Higher National Institutes Of Health Stroke Scale Research Articles

The effect of asymptomatic intracranial hemorrhage after mechanical thrombectomy on clinical outcome

Background and objectiveWhether asymptomatic intracranial hemorrhage (ICH) affects the clinical outcomes in patients with acute large vessel occlusion treated with mechanical thrombectomy (MT) remains unclear. This study aimed to address this uncertainty. MethodsWe retrospectively analyzed patients with acute ischemic stroke and internal carotid or middle cerebral (M1 segment) artery occlusion treated with MT between April 2011 and March 2021 at a single center. All patients had a premorbid modified Rankin scale (mRS) score ≤ 2 and an anterior circulation occlusion and underwent magnetic resonance imaging at admission. Asymptomatic ICH was defined as ICH without symptomatic ICH defined by the SITS-MOST criteria. A favorable outcome was defined as an mRS score ≤ 2 at 90 days after stroke onset. ResultsOur study included 349 patients; 62% were men, the median age was 76 [67–83] years, and the median National Institutes of Health Stroke Scale (NIHSS) score was 15 [8–21]. As determined via computed tomography, 103 (30%) patients had ICH (20 symptomatic and 83 asymptomatic). The favorable outcome rate was significantly lower for asymptomatic vs. no ICH (30% vs. 67%, p < 0.01). In a multivariate regression analysis, a high NIHSS score (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.02–1.10; p < 0.01) and low Alberta Stroke Program Early CT Score (OR, 0.78; 95% CI, 0.65–0.92; p < 0.01) were independent risk factors for ICH. ConclusionsAsymptomatic ICH is associated with poor clinical outcome at 90 days after stroke onset.

Indicators of cognitive impairment of varying severity in the acute period of ischemic stroke

To assess phenotype and identify biomarkers of cognitive impairment (CI) of varying severity in patients in the acute period of ischemic stroke (IS) based on the analysis of clinical and paraclinical indicators. Two hundred and forty patients with diagnosed IS and presence of CI were examined. Depending on the scores on the Montreal Cognitive Assessment Scale, patients were divided into two groups: group 1 (n=182) with mild CI, group 2 (n=58) with dementia. On admission, stroke severity according to the National Institutes of Health Stroke Scale (NIHSS), activities of daily living assessed by the Barthel Scale and patient independence assessed by the modified Rankin Scale (mRS) were determined. Neuropsychological examination was performed on day 14 and included investigation of episodic memory, executive functions, speech, gnosis, praxis, and the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) parameters. Immunological diagnostics included a study of the concentration of cytokines of various groups (interleukin (IL)-1b, IL-6, IL-16, granulocyte-macrophage colony-stimulating factor (GM-CSF), chemokines CXCL10, CXCL11, CXCL9, tumor necrosis factor α (TNFα)). Neuroimaging parameters were assessed using brain MRI data with verification of the STRIVE criteria and the medial temporal lobe atrophy scale (MTA). The standard application software package SPSS Statistics, Pandas and SciPy libraries were used for statistical analysis. Patients of group 2 had lower scores in all cognitive domains with the greatest reduction in perception, constructive praxis, semantic information processing and mnestic function. These analyses revealed a higher degree of IQCODE, prevalence of features corresponding to STRIVE/MTA criteria in patients of group 2, while patients of group 1 had higher NIHSS and mRS scores. When serum concentrations of cytokines were assessed, patients of group 1 showed higher concentrations of IL-1b, IL-6, GM-CSF and TNFα, while group 2 patients had higher concentrations of cytokine CXCL10. The presence of pre-stroke CI, baseline indicators of the patient's functional status, neuroimaging parameters of MTA/STRIVE and age are reflected in the structure and severity of cognitive deficit in the acute period of IS. Investigation of the role of interleukins, GM-CSF, TNFα and CXCL10 in the pathogenesis of IS and their association with the progression of post-stroke CI requires further studies with a larger sample size and longer follow-up period.

Efficacy and Safety of Human Urinary Kallidinogenase for Acute Ischemic Stroke: A Retrospective Single-Center Study.

The aim of this study was to investigate the outcomes of human urinary kallidinogenase (HUK) after recombinant tissue-type plasminogen activator treatment in patients with acute ischemic stroke (AIS). In this retrospective study conducted from December 2018 to August 2020, 313 patients with AIS patients who received recombinant tissue-type plasminogen activator treatment were enrolled. Among them, 148 patients received basic therapy, and 165 patients received HUK treatment. Demographics and clinical characteristics were analyzed after treatment, and patients were monitored for stroke recurrence for 12 months. National Institute of Health Stroke Scale (NIHSS) and modified Rankin Scale scores were used to assess the efficacy of treatment. Logistic regression analysis was used to identify risk factors for recurrence. There were no differences in baseline clinical characteristics between the 2 groups in the database. After 14 days of treatment, the HUK group had significantly lower NIHSS and modified Rankin Scale scores than the control group ( P <0.01). The recurrence rates in the HUK and control groups were 12.84% and 21.82%, respectively, with patients treated with HUK having better outcomes ( P <0.001). Logistic analysis indicated that high homocysteine levels and high NIHSS scores at diagnosis were risk factors for AIS recurrence. In addition, HUK treatment was found to reduce the risk of recurrence. Treatment with HUK after intravenous thrombolysis can significantly improve the neurological function of AIS patients and reduce stroke recurrence.

Analysis of risk factors for pulmonary infection in acute ischemic stroke patients following intravenous thrombolysis with alteplase.

To identify the risk factors for pulmonary infection in acute ischemic stroke patients treated with intravenous thrombolysis using alteplase. A retrospective analysis was conducted on 110 acute ischemic stroke patients who received intravenous alteplase thrombolysis between January 2019 and November 2022. The patients were categorized into a pulmonary infection group (40 cases) and a non-infection group (70 cases). Multivariate logistic regression analysis identified the following independent risk factors for pulmonary infection: age, National Institutes of Health Stroke Scale (NIHSS) score at admission, underlying lung disease, hypertension, mechanical ventilation, aspiration, confusion, and elevated C-reactive protein (CRP) levels (all P<0.05). The sensitivity and specificity of CRP ifor predicting pulmonary infection were 88.57% and 75.00%, respectively. The NIHSS score demonstrated a sensitivity of 87.14% and a specificity of 70.00%. Further stratification of patients into a good prognosis group (75 cases) and a poor prognosis group (35 cases) revealed that high NIHSS scores at admission, increased fibrinogen (FIB) levels, a thrombolysis window exceeding 3 hours, and concurrent pulmonary infection were independent risk factors for poor prognosis. The area under the ROC curve for NIHSS in predicting prognosis was 0.890, and for FIB, it was 0.854 (P<0.001). The sensitivity and specificity of NIHSS for predicting poor prognosis were 89.33% and 82.86%, respectively, while for FIB, they were 84.00% and 82.86%. These findings indicate that factors such as age, NIHSS score, underlying lung disease, hypertension, and elevated CRP levels significantly contribute to the risk of pulmonary infection in acute ischemic stroke patients. Clinicians should closely monitor these values to manage the risk of pulmonary infection effectively.

Repeated intravenous thrombolysis in recurrent ischemic stroke within 3 months: a systematic review

BackgroundRepeated intravenous thrombolysis (RIVT) within 3 months is an off-guideline therapy, however, may be an effective and safe way to treat early recurrent ischemic stroke. This study was conducted to assess the potential influencing factors on the efficacy and safety of RIVT in recurrent ischemic stroke within 3 months and to explore the strategy of RIVT within 3 months.MethodsPubMed, Cochrane Library, Embase, China National Knowledge Infrastructure, and Wanfang Database were searched for cases of RIVT in recurrent ischemic stroke within 3 months up to February 1, 2023. Clinical characteristics were compared and analyzed between the good-outcome and poor-outcome groups and between the symptomatic intracranial hemorrhage (sICH) and non-sICH groups respectively.ResultsA total of 16 studies including 24 cases of RIVT within 3 months were retrospectively analyzed in the present study. The patients’ ages ranged from 42 to 87 years (median 73.5 years) and the intervals between thrombolysis were from 0.25 to 90 days (median 9.5 days). Comparing the clinical characteristics between the good-outcome group and the poor-outcome group, no statistically significant differences were found (P > 0.05), but the differences in baseline National Institutes of Health stroke scale (NIHSS) score of the recurrent stroke (P = 0.056) and good outcome after the previous IVT (P = 0.054) nearly reached statistical significance. Comparing the data between the non-sICH group and the sICH group, statistically significant differences were found in terms of the proportion of cardiogenic embolism (P = 0.036), baseline NIHSS score in the recurrent stroke (P = 0.007) and the interval between thrombolysis (P = 0.041), but no significant difference was found by regression analysis.ConclusionIn patients with recurrent ischemic stroke within 3 months, those with a good outcome after the previous IVT and a low baseline NIHSS score in the recurrent stroke may be considered for RIVT, whereas those with a high baseline NIHSS score, a short interval between thrombolysis, and cardiogenic embolism may suffer a higher risk of sICH. Due to sample size and publication bias, more studies with larger sample sizes and more rigorous designs are needed to confirm this conclusion.

Association between arterial tortuosity and early neurological deterioration in lenticulostriate artery infarction

Early neurological deterioration (END) in lenticulostriate artery (LSA) infarction is associated with perforating artery hypoperfusion. As middle cerebral artery (MCA) tortuosity may alter hemodynamics, we investigated the association between MCA tortuosity and END in LSA infarction. We reviewed patients with acute LSA infarction without significant MCA stenosis. END was defined as an increase of ≥ 2 or ≥ 1 in the National Institutes of Health Stroke Scale (NIHSS) total or motor score, respectively, within first 72 h. The MCA tortuosity index (actual /straight length) was measured. Stroke mechanisms were categorized as branch atheromatous disease (BAD; lesions > 10 mm and 4 axial slices) and lipohyalinotic degeneration (LD; lesion smaller than BAD). Factors associated with END in LD and BAD were investigated. END occurred in 104/390 (26.7%) patients. A high MCA tortuosity index (adjusted odds ratio, aOR 10.63, 95% confidence interval [2.57–44.08], p = 0.001) was independently associated with END. In patients with BAD, high initial NIHSS score (aOR 1.40 [1.03–1.89], p = 0.031) and presence of parental artery disease (stenosis < 50%; aOR 10.38 [1.85–58.08], p = 0.008) were associated with END. In patients with LD, high MCA tortuosity (aOR 41.78 [7.37–237.04], p < 0.001) was associated with END. The mechanism causing END in patients with LD and BAD may differ.

Predictors for hemorrhagic transformation and cerebral edema in stroke patients with first-pass complete recanalization.

Predictors of radiological complications attributable to reperfusion injury remain unknown when baseline setting is optimal for endovascular treatment and procedural setting is the best in stroke patients with large vessel occlusion (LVO). To identify clinical and radiological/procedural predictors for hemorrhagic transformation (HT) and cerebral edema (CED) at 24 hr in patients obtaining complete recanalization in one pass of thrombectomy for ischemic stroke ⩽ 6 h from symptom onset with intra-cranial anterior circulation LVO and ASPECTS ⩾ 6. We conducted a cohort study on prospectively collected data from 1400 patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke. HT was reported in 248 (18%) patients and early CED was reported in 260 (19.2%) patients. In the logistic regression model including predictors from a first model with clinical variables and from a second model with radiological/procedural variables, diabetes mellitus (odds ratio (OR) = 1.832, 95% confidence interval (CI) = 1.201-2.795), higher National Institutes of Health Stroke Scale (NIHSS) (OR = 1.076, 95% CI = 1.044-1.110), lower Alberta Stroke Program Early CT (ASPECTS) (OR = 0.815, 95% CI = 0.694-0.957), and longer onset-to-groin time (OR = 1.005, 95% CI = 1.002-1.007) were predictors of HT, whereas general anesthesia was inversely associated with HT (OR = 0.540, 95% CI = 0.355-0.820). Higher NIHSS (OR = 1.049, 95% CI = 1.021-1.077), lower ASPECTS (OR = 0.700, 95% CI = 0.613-0.801), intravenous thrombolysis (OR = 1.464, 95% CI = 1.061-2.020), longer onset-to-groin time (OR = 1.002, 95% CI = 1.001-1.005), and longer procedure time (OR = 1.009, 95% CI = 1.004-1.015) were predictors of early CED. After repeating a fourth logistic regression model including also good collaterals, the same variables remained predictors for HT and/or early CED, except diabetes mellitus and thrombolysis, while good collaterals were inversely associated with early CED (OR = 0.385, 95% CI = 0.248-0.599). Higher NIHSS, lower ASPECTS, and longer onset-to-groin time were predictors for both HT and early CED. General anesthesia and good collaterals were inversely associated with HT and early CED, respectively. Longer procedure time was predictor of early CED.

The relationship between neurological function trajectory, assessed by repeated NIHSS measurement, and long-term cardiovascular events, recurrent stroke, and mortality after ischemic stroke.

Clinically significant changes in neurological deficits frequently occur after stroke onset, reflecting further neurological injury or neurological improvement. However, the National Institutes of Health Stroke Scale (NIHSS) score is only evaluated once in most studies, usually at stroke onset. Utilizing repeated measures of NIHSS scores to identify different trajectories of neurological function may be more informative and provide more useful predictive information. We determined the association of neurological function trajectories with long-term clinical outcomes after ischemic stroke. A total of 4025 participants with ischemic stroke from the China Antihypertensive Trial in Acute Ischemic Stroke were included. Patients were recruited from 26 hospitals across China between August 2009 and May 2013. A group-based trajectory model was used to identify distinct neurological function trajectories, as measured by NIHSS at admission, 14 days or hospital discharge, and 3 months. Study outcomes were cardiovascular events, recurrent stroke, and all-cause mortality during 3-24 months after ischemic stroke onset. Cox proportional hazards models were used to examine the associations of neurological function trajectories with outcomes. We identified three distinct subgroups of NIHSS trajectories: persistent severe (persistent high NIHSS scores during the 3-month follow-up), moderate (NIHSS scores started at around 5 and gradually reduced), and mild (NIHSS scores always below 2). The three trajectory groups had different clinical profiles and different risk of stroke outcomes at 24-month follow-up. Compared to the mild trajectory group, patients in the persistent severe trajectory group had a higher risk of cardiovascular events (multivariable-adjusted hazard ratios (95% confidence intervals) = 1.77 (1.10-2.86)), recurrent stroke (1.82 (1.10-3.00)), and all-cause mortality (5.64 (3.37-9.43)). Those with moderate trajectory had an intermediate risk: 1.45 (1.03-2.04) for cardiovascular events and 1.52 (1.06-2.19) for recurrent stroke. Longitudinal neurological function trajectories derived from repeated NIHSS measurements during the first 3 months after stroke provide additional predictive information and are associated with long-term clinical outcomes. The trajectories characterized by persistent severe and moderate neurological impairment were associated with increased risk of subsequent cardiovascular events.

Clinical and paraclinical predictors of early neurological deterioration and poor outcome in spontaneous intracerebral hemorrhage

BackgroundSpontaneous intracerebral hemorrhage (sICH) is the second most common form of stroke. It is a major cause of morbidity and mortality. Several clinical and radiological parameters are related to its poor outcome. The aim of this study is to elucidate the clinical, laboratory, and radiological factors associated with early neurological deterioration and poor outcome in patients with ICH.Resultsseventy patients diagnosed with sICH were evaluated within the first 72 h from the onset of symptoms by Clinical, radiological, and laboratory parameters. Patients were assessed for early neurological deterioration (END) during the hospital stay (up to 7 days from admission) using Glasgow coma scale (GSC), and the National Institutes of Health Stroke Scale (NIHSS), and within 3 months from stroke onset using modified Rankin scale (mRS). ICH score and Functional Outcome in Patients with Primary Intracerebral Hemorrhage (FUNC) Score were calculated for prognostication. 27.1% and 71.42% of patients had END and showed unfavorable outcome, respectively. Clinical indices, as NIHSS > 7 on admission and age > 51 years, radiological characteristics, as large hematoma size, leukoaraiosis, and mass effect detected on CT scan, as well as serum biomarkers; serum urea level > 50 mg/dL, high neutrophil:lymphocyte ratio on admission, high ALT and AST, as well as low total, LDL, and HDL cholesterol levels, all were significantly associated with poor outcome in the patients. Stepwise multivariate logistic regression analysis found the presence of aspiration to be an independent predictor of END, and the scores of NIHSS > 7 on admission, age > 51 years, and urea level > 50 mg/dL were independent predictors of poor outcome.ConclusionsThere are several predictors for END as well as poor outcome in ICH. Some are clinical, others are radiological and laboratory. Aspiration was an independent predictor of END during hospital stay (3–7 days) in patients with ICH, while older age, high NIHSS and urea level on admission were independent predictors of poor outcome.

The REMIT scale: A novel prediction scale for embolism in hyperacute stroke with large vessel occlusion

Background and purposeLarge vessel occlusion (LVO) in hyperacute ischemic stroke occurs mainly by one of two mechanisms, embolism or atherosclerosis. However, the mechanism is difficult to identify prior to treatment. We aimed to investigate the factors associated with embolic LVO in hyperacute ischemic stroke, and to develop a preoperative predictive scale for the event. Materials and methodsThis retrospective multicenter study was conducted with consecutive ischemic stroke patients with LVO who underwent thrombectomy, thrombolysis, or both. The embolic LVO was defined as an occlusion that underwent recanalization with no residual stenosis. Multivariate logistic regression analysis for embolic LVO was performed to identity the independent risk factors. With this approach, a novel prediction scale (Rating of Embolic Occlusion for Mechanical Thrombectomy [REMIT] scale) was developed. ResultsA total of 162 patients (104 men; median age 76 years; interquartile range 68–83) were included in this study. Embolic LVO was observed in 121 patients (75%). Multivariate logistic regression analysis showed that embolic LVO was independently associated with high brain natriuretic peptide (BNP), high National Institutes of Health Stroke Scale (NIHSS) on admission, and absence of non-culprit stenosis (NoCS). The REMIT scale comprises high BNP (>100 pg/dL), high NIHSS (>14) and absence of NoCS, with one point for each risk factor. The frequencies of embolic LVO for the REMIT scale scores were as follows: score 0, 25%; score 1, 60%; score 2, 87%; score 3, 97% (C-statistic 0.80, P < 0.001). ConclusionThe novel REMIT scale has predictive value for embolic LVO.

Atrial Fibrillation and Stroke: Predictors of Anticoagulation Therapy Modification (P6-5.010)

<h3>Objective:</h3> Analyze predictors of therapy modification in patients with atrial fibrillation (AF) experiencing stroke despite adequate anticoagulation (AC) for secondary stroke prevention. <h3>Background:</h3> The ideal strategy to treat persons with AF experiencing stroke despite adequate AC with direct-acting anticoagulants (DOACs) or vitamin K antagonists (VKAs) is not known. <h3>Design/Methods:</h3> Patients admitted between 2012 and 2021 at our hospital with stroke despite AC for AF were enrolled. Baseline characteristics including National Institute of Health Stroke Scale (NIHSS), AC therapy, modified Rankin Scale (mRS), occurrence of intracerebral hemorrhage (ICH) on first image, and discharge antithrombotic therapy were collected. Logistic regression analyses were performed to identify factors associated with the decision to change AC after stroke. <h3>Results:</h3> 595 patients were included. Of these, 291 (48.9%) were on DOACs therapy and 125 (43%) had their AC modified from DOACs at discharge (16% switched to warfarin, 58.4% to no AC and 25.6% to antiplatelet agents or enoxaparin). Of the 304 patients using VKAs, 53% had their discharge antithrombotic modified, with 26% switched to DOACs. Therapy change in patients on DOACs was associated with older age (OR 1.04, 95%CI 1.01–1.06), higher admission NIHSS (OR 1.06, 95%CI 1.03–1.10), discharge mRS ≥3 (OR 3.51, 95%CI 1.98–6.49), and ICH (OR 5.67, 95%CI 2.99–11.35). For warfarin, therapy change was associated with older age (OR 1.03, 95%CI 1.01 1.06), higher NIHSS (OR 1.04, 95%CI 1.00–1.07), heart failure (OR 1.90, 95%CI 1.13–3.27) and ICH (OR 3.81, 95%CI 1.93–8.14). Patients discharged with DOACs, compared to those with warfarin, were more likely to be younger, had higher rates of cardiovascular risk factors and ICH, and lower admission NIHSS. <h3>Conclusions:</h3> Older age, more severe strokes, and occurrence of ICH were associated with the decision to change or stop AC. Variation in practice exists and further research is needed to assess the clinical impact of antithrombotic therapy modification in this population. <b>Disclosure:</b> Mrs. Carvalho de Oliveira has nothing to disclose. Mr. Webb has nothing to disclose. Dr. Ponciano has nothing to disclose. Prof. Farias Da Guarda has nothing to disclose. Ms. Yilmaz has nothing to disclose. An immediate family member of Dr. Singhal has received personal compensation for serving as an employee of Biogen. Dr. Singhal has received personal compensation in the range of $5,000-$9,999 for serving as an Expert Witness for Medicolegal Firms. Dr. Singhal has received research support from NIH-NINDS. Dr. Singhal has received publishing royalties from a publication relating to health care. Dr. Singhal has received publishing royalties from a publication relating to health care. Dr. Singhal has received personal compensation in the range of $500-$4,999 for serving as a Honorarium (Education) with Biogen. Dr. Viswanathan has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Alnylam Pharmaceuticals. Dr. Viswanathan has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Biogen. Dr. Viswanathan has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Roche Pharmaceuticals. Dr. Asad has nothing to disclose.

Effect of Alteplase on Ischemic Stroke Mortality Is Dependent on Stroke Severity.

Although intravenous alteplase (IV-tPA) has a beneficial effect on functional outcome after ischemic stroke (IS), prior studies of IV-tPA's impact on post-stroke mortality did not have sufficient representation of more severe stroke. We determined if the interaction between the baseline National Institutes of Health (NIH) Stroke Scale (NIHSS) and IV-tPA modified the risk of mortality after IS in two cohorts: (1) National Inpatient Sample 2016-2020, and (2) a harmonized cohort of IS patients from the NINDS IV-tPA, ALIAS part 2, SHINE, FAST-MAG, IMS-III, POINT, and DEFUSE 3 trials. We fit logistic regression models to the outcome of in-hospital mortality (National Inpatient Sample [NIS] cohort) or mortality within 90 days (harmonized cohort), adjusted for baseline variables. We included 198,668 patients in the NIS cohort, of which 14.0% received IV-tPA and 3.4% died in hospital. We included 7,138 patients in the harmonized cohort, of which 33.2% received IV-tPA and 9.4% died by 90 days. Mortality in the NIS cohort was associated with older age, female sex, non-Hispanic white race, atrial fibrillation, and higher NIHSS. In the harmonized cohort, mortality was associated with older age, diabetes, atrial fibrillation, and higher NIHSS. In both cohorts, the interaction between NIHSS and IV-tPA was significant. In the NIS cohort, the separation became significant at NIHSS 15 and in the harmonized cohort at NIHSS 23, at which point, IV-tPA began to have a significant benefit for both in-hospital and 90-day mortality, respectively. IV-tPA is associated with a reduction in both in-hospital and 90-day mortality for patients with more severe IS. ANN NEUROL 2023;93:1106-1116.

Abstract WP162: Primary Results Of Mechanical Thrombectomy For Acute Ischemic Stroke In Clinical Practice: K-net Registry

Background: Endovascular treatment (EVT) for acute large vessel occlusion has been found to be effective in several randomized controlled trials. We conducted a prospective cohort study to evaluate the real-world efficacy of EVT in patients with acute ischemic stroke in a metropolitan area with a high population density and a large number of comprehensive stroke centers. Methods: We analyzed the Kanagawa Intravenous and Endovascular Treatment of Acute Ischemic Stroke registry, a prospective, multicenter observational study of patients treated by EVT and/or intravenous tissue-type plasminogen activator (tPA), in Kanagawa, Japan. Of the 2488 patients enrolled from January 2018 to June 2020, 1764 patients treated with EVT were included. The primary outcome was a good outcome, which was defined as a modified Rankin Scale (mRS) of 0 to 2 at 90 days. Secondary analysis included predicting a good outcome using multivariate logistic regression analysis. Results: The median age was 77 years and the median National Institute of Health Stroke Scale (NIHSS) score was 18. Pretreatment mRS score 0-2 was 87%, and direct transport was 92%. The rate of occlusion in anterior circulation was 90.3%. Successful recanalization was observed in 88.7%. The median time from onset to recanalization was 193 minutes. Good outcomes at 90 days were 43.3% in anterior circulation and 41.9% in posterior circulation. Furthermore, 49.3% of patients with anterior circulation obstruction who had pre-stroke mRS 0-2 had good outcome, which was higher than the HERMES trial. Overall mortality was 12.6%. Significant predictors for a good outcome were: age, male, direct transfer, NIHSS score, Alberta Stroke Program Early Computed Tomography Score, intravenous tPA, and successful recanalization. Conclusions: EVT in routine clinical use in a metropolitan area showed comparable good outcomes and lower mortality compared to previous registries and RCTs, despite the high proportion of patients with older age, pretreatment mRS score of &gt; 2, posterior circulation occlusion, and higher NIHSS. Those results may have been associated with more direct transport and faster onset-to-recanalization times.

Predictors and long-term outcome of intracranial hemorrhage after thrombolytic therapy for acute ischemic stroke-A prospective single-center study.

Acute ischemic stroke (AIS) is a potentially devastating disease with high disability and mortality. Recombinant tissue plasminogen activator (rt-PA) is an effective treatment with a 2-8% possible risk for symptomatic intracranial hemorrhage (sICH). Our aim was to investigate the risk factors and long-term clinical outcomes of ICH in patients after rt-PA treatment. Consecutive patients with AIS, thrombolysed at the Department of Neurology, University of Debrecen, between 1 January 2004 and 31 August 2016 were enrolled prospectively. Risk factors, stroke severity based on the National Institute of Health Stroke Scale (NIHSS), functional outcome using the modified Rankin scale, and mortality at 1 year were compared in patients with and without ICH following rt-PA treatment. We evaluated clinical characteristics and prognosis by hemorrhage type based on the Heidelberg Bleeding Classification. Descriptive statistics, the chi-square test, the Mann-Whitney U-test, ANOVA, the Kruskal-Wallis test, a survival analysis, and logistic regression were performed as appropriate. Out of 1,252 patients with thrombolysis, ICH developed in 138 patients, with 37 (2.95%) being symptomatic. Mean ages in the ICH and non-ICH groups differed significantly (p = 0.041). On admission, the 24-h NIHSS after thrombolysis was higher in patients with ICH (p < 0.0001). Large vessel occlusion was more prevalent in patients with ICH (p = 0.0095). The ICH risk was lower after intravenous thrombolysis than intra-arterial or combined thrombolysis (p < 0.0001). Both at 3 months and 1 year, the outcome was worse in patients with ICH compared to patients without ICH group (p < 0.0001). Mortality and poor outcome were more prevalent in all hemorrhage types with a tendency for massive bleeding associated with unfavorable prognosis. At 3 months with the logistic regression model, the worse outcome was detected in patients with ICH after thrombolysis, at 1 year in patients with ICH after thrombolysis and smoking. Older age, higher NIHSS, large vessel occlusion, and intra-arterial thrombolysis may correlate with ICH. The unfavorable outcome is more common in patients with ICH. Precise scoring of post-thrombolysis bleeding might be a useful tool in the evaluation of the patient's prognosis. Our findings may help to identify predictors and estimate the prognosis of ICH in patients with AIS treated with rt-PA.

Abstract TP107: Utility of routine 24h follow-up CT after thrombolysis

Background: 24h CT is routinely acquired post-thrombolysis. Parenchymal hematoma and brain edema are feared complications. Predicting complications that change management would help reduce unnecessary imaging. Objective: To evaluate the utility of 24h per-protocol CT scan for stroke patients after thrombolysis. Methods: A prospectively collected cohort of consecutive patients presenting with acute ischemic stroke to our hospital from 2013- 2021 who were treated with IV tPA without undergoing endovascular therapy was entered into our IRB-approved stroke registry. Neuroimaging performed within 48h after admission was reviewed. Patients’ demographics, past medical history, admission National Institute of Health Stroke Scale (NIHSS) score, and medical variables were obtained. The primary outcome was significant radiologically findings (parenchymal hematoma or midline shift/herniation) leading to change in management (additional monitoring, emergent procedure, administration of mannitol or alteration in blood pressure goal). Results: From 2013 to 2021, 875 patients (mean age 69) who had IV tPA without undergoing endovascular therapy were identified, of which 472 (47.1%) were female. Median (IQR) NIHSS score was 9 (4-16) on admission. Imaging findings: 339 (38.7%) had expected evolving infarctions; 106(13.3%) developed any type of hemorrhagic transformation, including 66 (7.5%) who had hemorrhagic infarction and 50 (5.7%) parenchymal hematomas; 142(16.2%) developed any kind of mass effect, including 63 (7.2%) who had mild mass effect and 79 (9.0%) midline shift/herniation. There were 124 patients (12.1%) had significant findings (including parenchymal hematoma and midline shift/brain herniation) leading to change in the management. Patients who had significant findings had higher NIHSS score 16 (8-21) than those without 8 (4-15) (p&lt;0.001). NIHSS was the only significant outcome predictor both in univariate and the multivariable analysis. Conclusions and interpretations: Our study showed that patients with high NIHSS score were more likely to have significant findings. 24-hour follow-up CT scan should be based on the risk of developing significant complications.

Impacts of stress hyperglycemia ratio on early neurological deterioration and functional outcome after endovascular treatment in patients with acute ischemic stroke.

Hyperglycemia has been associated with unfavorable outcome of acute ischemic stroke, but this association has not been verified in patients with endovascular thrombectomy treatment. This study aimed to assess the impact of stress hyperglycemia ratio on early neurological deterioration and favorable outcome after thrombectomy in patients with acute ischemic stroke. Stroke patients with endovascular thrombectomy in two comprehensive centers were enrolled. Early neurological deterioration was defined as ≥4 points increase of National Institutes of Health Stroke Scale (NIHSS) at 24 hours after endovascular procedure. Favorable outcome was defined as modified Rankin Scale (mRS) score of 0-2 at 90 days of stroke onset. Multivariate regression analysis was used to identify the predictors for early neurological deterioration and favorable outcome. Among the 559 enrolled, 74 (13.2%) patients developed early neurological deterioration. The predictors for early neurological deterioration were high stress hyperglycemia ratio at baseline (OR =5.77; 95% CI, 1.878-17.742; P =0.002), symptomatic intracranial hemorrhage (OR =4.90; 95% CI, 2.439-9.835; P <0.001) and high NIHSS score after 24 hours (OR =1.11; 95% CI, 1.071-1.151; P <0.001). The predictors for favorable outcome were stress hyperglycemia ratio (OR =0.196, 95% CI, 0.077-0.502; P =0.001), age (OR =0.942, 95% CI, 0.909-0.977; P =0.001), NIHSS score 24 hours after onset (OR =0.757, 95% CI =0.693-0.827; P <0.001), groin puncture to recanalization time (OR =0.987, 95% CI, 0.975-0.998; P =0.025), poor collateral status before treatment (ASITN/SIR grade 0-3, OR =62.017, 95% CI, 25.920-148.382; P <0.001), successful recanalization (mTICI 2b or 3, OR =7.415, 95% CI, 1.942-28.313; P =0.001). High stress hyperglycemia ratio may be related to early neurological deterioration and decreased likelihood of favourable outcomes after endovascular thrombectomy in patients with acute ischemic stroke.

Outcomes after endovascular mechanical thrombectomy for low compared to high National Institutes of Health Stroke Scale (NIHSS): A multicenter study

ObjectiveThe role of endovascular mechanical thrombectomy (MT) in patients presenting with “minor” stroke is uncertain. We aimed to compare outcomes after MT for ischemic stroke patients presenting with National Institutes of Health Stroke Scale (NIHSS) 5 and – within the low NIHSS cohort – identify predictors of a favorable outcome, mortality, and symptomatic intracranial hemorrhage (ICH). MethodsWe retrospectively analyzed a prospectively maintained, international, multicenter database. ResultsThe study cohort comprised a total of 7568 patients from 29 centers. NIHSS was low (<5) in 604 patients (8%), and > 5 in 6964 (92%). Patients with low NIHSS were younger (67 + 14.8 versus 69.6 + 14.7 years, p < 0.001), more likely to have diabetes (31.5% versus 26.9%, p = 0.016), and less likely to have atrial fibrillation (26.6% versus 37.6%, p < 0.001) compared to those with higher NIHSS. Radiographic outcomes (TICI > 2B 84.6% and 84.3%, p = 0.412) and complication rates (8.1% and 7.2%, p = 0.463) were similar between the low and high NIHSS groups, respectively. Clinical outcomes at every follow up interval, including NIHSS at 24 h and discharge, and mRS at discharge and 90 days, were better in the low NIHSS group, however patients in the low NIHSS group experienced a relative decline in NIHSS from admit to discharge. Mortality was lower in the low NIHSS group (10.4% versus 24.5%, p < 0.001). ConclusionsRelative to patients with high NIHSS, MT is safe and effective for stroke patients with low NIHSS, and it is reasonable to offer it to appropriately selected patients presenting with minor stroke symptoms. Our findings justify efforts towards a randomized trial comparing MT versus medical management for patients with low NIHSS.

National Institutes of Health Stroke Scale (NIHSS) scoring inconsistencies between neurologists and emergency room nurses.

Little is known about the consistency of initial NIHSS scores between neurologists and RNs in clinical practice. A cohort study of patients with a code stroke was conducted at an urban academic Primary Stroke Center in the Midwest between January 1, 2018, and December 31, 2019 to determine consistency in National Institutes of Health Stroke Scale Scores (NIHSS) between neurologists and registered nurses (RNs). Among the 438 patients included in this study 65.3% (n = 286) of neurologist-RN NIHSS scoring pairs had congruent scores. One-in-three, (34.7%, n = 152) of neurologist-RN NIHSS scoring pairs had a clinically meaningful scoring difference of two points or greater. Higher NIHSS (p ≤ 0.01) and aphasia (p ≤ 0.01) were each associated with incongruent scoring between neurologist and emergency room RN pairs. One-in-three initial NIHSS assessed by both a neurologist and RN had a clinically meaningful score difference between providers. More severe stroke, as indicated by a higher NIHSS was associated with scoring inconsistency between neurologist-RN pairs. Subjective scoring measures, especially those involving a patient having aphasia, was associated with greater score incongruency. Score differences may be attributed to differences in NIHSS training requirements between neurologists and RNs.

Factors affecting the outcomes of tirofiban after endovascular treatment in acute ischemic stroke: Experience from a single center.

To investigate the predicted factors influencing the outcomes in acute ischemic stroke (AIS) patients who received tirofiban after endovascular treatment (EVT) and the optimal administration of tirofiban. In this retrospective study, AIS patients who received EVT followed by tirofiban between January 2017 and October 2021 were enrolled. The dose and duration of tirofiban were adjusted by trained clinicians according to the patient's clinical status. A reduction of at least four points on the National Institutes of Health Stroke Scale (NIHSS) after tirofiban compared with that before tirofiban was defined as an effective response. A modified ranking scale (mRS) of 0-2 was defined as a favorable outcome at a 90-day follow-up. A total of 260 consecutive patients were enrolled, and 36.5% of patients achieved a favorable outcome. The modified thrombolysis in cerebral infarction (mTICI) 2b-3 occurred in 93.5% of patients. Symptomatic intracerebral hemorrhage (sICH) occurred in 6.2% of patients, and the mortality at 90-day follow-up was 16.9%. Duration of tirofiban >24 h (adjusted OR: 2.545; 95% CI: 1.008-6.423; p=0.048) and effective response to tirofiban (adjusted OR: 25.562; 95% CI: 9.794-66.715; p < 0.001) were related to the favorable outcome (mRS 0-2). Higher NIHSS (adjusted OR: 0.855; 95% CI: 0.809-0.904; p < 0.001) and glucose level on admission (adjusted OR: 0.843; 95% CI: 0.731-0.971; p=0.018) were predictive for the unfavorable outcome (mRS 3-6). An effective response to tirofiban is an independent factor in predicting the long-term efficacy outcome, and extending the duration of tirofiban is beneficial for neurological improvement.

Clinical outcomes of delayed mechanical thrombectomy: Descriptive analysis and development of a screening tool.

Limited data guide the selection of patients with large vessel occlusion ischaemic stroke who may benefit from referral to a distant tertiary centre for mechanical thrombectomy (MT). We aimed to characterize this population, describe clinical outcomes and develop a screening system to identify patients most likely to benfit from delayed mechanical thrombectomy (MT). We undertook a retrospective cohort analysis enrolling patients transferred from regional sites to one of two MT comprehensive stroke units with a time from non-contrast computed tomography (NCCT) of the brain to reperfusion of 4 h or more. We describe Alberta Stroke Programme Early Computed Tomography Score (ASPECTS), National Institute of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) in our patients and compare these patients to those in extended-time-window trials. Lastly, we developed and validated a scoring model to help clinicians identify appropriate patients based on variables associated with poor outcomes. We included 563 patients, 46% of whom received thrombolysis; the median (interquartile range [IQR]) ASPECTS was 8 (7-10) and the median (IQR) NIHSS score was 16 (11-20). The median (IQR) symptom to mechanical reperfusion time was 390(300-580)min. Eight patients (1%) had a symptomatic haemorrhage. We achieved good clinical outcome (defined as mRS score ≤2) in 299 patients (54%). Age, diabetes, NIHSS score and ASPECTS were used to create a weighted scoring system with a validated area under the curve of 0.83 (95% confidence interval 0.74-0.92). Our study shows, in highly selected patients, that delayed MT many hours after baseline NCCT is associated with good clinical outcomes. However, older patients with diabetes, high NIHSS score and low ASPECTS may not benefit from transfer to a hub centre many hours away for MT in this model of care.