Initial NIH Stroke Scale Score Research Articles

Case Report: Delayed Cerebral Ischemia with Infarction following an Undiagnosed Aneurysmal Rupture - The Diagnostic and Management Challenge

Delayed Cerebral Ischemia (DCI) typically occurs a few days after a patient suffers subarachnoid hemorrhage and can lead to a range of poor outcomes. It is primarily driven by vasospasm and its delayed and variable presentation complicates diagnosis and treatment. Here we report a case of DCI in a 31-yearold man who presented with acute onset aphasia, right-sided weakness, and difficulty swallowing. He had experienced a severe headache accompanied by nausea and vomiting 5 days prior, with an initial NIH stroke scale score of 10. Imaging revealed a left internal carotid artery aneurysm and a watershed infarct between the anterior cerebral artery and middle cerebral artery. The patient was treated with aneurysmal coiling, intraarterial verapamil, and oral nimodipine for suspected DCI secondary to subarachnoid hemorrhage. Close monitoring of the patient and treatment led to the resolution of neurological deficits over the subsequent days., with imaging confirming reperfusion. This case presents a unique challenge due to the delayed presentation and vague history. Diagnosis and treatment of DCI following aneurysmal rupture are complicated due to its delayed and variable onset. It is crucial to consider acute aneurysmal subarachnoid hemorrhage and DCI when evaluating patients who present with multiple stroke-like symptoms over several days as the management and prognosis differ from other cases of acute ischemic stroke.

Abstract WP87: To Walk-In or Not to Walk-In: Effects of ED Mode of Arrival on Acute Stroke Treatment and Hospitalization Outcomes in a Large Integrated Healthcare System

Background: Prior studies reported that only half of stroke patients arrived at emergency departments (ED) via emergency medical services (EMS). We sought to assess predictors of ED mode of arrival and its effects on acute stroke care and inpatient outcomes in a large racial-ethnically diverse cohort. Methods: In 2016, we launched a system-wide standardized telestroke program for 21 certified stroke centers. Non-cancelled stroke alerts included those patients who were potential candidates for further workup for acute ischemic stroke treatment. This study cohort included non-cancelled stroke alerts seen by Telestroke in 2021. Assessment included demographics, ED arrival mode , initial NIH Stroke Scale (NIHSS), neuroimaging results, IV thrombolytic, door-to-needle (DTN) time, large vessel occlusion (LVO), thrombectomy referral, hospital length of stay and discharge disposition. Clustered logistic regression was used to evaluate ED arrival mode’s effects on short-term outcomes. Results: Of the 7744 stroke alerts seen by Telestroke in 2021, 3264 (42.2%) were non-canceled. Among these, 2014 (61.7%) were in the early window (0-4.5 hours from last seen well). More of those arriving in the early window came via EMS compared to those seen in the extended window [1625 (80.7%) versus 729 (58.3%) respectively]. Among non-canceled ED stroke alerts, compared to patients who arrived via EMS, walk-in patients were younger, more Hispanic, had lower initial NIHSS scores, longer times for ED to contact Telestroke, slower DTN times, but less mortality [Table]. In multivariate analysis, walk-in patients were less likely to have a DTN time within 30 minutes (OR=0.37, 95% CI 0.25-0.34; p=<0.001). Conclusions: In our cohort, there were several differences between walk-in patients and those who arrived via EMS. Further research is needed to understand these differences, the reasons for choosing walk-in, and whether ED mode of arrival affects clinical outcomes.

Abstract Number ‐ 259: Recanalization Before Completion of Alteplase Infusion Leads to Improved Outcomes: A Retrospective Analysis

Introduction The recently published CHOICE trial found that intra‐arterial infusion of alteplase improved clinical outcomes in patients undergoing EVT for LVO AIS, an effect that was possibly due to a reduction in reperfusion‐related injury. Here, we examine whether intravenous alteplase, administered after successful endovascular reperfusion, results in improved clinical outcomes. Methods From our prospectively collected multicenter institutional registry drawn from four comprehensive stroke centers in the greater Houston area, we identified cases who underwent EVT with substantial reperfusion (TICI 2b/3) prior to termination of the intravenous alteplase continuous drip. Control patients were then identified as patients who underwent EVT with TICI 2b/3 after completion of intravenous alteplase, matching on age, baseline Modified Rankin Scale (mRS), initial NIH Stroke Scale (NIHSS), and comorbidities. The primary outcome was 90 day disability and was determined by mRS shift analysis, comparing the case and control populations. Results Among 21 cases and 24 matched controls, there were no significant difference between the mean age, gender, race, initial NIHSS, baseline mRS, or ASPECT score. Time from last known well to recanalization was longer in controls (48 min vs 151 min, p< 0.01). Patients who achieved reperfusion prior to termination of the alteplase continuous drip had better 90 day clinical outcomes relative to their presentation mRS when compared to patients who achieved reperfusion after termination of the alteplase. A change in mRS of 1 or less was seen in 71% vs 33% in the continued infusion group vs controls respectively. Conclusions Patients undergoing EVT who continued to be treated with intravenous alteplase following reperfusion had better 90d clinical outcomes relative to those with reperfusion after infusion termination. These findings further support the possible efficacy of thrombolytics following endovascular reperfusion.

Pre-admission antithrombotic use is associated with 3-month mRS score after thrombectomy for acute ischemic stroke.

In patients who undergo thrombectomy for acute ischemic stroke, the relationship between pre-admission antithrombotic (anticoagulation or antiplatelet) use and both radiographic and functional outcome is not well understood. We sought to explore the relationship between pre-admission antithrombotic use in patients who underwent thrombectomy for acute ischemic stroke at two medical centers in New York City between December 2018 and November 2020. Analyses were performed using analysis of variance and Pearson’s chi-squared tests. Of 234 patients in the analysis cohort, 65 (28%) were on anticoagulation, 64 (27%) were on antiplatelet, and 105 (45%) with no antithrombotic use pre-admission. 3-month Modified Rankin Scale (mRS) score of 3–6 was associated with pre-admission antithrombotic use (71% anticoagulation vs. 77% antiplatelet vs. 56% no antithrombotic, p = 0.04). There was no relationship between pre-admission antithrombotic use and Thrombolysis in Cerebral Iinfarction (TICI) score, post-procedure Alberta Stroke Program Early CT Score (ASPECTS) score, rate of hemorrhagic conversion, length of hospital admission, discharge NIH Stroke Scale (NIHSS), discharge mRS score, or mortality. When initial NIHSS score, post-procedure ASPECTS score, and age at admission were included in multivariate analysis, pre-admission antithrombotic use was still significantly associated with a 3-month mRS score of 3–6 (OR 2.36, 95% CI 1.03–5.54, p = 0.04). In this cohort of patients with acute ischemic stroke who underwent thrombectomy, pre-admission antithrombotic use was associated with 3-month mRS score, but no other measures of radiographic or functional outcome. Further research is needed on the relationship between use of specific anticoagulation or antiplatelet agents and outcome after acute ischemic stroke, but moreover, improve stroke prevention.

Impact of Neuroimaging Patterns for the Detection of Atrial Fibrillation by Implantable Loop Recorders in Patients With Embolic Stroke of Undetermined Source.

ObjectivesAtrial fibrillation (AF) is a well-known etiology of embolic stroke of undetermined source (ESUS), although the optimal detection strategy of AF was not been fully evaluated yet. We assessed AF detection rate by implantable loop recorder (ILR) in patients with ESUS and compared the clinical characteristics and neuroimaging patterns between the patients with AF and AF-free patients.MethodsWe reviewed clinical characteristics and neuroimaging patterns of consecutive patients with who were admitted to our comprehensive stroke center for ESUS and underwent ILR insertion between August 1, 2019, and January 31, 202. The inclusion criteria were (1) 18 years of age or older; (2) classified as having cryptogenic stroke extracted from the group with undetermined stroke according to ESUS International Working Group; and (3) underwent ILR insertion during or after admission due to index ischemic events. Ischemic stroke pattern was classified as (1) tiny-scattered infarction, (2) whole-territorial infarction, (3) lobar infarction and (4) multiple-territorial infarction. Interrogations of data retrieved from the ILR were performed by cardiologists in every month after the implantation.ResultsIn this study, 41 ESUS patients who received an ILR implantation were enrolled (mean age, 64 years; male sex, 65.9%). The rate of AF detection at 6 months was 34% (14 patients), and the mean time from ILR insertion to AF detection was 52.5 days [interquartile range (IQR), 45.0–69.5]. The median initial NIH stroke scale scores were significantly greater in patients with AF than those without AF (6.5 vs. 3.0, p = 0.019). Whole-territorial infarction pattern was significantly more frequent in patients with AF than in those without AF (64.3% vs.11.1%, p = 0.002).ConclusionsHigher covert AF detection rates within the ESUS patients were most often associated with higher NIHSS and whole-territorial infarction patterns on brain imaging.

Abstract 1122‐000237: Prior Vascular Risk Factors Affecting Presentation Time and Utilization of Acute Ischemic Stroke Therapies

Introduction : Multiple factors have been reported to influence the time between onset of symptoms in acute ischemic stroke and hospital presentation. Although education level is one independent factor in presentation, as we previously reported, health literacy has not been fully assessed regarding specific patient knowledge on stroke or its known risk factors. This study aims to determine whether having a history of vascular risk factors such as prior stroke, coronary artery disease (CAD), or atrial fibrillation (AF) influence presentation time and acute ischemic stroke therapy utilization. Methods : This study included 250 acute ischemic stroke patients presenting to a large academic community hospital from February to December 2018. Educational level was defined within four categories: Grade School, High School, College or Higher, and Unknown. Last seen normal, symptom onset, and arrival times were acquired. Vascular risk factors chosen for this study included prior stroke, CAD, and AF. History of vascular risk factors was verified by medical documentation showing prior diagnosis by physician. Initial NIH Stroke Scale score, stroke location, vessel involved, LDL, hemoglobin A1c, gender, and race were also obtained. Patients were categorized based on their level of education, the presence or absence of vascular risk factors, and utilization of tPA or thrombectomy (MT). The primary outcomes were onset‐to‐arrival time (OTA), in minutes, and utilization rates of acute ischemic stroke therapies (either tPA, MT, or both). Subgroup analysis was conducted to associate education level with each vascular risk factor, comparing OTA and acute ischemic stroke therapy utilization rate. Results : As previously reported, educational level was inversely associated with OTA and positively associated with utilization of at least one acute ischemic stroke therapy. Prior stroke, CAD, and AF showed a substantial OTA decrease for all education groups except for College. Prior stroke decreased OTA in Grade School by 24% (764 vs. 579); High School by 30% (222 vs. 154) and College by 20% (52 vs. 41). CAD decreased OTA in Grade School by 65% (734 vs. 253), High School by 14% (209 vs. 180), and College by 3% (50 vs 49). AF decreased OTA in Grade School by 88% (764 vs. 91) and High School by 56% (216 vs. 95), but increased in College by 35% (47 vs. 64). History of prior stroke decreased utilization of both tPA and MT by 14%; CAD increased tPA use by 8% and MT by 5%; while AF increased tPA use by 9% and MT by 12%. Conclusions : Having at least one prior vascular risk factor (prior stroke, CAD, AF), diagnosed by a physician, was associated with lower OTA in Grade School and High School educated patients. A history of prior stroke was associated with lower acute stroke therapy utilization (tpa and MT), while both CAD and AF were associated with increased acute stroke therapy utilization.

Early increment of soluble triggering receptor expressed on myeloid cells 2 in plasma might be a predictor of poor outcome after ischemic stroke

Soluble triggering receptor expressed on myeloid cells 2 (sTREM2) is derived from cleavage of TREM2, which is expressed on the cell surface of microlgia and other tissue-specific macrophages. In the present study, the changes in the sTREM2 levels after ischemic stroke (IS) and their association with clinical outcomes were evaluated. A total of 43 patients diagnosed with non-cardioembolic IS between June 2011 and May 2014 were consecutively included in this study. Patients treated with intravenous thrombolysis or intra-arterial thrombectomy were excluded. Plasma samples were collected three times (days 1, 7, and 90) after ictus. The sTREM2 level was measured in the samples using the highly sensitive solid-phase proximity ligation assay (SP-PLA). Among the 43 subjects, higher initial NIH stroke scale (NIHSS) score (P = 0.005), early increment of sTREM2 (P < 0.001), and late decrement of sTREM2 (P = 0.002), were more common in patients with poor outcome. Based on multivariate analysis, initial NIHSS score (P = 0.015) and early increment of sTREM2 (P = 0.032) were independently associated with poor outcome. The results from the present study indicate that increment of sTREM2 level at the early phase was a predictor of poor outcome. Serial follow-up of sTREM2 may aid prognosis after stroke.

Is spontaneous normalization of systolic blood pressure within 24 hours after ischemic stroke onset related with favorable outcomes?

BackgroundIn acute ischemic stroke, blood pressure (BP) tends to rise initially and fall to a baseline level within 24–48 hours. Previous studies reported several different effects of BPs during acute ischemic stroke on clinical outcomes, which was partly due to the different time intervals from stroke onset to BP measurement.MethodsAll patients with acute ischemic stroke (onset ≤3 hours) who lived independently before the stroke, were consecutively enrolled for a 62-month period. BPs at 0, 12, and 24 hours after admission were collected. A favorable outcome was defined as a modified Rankin Scale (mRS) score 0–2 at discharge. For different standards of BP management, patients were grouped and analyzed according to intravenous (IV) tissue plasminogen activator (tPA) treatment and favorable outcome.ResultsAmong the 446 enrolled patients, 227 patients underwent IV tPA treatment and 216 had mRS score 0–2 at discharge. Patients with favorable outcomes had lower initial NIH Stroke Scale (NIHSS) scores, less frequent progressive neurological deficits, and lower systolic BP (SBP) 12 and 24 hours after admission than patients with unfavorable outcomes, regardless of whether they underwent tPA treatment or not (p <0.05). The BP decreased over a period of 24 hours after admission. In logistic regression analysis, the independent variables associated with favorable outcome were the initial NIHSS score, a progressive neurological deficit, a previous stroke, and the SBP 24 hours after admission in the patients who underwent tPA treatment and the initial NIHSS score and a progressive neurological deficit in the patients who did not undergo tPA treatment (p <0.05).ConclusionsThe SBPs at 12 and 24 hours after admission were lower in acute stroke patients with favorable outcomes than in the other patients, regardless of whether the patients underwent tPA therapy and the SBP at 24 hours was an independent predictor of favorable outcomes among the patients who underwent tPA treatment.

MRI-based thrombolytic therapy in patients with acute ischemic stroke presenting with a low NIHSS.

Treatment of patients with stroke presenting with minor deficits remains controversial, and the recent Potential of rtPA for Ischemic Strokes with Mild Symptoms (PRISMS) trial, which randomized patients to thrombolysis vs aspirin, did not show benefit. We studied the safety and efficacy of thrombolysis in a population of patients with acute stroke presenting with low NIH Stroke Scale (NIHSS) scores screened using MRI. The NIH Natural History of Stroke database was reviewed from January 2006 to December 2016 to identify all patients with an initial NIHSS score ≤5 who received thrombolysis within 4.5 hours of symptom onset after being screened with MRI. The 24-hour postthrombolysis MRIs were reviewed for hemorrhagic transformation. Primary outcomes were symptomatic intracranial hemorrhage (sICH) and favorable 90-day outcome modified Rankin Scale score 0-1. Subgroup analysis was performed on patients who would have been eligible for the PRISMS trial, which enrolled patients with a nondisabling neurologic deficit. A total of 121 patients were included in the study with a median age of 65 and an NIHSS score of 3; 63% were women. The rate of any hemorrhagic transformation was 13%, with 11% of them being limited to petechial hemorrhage. The rate of sICH was <1%. Sixty-six patients had 90-day outcome data; of those, 74% had a favorable outcome. For the subgroup of 81 PRISMS-eligible patients, none experienced sICH. Fifty of these patients had 90-day outcome data; of these, 84% had a favorable outcome. Thrombolytic therapy was safe in our patients with stroke with minor deficits who were initially evaluated by MRI. Future studies of this population may benefit from MRI selection. This study provides Class IV evidence that for patients with acute ischemic stroke and NIHSS ≤5 screened with MRI, IV tissue plasminogen activator is safe.

Frequency of early rapid improvement in stroke severity during interfacility transfer.

As interfacility transfer of patients with stroke becomes increasingly common, understanding fluctuations in deficits during transfer may help predict resource needs. We sought to characterize changes in NIH Stroke Scale (NIHSS) scores during transfer and identify factors associated with early rapid improvement (ERI). We used prospectively collected data from our Comprehensive Stroke Center's (CSCs) stroke and telestroke network databases. We calculated changes in NIHSS scores for all patients transferred to our CSC after an initial telestroke evaluation from January 2010 to December 2015. Logistic regression identified factors associated with ERI, controlling for patient characteristics available on arrival. Among the 505 patients included, the median initial NIHSS score was 11 (interquartile range [IQR] 5-18), and on CSC arrival, it was 9 (IQR 3-17), with a median change of 0 (-3 to -0). Of note, 74.5% of scores changed by fewer than 4 points (7% increased ≥4 points, and 19% decreased ≥4). In 85% of cases, the NIHSS score change did not cross a threshold to alter eligibility for thrombectomy. In multivariable modeling, ERI was associated with ability to ambulate before the index stroke (odds ratio [OR] 5.79, p = 0.02) and higher initial NIHSS (OR 1.06 per point, p = 0.001). These findings may be valuable for resource planning and for inclusion in thrombectomy alert activation processes at the receiving hospital.

Abstract WP234: Improved Response, Neurologic Evaluation, and Treatment Timing With a Mobile Stroke Unit in a Large Urban Population

Background: The University of Colorado Mobile Stroke Unit (UC MSU) began clinical operation in January 2016, providing ambulance-mounted CT scanning and tele-stroke neurologic assessment in the Denver, CO, metropolitan area. As one of the first U.S. tertiary stroke centers to utilize a mobile stroke protocol we sought to evaluate characteristics of response, neurologic evaluation, and treatment of the MSU. Methods: The study assessed patient, stroke, ambulance response, neurologic evaluation, and treatment characteristics of the UC MSU for its initial year in service. Variables included time from stroke alert (MSU dispatch) to brain CT in the field, treatment decision, tPA administration, and transport to a hospital stroke center. Time intervals from last seen normal were calculated for all patients. Study variables were compared for patients treated with thrombolysis on the MSU, and those who were not; and with reported times for other MSUs, and hospitals. Results: Between Jan. 15, 2016 and Jan. 9, 2017, 47 individuals received prehospital management with the UC MSU. Median age was 67 years (IQR 58-77), and 51% were female. Median initial NIH Stroke Scale score was 5 (IQR 2-11), and 36% were moderate to severe (NIHSS ≥8). Thirteen (28%) of patients were treated with IV tPA on the MSU. Median times from stroke alert to MSU arrival on the scene and first CT were 7 minutes (IQR 5-8), and 20 minutes (IQR 18-24), respectively. Median time to tPA administration was 39 minutes (IQR 35-45) from stroke alert, and 52 minutes (IQR 48-77) from the last time the patient was seen normal. Times from stroke alert and last seen normal to arrival at a stroke hospital were a median of 51 minutes (IQR 45-54) and 71 minutes (IQR 56-118), respectively. Conclusions: In this study of the initial year of an urban MSU’s operation, time intervals from stroke alert to initial brain CT imaging, neurologic evaluation and administration of thrombolysis were found to be substantially reduced compared to conventional, hospital-based stroke protocols, and some earlier MSUs. Intervals from last seen normal to these procedure time points were similarly reduced. These results suggest prehospital management with an MSU has potential to aid the goal of earlier thrombolysis after ischemic stroke symptom onset.

Abstract WMP27: Current Generation Anticonvulsant Prophylaxis After Ischemic Stroke

Introduction: Ischemic strokes (IS) are the leading cause of seizure development in the elderly and recent reports associate post-IS seizures with increased morbidity and mortality. Yet, there is a scarcity of studies defining the role of anticonvulsant prophylaxis in the prevention of seizures after IS. As a result, AHA/ASA guidelines do not recommend the prophylactic administration of anticonvulsants in this setting. Here, the ability of newer generation anticonvulsants, mainly levetiracetam, to prevent post-IS seizures is analyzed. Methods: We performed a review of our clinical database from 2010-2015 including patients that suffered IS. Patient demographics, seizure incidence, and functional outcomes were collected. Patients that received prophylaxis and those who did not were divided. Logistic regression and quantile regression models assessed relationships between outcomes and risk factors, each analysis was corrected for age, gender, and initial NIH stroke scale (NIHSS) score. Results: From a total of 1771 patients included in this study, the mean age was 69 and 51.1% were male. Median initial NIHSS score was 6.0 (IQR, 2-14), with prophylaxis and 3.0 (1.0-7.0) without. Of the 534 patients that had prophylactic anticonvulsants, 352 (65.9%) first received levetiracetam and 127 (23.8%) received gabapentin. Those with prophylaxis had 36 (6.7%) seizures and without experienced 47 (3.6%). Despite correcting for the initial severity of stroke, prophylaxis independently and significantly increased the odds of a seizure (adjusted OR, 1.76; 95% CI, 1.09-2.87; p=0.02). Furthermore, prophylaxis was associated with an increased discharge NIHSS score (adjusted difference, 1.0; 95% CI, 1.0-1.0; p&lt;0.001) but not an increase in mRS score at discharge. Patients with prophylaxis also had longer hospital stays (adjusted difference, 1.0 days; 95% CI, 0.7-1.3, p&lt;0.001) and higher total hospital costs (adjusted difference, $9,103; 95% CI, 5,707-12,498; p&lt;0.001). Conclusions: Post-IS anticonvulsant prophylaxis is not associated with improved outcomes or a reduced seizure incidence. Instead, prophylaxis here was associated with an increased odds of having a seizure after IS, a worse NIHSS score at discharge with longer hospital stays and higher costs.

Wake-up stroke is not associated with sleep-disordered breathing in women.

We sought to investigate the frequency of wake-up stroke (WUS) and its association with sleep-disordered breathing (SDB) in women. Within a population-based study, women with acute ischemic stroke were asked about their stroke symptom onset time. SDB screening was performed with the well-validated ApneaLink Plus device; SDB was defined by a respiratory event index ≥10. Logistic regression was used to test the association between SDB presence and severity and WUS unadjusted and adjusted for potential confounders including prestroke depression and sleep duration. Among 466 participants, the median age was 67.0 years (interquartile range [IQR] 58.0, 77.0), 55% were Mexican American, and the median initial NIH Stroke Scale score was 3.0 (IQR 1.0, 6.0). Stroke symptom onset occurred during nocturnal sleep (25.3%), during a nap (3.9%), during wakefulness (65.9%), or unknown (4.9%). In those with SDB screening performed (n = 259), a median of 11 days (IQR 5, 17) poststroke, WUS was not associated with the presence or severity (respiratory event index) of SDB in unadjusted or adjusted analysis. In this population-based study, WUS represented about 30% of all generally mild severity ischemic strokes in women and was not associated with SDB.

Reduction in time to treatment in prehospital telemedicine evaluation and thrombolysis

To compare the times to evaluation and thrombolytic treatment of patients treated with a telemedicine-enabled mobile stroke treatment unit (MSTU) vs those among patients brought to the emergency department (ED) via a traditional ambulance. We implemented a MSTU with telemedicine at our institution starting July 18, 2014. A vascular neurologist evaluated each patient via telemedicine and a neuroradiologist and vascular neurologist remotely assessed images obtained by the MSTU CT. Data were entered in a prospective registry. The evaluation and treatment of the first 100 MSTU patients (July 18, 2014-November 1, 2014) was compared to a control group of 53 patients brought to the ED via a traditional ambulance in 2014. Times were expressed as medians with their interquartile ranges. Patient and stroke severity characteristics were similar between 100 MSTU and 53 ED control patients (initial NIH Stroke Scale score 6 vs 7, p = 0.679). There was a significant reduction of median alarm-to-CT scan completion times (33 minutes MSTU vs 56 minutes controls, p < 0.0001), median alarm-to-thrombolysis times (55.5 minutes MSTU vs 94 minutes controls, p < 0.0001), median door-to-thrombolysis times (31.5 minutes MSTU vs 58 minutes controls, p = 0.0012), and symptom-onset-to-thrombolysis times (97 minutes MSTU vs 122.5 minutes controls, p = 0.0485). Sixteen patients evaluated on MSTU received thrombolysis, 25% of whom received it within 60 minutes of symptom onset. Compared with the traditional ambulance model, telemedicine-enabled ambulance-based thrombolysis resulted in significantly decreased time to imaging and treatment.

Aspirin resistance is associated with increased stroke severity and infarct volume.

To investigate whether aspirin resistance is associated with initial stroke severity and infarct volume, using diffusion-weighted imaging (DWI) in patients with acute ischemic stroke that occurred while taking aspirin. We studied a total of 310 patients who were admitted within 48 hours of acute ischemic stroke onset. All patients had been taking aspirin for at least 7 days before stroke onset. Aspirin resistance, defined as high residual platelet reactivity (HRPR) on aspirin treatment, was measured using the VerifyNow assay and defined as an aspirin reaction unit ≥550. Initial stroke severity was assessed using the NIH Stroke Scale (NIHSS) score. Infarct volume was measured using DWI. HRPR occurred in 86 patients (27.7%). The initial NIHSS score (median [interquartile range]) was higher in patients with HRPR than in the non-HRPR group (6 [3-15] vs 3 [1-8], p < 0.001). DWI infarct volumes were also larger in the HRPR group compared to the non-HRPR group (5.4 [0.8-43.2] vs 1.7 [0.4-10.3], p = 0.002). A multivariable median regression analysis showed that HRPR was significantly associated with an increase of 2.1 points on the NIHSS (95% confidence interval 0.8-4.0, p < 0.001) and an increase of 2.3 cm(3) in DWI infarct volume (95% confidence interval 0.4-3.9, p < 0.001). Aspirin resistance is associated with an increased risk of severe stroke and large infarct volume in patients taking aspirin before stroke onset.

Abstract WP115: Atrial Fibrillation and Acute Stroke Recurrence in Minor Stroke Patients With Carotid Stenosis

Background &amp; Purpose: Carotid stenosis (CS) and atrial fibrillation (AF) can be associated with a bad outcome even in minor stroke. We investigated acute stroke recurrence and short-term outcome in Japanese minor stroke patients with CS with or without AF. Subjects &amp; Methods: Among the consecutive 6246 stroke patients who were admitted to the 7 stroke centers within 48 hurs after the onset, 429 patients with acute ischemic stroke with extracranial carotid stenosis (50% or more in diameter measured by using MR angiography or carotid ultrasonography), the initial NIH stroke scale (NIHSS) score of 7 or less, and prior modified Rankin scale (mRS) of 0 or 1 were included in the present study. Patients who were planned for carotid endarterectomy within 3 weeks were excluded. We observed a stroke recurrence and outcome during 3 months. Stroke recurrence was defined as a neurological deterioration (NIHSS score worsening of ≥1 point) with a new ischemic lesion on diffusion weighted image. Good outcome was defined as a mRS score of 0 or 1 at 3 months. Results: AF was observed in 94 (22%) patients at hospital discharge. The acute stroke recurrence rate was not different between patients with (11%) and without AF (12%), however, good outcome was less frequent in patients with (39%) than without AF (66%). The Degree of carotid stenosis in NASCET method was more severe in patients with than without acute stroke recurrence (66% vs 59%). The initial diastolic blood pressure, pulse rate, NIHSS Score, WBC, TG, glucose, HbA1c, CRP, and D-dimer values were lower in patients with than without good outcome at 3 months. On the multivariate analysis, AF was negatively associated with good outcome (OR 0.36, 95%CI 0.20-0.0.64). The initial D-dimer value (OR 0.84, 95%CI 0.75-0.94) was also negatively associated with good outcome. Among 94 patients with both CS and AF, combined treatment with both antiplatelet and anticoagulant agents was more frequent in patients with than without good outcome. Conclusions: AF and the initial D-dimer value were significant negative predictors for good outcome in patients with CS. Optimal antithrombotic treatment in patients with both CS and AF should be investigated.

Abstract TMP66: Sex Disparity in Stroke Quality of Care in a Community-Based Study

Introduction: Studies have suggested that women may receive lower quality of care (QOC) than men, although population-based studies are lacking. We investigated sex disparities in QOC in the Brain Attack Surveillance in Corpus Christi Project. Methods: All ischemic stroke patients admitted to one of six Nueces County community hospitals between Feb 2009 and Jun 2012 were prospectively identified. Data regarding compliance with seven performance measures (PMs) were extracted from the medical records. A composite score of QOC representing the number of achieved PMs over all patient-appropriate PMs was calculated. Multivariable models with generalized estimating equations assessed the association between sex and the composite score and between sex and individual PMs. Models were adjusted for hospital clustering, age, and ethnicity, while the model assessing composite score was also adjusted for insurance status, education, pre-stroke functional status (Rankin 0-2), initial NIH stroke scale score, and comorbidity index. Results: Compared to men, women were older (median age 72 vs 65), less likely to have a pre-stroke Rankin 0-2 (69% vs 83%), and less likely to identify as married/living together (38% vs 61%). Results for the association of sex with individual PMs are shown below. Women were less likely to receive DVT prophylaxis at 48 hours, an antithrombotic at 48 hours, and to be discharged on an antithrombotic. Women were less likely to be discharged on a cholesterol medication, although this finding was of borderline significance. Women had a lower composite score (mean difference -0.030, 95% CI -0.057 to -0.003). Conclusions: In this population-based study, women had a lower overall stroke QOC, although absolute differences in most individual PMs were small. Further investigation into the factors contributing to the gender disparity in guideline-concordant stroke therapy should be pursued.

Abstract WP76: Utility of Individual NIH Stroke Scale Items as a Predictor of Functional Outcomes in Acute Ischemic Stroke Patients Presenting With Mild Neurologic Deficits

Introduction: Predicting outcomes of acute stroke patients initially presenting with mild neurologic deficits is important in making decision for thrombolytic therapy. Previous researches with a small sample size have failed to find specific items of NIH Stroke Scale or clinical syndromes to be predictive of functional outcome. Hypothesis: We hypothesized that certain items of the NIH Stroke Scale or their combinations would be independently associated with unfavorable functional outcome after mild stroke Methods: Using a multicenter stroke registry database, we identified patients with acute ischemic stroke who presented within 4.5 hours of symptom onset and had initial NIH Stroke Scale scores ≤ 5. Functional outcomes at three months after the stroke were classified as favorable (modified Rankin Scale score [mRS] 0 to 1) or unfavorable (mRS 2-6). The individual NIH Stroke Scale items were dichotomized as absent (0) or present (≥1) for the analysis. The NIH Stroke Scale items and the total score were tested for predicting the outcomes in multivariable models adjusting for demographics and clinical characteristics. Area under the ROC curve (AUC) was used to assess the performance of multivariable models. Results: Among 2,209 patients who met the eligible criteria, 588 patients (26.6%) exhibited unfavorable functional outcome (mRS 2-6) at three months. The most frequently present items were item 10 (dysarthria, 37.5%), item 4 (facial palsy, 21.1%), item 8 (sensory, 15.0%), and items indicating limb paralysis. Among 15 items of NIH Stroke Scale, all items except for item 8 (sensory) and item 11 (extinction) were significantly associated with unfavorable functional outcomes in bivariate analysis (P &lt;0.05), and many of them remained significant in multivariable analyses. In multivariable analyses, the model including the total NIH Stroke Scale scores exhibited similar AUC (0.759; 95% CI, 0.740 -0.776; P=0.75 for pairwise comparison) compared to the model with all NIH Stroke Scale items (0.758; 0.739 - 0.775) in predicting functional outcomes after the stroke. Conclusions: Simply using the total score was as effective as using all NIH Stroke Scale items in predicting outcomes of patients presented with mild stroke symptom.

Abstract WMP65: A Dichotomized Cincinnati Prehospital Stroke Score is Correlated With Revascularization Therapy in Acute Stroke

Introduction: Early revascularization improves outcomes in patients with acute stroke, and prehospital identification of patients with large vessel occlusions can result in preferential transport to centers with endovascular capability. Several stroke severity scales have been developed to assist with prehospital triage, but emergency medical services (EMS) provider training on new assessment scales presents challenges. Hypothesis: A dichotomized Cincinnati Prehospital Stroke Scale (CPSS) with a cut-off of 2 correlates with acute stroke revascularization in a large US city. Methods: Patients with confirmed stroke arriving via EMS between August 2012 and April 2014 at a high-volume stroke center in a large urban city with a single municipal EMS provider were identified. Demographics, prehospital CPSS, initial NIH stroke scale score (NIHSS) at hospital arrival, and type of revascularization (intravenous tissue plasminogen activator [IVtPA] or endovascular) were captured. Spearman’s rank correlation and Mann-Whitney U Test were performed after applying skewness/kurtosis tests. The Youden index was used to identify the optimal cut-off for the dichotomized CPSS. Multivariate logistic regression controlling for age, sex, and race determined the odds ratio (OR) for revascularization. Results: A total of 144 patients were included; 51% were male, 57% were white, and 33% were black. The mean age was 68.8 years (SD 16.1). A total of 31 patients (21.5%) underwent revascularization, most often with IVtPA alone (n=30). CPSS was ≥2 in 42% of patients, and the median NIHSS in patients with CPSS &lt;2 vs CPSS ≥2 was 2 vs 8 (p&lt;0.0001). CPSS and NIHSS in patients presenting within 4.5 hours were strongly correlated (Spearman's rho = 0.57, p&lt;0.0001). The optimum CPSS cut-off that predicted revascularization was 2, with a sensitivity of 0.79, specificity of 0.81, and a Youden index of 0.61. CPSS ≥2 was strongly associated with revascularization (adjusted OR 14.5, 95% CI 5.0-42.4). Conclusions: Prehospital dichotomized CPSS with a cut-off of 2 is well correlated with acute stroke revascularization in a large US city. Further studies should investigate how the dichotomized CPSS performs in the prehospital identification of stroke patients with large vessel occlusions.

Quality of life in patients with TIA and minor ischemic stroke.

We investigated health-related quality of life (HRQOL) in patients with TIA and minor ischemic stroke (MIS) using Neuro-QOL, a validated, patient-reported outcome measurement system. Consecutive patients with TIA or MIS who had (1) modified Rankin Scale (mRS) score of 0 or 1 at baseline, (2) initial NIH Stroke Scale score of ≤5, (3) no acute reperfusion treatment, and (4) 3-month follow-up, were recruited. Recurrent stroke, disability by mRS and Barthel Index, and Neuro-QOL scores in 5 prespecified domains were prospectively recorded. We assessed the proportion of patients with impaired HRQOL, defined as T scores more than 0.5 SD worse than the general population average, and identified predictors of impaired HRQOL using logistic regression. Among 332 patients who met study criteria (mean age 65.7 years, 52.4% male), 47 (14.2%) had recurrent stroke within 90 days and 41 (12.3%) were disabled (mRS >1 or Barthel Index <95) at 3 months. Any HRQOL impairment was noted in 119 patients (35.8%). In multivariate analysis, age (adjusted odds ratio [OR] 1.02, 95% confidence interval [CI] 1.01-1.04), initial NIH Stroke Scale score (adjusted OR 1.39, 95% CI 1.17-1.64), recurrent stroke (adjusted OR 2.10, 95% CI 1.06-4.13), and proxy reporting (adjusted OR 3.94, 95% CI 1.54-10.10) were independent predictors of impaired HRQOL at 3 months. Impairment in HRQOL is common at 3 months after MIS and TIA. Predictors of impaired HRQOL include age, index stroke severity, and recurrent stroke. Future studies should include HRQOL measures in outcome assessment, as these may be more sensitive to mild deficits than traditional disability scales.