke cognitive status and 90-day case-fatality. Methods: Patients with ischemic stroke (IS) or spontaneous intracerebral hemorrhage (ICH) were prospectively identified among residents of Dijon, France, between 2013 and 2015, using a population-based registry. Association between pre-stroke cognitive status and case-fatality at 90 days was evaluated using Cox regression. Results: Seven hundred sixty-two patients were identified, and information about pre-stroke cognitive status was obtained for 716 (92.6%) of them, including 603 IS (84.2%) and 113 ICH (15.8%). Before stroke, 99 (13.8%) patients had mild cognitive impairment (MCI) and 98 (13.7%) had dementia. Patients with cognitive impairment were older, had a higher prevalence of several risk factors, more severe stroke, more frequent ICH, and less admission to stroke unit. Case-fatality rate at 90 days was 11.7% in patients without cognitive impairment, 32.3% in MCI patients, and 55.1% in patients with dementia. In multivariable analyses, pre-existing MCI (hazard ratio [HR] 2.22, 95% CI 1.21–4.05, p = 0.009) and dementia (HR 4.35, 95% CI 2.49–7.61, p < 0.001) were both associated with 90-day case-fatality. Conclusion: Pre-stroke MCI and dementia were both associated with increased mortality. These associations were not fully explained by baseline characteristics, pre-stroke dependency, stroke severity or patient management, and underlying reasons need to be investigated.

Association Between Levels of Serum Insulin-like Growth Factor I and Functional Recovery, Mortality, and Recurrent Stroke at a 7-year Follow-up.

The association of serum insulin-like growth factor I (s-IGF-I) with favorable outcome after ischemic stroke (IS) beyond 2 years is unknown. We investigated whether the levels of s-IGF-I 3 months post-stroke were associated with functional recovery up to 7 years after IS, considering also mortality and recurrent strokes. Patients (N=324; 65% males; mean age, 55 years) with s-IGF-I levels assessed 3 months after the index IS were included from the Sahlgrenska Academy Study on Ischemic Stroke (SAHLSIS). The modified Rankin Scale (mRS) was used to evaluate outcomes at 3 months, 2 and 7 years after IS, and recovery was defined as an improvement, no change, or deterioration in the shifts of mRS score. Baseline stroke severity was determined using the National Institutes of Health Stroke Scale (NIHSS). The mRS score distributions were better in the above-median s-IGF-I group (>146.7 ng/ml). The s-IGF-I level was not associated with recurrent stroke (N=79) or death (N=44), although it correlated with recovery (r=0.12, P=0.035). In the regression analysis, s-IGF-I associated with recovery between 3 months and 7 years (but not between 2 and 7 years). The associations did not withstand adjustment for age and sex. For comparison, the corresponding associations between 3 months and 2 years withstood all adjustments. The association for s-IGF-I with long-term post-stroke recovery persists after 7 years, which is also reflected in the mRS score distributions at all time-points. The effects are however modest, and not driven by mortality or recurrent stroke.

013 The impact of aggressive blood pressure management in the post-thrombolysis setting

IntroductionHigh blood pressure (BP) post-thrombolysis has been associated with an increased rate of bleeding and poorer outcome. We noted frequent BPs of &gt;180 mmHg with a target of keeping BP &lt;180. We tested whether a more aggressive target of SBP &lt;160 mmHg would result in fewer BP protocol violations.MethodsPatients were prospectively captured comparing patients thrombolysed during the 12 months before and 12 months following the introduction of a new more aggressive BP protocol, allowing for a 6 month transition period. Results were adjusted for baseline function and stroke severity using regression analysis.ResultsPre-protocol change 68 and post- 100 patients were thrombolysed. Baseline characteristics were similar between groups. There was a trend for a lower rate of SBPs &gt;180 mmHg (adjusted OR 0.49; 95% CI 0.31–1.1; p=0.097) and a significantly higher rate of SBPs &lt;120 mmHg (adjusted OR 3.06; 95% CI 1.52–6.17; p=0.002) in the aggressive BP protocol group; although events of extreme SBPs (&gt;200 and &lt;100 mmHg) were similar between groups. Favourable outcomes (mRS = 0–2) at 3 months were similar between groups (adjusted OR 1.27; 95% CI 0.58–2.8; p=0.56) as was the rate of symptomatic haemorrhages (adjusted OR 1.26; 95% CI 0.28–5.7; p=0.76). Model fit was improved by adding study group to the model.ConclusionsMore aggressive post-thrombolysis BP management lowered the overall BP, but did not result in improved patient outcomes. Potential explanations include a small sample size, reduced cerebral perfusion off-setting reduced bleeding risk, or high BP being merely an epiphenomenon of worse outcome rather than causative.

Absolute blood eosinophil count could be a potential biomarker for predicting haemorrhagic transformation after intravenous thrombolysis for acute ischaemic stroke

BackgroundImmune cells are involved in all stages of acute ischaemic stroke (AIS) and possess both neuroprotective and neurodamaging properties. It has been suggested that immune system activation after stroke may be associated with the development of haemorrhagic transformation (HT), which is the main complication limiting the clinical use of intravenous thrombolysis with recombinant tissue plasminogen activator (rtPA) for AIS. The purpose of our study was to analyse the association between absolute eosinophil count (AEC) at admission and the occurrence of HT after intravenous rtPA therapy for AIS.MethodsIn this retrospective study we enrolled AIS patients who were treated with rtPA within 4.5 h of symptom onset. Baseline stroke severity was evaluated using the National Institutes of Health Stroke Scale (NIHSS). Patients underwent head computed tomography scans at admission which were repeated 24 h after treatment with rtPA or promptly in case of clinical deterioration. HT was defined as blood at any site in the brain on follow-up head computed tomography scans. Spearman’s rank correlation test was used to analyse the correlation between AEC and NIHSS scores. The optimal AEC cut-off value for predicting HT was calculated using the area under the receiver operating characteristic curve. Multiple logistic regression was used to determine the association between AEC included as a binary variable and the incidence of HT.ResultsThe data of 201 patients was analysed (59.7% females; median age 77 years); 23 (11.4%) of them developed HT. The median of AEC was 62.5% greater in the non-HT group compared to the HT group (0.13 × 109/l and 0.08 × 109/l, respectively, p = 0.026). No correlation was found between AEC and baseline NIHSS scores (r = 0.061, p = 0.393). AEC ≥ 0.11 × 109/l predicted the occurrence of HT with 69.6% sensitivity and 60.7% specificity. AEC ≥ 0.11 × 109/l was independently associated with a 78% reduction in the odds of developing HT (adjusted odds ratio = 0.223, 95% confidence interval = 0.069–0.723, p = 0.012).ConclusionHigher values of AEC were associated with lower odds of developing HT, thus, AEC at admission could be considered an independent predictive marker of HT after treatment with rtPA for AIS.

Meta-Regression to Identify Patients Deriving the Greatest Benefit from Dual Antiplatelet Therapy after Stroke or Transient Ischemic Attack Without Thrombolytic or Thrombectomy Treatment

The patient's profile drawing the greatest benefit from dual antiplatelet therapy (DAPT) after a noncardioembolic, ischemic cerebrovascular event is not well characterized. Aim of this metaregression analysis was to compare DAPT versus single antiplatelet therapy (SAPT) in patients with stroke or transient ischemic attack (TIA). We searched randomized trials evaluating clinical outcome with aspirin plus a P2Y12 inhibitor versus SAPT in patients with noncardioembolic stroke or TIA. Primary end point was the incidence of recurrent stroke; safety outcome measure was major bleeding. Eleven trials were included in the analysis, enrolling 24,175 patients treated with DAPT (aspirin plus clopidogrel, n = 12,074) or SAPT (n = 12,101) after a stroke or TIA event. In the DAPT group the rates of recurrent stroke were lower (7.1% vs 8.8% with SAPT; odds ratios [OR] 0.74, 95% confidence interval 0.62 to 0.88; p = 0.0007) and the incidence of major bleeding was twofold higher (OR 2.01, 1.35 to 3.01; p = 0.0006). Metaregression indicated a positive correlation between prevention of recurrent stroke by DAPT and baseline stroke severity (p = 0.019), baseline risk profile (p = 0.0001), or prevalence of carotid atherosclerosis (p = 0.040). DAPT was more effective when initiated ≤7 days (OR 0.67, 0.58 to 0.77; p < 0.00001) and used for ≤3 months (OR 0.66, 0.58 to 0.76; p < 0.00001) after the event. In conclusion, in patients with stroke or TIA, the highest benefit of DAPT was observed in patients with higher baseline risk profile, greater stroke severity, or concomitant carotid disease, and when DAPT was initiated early and given for ≤3 months.

Amide Proton Transfer MRI Signal as a Surrogate Biomarker of Ischemic Stroke Recovery in Patients With Supportive Treatment.

Background: Amide proton transfer (APT) MR imaging has shown great potential in the evaluation of stroke severity because of its sensitivity to acid environments. However, this promising MRI technique has not been used to assess treatment efficacy with regard to stroke recovery.Purpose: To assess the therapeutic effect of supportive treatment in ischemic stroke patients using the pH-sensitive APT MRI technique.Material and Methods: Forty-three ischemic stroke patients at an early stage were recruited and scanned with conventional and APT MRI sequences at 3T before treatment. After treatment, 26 patients underwent a follow-up MRI scan (one to three times on different days). The magnetization-transfer-ratio asymmetry at 3.5 ppm, usually called the APT-weighted (APTW) signal, was measured. The APTW signal changes following treatment were analyzed.Results: Baseline APTW signal intensities in the infarcted lesions inversely correlated with baseline stroke severity. Lesion APTW values gradually increased with time in 24 cases (92.3%) with a follow-up MRI scan, showing clinical symptom improvements. Two cases (7.7%) showed further decreased APTW signal in the follow-up scan, accompanied by clinical symptom aggravation. Compared to the baseline, significant APTW signal increases were found for all post-treatment patients (efficacious), whether based on post-treatment or on stroke onset times. The increase in APTW signal in the ischemic stroke lesion after treatment was associated with an improvement in clinical symptoms.Conclusion: The APTW signal would be a useful imaging biomarker by which to assess the therapeutic efficacy of ischemic stroke treatment.

Abstract TP158: Risk prediction for symptomatic Intracranial Hemorrhage (sICH) in Acute Ischemic Stroke (AIS) Patients Treated With Intravenous Thrombolysis (IVT): Does Infarct Location Matter?

Introduction: There are mounting data supporting a substantially lower risk of sICH in AIS patients with posterior circulation stroke (PCS) following treatment with IVT. However, stroke location is not included in any of the numerous risk prediction scores for sICH complicating IVT in AIS. We sought to compare the safety and efficacy of IVT for AIS with respect to the location of acute cerebral ischemia in a high-volume tertiary care stroke center. Methods: Consecutive AIS patients treated with IVT during a five-year period were evaluated. Baseline stroke severity and early hypodensity on baseline CT were assessed by NIHSS-score and ASPECTS by certified physicians. Stroke location was classified as posterior (PCS) vs. anterior circulation (ACS), and supratentorial (STN) vs. infraterorial (ITN) infarction. Safety of IVT was evaluated using the SITS-MOST sICH definition. Three-month functional status was assessed using modified Rankin Scale (mRS) scores. Results: Out of total 1008 IVT-treated AIS patients [52% men, mean age 64±15years, median baseline NIHSS-score: 8 pts (IQR: 4-4)], 181 (18%) had PC and 88 (9%) had STN location. The rates of sICH were lower in patients with PCS [2.8% vs. 6.9%; p=0.039 by Fisher’s exact test (FET)] and ITN infarction (0% vs. 6.7%; p=0.005 by FET). PCS and ITN strokes (OR computed using Firth’s penalized likelihood method for rare events: 0.11; 95%CI: 0.01-1.82) were not independently associated with lower likelihood of sICH on multivariable logistic regression models adjusting for multiple potential confounders including demographics, vascular risk factors, onset-to-treatment time, baseline stroke severity, serum glucose, BP parameters and ASPECTS, pretreatment with antiplatelets (single or dual), statins and oral anticoagulants. Conclusions: Our study indicates that infarct location appears not to be independently related to the risk of sICH in AIS patients treated with IVT.

Abstract WP113: Racial Disparities in Patient Selection for Drip and Ship Thrombolytic Therapy for Acute Ischemic Stroke

Introduction: There is preliminary data indicating potential racial disparities in use of intravenous thrombolysis (IVT) for acute ischemic stroke (AIS). We sought to compare “drip and ship” (DNS) tPA use between African-Americans (AA) and Caucasians (CS) in a high-volume tertiary care stroke center. Methods: AIS patients treated with IVT during a seven-year period were evaluated. Baseline stroke severity and early hypodensity on baseline CT were assessed by NIHSS-score and ASPECTS by certified physicians. All patients who received IVT at an outside facility with subsequent transfer to our center were included in the DNS group. Safety of IVT was evaluated SITS-MOST symptomatic intracranial hemorrhage (sICH) definition. Three-month functional status was assessed using modified Rankin Scale (mRS) scores. Results: Out of total 1339 IVT-treated AIS patients [51% men, 63% AA, mean age 63±15years, median baseline NIHSS-score: 7 pts (IQR: 3-13)], 521 (39%) were treated using the DNS approach. DNS tPA use was less common in AA compared to CS (33% vs. 51%; p &lt; 0.001). AA race was independently associated with lower likelihood of DNS tPA use (OR: 0.46; 95%CI: 0.35-0.62; p&lt;0.001) on multivariable logistic regression models adjusting for multiple potential confounders including demographics, vascular risk factors, onset-to-treatment time, door-to-needle time, baseline stroke severity, serum glucose, BP parameters and ASPECTS. Among DNS patients, the rates of sICH, three-month favorable functional outcome (mRS-scores of 0-1) and mortality did not differ between AA and CS. Using geospatial software, the observed treatment disparity could not be explained by racial zipcode. distribution. Conclusions: Our study uncovers substantial racial disparities in the selection of AIS patients for DNS thrombolytic therapy that cannot be explained by racial geographic proximity to the primary stroke center.

Abstract TP24: Impact of Pretreatment With Intravenous Thrombolysis on Reperfusion Status in Emergent Large Vessel Occlusion (ELVO) Patients Treated With Mechanical Thrombectomy (MT)

Introduction: It currently remains unclear whether pre-treatment with intravenous thrombolysis (IVT) provides any additional benefits to emergent large vessel occlusion (ELVO) patients undergoing mechanical thrombectomy (MT). We sought to evaluate the impact of pretreatment with IVT on the rate and the speed of complete reperfusion (CR) in LVO patients treated with MT in a high-volume tertiary care stroke center. Methods: Consecutive ELVO patients treated with MT during a five-year period were evaluated. Baseline stroke severity was assessed by NIHSS-score. Standard safety [symptomatic Intracranial Hemorrhage (sICH) by SITS-MOST definition] and efficacy outcomes [CR (modified Thrombolysis in Cerebral Infarction IIb/III), 3-month functional independence (FI; modified Rankin Scale scores of 0-2)] were compared between patients who underwent combined IVT and MT (IVT+MT) vs. direct MT (dMT). The elapsed time between groin puncture to beginning of reperfusion (GPTBRT) and the numbers of device passes (DP) required to achieve CR were also documented. Results: A total of 287 and 132 patients were treated with IVT+MT and dMT respectively. The IVT+MT group had higher CR (74% vs. 63%; p=0.023) and FI (52% vs.38%; p=0.008) rates and shorter median GPTBRT (48 vs. 70 min; p&lt;0.001). The two groups did not differ in sICH rates (7% vs. 9%; p=0.368). Among patients who achieved CR, the median number of required DP was lower in the IVT+MT subgroup (1 vs. 2; p&lt;0.001) and the rate of patients requiring ≤2 DP was higher (98% vs. 77%; p&lt;0.001). IVT+MT was independently related to higher odds of CR (OR:1.64; 95%:1.03-2.61; p=0.036) and shorter GPTBRT (unstandardized linear regression coefficient: -20; 95%CI: -12, -27; p&lt;0.001) on multivariable analyses adjusting for potential confounders including demographics, vascular risk factors, collateral status, stroke severity, location of occlusion and onset to groin puncture time. Among patients with CR, IVT+MT was independently associated with higher likelihood of ≤2 DP (OR:14.75; 95%:4.72-46.04; p&lt;0.001). Conclusions: IVT pretreatment increases the rates of CR and shortens the duration of endovascular procedure by requiring fewer DP in ELVO patients treated with MT.

Abstract TP416: Safety and Efficacy Outcomes of Intravenous Thrombolysis (IVT) for In-Hospital Stroke

Introduction: Cross-sectional data suggest that IVT in patients with in-hospital (IHS) acute ischemic stroke (AIS) onset is associated with unfavourable outcomes compared to out-of-hospital (OHS) stroke onset patients. We sought to compare safety and efficacy outcomes between IHS and OHS patients treated with IVT. Methods: Consecutive AIS patients treated with IVT during a five-year period in a tertiary care stroke center were prospectively evaluated. Demographics, vascular risk factors, admission blood pressure and serum glucose levels were documented. Baseline stroke severity and early hypodensity on baseline CT were assessed using NIHSS-score and ASPECTS by certified physicians. Three-month functional outcome was evaluated by mRS-score. We compared the following outcomes between IHS and OHS patients: 1.symptomatic intracranial hemorrhage (sICH) 2.favourable functional outcome (FFO) [3-month mRS scores of 0-1], 3.Functional independence (FI) [3-month mRS scores of 0-2], 4. Mortality at three months. Results: Of 1264 IVT-treated AIS patients, we identified 51 (4%) subjects with IHS. Baseline median NIHSS-score was higher in IHS (10 points; IQR: 6-16 vs. 6 points; IQR: 3-12; p=0.004), while median onset-to-treatment was shorter (75 min; IQR: 37-115 vs. 135 min; IQR: 100-185; p&lt;0.001). In univariable analyses, IHS patients had higher three-month mortality rates (21% vs. 9%; p=0.009). There were no differences (p&gt;0.1) between the two groups in FFO, FI and sICH rates. IHS was associated with higher likelihood three-month mortality (OR: 3.1; 95%CI: 1.2-7.8; p=0.016) on multivariable logistic regression models adjusting for demographics, risk factors, onset-to-treatment time, admission blood pressure and serum glucose levels, baseline NIHSS and ASPECTS. Conclusions: IHS patients treated with IVT have more severe strokes and higher mortality rates compared to OHS patients. IVT for IHS is not associated with higher hemorrhagic complications.

Abstract TP19: Impact of Single-Pass Complete Reperfusion on Clinical Outcomes in Emergent Large Vessel Occlusion (ELVO) Patients Treated With Mechanical Thrombectomy (MT)

Introduction: There is mounting evidence indicating that first pass (FP) complete reperfusion (CR) may reduce peri-procedural complications for emergent large vessel occlusion (ELVO) patients treated with mechanical thrombectomy (MT). We investigated the impact of device passes (DP) on the clinical outcomes of ELVO patients who achieved CR following treatment with MT in a high-volume tertiary care stroke center. Methods: Consecutive ELVO patients with CR (modified Thrombolysis in Cerebral Infarction grades IIb/III) at the end of MT were evaluated during a five-year period. Baseline stroke severity was assessed by NIHSS-score. The numbers of DP during the procedure were documented. Standard safety outcomes included symptomatic Intracranial Hemorrhage (sICH) by SITS-MOST criteria and three-month mortality. Standard efficacy outcomes included neurological improvement at 24 hours (determined by the relative reduction in NIHSS-score compared to baseline) and functional improvement at three months [determined as the shift in modified Rankin Scale (mRS) scores]. Results: Among 258 ELVO patients achieving CR during MT the rate of FPCR was 67% (n=173). Patients with FPCR had greater median relative NIHSS-reduction at 24 hours (46% vs. 33%; p=0.033), lower median mRS-scores at three months (2 vs. 3; p=0.034) and lower three-month mortality rates (12% vs. 26%; p=0.005) compared to the rest. The two groups did not differ in sICH rates (5% vs. 10%; p=0.200). FPCR was associated with lower odds of three-month mortality (OR:1.64; 95%:1.03-2.61; p=0.036) on multivariable logistic regression models adjusting for potential confounders (demographics, risk factors, occlusion site, collateral status, stroke severity, onset to groin puncture time, baseline blood pressure and serum glucose values). Conclusions: FPCR appears to impact favourably clinical outcomes in ELVO patients treated with MT. CR following FP results in greater neurological and functional improvement at 24 hours and 3 months respectively.

Abstract WP15: Safety of Dual Antiplatelet Treatment in Emergent Large Vessel Occlusion (ELVO) Patients Treated With Mechanical Thrombectomy (MT) and Extracranial Internal Carotid Artery Stenting

Introduction: Extracranial Internal carotid artery (ExICA) stenting may be required during mechanical thrombectomy (MT) for anterior circulation large vessel occlusions (ACLVO) with coexisting ExICA steno-occlusive disease. We sought to evaluate the safety of acute dual antiplatelet therapy (DAP) in this high-risk MT subgroup. Methods: Consecutive ACLVO patients treated with MT were evaluated during a five-year period. All patients receiving ExICA stenting during MT were also acutely treated with DAP coupled with heparin or eptifibatide drips. Baseline stroke severity and early hypodensity on baseline CT were assessed using NIHSS-score and ASPECTS. Complete reperfusion (CR) was defined as modified Thrombolysis in Cerebral Infarction grades IIb/III) at the end of MT. Final infarct volume (FIV) on brain MRI was assessed at 24-48 hours using standardized methodology. Safety outcomes included symptomatic Intracranial Hemorrhage (sICH) documented by SITS-MOST criteria, infarct in new unaffected territory (INT) determined according to ESCAPE trial methodology and three-month mortality. We also assessed 3-month functional outcomes using modified Rankin Scale (mRS) scores. Results: Among 309 ACLVO patients treated with MT, 24 received additional ExICA stenting. Eptifibatide and heparin drips were administered in 15 (65% of stenting subgroup: 9 patients: aspirin + clopidogrel, 6 patients: aspirin + ticagrelor) and 8 (35% of stenting subgroup: 6 patients: aspirin + clopidogrel, 2 patients: aspirin + ticagrelor) cases respectively. Patients with and without ExICA stenting had similar (p&gt;0.1) median baseline NIHSS-scores (15 vs. 16 points) and ASPECTS (10 vs. 10 points). The two groups did not differ (p&gt;0.1) in terms of median FIV (20 vs. 15 cm 3 ) and median 3-month mRS-scores (2 vs. 2). Patients with ExICA stenting had similar (p&gt;0.1) rates of sICH (5% vs. 8%), INT (0% vs. 9%), CR (74% vs. 70%) and 3-month mRS-scores of 0-2 (55% vs. 51%) compared to the rest. Conclusions: DAP coupled with eptifibatide or heparin drips does not appear to increase peri-procedural complications or to worsen clinical outcome of ELVO patients treated with MT and ExICA stenting.