Clinical Outcome In Acute Ischemic Stroke Research Articles

Antihypertensive Interventions in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis Evaluating Clinical Outcomes Through an Emergency Medicine Paradigm.

High blood pressure (HBP) is usually prominent after the onset of acute ischemic stroke (AIS). Although previous studies have found that about half of patients with AIShave a background of hypertension, there is no clear etiology for HBP in AIS. The literature reveals discrepancies in the relationship between HBP and clinical outcomes of AIS, pointing towardthe contested effect of blood pressure (BP) reduction clinical outcomes. Thus, the potential benefits and hazards of HBP treatment were explored in the context of clinical outcomes after AIS. An electronic database and a manual search were carried out to identify all the articles related to this topic and published between 2000 and January 2023. The Review Manager software was also used to perform the meta-analysis and quality appraisal. In analyses related to patients not treated with reperfusion therapies, mortality, and dependency outcomes were categorized as short-term (<3 months) or long-term (≥3 months). Our search strategy yielded 2459 articles, of which only 15 met the inclusion criteria. The results of our meta-analysis demonstrate that in patients not treated with reperfusion therapies, BPlowering had no significant impact on either short-term or long-term mortality (risk ratio (RR): 1.18; 95% confidence interval (CI): 0.81-1.73; p = 0.39, and RR: 1.04; 95% CI: 0.77-1.40; p = 0.81, respectively) and dependency (RR: 1.12; 95% CI: 0.97-1.30; p = 0.11, and RR: 0.98; 95% CI: 0.90-1.07; p = 0.61, respectively). Furthermore, BP lowering prior to reperfusion showed no significant effect on mortality (RR: 0.7; 95% CI: 0.23-2.26; p = 0.58), but it did significantly reduce the risk of dependency (RR: 0.89; 95% CI: 0.85-0.94; p < 0.00001). When the dataset was restricted to patients who had successful reperfusion, intensive BP lowering (target systolic BP <120 mmHg) was found to increase the risk of dependency (RR: 1.23; 95% CI: 1.09-1.39; p = 0.0009). In addition, BP reduction had an insignificant effect on the risk of recurrent strokes and combined vascular events (RR: 1.00; 95% CI: 0.54-1.84; p = 1.00, and RR: 0.99; 95% CI: 0.70-1.41; p = 0.95, respectively). Lowering BP in patients not treated with reperfusion therapies is not beneficial in reducing the risk of either short or long-term mortality and dependency. However, BPR before reperfusion reduces the risk of dependency, while aggressive BPR (target systolic blood pressure (SBP) <120 mmHg) after successful reperfusion increases the risk of dependency. Therefore, we recommend BPR as early as possible for patients undergoing reperfusion therapies but suggest against aggressive BPR in patients who have undergone successful reperfusion.

Anterior ischemic stroke: Analysis of the multivariable CT-based models for prediction of clinical outcome

ObjectiveTo determine the predictive value of multiple CT-based measurements, individually and collectively, including arterial collateral filling (AC), tissue perfusion parameters, as well as cortical venous (CV) and medullary venous (MV) outflow, in patients with acute ischemic stroke (AIS). MethodsWe retrospectively reviewed a database of patients with AIS in the middle cerebral artery distribution, who underwent evaluation by multiphase CT-angiography and perfusion. AC pial filling was evaluated using a multiphase CTA imaging. The CV status was scored using the adopted PRECISE system based on contrast opacification of the main cortical veins. The MV status was defined by the degree of contrast opacification of medullary veins in one cerebral hemisphere as compared to the contralateral hemisphere. The perfusion parameters were calculated using FDA-approved automated software. A good clinical outcome was defined as a Modified Rankin Scale of 0-2 at 90 days. ResultsA total of 64 patients were included. Each of the CT-based measurements could predict clinical outcomes independently (P<0.05). AC pial filling and perfusion core based models did slightly better compared to each of the other models (AUC = 0.66). Among models with two variables, the perfusion core combined with MV status had the highest AUC=0.73 followed by a combination of MV status and AC (AUC=0.72). Multivariable modeling with all four variables resulted in the highest predictive value (AUC=0.77). ConclusionThe combination of arterial collateral flow, tissue perfusion, and venous outflow provides a more accurate prediction of clinical outcome in AIS than each variable alone. This additive effect of these techniques suggests that the information collected by each of these methods only partially overlaps.

CHA2DS2-VASc score as an independent outcome predictor in patients hospitalized with acute ischemic stroke.

PurposeAtrial fibrillation (AF) is a significant independent risk factor for 1-year mortality in patients with first acute ischemic stroke (AIS). The CHA2DS2-VASc score was initially developed to assess the risk of stroke in patients with AF. Recently, this scoring system has been demonstrated to have clinical value for predicting long-term clinical outcomes in AIS but the evidence is insufficient. This large-scale prospective cohort study investigated the independent predictive value of the score in such patients.MethodsWe included patients with AIS from the Taiwan Stroke Registry (TSR) during 2006–2016 as the present study population. Patients were divided into those with high (≥2) and low (<2) CHA2DS2-VASc scores. We further analyzed and classified patients according to the presence of AF. The clinical endpoint was major adverse cardiac and cerebrovascular events (MACCEs) at 1 year after the index AIS.ResultsA total of 62,227 patients with AIS were enrolled. The median age was 70.3 years, and 59% of the patients were women. After confounding factors were controlled, patients with high CHA2DS2-VASc scores had significantly higher incidence of 1-year MACCEs (adjusted hazard ratio [HR] = 1.63; 95% confidence interval [CI] = 1.52, 1.76), re-stroke (adjusted HR = 1.28; 95% CI = 1.16, 1.42), and all-cause mortality (adjusted HR = 2.03; 95% CI = 1.83, 2.24) than those with low CHA2DS2-VASc scores did. In the comparison between AF and non-AF groups, the AF group had increased MACCEs (adjusted HR = 1.74; 95% CI = 1.60, 1.89), myocardial infarction (adjusted HR = 4.86; 95% CI = 2.07, 11.4), re-stroke (adjusted HR = 1.47; 95% CI = 1.26, 1.71), and all-cause mortality (adjusted HR = 1.90; 95% CI = 1.72, 2.10). The Kaplan–Meier curve revealed that both CHA2DS2-VASc scores and AF were independent risk predictors for 1-year MACCEs and mortality.ConclusionsThe CHA2DS2-VASc score and AF appeared to consistently predict 1-year MACCEs of AIS patients and provide more accurate risk stratification. Therefore, increased use of the CHA2DS2-VASc score may help improve the holistic clinical assessment of AIS patients with or without AF.

Abstract WMP57: Acute Stroke Interventions And Clinical Outcomes In Patients With Solid Organ Malignancies

Background: There is limited data regarding the safety of acute ischemic stroke (AIS) treatments in patients with solid organ malignancy (SOM). We aimed to evaluate the nationwide use of acute stroke interventions and clinical outcomes in this patient population. Methods: Adult hospitalizations with primary diagnosis of AIS were identified from the Nationwide Readmissions Database 2016-2018. Logistic regression was used to compare the differences in interventions and clinical outcomes in patients with and without SOM. Survival analysis was used to evaluate recurrent AIS after discharge. Results: There were 1385840 hospitalizations due to AIS (mean±SD age 70.4±14.0 years, female 50.2%). Of these, 50553 (3.7%) had a concurrent diagnosis of SOM. Patients with SOM were older, more likely to be male, and had a lower prevalence of comorbid cerebrovascular risk factors, except atrial fibrillation and tobacco use. The five most common malignancies were of lung, prostate, breast, pancreas, and colorectal origins. After adjustment for baseline differences, patients with SOM were more likely to have intraparenchymal hemorrhage (IPH) [odds ratio (OR): 1.1, 95% confidence interval (CI): 1.0-1.2], in-hospital mortality (OR: 2.1, 95% CI: 2.0-2.2), and discharge disposition other than to home (OR: 1.6, 95% CI: 1.6-1.7). The risk of IPH was higher only in pancreatic cancer, in-hospital mortality in all types except prostate cancer, and adverse discharge disposition in all types except prostate and breast cancers. Patients with SOM were less likely to receive intravenous thrombolysis (tPA) but more likely to undergo endovascular thrombectomy (ET). Among the subgroups of patients treated with tPA or ET, outcomes were comparable between patients with and without SOM, except patients with lung cancer remained at a higher risk of mortality and adverse disposition despite these interventions. Patients with SOM had higher risk of readmission due to recurrent AIS within 1 year of discharge (hazards ratio: 1.2, 95% CI: 1.1-1.3), and this risk was entirely driven by lung and pancreatic cancers. Conclusion: Clinical outcomes of AIS in the setting of SOM vary according to the malignancy site. Acute stroke interventions when performed, appear to be safe in most patients with SOM.

Clinical Outcome of Acute Ischemic Strokes in Patients with COVID-19

Introduction: Acute ischemic stroke (AIS) and thrombotic events (TEs) were reported in patients with COVID-19. Clinical outcome of AIS in the course of COVID-19 remains unknown. We compared early clinical outcome and mortality of COVID-positive (+) patients admitted for AIS with COVID-negative (−) ones. We hypothesized that COVID+ patients would have poorer clinical outcomes and present a higher rate of TEs and mortality compared with COVID− ones. Methods: In this multicentric observational retrospective study, we enrolled patients over 18 years old admitted for AIS in 3 stroke units of the Parisian region during lockdown from March 17, 2020, to May 2, 2020. COVID-19 status as well as demographic, clinical, biological, and imaging data was collected retrospectively from medical records. Poor outcome was defined as modified Rankin score (mRS) 3–6 (3–6) at discharge. We also compared TE frequency and mortality rate through a composite criterion in both groups. Results: Two hundred and sixteen patients were enrolled; mean age was 68 years old, and 63% were male. Forty patients were CO­VID+ (18.5%) and 176 were COVID−. Obesity was statistically more frequent in the COVID+ group (36 vs. 13% p < 0.01). The percentage of patients with mRS (3–6) at discharge was higher in the COVID+ group compared with the COVID− group (60 vs. 41%, p = 0.034). The main predictor of presenting a mRS (3–6) at discharge was high NIHSS score at admission (OR, CI 95%: 1.325, 1.22–1.43). Mortality rate was higher in the COVID+ group (12 vs. 3.4%, p = 0.033) as well as TE frequency (15 vs. 2.8%, p < 0.01). Conclusion: In this study, patients with AIS infected by SARS-CoV-2 showed a poorer early outcome than COVID− ones. However, when compared to other factors, COVID-19 was not a significant predictor of poor outcome. Vascular morbidity and mortality rates were significantly higher in the COVID+ group compared with the COVID− group.

Relationship Between High Sensitivity TNF-? WITH clinical outcome During Admission In Acute Ischemic Stroke

Background : Tumor necrosis factor alpha (TNF-?), together with other pro-inflammatory cytokines suchas Interleukin-1b (IL-1b), IL- 6 and IL-8, play a role in the ischemic injury of the central nervous system.TNF-? has adverse effects on ischemic brain tissue. The mechanism generated is a multicomplex process. Inother studies, an increase in TNF-? can actually have neuroprotective effects. This study aims to determinethe relation between the levels of the High Sensitivity TNF-? with clinical outcome in acute ischemic stroke.Method : Thirty patients with acute ischemic stroke patients who admitted in Dr. Soetomo hospital Surabayaduring the period December 2011 to February 2012. 2 cc of vein blood for examination High sensitivityTNF-? was drawn during admission from acute ischemic stroke. Clinical outcome in acute stroke wasmeasured by NIHSS score.Results: From 30 research samples, the mean age of patients was 59.53 ± 11.51 years. The mean HighSensitivity TNF-? level in the study subjects was 2 ± 0.99 pg / ml. NIHSS examination showed the medianvalue of the NIHSS was 5 with a range of 2-19. There is a correlation but not statistically significant withthe strength is very weak between High Sensitivity TNF-? with the NIHSS in patients with acute thromboticstroke (r = 0.100 and p = 0.600).Conclusion: There is relationship between serum levels of High sensitivity TNF-? with clinical outcome inacute ischemic stroke patients.

D-dimer and its Combination with Blood Lipid on Prognosis of Patients with Acute Ischemic Stroke

BackgroundPrevious studies indicate that the levels of d-dimer and blood lipids at admission affect the prognosis of patients with acute ischemic stroke (AIS), however, whether there is a dose-response effect of d-dimer on prognosis, or a combined effect of d-dimer with blood lipids on prognosis, remains unclear. MethodsIn this prospective cohort study, 1485 AIS patients were recruited. All participants received medical care within 24 h from the onset of stroke, the level of d-dimer and related indices were measured at admission. Then, National Institutes of Health Stroke Scale (NIHSS) scores were obtained at the time of admission and discharge. Afterwards, 3-, 6- and 12- month follow-up was conducted to obtain Modified Rankin Scale (mRS) scores after discharge. ResultsA high level of d-dimer at admission was associated with clinical outcome of AIS, after adjusting other relevant factors, with an OR (95%CI) of 2.934(1.914–4.500), 3.052(1.912–4.872), 3.306(1.873–5.835) and 2.828(1.447–5.527) at discharge, at 3-, 6-, and 12-month follow-up respectively, a dose-response effect was observed during follow-up (p = 0.00001). When d-dimer was combined with total cholesterol (TC), after adjusting other relevant factors, OR (95%CI) was 2.799 (1.708–4.587), 2.473 (1.475–4.147), 2.381 (1.333–4.255), and 2.619 (1.320–5.193), at each follow-up period respectively. When combined with low-density lipoprotein (LDL), OR (95%CI) was 3.105 (1.729–5.577), 3.280 (1.762–6.104), 2.744 (1.344–5.604), and 4.400 (1.883–10.282), respectively. ConclusionsD-dimer levels at admission may predict the prognosis of AIS patients in a dose-response pattern. Moreover, d-dimer combined with TC or LDL predict prognosis of AIS.

The global burden of cerebral small vessel disease related to neurological deficit severity and clinical outcomes of acute ischemic stroke after IV rt-PA treatment.

Various types of cerebral small vessel diseases (CSVD) are commonly coexisting and the clinical outcome possibly is determined by their combined effect. The present study was designed to explore the possible relationship between the global burden of CSVD and clinical outcomes after recombinant tissue plasminogen activator (rt-PA) treatment of ischemic stroke. We enrolled patients with acute ischemic stroke (AIS) after IV rt-PA treatment between August 2016 and July 2018. According to the total burden rating scale of CSVD, we calculated the total CSVD score for white matter hyperintensities, lacunar infarction, cerebral microbleeds, and perivascular spaces. All patients were assessed on the basis of the National Institutes of Health Stroke Scale (NIHSS) score and the modified Rankin Scale (mRS) score at 90days after stroke. We used multivariate logistic regression analysis to examine the associations between global burden of CSVD and degree of neurological deficit and clinical outcomes. ROC curve analysis was used to determine cut-off values of the total CSVD score in predicting poor outcomes. The results showed that the total CSVD score was independently associated with moderate to severe stroke (OR 2.187, 95%CI 1.495-3.119, P < 0.001). Initial NIHSS (OR 1.23, 95%CI 1.144-1.330, P < 0.001), OTT (OR 1.007, 95%CI 1.000-1.014, P = 0.037), and CSVD score (OR 3.157, 95%CI 2.120-4.703, P < 0.001) was significantly related to poor functional outcome at 3months. The total CVSD score cut-off value of 1.5 was determined at best to distinguish between good prognosis and poor outcome (AUC 0.7534 [95%CI 0.6883-0.8185]). The global burden of CSVD was independently associated with neurological deficit severity and clinical outcomes of AIS after IV rt-PA treatment. The total CVSD score is a reliable predictor for poor outcomes of AIS after IV rt-PA treatment.

Does the Magnitude of the Electrocardiogram QT Interval Dispersion Predict Stroke Outcome?

BackgroundQT dispersion, maximal interlead difference in QT interval on 12-lead electrocardiogram (ECG), measures cardiac repolarization abnormalities. Data are conflicting whether QT dispersion predicts adverse outcome in acute ischemic stroke (AIS) patients. Our objective is to determine if QT dispersion predicts: (1) short-term clinical outcome in AIS, and (2) stroke location (insular versus noninsular cortex). MethodsAdmission ECGs from 412 consecutive patients with acute stroke symptoms from 2 university-based stroke centers were reviewed. QT dispersion was measured. A neuroradiologist reviewed brain imaging for insular cortex involvement. Favorable clinical outcomes at discharge were modified Rankin Scale (mRS) score of 0-1, discharge National Institutes of Health Stroke Scale (NIHSS) score less than 2, and discharge to home. Multiple logistic regressions were performed for each outcome measure and to determine the association between insular infarct and QT dispersion. ResultsOf 145 subjects in the final analysis, median age was 65 years (interquartile range [IQR] 56-75), male patients were 38%, black patients were 68%, median QT dispersion was 78 milliseconds (IQR 59-98), and median admission NIHSS score was 4 (IQR 2-6). QT dispersion did not predict short-term clinical outcome for mRS score (odds ratio [OR] = 1.001, 95% confidence interval [CI] .99-1.01, P = .85), NIHSS at discharge (OR = .994, 95% CI .98-1.01, P = .30), or discharge disposition (OR = 1.001, 95% CI .99-1.01, P = .81). Insular cortex involvement did not correlate with QT dispersion magnitude (OR = 1.009, 95% CI .99-1.02, P = .45). ConclusionsWe could not demonstrate that QT dispersion is useful in predicting short-term clinical outcome at discharge in AIS. Further, the magnitude of QT dispersion did not predict insular cortical stroke location.

Clinical Outcome And Arginine Serum of Acute Ischemic Stroke Patients Supplemented by Snakehead Fish Extract

Background: Levels of arginine associated with clinical outcome in acute ischemic stroke (AIS). Arginine is a protein needed to synthesis nitric oxide (NO), a potential vasodilator and antioxidant. Snakehead fish is a source of protein which has antioxidant activity. Snakehead fish contains mineral, vitamin, and amino acids. One of the amino acids that were found quite high in snakehead fish extract is arginine. The aim of this study was done to determine the effect of snakehead fish extracts (SFE) on serum arginin levels and clinical outcome of AIS patients.Methods: It was double-blind randomized pretest-posttest control group design, with. AIS patients were divided into two groups i.e. snakehead fish extracts (SFE) and control. SFE group were administered 15 grams SFE for 7 days . Arginine serum levels and clinical outcome (measured by National Institute of Health Stroke Scale = NIHSS) were measured before and after treatment, other related factors were also analyzed in Logistic regression.Results: A total of 42 subjects who were performed random allocation as SFE or control group. There was no differences in subject characteristics between the two groups. There was a differences Δ arginine serum levels between SFE and control (33.6±19.95 μmol/L; 0.3±2.51 μmol/L; p<0.001). Change in NIHSS score in SFE improved significantly compared to the control group (4.14 ± 2.03; 2.52 ± 1.81;p=0.009 ). Logistic regression analysis showed only female gender factor that affected on improvement of NIHSS (OR=7; p=0,01).Conclusion: There is Clinical outcome improvement and enhancement of arginine serum levels in AIS patient with snakehead fish extract supplementation.

Abstract WP326: Fever Promotes Worse Outcomes in Reperfused Patients Irrespective of Febrile Duration

Introduction: Fever following acute ischemic stroke (AIS) promotes greater consumption of ischemic penumbra despite reperfusion; however, the influence of timing of onset and duration of fever remains unexplored. We assessed the impact of such temporal features on infarct growth and clinical outcome in AIS, hypothesizing a dose-dependent negative response to sustained fever. Methods: Retrospective study of AIS patients presenting with proximal large vessel occlusion within 12h of onset, and achieving reperfusion (mTICI 2b/3). Pretreatment CTP was obtained in all subjects in a fully automated environment (RAPID) for segmentation of ischemic core and penumbral mismatch volumes. Final infarct volumes (FIV) were measured by DWI, and relative infarct growth (RIG) computed as (FIV-CTPcore/CTPmismatch). Systemic temperatures were obtained up to q15 minutes from presentation to DWI. Fever (&gt;37.5) onset and duration were documented. Pearson’s correlation and linear and logistic regressions tested the association of fever onset and duration vs. RIG and favorable clinical outcome (90d mRS≤2). Results: 119 subjects (59 men, age 63±14 yrs) met inclusion. Median[IQR] NIHSS=18[8]; last known well to groin puncture=355min[310]; median[IQR] core, mismatch, and FIV=9.6[23.8], 109[104], and 19.6[37]ml, respectively. Median fever duration=9h. Fever duration and time to onset were not independently associated with RIG (p=0.4, 0.6). The best fit model for prediction of RIG included fever, procedure duration and initial core. The OR for 90d mRS≤2 in febrile patients controlling for fever onset, age, NIHSS, core and procedure parameters was 0.6 (0.14-2.85). The adjusted OR for 90d mRS≤2 given one additional hour of febrile time was non-significant (0.99, 0.9-1.0). Earlier timing of fever onset was independently correlated to clinical outcome (p=0.04). Conclusions: While fever promotes infarct growth despite reperfusion, these findings suggest duration of fever is less influential upon imaging and clinical outcomes than hypothesized, with the negative impact of fever in the early aftermath of AIS driving worse outcomes irrespective of duration. The findings underscore the importance of temperature control during early temperature dysregulation after AIS.

Changes in serum vascular endothelial growth factor and endostatin concentrations associated with circulating endothelial progenitor cells after acute ischemic stroke.

Angiogenesis is an important pathophysiological response to cerebral ischemia, and can be modulated by vascular endothelial growth factor (VEGF) and endostatin. Circulating endothelial progenitor cells (EPCs) also play an important role as an endogenous repair mechanism for ischemic injury. We sought to investigate early changes in the expression of VEGF and endostatin in serum and the circulating EPCs in patients with acute ischemic stroke (AIS) and analyzed the relations between them. The peripheral blood and serum samples were obtained from 30 patients at 1, 3, 5 and 7 d after AIS. Flow cytometry was used to quantify EPCs, and VEGF and endostatin were measured by enzyme linked immunosorbent assay. Correlation analysis was performed to assess the relations between them. Receiver operating characteristic (ROC) curve was used to appraise the value of EPCs levels in predicting the 90-day prognosis after AIS. Compared with control subjects, circulating EPCs numbers increased from a very lower initial level (P < 0.001) until 7 d after AIS. Serum VEGF and endostatin levels increased and peaked at 3 d and 5 d post-stroke (both P < 0.001), respectively. A significant correlation (P = 0.001) was found between peak serum VEGF concentration and peak endostatin concentration. VEGF/endostatin ratio at day 1 and day 3 after AIS significantly correlated with circulating EPCs numbers at day 5 (P < 0.001) and day 7 post-stroke (P < 0.001). ROC curve analysis suggested that circulating EPCs number at day 7 had a significantly predictive power for good prognosis. VEGF and endostatin may mediate EPCs proliferation in the early phase of ischemic stroke, and the circulating EPCs levels can be a predictor of clinical outcome in AIS.

Abstract WMP23: Regional Assessment of Multi-phase CTA and CT Perfusion are Equivalent in Predicting Tissue Fate in Ischemic Stroke

Introduction: The use of CT Perfusion (CTP) in acute ischemic stroke (AIS) to determine patients with large ischemic core is still hampered by slow processing time, among other technical/standardization issues. Multi-phase CTA (mCTA) may be quicker and more practical in this regard. We sought to determine i) the performance of mCTA and CTP to predict regional infarction and ii) which mCTA construct(s) corresponds to which CTP parameter . Methods: mCTA and CTP was performed less than 12hrs from ictus in 77 patients with MCA-M1 occlusions. Regional analysis was performed within M2-M6 ASPECTS-regions. mCTA: regional pial vessels were assessed according to three constructs: i) Delay in maximal pial vessel enhancement compared to contralateral hemisphere; ii) Washout of contrast within pial vessels; iii) Extent of maximal pial vessel enhancement compared to contralateral hemisphere (Figure 1). CTP-CBF, CBV, MTT, IRF-T0, and Tmax values were determined. 24-hour MR-DWI or NCCT was used for final infarction. Results: There was a negligible difference in the predictive accuracy of mCTA and CTP in discriminating infarction (i.e., 84.59% and 83.04%, respectively). mCTA-Extent had the largest discriminatory power, while CTP-Tmax had the largest discriminatory power. Conclusion: Herein we show that mCTA assessments, even within small brain regions can help determine tissue fate when adjusted for recanalization, and is as good as CTP. mCTA may be a more practical modality to obtain similar prognostic information for radiological and clinical outcomes in AIS, informing acute treatment and tertiary centre triaging.

Abstract TP33: Ischemic Stroke Outcomes in Medical vs Endovascular Treatment of Proximal Carotid Artery Occlusion

Background: Acute ischemic stroke (AIS) due to proximal carotid artery occlusion (pCAO) can be associated with significant neurological deficits and poor outcome without timely intervention and successful reperfusion. Intravenous thrombolytics (IT) have low recanalization rates in pCAO and these patients were excluded from recent randomized controlled trials which showed superiority of endovascular therapy (EVT) over IT. Purpose: The purpose of this study is to investigate clinical outcomes in AIS due to pCAO treated with medical vs. endovascular treatment. Methods: We conducted a retrospective chart review of patients who underwent IT or EVT±IT for all types of pCAO from January 2008 to June 2015. Our primary outcome was the functional outcome at discharge measured by modified Rankin score (mRS) 0-3. The secondary outcomes were hemorrhagic transformation (HT), neurological worsening (NW), symptomatic hemorrhage (sICH) and death. Logistic regression analysis was used to compare outcomes between the two groups. Results: A total of 133 patients were included in the study. Baseline characteristics are depicted in table 1. There were no significant differences between the two groups. IV tPA was given in 56% IT vs. 72% EVT (p=0.14). While there was a shift towards better outcomes in the mRS distribution in EVT group (22% vs. 16%) as shown in Figure 1, the treatment effect did not reach significance (OR 1.71, 95% CI (0.55, 5.34), p=0.35). There was also no difference in HT (26% vs. 14%, p=0.14), or NW (26% vs. 21%, p=0.6). However, sICH was higher in EVT (3.7% vs. 0%, p=0.2). Conclusion: Our study did not show difference in discharge functional outcomes between EVT and IT in AIS with pCAO. Our results are limited by small sample size and retrospective nature. Future prospective studies randomizing patients to medical vs. endovascular treatments are warranted to guide management.

Abstract 137: Gastrointestinal Bleeding in Acute Ischemic Stroke: A Nationwide Inpatient Sample Study

Introduction: Gastrointestinal bleeding (GIB) has been reported as a complication in acute cerebrovascular ailments. Here, we examined the incidence, risk factors, and outcomes of GIB in acute ischemic stroke (AIS) using the largest all-payer inpatient database in the U.S. Methods: The Nationwide Inpatient Sample (2002-2011) was queried to identify all adult patients with a primary diagnosis of AIS both with and without a secondary diagnosis of GIB. We utilized multivariate analyses, adjusting for patient and hospital factors, to identify risk factors for GIB in AIS patients and to determine the effect of GIB on in-hospital complications and outcomes. Results: Of 3,988,667 patients admitted with AIS, there were 49,348 cases of GIB (1,237 per 100,000 patients) with 25.7% receiving blood transfusions. Multivariate analysis revealed several independent predictors of GIB in AIS: age 55-64 (OR: 1.39, 95% CI: 1.33-1.45), age 65-74 (OR: 1.52, 95% CI: 1.44-1.59), age 75+ (OR: 1.79, 95% CI: 1.71-1.88), alcohol use (OR: 1.23, 95% CI: 1.17-1.30), coagulopathy (OR: 1.69, 95% CI: 1.62-1.77), cancer (OR: 1.70, 95% CI: 1.60-1.80), fluid/electrolyte disturbance (OR: 1.91, 95% CI: 1.87-1.96), liver disease (OR: 2.44, 95% CI: 2.29-2.60), and history of peptic ulcer disease (OR: 2.47, 95% CI: 2.13-2.86) (all p&lt;0.0001). Administration of thrombolytic therapy decreased the likelihood of GIB by 10% (p&lt;0.0001). In further multivariate models, GIB was determined to be an independent predictor of septicemia (OR: 1.47, 95% CI: 1.39-1.55), gastrostomy (OR: 1.75, 95% CI: 1.70-1.81), pulmonary embolism (OR: 1.75, 95% CI: 1.55-2.00), intubation (OR: 2.04, 95% CI: 1.95-2.13), and blood transfusion (OR: 11.31, 95% CI: 11.00-11.63; all p&lt;0.0001). The occurrence of GIB increased hospital length of stay by an average of 5.8 days and total costs by $14,120 per patient (all p&lt;0.0001). GIB was independently associated with a 46% increased likelihood of severe disability and 82% increased likelihood of in-hospital death (all p&lt;0.0001). Conclusion: Age and several preexisting comorbidities are strong risk factors for GIB in AIS. GIB occurrence precipitates further in-hospital complications and adverse clinical outcomes in AIS, significantly increasing disability and mortality.

Abstract WP64: The Utility of Computed Tomography Angiographic Collateral Flow as a Predictor of Clinical Outcome in Acute Ischemic Stroke With ICA Occlusion

Introduction: Rapid assessment of collateral status is an important issue for therapeutic decision making in acute ischemic stroke(AIS), because collaterals may affect revascularization, ischemic severity and clinical outcomes. CT angiography(CTA) is non-invasive and more feasible as a fast diagnostic tool than conventional angiography, therefore it was commonly used as the initial evaluation tool in AIS. Hypothesis: To examine correlation between collateral status observed by CTA and clinical outcomes in patients with acute ICA occlusion. Methods: The patients with ICA occlusion who underwent CTA within 6h of symptom onset were collected retrospectively. We assessed collateral status using CTA and evaluate correlation between collateral grades and clinical outcome. Collateral grades were classified as grade 1-4(Figure1). Clinical outcome was measured by major neurologic improvement(MNI) and good functional outcome. MNI was defined by a ≥8 point improvement in NIH Stroke Scale and good functional outcome was defined as modified Rankin scale at 90 days of 0 to 2. Results: A total of 50 patients were included in this study. In analysis of CTA collateral, 13 patients were classified as grade1, 8 patients as grade2, 9 patients as grade3, and 20 patients as grade4, respectively. In grade 1 patients, there were no patients who showed MNI or good outcome. In contrast, among grade 4 patients, 3 patients(15%) showed MNI and 10 patients(50%) had good functional outcome. Especially, patients in group 4 with successful recanalization demonstrated favorable outcome (2 of 10 MNI, 8 of 10 good functional outcome). In grade2 and 3 patients, the proportion of MNI and good functional outcome was between that of grade1 and 4 patients (grade2: no MNI, good functional outcome 2 of 12, grade 3: MNI 2 of 9, good functional outcome 1 of 9). Conclusions: Collateral flow status assessed by CTA can predict clinical outcomes in AIS, and further studies are needed to verify this correlation.

Impact of Anesthesia on Mortality During Endovascular Clot Removal for Acute Ischemic Stroke

Endovascular clot retrieval is a technique available for removing intracranial arterial occlusions in acute ischemic stroke (AIS). This rescue therapy can be performed with moderate conscious sedation (CS) or general anesthesia (GA). The effect of GA on clinical outcome in AIS remains controversial. Therefore, we retrospectively investigated whether the use of CS or GA during endovascular intervention for AIS influenced outcomes. Patients who underwent emergent endovascular intervention for intracranial arterial occlusion during the years 2006 to 2012 were included in this study. Statistical analysis using the Spearman ρ was performed to examine demographic data and clinical outcomes between patients in the GA and CS groups. Binary logistic regression was used to determine the predictors of mortality. A total of 109 patients fit the inclusion criteria. Among them, 35 patients had GA and 74 patients had CS. Patients needing intubation upon admission for airway protection were more likely to receive GA (P<0.001). The duration of the procedure and the time-to-revascularization from symptom onset were significantly longer in the GA group. Mortality was higher in the GA group compared with the CS group (40% vs. 22%, P=0.045). Multivariate analysis, controlled for confounding variables, identified GA and elevated postprocedure glucose level to be significant predictors of mortality. Larger prospectively randomized multicenter trials evaluating the effects of GA and CS on clinical and radiographic outcomes seems warranted.

Various blood glucose parameters that indicate hyperglycemia after intravenous thrombolysis in acute ischemic stroke could predict worse outcome.

BackgroundHyperglycemia is common after stroke, and it is well known to worsen its outcome. However, it is important to consider that blood glucose (BG) levels can undergo dynamic changes during the acute stage of ischemic stroke. We sought to investigate the clinical significance of various glucose parameters within first 24 hours in acute ischemic stroke (AIS). The study focused on hyperacute stage patients who underwent IVT and investigated which parameters of glucose demonstrated to be helpful for predicting outcome.MethodsThis was a retrospective study of consecutive patients with AIS at a single stroke center. Patients were consecutively enrolled if they were treated with IV-tPA within 3 hours of symptom onset. BG was measured immediately upon arrival in ER, after IVT and every 6–8 hours during the first 24 hours after IVT. The various parameters of BG were the following: BG before IVT, BG after IVT, mean BG (mBG), maximal BG (max BG), standard deviation of BG (sdBG), and standard deviation of mean BG (sdmBG).Results207 patients (127 men and 80 women) were included in this study. Seventy seven of 207 patients had favorable outcomes at 3 months. High BG after IVT, mBG and max BG were independently associated with mRS>2 at 3 months (adjusted by age, NIHSS, and atrial fibrillation). Several parameters of BG were also independently associated with early mortality within 3 months (BG after IVT, mBG, and max BG). BG after IVT and mBG over 180 mg/dL were independently associated with early mortality within 3 months.ConclusionSerial measurements of BG might be a better predictor of clinical outcome in patients with AIS treated with IVT than single BG measurements before IVT. Therefore, these results suggest that variable parameters of BG could be important for the prediction of clinical outcome in AIS treated with IVT.

Abstract 3436: Specific NIH Stroke Scale Items Strongly Predict Hospital Arrival Mode, Thrombolysis Administration, and Clinical Outcomes in Acute Ischemic Stroke

Background: The 11-item National Institutes of Health Stroke Scale (NIHSS) is widely used as an index of stroke severity and prognostication. However, no studies have specifically examined the influence of NIHSS items on care processes and outcomes in Acute Ischemic Stroke (AIS). Furthermore, potential distinctions in neurologic signs of AIS that may contribute to disparities in race-ethnic treatment rates and outcomes have not been evaluated. We assessed the relation of neurological signs on the NIHSS to arrival mode, thrombolysis treatment and clinical outcomes in AIS, and also evaluated the influence of race-ethnicity. Methods: We analyzed the dataset of a hospital network comprising prospectively collected data on AIS patients presenting within 12 hours of ictus between June 2004 and May 2011. Outcomes evaluated were mode of arrival (ambulance vs. other), IV thrombolysis (yes vs. no), discharge destination (home vs. other), unfavorable day-90 functional activity (modified Rankin Scale (mRS) score &gt;1), unfavorable day-90 disability (Barthel Index &lt;95), and day-90 mortality. Outcomes were adjusted for pre-specified covariates in a multivariable logistic regression model. Results: Of 972 AIS patients 462 (48%) were women, 635 (65%) Non-Hispanic White, 162 (17%) White Hispanic, 106 (11%) Black, and 69 (7%) other race/ethnicity. Overall, the presence of extinction/neglect was the strongest predictor of arriving by ambulance (adjusted OR 2.32, 95% CI: 1.53-3.51), and abnormal level of consciousness (LOC) was the strongest predictor of receipt of IV thrombolysis (adjusted OR 2.25, 95% CI: 1.67-3.04), while limb ataxia was the only NIHSS item not significantly associated with either arrival mode or thrombolysis treatment. Presence of gaze preference was the strongest predictor of not going home directly from the hospital (adjusted OR 0.2, 95% CI: 0.14-0.29), unfavorable day-90 functional activity (adjusted OR 0.21, 95% CI: 0.12-0.37) and poor mortality outcome (adjusted OR 5.92, 95% CI: 3.42-10.25), while abnormal LOC was the strongest predictor of unfavorable day-90 disability (adjusted OR 0.27, 95% CI: 0.15-0.47). White Hispanic AIS patients with sensory symptoms were less likely to arrive by ambulance (adjusted OR 0.31, 95%CI: 0.13-0.74) but more likely to go home directly (adjusted OR 2.81, 95% CI: 21.31-6.02), while Black AIS patients with abnormal level of consciousness were more likely to receive IV thrombolysis (adjusted OR 4.69, 1.80-12.26). Conclusions: Specific items on the NIHSS are strongly related to hospital arrival mode, thrombolysis treatment, and clinical outcomes among AIS patients. Some of these associations vary by race and ethnicity. These results could aid prognostication and identify areas in the community, pre-hospital and emergency department phases of stroke care requiring more education, training, or intervention, to boost AIS outcomes.