Lower Stroke Severity Research Articles

Are There Differences between Traumatic and Spontaneous Cervical Artery Dissections?

(1) Background: Cervical arterial dissections (CeAD) are a common cause of stroke in young adults. CeAD can be spontaneous (sCeAD) or traumatic (tCeAD). Whether CeAD subtypes differ in clinical, radiological, and outcome characteristics remains unexplored. (2) Methods: Patients with CeAD were identified and divided between sCeAD and tCeAD. Demographics, clinical features, risk factors, imaging findings, treatments, and outcomes were compared between the groups. Logistic regressions were used to determine characteristics associated with favorable outcome. (3) Results: Overall, 154 patients were included (106 sCeAD and 48 tCeAD). Patients with sCeAD were significantly older (mean ± SD 46 ± 12 vs. 35 ± 14, p < 0.001) and were more likely to have hyperlipidemia (19% vs. 4%, p = 0.016), but other risk factors did not differ. Patients with tCeAD less often had signs of early infarction on imaging (21% vs. 49%, p = 0.001) and had lower stroke severity on admission (NIHSS, median, interquartile range [IQR] 0 (0-9) vs. 2 (0-4), p = 0.012), but more often had symptomatic intracranial hemorrhages (12.5% vs. 2%, p = 0.006). Patients with tCeAD less often had favorable outcomes at 90 days (78% vs. 97%, p < 0.001). In the regression analysis, the only variables associated with favorable outcome were age (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.03-1.24), initial stroke severity (OR 0.84, 95% CI 0.73-0.97), degree of vessel stenosis (OR 0.35, 95% CI 0.14-0.83), and involvement of multiple vessels on presentation (OR 0.04, 95% CI 0.02-0.70), whereas dissection subtype was not associated (OR 0.45, 95% CI 0.03-68.80). (4) Conclusions: Dissection subtype is not an independent modifier of the chances of attaining functional independence.

Age and Stroke Severity Matter Most for Clinical Outcome in Acute Arteriosclerotic Tandem Lesions.

Background: Tandem lesions (TLs) cause up to 15-30% of all acute ischemic strokes (AISs). Endovascular treatment (EVT) is regarded as the first-line treatment; however, uncertainties remain with respect to the treatment and predictive outcome parameters. Here, we aimed to identify the clinical and demographic factors associated with functional short- and long-term outcomes in AIS patients with arteriosclerotic TLs undergoing EVT. Methods: This was a retrospective, mono-centric cohort study of 116 consecutive AIS patients with arteriosclerotic TLs who were endovascularly treated at a stroke center, with analysis of the relevant demographic, procedural, and imaging data. Results: A total of 116 patients were included in this study, with a median age of 72 years (IQR 63-80), 31% of whom were female (n = 36). The median NIHSS on admission was 14 (IQR 7-19), with a median ASPECT score of 9 (IQR 8-10) and median NASCET score of 99% (IQR 88-100%). A total of 52% of the patients received intravenous thrombolysis. In 77% (n = 89) of the patients, an antegrade EVT approach was used, with a good recanalization (mTICI2b3) achieved in 83% of patients (n = 96). Symptomatic intracerebral hemorrhage occurred in 12.7% (n = 15) of patients. A favorable outcome (mRS0-2) and mortality at 3 months were obtained for 40% (n = 47) and 28% of patients (n = 32), respectively. Age and NIHSS on admission were strongly associated with outcome parameters. Diabetes mellitus and previous neurological disorders were independently associated with long-term mortality (median 11 months, IQR 0-42). Conclusions: Younger age, lower stroke severity, and good recanalization were found to be independently associated with a favorable outcome. In contrast, older age, higher stroke severity, previous neurological disorders, and diabetes were correlated with mortality. The endovascular treatment of acute arteriosclerotic tandem lesions is feasible and relatively safe.

Association between serum triglycerides and stroke type, severity, and prognosis. Analysis in 6558 patients

Background and objectivesHypertriglyceridemia (HT) may increase the risk of stroke. Limited studies have shown that stroke severity and infarction size are smaller in patients with HT. We explored the relationship between triglyceride levels and stroke risk factors, severity and outcome in a large prospective database.DesignProspective Cross-sectional study.SettingWe retrospectively interrogated the Qatar Stroke Database in all patients admitted between 2014-2022 with acute ischemic stroke and evaluated the relationship between triglyceride, diabetes, stroke severity (measured on NIHSS), stroke type (TOAST classification) and the short- (mRS at 90 days) and long-term outcomes (MACE at 1 year) in patients with HT.ParticipantsSix thousand five hundred fifty-eight patients ≥20 years were included in this studyResultsSix thousand five hundred fifty-eight patients with ischemic stroke [mean age 54.6 ± 12. 9; male 82.1%) were included. Triglyceride levels upon admission were low-normal (≤1.1 mmol/L) in 2019 patients, high-normal (1.2-1.7 mmol/L) in 2142 patients, borderline-high (1.8-2.2 mmol/L) in 1072 patients and high (≥2.3 mmol/L) in 1325 patients. Higher triglyceride levels were associated with stroke and increased likelihood of having diabetes, obesity, active smoking, and small vessel/lacunar stroke type. An inverse relationship was noted whereby higher triglyceride levels were associated with lower stroke severity and reduced likelihood of poorer outcome (mRS 3-6) at discharge and 90 days. Long-term MACE events were less frequent in patients with higher triglyceride levels. After adjusting age, gender, diabetes, prior stroke, CAD, and obesity, multivariate analysis showed that hypertension and triglyceride levels were higher in mild ischemic strokes patients.ConclusionsIncreasing triglycerides are associated with higher risk of small vessel disease and requires further prospective cohort studies for confirmation.

Time to Anticoagulation Reversal and Outcomes After Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) is the deadliest stroke subtype, and mortality rates are especially high in anticoagulation-associated ICH. Recently, specific anticoagulation reversal strategies have been developed, but it is not clear whether there is a time-dependent treatment effect for door-to-treatment (DTT) times in clinical practice. To evaluate whether DTT time is associated with outcome among patients with anticoagulation-associated ICH treated with reversal interventions. This cohort study used data from the American Heart Association Get With The Guidelines-Stroke quality improvement registry. Patients with ICH who presented within 24 hours of symptom onset across 465 US hospitals from 2015 to 2021 were included. Data were analyzed from January to September 2023. Anticoagulation-associated ICH. DTT times and outcomes were analyzed using logistic regression modeling, adjusted for demographic, history, baseline, and hospital characteristics, with hospital-specific random intercepts to account for clustering by site. The primary outcome of interest was the composite inpatient mortality and discharge to hospice. Additional prespecified secondary outcomes, including functional outcome (discharge modified Rankin Scale score, ambulatory status, and discharge venue), were also examined. Of 9492 patients with anticoagulation-associated ICH and documented reversal intervention status, 4232 (44.6%) were female, and the median (IQR) age was 77 (68-84) years. A total of 7469 (78.7%) received reversal therapy, including 4616 of 5429 (85.0%) taking warfarin and 2856 of 4069 (70.2%) taking a non-vitamin K antagonist oral anticoagulant. For the 5224 patients taking a reversal intervention with documented workflow times, the median (IQR) onset-to-treatment time was 232 (142-482) minutes and the median (IQR) DTT time was 82 (58-117) minutes, with a DTT time of 60 minutes or less in 1449 (27.7%). A DTT time of 60 minutes or less was associated with decreased mortality and discharge to hospice (adjusted odds ratio, 0.82; 95% CI, 0.69-0.99) but no difference in functional outcome (ie, a modified Rankin Scale score of 0 to 3; adjusted odds ratio, 0.91; 95% CI, 0.67-1.24). Factors associated with a DTT time of 60 minutes or less included White race, higher systolic blood pressure, and lower stroke severity. In US hospitals participating in Get With The Guidelines-Stroke, earlier anticoagulation reversal was associated with improved survival for patients with ICH. These findings support intensive efforts to accelerate evaluation and treatment for patients with this devastating form of stroke.

Neuroprotective effects of oral metformin before stroke on cerebral small-vessel disease

BackgroundMetformin (MET) treatment prior to stroke might have neuroprotective effects other than hypoglycemic effects. This study evaluated whether MET treatment prior to stroke is associated with neurological severity and functional outcome in patients with stroke who were not indicated for endovascular treatment and whether the effects of MET differ for each ischemic stroke subtype. MethodsWe investigated 160 type 2 diabetes mellitus patients with ischemic stroke without endovascular treatment who were taking some oral antidiabetic agents prior to stroke in two tertiary hospitals. Lower neurological severity was defined as a National Institutes of Health Stroke Scale score of 3 or lower on admission, and favorable functional outcome was defined as a modified Rankin Scale score = 0–2 at discharge. We analyzed the effects of MET on the neurological severity and functional outcome in each ischemic stroke subtype on logistic regression analysis with adjustments for multiple confounding factors. ResultsMET treatment prior to stroke was associated with lower stroke severity and favorable functional outcome. In the stroke subtypes, MET use affected both neurological severity (P = 0.037) and functional outcome (P = 0.041) in only patients with small-vessel disease (SVD). ConclusionsMET may be useful to improve the outcome of patients with SVD.

Systolic blood pressure in acute ischemic stroke and impact on clinical outcomes.

Stroke is one of the largest healthcare burdens in the United States and globally. It continues to be one of the leading causes of morbidity and mortality. Patients with acute ischemic stroke (AIS) often present with elevated blood pressure (BP). The objective of our study was to evaluate the association of systolic blood pressure (SBP) in the emergency department (ED) with stroke severity in patients with AIS. This observational study was conducted at an ED with an annual census of 80,000 visits, approximately half (400) of which are for AIS. The cohort consisted of adult patients who presented to the ED within 24h of stroke symptom onset. BP was measured at triage by a nurse blinded to the study. Stroke severity was measured utilizing the National Institutes of Health Stroke Scale (NIHSS). Statistical analyses were performed utilizing JMP 14.0. This study was approved by our medical school's institutional review board. Patients with higher SBP had significantly lower NIHSS scores (p=0.0038). This association was significant even after adjusting for age and gender. By contrast, diastolic blood pressure (DBP) did not appear to impact stroke severity. There was no difference in the DBP values between men and women. Higher SBP was also significantly associated with being discharged home as well as being less likely to die in the hospital or discharged to hospice. The DBP did not demonstrate this association. Neither the SDP nor the DBP were significantly associated with the hospital length of stay (LOS). In multivariate models that included age, gender, basal metabolic index (BMI), comorbidities, and ED presentation, elevated SBP was associated with better prognosis. In this cohort of patients presenting with stroke-like symptoms to the ED, higher SBP was associated with lower stroke severity and higher rates of being discharged to home rather than hospice or death.

Abstract WMP67: Cerebral Collateral Flow State Correlates With Stroke Severity And Functional Outcomes

Introduction: Hypoperfusion index ratio (HIR) measured by computerized tomography perfusion (CTP) has been shown to predict collateral flow state in acute ischemic stroke (AIS). Low HIR (&lt;0.4) is indicative of good collateral flow state. Hypothesis: Good collateral flow state correlates with lower stroke severity and better clinical outcome at discharge. Methods: Data from AIS patients who underwent CTP during initial stroke evaluation were linked with Get With the Guideline database in a comprehensive stroke center between 2018 and 2020. Patients with good collateral flow (HIR&lt;0.4) were compared to those with poor collateral flow (≥0.4) group. They were stratified based on modified Rankin Score (mRS) at discharge into good outcome (mRS 0-2) or poor outcome (mRS 3-6). In addition to demographics, and risk factors data was collected on the initial stroke severity using the NIH stroke scale (NIHSS). Continuous variables were compared using t-test (parametric) and Mann-Whitney U test (non-parametric). Univariate and multivariable analyses (multiple logistic regression) were used to test the association between good collateral flow state and good discharge outcome. Results: CT perfusion data was obtained in 1442 patients, after excluding patients who underwent thrombectomy and all non-vascular etiologies of stroke like presentation, there was 890 patients (age 68±14, 52% male, 50% white, 50% black/others), of who 756 (85%) demonstrated good collateral flow and 134 (15%) showed poor collateral flow. Those with good collateral flow were younger (68±14 vs. 70±15, p=0.07) and lower median NIHSS (6 IQR 3-10 vs. 13 IQR 6-18, p&lt;0.001). Good collateral flow was associated with good outcome on discharge (OR 2.2, 95% CI 1.5-3.3). The association remained significant after adjustment for age, gender, race, hypertension, diabetes, coronary artery disease, congestive heart failure and atrial fibrillation (adjusted OR 2.2 (1.4-3.3). Conclusions: In patients presenting with AIS, good collateral flow state was associated with lower stroke severity. It was independently associated with good outcome after adjustment for several comorbidities. Based on our study results, CT perfusion imaging may have utility in predicting stroke severity and discharge outcome.

Abstract WP6: Strokes Averted by Intravenous Thrombolysis: A Secondary Analysis of the BEST-MSU Trial

Introduction: While the goal of IV tissue plasminogen activator (TPA) is to prevent infarction, few data exist on averted stroke. Methods: Secondary analysis of a multicenter trial from 2014-2020 comparing outcomes between patients treated for stroke by mobile stroke unit (MSU) vs standard care (SC). The analytical cohort were patients with suspected stroke treated with IV TPA. The primary outcome was a time-defined averted stroke diagnosis, defined as a final diagnosis of stroke with resolution of presenting symptoms/signs by 24 hours. The secondary outcome was a tissue-defined averted stroke diagnosis, defined as a final diagnosis of stroke with resolution of presenting symptoms/signs by 24 hours and no acute infarction/hemorrhage on imaging. We used multivariable logistic regression to evaluate associations between study exposures (demographics, comorbidities, stroke characteristics) and outcomes. Results: Among 1009 patients with a median last known well-to-TPA time of 87 minutes, 276 patients (27%) had a time-defined averted stroke (31% MSU, 21% SC) and 159 patients (16%) had a tissue-defined averted stroke (18% MSU, 11% SC). Factors independently associated with time-defined averted stroke were younger age (OR, 0.98; 95% CI, 0.96-0.99), female sex (0R, 0.51; 95% CI, 0.36-0.74), hyperlipidemia (OR, 1.81, 95% CI, 1.24-2.64), normal premorbid function (0R, 2.22; 95% CI, 1.37-3.67), lower glucose (OR, 0.996; 95% CI, 0.993-0.999), lower MAP (OR, 0.991; 95% CI, 0.983-0.998), MSU care (OR, 1.77; 95% CI, 1.21-2.62), lower NIH stroke scale (OR, 0.89; 95% CI, 0.86-0.93), and no large vessel occlusion (LVO) (OR, 0.52; 95% CI, 0.32-0.83). For tissue-based averted stroke, younger age, female sex, hyperlipidemia, lower MAP, MSU treatment, lower NIH stroke scale, and no LVO were significantly associated. Conclusion: In a modern acute stroke trial, one-in-four patients treated with TPA for stroke recovered within 24 hours and one-in-six had no demonstrable brain injury on imaging. Younger age, female sex, hyperlipidemia, lower MAP, MSU care, lower stroke severity, and no LVO may increase the odds of averting stroke.

Factors associated with paid employment 12 months after stroke in A Very Early Rehabilitation Trial (AVERT).

Returning to work is an important outcome for stroke survivors. This sub-study of a randomised controlled trial aimed to provide characteristics of working-age stroke participants and identify factors associated with return to work at 12 months. We used paid employment data collected as part of A Very Early Rehabilitation Trial (AVERT, n=2104), an international randomised controlled trial studying the effects of very early mobilisation after stroke at 56 acute stroke units across Australia, New Zealand, the United Kingdom, Malaysia and Singapore. For the present analysis, data for trial participants < 65 years old were included if they were working at the time of stroke and had complete 12-month return-to-work data. The primary outcome was 12-month return to paid work. Univariable and multivariable logistic regression analyses were conducted to determine the association of multiple factors with return to work. In total, 376 AVERT participants met the inclusion criteria for this sub-study. By 12 months, 221 (59%) participants had returned to work at a median of 38 hr per week. Similar rates were found across geographic regions. On univariable analysis, the odds of returning to paid employment were increased with younger age (OR per year 0.95, 95%CI 0.92-0.97), no previous diabetes (0.4, 0.24-0.67), lower stroke severity (OR per National Institutes of Health Stroke Scale point 0.82, 0.78-0.86), less 3-month depressive traits (Irritability Depression Anxiety [IDA] scale) (OR per IDA point 0.87, 0.80-0.93), less 3-month disability (modified Rankin Scale), and prior full-time work (2.04, 1.23-3.38). On multivariable analysis, return to work remained associated with younger age (OR 0.94, 95%CI 0.91-0.98), lower stroke severity (0.92, 0.86-0.99), prior full-time work (2.33, 1.24-4.40), and less 3-month disability. Return to work at 12 months after stroke was associated with young age, acute stroke severity, 3-month disability and full-time employment before stroke. Greater understanding of this topic could help in developing programs to support successful resumption of work post-stroke.

Early anticoagulation in atrial fibrillation-related acute ischaemic stroke: efficacy and safety profile.

To evaluate the effects of early anticoagulation on functional outcome, recurrent ischaemic events and haemorrhagic complications in Atrial Fibrillation (AF)-related acute ischaemic strokes (AIS). We retrospectively evaluated patients hospitalised in a Stroke Unit due to AF-related AIS. Patients were divided according to anticoagulation initiation timing (0-4days, 5-14days, no anticoagulation by the 14th day). We assessed the following outcomes at 3 months: favourable functional outcome [modified Rankin Scale (mRS) score 0-2 or equal to pre-stroke], recurrent ischaemic events and haemorrhagic complications after anticoagulation initiation. We included 395 patients. Anticoagulation was initiated at days 0-4 in 33.9% of patients, days 5-14 in 25.3% and not initiated by the day 14 in 40.8%. Factors associated with earlier anticoagulation included lower previous mRS, valvular AF and lower stroke severity. Favourable functional outcome occurred in 40.2% of patients, with lower odds in those anticoagulated at 5-14 versus 0-4days (OR: 0.47, 95% CI: 0.23-0.94), independently of age, previous mRS and stroke severity. Recurrent ischaemic events occurred in 8.3% of patients, with higher odds in non-anticoagulated patients by the 14th day, compared to the remainder groups (OR: 3.26, 95% CI: 1.29-8.22 vs. 0-4days and OR: 8.16, 95% CI: 1.76-37.9 vs. 5-14days). In patients who started anticoagulation (n = 288), haemorrhagic complications occurred in 10.8%, being more frequent in those who started at 0-4days vs. > 14days. However, it did not abolish the 0-4-day initiation's benefit on functional outcome. Early anticoagulation was associated with lower ischaemic recurrence and better functional outcome at 3 months. Additional studies are needed to better clarify its haemorrhagic risk.

Frequency, Characteristics, and Outcomes of Endovascular Thrombectomy in Patients With Stroke Beyond 6 Hours of Onset in US Clinical Practice.

In 2018, 2 randomized controlled trials showed the benefit of endovascular thrombectomy (EVT) in acute ischemic stroke patients treated 6 to 24 hours from last known well using imaging-guided selection. However, little is known about outcomes in contemporary nontrial settings. We assessed the frequency of EVT and outcomes beyond 6 hours in the US Get With The Guidelines-Stroke clinical registry. We analyzed all acute ischemic stroke patients treated with EVT between January 1, 2009 and October, 1, 2018, at Get With The Guidelines-Stroke hospitals in the United States. We assessed trends over time in frequency of EVT beyond 6 hours, compared patient characteristics and outcomes between those treated within versus beyond 6 hours, and evaluated the associations between EVT time and outcomes. We identified 53 702 patients at 697 sites treated with EVT during the study period. Treatment after 6 hours from last known well occurred in 17 720 (33%) of all 53 702 EVT cases (median 4.7 hours, interquartile range, 3.3-7 hours). The proportion of EVT cases treated after 6 hours from last known well varied widely across sites (median 30%, interquartile range, 24%-38%). Compared with patients treated within 6 hours, those treated beyond six hours were younger, less likely to have atrial fibrillation, less likely to arrive by ambulance, had lower stroke severity, were less likely to be anticoagulated, and more likely to be treated at centers with higher EVT volumes. After adjusting for patient and hospital characteristics, patients receiving EVT beyond 6 hours had less favorable in-hospital mortality, ambulation at discharge, and discharge disposition compared to those treated within 6 hours. EVT is frequently performed for patients with ischemic stroke after 6 hours from last known well, accounting for one-third of cases nationally, and adjusted functional outcomes at discharge are worse in these patients compared to those treated with EVT within 6 hours. Further efforts are needed for optimal EVT outcomes in clinical practice settings.

Trends in the seeking of emergency service for ischemic stroke and its risk factors during the COVID-19 pandemic, a study from Taiwan

Background &amp; Objectives: COVID-19 may influence the health seeking behavior of acute ischemic stroke patients. This study aimed to determine the characteristics of the patients who visited the emergency room in a centre designated for stroke care in Taiwan. Methods: This was a retrospective database-based study comparing the severity of ischemic stroke, intracerebral hemorrhage (ICH), and risk factors of patients seen between 2019 and 2020 in the National Taiwan University Hospital Yunlin Branch. Patients with or without thrombolysis therapy were analysed. Results: The median NIHSS of ischemic stroke patients were lower in 2019 than in 2020 (p = 0.015). The difference was seen in non-thrombolysis patients (2019: 3[1-6] vs. 4 [2-7.5], p = 0.012) but not in thrombolysis patients. The frequency of minor stroke was higher in 2019 (45.1%) than in 2020 (37.9%, p = 0.038). The discharge mRS was lower overall (p = 0.004) and in non-thrombolysis patients (0.003), but not in thrombolysis patients in 2019. As for the ICH patients, the severity of ICH score (p = 0.021) and discharge mRS (p = 0.001) were also lower in 2019. The frequencies of risk factors of stroke were higher in 2019 than in 2020, including smoking (24% vs. 18.2%, p = 0.046), alcohol (11.9% vs. 7.5%, p = 0.039), hypertension (72.9% vs. 66.2%, p = 0.039), history of stroke (16.5% vs. 11.6%, p = 0.047), and atrial fibrillation (11.9% vs. 7.5%, p = 0.039). Conclusions: This study in Taiwan revealed a decline in the willingness to seek emergency services under the influence of COVID-19 among patients with lower stroke severity, especially those with more risk factors.

Association of Serum Bilirubin with the Severity and Outcomes of Intracerebral Hemorrhages

Intracerebral hemorrhage (ICH) is the second most common subtype of stroke, and it is often associated with a high mortality rate and significant morbidity among survivors. Recent studies have shown that bilirubin, a product of heme metabolism, can exhibit cytoprotective, antioxidant and, anti-inflammatory properties. However, little is known about the role of bilirubin in combating several pathophysiological pathways caused by intracerebral bleeding in patients with ICH. In this study, data were collected retrospectively on 276 patients with ICH who were admitted to a university hospital between 5 January 2014 and 31 December 2017. We assessed the relationship between levels of total, direct, and indirect serum bilirubin and assessments of initial stroke severity and clinical outcomes by using Spearman’s rank correlation and Kruskal-Wallis H tests. A secondary examination of the carrier protein albumin was also undertaken. Our study found that higher levels of direct bilirubin were correlated with worse admission Glasgow Coma Scales (GCS) (rs = −0.17, p = 0.011), worse admission ICH Scores (rs = 0.19, p = 0.008), and worse discharge modified Rankin Scales (mRS) (rs = 0.15, p = 0.045). Direct bilirubin was still significantly correlated with discharge mRS after adjusting for temperature at admission (rs = 0.16, p = 0.047), oxygen saturation at admission (rs = 0.15, p = 0.048), white blood cell count (rs = 0.18, p = 0.023), or Troponin T (rs = 0.25, p = 0.001) using partial Spearman’s correlation. No statistical significance was found between levels of total or indirect bilirubin and assessments of stroke severity and outcomes. In contrast, higher levels of albumin were correlated with better admission GCS (rs = 0.13, p = 0.027), discharge GCS (rs = 0.15, p = 0.013), and discharge mRS (rs = −0.16, p = 0.023). We found that levels of total bilirubin, direct bilirubin, and albumin were all significantly related to discharge outcomes classified by discharge destinations (p = 0.036, p = 0.014, p = 0.016, respectively; Kruskal-Wallis H tests). In conclusion, higher direct bilirubin levels were associated with greater stroke severity at presentation and worse outcomes at discharge among patients with ICH. Higher levels of albumin were associated with lower stroke severity and better clinical outcomes. Future prospective studies on the free bioactive bilirubin are needed to better understand the intricate relationships between bilirubin and ICH.

Functional outcomes among stroke patients in Alagoas, Brazil: observational study.

Stroke is the principal cause of disability around the world and the ensuing functional dependence (FD) can be correlated with different factors. To determine how demographic factors and clinical characteristics after stroke distinguish patients who achieve functional independence from those who do not. Observational study at specialized neurovascular clinic in Alagoas, Brazil. FD was classified according to the modified Rankin scale (mRs): 0 to 2 points were classified as independent (FD-), and 3 to 5 points were classified as dependent (FD+). Logistic regression analysis included age, sedentary lifestyle, the Center for Epidemiological Studies - Depression Scale (CES-D) and the National Institutes of Health Stroke Scale (NIHSS). The Mann-Whitney test and χ2 test were used to compare groups. We included 190 stroke patients with a mean age of 60.02 ± 14.22 years. We found that 34.8% of the patients were classified as FD+. Lower NIHSS and CES-D scores were more associated with achieving functional independence. Most of the patients had access to physical therapy, and the mean duration of rehabilitation therapy was 65.2 minutes per week. Females had higher prevalence of depressive symptoms (P = 0.005) and rehabilitation time was shorter for hemorrhagic stroke (P = 0.02). We found a FD rate four times greater than in another Brazilian study. Lower stroke severity and fewer depressive symptoms were associated with achieving functional independence. Less than half of the patients were referred to a rehabilitation service at hospital discharge and few had access to multidisciplinary treatment.

Abstract MP23: Clinical and Demographic Factors Influence Clinical Trial Enrollment

Introduction: Inclusion of diverse patients in clinical trials is essential to represent patient populations and to ensure that results are generalizable. Analysis of this topic is motivated by prior reports of clinical trials underrepresenting historically disadvantaged groups. We aimed to understand if the clinical trial population is representative of the overall stroke population in our community. Methods: We obtained clinical and demographic data from hospital administrative records including all acute ischemic stroke patients between March 2019 and February 2020. Consent was counted when a signed consent for study participation was documented in the inpatient record. Enrollment in studies with a primary inpatient population at the time of consent (MOST, TIMELESS, ARCADIA, SleepSMART, and STRONG) were included. Patients with consent (CP) and without consent (NCP) were compared using chi-square analysis and t-test probability with SPSS. Results: During the study period, 504 patients met the above criteria; 55 were consented to participate in clinical trials. Overall CP did not differ from NCP in % women (45.5% vs 41.2%, not significant), Hispanic ethnicity, discharge medications, hypertension, diabetes, heart failure, drug and alcohol abuse, atrial fibrillation, and payer (Medicare versus non-Medicare). Median age was lower in CP compared to NCP (63 ± 12.8 vs. 67 ± 13.9, p=.046). The mean NIHSS was lower in CP (6.37 ± 5.95 vs. 8.21 ± 8.91, p=.048). The CP group had lower incidence of prior stroke (9.1% vs. 20.9%, p=.037), less dyslipidemia (12.7% vs. 30.1%, p=.007), fewer comorbidities on average (1.9 ± 1.1 vs. 2.2 ± 1.5, p=.044), was less likely to identify as Asian (0% vs. 8.4%, p=.015) and more likely to identify as white (59.3% vs. 45.7%, p=.045). The CP group was more likely to have migraine (12.7% vs. 1.8% p&lt;.001) and were discharged on more stroke risk-factor modifying medications (2.2 ± .558 vs. 1.9 ± .902, p=.001). Conclusions: While the study population is largely representative, they are more likely to be White, with lower stroke severity, fewer medical comorbidities and less likely to be Asian. We plan to expand this analysis to include more study centers and to guide future clinical trial design.

The Effect of Transoesophageal Echocardiography on Treatment Change in a High-Volume Stroke Unit.

Background and purpose—current guidelines recommend the use of transesophageal echocardiography (TEE) in relation to cardio-embolic sources of stroke. Methods—by using an hospital-based cohort, we retrospectively analyzed consecutive patients with acute ischemic stroke (AIS), acute hemorrhagic stroke (AHS) and transient ischemic attack (TIA) who were admitted in Strasbourg Stroke Center, France between November 2017 to December 2018. TEE reports were screened for detection of potential cardiac sources of embolism and the subsequent change in medical management. We performed univariate and multivariate analyses to identify predictors of relevant TEE findings. Results-out of the 990 patients admitted with confirmed stroke, 432 patients (42.6%) underwent TEE. Patients with TEE were younger (62.8 ± 14.8 vs. 73.8, p < 0.001), presented less comorbidities and lower stroke severity assessed by lower NIHSS (2 IQR (0–4) vs. 3 IQR (0–10), p < 0.01) and Modified Rankin Scale (1 IQR (0–1) vs. 1 (0–3), p < 0.01). A total of 227 examinations (52.5%) demonstrated abnormal findings considered as potential cardiac sources of embolism and 31 examinations (7.1%) were followed by subsequent change in medical management. Age (HR: 0.948, 95% CI 0.923 to 0.974; p < 0.001), previous AIS (HR: 3.542, 95% CI 1.290 to 9.722; p = 0.01), previous TIA (HR: 7.830, CI 95% 2214 to 27,689; p = 0.001) and superficial middle cerebral artery territory infarction (HR: 2.774, CI 95% 1.168–6.589; p = 0.021) were strong independent predictors with change in medical management following TEE. Conclusions—additional TEE changed the medical course of stroke patients in 7.1% in a French high-volume stroke unit.

Prestroke statin use enhances collateralization in acute ischemic stroke patients

Statin therapy has been shown to be effective in the prevention of ischemic stroke. In addition, recent studies have suggested that prior statin therapy could lower the initial stroke severity and improve stroke functional outcomes in the event of stroke. It was speculated that prestroke statin use may enhance collateral circulation and result in favorable functional outcomes. The aim of the study was to investigate the association of prestroke statin use with leptomeningeal collaterals and to determine the association of prestroke statin use with stroke severity and functional outcome in acute ischemic stroke patients. We prospectively and consecutively enrolled 239 acute ischemic stroke patients with acute infarction due to occlusion of the middle cerebral artery within 24 h in the neurology department of West China Hospital from May 2011 to April 2017. Computed tomographic angiography (CTA) imaging was performed for all patients to detect middle cerebral artery thrombus; regional leptomeningeal collateral score (rLMCS) was used to assess the degree of collateral circulation; the National Institutes of Health Stroke Scale (NIHSS) was used to measure stroke severity at admission; the modified Rankin scale (mRS) was used to measure outcome at 90 days; and premorbid medications were recorded. Univariate and multivariate analyses were performed. Overall, 239 patients met the inclusion criteria. Fifty-four patients used statins, and 185 did not use statins before stroke onset. Prestroke statin use was independently associated with good collateral circulation (rLMCS > 10) (odds ratio [OR], 4.786; 95% confidence interval [CI], 1.195-19.171; P = 0.027). Prestroke statin use was not independently associated with lower stroke severity (NIHSS score≤14) (OR, 1.955; 95% CI, 0.657-5.816; p = 0.228), but prestroke statin use was independently associated with favorable outcome (mRS score≤2) (OR, 3.868; 95% CI, 1.325-11.289; P = 0.013). Our findings suggest that prestroke statin use was associated with good leptomeningeal collaterals and clinical outcomes in acute ischemic stroke (AIS) patients presenting with occlusion of the middle cerebral artery. However, clinical studies should be conducted to verify this claim.

Pre-stroke adherence to a Mediterranean diet pattern is associated with lower acute ischemic stroke severity: a cross-sectional analysis of a prospective hospital-register study

BackgroundHigh adherence to a Mediterranean Diet is associated with reduced incidence and mortality of acute ischemic stroke (AIS) but may also be associated with severity. Our purpose was to investigate the association of adherence to a Mediterranean diet and severity in a prospective hospital register of AIS patients.MethodsWe included AIS patients admitted from February 2017 to July 2019. All were assessed by a neurologist with a standard stroke protocol, including NIHSS. Adherence to Mediterranean diet was prospectively measured by the 14-point Mediterranean Diet Adherence Screener (MEDAS) and defined as low (0–6 points) or high (7–14 points). Demographic and clinical characteristics were compared by group with univariate analysis. A Generalized Linear Model (GLM) was used to investigate the association of admission NIHSS as a continuous ordinal variable and an ordinal logistic regression (OLR) analysis to determine the independent association of the NIHSS quartiles with adherence to Mediterranean diet.ResultsThree hundred sixty-eight patients were included, mean age 68.3 (17.7), 158 (42.9%) females. The median NIHSS score was 3 (IQR 1–9) and the median MEDAS score was 6 (IQR 4.5–8). Patients with high MEDAS scores had significantly lower; admission NIHSS scores, sedentary lifestyle, body mass index, total and LDL cholesterol levels, but higher alcohol consumption. After adjustments, high adherence to Mediterranean diet remained independently associated with lower stroke severity both in the GLM (β coefficient = − 0.19, p = 0.01) and in the OLR model (OR for lower NIHSS quartiles 0.6 (95% CI 0.37–0.98, p = 0.04).ConclusionsHigher pre-stroke adherence to a Mediterranean diet is independently associated with lower AIS severity.

Absence of an infarct on MRI is not uncommon after clinical diagnosis of ischemic stroke

IntroductionAn infarct on brain MRI is often seen as gold standard when diagnosing ischemic stroke. Although MRI has high sensitivity in detecting a lesion shortly after ischemic stroke, this rapidly declines when time progresses. We assessed the occurrence of a negative MRI 4–6 weeks after a discharge diagnosis of ischemic stroke, and compared the clinical characteristics of patients with a positive or negative MRI. Patients and methodsThe first 125 patients from a prospective longitudinal study of cognitive recovery after ischemic stroke were included in this study. Clinical characteristics were collected during admission. Per protocol, 4–6 weeks after stroke a brain MRI was performed. We operationalized different levels of certainty of the clinical diagnosis of ischemic stroke of a panel of 3 expert vascular neurologists. ResultsThirty patients (24%) were MRI negative. Patients that were MRI negative had lower stroke severity at admission, shorter duration of hospital-stay, and better functional status at discharge. The panel judged that 18/30 (60%) MRI negative patients and 27/30 (90%) MRI positive patients had a likely diagnosis of ischemic stroke. Compared to MRI negative patients with a less likely diagnosis, those with a likely diagnosis had higher admission stroke severity and more often received an acute intervention. Discussion and conclusionAbsence of an infarct on MRI is not uncommon 4–6 weeks after a clinical diagnosis of ischemic stroke. The relatively high proportion of MRI negative strokes with a likely clinical diagnosis of ischemic stroke indicates that neurologists should be cautious ruling out the diagnosis based on MRI beyond the acute stroke stage.

Development and Validation of a Prognostic Tool for Direct Enteral Tube Insertion After Acute Stroke.

Background and Purpose- We aimed to create a novel prognostic risk score to estimate outcomes after direct enteral tube placement in acute stroke. Methods- We used the Ontario Stroke Registry and linked databases to obtain clinical information on all patients with direct enteral tube insertion after ischemic stroke or intracerebral hemorrhage from July 1, 2003 to June 30, 2010 (derivation cohort) and July 1, 2010 to March 31, 2013 (validation cohort). We used multivariable regression to assign scores to predictor variables for 3 outcomes after tube placement: favorable outcome (discharge modified Rankin Scale score 0-3 and alive at 90 days), poor outcome (discharge modified Rankin Scale score 5 or death at 90 days), and 30-day mortality. Results- Variables associated with a favorable outcome were younger age, preadmission independence, ischemic stroke rather than intracerebral hemorrhage, lower stroke severity, and a shorter time between stroke and tube placement. Variables associated with a poor outcome were older age, preadmission dependence, atrial fibrillation, greater stroke severity, and tracheostomy. Age, preadmission dependence, atrial fibrillation, cancer, chronic obstructive pulmonary disease, and shorter time to tube placement were associated with increased 30-day mortality. Using these variables, we created an online calculator to facilitate estimation of individual patient risk of favorable and poor outcomes. C-statistic in the validation cohort was 0.82 for favorable outcome, 0.65 for poor outcome, and 0.62 for 30-day mortality, and calibration was adequate. Conclusions- We developed risk scores to estimate outcomes after direct enteral tube insertion for acute dysphagic stroke. This information may be useful in discussions with patients and families when there is prognostic uncertainty surrounding outcomes with direct enteral tube placement after stroke.