Hours Of Symptom Onset Research Articles

Assessment of Perfusion Volumes by a New Automated Software for Computed Tomography Perfusion

IntroductionTo compare the perfusion volumes assessed by a new automated CT perfusion (CTP) software iStroke with the circular singular value decomposition software RAPID and determine its predictive value for functional...

Stroke and high-risk TIA outcomes with reduction of treatment duration when treatment initiated in emergency rooms (SHORTER-study).

Following transient ischemic attack (TIA) and minor stroke, the risk of recurrent stroke can be significantly reduced with short-duration dual antiplatelet therapy (DAPT). We wish to investigate whether 10 days of DAPT is as effective as 21 days' treatment. This is an open-label, randomized, parallel-group study comparing whether 10 days of DAPT treatment (ASA + clopidogrel) is non-inferior to 21 days of DAPT in patients with acute ischemic stroke (AIS) or high-risk TIA. In both groups, DAPT is started within 24 hours of symptom onset. This study is being conducted in approximately 15 study sites in the Kingdom of Saudi Arabia. The planned sample size is 1932. Non-inferiority of 10 days compared to 21 days of DAPT in the prevention of the composite endpoint of stroke and death at 90 days in AIS/TIA patients. The primary safety outcome is major intra-cranial and systemic hemorrhage. Enrolment started in the second quarter of 2023, and the completion of the study is expected in the fourth quarter of 2025. The trial is expected to show that 10 days of DAPT is non-inferior for the prevention of early recurrence of vascular events in patients with high-risk TIAs and minor strokes.

Family history of sudden cardiac death among vctims of sudden death in yazd, iran

Objectives: A positive family history of Sudden Cardiac Death (SCD) is an independent risk factor for mortality. This study aimed to determine the prevalence of a positive family history of SCD and its associated risk factors among victims of sudden death in Yazd.
 Methods: This cross-sectional study investigated SCD cases in Yazd, Iran, in 2011. The study included victims who were aged 20 years or older, and the cause of death was the cardiac arrest within one hour of symptom onset. The data obtained from families of SCD victims through verbal autopsy interviews.
 Results: A total of 317 cases of SCD occurred among victims, resulting in an incidence rate of 139.4 per 100,000 population 26.2% had a positive family history of SCD, with a mean age of 60.4 ± 12.3 years. Individuals with a positive family history of SCD had a significantly younger mean age at the time of death (60.9 ± 12.3 vs. 66.9 ± 16.5 years, P = 0.018). The prevalence of diabetes mellitus (odds ratio 1.43, CI 95% = 1.03–1.99, P = 0.042), dyslipidemia (odds ratio 1.47, CI 95% = 1.07–2.1, P = 0.038), chronic coronary artery disease (P =0.027), and revascularization (P = 0.049) had a significant association with positive family history of SCD.
 Conclusions: This study highlights the importance of assessing family history as a risk factor for SCD, along with other risk factors such as diabetes, dyslipidemia, and chronic coronary artery disease.

Clopidogrel Plus Aspirin vs Aspirin Alone in Patients With Acute Mild to Moderate Stroke

Dual antiplatelet therapy has been demonstrated to be superior to single antiplatelet in reducing recurrent stroke among patients with transient ischemic attack or minor stroke, but robust evidence for its effect in patients with mild to moderate ischemic stroke is lacking. To evaluate whether dual antiplatelet therapy is superior to single antiplatelet among patients with mild to moderate ischemic stroke. This was a multicenter, open-label, blinded end point, randomized clinical trial conducted at 66 hospitals in China from December 20, 2016, through August 9, 2022. The date of final follow-up was October 30, 2022. The analysis was reported on March 12, 2023. Of 3065 patients with ischemic stroke, 3000 patients with acute mild to moderate stroke within 48 hours of symptom onset were enrolled, after excluding 65 patients who did not meet eligibility criteria or had no randomization outcome. Within 48 hours after symptom onset, patients were randomly assigned to receive clopidogrel plus aspirin (n = 1541) or aspirin alone (n = 1459) in a 1:1 ratio. The primary end point was early neurologic deterioration at 7 days, defined as an increase of 2 or more points in National Institutes of Health Stroke Scale (NIHSS) score, but not as a result of cerebral hemorrhage, compared with baseline. The superiority of clopidogrel plus aspirin to aspirin alone was assessed based on a modified intention-to-treat population, which included all randomized participants with at least 1 efficacy evaluation regardless of treatment allocation. Bleeding events were safety end points. Of the 3000 randomized patients, 1942 (64.6%) were men, the mean (SD) age was 65.9 (10.6) years, median (IQR) NIHSS score at admission was 5 (4-6), and 1830 (61.0%) had a stroke of undetermined cause. A total of 2915 patients were included in the modified intention-to-treat analysis. Early neurologic deterioration occurred in 72 of 1502 (4.8%) in the dual antiplatelet therapy group vs 95 of 1413 (6.7%) in the aspirin alone group (risk difference -1.9%; 95% CI, -3.6 to -0.2; P = .03). Similar bleeding events were found between 2 groups. Among Chinese patients with acute mild to moderate ischemic stroke, clopidogrel plus aspirin was superior to aspirin alone with regard to reducing early neurologic deterioration at 7 days with similar safety profile. These findings indicate that dual antiplatelet therapy may be a superior choice to aspirin alone in treating patients with acute mild to moderate stroke. ClinicalTrials.gov Identifier: NCT02869009.

The testamentary capacity in acute stroke. A cross-sectional study.

Succession law, which governs the creation and validity of wills, is closely tied to testamentary capacity (TC), the cognitive competence required for a valid will. This study explores TC in acute stroke patients and its connections to demographic and clinical characteristics. The research included first-time stroke patients admitted within 24 hours of symptom onset, meeting specific criteria. Data were collected, and assessment tools like the Addenbrooke's Cognitive Examination III (ACE-III) and Testamentary Capacity Assessment Tool (TCAT) were used. The study found that TCAT scores were not significantly affected by age or gender but positively correlated with education, the Barthel Index and ACE-III scores. They were negatively associated with National Institutes of Health Stroke Scale (NIHSS) and Modified Rankin Scale (mRS) scores. Specific cognitive domains, particularly memory and attention, were independent determinants of TCAT scores. This research introduces TCAT as a valuable tool for evaluating testamentary capacity in stroke patients and highlights the multifaceted nature of TC, emphasizing the need for a nuanced approach. As the population ages and complex medical conditions become more prevalent, understanding the interplay between cognitive functioning and testamentary capacity becomes increasingly crucial for both legal and medical professionals.

Ovarian torsion: A retrospective case series at a tertiary care center emergency department.

Ovarian torsion (OT) is a gynecological emergency that can have diverse clinical presentations makings its diagnosis especially challenging. Few studies exist in the literature describing the clinical presentation as well as the management of OT in the emergency department (ED). This study aims to describe the clinical presentation, physical examination, emergency management, radiographic and intraoperative findings, histopathology reports and the time-to-intervention metrics of OT cases presenting to the emergency room of our tertiary care center. Data was collected by a retrospective chart review of all OT cases that presented to our ED over a period of 1 year. A total of 20 cases were included in the final analysis. The incidence of OT in the ED was 157.4 per 100 000 visits of women in the reproductive age group. All patients were women of reproductive age, with a mean age of 27.3 years. A total of 15 patients (78.9%) presented within 24 hours of symptom onset. The most common presenting symptom was abdominal pain (95%, 19/20) with most localizing to the right lower quadrant (60%, 12/20), followed by nausea and vomiting (90%, 18/20). Almost all patients (95%, 19/20) required opioids for pain management. The majority (80%, 16/20) were diagnosed by ultrasound prior to surgery, whereas (20%, 4/20) went straight to surgery based on a high index of clinical suspicion. Among those who underwent ultrasound, ovarian cyst was present in (75%, 12/16) while (68.9%, 11/16) showed ovarian enlargement and (50%, 8/16) showed abnormal ovarian blood flow. All patients except one patient underwent operative management. Out of the 19 patients who underwent surgery, the majority of patients (94.7%, 18/19) had viable ovaries with the exception of 1 patient (5.3%) who required a salpingo-oophorectomy post ovarian detorsion. A total of 13 cases included histopathologic review of specimens out of which 6 (46.2%) had a mature cystic teratoma. The mean time from door to ultrasonography was 1.4 hours and from door to surgery was 11.4 hours. Our study provides valuable insights into the incidence, clinical presentation, physical examination, emergency management, ultrasonographic and intraoperative findings, histopathology reports as well as the time-to-intervention metrics of OT patients presenting to the ED.

Use of the SONAS Ultrasound Device for the Assessment of Cerebral Perfusion in Acute Ischemic Stroke

Background Early recognition of large‐vessel occlusion in acute ischemic stroke is pivotal to ensuring timely and effective treatment. However, current prehospital evaluation strategies largely rely on stroke scales that lack sensitivity and specificity. Recently, a novel, portable, noninvasive brain perfusion ultrasound device (SONAS) was developed as a diagnostic aid and demonstrated robust correlation with magnetic resonance imaging–based brain perfusion imaging. The present study aimed to investigate the feasibility and diagnostic performance of the SONAS device in identifying alterations in cerebral blood flow in patients with acute ischemic stroke with suspected or known perfusion deficits. Methods We performed a phase II, single‐arm, prospective study using SONAS in a close timely relation to computed tomography perfusion imaging in subjects diagnosed with acute ischemic stroke and suspected or known large‐vessel pathology, presenting within 24 hours of symptom onset between April 2019 through December 2019. Performance end points included successful measurement of time‐to‐peak in each hemisphere and comparison of perfusion deficits measured by SONAS to the reference standard computed tomography perfusion imaging. Safety end points included frequency, severity, and outcome of adverse events. Results A total of 20 subjects were enrolled. Eighteen subjects (90%) had microbubble signals successfully detected on initial assessment by SONAS. The diagnostic accuracy of the SONAS device in identifying a perfusion deficit was 88.9%. The sensitivity was 14 of 15 (93.3%), and the specificity was 2 of 3 (66.7%). No adverse events were reported secondary to SONAS or the contrast agent used. Conclusion In this clinical study, we demonstrated that the SONAS system is a safe tool that can aid in identifying cerebral perfusion deficits in this selected population of patients with acute ischemic stroke with suspected or known perfusion deficits. Future studies should assess the efficacy and impact on clinical outcomes of using SONAS in a real‐world “in the field” setting on a large subset of patients with suspected stroke and in addition to prehospital stroke scales.

Time to Anticoagulation Reversal and Outcomes After Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) is the deadliest stroke subtype, and mortality rates are especially high in anticoagulation-associated ICH. Recently, specific anticoagulation reversal strategies have been developed, but it is not clear whether there is a time-dependent treatment effect for door-to-treatment (DTT) times in clinical practice. To evaluate whether DTT time is associated with outcome among patients with anticoagulation-associated ICH treated with reversal interventions. This cohort study used data from the American Heart Association Get With The Guidelines-Stroke quality improvement registry. Patients with ICH who presented within 24 hours of symptom onset across 465 US hospitals from 2015 to 2021 were included. Data were analyzed from January to September 2023. Anticoagulation-associated ICH. DTT times and outcomes were analyzed using logistic regression modeling, adjusted for demographic, history, baseline, and hospital characteristics, with hospital-specific random intercepts to account for clustering by site. The primary outcome of interest was the composite inpatient mortality and discharge to hospice. Additional prespecified secondary outcomes, including functional outcome (discharge modified Rankin Scale score, ambulatory status, and discharge venue), were also examined. Of 9492 patients with anticoagulation-associated ICH and documented reversal intervention status, 4232 (44.6%) were female, and the median (IQR) age was 77 (68-84) years. A total of 7469 (78.7%) received reversal therapy, including 4616 of 5429 (85.0%) taking warfarin and 2856 of 4069 (70.2%) taking a non-vitamin K antagonist oral anticoagulant. For the 5224 patients taking a reversal intervention with documented workflow times, the median (IQR) onset-to-treatment time was 232 (142-482) minutes and the median (IQR) DTT time was 82 (58-117) minutes, with a DTT time of 60 minutes or less in 1449 (27.7%). A DTT time of 60 minutes or less was associated with decreased mortality and discharge to hospice (adjusted odds ratio, 0.82; 95% CI, 0.69-0.99) but no difference in functional outcome (ie, a modified Rankin Scale score of 0 to 3; adjusted odds ratio, 0.91; 95% CI, 0.67-1.24). Factors associated with a DTT time of 60 minutes or less included White race, higher systolic blood pressure, and lower stroke severity. In US hospitals participating in Get With The Guidelines-Stroke, earlier anticoagulation reversal was associated with improved survival for patients with ICH. These findings support intensive efforts to accelerate evaluation and treatment for patients with this devastating form of stroke.

Abstract TMP61: Induced Hypertension in Acute Ischemic Stroke: Systematic Review and Meta-Analysis

Background and Objectives: It is unclear whether induced hypertension in acute ischemic stroke (AIS) may improve long-term outcomes. We conducted a systematic review and meta-analysis to compare the safety and efficacy of induced hypertension vs standard medical care in patients presenting with acute ischemic stroke within 72 hours of symptom onset. Methods: Two reviewers systematically searched PubMed using the prespecified terms “induced hypertension” or “blood pressure augmentation” plus “ischemic stroke” for clinical trials that reported functional independence (mRS 0-2) at 90 days. The safety outcome was symptomatic intracranial hemorrhage (sICH). Pooled odds ratio (OR) and 95% CI across trials were synthesized using fixed-effect model based on Mantel-Haenszel methods. Forest plots were constructed. Results: Three clinical trials with 270 AIS patients treated with induced hypertension (n=126) or standard medical care (n= 144) were included. Mean age was 66.6 years, 35.2% were women, and the mean initial NIHSS was 7.5. The rate of functional independence at 90 days was higher in patients treated with induced hypertension (70.6%) versus control (54.9%) (OR 1.88; 95% CI 1.13-3.11; p=0.01). sICH did not differ between patients treated with induced hypertension (<1%) versus control (<1%) (OR 1.03; 95% CI 0.14-7.45; p=0.98). Discussion: Among patients presenting with acute ischemic stroke with 72 hours of symptoms onset, induced hypertension resulted in better functional outcome at 90 days than standard medical care and did not increase risk of sICH. Large RCTs to test this observation are ongoing and needed to guide clinical practice.

Abstract TP141: Understanding Potential Limitations of CTP Imaging in Early Window Large Vessel Anterior Circulation Strokes

Background: Computerized tomography perfusion (CTP) imaging serves as a valuable modality for the assessment of individuals with a large vessel anterior circulation stroke. Current literature proposes that employing CTP imaging in patients within the initial time frame of less than 8 hours, may lead to an overestimation of the projected infarct core, specifically when utilizing cerebral blood flow (CBF) less than 30%. The hypoperfusion intensity ratio (HIR) may result in overestimation. We sought to further investigate the interplay of CTP parameters in patients presenting within 8 hours of symptom onset of stroke, to assess the accuracy of core infarct estimation. Methods: A retrospective cohort study analyzing patients with large vessel anterior occlusion (LVAO) who underwent CTP and mechanical thrombectomy within 24 hours of symptom onset between January 2017 to December 2022. RAPID software estimates the infarct core using CBF <30%. DWI-MRI determined final infarct volume. A multivariate logistic regression model was employed to assess the impact of HIR and reperfusion success on outcomes. Results: Ninety-seven patients were identified within an 8-hour time window. CBF<30% overestimated core infarct volume (mL) in 22 patients (22.6%) with a mean of 15.72 (range 4.4-37.7) and a median of 22.85. Of these, 2 patients experienced poor reperfusion (9%) while 20 had successful reperfusion (91%). Of the patients who did have successful reperfusion, an average of 13.57mL core was overpredicted compared to the DWI volumes. A multivariate logistic regression model adjusting for degree of reperfusion, administration of thrombolytic, and time from symptom onset showed that HIR strongly predicted the probability of core estimation with an odds ratio of 148.6, 95% CI [21.0-1048.8], (p<0.001). Conclusion: HIR exceeding 0.4 demonstrates a predictive capacity for core overestimation in early-window LVAO patients. Our study affirms this observation with statistical significance. The integration of HIR as a parameter for early-window LVAO core computation shows promise, and has potential ramifications for patient selection for thrombectomy. In this context, utilization of further databases is imperative for validation and broader application of HIR.

Abstract WP172: A Novel Score to Predict Early Time From Symptom Onset to Hospital Arrival in Patients With Intracerebral Hemorrhage

Introduction: Up to 40% of ICH patients have unknown onset time, leading to uncertainty regarding the use of hyperacute ICH treatments and their exclusion from acute ICH treatment trials. We aimed to develop a prediction score that can reliably identify ICH patients presenting within 3 hours of symptom onset. Methods: Spontaneous ICH patients participating in the iDEF trial with available prerequisite data were analyzed. A stepwise multivariable logistic regression model was used to determine predictors of early presentation (symptom onset-to-baseline CT scan time ≤3 hours) with a p-value < 0.15. To develop the prediction score, we allocated scores proportional to the standardized odds ratio (OR) of each binary variable. Continuous variables were dichotomized using the lowest threshold above which there was no additional gain in the positive predictive value (PPV) for early presentation. Results: Of 291 iDEF participants, 132 (45%) presented early. Baseline NIHSS (OR 1.05 per 1-score increase; 95% CI, 0.99-1.11), Glasgow Coma Scale (1.18 per 1-score increase; 1.01-1.39), ICH volume (1.17 per 10-ml increase; 0.98-1.39), absolute perihematomal edema volume (0.81 per 10-ml increase; 0.66-1.00), irregular hematoma shape (2.24; 1.12-4.48), blend sign (0.45; 0.21-0.97), white blood cell count (0.89 per 10 3 cell/ml increase; 0.82-0.96), and blood glucose levels (0.91 per mmol/l increase; 0.82-0.99) were associated with early presentation (c-statistic=0.71). The PPV for an early ICH presentation score (Figure) of >7 was 69%. Conclusion: This novel early ICH presentation score using readily available clinical, neuroimaging, and laboratory data has good performance for identification of ICH patients presenting within 3 hours of symptom onset. If validated in external datasets, the early ICH presentation score can be used to improve recruitment feasibility in acute ICH trials and support clinical decision-making in ICH patients with an unknown symptom onset time.

Abstract WP38: Nurse-Driven Emergency Evaluation Improves Timely Acute Stroke Response

Background: Stroke is associated with high rates of death and disability; prompt and effective interventions are imperative. Depending on emergency department (ED) physicians to initiate stroke codes may delay critical time targets, especially for patients arriving by private vehicle (POV). This study examines existing stroke care protocols in the ED of a Comprehensive Stroke Center and evaluates a new nurse-driven acute stroke response protocol. Purpose: The primary goal of this initiative was to improve outcomes for patients arriving by POV, by reducing triage delays and accelerating time-sensitive acute stroke interventions. Methods: This retrospective study implemented a nurse-led stroke activation process, in lieu of the conventional physician-led method. Nurses received comprehensive training in intervention goals and identification of stroke symptoms and last known-well times. The nurse-led model targeted patients presenting to the ED with a minimum of 2 stroke symptoms within 6 hours of symptom onset—an assessment tool, incorporating the FAST algorithm (Face, Arm, Speech, Time) and key National Institutes of Health Stroke Scale (NIHSS) exam components, enhanced symptom specificity. Critical intervention times were evaluated for improvement. Results: ED POV arrival patients with acute stroke symptoms were studied from 11/7/21-7/31/23; the nurse-driven process was implemented on 11/7/22. Pre-intervention review included 247 patients with 216 patients in the post-intervention review. Median door-to-activation times fell from 17 to 10 minutes, door-to-CT from 24 to 19 minutes, and door-to-needle times from 49 to 43.5 minutes. Median NIHSS scores in tPA-treated patients were compared pre- and post-intervention. In the physician-led group, initial median NIHSS scores were 6, reducing to 1 at discharge. The nurse-led group showed an initial median NIHSS score of 5, also reducing to 1 at discharge. Conclusions: The nurse-driven method effectively shortened critical time metrics in the stroke code process, while maintaining optimal patient outcomes. A paradigm shift towards ED triage nurse-led stroke code activation for acute stroke may lead to higher quality acute stroke care.

Risk Factors and Prognosis of Early Neurological Deterioration after Bridging Therapy.

Early neurological deterioration (END) after bridging therapy (BT) of acute ischemic stroke (AIS) patients is associated with poor outcomes. We aimed to study the incidence, risk factors and prognosis of END after BT. From January to December 2021, the clinical data of AIS patients treated by BT (intravenous thrombolysis with alteplase prior to mechanical thrombectomy) from three comprehensive stroke centers were analyzed. Patients were divided into non-END group and END group according to whether they developed END within 72 hours of symptom onset. Modified Rankin scale (mRS) was used to assess the patient's prognosis at 90 days, and favorable outcomes were defined as mRS≤2. The incidence of END was investigated, and binary logistic regression analysis was used to explore its associated factors. The incidence of END after BT was 33.67%. The eligible 90 patients included 29 cases in the END group and 61 cases in the non-END group. Multivariate Logistic regression analysis showed that increase of systolic blood pressure (SBP) (OR=1.026, 95%CI:1.001-1.051, p =0.043), higher level of blood glucose at admission (OR=1.389, 95%CI:1.092-1.176, p =0.007) and large artery atherosclerosis (LAA) subtype (OR=8.009, 95%CI:2.357-27.223, p =0.001) were independent risk factors of END. Compared with the non-END group, the END group had significantly lower rates of good outcomes (6.90% versus 65.57%, p =0.001) while higher rates of mortality (44.83% versus 4.92%, p =0.001). It was found that the incidence of END after BT in AIS patients was 33.67%. An increase in SBP, higher glucose levels at admission, and LAA were independent risk factors of END that predicted a poor prognosis.

Abstract 44: Portable Optical Blood Flow Monitor for the Detection of Large Vessel Occlusion

Introduction: Early detection of large vessel occlusion (LVO) facilitates triage to appropriate stroke centers and reduces treatment times. Prehospital stroke scales are insensitive, so we investigated the ability of the Openwater Headset, a portable optical blood flow monitor, to detect LVO in patients undergoing acute stroke evaluation. Hypothesis: We hypothesized that the Openwater Headset would detect LVO with greater sensitivity and specificity than prehospital scales. Methods: At two comprehensive stroke centers, eligible patients presented to the emergency department or were transferred from another facility for acute stroke evaluation within 24 hours of symptom onset and NIHSS ≥2. Eligible patients underwent emergent vascular imaging as per routine care. LVO was defined as occlusion of the ICA or the first/second segment of the MCA. Each patient underwent a 70-second bedside optical blood flow evaluation with the Openwater Headset (prior to endovascular therapy, if applicable). The Openwater Headset generated blood flow waveforms based on the relative change in the speckle contrast, acquired at 40 Hz. A deep neural network was trained to identify waveform features that discriminate LVO status ( Figure 1a ), withholding a validation set to test model performance. ROC analysis compared Openwater Headset performance with that of prehospital stroke scales. Results: 135 patients completed the optical evaluation a median of 6 hours after symptom onset (IQR: 3-14). The median NIHSS was 9 (IQR: 4-18). 52 patients (39%) had a LVO. The Openwater LVO stroke alert algorithm had 81% sensitivity and 80% specificity for the presence of LVO (AUC 0.85 by ROC analysis), exceeding that of prehospital stroke scales ( Figure 1b ). Conclusions: The Openwater Headset outperformed prehospital stoke scales for LVO detection in patients who underwent acute stroke evaluation, but further investigation is needed to assess performance in pre-hospital settings.

Abstract 57: Rapid Prehospital Diagnosis of Intracerebral Hemorrhage by Measuring GFAP on a Point-of-Care Platform

Background: The rapid differentiation between intracerebral hemorrhage (ICH) and ischemic stroke (IS) in patients with symptoms of acute stroke is decisive for triage and initiation of targeted therapies. Glial fibrillary acidic protein (GFAP) is a highly promising blood biomarker indicating acute ICH. In this study we investigated the potential of a new GFAP plasma test on a point-of-care (POC) platform for rapidly distinguishing ICH from IS in the prehospital phase. Methods: Patients with symptoms of acute stroke admitted within 6 hours of symptom onset were enrolled. Blood samples were collected already in the prehospital phase in most patients. Plasma GFAP measurements were performed on the i-STAT Alinity® (Abbott) device (duration of analysis 15 min). The primary endpoint was the final diagnosis at hospital discharge categorized as ICH, IS or stroke mimics. Results: 155 patients were enrolled (mean age 75±13, 49% females; final diagnosis 33 ICH, 115 IS, 7 stroke mimics). Prehospital GFAP serum concentrations were strongly elevated in ICH patients compared to IS patients (mean 2283±3821 pg/mL, median 144 [IQR 52.5-2562] vs. mean 45±25 pg/mL, median 29 [IQR 29-53]; p<0.001). In patients with a moderate to severe neurological deficit (NIHSS > 7), GFAP values below 30 pg/mL were associated with a negative predictive value of 100% (i.e. ruling out ICH). The probability of ICH increased in parallel with higher GFAP levels. GFAP concentrations above 120 pg/mL indicated ICH with a positive predictive value of 94%. Conclusion: Rapid prehospital GFAP measurements on a point-of-care platform allow a reliable differentiation between patients with IS and ICH. This opens the potential for optimized triage and for the administration of antidots in severely affected patients with suspected anticoagulation-associated ICH.

Abstract WP23: Hemorrhagic Transformation Following Anticoagulation in Victims of Acute Ischemic Stroke Secondary to Intra-Cardiac Thrombi

Introduction: Hemorrhagic transformation (HT) following acute ischemic stroke (AIS) is a common consideration especially when therapeutic anticoagulation is indicated in cases such as left ventricular or left atrial appendage thrombi. Although there have been multiple studies investigating the safe timing of anticoagulation initiation following AIS in patients with atrial fibrillation, the results varied. Evaluating the infarct volume and correlating it to time of anticoagulation initiation and HT can be detrimental to patient safety. Methods: We performed a retrospective review of all patients who were diagnosed with AIS secondary to cardio-embolic mechanisms and were admitted to our hospital between January 1, 2018, and December 31, 2022. The inclusion criteria consisted of patients aged 18 to 100 years who were found to have intra-cardiac thrombi and were initiated on anticoagulation within 80 hours of symptom onset. Infarct volume was measured using the ABC/2 formula. Statistical analysis was conducted using the R statistical program. For variables with a normal distribution, we used the mean and standard deviation (SD), and for variables with skewed distribution, we reported the median with interquartile range (IQR). Results: A total of 597 patient charts were reviewed for this study. After applying the inclusion criteria, 36 patients were deemed eligible for inclusion in the analysis. Among the included patients, a majority were male, constituting 80.6% (n=29) of the sample. The infarct volume among the included patients ranged from 0 ml to 100 ml. A breakdown of infarct volumes is as follows: Twenty-three patients (63.9%) had infarct volumes of 10 ml or less. Seven patients (19.4%) had infarct volumes ranging between 11 - 20 ml. Six patients (16.7%) had infarct volumes that exceeded 21 ml, with the largest infarct measuring 100 ml. There was no clinically significant HT. There were no surgical interventions required for any of our study subjects. Conclusion: The initiation of anticoagulation within 80 hours following AIS secondary to intra-cardiac thrombi may be safe, especially in patients with infarct volumes of 20 ml or less when using the ABC/2 formula.

Rationale and design of ProUrokinase in Mild IsChemic strokE (PUMICE): a multicentre, prospective, randomised, open-label, blinded-endpoint controlled trial.

Recombinant human prourokinase (rhPro-UK) is a new generation of specific plasminogen activator, that is non-inferior to alteplase in acute ischemic stroke. We aimed to investigate the efficacy and safety of rhPro-UK compared with standard medical treatment in acute mild ischemic stroke within 4.5 hours of symptom onset. Prourokinase in mild ischemic stroke is a multicentre, prospective, randomised, open-label, blinded-endpoint controlled trial. Patients who had an acute ischemic stroke within 4.5 hours from symptom onset and with baseline National Institutes of Health Stroke Scale (NIHSS) score ≤ 5 will be recruited. Patients will be randomly assigned (1:1) to receive intravenous rhPro-UK (35 mg) or standard medical treatment. The follow-up duration will be 90 days. The calculated sample size is 1446. Primary efficacy outcome is an excellent functional outcome, defined as a modified Rankin Scale (mRS) score ≤ 1 at 90 days. Secondary efficacy outcomes include ordinal distribution of mRS at 90 days, mRS score ≤ 2 at 90 days, early neurological improvement at 24 hours (a decrease of NIHSS score ≥ 4 points compared with baseline or NIHSS score ≤ 1 point), Barthel index of 75-100 points at 90 days, quality of life at 90 days, and activities of daily living at 90 days. Safety outcomes are symptomatic intracranial haemorrhage within 36 hours, mortality at 90 days, moderate and severe systematic bleeding at 90 days, and adverse events/serious adverse events within 90 days. This large phase III randomised clinical trial will answer the question of whether thrombolysis is beneficial for acute mild ischemic stroke, and may provide evidence for rhPro-UK in patients had an acute mild ischemic stroke within 4.5 hours of symptom onset. NCT05507645.

Argatroban in Patients With Acute Ischemic Stroke With Early Neurological Deterioration

The effect of argatroban in patients with acute ischemic stroke (AIS) and early neurological deterioration (END) is unknown. To assess the efficacy of argatroban for END in AIS. This open-label, blinded-end point, randomized clinical trial was conducted from April 4, 2020, through July 31, 2022. The date of final follow-up was October 31, 2022. This was a multicenter trial. Eligible patients were adults with AIS who experienced END, which was defined as an increase of 2 or more points on the National Institutes of Health Stroke Scale within 48 hours from symptom onset. Patients who withdrew consent, experienced duplicate randomization, or were lost to follow-up were excluded from the study. Patients were randomly assigned to the argatroban group and control group within 48 hours of symptom onset. Both groups received standard therapy based on guidelines, including oral mono or dual antiplatelet therapy. The argatroban group received intravenous argatroban for 7 days (continuous infusion at a dose of 60 mg per day for 2 days, followed by 20 mg per day for 5 days) in addition to standard therapy. The primary end point was good functional outcome at 90 days, defined as a modified Rankin Scale score of 0 to 3. A total of 628 patients (mean [SD] age, 65 [11.9] years; 400 male [63.7%]) were included in this study (argatroban group, 314 [50%] and control group, 314 [50%]). Of these, 18 withdrew consent, 1 had duplicate randomization, and 8 were lost to follow-up. A total of 601 patients with stroke were included in the intention-to-treat analysis. Finally, 564 patients were included in the per-protocol analysis as 6 participants in the argatroban group and 31 participants in the control group did not follow the complete protocol. The number of patients with good functional outcome at 90 days was 240 (80.5%) in the argatroban group and 222 (73.3%) in the control group (risk difference, 7.2%; 95% CI, 0.6%-14.0%; risk ratio, 1.10; 95% CI, 1.01-1.20; P = .04). The proportion of symptomatic intracranial hemorrhage was 3 of 317 (0.9%) in the argatroban group and 2 of 272 (0.7%) in the control group (P = .78). Among patients with AIS with END, treatment with argatroban and antiplatelet therapy resulted in a better functional outcome at 90 days. This trial provided evidence to support the use of argatroban in reducing disability for patients with END. ClinicalTrials.gov Identifier: NCT04275180.

Correlation Between Magnitude of ST Segment Elevation and the Proximal Right Coronary Artery Lesion in Acute Inferior Myocardial Infarction

Introduction: The determination of the probable site of occlusion within RCA in acute inferior MI is very important because proximal occlusions are likely to cause greater myocardial damage and an early invasive strategy may be planned in such cases. Furthermore, identification of infarct-related artery and its site in acute inferior myocardial infarction not only guide decision regarding the urgency of revascularization but also guide to avoid therapy that may adversely affect the outcome. Objective: To predict the site of lesion in right coronary artery in acute inferior myocardial infarction by the magnitude of ST segment elevation in inferior leads (II, III and aVF). Methodology: This cross-sectional study was conducted in the Department of Cardiology, Sylhet MAG Osmani Medical College Hospital, from January 2014 to December 2015. A total of 50 consecutive patients with inferior MI who present within 12 hours of symptom onset and received fibrinolytic therapy were selected according to inclusion and exclusion criteria. Using 12-lead ECG, height of ST segment elevation in leads II, III and aVF were measured & coronary angiography(CAG) was performed during index hospital period .CAG which showed culprit lesion in RCA were only taken for the study. The sum of STsegment elevation in inferior leads were then correlated with the proximal lesion in RCA. Results: The age of the patients ranged from 31 to 70 years with the mean age of 51.1 (SD 9.2) years. Majorities (88%) of the patients were male and ratio of male to female was 7.33:1.Out of 50 patients, 26(52%) had the lesion in proximal, 19 (38%) in mid and 05 (10%) in distal RCA. Patients with proximal RCA lesion showed a mean ST segment elevation of 12.5(SD 1.07) mm, with mid RCA lesion 8.5 (SD 0.80) mm and distal RCA lesion 6.5(SD 0.42) mm. There was a positive correlation of sum of ST segment elevation in inferior leads II, III and aVF to the proximal lesion in RCA (r=0.923, P < 0.05). Conclusion: From the study it is concluded that the magnitude of ST segment elevation in inferior leads (II,III, aVF) can predict site of lesion in RCA in acute inferior wall myocardial infarction; the greater the sum of the height of ST segment elevation in inferior leads, the higher is the probability of lying the lesion in proximal right coronary artery. Bangladesh Heart Journal 2024; 39(1): 44-48

Ventral Anterior Cingulate Atrophy as a Predisposing Factor for Transient Global Amnesia.

This study aimed to evaluate the brain magnetic resonance imaging (MRI) of patients with acute transient global amnesia (TGA) using volumetric analysis to verify whether the brains of TGA patients have pre-existing structural abnormalities. We evaluated the brain MRI data from 87 TGA patients and 20 age- and sex-matched control subjects. We included brain MRIs obtained from TGA patients within 72 hours of symptom onset to verify the pre-existence of structural change. For voxel-based morphometric analyses, statistical parametric mapping was employed to analyze the structural differences between patients with TGA and control subjects. TGA patients exhibited significant volume reductions in the bilateral ventral anterior cingulate cortices (corrected p<0.05). TGA patients might have pre-existing structural changes in bilateral ventral anterior cingulate cortices prior to TGA attacks.