Prestroke Modified Rankin Score Research Articles

Abstract TMP17: Predicting Neurosurgical Intervention After Intracerebral Hemorrhage (ICH) Transfer

This is a retrospective chart review to ascertain the rates of neurosurgical intervention following transfer of patients with non-traumatic intracerebral hemorrhage (ICH) to a Comprehensive Stroke Center (CSC) and characterize predictors of need for surgical intervention. Introduction: While neurosurgical intervention is required in a minority of cases, it has become standard practice for all ICH patients to be transferred to our tertiary care center, without consideration of additional factors. This creates significant burden and stress to patients and families as well as hospital resources. Hypothesis: We hypothesize that only a minority of ICH patients require neurosurgical intervention and that we will be able to identify predictors that will assist in identifying patients who are at risk for needing neurosurgical intervention. Methods: We retrospectively reviewed the EMR from all ICH patients transferred to a 700-bed CSC from 2020-2023. We collected: age, sex, pre-stroke modified Rankin score, ICH score, BP management, anticoagulant reversal, any neurosurgical intervention performed, length of stay (LOS), and 30-day mortality. The data was stored and analyzed in a secure online database. Results: Of the 420 completed charts, 55% of patients were male with an average age of 67.7 years. Only 14.25% (61/420) of all patients underwent neurosurgical intervention. Predictors for surgery included: age (average age of patients who underwent surgery was 61.2 years); size and location of the hematoma (the majority of patients who underwent surgery (58/61) had ICH volume >30cc, were subtentorial in location, or had IVH extension); higher ICH score (23.96% with ICH ≥2 vs. 6.67% with ICH 0-1); and lower GCS (41.5% GCS <12 vs. 9.8% GCS ≥ 12). Average hospital length of stay was 10.5 days. Mortality rate at 30-days was 24.5% overall and higher in patients who underwent neurosurgical intervention (32.8%). Conclusion: Only a small percentage of patients with ICH transferred to our CSC require neurosurgical intervention. There are many predictive factors allowing for a more thoughtful approach to better utilize health care resources. We recommend further studies to develop better strategies to triage these patients.

Prediction of acute cerebrovascular stroke disability using mSOAR score (Stroke subtype, Oxfordshire Community Stroke Project, age, mRS and NIHSS)

BackgroundStroke is among the most prevalent causes of disability. An easy reliable tool to predict stroke outcomes will help manage neurological and non-neurological events and rehabilitation. The modified SOAR (mSOAR) score, which includes stroke subtype, Oxfordshire Community Stroke Project (OCSP) classification, age, pre-stroke modified Rankin score (mRS), and National Institutes of Health Stroke Scale (NIHSS) is simple and easily calculated prognostic tool. The objective of this research was to test the ability of the mSOAR score to predict post-stroke disability as measured by mRS at discharge and 1 month after stroke onset.ResultsOne hundred stroke patients (aged ≥ 18 years) were included. All subjects underwent complete neurologic examination, non-contrast head computed tomography. OCSP classification, Stroke subtype, NIHSS, and mRS score on discharge and 1 month after stroke onset were assessed for all patients. The mSOAR score was significantly correlated with mRS on discharge, after 1 month of stroke, and with the length of hospital stay. mSOAR score had high sensitivity and specificity for predicting moderate-to-severe disability on discharge and after 1 month of stroke onset.ConclusionThe mSOAR is an excellent and accurate tool for predicting the severity of disability on discharge and 1-month post-stroke.

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 TP150: Outcome Of Patients With Lacunar Strokes In The Era Of Thrombectomy

Introduction: Endovascular treatment (EVT), in particular mechanical thrombectomy, has dramatically improved the clinical outcome of patients with large vessels occlusion (LVO) of the anterior circulation. In contrast, the benefits of EVT cannot be applied to lacunar strokes (LS). The absence of a LVO in LS has been historically associated with a more favorable outcome, but in the new era of EVT, this assumption may not be correct anymore. We aimed to test the general assumption that LS have a better prognosis than other stroke subtypes, and analyze the outcome of LS treated with IVT as compared to strokes with LVO treated with IVT and/or mechanical thrombectomy in the multicentric Swiss Stroke Registry. Methods: retrospective propensity score matching analysis of patients from the Swiss stroke registry (SSR) with lacunar stroke treated with thrombolysis versus LVO of the medial cerebral artery treated with EVT (with or without thrombolysis). Primary endpoint was a shift analysis of mRs at 90 days after stroke. Secondary outcomes were favorable functional outcome (mRS 0-1), independence (mRS 0-2), survival with high disability (mRS 3-5) and mortality (mRS 6) at 90 days. Results: From 13'227 patients, the propensity score method matched (sex, age, NIHSS, time to treatment, prior anticoagulation, pre-stroke modified Rankin Score, mRs) 538 patients (269 in each group. There was no difference between groups in mRs shift analysis at 90 days after stroke (OR=0.99, 95%CI=0.73-1.35, p=0.952). There was also no significant difference in mRS 0-1 (59.9% vs 55.8% respectively; OR=0.79, 95%CI=0.55-1.16, p=0.75). LS+IVT patients showed a non-significant trend towards mRS 3-5 (OR=1.23, 95%CI=0.78-1.94, p=0.38), while patients treated with EVT had a slightly, non-significant, higher mortality (6.3% vs 1.9%, p=0.38). Conclusions: Lacunar strokes - which cannot directly benefit from thrombectomy therapy - when treated with IVT and matched on key prognostic variables, seem to have similar outcomes as LVO strokes treated with EVT. This observation confirms that lacunar stroke is not a benign entity and therefore suggests that reperfusion therapy should be addressed with the same intensity as LVO stroke.

Time trends in stroke severity in the years 2005 to 2020: results from the Austrian Stroke Unit Registry

With aging population, there is an increase of atrial fibrillation (AF) and other vascular risk factors. We investigated trends in stroke severity at hospital admission with respect to AF and other risk factors in a prospective national stroke registry from 2005 to 2020. Data from the prospective Austrian Stroke Unit Registry were used to study demographic and clinical factors associated with the change in admission stroke severity over years. Time trends in admission stroke severity of patients with pre-stroke modified Rankin Score ≤ 3 were investigated with respect to clinical variables and predefined age groups 18-54, 55-64, 65-74, 75-84 and ≥ 85years. Time trends were studied using robust generalized linear models assuming normal distribution with a log link. Stroke severity on admission was assessed according to the National Institutes of Health Stroke Scale Score (NIHSS). In total, 140,312 patients with acute ischemic stroke were included in the analysis. Within the study period, mean patients' age increased from 70 to 72years (p < 0.001) and median NIHSS at admission decreased from 4 to 3 (p < 0.001). The frequency of AF increased from 25 to 32% (p < 0.001). The decrease in median admission NIHSS was evident in all relevant subgroups but more pronounced in patients with risk factors including AF, diabetes, hypercholesterolemia, smoking, elderly patients and those with pre-stroke disability. Despite an aging population and generally increasing AF frequency, we observed a consistent trend towards less disabling strokes on admission.

Estimated number of eligible patients for mechanical thrombectomy based on NIHSS and population-based Brest stroke registry

BackgroundSince 2015, mechanical thrombectomy (MT) is indicated as a treatment for patients with large vessel occlusion (LVO) at the acute phase of ischemic stroke. However, the number of stroke patients eligible for MT is poorly known. ObjectiveThe objective of our study was to estimate the number of patients eligible for thrombectomy within the first 24hours of an ischemic stroke, based on the clinical National Institute of Health Stroke Scale (NIHSS). MethodOur study concerned all ischemic strokes which occurred between January 2013 and December 2016 recorded in the population-based Brest Stroke Registry (BSR). Based on positive predictive value and negative predictive value from articles evaluating the performance of a defined NIHSS threshold to identify LVO, we first estimated the frequency of patients with LVO and then the frequency of patients eligible for MT depending on pre-stroke modified Rankin score (mRS). Our results were extrapolated to regions of metropolitan France. Two scenarios were considered: one called “stringent criteria” with mRS ≤1 and one called “real-life” criteria with mRS ≤2. ResultWe analyzed data from 2,025 ischemic strokes with symptom onset ≤24hours. No statistical difference between patient characteristics according to the time of hospital admission (≤6H vs. 6–24H) was observed. Based on NIHSS scores, between 23.90% and 44.20% of ischemic strokes admitted within the first six hours had LVO clinical characteristics. Among them, 14.53% to 26.87% met the ``stringent eligibility'' criteria for MT and 16.9 to 31.25% for ``real-life'' criteria. Eligible patients represented 6.32% to 11.70% of all ischemic strokes, irrespective of admission time. In France, 75 to 162 persons per million inhabitants per year were eligible for endovascular therapy, depending on including criteria. Based on activity levels recorded by the French Neuroradiology Society (SFNR) in 2018, the estimated needed increase in MT showed a heterogeneous pattern region-by-region, with the greatest need in Brittany, Pays de la Loire, and Corsica. ConclusionBased on NIHSS, our study provides coherent information concerning the estimated number of MT procedures to be performed in France: 4,877 to 10,494 ischemic strokes would be eligible each year in metropolitan France compared to the 6,596 thrombectomy procedures actually performed in 2018. Depending on the region, an estimated 10–20% to 90–100% increase in MT activity would be necessary to meet patient needs. These data suggest that there is still room for improvement in thrombectomy activity, particularly in certain regions of France, to allow equal access to MT to the entire French population.

Abstract WP199: Disparities In Post-stroke Evaluation And Treatment According To Pre-stroke Functional Status

Introduction: Stroke patients with a pre-existing disability are less likely to receive acute stroke treatments compared to those without a pre-existing disability. Using the Greater Cincinnati Northern Kentucky (GCNK) Stroke Study, we aimed to understand the disparities in inpatient and outpatient continuum of stroke care according to the patients’ pre-stroke functional status. Methods: We ascertained all hospitalized stroke patients ≥18 years old in year 2015 using ICD-9 430-436; ICD-10 I60-I67, G45-G46 within GCNK population; all cases were physician-reviewed. Per-stroke functional status was ascertained by trained research nurses during medical record review. We compared rates of in-hospital rehabilitative therapies, initiation of stroke prevention treatments, inpatient stroke workup (cardiac/vessel imaging), in-hospital and post-discharge rehabilitative therapies between ischemic stroke patients with pre-stroke modified Rankin score (mRS) 0-1 vs ≥2. Logistic regression was used to evaluate the association between pre-stroke mRS and these outcomes adjusting for age, presenting NIHSS, and insurance status. Results: Of 2476 patients with ischemic stroke in the GCNK population during 2015, 1326 (53%) had a pre-stroke mRS ≥2. Compared to those with pre-stroke mRS 0-1, these patients were less likely to receive complete stroke workup (aOR 0.86 [0.71-1.04]) and certain stroke prevention treatments (aOR 0.46[0.26-0.81], p&lt;0.01), but more likely to require in-hospital and post-discharge rehabilitative therapies (aOR 2.6[2.11-3.21] and 2.27[1.86-2.77], p&lt;0.01, respectively). Conclusions: Ischemic stroke patients with pre-stroke disability were less likely to receive complete in-hospital stroke workup and initiation of certain stroke preventive treatments. Further research into factors driving medical decision-making for stroke patients with a pre-stroke disability is urgently needed to ensure optimal continuum of stroke care.

Predicting 10-year stroke mortality: development and validation of a nomogram

Predicting long-term stroke mortality is a clinically important and unmet need. We aimed to develop and internally validate a 10-year ischaemic stroke mortality prediction score. In this UK cohort study, 10,366 patients with first-ever ischaemic stroke between January 2003 and December 2016 were followed up for a median (interquartile range) of 5.47 (2.96–9.15) years. A Cox proportional-hazards model was used to predict 10-year post-admission mortality. The predictors associated with 10-year mortality included age, sex, Oxfordshire Community Stroke Project classification, estimated glomerular filtration rate (eGFR), pre-stroke modified Rankin Score, admission haemoglobin, sodium, white blood cell count and comorbidities (atrial fibrillation, coronary heart disease, heart failure, cancer, hypertension, chronic obstructive pulmonary disease, liver disease and peripheral vascular disease). The model was internally validated using bootstrap resampling to assess optimism in discrimination and calibration. A nomogram was created to facilitate application of the score at the point of care. Mean age (SD) was 78.5 ± 10.9 years, 52% female. Most strokes were partial anterior circulation syndromes (38%). 10-year mortality predictors were: total anterior circulation stroke (hazard ratio, 95% confidence intervals) (2.87, 2.62–3.14), eGFR < 15 (1.97, 1.55–2.52), 1-year increment in age (1.04, 1.04–1.05), liver disease (1.50, 1.20–1.87), peripheral vascular disease (1.39, 1.23–1.57), cancers (1.37, 1.27–1.47), heart failure (1.24, 1.15–1.34), 1-point increment in pre-stroke mRS (1.20, 1.17–1.22), atrial fibrillation (1.17, 1.10–1.24), coronary heart disease (1.09, 1.02–1.16), chronic obstructive pulmonary disease (1.13, 1.03–1.25) and hypertension (0.77, 0.72–0.82). Upon internal validation, the optimism-adjusted c-statistic was 0.76 and calibration slope was 0.98. Our 10-year mortality model uses routinely collected point-of-care information. It is the first 10-year mortality score in stroke. While the model was internally validated, further external validation is also warranted.

Abstract P486: Mechanical Embolectomy Using a Novel Telescopic System Featuring a Specialized Delivery and 0.088” Aspiration Catheter for the Treatment of Acute Ischemic Stroke: Preliminary Results of the SUMMIT NZ Trial

Background: The treatment approach of aspiration rather than use of a stent retriever as first-line therapy is increasingly regarded as standard of care for acute ischemic stroke. Continued technological advances include the ongoing development of aspiration embolectomy catheters that are larger in bore, guided by delivery catheters that are more maneuverable through the tortuous neurovasculature. Methods: SUMMIT NZ (ACTRN12619000890134p) was designed as a prospective, single-arm, open label clinical trial at two sites in New Zealand. Eligible participants were patients presenting with acute ischemic stroke from either anterior or posterior circulation large-vessel occlusion within 24 hours of onset, a National Institutes of Health Stroke Scale Score ≥ 6 and a pre-stroke modified Rankin Score of ≤ 2. A novel tapered tip delivery catheter was specifically designed to deliver 0.070” and 0.088” aspiration catheters telescoped through a specialized 8F 90 cm introducer sheath (Route 92 Medical, Inc. San Mateo, CA). The primary effectiveness endpoint was arterial revascularization as measured by a modified Thrombosis in Cerebrovascular Infarction (mTICI) score of 2b or greater at the end of angiography after all endovascular treatments as adjudicated by an independent core laboratory. The primary safety endpoints were device-related peri-procedural complications such as dissection or perforation, symptomatic Intracranial Cerebral Hemorrhage (SICH) at 24 hours and embolization to a previously uninvolved territory. Results: From September 27, 2019 to June 23, 2020, 18 subjects (mean age 69.5, NIHSSS 15.2, time last known well 6.2 hours) were enrolled with a diagnosis of acute ischemic stroke. Acute occlusion was located in the middle cerebral artery (78%, 14/18) and internal carotid artery (22%, 4/18). Successful revascularization was achieved in 94% (17/18) of subjects. No serious adverse device effects have been reported. Conclusions: Preliminary findings suggest that aspiration first mechanical embolectomy using a novel telescoping system including an 0.088” inner diameter aspiration catheter achieves a high rate of arterial revascularization with an acceptable safety profile. A full report on enrollment and results are to be presented.

Life Support Limitations in Mechanically Ventilated Stroke Patients.

The determinants of decisions to limit life support (withholding or withdrawal) in ventilated stroke patients have been evaluated mainly for patients with intracranial hemorrhages. We aimed to evaluate the frequency of life support limitations in ventilated ischemic and hemorrhagic stroke patients compared with a nonbrain-injured population and to determine factors associated with such decisions. Multicenter prospective French observational study. Fourteen ICUs of the French OutcomeRea network. From 2005 to 2016, we included stroke patients and nonbrain-injured patients requiring invasive ventilation within 24 hours of ICU admission. None. We identified 373 stroke patients (ischemic, n = 167 [45%]; hemorrhagic, n = 206 [55%]) and 5,683 nonbrain-injured patients. Decisions to limit life support were taken in 41% of ischemic stroke cases (vs nonbrain-injured patients, subdistribution hazard ratio, 3.59 [95% CI, 2.78-4.65]) and in 33% of hemorrhagic stroke cases (vs nonbrain-injured patients, subdistribution hazard ratio, 3.9 [95% CI, 2.97-5.11]). Time from ICU admission to the first limitation was longer in ischemic than in hemorrhagic stroke (5 [3-9] vs 2 d [1-6] d; p < 0.01). Limitation of life support preceded ICU death in 70% of ischemic strokes and 45% of hemorrhagic strokes (p < 0.01). Life support limitations in ischemic stroke were increased by a vertebrobasilar location (vs anterior circulation, subdistribution hazard ratio, 1.61 [95% CI, 1.01-2.59]) and a prestroke modified Rankin score greater than 2 (2.38 [1.27-4.55]). In hemorrhagic stroke, an age greater than 70 years (2.29 [1.43-3.69]) and a Glasgow Coma Scale score less than 8 (2.15 [1.08-4.3]) were associated with an increased risk of limitation, whereas a higher nonneurologic admission Sequential Organ Failure Assessment score was associated with a reduced risk (per point, 0.89 [0.82-0.97]). In ventilated stroke patients, decisions to limit life support are more than three times more frequent than in nonbrain-injured patients, with different timing and associated risk factors between ischemic and hemorrhagic strokes.

Abstract WP217: A New Index for Multiple Chronic Conditions Predicts Post-Stroke Functional Outcome: A Machine Learning Approach in the Brain Attack Surveillance in Corpus Christi Project

Introduction: Multiple chronic conditions (MCC) diminish the pre-stroke reserve that aids post-stroke adaptation and recovery. Through machine learning, we developed a MCC index that integrates pre-stroke comorbid conditions, functional and cognitive factors, as well as their interactions, to predict post-stroke functional outcome (FO) in a bi-ethnic, population-based cohort study. Methods: Ischemic stroke patients (2008-2017) were interviewed at baseline and 90 days. FO score (range 1-4, higher scores worse) at 90 days was measured by averaging 22 activities of daily living (ADL)/instrumental activities of daily living (IADL) and dichotomizing the score into favorable (1-3) and unfavorable FO (&gt;3, a lot of difficulty with ADL/IADLs). Multiple linear regression was fit with a Lasso penalty to select predictors among 22 chronic conditions from ICD codes and medical records, pre-stroke function, cognitive impairment, social support, marital status, depression, age, initial stroke severity (NIHSS) and all pairwise interactions. We developed an MCC index by weighting selected predictors using β-coefficients. Adjusted R 2 , discrimination and calibration of the model were assessed. Results: Among 1,035 stroke survivors, 69% were Mexican American, 51% were female, mean age was 68 (SD=12), and median initial NIHSS was 4 (IQR:2-8). Median FO score was 2.36 (IQR:1.55-3.41); 32% had unfavorable FO. The final model contained the pre-stroke modified Rankin Score (mRS), initial NIHSS, age, congestive heart failure (CHF), weight loss, diabetes, other neurological disease, initial NIHSS х pre-stroke mRS, dementia х age, CHF х renal failure and pre-stroke mRS х history of stroke/TIA, which explained 44% of variability in FO score. The MCC index was well calibrated (p=0.28) and predicted unfavorable FO well (c-statistic, 0.84) in the internal validation dataset. Conclusion: A new MCC assessment tool was developed and validated to improve the prediction of post-stroke FO. Weight loss, other neurological disease and interactions between MCC were discovered as novel predictors. Efforts to improve stroke prognosis may benefit from a better understanding, prevention and management of MCC in population at high risk for stroke.

Anaemia and incidence of post stroke dementia

ObjectivesTo assess the impact of anaemia on incidence of post-stroke dementia. Patients and MethodsWe used data from a UK regional stroke register. To be eligible, patient must have survived to discharge and had anaemia by WHO criteria. Dementia status and other prevalent co-morbidities were assessed using ICD-10 codes. Patients were followed till May 2015 (mean follow-up 3.7 years, total person years = 27,769). Hazard Ratio for incident dementia was calculated using Cox-proportional hazards model controlling for potential confounders. Fine and Gray model was additionally constructed using mortality as the competing risk. ResultsA total of 7454 stroke patients were included with mean age SD of 75.912.3 years 50.2 % men). Those with anaemia were older, has higher disability and co-morbidity burden prior to stroke. We observed a large amount of variation in the dementia incidence rates over time and that the hazard ratio increased every year. The significant association between anaemia and dementia incidence was lost after controlling for pre-stroke Modified Rankin score (HR1.17(0.97,1.40)). With every 20 g/dL increase in Hb was associated with a significant reduction in the risk of dementia after adjustment for age, sex, stroke factors and disability but lost significance after adjustment for vascular risk factors. Competing risk analyses showed similar results. ConclusionWhilst we found no evidence of anaemia as a risk factor for post-stroke dementia, the findings may be limited by potential under recognition of post stroke dementia.

Temporal trends in intracerebral hemorrhage: Evidence from the Austrian Stroke Unit Registry.

BackgroundTo assess changes in frequency, severity, complications, therapy and outcome of intracerebral hemorrhage in patients treated in stroke units in Austria, we evaluated data from the Austrian Stroke Unit Registry between 2008 and 2016.Methods and findingsData of 6707 cases of ICH covering a time span of 9 years and including information on age, risk factors, pre-stroke modified Rankin Score (mRS), baseline stroke severity (NIHSS), complications, therapy, functional outcome, and mortality were extracted from the Austrian Stroke Unit Registry. A multivariate regularized logistic regression model and linear models for temporal dependence were computed for analyzing statistical inference and time trends. Bonferroni correction was applied to correct for multiple testing.Between 2008 and 2016, the proportion of ICH admissions to stroke units in Austria declined, with a shift among patients towards older age (>70 years, p = 0.04) and lower admission NIHSS scores. While no significant time trends in risk factors, pre-stroke mRS and medical complications were observed, therapeutic interventions declined significantly (p<0.001). Three-month mortality increased over the years independently (p = 0.003).ConclusionsDespite declining incidence and clinical severity of ICH we observed a clear increase in three-month mortality. This effect seems to be independent of predictors including age, admission NIHSS, pre-morbid MRS, or medical complications. The observations from this large retrospective database cohort study underline an urgent call for action in the therapy of ICH.

Hyperglycaemia and the SOAR stroke score in predicting mortality.

We assessed the association between admission blood glucose levels and acute stroke mortality and examined whether there was any incremental value of adding glucose status to the validated acute stroke mortality predictor - the SOAR (stroke subtype, Oxford Community Stroke Project classification, age, and pre-stroke modified Rankin) score. Data from Norfolk and Norwich University Hospital stroke and Transient Ischaemic Attack register (2003-2013) and Anglia Stroke Clinical Network Evaluation Study (2009-2012) were analysed. Multivariable logistic regression analysis assessed the association between admission blood glucose levels with inpatient and 7-day mortality. The prognostic ability of the SOAR score was then compared with the SOAR with glucose score. A total of 5575 acute stroke patients (ischaemic stroke: 89.2%) with mean age (standard deviation) of 76.97 ( ± 11.88 ) years were included. Both borderline hyperglycaemia (7.9-11.0 mmol/L) and hyperglycaemia (>11.0 mmol/L) when compared to normoglycaemia (4.0-7.8 mmol/L) were associated with both 7-day and inpatient mortality after controlling for sex, age, Oxford Community Stroke Project classification and pre-stroke modified Rankin score. Both the SOAR stroke score and SOAR-G score were good predictors of inpatient stroke mortality [area under the curve: 0.82 (95% confidence interval: 0.81-0.84) and 0.83 (95% confidence interval: 0.81-0.84)], respectively. These scores were also good at predicting outcomes in both patients with and without diabetes. High blood glucose levels at admission were associated with worse acute stroke mortality outcomes. The constituents of the SOAR stroke score were good at predicting mortality after stroke.

MSOAR: an effective bedside stroke prognosis tool

The modified-SOAR (mSOAR) score is composed of the stroke subtype, Oxfordshire Community Stroke Project classification, age, pre-stroke modified Rankin score (mRS) and the National Institutes of Health Stroke Scale score. It has previously been shown to be a reliable predictor of mortality and length of -hospital stay. This study sought to identify whether the mSOAR can also be used to predict patient disability on discharge. A post-hoc calculation of mSOAR using Sentinel Stroke National Audit Programme (SSNAP) data and electronic discharge -summaries was performed on all stroke admissions to Bridgend Hospital over an 11-month period. This study included 230 patients, of which 88% had suffered infarcts and 23% had experienced a previous cerebrovascular episode or transient ischaemic attack; 52% were female. The mortality rate was 13% and 57% had slight disability or less (mRS≤2) on discharge. Each increase in mSOAR score was associated with significantly worse discharge disability (p<0.05). We conclude that the mSOAR score is an excellent tool for predicting both discharge disability and mortality. As such, it's useful for admission prognosis discussions with patients, their relatives and the multidisciplinary team and for early supported discharge decision making.

Addition of sodium criterion to SOAR stroke score.

To examine the usefulness of including sodium (Na) levels as a criterion to the SOAR stroke score in predicting inpatient and 7-day mortality in stroke. Data from the Norfolk and Norwich University Hospital Stroke & TIA register (2003-2015) were analysed. Univariate and then multivariate models controlling for SOAR variables were used to assess the association between admission sodium levels and inpatient and 7-day mortality. The prognostic ability of the SOAR and SOAR Na scores for mortality outcomes at both time points were then compared using the Area Under the Curve (AUC) values from the Receiver Operating Characteristic curves. A total of 8493 cases were included (male=47.4%, mean (SD) 77.7 (11.6) years). Compared with normonatremia (135-145mmol/L), hypernatraemia (>145 mmol/L) was associated with inpatient mortality and moderate (125-129mmol/L) and severe hypontraemia (<125mmol/L) with 7-day mortality after adjustment for stroke type, Oxfordshire Community Stroke Project classification, age, prestroke modified Rankin score and sex. The SOAR and SOAR-Na scores both performed wellin predicting inpatient mortality with AUC values of .794 (.78-.81) and .796 (.78-.81), respectively. 7-day mortality showed similar results. Both scores were less predictive in those with chronic kidney disease (CKD) and more so in those with hypoglycaemia. The SOAR-Na did not perform considerably better than the SOAR stroke score. However, the performance of SOAR-Na in those with CKD and dysglycaemias requires further investigation.

Hyponatremia predicts mortality after stroke.

Hyponatremia, the commonest electrolyte imbalance encountered in clinical practice, is associated with adverse outcomes. Despite this, understanding of the association between hyponatremia and stroke mortality outcome is limited. To investigate the association between admission serum sodium and mortality at various time-points after stroke. Cases of acute stroke admitted to Norfolk and Norwich University Hospital consecutively from January 2003 until June 2013 were included, with mortality outcomes ascertained until the end of December 2013. Odds ratios or hazards ratios for death were constructed for various time-points (within seven-days, 8-30 days, within one-year, and over full follow-up). There were 8540 participants included (47·4% male, mean age 77·3 (±12·0) years). Point prevalence of hypernatremia and hyponatremia were 3·3% and 13·8%, respectively. In fully adjusted models controlling for age, gender, prestroke modified Rankin score, stroke type, Oxford community stroke project class, and laboratory biochemical and hematological results, the odds ratio (up to one-year)/hazards ratio (for full follow-up) for the above time-points were 1·00, 1·11, 1·03, 1·05 for mild hyponatremia; 1·97, 0·78, 1·11, 1·2 for moderate hyponatremia; 3·31, 1·57, 2·45, 1·67 for severe hyponatremia; and 0·47, 1·23, 1·30, 1·10 for hypernatremia. When stratified by age groups, outcomes were poorer in younger hyponatremic patients (aged <75 years). Hyponatremia is prevalent in acute stroke admissions and is independently associated with higher mortality in patients <75 years.

The SOAR stroke score predicts hospital length of stay in acute stroke: an external validation study.

The objective of this study is to externally validate the SOAR stroke score (Stroke subtype, Oxfordshire Community Stroke Project Classification, Age and prestroke modified Rankin score) in predicting hospital length of stay (LOS) following an admission for acute stroke. We conducted a multi-centre observational study in eight National Health Service hospital trusts in the Anglia Stroke & Heart Clinical Network between September 2008 and April 2011. The usefulness of the SOAR stroke score in predicting hospital LOS in the acute settings was examined for all stroke and then stratified by discharge status (discharged alive or died during the admission). A total of 3596 patients (mean age 77 years) with first-ever or recurrent stroke (92% ischaemic) were included. Increasing LOS was observed with increasing SOAR stroke score (p < 0.001 for both mean and median) and the SOAR stroke score of 0 had the shortest mean LOS (12 ± 20 days) while the SOAR stroke score of 6 had the longest mean LOS (26 ± 28 days). Among patients who were discharged alive, increasing SOAR stroke score had a significantly higher mean and median LOS (p < 0.001 for both mean and median) and the LOS peaked among patients with score value of 6 [mean (SD) 35 ± 31 days, median (IQR) 23 (14-48) days]. For patients who died as in-patient, there was no significant difference in mean or median LOS with increasing SOAR stroke score (p = 0.68 and p = 0.79, respectively). This external validation study confirms the usefulness of the SOAR stroke score in predicting LOS in patients with acute stroke especially in those who are likely to survive to discharge. This provides a simple prognostic score useful for clinicians, patients and service providers.

Abstract T MP85: Does Pre-Stroke Disability Affect Acute Evaluation, Treatment and Outcomes After Stroke?

Background: Pre-stroke disability is expected to influence outcome in stroke. Enrollment of clinical trials in stroke is frequently limited to patients with pre-stroke modified Rankin score (mRS) of ≤2. Our objective is to explore evaluation, treatment and outcomes in stroke patients with pre-stroke mRS 3-5. Methods: We included all patients from the acute stroke code database (UCSD SPOTRIAS from Mar 2005 - Jul 2013 with known pre-stroke mRS, baseline NIHSS and 90-day mRS and confirmed diagnoses: Acute ischemic stroke (AIS), transient ischemic attack (TIA), intracerebral hemorrhage (ICH). We assessed onset time to arrival, arrival time to- (CT, exam, treatment, decision) and outcomes (90-day mRS, discharge destination) by pre-stroke disability stratified by mRS (Group 1: mRS 3-5, Group 2: mRS 0-2). Good outcome was defined as discharge to home or acute rehab, or return to pre-stroke mRS or better. Results: A total of 572 patients with AIS (416, 73%), TIA (133, 23%), and ICH (23, 4%) were identified. Group 1patients with pre-stroke mRS 3-5 (69, 12%) were older (mean ± SD: 80 ±11 versus 68 ± 7 y, p&lt;0.001), mostly women (70% vs. 41%, p&lt;0.001), had history of hypertension (84% vs. 71%, p=0.029), prior cerebrovascular disease (43% vs. 28%, p=0.012), neuropsychiatric disease (23% vs. 6%, p&lt;0.001), other CNS disease (35% vs. 6%, p&lt;0.001), and higher baseline NIHSS (mean ± SD: 14.9 ± 9 vs. 6.4 ± 8, p&lt;0.001) compared to Group 2. Majority (61%) of Group 1 had a mRS score of 3 followed by mRS 4 (38%). There were no differences in onset to arrival, arrival time to- stroke code initiation, neuro exam, CT imaging, and treatment decision between groups. No difference in stroke patients eligible for IV thrombolysis (44% vs. 36%, p=0.23) or treated with IV r-tPA. Discharge to home or acute rehab was less frequent in ischemic stroke patients of Group 1 (44% vs. 77%, p&lt;0.001). However, patients returning to a pre-stroke mRS score or better at 90 days was not different between groups (40% vs. 47%, p=0.39). C onclusions: Using return to baseline as good outcome measure demonstrated patients with pre-stroke disability benefit from acute evaluation and treatment. Patients with pre-stroke moderate disability (mRS 3) may particularly be considered for inclusion in future clinical trials.

Abstract 2200: Altered Mental Status “Code Strokes” Rarely Result in Ischemic Diagnosis

Background: The clinical diagnosis of acute ischemic stroke remains challenging, especially with many diagnoses mimicking ischemia. Frequently, Code Stroke activations are initiated in patients who are found not to have focal brain ischemia. To better understand the frequency, diagnoses and outcomes of mimics, we analyzed our Code Stroke population for patients with altered mental status (AMS) but without focal neurological deficits. Methods: We analyzed all patients from the University of California San Diego (UCSD) Code Stroke database, in whom scoring of the entire NIHSS upon admission was available, from 2004 to 2010. Patients with AMS but without focal neurological deficit were defined by initial NIHSS score: On questions 1a or 1b or 1c: ≥ 1; and 5a=5b (motor arm) and 6a=6b (motor leg) and 9=0 (aphasia). The final diagnosis was based on Code Stroke review by a panel of cerebro-vascular subspecialty trained physicians. Univariate logistic regression was used to examine the association between outcomes (90 day mRS, discharge disposition and death) and age, gender, race, ethnicity, baseline NIHSS, pre-stroke modified Rankin score, prior stroke, hypertension and diabetes. Good outcome was defined at mRS (0-1) at 90 days. Good discharge disposition was defined as discharge home or to acute rehabilitation. Results: We identified 108 patients who met our inclusion criteria. Of those, 18 (17%) had a diagnosis of acute ischemic stroke, 10 (9%) TIA and 75 (69%) were categorized as other. Of those “other” patients, 14/75 (19%) were diagnosed with seizure post-ictal, 15 (20%) with toxic-metabolic encephalopathy, 6 (8%) somatization and 7 (9%) intoxication. Only 5/108 patients were treated with thrombolysis. Discharge dispositions were known in 107/108 (99%). 73/107 (68%) of all patients and 56 out of the 75 (75%) patients diagnosed with “other” had good outcomes. Only baseline NIHSS was associated with discharge disposition with p=0.0025. Conclusion: Only 1 in 4 (26%) Code Stroke patients that presented with AMS and no signs of focal neurological impairment were noted to have a cerebral ischemia diagnosis. Alteplase was rarely used (none in the non-ischemic patients) and most of the “other” non-ischemic patients (75%) had good discharge disposition and clinical outcome. In this cohort, most patients who presented with AMS but without lateralizing signs on their neurological exam were not diagnosed with acute ischemic event. Therefore perhaps more common etiologies should be explored prior to initiating a code stroke solely for the presentation of AMS.