Hours Of Stroke Symptom Onset Research Articles

Continuous transcranial ultrasound in large vessel stroke: Image guidance for high-intensity focused sonothrombolysis.

Sonothrombolysis is a potential adjunctive therapy for large vessel occlusion (LVO) stroke. Bedside ultrasound image-guided high-intensity focused ultrasound (HIFU) therapy could deliver higher energy therapeutic ultrasound to the thrombus with higher precision than what was previously accomplished in human trials. The aim is to test the feasibility of diagnostic transcranial contrast-enhanced ultrasound (CEUS) to image the occlusion site and continuously maintain the guidance image on-target for a sufficient exposure time for HIFU to be effective during LVO stroke evaluation and treatment. This prospective, single center, observational cohort study included adult patients, presenting within 6 hours of stroke symptom onset, with LVO identified on computed tomography angiography (CTA). A hand-held CEUS imaging study was initiated following CTA and lasted up to 30 minutes. The primary outcome is the proportion of patients where a guidance CEUS image of the occlusion was achieved. A CEUS image of the occluded artery was obtained in 32/35 of the included patients. The median total imaging time was 23 minutes (interquartile range 15-30). Patients undergoing thrombectomy had a lower total imaging time (17 vs. 29.5 minutes, p=.002). When imaging was successful, on-target image was maintained for only 58% (standard deviation 23.8%) of total imaging time. No complications related to CEUS were observed. This feasibility study explored the use of diagnostic transcranial CEUS for continuous imaging of occlusion sites in LVO strokes. Challenges in maintaining target image during HIFU were identified, highlighting the need for technical advances for clinical application.

Deciphering the contextual barriers to mainstreaming the implementation of stroke thrombolysis in a Ghanaian hospital: Findings from the activate mixed-methods study

BackgroundEach year, stroke-related death and disability claim over 143 million years of healthy life globally. Despite accounting for much of the global stroke burden, acute stroke care in Low-and-Middle-Income Countries remains suboptimal. Thrombolysis, an effective treatment option for stroke, is only received by a minority of stroke patients in these settings. AimTo determine the context-specific barriers and facilitators for the implementation of mainstream stroke thrombolysis in a Ghanaian hospital. MethodsWe employed a mixed-methods approach involving key stakeholders (recipients, providers, and leaders) in the acute stroke care continuum. Surveys were administered to acute stroke patients, and in-depth key informant interviews were conducted with experts in stroke care, including a neurologist, medical director, neurology residents, a stroke nurse, emergency physicians, a radiologist, and a pharmacist. The data collected from these interviews were transcribed and analysed using content analysis with the CFIR (Consolidated Framework for Implementation Research) model as a guiding template. Two independent coders were involved in the analysis process to ensure reliability and accuracy. ResultsThe stroke thrombolysis rate over a 6-month period was 0.83% (2 out of 242), with an average door-to-needle time among thrombolyzed patients being 2 hours, 37 minutes. Only 12.8% of patients (31 out of 242) presented within 4.5 hours of stroke symptom onset. The most significant obstacle to the implementation of acute stroke thrombolysis was related to the characteristics of the individuals involved, notably delays in presenting to the hospital among stroke patients due to a lack of knowledge about stroke symptoms and cultural beliefs. Additionally, a significant bottleneck that contributed to the discrepancy between the number of patients who presented within the 4.5-6 hour window and the number of patients who actually received thrombolysis was the inability to pay for the cost of thrombolytic agents. This was followed by challenges in the implementation processes. ConclusionsAddressing challenges related to stroke awareness, and financial constraints via multi-level stakeholder engagement, and enactment of stroke protocols are crucial steps in ensuring a successful implementation of a stroke thrombolysis program in a resource-limited setting.

C-Reactive protein as a biomarker affecting neurorehabilitation outcomes in post-stroke patients: state of knowledge and global trends in research

Background: C-reactive protein (CRP) is a commonly determined biomarker of inflammation and may reflect the progression of a vascular disease. CRP values within 12 to 24 hours of stroke symptom onset are an independent predictor of adverse functional outcome in terms of the level of motor recovery in the first year of follow-up. Objective: This study aims to provide a complementary analysis of the scientific literature and critically review studies on the use of CRP as a potential biomarker associated with stroke and affecting the achievement of neurorehabilitation progress in post-stroke patients. Methods: This critical review of the literature was prepared based on the following inclusion criteria: (1) original research, (2) studies indexed in PubMed, Scopus and PEDro databases, (3) full-text articles in English, (4) papers published in 2012 – 2022, and (5) papers addressing the use of PCR assay as a biomarker of rehabilitation effectiveness. Results: Based on a review of PubMed, Scopus and PEDro databases, 47, 56 and 9 papers, respectively, were selected based on precisely selected keywords and included in full for further full text review. In this review, the most important scientific rationale was included in response to the aim of this paper. Summary: Recognition of the role of inflammatory and immunological factors in the development of atherosclerosis and the occurrence of ischaemic stroke provides scope for the search for new methods of stroke risk assessment and the development of new methods to prevent stroke. Further empirical validation and unequivocal demonstration of the levels of CRP as a potential marker that affects the health status of a post-stroke patient are needed to ensure the greatest possible level of motor recovery and ability to function independently in terms of all activities of daily living.

Achieving More Rapid Door-to-Needle Times and Improved Outcomes in Acute Ischemic Stroke in a Nationwide Quality Improvement Intervention.

The benefits of tPA (tissue-type plasminogen activator) in acute ischemic stroke are time-dependent. However, delivery of thrombolytic therapy rapidly after hospital arrival was initially occurring infrequently in hospitals in the United States, discrepant with national guidelines. We evaluated door-to-needle (DTN) times and clinical outcomes among patients with acute ischemic stroke receiving tPA before and after initiation of 2 successive nationwide quality improvement initiatives: Target: Stroke Phase I (2010-2013) and Target: Stroke Phase II (2014-2018) from 913 Get With The Guidelines-Stroke hospitals in the United States between April 2003 and September 2018. Among 154 221 patients receiving tPA within 3 hours of stroke symptom onset (median age 72 years, 50.1% female), median DTN times decreased from 78 minutes (interquartile range, 60-98) preintervention, to 66 minutes (51-87) during Phase I, and 50 minutes (37-66) during Phase II (P<0.001). Proportions of patients with DTN ≤60 minutes increased from 26.4% to 42.7% to 68.6% (P<0.001). Proportions of patients with DTN ≤45 minutes increased from 10.1% to 17.7% to 41.4% (P<0.001). By the end of the second intervention, 75.4% and 51.7% patients achieved 60-minute and 45-minute DTN goals. Compared with the preintervention period, hospitals during the second intervention period (2014-2018) achieved higher rates of tPA use (11.7% versus 5.6%; adjusted odds ratio, 2.43 [95% CI, 2.31-2.56]), lower in-hospital mortality (6.0% versus 10.0%; adjusted odds ratio, 0.69 [0.64-0.73]), fewer bleeding complication (3.4% versus 5.5%; adjusted odds ratio, 0.68 [0.62-0.74]), and higher rates of discharge to home (49.6% versus 35.7%; adjusted odds ratio, 1.43 [1.38-1.50]). Similar findings were found in sensitivity analyses of 185 501 patients receiving tPA within 4.5 hours of symptom onset. A nationwide quality improvement program for acute ischemic stroke was associated with substantial improvement in the timeliness of thrombolytic therapy start, increased thrombolytic treatment, and improved clinical outcomes.

Intravenous alteplase has different effects on the efficacy of aspiration and stent retriever thrombectomy: analysis of the COMPASS trial

BackgroundThere is conflicting evidence on the utility of intravenous (IV) alteplase in patients with emergent large vessel occlusion (ELVO) treated with mechanical thrombectomy (MT).MethodsThis was a post hoc analysis of...

Should Tenecteplase be Given in Clinical Practice for Acute Ischemic Stroke Thrombolysis?

Should Tenecteplase be Given in Clinical Practice for Acute Ischemic Stroke Thrombolysis?

Assessment of Ischemic Volumes by Using Relative Filling Time Delay on CTP Source Image in Patients with Acute Stroke with Anterior Circulation Large Vessel Occlusions.

Thrombectomy up to 24 hours after stroke onset in patients with specific ischemic brain volumes remains a challenge, because many stroke centers do not apply specialized software to calculate ischemic volumes at advanced imaging. We aimed to establish the association between relative filling time delay on CTP source imaging and ischemic volume parameters and the infarct penumbra to core volume mismatch in patients with acute ischemic stroke. Consecutive patients with acute ischemic stroke and with M1 segment MCA with or without terminal ICA occlusions on baseline CTA and CTP within 24 hours of stroke symptom onset were included. Ischemic volumes were analyzed with software based on CTP maps. Relative filling time delay was classified into 4 grades-grade 0: relative filling time delay = 0 seconds; grade 1: relative filling time delay >0 to ≤4 seconds; grade 2: relative filling time delay >4 to ≤8 seconds; and grade 3: relative filling time delay > 8 seconds. Differences in ischemic volume parameters among relative filling time delay grades were tested. We recruited 138 patients (median age, 69 years; 62.3% male). Different median volumes of the infarct core (grade 0, 7.3 mL; grade 1, 23.3 mL; grade 2, 45.7 mL; grade 3, 135 mL [P < .001]) and the penumbra (grade 0, 47.6 mL; grade 1, 90 mL; grade 2, 110 mL; grade 3, 92 mL [P = .043]) were observed among relative filling time delay grades. Target mismatch (defined by the criteria of the DEFUSE 3 trial) was identified in 71.7% of the patients (99/138). A relative filling time delay grade ≤ 1 independently predicted target mismatch, with a sensitivity of 0.79 (95% CI, 0.7-0.87) and a specificity of 0.66 (95% CI, 0.49-0.8). Relative filling time delay grade based on CTP source imaging is a simple and effective parameter for evaluating ischemic volumes and target mismatch in patients with acute ischemic stroke. Further studies that compare relative filling time delay grade with clinical functional outcomes are necessary.

Effects of Oral Antiplatelet Agents and Tirofiban on Functional Outcomes of Patients with Non-Disabling Minor Acute Ischemic Stroke

Background and purposeOver half of patients with acute ischemic stroke present with minor neurologic deficits. We investigated the effects of oral antiplatelet agents vs. tirofiban, a highly selective GP IIb/IIIa antiplatelet drug, on functional outcomes of stroke patients with non-disabling neurologic deficits. MethodsThis retrospective study analyzed data of 125 patients with minor stroke who had National Institutes of Health Stroke Scale (NIHSS) scores of 5 or less within 6 hours of stroke symptom onset between January 2010 and June 2018. All patients were selected from the Department of Neurology at the Third Affiliated Hospital of Army Medical University. There were 54 cases in each group after propensity score matching, in which patients received oral antiplatelet agents (n = 64) and tirofiban (n = 61). Safety outcomes were assessed by incident intracranial hemorrhage, systemic bleeding and death. Efficacy outcomes were assessed using the NIHSS score at 24 hrs, 7 days or at discharge, and clinical deterioration. The modified rankin scale (mRs) was assessed at 90 days. ResultsNo significant differences were found in the incidence of intracranial hemorrhage, systemic bleeding or death between groups (P>0.05). Although neurological function improved significantly in both groups, NIHSS scores were lower in the tirofiban group compared with those in the oral antiplatelet agents group at 24 hrs (1 versus 3, P = 0.000), 7 days or at discharge (0 versus 2, P = 0.000). The clinical deterioration rate was higher in the oral antiplatelet agents group than in the tirofiban group, but without significance (16.7% versus 5.6%, P = 0.126). Functional outcomes (mRs = 0) were more favorable in the tirofiban group than in the oral antiplatelet agents group (66.7% vs. 44.4%; adjusted odds ratio 3.32; 95% CI: 1.38–7.99; P = 0. 008). ConclusionIntravenous tirofiban seems to be safe and effective with more favorable functional outcomes than oral antiplatelet agents, suggesting that tirofiban is a viable treatment choice for selected patients with non-disabling minor acute ischemic stroke.

Endovascular Treatment of Acute Ischemic Stroke.

This article reviews the actual indications for mechanical thrombectomy in patients with acute ischemic stroke and how the opportunities for endovascular therapy can be expanded by using the concept of clinical-imaging or perfusion-imaging mismatch (as a surrogate for salvageable tissue) rather than time of ischemia. Six randomized controlled trials undoubtedly confirmed the benefits of using endovascular thrombectomy on the clinical outcome of patients with stroke with large vessel occlusion within 6 hours from symptom onset compared with those receiving only standard medical care. In a meta-analysis of individual patient data, the number needed to treat with endovascular thrombectomy to reduce disability by at least one level on the modified Rankin Scale for one patient was 2.6. Recently, the concept of "tissue window" versus time window has proved useful for selecting patients for mechanical thrombectomy up to 24 hours from symptom onset. The DAWN (DWI or CTP Assessment With Clinical Mismatch in the Triage of Wake-Up and Late Presenting Strokes Undergoing Neurointervention) trial included patients at a median of 12.5 hours from onset and showed the largest effect in functional outcome ever described in any acute stroke treatment trial (35.5% increase in functional independence). In DEFUSE 3 (Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution 3), patients treated with mechanical thrombectomy at a median of 11 hours after onset had a 28% increase in functional independence and an additional 20% absolute reduction in death or severe disability. For patients with acute ischemic stroke and a large vessel occlusion in the proximal anterior circulation who can be treated within 6 hours of stroke symptom onset, mechanical thrombectomy with a second-generation stent retriever or a catheter aspiration device should be indicated regardless of whether the patient received treatment with intravenous (IV) recombinant tissue plasminogen activator (rtPA) in patients with limited signs of early ischemic changes on neuroimaging. Two clinical trials completely disrupted the time window concept in acute ischemic stroke, showing excellent clinical outcomes in patients treated up to 24 hours from symptom onset. Time of ischemia is, on average, a good biomarker for tissue viability; however, the window of opportunity for treatment varies across different individuals because of a range of compensatory mechanisms. Adjusting time to the adequacy of collateral flow leads to the concept of tissue window, a paradigm shift in stroke reperfusion therapy.

Update on Treatment of Acute Ischemic Stroke.

The article "Update on Treatment of Acute Ischemic Stroke" by Dr Rabinstein was first published in the February 2017 Cerebrovascular Disease issue of Continuum: Lifelong Learning in Neurology as "Treatment of Acute Ischemic Stroke" and has been updated by Dr Rabinstein for this issue at the request of the Editor-in-Chief. PURPOSE OF REVIEWThis article provides an update on the state of the art of the treatment of acute ischemic stroke with particular emphasis on the indications for reperfusion therapy.RECENT FINDINGSIn addition to the previously established indications for intravenous (IV) thrombolysis with recombinant tissue plasminogen activator (rtPA) within 4.5 hours of stroke symptom onset and endovascular therapy with mechanical thrombectomy for patients with large artery occlusion who can be treated within 6 hours of symptom onset, recent randomized controlled trials have now established new indications for emergency reperfusion in patients with wake-up stroke or delayed presentation (up to 24 hours from last known well in the case of mechanical thrombectomy). Identification of patients who may benefit from acute reperfusion therapy within this extended time window requires screening with perfusion brain imaging or, in the case of IV thrombolysis for wake-up strokes, emergency brain MRI. Collateral status and time to reperfusion remain the primary determinants of outcome.SUMMARYTimely successful reperfusion is the most effective treatment for patients with acute ischemic stroke. Recent evidence supports the expansion of the time window for reperfusion treatment in carefully selected patients.

345 Impact of Emergency Department Blood Pressure on Stroke Severity

To evaluate the association of systolic blood pressure (sBP) in the emergency department (ED) with ED stroke severity in patients with acute ischemic stroke (AIS) This observational study was conducted at an ED with an annual census of 80,000 visits, with approximately 400 for AIS. The cohort consisted of adult patients who presented to the ED within 24 hours of stroke symptom onset. Blood pressure measured at triage by a nurse blinded to the study. Stroke severity was measured using the National Institutes of Health Scale (NIHSS). The cohort consisted of 653 patients of which 37% was Hispanic, 16% Black, and 43% White. Fifty-four percent were male. The median systolic BP (sBP) was 157 mmHg with an interquartile range of 136-186. The Median NIHSS was 4, with an IQR between 1-11. Patients with higher sBP had significantly lower NIHSS scores (P=0.0044). This association was significant even after adjusting for age and sex. By contrast, the diastolic BP did not appear to impact stroke severity. The median dBP was 82 mmHg, with an IQR between 70-93. There was no difference in dBP values between men and women. There appears to be a protective effect of systolic blood pressure, where a higher sBP is associated with lower stroke severity. This reinforces the concept of permissive hypertension in the acute phase of ischemic stroke.

Abstract TP328: Cost-Utility of Intravenous Recombinant Tissue Plasminogen Activator in the Treatment of Acute Ischemic Stroke: a Systematic Review

Background: Intravenous recombinant tissue plasminogen activator (IV rtPA) is a recommended thrombolytic for the treatment of acute ischemic stroke that has shown to improve outcomes in various trials, but its cost-utility within varying time windows has not been systematically reviewed. Method: A systematic review was conducted using 2 reviewers and 1 adjudicator. Search strategies were implemented in PUBMED/MEDLINE, EMBASE, Web of Science, and Cochrane Review. Forms and data were managed through RedCap. Studies that met specific inclusion criteria, such as authors citing the time window and analytic horizon they investigated, and specifying the type of model they implemented, were further assessed for cost-utility benefit. Results: Of the 385 results from the implemented search strategy, 18 studies met inclusion criteria, with 94% agreement between reviewers. Eleven studies looked at the time window within 3 hours of stroke symptom onset, 3 looked between 3 to 4.5 hours, 3 looked within 4.5 hours of onset, and 1 looked within 6 hours of onset. All but 1 study with an analytic horizon of 1 year looking at a 0-3 hour time window showed that that IV rtPA was either dominant or cost-effective at a willingness to pay of $50,000/QALY. Conclusion: IV rtPA shows to be cost-effective across a variety of assumptions, both at a national and international level. The analytic horizon and time window do significantly impact the cost-effectiveness of IV rtPA, but even at later time windows, the IV rtPA shows to be cost-effective relative to standard treatment and care.

Endovascular therapy for acute ischaemic stroke: the Pragmatic Ischaemic Stroke Thrombectomy Evaluation (PISTE) randomised, controlled trial

ObjectiveThe Pragmatic Ischaemic Thrombectomy Evaluation (PISTE) trial was a multicentre, randomised, controlled clinical trial comparing intravenous thrombolysis (IVT) alone with IVT and adjunctive intra-arterial mechanical thrombectomy (MT) in patients who...

A Community-Engaged Assessment of Barriers and Facilitators to Rapid Stroke Treatment.

Treatment for acute ischemic stroke must be initiated within hours of stroke symptom onset, and the sooner it is administered, the better. In South Carolina, 76% of the population can access expert stroke care, and rural hospitals may provide specialized treatment using telemedicine, but many stroke sufferers seek care too late to achieve full benefit. Using a community-engaged approach in a southern rural community, we explored barriers and facilitators to early stroke care and implications for improvement. The Community-Engaged Assessment to facilitate Stroke Elimination (CEASE) study was guided by a community advisory group to ensure community centeredness and local relevance. In a qualitative descriptive study, eight focus groups were conducted including 52 individuals: recent stroke survivors, family members, emergency medical personnel, hospital emergency department staff, primary care providers, and community leaders. From analysis of focus group transcripts came six themes: lack of trust in healthcare system and providers; weak relationships fueled by poor communication; low health literacy; financial limitations related to health care; community-based education; and faith as a message of hope. A hierarchy model for improving early community-based stroke care was developed through consensus dialogue by community representatives and the research team. This model can be used to inform a community-partnered, stakeholder-informed intervention to improve stroke care in a rural southern community with the goal of improving stroke education, care, and outcome. © 2016 Wiley Periodicals, Inc.

Abstract 201: Time is Brain: Results From the Escape Randomized Controlled Trial

Introduction: The ESCAPE trial used innovative imaging and aggressive target time metrics to demonstrate the benefit of additional endovascular treatment over standard care in patients with disabling acute ischemic stroke. We analyze the impact of time from onset to reperfusion and from imaging to reperfusion on clinical outcome. Methods: The trial enrolled 316 patients fulfilling eligibility criteria and presenting within 12 hours of stroke symptom onset from 22 sites across 3 continents between February 2013 and October 2014. Logistic regression models were used to estimate the probability of functionally independent outcome (modified Rankin Scale 0-2 at 90 days) based on time from stroke symptom onset to qualifying CT, stroke symptom onset to first reperfusion and qualifying CT to reperfusion after adjusting for age, sex, baseline NIHSS, occlusion site, baseline Alberta Stroke Program Early CT Score (ASPECTS), intravenous alteplase administration (and time from stroke symptom onset to qualifying CT when the predictor time variable was time from qualifying CT to reperfusion). Results: A 30-minute increase in time from qualifying CT to reperfusion decreases the probability of functionally independent outcome (mRS 0-2 at 90 days) by an absolute reduction of 8.5% (p=0.006). Similar trends in relationship between outcome and time from qualifying CT to reperfusion were noted for mRS cut-points 0-1 vs. 2-6 (p=0.08) and 0-3 vs. 4-6 (p=0.04). There was no relationship between clinical outcome and stroke symptom onset to qualifying CT for any mRS cut-point. A modest relationship was noted between stroke symptom onset to reperfusion time and the probability of achieving functionally independent outcome (mRS 0-2 vs. 3-6) (p = 0.04). Conclusions and Relevance: The ESCAPE trial data with imaging based selection reveals that imaging-to-reperfusion time is more important than onset-to-imaging time as a predictor of outcome. Trial Registration at clinicaltrials.gov NCT01778335

Abstract 5: Analysis of Workflow Aad Determinants of Delays in the Escape Randomized Controlled Trial

Introduction: The ESCAPE trial used innovative imaging and aggressive target time metrics to demonstrate the benefit of additional endovascular treatment over standard care in patients with disabling acute ischemic stroke. We performed a detailed analysis of workflow and determine modifiable factors resulting in delays. Methods: The trial enrolled 316 patients fulfilling eligibility criteria and presenting within 12 hours of stroke symptom onset from 22 sites across 3 continents between February 2013 and October 2014. We considered four specific interval times: onset-to-ED arrival, ED-arrival-to-qualifying CT scan, qualifying CT scan-to-groin puncture, groin puncture-to-reperfusion. Missing times were not imputed. When reperfusion was not achieved, the reperfusion time was considered missing and was not imputed. Interval times from stroke symptom onset to first reperfusion are reported using medians and inter-quartile range. To assess the relationship between patient, hospital and health system characteristics as predictors of longer interval times, a negative binomial regression provided the best fit to the data. Results: Stroke symptom onset to arrival in emergency room of endovascular capable hospital time was 42% (34 mins) longer among patients who received intravenous alteplase at the referring hospital (drip and ship) vs. patients directly transferred to the endovascular capable hospital (direct to mother ship) (Figure). Qualifying CT to groin puncture time was 15% (8 mins) shorter among patients presenting during work hours vs. off hours. Time from qualifying CT to groin puncture was 41% (24 min) shorter in drip and ship patients than vs. when intravenous alteplase was administered after qualifying CT (mothership). General anesthesia prolonged this time by 43% (22 min). Balloon guide catheter during endovascular procedure shortened time from groin puncture to reperfusion by 21% (8 mins). Conclusions: Inefficiencies in triaging systems, presentation during off hours, intravenous alteplase administration, GA utilization and endovascular techniques offer major opportunities for improvement.

Analysis of the Outcome and Prognostic Factors of Decompressive Craniectomy between Young and Elderly Patients for Acute Middle Cerebral Artery Infarction.

ObjectiveWe compared the effect of decompressive craniectomy between patients < 65 and ≥ 65 years age and investigated prognostics factors that may help predict favorable outcome in acute stroke patients undergoing decompressive surgery.Materials and Methods52 patients diagnosed with acute middle cerebral artery (MCA) territory infarction that underwent decompressive craniectomy were retrospectively reviewed. The outcome of all patients were evaluated by assessing the Glasgow coma scale, Glasgow outcome scale (GOS), and Modified Rankin scale (mRS) six months after the onset of the disease. 21 patients were preoperatively evaluated with a computed tomography angiography (CTA). Leptomeningeal collateral (LMC) circulation was graded using CTA by experienced neurosurgeons to assess its prognostic value.ResultsThe thirty day mortality for patients ≥ 65 was 35.0% compared to 37.5% in patients < 65. There was no significant difference in the clinical and function outcome between the two groups (4.8 ± 1.2 vs. 4.5 ± 1.5, p = 0.474). Mortality was lower with early surgery (within 24 hours) group for both age groups (25% vs. 37.5% in ≥ 65, 20% vs. 40.7% in < 65). Longer intensive care units stay time and good collateral supply score were correlated with favorable outcome (p = 0.028, p = 0.018).ConclusionDecompressive craniectomy within 24 hours of stroke symptom onset improved survival in both the < 65 and ≥ 65 age groups. There was no significant difference in the functional outcome of both age groups. Unlike previous reports, old age, delayed operation, and multiple of infarct territories were not predictive of poor functional outcome. The presence of good collateral circulation may be a predictor of positive clinical outcome in acute ischemic stroke patients undergoing decompressive craniectomy.

Abstract 178: Reporting of Imaging Time Intervals in patients with Acute Ischemic Stroke undergoing Perfusion Imaging: A Systematic review and Meta-analysis

BACKGROUND: Recent STIR guidelines stress the importance of speed and the need to balance the benefits of multi-modal imaging against potential treatment delay. It is essential that studies report on relevant imaging time intervals (ITIs) including image acquisition and interpretation times. We analyzed frequency of various ITIs reported. METHODS: The search strategy was conducted by combining the themes of acute ischemic stroke, perfusion imaging, and CT/MRI. Two independent reviewers screened at all levels and disagreements were settled through consensus. The inclusion criteria was CT/MR perfusion within 24 hours of stroke symptom onset and thresholds reporting for core, penumbra, and/or normal/not at risk tissue. We collected data on relevant a priori specified ITIs from each study (Table 1) and report these as medians (of either mean or median interval time in each individual study). RESULTS: The search resulted in 9184 abstracts from EMBASE, 7249 abstracts from MEDLINE resulting in 11919 abstracts after duplicates. Of 711 studies identified for full-text review, 94 studies reported at least one relevant time interval. Pooled estimates (medians with IQR) are reported for each ITI (Table 1). We noted lack of clarity on whether these ITIs were reporting beginning or end of image (CT or MRI) acquisition. Only 3/94 (3.4%) studies reported admission to imaging time. 54/134 (40%) studies reported image acquisition time; no studies reported on image interpretation times. CT acquisition (30 studies) ranged from 30-120 seconds with a median of 47 (41.25-58.75) seconds. MRI acquisition ranged from 46-144 seconds with a median of 69.50 (60.0-84.25) seconds. CONCLUSION: ITIs are significantly under-reported in studies that describe the use of multi-modal imaging (CT/MR perfusion). There exists significant heterogeneity in the definitions of many ITIs. Admission to end of imaging acquisition, an important marker of optimized workflow is minimally reported.

Racial and Gender Differences in Stroke Severity, Outcomes, and Treatment in Patients with Acute Ischemic Stroke

Previous research has indicated that women and blacks have worse outcomes after acute ischemic stroke (AIS). Little research has been done to investigate the combined influence of race and gender in the presentation, treatment, and outcome of patients with AIS. We sought to determine the association of race and gender on initial stroke severity, thrombolysis, and functional outcome after AIS. AIS patients who presented to 2 academic medical centers in the United States (2004-2011) were identified through prospective registries. In-hospital strokes were excluded. Stroke severity, measured by admission National Institutes of Health Stroke Scale (NIHSS) scores, treatment with tissue plasminogen activator (tPA), neurologic deterioration (defined by a ≥2-point increase in NIHSS score), and functional outcome at discharge, measured by the modified Rankin Scale, were investigated. These outcomes were compared across race/gender groups. A subanalysis was conducted to assess race/gender differences in exclusion criteria for tPA. Of the 4925 patients included in this study, 2346 (47.6%) were women and 2310 (46.9%) were black. White women had the highest median NIHSS score on admission (8), whereas white men had the lowest median NIHSS score on admission (6). There were no differences in outcomes between black men and white men. A smaller percentage of black women than white women were treated with tPA (27.6% versus 36.6%, P < .0001), partially because of a greater proportion of white women presenting within 3 hours (51% versus 45.5%, P = .0005). Black women had decreased odds of poor functional outcome relative to white women (odds ratio [OR] = .85, 95% confidence interval [CI] .72-1.00), but after adjustment for baseline differences in age, NIHSS, and tPA use, this association was no longer significant (OR = 1.2, 95% CI .92-1.46, P = .22). Black women with an NIHSS score less than 7 on admission were at lower odds of receiving tPA than the other race/gender groups, even after adjusting for arriving within 3 hours and admission glucose (OR = .66, 95% CI .44-.99, P = .0433). Race and gender were not significantly associated with short-term outcome, although black women were significantly less likely to be treated with tPA. Black women had more tPA exclusions than any other group. The primary reason for tPA exclusion in this study was not arriving within 3 hours of stroke symptom onset. Given the growth in incident strokes projected in minority groups in the next 4 decades, identifying factors that contribute to black women not arriving to the emergency department in time are of great importance.

Acute Basilar Artery Occlusion: Outcome of Mechanical Thrombectomy with Solitaire Stent within 8 Hours of Stroke Onset

Mechanical thrombectomy with a stent retriever applied shortly after symptom onset could increase good functional outcomes and improve survival in patients with acute basilar artery occlusion, but this has not yet been studied. This study evaluated the efficacy and safety of mechanical thrombectomy with a Solitaire stent within 8 hours of stroke onset in patients with acute basilar artery occlusion. We analyzed 25 consecutive patients with acute basilar artery occlusion who were treated with mechanical thrombectomy by use of the Solitaire stent within 8 hours of stroke symptom onset. Successful recanalization was defined as TICI grade 2b or 3. Good outcome was defined as mRS score of 0-2 at 3 months. Clinical and radiologic data in patients with good outcomes were compared with those with poor outcomes. Successful recanalization was achieved in 96% (24/25) of patients, and 48% (12/25) of patients had good outcomes. Eighty-eight percent (22/25) of patients survived to 3 months. The median NIHSS score on admission was significantly lower in patients with good outcomes than in those with poor outcomes (9.5 versus 14, P = .005). Procedure-related complications occurred in 2 patients (8%). No symptomatic intracerebral hemorrhages occurred. The current study suggests that mechanical thrombectomy by use of a Solitaire stent within 8 hours of stroke onset increases good outcomes and improves survival in patients with acute basilar artery occlusion.