Discharge National Institutes Of Health Stroke Scale Research Articles

Abstract TMP36: Improve Patient Outcomes In A Specialized Neurological Emergency Department

Improved Patient Outcomes In A Specialized Neurological Emergency Department Introduction: Stroke is now the fifth leading cause of death in the U.S., but remains the leading cause of long term disability. Target: Stroke helps hospitals achieve improved stroke outcomes through reduced door-to-needle times for eligible stroke patients. Phase III of the American Heart Association/American Stroke Association initiative set more aggressive targets for timely treatment with IV alteplase. To achieve rapid treatment times and better patient outcomes, we created a neurologic emergency department (Neuro ED). Neuro ED hours are staffed by emergency physicians with specialized neuroscience training and administer IV alteplase independently, compared to the traditional ED (TED) where emergency providers consult neurology. Methods: This is a retrospective observational study from 2019-2021 comparing outcomes of acute ischemic stroke patients who received IV alteplase following implementation of the Neuro ED compared to a TED. The following metrics were calculated for each patient: Door to Needle times (DTN), door to CT times (DTCT), and pre and post National Institute of Health Stroke Scale (NIHSS) Results: 74 patients were treated in the Neuro ED and 45 patients were treated in the TED. Average DTN times in the Neuro ED were 27 minutes compared to 65 minutes in the TED. Patients treated in the Neuro ED achieved DTN times of 45 min or less 87% of cases, while only 24% of the time in the TED. Patients treated in the Neuro ED achieved DTN times of 30 min or less 65% of cases, with only 4% of cases in the TED. Average DTCT times in the Neuro ED were 8 minutes faster than the TED. No differences in admission NIHSS were found with an average of 8.75, but a significant improvement was found in discharge NIHSS. Average discharge NIHSS was 3.8 for Neuro ED stroke patients compared with 5.6 for TED patients (p<0.001). Conclusion: Implementation of a Neuro ED led to swift management and improved symptoms for stroke patients. A dedicated Neuro ED is highly effective in improving DTN times, DTCT times, and overall stroke outcomes.

Computed Tomography Perfusion Deficit as an Indicator for Reperfusion in Large-vessel Occlusions with Low National Institutes of Health Stroke Scale Scores in Acute Ischaemic Stroke: A Retrospective Review

Background: Endovascular thrombectomy (EVT) has proven to be successful in acute ischaemic stroke (AIS) with a National Institutes of Health Stroke Scale (NIHSS) score of >8, but remains controversial in AIS with an NIHSS score of <8. This study evaluated computed tomography (CT) perfusion indicators for EVT in large-vessel occlusion (LVO) ischaemic strokes with low NIHSS scores. Methods: We retrospectively reviewed data from 49 patients with AIS, LVO and an NIHSS score of <8 who received medical therapy (n=27), or rescue (n=10) or urgent (n=12) thrombectomy. Therapy decision was made from clinical course and perfusion imaging. The urgent group underwent EVT in <6 hours. The rescue group underwent EVT in >6 hours due to increasing NIHSS scores; this included patients who presented after 6 hours and underwent urgent EVT. Modified Rankin scores were obtained at 3 months to assess outcomes. Results: More patients in the urgent group (91.7%) had a discharge NIHSS improvement (>1) compared with the rescue (50.0%) and medical (51.9%) groups (p=0.02). The urgent group displayed thrombolysis in cerebral infarction (TICI) scores of 2b/3 in 100% of patients, whereas the rescue group displayed TICI scores of 2b/3 in 80% and 1/2a in 20% (p=0.076). The perfusion core (cerebral blood flow [CBF] <30%) was not different between the groups (2.1 cm3, 1.0 cm3 and 9.2 cm3, for urgent, rescue and medical groups, respectively). The perfusion penumbra (time to max [Tmax] >6 s) and mismatch (Tmax minus CBF) were significantly larger for the urgent and rescue groups. Penumbra volume was 80.1 cm3, 107.5 cm3 versus 50.6 cm3 (p=0.011), and mismatch was 78.0 cm3, 106.5 cm3 versus 41.5 cm3 (p=0.002) for urgent and rescue thrombectomy versus medical therapy, respectively. Conclusion: The biggest driver of urgent reperfusion was a larger penumbra seen on CT perfusion, which appeared to show better outcomes in NIHSS scores at discharge without any difference in 3-month outcomes graded by modified Rankin scores. Our data suggest that larger perfusion deficits on CT imaging may serve as a tool for patient selection for EVT in LVO with an NIHSS score of <8 and should be investigated further.

Endovascular thrombectomy for acute ischemic stroke in patients with cancer: a propensity-matched analysis

BackgroundThere is a paucity of data and a belief that endovascular thrombectomy (EVT) has low efficacy for acute ischemic stroke (AIS) in patients with cancer. We aimed to critically compare...

Third Ventricle Volume Predicts Functional Outcome in Chronic Subdural Hematoma.

There is a lack of evidence demonstrating the utility of computed tomography (CT) to predict chronic subdural hematoma (CSDH) clinical outcomes. We aim to analyze the role of tomographic volumetric analysis in patients with CSDH. We performed a retrospective study of patients undergoing burr-hole craniostomy (BHC) for CSDH over five years at a tertiary care center. Degree of midline shift, radiographic density, subdural hematoma volume, acute blood volume, and third ventricle (3VV) and fourth ventricle (4VV) volume were estimated using semiautomatic segmentation of preoperative CT. Postoperative functional outcome was measured by two endpoints: National Institute of Health Stroke Scale (NIHSS) at discharge and short-term modified Rankin Scale (mRS) at 6-week follow-up. Univariate and multivariate analyses were performed using nonparametric tests. Discriminative capacity and optimal thresholds of independent variables were calculated by means of receiving-operative curves (ROC). A total of 79 patients were included for analysis with a median age of 78.5years. Greater preoperative 3VV independently correlated with poor discharge NIHSS (p=.01) and short-term mRS (p=.03). A cutoff value of 0.545mL demonstrated the highest sensitivity (77.1%) and specificity (88.8%) with an odds ratio for an mRS functional dependence of 9.29 (p=.001). Greater preoperative tomographic 3VV independently prognosticates poor discharge NIHSS and 6-week mRS. A threshold 3VV of 0.545mL can be used to identify patients at higher risk of being dependent at first protocolized follow-up.

Higher uric acid is associated with better discharge recovery and short-term outcome in stroke patients treated with thrombolysis.

Uric acid (UA) possesses antioxidant features and potential neuroprotective effects. However, conflicting results regarding the association between serum uric acid (SUA) levels and the prognosis of stroke have been obtained. We aimed to assess whether SUA is related to discharge recovery and short-term outcomes in patients who underwent thrombolysis therapy. We recruited 393 consecutive patients who were diagnosed with acute ischaemic stroke (AIS) and treated with thrombolysis. The demographic information, including sex and age, was collected. Haematology tests, including SUA, fasting plasma glucose (FPG), and blood lipid parameters, were performed under fasting conditions the morning after admission. The modified Rankin Scale (mRS) was used to assess the functional outcome of patients at discharge and 3 months after onset. A negative correlation was observed between the levels of SUA and the National Institute of Health Stroke Scale (NIHSS) score at discharge (r = - 0.171, P = 0.003). Additionally, a positive correlation was observed between the levels of SUA and the difference between the baseline NIHSS and discharge NIHSS (r = 0.118, P = 0.032). The levels of SUA in the patients with good outcomes (353.76 ± 93.05) were higher than those in the patients with poor outcomes (301.99 ± 92.24; P = 0.015) at 3 months. The multivariate logistic regression analysis demonstrated that a higher SUA level (odds ratio 0.988, 95% confidence interval 0.985-0.991, P = 0.002) was an independent predictor of a good outcome at 3 months. Higher SUA levels were associated with better discharge recovery and 3-month outcomes in patients with ischaemic stroke who received thrombolysis.

Prediction of Infarct Growth and Neurological Deterioration in Patients with Vertebrobasilar Artery Occlusions.

We aimed to identify predictors of infarct growth and neurological deterioration (ND) in vertebrobasilar occlusions (VBOs) with a focus on clinical-core mismatch. From 2010 to 2018, VBO patients were selected from a university hospital registry. In total, 138 VBO patients were included. In these patients, a posterior circulation Alberta Stroke Program Early CT score (PC-ASPECTS) less than 6 was associated with futile outcome. Within patients with feasible cores, a decrease in PC-ASPECTS score of 2 or more on follow-up imaging was classified as infarct growth and could be predicted by a National Institutes of Health Stroke Scale (NIHSS) mental status subset of 1 or higher (odds ratio (OR): 3.34, 95% confidence interval (CI) (1.19–9.38), p = 0.022). Among the 73 patients who did not undergo reperfusion therapy, 13 patients experienced ND (increase in discharge NIHSS score of 4 or more compared to the initial presentation). Incomplete occlusion (vs. complete occlusion, OR 6.17, 95% CI (1.11–34.25), p = 0.037), poorer collateral status (BATMAN score, OR: 1.91, 95% CI (1.17–3.48), p = 0.009), and larger infarct cores (PC-ASPECTS, OR: 1.96, 95% CI (1.11–3.48), p = 0.021) were predictive of ND. In patients with VBO, an initial PC-ASPECTS of 6 or more, but with a decrease in the mental status subset of 1 or more can predict infarct growth, and may be used as a criterion for clinical-core mismatch. ND in VBO patients presenting with milder symptoms can be predicted by incomplete occlusion, poor collaterals, and larger infarct cores.

Intra-Arterial Glycoprotein IIb/IIIa Inhibitor Treatment for Symptomatic Intracranial Atherosclerotic Stenosis Presenting as Large Vessel Occlusions.

IntroductionThere is no consensus on the optimal treatment for acute ischemic stroke (AIS) large vessel occlusions (LVOs) or near-occlusions with underlying intracranial atherosclerotic stenosis (ICAS). We report the first American series using intra-arterial (IA) glycoprotein IIb/IIIa inhibitors (GPIs) as a stand-alone revascularization technique for ICAS presenting with large vessel ischemic syndromes.MethodsRecords at two centers of 140 patients presenting with AIS undergoing stroke intervention from January 2017 to June 2019 were retrospectively reviewed. Patients treated with IA GPIs were identified, and baseline factors, imaging, procedural characteristics, hospital course, and outcomes were collected. Six patients with ICAS underlying their acute symptomatic near occlusion or LVO were treated with IA GPI. Four near-occlusions were treated with IA GPI as the first-line therapy, while two LVOs were treated with IA GPI as an adjunct therapy to thrombectomy.ResultsThe mean age was 61.3 years (range 36-79), presentation National Institute of Health Stroke Scale (NIHSS) was 10 (4-18), time from last seen well to treatment was 434.5 minutes (164-1290), and time from groin puncture to revascularization was 67.3 minutes (26-94). Three patients received intravenous (IV) tissue plasminogen activator (tPA), and all patients received an IA weight-based GPI infusion. Five patients had thrombolysis in cerebral ischemia (TICI) 3, and one patient had TICI 2b. The mean discharge NIHSS was 2.5 (0-8). The mean modified Rankin scale was 1.3 (range 0-4) at discharge and .8 at three months. No patients had a postprocedural symptomatic hemorrhage.ConclusionOur results highlight the utility of IA GPI administration as the first-line therapy for symptomatic ICAS near occlusions or as a rescue technique after failed thrombectomy for LVO patients suspected of underlying ICAS.

Hypoxia-inducible factor-1α in acute ischemic stroke: neuroprotection for better clinical outcome

BackgroundHypoxia-inducible factor-1α (HIF-1α) is a transcription factor which maintains cellular homeostasis in response to hypoxia. It can trigger apoptosis while stimulating angiogenesis process and decrease neurological deficit after an ischemic stroke. Up until now, this protein complex has not been widely investigated especially in stroke patient. ObjectiveHere, we examined the potential of HIF-1α as a marker for neuroplasticity process after ischemic stroke. MethodsSerum HIF-1α were measured in acute ischemic stroke patients. National Institute of Health Stroke Scale (NIHSS) were assessed on the admission and discharge day (between days 7 and 14). Ischemic stroke divided into 2 groups: large vessel disease (LVD, n = 31) and small vessel disease (SVD, n = 27). Statistical significances were calculated with Spearman rank test. ResultsA total of 58 patients, 31 with large artery atherosclerosis LVD and 27 with small vessel disease (SVD) were included in this study. HIF-1α level in LVD group was 0.5225 ± 0.2459 ng/mL and in SVD group was 0.3815 ± 0.121 ng/mL. HIF-1α was higher (p = 0.004) in LVD group than in SVD group. The initial NIHSS score in LVD group was 15.46 ± 2.61 and discharge NIHSS score was 13.31 ± 3.449. Initial NIHSS score in SVD group was 6.07 ± 1.82 and the discharge NIHSS was 5.703 ± 1.7055. In both SVD and LVD group, HIF-1α were significantly correlated with initial NIHSS (both p < 0.001) and discharge NIHSS (p < 0.0383 r = 0.94, p < 0.001, r = 0.93, respectively). ConclusionsHIF-1α has a strong correlation with NIHSS and it may be used as predictor in acute ischemic stroke outcome.

Effect of Newer Generation Anticonvulsant Prophylaxis on Seizure Incidence After Spontaneous Intracerebral Hemorrhage

The role of prophylactic antiepileptic drugs (AEDs) in preventing seizures and/or improving the outcomes after intracerebral hemorrhage (ICH) has remained controversial. The current guidelines have recommended against AED prophylaxis. However, these recommendations were based on older studies that had primarily used phenytoin as the AED of choice. Newer medications, such as levetiracetam, have yet to be extensively studied. We performed a retrospective review of patients with ICH from 2010 to 2015. The patient demographic data, seizure data, and outcomes were collected. The results were analyzed using descriptive statistics, binary logistic regression, and quantile regression. The primary outcome was seizure incidence. A total of 360 patients with a median age of 70 years had met the inclusion criteria. Of the 360 patients, 30 (8.3%) had had recorded seizure events, 54% were men, and 81% had a history of hypertension. The median admission National Institutes of Health stroke scale (NIHSS) score was 7 (interquartile range [IQR], 14), and the median discharge NIHSS score was 5.0 (IQR, 13). The median hematoma size was 7.1 mL (IQR, 13 mL), and 143 patients (40%) had had cortical involvement. Of the 360 patients, 273 (76%) had received prophylaxis and 87 (24%) had not. After adjustment for the admission NIHSS and the presence of cortical involvement, the rate of new seizure events after ICH remained significantly lower for the patients who had received AED prophylaxis (adjusted odds ratio, 0.28; 95% confidence interval, 0.11-0.71; P= 0.008). The administration of, predominantly, levetiracetam for AED prophylaxis after ICH reduced the odds of new seizure events, independently of the admission NIHSS score and the presence of cortical involvement.

Acute Neurological Deterioration in Large Vessel Occlusions and Mild Symptoms Managed Medically.

Background and Purpose- It is unclear which factors predict acute neurological deterioration in patients with large vessel occlusion and mild symptoms. We aim to evaluate the frequency, timing, and potential predictors of acute neurological deterioration ≥4 National Institutes of Health Stroke Scale (NIHSS) points in medically managed patients with large vessel occlusion and mild presentation. Methods- Single-center retrospective study of patients with consecutive minor stroke (defined as NIHSS score of ≤5 on presentation) and large vessel occlusion from January 2014 to December 2017. Primary outcome was acute neurological deterioration ≥4 NIHSS points during the hospitalization. Secondary outcomes included ΔNIHSS (defined as discharge minus admission NIHSS score). Results- Among 1133 patients with acute minor strokes, 122 (10.6%) had visible occlusions on computed tomography angiography/magnetic resonance angiography. Twenty-four (19.7%) patients had ≥4 points deterioration on NIHSS at a median of 3.6 (1-16) hours from arrival. No clinical or radiological predictors of acute neurological deterioration ≥4 NIHSS points were observed on multivariable analysis. Rescue endovascular thrombectomy was performed more often in the ones with acute neurological deterioration ≥4 NIHSS points compared with patients with no deterioration (54% versus 0%; P<0.001). Acute neurological deterioration ≥4 NIHSS points was associated with ΔNIHSS ≥4 points (33% versus 4.9%; P<0.01) and a trend toward lower independence rates at discharge (50% versus 70%; P=0.06) compared with the group with no deterioration. In patients with any degree of neurological worsening, patients who underwent rescue thrombectomy were more likely to be independent at discharge (73% versus 38%; P=0.02) and to have a favorable ΔNIHSS (-2 [-3 to 0] versus 0 [-1 to 6]; P=0.05) compared with the ones not offered rescue thrombectomy. Conclusions- Acute neurological deterioration ≥4 NIHSS points was observed in a fifth of patients with large vessel occlusion and mild symptoms, occurred very early in the hospital course, impacted functional outcomes, and could not be predicted by any of the studied clinical and radiological variables. Rescue thrombectomy was associated with improved clinical outcomes at discharge in patients with neurological deterioration.

Low-dose statin pretreatment improves function and prognosis of recurrent ischemic stroke patients.

Background:Statins are effective in improving the prognosis of stroke patients. In clinical practice, low-dose statins are often administered to stroke patients in Asian countries but their effects on the prognosis of recurrent ischemic stroke patients are still unclear.Methods:Data of consecutive recurrent ischemic stroke patients were prospectively collected. The National Institutes of Health Stroke Scale (NIHSS) of admission and discharge and the modified Rankin scale (mRs) of 90 days after stroke onset were adopted to evaluate primary outcomes. Secondary outcomes included the subgroup analysis.Results:Among 219 patients (mean age 65.41 ± 11.58 years), 150 (68.5%) were male. The low-dose statin group had a higher percentage of milder stroke at admission (p < 0.001) and discharge (p < 0.001), and favorable functional outcome at 90 days (p < 0.001). Univariable regression analysis showed that the use of low-dose statins was inversely associated with higher discharge NIHSS [odds ratio (OR) = 0.36, p = 0.009] and higher mRs at 90 days (OR = 0.230, p < 0.001). Multivariable logistic regression analysis revealed that low-dose statins also had a significantly inverse association with higher mRs at 90 days (OR = 0.098, p = 0.049). According to subgroup analysis, a significant effect was found in the good-persistency subgroup (NIHSS score at discharge: OR = 0.051, p = 0.004; mRs score at 3 months: OR = 0.053, p = 0.005), but not in the poor-persistency subgroup.Conclusion:Low-dose statin pretreatment alleviated stroke severity and improved functional outcomes of recurrent stroke patients.

Endovascular management of acute large vessel occlusion stroke in pregnancy is safe and feasible

IntroductionStroke is a leading cause of adult death and disability. Although acute ischemic stroke (AIS) in pregnancy is rare, it has devastating consequences on the life of the mother and...

Pre-thrombectomy intravenous thrombolytics are associated with increased hospital bills without improved outcomes compared with mechanical thrombectomy alone

ObjectiveTo investigate whether significant differences exist in hospital bills and patient outcomes between patients who undergo endovascular thrombectomy (EVT) alone and those who undergo EVT with pretreatment intravenous tissue plasminogen...

Initial National Institute of Health Stroke Scale to Early Predict the Improvement of Swallowing in Patients with Acute Ischemic Stroke

Objectives: To study the applicability of National Institutes of Health Stroke Scale (NIHSS) in early predicting the prognosis of poststroke dysphagia in an acute ward. Methods: This is an observational retrospective cohort study including adult patients with ischemic stroke. Patients with various factors affecting swallowing were excluded to obtain a representative sample of 165 patients. The main outcome measure was the improvements of oral intake function. Results: The scores of facial palsy (NIHSS item 4) (odds ratio [OR]: 0.484, 95% confidence interval [CI]: 0.279-0.838, P = .0096] and language/aphasia (NIHSS item 9) (OR: 0.562, 95% CI: 0.321-0.982, P = .0430) demonstrated significantly negative effects on the early improvement of dysphagia. Moreover, the improved patients had a 4.14-fold (95% CI: 2.53-11.23, P = .005) increased odds of returning home compared with nonimproved patients. Conclusions: Our findings provide evidence that early improvement of poststroke dysphagia was significantly associated with a favorable discharge destination and NIHSS items of facial palsy and language/aphasia can be used at the onset of stroke to identify dysphagic patients at risk of achieving limited improvement. These findings provide valuable prognostic indicators for clinicians to make a precise outcome prediction at very early stage.

Role of the intact hemisphere in determining the rehabilitation potential in the acute period of ischemic stroke: a diffusion and perfusion model

The promising approaches to determining the rehabilitation potential of ischemic stroke (IS) patients include an assessment of the microstructural integrity of the brain matter by diffusion tensor imaging (DTI), the main indicator of which is fractional anisotropy (FA). The role of the intact hemisphere in the rehabilitation process after IS remains a controversial subject. The hypothesis for the investigation is that the development of a diffusion and perfusion model (DPM) based on the assessment of FA in combination with data on cerebral blood flow velocity (CBFV) and the impact of the focus will be able to predict the patients' neurological status by the end of the acute period of IS. Objective: to investigate the role of diffusion and perfusion characteristics of the intact hemisphere in determining the rehabilitation potential in the acute period of IS and to develop a prognostic DPM. Patients and methods. The investigation enrolled 100 patients with IS and 10 individuals in the control group. All the examinees underwent brain MRI. Perfusion-weighted sequence without bolus injection of a contrast agent was used to quantify CBFV in 10 areas according to the Alberta stroke program early CT score (ASPECTS). Values for FA in 10 areas of both hemispheres were calculated using DTI findings. Neurological and functional statuses were evaluated over time with the National Institute of Health Stroke Scale (NIHSS) and the modified Rankin scale. Results. The NIHSS score at discharge was associated with FA and CBFV in 4 and 6 of the 10 areas of the intact hemisphere, respectively. DPM for predicting the rehabilitation potential included the key parameters correlating with a discharge NIHSS score (in order of decreasing the significance): admission NIHSS value (r = 0.55; p < 0.001), the size of a focus (r = 0.42; p < 0.001), FA in the contralateral cingulum bundle FA (r = -0.28; p = 0.007), and CBFV in M2 white matter [r = -0.24; p = 0.025; R2 = 0.642; p(F) <0.001]. Conclusion. In addition to the NIHSS score at admission, the size of a focus, DPM values (FA in the contralateral cingulum bundle and CBFV in the white matter) allow prediction of the rehabilitation potential in IS.

Abstract TP111: Outcomes After thrombolysis of Acute Ischemic Stroke Patients With M2 Occlusion

Introduction: The American Heart Association Stroke Guidelines recommend intra-arterial therapy (IAT) for acute ischemic stroke with large vessel occlusions involving the internal carotid and proximal middle cerebral artery, but the role of IAT for M2 occlusions is unclear. We sought to report the outcomes of acute ischemic stroke patients with M2 occlusions who received intravenous tissue plasminogen activator (IVtPA). Methods: Among 322 acute ischemic stroke patients who received IVtPA from July 1, 2016 to July 1, 2017, we identified 23 patients (7%) with imaging-confirmed M2 occlusions. Two patients with M2 occlusions who underwent IAT were excluded. Data was abstracted on demographics, time of Last Known Normal (LKN), National Institutes of Health Stroke Scale (NIHSS), neuroimaging, clinical presentation, and 90-day modified Rankin Scale (mRS). Good outcome was defined as 90-day mRS of &lt; 2. Results: Among the 21 ischemic stroke patients who received IVtPA for M2 occlusions, the mean age was 64.3 years (range, 21 to 88) and 10 (48%) were male. IVtPA was administered from LKN at a mean 2.5 hours (range, 0.8 to 5.1). Most patients (90%) were transferred from outside facilities. Initial NIHSS prior to IVtPA was a mean of 11.2 (range, 3 to 29). All patients had CT angiogram which was done at a mean of 4.0 hours from LKN (range, 1.2 to 7) and showed 10 (48%) right-sided and 11 (52%) left-sided M2 occlusions. Most (20/21) had CT perfusion, which was done at a mean of 4.1 hours from LKN (range, 1.2 to 7.3) and all showed mismatch in the corresponding territory of the arterial occlusion. MRI brain was performed in 19/21 patients at a mean of 21 hours from LKN (range, 3 to 53) and restricted diffusion in the corresponding arterial territory was seen in 17 (89%). Discharge NIHSS was a mean of 8.1 (range, 0 to 24). Among 20 patients with 90-day mRS data available, good clinical outcome was seen in 7 (35%). Conclusions: Among acute ischemic stroke patients with M2 occlusions, good clinical outcome was seen in only 35%, despite receiving IVtPA. Further studies are warranted to investigate the potential role of IAT in improving the natural history of medically treated acute ischemic stroke with M2 occlusions.

Beneficial effects of pre-stroke statins use in cardioembolic stroke patients with atrial fibrillation: a hospital-based retrospective analysis.

IntroductionStatins are widely used in stroke patients. The AHA/ASA guidelines recommend aggressive statin therapy in atherosclerotic stroke patients. Their beneficial effects are due to both their hypolipemic and pleiotropic properties. The aim of this study was to establish potential benefits from statin use in ischemic stroke patients with the diagnosis of atrial fibrillation (AF).Material and methodsIschemic stroke patients with AF were enrolled in the study. Group I, the statin group (n = 181), consisted of patients who had been treated with statins before stroke. Group II, the non-statin group (n = 153), consisted of patients who had not received such treatment in the last year. In-hospital mortality and neurological deficit on admission and at discharge were analyzed using the National Institutes of Health Stroke Scale (NIHSS) score.ResultsPatients from the non-statin group had greater initial and discharge NIHSS scores (10 vs. 11.9, probability value p < 0.05; 7.6 vs. 9.5, p < 0.05 respectively). The improvement in NIHSS score was greater in the statin group (73.5% vs. 59.5%, p < 0.01). In-hospital mortality was more frequent in the non-statin group (9.9% vs. 18.3%, p < 0.05).ConclusionsDespite the predominant use of statins in atherothrombotic stroke patients, we demonstrated the beneficial effects of statins in cardioembolic stroke patients. Detailed cardiovascular screening for statin therapy should be carried out in all AF patients with regard to primary and secondary stroke prevention.

282 Impact of Emergency Medical Services Vehicle Use by Acute Ischemic Stroke Patients on Functional Outcomes: An Observational Study

Previous studies have documented the impact of emergency medical services (EMS) vehicle use on speedy thrombolytic treatment, but not on patient functional outcomes. We assessed the association of EMS use with likelihood and timeliness of intravenous (IV) thrombolytic treatment and functional outcomes at discharge and 90 days. Prospective observational study using Get With The Guidelines Stroke data on AIS patients with cerebrovascular imaging evidence, discharged 4/2016 to 10/2017 from a non-profit hospital’s primary stroke center unit in Columbia, South Carolina. Key outcomes of interest were: National Institutes of Health Stroke Scale (NIHSS) change from arrival to discharge (continuous variable), discharge disposition (discharged to home versus otherwise), and 90-day modified Rankin Scale, mRS 0-1 versus otherwise, (ascertained by phone calls to patients discharged from 4/2018 to 8/2017 within 75-105 days of discharge using a standardized script, supplemented by medical record data on neurology follow-up visits). Multiple logistic and linear regression analyses were used as appropriate. Of 1,166 total AIS discharges, 328 were excluded (transfer patients or hospice assigned pre-admission). Among 838 study-eligible patients, 52.4% were black, 72.2% arrived by EMS, mean admission NIHSS (available for 96.7% of patients) was 6.8 (±7.3; median 4.0, range 0 - 37), mean stroke-relevant comorbidities per patient 3.7 (±1.9), alteplase received 114 (13.6%), and 92 expired or assigned to hospice. Mean door to imaging (DTI) time was 98.8 minutes (±151.0; median 49), and mean door to needle (DTN) time for IV alteplase recipients, 46.2 minutes (±31.2; median 38.0). In bivariate analyses, EMS arrivals were older (mean age 70 years versus 63.6 for other transport), more severe (mean NIHSS 8.3 (±7.7) versus 2.9 (±3.7), more likely to have contraindications to alteplase, and had worse discharge outcomes. Adjusted for demographic and other factors, EMS use was highly associated with stroke severity (adjusted odds 4.1 for moderate stroke (NIHSS 6-15) versus mild stroke (NIHSS 0-5), and 12.3 for severe stroke (NIHSS>15), p<0.001). Adjusted for stroke severity, comorbidities, endovascular treatment and other relevant factors as appropriate, EMS arrival (relative to other transport) was associated with: 5-fold higher odds of IV alteplase, 88.5 minutes lower DTI (p<0.01; 57% reduction), and, among severe stroke patients, 5.7 points better improvement in discharge NHISS over admission NIHSS (all p<0.001). Insurance status and race were not significant factors in alteplase use, DTI or DTN. Discharge disposition was not significantly associated with arrival mode. 90-day mRS was ascertained for 430 patients (59.2% of eligible, despite 87.1% of eligibles fully pursued per protocol). The study lacked statistical power to assess EMS impact on 90-day mRS, given the effect magnitude of stroke severity on both EMS use and 90-day outcomes. However, discharge NIHSS accurately predicted 90-day mRS, (adjusted beta 0.20; score ranges of the 2 scales, 0-37 versus 0-6; model R2 = 0.42), supporting that EMS use may produce better long-term outcomes in severe stroke patients. This study breaks new ground, documenting a positive impact of EMS use on functional outcomes in severe stroke. Given evidence of equitable care regardless of insurance status/race at the study center, findings may be generalizable despite being a single-center observational study.

Baseline NIH Stroke Scale is an inferior predictor of functional outcome in the era of acute stroke intervention.

Background and aims Baseline National Institutes of Health Stroke Scale (NIHSS) scores have frequently been used for prognostication after ischemic stroke. With the increasing utilization of acute stroke interventions, we aimed to determine whether baseline NIHSS scores are still able to reliably predict post-stroke functional outcome. Methods We retrospectively analyzed prospectively collected data from a high-volume tertiary-care center. We tested strength of association between NIHSS scores at baseline and 24 h with discharge NIHSS using Spearman correlation, and diagnostic accuracy of NIHSS scores in predicting favorable outcome at three months (defined as modified Rankin Scale 0-2) using receiver operating characteristic curve analysis with area under the curve. Results There were 1183 patients in our cohort, with median baseline NIHSS 8 (IQR 3-17), 24-h NIHSS 4 (IQR 1-11), and discharge NIHSS 2 (IQR 1-8). Correlation with discharge NIHSS was r = 0.60 for baseline NIHSS and r = 0.88 for 24-h NIHSS. Of all patients with follow-up data, 425/1037 (41%) had favorable functional outcome at three months. Receiver operating characteristic curve analysis for predicting favorable outcome showed area under the curve 0.698 (95% CI 0.664-0.732) for baseline NIHSS, 0.800 (95% CI 0.772-0.827) for 24-h NIHSS, and 0.819 (95% CI 0.793-0.845) for discharge NIHSS; 24 h and discharge NIHSS maintained robust predictive accuracy for patients receiving mechanical thrombectomy (AUC 0.846, 95% CI 0.798-0.895; AUC 0.873, 95% CI 0.832-0.914, respectively), while accuracy for baseline NIHSS decreased (AUC 0.635, 95% CI 0.566-0.704). Conclusion Baseline NIHSS scores are inferior to 24 h and discharge scores in predicting post-stroke functional outcomes, especially in patients receiving mechanical thrombectomy.

Abstract WP26: The Effects of Blood Pressure Variation Within 24 Hours of Intracerebral Large Vessel Occlusion Mechanical Thrombectomy and Clinical Outcomes

Introduction: Mechanical thrombectomy (MT) is now the standard of care for acute intracranial large vessel occlusion (LVO). There are currently no established guidelines for post MT blood pressure parameters in LVO patients. Our study examines the influence of blood pressure fluctuation and variation within the first 24 hours on clinical outcomes in post MT LVO patients. Methods: A hospital based stroke registry retrospectively identified 111 consecutive patients undergoing MT for LVO (2012-2015). Blood pressure recordings within the 1st 24 hours post MT were analyzed: Maximum (Max), minimum, median and standard deviation (SD) of the systolic (SBP), diastolic (DBP) and mean arterial pressures (MAP) were calculated individually and as composite aggregates. Good outcomes were defined as National Institute of Health Stroke Scale (NIHSS) improvement of &gt;=10 at discharge and or discharge NIHSS&lt;=2 Poor outcomes were defined as post-MT intracerebral hemorrhagic (ICH) and mortality. Univariate (UV). and multivariate logistic regression (MV) were used to identify effect of blood pressure variation on good and poor outcomes. IBM-SPSS version 21 was used for data analysis. Results: On UV analysis a lesser degree of 24 hour post MT SBP (median 16, IQR (Inter Quartile Range) 13, 23 mmHg, p=0.03) and DBP (Median 10, IQR 8, 12 mmHg p .04) SD were associated with good outcome. Maximum SBP was associated with higher rates of mortality (median 188, IQR 174-195 mmHg, p=0.03) and ICH (median 179, IQR 167-196 mmHg, p=0.05). There is no statistically significant association between Post MT 24 hours DBP or MAP maximum, minimum, median and SD values with associated poor outcomes. On MV, SBP variance and maximum SBP were found to be significantly associated with good outcomes (Odds Ratio (OR) 1.09, 95%CI (Confidence interval) 1 - 1.2, p=0.04) and mortality (OR 1.02, 95%CI 1 - 1.004, p=0.02) respectively. Conclusion: Importance of proper blood pressure regulation within the 1st 24 hours of an LVO MT cannot be understated. To maintain good outcomes after MT, minimizing SBP SD becomes important. With the underlying premise of post cerebral ischemia induced vasomotor dysregulation, controlling Max SBP also decreases ICH and mortality. A prospective study is warranted to reinforce our findings.