Initial NIHSS Score Research Articles

Longitudinal microstructural alterations surrounding subcortical ischemic stroke lesions detected by free-water imaging.

In this study we explore the spatio-temporal trajectory and clinical relevance of microstructural white matter changes within and beyond subcortical stroke lesions detected by free-water imaging. Twenty-seven patients with subcortical infarct with mean age of 66.73 (SD 11.57) and median initial NIHSS score of 4 (IQR 3-7) received diffusion MRI 3-5 days, 1 month, 3 months, and 12 months after symptom-onset. Extracellular free-water and fractional anisotropy of the tissue (FAT) were averaged within stroke lesions and the surrounding tissue. Linear models showed increased free-water and decreased FAT in the white matter of patients with subcortical stroke (lesion [free-water/FAT, mean relative difference in %, ipsilesional vs. contralesional hemisphere at 3-5 days, 1 month, 3 months, and 12 months after symptom-onset]: +41/-34, +111/-37, +208/-26, +251/-18; perilesional tissue [range in %]: +[5-24]/-[0.2-7], +[2-20]/-[3-16], +[5-43]/-[2-16], +[10-110]/-[2-12]). Microstructural changes were most prominent within the lesion and gradually became less pronounced with increasing distance from the lesion. While free-water elevations continuously increased over time and peaked after 12 months, FAT decreases were most evident 1 month post-stroke, gradually returning to baseline values thereafter. Higher perilesional free-water and higher lesional FAT at baseline were correlated with greater reductions in lesion size (rho = -0.51, p = .03) in unadjusted analyses only, while there were no associations with clinical measures. In summary, we find a characteristic spatio-temporal pattern of extracellular and cellular alterations beyond subcortical stroke lesions, indicating a dynamic parenchymal response to ischemia characterized by vasogenic edema, cellular damage, and white matter atrophy.

Effects of Prior Metformin Use on Stroke Outcomes in Diabetes Patients with Acute Ischemic Stroke Receiving Endovascular Treatment.

Diabetes mellitus (DM) predisposes individuals to vascular injury, leading to poor outcomes after ischemic stroke and symptomatic hemorrhagic transformation (SHT) after thrombolytic and endovascular treatment (EVT). Metformin (MET), an oral antidiabetic drug, has shown potential neuroprotective effects, but its impact on stroke prognosis in DM patients undergoing EVT remains unclear. In a multicenter study, 231 patients with DM undergoing EVT for acute ischemic stroke were enrolled. Prior MET use was identified, and patients were stratified into MET+ and MET- groups. Demographics, clinical data, and outcomes were compared between groups. Multivariate analysis was used to assess the effect of MET on stroke prognosis. Of the enrolled patients, 59.3% were previously on MET. MET+ patients had lower initial infarct volumes and NIHSS scores compared to MET-taking patients. Multivariate analysis showed that MET+ was associated with a lower risk of stroke progression and SHT (with stroke progression as follows: odd ratio [OR] 0.24, 95% confidence interval [CI] [0.12-0.48], p < 0.001; SHT: OR 0.33, 95% CI [0.14-0.75], p = 0.01) and was also associated with better 3-month functional outcomes (mRS 0-2) after EVT. Prestroke MET use in DM patients undergoing EVT is associated with improved stroke prognosis, including reduced risk of stroke progression and SHT and better functional outcomes. These findings suggest the potential neuroprotective role of MET in this population and highlight its clinical utility as an adjunctive therapy in the management of ischemic stroke. Further research is warranted to elucidate the underlying mechanisms and to optimize MET therapy in this setting.

Abstract 144: Value of CT Perfusion Imaging Among Patients With Minor Stroke

Introduction: CTP has increasingly been incorporated into the evaluation of all patients with suspected acute ischemic stroke (AIS), including those with minor symptoms. We aimed to assess the incremental value of CTP in acute treatment decision-making among patients with low NIHSS. Methods: We performed a retrospective cohort study of all patients who underwent CTP upon presentation to the ED at three academic, urban hospitals in Philadelphia, PA between January 1, 2022 and December 31, 2022. We collected data on initial NIHSS score, AIS treatment decisions, subsequent neuroimaging, and final diagnosis. Results: There were 531 patients with a median age of 64.5 years (IQR 54-73) and 56% were women. 73% were Black or African American, 20% White, and 4% Asian. Frequency of CTP imaging by initial NIHSS score is presented in the Figure. Among 90 patients (16.9%) with NIHSS≤2, CTP imaging was cited as justification for AIS treatment (thrombolysis, thrombectomy, or both) in 0 (0%, 95% CI: 0-4%). Specifically, among 41 patients (7.7%) with NIHSS≤1, 0 received thrombolysis or thrombectomy, and 12 (29.2%) were ultimately diagnosed with AIS on CT/MRI. Among 49 with NIHSS=2 (9.2%), 2 patients received thrombolysis (based on clinical exam, CTP was normal) and one later underwent thrombectomy based on clinical decompensation with repeat NIHSS=7, and 28.6% had AIS on CT/MRI. Meanwhile, among 33 patients with NIHSS=3, acute treatment was given to 3 and CTP influenced AIS treatment decisions in 2 (6.1%). Among 59 patients with NIHSS=4, acute treatment was given to 4 and CTP influenced decision-making in 3 (5.1%). CTP mismatch ratio was &gt; 1.7 in all 5 patients who received acute treatment and had NIHSS of 3 or 4. Conclusions: CTP is frequently performed in patients with low NIHSS. It had limited impact on acute treatment decisions, notably none among those with NIHSS≤2, suggesting that CTP may be over-utilized in this subset of patients with AIS.

Abstract 119: Stroke Recovery and Genetic Variation: Main Results of the STRONG Study

Introduction: The STRONG (Stroke, sTress, RehabilitatiON, and Genetics) study performed detailed behavioral phenotyping to evaluate genetic variants in relation to stroke recovery and stress responses. Methods: Adults with a new stroke enrolled at 28 US sites were assessed 4 times over 1 year. Three pre-specified gene variants (ApoE-e4, rs6265 (BDNF), &amp; a dopamine polygenic score) were examined for associations with change in grip strength, function (SIS-ADL), mood (PHQ8), and cognition (tMoCA). Seven candidate gene variants (HTTLPR, rs324420, rs4291, rs6265, rs4680, rs53576, rs1360780) were examined for associations with post-stroke trauma, mood, &amp; PTSD. Data were Holm-Bonferroni corrected. Next, genome-wide association studies (GWAS) were performed to identify variants associated with 8 stroke outcomes of interest. Results: The 763 enrollees had age 63.1±14.9 yrs; initial NIHSS score 4 [2-9]; 41.2% Female; 69.4% White. Presence of the BDNF rs6265 polymorphism (in 27.1% of patients) was associated with a 0.9 point reduction in 1 yr tMoCA score (p=10^-5). Two of the 7 stress-related gene candidates [rs4291 (ACE) and rs4680 (COMT)] were risk factors linking increased post-stroke trauma with higher 1yr PHQ8 &amp; PTSD scores (p&lt;0.05). In GWAS, 4 of the 8 behavioral outcomes had significant (p&lt;5x10^-8) associations with genetic variants. Change in grip strength (from acute to d90) had the largest number of genome-wide significant (147 at p&lt;5x10^-8) and suggestive (2,541 at p&lt;5x10^-6) associations; variants with p&lt;5x10^-6 were then mapped to corresponding genes and their protein products to construct an interaction network, which had significant enrichment of protein-protein interactions (283 proteins, 69 edges, p=0.008) and which mapped (FDR&lt;0.05) to multiple gene ontology biological processes pertaining to the nervous system, including nervous system development, neurogenesis, and neuron differentiation. Conclusions: Stroke recovery occurs across many dimensions and so benefits from detailed characterization over time. Building on such assessments, current results from candidate genetic variants and GWAS provide insights into the biology of stroke recovery and inform therapeutic targets for promoting improved stroke recovery.

Abstract TP195: Impact of Intracranial Atherosclerotic Disease on Thrombectomy Outcomes in Acute Cerebral Infarction With Large Vessel Occlusion

Introduction: In acute cerebral infarction with Large Vessel Occlusion (LVO), Intracranial Atherosclerotic Disease (ICAD) often causes vascular occlusion. Previous studies have noted that ICAD-related LVOs, compared to embolic occlusions, have longer procedural times and lower successful reperfusion rates. However, clinical outcomes remain similar. This study compares post-thrombectomy outcomes in both groups, matched by initial NIHSS scores. Method: From October 2017 to March 2023, we studied LVO cases undergoing thrombectomy for acute ischemic stroke. Our primary focus was on evaluating thrombectomy outcomes within two distinct groups— ICAD-related LVO group (ICAD group) and Embolic LVO group (Embolic group)—matched based on preoperative NIHSS scores. ICAD group was defined as persistent occlusion or residual stenosis at the initial occlusion site. Patient outcomes at 3 months were assessed using modified Rankin Scale (mRS) scores, defining devastating outcomes as mRS 5-6. Successful recanalization was defined as Thrombolysis in Cerebral Ischemia score ≥2b. Logistic regression identified factors independently associated with devastating outcomes. Result: Analyzing 2407 cases, we extracted matched pairs (33 each) adjusted by NIHSS. ICAD group had lower atrial fibrillation frequency, lower BNP levels, more M1 occlusions, and fewer M2 occlusions compared to the Embolic group. In treatment outcomes, ICAD group had lower successful recanalization (82% vs 43%, P =0.001), higher reocclusion rates (0% vs 21%, P =0.005), and longer puncture-to-reperfusion time (median 51 vs 88 minutes, P &lt;0.001). Devastating outcomes were higher in ICAD group (15% vs 39%, P =0.027). Multivariate analysis showed ICAD's independent association with devastating outcomes (Odds ratio, 6.54; 95% CI, 1.56-27.4; P =0.010) along with age, NIHSS, and tPA absence. Conclusion: In thrombectomy-treated LVO patients, matching based on admission NIHSS scores revealed significantly higher devastating outcomes in the ICAD group when compared to the Embolic group.

Abstract WP96: Impact of Stroke Severity and Social Determinants of Health on Arrival to Last Known Well Time

Introduction: Timely administration of thrombolytic therapy remains the cornerstone of ischemic stroke management and is associated with better functional outcomes. The population served by our hospital is notable for a large socioeconomic range of patients. We examined arrival times for ischemic strokes and the timeliness of intervention with our goal to better understand our population and develop methods for improved community outreach and education. Methods: This retrospective study looked at ischemic stroke patients discharged between January-May 2023. Patient characteristics and demographics were mined from the Get With The Guidelines™-Stroke database from NYC Health+Hospitals/Kings County. A total of 284 patients were reviewed. Covariates included in this study: age, sex, ethnicity, initial NIHSS score, payment source, and history of previous stroke. Adjusted linear regressions were used to analyze data at alpha = 0.05. Results: The median time of arrival to hospital from last known well time (LKWT) is 296min; 37.32% of patients arrived within the 4.5hr window. The average NIHSS score on arrival for patients within the 4.5 hours window is 7.3; patients outside of the 4.5hr window (or unknown LKWT) have an average NIHSS of 5.17. (See distribution of NIHSS score by LKWT category in Fig. 1 below.) Out of the 284 patients, a noted association was seen between severity of NIHSS and LKWT reported: the LKWT was lower by 16.47min (23.68-9.24, p &gt; 0.02) for every increase in NIHSS point. Additionally, compared to patients with no health insurance, those with private insurance have a decrease in LKWT of 1506.04min (1878.6-1133.5, p &lt; 0.0001), and those with Medicare/Medicaid have a decrease in time of 1291.83min (1652.1-931.5, p &gt; 0.0004). Conclusion: Review of patients in early 2023 showed a relationship between LKWT reporting and stroke severity as well as insurance status. These findings will help direct future projects in community education and outreach.

Abstract WMP31: Lifetime Trauma Exposure Types Are Linked to Stroke Recovery: Findings From the STRONG Study

Introduction: The STRONG (Stroke, sTress, RehabilitatiON, and Genetics) study has documented the role of cumulative lifetime stress/trauma exposure (LSE) in stroke recovery. Understanding the types of trauma most closely linked with functional outcomes may identify specific risk factors for stroke recovery. We examined specific types of life stress linked with functional and cognitive disability at 1-year post-stroke. Methods: Adults with a new stroke enrolled at 28 US sites were assessed 4 times over 1 year. Assessments included LSE 90 days post-stroke, and Stroke Impact Scale (SIS), modified Rankin Scale (mRS), &amp; Telephone Montreal Cognitive Assessment (tMOCA) at 1-year post-stroke. Bivariate and multivariate analyses examined relationships among LSE and outcomes. Results: The 763 enrollees had age 63.1±14.9 yrs; initial NIHSS score 4 [2-9]; 41.2% Female; 69.4% White. Controlling for age, gender, race, and 3-mo NIHSS score, lifetime exposure to being raped was associated with worse SIS-ADL, mRS, and tMOCA scores 12-mo post-stroke. Several other LSE were also independently associated with worse 12-mo SIS-ADL scores: witnessing a family member be injured or killed, divorce, and emotional abuse. Having a loved one be seriously ill was associated with better 12-mo t-MOCA scores. These findings were robust when early post-stroke acute stress levels were also included in the model. Women were significantly more likely to report being raped, experiencing emotional abuse, and having a seriously ill loved one. Demographics were not significantly associated with divorce or witnessing a family member injured or killed. Conclusions: Assessing specific types of exposure to LSE early in the post-stroke period may help identify at-risk patients who might benefit from additional post-stroke support to enhance their long-term functional and cognitive abilities.

Abstract 106: Circulating Interleukin-6 Levels Early During Active Stroke Estimate Time of Stroke Onset: Potential New Clinical Biomarker Tool From a Mobile Stroke Unit

Background: Circulating interleukin-6 (IL-6) concentrations are elevated in acute stroke but the timing of the IL-6 response in humans is unknown. We used a mobile stroke unit (MSU) to identify IL-6 levels within minutes of symptom onset. The results suggest a tool for estimating onset time for nearly 200,000 stroke patients annually in the U.S. in whom this is unknown. Methods: The study is a prospective, cohort investigation of ultra-early blood-derived IL-6 in acute stroke. Blood was obtained on the MSU, at 24 hours, and from hospital stroke patients and healthy controls. Plasma IL-6 was analyzed with ELISA. Confirmed strokes, mimics and controls were compared. Variables included demographics, DWI lesion volume, mRS, and NIHSS. Results: Forty-two adults were analyzed, including 28 patients treated on the MSU between August 2021 and May 2023, and 14 controls. Nineteen (68%) MSU patients were diagnosed as stroke, with 17 (61%) confirmed and 2 likely TIA or stroke averted by thrombolysis; 9 were stroke mimics. For confirmed stroke patients, median age was 72 (range 36-87) years, 47% were female, and 82% white. Median initial NIHSS score was 7 (range 1-22) and 12 (71%) received intravenous thrombolysis with tPA or TNK. Blood was obtained a median of 57 (range 26-158) minutes after symptom onset. IL-6 was elevated in all 17 confirmed stroke patients, a median of 3 times normal, as early as 26 minutes after symptom onset (median 6.4 pg/mL). In 15 (88%) cases, IL-6 increased over 24 hours, (median Δ 8.9 pg/mL). For mimics and healthy controls, median IL-6 was 5.9 and 2.3 pg/mL, respectively. Initial IL-6 in strokes was not associated with lesion volume (Spearman’s r= -0.035, p=894) or initial NIHSS (Spearman’s r=-0.043, p=869). Based on IL-6 trajectories observed, a cutoff for IL-6 set at 8 pg/mL had a sensitivity of 79% and specificity of 36% for estimating the stroke onset time was in the 4.5-hour thrombolysis window. Conclusions: This study found IL-6 was elevated in all confirmed strokes and increased in a linear fashion during the first 2.5 hours. IL-6 was independent of lesion volume and NIHSS. This suggests a rapid measurement of IL-6 from blood early in acute stroke may estimate onset time. The findings may aid development of immunomodulatory therapies for IL-6 in acute stroke.

Automated evaluation of collateral circulation for outcome prediction in acute ischemic stroke

IntroductionThe assessment of collateral circulation in acute ischemic stroke management is essential. Modern tools, such as Brainomix's e-CTA, powered by artificial intelligence, provide detailed insights into collateral assessment. This retrospective study aims to identify factors contributing to favorable collateral status and compare outcomes between patients with good collaterals (grade 3) and fair collaterals (grade 0–2). MethodThis retrospective study included 97 patients admitted to the Stroke Unit at the Hospital de Clínicas of the Federal University of Paraná, Brazil, from September 2021 to January 2023. Comparative analyses involved demographic factors, cardiovascular risk factors, and the combined outcome of mortality and moderate to severe disability at discharge, 30-day, and 90-day follow-ups. ResultsAmong the 97 cases, 58.8 % showed 'good collaterals' with a grade 3 status. Variables affecting collateral status included age (p = 0.042), neutrophil-lymphocyte ratio (p = 0.005), and initial NIHSS scores (p<0.001). The presence of good collaterals according to e-CTA reduced the odds of death and moderate-severe disability at discharge (p = 0.003; OR 0.27) and at 30 days (p = 0.015; OR 0.33), although this effect diminished at the 90-day mark after multivariate analysis. DiscussionAutomated collateral assessment through e-CTA is a valuable tool in acute ischemic stroke evaluation. Good e-CTA collateral score serve as a promising imaging biomarker, guiding informed clinical decisions during Stroke Unit hospitalizations. This study highlights the relationship between collaterals and stroke outcomes and underscores the potential for AI-driven tools to enhance stroke care management.

Seasonal Variations in Stroke and a Comparison of the Predictors of Unfavorable Outcomes among Patients with Acute Ischemic Stroke and Cardioembolic Stroke.

We investigated the seasonal variations in stroke in 4040 retrospectively enrolled patients with acute ischemic stroke (AIS) admitted between January 2011 and December 2022, particularly those with cardioembolic (CE) stroke, and compared predictors of unfavorable outcomes between AIS patients and CE stroke patients. The classification of stroke subtypes was based on the Trial of ORG 10172 in Acute Stroke Treatment. Stroke occurrence was stratified by seasons and weekdays or holidays. Of all AIS cases, 18% were of CE stroke. Of all five ischemic stroke subtypes, CE stroke patients were the oldest; received the most thrombolysis and thrombectomy; had the highest initial National Institutes of Stroke Scale (NIHSS) and discharge modified Rankin Scale (mRS) scores; and had the highest rate of in-hospital complications, unfavorable outcomes (mRS > 2), and mortality. The highest CE stroke prevalence was noted in patients aged ≥ 85 years (30.9%); moreover, CE stroke prevalence increased from 14.9% in summer to 23.0% in winter. The main predictors of death in patients with CE stroke were age > 86 years, heart rate > 79 beats/min, initial NIHSS score > 16, neutrophil-to-lymphocyte ratio (NLR) > 6.4, glucose > 159 mg/dL, cancer history, in-hospital complications, and neurological deterioration (ND). The three most dominant factors influencing death, noted in not only patients with AIS but also those with CE stroke, are high initial NIHSS score, ND, and high NLR. We selected the most significant factors to establish nomograms for predicting fatal outcomes. Effective heart rhythm monitoring, particularly in older patients and during winter, may help develop stroke prevention strategies and facilitate early AF detection.

Effects of elevated remnant cholesterol on outcomes of acute ischemic stroke patients receiving mechanical thrombectomy.

Large cohort studies provided evidence that elevated remnant cholesterol (RC) was an important risk factor for ischemic stroke. However, the association between high RC and clinical outcomes in acute ischemic stroke (AIS) individuals was still undetermined. This retrospective study enrolled 165 AIS patients undergoing mechanical thrombectomy in one tertiary stroke center. We divided patients into two groups based on the median of their RC levels (0.49 mmol/L). The modified Rankin Scale (mRS) was used to evaluate the primary outcome 90 days after the onset of symptoms. The mRS scores ≤ 2 and ≤ 1 at 90 days were deemed as favorable and excellent outcomes, respectively. In the overall AIS patients undergoing mechanical thrombectomy, there was no obvious distinction between the high and low RC group at 90-day favorable outcome (41.0% vs. 47.1%, P = 0.431) or excellent outcome (23.1% vs. 31.0%, P = 0.252). In the subgroup analysis stratified by stroke etiology, non-large artery atherosclerosis (non-LAA) stroke patients yielded with less favorable or excellent prognosis in the high RC group (26.8% vs. 46.8%, adjusted OR = 0.31, 95%CI: 0.11-0.85, P = 0.023; or 12.2% vs. 29.0%, adjusted OR = 0.18, 95%CI: 0.04-0.80, P = 0.024, respectively.). Post hoc power analyses indicated that the power was sufficient for favorable outcome (80.38%) and excellent outcome (88.72%) in non-LAA stroke patients. Additionally, RC can enhance the risk prediction value of a poor outcome (mRS scores 3-6) based on traditional risk indicators (including age, initial NIHSS score, operative duration, and neutrophil-to-lymphocyte ratio) for non-LAA stroke patients (AUC = 0.86, 95%CI: 0.79-0.94, P < 0.001). In AIS patients undergoing mechanical thrombectomy, elevated RC was independently related to poor outcome for non-LAA stroke patients, but not to short-term prognosis of LAA stroke patients.

Serum neurofilament light chain: a predictive marker for outcomes following mild-to-moderate ischemic stroke.

Biomarkers that reflect brain damage or predict functional outcomes may aid in guiding personalized stroke treatments. Serum neurofilament light chain (sNfL) emerges as a promising candidate for fulfilling this role. This prospective, observational cohort investigation included 319 acute ischemic stroke (IS) patients. The endpoints were the incidence of early neurological deterioration (END, an elevation of two or more points in the National Institute of Health stroke scale score within a week of hospitalization compared with the baseline) and functional outcome at 3 months (an mRS score of >2 at 3 months was categorized as an unfavorable/poor functional outcome). The association of sNfL, which was assessed within 24 h of admission, with END and unfavorable functional outcomes at follow-up was assessed via multivariate logistic regression, whereas the predictive value of sNfL for unfavorable functional outcomes and END was elucidated by the receiver operating characteristic curve (ROC). Of 319 IS individuals, 89 (27.90%) suffered from END. sNfL not only reflects the severity of stroke measured by NIHSS score (p < 0.05) but also closely related to the severity of age-related white matter changes. Higher initial NIHSS score, severe white matter lesions, diabetes mellitus, and upregulated sNfL were significant predictors of END. Similarly, the multivariate logistic regression analysis results showed that elevated sNfL, a higher baseline NIHSS score, and severe white matter lesions were substantially linked with unfavorable outcomes for 3 months. Similarly, sNfL was valuable for the prediction of the 3 months of poor outcome (95%CI, 0.504-0.642, p = 0.044). Kaplan-Meier analysis shows that patients with elevated sNfL levels are more likely to reach combined cerebrovascular endpoints (log-rank test p < 0.05). This investigation suggests that sNfL can serve as a valuable biomarker for predicting END and 3-month poor functional outcomes after an IS and has the potential to forecast long-term cardiovascular outcomes.

A nomogram predicts early neurological deterioration after mechanical thrombectomy in patients with ischemic stroke.

Early neurological deterioration (END) is common in acute ischemic stroke and is directly associated with poor outcome after stroke. Our aim is to develop and validate a nomogram to predict the risk of END after mechanical thrombectomy (MT) in acute ischemic stroke patients with anterior circulation large-vessel occlusion. We conducted a real-world, multi-center study in patients with stroke treated with mechanical thrombectomy. END was defined as a worsening by 2 or more NIHSS points within 72-hour after stroke onset compared to admission. Multivariable logistic regression was used to determine the independent predictors of END, and the discrimination of the scale was assessed using the C-index. Calibration curves were constructed to evaluate the calibration of the nomogram, and decision curves were used to describe the benefits of using the nomogram. A total of 1007 patients were included in our study. Multivariate logistic regression analysis found age, admission systolic blood pressure, initial NIHSS scores, history of hyperlipemia, and location of occlusion were independent predictors of END. We developed a nomogram that included these 6 factors, and it revealed a prognostic accuracy with a C-index of 0.678 in the derivation group and 0.650 in the validation group. The calibration curves showed that the nomogram provided a good fit to the data, and the decision curves demonstrated a large net benefit. Our study established and validated a nomogram to stratify the risk of END before mechanical embolectomy and identify high-risk patients, who should be more cautious when making clinical decisions.

Thrombolysis and thrombectomy for stroke in octogenarians and nonagenarians: A regional observational study

IntroductionElderly patients are a growing population in stroke units, characterized by higher frailty, but underrepresented in clinical trials about acute care. We investigated efficacy of intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) in elderlies in current practice. MethodsWe assessed consecutive patients with acute ischemic stroke (AIS) hospitalized in the four stroke units of the French Northern Alps Emergency Network between 2015 and 2020. We compared baseline characteristics, early neurological evolution and outcome of patients aged 80–89 and≥90years old (yo). ResultsAmong 8367 patients, 2744 (32.8%) were 80–89 yo and 541 (6.5%) were≥90 yo. IVT and/or MT were performed in 787 patients≥80 yo (632 patients aged 80–89, 155 patients aged>90). Early neurological improvement was more frequent in patients≥80 yo treated by IVT and/or MT compared to untreated patients (45.6% versus 38.4%, P=0.002). After adjustment, reperfusion treatments improved likelihood of good outcome at discharge (OR=2.0 [1.6–2.7]) and reduced in-hospital mortality (OR=0.5 [0.4–0.7]). Age and initial NIHSS score were independent factors of poor functional outcome at discharge and in-hospital mortality. The rate of successful recanalization was comparable between octogenarians and nonagenarians (87% versus 85.2%, P=0.8). Octogenarians had better functional outcome at discharge compared to nonagenarians [modified Rankin scale (mRS) 0–2: 36% versus 25.7%, P=0.02], whatever IVT or MT strategy. In-hospital mortality was lower for octogenarians compared to nonagenarians (19.5% versus 27.1%, P=0.04). DiscussionIVT and MT improve early neurological recovery and functional outcome at discharge of both octogenarians and nonagenarians in current practice. Despite a poorer outcome for nonagenarians than octogenarians, these reperfusion treatments should not be withheld on the basis of age only.

D-dimer to fibrinogen ratio predicts early neurological deterioration in ischemic stroke with atrial fibrillation

IntroductionThe D-dimer to fibrinogen ratio (DFR) is a good indicator of clot-producing activity in thrombotic disease, but its clinical usefulness in stroke patients with nonvalvular atrial fibrillation (NVAF) has not been studied. We evaluated the association between the DFR and early neurological deterioration (END) in acute ischemic stroke (AIS) patients with NVAF. MethodsWe included consecutive AIS patients with NVAF between 2013 and 2015 from the registry of a real-world prospective cohort from 11 large centers in South Korea. END was defined as an increase ≥2 in the total NIHSS score or ≥ 1 in the motor NIHSS score within the first 72 h of admission. The DFR was calculated as follows: DFR = D-dimer (mg/L)/fibrinogen (mg/dL) x 100. ResultsA total of 1018 AIS patients with NVAF were evaluated. In multivariable logistic regression analysis, the highest DFR tertile was closely associated with END (adjusted odds ratio [aOR] = 2.14, 95 % confidence interval [CI]: 1.24–3.69). Hypertension (aOR = 1.71, 95 % CI: 1.09–2.70), initial NIHSS score (aOR = 1.05, 95 % CI: 1.02–1.07) and use of anticoagulants (aOR = 0.41, 95 % CI: 0.28–0.60) were also correlated with END. In addition to END, the DFR was correlated with discharge NIHSS and modified Rankin Scale (mRS) scores and the 3-month mRS score. ConclusionsHigh DFR values were associated with END in AIS patients with NVAF. As the DFR is an indicator directly related to the main pathological mechanism of NVAF patients (fibrinolysis and coagulation), it may be useful in predicting their prognosis.

ASSOCIATION OF LEUKOARAIOSIS WITH CLINICAL OUTCOME IN ISCHEMIC STROKE: A CROSS-SECTIONALANALYTICAL STUDY

Background And Purpose: Cerebral Leukoaraiosis or white matter hyperintensities are frequently seen in acute stroke, but its clinical consequences on functional recovery are less studied. We aimed to determine the various risk factors associated with leukoaraiosis and to correlate leukoaraiosis with poor clinical outcomes post-stroke. Methods: 100 patients with acute stroke were included in the study and were evaluated at presentation and 3 months post-stroke with NIHSS and MRS scores. All patients underwent an MRI and leukoaraiosis was graded using the Fazekas scale. Results: 64 % of the study population had leukoaraiosis. Severe leukoaraiosis was seen in 19%, moderate in 22%, mild in 23% and 36% had no leukoaraiosis. White matter hyperintensities are common in hypertensives and those above 65 years of age. In multivariable analysis age, initial NIHSS score, and severe leukoaraiosis were independent predictors of poor outcome at 3 months post-stroke. Conclusion: Severe WMH were independently associated with poor functional outcome in post-stroke patients

Dual anti-platelet aggregation Versus Aspirin alone in acute minor ischemic stroke and high-risk TIA: A Tunisian Study (S20.006)

<h3>Objective:</h3> The aim of our work was to study the role of DAAP, in comparison with aspirin alone, in improving motor deficit and in preventing ischemic recurrence, while taking into account the possible hemorrhagic risk. <h3>Background:</h3> Even though the benefit of aspirin is well known to prevent recurrence of thrombotic events after any transient ischemic attack (TIA) or ischemic stroke, the role of dual anti-platelet aggregation (DAAP) is not definitively established and remains a controversial subject. <h3>Design/Methods:</h3> We conducted a retrospective review study in the Neurology Department at the Fattouma Bourguiba University Hospital of Monastir over a four-year period, from January 1, 2018 to February 18, 2022. We compared two groups of patients, of which one group had the DAAP (as in the CHANCE study) and one group received aspirin alone. We compared the initial NIHSS score, at discharge, at 1, 3, 6 months and 1 year, the risk of reocurrence, the risk of bleeding and vascular death. <h3>Results:</h3> 408 patients were included in this study. The mean age was 62.49 years (≥ 40) and 64,2% were males. DAAP was administered in 111 patients (27.2%), among them 17.1% received the initial doses of 300mg of Clopidogrel. Compared to non-DAAP group: 279 (72.8%). The median time from the onset of the admission was 18,8 hours. NIHSS score at discharge was ≤ 2 in 60,2% in the DAAP group vs 38% of patients in the non-DAAP group (p=0,034). Ischemic recurrence occurred in 3% of patients in the clopidogrel-aspirin group and in 4% in the aspirin alone group (p=0,04). There was no significant difference about the occurrence of any bleeding event (0,9% vs 2,6% p=0,173) nor Vascular Death. <h3>Conclusions:</h3> Our results are consistent with those of the literature about the superiority of dual anti-platelet aggregation (DAAP) in minor strokes. <b>Disclosure:</b> Miss Saad has nothing to disclose. Mariem Mhiri has nothing to disclose. Dr. Ben Dhia has nothing to disclose. Ms. Abbes has nothing to disclose. Dr. Gouta has nothing to disclose. Mouna Aissi has nothing to disclose. MAHBOUBA FRIH has nothing to disclose.

Prediction of Poor Outcome after Successful Thrombectomy in Patients with Severe Acute Ischemic Stroke: A Pilot Retrospective Study

Several baseline hematologic and metabolic laboratory parameters have been linked to acute ischemic stroke (AIS) clinical outcomes in patients who successfully recanalized. However, no study has directly investigated these relationships within the severe stroke subgroup. The goal of this study is to identify potential predictive clinical, lab, and radiographic biomarkers in patients who present with severe AIS due to large vessel occlusion and have been successfully treated with mechanical thrombectomy. This single-center, retrospective study included patients who experienced AIS secondary to large vessel occlusion with an initial NIHSS score ≥ 21 and were recanalized successfully with mechanical thrombectomy. Retrospectively, demographic, clinical, and radiologic data from electronic medical records were extracted, and laboratory baseline parameters were obtained from emergency department records. The clinical outcome was defined as the modified Rankin Scale (mRS) score at 90 days, which was dichotomized into favorable functional outcome (mRS 0-3) or unfavorable functional outcome (mRS 4-6). Multivariate logistic regression was used to build predictive models. A total of 53 patients were included. There were 26 patients in the favorable outcome group and 27 in the unfavorable outcome group. Age and platelet count (PC) were found to be predictors of unfavorable outcomes in the multivariate logistic regression analysis. The areas under the receiver operating characteristic (ROC) curve of models 1 (age only model), 2 (PC only model), and 3 (age and PC model) were 0.71, 0.68, and 0.79, respectively. This is the first study to reveal that elevated PC is an independent predictor of unfavorable outcomes in this specialized group.

Abstract TP60: Intravenous Thrombolytic Administration For Acute Ischemic Stroke Is Associated With Decreased 30-day Readmission As Well As 1-year Mortality And Recurrent Stroke

Background: Reducing 30-day readmission can potentially improve quality of stroke care. We investigated factors associated with 30-day readmission,1-year mortality and stroke recurrence post-ischemic stroke. Methods: Cohort included primary ischemic stroke discharges 1/1/2015 to 3/31/2021 from a large racial-ethnically diverse integrated healthcare delivery system. Assessment included demographics, comorbidity, NIHSS, IV thrombolytic, thrombectomy, hospital complications, and mRS score at discharge. Multivariate analysis was done to determine predictors for 30-day readmission, 1-year mortality and stroke recurrence. Results: Of 13,053 ischemic stroke patients,1,790 (13.7%) were readmitted within 30 days. The median time to readmission was 10 days (IQR 4-19). Readmission was most-commonly stroke-related (21.6%). Being older, having higher initial NIHSS or co-morbidity score or more hospital complications, not receiving IV thrombolysis, and being more disabled at discharged were seen more often among those who were readmitted (Table). In multivariate analysis, being older, having higher initial NIHSS and co-morbidity score were associated with higher odds of being readmitted by 30-day and having higher mortality and stroke recurrence at 1-year. Adjusted odds for stroke recurrence were elevated for black patients. Being readmitted by 30-day also predicted greater odds of 1-year stroke recurrence and 1-year mortality. On the other hand, receiving IV thrombolysis was associated with significantly less odds of being readmitted at 30-day (OR=0.74; 95% CI = 0.59 - 0.93) and less stroke recurrence (OR=0.75; 95% CI =0.64 - 0.87) and less mortality at 1-year (OR=0.57; 95% CI = 0.42 - 0.76). Conclusions: A number of factors predicted 30-day readmission as well as 1-year stroke recurrence and mortality. Receiving IV thrombolytic for acute stroke was strongly associated with lower odds of developing bad outcomes.

Abstract WMP43: Health Care Disparities In Reperfusion Therapy For Patients With Acute Ischemic Stroke Across Hospitals

Background: Medical care disparities are wide, and stroke in no exception. Reperfusion therapy is the standard treatment for acute ischemic stroke, but its use may vary across hospitals. Methods: Data from 75,870 patients admitted to 247 acute stroke hospitals nationwide were obtained through the 2013-2018 acute stroke quality evaluation program conducted by the Health Insurance Review and Assessment Service. The primary outcome was the hospital reperfusion therapy rate (RTR), defined as the proportion of intravenous tissue plasminogen activator (IVT) and/or endovascular thrombectomy (EVT) cases in patients potentially eligible for reperfusion therapy (onset-to-arrival time ≤ 6 hours and initial NIHSS score ≥ 4). Hospital RTRs, adjusted for age, sex, onset-to-arrival time, and initial stroke severity, were analyzed with hospital characteristics. Results: During the study period, 10,513 stroke patients were potentially eligible for reperfusion treatment and were admitted to 247 acute care hospitals. The RTR of the study population was 52.9%. The mean hospital RTR was 34.8% [median (IQR) 37.5% (9.8 - 56.2)]. A higher number of beds and average monthly stroke admissions were associated with a higher hospital RTR. Multivariable analysis revealed the average stroke admission per month, presence of stroke unit, the average IVT per month, and the average EVT per month were the independent determinants for hospital RTR. Hospital RTR was inversely correlated with 1-year mortality regardless of hospital stroke volume. Conclusions: RTRs vary widely across hospitals. The higher the hospital stroke volume, the higher the hospital RTRs. High hospital RTRs correlates with low 1-year mortality regardless of hospital stroke volume.