Discharge mRS Research Articles

Abstract P77: Acute Stroke Trends and Outcomes During the COVID-19 Pandemic in a Multi-System Hospital System in the Western US

Introduction: We aimed to evaluate the impact of Covid-19 pandemic on stroke systems of care and outcomes within a large multi-hospital system in the Western US. Methods: Retrospective data from 37 hospitals within a large multi-hospital stroke registry was analyzed. All patients with a confirmed discharge diagnosis of stroke or TIA during the pandemic (March and April 2020) were compared to cohorts during the same periods in 2018 and 2019. Analyzed factors included demographics, stroke mechanism, admission NIHSS, reperfusion therapy rates (IV TPA and EVT), reperfusion performance metrics (door-to-CT, door-to-needle, door-to-puncture, door-to-first pass), TICI score, discharge and 90-day mRS, discharge disposition, and length of stay. Analyses were conducted using ANOVA, Kruskal-Wallis, or Person’s Chi-square test, as appropriate, adjusting for multiple comparisons. Results: Among the 7,201 analyzed patients, 2,378 (33.0%) were admitted in 2018, 2,613 (36.3%) in 2019 and 2,210 (30.7%) in 2020. Fewer patients were hospitalized with TIA during the pandemic compared to 2018 and 2019 (23.6% vs 36.8% vs 39.6%, p<.001). More patients arrived via EMS (52.2% vs 45.7% vs 45.4 %) and fewer via private car (29.8% vs 37.8% vs 38.7%) (p<.001) during the pandemic. Median door-to-CT (in minutes) (26 vs 35 vs 33, p<.001) time was significantly shorter during the pandemic. Additionally, a greater percentage of patients were treated with EVT during the pandemic (7.5 vs 5.7 vs 5.4, p=.005). Shorter arrival-to-first pass times (in minutes) occurred in 2020 compared to previous years (103 vs 119 vs 115, p=0.091) but this difference did not reach statistical significance. Fewer patients were discharged to a skilled nursing facility during the pandemic (12.7%) compared to 2018 and 2019 (15.1% and 15.2%, p=.012). There were no other significant differences in stroke admission volumes, treatment trends, or outcomes between the pandemic and pre-pandemic periods. Conclusion: Fewer walk-in strokes and TIAs were hospitalized during the pandemic while an increased rate of thrombectomy procedures occurred compared to the pre-pandemic era. Despite anticipated delays in acute stroke care, our study demonstrates improvement in key triage and treatment times and similar outcomes.

Abstract MP35: Blood Pressure Reductions Before Arrival at a Thrombectomy-Capable Hospital Are Associated With Neurologic Worsening in Patients With Large-Vessel Occlusion

Introduction: Decreases in blood pressure (BP) during thrombectomy are associated with infarct progression and worse outcomes. Many patients present first to a primary stroke center (PSC) and are later transferred to a comprehensive stroke center (CSC) to undergo thrombectomy. During this period, important BP variations might occur. We evaluated the association of BP reductions with neurological worsening and functional outcomes. Methods: We prospectively collected hemodynamic, clinical, and radiographic data on consecutive patients with LVO ischemic stroke who were transferred from a PSC for possible thrombectomy between 2018 and 2020. We assessed systolic BP (SBP) and mean arterial pressure (MAP) at five time points: earliest recorded, average pre-PSC, PSC admission, average PSC, and CSC admission. We measured neurologic worsening as a change in NIHSS (ΔNIHSS) from PSC to CSC >3 and functional outcome using the modified Rankin Scale (mRS) at discharge and 90 days. Relationships between variables of interest were evaluated using linear regression. Results: Of 91 patients (mean age 70±16 years, mean NIHSS 12) included, 13 (14%) experienced early neurologic deterioration (ΔNIHSS>3), and 34 (37%) achieved a good outcome at discharge (mRS<3). We found that patients with good outcome had significantly lower SBP at all five assessed time points compared to patients with poor outcome (Figure 1, p<0.05). Percent change in MAP from initial presentation to CSC arrival was independently associated with ΔNIHSS after adjusting for age, sex, and transfer time (p=0.03, β=0.27). Conclusions: Patients with poor outcomes have higher BP throughout the pre-CSC period, possibly reflecting an augmented hypertensive response. Reductions in SBP and MAP before arrival at the CSC are associated with neurologic worsening. These results suggest that BP management strategies in the pre-CSC period to avoid large reductions in BP may improve outcomes in patients affected by LVO stroke.

Abstract P242: Impact of Covid-19 on Acute Ischemic Stroke Care at Henry Ford Hospital’s Detroit and West Bloomfield Campuses

Background: Coronavirus 2019 (COVID19) has impacted acute stroke (AS) care with several reports globally showing drops in AS volumes during the pandemic. We studied the impact of COVID19 on AS and transient ischemic attack (TIA) care in a health system serving Southeast Michigan as we rolled out a policy aimed at limiting admissions and transfers. Methods: In this retrospective study conducted at 2 hospitals, we included consecutive patients presenting to the emergency department (ED) for whom a Stroke Alert (SA) was activated during the period 3/20 to 5/20/20 (COVID) and a similar period in 2019 (pre-COVID). We compared demographics, time metrics, and discharge outcomes. Results: 264 patients were seen pre-COVID compared to 121 during COVID (p<0.001). Patients seen during COVID had an equal proportion of males (55% vs 51%, p=0.444), were majority African American (57 vs 58%, p=0.74), but had a higher presenting NIHSS (median: 5 vs 2, p=0.01) and longer times since last-known-well to ED arrival (median: 9.4 vs 4.8 hours, p=0.03) compared to pre-COVID. Fewer patients were transferred from other centers (42 vs 27% p=0.008). SA activation on arrival (median: 9.6 vs 15 min, p=0.004) and imaging initiation from arrival (median: 26.4 vs 34.8 min, p=0.042) were faster as well as a trend toward statistical significance for time to tPA administration (median: 37.8 vs 51 min, p=0.051) compared to pre-COVID. There were higher rates of AS and TIA (69% vs 55%) and lower rates of stroke mimics (17 vs 37%, p<0.001). Patients discharged from the stroke unit had significantly higher discharge NIHSS (median: 3 vs 2, p=0.002) and were more likely to have an unfavorable discharge mRS (3-6) (56 vs 33%, p=0.004). There were no significant differences in medical, social histories, time to first pass for patient undergoing thrombectomy and stroke etiologies between the groups. In 2020, 9 patients (8%) were COVID19 positive, 2 had unfavorable mRS 3-5 while 3 died. Conclusion: There was greater than 50% reduction in stroke admissions during the COVID19 pandemic which is consistent with other reports. Although patients were managed more quickly, they tended to have more severe strokes, fewer stroke mimic diagnoses, and worse outcomes compared to patients treated in the pre-COVID period.

Abstract MP21: Mobile Interventional Stroke Teams Lead to Improved Outcomes in the Early Time Window for LVO Stroke

Introduction: Endovascular therapy (EVT) for large vessel occlusion (LVO) stroke is time-sensitive. At Mount Sinai Health System, we developed a novel Mobile Interventional Stroke Team (MIST) that travels to Thrombectomy Capable Stroke Centers to perform EVT, as opposed to transferring patients in the Drip-and-Ship (DS) model. We have shown significantly faster initial door-to-recanalization times and improved discharge outcomes. The effect of the MIST stratified by time of presentation has yet to be studied. Hypothesis: In patients presenting with a last known well [LKW] of <6 hours, the MIST model leads to better clinical outcomes as compared to the DS model. Methods: In a prospectively collected stroke database at a multicenter health system, patients undergoing EVT performed by a MIST or after transfer in a DS model from January 2017 to March 2020 with baseline mRS 0-2 were selected. Patients presenting in the early time window and late time window (LKW >6 hours) were analyzed separately. The primary endpoint was the proportion with a good outcome (mRS of 0-2) at 90 days. Secondary endpoints included discharge NIHSS and mRS. Results: In the 242 selected patients, the MIST and DS cohorts were similar in age, gender, initial NIHSS, pre-stroke mRS, and procedural details. In the early window, 54% (39/72) had a good 90-day outcome in the MIST model, as compared to 28% (25/88) in the DS model (p<0.01). In the late window, good 90-day outcomes were similar (29% vs 43%; p=0.40). The median NIHSS at discharge was 4.0 and 12.0 in the early window (p<0.01) and 5.0 and 11.0 in the late window (p=0.16) in the MIST and DS models, respectively. The early window discharge mRS was significantly better in the MIST model (p<0.01) and similar in the late window (p=0.74). Conclusions: The MIST model used in the early time window produces better 90-day outcomes compared to the DS model. This is likely due to the MIST’s ability to capture fast progressors in the early window.

Abstract 26: Treatment Choice and Discharge Outcomes in Patients Presenting With Large Vessel Occlusion and Low National Institutes of Health Stroke Scale

Introduction: Since 2015, endovascular thrombectomy (EVT) has been widely accepted as the standard of care for patients presenting proximal anterior circulation large vessel occlusion (LVO). However, patient selection for EVT remains uncertain in patients presenting with LVO and low NIHSS. Methods: Retrospective data from 37 hospitals within a large multi-hospital system stroke registry were analyzed and included patients age 18 or over, discharged between January 2016 and May 2020, with an admission NIHSS < 6, and who had a LVO visualized in the internal carotid artery or middle cerebral artery. Patients treated with EVT (with or without IV alteplase), IV alteplase alone, or best medical management (BMM) without IV alteplase or EVT were compared with regard to modified Rankin scale (mRS) at hospital discharge and hospital length of stay (LOS). Pearson’s chi-square square test and Mann-Whitney U test were conducted. Results: Discharge mRS analysis included 742 patients, 211 (28.4%) treated with EVT (with or without IV alteplase), 107 (14.4%) treated with IV alteplase alone, and 424 (57.2%) treated with BMM. A greater proportion of patients treated with IV alteplase alone (71.0%) had no or slight disability (mRS 0-2) compared to EVT (with or without IV alteplase) (51.7%), or BMM (52.6%) (p=.001). Analyses of LOS included 1,037 patients, 298 (28.7%) treated with EVT (with or without IV alteplase), 157 (15.1%) treated with IV alteplase alone, and 582 (56.1%) treated with BMM. Patients treated with IV alteplase alone had significantly shorter LOS (2.0 days, [Interquartile Range:3.0]) compared to EVT (with or without IV alteplase) (3.0 days [4.0]), or BMM (3.0 days [4.0]) (p<.001). Conclusion: Amongst this cohort of patients presenting with anterior circulation LVO and low NIHSS, better discharge outcomes were seen in patients treated with IV alteplase alone, compared to EVT (with or without IV alteplase) or BMM. The best treatment for this patient population remains unclear, and further research is needed.

Abstract P274: Evaluation of Glycemic Variability and Discharge Outcomes in Patients Presenting With Ischemic Stroke Following Intravenous Thrombolysis

Presentation Objective: Does glycemic variability worsen Modified Rankin Score (mRS) following ischemic stroke in patients treated with thrombolytics (tPA)? Background/Purpose: Acute hyperglycemia and strict glucose control have been identified as predictors of hemorrhage, increased length of stay and hypoglycemia following ischemic stroke. However, the role of glucose variability in patients with ischemic stroke treated with tPA is largely unknown. The aim of this study was to evaluate the role of glycemic variability on discharge outcomes in patients treated with tPA for ischemic stroke. Methodology: A retrospective review of adults with ischemic stroke who received tPA was completed. Patients hospitalized for at least 48 hours with image-confirmed ischemic stroke and symptom onset within 4.5 hours of presentation were included. Glycemic variability was measured using the J-index calculation and groups were defined as patients with normal or abnormal J-indices. Logistic regression models were developed to determine odds ratios for defined outcomes including NIHSS score, mRS and disposition at discharge. Statistical significance was a p-value of <0.05. Results: Of the 229 patients included, 132 (58%) had a normal J-index (4.7 – 23.6). In the univariate analysis, abnormal J-index was associated with higher rates of hypertension (94% vs 73%), type 2 diabetes mellitus (74% vs 12%), chronic kidney disease (34% vs 11%), higher initial blood glucose values (220 ±172 vs 111 ±20) and HbA1c, and worse outcomes in terms of NIHSS score, mRS and disposition at discharge. In the multivariate analysis, patients with an abnormal J-index had higher odds of unfavorable outcomes in terms of discharge mRS (OR 2.1; 95% CI 1.0 – 4.3, p=0.045) and hemorrhagic transformation (OR 4.1; 95% CI 1.7 – 10.2, p=0.002). There was no difference in discharge disposition (OR 1.4; 95% CI 0.7 – 3.0 p=0.4). Conclusion: Glycemic variability, following ischemic stroke, may result in unfavorable patient outcomes in patients treated with tPA. Additional studies are needed to determine the appropriate glucose management strategy.

Abstract P111: Ischemic Stroke Associated With Covid-19 and Racial Outcome Disparity in North America

Introduction: Underlying biological, genetic, or epigenetic characteristics may predispose to health differences and outcomes with COVID-19 associated stroke. Social determinants of health, access and geographical differences pertaining both to population density and other location-based factors may also be important. Methods: We report 69 cases of acute stroke in patients positive for SARS-CoV-2, in a dichotomized analysis of ischemic stroke outcomes between patients of African American background versus all other backgrounds. All patients presented to 14 major hospitals in the United States and Canada, from March 14-April 14, 2020. All patients had nasopharyngeal swab samples that were positive for SARS-CoV-2 on qualitative RT-PCR assays. Results: We found no significant difference in age (64.4 versus 62.9 years) or the proportion of females (51.9% versus 38.1%) (table 1). Diabetes mellitus was present significantly less in African American cases versus others (37% vs. 66.7%). The African American cohort had a similar mean NIHSS score of 16.3 compared with 14.9 in other races (p=0.63). The door-to-CT time was also similar (23 versus 19 minutes). The proportion of patients presenting with a large vessel occlusion was not significantly different (40.7% versus 47%). We noted 14.8% of African American cases received intravenous tPA compared to 31% in other races but was not significantly different. The proportion of thrombectomy cases mirrored this (14.8% versus 31%). Regarding stroke functional outcomes, there was no difference between African Americans and other races with respect to discharge mRS or proportion of favorable outcome (mRS 0-2). Symptomatic intracranial hemorrhage (sICH) was significantly higher for African Americans (11.1% versus 3%, p<0.001). Mortality was significantly higher in African Americans compared to other races (51.9% vs. 28.6%, p=0.03). Discussion: The reasons for increased mortality in African Americans with COVID-19-associated stroke are unknown. The finding in this study that mortality rate of COVID-19 positive stroke patients is greater than that previously reported in either COVID-19 respiratory infection alone or acute ischemic stroke alone, suggests an interaction that also warrants further study.

Factors Impacting Hydrocephalus Incidence in Intracerebral Hemorrhage: A Retrospective Analysis

To test which intracerebral hemorrhage (ICH) characteristics impact incidence of hydrocephalus and characterize subsequent impact on outcomes. A search of the electronic medical record of Sinai Grace Hospital between January 2009 and April 2018 using International Classification of Diseases, Ninth Revision and Tenth Revision codes for ICH identified 847 patients. After excluding patients with hemorrhagic conversion of stroke, subarachnoid hemorrhage, and traumatic hemorrhage, 560 patients remained for analysis. Generalized linear modeling was used to assess variance in modified Rankin Scale (mRS) score and length of stay. Incidence of hydrocephalus on arrival varied with ICH volume (P < 0.001), intraventricular hemorrhage (IVH) status (P < 0.001), bleed location (P < 0.001), and external ventricular drain (EVD) status (P < 0.001). An EVD was inserted in 47% of patients presenting with IVH (n= 102/217), while 4% of patients without IVH received an EVD (n= 14/343) (P < 0.001). Hemorrhage locations had different rates of EVD placement: thalamic 43%, basal ganglia 22%, cerebellar 28%, brainstem 21%, lobar 7% (P < 0.001). Shunt dependency did not vary between bleed locations (P= 0.072). Variance in mRS score was explained by IVH, bleed location, hydrocephalus on arrival, and ICH volumes. In particular, cerebellar hemorrhage location was associated with better outcomes (mean discharge mRS score of 3.3 vs. 3.9, P < 0.001). Bleed characteristics affect incidence of hydrocephalus on admission, rates of long-term shunt dependency, and outcomes. Hemorrhage location did not predict shunt dependency; however, it did predict outcomes. Specifically, cerebellar ICH was associated with a better discharge mRS score.

Age and discharge modified Rankin score are associated with 90-Day functional outcome after basilar artery occlusion treated with endovascular therapy.

Prognostic factors for functional outcome after basilar artery occlusion (BAO) treated with modern endovascular therapy (EVT) are sparse. We investigated the association between clinical characteristics, readily available imaging variables, and outcome in BAO patients treated with EVT. Retrospective analysis from a large healthcare system's prospectively collected code stroke registry of acute BAO patients treated with EVT between January 2017-January 2020. The primary outcome measure was a favorable 90-day modified Rankin score (mRS) of 0-2. 65 patients (median age 67 years, 57% male, median NIHSS 16) met the study inclusion criteria. Thrombolysis in Cerebral Infarction (TICI) 2 b-3 revascularization was achieved in 57/65 patients (88%) with a median time to revascularization of 445 minutes [IQR 302-840]. Ninety-day good outcome was seen in 35% (23/65) of patients. In a univariate analysis, age, history of ischemic stroke, baseline NIHSS, BAO site, and discharge mRS were associated with significant differences between the good and poor outcome groups. A multivariable logistic regression analysis demonstrated an independent association with 90-day good outcome and younger age (per 1-year, OR 0.79, 95% CI 0.64, 0.98) and good discharge mRS (0-2) (OR > 999.99, 95% CI 13.26, > 999.99). Patients presenting with an acute BAO treated with modern EVT have a good 90-day outcome in over one-third of cases. Age and discharge mRS are independently associated with good 90-day outcome. Additional studies may focus on factors that can enhance discharge function after BAO, a novel prognostic indicator for favorable 90-day outcome in our study.

Increased P450 aromatase levels in post-menopausal women after acute ischemic stroke

BackgroundSex differences in stroke have been attributed to the neuroprotective effects of estrogen, yet most clinical trials of estrogen supplementation for stroke prevention have failed. The contribution of sex hormones to stroke outcome remains a subject of debate. Aromatization of testosterone to estradiol in neural tissue leads to sexual differentiation. Emerging data suggests aromatase activity increases in response to brain injury, and increased aromatase expression is seen in the ischemic penumbra in animal models. The objective of this study was to examine the levels of endogenous sex steroids after acute ischemic stroke and determine if levels of sex steroids were associated with acute stroke outcomes.MethodsPeripheral blood from ischemic stroke patients and controls was collected under an approved IRB within 24 h of symptom onset. 17β-estradiol, testosterone, and aromatase levels were measured in the serum of both men and women using ELISA. Hormone levels were compared in men vs. women in stroke and control groups and correlated with outcomes (NIHSS and change in the modified Rankin Scale (mRS), defined as the difference of premorbid and discharge mRS) using multivariate regression.ResultsWe found no significant difference in estradiol levels 24 h after stroke in men (p = 0.86) or women (p = 0.10). In men, testosterone significantly decreased after stroke as compared with controls (1.83 ± 0.12 vs. 2.86 ± 0.65, p = 0.01). Aromatase levels were significantly increased in women after stroke as compared with controls (2.27 ± 0.22 vs. 0.97 ± 0.22, p = 0.002), but not in men (p = 0.84). Estradiol levels positively correlated with change in mRS in both women (r = 0.38, p = 0.02) and men (r = 0.3, p = 0.04).ConclusionsEstradiol levels correlated with functional outcomes (change in mRS) in both men and women, at least in the acute phase (24 h) of stroke. However, no significant difference in estradiol levels is seen 24 h post-stroke in men or women. Testosterone levels decrease at 24 h after stroke in men. As seen in animal models, aromatase levels increase after acute ischemic stroke, but this was only true for women. These indicate an active aromatization process in post-menopausal women after acute ischemic stroke.

Real-world comparative safety and efficacy of tenecteplase versus alteplase in acute ischemic stroke patients with large vessel occlusion.

Background and aims:Tenecteplase has recently emerged as an alternative thrombolytic agent in acute ischemic stroke (AIS) patients with large vessel occlusion (LVO), possibly superior in achieving early reperfusion compared with alteplase. We aimed to compare the safety and efficacy of intravenous tenecteplase with intravenous alteplase for AIS patients with LVO in everyday clinical practice settings.Methods:We prospectively evaluated patients with AIS due to LVO, treated with intravenous thrombolysis (IVT) with or without mechanical thrombectomy in two tertiary stroke centers. Patients were treated with standard-dose alteplase (0.9 mg/kg) or 0.25 mg/kg tenecteplase. Safety outcomes included prevalence of symptomatic intracranial hemorrhage (sICH) and mortality. Efficacy outcomes included averted thrombectomy, major neurological improvement at 24 h (defined as decrease in baseline NIHSS score of 8 points or greater) and functional status on discharge and on 3 months assessed by modified Rankin Scale (mRS).Results:Nineteen AIS patients with LVO received tenecteplase and 39 received alteplase. We observed a non-significant higher rate of averted thrombectomies (32% versus 18%, p = 0.243) and a non-significant higher rate of sICH (16% versus 5%, p = 0.201) in the tenecteplase group. The rate of 24 h major neurological improvement was higher in the tenecteplase group (64% versus 33%, p = 0.046) but this was marginally attenuated in multivariable analyses (adjusted OR 10.22, 95% CI: 0.73–142.98; p = 0.084). Discharge mRS, 3-months mRS, and 3-month functional independence (mRS scores of 0–2) did not differ (p > 0.2) between the two groups. The rates of 3-month mortality (11% versus 18%, p = 0.703) were similar in the two groups. No independent association between thrombolytic agent and safety or efficacy outcomes emerged in multivariable regression analyses.Conclusion:The present pilot observational study highlights that AIS patients with LVO treated with 0.25 mg/kg bolus administration of tenecteplase had increased likelihood to achieve early neurological improvement compared with AIS patients treated with alteplase, but this association was attenuated after adjustment for potential confounders. There were no significant differences in 3-month functional or safety outcomes between the two groups. This preliminary real-world observation requires independent confirmation in larger, multicenter studies.

Comparison of Clinical Characteristics of COVID-19-Related and Unrelated Acute Stroke Patients During the COVID-19 Pandemic in Turkey.

Objectives:Data on the co-occurrence of stroke and coronavirus disease 2019 (COVID-19) infection are limited and need to be improved. In our study, we aimed to evaluate the clinical and laboratory characteristics of COVID-19-related patients admitted to our center with acute stroke and compare them with acute stroke patients without COVID-19 infection during the same period.Methods:One hundred and eighty-four patients admitted with acute stroke from March 11, 2020, to May 11, 2020, were included in the study. Demographic and clinical characteristics, work-up studies, and clinical scales including National Institutes of Health Stroke Scale (NIHSS), modified Rankin scale (mRS) scores were examined retrospectively. All patients diagnosed with acute stroke who were also evaluated for COVID-19 before hospitalization were divided into two groups: COVID-19-related and unrelated cases.Results:COVID-19-related and unrelated acute stroke patients had similar characteristics in terms of age, gender, and stroke risk factors. The admission NIHSS (mean NIHSS: 9.8 vs. 5.9) scores and the discharge mRS values (mean mRS: 3.9 vs. 2.4) were significantly higher in the COVID-19-related stroke group (p=0.002 and p=0.001, respectively). The prognosis of the COVID-19-related stroke group was significantly worse (69.6% vs. 39.8%) and the mortality rate (39.1% vs. 6.2%) was significantly higher than the COVID-19-unrelated stroke group (p=0.007 vs. p=0.000, respectively). The proportion of patients with large infarcts in the COVID-19-related acute ischemic stroke group was significantly higher than the one in the COVID-19-unrelated acute ischemic stroke group (57.9% vs. 21.9%, p=0.003).Conclusion:This is the first comparative study to evaluate the clinical presentation and outcome of COVID-19-related acute ischemic and hemorrhagic stroke patients in Turkey. Our results suggest that COVID-19-related acute stroke is associated with more severe clinical presentation and worse outcome. This seems to be linked to the coagulation abnormalities induced by COVID-19 infection.

Impact of bridging thrombolysis on clinical outcome in stroke patients undergoing endovascular thrombectomy: a retrospective analysis of a regional stroke registry

PurposeIt is unclear whether stroke patients undergoing endovascular thrombectomy (EVT) should receive bridging intravenous thrombolysis (IVT), if eligible. This study aims at analyzing the impact of bridging IVT on short-term clinical outcome.MethodsIn a prospective regional stroke registry, all stroke patients with premorbid modified Rankin Scale (mRS) score of 0–2 who were admitted within 4.5 h after onset and treated with EVT were analyzed retrospectively. Patients receiving “IVT prior to EVT” (IVEVT) were compared to those undergoing “EVT only” regarding the ratio of good outcome, discharge mRS, mRS shift, hospital mortality, and occurrence of symptomatic intracranial hemorrhage.ResultsIn total, 2022 patients were included, 816 patients (40.4%) achieved good clinical outcome; 1293 patients (63.9%) received bridging IVT. There was no significant difference between both groups regarding the ratio of good outcome (IVEVT 41.4% vs. EVT 38.5%, P = 0.231), discharge mRS (median, IVEVT 3 vs. EVT 3, P = 0.178), mRS shift (median, IVEVT 3 vs. EVT 3, P = 0.960), and hospital mortality (IVEVT 19.3% vs. EVT 19.5%, P = 0.984). Bridging IVT was not a predictor of outcome (adjusted OR 1.00, 95% CI 0.79–1.26, P = 0.979). However, it was an independent predictor of symptomatic intracranial hemorrhage (adjusted OR 1.79, 95% CI 1.21–2.72, P = 0.005).ConclusionsThe results of the present study suggest that bridging IVT does not seem to improve short-term clinical outcome of patients undergoing EVT. Nonetheless, there might be a subgroup of patients that benefits from IVT. This needs to be addressed in randomized controlled trials.

Effect of Recanalization on Cerebral Edema, Long-Term Outcome, and Quality of Life in Patients with Large Hemispheric Infarctions

ObjectivesSpace-occupying cerebral edema is the main cause of mortality and poor functional outcome in patients with large cerebral artery occlusion (LVO). We aimed to determine whether recanalization of LVO would augment cerebral edema volume and the impact on functional outcome and quality of life (QoL). Materials and MethodsProspectively, 43 patients with large middle cerebral artery territory infarction or NIHSS ≥ 12 on admission were enrolled. The degree of recanalization (partial and complete versus no recanalization) was assessed by computed tomography (CT)-angiography or Duplex ultrasound more than 24 h after symptom onset. Cerebral edema volume was measured on follow up CTs by computer-based planimetry. Mortality, functional outcome (by modified Ranking Scale (mRS) and Barthel Index (BI)) were assessed at discharge and 12 months, and QoL (by SF-36 and EQ-5D-3L) at 12 months. ResultsMean cerebral edema volume was 333±141 ml without recanalization (n=13, group 1) and 276±140 ml with partial or complete recanalization (n=30, group 2, p= 0.23). There were no significant differences in mortality at discharge (38% versus 23%), at 12 months (58% versus 48%), in functional outcome at discharge (mRS 0–3: 0% both; mRS 4–5: 62% versus 77%) and at 12 months (mRS 0–3: 0% versus 11%; mRS 4–5: 42% versus 41%). The BI improved significantly from discharge to 12 months only in group 2 (p=0.001). Mean physical component score in SF-36 was 25.6±6.4, psychological component score was 41.9±14.1. In the EQ-5D-3L, most patients reported problems with activities of daily living, reduced mobility, and selfcare. ConclusionsRecanalization of a large cerebral artery occlusion in the anterior circulation territories is not associated with amplification of post-ischemic cerebral edema but may be correlated with better long-term functional outcome. QoL was low and mainly dependent on physical disability. The association between recanalization, collateral status and development of cerebral edema after LVO and the effect on functional outcome and quality of life should be explored in a larger patient population.

The prevalence, mortality rate and functional outcome of intracerebral hemorrhage according to age sex and ethnic group in the state of Qatar

ObjectiveTo investigate the prevalence of intracerebral hemorrhage (ICH) using stroke database from the main tertiary hospital in Qatar (Hamad General Hospital) over the period of Dec 2013 to Oct 2017. MethodsThe prevalence of ICH was calculated based on age groups and ethnicity (Qatari nationals, non-Qatari Arab, South east Indian (SI) and Far East Asians (FE)). Thirty-day case fatality rate, poor clinical outcome at discharge (modified Rankin scale (mRS):3−6) and poor long-term outcome (mRS at 90 days: 3−6) were calculated per each age group sex and ethnicity. ResultThere were 653/4039 (16 %) with ICH. The median age was 53 (IQ range: 45–64) with a male/female ratio: 557/96 (85.3/14.7 %). The 30-day mortality rate was 14.7 % (96/653), poor outcome at discharge (mRS 3−6): 66.8 % (436/653) and poor long-term outcome (mRS 90 days:3−6) 50.1 % (199/397). The prevalence of ICH in Qatar was 24.9 per 100 000. The highest mortality rate was seen in the elderly (≥ 70 years old) (16/67 (23.9 %)) and young group (48/291 (16.5 %)).The most common ethnic group among our ICH population are the following: FE (40.59 per 100 000), Qatari (25.26 per 100 000) and SI ethnic group (24.97 per 100 000). In multiple logistic regression analysis only, old age (≥ 70 years old) was associated with 30 days mortality (adj OR: 2.51, 95 % CI: 1.14–5.54, P = 0.023). Similar regression analysis was also observed that age ≥ 70 years old (adj. OR: 4.18, 95 % CI: 1.27–13.77, P = 0.019), sex (male) (adj. OR: 0.21, 95 % CI: 0.08−0.56, P = 0.002), and ethnicity (SI vs Qatari: adj. OR: 4.08, 95 % CI: 1.28–12.92, P = 0.017); (FE vs Qatari: adj. OR: 2.22, 95 % CI: 0.65–7.67, P = 0.203) are statistically associated with poor outcome. ConclusionThe prevalence of ICH was high in the elderly and in the FE, Qatari, and SI ethnic group. Further studies are needed to better understand the differences in ICH prognosis in multiethnic groups.

Cerebral Microbleeds and Leukoencephalopathy in Critically Ill Patients With COVID-19.

We conducted this study to investigate the prevalence and distribution of cerebral microbleeds and leukoencephalopathy in hospitalized patients with coronavirus disease 2019 (COVID-19) and correlate with clinical, laboratory, and functional outcomes. We performed a retrospective chart review of 4131 COVID-19 positive adult patients who were admitted to 3 tertiary care hospitals of an academic medical center at the epicenter of the COVID-19 pandemic in New York City from March 1, 2020, to May 10, 2020, to identify patients who had magnetic resonance imaging (MRI) of the brain. We evaluated the MRIs in detail, and identified a subset of patients with leukoencephalopathy and/or cerebral microbleeds. We compared clinical, laboratory, and functional outcomes for these patients to patients who had a brain MRI that did not show these findings. Of 115 patients who had an MRI of the brain performed, 35 (30.4%) patients had leukoencephalopathy and/or cerebral microbleeds. Patients with leukoencephalopathy and/or cerebral microbleeds had neuroimaging performed later during the hospitalization course (27 versus 10.6 days; P<0.001), were clinically sicker at the time of brain MRI (median GCS 6 versus 14; P<0.001), and had higher peak D-dimer levels (8018±6677 versus 3183±3482; P<0.001), lower nadir platelet count (116.9±62.2 versus 158.3±76.2; P=0.03), higher peak international normalized ratio (2.2 versus 1.57; P<0.001) values when compared with patients who had a brain MRI that did not show these findings. They required longer ventilator support (34.6 versus 9.1 days; P<0.001) and were more likely to have moderate and severe acute respiratory distress syndrome score (88.6% versus 23.8%, P<0.001). These patients had longer hospitalizations (42.1 versus 20.9 days; P<0.001), overall worse functional status on discharge (mRS 5 versus 4; P=0.001), and higher mortality (20% versus 9%; P=0.144). The presence of leukoencephalopathy and/or cerebral microbleeds is associated with a critical illness, increased mortality, and worse functional outcome in patients with COVID-19.

Predictors of mortality for patients with COVID-19 and large vessel occlusion.

BackgroundThis study evaluates the mortality risk of patients with emergent large vessel occlusion (ELVO) and COVID-19 during the pandemic.MethodsWe performed a retrospective cohort study of two cohorts of consecutive patients with ELVO admitted to a quaternary hospital from March 1 to April 17, 2020. We abstracted data from electronic health records on baseline, biomarker profiles, key time points, quality measures and radiographic data.ResultsOf 179 patients admitted with ischemic stroke, 36 had ELVO. Patients with COVID-19 and ELVO had a higher risk of mortality during the pandemic versus patients without COVID-19 (OR 16.63, p = 0.004). An age-based sub-analysis showed in-hospital mortality in 60% of COVID-19 positive patients between 61-70 years-old, 66.7% in between 51-60 years-old, 50% in between 41-50 years-old and 33.3% in between 31-40 years old. Patients that presented with pulmonary symptoms at time of stroke presentation had 71.4% mortality rate. 27.3% of COVID-19 patients presenting with ELVO had a good outcome at discharge (mRS 0-2). Patients with a history of cigarette smoking (p = 0.003), elevated d-dimer (p = 0.007), failure to recanalize (p = 0.007), and elevated ferritin levels (p = 0.006) had an increased risk of mortality.ConclusionPatients with COVID-19 and ELVO had a significantly higher risk for mortality compared to COVID-19 negative patients with ELVO. A small percentage of COVID-19 ELVO patients had good outcomes. Age greater than 60 and pulmonary symptoms at presentation have higher risk for mortality. Other risk factors for mortality were a history of cigarette smoking, elevated, failure to recanalize, elevated d-dimer and ferritin levels.

A study on elevation of troponin I in ischemic stroke as an independent prognostic marker of outcomes

Background: Stroke is the second leading cause of death worldwide, comprising approximately 10% of all deaths. A substantial number of stroke patients have elevated cardiac troponin levels and are associated with poorer prognosis.&#x0D; Methods: This was a prospective observational study conducted for 1 year at Tribhuvan University Teaching Hospital, in which 101 acute ischemic stroke patients were enrolled. Data included vital signs, laboratory parameters, and clinical features evaluated at the time of admission. The National Institute of Health Stroke Scale (NIHSS) and modified Rankin scale (mRS) were used to assess stroke severity and outcomes.&#x0D; Results: Elevated troponin I (&gt; 0.034 ng/mL) was observed in eight (7.9%) patients. Compared to patients with normal troponin I, patients with elevated troponin I were older(mean age 61vs 59.68 years), had higher blood glucose( 10.6 vs. 7.04 mmol/L), higher median white blood cells( 9.3 vs. 8.9 1,000/m3) and creatinine levels(119.5 μmol/L vs. 95.9 μmol/L), higher mean NIHSS scores on admission(16 vs. 8.6), and discharge(14.5 vs. 6.8), higher median mRS scores( 4.13 vs. 1.8) at discharge(p&lt;0.001). Poor outcomes were observed in 34(33.66%) patients of 101 patients and death occurred in five (4.9%) patients. Patients with abnormal troponin I had poorer outcomes than normal troponin I level patients (p=&lt;0.001) and significantly higher deaths (p=0.006). Univariate analysis of continuous variables revealed that patients with poor outcomes compared to good outcomes had higher troponin levels (0.029 vs. 0.013 ng/mL, p=0.001), creatinine levels (113.5 vs. 89.8μmol/L, p=0.007), NIHSS score on admission (13.4 vs. 5.10, p&lt;0.001),discharge (12.4 vs. 5.1, p&lt;0.001), and higher mRS scores at discharge (3.71 vs. 1.16, p&lt;0.001).Multiple logistic regression analysis revealed that NIHSS score on admission&gt;13(OR 15.902; 95%CI[3.65-69.28],p=&lt;0.001) and abnormal troponin I level, troponin I&gt;0.029 ng/mL (odds ratio[OR]:28.451; 95% CI[2.785-290.6],p=0.005) were significant predictors of poor outcomes. Significant predictor of in hospital mortality only included troponin I level &gt;0.04 ng/mL (0R 0.071; 95% CI [0.005-1.037], P=0.05).&#x0D; Conclusion: Troponin I provide better information than age and other laboratory parameters in the prediction of outcomes of stroke. Elevation of troponin I during acute stroke is a strong predictor of both poor outcomes and in-hospital mortality.

Distribution and predictive performance of the temporal phase of dynamic spot sign appearance in acute intracerebral hemorrhage.

Dynamic CT angiography (dCTA) contrast extravasation, known as the "dynamic spot sign", can predict hematoma expansion (HE) in intracerebral hemorrhage (ICH). Recent reports suggest the phase of spot sign appearance is related to the magnitude of HE. We used dCTA to explore the association between the phase of spot sign appearance and HE, clinical outcome, and contrast extravasation rates. We assessed consecutive patients who presented with primary ICH within 4.5 hours from symptom onset who underwent a standardized dCTA protocol and were spot sign positive. The independent variable was the phase of spot sign appearance. The primary outcome was significant HE (either 6 mL or 33% growth). Secondary outcomes included total absolute HE, mortality, and discharge mRS. Mann-Whitney U, Fisher's exact test, and logistic regression were used, as appropriate. Of the 35 patients with spot signs, 27/35 (77%) appeared in the arterial phase and 8/35 (23%) appeared in the venous phase. Thirty patients had follow-up CT scans. Significant HE was seen in 14/23 (60.87%) and 3/7 (42.86%) of arterial and venous cohorts, respectively (p = 0.67). The sensitivity and specificity in predicting significant HE were 82% and 31% for the arterial phase and 18% and 69% for the venous phase, respectively. There was a non-significant trend towards greater total HE, in-hospital mortality, and discharge mRS of 4-6 in the arterial spot sign cohort. Arterial spot signs demonstrated a higher median contrast extravasation rate (0.137 mL/min) compared to venous spot signs (0.109 mL/min). Our exploratory analyses suggest that spot sign appearance in the arterial phase may be more likely associated with HE and poorer prognosis in ICH. This may be related to higher extravasation rates of arterial phase spot signs. However, further studies with larger sample sizes are warranted to confirm the findings.

Risk of Intracranial Hemorrhage and Short-Term Outcome in Patients with Minor Head Injury

To examine the occurrence of traumatic intracranial hemorrhage (tICH) and outcome in patients with minor head injury and assess the probable risk factors. Patients with minor head injury who visited our hospital from January 2015 to July 2017 were registered consecutively, and enrolled patients were aged ≥18 years, visited within 24 hours of the injury, and had a Glasgow Coma Scale score of 15 at outpatient clinic or before the injury. Of the 1122 enrolled patients, 55 (4.9%) had tICH. An antiplatelet agent was administered in 114 patients, an anticoagulant agent was administered in 49 patients, and none of them were administered in 948 patients. A multivariate analysis of tICH identified it as a risk factor, showing significant difference between antiplatelet medication (P= 0.0312), fall from stairs (P= 0.0057), traffic accident (P= 0.0117), neurologic symptoms (P= 0.0091), and modified Rankin Scale (mRS) score before trauma (P < 0.0001). We also analyzed association of enlargement of tICH with different parameters and only anticoagulant medication indicated an increased risk (P= 0.0005). Thirty patients (2.6%) were dependent or died at discharge (mRS 3-6). The mRS score before trauma (P < 0.0001), tICH (P < 0.0001), spinal injury (P < 0.0001), and enlargement of intracranial hemorrhage (P= 0.0008) indicated an increased probability of morbidity (mRS 3-6) in multivariate analysis. Antiplatelet and anticoagulant medications were risk factor for tICH and enlargement of tICH in patients with minor head injury, respectively. A pretrauma condition of disability/dependence is an important risk factor for tICH and outcome.