Mild Ischemic Stroke Patients Research Articles

Association of perfusion variables with functional outcome in acute mild ischemic stroke patients or transient ischemic attack

ObjectiveSome patients with acute minor stroke or transient ischemic attack (TIA) are at risk for a poor prognosis. There are a limited number of studies that have investigated the functional prognosis of acute mild ischemic stroke or TIA based on imaging indicators. This study aims to explore the relationship between Perfusion Variables and poor prognosis in patients with mild ischemic stroke or TIA. Materials and methodsA retrospective analysis was conducted on a cohort of 344 patients with mild ischemic stroke or TIA, who were admitted and treated at the First Affiliated Hospital of Soochow University between January 2016 and March 2022. The criteria were National Institutes of Health Stroke Scale (NIHSS) scores of ≤5. Poor outcome was defined as a modified Rankin Scale (mRS) score of ≥2 points at 90 days. Multivariate logistic regression was performed to identify the risk factors associated with clinical outcomes. The receiver operating characteristic (ROC) analysis was used to explore the cutoff value of factors. ResultsFollowing a 3-month follow-up period, 49 (12.4 %) out of the 344 patients with mild stroke or TIA demonstrated a poor prognosis. Multivariable regression analysis identified mismatch volume as independent predictors of a poor 90-day prognosis. The ROC curve analysis indicated that a mismatch volume exceeding 16.5 ml was associated with a higher risk of unfavorable functional outcomes. ConclusionA mismatch volume of ≥16.5mL predicted poor functional outcome in mild stroke or TIA patients.

Best medical management versus intravenous thrombolysis for mild non-disabling ischemic stroke: A prospective noninferiority registry study

ObjectivesThe efficacy and safety of intravenous thrombolysis uncertain in patients with non-disabling mild ischemic stroke. Our aim was to investigate whether best medical management only is noninferior to intravenous thrombolysis plus best medical management therapy for achieving favorable functional outcome at 90 days. Materials and methodsIn a prospective acute ischemic stroke registry from 2018 through 2020, 314 non-disabling mild ischemic stroke patients received best medical management only and 638 underwent intravenous thrombolysis plus best medical management. The primary outcome was modified Rankin Scale ≤1 at Day 90. The noninferiority margin was −5%. Secondary outcomes of hemorrhagic transformation, early neurologic deterioration and mortality were also evaluated. ResultsThe best medical management only was noninferior to the combined therapy of intravenous thrombolysis and best medical management with regard to the primary outcome (unadjusted risk difference, 1.16%; 95% CI, −3.48% ∼ 5.8%; p = 0.0046 for noninferiority; adjusted risk difference, 3.01%; 95% CI, −3.39% ∼ 9.41%). After propensity score matching, p < 0.0001 for noninferiority. RD, 4.03%; 95% CI, −1.59% ∼ 9.69%. p < 0.0001 for noninferiority. Adjusted RD, 5.23%; 95% CI, −1.88% ∼ 9.97%. The occurrence of hemorrhagic transformation was significantly increased in the group of combination therapy (OR, 4.26; 95% CI, 1.30 to 13.99; p = 0.008), while no significant difference was detected in early neurologic deterioration (OR, 1.11; 95% CI, 0.49–2.52; p = 0.808) and mortality (OR, 0.57; 95% CI, 0.20 to 1.69; p = 0.214) between groups. ConclusionsIn the present study, we found the best medical management only was noninferior to the combination therapy of intravenous thrombolysis plus best medical management for non-disabling mild ischemic stroke within 4.5 h after onset. Best medical management may be a treatment of choice for non-disabling mild ischemic stroke patients. Further randomized controlled studies are warranted.

Differences in symmetrical low-frequency oscillations among healthy subjects, and those with stroke or peripheral arterial disease

ObjectiveLow-frequency oscillations (LFOs) observed in near-infrared spectroscopy (NIRS) reflect autonomic physiological processes, and may serve as useful indicators for detecting and monitoring circulatory dysfunction. The aim of this study was to reveal whether LFOs can be used as vascular perfusion biomarkers to differentiate different types and degrees of vascular lesions based on clinical patient data. Materials and Methods: In this study, healthy controls, ischemic stroke patients and peripheral atherosclerosis patients completed a resting-state LFO detection experiment. LFOs were collected simultaneously at peripheral right and left earlobes, fingertips and toes, along with coherence and phase shift analyses processing. Results: The results showed that the coherence coefficients of symmetric peripheral positions and the absolute value-phase shifts of fingers and toes can be used to distinguish healthy individuals, ischemic stroke patients and peripheral atherosclerosis patients. The symmetric earlobes’ absolute value-phase shifts could be used to differentiate mild and severe ischemic stroke patients; the coherence coefficients and absolute value-phase shifts of the symmetric toes could be used to differentiate mild and severe peripheral arteriosclerosis patients. The accuracy of differentiating between types of patients was 70%; those with different degrees of peripheral atherosclerosis was 85%, and those with different degrees of ischemic stroke was 72%. Conclusions: LFOs can serve as vascular perfusion biomarkers to differentiate types and degrees of vascular lesions. Therefore, LFOs have the potential to provide valuable patient information to assist researchers and clinicians in identifying specific peripheral circulatory damage subgroups.

Systemic inflammation response index predicts 3-month outcome in patients with mild acute ischemic stroke receiving intravenous thrombolysis.

A crucial aspect of stroke progression is the inflammatory response. As novel inflammatory and prognostic markers, the systemic immune inflammation index (SII) and the systemic inflammation response index (SIRI) have recently been studied. The objective of our study was to evaluate the prognostic value of SII and SIRI in mild acute ischemic stroke (AIS) patients following intravenous thrombolysis (IVT). Our study screened the clinical data of patients with mild AIS admitted to the Minhang Hospital of Fudan University for retrospective analysis. The SIRI and SII were examined by the emergency laboratory before IVT. Functional outcome was evaluated 3 months after the onset of stroke using the modified Rankin Scale (mRS). mRS ≥ 2 was defined as an unfavorable outcome. The relationship between SIRI and SII and the 3-month prognosis was determined using both univariate and multivariate analysis. Receiver operating characteristic curve was performed to evaluate the predictive value of SIRI for AIS prognosis. A total of 240 patients were included in this study. Both SIRI and SII were higher in the unfavorable outcome group than in the favorable outcome group [1.28 (0.70-1.88) vs. 0.79 (0.51-1.08), P < 0.001 and 531.93 (377.55-797.12) vs. 397.23 (263.32-577.65), P < 0.001]. Multivariate logistic regression analyses showed that SIRI was significantly associated with 3-month unfavorable outcome of mild AIS patients [odds ratio (OR) = 2.938, 95% confidence interval (CI) = 1.805-4.782, P < 0.001], conversely, SII had no prognostic value. When SIRI combined with the established clinical factors, the area under the curve (AUC) showed a significant improvement (0.773 vs. 0.683, P for comparison = 0.0017). Higher SIRI could be valuable in predicting poor clinical outcomes for patients with mild AIS following IVT.

Impact of glycosylated hemoglobin on early neurological deterioration in acute mild ischemic stroke patients treated with intravenous thrombolysis.

In patients with acute mild ischemic stroke treated with intravenous thrombolysis, the relationship between chronic hyperglycemic status and their early neurological deterioration (END) and clinical outcomes is unclear. We attempted to analyze the relationship between glycated hemoglobin (HbA1c) levels and END and 90-day functional outcomes. The research comprised 267 patients with acute mild ischemic stroke. The incidence of END and functional outcomes at 90 days were evaluated between subgroups. END was defined in this study as a rise of at least 1 point in the National Institutes of Health Stroke Scale (NIHSS) score within 72 h of admission, with an excellent outcome of a modified Rankin Scale (mRS) score of 0-1 at 90 days following stroke beginning. The association between HbA1c and END, and clinical outcomes in patients with mild stroke, was assessed by logistic regression after adjusting for confounding factors. In addition, we used receiver operating characteristic (ROC) curves to predict the predictive value of HbA1c for the incidence of END. There were 38 patients who suffered END and 105 patients who had disabled functional outcomes at 90 days. In multivariate analysis, elevated HbA1c levels were associated with END (adjusted OR = 1.476; 95% CI: 1.129-1.928; p = 0.004). With HbA1c greater than 7.75%, the ROC curve predicted a higher risk of END. However, they were not associated with patients' functional outcomes at 90 days. HbA1c levels were an independent predictor of END in patients with mild stroke, while there was no effect on functional outcomes at 90 days. The impact of HbA1c on functional prognosis may be a contributing factor rather than a direct factor.

Endovascular treatment vs drug therapy alone in patients with mild ischemic stroke and large infarct cores.

BACKGROUNDTreatment decision making is strictly associated with the outcomes in patients with ischemic stroke who show a large core infarct. Medical care alone may result in suboptimal treatment efficacy, and endovascular treatment may be accompanied by safety issues. Whether endovascular treatment is superior to medical care is not well investigated in the clinical studies.AIMTo investigate the efficacy of endovascular treatment and drug therapy alone in mild ischemic stroke patients with large infarct cores.METHODSFifty patients with mild ischemic stroke and 50 patients with acute ischemic stroke caused by anterior large vessel occlusion were selected at the First Affiliated Hospital of Hebei North University between January 2021 and December 2021. Patients were divided into an endovascular therapy group and a drug therapy group according to different treatment methods. In the endovascular therapy group, there were 28 patients with minor stroke and 22 patients with large infarct cores. The drug therapy group had 22 patients with minor stroke and 28 patients with large infarct cores. The National Institutes of Health Stroke Scale (NIHSS) scores were collected and compared between the two groups immediately after the operation and 24 h and 7 d after the operation. The modified Rankin scale (mRS) and/or activity of daily living were assessed at hospital discharge.RESULTSThere was no significant difference in NIHSS scores between the two groups before the operation (P > 0.05). NIHSS scores were lower in the endovascular therapy group than in the drug therapy group at 24 h and 7 d after the operation and at hospital discharge (all P < 0.05). The incidence of early neurologic deterioration was significantly lower in the endovascular therapy group than in the drug therapy group (P < 0.05). At hospital discharge, the mRS score was lower in the endovascular treatment group than in the drug therapy group, and the activity of daily living score was better in the endovascular treatment group than in the drug therapy group (all P < 0.05). During a follow-up of 3 mo, 17 patients (34.0%) had good prognosis (mRS ≤ 2), 33 patients (66.0%) had poor prognosis (mRS > 2), and 11 patients (22.0%) died. In the medical treatment group, 16 patients (mRS ≤ 2) had good prognosis (32.0%), 34 patients (mRS > 2) had poor prognosis (68.0%), and 14 patients (28.0%) died. There was no significant difference in prognosis and mortality between the two groups (P > 0.05).CONCLUSIONEndovascular therapy can improve NIHSS score and mRS score in patients with mild ischemic stroke and large infarct cores. It is suitable for clinical application.

Associations of Peak-Width Skeletonized Mean Diffusivity and Post-Stroke Cognition.

Post-stroke cognitive impairment is common and can have major impact on life after stroke. Peak-width of Skeletonized Mean Diffusivity (PSMD) is a diffusion imaging marker of white matter microstructure and is also associated with cognition. Here, we examined associations between PSMD and post-stroke global cognition in an ongoing study of mild ischemic stroke patients. We studied cross-sectional associations between PSMD and cognition at both 3-months (N = 229) and 1-year (N = 173) post-stroke, adjusted for premorbid IQ, sex, age, stroke severity and disability, as well as the association between baseline PSMD and 1-year cognition. At baseline, (mean age = 65.9 years (SD = 11.1); 34% female), lower Montreal Cognitive Assessment (MoCA) scores were associated with older age, lower premorbid IQ and higher stroke severity, but not with PSMD (βstandardized = −0.116, 95% CI −0.241, 0.009; p = 0.069). At 1-year, premorbid IQ, older age, higher stroke severity and higher PSMD (βstandardized = −0.301, 95% CI −0.434, −0.168; p < 0.001) were associated with lower MoCA. Higher baseline PSMD was associated with lower 1-year MoCA (βstandardized = −0.182, 95% CI −0.308, −0.056; p = 0.005). PSMD becomes more associated with global cognition at 1-year post-stroke, possibly once acute effects have settled. Additionally, PSMD in the subacute phase after a mild stroke could help predict long-term cognitive impairment.

Machine Learning-Based Prediction of Subsequent Vascular Events After 6 Months in Chinese Patients with Minor Ischemic Stroke.

BackgroundTo develop and validate a machine learning model for predicting subsequent vascular events (SVE) 6 months after mild ischemic stroke (MIS) in Chinese patients.MethodsA retrospective analysis was performed on 495 newly diagnosed MIS patients by collecting their basic information, past medical history, initial NIHSS score, symptoms, obstruction sites of MIS, and MRI results. According to the ratio of 7:3, the dataset was divided into a training set (n=346) and a testing set (n=149) through stratified random sampling. In the training set, the recursive feature elimination (RFE) was used to select the optimal combination of features, and two machine learning algorithms, including the logistic regression (LR) and support vector machines (SVM), were used to build the prediction model, which was further validated by using 5-fold cross-validation. The receiver operating characteristic (ROC) curve was used on the testing set to evaluate the model’s performance, and the area under the curve (AUC), sensitivity, specificity, and accuracy were calculated. The calibration curve and decision curve of the two models were further compared.ResultsSVE occurred in 56 cases (11.3%) of 495 patients with MIS during the 6-month follow-up. Finally, the best 15 predictive features were selected, and the top three predictive features were diabetes, posterior cerebral artery lesion, and fasting blood glucose in order. In the testing set, the AUC of the LR model was 0.929 (95% CI: 0.875–0.964), and its accuracy, sensitivity, and specificity were 0.832, 0.765, and 0.841, respectively. The AUC of the SVM model was 0.992 (95% CI: 0.962–1.000), and its accuracy, sensitivity, and specificity were 0.966, 0.824, and 0.985, respectively. The SVM model’s discrimination, calibration, and clinical validity are better than those of the LR model.ConclusionThe predictive models developed using machine learning methods can predict the risk of SVE after 6 months following MIS in Chinese patients.

Intravenous Alteplase Treatment of Acute Ischemic Stroke Patients Exhibiting Mild Neurological Deficits.

Alteplase is increasingly used for treating ischemic stroke cases with low NIHSS scores, but the guidelines and evidence regarding outcomes are lacking. So, the authors conducted an updated meta-analysis to better understand the effects of alteplase for the treatment of acute mild ischemic stroke. PubMed, Cochrane, EMBASE were systematically explored for all relevant investigations published as in September 2021. Study quality was assessed as per the Cochrane system criteria, and Stata 15.1 was utilised to carry out a meta-analysis. In total, 16 trials incorporating 5,846 patients were analysed (1,926 and 3,920 cases in the rt-PA and non-thrombolytic groups, respectively). The main outcome measure revealed that the treatment of rt-PA was correlated with better odds of a modified Rankin Scale (mRS) score of 0-1 relating to the non-thrombolytic group (OR = 1.12, 95% CI = 1.02-1.23, p <0.05), and with moderate heterogeneity (I2 = 0.0%, p = 0.930). For the secondary study outcomes, symptomatic intracranial hemorrhage incidence was 4.46 times greater in the group of rt-PA, relating to the non-thrombolytic group (OR = 4.46, 95% CI = 2.75-7.23, p <0.001). There were no considerable differences in the mortality between the two groups (OR = 0.64, 95% CI = 0.39-1.03, p >0.05). No significant heterogeneity was detected in secondary study outcomes. Subgroup analysis showed that the function outcomes was the best within 3-4.5 hours; and the risk and mortality of sICH were the lowest within 3-4.5 hours. Intravenous rt-PA administration is associated with improved functional outcomes at three months after the stroke in mild ischemic stroke patients. Key Words: Acute ischemic stroke, Mild, Alteplase, Meta-analysis.

Abstract WP85: Provider Perspectives On Stroke Treatment In Nebraska: Urban Vs. Rural Disparities

Introduction: Mission: Lifeline Stroke Nebraska (NE) is a four-year project which aims to improve stroke systems of care within the state through various interventions, including education of healthcare providers. Timely in-hospital treatment of stroke patients is key to reducing death and disability in stroke patients. Methods: An anonymous survey was administered to physicians and advanced practice providers that work in the ED at NE hospitals to assess the comfort/confidence level in administering IV thrombolytics and to learn more about the reasons for giving (and not giving) IV thrombolytics in various scenarios, including when an ischemic stroke is mild (NIHSS &lt;4). A total of 110 providers completed the survey between February and April of 2021. Results: Critical Access Hospital (CAH) providers represented 70% of respondents. Only 50% of providers at certified centers and 29% at CAHs feel comfortable/confident in giving IV thrombolytics to ischemic stroke patients before consulting another provider. After consulting another clinician, this percentage increases to 89.7% in CAH providers but does not change in certified center providers. Overall, only 26.5% of certified center providers and 21.8% of CAH providers stated they are likely to give IV thrombolytic to a mild ischemic stroke patient. Certified center providers indicated that improved feedback on patient outcomes post IV thrombolytic therapy (41.2%) is the top item that would increase their comfort/confidence with administering IV thrombolytic. Qualitative feedback from certified center providers also shows there is hesitancy in administering IV thrombolytics to stroke patients and a desire to see more research showing the benefits. CAH providers identified access to telestroke (78.2%) and annual stroke education including updated guidelines on IV thrombolytic administration (66.7%) as the top items that would increase their comfort/confidence. Conclusions: These results indicate there is hesitancy to use IV thrombolytics to treat mild ischemic stroke patients and a need for more telestroke/neurology consultation options for providers in CAHs. From these conclusions, Mission: Lifeline is catering educational opportunities to the needs of rural and urban providers in NE

Radiographic Characteristics of Mild Ischemic Stroke Patients With Visible Intracranial Occlusion: The INTERRSeCT Study.

Early neurological deterioration occurs in one-third of mild strokes primarily due to the presence of a relevant intracranial occlusion. We studied vascular occlusive patterns, thrombus characteristics, and recanalization rates in these patients. Among patients enrolled in INTERRSeCT (Identifying New Approaches to Optimize Thrombus Characterization for Predicting Early Recanalization and Reperfusion With IV Alteplase and Other Treatments Using Serial CT Angiography), a multicenter prospective study of acute ischemic strokes with a visible intracranial occlusion, we compared characteristics of mild (National Institutes of Health Stroke Scale score, ≤5) to moderate/severe strokes. Among 575 patients, 12.9% had a National Institutes of Health Stroke Scale score ≤5 (median age, 70.5 [63-79]; 58% male; median National Institutes of Health Stroke Scale score, 4 [2-4]). Demographics and vascular risk factors were similar between the two groups. As compared with those with a National Institutes of Health Stroke Scale score >5, mild patients had longer symptom onset to assessment times (onset to computed tomography [240 versus 167 minutes] and computed tomography angiography [246 versus 172 minutes]), more distal occlusions (M3, anterior cerebral artery and posterior cerebral artery; 22% versus 6%), higher clot burden score (median, 9 [6-9] versus 6 [4-9]), similar favorable thrombus permeability (residual flow grades I-II, 21% versus 19%), higher collateral flow (9.1 versus 7.6), and lower intravenous alteplase treatment rates (55% versus 85%). Mild patients were more likely to recanalize (revised arterial occlusion scale score 2b/3, 45%; 49% with alteplase) compared with moderate/severe strokes (26%; 29% with alteplase). In an adjusted model for sex, alteplase, residual flow, and time between the two vessel imagings, intravenous alteplase use (odds ratio, 3.80 [95% CI, 1.11-13.00]) and residual flow grade (odds ratio, 8.70 [95% CI, 1.26-60.13]) were associated with successful recanalization among mild patients. Mild strokes with visible intracranial occlusions have different vascular occlusive patterns but similar thrombus permeability compared with moderate/severe strokes. Higher thrombus permeability and alteplase use were associated with successful recanalization, although the majority do not recanalize. Randomized controlled trials are needed to assess the efficacy of new thrombolytics and endovascular therapy in this population.

Characteristics and Outcomes of Intravenous Thrombolysis in Mild Ischemic Stroke Patients

Objective: This study assessed the characteristics of intravenous thrombolysis (IVT) with respect to early neurological deterioration (END) and functional outcome in mild ischemic stroke patients.Methods: Data were obtained from acute mild ischemic stroke patients (defined as having a National Institute of Health Stroke Score (NIHSS) ≤ 5) treated with IVT in our hospital from July 2017 to December 2020. END was defined as the NIHSS increased ≥1 over the baseline at 24 h after IVT. A modified Rankin scale (mRS) ≤ 1 at 3 months was considered as a favorable outcome, and an mRS ≥2 at 3 months was an unfavorable outcome.Results: Two hundred thirty-three acute mild ischemic stroke patients (all patients underwent MRI and DWI restriction) with IVT were included in this study. Thirty-one patients experienced END, and 57 patients experienced an unfavorable outcome at 3 months. With multivariate analysis, END was associated with an elevated baseline systolic blood pressure (SBP) (OR = 1.324, 95% CI, 1.053–1.664, p = 0.016) and coronary heart disease (OR = 4.933, 95% CI, 1.249–19.482, p = 0.023). An unfavorable outcome at 3 months after IVT was independently associated with a baseline elevated SBP (OR = 1.213, 95% CI, 1.005–1.465, p = 0.045), baseline NIHSS (OR = 1.515, 95% CI, 1.186–1.935, p = 0.001), prior hyperlipemia (OR = 3.065, 95% CI, 1.107–8.482, p = 0.031), cardioembolic stroke (OR = 0.323, 95% CI, 0.120–0.871, p = 0.025), and END at 24 h (OR = 4.531, 95% CI, 1.950–10.533, p < 0.001) in mild ischemic stroke patients.Conclusion: In mild ischemic stroke patients with IVT, an elevated baseline SBP and coronary heart disease were associated with END. The elevated baseline SBP, baseline NIHSS, a history of prior hyperlipemia, cardioembolic stroke, and END at 24 h after IVT were useful in predicting an unfavorable outcome at 3 months.

Central Triage of Acute Stroke Patients Across a Distributive Stroke Network Is Safe and Reduces Transfer Denials.

Mechanical thrombectomy has dramatically increased patient volumes transferred to comprehensive stroke centers (CSCs), resulting in transfer denials for patients who need higher level of care only available at a CSC. We hypothesized that a distributive stroke network (DSN), triaging low severity acute stroke patients to a primary stroke center (PSC) upon initial telestroke consultation, would safely reduce transfer denials, thereby providing additional volume to treat severe strokes at a CSC. In 2017, a DSN was implemented, in which mild stroke patients were centrally triaged, via telestroke consultation, to a PSC based upon a simple clinical severity algorithm, while higher acuity/severity strokes were triaged to the CSC. In an observational cohort study, data on acute ischemic stroke patients presenting to regional community hospitals were collected pre- versus post-DSN implementation. Safety outcomes and rate of CSC transfer denials were compared pre-DSN versus post-DSN. The pre-DSN cohort (n=150), triaged to the CSC, had a similar rate of symptomatic intracerebral hemorrhage and discharge location compared with the post-DSN cohort (n=150), triaged to the PSC. Time to stroke unit admission was faster post-DSN (2 hours 40 minutes) versus pre-DSN (3 hours 29 minutes; P<0.001). Transfer denials were reduced post-DSN (3.8%) versus pre-DSN (1.8%; P=0.02), despite an increase in telestroke consultation volume over the same period (median, 3 calls per day pre-DSN versus 5 calls per day post-DSN; P=0.001). No patients who were triaged to the PSC required subsequent transfer to the CSC. A DSN, triaging mild ischemic stroke patients from community hospitals to a PSC, safely reduced transfer denials to the CSC, allowing greater capacity at the CSC to treat higher acuity stroke patients.

Assessing executive function following the early stage of mild Ischemic stroke with three brief screening tests

ObjectiveExecutive dysfunction following stroke is well documented, but less is known about whether it occurs in mild stroke patients. The purpose of the study was to investigate executive impairment in this population and explore the correlation between executive function tests and cognitive tests of other domains. MethodsCross-sectional study was undertaken to compare 139 mild ischemic stroke patients (National Institute of Health Stroke Scale (NIHSS) ≤ 7) aged 40–80 with 131 normal controls matched age, gender and levels of education. All participants were administered a neuropsychological test battery including three measures of executive functioning: Clock Drawing Test (CDT), Trial Making Test-A and B (TMT-A and B), and Stroop Color Word Test (SCWT). The CDT was evaluated using three quantitative scoring rubrics, with a total score of 3,10,18, respectively and a qualitative scoring method with six types of errors. Spearman's correlations were made to analyze the correlation between executive function tests and other neuropsychological tests. ResultsControl group performed better than stroke group on most executive function tests at a statistical significance. Qualitative CDT showed that errors of “graphic difficulties”, “conceptual deficits” and “spatial and/or planning deficits” occurred frequently in the early stage of mild stroke. Correlation data clarified that among the executive function tests, time for TMT-B correlated with global cognition most. ConclusionExecutive dysfunction is common following even mild strokes, and that relatively brief measures such as CDT, TMT and SCWT can be employed for it before discharge as part of rehabilitation planning.

Abstract TP299: Association Between Rates of Dysphagia Screening Failure and Short-Term Outcomes in Patients With Mild Stroke

Intro: Guidelines advocate screening all acute stroke patients for dysphagia. However, limited data are available regarding how many patients with mild presentation fail initial screening. We sought to evaluate the rates and predictors of dysphagia screening failure in mild acute ischemic stroke patients (NIHSS &lt; 5). Methods: Using GWTG stroke registry data from three large comprehensive stroke centers in the Northeast, South and West, we analyzed 8,687 stroke admissions from 06/2008 - 12/2018. Patients with mild stroke (NIHSS&lt;5) were identified and dysphagia failure rate was evaluated. Using univariate and multivariable regression (MV) analysis (using factors with p&lt;0.1, in bold), we evaluated factors associated with dysphagia screen failure in mild stroke patients. Results: Of the 8,687 patients, 3,614 (41%) had NIHSS &lt; 5. Dysphagia screening failure was seen in 30.2% in the entire cohort while only 10.3% (373/3,614) in patients with NIHSS &lt; 5. Mild stroke patients who failed dysphagia screening were older, more often had stroke risk factors of hypertension, hyperlipidemia, CAD/MI. They had higher median NIHSS and more often had language disturbance on presentation. Patients who failed dysphagia screening were less likely to be discharged home. On MV analysis, age (1.01, 95% 1.00, 1.02), hypertension (1.45, 95% 1.10, 1.91), NIHSS (1.62 95% 1.48, 1.77) and language disturbance at presentation (1.89 95% 1.13, 2.32) were significantly associated with initial dysphagia. Conclusion: Dysphagia screen failure rates are significantly less frequent in patients with mild symptoms and even lower for those with NIHSS of 0-1 at presentation. Factors associated with failure - older age, higher NIHSS and language disturbance at presentation may help focus efforts to avoid complications in these patients who might otherwise do well. This focused approach of screening patients all patients but targeting mild patients with dysphagia may hold potential for improved outcomes.

Abstract WMP16: Radiographic Characteristics of Mild Ischemic Stroke Patients With Visible Intracranial Occlusion; Data From the INTERRSeCT Multi-Center Prospective Imaging Study

Background: Early neurological deterioration occurs in one third of mild ischemic strokes primarily due to the presence of a visible intracranial vessel occlusion. We studied the clinical and vascular occlusive patterns, thrombus characteristics and recanalization rates in patients with mild ischemic stroke and a visible intracranial vessel occlusion. Methods: We studied patients enrolled in the INTERRSeCT multi-center prospective study of acute ischemic strokes with visible intracranial occlusions. We compared the clinical, thrombus characteristics and recanalization rates between two groups, 1) mild ischemic NIHSS≤5 and 2) moderate/severe strokes NIHSS &gt;5, with or without IV alteplase treatment. Vessel imaging with CT angiography (CTA) was initiated within 12 hrs of symptom onset followed by repeat imaging with CTA or cerebral angiogram (before endovascular therapy; EVT) within 4 +/- 2 hrs. Results: Among 575 patients with a visible intracranial occlusion, 12.9% had mild strokes with similar patient characteristics compared to the moderate/severe stroke group. Residual flow grades were similar between the two groups (residual flow grades I-II, 21% vs 19%). The mild stroke group had longer symptom-onset-to -CT (240 vs 167 min, p=0.02) and -CTA (246 vs 172 min, p=0.02) times, longer CT to needle time (35 vs 26 min, p&lt;0.01), more distal occlusions (49% in M2 of the middle cerebral artery), lower clot burden scores 9 (6-9) vs 6 (4-9) (p&lt;0.001), better collateral flow (9.1 vs 7.6, p=0.001) and no association between residual flow grade and recanalization. The mild stroke group was less likely to receive IV alteplase (62% vs 84%), but more likely to recanalize (rAOL2b and 3) with (46% vs 29%) and without (38% vs 26%) IV alteplase. Conclusion: Some thrombus characteristics that predict recanalization in more severe strokes do not predict recanalization in mild strokes, such as residual blood flow through intracranial occlusions, though they have similar cardiovascular risk factors. Less than half of patients with mild strokes recanalized with IV alteplase which was associated with longer decision-making times suggesting that more aggressive use of thrombolytics and/or EVT may be viable treatment options in this population.

Impact of intravenous thrombolysis on functional outcome in patients with mild ischemic stroke without large vessel occlusion or rapidly improving symptoms.

Optimal treatment strategy in patients with mild ischemic stroke remains uncertain. While functional dependency or death has been reported in up to one-third of non-thrombolyzed mild ischemic stroke patients, intravenous thrombolysis is currently not recommended in this patient group. Emerging evidence suggests two risk factors-rapid early improvement and large vessel occlusion-as main associates of unfavorable outcome in mild ischemic stroke patients not undergoing intravenous thrombolysis. To analyze natural course as well as safety and three-month outcome of intravenous thrombolysis in mild ischemic stroke without rapid early improvement or large vessel occlusion. Mild ischemic stroke was defined by a National Institute of Health Stroke Scale score ≤6. We used the modified Rankin Scale (mRS) to compare three-month functional outcome in 370 consecutive mild ischemic stroke patients without early rapid improvement and without large vessel occlusion, who either underwent intravenous thrombolysis (n = 108) or received best medical treatment (n = 262). Favorable outcome (mRS ≤ 1) was common in both groups (intravenous thrombolysis: 91%; no intravenous thrombolysis: 90%). Although intravenous thrombolysis use was independently associated with a higher risk of asymptomatic hemorrhagic transformation (OR = 4.62, p = 0.002), intravenous thrombolysis appeared as an independent predictor of mRS = 0 at three months (OR = 3.33, p < 0.0001). Mild ischemic stroke patients without rapidly improving symptoms and without large vessel occlusion have a high chance of favorable three-month outcome, irrespective of treatment type. Patients receiving intravenous thrombolysis, however, more often achieved complete remission of symptoms, which particularly in mild ischemic stroke may constitute a meaningful endpoint.

Efficacy and safety of endovascular thrombectomy in mild ischemic stroke: results from a retrospective study and meta-analysis of previous trials

BackgroundMechanical thrombectomy has been proven as a standard care for moderate to severe ischemic stroke with anterior large vessel occlusion (LVO); however, whether it is equally effective in mild ischemic stroke (MIS) is controversial.MethodsIn this retrospective study, a total of 177 Chinese patients presenting with MIS (NIHSS ≤8) and LVO between January 2014 and September 2017 from seven comprehensive stroke centers were identified. Odds of good outcome with endovascular thrombectomy versus medical treatment were obtained by logistic regression analysis and propensity-score matching method, and a meta-analysis pooled results from six studies (n = 733).ResultsGood outcome (mRS: 0–1) was 58.2% (46/79) in the thrombectomy and 46.9% (46/98) in the medical group, which showed no statistical significance before adjustment (P = 0.13; OR = 1.57, 95% CI: 0.86 to 2.86). The adjusted ORs of thrombectomy versus medical group were 3.23 (95% CI, 1.35 to 7.73; P = 0.008) by multivariable logistic analysis, 2.78 (1.12 to 6.89; P = 0.02) by propensity score matching analysis, and 3.20 (1.22 to 8.37; P = 0.01) by propensity score matching analysis with additional adjustments, respectively. Thrombectomy treatment did not result in excessive mortality or symptomatic intracranial hemorrhage after adjustments. The meta-analysis did not confirm the associations between good outcome and endovascular treatment.ConclusionsThe current study indicates that endovascular thrombectomy is associated with good functional outcome in MIS patients with LVO, and without additional risk of symptomatic intracranial hemorrhage and mortality. Although the meta-analysis failed to demonstrate its superiority compared to medical treatment, randomized clinical trials are needed.

Abstract WP369: Triaging Acute Ischemic Stroke Patients Across a Network of Hospitals is Safe and Reduces Transfer Denials for Thrombectomy

Introduction: The introduction of thrombectomy into evidence-based stroke care has dramatically increased the volume of stroke patients transferred to comprehensive stroke centers (CSC), often overwhelming their capacity. This has led to increased transfer denials of severe stroke patients who needed thrombectomy. Hypothesis: A “distributive stroke network” (DSN) to triage low severity acute stroke patients to a primary stroke center (PSC) upon initial neurology consultation will be safe, thereby providing additional volume to treat severe strokes at a CSC. Methods: A clinical severity algorithm for external consultations based on NIHSS and time since last known well was created to triage mild acute ischemic stroke patients (both tPA-treated and untreated) to the PSC, while triaging more severe strokes to the CSC. We evaluated clinical outcomes, safety endpoints, stroke consultation volumes, and transfer denials by comparing a stroke cohort after DSN implementation, to a cohort (matched for NIHSS and acuity) admitted to the CSC prior to DSN implementation. Results: The pre-DSN CSC cohort had similar demographics to the post-DSN PSC cohort. Safety outcomes (symptomatic hemorrhage or the need for PSC to CSC transfer) and favorable discharge outcome (home/inpatient rehabilitation vs. nursing home/death) did not differ between pre- and post-DSN cohorts. The post-DSN PSC cohort had a faster time from consult to admission (3 vs. 5 hours) and shorter hospital length of stay (LOS) (2 vs. 3.5 days) compared to the pre-DSN CSC cohort. After DSN implementation, there were fewer CSC stroke transfer denials. Total consultation rates increased over the same period. Conclusion: Triaging external patients to a PSC or CSC during initial consultation (distributive stroke network) based on stroke severity and acuity significantly reduced transfer denials to the CSC. In addition, this DSN algorithm was safe, led to faster admission, and a shorter LOS.

Abstract TP399: Complications from IV Alteplase in Mild Stroke Patients in a Multi-state Health System

Introduction: The rate of complications from IV alteplase (tPA) for acute ischemic stroke is necessary for discussing risk and benefit when deciding whether to treat. Symptomatic intracerebral hemorrhage (sICH) rate is often quoted as 6.4% based on the NINDS trials. This risk often makes patients and physicians wary of tPA treatment for mild ischemic stroke (MIS). However, NINDS excluded these patients, so risk in MIS is not clear. The Objective of this study was to examine rates of tPA-related complications in MIS compared to moderate-to-severe stroke using real-world data. Methods: Data from a multi-state hospital system included tPA-treated patients discharged between January 2011 and May 2018. Patients who were &lt;18 years old, received thrombectomy, transferred to another hospital, or had inpatient stroke were excluded. Outcomes included percentage of patients who experienced any complication, sICH, life-threatening systemic hemorrhage, other serious complication, or in-hospital mortality or discharge to hospice. Chi-squared and Fisher’s exact tests and generalized linear models were used to compare outcomes between patients with mild (NIHSS ≤ 5) and moderate-to-severe (NIHSS &gt;5) strokes. Results: A total of 3,067 patients met inclusion criteria with 36% (1,111) having a mild stroke. When compared to MIS patients, moderate-to-severe stroke patients were more likely to have sICH (4.4% vs. 1.3%; p&lt;.001), life-threatening systemic hemorrhage (0.8% vs. 0%; p&lt;.001), and other serious complication (2.1% vs. 0.5%; p&lt;.001). In multivariate analysis, patients with moderate-to-severe stroke were 3.69 (95% CI: 2.26, 6.01) times more likely to have any complication and 7.66 (95% CI: 4.82, 12.16) times more likely to die or be discharged to hospice after adjusting for age, sex, hospital, and history of atrial fibrillation, hypertension, diabetes, and coronary artery disease or prior myocardial infarction. Conclusion: Patients with mild strokes that received IV-alteplase had fewer treatment-related complications and were less likely to experience in-hospital mortality or discharge to hospice compared to those with moderate-to-severe strokes. This may inform decision-making in treatment of mild ischemic strokes.