Pre-stroke mRS Research Articles

Asymptomatic Intracranial Hemorrhage Is Associated With Poor Outcomes After Mechanical Thrombectomy for Large Vessel Occlusion

Asymptomatic Intracranial Hemorrhage Is Associated With Poor Outcomes After Mechanical Thrombectomy for Large Vessel Occlusion

Predictors and Outcomes of Salvaging the Corticospinal Tract After Thrombectomy in Basilar Artery Occlusion Stroke.

BackgroundRegional eloquence of brainstem structures may contribute to neurological status in basilar artery occlusion (BAO) stroke. The corticospinal tract (CST) which is vulnerable to BAO is important for motor activity. This study investigated the impact of CST salvage on outcomes and its associated factors in patients with BAO treated with thrombectomy.MethodsWe retrospectively investigated 88 patients with BAO admitted ≤24 h after onset and presented with motor deficits and who underwent thrombectomy. Patients with a pre-stroke modified Rankin Scale (mRS) score of 4–5 who did not undergo baseline brain computed tomography angiography were excluded. CST salvage was evaluated using follow-up imaging (magnetic resonance imaging [MRI] or computed tomography when MRI was not available) after thrombectomy. A good outcome was defined as a 3-month mRS score of ≤2 or 3 if a patient's pre-stroke mRS score was 3. The associations between CST salvage and outcomes and clinical parameters were analyzed using logistic regression analyses.ResultsThirty-nine (44.3%) patients had CST salvage and the same number of patients had good outcomes. CST salvage was independently associated with a good outcome [adjusted odds ratio (aOR): 18.52, 95% confidence interval (CI): 4.31–79.67, p < 0.001]. After adjusting for confounders, atrial fibrillation (aOR: 3.92, 95% CI: 1.18–13.00, p = 0.026), location of occlusion (mid-BAO; aOR: 0.21, 95% CI: 0.06–0.72, p = 0.013), length of occlusion (involved segment of BAO <2; aOR: 4.77, 95% CI: 1.30–17.59, p = 0.019), and onset-to-puncture-time ≤180 min (aOR: 4.84, 95% CI: 1.13–20.75, p = 0.034) were significantly associated with CST salvage.ConclusionCST salvage was associated with good functional outcomes in patients with BAO treated with thrombectomy. The presence of atrial fibrillation, location and length of BAO may predict CST salvage after thrombectomy, and rapid treatment with thrombectomy may protect this eloquent tract in these patients.

Full Reperfusion Without Functional Independence After Mechanical Thrombectomy in the Anterior Circulation

Background and PurposePrediction of futile recanalization (FR), i.e. failure of long-term functional independence despite full reperfusion in mechanical thrombectomy (MT), is instrumental in patients undergoing endovascular therapy.MethodsRetrospective single-center analysis of patients treated for anterior circulation LVO ensuing successful MT (mTICI 2c–3) between January 2014 and April 2019. FR was defined as modified Rankin Scale (mRS) 90 days after stroke onset > 2 or mRS > pre-stroke mRS. Multivariable analysis was performed with variables available before treatment initiation regarding their association with FR. Performance of the regression model was then compared with a model including parameters available after MT.ResultsSuccessful MT was experienced by 549/1146 patients in total. FR occurred in 262/549 (47.7%) patients. Independent predictors of FR were male sex, odds ratio (OR) with 95% confidence interval (CI) 1.98 (1.31–3.05, p 0.001), age (OR 1.05, CI 1.03–1.07, p < 0.001), NIHSS on admission (OR 1.10, CI 1.06–1.13, p < 0.001), pre-stroke mRS (OR 1.22, CI 1.03–1.46, p 0.025), neutrophile-lymphocyte ratio (OR 1.03, CI 1.00–1.06, p 0.022), baseline ASPECTS (OR 0.77, CI 0.68–0.88, p < 0.001), and absence of bridging i.v. lysis (OR 1.62, 1.09–2.42, p 0.016). The prediction model’s Area Under the Curve was 0.78 (CI 0.74–0.82) and increased with parameters available after MT to 0.86 (CI 0.83–0.89) with failure of early neurological improvement being the most important predictor of FR (OR 15.0, CI 7.2–33.8).ConclusionA variety of preinterventional factors may predict FR with substantial certainty, but the prediction model can still be improved by considering parameters only available after MT, in particular early neurological improvement.

Benefit of successful reperfusion achieved by endovascular thrombectomy for patients with ischemic stroke and moderate pre-stroke disability (mRS 3): results from the MR CLEAN Registry

BackgroundPre-stroke dependent patients (modified Rankin Scale score (mRS) ≥3) were excluded from most trials on endovascular treatment (EVT) for acute ischemic stroke (AIS) in the anterior circulation. Therefore, little evidence...

Successful thrombectomy is beneficial in patients with pre-stroke disability: Results from an international multicenter cohort study

BackgroundPatients with pre-stroke disability, defined as a modified Rankin Scale (mRS) ≥3, were excluded from most trials of endovascular thrombectomy (EVT) for acute stroke. We sought to evaluate the prognostic factors associated with favorable outcome in stroke patients with known disability undergoing EVT, and the impact of successful reperfusion. MethodsConsecutive acute stroke patients with pre-stroke disability, undergoing EVT, were retrospectively collected between 2016 to 2019 from a Canadian cohort and a multicenter French cohort (Endovascular Treatment in Ischemic Stroke registry-ETIS). Favorable outcome was defined as an mRS equal to pre-stroke mRS. Patients achieving successful reperfusion (defined as a modified Thrombolysis in Cerebral Infarction score of 2b/3) were compared with patients without successful reperfusion to determine if successful EVT was associated with better functional outcomes. ResultsAmong 6220 patients treated with EVT, 280 (4.5%) patients with a pre-stroke mRS ≥3 were included. Sixty-one patients (21.8%) had a favorable outcome and 146 (52.1%) died at 3 months. Patients with successful reperfusion had a higher proportion of favorable 90-day mRS (27.6% versus 19.6%, p = 0.025) and a lower mortality (48.3% versus 69.6%, p = 0.008) than patients without successful reperfusion. After adjusting for baseline prognostic factors, successful reperfusion defined by TICI ≥2b was associated with favorable functional outcome (OR 3.16 CI95% [1.11–11.5]; p 0.048). ConclusionIn patients with pre-stroke disability, successful reperfusion is associated with a greater proportion of favorable outcome and lower mortality.

Benefit from successful recanalization in an Italian cohort of stroke patients receiving endovascular treatments according to the DIRECT-MT trial criteria.

To identify predictors of 3-month mRS score and to estimate the benefit from successful recanalization across baseline subgroups of Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS) cohort of stroke patients receiving endovascular treatments according to the DIRECT-MT criteria. Using a model of propensity score matching, we retrospectively identified an IRETAS cohort of 137 patients receiving bridging who were matched with 137 patients receiving MT alone according to the DIRECT-MT criteria. Differences were found between DIRECT-MT and IRETAS cohorts for 3-month mRS score 0 to 1 (23.5% vs. 33.1%) and 0 to 2 (36.7% vs. 47.1%), successful (82% vs. 76.7%) and complete recanalization (32.3% vs. 58.8%). Among unfavorable predictors for 3-month mRS shift, diabetes mellitus (18.9% vs. 13.9%) and asymptomatic intracerebral hemorhage (ICH) (34.8% vs. 25.5%) were more frequent in the DIRECT-MT, whereas age ≥80 years (23.7% vs. 15.3%) and pre-stroke mRS score >0 (16.1% vs. 7.8%) were more frequent in the IRETAS.The direction of effect on the 3-month mRS shift (6 to 0) favored successful recanalization across all strata. Greatest benefit from successful recanalization was observed in patients with most severe strokes (NIHSS ≥20, OR:4.002; 16-19, OR:3.292; 2-5, OR:2.470) and most proximal occlusion site (intra-cranial ICA, OR:4.092; M1-MCA, OR:3.705; M2-MCA, OR:2.001), in younger patients (18-59 years, OR:3.677; 60-79, OR:3.267; ≥80, OR:1.993), and in patients who started the treatment earlier (onset-to-groin time ≤205 min, OR:4.361; onset-to-groin time >205, OR:2.326). The benefit from successful recanalization for 3-month mRS shift in the direction of favorable outcome was different across baseline subgroups.

Seeing the good in the bad: actual clinical outcome of thrombectomy stroke patients with formally unfavorable outcome.

PurposeClinical outcome of stroke patients is usually classified into favorable (modified Rankin scale (mRS) 0–2) and unfavorable (mRS 3–5) outcome according to the modified Rankin scale. We took a closer look at the clinical course of thrombectomy stroke patients with formal unfavorable outcome and assessed whether we could achieve our treatment goals and/or neurological improvement in these patients.MethodsWe studied 107 patients with occlusions in the terminal carotid artery or the M1 segment of the middle cerebral artery, in whom complete recanalization (eTICI 3) could be achieved, and who had an mRS of 3–5 at 90 days. We analyzed whether an individual treatment goal (i.e., preventing aphasia) and neurological improvement (NIHSS) could be achieved. In addition, we examined whether there was clinical improvement on the mRS.ResultsThe treatment goal was achieved in 52% (53/103) and neurological improvement in 65% (67/103). mRS 90 days post-stroke was better than mRS upon admission in 36% (38/107) and better than or equal to mRS upon admission in 80% (86/107). Of the 93 patients with known pre-stroke mRS, 18% (17/93) already had an mRS ≥ 3, with 15 of these 17 patients having a worse mRS on admission than before. Of these 17 patients, 18% regained baseline, and 24% improved from admission.ConclusionDichotomizing the mRS into favorable and unfavorable outcome does not do justice to the full spectrum of stroke. Patients with formal unfavorable outcome after mRS can improve neurologically, achieve treatment goals, and even regain their admission or pre-stroke mRS.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00234-022-02920-1.

Thrombectomy versus medical management for basilar artery occlusion with low-to-moderate symptoms (nihss

Patients with acute basilar artery occlusion (BAO) and mild symptoms are poorly represented in thrombectomy studies. The recent BASICS randomized controlled trial suggested that thrombectomy could be beneficial in patients with BAO and moderate or severe deficit (National Institute of Health Stroke Scale [NIHSS] greater than or equal To 10) but did not find any benefit of thrombectomy over best medical treatment (BMT) in patients with low-to-mild symptoms (NIHSS <10). To compare thrombectomy and BMT in patients with BAO and low-to-mild symptoms (NIHSS <10). Prospective non-randomized multicenter study of all consecutive patients presenting with an acute and symptomatic BAO (confirmed on noninvasive brain imaging) to 8 comprehensive stroke centers in France between January 2012 and May 2019. Patients with an initial NIHSS<10 were divided into groups received either BMT or BMT + thrombectomy.Adjustments were made using propensity-score analysis to compare both groups in terms of efficacy and safety outcomes. The main outcome was the proportion of patients achieving a favorable outcome (mRS 0-2 or equal to pre-stroke mRS) at three months follow-up. Secondary outcomes included the proportion of excellent clinical outcome (mRS 0-1 or equal to pre-stroke mRS), good clinical outcome (mRS 0-3 or equal to pre-stroke mRS) and the mortality rate at 3 months follow-up. Safety outcomes included hemorrhagic transformation at day 1 and mortality at 3 months. A total of 127 patients were included in the present study: 64 patients in the thrombectomy group and 63 patients in the BMT group. There was no difference between groups for the rate of favorable or good clinical outcome at 3 months, and rates of mortality were not significantly different. After propensity-score adjustment, thrombectomy was associated with a significantly higher chance of excellent outcome at 3 months (mRS 0-1 or equal to pre-stroke mRS) (adjusted OR, 2.68; 95%CI, 1.04 to 6.90; P=0.041). Among patients with a stroke secondary to BAO and low-to-mild symptoms (NIHSS<10), thrombectomy is associated with increased chances of having no symptom or disability at 3 months. Déclaration de liens d'intérêts Les auteurs n'ont pas transmis leur déclaration de liens d'intérêts.

Prognostic significance of age in patients with acute ischaemic stroke treated with intravenous thrombolysis

To assess the influence of age on long-term functional outcome in patients with acute ischaemic stroke (AIS) treated with intravenous thrombolysis (IVT). We performed retrospective analysis of 362 AIS patients treated with IVT or IVT and subsequent mechanical thrombectomy in the University Hospital in Krakow, Poland. Patients were categorised into four subgroups by age: (I) below the age of 60, (II) 60 to 69, (III) 70 to 79, and (IV) 80 or more. The outcomes were assessed with modified Rankin scale (mRS) 90 days after stroke onset, and defined as favourable (mRS 0-2), poor (mRS 3-5), or death (mRS = 6). Patients aged 80 or more compared to those below 60 were more often women (72.64% vs. 26.76%, < 0.001), more often suffered from hypertension (94.34% vs. 60.56%, p < 0.001), ischaemic heart disease (27.36% vs. 8.45%, p = 0.002), atrial fibrillation (49.06% vs. 5.63%, p < 0.001), and premorbid disability (pre-stroke mRS ≥ 1: 17.92% vs. 1.41%, p < 0.001), less often were active smokers (0% vs. 27.14%, p < 0.001), more often had cardioembolic aetiology (50.00% vs. 16.90%, p < 0.001), and less often other stroke aetiology (1.89% vs. 15.49%, < 0.008), had shorter time from stroke onset to IVT (125 [93-180] vs. 140 [110-186] min, p < 0.008), less often underwent mechanical thrombectomy (18.87% vs. 46.48%, p < 0.001), had higher CRP levels (10.3 [3.2-39.8] vs. 4.3 [2.1-9.6] mg/L, p = 0.003), higher maximal systolic blood pressure within 24 hours after IVT (153 [140-170] vs. 138 [120-145] mmHg, p < 0.001), and higher creatinine concentration (88 [68-108] vs. 77 [67-87] μmol/l, p = 0.004), less often had a favourable outcome (48.04% vs. 85.51%, odds ratio [OR] 0.16, 95%CI: 0.07-0.34, p < 0.001), and had a greater risk of death (26.47% vs. 5.80%, OR 5.85, 95%CI: 1.95-17.59, p < 0.001) within three months of stroke onset. Multivariable logistic regression analysis showed that the independent predictors of worse outcome in patients aged 80 or more were NIHSS score after IVT (OR 0.64, 95%CI: 0.53-0.78, p < 0.001), pre-stroke mRS score ≥ 1 (OR 0.10, 95%CI: 0.02-0.61, p = 0.012), and CRP levels (OR 0.96, 95%CI: 0.93-0.99, p = 0.007). AIS patients treated with reperfusion therapy and aged 80 or more have around a six times higher risk of an unfavourable outcome or death within three months of stroke onset compared to those aged below 60. Higher NIHSS score after IVT, any signs of disability before stroke as measured with mRS, and higher CRP levels are independent risk factors for worse prognosis in the elderly.

Clinical outcome of patients with mild pre-stroke morbidity following endovascular treatment: a HERMES substudy

BackgroundAnalyses of the effect of pre-stroke functional levels on the outcome of endovascular therapy (EVT) have focused on the course of patients with moderate to substantial pre-stroke disability. The effect...

Is Frailty Index a better predictor than pre-stroke modified Rankin Scale for neurocognitive outcomes 3-months post-stroke?

BackgroundThe prognostic value of frailty measures for post-stroke neurocognitive disorder (NCD) remains to be evaluated.AimsThe aim of this study was to compare the predictive value of pre-stroke FI with pre-stroke modified Rankin Scale (mRS) for post-stroke cognitive impairment. Further, we explored the added value of including FI in prediction models for cognitive prognosis post-stroke.MethodsWe generated a 36-item Frailty Index (FI), based on the Rockwood FI, to measure frailty based on pre-stroke medical conditions recorded in the Nor-COAST multicentre prospective study baseline assessments. Consecutive participants with a FI score and completed cognitive test battery at three months were included. We generated Odds Ratio (OR) with NCD as the dependent variable. The predictors of primary interest were pre-stroke frailty and mRS. We also measured the predictive values of mRS and FI by the area (AUC) under the receiver operating characteristic curve.Results598 participants (43.0% women, mean/SD age = 71.6/11.9, mean/SD education = 12.5/3.8, mean/SD pre-stroke mRS = 0.8/1.0, mean/SD GDS pre-stroke = 1.4/0.8, mean/SD NIHSS day 1 3/4), had a FI mean/SD score = 0.14/0.10. The logistic regression analyses showed that FI (OR 3.09), as well as the mRS (OR 2.21), were strong predictors of major NCD. When FI and mRS were entered as predictors simultaneously, the OR for mRS decreased relatively more than that for FI. AUC for NCD post-stroke was higher for FI than for mRS, both for major NCD (0.762 vs 0.677) and for any NCD (0.681 vs 0.638).ConclusionsFI is a stronger predictor of post-stroke NCD than pre-stroke mRS and could be a part of the prediction models for cognitive prognosis post-stroke.Trial RegistrationClinicalTrials.gov Identifier: NCT02650531.

Association of ischemic stroke onset time with presenting severity, acute progression, and long-term outcome: A cohort study.

Preclinical data suggest circadian variation in ischemic stroke progression, with more active cell death and infarct growth in rodent models with inactive phase (daytime) than active phase (nighttime) stroke onset. We aimed to examine the association of stroke onset time with presenting severity, early neurological deterioration (END), and long-term functional outcome in human ischemic stroke. In a Korean nationwide multicenter observational cohort study from May 2011 to July 2020, we assessed circadian effects on initial stroke severity (National Institutes of Health Stroke Scale [NIHSS] score at admission), END, and favorable functional outcome (3-month modified Rankin Scale [mRS] score 0 to 2 versus 3 to 6). We included 17,461 consecutive patients with witnessed ischemic stroke within 6 hours of onset. Stroke onset time was divided into 2 groups (day-onset [06:00 to 18:00] versus night-onset [18:00 to 06:00]) and into 6 groups by 4-hour intervals. We used mixed-effects ordered or logistic regression models while accounting for clustering by hospitals. Mean age was 66.9 (SD 13.4) years, and 6,900 (39.5%) were women. END occurred in 2,219 (12.7%) patients. After adjusting for covariates including age, sex, previous stroke, prestroke mRS score, admission NIHSS score, hypertension, diabetes, hyperlipidemia, smoking, atrial fibrillation, prestroke antiplatelet use, prestroke statin use, revascularization, season of stroke onset, and time from onset to hospital arrival, night-onset stroke was more prone to END (adjusted incidence 14.4% versus 12.8%, p = 0.006) and had a lower likelihood of favorable outcome (adjusted odds ratio, 0.88 [95% CI, 0.79 to 0.98]; p = 0.03) compared with day-onset stroke. When stroke onset times were grouped by 4-hour intervals, a monotonic gradient in presenting NIHSS score was noted, rising from a nadir in 06:00 to 10:00 to a peak in 02:00 to 06:00. The 18:00 to 22:00 and 22:00 to 02:00 onset stroke patients were more likely to experience END than the 06:00 to 10:00 onset stroke patients. At 3 months, there was a monotonic gradient in the rate of favorable functional outcome, falling from a peak at 06:00 to 10:00 to a nadir at 22:00 to 02:00. Study limitations include the lack of information on sleep disorders and patient work/activity schedules. Night-onset strokes, compared with day-onset strokes, are associated with higher presenting neurologic severity, more frequent END, and worse 3-month functional outcome. These findings suggest that circadian time of onset is an important additional variable for inclusion in epidemiologic natural history studies and in treatment trials of neuroprotective and reperfusion agents for acute ischemic stroke.

Abstract WMP89: Comparative Outcome Of Patients With And Without Mild Pre-Stroke Morbidity Following Endovascular Treatment - Results From The Hermes Meta-analysis

Introduction: Analyses of the effect of prestroke functional levels upon outcome of endovascular therapy (EVT) have focused on the course of patients with moderate to substantial prestroke disability. The effect of complete freedom from pre-existing disability (modified Rankin Scale [mRS]=0) vs. predominantly mild pre-existing disability (mRS≥1) has not been well delineated. Methods: Data were from the HERMES collaboration, a meta-analysis of 7 randomized controlled trials that tested the safety and efficacy of EVT. Two multivariable ordinal logistic regression models were used to compare the association between EVT and 90-day mRS (primary outcome) in patients who were asymptomatic prestroke (mRS=0) and those who had predominantly mild disability prestroke (mRS≥1). Secondary outcomes included successful reperfusion (in the EVT subgroup) and symptomatic intracranial hemorrhage (sICH) at 24 hours. Results: We included 1764 patients in the analysis, of whom 223 (12.6%) had a prestroke mRS≥1 (162 mRS 1, 61 mRS≥2). Patients with prestroke mRS≥1 had worse outcomes compared to those with prestroke mRS=0 (adjusted odds ratio [aOR] 0.42 (95%CI:0.28-0.63). Nonetheless, a significant benefit of EVT was observed in the mRS≥1 subgroup (common OR:1.79 (95%CI:1.11-2.89, Figure). No significant differences were observed with regards to rates of reperfusion (aOR:0.91, 95%CI:0.52-1.57) and sICH (aOR:1.03, 95%CI:0.37-2.93) between patients asymptomatic vs. predominantly with mild disability prestroke. Conclusion: Patients completely asymptomatic prior to onset have better outcomes from EVT than those with mild disability. Patients with prestroke mRS=1 still do more often achieve good functional outcomes with EVT compared to conservative management, with similar rates of reperfusion and sICH. These findings indicate even mild pre-existing symptoms exert prognostic (outcome) but not predictive (different response to therapy) in patients eligible for EVT.

Abstract 132: Projections Of Endovascular Therapy-eligible Patients For The Us Population In 2021

Introduction: Endovascular (EVT) eligibility estimates using population-based, NIH-funded Greater Cincinnati Northern Kentucky (GCNK) Stroke Study 2010 data have been reported. Given the evolving EVT landscape, we present updated estimates of annual EVT eligibility using the 2015 GCNK epidemiological data and extrapolate to the 2021 US census. We project the potential increase in eligible patients in the US for each possible expanded indication with a randomized trial currently planned/underway. Methods: We ascertained all hospitalized AIS patients ≥18 years old in 2015 using ICD-9 430-436; ICD-10 I60-I67, G45-G46 within GCNK population; all cases were physician-reviewed. Patients presenting within 0-5 hrs of last known well (LKW) were considered EVT eligible if they had a pre-stroke mRS&lt;2, NIHSS ≥6 and ASPECTS ≥6. Those within 5-23 hrs of LKW were considered EVT-eligible if they had a pre-stroke mRS &lt;3, NIHSS≥6, and favorable perfusion imaging. Expanded EVT eligible patients were defined as those with NIHSS &lt;6, and pre-stroke mRS &gt;1 (for 0-5 hrs) or ≥2 (for 5-23 hrs), or larger core. Estimates of vessel occlusion and favorable imaging were applied based on literature review and expert opinions. The derived estimates were age, race and sex-adjusted to the 2015 US adult population and extrapolated to 2021 population. Results: Among the 1.3 million total (1.05m adult) GCNK population in 2015, 2741 adults had an ischemic stroke and 2176 had data available for this analysis. A total of 1978 presented within 23 hrs of LKW, and 1233 within 0-5 hrs of LKW. Further results are outlined in the figure. Conclusions: It is estimated 18,484 adult patients in the US in 2021 meet strict EVT eligibility criteria. An estimated 15,699 patients with low NIHSS, 9621 with unfavorable imaging, and 28,107 with pre-stroke disability may become eligible for EVT in the future annually. US stroke systems should be optimized to handle all EVT-eligible stroke patients both now and in the future.

Abstract WMP12: Disparities In Acute Stroke Care According To Pre-stroke Functional Status

Introduction: Disparities in acute ischemic stroke (IS) care due to patients’ pre-stroke disabilities remain understudied. Using the Greater Cincinnati Northern Kentucky (GCNK) Stroke Study, we aimed to understand the differences in acute stroke presentation and care according to patients’ pre-stroke functional status. Methods: We ascertained all hospitalized IS patients ≥18 years old presenting to emergency departments in the GCNK region in 2015 using ICD-9 430-436; ICD-10 I60-I67, G45-G46; all cases were physician-reviewed. Trained nurses ascertained pre-stroke functional status from the medical record. Acute IS presentation, time metrics, and treatment were compared between patients with pre-stroke mRS 0-1 vs ≥2 using Wilcoxon rank-sum or chi-square tests. Logistic regression was used to evaluate the association between pre-stroke mRS and intravenous thrombolysis (IVT) and endovascular treatment adjusting for age, presenting NIHSS, time to presentation, and baseline anticoagulation use. Results: Of 2191 patients with IS, 1134 had a pre-stroke mRS ≥2. Patients in the latter group were older, more likely be female, had higher rates of medical comorbidities, had higher presenting NIHSS (3[1-8] vs 2[1-5], p&lt;0.01, Table). They were less likely to receive IVT (aOR 0.43[0.28-0.68], p&lt;0.01, for patients presenting within 0-4 hours) and EVT (aOR 0.32[0.13-0.78], p=0.01, for patients presenting within 0-23.5 hours). They had a higher rate of presentation via EMS, but the time from stroke onset to ED presentation was longer. Conclusions: Acute IS patients with pre-stroke disability presented later, with more severe strokes, and were less likely to receive reperfusion treatments. Further research into factors driving acute stroke medical decision-making for patients with a pre-stroke disability is needed to ensure optimal acute neurovascular care for all IS patients across the nation and worldwide.

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.

Abstract WP6: Recovery To Baseline Function In Patients With Acute Stroke And Pre-existing Disability: A Natural History Study

Introduction: One in 3 strokes occur in patients with pre-stroke disability. This excludes many from acute treatment trials, but whether these patients benefit from aggressive treatment is unknown. Methods: A prospective stroke center registry (10/2019-04/2021) of consecutive adult patients with acute stroke was queried for patients with pre-stroke modified Rankin Scale (mRS) of 0-4. Multivariable logistic regression was used to estimate odds of full functional recovery (FFR) at 90 days (mRS 0-2 or return to pre-stroke mRS), comparing those with significant pre-stroke disability (mRS 3, 4) to those without (mRS 0-2). Results: Of 1228 patients, 1190 (97%) had pre-stroke mRS 0-4, with 856 (70%) included patients also having 90d follow-up mRS. The median age was 68y (IQR 59-78), with a median NIH Stroke Scale (NIHSS) of 5 (IQR 2-17). Compared to those with mRS 0-2 (n=722), patients with a pre-stroke mRS of 3 (n=96) or 4 (n=38) had more frequent comorbidities and were less likely to achieve FFR (Table). After multivariable adjustment, the odds of FFR was no less for patients with prestroke mRS of 3 (ORadj 1.37, 95%CI 0.80-2.34) or 4 (ORadj 0.59, 95%CI 0.25-1.39). In that model, FFR was less likely among the elderly (ORadj per year 0.96, 95%CI 0.95-0.97) and higher NIHSS (ORadj per point 0.89, 95%CI 0.88-0.91). Thrombolysis was strongly associated with FFR (ORadj 2.70, 95%CI 1.59-4.60). Conclusions: In this single center analysis, stroke recovery in the setting of pre-existing disability was driven by age and stroke severity. Thrombolysis remained predictive of FFR irrespective of age and stroke severity, but was underutilized in patients with pre-stroke disability.

Abstract TP136: Disparities In Care Of Patients With Intracerebral Hemorrhage According To Baseline Functional Status

Introduction: Disparities exist in acute ischemic stroke care according to patients’ pre-stroke functional status. However, the effects of baseline disability on the presentation and care of patients with intracerebral hemorrhage (ICH) are unknown. We aimed to understand this using the Greater Cincinnati Northern Kentucky (GCNK) Stroke Study. Methods: We ascertained all hospitalized ICH patients ≥18 years old in 2015 using ICD-9 430-436; ICD-10 I60-I67, G45-G46 GCNK) population; all cases were physician-reviewed. Per-stroke functional status was ascertained by medical record review. Baseline NIHSS, Glasgow coma scale (GCS), imaging modalities (CT/MRI), in-hospital rehabilitative therapies (rate and frequency), initiation of antihypertensive treatment, and discharge disposition between patients with pre-ICH mRS 0-1 vs ≥2 were compared using Wilcoxon rank-sum or chi-square tests. Logistic regression was used to evaluate the association between pre-stroke mRS and in-hospital therapy, post-discharge therapy, and ICH workup adjusting for age, Glasgow score, insurance status, and ICH location. Results: Of 350 patients with ICH, 187 (53%) had a pre-ICH mRS ≥2. Compared to those with pre-stroke mRS 0-1, these patients had more severe clinical presentation as measured by NIHSS and GCS (table). Among patients who were not made comfort care, no association between pre-ICH mRS and performance of inpatient MRI or in-hospital and post-discharge rehabilitative therapies was found in adjusted analyses. Conclusions: Patients with pre-ICH mRS &gt;2 were made comfort care at a higher rate, but for those not made comfort care there were no post-ICH disparities of care seen in the 2015 GCNK population-based cohort of 350 patients.

Abstract 115: Predictors Of Post-stroke Depression And Suicidal Ideation Among Acute Stroke Survivors

Introduction: Approximately a third of stroke survivors are diagnosed with Post-Stroke Depression (PSD) and half are more likely to commit suicide compared to the general population. The aim of this study was to examine the relationship between demographic and clinical variables and PSD and suicidal ideation among post-stroke survivors. Methods: This was a retrospective review of a clinical registry from a comprehensive stroke center between 10/2018 and 3/2020. Patients were eligible if a Patient Health Questionnaire 9-Item (PHQ-9) was available. Question 9 of the PHQ-9 was screened for suicidal ideation. Results: The study cohort consisted of a total of 194 patients who had an acute (primarily ischemic or intracerebral) stroke who completed a 90-day telephonic PHQ-9. The mean age (years) and NIH Stroke Scale were 64 ± 15 and 7.4 ± 7.3, respectively. The sample was comprised of 56% men, 39% Whites, 31% Blacks, 27% Asians, and 10% Hispanics. The mean PHQ-9 score was 5.9 ± 6.3. Seven percent reported suicidal ideation. Univariate analysis revealed that pre-stroke depression history and 90-day post-dicharge mRS scores were significantly associated with PHQ-9 scores (p=0.005 and p=0.003, respectively). After adjusting for age, stroke type, NIHSS arrival score, pre-morbid mRS score, mRS score at 7 days, and hospital length of stay, multiple linear regression analysis with bootstrap estimates found that pre-stroke depression and 90-day post-dicharge mRS scores remained significant (p&lt;0.001 and p=.004, respectively; see Table 1). Although both days 7 (p=0.014) and 90 (p=0.049) mRS scores were found to be significantly different than those with and without suicidal ideation, the effect size in patients with suicidal ideation was larger for day 90 (d=.66) than for day 7 (d=.36) mRS scores. Conclusion: Patients with a history of depression and those with higher mRS scores at 90 days should be screened for suicidal ideation and actively managed for depression.

Abstract 63: Recanalization Treatments In Pediatric Stroke: Safety And Efficacy Data Issued From The French KidClot Study

Background: Safety and efficacy of recanalization treatments, i.e. intravenous thrombolysis (IVT) and/or mechanical thrombectomy (MT), have to be refined in pediatric stroke. Methods: The French KIDCLOT multisourcing nationwide retrospective study (NCT03887143) collected data of consecutive children aged &gt;28 days and &lt;18 years old with acute arterial ischemic stroke who had a recanalization treatment, during a 41 month-period. Results: 68 patients, 44 boys (64.7%), median age at stroke onset 11.5 years old, were included. Pre-stroke mRS was 0 for 89.7%. Main stroke etiologies were cardio-embolic (30.9%), focal cerebral arteriopathy (FCA, 25%), cervical (carotid/vertebral) arteriopathy (13.2%), and thrombotic (11.8%). 70 pediatric procedures were recorded: IVT alone (n=31), MT alone (n=23), combined IVT and MT (n=14), and DSA without recanalization treatment (n=4). Median stroke onset to first recanalization treatment delay was shorter in adult stroke units than in pediatric wards (188 vs. 264 minutes respectively, p=0.0087). An early complication was reported for 6 procedures, including two significant intracranial hemorrhages. After MT, cardio-embolic stroke patients achieved good arterial recanalization more frequently than FCA patients (88.9% vs 33.3%). Although high initial severity markers (median NIHSScore=13.5, decreased consciousness in 52.2%, decompressive craniectomy in 17.1%), outcome was relatively good in the 65/68 survivors (median mRS=1 and PSOM=1.2 at 12 month-follow-up). Conclusions: This study provides encouraging safety data despite severe stroke presentations. It suggests potential ways to improve recanalization treatments efficacy in children: reducing management delays in pediatric wards and optimizing etiological orientation since the hyperacute phase, as cardio-embolic strokes seem to display a better recanalization rate profile.