Cases Of Acute Ischemic Stroke Research Articles

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

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

Large Vessel Occlusion Related Ischemic Stroke From Vitamin B12-Deficiency Related Homocysteine (P8-5.029)

<h3>Objective:</h3> <h3>Introduction:</h3> Vitamin-B12 deficiency-related homocysteinemia is an infrequent cause of stroke. Homocysteinemia is associated with hypercoagulability, increased cholesterol-synthesis, increased oxidative-stress, reduced apolipoprotein-A1 synthesis needed to make protective high-density lipoprotein (HDL), along with cumulative mechanisms that impair endothelial function¹. We present a case of acute ischemic large vessel stroke in a young patient who was incidentally found to have low Vitamin-B12 related homocysteinemia. <h3>Background:</h3> N/A <h3>Design/Methods:</h3> <h3>Case report:</h3> 33-year-old male presented with acute onset motor-aphasia 30 minutes prior to arrival. Exam was significant for complete motor aphasia, facio-bucco-lingual apraxia and a right nasolabial-fold flattening. CT-head was negative for hemorrhage or acute ischemia and CT angiogram revealed an abrupt cut off of the left M1 segment. Patient received thrombolysis with Tenecteplase (TNK) and was emergently taken for mechanical-thrombectomy. On conventional angiogram, the M1 segment showed restored patency after TNK. Work up for secondary causes of stroke including telemetry, transesophageal echocardiogram, hypercoagulability labs, antinuclear antibody (ANA), and syphilis serology were unremarkable. Vitamin-B12 levels were significantly low at &lt; 148 (normal 213–816pg/ml), folate levels were borderline low at 5.0 (5.4–20ng/ml) and homocysteine was significantly elevated at 35 (5.1–15.4mcmol/l). Patient was treated with dual antiplatelet therapy with aspirin 81mg , clopidogrel 75mg and initiated on B12 and folate supplements. Patient was discharged home with near-complete symptom resolution and occasional word-finding difficulty. <h3>Results:</h3> N/A <h3>Conclusions:</h3> <h3>Discussion:</h3> Vitamin-B12 deficiency increases homocysteine levels which is associated with premature atherosclerosis² and is a risk factor for thrombotic events. While vitamin-supplementation can lower homocysteine levels, the benefits as primary-prophylaxis remain uncertain³. It is worthwhile to consider vitamin-supplementation with folic-acid (2.5 mg) and B-complex vitamin (50 mg B6 and 1 mg B12) ¹ supplements in patients with cryptogenic-strokes who have vitamin-B12 deficiency and homocysteinemia as a plausible cause for stroke. Further studies are needed to understand the pathophysiology of these two entities as risk factors for stroke. <b>Disclosure:</b> Dr. Harish has nothing to disclose. Dr. Rau has nothing to disclose. Dr. Diaz Rojas has nothing to disclose.

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.

Can a Single Acute Ischemic Stroke Simulation Course Facilitate Mastery? (P9-2.001)

<h3>Objective:</h3> To assess the impact of an acute ischemic stroke (AIS) simulation course on residents’ performance, confidence, and knowledge. <h3>Background:</h3> Previous studies have demonstrated that simulation can promote mastery learning in non-stroke neurological emergencies. <h3>Design/Methods:</h3> We designed an AIS simulation course with three independent scenarios based on previously reported consensus. For each scenario a Minimum Passing Score (MPS) and Mastery Score (MS) was determined by the Angoff method. Thirteen junior neurology residents completed a 20-point knowledge test and 7-point Likert scale confidence survey about AIS before the course and after didactic teaching. A week later, each resident participated in a scored AIS case and then practiced stroke care in second unscored case. Residents again completed the knowledge and confidence assessments. Several weeks later, without notice, each resident was evaluated in a third AIS scenario. For comparison, eight senior residents completed the knowledge test, confidence survey, and the third acute stroke case. Pre-post and between groups comparisons were conducted using paired t-tests and independent t-tests, respectively. <h3>Results:</h3> Junior residents scored better on the knowledge test after the didactic session (mean score pre: 40% to post: 52.2%, p&lt;0.05), but only 3 (23%) initially achieved the MPS score in the first AIS simulation. After the simulation course, 9 junior residents (69%) achieved the MPS threshold. Although none achieved Mastery, junior residents’ mean score in the simulation improved (10.3 (SD=2.8) vs 15.7 (SD=2.6), p&lt;0.001) and their confidence increased (pre mean=3.3 (SD=1.9) vs. post mean =4.9 (SD=1.2), p&lt; 0.001). Eight seniors completed the simulation: five reached MPS (63%) and one achieved Mastery. The simulation scores of the post-course juniors and seniors were similar (mean=15.7 (SD=2.6) vs mean=16.0 (SD=2.5), p=0.793). <h3>Conclusions:</h3> This pilot study suggests that a brief AIS simulation course may improves junior residents’ performance and confidence to a level similar to senior residents, but not to mastery. <b>Disclosure:</b> Dr. Albin has received personal compensation in the range of $5,000-$9,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Continuum: Life Long Learning in Neurology. Dr. Albin has received research support from American Academy of Neurology. Dr. Albin has received publishing royalties from a publication relating to health care. Dr. Albin has received personal compensation in the range of $500-$4,999 for serving as a Instructor with Resuscitation Leadership Academy. Dr. Sigman has nothing to disclose. Dr. Pergakis has nothing to disclose. Dr. Bhatt has nothing to disclose. Dr. Hutto has nothing to disclose. Dr. Koneru has nothing to disclose. Dr. Osehobo has nothing to disclose. Dr. Vizcarra has nothing to disclose. The institution of Dr. Morris has received research support from American Board of Psychiatry and Neurology. The institution of Dr. Morris has received research support from UMB ICTR through NIH NCATS&amp;CTSA grant 1UL1TR003098. The institution of Dr. Morris has received research support from University of Maryland Medical Center.

Neighborhood Deprivation and Polygenic Contribution to Acute Ischemic Stroke: Results from the All of Us Research Program (S49.007)

<h3>Objective:</h3> We hypothesize that neighborhood deprivation, a geographic metric that captures several social determinants of health, modifies the effect of genetic variation on risk of acute ischemic stroke (AIS). <h3>Background:</h3> The interaction between social determinants of health and genetic risk factors in their association with AIS is poorly understood. <h3>Design/Methods:</h3> We ran a cross-sectional study in <i>All of Us</i>, a large population study that aims to enroll one million Americans. We ascertained AIS cases using Observational Medical Outcomes Partnership codes. We evaluated neighborhood deprivation using the deprivation index, an aggregate variable derived from six American Community Survey metrics divided into tertiles. We modeled the polygenic contribution to AIS through a polygenic risk score that included 530 known genetic risk variants for cardiometabolic risk factors. We used multivariable logistic regression to model AIS likelihood as a function of neighborhood deprivation and polygenic risk, using product terms to test for interaction, and adjusting for age, sex, and ethnicity. <h3>Results:</h3> Of the 372,397 participants currently enrolled in <i>All of Us</i>, 147,492 had available genetic and deprivation index data; of these, 3,201 (2.2%) had strokes. Both neighborhood deprivation and the polygenic risk score were independently associated with AIS (both p&lt;0.05). We found a significant interaction between neighborhood deprivation and polygenic risk (interaction p=0.02): the polygenic risk score was significantly associated with the likelihood of AIS in the least deprived areas (OR 1.08, 95%CI 1.02–1.15; p=0.01) but was not associated with AIS in moderately and highly deprived areas (both p&gt;0.05). <h3>Conclusions:</h3> Among study participants enrolled in All of Us, those living in areas of low neighborhood deprivation were more susceptible to the effects of polygenic variation. It is possible that social determinants of health associated with a higher likelihood of AIS dilute the contribution of genetic risk factors. <b>Disclosure:</b> Dr. Rivier has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Pyxis Partners. Dr. Acosta has nothing to disclose. Dr. Renedo has nothing to disclose. Thomas Gill has nothing to disclose. Dr. Sheth has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Ceribell. Dr. Sheth has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Zoll. Dr. Sheth has received personal compensation in the range of $10,000-$49,999 for serving on a Scientific Advisory or Data Safety Monitoring board for NControl. Dr. Sheth has received stock or an ownership interest from Astrocyte. Dr. Sheth has received stock or an ownership interest from Alva. The institution of Dr. Sheth has received research support from Biogen. The institution of Dr. Sheth has received research support from Novartis. The institution of Dr. Sheth has received research support from Bard. The institution of Dr. Sheth has received research support from Hyperfine. Dr. Sheth has received intellectual property interests from a discovery or technology relating to health care. The institution of Dr. Falcone has received research support from NIH. The institution of Dr. Falcone has received research support from AHA.

Total oxidant/antioxidant status, copper and zinc levels in acute ischemic stroke patients after mechanical thrombectomy

Background and purposeWe aimed to identify the relationship of total antioxidant status, total oxidant status, and copper (Cu) and zinc (Zn) situations with the short-term prognostic and stroke severity in acute ischemic stroke cases who were successfully recanalized by mechanical thrombectomy. MethodsA study of 36 acute ischemic stroke patients and 22 controls were prospectively studied. Tube samples were attained at admission and 24 h after recanalization. In patients who were successfully recanalized (thrombolysis in cerebral infarction ≥ 2b), a 3-month modified Rankin scale (mRS) score of 0–2 was considered a good prognosis, and a score of 3–6 was considered a poor prognosis. ResultsAdmission Cu levels were significantly higher in the poor prognosis group (p = 0.031). In the multivariate logistic regression analysis, Cu was not associated with poor prognosis (p = 0.357). Cu and Zn levels were lower in the patients group compared to controls (p = 0.014 and p = 0.010, respectively). There was no correlation between National Institute of Health Stroke Scale and biomarkers (p > 0.05). The temporal variation of biomarkers did not differ significantly between the good prognosis and poor prognosis groups (p interaction > 0.05). ConclusionsHigh admission Cu levels were associated with poor prognosis, but this association was limited. In addition, Cu and Zn levels were statistically lower in patients. There was no relationship between total antioxidant/oxidant status and short-term prognosis or stroke severity

Variation in US acute ischemic stroke treatment by hospital regions: limited endovascular access despite evidence

BackgroundAlthough national organizations recognize the importance of regionalized acute ischemic stroke (AIS) care, data informing expansion are sparse. We assessed real-world regional variation in emergent AIS treatment, including growth in...

An in-hospital stroke system to optimize emergency management of acute ischemic stroke by reducing door-to-needle time

BackgroundDoor-to-needle time (DNT) is a critical consideration in emergency management of acute ischemic stroke (AIS). Deficiencies in the widely applied standard hospital workflow process, based on international guidelines, impede rapid treatment of AIS patients. We developed an in-hospital stroke system to reduce DNT and optimize hospitals' emergency procedures. ObjectivesTo investigate the effect of the in-hospital stroke system on the hospital workflow for AIS patients. MethodsWe performed a retrospective study on AIS patients between June 2017 and December 2021. AIS cases were assigned to a pre-intervention group (before the in-hospital stroke system was established) and a post-intervention group (after the system's establishment). We compared the two groups' demographic features, clinical characteristics, treatments and outcomes, and time metrics data. ResultsWe analyzed 1031 cases, comprising 474 and 557 cases in the pre-intervention and post-intervention groups, respectively. Baseline data were similar for both groups. Significantly more patients in the post-intervention group (41.11%) were treated with intravenous thrombolysis (IVT) or endovascular therapy (ET) compared with those in the pre-intervention group (8.65%) (p < 0.001). DNT was markedly improved (decreasing from 118 (80.5–137) min to 26 (21–38) min among patients in the post-intervention group treated with IVT or bridging ET. Consequently, a much higher proportion of these patients (92.64%) received IVT within 60 min compared with those in the pre-intervention group (17.39%) (p < 0.001). Consequently, their hospital stays were shorter (8 [6–11] days vs. 10 [8–12] days for the pre-intervention group; p < 0.001), and they showed improved National Institutes of Health Stroke Scale (NIHSS) scores at discharge (−2 [−5–0] vs. −1 [−2–0], p < 0.001). ConclusionDNT was significantly reduced following implementation of the in-hospital stroke system, which contributed to improved patient outcomes measured by the length of hospital stay and NIHSS scores.

Impact of the COVID-19 pandemic on acute stroke care: Ananalysis of the 24-month data from a comprehensive strokecenter in Shanghai, China.

Whether the coronavirus disease-2019 (COVID-19) pandemic is associated with a long-term negative impact on acute stroke care remains uncertain. This study aims to compare the timing of key aspects of stroke codes between patients before and after the COVID-19 pandemic. This retrospective cohort study was conducted at an academic hospital in Shanghai, China and included all adult patients with acute ischemic stroke hospitalized via the emergency department (ED) stroke pathway during the 24 months since the COVID-19 outbreak (COVID-19: January 1, 2020-December 31, 2021). The comparison cohort included patients with ED stroke pathway visits and hospitalizations during the same period (pre-COVID-19: January 1, 2018-December 31, 2019). We compared critical time points of prehospital and intrahospital acute stroke care between patients during the COVID-19 era and patients during the pre-COVID-19 era using t test, χ2 , and Mann-Whitney U test where appropriate. A total of 1194 acute ischemic stroke cases were enrolled, including 606 patients in COVID-19 and 588 patients in pre-COVID-19. During the COVID-19 pandemic, the median onset-to-hospital time was about 108 min longer compared with the same period of pre-COVID-19 (300 vs 192 min, p=0.01). Accordingly, the median onset-to-needle time was 169 min in COVID-19 and 113 min in pre-COVID-19 (p=0.0001), and the proportion of patients with onset-to-hospital time within 4.5h was lower (292/606 [48.2%] vs 328/558 [58.8%], p=0.0003) during the pandemic period. Furthermore, the median door-to-inpatient admission and door-to-inpatient rehabilitation times increased from 28 to 37 h and from 3 to 4 days (p=0.014 and 0.0001). During the 24 months of COVID-19, a prolongation of stroke onset to hospital arrival and to intravenous rt-PA administration times were noted. Meanwhile, acute stroke patients needed to stay in the ED for a longer time before hospitalization. Educational system support and process optimization should be pursued in order to acquire timely delivery of stroke care during the pandemic.

Abstract Number ‐ 25: Acute Ischemic Stroke Intervention With Penumbra RED Reperfusion Catheters: Updated Subset Analysis From INSIGHT Registry

Introduction The prospective INSIGHT Registry is a multicenter ‘multi‐omic’ analysis of thrombi associated with acute hemorrhagic or ischemic stroke. This updated interim analysis evaluated the performance of Penumbra RED catheters used during aspiration thrombectomy for acute ischemic stroke (AIS). Methods All AIS cases in which Penumbra RED aspiration catheters (RED 62, 68, or 72) were utilized as a frontline treatment were included in the analysis. Retrieved clot fragments were classified based on their gross appearance. Key time metrics and procedural data were also collected, including first‐pass / post‐procedure modified Treatment in Cerebral Ischemia (mTICI) score. Results Of 400 patients enrolled across 25 US centers, 161 underwent thrombectomy with Penumbra RED catheters over ten months (Jul 2021 through Apr 2022). The mean patient age was 70.7 years, and 50.9% were female. The middle cerebral artery first segment (M1) was the most common primary occlusion site (60.4%; 96/159). IV t‐PA was administered before the procedure in 13.7% (22/161) of patients. The median time from stroke onset / last known well to mTICI≥ 2b was 5.0 hrs. [IQR 3‐11], and the median time from a puncture to mTICI≥ 2b was 23.0 mins [IQR 15‐31]. Firm‐red clots represented 45.3% (67/148), while soft‐red clots were found in 37.8% (56/148) of retrieved clots. In turn, firm‐white and soft‐white clots were seen in 11.5% (17/148) and 5.4% (8/148) of cases, respectively. Rates of the first pass and final mTICI≥ 2b scores by clot type are shown in Table 1. Conclusions Aspiration thrombectomy with Penumbra RED catheters resulted in good revascularization rates for all clot types.

Frequency of Hyperuricemia In Patients Presenting with Acute Ischaemic Stroke

Hyperuricemia refers to elevated serum uric acid concentration above the upper limit of normal. Objective: To determine hyperuricemia in patients presenting with acute ischemic stroke to the Neurology ward of Lady Reading Hospital, Peshawar. Methods: A total of 153 patients were observed to the frequency of hyperuricemia in patients presenting with acute ischemic stroke. Study design was cross sectional study which was conducted for the period of 6 months. The total Sample size was calculated by using WHO sample size calculator. It was calculated using the World Health Organization software. Results: A total of 153 patients were observed to the frequency of hyperuricemia in patients presenting with acute ischemic stroke. Mean age of study participants was 52.45±1.14 years. Distribution of hyperuricemia was 114(74.5%). Mean serum uric acid level among cases of acute ischemic stroke was 06.15 ± 01.91 mg/dl while the mean serum uric acid level among control group was 05.1 ± 01.4 mg/dl. The results were highly significant p-value &lt; 0.0001. Conclusions: Serum uric acid levels can be used to predict stroke risk. Moreover, serum uric acid can be utilized to stratify risk following a stroke. Long-term prospective research is needed to determine the involvement of serum uric acid in ischemic stroke. A trial of serum uric acid reducing medications in stroke patients as well as those at high risk of stroke may also be worthwhile.

Editors' Note: Acute Arterial Ischemic Stroke Following COVID-19 Vaccination: A Systematic Review and Meta-analysis.

Dr. Stefanou et al. analyzed the risk of acute ischemic stroke (AIS) after COVID-19 vaccination and its potential association with thrombotic-thrombocytopenia syndrome (TTS) in a systematic review and meta-analysis of 2 randomized-controlled trials (RCTs), 3 cohort studies, and 11 registry-based studies. They found 17,481 AIS cases among 782,989,363 COVID-19 vaccinations, giving a pooled proportion of postvaccination AIS of 4.7 cases per 100,000 vaccinations, with no difference observed between mRNA-based and adenovirus-based vaccinations. The pooled proportion of TTS in AIS cases was 3.1%. In response, Dr. Du notes that the rate of AIS cases was lower than the age-standardized global AIS prevalence and incidence rates per 100,000 individuals per year, suggesting that the vaccinations may be associated with a lower risk of AIS. In this regard, Dr. Du cites a previous study that found a significant association between COVID-19 vaccination and lower risks of myocardial infarction and ischemic stroke. Responding to these comments, the authors caution that their crude estimate of new AIS events per 100,000 vaccination, without age standardization or annualization, was not directly comparable with age-standardized AIS estimates per 100,000 individuals per year in the general population. These exchange raises demonstrate relevant complexities when seeking to compare the risk of postvaccination AIS with the “background” risk in the general population while motivating additional studies to investigate whether COVID-19 vaccination might reduce AIS risk at a population level. Dr. Stefanou et al. analyzed the risk of acute ischemic stroke (AIS) after COVID-19 vaccination and its potential association with thrombotic-thrombocytopenia syndrome (TTS) in a systematic review and meta-analysis of 2 randomized-controlled trials (RCTs), 3 cohort studies, and 11 registry-based studies. They found 17,481 AIS cases among 782,989,363 COVID-19 vaccinations, giving a pooled proportion of postvaccination AIS of 4.7 cases per 100,000 vaccinations, with no difference observed between mRNA-based and adenovirus-based vaccinations. The pooled proportion of TTS in AIS cases was 3.1%. In response, Dr. Du notes that the rate of AIS cases was lower than the age-standardized global AIS prevalence and incidence rates per 100,000 individuals per year, suggesting that the vaccinations may be associated with a lower risk of AIS. In this regard, Dr. Du cites a previous study that found a significant association between COVID-19 vaccination and lower risks of myocardial infarction and ischemic stroke. Responding to these comments, the authors caution that their crude estimate of new AIS events per 100,000 vaccination, without age standardization or annualization, was not directly comparable with age-standardized AIS estimates per 100,000 individuals per year in the general population. These exchange raises demonstrate relevant complexities when seeking to compare the risk of postvaccination AIS with the “background” risk in the general population while motivating additional studies to investigate whether COVID-19 vaccination might reduce AIS risk at a population level.

Abstract TP161: Predictors Of Undiagnosed Risk Factors For Cerebrovascular Ischemic Events: A Population-based Study

Introduction: Primary prevention reduces the burden of acute ischemic stroke (AIS), yet cerebrovascular risk factors (RF) remain underdiagnosed in certain populations. We aimed to identify predictors of undiagnosed RF among patients with cerebrovascular ischemic events in a large bi-racial population. Methods: Individuals 20 years and older with an incident TIA or AIS from the population-based Greater Cincinnati/Northern Kentucky 2015 stroke study period were screened for inclusion. We included all hospital ascertained, physician-verified cases of AIS and TIAs. Outpatient and ED-only cases were excluded. Abstracted medical record data included determination of newly diagnosed hypertension (HTN), diabetes mellitus (DM), hyperlipidemia (HLD) or atrial fibrillation (AF). Multivariable models were used to identify predictors for each undiagnosed RF. Model variables included: age, sex, race, insurance status and number of cerebrovascular RF (additionally including coronary artery disease and smoking). Results: A total of 1604 ischemic events were included (1485 stroke, 119 TIA) with 52.9% female; 22.4% Black; median age 70 (IQR 59, 82)). Only 6% (n=102) had no history of RF. The prevalence of each undiagnosed RF was: HTN 4.1%; HLD 7.9%; DM 3.1%; AF 3.2%. In unadjusted bivariate analysis, uninsured/unknown status was predictive of undiagnosed HTN (OR = 3.97, 95% CI 1.48, 10.68; p =.006) and HLD (OR=5.53, 95% CI 2.68, 11.4; p &lt;.0001). After adjustment, insurance status remained a predictor for only undiagnosed HLD ( Table 1 ). No relationship was found with race. Conclusions: The most consistent predictor for an undiagnosed RF was absence of other RF and lack of insurance, both suggestive of suboptimal cardiovascular screening in this population. Further studies assessing known but undertreated RF and socioeconomic factors could be of benefit.

Abstract WP145: Racial Disparity In Outcomes Of Acute Ischemic Stroke In The United States: A 20-year Analysis Of The National Inpatient Sample From 2000-2019

Background: Acute ischemic stroke (AIS) is associated with a high rate of morbidity and mortality. We aimed to characterize racial disparities in patients with AIS over a 20 year period and examine the prognostic impact of race on functional outcomes. Methods: A query of the 2000-2019 National Inpatient Sample was performed for patients admitted with AIS (ICD9 433, 43401, 43411, 43491, ICD-10 I63). Demographics, comorbidities, and outcomes were identified. Discharge location was used as a surrogate for functional outcome. Univariate analysis with t-tests or chi-square performed as appropriate, and significant variables were entered into a multivariate regression to generate adjusted odds ratios (AOR)/β-coefficients for race on outcomes. Significance set at an alpha level of &lt;0.001. All analysis performed in R version 4.1.3. Results: A total of 10,415,286 patients with AIS were identified. Mean Age was 70.91±13.8 years. Patients were 61% White, 14.3 % Black, 6.6% Hispanic, and 2.4% Asian. Average NIH Stroke Scale differed significantly among the groups, with Asian patients having more severe disease than White, Black, or Hispanic patients (p&lt;0.001). After multivariate analysis, Black patients had worse odds for discharge home than white patients (AOR 0.8, 95%CI: 0.77-0.83, p&lt;0.001) with a higher likelihood of discharge to nursing/long-term care facilities (AOR 1.3, 95%CI: 1.26-1.34, p&lt;0.001). In hospital mortality was less in Black (AOR 0.64, 95%CI: 0.58-0.7) and Hispanic (AOR 0.78, 95% CI: 0.69-0.87) patients (p&lt;0.001). Conclusions: This 20 year nationally representative analysis of racial disparities in patients with AIS shows that while Black patients have worse odds of discharge home, they are less likely than White patients to die in the hospital. White patients make up the majority of cases, but their percentage of total AIS cases decreased while Black patients increased over the twenty year study period.

Abstract HUP1: Neighborhood Deprivation And Polygenic Contribution To Acute Ischemic Stroke: Results From The All Of Us Research Program

Background: The interaction between social determinants of health and genetic risk factors in causing acute ischemic stroke (AIS) is poorly understood. We hypothesize that community deprivation, a geographic metric that captures several social determinants of health, modifies the effect of genetic variation on risk of AIS. Methods: We analyzed data from All of Us , a large population study that aims to enroll one million Americans. We ascertained AIS cases using Observational Medical Outcomes Partnership codes. We evaluated community deprivation using the deprivation index, an aggregate variable derived from six metrics of the American Community Survey that was divided into tertiles. We modeled the polygenic contribution to AIS through a polygenic risk score that included 530 known genetic risk variants for cardiometabolic risk factors. We used multivariable logistic regression to model AIS risk as a function of community deprivation and polygenic risk, using product terms to test for interaction. Results: Out of 372,397 participants currently enrolled in All of Us , 147,492 had available genetic and deprivation index data, including 3,201 (2.2%) strokes. Both community deprivation and the polygenic risk score were independently associated with AIS risk (both p&lt;0.05). We found a significant interaction between community deprivation and polygenic risk (interaction p=0.02, Figure): the polygenic risk score was significantly associated with AIS risk in areas with low community deprivation (OR 1.08, 95%CI 1.02-1.15; p=0.01) but was not associated with this risk in areas of intermediate and high deprivation (both p&gt;0.05). Conclusion: Among study participants enrolled in All of Us, those living in areas of low community deprivation were more susceptible to the effects of polygenic variation. We speculate that in areas with high deprivation, several social determinants of health known to lead to higher risk of AIS dilute the contribution of genetic risk factors.

Abstract 32: Neighborhood Deprivation And Polygenic Contribution To Acute Ischemic Stroke: Results From The All Of Us Research Program

Background: The interaction between social determinants of health and genetic risk factors in causing acute ischemic stroke (AIS) is poorly understood. We hypothesize that community deprivation, a geographic metric that captures several social determinants of health, modifies the effect of genetic variation on risk of AIS. Methods: We analyzed data from All of Us , a large population study that aims to enroll one million Americans. We ascertained AIS cases using Observational Medical Outcomes Partnership codes. We evaluated community deprivation using the deprivation index, an aggregate variable derived from six metrics of the American Community Survey that was divided into tertiles. We modeled the polygenic contribution to AIS through a polygenic risk score that included 530 known genetic risk variants for cardiometabolic risk factors. We used multivariable logistic regression to model AIS risk as a function of community deprivation and polygenic risk, using product terms to test for interaction. Results: Out of 372,397 participants currently enrolled in All of Us , 147,492 had available genetic and deprivation index data, including 3,201 (2.2%) strokes. Both community deprivation and the polygenic risk score were independently associated with AIS risk (both p&lt;0.05). We found a significant interaction between community deprivation and polygenic risk (interaction p=0.02, Figure): the polygenic risk score was significantly associated with AIS risk in areas with low community deprivation (OR 1.08, 95%CI 1.02-1.15; p=0.01) but was not associated with this risk in areas of intermediate and high deprivation (both p&gt;0.05). Conclusion: Among study participants enrolled in All of Us, those living in areas of low community deprivation were more susceptible to the effects of polygenic variation. We speculate that in areas with high deprivation, several social determinants of health known to lead to higher risk of AIS dilute the contribution of genetic risk factors.

Abstract WP14: A Patient-level Data Euclidean-matched Analysis Of Reperfusion Therapies In Acute Ischemic Stroke From The Latin American Stroke Registry (lase)

Introduction: As acute stroke therapies expand to less well-resourced regions, it is imperative to study real-world data to assess outcomes and the quality of stroke care. The present study analyzes clinical, and imaging outcomes after acute IV thrombolysis (IV-tPA) compared to mechanical thrombectomy (MT) or combined therapy in the LASE. Methods: A retrospective analysis of consecutive acute ischemic stroke cases in 17 centers from 9 Latin American (LA) countries since 2012 was performed using weighted Euclidean matching of nearest neighbors in 3-D space of baseline NIHSS, age, and glucose. Results: 950 patients receiving only IV-tPA were matched to 127 treated with MT+IV-tPA. Matching resulted in 97 pairs well balanced for age (69.1 vs. 69.3), baseline NIHSS (17 vs. 17), and glucose (124.3 vs. 124.5), all p&gt;0.2. 3-month mRS 0-1 (38.3% vs 29.8%, p=0.23) and mRS 0-2 (46.8% vs 41.5%, p=0.54) were non-significantly higher in the MT+IV-tPA group, with higher hemorrhage (26.6% vs 15.5%, p=0.05) and trends for higher death (15.1% vs 9.5%, p=0.40) and symptomatic hemorrhage (7.4% vs 6.2%, p=1.0). One hundred one patients receiving only MT were matched to 127 patients with MT+IV-tPA, resulting in 61 pairs; MT+IV-tPA showed trends for higher rates of 3-month mRS 0-1 (45.0% vs 35.6%, p=0.31), mRS 0-2 (48.3% vs 42.4%, p=0.54); with trends for lower rates of death (16.9% vs 20.0%, p=1.0) and symptomatic hemorrhage (8.3% vs 11.1%, p=0.75). Conclusions: In this real-world LA sample, trends for better functional outcomes were demonstrated with MT+IV-tPA compared to either treatment alone, as in non-LA populations. A trend for higher adverse events in the combined group requires further investigation.

Reasons withholding intravenous thrombolysis for acute ischemic stroke in an Indonesian Tertiary Center

BackgroundIntravenous thrombolysis is the current therapy of choice in patients with acute ischemic stroke (AIS). While highly effective, the rate at which the procedure is employed is low. Studies evaluating the causes withholding thrombolytic treatment in developing nations remain scarce. We aim to determine the factors withholding thrombolytic treatment in AIS patients.MethodsThis is a retrospective study of AIS patients at Siloam Hospitals Lippo Village, Indonesia, in a 10-month period between April 2019 to February 2020. Patient data were collected from the medical records.ResultsOne hundred and forty-five cases of AIS were found within a 10-month period (April 2019 to February 2020). Thrombolysis was performed in 6.90% of all patients with AIS (21.28% when adjusted for eligible patients with onset ≤ 4.5 h). Prehospital delay exceeding 4.5 h was the most common cause of withholding thrombolytic treatment (68.28% of patients present above 4.5 h or with unknown onset). Among patients presenting ≤ 4.5 h, causes withholding thrombolysis include clinical improvement (35.14%), mild non-disabling symptoms (32.43%), patient/family refusal (18.92%), extensive infarction (5.41%), seizures at onset (2.7%), as well as history of acute bleeding diathesis (2.7%) and gastrointestinal bleeding (2.7%).ConclusionsPrehospital delay constitutes the primary obstacle toward receiving thrombolytic therapy for AIS, especially in developing countries. Among patients with onset below 4.5 h, other notable causes include clinical improvement, mild non-disabling symptoms, and patient/family refusal. Of note, the rate of patient/family refusal in our study was much higher compared to previous findings, which may reflect possible socio-economic, communication, or educational issues.

Neutrophil lymphocyte ratio (NLR) and systemic immune inflammatory index (SII) for the differential diagnosis of CT-negative mild acute ischemic stroke and transient ischemic attack

Background: A number of acute ischemic stroke (AIS) cases may be misdiagnosed as transient ischemic attack (TIA), due to no infarct on initial computed tomography scan and/or mild deficits upon presentation. Several studies have found that the neutrophil–lymphocyte ratio (NLR) is an accurate differential diagnostic biomarker for AIS versus TIA; however, no study has evaluated the use of the NLR in differentiating CT negative AIS from TIA. Furthermore, the systemic immune-inflammation index (SII) is a relatively novel immune biomarker that has been shown to be positively correlated with AIS severity, poor functional outcomes and mortality. The purpose of this study is to determine if NLR or SII can be used as a diagnostic biomarker for the differential diagnosis of mild AIS with a negative CT upon admission and TIA. Methods: We performed a retrospective medical record review of patients diagnosed with either AIS or TIA. We collected peripheral white blood cell counts within 24 h of symptom onset and calculated the NLR and SII. Logistic regression was utilized to determine if NLR or SII are significant predictors of CT negative mild AIS. Results: CT negative mild AIS patients were 2 times as likely to have an NLR ≥ 2.71 compared to TIA patients, and CT negative mild AIS patients were 2.1 times as likely to have an SII ≥ 595 compared to TIA patients. Conclusion: NLR and SII are easily obtained biomarkers that can be used in early clinical decision making in cases of mild AIS with negative CT scan upon admission.

Nationally Certified Stroke Centers Outperform Self-Attested Stroke Centers in the Florida Stroke Registry.

The Florida Stroke Act, signed into law in 2004, set criteria for Comprehensive Stroke Centers (CSC). For a set time period, Florida hospitals were permitted to either receive national certification (NC) or could self-attest (SA) as fulfilling CSC criteria. The aim of this project was to evaluate the quality of ischemic stroke care in NC versus SA stroke centers in Florida, using well-known, guideline-driven ischemic stroke outcome metrics. A total of 37 CSCs (74% of Florida CSCs) in the Florida Stroke Registry from January 2013 through December 2018 were analyzed, including 19 SA CSCs and 18 NC (13 CSCs and 5 Thrombectomy-Capable Stroke Center). Hospital- and patient-level characteristics and stroke metrics were evaluated, adjusting for demographics, medical comorbidities, and stroke severity. A total of 78 424 acute ischemic stroke cases, 36 089 from SA CSCs and 42 335 from NC CSC/Thrombectomy-Capable Stroke Centers were analyzed. NC centers had older patients (73 [61-83] versus 71 [60-81]; P<0.001) with more severe strokes (median National Institutes of Health Stroke Scale score of 5 versus 4; P<0.001). NC had higher intravenous tissue-type plasminogen activator utilization (15% versus 13%; P<0.001), endovascular treatment (10% versus 7%; P<0.001) and faster median door-to-computed tomography (23 minutes [11-73] versus 31 [12-78]; P<0.001), door-to-needle (37 minutes [26-50] versus 45 [34-58]; P<0.001) and door-to-puncture times (77 minutes [50-113] versus 93 [62-140]; P<0.001). In adjusted analysis, patients arriving to NC hospitals by 3 hours were more likely to get intravenous tissue-type plasminogen activator in the 3- to 4.5-hour window (adjusted odds ratio, 1.87 [95% CI, 1.30-2.68]; P=0.001) and more likely to be treated with intravenous tissue-type plasminogen activator within 45 minutes (adjusted odds ratio, 1.61 [95% CI, 1.04-2.50]; P=0.04) compared with SA CSCs. Among Florida-Stroke Registry CSCs, acute ischemic stroke performance and treatment measures at NC centers are superior to SA CSCs. These findings have implications for stroke systems of care in Florida and support legislation updates requiring NC and removal of SA claims.