Median NIH Stroke Scale Research Articles

Clinical and radiographic outcomes after mechanical thrombectomy in medium-vessel posterior cerebral artery occlusions: Subgroup analysis from STAR.

Whereas mechanical thrombectomy (MT) has become standard-of-care treatment for patients with salvageable brain tissue after acute stroke caused by large-vessel occlusions, the results of MT in patients with medium-vessel occlusions (MEVOs), particularly in the posterior cerebral artery (PCA), are not well known. Using data from the international Stroke Thrombectomy and Aneurysm Registry (STAR), we assessed presenting characteristics and clinical outcomes for patients who underwent MT for primary occlusions in the P2 PCA segment. As a subanalysis, we compared the PCA MeVO outcomes with STAR's anterior circulation MeVO outcomes, namely middle cerebral artery (MCA) M2 and M3 segments. Of the 9812 patients in STAR, 43 underwent MT for isolated PCA MeVOs. The patients' median age was 69 years (interquartile range 61-79), and 48.8% were female. The median NIH Stroke Scale score was 9 (range 6-17). After recanalization, 67.4% of patients achieved successful recanalization (modified treatment in cerebral infarction score [mTICI] ≥ 2b), with a first-pass success rate of 44.2%, and 39.6% achieved a modified Rankin score of 0-2 at 90 days. Nine patients (20.9%) had died by the 90-day follow-up. In comparison with M2 and M3 MeVOs, there were no differences in presenting characteristics among the three groups. Patients with PCA MeVOs were less likely to undergo intra-arterial thrombolysis (4.7% PCA vs. 10.1% M2 vs. 16.2% M3, p = 0.046) or to achieve successful recanalization (mTICI ≥ 2b, 67.4%, 86.7%, 82.3%, respectively, p < 0.001); however, there were no differences in the rates of successful first-pass recanalization (44.2%, 49.8%, 52.3%, respectively, p = 0.65). We describe the STAR experience performing MT in patients with PCA MeVOs. Our analysis supports that successful first-pass recanalization can be achieved in PCA MEVOs at a rate similar to that in MCA MeVOs, although further study and possible innovation may be necessary to improve successful PCA MeVO recanalization rates.

Role of mechanical thrombectomy among large vessel stroke patients during the coronavirus disease (COVID-19) pandemic

PurposeThe aim of our study is to provide insights derived from experience at multiple centers regarding the outcomes of mechanical thrombectomy (MT) for large vessel occlusion (LVO) in COVID-19 patients and compare them with those in non-COVID-19 patients during the coronavirus disease (COVID-19) pandemic.ResultsCOVID‐19 positive patients were younger than COVID‐19 negative patients (62.1 ± 2.69 versus 69.5 ± 2.2, P < 0.001). There was a significant difference between COVID-19 and non-COVID-19 groups in the median D-dimer levels (6 vs. 4.5; P < 0.001), median ESR levels (63 vs. 38; P < 0.001) and median CRP levels (110 vs. 48.5; P < 0.001), respectively. Median time from stroke symptoms onset to hospital admission was significantly higher among COVID-19 positive patients (366 vs. 155 min; P < 0.001). COVID‐19 positive patients with LVO presented with a higher median NIH Stroke Scale score at presentation (16 versus 8, P < 0.001) and lower median Alberta Stroke Program Early CT Score (ASPECTS) on admission (6 versus 8, P < 0.001). Patients with COVID-19 had significantly higher percentages of poor functional outcomes as scored using the mRS grades 3–5 in comparison to non-COVID-19 patients (69.2% vs. 13.6%; P = 0.002), but there was no significant difference between both groups in complications such as early cerebral re-occlusion, intracerebral hemorrhage, or in-hospital mortality (P > 0.05).ConclusionMechanical thrombectomy has effectively managed patients with LVO stroke. LVO stroke in COVID-19 patients occur at a young age, and have multi-territory vascular involvement. Poor functional outcomes post thrombectomy in COVID-19 patients, irrespective of timely, successful angiographic recanalization.

The National Institutes of Health Stroke Scale is comparable to the ICH score in predicting outcomes in spontaneous acute intracerebral hemorrhage.

Validating the National Institutes of Health NIH Stroke Scale (NIHSS) as a tool to assess deficit severity and prognosis in patients with acute intracerebral hemorrhage would harmonize the assessment of intracerebral hemorrhage (ICH) and acute ischemic stroke (AIS) patients, enable clinical use of a readily implementable and non-imaging dependent prognostic tool, and improve monitoring of ICH care quality in administrative datasets. Among randomized trial ICH patients, the relation between NIHSS scores early after Emergency Department arrival and 3-month outcomes of dependency or death (modified Rankin Scale, mRS 3-6) and case fatality was examined. NIHSS predictive performance was compared to a current standard prognostic scale, the intracerebral hemorrhage score (ICH score). Among the 384 patients, the mean age was 65 (±13), with 66% being male. The median NIHSS score was 16 (interquartile range (IQR) 9-25), the mean initial hematoma volume was 29 mL (±38), and the ICH score median was 1 (IQR 0-2). At 3 months, the mRS had a median of 4 (IQR 2-6), with dependency or death occurring in 70% and case fatality in 26%. The NIHSS and ICH scores were strongly correlated (r = 0.73), and each was strongly correlated with the 90-day mRS (NIHSS, r = 0.61; ICH score, r = 0.62). The NIHSS performed comparably to the ICH score in predicting both dependency or death (c = 0.80 vs. 0.80, p = 0.83) and case fatality (c = 0.78 vs. 0.80, p = 0.29). At threshold values, the NIHSS predicted dependency or death with 74.1% accuracy (NIHSS 17.5) and case fatality with 75.0% accuracy (NIHSS 18.5). The NIHSS forecasts 3-month functional and case fatality outcomes with accuracy comparable to the ICH Score. Widely documented in routine clinical care and administrative data, the NIHSS can serve as a valuable measure for clinical prognostication, therapy development, and case-mix risk adjustment in ICH patients.Clinical trial registrationClinicaltrials.gov, NCT00059332.

IV Thrombolysis in Basilar Artery Occlusion: Outcomes and Comparison With Endovascular Thrombectomy.

Recanalization is considered a prerequisite for favorable outcome in basilar artery occlusion (BAO). Intravenous thrombolysis (IVT) has been successfully used for eligible patients with BAO well beyond the 4.5-hour time window but has been largely underrepresented in the best medical management arms in recent randomized controlled trials of recanalization therapy in BAO. We aimed to analyze the outcomes of patients with BAO treated with IVT only and to compare IVT with endovascular thrombectomy (EVT). This observational single-center, retrospective cohort study included consecutive patients with BAO treated with IVT and/or EVT up to 48 hours of symptom onset during 1995-2022. The primary outcome was favorable functional outcome (modified Rankin Scale 0-3) at 3 months collected by a stroke physician by phone. In the first part, we described the outcomes and factors associated with functional outcome in the IVT-only cohort during 1995-2022. In the second part, we used doubly robust inverse probability-weighted regression adjustment models to compare functional outcome of patients treated with IVT vs EVT+/-IVT during 2010-2022. In the whole cohort of 376 patients with acute BAO treated with recanalization therapy, 245 (65.2%) received only IVT. In the IVT-only cohort, most patients had moderate-to-severe clinical presentation (median NIH Stroke Scale 18) but no extensive early ischemic changes in the posterior circulation on admission. Half of them had onset-to-treatment time over 6 hours. 46.5% of the IVT-treated patients achieved 3-month favorable functional outcome, whereas mortality was 35.9%. sICH occurred in 11.1%. In a multivariable analysis, younger age, milder symptom severity, and less baseline ischemic changes predicted favorable functional outcome. In the 2010-2022 cohort, when compared with patients treated with EVT+/-IVT (n = 121), the IVT-only cohort (n = 122) had higher odds for favorable functional outcome (IVT 58.2% vs EVT 43.0% (aOR 2.82 [95% CI 1.31-6.05]). IVT alone produced outcomes comparable with those in recent trials of endovascular BAO recanalization. Furthermore, in head-to-head comparison in our cohort, the IVT-only approach was more often associated with favorable outcome than EVT+/-IVT. Thus, it should not be overlooked as the first-line recanalization therapy in acute BAO, even in longer time windows. This study provides Class IV evidence that tPA is as effective as thrombectomy for basilar artery thrombosis.

Genome-Wide Association Studies of 3 Distinct Recovery Phenotypes in Mild Ischemic Stroke.

Stroke genetic research has made substantial progress in the past decade. Its recovery application, however, remains behind, in part due to its reliance on the modified Rankin Scale (mRS) score as a measure of poststroke outcome. The mRS does not map well to biological processes because numerous psychosocial factors drive much of what the mRS captures. Second, the mRS contains multiple disparate biological events into a single measure further limiting its use for biological discovery. This led us to investigate the effect of distinct stroke recovery phenotypes on genetic variation associations with Genome-Wide Association Studies (GWASs) by repurposing the NIH Stroke Scale (NIHSS) and its subscores. In the Vitamin Intervention for Stroke Prevention cohort, we estimated changes in cognition, motor, and global impairments over 2 years using specific measures. We included genotyped participants with a total NIHSS score greater than zero at randomization and excluded those with recurrent stroke during the trial. A GWAS linear mixed-effects model predicted score changes, with participant as a random effect, and included initial score, age, sex, treatment group, and the first 5 ancestry principal components. In total, 1,270 participants (64% male) were included with a median NIHSS score of 2 (interquartile range [IQR] 1-3) and median age 68 (IQR 59-75) years. At randomization, 20% had cognitive deficits (NIHSS Cog-4 score >0) and 70% had ≥1 motor deficits (impairment score >1). At 2 years, these percentages improved to 7.2% with cognitive deficits and 30% with motor deficits. GWAS identified novel suggestive gene-impairment associations (p < 5e-6) for cognition (CAMK2D, EVX2, LINC0143, PTPRM, SGMS1, and SMAD2), motor (ACBD6, KDM4B, MARK4, PTPRS, ROBO1, and ROBO2), and global (MSR1 and ROBO2) impairments. Defining domain-specific stroke recovery phenotypes and using longitudinal clinical trial designs can help detect novel genes associated with chronic recovery. These data support the use of granular endpoints to identify genetic associations related to stroke recovery.

Abstract 86: Outcomes of Endovascular Therapy for Late Large Vessel Occlusion in Patients With Pre-Stroke Disability

Background: There is a paucity of research to develop evidence-based recommendations for endovascular management in the extended time window (&gt;6 hours after time last seen well [TLSW]) for large vessel occlusion (LVO) patients with pre-stroke disability. Methods: We analyzed data from a multinational cohort (66 sites, 10 countries from 2014 to 2022) of acute ischemic stroke patients with pre-stroke modified Rankin Scale (mRS) 0-4 and anterior or posterior circulation LVO who received endovascular therapy 6-24 hours after TLSW. The primary outcome was the composite of functional independence (FI, mRS 0-2) or return to pre-stroke mRS (return of Rankin, RoR) at 90 days. Outcomes were compared between patients with pre-stroke disability (pre-stroke mRS 2-4) vs those without (mRS 0-1). Results: There were 2231 patients (median age 77 years; median NIH Stroke Scale 16) included in the present study, of whom 564 (25.3%) had pre-stroke disability. The primary outcome (FI or ROR) was seen in 30.7% of patients with pre-stroke disability (FI, 16.5%; RoR 30.7%), compared with 44.1% of those without (FI, 44.1%; RoR 13.0%) ( P &lt;0.0001, Figure 1 ). In both multivariable logistic regression and inverse probability of treatment weighting analysis, pre-stroke disability was not associated with a lower odds of achieving FI or RoR (adjusted odds ratio [aOR] 0.76, 95% confidence interval [CI] 0.50-1.15 and aOR 0.73, 95% CI 0.43-1.25, respectively). FI or ROR was achieved at a higher percentage with reperfusion with mTICI ≥2b than with mTICI 0-2a, both in patients with pre-stroke disability (34.8% vs 10.8%, P &lt;0.0001) and in those without (49.2% vs 12.1%, P &lt;0.0001). Symptomatic intracranial hemorrhage occurred in 6.3% in both groups ( P =0.995). Conclusions: A substantial proportion of late LVO patients with pre-stroke disability regained pre-stroke mRS after EVT and did not have a worse functional prognosis than patients without pre-stroke disability when their pre-stroke mRS was considered.

Abstract WMP2: A Randomized, Double-Blind, Placebo-Controlled, Phase II Trial in Acute Non-Cardioembolic Ischemic Stroke With Adrenomedullin

Background: Adrenomedullin (AM), a vasoactive peptide, has strong anti-inflammatory and angiogenic properties, which have been reported to ameliorate the consequences of ischemic stroke (IS) in several animal models. This phase II clinical trial aimed to test the safety and tolerability of intravenous (IV) AM administration in acute IS (AIS) patients within 24 hours of onset. Methods: The AdrenoMedullin For Ischemic Stroke study is an investigator-initiated, randomized, double-blind, phase II trial. Patients with non-cardioembolic IS within 24 hours after stroke onset and baseline NIH Stroke Scale (NIHSS) score ≥1 were randomly allocated to the intermittent IV AM (I-AM group) (30 μg/kg in total for 7 days, n=20) or placebo group (n=10) in the first cohort and a combination of continuous (the first 3 days) and intermittent (the following 4 days) IV AM (C/I-AM group) (56 μg/kg in total for 7 days, n=20) or placebo group (n=10) in the second cohort. The primary endpoint was serious adverse events related to the protocol treatment and secondary efficacy endpoints were favorable outcomes (mRS 0-2 at 90 days) and good outcomes (mRS 0-3 at 90 days). Results: The population of 60 patients had a median age of 75 years, 21 patients (35%) were female, and the median NIHSS score was 3. The primary endpoint did not occur in all groups. In the secondary efficacy endpoints, the rates of favorable outcome (75.0% vs. 68.9%, adjusted odds ratio [aOR], 1.45; 95% confidential interval [CI], 0.32-6.53) and good outcome (90.0% vs. 73.7%, aOR 3.86; 95% CI, 0.67-22.11) in the I-AM group were not statistically different from those in the placebo group. The rates of good outcomes in the C/I-AM group were comparable with those in the placebo group (85.0% vs. 73.7%, aOR 1.56; 95% CI, 0.72-3.39). Conclusions: Treatment with IV AM within 24 hours of AIS onset is safe. Intermittent IV AM may contribute to improved AIS prognosis. The efficacy and safety of AM will need confirmation in the next phase of clinical trials.

Abstract TP75: Age at Time of Stroke Does Not Predict Post-Stroke Fatigue

Introduction: Post-stroke fatigue (PSF) is a long-term sequelae of stroke that negatively impacts patients and their rehabilitation. Approximately 38% of people hospitalized for a stroke are less than 65 years old. Studies regarding PSF and age are sparse and vary in their results. We examined whether age at time of ischemic stroke correlates with the severity of PSF of ischemic stroke patients in a predominantly Afro-Caribbean population. Methods: An IRB-approved prospective, observational study. Patients above 18 years of age with a diagnosis of ischemic stroke in the past 3 years were enrolled after informed consent. Patients with treated depression, significant cognitive impairment, or active cancer were excluded. The Fatigue Assessment Scale (FAS) was used to measure the level of PSF. Linear regression analysis was used to examine the relationship between age at time of stroke and severity of FAS score, adjusted for sex, NIH Stroke Scale (NIHSS), Modified Rankin Scale (mRS), and Beck Depression Inventory (BDI) scores. A general linear model was used to predict log-log-transformed total FAS score from age at stroke, BDI score, mRS score, NIHSS score, and sex. First-order interactions among predictors were investigated; model residuals were examined for skew and for outliers. Results: Of the 121 patients included, 55.4% are female, the mean age is 65.3 +/- 12.1 years old, 93.4% have hypertension, and 60.3% have diabetes mellitus. The median FAS score is 19 (IQR 15-25), median NIHSS score is 3 (IQR 2-5), and median mRS score is 1 (IQR 0-2). Crude Spearman Correlation between age at stroke and total FAS score was -0.07. Age at stroke was not an independent predictor of FAS score (p=0.545). R 2 for the model was 0.38. Both BDI score (p&lt;0.001) &amp; mRS score (p=0.024) were positively associated with transformed FAS score. Conclusion: Our data suggests that age at time of stroke is not independently correlated with severity of PSF in a predominantly Afro-Caribbean population.

Abstract WP131: A Proposed Weighted-ASPECTS Based on the NIH Stroke Scale

The Alberta Stroke Program Early CT score (ASPECTS) is a 10-item score of the territory of the middle cerebral artery (MCA). Helpful in defining the extent of ischemia, prognosis, and neurological severity, the role of each item in the score is not clear in the literature. Variables such as age, cerebral hemisphere, vascular occlusion, and collateral status seem to influence the role of each item in terms of neurological severity measured by the NIH Stroke Scale (NIHSS). Recognizing the clinical role of these items can be useful for accurately measuring the clinical-radiological mismatch and maybe allow for expanded therapeutic windows in stroke. We aim to identify the correlation of each ASPECTS item with neurological severity. In an ambispective analysis, patients with ischemic Stroke from a national network of hospitals were included. We conducted a linear regression model, with the NIHSS scores at admission serving as the dependent variable. Models were adjusted for age, time from stroke symptom onset and hemisphere involvement. We excluded patients with an ASPECTS of 10 and those without an arterial-CT brain scan at admission. In total, 587 patients from 32 hospitals were included in the final analysis. Males represented 39.5% of the sample, with a mean age of 68 (±16) years. The median NIHSS score was 11 [5, 17], and the median ASPECTS was 8 [6, 9]. Among patients without occlusion of MCA 1, 2, and 3 (n=352), factors significantly associated with NIHSS scores included age (beta-coefficient 0.08), time from stroke onset (-0.001), left hemisphere (1.58), and ASPECTS subitems M1 (4.7), M3 (2.5), M4 (1.9), M5 (1.8), Insula (1.7), and Lentiform (2.8). In patients with proximal occlusion (n=235), factors significantly associated with NIHSS scores were age (0.07), left hemisphere (4.1), ASPECTS subitems M6 (2.4) and Lentiform (2.4), MCA 1 occlusion (3.3), and absent collateral status (5.8). Our results confirm the different roles of each ASPECTS item on neurological severity in acute stroke patients. Adjusted equations with confidence intervals were created to predict the NIHSS score. Our results bring to the literature an innovative tool for numerically assessing the clinical-radiological mismatch using a simple and accessible neuroimaging method.

A case–control comparison of acute-phase peripheral blood gene expression in participants diagnosed with minor ischaemic stroke or stroke mimics

BackgroundPast studies suggest that there are changes in peripheral blood cell gene expression in response to ischaemic stroke; however, the specific changes which occur during the acute phase are poorly characterised. The current study aimed to identify peripheral blood cell genes specifically associated with the early response to ischaemic stroke using whole blood samples collected from participants diagnosed with ischaemic stroke (n = 29) or stroke mimics (n = 27) following emergency presentation to hospital. Long non-coding RNA (lncRNA), mRNA and micro-RNA (miRNA) abundance was measured by RNA-seq, and the consensusDE package was used to identify genes which were differentially expressed between groups. A sensitivity analysis excluding two participants with metastatic disease was also conducted.ResultsThe mean time from symptom onset to blood collection was 2.6 h. Most strokes were mild (median NIH stroke scale score 2.0). Ten mRNAs (all down-regulated in samples provided by patients experiencing ischaemic stroke) and 30 miRNAs (14 over-expressed and 16 under-expressed in participants with ischaemic stroke) were significantly different between groups in the whole cohort and sensitivity analyses. No significant over-representation of gene ontology categories by the differentially expressed genes was observed. Random forest analysis suggested a panel of differentially expressed genes (ADGRG7 and miRNAs 96, 532, 6766, 6798 and 6804) as potential ischaemic stroke biomarkers, although modelling analyses demonstrated that these genes had poor diagnostic performance.ConclusionsThis study provides evidence suggesting that the early response to minor ischaemic stroke is predominantly reflected by changes in the expression of miRNAs in peripheral blood cells. Further work in independent cohorts particularly in patients with more severe stroke is needed to validate these findings and investigate their clinical relevance.

Extended Window Thrombolytics for Ischemic Stroke: A Telestroke versus In-person Experience.

Telestroke evaluation of patients with acute ischemic stroke is supported by American Heart and Stroke Association Guidelines. However, there is no data on outcomes or safety of administering IV thrombolytic stroke therapy using extended window criteria (>4.5h since onset of symptoms with a hyperacute MRI diffusion T2/FLAIR mismatch) via telestroke. Here, we report adverse events and outcomes of extended-window thrombolysis by telestroke vs in-person care. We performed a retrospective cohort review from 2020 to 2022 of prospectively collected multinstitutional databases from a large, not-for-profit health system with both in-person stroke and telestroke care. The primary outcome was frequency of symptomatic intracranial hemorrhage (sICH). Secondary outcomes were favorable functional outcome at hospital discharge (modified Rankin Scale, mRS, 0-3) and discharge disposition. A total of 33 patients were treated with extended-window thrombolysis (n = 20 in-person, n = 13 telestroke). The median NIH stroke scale was 6, and time since last known normal was similar (median [95% CI]: in-person 13h [11-15h] vs telestroke 12h [9-16h], P = .33). The sICH frequency was low and occurred in one patient (4.8% in-person vs 0% by telestroke). Favorable outcome at discharge was not different between in-person and telestroke care (median mRS [95% CI]: 2 [1-3] vs 1 [0-2], OR .0 [.0-1.8], P = .27), and discharge deposition was also similar. In patients eligible for extended window acute stroke treatment with thrombolytics, there was no difference in adverse events between telestroke and in-person care.

Peri-device leak after left atrial appendage closure: echocardiographic characteristics and thromboembolism risk

Abstract Background Structural variations in left atrial appendage (LAA) ostial morphology can contribute to incomplete closure of the LAA and peri-device leak (PDL) after LAA closure (LAAC). Prior data suggests that there is an increased residual risk of thromboembolism in patients with PDL after LAAC. However, there is a paucity of information on the interpretation of imaging data to risk stratify patients with PDL. Purpose We evaluated echocardiographic characteristics on post-LAAC imaging, and their association with residual risk of thromboembolism. Methods We analyzed data from follow up imaging with transesophageal echocardiograms (TEEs) which were performed at ∼1-year follow up after the LAAC with either the Watchman or Watchman-FLX device (Boston Scientific Inc). The images were reviewed in a blinded manner with regard to thromboembolic events after LAAC. In our analyses, we further classified the TEE images into 3 categories: 1) no leak, and completely thrombosed distal LAA, 2) no leak, but echolucent distal LAA (indicative of some residual, but undetectable, connection), or 3) presence of leak and echolucent distal LAA (Figure 1). Results A total of 650 patients underwent LAAC at our center between 3/2015 and 12/2021: age 75.8±8.9 years, 64% male, and CHA2DS2-Vasc 4.2±1.4. TEE imaging data (performed at 1-year or later after LAAC) was available for review in 460 patients. In 238 of 460 patients (51.7%) there was no leak and the LAA was completely thrombosed (Cohort 1). In 83 of 460 (18%) patients there no detectable leak but the LAA was echolucent (Cohort 2), and in 139 of 460 (30.2%) patients there was a discernible leak and the LAA was echolucent (Cohort 3). In this subset of 460 patients, there were 29 (3.2% per year) thromboembolic events (stroke or transient ischemic attack) over 2.0±0.2 years of follow-up; of these, only 3 (0.6% per year) strokes were disabling, and none were fatal. The median NIH stroke scale in patients with stroke/TIA was 2 (range 0-14; NIHSS &amp;lt; 5 is considered mild to moderate severity). During follow-up (2.0±0.2 years), the incidence of thromboembolism was highest in Cohort 3 (7.5% per year) in comparison to Cohort 2 (3.1% per year) and Cohort 1 (0.84% per year) (Figure 2). Upon analysis with 2 separate multivariable models, the risk of thromboembolism was highest in Cohort 3 vs Cohort 1 (adjusted OR 10.0, 95% CI: 3.3-30.0; p &amp;lt; 0.001) after adjusting for age, gender, CHA2DS2-VASc and LVEF. In contrast, when comparing Cohort 2 vs Cohort 1 in a multivariable model, the difference in thromboembolic risk was an adjusted OR 3.4 (95% CI: 0. 9-13.1; p = 0.07). Conclusions The presence of PDL after LAAC is not uncommon and confers a significant residual thromboembolic risk in patients with AF. TEE imaging characteristics aid in risk stratification of patients with PDL, and may help guide management decisions such as leak closure or resumption/continuation of anticoagulation to mitigate stroke risk.Figure 1:Classification based on reviewFigure 2:Comparison of incidence of th

Abstract 251: Characterizing coma in patients presenting with large vessel occlusion stroke

Introduction Coma is an unresponsive state of disordered consciousness characterized by impaired arousal and awareness. The epidemiology and pathophysiology of coma in ischemic stroke has been underexplored. We sought to characterize the incidence and clinical features of coma as a presentation of large vessel occlusion (LVO) stroke. Methods Individuals who presented with LVO were retrospectively identified from July 2018 to December 2020. Coma was defined as an unresponsive state of impaired arousal and awareness, operationalized as a score of 3 on NIH Stroke Scale (NIHSS) item 1a. Results A total of 28/637 (4.4%) patients with LVO stroke were identified as presenting with coma. The median NIHSS was 32 (IQR 29‐34) for those with coma versus 11 (5‐18) for those without (p&lt;0.0001). In coma, occlusion locations included basilar (13), vertebral (2), internal carotid (5), and middle cerebral (9) arteries. 8/28 were treated with endovascular thrombectomy (EVT), and 20/28 died during the admission. 65% of patients not treated with EVT had delayed presentations or large established infarcts. In models accounting for pre‐stroke modified Rankin Scale (mRS) score, basilar artery occlusion location, intravenous thrombolysis, and EVT, coma independently increased the odds of transitioning to comfort care during the admission (aOR 6.75; 95%CI 2.87,15.84; p &lt;0.001) and decreased the odds of 90‐day mRS 0‐2 (aOR 0.12; 95%CI 0.03,0.55; p=0.007). Conclusion It is not uncommon for patients with LVO to present with coma, and delayed recognition of LVO can lead to poor outcomes, emphasizing the need for maintaining a high index of suspicion. While more commonly thought to result from posterior LVO, coma in our cohort was similarly likely to result from anterior LVO. Efforts to improve early diagnosis and care of patients with LVO presenting with coma are crucial, given the poor outcomes.

Abstract 044: Single‐Step Intracranial Angioplasty followed by Atlas Stent Deployment Through Mini Trek Rx Balloon

Introduction The current FDA approved intracranial stent delivery system requires a multi‐step deployment involving the use of exchange length microwire (ELW), typically 0.014‐inch 300 cm wire, to navigate the balloon catheter, which is then exchanged, after performing the angioplasty, over the ELW to a 0.017’ microcatheter that is used to deploy the intracranial stent. Herein, we describe a single‐step approach to deploy Neuroform Atlas stent (Stryker Neurovascular, Fremont, CA) which is a hybrid laser‐cut, nitinol self‐expanding stent without the need for ELW or lesion re‐access using MINI TREK RX (Abbott Vascular, Inc., Santa Clara, CA, USA) semi compliant balloon adapted from cardiovascular literature which showed a pre‐dilation angioplasty capability in coronary stenotic lesions. Methods We performed a retrospective review of prospectively maintained mechanical thrombectomy (MT) databases of 2 comprehensive stroke centers between November 2020, and May 2023. The inclusion criteria were consecutive large vessel occlusion stroke patients in whom single step MINI TREK RX balloon angioplasty followed by Neuroform Atlas intracranial stent deployment was performed without using ELW (Figure‐1). There was no restriction on time from last known well (TLKW) to MT. During the standard mechanical thrombectomy procedure, intracranial atherosclerotic disease/ significant stenotic lesion was suspected by immediate re‐occlusion/ persistent occlusion following at least 1 thrombectomy pass. This is followed by pursuing intracranial angioplasty and stent placement as a rescue recanalization measure. The primary outcome was successful reperfusion defined as a Modified Treatment in Cerebral Ischemia (mTICI) score of 2b or greater at the end of the procedure. Secondary outcomes included NIH Stroke Scale (NIHSS) at 24 hours, NIHSS at discharge, median modified Rankin Scale (mRS) score at discharge and at 90‐day follow‐up. Safety measures included rates of symptomatic intracranial hemorrhage (sICH) and mortality at 90 days. Results Among 9 patients who met our criteria, the median age was 63 (51‐69.5) years and 55.6% were females. Most patients had left middle cerebral artery‐ M1 occlusion (66.7%) and one third received thrombolytics (33.3%). All patients underwent the single‐step approach and achieved successful reperfusion (m TICI 2b‐3) with 2 median number of passes. The median NIHSS was reduced from 13.5 (8.5‐17.5) at baseline to 4 (1‐16.5) at discharge. In addition, median mRS was 1 (1‐3.5) at discharge and 3 (3‐4) at 90 days. None of the patients included in this series had sICH while only one patient with basilar artery occlusion underwent ventriculostomy during hospital stay and was sedated/intubated and died. Conclusion This preliminary experience showed technical feasibility and success of using single‐ step to deploy Neuroform Atlas stent after performing angioplasty using MINI TREK RX without the need for ELW or lesion re‐access. Prospective studies with larger sample size and long‐term clinical follow‐up are warranted to confirm these results.

Delirium detection using wearable sensors and machine learning in patients with intracerebral hemorrhage

ObjectiveDelirium is associated with worse outcomes in patients with stroke and neurocritical illness, but delirium detection in these patients can be challenging with existing screening tools. To address this gap, we aimed to develop and evaluate machine learning models that detect episodes of post-stroke delirium based on data from wearable activity monitors in conjunction with stroke-related clinical features.DesignProspective observational cohort study.SettingNeurocritical Care and Stroke Units at an academic medical center.PatientsWe recruited 39 patients with moderate-to-severe acute intracerebral hemorrhage (ICH) and hemiparesis over a 1-year period [mean (SD) age 71.3 (12.20), 54% male, median (IQR) initial NIH Stroke Scale 14.5 (6), median (IQR) ICH score 2 (1)].Measurements and main resultsEach patient received daily assessments for delirium by an attending neurologist, while activity data were recorded throughout each patient's hospitalization using wrist-worn actigraph devices (on both paretic and non-paretic arms). We compared the predictive accuracy of Random Forest, SVM and XGBoost machine learning methods in classifying daily delirium status using clinical information alone and combined with actigraph data. Among our study cohort, 85% of patients (n = 33) had at least one delirium episode, while 71% of monitoring days (n = 209) were rated as days with delirium. Clinical information alone had a low accuracy in detecting delirium on a day-to-day basis [accuracy mean (SD) 62% (18%), F1 score mean (SD) 50% (17%)]. Prediction performance improved significantly (p &amp;lt; 0.001) with the addition of actigraph data [accuracy mean (SD) 74% (10%), F1 score 65% (10%)]. Among actigraphy features, night-time actigraph data were especially relevant for classification accuracy.ConclusionsWe found that actigraphy in conjunction with machine learning models improves clinical detection of delirium in patients with stroke, thus paving the way to make actigraph-assisted predictions clinically actionable.

The Relationship Between Periodontal Disease (PD) and Recurrent Vascular Events in Ischemic Stroke/Transient Ischemic Attack (TIA) Patients: A Hospital-Based Cohort Study

Background In this cohort study, the association between periodontal disease (PD) andrecurrent vascular events was determined among the subjectswithischemic stroke/transient ischemic attack (TIA), and the extent and severity of periodontal disease were estimated among these subjects. Methods This prospective, longitudinal, hospital-based cohort study included 153 individuals who had a stroke or TIA. They were divided into two groups: high periodontal disease (HPD) (N=55, mean age: 59.40±12.21) and low periodontal disease (LPD) (N=98, mean age: 53.03±12.82). Clinical attachment loss (CAL) and probing pocket depth (PPD) were used to measure the severity of the periodontal disease. TOAST criteria were used to determine the ischemic stroke etiology, and the NIH Stroke Scale (NIHSS) was used to determine theischemic stroke severity. A follow-up survey found that vascular incidents recurred. Results HPD individualsexhibited a higher median NIHSS (eight) than LPD patients (seven) in a subset of stroke population (N=23). Thirty-eight cardiovascular events occurred in the first three months after enrollment, including 23 strokes and seven TIAs, and five myocardial infarctions(MIs). There were three deaths from vascular causes. There was a non-significant association between PD and composite vascular events (HR 1.06, 95% CI, 1.03 to 1.09, p=0.71). Compound vascular events were not related to severe HPD (HR 1.31, 95 % CI 0.54 to 3.16, p=0.07). Conclusion In stroke/TIA patients, there is no link between high periodontal disease and recurrent vascular episodes. The proportions of stroke subtypes were not substantially differentbetween HPDand LPD.

Abstract Number ‐ 209: Short‐ and long‐term outcomes of mechanical thrombectomy in acute ischemic stroke patients with active cancer

Introduction We aim to investigate the difference in mechanical thrombectomy (MT) outcome for cancer‐related stroke (CRS) with active and inactive cancer. Methods Of the consecutive acute ischemic stroke (AIS) patients admitted to our institute from 2010 to 2021, patients with cancer who received MT within 24 hours of onset and were enrolled.Outcomes including the favorable outcome (modified Rankin Scale score of 0 to 2) at3 months, 1‐year,and death within 3 months or 1‐yearwere assessed between patients with active and inactive cancer among patients with cancer. The rate offirst pass effect (FPE, extendedThrombolysis in Cerebral Infarction[eTICI] 2c/3 after first pass) and final eTICI 2c/3 achievement were also assessed. Active cancer was defined as a cancer that was diagnosed within 6 months; required chemotherapy or surgical treatment within 6 months; or was recurrent, metastatic, or inoperable. Results Of 59 patients (26 women; median age, 80 years; median NIH Stroke Scale score[NIHSS] 17), 19 (32.2%) patients had an active cancer. Patients with active cancer has less atrial fibrillation (47% vs. 78%,P&lt; 0.01) and higher medianD‐dimer(4.60μg/mLvs. 2.00μg/mL,P&lt; 0.01). There were no significant differences in the favorable outcome at 3 months (26% vs. 45%,P = 0.26) and at 1 year (26% vs. 45%,P = 0.26) between both groups, but death within 3 months (32% vs. 5%,P&lt; 0.01) and within 1 year (42% vs. 8%,P&lt; 0.01) were more frequent in patients with active cancer than those with inactive cancer. Conclusions Long‐term clinical outcomes of patients with active cancer were worse than those with inactive cancer.

Abstract TP109: The Impact Of Atrial Fibrillation (Afib) On The Discharge Disposition In Patients Who Received Acute Stroke Intervention Therapies? Results From A Large Health System In Six Western States Of The United States

Introduction: Limited studies indicate patients with acute ischemic stroke (AIS) due to atrial fibrillation (Afib) may not respond as well to intravenous thrombolysis (IVT) compared to those without Afib, resulting in poor outcomes. This study compares the length of stay (LOS) at the hospital and discharge disposition (home, inpatient rehabilitation, nursing home facility, or death) in patients receiving acute stroke treatment with IVT and/or thrombectomy (EVT) in Afib and non-Afib groups. Methods: Data from a multi-state health system’s stroke registry for patients who received acute stroke treatment and were discharged between 2018 and 2022 were used. Patients were stratified into three groups: 1, EVT only with or without history of Afib; 2, IVT plus EVT with or without history of Afib; 3, IVT only with or without history of Afib.Multivariable mixed-effect regressions were performed to evaluate if patients with Afib had an effect on LOS or discharge disposition within the three treatment groups adjusting for patient age, sex, race and ethnicity, NIHSS on admission, blood glucose on admission, SBP on admission, and history of diabetes, CAD/prior MI, carotid stenosis, smoking, dyslipidemia, heart failure, being overweight, or renal insufficiency. Results: Among patients with AIS, the median age at arrival was 72 years, 51% male, 70% white, and non-Hispanic; the median NIH Stroke scale was 9.Discharge disposition and LOS were assessed in a cohort of 7820 patients: In group 1(EVT, n: 2388): 37.4% had Afib and 53.3% discharged home, median LOS 5.42 days. In group 2(IVT/EVT, n: 978): 28.5% had Afib and 58.8% discharged home , median LOS 4.25 days. Among group 3(IVT, n: 4454) 14.4% had Afib and 67.8% discharged home, median LOS 2.90 days. After adjustment, there was no association between Afib and either outcome in the three treatment groups. Conclusions: The history of Afib in a patient with AIS does not have a significant negative impact on the LOS or discharge disposition.

Abstract TMP75: Blood Brain Barrier Disruption And Neurologic Outcomes In Intracranial Hemorrhage Patients

Introduction: Patients with primary intracerebral hemorrhage (ICH) are known to demonstrate disruption of the blood-brain barrier (BBB) particularly in peri-hematomal regions. However, disruption of the BBB may also occur throughout the brain, even in areas remote from the acute bleed. We aimed to study the clinical significance of this finding. Methods: We performed a retrospective review of our prospectively collected ICH database from January 2020 to January 2022 to identify consecutive patients who had MR perfusion study performed within 5 days from admission. BBB permeability data was analyzed blinded to the clinical data. Baseline demographics, admission systolic blood pressure and NIH stroke scale (NIHSS) score were collected during the hospitalization. A measure of whole brain BBB permeability was computed from the perfusion MR scans. Primary outcome was good neurologic outcome defined as a modified Rankin Scale (mRS) score of 0-3 at 90 days. We examined the association between the BBB permeability and clinical outcome. Results: A total of 24 ICH patients were identified. Median age was 60 years old (Interquartile range (IQR) 57-70), with 11 females (45.8%) and 13 males (54.2%). Median hematoma volume was 40.3mL (IQR 14.9-53.2mL), with a median admission NIHSS of 17.5 (IQR 15-22). Thirteen out of 24 patients achieved a good neurologic outcome at 3 months (54.2%). Patients who achieved a good neurologic outcome were more likely to have a lower admission NIHSS (16 vs 20 p=0.04), smaller baseline hematoma volume (24.6mL vs 48.4 mL), (p=0.02), and a lower NIHSS at discharge (4 vs 19), (p=0.003). Median whole brain BBB permeability was insignificantly lower in patients who achieved a better neurologic outcome (1.8 vs 2.1, p=0.17). However, a threshold of whole brain BBB permeability less than 1.9% significantly correlated with improved neurologic outcome at 3 months (Odds Ratio=0.11, 95% Confidence Interval (0.02-0.71), p=0.02). Additionally, the same threshold was significantly associated with a lower NIHSS at discharge (5 vs 17.5, p=0.03). Conclusion: Diffuse disruption of the BBB in the days after presenting with ICH is associated with worse clinical outcome if the disruption is severe.

Abstract WP161: Does History Of Atrial Fibrillation (Afib) Impact TICI Scores In Acute Ischemic Stroke Patients Receiving Endovascular Treatment With Or Without Iv Thrombolytics? Results From A Large Health System In Six Western States Of The United States

Introduction: Despite the importance of Afib in stroke, it is unclear whether patients with acute ischemic stroke (AIS) and Afib have a different response to reperfusion with IV thrombolysis (IVT) and/or endovascular treatment (EVT) compared to non-Afib patients. Patients with AIS due to Afib may have difficulty achieving favorable TICI scores (The thrombolysis in cerebral infarction).This study aimed to compare the TICI scores in patients with and without a history of Afib treated with EVT and/or IVT. Methods: Data on consecutive AIS patients (a multi-state health system’s stroke registry) treated with EVT and/or IVT for five years (2018 -2022) were evaluated. Patients were stratified into two groups, 1- EVT only with or without a history of Afib; 2- IVT plus EVT with or without a history of Afib.Multivariable mixed effect logistic regressions were performed to evaluate if patients with AFib showed a difference in TICI scores (favorable outcome : TICI: 2b-3) within the two treatment groups adjusting for patient age, sex, race and ethnicity, NIHSS on admission, blood glucose on admission, SBP on admission and history of diabetes, CAD/prior MI, carotid stenosis, smoking, dyslipidemia, heart failure, or being overweight. Results: The cohort consists of 3311 patients with a median age at arrival 73 years and median NIH Stroke scale 16, who were 51.7% females, 68% white, 23.9% diabetes mellitus, 51.6% dyslipidemia , 20.5% CAD , 13.6% smoking, 53.6% overweight, 14.9% HF.In group 1 (EVT) :2350 patients:37.3% had Afib and 93.6% achieved a score of TICI 2b-3 .In group 2 (EVT+IVT): There were 961 patients, 28.7% having Afib with 94.9% achieving TICI 2b-3. After adjustment, there was no difference in the TICI scores between two groups . Conclusions: In this study, atrial fibrillation did not significantly impact TICI scores in AIS patients treated with EVT. The study also supports the efficacy of EVT in combination with IVT in the population with Afib.