NIHSS Score Improvement Research Articles

Presentation, Treatment and Outcomes of Acute Basilar Artery Occlusion: A Retrospective Analysis

IntroductionWe aim to assess the clinical presentation, treatment, and outcomes in patients with acute basilar artery occlusion (BAO) after receiving medical management (MM) (including IV thrombolysis, antiplatelet, anticoagulation) and endovascular therapy (EVT) (including intra-arterial thrombolysis, stent placement, mechanical thrombectomy). MethodsThis is a retrospective cohort study including all adult patients treated at three Mayo Clinic stroke centers with acute BAO from 2008 to 2021. Chart review was conducted to extract details of presentation, treatment, and outcome. Comparisons of treatment outcomes between patients treated with MM and EVT were analyzed and include changes of modified Rankin Scale (mRS) and NIHSS score change from admission to discharge. ResultsA total of 182 patients were included in our final analysis: 95 in the MM group and 87 in the EVT group. There was a statistically significant difference in favorable functional outcome at discharge (mRS 0-3) favoring the MM group compared to EVT group (56.0% vs 34.9%; OR 0.42, p=0.005) and the difference remained significant in multivariate analysis (OR 0.38, p=0.048). There were significantly increased odds of having NIHSS improvement of more than 5 points (OR 3.94 p<0.001), and 10 points (OR 3.92 p<0.001) in patients treated with EVT compared to MM. ConclusionOur data demonstrates that although in general patients who received EVT had lower odds of having favorable outcomes at discharge, they were also more likely to have NIHSS score improvement of more than 5 and 10 points from presentation to discharge compared to MM, suggesting EVT could be beneficial in some patients.

Abstract TP192: Combined Intra-Venous and Intra-Arterial Thrombolysis versus Intra-Venous Thrombolysis Alone in Stroke Patients Undergoing Mechanical Thrombectomy for Large Vessel Occlusion: A Propensity-Matched Analysis

Introduction: The combination of intravenous or intra-arterial thrombolysis with mechanical thrombectomy (MT) for acute ischemic stroke (AIS) has been thoroughly investigated. However, no study has explored the outcomes of combining both intravenous and intra-arterial thrombolysis with MT. Methods: Data from Stroke Thrombectomy and Aneurysm Registry (STAR) from 2013 to 2023 was utilized. We compared AIS patients with LVO who underwent MT with combined intra-venous and intra-arterial thrombolysis (IV+IA) and with intra-venous thrombolysis alone (IV). We performed propensity score (PS) matching between the two groups using age, sex, premorbid mRS, admission NIHSS, occluded vessel, ASPECTS score, time from symptoms onset to arterial puncture, and frontline technique. Primary outcomes were any intracranial hemorrhage (ICH) and symptomatic ICH (sICH). Secondary outcomes included successful recanalization (mTICI ≥2C), early neurological improvement (defined as 4 or more points improvement in NIHSS score in 24 hours), 90-day modified Rankin Scale (mRS) 0-2, mRS 0-1, and mortality. Results: A total of 2495 LVO-related AIS patients were included, consisting of the IA+IV group (n = 266) and the IV group (n = 2228). Propensity matching yielded 192 well-matched patients in each group. No significant differences were observed between the groups in either ICH or sICH (odds ratio [OR]: 0.96, 95% confidence interval [CI]: 0.61-1.52, p = 0.60; OR: 0.92, 95% CI: 0.42-2.03, p &gt; 0.90, respectively). The IA+IV group had a significantly lower proportion of successful recanalization (OR: 0.41, 95% CI: 0.27-0.62, p &lt; 0.001), and early neurological improvement (OR: 0.55, 95% CI: 0.30-1.00). However, 90-day mRS 0-2, mRS 0-1, and mortality rates showed no significant differences between the two groups. Conclusion: The findings of this study suggest that the combined use of IA and IV thrombolysis in AIS patients undergoing MT is safe. Although the IA+IV group demonstrated lower rates of recanalization and early neurological improvement, long-term functional outcomes and mortality rates were comparable to the IV-thrombolysis group, indicating a potential delayed benefit of additional IA thrombolysis therapy.

Abstract WP31: Real World Comparison of Outcomes of IV Tenecteplase versus IV Alteplase for Acute Ischemic Stroke

Background: Tenecteplase (TNK) has been reported to be non-inferior to alteplase from a clinical outcome and safety standpoint according to recent studies. In our study, we compare the outcomes of IV TNK &amp; IV alteplase for acute ischemic stroke patients. Materials and Methods: We evaluated acute AIS patients treated with IVT between10/2020-03/2023 at theDepartment of Neurology, Hackensack MeridianHealth, JFKMedical Center. All analyses was done using SPSS version 29 software. Results: Among the total 270 patients, 150(55.6%) received IV alteplase and 120(44.4%) received IV TNK. Major neurological improvement (defined as improvement in NIHSS score by 8 or more points at 24hours) was observed with TNK. Any intracranial hemorrhage was higher among patients treated with IV TNK compared to alteplase (25% versus 14.7%, p=0.024). Symptomatic intracranial hemorrhage(sICH) was higher inTNK group (8.3% versus3.3%, p=0.075). The proportion of routine discharge was higher among alteplase patients, while non-routine discharge was higher among TNK patients (51.7% vs. 28%, p&lt;0.001). In the logistic regression analysis, patients treated with IV TNK were at a significantly higher risk of any intracranial hemorrhage(odds ratio[OR], 1.93, 95% confidence interval [CI]1.051-3.57, p=0.034). After adjusting for age, gender, NIHSS, thrombectomy, hypertension, diabetes, hyperlipidemia, CHF, previous TIA and previous stroke, there was anon-significant higher rate of intracranial hemorrhage. A nonsignificant decrease in the odds of symptomatic intracranial hemorrhage (sICH) was seen with TNK. There were significantly higher rates of non-routine discharge (OR, 3.078, 95% CI 1.8-5.19, p&lt;0.001) and death (OR, 4.84, 95% CI1.20-19.66, p=0.002) inpatients treated with IV TNK. After adjusting for the above-mentioned factors, there was a significantly higher rate of non-routine discharge in the TNK group and a higher trend of death in the TNK group. Conclusions: We found that IV TNK was associated with higher rates of intracranial hemorrhage compared to IV alteplase in patients with acute ischemic stroke.

Meta-analysis of the efficacy and safety of Ginkgolide Meglumine Injection combined with Butylphthalide in the treatment of Acute Ischemic Stroke.

To evaluate the efficacy and safety of Ginkgolide Meglumine Injection (GMI) combined with Butylphthalide in the treatment of Acute Ischemic Stroke (AIS), and provide reference for rational clinical medication. PubMed, Embase, Web of science, CNKI, Wanfang, VIP and other databases were searched for published studies on the treatment of AIS with GMI combined with Butylphthalide in both Chinese and English. The search period was from the establishment of the database to July 2023. The included studies that met the inclusion criteria were analyzed using RevMan 5.3 software for Meta-analysis. A total of 25 studies involving 2362 patients (experimental group = 1182, control group = 1180) were included. The results of meta-analysis showed that the overall effective rate of the experimental group was significantly higher than that of the control group [RR = 1.21, 95% CI (1.16, 1.26), P< 0.00001]. In addition, compared with the control group, the experimental group showed significant improvement in NIHSS score [SMD = -1.59, % CI (-2.00-1.18), P< 0.00001] and ADL score [SMD = 2.12, 95% CI (1.52, -2.72), P<0.00001], significant decrease in CRP [SMD = -2.24, 95% CI (-3.31, -1.18), P<0.0001] and TNF-α [SMD = -2.74, 95% CI (-4.45, -1.03), P< 0.005] levels, and improvement in plasma viscosity [SMD = -0.86, 95% CI (-1.07, -0.66), P< 0.00001]. However, the influence on homocysteine level remains inconclusive. Furthermore, there was no significant difference in the incidence of adverse reactions between the two groups [SMD = 0.95, 95% CI (0.71, 1.28), P> 0.05]. GMI combined with Butylphthalide shows good clinical application effects and good safety in the treatment of AIS. However, more large-sample, multicenter, randomized controlled are needed to confirm these findings.

Predictive value of net water uptake with respect to early neurological improvement after endovascular treatment in patients with acute anterior circulation large vessel occlusion stroke

Objective: To investigate the value of net water uptake (NWU) for predicting early neurological improvement (ENI) after endovascular treatment in patients with acute anterior circulation large vessel occlusion stroke. Methods: A case-control study. A total of 132 patients (80 men, 52 women, median age 68 years) with acute anterior circulation large vessel occlusive stroke receiving endovascular treatment were retrospectively analyzed at Jinling Hospital from October 2014 to September 2019. Patients were divided into two groups based on the occurrence of ENI, which was defined as either an improvement of NIHSS score of ≥4 points, or an NIHSS score of 0 or 1 at 24 hours after endovascular treatment. The rank sum test, Chi square test, and other methods were used to compare differences in baseline characteristics between the two groups. Logistic regression analysis was used to investigate independent predictors of postoperative ENI. Receiver operating characteristic curve analysis used to assess the capacity of NWU to predict ENI. Results: Of the 132 patients in the study, ENI occurred in 47 and did not occur in 85. In multivariate logistic regression analysis age [odds ratio (OR)=0.940, 95% confidence interval (CI) 0.903-0.979, P=0.003], time from stroke onset to puncture (OR=0.995, 95%CI 0.991-0.999, P=0.025), time from puncture to recanalization/end of operation (OR=0.985, 95%CI 0.974-0.996, P=0.007), NWU (OR=0.762, 95%CI 0.620-0.937, P=0.010), and mTICI (OR=1.644, 95%CI 1.043-2.590, P=0.032) were predictive factors for ENI. Receiver operating characteristic curve analysis indicated that NWU could effectively predict ENI (area under the curve=0.642, 95%CI 0.543-0.741, P=0.007), and prediction accuracy was improved when it was combined with other clinical parameters. Conclusion: NWU is an independent predictor of ENI in patients with acute anterior circulation large vessel occlusive stroke undergoing endovascular treatment.

The Role of Citicoline in Neuroprotection and Neuro Repair in Acute Stroke

Objective: To determine the efficacy and safety of Citicoline in acute stroke.&#x0D; Study Design: Comparative cross-sectional study.&#x0D; Place of Study and Duration: Combined Military Hospital, Jhelum Pakistan, from Dec 2017 to May 2018.&#x0D; Methodology: Thirty patients with a new onset of stroke, either ischemic or hemorrhagic, were included in the study. This sample of the population was further categorized into four Groups based on the National Institute of Health Stroke Scale scoring system. Half of the patients were medicated with Citicoline and standard stroke treatment and were examined as cases. The rest of the patients were treated with standard stroke management alone and were examined as Controls. The baseline guidelines of the patients were assessed by the Canadian Neurological Stroke Scale. However, for ease of comparison, the CNSS was converted into the National Institute of Health Stoke Scale using the following formula: NIHSS=23-2xCNSS.&#x0D; Results: In our study, baseline improvement in NIHSS score was higher in the Citicoline Group than in the Control Group(68% in the case Group vs. 53% in the Control Group). There was a 30% drop in NIHSS score in Cases compared to the ControlGroup (p&gt;0.05).&#x0D; Conclusion: This study could not prove the effectiveness of Citicoline despite a favourable improvement in NIHSS score in cases. Though Citicoline is a well-tolerated and safe drug, it is ineffective in improving neurological outcomes in patients with acute stroke.

Tenecteplase to Replace Alteplase? Comparing Thrombolytic Therapies for Acute Ischemic Stroke: June 2023 Annals of Emergency Medicine Journal Club.

Tenecteplase to Replace Alteplase? Comparing Thrombolytic Therapies for Acute Ischemic Stroke: June 2023 Annals of Emergency Medicine Journal Club.

Abstract Number ‐ 277: Mobile Stroke Unit Direct to Angiosuite Process Metrics and Clinical Outcomes

Introduction Mobile Stroke Units (MSUs) speed treatment with tPA, but did not affect time from alert to puncture time for endovascular therapy (EVT) in the Benefits of Stroke Treatment Using a Mobile Stroke Unit (BEST‐MSU), a prospective multicenter controlled trial comparing MSU with standard EMS management. The lack of improvement in EVT treatment time could be because the CTA to identify large vessel occlusions (LVOs), and alerting of the EVT team, were delayed in most MSU patients until after Emergency Department (ED) arrival. The impact of identifying LVOs by imaging on the MSU enabling a direct (from MSU) to angiosuite (DTAS) protocol has yet to be studied. Methods We conducted a pre‐specified substudy of tPA‐eligible stroke patients with LVOs on computed tomography (CT) and/or CT angiography (CTA) who were enrolled into the MSU arm of the BEST‐MSU study. We compared alert to puncture time and other process metrics, mean utility‐weighted modified Rankin Scale (uw‐mRS) and functional independence (mRS 0–2) at 90 days, and rate of early neurologic recovery (30% improvement in NIHSS score) at 24 hours in patients who were managed by DTAS vs post‐ED arrival diagnosis and alerting. Results A total of 169 MSU patients with LVOs were identified; 22 in the DTAS group and 111 in the non DTAS group. Data were not available for 36 LVO patients. Baseline characteristics including age, sex, ethnicity, prestroke mRS, and initial NIHSS were comparable between the groups. 100.0% of patients in the DTAS group vs 90.1% in the non DTAS received tPA (p = 0.264). EVT was performed on 85.0% of patients in the DTAS group vs 77.1% in the non DTAS group (p = 0.634). DTAS group had a faster alert to puncture time (108.00 min [94.75,124.75.] vs 150.50 min [121.25, 179.00], p&lt; 0.001) and door to puncture time (37.00 min [25.50,62.75 vs 86.50 min [62.50,116.00], p&lt; 0.001). The mean score on the uw‐mRS at 90 days was 0.626 ±0.367 in the DTAS group and 0.660 ±0.382 in the non DTAS group and after adjustment for age, baseline NIHSS, premorbid functional status, prior stroke/TIA and site, no significant difference was observed; (p = 0.54). In an unadjusted analysis, early neurologic recovery (72.7% vs 67.6%, (OR = 0.634, 95% CI [0.46,3.82]) and functional independence (50.0% vs 51.4%, p = 1.000) were comparable between DTAS and non DTAS patients. Patients in the DTAS group were less likely to receive general anesthesia (36.4% vs 71.2%, p = 0.004). Rates of recanalization (77.3% vs73,4%, p = 0.947) and post procedural PH‐2 hemorrhage (4.5% vs 0.9%, p = 0.746) were similar in the DTAS and non DTAS group respectively. Conclusions In tPA‐eligible LVO stroke patients, DTAS management resulted in shorter alert to puncture (42 minutes) and door to puncture times (50 minutes) with similar safety and clinical outcomes compared with non DTAS management. MSU DTAS represents an optimized pathway for LVO patients triaged and treated in the field.

AXS Vecta 0.071-0.074 Inch Aspiration Catheters for Mechanical Thrombectomy: Case Series and Literature Review.

Aspiration catheters are widely used for thrombectomy either alone or in combination with a stent-retriever, with a distal inner diameter and trackability keys to their success. In an illustrative case series, we report our clinical experience with AXS Vecta (Stryker Neurovascular, Fremont, CA, USA), available in both 0.071-inch and 0.074-inch distal inner diameters, including the first 2 Vecta 74 cases reported. A literature review on AXS Vecta is also provided. In our series, 9 thrombectomies were performed (Vecta 71: 2 M1, 5 M2 occlusions; Vecta 74: 1 M1 and 1 ICA-terminus occlusion). The AXS Vecta was successfully delivered to the target site in all cases. In 7 of 9 cases, the catheter was delivered over a Tenzing 7 delivery catheter (Route 92 Medical, San Mateo, CA, USA). For 2 of 9 combination approach cases, Vecta was delivered using the stent-retriever wire as a rail. The median improvement in NIHSS score during hospitalization was 9 (IQR 5-12). Successful mTICI 2C or 3 recanalization was achieved in 8 of 9 (89%) patients after a median 2 (IQR 1-2) passes. Our median groin-to-reperfusion time was 23 (IQR 12.5-32) minutes, with no procedural complications. Two previous clinical studies of a total of 29 patients treated with Vecta 71 reported successful mTICI 2b-3 recanalization in 89-90% of cases. The Median groin-to-reperfusion time was 30 minutes. Complications were seen in 2 of 29 (6.9%) cases (vessel perforation and/or intracerebral hemorrhage). These data support the efficacy, deliverability, and safety of AXS Vecta for mechanical thrombectomy.

OUTCOME OF INTRAVENOUS THROMBOLYSIS WITH TENECTEPLASE IN ACUTE ISCHEMIC STROKE.

Tenecteplase is a modied tissue plasminogen activator and newer thrombolytic agent. It has a longer half life ,which is more brin specic, produces less systemic depletion of circulating brinogen, and is more resistant to plasminogen activator inhibitor. Because of its pharmacodynamic properties which results in rapid reperfusion and lower intracranial hemorrhages. Hence the objective is to study the efcacy of tenectaplase in acute ischemic stroke including, neurological and functional outcome at 3 months which is assessed by mRS scale and also to know the complications arising out of thrombolysis with tenectaplase. This is Methods- prospective observational study of 40 cases of acute ischemic stroke undergoing thrombolysis with tenecteplase within 4.5 hours of onset. Dose of 0.2 mg /kg of tenecteplase was used for thrombolysis and outcome was evaluated with improvement in NIHSS score at arrival , 24 hrs, 1 week and at discharge, 1 and 3 month and mRS scale at 1 and 3 months. In our study, 67.5% (27 out of 40) patients met the primary clinical efcacy outc Result- ome by achieving an improvement in NIHSS score of 4 or more points at 24 h and 67% (27out of 40 patients) met the secondary clinical efcacy outcome by having an mRS scale of 0 or 1 at 3 months. Adverse events were noted in 7 patients (17.5%) of which 4 developed ICH and 3 patients showed poor clinical outcome. ConclusionTenecteplase appears to be a safe and effective agent for acute ischemic stroke because of signicant improvement in NIHSS , low disability rates were observed in the present study

Middle Cerebral Artery M2 Thrombectomy: Safety and Technical Considerations in the German Stroke Registry (GSR).

There is ongoing debate concerning the safety and efficacy of various mechanical thrombectomy (MT) approaches for M2 occlusions. We compared these for MT in M2 versus M1 occlusions. Subgroup analyses of different technical approaches within the M2 MT cohort were also performed. Patients were included from the German Stroke Registry (GSR), a multicenter registry of consecutive MT patients. Primary outcomes were reperfusion success events. Secondary outcomes were early clinical improvement (improvement in NIHSS score > 4) and independent survival at 90 days (mRS 0–2). Out of 3804 patients, 2689 presented with M1 (71%) and 1115 with isolated M2 occlusions (29%). The mean age was 76 (CI 65–82) and 77 (CI 66–83) years, respectively. Except for baseline NIHSS (15 (CI 10–18) vs. 11 (CI 6–16), p < 0.001) and ASPECTS (9 (CI 7–10) vs. 9 (CI 8–10, p < 0.001), baseline demographics were balanced. Apart from a more frequent use of dedicated small vessel stent retrievers (svSR) in M2 (17.4% vs. 3.0; p < 0.001), intraprocedural aspects were balanced. There was no difference in ICH at 24 h (11%; p = 1.0), adverse events (14.4% vs. 18.1%; p = 0.63), clinical improvement (62.5% vs. 61.4 %; p = 0.57), mortality (26.9% vs. 22.9%; p = 0.23). In M2 MT, conventional stent retriever (cSR) achieved higher rates of mTICI3 (54.0% vs. 37.7–42.0%; p < 0.001), requiring more MT-maneuvers (7, CI 2–8) vs. 2 (CI 2–7)/(CI 2–2); p < 0.001) and without impact on efficacy and outcome. Real-life MT in M2 can be performed with equal safety and efficacy as in M1 occlusions. Different recanalization techniques including the use of svSR did not result in significant differences regarding safety, efficacy and outcome.

Abstract 24: Mobile Stroke Units Associated With Favorable Clinical Outcome In Large Vessel Occlusion Stroke Patients: BEST-MSU Substudy

Introduction: Mobile Stroke Units (MSUs) improve clinical outcome in patients treated with tPA compared to standard management by Emergency Medical Services (EMS), but the impact of MSUs on outcomes in patients with large vessel occlusions (LVOs) having endovascular thrombectomy (EVT) has yet to be determined. Methods: A pre-specified substudy of tPA-eligible stroke patients with LVOs on CT and/or CTA who were enrolled in the Benefits of Stroke Treatment Using a Mobile Stroke Unit (BEST-MSU), a prospective multicenter controlled trial comparing MSU with standard EMS management, was conducted. The primary outcome was the score on the 90-day utility-weighted modified Rankin Scale (uw-mRS). Secondary outcomes were rate of early neurologic recovery (30% improvement in NIHSS score) at 24 hours and functional independence (mRS 0-1) at 90 days. Results: A total of 295 patients were included, 169 in the MSU group and 126 in the EMS group. Baseline characteristics were comparable between the groups, with the exception of baseline NIHSS (MSU median 19.0 [IQR 13.0, 23.0] vs EMS 16.0 [11.0, 20.0], p=0.003). 92% MSU vs 87% EMS LVO patients received tPA, and 78% vs 85% went on to have EVT. MSU LVO patients had faster tPA bolus from symptom onset (65.0 min [50.5, 92.0] vs 96.0 [79.3, 130.0], p&lt;0.001), however the two groups had similar onset to groin puncture (169.0 min [133.8, 212.3] vs 162.0 [135.3, 207.0], p=0.77). The mean (±SD) score on the uw-mRS at 90 days was 0.64±0.39 in the MSU group and 0.50±0.40 in the EMS group (mean difference 0.16, 95% CI [0.07, 0.25] after adjustment for age, baseline NIHSS, premorbid functional status, prior stroke/TIA and site; p&lt;0.001). Early neurologic recovery (68% vs 52%; adjusted OR 1.89 95% CI [1.14,3.17]) and functional independence (Figure 1, 42% vs 29%; 2.48 [1.38,4.55]) also favored the MSU group. Conclusions: In tPA-eligible LVO stroke patients, MSU management was associated with better clinical outcomes compared with standard EMS management.

Clinical effect of intravascular interventional therapy in the treatment of acute ischemic stroke and its influence on cognitive function, cerebral hemodynamics and inflammatory factors.

Objectives:To evaluate the clinical effect of intravascular interventional therapy in the treatment of acute ischemic stroke and its influence on cognitive function, cerebral hemodynamics and inflammatory factors as well as its clinical significance.Methods:Eighty patients with acute ischemic stroke admitted to Tangxian people’s Hospital from January 2018 to January 2020 were randomly divided into two groups. Patients in the control group were treated with conventional thrombolytic therapy on the basis of basic treatment, while patients in the experimental group were given intravascular interventional treatment on the basis of conventional treatment. Clinical effect, recovery of cognitive function and activities of daily living, improvement of cerebral hemodynamics indexes, and changes of inflammatory factors before and after treatment were analyzed by combining NIHSS score and symptom improvement before and two months after treatment, respectively.Results:The effective rate of the experimental group was 82.5% after treatment, and that of the control group was 60%, with a statistically significant difference (P =0.02). Mini-mental State Examination (MMSE) and Barthel scores of the experimental group were significantly improved compared with those of the control group after treatment, with statistically significant differences between the two groups (P=0.00). The mean cerebral vascular blood flow (Qm) of the experimental group increased significantly after treatment compared with that of the control group, while vascular characteristic impedance (ZCV) and peripheral resistance (Rv) decreased significantly in the experimental, with a statistically significant difference (ZCV, P=0.01; Rv, P=0.05); After treatment, TNF- A, CRP, IL-6 and other indicators in the experimental group were significantly lower than those in the control group, with statistically significant differences (P=0.00).Conclusions:Intravascular interventional therapy is an effective treatment regimen for acute ischemic stroke boasting a variety of advantages over conventional thrombolysis, such as significant symptom improvement, high efficacy, favourable recovery of cognitive function and activities of daily living, improvement of cerebral hsemodynamic indicators, and significant reduction of inflammatory cytokine levels.

Clinical comprehensive evaluation of Danhong Injection in treatment of stroke with blood stasis syndrome

This study systematically reviewed the existing research on Danhong Injection in the treatment of stroke with blood stasis syndrome. The methods of evidence-based medicine, epidemiology, clinical medicine, evidence-based pharmacy, drug economics, mathematical statistics, and health technology assessment(HTA) were employed to qualitatively and quantitatively evaluate the &quot;6+1&quot; dimensions(safety, effectiveness, economy, innovation, suitability, accessibility, and characteristics of traditional Chinese medicine) of Danhong Injection through questionnaire survey, public information, real world data, and secondary evaluation of literature. With the weights given by experts, the multi-criteria decision analysis(MCDA) model was employed to measure each dimension and highlight the clinical value of Danhong Injection. Multi-source safety evidence showed that Danhong Injection had been fully monitored and studied. The severity of adverse reactions was mostly moderate or mild, and the prognosis was good. So it was rated as grade A for safety. Compared with Ligustrazine Injection, Fufang Danshen Injection and conventional treatment of western medicine, Danhong Injection had obvious advantages in clinical response rate and NIHSS score improvement in the treatment of stroke with blood stasis syndrome. So it was rated as grade A for effectiveness. Compared with Ligustrazine Injection and Yinxing Damo Injection, Danhong Injection had a cost-effectiveness advantage in the treatment of stroke with blood stasis syndrome, and the economic results were good. According to the existing evidence, the Danhong Injection was rated as grade B for economy. Danhong Injection had won a number of national patents, which was rated as grade A for its good innovation in guaranteeing supply measures, scalability of production capacity, and production process. It had good suitability for clinicians, nurses, pharmacists, and patients using the drug, and met the needs of clinical medication, so it was rated as grade B for suitability. Danhong Injection is rich in medicinal materials, stable in price, and sustainable. However, its availability needed to be further improved due to the limitation of prescription use, so it was rated as grade B for accessibility. Danhong Injection can promote blood circulation, resolve blood stasis, warm vessels, and smooth collaterals. It had accumulated more than 30 000 pieces of empirical evidence for human use in the real world. It had prominent characteristics of traditional Chinese medicine and was rated as grade B. CSC v2.0 was used for calculation, and the clinical value of Danhong Injection was comprehensively evaluated as class A, which could be directly translated into relevant policy results of basic clinical medication management according to the Guidelines for the Management Clinical Comprehensive Evaluation of Drugs(trial version 2021).

Influence of Socio-Economic Status on Patients’ Choice of Thrombolytic Agent and It's Outcome in Acute Ischemic Stroke

Background and Purpose: Alteplase, a recombinant tissue-type plasminogen activator(rtPA) is the only FDA-approved thrombolytic drug in acute ischemic stroke(AIS). Tenecteplase is a modified rtPA which is cheaper. We aimed to study role of Socio-economic status(SES) in patients’ preference of thrombolytic agent and its outcome. Methods: This prospective observational study conducted in PGIMER, a tertiary care center in India, recruited AIS patients thrombolysed between July 2017 and September 2018. We studied variables including SES, thrombolytic agent chosen and outcomes like NIHSS scores at 24 hours and at discharge; and modified Rankin Scale(mRS) after 3months. Results: 39 patients received tenecteplase and 39 patients received alteplase. 7 patients belonged to upper class, all of whom(100%) chose alteplase. 30 patients belonged to upper middle class, of whom 25(83.3%) and 5(16.7%) patients chose alteplase and tenecteplase respectively. 25 patients belonged to lower middle class in which 7(28%) and 15(72%) chose alteplase and tenecteplase respectively. 20 patients were in upper lower class, of whom 4(20%) and 16(80%) chose alteplase and tenecteplase respectively. The difference in distribution of SES in tenecteplase and alteplase groups was significant(p=0.000). Median 3month-mRS scores were 3 and 3.5 in alteplase and tenecteplase groups respectively(p=0.608). There were no significant differences in NIHSS score improvement at 24 hours post-thrombolysis(p=0.537) or at discharge(p=0.429) among different SES categories. No correlation between SES and 3month-mRS score was found(Spearman’s rho=0.101, p=0.398). Conclusions: Majority of patients in upper and lower SES chose alteplase and tenecteplase respectively. However, there were no significant differences in outcomes among various SES categories. Funding: None to declare. Declaration of Interest: None to declare. Ethical Approval: Ethical clearance was obtained from institution’s Ethics committee.

Additional factors to corelate with a more than 30% NIHSS score improvement in patients 7\u2009days after fibrinolytic and/or endovascular treatment for ischemic stroke

BackgroundOur objective was to find which additional factors can influence the favorable result in stroke patients after receiving fibrinolytic and/or endovascular treatment, quantified as a more than 30% improvement of the NIHSS score at 7 days.MethodsThis is a retrospective study to find factors that could influence a favorable evolution of patients with stroke that underwent fibrinolytic and or thrombectomy using the NIHSS score changes. At the admission in the hospital, blood glucose, blood count, coagulation time, INR, aPTT, PT, platelet count, NIHSS questionnaire and ASPECTS score were collected. NIHSS was assessed at the admission, after 1 h, after 2 h, after 24 h and after 7 days.ResultsAs compared to the initial evaluation, at 7 days after admission 59% (72) of patients have improved with more than 30% the NIHSS. Higher levels of systolic blood pressure, glycemia and lower ASPECTS score at admission were observed in non-achievers. The value of INR contributed to model: for every unit increase of INR, the chance of better outcome decreases by 90,1%. High glycemia has also a negative impact: for every unit increase, the chance of better outcome decreases by 24%. Higher initial ASPECTS score is associated with better outcomes: each point increase of ASPECTS score at initial evaluation, increases the chance of better outcome by 154.2%.ConclusionMales, older age, diabetes, and hyperglycemia correlate with a worse outcome after cerebral stroke regardless of the benefit yielded fibrinolytic and/or thrombectomy therapy. In this study, patients with the above-mentioned factors did not improve more than 30% of baseline NIHSS score from admission to the 7th day.

Abstract TP248: Reduced Door-in-Door-Out Time Increases the Likelihood of Endovascular Thrombectomy for Large Vessel Occlusion Patients

Introduction: Endovascular thrombectomy (EVT) is recommended for patients with large vessel occlusion (LVO) presenting within 24 hours of last seen well (LSW). Unfortunately, patients transferred from spoke hospitals to receive EVT have poorer outcomes compared to those presenting directly to the hub, underscoring the importance of rapid transfer timing - door-in-door-out (DIDO). Methods: Data were analyzed from consecutive acute ischemic stroke patients with proximal large vessel occlusions (LVO) transferred to our comprehensive stroke center for EVT. The following variable were studied: DIDO, baseline NIHSS/mRS, presentation CT ASPECTs, site of LVO, treatment, and clinical outcome. Results: Ninety patients with internal carotid or middle cerebral artery (M1) occlusion at the spoke hospital were included in the study. At the hub hospital, 75% (68) underwent emergent cerebral angiography (DSA) with intent to perform EVT. Reasons for not undergoing angiography at hub hospital included large stroke burden (59%) and improvement in NIHSS score (41%). Overall, DIDO time was 184 (130-285) minutes. Mean DIDO time was significantly lower for patients who underwent DSA at hub hospital compared to patients who did not (207 versus 272 minutes, p=0.031). 92% (12) of patients with DIDO &lt;=120 minutes (n=13) underwent EVT compared to 73% (56) of patients with DIDO &gt;120 minutes (n=77). Every 30-minute delay after 120 minutes lead to a 6% reduction in the likelihood of EVT. Lower DIDO time [OR-0.92 (0.9-0.96), p=0.04] and higher ASPECTS score [OR-1.4 (1.1-1.9), p=0.013] at spoke hospital are predictors of EVT at hub hospital. Conclusion: Reduced DIDO times are associated with higher likelihood of receiving EVT. DIDO should be treated on par as in-hospital time metrics and methods should be in place to optimize transfer times.

Abstract TP93: Rapid and Appropriate Evaluation of Collateral Development by Four-Dimensional CT Angiography Covering Only 4-cm Width With a Focus on the Intracranial Internal Carotid Artery and the Middle Cerebral Artery to Identify Candidates of Thrombectomy

Introduction: Four-dimensional computed tomography (CT) angiography (4D-CTA) can visualize time sequential changes of bilateral internal carotid (ICA) and middle cerebral arteries (MCA). Therefore, 4D-CTA could find ICA or MCA occlusion and visualize collateral circulation in case of intracranial artery occlusion. Hypothesis: Four-dimensional CTA covering only 4-cm width with a focus on the intracranial ICA and the MCA can early visualize them because of small volumetric data and evaluate collateral development status to identify candidates of thrombectomy. Methods: We included acute ischemic stroke patients who 1) were admitted from August 2018 to July 2019 due to ICA or MCA occlusion, 2) underwent 4D-CTA covering only 4-cm width on admission and 3) underwent endovascular thrombectomy. We classified collateral status into good, moderate and poor collateral according to opacification of M2 and M3 branches distal to occlusion and evaluated successful recanalization of thrombolysis in cerebral infarction (TICI) grade 2b or 3 and improvement of NIHSS score 7 days after thrombectomy. Results: During the study period, 337 acute ischemic stroke patients were admitted, 92 patients suffered from ICA or MCA occlusion and 23 patients met our inclusive criteria. Median age was 81 years and median ASPECTS was 10. Image reconstruction time of 1,000 images was only 69 seconds and 4D-CTA with only 4-cm width demonstrated MCA occlusion in 14 patients, IC occlusion in 9 patients and collateral status as good in 4 patients, moderate in 13 patients and poor in 6 patients. Median onset-to-recanalization time was 5.2 hours, successful recanalization was achieved in 21 patients (91.3%), median NIHSS score on admission was 20, median 7-day NIHSS score decreased to 6 (p&lt;0.0001) and median decrease of NIHSS score was 13. Two patients without successful recanalization had no early improvement of NIHSS score, whereas 20 of 21 patients with successful recanalization obtained early neurological improvement. Conclusion: Four-dimensional CTA with only 4-cm width rapidly and appropriately evaluated collateral status to identify candidates of thrombectomy for ICA or MCA occlusion and achieved early neurological improvement following successful recanalization.

Microstructural Integrity of Salvaged Penumbra after Mechanical Thrombectomy.

There are sparse data on the microstructural integrity of salvaged penumbral tissue after mechanical thrombectomy of large-vessel occlusions. The aim of the study was to analyze possible microstructural alteration in the penumbra and their association with clinical symptoms as well as angiographic reperfusion success in patients undergoing mechanical thrombectomy. All patients who underwent mechanical thrombectomy for large-vessel occlusions in the anterior circulation and who received an admission CT perfusion together with postinterventional DTIs were included (n = 65). Angiographic reperfusion success by means of modified Thrombolysis in Cerebral Infarction (mTICI) scale and clinical outcome were recorded. Microstructural integrity was assessed by DTI evaluating the mean diffusivity index within the salvaged gray matter of the former penumbra. The mean diffusivity index was higher in completely recanalized patients (mTICI 3: -0.001 ± 0.034 versus mTICI <3: -0.030 ± 0.055, P = .03). There was a positive correlation between the mean diffusivity index and NIHSS score improvement (r = 0.49, P = .003) and the mean diffusivity index was associated with midterm functional outcome (r = -0.37, P = .04) after adjustment for confounders. In mediation analysis, the mean diffusivity index and infarction growth mediated the association between reperfusion success and clinical outcomes. The macroscopic salvaged penumbra included areas of microstructural integrity changes, most likely related to the initial hypoperfusion. These abnormalities were found early after mechanical thrombectomy, were dependent on angiographic results, and correlated with the clinical outcome. When confirmed, these findings prompt the evaluation of therapies for protection of the penumbral tissue integrity.

087 Endovascular clot retrieval (ECR) in the elderly. For better or worse in the real world?

IntroductionAcross multicentre trials ECR is safe and effective in octogenarians. Despite RCT evidence elderly patients may be denied ECR due to perceived poor risk-benefit. We examine impact of age on ECR outcomes and outcomes in transcatheter aortic valve implantation (TAVI) cases (where stroke risk is high), in a real world setting.MethodsWe analysed 311 consecutive ECR cases between 2016 and 2019 in 10 year age bands for ECR outcomes including 90 day mRS and mortality. Impact of premorbid function (mRS), NIHSS, recorded co-morbidities, and aetiology was assessed. TAVI case outcomes were examined.ResultsThirty one percent of ECR outcome cases were over 79 years of age; 90 day mortality was 34%; 25% had a 90 day mRS 0–2. Early NIHSS improvement was 5. Ninety-day mortality and mRS 0–2 for 10–19 (n=3), 20–29 (n=2), 30–39 (n=4), 40–49 (n=23), 50–59 (n=27), 60–69 (n=69), 70–79 (n=84),80–89 (n=62) and 90–99 (n=11) years were 0 and 100%, 0 and 100%, 33 and 67%, 4 and 78%, 15 and 52%, 13 and 49%, 17 and 33%, 24 and 2% and 55 and 18%, respectively. There was 9% lost to follow-up.Six TAVI cases had a NIHSS of 8–20 and pre-morbid mRS&lt;3, four with mRS 0. Mean 24 hour NIHSS improvement was 8.ConclusionWithout age exclusions older patients had worse unadjusted outcomes. However, patients over 79 years had clinically important early improvement in NIHSS score and ninety day outcomes were comparable to favourable RCT data and TAVI patients also had early improvement.