Single Comprehensive Stroke Center Research Articles

An Experience of a Single Comprehensive Stroke Center after Implementation of Routine Tenecteplase Administration for Acute Ischemic Stroke Treatment. (P7-5.023)

<h3>Objective:</h3> The objectives of this study were to determine if there is a significant difference between Alteplase and Tenecteplase in improvement of NIHSS, door to needle time (DTNT), disability at discharge determined by modified Rankin scale (mRS), and rate of intracranial hemorrhage (ICH). <h3>Background:</h3> There is growing interest in using Tenecteplase for acute ischemic stroke (AIS) treatment. Currently there is no clear consensus on its indication and dosage. We transitioned to Tenecteplase administration for AIS treatment in March 2021, at a dosage of 0.25 mg/kg. <h3>Design/Methods:</h3> A retrospective comparison analysis on the outcomes of AIS patients who were treated with Alteplase between April 2020 – March 2021 or Tenecteplase between April 2021 – March 2022. <h3>Results:</h3> Of 216 patients, 45.8% (n = 99) were given Alteplase and 54.1% (n = 117) were given Tenecteplase. There was no significant difference in baseline characteristics except hyperlipidemia, substance use, and history of smoking. No mean difference in mRS was measured at admission or discharge between Alteplase (1.42+/− 1.77) and Tenecteplase (1.32 +/− 1.56, p-value 0.703) and delta NIHSS between Alteplase and Tenecteplase (p-value 0.926). There was no difference in DTNT between both groups (p-value 0.172). Successful recanalization ratio was not significantly different. Symptomatic ICH was of no significant difference between the two groups: occurring in 5.05% patients receiving Alteplase and 5.13% patients receiving Tenecteplase (p-value 0.682). Rate of mortality was 13.13% (n = 13) in Alteplase and 11.11% (n = 13) in Tenecteplase, also of no significant difference (p-value 0.683). <h3>Conclusions:</h3> The results suggest that Tenecteplase has a similar efficacy and safety profile to Alteplase in real world practice. These findings are similar to results of previous randomized trials. At the dose of 0.25 mg/kg, Tenecteplase appears to be a reasonable alternative to Alteplase for use with acute ischemic strokes within 4.5 hours of onset. <b>Disclosure:</b> Dr. Cawley has nothing to disclose. Dr. Simon has nothing to disclose. Dr. Radomski has nothing to disclose. Dr. Kuns has nothing to disclose. Dr. Bejleri has nothing to disclose. Dr. Seol has nothing to disclose. Dr. Razak has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Janssen Pharmaceuticals.

Abstract Number ‐ 189: Comparative Device Analysis for First Pass Stent Retriever Mechanical Thrombectomy

Introduction Limited data is available regarding comparative outcomes amongst FDA‐approved devices for mechanical thrombectomy (MT). The objective of this study is to assess procedural efficacy, clinical outcomes, and safety of currently available stent retriever devices when used during first pass thrombectomy for acute ischemic stroke. Methods A retrospective analysis was performed on all patients who underwent MT for large vessel occlusion (LVO) at a single comprehensive stroke center between January 2016 and January 2022. All patients who underwent MT with a stent retriever (Solitaire, Embotrap, Trevo) during first pass were included in the analysis. Primary efficacy and safety outcomes included time to recanalization, attainment of first‐pass effect (FPE), recanalization TICI score, 90‐day modified Rankin scale (mRS), and incidence of hemorrhagic transformation. One‐way ANOVA was used to compare median time to recanalization amongst cohorts. Chi‐squared test was used to compare frequencies of outcome measures amongst cohorts. Results During the study period, 234 patients underwent MT for LVO with use of stent retriever device during the first pass. In these cases, the type of stent retriever utilized was Solitaire (n = 163), Embotrap (n = 45), or Trevo (n = 26). There were no significant differences between cohorts in terms of age, gender, ethnicity, initial NIH stroke scale, or level of occlusion, or comorbidities. No significant differences were observed between cohorts for any primary outcome measures. The median time to recanalization was 53 min [Solitaire], 49 min [Embotrap], 63 min [Trevo] (p = 0.17). First‐pass effect was attained in 28.6% [Solitaire], 38.4% [Embotrap], 26.9% [Trevo] (p = 0.41). TICI 2b or greater recanalization was attained in 80.3% [Solitaire], 88.9% [Embotrap], 84.6% [Trevo] (p = 0.38). 90‐day mRS of 0–2 was observed in 36.6% [Solitaire], 38.9% [Embotrap], 34.8% [Trevo] (p = 0.95). Hemorrhagic transformation was observed in 45.9% [Solitaire], 36.8% [Embotrap], 34.6% [Trevo] (p = 0.40). Conclusions The type of stent retriever chosen for first pass thrombectomy did not predict procedural efficacy, clinical outcomes, or safety in our single center analysis.

Abstract Number ‐ 30: Predictors of Intracranial Hemorrhage and Successful Reperfusion After Mechanical Thrombectomy in Acute Ischemic Stroke

Introduction Mechanical thrombectomy (MT) has become the current standard of care for large vessel occlusion stroke but is associated with an increased risk of intracranial hemorrhage (ICH). Recent study showed that even asymptomatic ICH may decrease the likelihood of an excellent functional outcome at 90 days. This study aims to identify predictors for ICH in patients with acute ischemic stroke undergoing MT. Also, we try to identify the predictors for successful reperfusion TICI 2b/3. Methods We retrospectively reviewed all MT patients who were treated at a single comprehensive stroke center from 12/2016 to 09/2021. Variables included Ethnicity, age, gender, time from last know well to arrival, medical history, antithrombotic use, initial NIHSS, blood glucose, blood pressure, IV tPA, time from door to puncture, time from puncture to first pass, type of LVO, MT devices and TICI score. Primary Outcome was any ICH within 36 hours after MT. Secondary outcome was successful reperfusion, TICI 2b/3. Results Among 273 patients (68.8±14, Male 51.6%), 41.7% was Hispanic. 75 patients (27.5%) experienced any ICH after thrombectomy.Although ICH is common post MT and most of the researchers believe that only symptomatic ICH negatively impacts outcome, it is challenging to get an accurate post MT evaluation. Our patient cohort confirmed that ICH after MT may decrease the likelihood of excellent and favorable outcome upon discharge. Patients with history of drugs or ETOH abuse had higher risk of ICH post MT. TICI 2b/3 was associated with higher chance of favorable mRS (0‐3) upon discharge but paradoxically associated with higher chance of ICH post MT. (OR 3.01).Among all the variables, time from LKW to arrival was significantly shorter in patients achieved TICI 2b/3, 223min VS 414min. Door to puncture time was significantly faster in patients with TICI2b/3, 95min VS 121min. Puncture to first pass time was also significantly faster in patients with TICI2b/3, 19min VS 26min.Multiple logistic regression model showed that lower initial BG and NIHSS, ICA or M1 LVO and shorter door to first pass time were associated with favorable outcomes. Conclusions Compared to other clinical studies (usually only had 5–8% Hispanic patients), our study has significantly better representation of Hispanic population in which 41.7% of our patients are Hispanic. This emphasized the uniqueness and meaning of our study.Our patient cohort confirmed that it is important to avoid any ICH post MT, since it may decrease favorable and excellent outcome upon discharge. Extra attention is needed for patients with history of drugs or ETOH abuse because it is associated with significantly higher risk of ICH post MT in our patient cohort.ICH was commonly seen in TICI 2b/3 patients and may be due to successful reperfusion. Therefore, aggressive BP management (SBP&lt;140) after MT is recommended if TICI 2b/3 achieved to avoid ICH expanding and worsening outcome. Also, angio‐CT scan after TICI 2b/3 may be necessary in the future. Favorable outcomes were reached more often if patients had lower initial BG and NIHSS, ICA or M1 LVO, shorter door to first pass time and can achieve TICI 2b/3 after MT.

Oral health and functional outcomes following mechanical thrombectomy for ischemic stroke

BackgroundAn association between poor dentition and the risk of ischemic stroke has previously been reported in the literature. In this study we assessed oral hygiene (OH), including tooth loss and...

Systemic inflammation and immune index predicting outcomes in patients with intracerebral hemorrhage.

Recent evidence has suggested that systemic inflammatory and immune index (SIRI) and systematic inflammation index (SII) could predict prognosis in stroke patients. This study aimed to determine the effects of SIRI and SII on predicting in-hospital infections and unfavorable outcomes in patients with acute intracerebral hemorrhage (ICH). We used the data from a prospective and registry-based study recruiting ICH patients between January 2014 and September 2016 in a single comprehensive stroke center. All patients were stratified by quartiles of SIRI or SII. Logistic regression analysis was used to estimate the associations with follow-up prognosis. The receiver operating characteristics (ROC) curves were performed to examine the predictive utility of these indexes for infections and prognosis. Six hundred and forty spontaneous ICH patients were enrolled in this study. Compared with the lowest quartile (Q1), SIRI or SII values both showed positive correlations with increased risks for poor 1-month outcomes (adjusted ORs in Q4 was 2.162 [95% CI: 1.240-3.772] for SIRI, 1.797 [95% CI: 1.052-3.070] for SII). Additionally, a higher level of SIRI, but not SII, was independently associated with a higher risk of infections and an unfavorable 3-month prognosis. The C-statistic for the combined SIRI and ICH score was higher than SIRI or ICH score alone for predicting in-hospital infections and poor outcomes. Elevated SIRI values were associated with in-hospital infections and poor functional outcomes. It may provide a new biomarker for ICH prognosis prediction, especially in the acute stage.

Prevalence, clinical features, and radiological pattern of artery of Percheron infarction: a challenging diagnosis.

Occlusion of artery of Percheron (AOP), a rare variant of paramedian branches of posterior cerebral artery, results in a characteristic pattern of ischemic lesions in bilateral paramedian thalami with or without midbrain and anterior thalami involvement. To evaluate the prevalence, the clinical, and the imaging features of AOP infarction in a single comprehensive stroke center experience. We retrospectively search in our stroke center database, patients with ischemic lesions in the AOP distribution. We collected clinical features and time between hospital admission and diagnosis. Imaging findings were categorized following a pre-selected classification. Of 2830 ischemic stroke admitted in our center, we identified 15 patients with AOP infarction (0.53%). Clinical manifestations were variable, but oculomotor disturbances, particularly vertical gaze palsy, were the most observed, followed by consciousness impairment, varying from drowsiness to coma. The most frequent imaging pattern was bilateral paramedian thalamic infarction with midbrain infarction, and the V-sign was recognized in 6 cases from this group. In 8 patients a fetal origin of the PCA was observed. The average time from first hospital admission to diagnosis was 28.09h. The prevalence of AOP infarction in our center was 0.53%. Diagnosis of AOP infarction can be challenging and should be suspected in case of sudden altered consciousness.

Abstract WMP86: Risk Of Hemorrhagic Transformation Is Related To Severity Of Hba1c Elevation In Patients Undergoing Mechanical Thrombectomy

Introduction: While prior studies have demonstrated hyperglycemia as an independent predictor of hemorrhagic transformation and poor clinical outcome following Mechanical Thrombectomy (MT), it is less clear to what extent HbA1c impacts these relationships. The objective of this study was to assess the association between severity of poor glycemic control, functional independence and hemorrhagic transformation. Methods: A retrospective analysis was performed on patients who underwent MT for large vessel occlusion (LVO) at a single comprehensive stroke center between January 2016 and January 2022. Primary safety and efficacy outcomes included the presence of hemorrhagic transformation and good 90-day functional outcome defined as modified Rankin scale (mRS) of 0-2. Good glycemic control was described as HbA1c &lt;6.4 mg/dl. Fisher’s Exact Probability Test was used to compare cohorts to those with good glycemic control and calculate odds ratios for given outcomes. Results: 657 patients were included in the analysis. Among these, the observed HbA1c value was &lt;6.5 (n=535), 6.5-8.0 (n=72), or &gt;8.0 (n=50). There were no significant differences between cohorts in terms of age, gender, ethnicity, initial NIH stroke scale, level of occlusion, or medical comorbidities. Patients with HbA1c ≥6.5 had a 17.0% lower incidence of good functional outcome vs those with good glycemic control (OR 0.47, CI: 0.32-0.88). An HbA1c threshold of ≥6.5 did not correlate with significant differences in HT incidence (OR 1.08, CI: 0.76-1.79). However, patients with HbA1c &gt; 8.0 had a 14.8% higher incidence of HT vs those with good glycemic control (OR 1.81, CI: 1.15-4.35). Conclusions: While suboptimal glucose control and diabetes (HbA1c ≥6.5) is associated with worse outcomes following MT for acute ischemic stroke, its effect on hemorrhagic transformation risk was only seen in those with poor glycemic control (HbA1c &gt;8.0) in our single center analysis.

Abstract TP64: Characterization Of Stroke Mimics Treated With Thrombolytics

Background: Stroke is a medical emergency. The effectiveness of stroke treatment is time dependent. Due to the urgency of treatment and the challenge of rapidly assessing stroke-like symptoms, patients with stroke mimics (non-stroke etiologies of focal neurologic symptoms) may be treated with thrombolysis. We aimed to understand characteristics of patients treated with IV tPA with a final diagnosis of stroke versus a stroke mimic. Methods: This retrospective cohort study identified patients who received tPA for stroke-like symptoms in the emergency department at a single urban Comprehensive Stroke Center over 26 months. Final diagnosis was based on ICD-10 codes. Demographic data, medical history and presenting symptoms were obtained through electronic medical record review. Characteristics of patients with strokes and mimics were compared using Chi-squared and t-tests. Results: Of 202 patients presenting with stroke-like symptoms who received tPA, final diagnosis was ischemic stroke in 166 (82%) and mimic in 36 (18%). A statistically significant difference was noted between the stroke and mimic groups in age (64 ±16.9 vs 57 ±13.8 years, p=0.015) and neared significance in sex (38% vs 56% female, p=0.052). There was no difference in initial NIHSS (7.8 ±7.2 vs 5.8 ±5.2, p=0.109), Hispanic ethnicity (13% vs 22%, p=0.170), presence of stroke risk factors (79% vs 78%, p=0.880), or race distribution (white 54% vs 61%, Black 28% vs 14%, multiple/other 18% vs 25%, p=0.199). The most common mimic symptoms included unilateral weakness (61%), unilateral numbness (53%), dysarthria (33%), ataxia (28%), vertigo (22%), and gait impairment (17%). The most common clinical diagnoses in mimics were headache, functional neurologic disorder, and toxic/metabolic disturbances (17% each). Conclusion: Of patients receiving tPA at our facility, stroke mimics comprised 18% and were significantly younger than patients with ischemic stroke. Further analysis of demographics within these two groups could identify characteristics that distinguish strokes from mimics, which may lower the rate of tPA administration to non-stroke presentations.

Mechanical Thrombectomy in Acute Ischemic Stroke COVID-19 and Non-COVID-19 Patients: A Single Comprehensive Stroke Center Study.

Coronavirus disease 2019 (COVID-19) increases the risk for thromboembolic events, such as acute ischemic stroke (AIS). Mechanical thrombectomy (MT) is a therapy of choice in early diagnosed AIS; however, its success and outcomes in COVID-19 patients are contradictory. This study presented our experience with MT performed in COVID-19 patients compared to a control group. The retrospective analysis included patients with AIS who underwent MT from April 2021 to April 2022 at our institution. There were 13 COVID-19-related patients (with active or past COVID-19 infection) and 55 non-COVID-19 patients (negative COVID-19 status). We analyzed patients' baseline clinical and laboratory data, modified Thrombolysis in Cerebral Infarction (mTICI) scale, used 24 h follow-up CT findings, and modified the Rankin scale. The COVID-19 group had higher values of leukocytes, neutrophils, neutrophil/leukocyte ratios, ASL, ALT, LDH and CRP, and lower values of lymphocytes compared to the control group. The AIS mostly occurred in posterior circulation in the COVID-19 group, while anterior circulation was more affected in the control group. Treatment approach and successful reperfusion did not differ between groups. In conclusion, although differences in some clinical and laboratory parameters between COVID-19 and non-COVID-19 groups were found, the outcomes of mechanical thrombectomy were equal.

Emergency admission plasma D-dimer: a novel predictor for symptomatic intracranial hemorrhage after thrombectomy in acute ischemic stroke

BackgroundSymptomatic intracranial hemorrhage (sICH) is a common and severe complication in patients with acute ischemic stroke (AIS) after treatment with thrombectomy.ObjectiveTo explore the ability of admission plasma D-dimer levels to...

CT Marker in Emergency Imaging of Acute Basilar Artery Occlusion: Thrombosis vs. Embolism.

Purpose: Acute basilar artery occlusion, a neurovascular emergency leading to high rates of morbidity and mortality, is usually diagnosed by CT imaging. The outcome is partly dependent on etiology, with a worse outcome in occlusions with underlying basilar artery stenosis. As this occlusion type requires a more complex angiographic therapy, this study aimed to develop new CT markers in emergency admission imaging to rapidly identify underlying stenosis. Methods: A total of 213 consecutive patients (female n = 91, age in years (mean/SD/range): 72/13/28–97), who received endovascular treatment at a single comprehensive stroke center for acute basilar artery occlusion, were included in this study. After applying strict inclusion criteria for imaging analyses, novel CT imaging markers, such as ‘absolute density loss’ (ADL) and relative thrombus attenuation (CTA-index), that measure perviousness, were assessed for n = 109 patients by use of CT-angiography and correlated to different occlusion patterns (thrombotic vs. embolic). Inter-observer agreement was assessed using an intraclass correlation coefficient for independent measures of a radiologist and a neuroradiologist. Associations between the imaging markers and clinical and interventional parameters were tested. Results: CT markers differ between the subgroups of basilar artery occlusions with and without underlying stenosis (for ADL: 169 vs. 227 HU (p = 0.03), for CTA-index: 0.55 vs. 0.70 (p < 0.001)), indicating a higher perviousness in the case of stenosis. A good inter-rater agreement was observed for ADL and CTA-index measures (ICC 0.92/0.88). For the case of embolic occlusions, a more pervious thrombus correlates to shorter time intervals, longer procedure times, and worse reperfusion success (p-values < 0.05, respectively). Conclusions: ADL and CTA-index are easy to assess in the emergency setting of acute basilar artery occlusion with the use of routinely acquired CT-angiography. They show a high potential to differentiate thrombotic from embolic occlusions, with an impact on therapeutic decisions and angiographic procedures. Measurements can be quickly performed with good reliability, facilitating implementation in clinical practice.

Long-term effect of field triage on times to endovascular treatment for emergent large vessel occlusion

BackgroundDelays to endovascular therapy (EVT) for stroke may be mitigated with direct field triage to EVT centers. We sought to compare times to treatment over a 5.5 year span between...

Yield of Echocardiography in Ischemic Stroke and Patients With Transient Ischemic Attack With Established Indications for Long-Term Direct Oral Anticoagulant Therapy: A Cross-Sectional Diagnostic Cohort Study.

BackgroundWe aimed to determine the diagnostic yield of transthoracic (TTE) and transesophageal echocardiography (TEE) in patients with ischemic stroke and transient ischemic attack with established indications for direct oral anticoagulants before the index event.Methods and ResultsThis was a retrospective cohort study of consecutive patients with preceding established indications for long‐term therapeutic direct oral anticoagulants presenting to a single comprehensive stroke center with ischemic stroke or transient ischemic attack. Choice of echocardiography modality was based on expert recommendations. The primary outcome was a composite of prespecified management‐relevant high‐risk findings adjudicated by an expert panel, based on TTE and TEE reports according to evidence‐based recommendations. Explorative analyses were performed to identify biomarkers associated with the primary outcome. Of 424 patients included (median [interquartile range] age, 78 [70–84] years; 175 [41%] women; National Institutes of Health Stroke Scale, 4 [1–12]; 67% atrial fibrillation), 292 (69%) underwent echocardiography, while 132 (31%) did not. Modality was TTE in 191 (45%) and TEE in 101 (24%). Median time from index event to echocardiography was 2 (1–3) days. TTE identified 26 of 191 (14%) patients with 35 management‐relevant pathologies. TEE identified 16 of 101(16%) patients with 20 management‐relevant pathologies. Most management‐relevant findings represented indicated coronary artery disease and valvular pathologies. In a further 3 of 191 (2%) patients with TTE and 4 of 101 (4%) patients with TEE, other relevant findings were identified. Variables associated with management‐relevant high‐risk pathologies included more severe stroke, diabetes, and laboratory biomarkers (NT‐proBNP [N‐terminal pro‐B‐type natriuretic peptide], C‐reactive protein, d‐dimer, and troponin levels).ConclusionsIn patients with established indications for long‐term direct oral anticoagulant therapy and stroke who received echocardiography, both TTE and TEE identified a relevant and similar proportion of management‐relevant high‐risk pathologies and predictive biomarkers could help to guide diagnostic workup in such patients.

The Impact of Mean Arterial Pressure and Volume Contraction in With Acute Ischemic Stroke.

Background and PurposeHydration at the time of stroke may impact functional outcomes. We sought to investigate the relationship between blood pressure, hydration status, and stroke severity in patients with acute ischemic stroke (AIS).MethodsWe evaluated hydration status, determined by blood urea nitrogen (BUN)/creatinine ratio, in consecutive patients with AIS from a single comprehensive stroke center. Baseline mean arterial pressure (MAP) was analyzed using a linear spline with a knot at 90 mmHg. Baseline stroke severity was defined based on admission NIH Stroke Scale scores (NIHSSS) and MRI diffusion-weighted imaging.ResultsAmong 108 eligible subjects, 55 (51%) presented in a volume contracted state. In adjusted models, in the total sample, for every 10 mmHg higher MAP up to 90 mmHg, NIHSSS was 2.8 points lower (p = 0.053), without further statistically significant association between MAP above 90 and NIHSSS. This relationship was entirely driven by the individuals in a volume contracted state: MAP was not associated with NIHSSS in individuals who were euvolemic. For individuals in a volume contracted state, each 10 mmHg higher MAP, up to 90 mmHg, was associated with 6.9 points lower NIHSSS (95% CI −11.1, −2.6). MAP values above 90 mmHg were not related to NIHSSS in either dehydrated or euvolemic patients.ConclusionsLower MAP contributes to more severe stroke in patients who are volume contracted, but not those who are euvolemic, suggesting that hydration status and blood pressure may jointly contribute to the outcome. Hydration status should be considered when setting blood pressure goals for patients with AIS.

Abstract TP43: Incidence And Characteristics Of Transient Ischemic Attack Mimics In Emergency Department Observation Unit

Objective: Transient Ischemic Attack (TIA) observation units in the emergency department (ED) were developed to expedite medical evaluation and to reduce recurrent strokes. However, TIA remains a clinically challenging diagnosis due to its reliance on patient history and has multiple mimics including complex migraine, seizure, and peripheral vertigo. This study attempts to review the proportion of common mimics in the TIA observation unit at a comprehensive stroke center. Methods: We included 1525 patients enrolled in a TIA registry over 7 years (2013-2020) in a single comprehensive stroke center. Inclusion criteria of TIA unit admissions are age &gt;18 years with focal neurological symptoms for &lt; 24 hours. This population excludes patients with refractory hypertension, baseline immobility, or recurrent deficits. While in the ED, patients were evaluated by neurologists and assigned a final diagnosis of TIA or mimics. Data on demographics, past medical history, home medications, magnetic resonance imaging (MRI) results, and 30-day follow-up were collected. Results: The mean age was 64.2 (SD 15.2), 52.3% were women, and 76.7% were White, 6.0% were Black, 13.6% were Hispanic, and 3.7% other ethnicities. We found 44.7% of patients had neurologist-adjudicated TIA and 15.2% had diffusion-weighted imaging (DWI) positive lesions on MRI. TIA mimics comprised 42% of the cohort, of which 28.9% had migraine, 14.1% had peripheral vertigo, 4.7% had seizure and 52.1% were classified in other miscellaneous diagnoses including medication effect, recrudescence of prior stroke deficits, anxiety, and radiculopathies. Among the 394 patients with the diagnosis of TIA the 30-day recurrent stroke or death rate was 1.3%. Conclusion: In our investigation of TIA unit admissions, we found a relatively high proportion of TIA mimics. In patients with a diagnosis of TIA, however, the rate of subsequent stroke or death is lower than that in prior observational studies. The potential benefit of a TIA unit in stroke prevention needs to be tested against the cost of stroke mimic TIA unit admission.

Abstract 80: Hospital Cost Of Direct To Angiography Suite Compared To Emergency Department Transfers For Large Vessel Occlusions Undergoing Mechanical Thrombectomy: A Propensity Adjusted Analysis

Introduction: Direct-to-angiography-suite (DTAS) transfer for patients with large vessel occlusions (LVOs) undergoing mechanical thrombectomy is associated with decreased workflow times and improved neurological outcomes. Herein, we sought to demonstrate a decrease in hospital cost associated with DTAS compared to emergency department (ED) transfers for patient undergoing mechanical thrombectomy for an LVO. Methods: A retrospective analysis was performed on all patients who underwent mechanical thrombectomy for an LVO at a single comprehensive stroke center from 2017 to 2021. All patients who were transferred DTAS or ED were included. Total hospital cost (sum of overhead, professional, diagnostic, and room charges throughout the entire index patient admission) was obtained from the hospital financial department for the index admission. A propensity adjusted (matched for age, sex, vessel occluded, co-morbidities, BMI, admission NIHSS, access site, and use of a stent retriever) was implemented. Mean difference in hospital cost was the primary outcome. Results: During the study period, 341 patients underwent mechanical thrombectomy for an LVO. Of these patients, 140 (41%) were transferred DTAS and 96 (28%) to the ED. There were no significant differences between cohorts in terms of age, sex, vessel occluded, admission NIHSS, co-morbidities, number of passes, TICI score, access site, stent retriever, major complications, or in-hospital mortality. The DTAS cohort ($33,061, sD $17,258) had a significantly lower hospital cost compared to ED transferred patients ($38,030, sD $18,572) (p=0.04). There was no significant difference between the ED (12.2, sD 11.8) and DTAS (11.6, sD 11.1) cohorts in discharge NIHSS. Following propensity score adjustment, linear regression analysis found DTAS (compared to ED transfer) to be significantly associated with a decrease in hospital cost ($-6,344; 95% CI: $-11,067 to $-1,623; p=0.009). Conclusion: DTAS transfer for patients undergoing an acute mechanical thrombectomy for a LVO was associated with a greater than $6,000 decrease total hospital cost compared to patients first transferred to the ED. The present study further supports DTAS transfer for patients undergoing mechanical thrombectomy for LVO.

Abstract TMP62: Carotid Web Stenting Is Comparable To Atherosclerotic Stenting With Lower Procedural Risk

Introduction: Carotid Web (CaW) is an underrecognized etiology for ischemic stroke. This entity has been shown to be amenable to endovascular stenting, similar to carotid atherosclerotic stenosis (CAS). We aimed to assess procedural characteristics of stenting for CaW as compared to CAS. Methods: We retrospectively analyzed a cohort of patients at a single comprehensive stroke center from October 2014 to March 2021 who had undergone endovascular stent placement for symptomatic CAS or CaW. Patients who received other intervention (e.g. thrombectomy, aneurysm repair) on the same day as stent placement were excluded. Baseline patient characteristics, procedural data, periprocedural complications, and follow-up statistics were analyzed. Results: In total, 105 patients underwent stent placement status post ischemic stroke or transient ischemic attack; 79 patients had CAS and 26 patients had CaW. Patients with CAS were older on average (CAS 63 vs CAS 53.5 years, p &amp;lt; 0.001 ) and less likely to be female (OR 0.116; 95% CI 0.041 to 0.326, p &amp;lt;0.001). CAS patients were more likely to have vascular risk factors such as hypertension, hyperlipidemia, and Diabetes ( Table ). Radiation, need for angioplasty, and filter time were significantly lower in CaW procedures. No significant difference was found between the two pathologies in periprocedural complications such as hypotension, need for vasopressors, or bradycardia. However, post-procedural restenosis only occurred in CAS stents. Conclusion: Stenting for CaW is comparable to stenting for CAS in terms of vasovagal side effects, but associated with lower filter times, lower radiation dose, lower need for angioplasty, and lower rates of restenosis.

Association between kidney function and intracerebral hematoma volume

Renal dysfunction has been reported to be associated with larger hematoma volume in intracerebral hemorrhage (ICH) due to concomitant nutritional imbalances and platelet dysfunction; however, this association remains controversial. This study analyzed the association between potential risk factors and hematoma volume in patients with ICH. This retrospective cohort study used data from 456 patients with ICH at a single comprehensive stroke center. We assessed the association of estimated glomerular filtration rate (eGFR) and Controlling Nutritional Status score with hematoma volume using multivariable non-linear regression models. The effect of the use of antithrombotic agents on hematoma volume was analyzed using outcome-adaptive double/debiased machine learning approach, considering many covariates. The median and interquartile range of age and eGFR were 64 (54–75) years and 56.1 (39.3–66.7) mL/min/1.73 m2, respectively. The multivariable non-linear regression model showed that (1) eGFR and hematoma volume had a positive linear association, which was not statistically significant, and (2) nutritional status was positively associated with hematoma volume, although not significantly. Outcome-adaptive double/debiased machine learning revealed that patients receiving antithrombotic agents did not present with significantly larger hematoma volume than those who were not receiving antithrombotic agents (estimated mean difference of hematoma volume [95% confidence interval] = 15.32 [−6.02 to 36.65]). Our analysis shows no statistically or clinically significant relationship between renal function and hematoma volume; however, nutritional status and the use of antithrombotic agents showed an increasing tendency of the degree of hematoma in patients with ICH.

Initial Stress Hyperglycemia Is Associated With Malignant Cerebral Edema, Hemorrhage, and Poor Functional Outcome After Mechanical Thrombectomy.

Malignant cerebral edema (MCE) and intracranial hemorrhage (ICH) are associated with poor neurological outcomes despite revascularization after mechanical thrombectomy (MT). The factors associated with the development of MCE and ICH after MT are not well understood. To determine periprocedural factors associated with MCE, ICH, and poor functional outcome. We retrospectively analyzed anterior cerebral circulation large vessel occlusion cases that underwent MT from 2012 to 2019 at a single Comprehensive Stroke Center. Multivariate logistic regression analyses were performed to determine significant predictors of MCE, ICH, and poor functional outcome (modified Rankin Scale, 3-6) at 90 d. Four hundred patients were included. Significant independent predictors of MCE after MT included initial stress glucose ratio (iSGR) (odds ratio [OR], 14.26; 95% CI, 3.82-53.26; P < .001), National Institutes of Health Stroke Scale (NIHSS) (OR, 1.10; 95% CI, 1.03-1.18; P = .008), internal carotid artery compared with M1 or M2 occlusion, and absence of successful revascularization (OR, 0.16; 95% CI, 0.06-0.44; P < .001). Significant independent predictors of poor functional outcome included MCE (OR, 7.47; 95% CI, 2.20-25.37; P = .001), iSGR (OR, 5.15; 95% CI, 1.82-14.53; P = .002), ICH (OR, 4.77; 95% CI, 1.20-18.69; P = .024), NIHSS (OR, 1.10; 95% CI, 1.05-1.16; P < .001), age (OR, 1.04; 95% CI, 1.03-1.07; P < .001), and thrombolysis in cerebral infarction 2C/3 recanalization (OR, 0.12; 95% CI, 0.05-0.29; P < .001). Elevated iSGR significantly increases the risk of MCE and ICH and is an independent predictor of poor functional outcome. Thrombolysis in cerebral infarction 2C/3 revascularization is associated with reduced risk of MCE, ICH, and poor functional outcome. Whether stress hyperglycemia represents a modifiable risk factor is uncertain, and further investigation is warranted.

Abstract 1122‐000091: Predictors of Symptomatic Hemorrhagic Transformation After Mechanical Thrombectomy in Acute Ischemic Stroke

Introduction : Mechanical thrombectomy (MT) has become the current standard of care for large vessel occlusion stroke but is associated with an increased risk of intracranial hemorrhage (ICH). Although several studies have investigated the risk factors, there is still limited, not well‐established data. This study aims to evaluate the risk factors of HT after MT. Methods : We retrospectively reviewed all MT patients who were treated at a single comprehensive stroke center from 12/2016 to 7/2019. Variables included initial NIHSS, blood glucose, initial systolic blood pressure, age, gender, IV tPA, time from door to recanalization, and TICI score. Outcome measures were HT on post‐procedure or 24‐hour post‐tPA head CT/MRI as well as modified Rankin scale (mRS) upon discharge. Results : Among 74 patients (68.8 ± 14 years, men 47.3%), 9 (12.2%) experienced hemorrhagic transformation after thrombectomy. Average admitting NIHSS was significantly higher in the HT group (22 vs 16.8, p = 0.041). TICI 3 after MT was protective for HT (OR 0.078, 95% CI 0.009‐0.663). IV tPA (OR 3.86, 95% CI 1.448‐10.326) was associated with good neurological outcome at discharge (mRS &lt; = 2), but HT was not (OR 0.114, 95% CI 0.013‐0.964). Patients with mRS &lt; = 2 upon discharge were younger (65.2±12 vs 71.9±15, p = 0.04) and had lower initial BG (124±45.8 vs 157±69.6, P = 0.02). Conclusions : TICI 3 score, decreased NIHSS, and lower BG were associated with less HT and better outcomes in our MT cohort. Admitting NIHSS &gt; = 20 may be a reasonable threshold to predict HT after MT. Our findings are consistent with the TICI‐ASPECTS‐glucose (TAG) score to predict sICH; however, we used initial NIHSS as a surrogate for ASPECTS. Further studies may utilize additional quantitative measures such as CTP data to predict HT.