Discharge mRS Score Research Articles

Longitudinal outcomes of ischemic versus hemorrhagic stroke: Differences may impact future trial design

ObjectivesPatients with intracerebral hemorrhage (ICH) are more likely to present with severe symptoms than those with ischemic stroke (IS); however, the way in which long-term outcomes differ between groups is less clear. Given that the tissue surrounding ICH is not always irreversibly infarcted, it may have the potential to recover more fully over time. Understanding the differences in expected outcome severity is critical in order to prognosticate and to determine appropriate outcome measures when designing clinical trials. Materials and MethodsWe used our prospectively collected stroke registry to identify and follow a cohort of 300 patients with ICH and 300 patients with IS, matched by age, sex, lesion size, location, and admission date. Paired t-tests were used to compare modified Rankin Scores (mRS) between groups at hospital discharge, 90-day, and >12-month follow-up time points. ResultsNot surprisingly, patients with ICH had worse discharge mRS scores compared to individuals with IS (4.20 (SD 0.09) versus 3.42 (SD 0.08)). However, rather than improving, the long-term outcomes remained significantly worse for ICH patients compared to their IS matches (4.02 (SD 0.15) versus 2.89 (SD 0.14) at 90 days, and 4.32 (SD 0.20) versus 3.16 (SD 0.22) at >12 months (p < 0.001 for all analyses)). ConclusionsThis study longitudinally followed matched cohorts of patients with ICH and IS, confirming that outcomes for those with ICH remain significantly worse over time. Results allow for better long-term prognostication, illustrate the need for further intervention trials to improve outcomes, and inform the development of evidence-based endpoints.

An International, Multicenter Feasibility Study on Active and Continuous Irrigation With Cerebrospinal Fluid Exchange for Improving Outcomes in Cerebral Ventriculitis.

Cerebral ventriculitis remains a challenging neurosurgical condition because of poor outcomes including mortality rates of nearly 80% and a prolonged course of treatment in survivors. Despite current conventional management, outcomes in some cases remain unsatisfactory, with no definitive therapeutic guidelines. This feasibility study aims to explore the use of a novel active, continuous irrigation and drainage system (IRRAflow [IRRAS AB]) combined with intraventricular drug delivery for patients with cerebral ventriculitis. We conducted a multicenter, international, retrospective study of patients with ventriculitis who were treated with use of the IRRAflow system. Data collected included patient demographics, comorbidities, admission Glasgow Coma Scale score, baseline modified Rankin Scale (mRS) score, and imaging findings. Catheter occlusions, infections, and shunt placement were recorded for outcome assessment, along with discharge mRS scores and in-hospital deaths. Four centers contributed data for a total of 21 patients who had IRRAflow placement for treatment of ventriculitis. Thirteen (61.9%) were men (mean age = 49.8 ± 14.87 years). The median baseline mRS score was 1. The median Glasgow Coma Scale score at admission was 13. The etiology of ventriculitis was iatrogenic in 12 (57.1%) patients and secondary to an abscess in 9 (42.9%). No cases reported hemorrhage or failure of IRRAflow placement. Antibiotics were administered through the IRRAflow system in 13 (61.9%) cases in addition to systemic dosing. Sixteen (76.2%) patients had significant clinical improvement and resolution of ventriculitis. Seven (33.3%) patients required shunt placement after resolution because of persistent hydrocephalus. There were 6 (28.6%) in-hospital deaths. The use of active irrigation with drainage for continuous delivery of intraventricular irrigation fluid with antibiotics led to dramatically low mortality. In our case series, it led to a marked improvement in neurological status, imaging findings, and cerebrospinal fluid profiles, making it a technically feasible and safe treatment for ventriculitis.

Anisocoria After Direct Light Stimulus is Associated with Poor Outcomes Following Acute Brain Injury.

Assessing pupil size and reactivity is the standard of care in neurocritically ill patients. Anisocoria observed in critically ill patients often prompts further investigation and treatment. This study explores anisocoria at rest and after light stimulus determined using quantitative pupillometry as a predictor of discharge modified Rankin Scale (mRS) scores. This analysis includes data from an international registry and includes patients with paired (left and right eye) quantitative pupillometry readings linked to discharge mRS scores. Anisocoria was defined as the absolute difference in pupil size using three common cut points (> 0.5mm, > 1mm, and > 2mm). Nonparametric models were constructed to explore patient outcome using three predictors: the presence of anisocoria at rest (in ambient light); the presence of anisocoria after light stimulus; and persistent anisocoria (present both at rest and after light). The primary outcome was discharge mRS score associated with the presence of anisocoria at rest versus after light stimulus using the three commonly defined cut points. This analysis included 152,905 paired observationsfrom 6,654 patients witha mean age of 57.0 (standard deviation 17.9) years, and a median hospital stay of 5 (interquartile range 3-12) days. The mean admission Glasgow Coma Scale score was 12.7 (standard deviation 3.5), and the median discharge mRS score was 2 (interquartile range 0-4). The ranges for absolute differences in pupil diameters were 0-5.76mm at rest and 0-6.84mm after light. Using an anisocoria cut point of > 0.5mm, patients with anisocoria after light had worse median mRS scores (2 [interquartile range 0-4]) than patients with anisocoria at rest (1 [interquartile range 0-3]; P < .0001). Patients with persistent anisocoria had worse median mRS scores (3 [interquartile range 1-4]) than those without persistent anisocoria (1 [interquartile range 0-3]; P < .0001). Similar findings were observed using a cut point for anisocoria of > 1mm and > 2mm. Anisocoria after light is a new biomarker that portends worse outcome than anisocoria at rest. After further validation, anisocoria after light should be considered for inclusion as a reported and trended assessment value.

Contemporary Prestroke Dual Antiplatelet Use and Symptomatic Intracerebral Hemorrhage Risk After Thrombolysis

Intravenous alteplase (IV-tPA) can be administered to patients with acute ischemic stroke but is associated with symptomatic intracerebral hemorrhage (sICH). It is unclear if patients taking prestroke dual antiplatelet therapy (DAPT) are at higher risk of sICH. To determine the associated risk of sICH in patients taking prestroke dual antiplatelet therapy receiving alteplase for acute ischemic stroke using propensity score matching analysis. This cohort study used data from the American Heart Association and American Stroke Association Get With The Guidelines-Stroke (GWTG-Stroke) registry between 2013 and 2021. Data were obtained from hospitals in the GWTG-Stroke registry. This study included patients hospitalized with acute ischemic stroke and treated with IV-tPA. Data were analyzed from January 2013 to December 2021. Prestroke DAPT before treatment with IV-tPA for acute ischemic stroke. sICH, In-hospital death, discharge modified Rankin scale score, and other life-threatening systemic hemorrhages. Of 409 673 participants, 321 819 patients (mean [SD] age, 68.6 [15.1] years; 164 587 female [51.1%]) who were hospitalized with acute ischemic stroke and treated with IV-tPA were included in the analysis. The rate of sICH was 2.9% (5200 of 182 344), 3.8% (4457 of 117 670), and 4.1% (893 of 21 805) among patients treated with no antiplatelet therapy, single antiplatelet therapy (SAPT), and DAPT, respectively (P < .001). In adjusted analyses after propensity score subclassification, both SAPT (odds ratio [OR], 1.13; 95% CI, 1.07-1.19) and DAPT (OR, 1.28; 95% CI, 1.14-1.42) were associated with increased risks of sICH. Prestroke antiplatelet medications were associated with lower odds of discharge mRS score of 2 or less compared with no medication (SAPT OR, 0.92; 95% CI, 0.90-0.95; DAPT OR, 0.94; 95% CI, 0.88-0.98). Results of a subgroup analysis of patients taking DAPT exposed to aspirin-clopidogrel vs aspirin-ticagrelor combination therapy were not significant (OR, 1.35; 95% CI, 0.84-1.86). Prestroke DAPT was associated with a significantly elevated risk of sICH among patients with ischemic stroke who were treated with thrombolysis; however, the absolute increase in risk was small. Patients exposed to antiplatelet medications did not have excess sICH compared with landmark trials, which demonstrated overall clinical benefit of thrombolysis therapy for acute ischemic stroke.

Triple platelet inhibition in intracranial thrombectomy with additional acute cervical stent angioplasty due to tandem lesion: a retrospective single-center analysis

BackgroundAcute stroke treatment with intracranial thrombectomy and treatment of ipsilateral carotid artery stenosis/occlusion (“tandem lesion”, TL) in one session is considered safe. However, the risk of stent restenosis after TL treatment is high, and antiplatelet therapy (APT) preventing restenosis must be well balanced to avoid intracranial hemorrhage. We investigated the safety and 90-day outcome of patients receiving TL treatment under triple-APT, focused on stent-patency and possible disadvantageous comorbidities.MethodsPatients receiving TL treatment in the setting of acute stroke between 2013 and 2022 were analyzed regarding peri-/postprocedural safety and stent patency after 90 days. All patients received intravenous eptifibatide and acetylsalicylic acid and one of the three drugs prasugrel, clopidogrel, or ticagrelor. Duplex imaging was performed 24 h after treatment, at discharge and 90 days, and digital subtraction angiography was performed if restenosis was suspected.Results176 patients were included. Periprocedural complications occurred in 2.3% of the patients at no periprocedural death, and in-hospital death in 13.6%. Discharge mRS score was maintained or improved at the 90-day follow-up in 86%, 4.54% had an in-stent restenosis requiring treatment at 90 days. No recorded comorbidity considered disadvantageous for stent patency showed statistical significance, the duration of the endovascular procedure had no significant effect on outcome.ConclusionIn our data, TL treatment with triple APT resulted in a low restenosis rate, low rates of sICH and a comparably high number of patients with favorable outcome. Aggressive APT in the initial phase may therefore have the potential to prevent recurrent stroke better than restrained platelet inhibition. Comorbidities did not influence stent patency.

Exploring the role of in-patient magnetic resonance imaging use among admitted ischemic stroke patients in improving patient outcomes and reducing healthcare resource utilization.

Despite the diagnostic and etiological significance of in-patient MRI in ischemic stroke (IS), its utilization is considered resource-intensive, expensive, and thus limiting feasibility and relevance. This study investigated the utilization of in-patient MRI for IS patients and its impact on patient and healthcare resource utilization outcomes. This retrospective registry-based study analyzed 1,956 IS patients admitted to Halifax's QEII Health Centre between 2015 and 2019. Firstly, temporal trends of MRI and other neuroimaging utilization were evaluated. Secondly, we categorized the cohort into two groups (MRI vs. No MRI; in addition to a non-contrast CT) and investigated adjusted differences in patient outcomes at admission, discharge, and post-discharge using logistic regression. Additionally, we analyzed healthcare resource utilization using Poisson log-linear regression. Furthermore, patient outcomes significantly associated with MRI use underwent subgroup analysis for stroke severity (mild stroke including transient ischemic attack vs. moderate and severe stroke) and any acute stage treatment (thrombolytic or thrombectomy or both vs. no treatment) subgroups, while using an age and sex-adjusted logistic regression model. MRI was used in 40.5% patients; non-contrast CT in 99.3%, CT angiogram in 61.8%, and CT perfusion in 50.3%. Higher MRI utilization was associated with male sex, younger age, mild stroke, wake-up stroke, and no thrombolytic or thrombectomy treatment. MRI use was independently associated with lower in-hospital mortality (adjusted OR, 0.23; 95% CI, 0.15-0.36), lower symptomatic neurological status changes (0.64; 0.43-0.94), higher home discharge (1.32; 1.07-1.63), good functional outcomes at discharge (mRS score 0-2) (1.38; 1.11-1.72), lower 30-day stroke re-admission rates (0.48; 0.26-0.89), shorter hospital stays (regression coefficient, 0.92; 95% CI, 0.90-0.94), and reduced direct costs of hospitalization (0.90; 0.89-0.91). Subgroup analysis revealed significantly positive association of MRI use with most patient outcomes in moderate and severe strokes subgroup and non-acutely treated subgroup. Conversely, outcomes in mild strokes (including TIAs) subgroup and acute treatment subgroup were comparable regardless of MRI use. A substantial proportion of admitted IS patients underwent MRI, and MRI use was associated with improved patient outcomes and reduced healthcare resource utilization. Considering the multifactorial nature of IS patient outcomes, further randomized controlled trials are suggested to investigate the role of increased MRI utilization in optimizing in-patient IS management.

Abstract WP126: Improved Stroke Outcomes Following Implementation of RapidAI Platform at Ascension-Illinois

Introduction: The rapid advancement of artificial intelligence (AI) technologies holds promise for improving healthcare outcomes. RapidAI is a software solution that utilizes AI to rapidly analyze imaging data to identify vascular occlusions and salvageable tissue. Physicians receive notifications and can review source images on the Rapid mobile app (RMA). Methods: Data for this study were obtained from the Get with the Guidelines Stroke database. The study focused on adult patients (18 years or older) admitted to Alexian Brothers Medical Center in Illinois between 2019-2022 who were diagnosed with acute ischemic stroke. Primary outcomes were the number of AIS patients treated with thrombolysis (IV tPA or IV TNK) and/or mechanical thrombectomy (MT) and time to treatment. Door to MT puncture times for transfer patients were analyzed separately from direct presentation patients. Discharge Modified Rankin score (mRS) was assessed as a secondary clinical outcome. Results: This analysis included 1,732 patients, 1,193 prior to installation of the RapidAI platform and 539 after installation of Rapid CTP, CTA, ASPECTS, LVO and RMA. Median door to femoral puncture time for MT cases decreased from 2 hr 28 min to 1 hr 58 min (p=0.012) post-Rapid for non-transfer patients. Door to femoral puncture times for transfer patients were unchanged. MT procedure volume increased from 9.6% to 14.5% (p=0.007). IV tPA/TNK volume and door-to-needle (DTN) times were unchanged; 15% treated with tPA/TNK pre-Rapid and 14% post-Rapid, DTN 48 vs 47 min. There was an improvement in the distribution of discharge mRS scores in post-Rapid patients (p&lt;0.0001). Discussion: Following implementation of the AI software platform there was a significant increase in patients treated with MT, faster door to MT times for non-transfer patients, and improved discharge mRS scores. These data support future studies expanding the use of AI technology to improve stroke outcomes.

Abstract 94: Sex Disparities in a Telestroke Network: From Treatment Times to Outcomes

Background: The structure of the stroke care delivery system in rural South Carolina has been changed by the Medical University of South Carolina tele-stroke program with &gt;40 spoke sites with improved treatment times and outcomes overall. Disparities at the level of primary stroke centers and acute stroke ready hospitals have not been well studied. The aim of this study is to retrospectively analyze data from the tele-stroke network for sex differences in stroke care processes at spoke sites to identify disparities in treatment times and outcomes between men and women. Methods: Data was collected and analyzed for 21,549 patients between 1/1/2012 and 12/31/2022 for whom a telestroke was paged out. Statistical analysis was completed using SPSS version 28 (IBM corporation, Armonk, NY). Variables with continuous outcomes were assessed using independent samples median tests and categorical variables were assessed using X 2 . Results: Of 10,713 (49.7%) males and 10,836 (50.3%) females, females were older (68.29±15.5 vs 66.09±13.7, p&lt;0.01) and more likely to be to be African American (20.4% vs16.8%, p&lt;0.05) as compared to males. Females were more likely to get thrombolytic therapy (29.06% vs 27.2%, p&lt;0.05) but there was no difference in endovascular therapy between both sexes. Treatment times showed that door-to-registration timing (F: 18±27 vs M: 17±26, p&lt;0.05) and door to telestroke page timing (F: 22±27 vs M: 20±26, p&lt;0.05) was significantly higher in females compared to males with ultimately door to needle time having the expected disparity between men and women (F: 59±36 vs M: 55±35, p&lt;0.05). Women also had significantly higher mean discharge NIHSS (M: 4.17±6.20 vs F: 4.61±6.70 (p&lt;0.001) and mRS score (M:2.24±1.93 vs F:2.43±1.95 (p&lt;0.001)). More males were discharged home (62.4% vs 60.4%, (p&lt;0.001) and more females were discharged to nursing home (8.1% vs 6.2%, p&lt;0.001) and hospice (3.9% vs 2.9%, p&lt;0.001) post admission. Conclusions: Females are older at the time of stroke onset, have longer times to treatment and poorer outcomes and discharge dispositions. Our findings highlight the opportunities to ameliorate sex disparities in developing telestroke networks in the United States. Future studies should target these disparities to improve outcomes.

Abstract HUP10: Sex Disparities In A Telestroke Network: From Treatment Times To Outcomes

Background: The structure of the stroke care delivery system in rural South Carolina has been changed by the Medical University of South Carolina tele-stroke program with &gt;40 spoke sites with improved treatment times and outcomes overall. Disparities at the level of primary stroke centers and acute stroke ready hospitals have not been well studied. The aim of this study is to retrospectively analyze data from the tele-stroke network for sex differences in stroke care processes at spoke sites to identify disparities in treatment times and outcomes between men and women. Methods: Data was collected and analyzed for 21,549 patients between 1/1/2012 and 12/31/2022 for whom a telestroke was paged out. Statistical analysis was completed using SPSS version 28 (IBM corporation, Armonk, NY). Variables with continuous outcomes were assessed using independent samples median tests and categorical variables were assessed using X 2 . Results: Of 10,713 (49.7%) males and 10,836 (50.3%) females, females were older (68.29±15.5 vs 66.09±13.7, p&lt;0.01) and more likely to be to be African American (20.4% vs16.8%, p&lt;0.05) as compared to males. Females were more likely to get thrombolytic therapy (29.06% vs 27.2%, p&lt;0.05) but there was no difference in endovascular therapy between both sexes. Treatment times showed that door-to-registration timing (F: 18±27 vs M: 17±26, p&lt;0.05) and door to telestroke page timing (F: 22±27 vs M: 20±26, p&lt;0.05) was significantly higher in females compared to males with ultimately door to needle time having the expected disparity between men and women (F: 59±36 vs M: 55±35, p&lt;0.05). Women also had significantly higher mean discharge NIHSS (M: 4.17±6.20 vs F: 4.61±6.70 (p&lt;0.001) and mRS score (M:2.24±1.93 vs F:2.43±1.95 (p&lt;0.001)). More males were discharged home (62.4% vs 60.4%, (p&lt;0.001) and more females were discharged to nursing home (8.1% vs 6.2%, p&lt;0.001) and hospice (3.9% vs 2.9%, p&lt;0.001) post admission. Conclusions: Females are older at the time of stroke onset, have longer times to treatment and poorer outcomes and discharge dispositions. Our findings highlight the opportunities to ameliorate sex disparities in developing telestroke networks in the United States. Future studies should target these disparities to improve outcomes.

Abstract TMP37: Improved Outcomes for Acute Ischemic Stroke Patients After Implementation of the RapidAI Platform in a Comprehensive Stroke Center in Santiago, Chile

Introduction: In Latin America (LATAM), the prevalence of stroke is alarmingly high. The advancement of artificial intelligence (AI) technologies has potential to dramatically improve healthcare outcomes. RapidAI is a software solution that utilizes AI to quickly analyze imaging data to identify vascular occlusions and salvageable tissue. Physicians receive notifications and can review source images on the Rapid mobile app (RMA). Methods: This was a retrospective analysis of 1,672 consecutive acute stroke patients (AIS) treated at Clinica Alemana de Santiago between 2014-2023. Primary outcomes were the number of AIS patients treated with thrombolysis (IV tPA), mechanical thrombectomy (MT), or decompressive craniectomies as well as time to treatment. Secondary outcomes included discharge Modified Rankin score (mRS) and hospital length of stay (LOS). Results: This analysis included 824 patients pre-RapidAI installation and 848 after installation of Rapid CTP with hypodensity, CTA, ASPECTS, LVO and RMA communication. The baseline NIHSS and last know well to hospital arrival was balanced between the 2 study cohorts. Median time to IV tPA improved by 42 minutes (80 to 38 minutes, p &lt; 0.0001). IV tPA utilization increased from 23% to 30% post-Rapid (p = 0.0033). MT procedure utilization increased from 5% pre-Rapid to 10% (p &lt; 0.0001). Decompressive craniectomies were reduced from 13 to 4, LOS was unchanged. There was a favorable shift in the distribution of mRS scores at discharge in post-Rapid patients (p = 0.031) and a significant increase in mRS 0-1 outcomes (61% vs 45%). Discussion: Following implementation of the AI software platform in a comprehensive stroke center like Clinica Alemana, there was a significant increase in patients treated with IV tPA, faster door to tPA and/or MT times, a decrease in the number of DCTs, and improved discharge mRS scores. This work supports future studies expanding the use of AI technology for improving stroke outcomes in LATAM.

The effect of green channel for stroke patients on treatment of severe aneurysmal subarachnoid hemorrhage

PurposeTo explore the effect of green channel for stroke patients on the treatment of severe aneurysmal subarachnoid hemorrhage. MethodsThis is a retrospective case-control study. The clinical data of patients with severe aneurysmal subarachnoid hemorrhage admitted to the emergency department of our hospital from January 2015 to June 2022 were retrospectively analyzed. Patients diagnosed with subarachnoid hemorrhage, confirmed intracranial aneurysm by preoperative CT angiography or digital subtraction, graded Hunt-Hess grade III, IV, and V, < 72 h from the onset to the time of consultation received surgical treatment in our hospital were included in this study. Patients with serious underlying diseases, such as heart, liver, kidney diseases, or malignant tumors, traumatic subarachnoid hemorrhage, previous history of cerebral hemorrhage, and incomplete data were excluded. The control group included patients with severe aneurysmal subarachnoid hemorrhage admitted from January 2015 to December 2018 before the establishment of the green channel for stroke patients, and the observation group included patients with severe aneurysmal subarachnoid hemorrhage admitted from January 2019 to June 2022 after the establishment of the green channel. The control group received routine treatment in the emergency department; the observation group received improved treatment of green channel for stroke patients. Gender, age, Hunt-Hess grade on admission, modified Rankin scale (mRS) on admission, aneurysm location, aneurysm size and whether accompanied by intracerebral hemorrhage, the time from onset to emergency department, the time from emergency department to vascular diagnostic examination, the time from onset to surgery, the time from emergency department to surgery, the time from hospital admission to surgery, length of hospital stay, complications, treatment effect were analyzed and compared between the 2 groups. SPSS 23.0 software was utilized to conduct comparisons between the 2 groups. The t-test, Chi-square test, or Mann-Whitney U test was chosen based on the data type. Statistical significance was established when p < 0.05. ResultsA total of 71 patients were included in this study, of whom 37 were in the control group and 34 were in the observation group. There were no statistical differences in age, gender, Hunt-Hess grade, mRS scores, aneurysm location, aneurysm size, intracerebral hemorrhage, the time from onset to emergency department, length of hospital stay, complications between the observation group and the control group (all p > 0.05). The time (min) from visit to vascular diagnostic test (60.50 vs. 120.00, p = 0.027), the time (min) from onset to surgery (1792.00 vs. 2868.00, p = 0.023), the time (min) from emergency department to surgery (1568.50 vs. 2778.00, p = 0.016), the time (min) from hospital admission to surgery (1188.50 vs. 2708.00, p = 0.043), all of them were shorter in the observation group than those in the control group. The relative values of admission and 7-day postoperative mRS scores and the relative values of admission and discharge mRS scores ≥ 2 were used as the criteria for determining better efficacy, and the treatment effect was better than that in the control group, and the differences were statistically significant (admission to 7 days postoperative mRS score ≥ 2, 17 (50.0 %) vs. 8 (21.6 %), p = 0.012; admission to discharge mRS score ≥ 2, 19 (55.9 %) vs. 11 (29.7 %), p = 0.026). ConclusionThe green channel for stroke patients with severe aneurysmal subarachnoid hemorrhage can effectively shorten the time from arrival at the emergency department to vascular diagnostic examination and the time from the emergency department to surgery, and achieve a better therapeutic effect, which is worth popularizing and applying.

Abstract 042: Cognitive outcomes in patients with carotid insufficiency after undergoing direct extracranial‐intracranial bypass

Introduction Extracranial‐intracranial (EC‐IC) bypass is a niche procedure that has been selectively used for flow augmentation or flow restoration in patients with intracranial carotid insufficiency.1 The underlying etiology varies but is most commonly related to Moya Moya disease (MMD) or intracranial carotid atherosclerotic disease (ICAD).2 Patients are often managed non‐operatively until they begin to develop symptoms such as transient ischemic attacks (TIAs) or strokes that are recalcitrant to maximal medical management, at which point bypass is pursued.1 This lag period, however, could put patients at risk for long term deficit, not only in the form of focal neurological deficits but also in terms of overall neurocognitive capability.3 Several reports have previously demonstrated some level of association between EC‐IC bypass and neurocognitive outcomes, though in isolated populations of either MMD or ICAD.4,5 We therefore aim to further assess the relationship between EC‐IC bypass and neurocognitive outcomes in patients with intracranial carotid insufficiency. Methods Patients ages 18 years and up undergoing EC‐IC bypass were identified from a single institution database between January 2020 and December 2021. Patient records were reviewed for demographic data including age and sex, as well as preoperative clinical information including comorbidities, operative indication, anticoagulation/antiplatelet therapy usage, prior ischemic stroke, modified Rankin score (mRS), and Montreal Cognitive Assessment (MOCA) score. Radiographic data was also collected including Suzuki grade, collateralization, and perfusion. Post‐operative clinical information including complications, discharge mRS, and discharge MOCA scores were identified. Follow‐up duration, MOCA scores, and mRS were also identified and recorded. Results Of the forty‐four patients that underwent EC‐IC bypass during the specified period, ten had cognitive assessments before and after surgery available for review. The indications for bypass in these cases were ICA steno‐occlusive disease resulting in strokes despite maximal medical management in 9 cases, and MMD in one case. Suzuki grade was IV in the MMD case. Pial collaterals were present in 7 cases, and ECA collaterals were present in 5. Prior ischemic strokes were present in 8 cases, with a preoperative mRS range from 1‐4 (median 1), and average MOCA of 20. Perfusion imaging demonstrated a Tmax mismatch in eight cases, with an average volume of 73.6 cc at risk. All patients underwent direct superficial temporal artery to middle cerebral artery bypass, with additional encephaloduroarteriomyosynangiosis (EDAMS). Follow up MOCA score was improved in 8 cases, unchanged in one case, and worsened in one case (average MOCA increased from 20 to 23). Follow up mRS ranged from 0‐2. Additionally, CT perfusion demonstrated notable improvements in Tmax &gt;4 seconds (decrease from 176 cc to 110 cc), Tmax &gt;6 seconds (decrease from 59 cc to 29 cc), and mismatch (decrease from 59 cc to 17 cc) at 6 month follow up. Conclusion Patients with carotid insufficiency from MMD or ICAD undergoing EC‐IC bypass demonstrate well below normal preoperative MOCA scores. This is suggestive of ongoing neurocognitive decline, which is an often overlooked issue in patients with these pathologies. MOCA and mRS both appear to improve in patients after bypass at longer term follow‐up, suggesting that bypass may be an effective method of addressing the issue of neurocognitive decline in patients with carotid insufficiency.

Safety and efficacy of endovascular recanalization in patients with mild anterior stroke due to large-vessel occlusion exceeding 24 hours

Background Endovascular recanalization (ER) has demonstrated efficacy as a treatment modality for patients presenting with acute ischemic stroke (AIS) caused by large-vessel occlusion (LVO) within a 24-hour timeframe. Nevertheless, the safety and effectiveness of ER in patients with a time of onset exceeding 24 h remain uncertain. Objective To evaluate the safety and efficacy of ER treatment for mild ischemic stroke beyond 24-h from symptom onset. Methods A retrospectively maintained database of mild AIS due to LVO from March2018 to September 2022 at a comprehensive stroke center was screened. Patients received ER or standard medical therapies (SMT) for anterior circulation AIS due to LVO > 24-h were selected. Results We included 47 LVO patients with mild AIS beyond 24-h who suffered neurological deterioration (ND). 34 of these patients underwent ER, the other 13 received SMT. The technical success rate of recanalization was 82.4% (28/34). Patients received ER had significantly lower NIHSS score at discharge and 90-day mRS score (p = 0.028, p = 0.037, respectively) compared to SMT. In addition, they had significantly lower 90-day recurrence of ischemic stroke and lower incidence of moderate-severe stroke (with a NIHSS score at least 5) (p = 0.037, p = 0.033). There were 4 patients (11.7%) had perioperative complications, and no symptomatic intracranial hemorrhage occurred. Conclusion ER treatment for mild AIS due to LVO encountered ND was generally safe and effective, even beyond 24-h, and resulted in a good prognosis and lower 90-day recurrence compared to SMT.

Incidence of mechanical thrombectomy among stroke patients brought directly to a comprehensive stroke center versus transfer from a primary stroke center in upstate New York.

Faster time to treatment for stroke is associated with improved outcomes. In cases of large vessel occlusion (LVO), standard of care treatment with thrombectomy can only be provided at a comprehensive stroke center (CSC). We examine the outcomes of patients who are directly brought to our center, a CSC, compared to those seen at a primary stroke center (PSC) and then transferred. Patients with LVO presenting to our center from 1/1/2019 to 12/31/2019 were included. Cohorts of patients presenting first to a PSC and presenting first to a CSC were compared. Demographics and outcome metrics (Discharge Modified Rankin Scale (mRS) and National Institute of Health Stroke Severity Scale (NIHSS) scores) were obtained for all LVO patients. Imaging was also assessed. Of 864 stroke admissions, 346 had LVO (40%) with 183 (53%) transferring from a PSC and 163 (47%) presenting directly. Similar percentages of each cohort were taken for thrombectomy (25.1% transfer and 31.3% direct). However, as distance between PSC and CSC increased, likelihood of thrombectomy decreased. Transfer patients were more likely to be excluded from thrombectomy secondary to a large volume of complete stroke (p = 0.0001). Direct presenters had lower discharge mRS scores than transfer patients (p < 0.01), however, severity of stroke upon admission was similar in the two groups. Patients transferred from a PSC were more likely to have a worse outcome at time of discharge than those presenting directly to our center. Large volume of completed stroke was a frequent reason for exclusion from thrombectomy. Optimizing stroke protocols to CSC in cases of LVOs may result in better outcomes.

Clinical Features, Etiologies and Mechanisms of In-hospital Acute Ischemic Stroke: A Retrospective Analysis (P6-5.014)

<h3>Objective:</h3> This study aims to investigate the etiologies and mechanisms of in-hospital stroke and to provide data for identifying the population at risk. <h3>Background:</h3> In-hospital stroke has a poor prognosis. Most studies have focused on delays in the acute-phase treatment of in-hospital stroke, prognostic analysis and improvement measures, and few studies have focused on the etiologies and mechanisms of in-hospital stroke and its prevention. <h3>Design/Methods:</h3> Patients with in-hospital acute ischemic stroke at a single center from June 2012 to April 2022 were consecutively enrolled. Demographic data, inpatient units, characteristics of stroke, common risk factors, laboratory tests and radiologic findings were collected. The TOAST stroke etiology and mechanism were determined by two experienced neurologists. The primary outcome was set as favorable functional outcome at discharge (mRS score 0–2). <h3>Results:</h3> A total of 204 patients were included, with a median age of 64 (IQR 52–72) and 61.8% male. In-hospital stroke accounts for 16.9% of all acute ischemic stroke admissions. The most common TOAST etiology was other causes (36.8%), with no statistical difference between perioperative and non-perioperative patients (P=0.061). The most common mechanism was embolism (57.8%), followed by hypoperfusion (42.2%), hypercoagulation (36.3%), small vessel mechanism (19.1%), discontinuation of antithrombotic drugs (13.2%), and iatrogenic injury (9.8%). Iatrogenic injury, hypoperfusion, embolism, and discontinuation of antithrombotic drugs were more common in perioperative stroke. 48.8% patients met the primary endpoint. Median NIHSS improvement (2 vs 1, P=0.002) and median mRS improvement (1 vs 0.5, P=0.016) at discharge were higher in perioperative patients. Advanced age and hypoperfusion were associated with poor prognosis. <h3>Conclusions:</h3> The etiologies and mechanisms of in-hospital stroke are complex and significantly different from that of community-onset stroke. Perioperative and non-perioperative in-hospital stroke have different mechanisms and prognostic features. Identifying the etiologies and mechanisms of stroke will help to prevent and treat in-hospital stroke appropriately. <b>Disclosure:</b> Dr. Wu has nothing to disclose. Mr. Han has nothing to disclose. Ms. Sha has nothing to disclose. Lixin Zhou has nothing to disclose. Jun Ni has nothing to disclose.

Functional and Safety Outcomes of Carotid Artery Stenting and Mechanical Thrombectomy for Large Vessel Occlusion Ischemic Stroke With Tandem Lesions

Approximately 10% to 20% of large vessel occlusion (LVO) strokes involve tandem lesions (TLs), defined as concomitant intracranial LVO and stenosis or occlusion of the cervical internal carotid artery. Mechanical thrombectomy (MT) may benefit patients with TLs; however, optimal management and procedural strategy of the cervical lesion remain unclear. To evaluate the association of carotid artery stenting (CAS) vs no stenting and medical management with functional and safety outcomes among patients with TL-LVOs. This cross-sectional study included consecutive patients with acute anterior circulation TLs admitted across 17 stroke centers in the US and Spain between January 1, 2015, and December 31, 2020. Data analysis was performed from August 2021 to February 2022. Inclusion criteria were age of 18 years or older, endovascular therapy for intracranial occlusion, and presence of extracranial internal carotid artery stenosis (>50%) demonstrated on pre-MT computed tomography angiography, magnetic resonance angiography, or digital subtraction angiography. Patients with TLs were divided into CAS vs nonstenting groups. Primary clinical and safety outcomes were 90-day functional independence measured by a modified Rankin Scale (mRS) score of 0 to 2 and symptomatic intracranial hemorrhage (sICH), respectively. Secondary outcomes were successful reperfusion (modified Thrombolysis in Cerebral Infarction score ≥2b), discharge mRS score, ordinal mRS score, and mortality at 90 days. Of 685 patients, 623 (mean [SD] age, 67 [12.2] years; 406 [65.2%] male) were included in the analysis, of whom 363 (58.4%) were in the CAS group and 260 (41.6%) were in the nonstenting group. The CAS group had a lower proportion of patients with atrial fibrillation (38 [10.6%] vs 49 [19.2%], P = .002), a higher proportion of preprocedural degree of cervical stenosis on digital subtraction angiography (90%-99%: 107 [32.2%] vs 42 [20.5%], P < .001) and atherosclerotic disease (296 [82.0%] vs 194 [74.6%], P = .003), a lower median (IQR) National Institutes of Health Stroke Scale score (15 [10-19] vs 17 [13-21], P < .001), and similar rates of intravenous thrombolysis and stroke time metrics when compared with the nonstenting group. After adjustment for confounders, the odds of favorable functional outcome (adjusted odds ratio [aOR], 1.67; 95% CI, 1.20-2.40; P = .007), favorable shift in mRS scores (aOR, 1.46; 95% CI, 1.02-2.10; P = .04), and successful reperfusion (aOR, 1.70; 95% CI, 1.02-3.60; P = .002) were significantly higher for the CAS group compared with the nonstenting group. Both groups had similar odds of sICH (aOR, 0.90; 95% CI, 0.46-2.40; P = .87) and 90-day mortality (aOR, 0.78; 95% CI, 0.50-1.20; P = .27). No heterogeneity was noted for 90-day functional outcome and sICH in prespecified subgroups. In this multicenter, international cross-sectional study, CAS of the cervical lesion during MT was associated with improvement in functional outcomes and reperfusion rates without an increased risk of sICH and mortality in patients with TLs.

Abstract Number ‐ 205: Impact of Automated Neuroimaging Triage Platform on Time Metrics at a Thrombectomy Capable Stroke Center

Introduction Rapid detection and appropriate triage of large vessel occlusion (LVO) strokes, upon arrival to a hospital system, is key to achieving better outcomes after endovascular thrombectomy (EVT) mediated recanalization of LVO strokes . Automated neuroimaging analyses has the potential to streamline intra‐ hospital workflow. We aim to study the change in vital intra‐hospital time metrics before and after adoption of an automated neuroimaging triage platform (ANTP). Methods We performed a retrospective analysis of prospectively collected data at our EVT capable stroke center between April 2019 and November 2021. IschemaView’s Rapid software was adopted in October 2020 for triage of stroke patients. Patients treated before were our control cohort and patients treated after were our intervention cohort. Confirmed LVO strokes presenting to our center within 24 hours of stroke onset were included. Results A total of 305 patients were included‐ control (n = 150) and intervention cohort (n = 155). Age (70±15 vs 72 ±15,p = .40), NIHSS score (13 ±8 vs 14 ±7, p = .24), and last‐known‐well to arrival (392 ±464 vs 376 ±427 min, p = .38) were comparable between the two groups. Time from arrival to non‐contrast CT head was also comparable between the two groups (150 ±712 vs 161 ±794, p = .89). Time from non‐contrast CT head to decision to EVT (36 ±54 vs 22 ±58, p = .06) and time from non‐contrast CT to groin puncture (41 ±61 vs 61 ±65, p = .01) were shorter in the intervention cohort compared to control cohort. Length of stay and discharge mRS score were similar between the two cohorts. Conclusions Automated neuroimaging triage platform has the potential to improve workflow by decreasing time from non‐contrast CT to EVT decision and groin puncture. Further studies are required to study impact on patient outcomes.

The Impact of COVID-19 Pandemic on Ischemic Stroke Patients in a Comprehensive Hospital.

PurposeThis study aimed to investigate the impact of characteristic ischemic stroke and outcomes during the first COVID-19 pandemic lockdown.Patients and MethodsA retrospective, observational cohort study of a comprehensive tertiary stroke center was conducted. Patients with ischemic stroke were divided into pre-COVID-19 lockdown (11/1/2019 to 1/30/2020) and COVID-19 lockdown (1/31/2020 to 4/30/2020) period groups. Patient data on stroke admission, thrombolysis, endovascular treatment, and 3-month routine follow-up were recorded. Data analysis was performed using SPSS according to values following a Gaussian distribution.ResultsThe pre-COVID-19 lockdown period group comprised 230 patients compared to 215 patients in the COVID-19 lockdown period group. Atrial fibrillation was more predominant in the COVID-19 lockdown period group (11.68% vs 5.65%, p=0.02) alongside patients who were currently smoking (38.8% vs 28.7%, p=0.02) and drinking alcohol (30.37% vs 20.00%, p=0.012) compared with that of the pre-COVID-19 lockdown period group. For patients receiving thrombolysis, the median door-to-CT time was longer in the COVID-19 lockdown period group (17.0 min (13.0, 24.0) vs 12.0 min (8.0, 17.3), p=0.012), median door to needle time was 48.0 minutes (35.5, 73.0) vs 43.5 minutes (38.0, 53.3), p=0.50, compared with that of the pre-COVID-19 lockdown period group. There were no differences for patients receiving mechanical thrombectomy. The median length of hospitalization (IQR) was no different. Discharge mRS scores (IQR) were higher in the COVID-19 lockdown period group (1.0 (1.0, 3.0) vs 1.0 (1.0, 2.0), p=0.022). Compared with the pre-COVID-19 lockdown period, hospitalization cost (Chinese Yuan) in the COVID-19 period group was higher (13,445.7 (11,009.7, 20,030.5) vs 10,799.2 (8692.4, 16,381.7), p=0.000). There was no difference observed in 3-month mRS scores.ConclusionPatients presenting with ischemic stroke during the COVID-19 pandemic lockdown period had longer median door-to-CT time and higher hospitalization costs. There were no significant differences in 3-month outcomes. Multidisciplinary collaboration and continuous workflow optimization may maintain stroke care during the COVID-19 pandemic lockdown.

Pre-admission antithrombotic use is associated with 3-month mRS score after thrombectomy for acute ischemic stroke.

In patients who undergo thrombectomy for acute ischemic stroke, the relationship between pre-admission antithrombotic (anticoagulation or antiplatelet) use and both radiographic and functional outcome is not well understood. We sought to explore the relationship between pre-admission antithrombotic use in patients who underwent thrombectomy for acute ischemic stroke at two medical centers in New York City between December 2018 and November 2020. Analyses were performed using analysis of variance and Pearson’s chi-squared tests. Of 234 patients in the analysis cohort, 65 (28%) were on anticoagulation, 64 (27%) were on antiplatelet, and 105 (45%) with no antithrombotic use pre-admission. 3-month Modified Rankin Scale (mRS) score of 3–6 was associated with pre-admission antithrombotic use (71% anticoagulation vs. 77% antiplatelet vs. 56% no antithrombotic, p = 0.04). There was no relationship between pre-admission antithrombotic use and Thrombolysis in Cerebral Iinfarction (TICI) score, post-procedure Alberta Stroke Program Early CT Score (ASPECTS) score, rate of hemorrhagic conversion, length of hospital admission, discharge NIH Stroke Scale (NIHSS), discharge mRS score, or mortality. When initial NIHSS score, post-procedure ASPECTS score, and age at admission were included in multivariate analysis, pre-admission antithrombotic use was still significantly associated with a 3-month mRS score of 3–6 (OR 2.36, 95% CI 1.03–5.54, p = 0.04). In this cohort of patients with acute ischemic stroke who underwent thrombectomy, pre-admission antithrombotic use was associated with 3-month mRS score, but no other measures of radiographic or functional outcome. Further research is needed on the relationship between use of specific anticoagulation or antiplatelet agents and outcome after acute ischemic stroke, but moreover, improve stroke prevention.

Machine learning is an effective method to predict the 90-day prognosis of patients with transient ischemic attack and minor stroke

ObjectiveWe aimed to investigate factors related to the 90-day poor prognosis (mRS≥3) in patients with transient ischemic attack (TIA) or minor stroke, construct 90-day poor prognosis prediction models for patients with TIA or minor stroke, and compare the predictive performance of machine learning models and Logistic model.MethodWe selected TIA and minor stroke patients from a prospective registry study (CNSR-III). Demographic characteristics,smoking history, drinking history(≥20g/day), physiological data, medical history,secondary prevention treatment, in-hospital evaluation and education,laboratory data, neurological severity, mRS score and TOAST classification of patients were assessed. Univariate and multivariate logistic regression analyses were performed in the training set to identify predictors associated with poor outcome (mRS≥3). The predictors were used to establish machine learning models and the traditional Logistic model, which were randomly divided into the training set and test set according to the ratio of 70:30. The training set was used to construct the prediction model, and the test set was used to evaluate the effect of the model. The evaluation indicators of the model included the area under the curve (AUC) of the discrimination index and the Brier score (or calibration plot) of the calibration index.ResultA total of 10967 patients with TIA and minor stroke were enrolled in this study, with an average age of 61.77 ± 11.18 years, and women accounted for 30.68%. Factors associated with the poor prognosis in TIA and minor stroke patients included sex, age, stroke history, heart rate, D-dimer, creatinine, TOAST classification, admission mRS, discharge mRS, and discharge NIHSS score. All models, both those constructed by Logistic regression and those by machine learning, performed well in predicting the 90-day poor prognosis (AUC >0.800). The best performing AUC in the test set was the Catboost model (AUC=0.839), followed by the XGBoost, GBDT, random forest and Adaboost model (AUCs equal to 0.838, 0, 835, 0.832, 0.823, respectively). The performance of Catboost and XGBoost in predicting poor prognosis at 90-day was better than the Logistic model, and the difference was statistically significant(P<0.05). All models, both those constructed by Logistic regression and those by machine learning had good calibration.ConclusionMachine learning algorithms were not inferior to the Logistic regression model in predicting the poor prognosis of patients with TIA and minor stroke at 90-day. Among them, the Catboost model had the best predictive performance. All models provided good discrimination.