Independent Predictors Of Good Outcome Research Articles

Abstract T MP10: Pittsburgh Response to Endovascular Therapy (PRE) Score Predicts Likelihood of Benefit From Endovascular Therapy in Anterior Circulation Large Vessel Occlusions

Background: Endovascular therapy seems to benefit a subset of patients with acute large vessel occlusions (LVO). The aim of this study was to develop a clinically useful tool to identify patients with anterior circulation large vessel occlusions who are likely to benefit from endovascular therapy. Methods: Adults with anterior circulation LVOs were included. In the derivation cohort (2008-2012) from Grady Memorial hospital (GMH), independent predictors (p<0.2) of good outcome (mRS 0-2 at 90 days) were determined using logistic regression. Highly weighted factors were used to derive the PRE score as a predictor of good outcome. Four risk-quartiles were created based on observed rates of good outcomes. The PRE score was validated in the UPMC database (n=322, 2007-2013) and in a database from Unitat d'Ictus Vall d'Hebron (UIVH), Barcelona (n=203, 2009-2012). Performance of PRE was compared with HIAT-2, THRIVE and ASPECTS in predicting good outcome. Results: In the derivation cohort (N=247, mean age 66±1, median NIHSS 18), independent predictors of good outcome included age (OR 0.96, 0.94-0.98), NIHSS (OR 0.92, 0.87-0.98) and ASPECTS (OR 1.96, 1.6-2.5). The PRE score was calculated as follows: PRE Score = Age + 2 x NIHSS - 10 x ASPECTS. PRE predicted good outcomes in the derivation cohort (AUC 0.79) as well as in the validation cohorts (UPMC: AUC 0.79 and UIVH: AUC 0.72) and comparative rates of good outcome were observed in the four PRE quartiles. PRE < 25 was associated with good outcome (OR 6.0, 3.5-10.5), and controlling for TICI 2B/3 reperfusion status further strengthened this association (OR 12.8, 4.5-36.2). PRE (AUC 0.79) performed better than HIAT2 (AUC 0.75), THRIVE (AUC 0.73) and ASPECTS (AUC 0.57) in predicting good outcomes after endovascular therapy. Conclusions: The PRE score is a validated tool to predict benefit from endovascular therapy in patients with anterior circulation LVO. PRE can aid in the selection of patients for endovascular reperfusion therapy.

Abstract T MP18: Physical Activity Prior to Stroke May Exert Neurorestorative Effects by Increasing Vascular Endothelial Growth Factor Expression after Acute Ischemic Stroke

Objective: Previous studies by our group have found an independent association between pre-stroke physical activity (PhA) and good functional outcome in a cohort of patients with a cerebral large vessel occlusion. In this study our aim was to evaluate the possible molecular mechanisms by which PhA exerts its neurorestorative effect by studying angiogenic and neurogenic growth factors at different timepoints after stroke onset. Methods: We included 159 consecutive previously independent patients with an acute stroke due to MCA or TICA occlusion within the first 8 hours from stroke onset. Pre-stroke PhA was evaluated with the international physical activity questionnaire (IPAQ) and subjects were classified into 2 groups: low and high level of pre-stroke PhA. We measured serum levels of Vascular Endothelial Grow Factor (VEGF), Granulocyte Colony-Stimulating Factor (G-CSF) and Brain-Derived Neurotrophic Factor (BDNF) at admission, day 7, and 3 months. We considered good functional outcome at 3 months (mRS ≤ 2) as primary endpoint. Results: Mean age was 68 and median NIHSS 17. Serum levels of VEGF, G-CSF and BDNF at admission were similar among patients with good (46.5%) and poor (53.5%) functional outcome, However, VEGF and G-CSF serum levels were significantly higher at 7 days and 3 months (p<0.05) in those patients who showed good functional outcome, emerging as independent predictors of good outcome in adjusted logistic regression analyses. When we studied the temporal profile of biomarkers in the different groups of pre-stroke PhA, we observed that those more physically active before stroke had a significantly higher increment of VEGF at day 7 compared to those with low PhA level. In a logistic regression model adjusted for age, sex, baseline NIHSS, reperfusion therapies administered, VEGF increment at day 7 and level of PhA previous to stroke, both VEGF increment and high level of pre-stroke PhA emerged as independent predictors of good functional outcome with and OR 7.7 and 33 respectively, p<0.05. Conclusion: Beneficial effect of pre-stroke PhA in stroke outcomes may be mediated by increasing the expression of VEGF in the first days after stroke, triggering angiogenesis processes.

Abstract 183: Examining the Effect of Intra-Arterial Therapy on Outcomes in IV tPA Ineligible Ischemic Stroke Patients

Background: Recent randomized trials (RCTs) have failed to show benefit of intra-arterial therapy (IAT) compared with patients given IV tPA alone. Many patients, however, are ineligible for IV tPA, who were not included in IMS-3, MR-RESCUE or SYNTHESIS. We investigated potential treatment effects of IAT in patients with acute ischemic stroke ineligible for tPA. Methods: In a US multicenter retrospective cohort study, we identified 476 AIS IV tPA ineligible patients with large artery occlusions (LAO) from 01/08 to 06/13. Inclusion criteria was <6hrs from symptom onset for anterior circulation and <12hrs for posterior circulation. Patients were divided into two arms (IAT vs No IAT). Logistic regression with good and bad (discharge mRS 0-2 and 4-6 respectively) outcome was performed to compare the two arms. Univariate and multivariate analyses evaluated independent predictors of good outcome after IAT. Results: Table 1 shows baseline characteristics. Presentation >4.5 hrs (52%), high INR (11%) and recent procedure (10%) were the main reasons for IV tPA ineligibility. IAT patients had 4 times greater odds of good (OR 3.9, 95%CI 1.5-10, p=0.004) and significantly less odds of poor outcome (OR 0.3, 95%CI 0.17-0.55, p<0.0001) compared to those without IAT. Significance was maintained under nearly all conditions after adjustment was made for covariates (Table 2). The distribution of mRS scores demonstrated a shift towards better outcomes in IAT treated patients (Fig 1) in spite of higher death rates in this group. In univariate analysis, good ASPECTS (8-10), good reperfusion (TICI ≥2b) and time were independent predictors of good outcome after IAT. Start of IAT in the first 3hrs from onset was associated with 5 times the odds of a good outcome than later IAT initiation (5.3, 95%CI 1.99-14.6, p=0.001). Conclusion: IAT may improve clinical outcomes in patients with LAO who are IV tPA ineligible. Testing for IAT efficacy in this patient population will require RCTs to validate our findings.

Abstract W P14: Endovascular Treatment for M2 Occlusions. A Descriptive Multicenter Experience on Behalf of the Catalan Stroke Code and Reperfusion Consortium (Cat-SCR).

Background: Patients with M2-MCA occlusion are not always considered for endovascular treatment. We aimed to study patients with an M2 occlusion treated with endovascular procedures. Methods: We studied patients prospectively included in the SONIIA register (January 2011-December 2012), a mandatory and externally audited register that monitors quality of reperfusion therapies in Catalonia under routine practice conditions. Baseline characteristics including NIHSS and occlusion location were collected. Complete recanalization was defined as a post-procedure TICI>2a, dramatic recovery: NIHSS drop>10 points or NIHSS<2 and good outcome as mRS<3 at 3 months. 24 hours CT scan determined the presence of hemorrhagic transformation (ECASS criteria) and infarct volume. Results: Of the 571 registered patients that received endovascular treatment, 65 (11.4%) presented an M2 occlusion on initial angiogram: mean age 66±15, female 47.7% median pre-procedure NIHSS 16(IQR:6). Mean time from symptom onset to groin puncture was 289±195 minutes, 35 patients (54%) received iv tPA before the procedure. Patients were treated with mechanic thrombectomy (n=49, 75.4%), ia tPA (n=3, 4.6%), both (n=7, 10.8%) or only diagnostic angiogram (n=6, 9.2%) according to interventionalist preferences. Patients who achieved complete recanalization (78.5%) had more often dramatic improvement (48% Vs 14.8%, p=0.023) smaller infarct volumes (8 vs. 82cc, p=0.013) and better outcome (66.3% Vs 30%; p=0.032) than those who did not recanalize. Rate of SICH was 9%. Independent predictors of dramatic improvement was complete recanalization (OR: 0,169 p=0.03 CI95%: 0.034-0.838) adjusted for age and baseline NIHSS Independent predictors of good outcome at 3 months were age (OR 1.067 p=0.033 CI95%: 1.005-1132) and baseline NIHSS (OR: 1.162 p=0.007 CI95%: 1.041-1.297) Conclusion: Endovascular treatment of M2 MCA occlusion seems safe. Induced recanalization may double the chances to achieve a favourable outcome

Abstract T P61: Patients With Acute Stroke Involving More Than One-Third Middle Cerebral Artery Territory Should Not be Excluded From Intravenous Thrombolysis

Background and aim: Involvement of more than one-third of middle cerebral artery (MCA) territory on initial brain CT is a relative contraindication for IV-tPA and often associated with increased bleeding risk. Involvement of more than 1/3 MCA territory on initial CT is associated with poor functional outcome at 3 months. We present the results of IV-thrombolysis among these patients at our tertiary care centre. Methods: Data from consecutive acute ischemic stroke (AIS) patients treated with IV-tPA within 4.5 hours between January 2009 to August 2012 were included. The collected data included demographic characteristics, vascular risk factors, National Institute of Health Stroke Scale (NIHSS) scores, and blood pressure levels before IV-tPA bolus. The presence of early stroke signs involving more than 1/3 of the MCA on the initial CT scan was measured by Alberta Stroke Program Early CT score (ASPECTS ≤7). Outcomes were assessed by modified Rankin Scale (mRS) score at 3 months. Results: A total of 97 AIS patients with more than one-third MCA involvement received IV-tPA during the study period. Median age was 70 yrs (range 38-89), 55% male, median NIHSS score 20 points (range 3-33) and median onset-to-treatment time 152 minutes (range 55-274). Forty-two (44%) patients achieved good functional outcomes at 3 months (mRS score 0-1). Factors associated with good outcome at 3 months on univariate analysis were younger age, hypertension, non-cardioembolic etiology and lower NIHSS score at presentation. After multivariate analysis, lower age (OR 0.965; 95%CI 0.941-0.989, p=0.005) and lower NIHSS scores at presentation were noted as independent predictor of good outcome at 3 months (OR 0.990; 95%CI 0.869-0,950 p= <0.001 ). The presence of more than1/3 MCA involvement on the ore-thrombolysis CT scan (ASPECTS <8) was not associated with a poor functional outcome at 3 months (OR 1.495 95% CI 0.881-2.540; p=0.136). Conclusions: Patients with acute stroke involving more than one-third of the MCA on initial brain CT scan, especially if associated with lower NIHSS score, should not be excluded from systemic thrombolysis.

Abstract W P35: Assessment of Collaterals on Day-2 CT Angiography Can Predict Functional Outcome in Thrombolyzed Anterior Circulation Acute Ischemic Stroke

Background: Several methods exist that assess the intracranial collaterals on CT-angiography (CTA) of the brain. We compared existing methods for quantification of collaterals on day-2 CTA in thrombolyzed AIS patients to assess their predictive value for functional outcome. Methods: Consecutive AIS patients treated with intravenous tissue plasminogen activator (IV-tPA) during 2007-2012 were included. Data were collected for demographics, vascular risk factors, NIHSS scores and stroke subtypes. Intracranial collaterals were evaluated by 2 independent neuroradiologists using 4 existing methods- Miteff’s system (grades middle cerebral artery (MCA) collateral branches with respect to sylvian fissure); Maas system (compares collaterals in affected hemisphere against the contralateral side); Modified Tan’s scale (collaterals in 50% or more of MCA territory classified as good); and 20-point collateral grading scale by Alberta Stroke Program Early CT score (ASPECTS) methodology. Good functional outcome at 3-months was determined by modified Rankin scale (mRS) scores of 0-1. Results: Day-2 CTA was performed in 150 patients with anterior circulation AIS treated with IV-tPA. Median age 66yrs (range 33-92), 47% males, median NIHSS 19 points (range 4-34) and median onset-to-treatment time 165 minutes (range 74-274). Overall, 67 (44.6%) patients achieved good functional outcome at 3-months. On univariable analysis- younger age, lower pre-tPA NIHSS scores, atrial fibrillation, good collaterals according to ASPECTS scoring and good collaterals by Maas methodology were significantly associated with good functional outcome. On multivariable analysis, lower NIHSS (OR 1.155 per NIHSS point; 95% CI 1.066-1.251, p=0.001), younger age (OR 1.052 per year; 95% CI 1.012-1.094, p=0.010), good collaterals by Maas methodology (OR 2.805 95% CI 1.122 -7.011, p =0.002) and good collaterals (score of 9 or more) by ASPECTS methodology (OR 3.769 ; 95%CI: 1.327- 10.708, p= 0.013 ) were found as independent predictors of good outcome. Conclusion: Of the existing intracranial collaterals scoring systems, only the ASPECTS and Maas methods are reliable predictor of favourable outcome in thrombolyzed anterior circulation AIS patients.

Type D Personality is Unrelated to Major Adverse Cardiovascular Events in Patients with Coronary Artery Disease Treated by Intracoronary Stenting

Previous research in cardiac patients suggested that type D personality, defined as a combination of negative affectivity (NA) and social inhibition (SI), was associated with adverse outcome. The objective of this prospective study was to examine the independent prognostic value of type D in patients with coronary artery disease (CAD). A total of 465 patients completed the Type D Scale (DS14) questionnaire before undergoing stent implantation and were followed up for 5years. In a Cox regression model adjusted for selected confounders, we found a trend towards NA for the prediction of nonfatal major adverse cardiovascular event (MACE, hazard ratio (HR) = 1.07, 95% confidence intervals (CIs) = 0.99-1.14, p = 0.074), while, in contrast, SI was a significant and independent predictor of better outcome (HR = 0.92, 95% CI = 0.86-0.99, p = 0.027). In a cohort of CAD patients, the type D pattern was not linked to adverse outcome, whereas SI was negatively associated with MACE.

Age Dependency of Successful Recanalization in Anterior Circulation Stroke: The ENDOSTROKE Study

Background: Clinical outcome after endovascular stroke therapy (EVT) for proximal anterior circulation stroke is often disappointing despite high recanalization rates. The ENDOSTROKE study aims to determine predictors of clinical outcome in patients undergoing EVT. Here we focus on the impact of age and recanalization on proximal middle cerebral artery (M1-MCA) or carotid T occlusion. Methods: ENDOSTROKE is an investigator-initiated, industrially independent multicenter registry launched in January, 2011, for consecutive patients undergoing EVT for large-vessel stroke. This analysis focuses on patients treated in 11 academic and nonacademic stroke centers with angiographically proven M1-MCA (n = 259) or carotid T occlusion (n = 103). Recanalization was defined as Thrombolysis in Myocardial Infarction (TIMI) score 2 or 3, and in patients with available Thrombolysis in Cerebral Ischemia (TICI) data (n = 309) as TICI scores 2b-3. Good outcome was defined as modified Rankin Scale (mRS) score of 0-2 assessed after 3 months or later. Results: The median age was 68 years (25th and 75th percentiles: 56, 76 years), and the median National Institutes of Health Stroke Scale (NIHSS) score at admission was 16 (13, 19); 41% of the patients had a favorable (mRS scores 0-2), and 59% had an unfavorable (mRS scores 3-6) outcome; 83% reached TIMI 2-3 flow. Independent predictors of good outcome were younger age, lower initial NIHSS scores, TIMI 2/3 recanalization and lower serum glucose levels. Outcome was highly dependent on patients' age: 60% of the patients within the lowest age quartile (range: 18-56 years) experienced good clinical outcome, decreasing stepwise over 47% (57-68 years) and 37% (69-76 years) to 17% in the highest age quartile (77-94 years). The proportion of patients with poor clinical outcome despite TIMI 2/3 recanalization (‘futile recanalization') increased dramatically from only 29% in the lowest age quartile over 34% and 40% (2nd and 3rd age quartiles) up to 53% in the highest age quartile. Results were similar in patients with available TICI scores, with ‘futile recanalization' rates increasing from 24% to 46% (lowest to highest age quartile). Conclusions: This study emphasizes the dramatic impact of patients' age on outcome in EVT for M1-MCA or carotid T occlusion, even in the presence of recanalization. Reasons for this age-related decrease in clinically successful recanalization rates urgently need clarification and may comprise patient-related factors (age-related increase in cardioembolic strokes, collateral status, comorbidities) as well as periprocedural issues (tortuous vessel anatomy in the elderly, age-dependent negative impact of general anesthesia in EVT).

Therapeutic Hypothermia After Recanalization in Patients With Acute Ischemic Stroke

Therapeutic hypothermia improves outcomes in experimental stroke models, especially after ischemia-reperfusion injury. We investigated the clinical and radiological effects of therapeutic hypothermia in acute ischemic stroke patients after recanalization. A prospective cohort study at 2 stroke centers was performed. We enrolled patients with acute ischemic stroke in the anterior circulation with an initial National Institutes of Health Stroke Scale≥10 who had successful recanalization (≥thrombolysis in cerebral ischemia, 2b). Patients at center A underwent a mild hypothermia (34.5°C) protocol, which included mechanical ventilation, and 48-hour hypothermia and 48-hour rewarming. Patients at center B were treated according to the guidelines without hypothermia. Cerebral edema, hemorrhagic transformation, good outcome (3-month modified Rankin Scale, ≤2), mortality, and safety profiles were compared. Potential variables at baseline and during the therapy were analyzed to evaluate for independent predictors of good outcome. The hypothermia group (n=39) had less cerebral edema (P=0.001), hemorrhagic transformation (P=0.016), and better outcome (P=0.017) compared with the normothermia group (n=36). Mortality, hemicraniectomy rate, and medical complications were not statistically different. After adjustment for potential confounders, therapeutic hypothermia (odds ratio, 3.0; 95% confidence interval, 1.0-8.9; P=0.047) and distal occlusion (odds ratio, 7.3; 95% confidence interval; 1.3-40.3; P=0.022) were the independent predictors for good outcome. Absence of cerebral edema (odds ratio, 5.4; 95% confidence interval, 1.6-18.2; P=0.006) and no medical complications (odds ratio, 9.3; 95% confidence interval, 2.2-39.9; P=0.003) were also independent predictors for good outcome during the therapy. In patients with ischemic stroke, after successful recanalization, therapeutic hypothermia may reduce risk of cerebral edema and hemorrhagic transformation, and lead to improved clinical outcomes.

Prediction of Midterm Performance of Active‐Fixation Leads Using Current of Injury

There are only limited prospective data on the clinical relevance of current of injury (COI) as a predictor of the midterm performance of active-fixation leads. This study sought to investigate whether it is possible to predict the midterm performance of active-fixation leads using COI recorded at the time of implantation. One hundred fifty patients (78 men; mean age, 63 ± 19 years) who received active-fixation pacing (n = 201) and defibrillator (n = 51) leads were studied. COI was measured from the intracardiac bipolar electrogram recorded at the time of lead implantation. The study outcome was good lead performance at 6 months, defined as P wave ≥ 1.5 mV, threshold <1.5 V for atrial lead, R-wave ≥ 5 mV, and threshold <1 V for ventricular lead. A total of 102 active-fixation atrial and 150 ventricular leads were implanted. During a 6-month follow-up, invasive intervention was required for seven atrial and seven ventricular leads. In multivariate analysis, COI was the only independent predictor of good outcome for the active-fixation atrial (odds ratio [OR]: 5.67, 95% confidence interval [CI]: 2.18-14.76, P = 0.001) and ventricular leads (OR: 3.99, 95% CI: 1.08-21.26, P = 0.002). Receiver-operating characteristic analysis identified ST-segment elevation ≥2.0 mV for the atrial leads (sensitivity, 75%; specificity, 89%) and ≥10.0 mV for the ventricular leads (sensitivity, 70%; specificity, 87%) as optimal cutoffs for good midterm performance. Midterm performance of active-fixation leads is predictable using COI recorded at the time of lead implantation. A ST-segment elevation ≥2.0 mV in the atrial leads and ≥10.0 mV in the ventricular leads are recommended to improve the lead performance at 6 months.

O-001 Pre-Treatment Imaging is Critical in Identifying Stroke Patients with Small and Medium Infarcts Who are Likely to Benefit from IA Therapy

Introduction/PurposeThe Penumbra START Trial is a multicentre, prospective, single-arm trial with a primary aim of determining whether core infarct size on pre-treatment neuroimaging predicts clinical response to intra-arterial acute stroke...

Prolonged Emergency Department Length of Stay is Not Associated with Worse Outcomes in Traumatic Brain Injury

BackgroundData suggest that prolonged Emergency Department length of stay (EDLOS) has a detrimental effect on outcomes in some critically ill patients. However, the relationship between EDLOS and outcomes in traumatic brain injury (TBI) has not been examined. ObjectiveOur objective was to determine the effect of EDLOS on neurologic outcomes in TBI patients. MethodsWe performed a retrospective analysis of a prospectively identified cohort of patients with moderate (Glasgow Coma Scale [GCS] score 9–13) and severe (GCS ≤ 8) TBI who presented to a Level 1 trauma center (2006–2010). Inclusion criteria were transfer to the intensive care unit (ICU) or operating room (OR) from the ED. Primary outcome was Glasgow Outcome Scale (GOS) score, a measure of neurologic function, at discharge. We used a proportional odds model to control for significant predictors of GOS in univariate analysis. ResultsTwo hundred and twenty-four patients were included in the analysis, 77 (34%) of which were transferred to the OR. Median EDLOS was 3.3 h and 81.2% of patients had a GOS score ≤3 (e.g., severe disability, vegetative, or deceased). In multivariable analyses, EDLOS was not associated with GOS score in either ICU bound (p = 0.57) or OR bound (p = 0.11) patients. Younger age, pupil reactivity, and absence of intubation were independent predictors of good outcomes in the ICU group. In OR patients, predictors of higher GOS score included presence of an epidural hemorrhage, absence of midline shift, and pupil reactivity. ConclusionsOur study demonstrates that EDLOS was not associated with poor outcomes in patients with moderate to severe TBI who required intensive care or early operative intervention in an academic Level 1 trauma center.

Retracted: Cardiopulmonary resuscitation: Outcome and its predictors among hospitalized elderly patients in Egypt

AimOur aim was to study the outcome and the predictors of in‐hospital cardiopulmonary resuscitation (CPR) among elderly patients admitted to Ain Shams University Hospitals, Egypt.MethodsWe carried out a cross‐sectional study for all elderly patients (age ≥60 years) who underwent CPR after cardiac arrest at Ain Shams University Hospitals, Egypt, during a 1.5‐year study period. We excluded patients who were declared dead on arrival.ResultsWe found 380 cases of elderly in‐hospital cardiac arrest that underwent CPR. Asystole was the most common arrhythmia detected at the time of arrest (85.1%), followed by ventricular tachycardia (8.7%) and ventricular fibrillation (6.2%). Return of spontaneous circulation was achieved in 32.6% of patients and 8.4% survived to discharge from hospital. Multivariate logistic regression analysis identified three independent predictors of better outcome (survival &gt;24 h): response time ≤5 min (OR 5.1, 95% CI 1.9–13.4), location of CPR in emergency department (OR 3.2, 95% CI 1.6–6.4) and pre‐arrest morbidity (PAM) score ≤7 (OR 3.1, 95% CI 1.6–6.1).ConclusionOutcome of CPR after in‐hospital cardiac arrest in our setting was poor. The response time ≤5 min, CPR in the emergency department and PAM score ≤7 were independent predictors of good outcome. Geriatr Gerontol Int 2014; 14: 309–314.

Abstract 11: Comparison Of Various Methods Of Assessment Of Intracranial Collaterals On The Pretreatment Ct-angiograms To Predict Outcomes In Acute Anterior Circulation Ischemic Stroke

Background: The presence of effective collateral blood flow patterns may influence response to intravenously administered tissue plasminogen activator (IV-tPA) in acute ischemic stroke (AIS). We compared various existing methods of scoring collaterals on the pre-treatment computed tomographic angiogram (CTA) of the brain for a reliable prediction of functional outcome in AIS patients. Methods: Consecutive AIS patients treated with IV-tPA within 4.5 hours of symptom-onset during 2007-2011 were included. Data were collected for demographics, vascular risk factors, National Institute of Health Stroke Scale (NIHSS) scores and stroke subtypes. Intracranial collaterals were evaluated by 2 independent blinded neuroradiologists via 4 predefined criteria- Miteff’s system that grades middle cerebral artery (MCA) collateral branches with respect to the sylvian fissure; Maas system that compares collaterals on the affected hemisphere against the unaffected side; modified Tan’s scale where collaterals in 50% or more of the MCA territory are classified as good; and a 20-point collateral grading scale in regions corresponding to Alberta Stroke Program Early CT score (ASPECTS) methodology. Good functional outcomes at 3-months were determined by modified Rankin scale (mRS) scores of 0-1. Results: CTA was performed in 115 patients with anterior circulation AIS before IV-tPA bolus. Median age 66yrs (range 35-92), 42% males, median NIHSS 19 points (range 3-30) and median onset-to-treatment time 155 minutes. Overall, 52 (45.2%) patients achieved good functional outcome at 3-months. Univariable analysis revealed younger age, absence of diabetes, lower pre-tPA NIHSS scores and good collaterals according to ASPECTS methodology as significantly associated with good functional outcomes. On multivariable logistic regression, only lower NIHSS (OR 1.111 per NIHSS point; 95% CI 1.023-1.206, p=0.013) and good collaterals by ASPECTS methodology (OR 1.117 per point; 95%CI 1.006-1.241, p=0.039) were found as independent predictors of good outcomes. Conclusion: Of the existing intracranial collaterals scoring systems, only the ASPECTS methodology serves as a reliable predictor of favorable outcomes at 3-months in patients with anterior circulation AIS.

Abstract TP391: Predictors of Discharge Location and Long-Term Living Destination Following Acute Care Hospitalization for Intracerebral Hemorrhage: The DECIPHER Study

Background: The goal of this analysis was to determine factors predictive of discharge location and long-term living destination in patients following primary intracerebral hemorrhage in the DECIPHER cohort. Methods: DECIPHER is a longitudinal, multicenter, MRI-based, natural history study of racial differences in primary ICH. Inclusion criteria for this analysis were: primary ICH, age ≥ 18, signed informed consent, discharge data at baseline and year 1, and NIH Stroke Scale (NIHSS) at baseline. Clinical and demographic data were collected on all subjects. Results: There were 135 DECIPHER surviving patients who met inclusion criteria (mean age, 58 +/- 13 years; mean admission NIHSS 8 (median 5), 53% male, 76% African American). The discharge locations for subjects directly following their acute hospitalization were: 41% home, 44% acute rehabilitation, and 15% skilled nursing facility. There was no difference in discharge location by race. At year 1, 87% of subjects were at home and 13% were at a skilled nursing facility, suggesting that the patients who were discharged to acute rehab following their hospitalization were likely to be at home at the year 1 time-point. On multivariate logistic regression analysis, significant predictors of discharge to home were younger age (p=0.001), lower baseline NIHSS (p&lt;0.001), and being married at stroke onset (p=0.001). Neither socioeconomic status nor hemorrhage volume (independent of NIHSS) entered into the predictive model. At year 1, 70% of subjects had a good functional outcome (mRS 0-2). In a predictive model of good outcome at 1 year, baseline NIHSS (p&lt;0.001), being married at baseline (p=0.011), and age (p=0.002) were all independent predictors, however, discharge to home versus acute rehabilitation at baseline did not enter into the model. Conclusions: In the DECIPHER cohort of patients hospitalized with primary ICH, there were no significant racial differences in discharge destination. In addition to younger age, and lower NIHSS score, being married was significantly associated with discharge home vs. acute rehabilitation. Being married was also an independent predictor of good outcome at 1 year, highlighting the important role of social support in various aspects of stroke recovery.

Abstract TMP1: Infarct Location And Volumes As Predictors Of Outcome After Endovascular Recanalization Of Basilar Artery Occlusion

Background and Purpose: Prognostic information after endovascular recanalization of basilar artery occlusion is important for guiding aggressiveness of subsequent care. While final infarct volumes have been shown to correlate with outcomes in anterior circulation strokes, no such relationship has been described in basilar artery occlusions. We sought to determine the relationship between the volume of final infarction, location of infarction and outcome of clinical course in patients treated with endovascular therapy for basilar artery occlusion at our institution. Methods: A retrospective review of our prospectively maintained endovascular stroke database identified 103 patients of which 59 patients underwent post treatment MRI. Automated software was used to measure infarct volume. Results: Patients included in the study had the following features: mean age 61, mean NIHSS 20, female 24%. Successful recanalization (TIMI 2/3) occurred in 53/59 patients (90%). Infarcts were divided into topographic regions (see Table). Good outcomes (mRS 0-2 at 3 months) were achieved in 32% of patients. 71% of patients with no brainstem infarct had a good outcome (p=0.03). 46% of patients with no thalamic infarct had a good outcome (p=0.049). In multivariate analysis, independent predictors of good outcomes were brainstem infarct volume (OR 0.25, 95% CI 0.11-0.61, p=0.002) and age (OR 0.84, CI 0.74-.91, p=0.0018). Patients with good outcomes had a mean brainstem infarct volume of 1.45 cc, while patients with poor outcomes had a mean brainstem infarct volume of 6 cc (p=0.002). Conclusions: Rate of good outcomes after recanalization of basilar artery occlusion is 32%. Presence and volume of brainstem infarct, presence of thalamic infarct and patient age are the strongest predictors of outcome. Further studies will address whether these parameters can be used prospectively in prognosticating outcomes after basilar artery occlusive disease.

Abstract TP8: Safety And Outcome After Endovascular Reperfusion Therapy In Elderly Patients With Acute Ischemic Stroke

Background: Age is a strong predictor of outcomes following acute ischemic stroke (AIS). Conflicting data exist on whether endovascular reperfusion therapy (ERT) should be offered to patients over 80 years of age. We compared the safety and efficacy of ERT in elderly (&gt; 80 years) compared to non-elderly (&lt; 80 years) patients with AIS. Methods: We collected data from a large multi-center prospective registry of AIS patients treated with ERT. Data were available on demographics, initial severity, angiographic results, hemorrhagic complications using the ECASS criteria, and 3-month functional outcomes using the modified Rankin Scale (mRS). The thrombolysis in myocardial infarction (TIMI) score was used to grade reperfusion. We compared baseline factors, procedural results, and clinical outcomes in those over &gt; 80 years versus those &lt; 80 years. P-value &lt; 0.05 was considered significant. Results: Among 1077 patients with anterior circulation AIS, 223 (20.7%) were &gt; 80 years. Elderly patients were more likely to have atrial fibrillation (54.3% vs. 31.4%, P &lt; 0.001) but less likely to have diabetes (16.1% vs. 24.6%; P=0.046) or smoking (13.2% vs. 32.6%, P&lt;0.001) history. Both groups were similar in other baseline factors, initial NIHSS score, location of occlusions, time from onset to groin puncture. TIMI 2 or 3 reperfusion was achieved in 64.5% of those &gt; 80 vs. 70.7% in those &lt; 80 (P=0.080). Rates of symptomatic hemorrhage and any intracranial hemorrhage were not different between groups. Good outcome at 3 months (mRS 0-2) was noted in 16.5% of elderly compared to 41.5% of non-elderly patients (P&lt;0.001). Amongst elderly patients, the only independent predictor of good outcome was initial NIHSS score (adj. OR 0.882, 95% CI 0.821-0.948); good outcomes were achieved in 32.1% of those with NIHSS score &lt; 10, 16.8% with NIHSS score 11-20, and only 5.9% with NIHSS score &gt; 20. Conclusions: Patients &gt; 80 years account for over one-fifth of those treated with ERT in this large registry and had worse outcomes compared with those &lt; 80 years despite similar initial severity, time to treatment, and procedural results. Other factors such as increased baseline disability, more rapid time to completed infarction, and reduced neural plasticity may be contributing to these findings.

Abstract TMP7: Acute Stroke Involving More Than 1/3 Mca Territory On Plain Ct Brain Is Not A Contraindication For Iv Thrombolysis.

Background and Purpose: Intravenously administered tissue plasminogen activator (IV- tPA) remains the only approved therapeutic agent to achieve arterial recanalization in acute ischemic stroke (AIS). Involvement of more than one-third of middle cerebral artery (MCA) territory on initial brain CT is a relative contraindication for IV-tPA and often associated with poor functional outcome at 3 months. We present the results of IV-thrombolysis among these patients at our tertiary center. Methods: Data for consecutive stroke patients treated with IV-tPA within 4.5 hours of symptom onset were retrospectively analyzed. Data was collected for demographic characteristics, vascular risk factors, National Institute of Health Stroke Scale (NIHSS) scores, and blood pressure levels before IV-tPA bolus. The presence of early stroke signs involving more than one-third of the MCA on the initial CT scan was measured by Alberta Stroke Program Early CT score (ASPECTS &lt;8). Outcomes were assessed by modified Rankin Scale (mRS) score at 3 months. Results: A total of 97 AIS patients with more than one-third MCA involvement received IV-tPA during the study period. Median age was 70 yrs (range 38-89), 54% male, median NIHSS score 20 points (range 3-30) and median onset-to-treatment time 152 minutes (range ). Forty-two (43.5%) patients achieved good functional outcomes at 3 months (mRS score 0-1). The factors associated with good outcome at 3 months on univariate analysis were younger age and lower NIHSS score at presentation. After multivariate analysis, lower NIHSS scores at presentation was noted as the only independent predictor of good outcome at 3 months (OR 0.918 95%CI 0.880 - 0.958 p=0.001. 1/3 MCA involvement on the initial CT scan (ASPECTS &lt;8) was not significantly associated with a poorer functional outcome at 3 months (OR 1.495 95% CI 0.881-2.540; p=0.136). Conclusions: Patients with acute stroke involving more than one-third of the MCA on initial brain CT scan, especially if associated with lower NIHSS score, should not be excluded from systemic thrombolysis.

Comparison of Paclitaxel-Eluting Stents (Taxus) and Everolimus-Eluting Stents (Xience) in Left Main Coronary Artery Disease With 3 Years Follow-Up (from the ESTROFA-LM Registry)

Evidence regarding therapy with drug-eluting stents in the left main coronary artery (LM) is based mostly on trials performed with first-generation drug-eluting stents. The aim of this study was to evaluate long-term clinical outcomes after treatment for unprotected LM disease with paclitaxel-eluting stents (PES) and everolimus-eluting stents (EES). The ESTROFA-LM is a multicenter retrospective registry including consecutive patients with unprotected LM disease treated with PES or EES. A total of 770 patients have been included at 21 centers, 415 with treated PES and 355 with EES. Treatment with 2 stents was more frequent with PES (17% vs 10.4%, p = 0.007), whereas intravascular ultrasound was more frequently used with EES (35.2% vs 26%, p = 0.006). The 3-year death and infarction survival rates were 86.1% for PES and 87.3% for EES (p = 0.50) and for death, infarction, and target lesion revascularization were 83.6% versus 82% (p = 0.60), respectively. Definite or probable thrombosis was 1.6% for PES and 1.4% for EES (p = 0.80). The use of 2 stents, age, diabetes, and acute coronary syndromes were independent predictors of mortality. In the subgroup of distal lesions, the use of intravascular ultrasound was an independent predictor of better outcome. Comparison of propensity score-matched groups did not yield differences between the 2 stents. In conclusion, the results of this multicenter registry show comparable safety and efficacy at 3 years for PES and EES in the treatment of LM disease. The use of bifurcation stenting techniques in distal lesions was a relevant independent predictor for events. The use of intravascular ultrasound appears to have a positive impact on patients treated for LM distal disease.

The Predictive Value of C-reactive Protein for Prognosis in Patients with Upper Tract Urothelial Carcinoma Treated with Radical Nephroureterectomy: A Multi-institutional Study

BackgroundFew studies have discussed the prognostic impact of serum C-reactive protein (CRP) level in upper tract urothelial carcinoma (UTUC). ObjectiveTo investigate whether the perioperative level of CRP provides additional prognostic information following radical nephroureterectomy (RNU). Design, setting, and participantsA total of 564 patients with UTUC from a retrospective multi-institutional cohort were included. The median follow-up was 32 mo. InterventionAll patients underwent RNU without neoadjuvant chemotherapy, while 106 patients (18.8%) received adjuvant chemotherapy. Outcome measurements and statistical analysisAssociations between perioperative CRP level and outcome were assessed using multivariate analysis. A serum CRP level >0.50mg/dl was defined as elevated. Results and limitationsPreoperative CRP (pre-CRP) level was elevated in 136 patients (24.1%). Multivariate analysis showed that pre-CRP elevation was an independent predictor of subsequent disease recurrence (hazard ratio [HR]: 1.47 for CRP 0.51–2.00; HR: 1.89 for CRP >2.00). Five-year recurrence-free survival rates were 69.2% in patients with pre-CRP levels ≤0.50mg/dl, 54.3% in patients with pre-CRP levels between 0.51 and 2.00mg/dl, and 35.4% in patients with pre-CRP levels >2.00mg/dl (p<0.001). Similar results were found in cancer-specific mortality, showing that pre-CRP elevation was an independent predictor of worse outcome (HR: 1.74 for CRP 0.51–2.00; HR: 2.31 for CRP >2.00). In a subgroup analysis of the elevated pre-CRP group, postoperative normalisation of CRP level was an independent predictor of better outcome. This study is limited by its retrospective nature as well as its heterogeneous group of patients and variable follow-up protocols resulting from the multi-institution design. ConclusionsSerum CRP may become a possible biomarker in UTUC, suggesting that patients with an elevated pre-CRP level could be predicted to have subsequent disease recurrence and cancer-specific mortality, while postoperative normalisation of CRP level was an independent predictor for prognosis.