Initial National Institutes Of Health Stroke Scale Research Articles

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

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

Clinical Outcome of Patients With Large Vessel Occlusion and Low National Institutes of Health Stroke Scale Scores: Subanalysis of the RESCUE-Japan Registry 2.

Background and Purpose- The treatment and prognosis of acute large vessel occlusion with mild symptoms have not been sufficiently studied. The present study aimed to investigate the clinical or radiological predictors of clinical outcome in patients with stroke with mild symptoms due to acute large vessel occlusion. Methods- Of 2420 patients with acute large vessel occlusion in the RESCUE-Japan Registry 2 (Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism-Japan Registry 2), a multicenter prospective registry in Japan, patients with modified Rankin Scale scores of 0 to 2 before onset and initial National Institutes of Health Stroke Scale (NIHSS) scores of 0 to 5 were examined in post hoc analysis. We examined the clinical and radiological characteristics associated with a favorable outcome (modified Rankin Scale score, 0-2 at 90 days) using multivariate analysis, as well as the factors associated with a favorable outcome in patients treated with endovascular therapy. Results- We analyzed 272 patients (median age, 73 years; median NIHSS score on admission, 3). Eighty-six (31.6%) patients were treated with intravenous recombinant tissue-type plasminogen activator, 54 (19.9%) underwent endovascular therapy, and 208 (76.5%) showed a favorable outcome. In multivariate analysis, age <75 years (odds ratio [OR], 2.42 [95% CI, 1.30-4.50]), initial NIHSS score 0 to 3 (OR, 3.08 [95% CI, 1.59-5.98]), intravenous recombinant tissue-type plasminogen activator (OR, 2. 86 [95% CI, 1.32-6.21]), and blood glucose level ≤140 mg/dL (OR, 2.37 [95% CI, 1.22-4.60]) were independently associated with a favorable outcome. However, endovascular therapy was not associated with a favorable outcome (OR, 1.65 [95% CI, 0.71-3.88]). Among 54 patients treated with endovascular therapy, good reperfusion status was more common in the favorable outcome group (88.6% versus 60.0%; P<0.05). Conclusions- Younger age, lower initial NIHSS score, intravenous recombinant tissue-type plasminogen activator, and absence of hyperglycemia were independently associated with a favorable outcome in patients with acute large vessel occlusion with low NIHSS scores. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT02419794.

Abstract WP459: Advanced Practice Providers versus Neurology Residents: Similar Stroke Code Quality Metrics and Functional Outcomes

Background: Advanced Practice Providers (APPs) are important members of stroke code teams. However, the impact of APP involvement on quality metrics and functional outcomes is unclear. We sought to evaluate if APPs perform similarly to neurology residents for stroke code quality metrics and functional outcome at 90 days. Methods: We retrospectively analyzed data of consecutive patients who underwent thrombectomy in a single center cohort. Demographics, National Institute of Health Stroke Scale (NIHSS), last known normal (LKN) to emergency department (ED) presentation time, ED door to skin puncture time, recanalization (mTICI IIb/III) rates, and modified rankin scale (mRS) at 90 days were compared between neurology residents and APPs. A multiple logistic regression was used to determine factors independently associated with a favorable mRS at 90 days. Results: A total of 172 patients were included in the study of which 80 (47%) were managed by neurology residents. Both groups (residents vs. APPs) were balanced for age ( p =0.87), NIHSS ( p =0.18), LKN to ED Door time ( p =0.19), ED door to skin puncture time ( p =0.08), recanalization rate ( p =0.28), and favorable outcome (mRS 0-2) ( p =0.27). The multiple logistic regression model found patients with recanalization were 8.9 times more likely to have a favorable outcome. Age and initial NIHSS were found to be negative predictors of mRS (Table 1). Resident or APP involvement in the stroke code process did not impact outcome ( p =0.08). Conclusion: APPs achieve similar acute stroke code metrics and functional outcomes when compared to neurology residents. Further studies are needed to confirm our findings.

Abstract WP262: Intravenous Thrombolysis in Acute Ischemic Stroke Patients With Infective Endocarditis

Introduction: Infective endocarditis (IE) is considered to be an absolute contraindication for intravenous tissue plasminogen activator treatment (IVtPA) in acute ischemic stroke. However during the hyperacute stroke evaluation, the exclusion of IE may be difficult. Methods: We reviewed consecutive patients hospitalized at our comprehensive stroke center from January 1, 2014 to March 31, 2019 with acute ischemic stroke who received IVtPA and identified patients who were diagnosed with infective endocarditis. Data was abstracted on demographics, medical history, clinical presentation, last known normal (LKN) time, initial National Institutes of Health Stroke Scale (NIHSS), neuroimaging, culture results, and 90 day modified Rankin Scale (mRS). Good functional outcome was defined as mRS ≤ 2. Results: Among 1022 acute ischemic stroke patients who received IVtPA, 5 patients (0.5%) were ultimately diagnosed with IE. Among the 5 patients with IE, the mean age was 53.4 years (range, 25-74) and 3 (60%) were female. The majority, 4 (80%) were white. Medical risk factors for IE were present in 3 (60%) and included intravenous drug use (1) and dialysis (2). Initial NIHSS was 4.6 (range, 1 to 8). Fever was present on initial presentation in only 1 patient (102.7 F). All patients met criteria for IVtPA and there were no protocol violations. The mean time from LKN to IVtPA was 3.0 hours (range, 1.9 to 4.4). Vascular imaging showed MCA occlusion in 4 (80%) and no occlusion in 1 (20%). One patient underwent endovascular thrombectomy with Thrombolysis in cerebral infarction scale 2A recanalization. Two patients (40%) developed hemorrhagic complications, including 1 patient who developed subarachnoid hemorrhage on Hospital Day #2 due to mycotic cerebral aneurysm. The blood culture results included MRSE (1), Streptococci viridans (2) and negative (2). TEE in all patients showed vegetations on the mitral valve. No patients had good functional outcome, and the mean 3 months mRS was 4.8 (range, 3 to 6). Conclusions: In a large series of acute ischemic stroke patients who received IVtPA, undiagnosed IE is rare (0.5%). Fever was not commonly present during initial evaluation. Despite affecting younger patients with initial mild deficits, patients with IE had poor functional outcomes.

Predictors of Good Outcomes in Patients with Failed Endovascular Thrombectomy.

ObjectiveEndovascular thrombectomy (EVT) fails in approximately 20% of anterior circulation large vessel occlusion (AC-LVO). Nonetheless, the factors that affect clinical outcomes of non-recanalized AC-LVO despite EVT are less studied. The purpose of this study was to identify the factors affecting clinical outcomes in non-recanalized AC-LVO patients despite EVT.Materials and MethodsThis was a retrospective analysis of clinical and imaging data from 136 consecutive patients who demonstrated recanalization failure (modified thrombolysis in cerebral ischemia [mTICI], 0–2a) despite EVT for AC-LVO. Data were collected in prospectively maintained registries at 16 stroke centers. Collateral status was categorized into good or poor based on the CT angiogram, and the mTICI was categorized as 0–1 or 2a on the final angiogram. Patients with good (modified Rankin Scale [mRS], 0–2) and poor outcomes (mRS, 3–6) were compared in multivariate analysis to evaluate the factors associated with a good outcome.ResultsThirty-five patients (25.7%) had good outcomes. The good outcome group was younger (odds ratio [OR], 0.962; 95% confidence interval [CI], 0.932–0.992; p = 0.015), had a lower incidence of hypertension (OR, 0.380; 95% CI, 0.173–0.839; p = 0.017) and distal internal carotid artery involvement (OR, 0.149; 95% CI, 0.043–0.520; p = 0.003), lower initial National Institute of Health Stroke Scale (NIHSS) (OR, 0.789; 95% CI, 0.713–0.873; p < 0.001) and good collateral status (OR, 13.818; 95% CI, 3.971–48.090; p < 0.001). In multivariate analysis, the initial NIHSS (OR, 0.760; 95% CI, 0.638–0.905; p = 0.002), good collateral status (OR, 14.130; 95% CI, 2.264–88.212; p = 0.005) and mTICI 2a recanalization (OR, 5.636; 95% CI, 1.216–26.119; p = 0.027) remained as independent factors with good outcome in non-recanalized patients.ConclusionBaseline NIHSS score, good collateral status, and mTICI 2a recanalization remained independently associated with clinical outcome in non-recanalized patients. mTICI 2a recanalization would benefit patients with good collaterals in non-recanalized AC-LVO patients despite EVT.

Changes in Language Function and Recovery-Related Prognostic Factors in First-Ever Left Hemispheric Ischemic Stroke.

ObjectiveTo investigate longitudinal changes in language function in left-hemispheric ischemic stroke patients as well as factors that influence language recovery until 1 year after stroke onset.MethodsWe analyzed data from 235 patients with first-ever left-hemispheric ischemic stroke. All patients completed the Korean version of the Frenchay Aphasia Screening Test (K-FAST) at 7 days (T1), 3 months (T2), 6 months (T3), and 1 year (T4) after stroke onset. Repeated measures analysis of variance (ANOVA) was used to investigate changes in language function between time points. Subgroup analysis was performed according to the K-FAST scores at T1. Stroke lesion volume was assessed using diffusion tensor images, and involvement of language-related brain regions was examined. Multiple regression analysis was used to analyze factors influencing improvement of K-FAST score.ResultsThe K-FAST scores at T1, T2, T3, and T4 differed significantly (p<0.05). In the subgroup analysis, only the severe group showed continuous significant improvement by 1 year. Factors that negatively influenced improvement of language function were the age at onset, initial National Institutes of Health Stroke Scale (NIHSS) score, and initial K-FAST score, whereas education level and stroke lesion volume positively affected recovery. Involvement of language-related brain regions did not significantly influence long-term language recovery after ischemic stroke.ConclusionRecovery of language function varied according to the severity of the initial language deficit. The age at stroke onset, education level, initial severity of aphasia, initial NIHSS score, and total stroke lesion volume were found to be important factors for recovery of language function.

Clinical Profile and Outcomes of Early Seizures in Asian Patients With Acute Intracerebral Hemorrhage.

Seizures are one of the most common complications of stroke. We aimed to establish the incidence and clinical profile of post-stroke early seizure (ES) in patients with intracerebral hemorrhage (ICH). Patients with ICH within 10 days of onset who were admitted to Landseed International Hospital were recruited consecutively between January 1, 2006, and December 31, 2009. The National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin Scale were used to access patients initial stroke severity and functional outcome at discharge, respectively. The occurrence of epileptic seizures within 30 days after onset of the index ICH was recorded. Early post-ICH seizure was defined by the occurrence of clinically identifid seizure episodes or non-epileptic seizure within 7 days after the stroke onset. A total of 297 ICH patients were included. The mean age of the participants was 62 ± 16 years, and 72% of them were male. A total of 9 (3%) participants had seizures during acute hospitalization. Patients with seizures had higher median NIHSS scores at baseline (34 vs. 16, p = 0.004). No difference was noted in the cortical involvement of ICH (22% for patients with seizures and 14% for those without, p = 0.156). Patients with seizures had higher in-hospital mortality ( 56% vs. 23%, p = 0.024). The multivariate Cox regression model showed the factors significantly associated with ES were higher initial NIHSS scores on admission (adjusted odds ratio [aOR] = 1.1 per 1 point increased, 95% confidence interval [CI] = 1.0-1.2) and coronary artery disease (aOR = 7.0, 95% CI = 1.3-36.4). The NIHSS scores and coronary heart disease were associated with ES in ICH, whereas cortical involvement was not. These findings may reflect difference in post-stroke seizure and primary ICH between Asian and Western populations.

Which Patients Require Physician-Led Inter-Hospital Transport in View of Endovascular Therapy?

Introduction: The current guidelines advocate the implementation of stroke networks to organize endovascular treatment (ET) for patients with acute ischemic stroke due to large vessel occlusion (LVO) after transfer from a Primary Stroke Centre (PSC) to a Comprehensive Stroke Centre (CSC). In France and in many other countries around the world, these transfers are carried out by a physician-led mobile medical team. However, with the recent broadening of ET indications, their availability is becoming more and more critical. Here, we retrospectively analysed data of patients transferred from a PSC to a CSC for potential ET to identify predictive factors of major complications (MC) at departure and during transport that absolutely require the presence of a physician during interhospital transfer. Methods: This observational, single-centre study included patients with evidence of intracranial LVO transferred for ET from Perpignan to a 156 km-distant CSC between January 1, 2015 and ­December 31, 2018. We compared 2 groups: MC group (patients who required emergency intervention by the medical team due to life-threatening complications, including need of mechanical ventilation at departure) and non-MC group (all other patients who experienced no or only minor complications that could be managed by the emergency paramedics alone). Results: Among the 253 patients who were transferred to the CSC, 185 (73.1%) had no complication, 57 (22.6%) minor complications, and 11 (4.3%) had MC. In multivariate analysis, MC was associated with basilar artery (BA) occlusion (p < 0.0001), initial National Institute of Health Stroke Scale (NIHSS) score >22 (p < 0.005), and history of atrial fibrillation (p < 0.04). Among the 168 patients treated with intravenous thrombolysis (IVT), only 1 patient (0.6%) had MC due to an IVT-related adverse event during transfer. Conclusions: Physician-led inter-hospital transports are warranted for patients with BA occlusion, initial NIHSS score >22, or history of atrial fibrillation. For the other patients, transfer without a physician may be considered, even if treated with IVT.

Brachial-ankle pulse wave velocity for predicting functional outcomes in patients with cryptogenic stroke

Even after extensive standard evaluation, the probable cause of stroke in some patients remains unclear; this condition is defined as cryptogenic stroke (CS). The prognosis of patients with CS is largely undetermined. We investigated whether higher brachial-ankle pulse wave velocities (baPWVs) can predict poor functional outcomes at 3 months after stroke onset in these patients. We investigated patients with CS with first-ever acute cerebral infarction who underwent baPWV measurements. The stroke subtypes were classified using the Trial of ORG 10172 in Acute Stroke Treatment classification. Poor functional outcomes were defined as modified Rankin Scale scores of >2 at 3 months after stroke onset. In total, 595 patients with CS were included; among them, 360 were men (60.5%). Their mean age was 65.0 ± 12.4 years. One-hundred-eleven patients (18.7%) had poor functional outcomes. In the multivariable logistic regression analysis, the cutoff baPWV value based on the receiver-operating characteristic curve was >1968 cm/s, which was determined as a strong independent predictor (OR 3.159, 95% CI 1.487–6.715, p = 0.003). The OR of the cutoff value was higher in the patients with CS with initial National Institutes of Health Stroke Scale (NIHSS) scores of ≥5 (OR 4.252, 95% CI 1.596–11.324, p = 0.004); that in the patients with initial NIHSS scores of <5 was not significant (OR 1.671, 95% CI 0.620–4.505, p = 0.310). baPWV measurement during the acute stroke phase might be useful in identifying patients with CS at high risks of having a poor neurological prognosis.

Impact of basal ganglia damage after successful endovascular recanalization for acute ischemic stroke involving lenticulostriate arteries.

Regional ischemic vulnerability of the brain reportedly differs between the cortex and basal ganglia and has been poorly assessed in the setting of endovascular mechanical thrombectomy. This study was conducted to determine the fate of an ischemic basal ganglia and its contribution to the clinical outcome after successful endovascular recanalization for acute ischemic stroke with large vessel occlusion involving the lenticulostriate arteries. Clinical and radiological findings were retrospectively analyzed in consecutive patients with acute ischemic stroke characterized by large vessel occlusion involving the lenticulostriate arteries. Mechanical thrombectomy was performed in all patients using a stent retriever. The fate of ischemic basal ganglia based on location (lentiform nucleus, caudate nucleus, and internal capsule) and insular cortex was assessed according to the Alberta Stroke Programme Early CT Score (ASPECTS). Of 170 patients with large intracranial vessel occlusion who achieved successful endovascular recanalization, defined as a thrombolysis in cerebral infarction grade of ≥ 2B, involvement of the lenticulostriate arteries was seen in 55 patients (internal carotid artery, n = 35; proximal middle cerebral artery, n = 20). Preoperative infarction was detected in the lentiform nucleus (66.7%), internal capsule (11.1%), and caudate nucleus (33.3%), all of which showed secondary advancement despite successful recanalization (85.4%, 27.3%, and 54.5%, respectively; p < 0.05). Lenticulostriate arteries with a lateral proximal and/or medial proximal origin significantly affected the development of mature infarction in the lentiform nucleus. Postoperative hemorrhagic transformation was detected in 25 of 55 patients, mostly in the lentiform nucleus. Involvement of insular ribbon infarction was significantly high in patients with hemorrhagic transformation in the basal ganglia. Age, initial National Institutes of Health Stroke Scale (NIHSS) score, initial ASPECTS, postoperative ASPECTS, postoperative infarction in the insular ribbon, and lesions in the middle cerebral artery area (M1-M6) were significantly different between patients with good and poor modified Rankin Scale scores. Interestingly, no differences were detected in postoperative infarction or hemorrhagic transformation in the basal ganglia. Multivariate analysis showed that only age (p = 0.02, OR 0.88) and the initial NIHSS score (p = 0.01, OR 0.86) independently affected favorable clinical outcomes. The basal ganglia are vulnerable and readily develop secondary infarction and hemorrhagic transformation despite successful recanalization. However, this does not have a significant impact on the clinical outcome of acute ischemic stroke with large vessel occlusion involving the lenticulostriate arteries.

Current Status of Interhospital Transfer in Acute Ischemic Stroke

Background Selecting the appropriate patients and reducing stroke onset to endovascular recanalization therapy (ERT) time are essential elements of a successful ERT. Since ERT is available only in large hospitals, proper patients transfer is important. The purpose of study is to examine the suitability of the transfer of acute stroke patients. Methods We retrospectively reviewed the medical records of patients who diagnosed as acute ischemic stroke from January to December in 2017. Patients were divided into two groups based on transfer (direct visit vs. transfer) and Alberta Stroke Program Early computed tomography (ASPECT) score (≥8 vs. <8) respectively. Each group was assessed by demographics, type and rate of reperfusion therapy, onset to reperfusion therapy time, stroke risk factors and neurological deficit severity. Interhospital distance and transfer time was calculated in transferred patients. Results Among the 455 patients, the 228 (50.2%) patients underwent interhospital transfer. The ratio of reperfusion therapy was not significant different between direct visit and transferred group (34.8% vs. 37.3%, p=0.397). The transferred patients tended to be older (p=0.003), female (p=0.001), more hypertension (p=0.019), less transient ischemic attack (p=0.001), longer onset to ERT time (178.55±85.92 vs. 131.48±82.89; p=0.001) lower ASPECT score (6.72±2.04 vs. 8.01±1.65; p<0.001) and higher National Institute of Health Stroke Scale (NIHSS) (p<0.001) and modified Rankin Scale (mRS) (p<0.001). High ASPECT score (≥8) patients were more direct visited (63.9%), shorter onset to ERT time (p=0.047), lower initial NIHSS and mRS (p<0.001), and greater in differences between mRS at admission and 3 months later (p=0.016). Conclusions This study suggests emergency and interhospital transfer of acute stroke patients is inefficient, and systematization of transfer is necessary. Key Words: Endovascular procedures, Neuroimaging, Patient transfer, Stroke

Restless legs syndrome is associated with arterial stiffness and clinical outcome in stroke patients

ObjectiveRestless legs syndrome (RLS) has been associated with vascular diseases, including cerebrovascular and cardiovascular diseases. Among the various mechanisms in RLS, peripheral vascular endothelial dysfunction in patients with RLS has recently been proposed as a vascular pathophysiology of RLS. This study investigated arterial stiffness related to RLS in acute ischemic stroke patients and its influence on stroke outcome. MethodsRLS in patients with acute ischemic stroke was assessed based on the four essential criteria of the International Restless Legs Syndrome Study Group described in 2003. The patients’ clinical and laboratory characteristics, arterial stiffness, small vessel disease occurrence, and burden on brain MRI were recorded. Stroke severity was determined using the National Institute of Health Stroke Scale (NIHSS), and clinical outcomes were determined using the modified Rankin Scale. ResultsOf 296 patients with acute ischemic stroke, 16 (5.4%) were diagnosed with restless legs syndrome. Logistic regression analysis showed that a 1 m/s increase in brachial arterial pulse wave velocity was associated with the diagnosis of RLS (odds ratio, 1.092; 95% confidence interval, 1.019–1.170, p = 0.012). Diagnosis of RLS in patients with acute ischemic stroke was associated with poor clinical outcome three months after stroke (modified Rankin Scale 3–6) (odds ratio, 4.263; 95% confidence interval, 1.229–14.792, p = 0.022) along with initial NIHSS score. ConclusionRLS in patients with acute ischemic stroke is associated with increased arterial stiffness and poor clinical outcomes.

The global burden of cerebral small vessel disease related to neurological deficit severity and clinical outcomes of acute ischemic stroke after IV rt-PA treatment.

Various types of cerebral small vessel diseases (CSVD) are commonly coexisting and the clinical outcome possibly is determined by their combined effect. The present study was designed to explore the possible relationship between the global burden of CSVD and clinical outcomes after recombinant tissue plasminogen activator (rt-PA) treatment of ischemic stroke. We enrolled patients with acute ischemic stroke (AIS) after IV rt-PA treatment between August 2016 and July 2018. According to the total burden rating scale of CSVD, we calculated the total CSVD score for white matter hyperintensities, lacunar infarction, cerebral microbleeds, and perivascular spaces. All patients were assessed on the basis of the National Institutes of Health Stroke Scale (NIHSS) score and the modified Rankin Scale (mRS) score at 90days after stroke. We used multivariate logistic regression analysis to examine the associations between global burden of CSVD and degree of neurological deficit and clinical outcomes. ROC curve analysis was used to determine cut-off values of the total CSVD score in predicting poor outcomes. The results showed that the total CSVD score was independently associated with moderate to severe stroke (OR 2.187, 95%CI 1.495-3.119, P < 0.001). Initial NIHSS (OR 1.23, 95%CI 1.144-1.330, P < 0.001), OTT (OR 1.007, 95%CI 1.000-1.014, P = 0.037), and CSVD score (OR 3.157, 95%CI 2.120-4.703, P < 0.001) was significantly related to poor functional outcome at 3months. The total CVSD score cut-off value of 1.5 was determined at best to distinguish between good prognosis and poor outcome (AUC 0.7534 [95%CI 0.6883-0.8185]). The global burden of CSVD was independently associated with neurological deficit severity and clinical outcomes of AIS after IV rt-PA treatment. The total CVSD score is a reliable predictor for poor outcomes of AIS after IV rt-PA treatment.

DWI-pc-ASPECT score in basilar artery occlusion: is 6 points or less always indicative of a bad outcome?

The prognosis of patients with acute basilar arterial occlusion after endovascular reperfusion therapy with diffusion-weighted imaging - posterior circulation-Alberta Stroke Program Early Computed Tomography Score (DWI-pc-ASPECTS) of 6 or less remains unclear. We aimed to assess the characteristics and prognosis of endovascular reperfusion therapy in patients with acute basilar arterial occlusion and DWI-pc-ASPECTS of 6 or less. We analysed data collected from 1 January 2012 to 31 January 2018 in a prospective neuro-interventional registry of consecutive patients treated with endovascular reperfusion therapy. Clinical and imaging data on patients with DWI-pc-ASPECTS of 6 or less who underwent endovascular reperfusion therapy for acute basilar arterial occlusion were collected for this study. A good clinical outcome was defined as a modified Rankin scale of 2 or less at 90 days. Forty-five acute basilar arterial occlusion patients with DWI-pc-ASPECTS of 6 or less were included. Among them, 11 (24.4%) patients had a good clinical outcome at 90 days. Patients with a good clinical outcome had less severe neurological symptoms at presentation (National Institutes of Health Stroke Scale (NIHSS) 19.0 (12.0-25.0) vs. 8.0 (6.0-11.5); P = 0.003) and were younger (72.5 years (57.0-80.0 years) vs. 63.0 years (55.5-69.0 years), P = 0.096) than those with a poor clinical outcome. The symptomatic intracranial haemorrhage rate was significantly higher in the poor clinical outcome group (13 (38.2%)) than in the good clinical outcome group (0 (0.0%)) (P = 0.045). In particular, in patients aged over 70 years, a favourable outcome was low (18 (52.9%) vs. 1 (9.1%); P = 0.027) even after successful recanalisation. In a multivariate model, a low initial NIHSS score (odds ratio 1.21; 95% confidence interval 1.07-1.44; P = 0.0093) and age over 70 years (odds ratio 15.27; 95% confidence interval 1.85-379.79; P = 0.0321) were independent predictors of poor clinical outcome. Even with DWI-pc-ASPECTS of 6 or less, good clinical outcome can be achieved after endovascular reperfusion therapy. Relatively mild initial symptoms and younger age can predict a better outcome in acute basilar arterial occlusion patients with DWI-pc-ASPECTS of 6 or less.

Abstract 151: Early Neurologic Decline in Acute Ischemic Stroke Patients Receiving Thrombolysis With Large Vessel Occlusion and Initial Mild Deficits

Introduction: A quarter of ischemic stroke patients with initial mild deficits have a poor outcome. We sought to determine the rate of early neurological decline in acute ischemic stroke patients with large vessel occlusion (LVO) who presented with mild deficits. Methods: Among 1022 acute ischemic stroke patients who received intravenous tissue plasminogen activator (IVtPA) admitted to our institution from January 1, 2014 to March 31, 2019, we identified 313 (30.6%) with LVO. We defined anterior circulation LVO as M1, M2, or carotid artery terminus (ICAT). Mild deficits were defined as National Institute of Health Stroke Scale (NIHSS) ≤ 7. Data was abstracted on demographics, neuroimaging, last known well (LKW), time to IVtPA, intra-arterial therapy (IAT) revascularization, Thrombolysis in Cerebral Infarction score (TICI), clinical presentation, and outcome. Early neurologic decline was defined as NIHSS worsening of ≥ 4 points within 24 hours. Results: Among 313 patients with LVO, we identified 94 (30%) who presented with initial low NIHSS (≤ 7) due to anterior circulation LVO. We excluded 13 patients who did not have natural history data (underwent IAT with mild deficits), leaving 81 patient for analysis. The mean age was 65.8 years (range 25 to 93) and 41% were female. IVtPA time from LKW was a mean 2.5 hours (range, 0.8 to 7). LVO sites were as follows: 5 (6%) ICAT, 23 (28%) M1, and 53 (65%) M2 occlusions. Among the 81 patients, 27 (33.3%) had early neurological decline. Patients with decline were significantly older (71.2 vs 63.1 years, p=0.03). Among the 27 patients with decline, the mean change in NIHSS was 10.5 (range, 4 to 22) and 12 patients (44%) underwent rescue IAT resulting in TICI 2B (6) and TICI 3 (6) revascularization. On hospital discharge, patients with decline were less likely to be discharged home (26% vs 65%, p=0.006). Conclusions: Among LVO patients who received IVtPA, 30% present with initial mild deficits. Early neurological decline occurred in one-third of LVO patients with initial mild deficits despite receiving IVtPA, and patients with decline were less likely to be discharged home. Clinicians need to be aware of the natural history of LVO with initial mid deficits, as patients who decline would be eligible for rescue IAT in the expanded 24 hour window.

Abstract WP109: Early Neurological Decline in Acute Ischemic Stroke Patients Receiving Thrombolysis With Large Vessel Occlusion and Initial Mild Deficits

Introduction: One quarter of ischemic stroke patients with initial mild deficits will have poor outcome. We sought to determine the rate of early neurological decline in acute ischemic stroke patients with large vessel occlusion (LVO) presenting with mild deficits. Methods: Among 322 acute ischemic stroke patients who received intravenous tissue plasminogen activator (IVtPA) from July 1, 2016 to July 1, 2017, we identified 76 (23.6%) with imaging confirmed anterior circulation LVO, defined as M1, M2, or carotid terminus (ICAT). Basilar artery occlusions were excluded. Mild deficits were defined as National Institutes of Health Stroke Scale (NIHSS) &lt; 7. Data was abstracted on demographics, neuroimaging, need for intra-arterial therapy (IAT) revascularization, final Thrombolysis in Cerebral Infarction score (TICI), and clinical presentation. Early neurological decline was defined as NIHSS worsening of &gt; 4 points within 24 hours. Results: Among 76 patients with LVO, we identified 22 (29%) who presented with initial low NIHSS (&lt; 7). The mean age was 64.7 years (range 26 to 93). IVtPA time from last known well (LKN) was a mean 2.7 hours (range 1.3 to 4.9). Most patients (91%) were transfers from outside facilities. LVO sites were as follows: 4 (18%) ICAT, 7 (32%) M1, and 11 (50%) M2. Most (19/22 86%) had CT perfusion imaging, and large mismatch was seen in 6/8 with worsening and 6/11 without worsening. Among the 22 patients with mild deficits initially, 9 (41%) had early neurological decline. Patients with early neurological decline were significantly older (77.8 vs 55.7 years, p=0.0008). Among 9 patients with decline, the mean change in NIHSS was 9 points (range, 4 to 18) and 3 (13.6%) underwent rescue therapy with IAT with TICI 2b (1) and TICI 3 (2) revascularization. On hospital discharge, LVO patients with neurological decline were significantly less likely to be discharged home compared with patients without decline (22% vs 69%, p=0.03). Conclusions: Among LVO patients who received IVtPA, 29% presented with mild deficits (NIHSS &lt;7). Among these patients with mild deficits, early neurological decline occurred in 41% despite receiving IVtPA and was associated with older age. CTP mismatch did not accurately predict which patients would worsen.

Abstract TP165: Association of Admission versus 24-Hour NIHSS Score With Early Ambulation After Stroke

Introduction: Predicting who will be ambulatory within the first several days after stroke may help support resource allocation, and discharge and rehabilitation planning. The National Institutes of Health Stroke Scale (NIHSS) is commonly used to rate stroke severity. Due to medical intervention or stroke progression, the NIHSS score at admission versus 24 hours can be drastically different. We explored whether presence of leg weakness at admission or 24 hours was most predictive of early ambulation, and other NIHSS score components associated with early ambulation. Methods: A consecutive sample of patients admitted to a stroke unit at a comprehensive stroke center was included in this retrospective study. Initial and 24-hour NIHSS scores were examined in conjunction with various demographic and stroke details. Multivariable logistic regression models identified predictors of ambulation within the first week of admission. Results: Of 513 stroke patients, 273 (53%) were able to walk with or without assistance within the first 3-5 days post-stroke. The multivariable model utilizing the 24-hour NIHSS combined right and left lower extremity weakness scores had greater predictive value (area under the curve [AUC] = 0.85; 95% confidence interval [CI] 0.81 - 0.88) than the initial score (AUC = 0.74; 95% CI 0.69 - 0.78). In the multivariable analysis, 24-hour combined leg weakness (odds ratio [OR] 0.29; 95% CI 0.22 - 0.39), ataxia (OR 0.63; 95% CI 0.43 - 0.91), and sensation (OR 0.58; 95% CI 0.37 - 0.91) scores were all associated with early ambulation capacity. Conclusions: The prediction of early ambulation is more accurate after 24 hours post-stroke. Leg weakness, ataxia, and sensory loss at 24 hours are all negatively associated with ability to ambulate after stroke.

Abstract TMP23: Short Term Outcomes in Patients Treated on a Mobile Stroke Unit

Introduction: Mobile Stroke Units (MSU) allow for the administration of intravenous tissue plasminogen activator (IV tPA) to eligible patients more quickly than those treated in the emergency department (ED). We aimed to describe whether patients who received IV tPA in the MSU had better short term outcomes than those treated in the ED. Methods: We reviewed the medical records of patients who received IV tPA for ischemic stroke or transient ischemic attack on the MSU from 2014-2017 and in the ED from 2015-2017 at a single tertiary referral center. Outcome measures including symptom onset to treatment time, post-thrombolysis National Institute of Health Stroke Scale (NIHSS) over the first 24 hours, length of hospital stay, and disposition after discharge were compared. Results: Of 270 patients diagnosed with ischemic stroke or transient ischemic attack and received IV tPA, 98 were treated on the MSU and 172 were treated in the ED. Both groups had similar pre-morbid modified Rankin scores and pre-treatment NIHSS. Patients treated on the MSU received IV tPA at a median of 76 minutes from their last known well (interquartile range (IQR) 56-117), while those in the ED were treated at a median of 116.5 minutes (IQR 84.75-162) (p&lt;0.00001). The median initial pre-treatment NIHSS of MSUtreated patients was 9.5 (IQR 6-16) while ED treated patients was 10 (IQR 5-19) (p=0.5485). The median 24 hour post-thrombolysis NIHSS for the MSU group was 4 (IQR 1-10) and that of the ED group was 5(IQR 2-13.25) (p=0.043).The median length of hospital stay for those treated in the MSU was 3 days (IQR 2-5) while that of patients treated in the ED was 5 days (IQR 3-8) (p=0.007). After discharge, 71patients treated in the MSU had a more favorable discharge disposition (home or acute rehabilitation facility vs skilled nursing facility, long term acute care facility, palliative care, or death) compared with 103 patients who received treatment in the ED (p=0.043). Conclusion: Patients treated with IV tPA on the MSU had a shorter symptom onset to treatment time, a shorter length of stay, were discharged with a more favorable disposition, and had a lower NIHSS 24 hours after treatment than those who received treatment in the ED indicating favorable short term outcomes.

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

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

Abstract 34: Outcomes of Thrombolysis on Mobile Stroke Unit

Introduction: Mobile stroke Units (MSU) can shorten the time to intravenous thrombolytic therapy (IVT) in patients with acute ischemic stroke. We aimed to demonstrate the effects of pre-hospital IVT on clinical outcomes. Methods: We reviewed patients received IVT from July 2014 to December 2017, and compared patients with pre-hospital IVT on MSU with patients brought to the ED via a conventional ambulance. The primary outcome was the modified Rankin scale score (mRS) of 1 or better at 90 days. Binary logistic regression model of 90-day mRS for 0-1 vs 2-6 was adjusted for age, initial National Institutes of Health Stroke Scale (NIHSS) score, and pre-morbid mRS. Results: Seventy eight patients were treated in the MSU and 153 patients were received IVT in the ED. There were no significant differences in gender, age, pre-morbid mRS, initial NIHSS score, and risk factors between the MSU group and the ED group. The MSU patients received thrombolysis 38 minutes earlier from onset than the ED patients (median 79 minutes compared to117 minutes, p&lt;0.001). In an unadjusted analysis, the difference in primary outcome between MSU group and ED group was not significant (41% with MSU vs 29% with ED, p=0.061, Figure). After adjustment for age, initial NIHSS score, and pre-morbid mRS, the odds ratio for mRS of 0-1 at 90 days with IVT on MSU compared to ED for was 2.09 (95% confidence interval (CI), 1.02-4.28, p = 0.044). Further adjustment for the time from onset to thrombolytic treatment, the effect of MSU on 90-day mRS was attenuated and no longer significant (odds ratio 1.65, 95% CI, 0.77-3.55, p=0.196). Conclusion: Pre-hospital IVT on MSU compared to conventional care shortened the time to thrombolytic treatment and was associated with improved functional outcomes in patients with acute ischemic stroke.