Discharge mRS Research Articles

Retrospective analysis of the discharge outcome of external ventricular drainage and conservative treatment in patients with severe intraventricular hemorrhage

Objective: To investigate the discharge outcome of external ventricular drainage(EVD) and conservative treatment in patients with severe intraventricular hemorrhage (SeIVH). Methods: From January 2011 to December 2016, patients with SeIVH admitted to the General Hospital of the PLA Rocket Force and the Army General Hospital received EVD treatment and were classified as the treatment group. According to intraventricular hemorrhage volume and age, patients received conservative treatment were pair matched and classified as control group. Then we compared the clinical outcome of moderate disability or less degree of discharge (mRS ≤3) and death incidence (mRS 6) between two groups. Results: A total of 361 patients with IVH were treated during these six years. Among them, 75 cases were chosen as treatment group. Another 75 cases were pair matched as control group from 286 cases. At the time of admission, the ventricular hemorrhage volume of two groups were (55.8±22.7) ml and (53.7±23.3) ml (P=0.569) respectively. Cerebral hemorrhage volume were (23.6±5.3) ml and (24.0±5.4) ml (P=0.631). And the median Glasgow coma score (GCS) were 4[IQR(3, 7)] and 5[IQR(4, 7)](P=0.131). At the discharge time, there were 16% (12/75) patients scored mRS≤3 in treatment group, while 2.7% (2/75) in control group (P<0.005). The absolute risk reduction (ARR) was 13.3%, and the number needed to treat (NNT) was 7.5. The mortality rate of treatment group was 13.3% (10/75), much lower than that of the control group 41.1% (31/75, P<0.001). ARR was 27.8% and NNT was 3.6. Conclusion: Although the prognosis of SeIVH was poor, compared with conservative treatment, EVD treatment significantly improved the outcome of these patients. Randomized controlled trials are needed to validate the efficacy of EVD.

Hypoalbuminemia, systemic inflammatory response syndrome, and functional outcome in intracerebral hemorrhage

PurposeHypoalbuminemia and systemic inflammatory response syndrome (SIRS) are reported in critically-ill patients, but their relationship is unclear. We sought to determine the association of admission serum albumin and SIRS with outcomes in patients with intracerebral hemorrhage (ICH). MethodsWe used a multicenter, multinational registry of ICH patients to select patients in whom SIRS parameters and serum albumin levels had been determined on admission. Hypoalbuminemia was defined as the lowest standardized quartile of albumin; SIRS according to standard criteria. Primary outcomes were modified Rankin Scale (mRS) at discharge and in-hospital mortality. Regression models were used to assess for the association of hypoalbuminemia and SIRS with discharge mRS and in-hospital mortality. ResultsOf 761 ICH patients included in the registry 518 met inclusion criteria; 129 (25%) met SIRS criteria on admission. Hypoalbuminemia was more frequent in patients with SIRS (42% versus 19%; p<0.001). SIRS was associated with worse outcomes (OR: 4.68, 95%CI, 2.52–8.76) and in-hospital all-cause mortality (OR: 2.18, 95% CI, 1.60–2.97), while hypoalbuminemia was not associated with all-cause mortality. ConclusionsIn patients with ICH, hypoalbuminemia is strongly associated with SIRS. SIRS, but not hypoalbuminemia, predicts poor outcome at discharge. Recognizing and managing SIRS early may prevent death or disability in ICH patients.

Temporal evolution of vasospasm and clinical outcome after intra-arterial vasodilator therapy in patients with aneurysmal subarachnoid hemorrhage.

Intra-arterial (IA) vasodilator therapy is one of the recommended treatments to minimize the impact of aneurysmal subarachnoid hemorrhage-induced cerebral vasospasm refractory to standard management. However, its usefulness and efficacy is not well established. We evaluated the effect IA vasodilator therapy on middle cerebral artery blood flow and on discharge outcome. We reviewed records for 115 adults admitted to Neurointensive Care Unit to test whether there was a difference in clinical outcome (discharge mRS) in those who received IA infusions. In a subset of 19 patients (33 vessels) treated using IA therapy, we tested whether therapy was effective in reversing the trends in blood flow. All measures of MCA blood flow increased from day -2 to -1 before infusion (maximum Peak Systolic Velocity (PSV) 232.2±9.4 to 262.4±12.5 cm/s [p = 0.02]; average PSV 202.1±8.5 to 229.9±10.9 [p = 0.02]; highest Mean Flow Velocity (MFV) 154.3±8.3 to 172.9±10.5 [p = 0.10]; average MFV 125.5±6.3 to 147.8±9.5 cm/s, [p = 0.02]) but not post-infusion (maximum PSV 261.2±14.6 cm/s [p = .89]; average PSV 223.4±11.4 [p = 0.56]; highest MFV 182.9±12.4 cm/s [p = 0.38]; average MFV 153.0±10.2 cm/s [p = 0.54]). After IA therapy, flow velocities were consistently reduced (day X infusion interaction p<0.01 for all measures). However, discharge mRS was higher in IA infusion group, even after adjusting for sex, age, and admission grades. Thus, while IA vasodilator therapy was effective in reversing the vasospasm-mediated deterioration in blood flow, clinical outcomes in the treated group were worse than the untreated group. There is need for a prospective randomized controlled trial to avoid potential confounding effect of selection bias.

Imaging characteristics associated with clinical outcomes in posterior reversible encephalopathy syndrome.

Posterior reversible encephalopathy syndrome (PRES) is a disorder of cerebrovascular autoregulation that can result in brain edema, hemorrhage, and infarction. We sought to investigate whether certain imaging characteristics in PRES are associated with clinically significant patient outcomes. We retrospectively reviewed all cases of PRES occurring between 2008 and 2014 at two major academic medical centers. Demographic, clinical, and radiographic data were collected. We analyzed imaging studies for vasogenic edema, hemorrhage, and diffusion restriction. We performed univariate analysis and stepwise logistic regression to assess the association between our radiologic findings of interest and clinical outcomes as defined by hospital discharge disposition and modified Rankin scale (mRS) at time of discharge. We identified 99 cases of PRES in 96 patients. The median age was 55years (IQR 30-65) and 74% were women. In 99 cases, 60% of patients had active cancer, 19% had history of bone marrow or organ transplantation, 14% had autoimmune disease, and 8% were peripartum. Imaging at clinical presentation showed extensive vasogenic edema in 39%, hemorrhage in 36%, hemorrhage with mass effect in 7%, and restricted diffusion in 16%. In our final logistic regression models, the presence of extensive vasogenic edema, hemorrhage with mass effect, or diffusion restriction was associated with worse clinical outcome as defined by both discharge disposition (OR=4.3; 95% CI: 1.4-36.3; p=0.047) and mRS (OR=3.6; 95% CI: 1.2-10.7; p=0.019). Extensive vasogenic edema, hemorrhage, and restricted diffusion on initial imaging in PRES are associated with worse clinical outcomes.

Safety results from the treatment of 109 cerebral aneurysms using the Woven EndoBridge technique: preliminary results in the United Kingdom.

OBJECTIVE The Woven Endobridge (WEB) device has been in clinical use for the treatment of brain aneurysms for the past 4 years. Observational studies to assess clinical outcome and related complications have been published. Clear evidence is required to better understand the safety profile of the WEB device. The authors here present a multicenter series that provides a detailed safety analysis focused on patient selection, procedural events, and technical issues of treated patients throughout the United Kingdom (UK). METHODS A nationwide password-protected database was set up to collect anonymous information across the UK (14 centers). Complications and clinical outcome were analyzed for the initial 109 patients (112 procedures). An independent root cause analysis classified the complications into groups (procedural, disease, device, ancillary device, and other). The modified Rankin Scale (mRS) was used as a marker of clinical outcome. RESULTS Each of the 109 patients had 1 aneurysm suitable for WEB treatment (109 aneurysms). Three patients had 2 procedures, making a total of 112 procedures performed. Eight procedures were abandoned because of access issues; 2 patients went on to have a successful procedure. All 109 patients had a preprocedure and discharge mRS scores recorded. One hundred patients had a recorded mRS score from a > 3-month follow-up. Deployment of the WEB device was successful in 103 (94.5%) of 109 patients and 104 (92.9%) of 112 procedures. One patient had 2 successful WEB procedures on separate occasions. Patients without a successfully implanted WEB device were included in the analysis. Selection analysis showed that the average patient age was 56.5 years among 34 men and 75 women. The percentage of incidental aneurysms was 58.7%, acute 16.5%, symptomatic 18.3%, and recurrent 6.4%. Further results analysis showed that 40 (36.7%) of 109 patients had recorded adverse events, including those unrelated to the WEB device. Events that could be related to the WEB device numbered 17 (15.6%) among the 109 patients. Two patients with device-related complications were symptomatic. Overall, 11 patients (10.1%) had persistent clinical sequelae. Thromboembolism was the most prevalent event, affecting 15.6% of the patients (17 of 109), and 6.4% of the patients (7 of 109) with a thromboembolism were symptomatic. Overall mortality before discharge was 0% and at the > 3-month follow-up was 5% (5 of 100 patients). Morbidity was defined as an mRS score increase to > 2. Overall morbidity at discharge was 1.8% (2 of 109) and at the > 3-month follow-up was 6% (6 of 100). No device-related morbidity or mortality was associated with this group. CONCLUSIONS The UK data show that the WEB device is safe for clinical use. Thromboembolic complication adds a risk that should be minimized with appropriate anticoagulation and correct sizing of the device. There is scope for further evaluation and standardization of an anticoagulation regimen for the WEB device.

Abstract WP302: Transferring Patients with Primary Intracerebral Hemorrhage to Comprehensive Stroke Centers

Introduction: The American Heart Association’s updated guidelines for management of patients with primary intracerebral hemorrhage (ICH) recommend monitoring and early care at centers with advanced nursing and neuro-critical care expertise. This entails frequent transfer of ICH patients to certified Comprehensive Stroke Centers (CSC) for higher level of care. We hypothesized that transferred patients (TP) to a CSC will differ from directly admitted patients (DAP) in terms of patient characteristics, treatment factors, and functional and quality of life (QOL) outcomes. Methods: We analyzed data from a prospectively collected ICH registry at our CSC. Patients with traumatic or secondary causes of ICH were excluded. We collected data on demographics, comorbidities, presentation lab values, clinical characteristics, radiological parameters, in-hospital treatment variables, and discharge and long term outcomes. Functional outcomes were captured as modified Rankin Scale (mRS) and EuroQol 5D (EQ-5D) was used to assess QOL indices. Results: Out of a total 192 primary ICH patients, 114 (59.4%) were transferred-in. TP were significantly older, had lower diastolic blood pressure, lower arrival National Institutes of Health Stroke Scale (NIHSS) score, and smaller hematoma volumes as compared to DAP. A higher proportion of TP had a good discharge functional outcome (mRS score 0 - 3) as compared to DAP (29.8% vs. 15.4%, p = 0.02), this trend was also observed for Day-90 mRS (34.2% vs. 24.4%, p = 0.09). TP also reported significantly better QOL indices at Day-90; EQ-5D total median (Q1, Q3) score [10 (6,16) vs. 15 (9.5,18), p = 0.02] and self-reported median (Q1,Q3) score [75 (50,88) vs. 62.5(40,70)], p &lt; 0.01]. Day-90 data are complete for approximately 50% patients. After adjusting for initial stroke severity, the discharge mRS was however not significantly different between TP and DAP. Conclusions: A larger proportion of ICH patients were transferred-in. Our data suggest that TP have lower disease severity, and better discharge and long term outcomes. However, they had similar treatment intensity as DAP at the CSC. We continue to capture day-90, 6 and 12-month functional and QOL data, which will be presented.

Abstract TP22: Outcomes After Endovascular Therapy in a Population With Mild Acute Ischemic Stroke: A 6.5 Year Observational Cohort Study at a High Volume Comprehensive Stroke Center

Introduction: Despite suffering mild acute ischemic strokes (AIS, NIHSS≤7), patients have a non-zero risk of significant morbidity and mortality. Intra-arterial therapy (IAT) is clearly effective in non-mild AIS, but mild AISs have been excluded from IAT trials, limiting our understanding of their outcomes after IAT. The objective of this study was to report on patient outcomes in a mild AIS population who received IAT. Methods: We included all adults (≥18) with a mild AIS admitted over 6.5 years to a high-volume comprehensive stroke center and who received IAT. Patients were excluded for any contraindication to IAT (n=240). Outcomes were symptomatic ICH (sICH), in-hospital mortality, discharge mRS ≤2, and an improvement in NIHSS at discharge (&gt;2 vs ≤2). Results: There were 55 patients included in the study (Table 1). Overall, patients were predominately aged 55-79 years, admitted with an NIHSS 4-7, or had hypertension. 72% of patients either had a cardioembolic or large vessel occlusion (LVO), and 73% arrived either 0h to 4.5h, or &gt;6h to &lt;12h from symptom onset. 15 patients also received IV-tPA. There were no sICHs. Mortality was 9%; a majority of deaths were in males, patients with ages 55-79, LVOs, or an early symptom to arrival time. 42% of patients showed a 3-point improvement in NIHSS at discharge; a majority of these patients were white, aged 55-79, or had hyperlipidemia. Ultimately, 45% were discharged with an mRS ≥2. There were no cerebral artery perforations or groin complications. Conclusions: These data highlight the safety of IAT in patients with mild AIS, mirroring the results seen in recent large randomized clinical trials showing efficacy of IAT in the non-mild AIS population. Patients in our study had a non-existent risk of sICH, and a mortality rate similar to literature examining IV-tPA administration in patients with mild AIS. Furthermore, a large proportion of patients showed a clinically meaningful improvement in NIHSS, or were discharged with a favorable mRS.

Abstract WP317: The Impact of Post-acute Discharge Disposition on Outcomes in the SWIFT PRIME Trial

Intro: Post-acute stroke care in an inpatient rehabilitation facility (IRF) demonstrates better outcomes compared to a skilled nursing facility (SNF). With advancements in endovascular acute stroke, the impact that post-acute care plays is unclear. Here, we analyze a successful endovascular acute stroke trial to demonstrate that more improvement is seen in patients discharged to an IRF compared to a SNF. Methods: From SWIFT PRIME, a prospective, multi-center randomized acute endovascular trial, subject characteristics, and modified Rankin scores (mRS) were obtained. Post-acute hospital discharge was classified as home, IRF, and SNF. A favorable outcome was defined as 90 day mRS ≤ 2 and improvement was defined as ≥ 1 point decrease in mRS score. The effect of each disposition on a favorable outcome was calculated overall and stratified by stroke severity class (defined as discharge mRS 0-3, 4, 5) Results: A total of 165 subjects (mean age 64.8 years, mean initial NIHSS= 16.5, and 50 % male) were analyzed. Discharge disposition included: 51 (31%) going home, 92 (56%) IRF, 22 (13%) SNF. The baseline characteristics were similar between patients that went to IRF and SNF: age (p =0.76), gender (p= 0.81), baseline NIHSS (p=0.055), final infarct volumes (p=0.20), and recanalization rates (p=0.19). However, IRF subjects had lower NIHSS (p&lt;0.001) and mRS (p=0.017) at day 7. Time to treatment defined as symptom onset to groin puncture was not significantly associated with discharge disposition (p=0.119). Only 1/22 (4.5%) subjects who were discharged to SNF achieved a 90 day mRS ≤2, compared to 41/92 (44.6%) in the IRF group or 48/51 (94.1%) in the home group (p &lt; 0.001). When stratified by stroke severity: for mRS=0-3, there were no differences in favorable outcomes; mRS=4, 1/7 (14.3%) showed improvement at SNF compared to 21/27 (77.8%) at IRF (p=0.008); mRS =5, 5/14 (35.7%) showed improvement at SNF compared to 28/37 (75.7%) at IRF (p=0.013). Conclusions: Despite having similar characteristics following acute stroke treatment, not only did subjects who went to SNF compared to IRF have more unfavorable outcomes, they were less likely to make improvement. These findings show the continued importance of post-stroke rehabilitation, even in the endovascular era.

Abstract TMP14: Should 45-Minute Door to Needle Time be the New Standard of Care? Analysis of Categorized Treatment Time in a Large, Multi-hospital Registry

Introduction: With the introduction of American Stroke Association’s Target Stroke and Target Stroke2, hospitals have emphasized faster door to needle time (DTN) for acute ischemic stroke based on criteria of less than 60 minutes and less than 45 minutes, but little is known about its impact on outcomes. In this study, we evaluated outcomes based on similarly categorized treatment times across a large multi-hospital system in the Pacific Northwest. Methods: Data obtained from a multi-hospital health system’s Get With The Guidelines registry included patients discharged between January 2011 and June 2016 and treated with IV alteplase. Primary outcomes were discharge disposition, modified Rankin score (mRS) at discharge and 90-days, disability categorized as none/slight (mRS≤2) and moderate or greater (mRS ≥3) and treatment-related hemorrhagic complications. DTN was categorized into three groups: &lt;45 minutes, 45-60 minutes, or &gt;60 minutes. Generalized linear mixed regression models were used to analyze the effect of DTN group on outcomes after adjusting for the following covariates: admit NIHSS score, gender, age, last known well to arrival time, intra-arterial intervention, and history of co-morbid conditions. Adjusted odds ratios (AOR) and p-values were reported. Results: A total of 2,434 patients met inclusion criteria. DTN times were broken down as follows: 25% percent (n=610) of patients were &lt; 45 minutes, 28.1% (n=684) were 45-60 minutes and 46.8% (n=1140) were &gt; 60 minutes. Patients with DTN &gt; 60 minutes were more likely than patients with DTN &lt; 45 minutes to have moderate or greater disability at 90 days (AOR=2.43; p=.042), have a treatment-related hemorrhage (AOR=2.00; p=.045), be discharged to a skilled nursing facility or inpatient rehab versus home (AOR=2.29; p=.022), or be discharged to hospice or expired versus home (AOR=2.47; p=.014). Patients with DTN between 45 and 60 minutes were also more likely than patients with DTN &lt; 45 minutes to be discharged to hospice or expired versus home (AOR=3.21;p=.022). There was no significant effect of DTN on discharge mRS (p=.691). Conclusion: DTN time less than 45 minutes is associated with reduced mortality, less severe disability, fewer hemorrhagic complications and higher rates of home discharge.

Abstract WP355: Predictors and Outcome of Intubation for Patients with Primary Intracerebral Hemorrhage

Background: Patients with primary intracerebral hemorrhage (pICH) are at risk of airway compromise and commonly undergo intubation. Poor outcomes have been reported for these patients. Factors predicting intubation prior to admission (PTA), and after admission are unknown. These factors may be helpful in predicting which pICH patients require intubation, and its optimal timing. Methods: Patients with pICH directly admitted or transferred from another facility to our center were included. Patients with SAH, SDH, epidural hemorrhage, underlying lesions, or infarct with hemorrhagic transformation were excluded. Intubation note from medical chart was used to determine the timing of intubation. Demographic and clinical data were recorded. The primary outcome was a discharge mRS (dmRS) of 4-6. Results: A total of 370 patients were included. Patients intubated PTA had a lower average GCS (6 vs. 9; p=0.0003) and a higher average NIHSS (26 vs. 18; p=0.0007) than those intubated after admission. Higher incidences of hematoma expansion (30.9% vs. 16.3%; p=0.0253), tracheostomies performed (17.5% vs. 4.8%; p=0.0004), ICH volumes &gt; 30cc (40% vs. 25.5%; p=0.0352), and pneumonia (35.1% vs. 5.4%; p&lt;0.0001) were seen in patients intubation after admission, when compared to other patients. Patients requiring intubation at any time had statistically non-significant higher incidences of cortical and brainstem hemorrhage (see Table 1), compared to patients not intubated. After adjusting for pneumonia and ICH score, intubation is significantly associated with a dmRS of 4-6 (OR 4.87, 95%CI 1.27-18.7, p=0.0208). Conclusions: Lower GCS and higher NIHSS significantly predict intubation in pICH patients PTA. ICH volumes &gt; 30cc, hematoma expansion and pneumonia significantly predict intubation after admission. Intubation is significantly associated with poor functional outcomes independent of ICH score and pneumonia. Location of ICH does not predict intubation.

Abstract WP14: Outcomes after Endovascular Therapy in a Population with Mild Acute Ischemic Stroke and Large Vessel Occlusion: Does Treatment Help?

Introduction: Patients with mild acute ischemic strokes (NIHSS ≤7, AISs) have been excluded from intra-arterial therapy (IAT) trials, limiting our understanding of their outcomes after IAT. Mild AIS with large vessel occlusions (LVOs) represent a fragile subset of mild AISs. Despite a low NIHSS, these patients can have a sudden failure of collateral circulation and deteriorate rapidly, resulting in significant disability. The objective of this study was to compare patient outcomes between those with mild AIS and LVO who did and did not received IAT. Methods: We included all adults (≥18) with a mild AIS due to an LVO admitted over 6.5 years to a high-volume comprehensive stroke center. Patients were excluded for any contraindication to IAT (n=240). Comparison groups were IAT vs. no therapy. Outcomes were sICH, in-hospital mortality, discharge mRS ≤2, and an improvement in NIHSS at discharge (&gt;2 vs ≤2). Fisher’s, chi-squared, and logistic regression compared outcomes between groups. Results: There were 75 patients included in the study (Table 1). Overall 21% received treatment, and a majority of patients were 55-79 years, presented with hypertension and hyperlipidemia, and arrived within 4.5h from symptom onset. 7 patients also received IV-tPA. The IAT group had a significantly larger proportion of males, and hypo-mild strokes (NIHSS 4-7). There was one sICH in the no therapy group, and overall few deaths (Table 1). There was no significant difference between groups in improvement in NIHSS, and after adjusting for admission NIHSS, there was no significant difference in favorable discharge mRS. There were no IAT procedure complications. Conclusions: It remains to be seen whether IAT is beneficial in patients with mild AIS and LVO. Future, interventional, multi-center studies are needed to definitively determine the efficacy of IAT. Though these data come from a small patient population, they offer an insight into the potential safety of IAT in a fragile stroke population.

Abstract TP16: Short-Term Thrombectomy Outcomes Beyond the Traditional 6-Hour Time Window: Analysis of a Multi-Hub Telestroke Network

Background/Purpose: Acute ischemic stroke patients with large vessel occlusions are traditionally treated with thrombectomy within a 6-hour time window. Often patients get groin punctures for thrombectomy beyond 6 hours. The purpose of our study is to report real world data comparing short-term outcome differences in patients who receive groin punctures within 6 hours versus beyond 6 hours in a multi-hub telestroke network. Method: Data obtained from the Providence Health and Services Get With the Guidelines stroke registry were used to identify AIS patients who received intra-arterial (IA) intervention and were discharged from the hospital between November 2014 and May 2016. Patients were categorized as having Last Known Well-to-Groin-Puncture times (LKW-to-GP) over six hours or LKW-to-GP below or equal to six hours. Outcomes were modified rankin score (mRS) at discharge (slight or no disability versus moderate disability to dead), discharge disposition (home versus not home), change in NIHSS from admittance to discharge, and length of stay (LOS). Multivariate analyses were used to determine impact of the LKW-to-GP group on outcomes adjusting for post thrombolysis in cerebral infarction (TICI) grade, pre-symptom onset mRS, and admission NIHSS score. Intracranial hemorrhage rates were compared between the two groups using Fisher’s exact test. Results: We identified 136 ischemic stroke patients, 46.3% female with a mean age of 70.7 years (±14.6), who received IA intervention and were discharged between November 2014 and May 2016. Of those, 21% (n=29) had LKW-to-GP below or equal to six hours and 79% (n=107) had LKW-to-GP above six hours. After adjusting for covariates, there were no statistically significant differences in discharge mRS (p=.284), discharge disposition (p=.736), length of stay (p=.473) and change in NIHSS (p=.135). Unadjusted intracranial hemorrhage rates (p=.101) between the two LKW-to-GP groups were also not significant. Conclusions: We discovered one in five patients were treated beyond the traditional time window in a multi-hub telestroke network. We found no statistically significant difference in short term outcomes in patients receiving thrombectomy beyond 6 hours compared to those receiving thrombectomy within 6 hours.

Abstract WP1: Thrombectomy Outcomes in Acute Ischemic Stroke due to Middle Cerebral Artery M2 Occlusion with Stent-Retriever, Aspiration, MERCI: Multi-Center Experience

Introduction: Recent trials demonstrated that mechanical thrombectomy improve functional outcome in anterior circulation acute ischemic stroke (AIS) due to emergent large vessel occlusion (ELVO) of the middle cerebral artery (MCA) M1 segment. However, such data regarding AIS due to MCA M2 segment ELVO is limited. Analysis of the STAR, SWIFT, and SWIFT-PRIME trials found thrombectomy in MCA M2 occlusion to be feasible in achieving successful reperfusion. The most optimal technique and/or device used for such reperfusion is not clearly defined. We aim to compare the outcome for the contemporary techniques and devices used for thrombectomy of AIS patients due to MCA M2 ELVO. Methods: A retrospective review of AIS patients with MCA M2 ELVO receiving thrombectomy from three tertiary care academic medical centers was conducted. Thrombectomy technique and thrombectomy device utilized were recorded. Outcomes were successful angiographic reperfusion (TICI ≥2b), favorable modified Rankin Scale (mRS≤2) at discharge and at 90 days, and rate of symptomatic intracerebral hemorrhage (sICH). Results: From October 1999 through June 2016, 253 AIS patients underwent thrombectomy for MCA M2 ELVO. Thrombectomy methods utilized were Stent-retriever (n=118), Aspiration only [manual or Penumbra device] (n=83), and MERCI retriever (n=52). Table 1 shows rate of outcomes measured. There was no difference in baseline NIHSS or in stroke onset to groin puncture time. Stent-retriever group showed a significantly higher recanalization rate, lower sICH rate, and favorable 90-day mRS versus Aspiration group or MERCI group, respectively. No significant difference was seen in discharge mRS between the groups. Conclusions: Thrombectomy for AIS patients with MCA M2 ELVO with Stent-retriever appears to be feasible with a significantly higher rate of recanalization, lower sICH rate, and favorable 90-day mRS when compared to Aspiration and MERCI.

Abstract TMP74: Evaluation of NIHSS-Onset to Groin Time and Prehospital Acute Stroke Severity Scale-onset to Groin Time Scores in Prediction of Outcomes After Endovascular Treatment in Acute Ischemic Stroke Patients: A Retrospective Single-center Study

Background: Prehospital triage tools are essential to identify large vessel occlusion (LVO) in order to triage patients to a comprehensive stroke center for timely endovascular treatment (ET). Prehospital Acute Stroke Severity Scale (PASS) (score range 0-3) was recently identified as a valuable tool to predict LVO. Several studies have shown that in patients treated with IV tPA, a score calculated by multiplying admission NIHSS by the time from symptom onset to tPA treatment (in hours) can predict outcome. In our study, we applied similar concept for patients with LVO who underwent successful ET. Methods: We retrospectively reviewed all LVO patients between January 2015 and June 2016 who received ET. We analyzed the association of time of symptom onset to groin time (OGT), NIHSS, PASS, NIHSS-OGT, and PASS-OGT with modified Rankin scale (mRS) at the time of discharge. Results: Fifty-four patients underwent ET during the study period. Patients with posterior circulation LVO and those treated after 6 hours from last known normal were excluded. A total of 34 patients were left for final analysis. Patients with a good outcome (mRS ≤2) had an average NIHSS-OGT score of 43.2 (95% CI: 29.7-56.8) and PASS-OGT score of 5.52 (95% CI: 4.48-6.56). Patient’s with poor to miserable outcomes (mRS 3-6) average NIHSS-OGT 84.7 (95% CI: 72.8-96.6) and PASS-OGT average 9.8 (95% CI: 8.3-11.2). For NIHSS-OGT cut off of 55 the sensitivity and specificity was 0.75 and 0.85 respectively; diagnostic odds ratio 16.5 (96% CI: 2.41-112.83). For PASS-OGT cut off of 6.5 the sensitivity and specificity were 0.88 and 0.76 respectively; diagnostic odds ratio 23.33 (95% CI: 2.37-229.33). The wide confidence intervals can be attributed to small sample size. Conclusion: Our study indicates NIHSS–OGT and PASS-OGT scores have a linear relationship with discharge mRS and can reliably predict early clinical outcomes after ET. Further confirmation with randomized control trials is needed.

Abstract 64: Glucocorticoid-associated Worsening in Reversible Cerebral Vasoconstriction Syndrome (RCVS): primum non nocere!

Objective: Factors predicting poor outcome in RCVS are not fully identified. Methods: We retrospectively analyzed clinical, imaging and angiography data in 162 RCVS patients. Uni- and multi-variable analysis were performed to identify predictors of persistent (non-transient) clinical worsening, radiological worsening, early angiographic progression, and poor discharge outcome (modified Rankin Scale score 4-6). Results: The mean age was 44±13 years, 78% women. Persistent clinical worsening occurred in 14% at 6.6±4.1 days after symptom onset; radiological worsening in 27% (mainly new infarcts), and angiographic progression in 15%. Clinical worsening correlated with angiographic progression and new non-hemorrhagic lesions. Age and gender did not independently predict any type of worsening. Infarction on baseline imaging predicted poor outcome. Prior serotonergic antidepressant use predicted clinical and angiographic worsening but not poor outcome. Intra-arterial vasodilator therapy independently predicted clinical worsening and poor discharge outcome but was offered to more severe cases. Glucocorticoid treatment was an independent predictor of clinical worsening (OR 10.2, 95% CI 3.3-31.6) as well as imaging and angiographic worsening and poor discharge outcome. Of N=23 with clinical worsening, 17 received glucocorticoids (15 within prior 2 days - FIGURE). There were no significant differences in baseline brain lesions and angiographic abnormalities between glucocorticoid-treated and untreated patients. Clinical worsening occurred in 37% of 46 treated vs. 5% of 116 not treated (p&lt;0.001); discharge mRS 4-6 occurred in 47% treated vs. 17% not-treated, and 61% of treated patients developed new brain lesions. Conclusion: Worsening in RCVS can be predicted from certain baseline features. Empiric glucocorticoids " until vasculitis is ruled out " is best avoided esp. since RCVS can be accurately diagnosed upon admission using our recent criteria.

Abstract WP376: Stress-Mediated Hyperglycemia or Undiagnosed Diabetes?

Background: “Stress mediated” hyperglycemia is often assumed to drive initial hyperglycemia during stroke admission. We sought to examine hemoglobin A1c (HbA1c) in relation to initial serum glucose. Methods: An observational design was used to examine glucose data from prospectively admitted acute stroke patients at 4 Comprehensive Stroke Centers. Data were entered and analyzed in SPSS using descriptive statistics, student t-tests, and Mann Whitney U. Results: 1226 patients were studied; 50% male, 63% White, 34% African American (AA); age averaged 69±13.5 years, and 93% were ischemic strokes. DM was known on admission in 37%. Admission HbA1c was 5.8±.7 in non-DM patients, compared to 7.8±1.8 in known DM patients (p&lt;0.001; 95% CI=1.7-2.1). Patients with admission glucose &gt;180mg/dL had significantly higher HbA1c (9.0±1.9) compared to lower glucose values (6.1±1.1, median 5.9; p&lt;0.001; 95% CI=2.5-3.2). Importantly, of those with an admission glucose &gt;180mg/dL, 94% met the diagnosis of DM by HbA1c, although 13% had not been previously diagnosed. Discharge mRS was significantly worse at a median of 4 (unable to walk independently) vs. 3 (p=0.001) in patients with admission glucose &gt;180mg/dL, despite having equivalent median admission NIHSS of 3 in each group (p=NS). Conclusions: Admission glucose &gt;180mg/dL should be recognized as a strong indicator of DM diagnosis and not be assumed to be stress mediated. Stroke nurses are encouraged to lead the early diagnosis/management of diabetes.

Abstract WP142: Intravenous Tissue Plasminogen Activator for Patients with Mild and Rapidly Improving Ischemic Strokes and Large Vessel Occlusions: Examining In-hospital Outcomes

Background: Upon hospital arrival, patients with mild or rapidly improving acute ischemic strokes (AIS) are frequently not treated with IV-tPA. Recent guidelines from the American Heart Association report that diagnosis on imaging of large vessel occlusion (LVO) despite mild stroke severity leads to increased risk of poorer outcomes. The objective of our study was to examine outcomes following tPA in this AIS population. Methods: The study included all AIS patients with an admission NIHSS ≤7 and diagnosis of a LVO on imaging from a single comprehensive stroke center between 2010-2016. Patients were excluded due to missing contraindications to tPA or with a symptom to arrival time of &gt;4.5 hours (n=234). We compared patients who received tPA to those who received no treatment because of mild or rapidly improving symptoms. Outcomes were sICH, improvement in NIHSS score, discharge mRS ≤2, and in-hospital mortality. Patient characteristics were compared univariately, and step-wise logistic regression was used to adjust for confounding variables. Entry criterion was P=0.2 and exit criterion was P=0.07. Results: There were 76 patients with an AIS diagnosis of LVO. Of these patients, 39 (51%) were treated with tPA and 37 (49%) were not treated. Overall, the median (IQR) age was 72 (61-82.5). Patients treated with tPA had a median admission NIHSS of 5 (3-6), and a larger proportion were male (77%) and smokers (4%). Patients without tPA treatment had a median NIHSS of 2 (1-3), and a larger proportion had hypertension (49%). All outcomes were not significantly different between groups after adjustment (Table 1). There were no patients with sICH. Conclusions: Our study suggests that tPA in mild LVO patients does not introduce additional risk in terms of sICH, in-hospital mortality, change in NIHSS, or discharge mRS. Further justification for withholding tPA in this group should be based on 90-day mRS scores, in order to better understand long-term functional outcomes.

Abstract TP332: Intracerebral Hemorrhage Volume to Edema Volume Ratio Predicts Poor Functional Outcome in Young Patients with Non-Lobar Primary Intracerebral Hemorrhage

Background and Purpose: Cerebral edema is known to contribute to clinical decline in patients with spontaneous ICH. We sought to evaluate the significance of cerebral edema on outcome in young patients with primary ICH. Methods: We performed a retrospective review of patients presenting to our CSC center from 2014-2015 with primary ICH, excluding patients with lobar ICH and age 55 and above. Patients were grouped according to functional outcome at discharge (mRS 0-3 vs. 4-6). Imaging characteristics of those with poor short-term functional outcome (mRS 4-6) were compared to those with mRS 0-3. Receiver Operating Characteristics curves were used to evaluate the discriminatory ability of imaging characteristics with regards to poor functional outcome. Results: A total of 38 patients met inclusion criteria (mean age 47, 42% black, 55% male). On presentation, patients with poor functional outcome had larger mean ICH volume (26 vs 9cc; p=0.020), higher ICH volume to edema volume ratios (2.0 vs. 0.7, p=0.010), more evidence of midline shift (38% vs. 6%, p=0.026), and IVH (52% vs. 17%, p=0.043). Groups did not differ in terms of edema volume, amount of midline shift, evidence of hydrocephalus, or herniation. ICH volume to edema volume ratio was a better discriminator of poor outcome (AUC=0.813, p=0.006) than ICH volume (AUC=0.802, p=0.008, Figure 1a). Further, ICH volume to edema volume ratio was a better discriminator of poor outcome (AUC=0.801, p=0.009) than ICH score (AUC=0.724, p=0.051, Figure 1b). Discussion: Among young patients with non-lobar primary ICH we observed that the ICH to edema ratio was a better predictor of poor functional status at discharge than ICH volume or ICH score.

Abstract TP426: Impact of Electrographic Seizure Activity on Outcomes Among Critically-ill Patients with Stroke

Introduction: Patients with severe acute stroke can suffer secondary neurological injury due to a variety of causes. The clinical impact of electrographic seizures among critically-ill stroke patients remains unclear. Methods: We retrospectively analyzed a cohort of consecutive stroke patients admitted to the Neuroscience Intensive Care Unit (NSICU) at the Mount Sinai Hospital who underwent ≥24 hours of continuous video EEG (cEEG) monitoring for alteration in level of consciousness or suspected non-convulsive seizures between May 2013 and June 2015. Results: Of 106 consecutive severe stroke patients admitted to the NSICU who underwent cEEG monitoring, 15 (14%) had clinical or electrographic seizures. The median duration of cEEG monitoring was 1.2 days. Observed seizures included purely electrographic seizures with no clinical correlate in 53%, subtle twitching or altered mental status in 33%, and generalized tonic-clonic seizures with an EEG correlate in 13%. Generalized or lateralized periodic discharges (PEDs) were present in 93% (14/15) of patients in the seizure group, compared to 20% (18/89) in the non-seizure group (P= 0.00). The survival rate at discharge was 53% in the seizure group compared to 73% in the non-seizure group (p = 0.12). Mean ICU length of stay was 16 days in both groups. Of the 11 survivors in the seizure group 100% were severely disabled at discharge (mRS 4 or 5) compared to 75% of the 65 survivors in the non-seizure group.(P=0.06). Conclusion: Critically-ill stroke patients with clinical or electrographic seizures in the ICU tend to have higher mortality and worse functional outcome at the time of discharge. PEDS are an important marker of patients at high risk for ictal activity. Careful identification of acute stroke patients that might benefit from seizure prophylaxis is warranted.

Abstract TP181: Albuminuria Should Be A Strong Predictor Of Acute Kidney Injury in Acute Ischemic Stroke Patients

Background: Acute kidney injury (AKI) in the setting of cardiovascular events is recognized as a high risk of poor clinical outcome. Although estimated glomerular filtration rate (eGFR) and albuminuria are known to be associated with ischemic stroke outcomes, solid evidence has not yet to be presented regarding the relationship among the two markers and AKI. The present study aimed to clarify this issue in patients with acute ischemic stroke. Methods: From a prospectively gathered registry, we examined acute ischemic stroke patients who were hospitalized within 48 hours after symptom from September 2014 to June 2016. Admission serum creatinine level was considered to be the baseline. AKI is defined by an increase in the serum creatinine level of ≥0.3 mg/dl within 48 hours; or percentage increase of 50% or more from the baseline value within 7 days after admission. We divided all patients into the AKI group and the non-AKI group, and compared clinical characteristics between the two groups. The factors associated with AKI were investigated by multivariate logistic regression analysis. Results: Three hundred and eighty-nine patients (245 males, 74 [65-82] years old) were enrolled in the study. AKI occurred in 14 patients (3.6%) with acute ischemic stroke patients. Compared with patients without AKI, patients with AKI had increased serum creatinine level (1.20 mg/dl vs. 0.80 mg/dl, p=0.033) and urine albumin level (259.6 mg/g vs. 38.7mg/g, P&lt;0.001). On the other hand, eGFR level was decreased in the AKI group than in the non-AKI group (45.5 ml/min/1.73 m 2 vs. 65.0 ml/min/1.73 m 2 , P=0.048). Poor clinical outcome at discharge (mRS ≥5) was frequently observed in the AKI group than the non-AKI group (42.9% vs. 16.5%, P=0.022). The optimal cut-off urine albumin value to distinguish the AKI from the non-AKI using receiver operating characteristics (ROC) curves was 170 mg/g, with 78.6% sensitivity and 79.2% specificity. Multivariate regression analysis showed that urine albumin level &gt; 170mg/g was an independent factor of AKI (odds ratio [OR] 12.73; 95% confidence interval [CI], 3.10-52.30, P&lt;0.001), but not eGFR &lt;60 ml/min/1.73 m 2 (OR 0.96; 95% CI 0.26-3.54, P=0.944). Conclusion: Albuminuria should be a strong predictor for AKI in acute ischemic stroke patients.