Initial NIH Stroke Scale Research Articles

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 <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 TP69: Administration of Tissue Plasminogen Activator: to Wait or not to Wait for Screening Coagulation Tests? Impact on Door to Needle Time and Symptomatic Intracerebral Hemorrhage

Introduction and Hypothesis: Administration of intravenous tissue plasminogen activator (IV tPA) is currently the only FDA approved medical treatment for acute ischemic stroke. To improve outcomes the goal is to have reduced door to needle time (DTN) to IV tPA. Guidelines recommend obtaining coagulation tests prior to IV tPA, but new prescribing information suggest physicians may not need to wait for coagulation test results in patients not on anticoagulation therapy. We assessed the hypothesis if not waiting for these tests prior to IV tPA reduced the DTN time, without affecting the rate of symptomatic intracerebral hemorrhage (SICH). Methods: The study is a retrospective analysis of prospectively collected data on acute ischemic stroke patients treated at a Joint Commission Certified Stroke Center. Based on differing physician practices, patients received IV tPA prior to results of screening coagulation tests or they received IV tPA after tests returned. Measures obtained from chart review included initial NIH stroke scale (NIHSS), DTN time, lab return time, abnormal lab results, and development of post IV tPA SICH (defined as ICH associated with an NIHSS increase ≥4). Results: From January 2013 to May 2015, 136 patients received IV tPA. (Mean age ± SD = 65 ± 15 years, 53% male, 46% African American, 51% Caucasian, and 2% other, median NIHSS = 10, mean DTN ± SD = 65 ± 35 min). Group one, 102 patients, received IV tPA after test results were available (Mean age ± SD = 66 ± 15 years, 51% male, 50% African American, 48% Caucasian, and 2% other, median NIHSS = 10, mean DTN ± SD = 71 ± 34 min). Group two, 34 patients, received IV tPA prior to test results being available (Mean age ± SD = 64 ± 15 years, 59% male, 35% African American, 62% Caucasian, and 3% other, median NIHSS = 12, mean DTN ± SD = 46 ± 31 min). Group two had a significantly reduced DTN time (t test p<0.0002). No abnormal screening coagulation tests were found upon final review. There was no difference between in the rates of SICH (group one 4%, group two 6%, Fisher's exact test p>0.99). Conclusions: Selection of appropriate patients to receive IV tPA without waiting for screening coagulation tests to be returned, significantly improved DTN time. There was no significant difference between the rates of SICH in the two groups.

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 <2 vs CPSS ≥2 was 2 vs 8 (p<0.0001). CPSS and NIHSS in patients presenting within 4.5 hours were strongly correlated (Spearman's rho = 0.57, p<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.

Distance to thrombus on MR angiography predicts outcome of middle cerebral artery occlusion treated with IV thrombolysis.

The distance to thrombus (DT) on CT angiography was recently proposed as a predictor of outcome in patients treated by intravenous thrombolysis (IVT) for stroke due to occlusion of the middle cerebral artery (MCA). The purpose of the present study was to validate its inter-rater reliability and its prognostic value on contrast-enhanced magnetic resonance angiography (CE-MRA). Furthermore, we investigated the relation between DT and FLAIR-vascular hyperintensities (FVH) as a surrogate of collateral circulation and hypoperfusion. Patients with acute MCA occlusions treated by IVT and diagnosed with magnetic resonance imaging (MRI) were included. Two readers measured DT. FVH and acute DWI lesion volumes were quantified. Clinical status was determined using the initial NIH stroke scale (NIHSS) and 90-day modified Rankin Scale (90d mRS). Sixty-one patients showed a lesion on diffusion-weighted magnetic resonance images and an occlusion of the MCA on CE-MRA. We found significant inverse correlations between DT and NIHSS scores at admission (ρ = -0.29; P = 0.02), DT and mRS at 90 days (ρ = -0.29; P = 0.04), and between DT and FVH (ρ = -0.32; P = 0.01). For a DT <22 mm, the likelihood of an unfavorable outcome (90d mRS 3-6 or NIHSS score improvement of ≤10 points at discharge) was >50 %. Initial DWI lesion volumes showed no correlation with the outcome. Excellent inter-rater agreement for DT was observed (Cronbach's α = 0.98; P < 0.001). DT on CE-MRA is reliably measurable, correlates inversely with FLAIR-vascular hyperintensities, and predicts outcome in patients with acute MCA occlusion treated with IVT.

Abstract W P151: Time is More Brain in Patients with Higher Hemoglobin A1C

Objective: The aim of our study was to determine if chronic hyperglycemia, demonstrated by elevated hemoglobin A1C (HbA1C), had an effect on outcome after IV tPA infusion for acute ischemic stroke. Materials: A comprehensive record review of diabetic patients who received IV tPA with ischemic stroke who presented to a community comprehensive stroke center during a 3-year period (2010-2013) was done. Two groups were made: HbA1C &gt;6% and &lt;6% (Group A &amp; Group B). Each group subdivided into 3 groups based on times from symptom onset to IV tPA: 180 mins. The groups were then compared to establish the number needed to harm (NNH) for IV tPA at different time periods. Harm was considered a worsening in the NIHSS of 3 or more. Mean initial NIH Stroke Scale (INIHSS) and discharge NIHSS (DNIHSS) were determined and 2-tailed t-tests were performed for the outer groups with SPSS V22. Results: A total of 1,565 patients with ischemic stroke were evaluated. Of those, 166 patients met study criteria. There were 100 patients with HbA1C over 6% (mean age 73.4, 55% female). Group A had a mean INIHSS/DNIHSS of 24.5/7.8, 13.3/10.6 and 8.65/8.23 at 180 mins, respectively. The mean change in INIHSS to DNIHSS between the 180 group with Group A was Patients with Group B had mean INIHSS/DNIHSS of 16.5/6.5, 13.23/7.6 and 11.6/6.5. The mean differences between INIHSS and DNIHSS in Group A patients in the 180 min time was 13.2 (95% CI 3.8-22.5, p=.01). The NNH for giving IV tPA to patients with HbA1C &gt;6% versus &lt;6% at different times was: 180= 4.8. For every 10 patients with HBA1C &gt;6% treated with IVtPA, one is harmed. This doubled when IVtPA is given after 180 mins. Conclusion: Compared with patients with HbA1C &lt;6%, patients with HbA1c &gt;6% have a significantly greater chance of suffering a bad outcome and incurring harm. More data needs to be collected with a larger prospective study to draw better conclusions.

Abstract W P300: Ethnic Differences in Post-Stroke Quality of Life in the Brain Attack Surveillance in Corpus Christi (BASIC) Project

Background: Mexican Americans (MAs) have worse stroke outcomes than non-Hispanic whites (NHWs), which could translate into worse quality of life (QOL). Our objective was to investigate ethnic differences in post-stroke QOL across multiple domains in a bi-ethnic community. Methods: Ischemic stroke survivors, identified through the population-based Brain Attack Surveillance in Corpus Christi (BASIC) Project in Nueces County, Texas, participated in in-person interviews 90 days post-stroke from May 2010 - June 2012. The validated short form stroke-specific QOL (SSQOL) was used to assess overall, physical, and psychosocial QOL; scores range from 1-5 with higher scores representing greater QOL. Tobit regression was used to model unadjusted associations between ethnicity and the 3 QOL domains. Models were then adjusted for the following demographic and clinical factors obtained from the medical record and patient interview: age, sex, education, insurance status, marital status, nursing home residence before stroke, prestroke modified Rankin scale, prestroke Informant Questionnaire on Cognitive Decline in the Elderly, initial NIH stroke scale, risk factors, BMI, and a comorbidity index. Results: A total of 335 ischemic strokes with complete data were identified (66% MA, 34% NHW). QOL was lower among MAs compared to NHWs, both overall (mean difference=-0.3, p=0.02) and in the physical domain (mean difference=-0.4, p=0.008); however, there was no difference in the psychosocial domain (p=0.22). After adjustment for demographic and clinical factors, MAs continued to experience poorer QOL compared to NHWs overall (mean difference=-0.5,p=0.049) and in the physical domain (mean difference=-0.3, p=0.006). Conclusions: Ethnic disparities in stroke outcome extend to QOL, with MAs experiencing substantially worse post-stroke QOL than NHWs. Interventions are urgently needed to improve stroke outcomes among the rapidly growing MA stroke population.

Abstract 169: IV t-PA May Result in Better Outcomes than Conservative Care in Patients with Mild Acute Ischemic Stroke and Large Vessel Occlusion

Introduction: Most patients with mild acute ischemic stroke (AIS) symptoms are excluded from acute stroke therapy (AST). Studies have shown that patients presenting with large vessel occlusions (LVO) and low NIH stroke scale (NIHSS) may have poorer outcomes than previously presumed. The optimal treatment strategy in this population is unknown. Methods: A retrospective chart review of patients with AIS presenting to our tertiary care center between 2010 and 2013 was carried out. Inclusion criteria included LVO as cause of AIS and initial NIHSS &lt; 8. Patients presenting &gt;24 hours after last known normal were excluded. Patient demographics, administered therapies and short-term clinical outcomes were analyzed. For patients lost to follow up, last known values were imputed. Favorable 30-day outcomes were defined as mRS 2, NIHSS 1 or at least 4 point decrease in NIHSS. Results: A total of 121 patients (56.19% males; mean age 63.85±14.08) met inclusion criteria. Anterior circulation was involved in 69.4% cases [MCA (46.28%), ICA (16.52%), ACA (2.47%), ICA-MCA (4.13%)] vs 33.88% posterior circulation cases [PCA (8.26%), Ba (5.7%), V (19%)]. Median admission NIHSS and pre-admission mRS were 4 &amp; 0 respectively, which were statistically significant predictors of favorable outcome. Only 23 patients (19%) received AST [IV t-PA: 13, intrarterial (IA) therapy: 6, IV + IA: 4]. AST patients had shorter time from onset of symptoms to evaluation (mean: 3.7 vs. 9.9 hours, p &lt; 0.001), higher NIHSS on arrival (median: 5 vs. 3, p = 0.024), and were more likely to have a history of stroke (39% vs. 18%, p = 0.049). The odds of a 30-day favorable mRS were 1.7 times higher in the treated group, although not statistically significant (95% CI: 0.58, 5.7; p = 0.333). Numbers in the subgroup analysis remained too small to reach statistical significance, but 85% of patients who received IV t-PA (and 70% with any treatment) had a favorable 30-day outcome versus 62% of patients with conservative care.Conclusion: Our study suggests that qualifying patients with LVO and mild AIS presenting early may have better outcomes if treated with IV t-PA. We propose that rapid evaluation of vessel status may support more aggressive treatment considerations in patients with mild AIS. Further prospective data is needed.

Abstract T P3: Safety of Eptifibatide after Full Dose IV tPA and Endovascular Treatment for Ischemic Stroke

Background and Objective: The safety of eptifibatide in combination with IV tPA for ischemic stroke has recently been demonstrated in the CLEAR-ER trial which used .6 mg/kg IV tPA plus eptifibatide (135 mcg/kg bolus and .75mcg/kg/min two-hour infusion) versus standard tPA (.9 mg/kg). Prior studies have also looked into the combination of intra-arterial (IA) tPA and eptifibatide at dosing and duration similar to cardiology literature. Our aim was to compare the safety and efficacy of eptifibatide after full dose IV tPA and endovascular treatment versus full dose IV tPA and endovascular treatment alone. Materials and Methods: We reviewed the records and procedure reports of patients who underwent endovascular treatment for ischemic stroke from 2010-2013 at a university affiliated comprehensive stroke center. Patients who received full dose IV tPA (.9 mg/kg) followed by endovascular treatment were compared with those who had the same treatment, but also received a bolus of 135 mcg/kg of eptifibatide followed by a .5 mcg/kg/min for 20 hours (based on IMPACT-II trial protocol). The initial and discharge NIH Stroke Scale as well as the discharge mRS (DCmRS) were evaluated. A DCmRS of 0 or 1 was considered a favorable outcome, and 2 or more was considered as a unfavorable. Initial stroke severity (NIHSS) was analyzed with logistic regression for baseline comparison and Fisher’s exact test were used for categorical data analysis. Results: We evaluated 2,016 patients with ischemic stroke, of which 230 received IV tPA and 91 (55% female) underwent endovascular treatment, 44 of them also received eptifibatide. Of the 44 patients who received eptifibatide (bolus and 20 hour infusion), 18% (n=8) had a favorable outcome, and in the group that did not receive eptifibatide , 9% (n=4) had a favorable outcome (OR=2.389, 95% CI 0.6645 to 8.589, p= 0.2217). Conclusion: Eptifibatide in combination with full dose IV tPA and endovascular treatment did not increase morbidity in our patient population, and may have improved outcome. Further, larger trials need to be conducted for more definitive results.

Abstract W MP108: Identifying Factors Predictive of Good Outcome among Patients with Severe Ischemic Stroke: the BASIC Project

Background: Utilizing a population-based stroke surveillance study, our objective was to identify possible socio-demographic, cultural and psychological factors that influence outcome among patients with severe stroke who survive at least 3 months. Methods: Ischemic strokes (IS) were identified utilizing the Brain Attack Surveillance in Corpus Christi (BASIC) Project. Severe stroke was defined as the highest quartile of the initial NIH Stroke Scale (NIHSS ≥ 8). Functional outcome was assessed at 90 days using the ADL/IADL score (0-4, higher worse). Good outcome was defined as ADL/IADL &lt;3. Single predictor logistic regression models were used to identify predictors of good outcome among those with severe stroke. Backward elimination was then used to select a final set of predictors. Next, models including selected predictors and pre-stroke social support or pre-stroke depression (PHQ-9) were used to evaluate their association with good outcome among a subset of patients who were asked about these factors. Only patients who were able to answer their own questions were asked about depression and social support. Results: From Feb 2009 to Jun 2012, 646 IS patients completed a baseline interview and subsequent 90-day outcome interview. Of 168 with severe stroke, 68 had a good outcome at 3 months (ADL/IADL &lt;3). One year older age (OR=0.94, 95% confidence interval (CI) 0.91, 0.97), Mexican American ethnicity (OR 0.30, 95%CI: 0.13, 0.68), stroke history (OR 0.27, 95%CI: 0.11, 0.66) and higher pre-stroke modified Rankin of 4-5 (OR 0.28, 95%CI: 0.08, 0.93) were associated with lower odds of good outcome. Among the subset of severe stroke patients (N=93) asked about pre-stroke depression and social support, higher pre-stroke depression score was associated with lower odds of good outcome (OR: 0.89, 95%CI 0.79, 0.99) while greater pre-stroke social support was associated with higher odds of good outcome (OR: 1.45, 95% CI 1.13, 1.86). Conclusion: Among IS survivors with severe stroke, pre-stroke depression and social support are important predictors of good outcome. These factors should be considered in crafting interventions to improve stroke outcome. Mexican American ethnicity and history of prior stroke are strongly negatively associated with good stroke outcome.

Abstract T P70: Outcome of Japanese Minor Stroke Patients Treated Without Intravenous Recombinant Tissue Plasminogen Activator Within 4.5 Hours After the Symptom Onset ~Fukuoka Stroke Registry~

Background &amp; Purpose: Patients with minor stroke with the initial NIH stroke scale score of 4 or less were often treated without recombinant tissue plasminogen activator (rt-PA) even when they are admitted within 4.5 hours after the symptom onset. We investigated the outcome of minor stroke within 4.5 hours after the symptom onset without intravenous recombinant tissue plasminogen activator therapy. Methods: Among consecutive 6246 acute ischemic stroke patients who were admitted to the 7 stroke centers, 963 patients with admission within 4.5 hours after the symptom onset, ischemic lesions on diffusion-weighted image, NIH stroke scale of 4 or less, and prior modified Rankin scale (mRS) of 0 or 1 were included in the present study. Thirty-four (3.5%) of the 963 patients were treated with intravenous rt-PA. In other 926 patients, we observed a neurological deterioration (a NIHSS score worsening of ≥2-point) and stroke recurrence during the first 3 weeks. A good outcome (3 months) at was defined as mRS of 0 or 1. Results: Stroke recurrence and neurological deterioration occurred in 3.7% and 9.2% of 926 patients during the first 3 weeks. A good outcome 3 months after admission was observed in 82.3%. Atrial fibrillation and diabetes mellitus were less frequent in patients with than without a good outcome. The initial NIH stroke scale score, LDL-cholesterol, glucose, HbA1c, d-dimer, and CRP values were lower, and the initial HDL-cholesterol and estimated GFR values were higher in patients with than without a good outcome. On multivariate analysis, age (OR 0.94, 95%CI 0.92~0.97), the initial NIH stroke scale score (OR 0.60, 95%CI 0.48~0.74), LDL-cholesterol (OR 0.99, 95%CI 0.98~1.00), and D-dimer (OR 0.92, 95%CI 0.85~0.99) were negatively associated with a good outcome. With regard to the ROC curve analysis, the most accurate cut-off value for predicting a good outcome was 74 years in age, 2 in NIH stroke scale score, 137mg/ml in LDL-cholesterol, and 0.80μg/ml in D-dimer. Conclusions: In minor stroke patients treated without rt-PA, age of 75 years or more, NIH stroke scale score of 3 or more, LDL-cholesterol of 138mg/ml or more, or D-dimer of 0.80μg/ml or more could be negative predictor for a good outcome. In such patients, treatment with rt-PA may be considered.

Automated analysis of perfusion weighted MRI using asymmetry in vascular territories

PurposeTo determine the feasibility of automatic vascular territory region of interest (ROI) construction as a method for standardized quantification of cerebral blood flow (CBF) images. Materials and methodsAn algorithm for automatic construction of vascular territory ROIs was performed on 10 healthy controls and 25 patients with perfusion abnormalities identified by retrospective chart review. The ROIs were used to quantify perfusion asymmetry for each territory, and perfusion asymmetry was compared in the two cohorts and against blinded neuroradiologist interpretation. The algorithm was additionally applied to a separate cohort of 23 prospectively enrolled patients and perfusion asymmetry was correlated against clinical variables. ResultsThere was significantly greater perfusion asymmetry in territories graded by neuroradiologists as hypoperfused compared to those graded as normally perfused (p<.05) and compared to healthy volunteers (p<.01). An ROC analysis showed that perfusion asymmetry was sensitive and specific for identifying hypoperfusion in vascular territories (84.9% sensitivity and 90.5% specificity for a threshold asymmetry index of .829). In the prospective cohort, perfusion asymmetry was correlated with initial NIH stroke scale (NIHSS) (p<.01) and length of stay (p<.05). ConclusionsAutomatic construction of vascular territory ROIs and calculation of perfusion asymmetry is a feasible method for analyzing CBF images. Because the technique is rapid and minimizes bias, it can facilitate analysis of larger scale research studies.

O-032 Predictors of Poor Outcomes Despite Successful Recanalization in Patients with Acute Ischemic Stroke

BackgroundRecanalization of the occluded artery is a powerful predictor of good outcome in acute ischemic stroke secondary to large artery occlusions. Mechanical thrombectomy with stent-trievers results in higher recanalization rates...

Abstract 10: Predictors of Poor Outcome in Acute Ischemic Stroke Patients after Successful Recanalization

Background: Recanalization of the occluded artery is a powerful predictor of good outcome in acute ischemic stroke secondary to large artery occlusions. Mechanical thrombectomy with stent-trievers results in higher recanalization rates and better outcomes compared to previous devices. However, despite successful recanalization rates (Treatment in Cerebral Infarction, TICI, score ≥ 2b) between 70 and 90%, good clinical outcomes assessed by modified Rankin Scale (mRS) ≤ 2 is present in 40-50% of patients . We aimed to evaluate predictors of poor outcomes (mRS &gt; 2) despite successful recanalization (TICI ≥ 2b) in the acute stroke patients treated with the Solitaire device of the North American Solitaire Stent Retriever Acute Stroke (NASA) registry. Methods: The NASA registry is a multicenter, non-sponsored, physician-conducted, post-marketing registry on the use of SOLITAIRE FR device in 354 acute, large vessel, ischemic stroke patients. Logistic regression was used to evaluate patient characteristics and treatment parameters for association with 90-day mRS score of 0-2 (good outcome) versus 3-6 (poor outcome) within patients who were recanalized successfully (Thrombolysis in Cerebral Infarction or TICI score 2b-3). Univariate tests were followed by development of a multivariable model based on stepwise selection with entry and retention criteria of p &lt; 0.05 from the set of factors with at least marginal significance (p ≤ 0.10) on univariate analysis. The c-statistic was calculated as a measure of predictive power. Results: Out of 354 patients, 256 (72.3%) were successfully recanalized (TICI ≥ 2b). Based on 90-day mRS score for 234 of these patients, there were 116 (49.6%) with mRS &gt; 2. Univariate analysis identified increased risk of mRS &gt; 2 for each of the following: age ≥ 80 years (upper quartile of data), occlusion site other than M1/M2, NIH Stroke Scale (NIHSS) score ≥ 18 (median), history of diabetes mellitus (DM), TICI = 2b, use of rescue therapy, not using a balloon-guided catheter (BGC) or intravenous tissue plasminogen activator (IV t-PA), and time to recanalization &gt; 30 minutes (all p ≤ 0.05). Three or more passes was marginally significant (p=0.097). In multivariable analysis, age ≥ 80 years, site other than M1/M2, initial NIHSS ≥18, DM, absence of IV t-PA, use of rescue therapy and three or more passes were significant independent predictors of poor 90-day outcome in a model with good predictive power (c-index = 0.80). Conclusions: Age, occlusion site, high NIHSS, diabetes, not receiving IV t-PA, use of rescue therapy and three or more passes, were associated with poor 90-day outcome despite successful recanalization.

Factors associated with unfavorable outcome in minor ischemic stroke

The purpose of this study was to elucidate the factors that correlate with unfavorable outcomes and to develop a simple validated model for assessing risk of unfavorable outcomes in patients with minor ischemic stroke. The derivation cohort included 1,313 patients hospitalized within 72 hours after onset with an initial NIH Stroke Scale score of 0 to 3 enrolled in a prospective, multicenter, observational study. Unfavorable outcome was defined as dependency (modified Rankin Scale score of 3-5) or death at 90 days. The predictive values of factors related to unfavorable outcome were evaluated. External validation was performed in 879 patients from a single-center stroke registry. In the derivation cohort, a total of 203 patients (15%) had unfavorable outcomes. On multivariable analysis, women (odds ratio [OR] 1.95, 95% confidence interval [CI] 1.30-2.94), age ≥72 years (OR 2.80, 95% CI 1.83-4.36), intra/extracranial vascular occlusive lesion (OR 2.80, 95% CI 1.82-4.28), leg weakness (OR 1.72, 95% CI 1.06-2.82), and extinction/inattention (OR 5.55, 95% CI 1.30-21.71) were independently associated with unfavorable outcome. Patients having both a vascular lesion and either leg weakness or extinction/inattention showed 4.63 (95% CI 2.23-9.33) times the risk of unfavorable outcome compared with those having neither. In the validation cohort, the risk was similar, at 3.77 (95% CI 1.64-8.37). Intra- and extracranial vascular imaging, NIH Stroke Scale items such as leg weakness and extinction/inattention, and their combination, as well as female sex and advanced age, may be useful for predicting unfavorable outcomes in patients with minor stroke.

Risk Factors for DVT/PE in Patients with Stroke and Intracranial Hemorrhage.

Objective: Deep venous thrombosis (DVT) and pulmonary embolus (PE) are serious problems for patients admitted to the hospital with stroke, subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH) and transient ischemic attack (TIA). The purpose of this paper is to further understand the factors that place certain patients at increased risk of DVT/PE.Methods: At a 600 bed hospital, a retrospective analysis of data from 2613 patients admitted with a diagnosis of stroke, SAH, ICH or TIA in the time range 1/2008 through 3/2012 was carried out. The data was taken from the hospital’s Get with the Guidelines database and included 28 variables. These included initial NIH stroke scale, length of stay, heart failure, ambulatory by day 2 after admission, altered mental status,and renal failure among others. Multiple analyses were carried out to determine whether there were univariable or multivariable effects of any of the factors on the risk for DVT/PE.Results: The risk of DVT/PE was highest in patients with SAH and ICH and smallest with TIA. Multivariable analyses were performed and revealed only altered level of consciousness or heart failure as significant risks for DVT/PE. With the limited available data, administration of subcutaneous heparin or other chemoprophylaxis did not reduce the risk of DVT/PE. Conclusion: Although many of the variables used to describe the stroke patient are correlated, in multivariable analyses only heart failure and altered level of consciousness were important risk factors for DVT/PE. The risk of DVT/PE was 7 fold greater in patients in patients with both of these risk factors.

Lower NIH Stroke Scale Scores Are Required to Accurately Predict a Good Prognosis in Posterior Circulation Stroke

Background: The NIH stroke scale (NIHSS) is an indispensable tool that aids in the determination of acute stroke prognosis and decision making. Patients with posterior circulation (PC) strokes often present with lower NIHSS scores, which may result in the withholding of thrombolytic treatment from these patients. However, whether these lower initial NIHSS scores predict better long-term prognoses is uncertain. We aimed to assess the utility of the NIHSS at presentation for predicting the functional outcome at 3 months in anterior circulation (AC) versus PC strokes. Methods: This was a retrospective analysis of a large prospectively collected database of adults with acute ischemic stroke. Univariate and multivariate analyses were conducted to identify factors associated with outcome. Additional analyses were performed to determine the receiver operating characteristic (ROC) curves for NIHSS scores and outcomes in AC and PC infarctions. Both the optimal cutoffs for maximal diagnostic accuracy and the cutoffs to obtain >80% sensitivity for poor outcomes were determined in AC and PC strokes. Results: The analysis included 1,197 patients with AC stroke and 372 with PC stroke. The median initial NIHSS score for patients with AC strokes was 7 and for PC strokes it was 2. The majority (71%) of PC stroke patients had baseline NIHSS scores ≤4, and 15% of these ‘minor' stroke patients had a poor outcome at 3 months. ROC analysis identified that the optimal NIHSS cutoff for outcome prediction after infarction in the AC was 8 and for infarction in the PC it was 4. To achieve >80% sensitivity for detecting patients with a subsequent poor outcome, the NIHSS cutoff for infarctions in the AC was 4 and for infarctions in the PC it was 2. Conclusion: The NIHSS cutoff that most accurately predicts outcomes is 4 points higher in AC compared to PC infarctions. There is potential for poor outcomes in patients with PC strokes and low NIHSS scores, suggesting that thrombolytic treatment should not be withheld from these patients based solely on the NIHSS.

Abstract T MP48: Determinants of Early and Late Recovery After Acute Ischemic Stroke: A Multicenter Stroke Registry-based Observational Study

Background: Recovery after acute ischemic stroke is usually bi-phasic. It begins early with speed and slows down after the first month. Many factors have been reported as determinants of functional outcomes. However, there is a paucity of information on their differential effects on early and late recovery. Methods: Using a multicenter prospective stroke registry database, we identified ischemic stroke patients who were hospitalized within 7 days of onset to 12 hospitals, who were discharged within 30 days. Early recovery was defined as improvement of ≥ 4 points or &gt; 50% in the NIH Stroke Scale (NIHSS) scores between baseline and discharge, and late recovery was as improvement of ≥ 1 point in mRS scores between discharge and 3 months. Multivariate logistic regression analysis was performed to estimate effects of independent variables considering a correlation between the two dependent variables, early and late recovery. Results: During 54 months, 11088 patients met the eligibility criteria. Early recovery was observed in 36% and median NIHSS change from baseline to discharge was 3 points. Late recovery was found in 33%. Multivariate analysis for revealed that 1) age, pre-stroke mRS, initial NIHSS and prior statin use were associated with both the early and late recovery, 2) onset to arrival time, large artery atherosclerosis, previous stroke, initial blood glucose level, congestive heart failure, thrombolytic treatment were with the early recovery only, and 3) cardioembolism and statin at discharge were with the late recovery only (p’s&lt;0.05). Tests for estimating equality showed that age, onset to arrival time, initial NIHSS, initial blood glucose level, systolic blood pressure, smoking, thrombolytic treatment had differential effects on early and late recovery (p’s&lt;0.05). Conclusion: Many of known determinants of 3-month functional outcome may have differential effects on early and late recovery of acute ischemic stroke.

Abstract W P112: Natural History and Outcomes of Ischemic Stroke Patients with Mild Presenting Symptoms and Large Vessel Occlusion

Introduction: Large vessel occlusion (LVO) is thought to be an independent predictor of clinical outcome in acute ischemic stroke (AIS). Despite various available treatment modalities, optimal therapy for LVO patients presenting with mild symptoms is not known. These patients remain a significant challenge in clinical practice. Methods: Retrospective chart review of AIS patients admitted between January 2010 and August 2012 at a large tertiary care center. Inclusion criteria: symptom onset within 8 hours, LVO as cause of symptoms, initial NIH stroke scale (NIHSS) &lt; 8. Patients with bilateral lesions, distal small vessel involvement or single vertebral artery disease were excluded. Tandem lesions were included. Patient demographics, administered therapies and short term clinical outcomes were analyzed. Results: A total of 51 patients (56.9% male; mean age 66.4±14.5) fulfilled our strict criteria for inclusion. MCA involvement was seen in 31 (60.8%), ICA 13 (25.5%), basilar 3 (5.9%) and tandem ICA-MCA in 4 (7.8%). A total of 15 (29.4%) received acute therapy with IV t-PA and/or endovascular intervention (TX); both were used only in 6 (11.8%). Follow-up at 30 days was available in 64.7% of patients: 58.3% with TX and 80% without. Mean NIHSS remained relatively stable showing 4.3±2.1 on admission, and 2.6±3.4 on discharge (NS), with 75.8% of patients having same or better NIHSS on follow-up. There was a significant difference in functional outcome: mRS≤2 was present in 98% of patients on admission, but only in 63.6% at follow-up. If extended the mRS range, 90.9% of patients had mRS≤3 on follow-up. Only 33.3% at follow-up had same or better mRS than on admission. Results were consistent, irrespective of receiving acute therapy. Conclusion: Acute LVO with mild presenting symptoms remains a difficult therapeutic challenge. Our data shows that despite stable gross clinical examination (by NIHSS) on follow-up, a large proportion of patients experience mild to moderately worse functional outcome, irrespective of receiving acute therapy. Our study limitations include retrospective analysis and suboptimal patient follow-up, especially in untreated patient population. We believe that a prospective, larger cohort is warranted to find optimal treatment approach.