NIH Stroke Score Research Articles

Abstract TMP24: Thrombolytics With ≤30 Minutes Door-to-Needle Time in Acute Ischemic Stroke: How Fast is Too Fast?

Introduction: Current Phase III of the American Heart Association Target Initiative aims to achieve secondary goals of door to-needle-times within 30 minutes in ≥50% of acute ischemic stroke patients. We sought to evaluate the influence of non-institutional factors (namely presenting patient characteristics) on administration times, safety, and feasibility of thrombolytics within ≤30 minutes of presentation. Method: A single center, retrospective study from March 2018 to March 2023 was conducted yielding 179 patients who received IV thrombolytic for suspected acute ischemic stroke. Patients were dichotomized into those treated within 30 minutes and >30 minutes. A univariate analysis using Chi-squared test of proportions (or Fisher exact when appropriate) was used to compare the patient characteristics on presentation and a multivariate logistic regression was utilized to explore independent predictors. Results: Of a total of 176 patients (after excluding patients with missing data), 60% (n=105) were ≤30 minutes. Age, gender, past medical history, last known well time and admission modified ranking score did not influence thrombolytic administration time (table 1). However, a presenting NIH stroke score of >4 was associated with a 2.5 OR (1.19-5.23) (p=0.0151) of achieving < 30min times. Although a higher rate of intracerebral hemorrhage was noted in the >30 minutes group, this was not statistically significant (11% vs 6.6%; p=0.283). Conclusion: In our study, acute thrombolytic within 30 minutes was feasible, safe, and only influenced by higher NIHSS. Institutional processes remain the mainstay of achieving this target.

Abstract 122: Associations of BDNF, PATJ and LOC105372028 Polymorphisms With Functional Outcomes in Probable LVO

Background: Several studies have investigated the association between the BDNF, PATJ, and LOC105372028 genes and functional outcome after ischemic stroke. Large vessel occlusion (LVO) is a distinct ischemic stroke presentation with a large impact on clinical function, thus these variants warrant investigation in this important subpopulation. Objective: To investigate whether single nucleotide polymorphisms (SNPs) in the BDNF (rs6265), PATJ (rs76221407), and LOC105372028 (rs1842681) loci are associated with functional outcome after LVO ischemic stroke. Methods: From the GISCOME (Genetics of Ischemic Stroke Functional Outcome) study, we investigated the subgroup with probable LVO, defined as NIHSS score of ≥7 in combination with one of the TOAST/CCS stroke subtypes cardio-embolic, large artery atherosclerosis, or undetermined cause, thus excluding patients with small artery occlusion or other known causes. The primary outcome was the modified Rank Scale (mRS) dichotomized as good (mRS score 0-2) versus poor (mRS score 3-6) at 3 months (allowing 60-190 days) post-stroke. We calculated the odds of poor outcome (mRS score 3-6) with a mixed-effects logistic regression model adjusting for stroke severity (total NIHSS), age, sex, hypertension, diabetes, current smoking, and ancestry (principal components 1-5) with study cohort as a random effect. Results: Among the 1,530 included patients with probable LVO, the median age was 73 years (inter quartile rage (IQR) 63-82, 771 (50.4%) were men, and the median initial NIH stroke score was 13 (IQR 9-18). At three months post-stroke, 38% had a mRS score of 0-2. The LOC105372028 variant was significantly associated with poor outcome at 3 months (OR 1.27 95% CI 1.02, 1.57), whereas the BDNF and PATJ variants were not (OR 1.10; 95% CI 0.87, 1.38, and OR 1.26 95% CI 0.70, 2.27, respectively). Conclusions: The LOC105372028 variant is associated with functional outcome in patients with probable LVO ischemic stroke, whereas the BDNF and PATJ variants are not.

Abstract TP38: Gender Disparities In Ischemic Stroke Thrombolytic Treatment In Nebraska Hospitals

Introduction: Mission: Lifeline Stroke Nebraska was a 4-year program to enhance stroke systems of care in Nebraska. With 68% of hospitals in Nebraska participating in GWTG-Stroke, analysis of stroke treatment data can be accomplished on disparities across the state. Methods: De-identified data was accessed through AHA GWTG-Stroke registry to assess stroke outcomes of patients at 49 participating NE hospitals in 2020. Data were analyzed based on AHA specified Mission: Lifeline reporting, achievement, and pre-hospital measures. The purpose of analysis was to describe patient characteristics and determine differences in IV thrombolytic treatment and mean patient NIH stroke score (NIHSS) upon admission. Percentages and counts were reported for categorical variables. The mean, standard deviation (SD) and median were reported for continuous variables. The Kruskal-Wallis rank sum, Wilcoxon sign rank, T-tests, chi-square and one-way ANOVA tests were used, where appropriate, to assess differences in stroke outcomes by age, gender, and race/ethnicity. Results: Of the 3,952 patient encounters registered in GWTG-Stroke from 01/01/2020 to 12/31/20, 2670 (67.5 %) were patients 18+ at time of admission with clinical diagnosis of ischemic stroke. Statistically significant differences in age, NIHSS at admission, and treatment with thrombolytics by gender were observed. Compared to males, females were older (72.7 vs. 68.1 years), had a lower mean NIHSS at admission (5.8 vs. 6.0), and a smaller proportion of females received thrombolytic treatment (42% vs. 58%). Conclusions: Overall, females were less likely to receive IV thrombolytic treatment compared to males. Women in the study were older with lower NIHSS than males. Results from this analysis align with those from the study “The Impact of Sex and Gender on Stroke” (Rexrode, et al.,2022) indicating that females may present different signs of a stroke than males. Our data showed the NIHSS scores to be lower for females possibly leading to lower frequency of treatment. As a part of the Mission: Lifeline initiative, this information was shared with hospitals and providers across the state. These results led to public awareness and education targeted to women, including a local podcast and social media.

Abstract TP108: Early Palliative Care Consultation In Patients With Disabling Stroke

Severe disability and critical illness due to stroke can be burdensome to patients, caregivers, and resource intensive, particularly in the elderly. Management of these patients is multifaceted and includes optimizing quality of life through palliative care (PC). PC in stroke patients can improve comfort while reducing overutilization of resources unlikely to prolong life or contribute meaningful quality. We investigated the impact of early PC involvement in disabled stroke patients, which we defined as NIH Stroke Score ≥ 5 and ICU admission. A screening program was implemented in 2019 at the Loyola University Medical Center for automatic PC consults in disabling stroke (ischemic or hemorrhagic) patients over age 70 or who require a ventilator. We hypothesized that early PC consultation via this protocol reduced resource consumption without compromising patient care. This pilot study gathered data prospectively for patients with a positive screen from 2020 to 2021 (“screening”, n=71), and retrospectively for those who met screening criteria in 2017 and 2018 prior to its application (“control”, n=193). Comparing the screening and control groups, there was no significant difference in age (75.9 ± 2.7 vs 72.1 ± 1.1, p>0.1), NIH stroke score (16.6 ± 0.5 vs 17.5 ± 0.9, p=0.2), stroke type (61% vs 69% ischemic, p>0.2), or proportion who expired (22% vs 18%, p=0.4). However, the screening group had more frequent code status change from full to DNR/DNI (42% versus 19%, p<0.01) and more frequent discharges to home (20% vs 8%, p<0.01) when compared to the control. These findings suggest that our samples were similar in stroke severity and screening did not affect mortality. More frequent code status changes with PC screening implies better early identification of patient centered goals of care during admission. Increased discharges to home among these patients may reduce overall long term health care utilization with clear future directives. In conclusion, our pilot study demonstrates that early palliative care involvement in patients with disabling stroke is feasible and expedites establishing goals of care without affecting the quality of care patients receive. We plan to further investigate resource utilization including ICU length of stay and cost.

Abstract TP131: Trends In Intracerebral Hemorrhage Patients With Seizures: A Propensity Score Matched 20-year Analysis Of The National Inpatient Sample

Introduction: Intracerebral hemorrhage (ICH) accounts for 15% of strokes, and an early sequelae of hemorrhagic stroke is seizure. Studies have shown up to 43% of ICH patients experience electrographic seizure within 72 hours of ictus. The clinical course of patients with seizures in ICH remains unclear. Methods: A query of the 2000-2019 National Inpatient Sample was performed for patients admitted with ICH (ICD9 431, 432.9, ICD-10 I61, I62.9). Demographics, comorbidities, and outcomes were identified. Univariate analysis with t-tests or chi-square performed as appropriate. A 1:1 nearest neighbor propensity score matched cohort was generated. Variables with standardized mean differences >0.1 used in multivariate regression to generate adjusted odds ratios (AOR)/β-coefficients for the presence of seizures on outcomes. Significance set at an alpha level of <0.001. All analysis performed in R version 4.1.3. Results: 2,000,868 patients with ICH were identified; 234,382 had seizures (11.7%). Patients with seizure had higher Elixhauser Comorbidity Score (15.12 ± 8.54 vs. 9.80 ± 8.98, p<0.001) and NIH Stroke Score (13.02 ± 9.85 vs. 11.17 ± 9.46, p<0.001). There were higher rates of coma, fluid/electrolyte dysfunction, CNS infections, craniotomy, and external ventricular drain placement (p<0.01). After propensity matching, patients with seizure were less likely to experience in-hospital mortality (AOR 0.85; 95% CI: 0.82-0.87), more likely to be discharged home or short-term hospital (AOR 1.31; 95% CI: 1.27-1.35), have shorter hospital stay (-0.63 days; 95% CI: -0.82 - -0.45), and lower hospital charges ($-3991.74; 95% CI: $-6196.22- -1787.27) (all p<0.001). Conclusions: The rate of seizure among ICH patients remains unchanged over the past 2 decades. Seizure is associated with more severe presentation; however, it does not independently worsen the clinical outcome.

Abstract WP181: Trends In Ischemic Stroke Patients With Central Nervous System Infections: A Propensity Score Matched 20-year Analysis Of The National Inpatient Sample

Introduction: Infection of the central nervous system (CNS) - including meningitis, encephalitis and brain abscess - is a feared complication in hospitalized patients. Studies of CNS infection in patients with acute ischemic stroke (AIS) are scarce. We aimed to characterize AIS patients with CNS infections and assess their clinical outcomes over a 20-year period. Methods: A query of the 2000-2019 National Inpatient Sample was performed for patients admitted with AIS (ICD9 433, 434.01, 434.11, 434.91, ICD-10 I63). Demographics, comorbidities, and outcomes were identified. Univariate analysis with t-tests or chi-square performed as appropriate. A 1:1 nearest neighbor propensity score matched cohort was generated. Variables with standardized mean differences >0.1 used in multivariate regression to generate adjusted odds ratios (AOR)/β-coefficients for the presence of CNS infections on outcomes. Significance set at an alpha level of <0.001. All analysis performed in R version 4.1.3. Results: Total of 10,415,286 patients with AIS were included; 74,731 (0.7%) had CNS infection. Infected patients had higher Elixhauser Comorbidity Score (12.02 ± 9.24 vs. 9.75 ± 8.82; p<0.001) and NIH Stroke Score (8.78 ± 8.86 vs. 6.65 ± 7.29; p<0.001). After propensity matching, these patients had lower rates of smoking, COPD and CKD, and higher rates of systemic inflammatory disease and burr hole drainage (p<0.001). Infected patients had longer hospital stay (3.88 days; 95% CI: 3.45-4.3), higher hospital charges ($49633.46; 95% CI: $44199.59-55067.33) and were less likely to be discharged home or short-term hospital (0.78; 95% CI: 0.74-0.82)(all p<0.001). Conclusion: In this 20 year nationally representative propensity matched analysis of patients with AIS, those with concomitant CNS infections had higher rates of comorbidities and had higher NIHSS. In addition to having longer and more expensive hospital stays, these patients were less likely to have good functional outcomes.

Abstract TP143: A Retrospective Study Comparing Clinical Outcomes For Thrombectomy-treated Patients With Large Vessel Occlusion Who Met Or Did Not Meet AHA/ASA Eligibility Criteria

Introduction: In 2015, the AHA/ASA Stroke Guidelines recommended thrombectomy to treat large vessel occlusions (LVOs) based on multiple clinical trials that demonstrated efficacy and safety. Given the strict eligibility criteria employed by these trials, the guidelines recommended thrombectomy for a limited patient population. However, in real-world settings, patients who do not meet eligibility criteria still undergo thrombectomy at the discretion of their treating physician. The purpose of this study is to compare clinical outcomes and complication rates of thrombectomy patients who do not meet the AHA/ASA criteria to those that do. Methods: Data from patients discharged from October 2017 to February 2021 with LKW <= 6 hours were retrospectively abstracted from electronic medical records. Patients under 18 or with posterior circulation stroke were excluded. Patients were grouped by AHA/ASA criteria for thrombectomy treatment into met (M) vs. not-met (NM). The M group criteria were defined as pre-stroke modified Rankin score (mRS) 0-1, occlusion of the internal carotid artery (ICA) or middle cerebral artery (M1), NIH stroke score (NIHSS) of >=6 on arrival, and ASPECTS>=6. All other patients were categorized as NM. Primary outcomes were 90-day mRS, median change from arrival to 90-day mRS, discharge disposition, and treatment complications. Descriptive analyses were performed using Chi-squared test, Fisher’s exact test, or median test, as appropriate. Results: Among 225 patients who met inclusion criteria, 151 (67.1%) M and 74 (32.9%) NM patients were identified. NM patients had worse mRS scores at 90-days (6.0 [4.29, 6.00] vs. 3.0 [0.00, 6.00]) compared to M patients. However, change from pre-stroke to 90-day mRS was not significant between groups (M: 3.0 [1.00, 5.00] vs NM: 3.0 [1.00, 4.00], p<.846.) No differences were found between M or NM for discharge disposition or treatment complications. Conclusions: While patients in the NM group had worse 90-day mRS scores compared to the M group, the change in mRS scores from pre-stroke to 90-day were the same for both. Results support that thrombectomy treatment of LVOs is safe and effective for both groups. Expansion of AHA/ASA guidelines should be considered.

Abstract TMP56: Trends In Alcohol Abuse In Patients With Acute Ischemic Stroke: A 20-year Analysis Of The Nationwide Inpatient Sample

Introduction: Heavy alcohol (EtOH) consumption has been long recognized for its damaging effects to the brain and is considered a risk factor for stroke. However, the relationship between EtOH abuse and stroke on in-hospital outcomes remains unclear. Objective: To characterize stroke patients with an EtOH abuse and examine the effects of alcohol abuse on patient outcomes over 20 years. Methods: A query of the 2000-2019 National Inpatient Sample was performed for patients admitted with AIS (ICD9 433, 43401, 43411, 43491, ICD-10 I63). Demographics, comorbidities, and outcomes were identified. Univariate analysis with t-tests or chi-square performed as appropriate. A 1:1 nearest neighbor propensity score matched cohort was generated. Variables with standardized mean differences >0.1 used in multivariate regression to generate adjusted odds ratios (AOR)/β-coefficients for EtOH abuse on outcomes. Significance set at an alpha level of <0.001. All analysis performed in R version 4.1.3. Results: A total of 10,415,286 patients with AIS were identified; 368,953 (3.5%) abused EtOH. EtOH abuse patients had higher Elixhauser Comorbidity Score (11.02 ± 10.38 vs. 9.72 ± 8.76; p<0.001) and NIH Stroke Score (7.19 ± 7.08 vs. 6.65 ± 7.30; p<0.001). Patients with EtOH abuse were more likely to be male, younger, smokers, covered on Medicaid, have atrial fibrillation, and be in the 0-25% percentile median income bracket (all p<0.001). After propensity matching, EtOH abuse patients had longer hospital stay (0.39 days; 95% CI: 0.28-0.5), lower hospital charges (-$3780.6; 95% CI: -$5053.16 - -$2508.04) and were less likely to be discharged home or short-term hospital (AOR 0.83; 95% CI: 0.81-0.85)(all p<0.001). Conclusion: In this 20 year nationally representative propensity matched analysis of patients with AIS, patients that abused EtOH had higher incidences of more severe disease with worse functional outcomes, as well as lower hospital charges despite longer hospital stays.

Abstract WP149: Racial Disparity In Intracerebral Hemorrhage Severity And Outcome: A 4-year Analysis Of The National Inpatient Sample From 2016-2019

Background: Racial disparity in ICH management and outcome is a major concern. We sought to evaluate the impact of race on ICH severity and outcome in a nationally representative database. Methods: A query of the 2000-2019 National Inpatient Sample was performed for patients admitted with ICH (ICD9 431, 432.9, ICD-10 I61, I62.9). Demographics, comorbidities, and outcomes were identified. Discharge location was used as a surrogate for functional outcome. Univariate analysis with t-tests or chi-square performed as appropriate, and significant variables were entered into a multivariate regression to generate adjusted odds ratios (AOR)/β-coefficients for race on outcomes. Significance set at an alpha level of <0.001. All analysis performed in R version 4.1.3. Results: A total of 390,015 patients with ICH were identified over the four years; 97,220 (24.9%) had a reported NIH Stroke Score (NIHSS). Mean Age was 69.22 ± 14.3 years. Patients were 61% White, 16.6 % Black, 9.9% Hispanic, and 4.8% Asian. Average NIHSS differed significantly among the groups, with Asian patients having more severe disease than White, Black, or Hispanic patients (p<0.001). After multivariate analysis, Hispanic patients had greater odds of discharge home compared to White patients (AOR 1.3, 95% CI 1.12-1.51, p<0.05). Black patients had greater odds of discharge to nursing care facilities (AOR 1.12, 95%CI: 1.02-1.23, p<0.001). In hospital mortality was less in Black (AOR 0.7, 95%CI: 0.6-0.81), Asian (AOR 0.66, 95% CI: 0.51-0.83) and Hispanic (AOR 0.67, 95%CI: 0.55-0.8) patients (all <0.05). Conclusions: This nationally representative analysis demonstrates that Black patients have worse hospital outcomes after ICH while the rate of in-hospital mortality seen in Whites was higher in comparison to other races. White patients were the majority of cases and had an overall stable trend of good discharge outcome. Incidence of in-hospital mortality was highest in the Black patients over four years.

Abstract TP66: Trends In Alcohol Abuse In Patients With Intracerebral Hemorrhage: A 20-year Analysis Of The Nationwide Inpatient Sample

Introduction: While chronic alcohol (EtOH) abuse has long been considered a risk factor for several cardiovascular disorders including ischemic stroke, the relationship between intracerebral hemorrhage (ICH) and EtOH abuse is less known. Objective: To characterize ICH patients with EtOH abuse and examine the effects of EtOH abuse on in-hospital outcomes over 20 years. Methods: A query of the 2000-2019 National Inpatient Sample was performed for patients admitted with ICH (ICD9 431, 432.9, ICD-10 I61, I62.9). Demographics, comorbidities, and outcomes were identified. Univariate analysis with t-tests or chi-square performed as appropriate. A 1:1 nearest neighbor propensity score matched cohort was generated. Variables with standardized mean differences >0.1 used in multivariate regression to generate adjusted odds ratios (AOR)/β-coefficients for EtOH abuse on outcomes. Significance set at an alpha level of <0.001. All analysis performed in R version 4.1.3. Results: In total, 2,000,868 patients with ICH were identified; 106,987 (5.3%) abused EtOH. EtOH abuse patients had higher Elixhauser Comorbidity Score (12.95 ± 10.51 vs. 10.28 ± 8.98; p<0.001) and a non-significantly lower NIH Stroke Score (11.0 ± 8.69 vs. 11.34 ± 9.53; p >0.001). Patients with EtOH abuse were more likely to be male, younger, smokers, on Medicaid, be in the 0-25% percentile median income bracket, and have atrial fibrillation, hyperlipidemia, diabetes, and seizures (all p<0.001). Patients with EtOH abuse had less in-hospital mortality, more discharge home or short term hospital, longer hospital stays and more hospital charges (all p<0.001), but after propensity matching and regression analysis these differences were no longer significant. Conclusion: This 20 year nationally representative propensity matched analysis of patients with ICH demonstrates that concomitant EtOH does not significantly worsen in-hospital outcomes despite a higher association of other comorbidities.

Effectiveness and safety of intravenous alteplase in patients with acute ischemic stroke: Results of a single centre study

: To evaluate effectiveness and safety of intravenous alteplase (tPA) for the treatment of acute ischemic stroke. In this prospective observational study, adult patients with ischemic stroke were treated with intravenous alteplase. We recorded baseline demographics and NIHS score was calculated at baseline, 2 hours, 24 hours and 7 days. Improvement was assessed by evaluating total NIH stroke score at different time points. Based on the neurological assessment, patients were categorised into three categories: unchanged (U), improving (I) and deteriorating (D). Blood pressure was closely monitored until 24 hours after infusion of alteplase. Both neurological assessment and blood pressure was monitored every 15 minutes for the first 2 hours after start of infusion, then every 30 minutes for next 6 hours, and hourly from the post infusion hour until 24 hours after infusion. Twenty-six patients [male 16 (61.50%); female 10 (38.50%)] between 34 to 86 years of age were enrolled in this study. Total NIHS score reduced from 10.77 (+5.01) at pre-treatment to 4.04 (+4.00) at 7 days. The improvement in NIHS score at two hours versus pre-treatment (p<0.001), at 24 hours versus 2 hours (p=0.002) and 7 days versus 24 hours (p<0.001) was statistically significant. Clinically no significant change was observed in the blood pressure of the patients till 24 hours after thrombolysis. At the end of 24 hours, 40% patients showed improved status and in 60% patients, status was unchanged. Intravenous alteplase is effective and safe treatment approach for treatment of acute ischemic stroke. No major complications were observed in this study.

P.159 Saskatchewan experience with mechanical thrombectomy under general anesthesia

Background: While mechanical thrombectomy (MT) has become broadly used, many nuances around its performance are still contentious. In particular, the optimal sedation strategy for MT is not clear in the literature. Methods: This study was a single-center retrospective cohort study of a prospectively collected database. Age, gender, pre-treatment NIH stroke score (NIHSS), Alberta stroke program early score CT (ASPECTS), quality of collateralization, whether the patient underwent thrombectomy, tandem carotid occlusion, and thrombolysis in cerebral infarction (TICI) score were recorded in the database. Results: We identified 228 patients having anterior circulation mechanical thrombectomy (MT). 91 were right-sided, 108 were left-sided. Collaterals were graded as good in 135 (71.4), moderate in 44 (23.2%), and poor in 10 (5.3%). The average pre-MT ASPECTS was 8.1 (range). We found significant differences between all patients, patients with good outcome (mRS 0-2) and death in age, baseline NIHSS, collateralization, and TICI revascularization score. Multivariate analysis was performed with showed significant associations of sidedness, collateralization, TICI score and hemorrhage with neurological outcome. Right-sided stroke, better collaterals, higher TICI score and absence of hemorrhage were associated with better outcomes. Conclusions: We found comparable outcomes to those reported in the literature with use of general anesthetic. We identify several factors that influence outcomes.

Safety and Efficacy of Tenecteplase in Older Patients With Large Vessel Occlusion: A Pooled Analysis of the EXTEND-IA TNK Trials.

Detailed study of tenecteplase (TNK) in patients older than 80 years is limited. The objective of our study was to assess the safety and efficacy of TNK at 0.25 and 0.40 mg/kg doses in patients older than 80 years with large vessel occlusion. We performed a pooled analysis of the EXTEND-IA TNK randomized controlled trials (n = 502). Patients were adults presenting with ischemic stroke due to occlusion of the intracranial internal carotid, middle cerebral, or basilar artery presenting within 4.5 hours of symptom onset. We compared the treatment effect of TNK 0.25 mg/kg, TNK 0.40 mg/kg, and alteplase 0.90 mg/kg, stratifying for patient age (>80 years). Outcomes evaluated include 90-day modified Rankin Scale (mRS) score, all-cause mortality, and symptomatic ICH. Treatment effect was adjusted for baseline NIH Stroke Score, age, and time from symptom onset to puncture via mixed effects proportional odds and logistic regression models. In patients >80 years (n = 137), TNK 0.25 mg/kg was associated with improved 90-day mRS (median 3 vs 4, adjusted common odds ratio (acOR) 2.70, 95% CI 1.23-5.94) and reduced mortality (acOR 0.34, 95% CI 0.13-0.91) vs 0.40 mg/kg. TNK 0.25 mg/kg was associated with improved 90-day mRS (median 3 vs 4, acOR 2.28, 95% CI 1.03-5.05) vs alteplase. No difference in 90-day mRS or mortality was detected between alteplase and TNK 0.40 mg/kg. Symptomatic ICH was observed in 4 patients treated with TNK 0.40 mg/kg, 1 patient treated with alteplase, and 0 patients treated with TNK 0.25 mg/kg. In patients ≤80 years, no differences in 90-day mRS, mortality, or symptomatic ICH were observed among TNK 0.25 mg/kg, alteplase, and TNK 0.40 mg/kg. TNK 0.25 mg/kg was associated with improved 90-day mRS and lower mortality in patients older than 80 years. No differences among the doses were observed in younger patients. NCT02388061, NCT03340493. This study provides Class II evidence that tenecteplase 0.25 mg/kg given before endovascular therapy in patients >80 years old with large vessel occlusion stroke is associated with better functional outcomes at 90 days and reduced mortality when compared to tenecteplase 0.40 mg/kg or alteplase 0.90 mg/kg.

Cervicocranial arterial dissection. Experience in 57 patients

Cervicocranial arterial dissection (CIAD) is an important cause of stroke. To describe the clinical and imaging characteristics of patients with CIAD. An anonymous registry was made including all patients admitted to a private hospital with a diagnosis of CIAD. Patients were subdivided as having an anterior or posterior circulation dissection (ACD or PCD, respectively). Fifty-seven patients aged 40 ± 8 years (60% women) were included in the study, 39 with PCD and 18 with ACD. Cervical pain was the most common symptom. CIAD was diagnosed with no clinical or imaging signs of stroke in 49% of patients. Fifty one percent of patients had focal neurological deficits and 72% had a NIH stroke score below five. No significant differences between patients with ACD or PCD were found. Fifty patients received antiplatelet therapy (simple or dual), seven patients were anticoagulated and 13 were subjected to stenting due to progression of stenosis with hemodynamic involvement or bilateral dissection with scarce collaterals. The lesion was located in V3 segment in 27 patients and cervical segment of the internal carotid in 16 cases. A favorable Modified Rankin Scale (0-2) was achieved in 85.9%, with a trend towards achieving better functional prognosis in PCD. Due to the greater availability of non-invasive imaging methods, 50% of these patients with CIAD did not have a stroke. Thus, an earlier and more timely management is feasible.

Safety and Efficacy of Low-Dose Tirofiban Combined With Intravenous Thrombolysis and Mechanical Thrombectomy in Acute Ischemic Stroke: A Matched-Control Analysis From a Nationwide Registry.

Purpose: Tirofiban administration to acute ischemic stroke patients undergoing mechanical thrombectomy with preceding intravenous thrombolysis remains controversial. The aim of the current study was to evaluate the safety and efficacy of low-dose tirofiban during mechanical thrombectomy in patients with preceding intravenous thrombolysis.Methods: Patients with acute ischemic stroke undergoing mechanical thrombectomy and preceding intravenous thrombolysis were derived from “ANGEL-ACT,” a multicenter, prospective registry study. The patients were dichotomized into tirofiban and non-tirofiban groups based on whether tirofiban was administered. Propensity score matching was used to minimize case bias. The primary safety endpoint was symptomatic intracerebral hemorrhage (sICH), defined as an intracerebral hemorrhage (ICH) associated with clinical deterioration as determined by the Heidelberg Bleeding Classification. All ICHs and hemorrhage types were recorded. Clinical outcomes included successful recanalization, dramatic clinical improvement, functional independence, and mortality at the 3-month follow-up timepoint. Successful recanalization was defined as a modified Thrombolysis in Cerebral Ischemia score of 2b or 3. Dramatic clinical improvement at 24 h was defined as a reduction in NIH stroke score of ≥10 points compared with admission, or a score ≤1. Functional independence was defined as a Modified Rankin Scale (mRS) score of 0–2 at 3-months.Results: The study included 201 patients, 81 in the tirofiban group and 120 in the non-tirofiban group, and each group included 68 patients after propensity score matching. Of the 201 patients, 52 (25.9%) suffered ICH, 15 (7.5%) suffered sICH, and 18 (9.0%) died within 3-months. The median mRS was 3 (0–4), 99 (49.3%) achieved functional independence. There were no statistically significant differences in safety outcomes, efficacy outcomes on successful recanalization, dramatic clinical improvement, or 3-month mRS between the tirofiban and non-tirofiban groups (all p > 0.05). Similar results were obtained after propensity score matching.Conclusion: In acute ischemic stroke patients who underwent mechanical thrombectomy and preceding intravenous thrombolysis, low-dose tirofiban was not associated with increased risk of sICH or ICH. Further randomized clinical trials are needed to confirm the effects of tirofiban in patients undergoing bridging therapy.

Abstract P510: Ct Angiographic Radiomics Signature Predicts Functional Outcome Following Endovascular Thrombectomy in Large Vessel Occlusion Stroke

Purpose: Endovascular thrombectomy (ET) is the standard of care in large vessel occlusion (LVO) stroke, with CTA and CT/MR perfusion guiding patient selection. We hypothesized that radiomics imaging features extracted from admission CTAs could predict post-ET outcome. Methods: We included patients with anterior circulation LVO who had ET at our institute, 01/2013–12/2019. We extracted 1116 radiomics features from each MCA supply territory. We applied and evaluated a framework of 6 feature selection techniques and 6 machine-learning classifiers for prediction of discharge and 3-month follow-up outcome, defined as favorable (modified Rankin score, mRS≤2) vs poor (mRS>2). Post-ET reperfusion success was determined by the modified thrombolysis in cerebral infarction (mTICI) scale. We used Bayesian optimization for hyperparameter tuning and performed 20 repetitions of 5-fold cross-validation, for which the average area under the receiver operating characteristic curve (AUC) across validation folds for each of our 36 feature-selection/machine-learning combinations was calculated. Results: 501 patients (228 male) were included, with mean age 70.3±15.5 years, median NIH stroke score 15 (interquartile range=6–24), and occlusions in ICA (n=123), M1 (n=318), and/or M2 (n=154). Functional outcome was available for 496 patients at discharge and for 375 at 3-months. Best performing models combining NIHSS, age, gender, IV thrombolytic treatment, and post-ET mTICI achieved an average AUC of 0.82±0.05, while models trained on radiomics and mTICI achieved an AUC of 0.71±0.05. Conclusion: The combination of automatically extracted CTA radiomics features and post-ET reperfusion success (mTICI) can predict LVO stroke functional outcome – even without baseline clinical variables. Such models may guide treatment decisions by predicting outcome for various degrees of post-ET reperfusion and automating assessment of baseline stroke CTA scans.

Abstract P311: Outpatient Evaluation of Transient Ischemic Attack and Minor, Non-Disabling Stroke During the COVID-19 Pandemic

Introduction: Reductions in hospital visits for stroke have been seen during the COVID-19 pandemic, partly reflecting perceived risks of in-hospital care. We recently implemented an evidence-based protocol for outpatient rapid evaluation of transient and minor, non-disabling stroke symptoms for patients seeking care 24 hours after symptom onset. We present our early experience through the pandemic. Methods: We conducted a retrospective review of patients evaluated in the RESCUE-TIA ( R apid E valuation of minor S troke and C erebrovasc U lar E vents including TIA ) clinic from December 2019-August 2020. The clinic sees patients with TIA symptoms or with fixed, non-disabling deficits seeking care > 24 hours after symptom onset. We introduced telemedicine in March 2020. Magnetic resonance brain and vascular imaging is available within 24 hours of visit. We summarized patient characteristics and quality data with standard descriptive statistics. Results: A total of 21 patients were seen in the RESCUE-TIA clinic, including 15 patients during the height of the pandemic in NY; 67% were seen by telemedicine. The median age was 75 years (interquartile range [IQR], 61-82), and 71% were women. The median NIH Stroke Score for patients with minor stroke was 0 (IQR, 0-1), and the median ABCD 2 score for TIA patients was 3 (IQR, 2-3). Median time from symptom onset to evaluation was 3 days (IQR, 2.5-17.5). Median time from evaluation to laboratory diagnostics was 8 hours (IQR, 2-21), and to completion of imaging was 1 day (IQR, 0-5). Outpatient telemetry commenced in a median of 5 days (IQR, 1-9), and echocardiography was completed in a median of 8 days (IQR, 0-10). One patient was referred to the emergency room for a carotid occlusion. Final diagnoses were TIA (n=12), ischemic stroke (n=5), transient global amnesia (n=2), migraine (n=1), and non-aneurysmal, distal subarachnoid hemorrhage (n=1). Secondary prevention was initiated or optimized in 94% of TIA and stroke patients. Recurrent TIA occurred in 1 patient after 67 days, and ischemic stroke occurred in 1 patient 55 days after TIA. Conclusion: Timely outpatient evaluation of patients with recent TIA and minor, non-disabling stroke is feasible and may be useful during the pandemic, especially during emergency room crowding.

Association of Blood Pressure and Cognition after Stroke

Background and Aim: It is unclear whether blood pressure (BP) is associated with cognition after stroke. We examined associations between systolic and diastolic BP (SBP, DBP), pulse pressure (PP), mean arterial pressure (MAP), and cognition, each measured 90 days after stroke. Methods: Cross-sectional analysis of prospectively obtained data of 432 dementia-free subjects greater than or equal to 45 (median age, 66; 45% female) with stroke (92% ischemic; median NIH stroke score, 3 [IQR, 2-6]) from the population-based Brain Attack Surveillance in Corpus Christi (BASIC) project in 2011-2013. Primary outcome: Modified Mini-Mental Status Examination (3MSE; range, 0-100). Secondary outcomes: Animal Fluency Test (AFT; range, 0-10) and Trail Making Tests A and B (number of correct items [range, 0-25]/completion time [Trails A: 0-180 seconds; Trails B: 0-300 second]). Linear or tobit regression adjusted associations for age, education, and race/ethnicity as well as variables significantly associated with BP and cognition. Results: Higher SBP, lower DBP, higher PP, and lower MAP each were associated with worse cognitive performance for all 4 tests (all P < .001). After adjusting for patient factors, no BP measures were associated with any of the 4 tests (all P > .05). Lower cognitive performance was associated with older age, less education, Mexican American ethnicity, diabetes, higher stroke severity, more depressive symptoms, and lower BMI. Among survivors with hypertension, anti-hypertensive medication use 90 days after stroke was significantly associated with higher AFT scores (P = .02) but not other tests (P > .15). Conclusions: Stroke survivors’ BP levels were not associated with cognitive performance at 90 days independent of sociodemographic and clinical factors.

Abstract P258: Factors Associated With Imaging Choice of Acute Ischemic Stroke Patients and the Related Health Outcomes

Introduction: Acute ischemic stroke (AIS) presents an ongoing challenge for population health and availability of healthcare resources. Imaging plays a critical role in both diagnosis and treatment decisions in AIS, but optimal utilization regarding advanced imaging with angiography and perfusion using either CTAP or MRAP remain uncertain according to national guidelines. Consequently, wide variation in AIS imaging exists in clinical practice, mostly defaulted to physician preferences and institutional factors, without a clear understanding of the benefits and risks involved in stroke care. Although CTAP and MRAP each have unique benefits and risks in the AIS setting, the effect of this risk-benefit tradeoff on health outcomes and utilization of resources is unknown. This study analyses the factors associated with imaging preferences and the related health outcomes. Method: We performed a retrospective study on an AIS registry consisting of consecutive patients admitted to our institution from November 1, 2011, through October 1, 2018. Imaging and treatment selections and modified Rankin Score (mRS) at discharge were the main outcomes. Independent variables include age, gender, race-ethnicity, and NIH stroke score (NIHSS) at admission. Multivariable logistic regression models were performed. P&lt;0.05 was considered statistically significant. Results: 1884 patients with curated imaging data during hospitalization were included. Among them, 32% were ≥80 years old, 47.4% female, 15.53% black, 60.3% white, and 24.4% with NIHSS≥10 at admission. CTAP and MRAP were performed in 21.1% and 72.2% patients, respectively. 46.1% received thrombolytics (IV-tPA), 1.3% had endovascular therapy (EVT), and 52.7% were not treated. The two clinical outcomes were independent functionality at discharge (mRS0-2) at 48.4%, and patients expired in hospital at 7.1%. Adjusted by all the factors, regression models showed that patients with NIHSS≥10 were more likely to receive CTAP (p&lt;0.0001, OR=3.39) and less likely to receive MRAP (p&lt;0.0001, OR=0.48); whereas age ≥80 was less likely to receive CTAP (p&lt;0.0001, OR=0.37) or MRAP (p&lt;0.0001, OR=0.37). NIHSS≥10 (p&lt;0.0001, OR=0.15) and IV-tPA (p=0.0006, OR=0.69) were negatively related to independent functionality at discharge, and MRAP (p&lt;0.0001, OR=1.97) was positively related to it. NIHSS≥10 (p=0.0212, OR=1.69) were positively related to mortality, while utilization of MRAP showed a negative relationship (p&lt;0.0001, OR=0.26) with it. Conclusion: Higher NIHSS was positively associated with mortality and utilization of CTAP, while it is negatively associated with MRAP. MRAP was positively related to independent functionality at discharge. Older age was negatively associated with CTAP or MRAP utilization.

Abstract WP279: Evaluation of a Novel Point-of-care Neuromonitoring Device to Detect Large Vessel Occlusion in Suspected Acute Stroke Patients

Study Objectives: Several prehospital stroke scales have been developed to provide quick and accurate triage to facilitate timely treatment. This study evaluated a portable, experimental EEG device using AI as a tool for detection of acute stroke and large vessel occlusion (LVO) among patients with neurological deficits. Both device performance and feasibility in the emergent setting were assessed. Methods: This observational study enrolled a convenience sample of emergency department (ED) patients evaluated for suspected stroke within 24 hours of symptom onset. LVO and stroke status were determined by local neuroradiologists blinded to device output. LVO was defined as an acute occlusion of any of the following arteries: ICA/MCA-(M1 or M2)/vertebral/ basilar. Controls were neurologically normal subjects (NIHSS=0). Results: From May 2018 to July 2019, eight urban US stroke centers enrolled 89 subjects being evaluated for stroke. In suspected stroke subjects, 68 had stroke (76%) and 23 had LVO (26%). Mean (± SD) age was 68 (± 14), 36% were female, and the median (IQR) NIH stroke score was 6 (3 - 12) among suspected stroke subjects. The median last known well time was 327 minutes (196 - 577). Device performance for detecting LVO is shown in Table 1. There were no severe adverse events related to use of the device. Conclusion: The neuromonitoring device performed well in identifying LVO in patients presenting with suspected stroke. The performance of the neuromonitoring device in the acute setting indicates that it may be able to support prehospital decision making when triaging suspected stroke subjects. Additional studies with larger sample sizes are needed to validate this study’s findings.