Tertiary Stroke Center Research Articles

Does stroke etiology influence outcome in the posterior circulation? An analysis of 107 consecutive acute basilar occlusion thrombectomies

Acute basilar artery occlusion (BAO) harbors a more guarded prognosis after thrombectomy compared with anterior circulation large-vessel occlusion. Whether this is a function of a greater proportion of atherosclerotic/intrinsic lesions is not well studied. The authors aimed to elucidate the prevalence and predictors of intracranial intrinsic atherosclerotic disease in patients with acute BAO and to compare angiographic and clinical outcomes between patients with BAO secondary to embolic versus intrinsic disease. A prospectively maintained stroke database was reviewed for all patients presenting between January 2013 and December 2019 to a tertiary care academic comprehensive stroke center with acute, nontandem BAO. Patient data were extracted, subdivided by stroke mechanism and treatment modality (embolic [thrombectomy only] and intrinsic [thrombectomy + stenting]), and angiographic and clinical results were compared. Of 107 patients, 83 (78%) had embolic occlusions (thrombectomy only) and 24 (22%) had intrinsic disease (thrombectomy + stenting). There was no significant difference in patient age, presenting National Institutes of Health Stroke Scale score, time to presentation, selected medical comorbidities (hypertension, hyperlipidemia, diabetes, and atrial fibrillation), prior stroke, and posterior circulation Alberta Stroke Program Early CT Score. Patients with intrinsic disease were more likely to be active smokers (50% vs 26%, p = 0.04) and more likely to be male (88% vs 48%, p = 0.001). Successful recanalization, defined as a modified Thrombolysis in Cerebral Infarction (mTICI) grade of 2b or 3, was achieved in 90% of patients and did not differ significantly between the embolic versus intrinsic groups (89% vs 92%, p > 0.99). A 90-day good outcome (modified Rankin Scale [mRS] score 0-2) was found in 37% of patients overall and did not differ significantly between the two groups (36% vs 41%, p = 0.41). Mortality was 40% overall and did not significantly differ between groups (41% vs 36%, p = 0.45). In the current study, demographic and clinical results for acute BAO showed that compared with intrinsic disease, thromboembolic disease is a more common mechanism of acute BAO, with 78% of patients undergoing thrombectomy alone. However, there was no significant difference in revascularization and outcome results between patients with embolic disease and those with intrinsic disease.

Is the weekend effect true in acute stroke patients at tertiary stroke center?

BackgroundThere is contradicting evidence on the outcome of emergency patients treated during weekends versus weekdays. We studied if outcome of ischemic stroke patients receiving intravenous thrombolysis (IVT) differs according to the treatment time. MethodsOur retrospective study included consecutive patients receiving IVT within 4.5 h of stroke onset between June 1995 and December 2018 at the Helsinki University Hospital. The patients were compared based on the treatment initiation either during weekdays (Monday to Friday) or weekend (Saturday and Sunday). The primary outcome was 3-month mortality and secondary outcomes comprised 3-month modified Rankin Scale (mRS) and incidence of symptomatic intracerebral hemorrhage (sICH). Additional analyses studied the effect of IVT treatment according to non-office hours, time of day, and season. ResultsOf the 3980 IVT-treated patients, 28.0% received treatment during weekends. Mortality was similar after weekend (10.0%) and weekday (10.6%) admissions in the multivariable regression analysis (OR 0.78; 95% CI 0.59–1.03). Neither 3-month mRS (OR 0.98; 95% CI 0.86–1.12), nor the occurrence of sICH (4.2% vs 4.6%; OR 0.87; 95% CI 0.60–1.26) differed between the groups. No outcome difference was observed between the office vs non-office hours or by the time of day. However, odds for worse outcome were higher during autumn (OR 1.19; 95% CI 1.04–1.35) and winter (OR 1.15; 95% CI 1.01–1.30). ConclusionWe did not discover any weekend effect for IVT-treated stroke patients. This confirms that with standardized procedures, an equal quality of care can be provided to patients requiring urgent treatment irrespective of time.

Admission Neutrophil to Lymphocyte Ratio for Predicting Outcome in Subarachnoid Hemorrhage

PurposeWe sought to evaluate the relationship between admission neutrophil-to-lymphocyte ratio (NLR) and functional outcome in aneurysmal subarachnoid hemorrhage (aSAH) patients. Material and methodsConsecutive patients with aSAH were treated at two tertiary stroke centers during a five-year period. Functional outcome was defined as discharge modified Rankin score dichotomized at scores 0-2 (good) vs. 3-6 (poor). Results474 aSAH patients were evaluated with a mean NLR 8.6 (SD 8.3). In multivariable logistic regression analysis, poor functional outcome was independently associated with higher NLR, older age, poorer clinical status on admission, prehospital statin use, and vasospasm. Increasing NLR analyzed as a continuous variable was independently associated with higher odds of poor functional outcome (OR 1.03, 95%CI 1.00-1.07, p=0.05) after adjustment for potential confounders. When dichotomized using ROC curve analysis, a threshold NLR value of greater than 6.48 was independently associated with higher odds of poor functional outcome (OR 1.71, 95%CI 1.07-2.74, p=0.03) after adjustment for potential confounders. ConclusionsHigher admission NLR is an independent predictor for poor functional outcome at discharge in aSAH patients. The evaluation of anti-inflammatory targets in the future may allow for improved functional outcome after aSAH.

Inadvertent hypothermia after endovascular therapy is not associated with improved outcome in stroke due to anterior circulation large vessel occlusion.

Hypothermia may be neuroprotective in acute ischemic stroke. Patients with anterior circulation large vessel occlusion (acLVO) are frequently hypothermic after endovascular therapy (EVT). We sought to determine whether this inadvertent hypothermia is associated with improved outcome. We extracted data of consecutive patients (January 2016 to May 2019) who received EVT for acLVO from our prospective EVT register of all patients screened for EVT at our tertiary stroke center. We assessed functional outcome at 3months and performed multivariate analysis to calculate adjusted risk ratios (aRRs) for favorable outcome (modified Rankin Scale scores = 0-2) and mortality across patients who were hypothermic (<36°C) and patients who were normothermic (≥36°C to <37.6°C) after EVT. Moreover, we compared the frequency of complications between these groups. Among 837 patients screened, 416 patients received EVT for acLVO and fulfilled inclusion criteria (200 [48.1%] male, mean age = 76±16years, median National Institutes of Health Stroke Scale score = 16, interquartile range [IQR] = 12-20). Of these, 209 patients (50.2%) were hypothermic (median temperature = 35.2°C, IQR = 34.7-35.7) and 207 patients were normothermic (median temperature = 36.4°C, IQR = 36.1-36.7) after EVT. In multivariate analysis, hypothermia was not associated with favorable outcome (aRR = 0.99, 95% confidence interval [CI] = 0.75-1.31) and mortality (aRR = 1.18, 95% CI = 0.84-1.66). More hypothermic patients suffered from pneumonia (36.4% vs. 25.6%, p=0.02) and bradyarrhythmia (52.6% vs. 16.4%, p<0.001), whereas thromboembolic events were distributed evenly (5.7% vs. 6.8%, not significant). Inadvertent hypothermia after EVT for acLVO is not associated with improved functional outcome or reduced mortality but is associated with an increased rate of pneumonia and bradyarrhythmia in patients with acute ischemic stroke.

Mean Platelet Volume as a Potential Marker of Large Vessel Occlusion and Predictor of Outcome in Acute Ischemic Stroke Patients Treated with Reperfusion Therapy.

(1) Background: An early diagnosis of a large vessel occlusion (LVO) is crucial in the management of the acute ischemic stroke (AIS). The laboratory predictors of LVO and a stroke outcome remain unknown. We have hypothesized that high MPV—a surrogate marker of the activated platelet—may be associated with LVO, and it may predict a worse AIS outcome. (2) Methods: This was a retrospective study of 361 patients with AIS who were treated with thrombolysis (tPA, 65.7%) and/or mechanical thrombectomy (MT, 34.3%) in a tertiary Stroke Center between 2011 and 2019. (3) Results: The mean MPV in the cohort was 9.86 ± 1.5 fL (1st–4th quartiles: <8.8, >10.80 fL). Patients in the 4th quartile compared to the 1st had a significantly (p < 0.01) more often incidence of an LVO related stroke (75% vs. 39%) and a severe stroke manifestation with a higher RACE score (5.2 ± 2.8 vs. 3.3 ± 2.4), NIHSS at baseline (mean ± SD, 14 ± 6.5 vs. 10.9 ± 5.2), and NIHSS at discharge (6.9 ± 7 vs. 3.9 ± 3.6). A multivariate analysis revealed that quartiles of MPV (OR 1.4; 95%CI 1.2–1.8) significantly predicted an LVO stroke, also after the adjustment for RACE < 5 (OR 1.4; 95%CI 1.08–1.89), but MPV quartiles did not predict a favorable stroke outcome (mRS ≤ 2) (OR 0.89; 95%CI 0.7–1.13). (4) Conclusion: Our data suggest that MPV is an independent predictor of LVO in patients with an acute ischemic stroke.

Delayed Neurological Improvement After Full Endovascular Reperfusion in Acute Anterior Circulation Ischemic Stroke.

We aimed to determine the prevalence and predictors of delayed neurological improvement (DNI) after complete endovascular reperfusion in anterior circulation acute ischemic stroke (AIS). Retrospective analysis of an online multicenter prospective reperfusion registry of patients with consecutive anterior circulation AIS treated with endovascular thrombectomy (EVT) from January 2018 to June 2019 in tertiary stroke centers of the NORDICTUS (NORD-Spain Network for Research and Innovation in ICTUS) network. We included patients with AIS with a proximal occlusion in whom a modified Thrombolysis in Cerebral Infarction 3 reperfusion pattern was obtained. DNI was defined if, despite absence of early neurological improvement during the first 24 hours, patients achieved functional independence on day 90. Clinical and radiological variables obtained before EVT were analyzed as potential predictors of DNI. Of 1565 patients with consecutive AIS treated with EVT, 1381 had proximal anterior circulation occlusions, 803 (58%) of whom achieved a modified Thrombolysis in Cerebral Infarction 3. Of these, 628 patients fulfilled all selection criteria and were included in the study. Mean age was 73.8 years, 323 (51.4%) were female, and median baseline National Institutes of Health Stroke Scale was 16. Absence of early neurological improvement was observed in 142 (22.6%) patients; 32 of these (22.5%) achieved good long-term outcome and constitute the DNI group. Predictors of DNI in multivariable-adjusted logistic regression were male sex (odds ratio, 6.4 [95% CI, 2.1–22.3] P=0.002), lower pre-EVT National Institutes of Health Stroke Scale score (odds ratio, 1.4 [95% CI, 1.2–1.5], P<0.001), and intravenous thrombolysis (odds ratio, 9.1 [95% CI, 2.7–30.90], P<0.001). One-quarter of patients with anterior circulation AIS who do not clinically improve within the first 24 hours after complete cerebral endovascular recanalization will achieve long-term functional independence, regardless of the poor early clinical course. Male sex, lower initial clinical severity, and use of intravenous thrombolysis before EVT predicted this clinical pattern.

Impact of intravenous alteplase on sub-angiographic emboli in high-resolution diffusion-weighted imaging following successful thrombectomy

ObjectiveThrombus microfragmentation causing peripheral emboli (PE) during mechanical thrombectomy (MT) may modulate treatment effects, even in cases with successful reperfusion. This study aims to investigate whether intravenous alteplase is of potential benefit in reducing PE after successful MT.MethodsPatients from a prospective study treated at a tertiary care stroke center between 08/2017 and 12/2019 were analyzed. The main inclusion criterion was successful reperfusion after MT (defined as expanded thrombolysis in cerebral infarction (eTICI) scale ≥ 2b50) of large vessel occlusion anterior circulation stroke. All patients received a high-resolution diffusion-weighted imaging (DWI) follow-up 24 h after MT for PE detection. Patients were grouped as “direct MT” (no alteplase) or as MT plus additional intravenous alteplase. The number and volume of ischemic core lesions and PE were then quantified and analyzed.ResultsFifty-six patients were prospectively enrolled. Additional intravenous alteplase was administered in 46.3% (26/56). There were no statistically significant differences of PE compared by groups of direct MT and additional intravenous alteplase administration regarding mean numbers (12.1, 95% CI 8.6–15.5 vs. 11.1, 95% CI 7.0–15.1; p = 0.701), and median volume (0.70 mL, IQR 0.21–1.55 vs. 0.39 mL, IQR 0.10–1.62; p = 0.554). In uni- and multivariable linear regression analysis, higher eTICI scores were significantly associated with reduced PE, while the administration of alteplase was neither associated with numbers nor volume of peripheral emboli. Additional alteplase did not alter reperfusion success.ConclusionsIntravenous alteplase neither affects the number nor volume of sub-angiographic DWI-PE after successful endovascular reperfusion. In the light of currently running randomized trials, further studies are warranted to validate these findings.Key Points• Thrombus microfragmentation during endovascular stroke treatment may cause peripheral emboli that are only detectable on diffusion-weighted imaging and may directly compromise treatment effects.• In this prospective study, the application of intravenous alteplase did not influence the occurrence of peripheral emboli detected on high-resolution diffusion-weighted imaging.• A higher degree of recanalization was associated with a reduced number and volume of peripheral emboli and better functional outcome, while contrariwise, peripheral emboli did not modify the effect of recanalization on modified Rankin Scale scores at day 90.

Novel peripheral blood cell ratios: Effective 3-month post-mechanical thrombectomy prognostic biomarkers for acute ischemic stroke patients

BackgroundRed blood cell distribution width to platelet ratio (RPR), Monocyte to high-density lipoprotein ratio (MHR), and Neutrophil to lymphocyte ratio (NLR) are novel inflammatory biomarkers in laboratory tests, which are associated with clinical outcomes in malignancy, cardiovascular and cerebrovascular diseases. This study aimed to determine their predictive value for the prognosis of acute ischemic stroke after mechanical thrombectomy (MT). MethodsA total of 286 patients with acute ischemic stroke (AIS) admitted to a tertiary stroke center in China between January 2018 and February 2020 were treated by MT. Demographic characteristics, risk factors, clinical data, laboratory parameters, and clinical outcomes were recorded. The clinical outcome was disability or death at discharge or 90 days (defined as a modified Rankin Scale score of 3–6). The relationship between RPR, MHR, and NLR and functional outcomes was investigated by binary Logistic regression analysis, and further assessed by receiver operating characteristic curve (ROC). The Kaplan-Meier method was used to analyze the survival rate of prognosis factors. ResultsA total of 286 patients with AIS underwent MT (median age, 70.00; Interquartile range [IQR], 63.00–77.00; 41.6% female). Patients with unfavorable outcome showed higher RPR, MHR, and NLR than those with favorable outcome (RPR, [8.63; IQR, 6.30–10.78] vs [6.17; IQR, 5.11–7.35], P < 0.001; MHR, [0.40; IQR, 0.31–0.53] vs [0.34; IQR, 0.27–0.47], P = 0.005; NLR, [5.28; IQR, 3.63–8.02] vs [3.44; IQR, 2.63–4.63], P < 0.001). In multivariate and ROC curve analysis, higher RPR (>8.565) (odds ratio [OR], 1.671; 95% confidence interval [CI], 1.127–2.479; P = 0.011) and higher MHR (>0.368) (OR, 9.374; 95% CI, 1.160–75.767; P = 0.036), higher NLR (>4.030) (OR, 1.957; 95% CI, 1.382–2.770; P < 0.001) were independently associated with unfavorable outcome. The combined predictive value of the three indexes was higher than that of a single index. Kaplan-Meier survival curve analysis showed that the 90-day survival rate (82.1% vs 66.2%) was significantly different between the low RPR group and the high RPR group (χ2 = 4.960, P = 0.026). ConclusionHigher RPR, MHR, and NLR might be independent risk factors for predicting 3-month poor prognosis in patients with AIS who underwent MT.

Automating Stroke Data Extraction From Free-Text Radiology Reports Using Natural Language Processing: Instrument Validation Study.

BackgroundDiagnostic neurovascular imaging data are important in stroke research, but obtaining these data typically requires laborious manual chart reviews.ObjectiveWe aimed to determine the accuracy of a natural language processing (NLP) approach to extract information on the presence and location of vascular occlusions as well as other stroke-related attributes based on free-text reports.MethodsFrom the full reports of 1320 consecutive computed tomography (CT), CT angiography, and CT perfusion scans of the head and neck performed at a tertiary stroke center between October 2017 and January 2019, we manually extracted data on the presence of proximal large vessel occlusion (primary outcome), as well as distal vessel occlusion, ischemia, hemorrhage, Alberta stroke program early CT score (ASPECTS), and collateral status (secondary outcomes). Reports were randomly split into training (n=921) and validation (n=399) sets, and attributes were extracted using rule-based NLP. We reported the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and the overall accuracy of the NLP approach relative to the manually extracted data.ResultsThe overall prevalence of large vessel occlusion was 12.2%. In the training sample, the NLP approach identified this attribute with an overall accuracy of 97.3% (95.5% sensitivity, 98.1% specificity, 84.1% PPV, and 99.4% NPV). In the validation set, the overall accuracy was 95.2% (90.0% sensitivity, 97.4% specificity, 76.3% PPV, and 98.5% NPV). The accuracy of identifying distal or basilar occlusion as well as hemorrhage was also high, but there were limitations in identifying cerebral ischemia, ASPECTS, and collateral status.ConclusionsNLP may improve the efficiency of large-scale imaging data collection for stroke surveillance and research.

Frequency, clinical presentation and outcome of vigilance impairment in patients with uni- and bilateral ischemic infarction of the paramedian thalamus

Ischemic stroke of the paramedian thalamus is a rare differential diagnosis in sudden altered vigilance states. While efforts to describe clinical symptomatology exist, data on the frequency of paramedian thalamic stroke as a cause of sudden impaired vigilance and on accompanying clinical signs and outcome are scarce. We retrospectively analyzed consecutive patients admitted to a tertiary stroke center between 2010 and 2019 diagnosed with paramedian thalamic stroke. We evaluated frequency of vigilance impairment (VI) due to paramedian thalamic stroke, accompanying clinical signs and short-term outcome in uni- versus bilateral paramedian lesion location. Of 3896 ischemic stroke patients, 53 showed a paramedian thalamic stroke location (1.4%). VI was seen in 29/53 patients with paramedian thalamic stroke and in 414/3896 with any stroke (10.6%). Paramedian thalamic stroke was identified as causal to VI in 3.4% of all patients with initial VI in the emergency department and in 0.7% of all ischemic stroke patients treated in our center. Accompanying clinical signs were detected in 21 of these 29 patients (72.4%) and facilitated a timely diagnosis. VI was significantly more common after bilateral than unilateral lesions (92.0% vs. 21.4%; p < 0.001). Patients with bilateral paramedian lesions were more severely affected, had longer hospital stays and more frequently required in-patient rehabilitation. Paramedian thalamic lesions account for about 1 in 15 stroke patients presenting with impaired vigilance. Bilateral paramedian lesion location is associated with worse stroke severity and short-term outcome. Paying attention to accompanying clinical signs is of importance as they may facilitate a timely diagnosis.

The stroke care landscape for 2021

British Journal of Neuroscience NursingVol. 17, No. Sup2 EditorialThe stroke care landscape for 2021Mary O'HaraMary O'HaraSearch for more papers by this authorMary O'HaraPublished Online:26 Apr 2021https://doi.org/10.12968/bjnn.2021.17.Sup2.S3AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References D'Anna L, Brown M, Oishi S et al.. Impact of national lockdown on the hyperacute stroke care and rapid transient ischaemic attack outpatient service in a comprehensive tertiary stroke centre during the COVID-19 pandemic. Front Neurol. 2021;12:37. https://doi.org/10.3389/fneur.2021.627493 Crossref, Google ScholarDepartment of Health and Social Care. Guidance on care home visiting. 2021. https://tinyurl.com/3eb4hpav (accessed 25 March 2021) Google ScholarNHS England/NHS Improvement. Integrating care: Next steps to building strong and effective integrated care systems across England. 2021. https://tinyurl.com/edvp5uc4 (accessed 25 March 2021) Google Scholar FiguresReferencesRelatedDetails 1 April 2021Volume 17Issue Sup2ISSN (print): 1747-0307ISSN (online): 2052-2800 Metrics History Published online 26 April 2021 Published in print 1 April 2021 Information© MA Healthcare LimitedPDF download

Consequences of COVID-19 pandemic lockdown on emergency and stroke care in a German tertiary stroke center

BackgroundCOVID-19 pandemic caused a decline in stroke care in several countries. The objective was to describe lockdown stroke care in a tertiary stroke center in Düsseldorf, Germany near Heinsberg, a German hot spot for COVID-19 in spring 2020.MethodsIn a retrospective, observational, single-center study, we compared all patients treated in our emergency department (ED), patients seen by a neurologist in the ED, ED patients suffering from ischemic and hemorrhagic strokes and transient ischemic attacks (TIAs) as well as stroke patients admitted to our stroke unit during lockdown in spring 2020 (16 March 2020–12 April 2020) to those cared for during the same period in 2019 and lockdown light in fall 2020 (2 November – 29 November 2020).ResultsIn spring 2020 lockdown the mean number of patients admitted to our ED dropped by 37.4%, seen by a neurologist by 35.6%, ED stroke patients by 19.2% and number of patients admitted to our stroke unit by 10% compared to the same period in 2019. In fall lockdown light 2020 effects were comparable but less pronounced. Thrombolysis rate was stable during spring and fall lockdown, however, endovascular treatment (EVT) rate declined by 58% in spring lockdown and by 51% in fall lockdown compared to the period in 2019.ConclusionsOur study indicates a profound reduction of overall ED patients, neurological ED patients and EVT during COVID-19 pandemic caused lockdowns. Planning for pandemic scenarios should include access to effective emergency therapies.

Abstract P404: Causes of Recrudescent Stroke Symptoms in Emergent Stroke Evaluations

Introduction: Recrudescent symptoms of remote central nervous system lesions (primarily due to prior ischemic or hemorrhagic stroke) is a specific stroke mimic that is commonly in the differential diagnosis in patients presenting for emergent stroke evaluation. To date, best practices have yet to be established in terms of ensuring accurate diagnosis and the relative rates of causative systemic illnesses are not well described. We seek to better delineate the etiologies of recrudescent stroke symptoms seen at a tertiary care medical center via emergency stroke evaluation “Code Brain” (CB) as a first step towards clarifying diagnostic criteria for this entity. Methods: Data was obtained via retrospective chart review from consecutive patients via departmental database listing all CB consults seen at a tertiary care comprehensive stroke center in Los Angeles, California between the timeframe of January 2018- June 2020. Diagnoses for each case were adjudicated by faculty Vascular neurologists, in collaboration with Vascular neurology fellows and Neurology residents. Those cases with a diagnosis of stroke recrudescence were reviewed in detail for the extent of neuroimaging they underwent, as well as for identified causes of recrudescence. Results: Records of 3,998 consecutive CB activations were reviewed. 2.1% (n=85) were found after screening to have clinical diagnosis of recrudescence or chronic stroke. Of these 85 patients, 29.4% (n=25) were not found to have a causative etiology for recrudescent neurologic deficit. Of these 25 patients, 36.0% (n=9) did not undergo MRI to evaluate for interval ischemic lesion, as compared to 46.6% of those whom a causative etiology was identified. This difference (10.6%, 95% CI -12.30 to 30.67%, p=0.3719) was not significant. Discussion: At our comprehensive stroke center, recrudescent stroke is an uncommon diagnosis amongst all CB evaluations, despite being commonly considered. Despite a diagnosis of recrudescence, MRI brain is not always performed to rule out acute ischemic stroke. Standardized neuroimaging protocols should be considered in making the diagnosis of stroke recrudescence.

Abstract P282: Which Telestroke Transfers to the Hub Expire or Receive Hospice Within 48 Hours of Arrival?

Introduction: Telestroke (TS) expands access to acute stroke care and facilitates swift transfer of patients to tertiary stroke centers. However, patients transferred from spoke hospitals who expire shortly after arrival raises the question of whether there is opportunity to predict futility of transfer to a higher level of care. We examined acute ischemic stroke (AIS) patients transferred to our hub from TS spoke hospitals and identified who expired or went on to hospice within 48 hours of arrival. Methods: In our TS network, we identified AIS patients who were transferred from spoke hospitals following TS consultation (9/2015 - 12/2018). We compared demographic and clinical characteristics of patients who expired or went on to hospice within the first 48 hours versus those who did not. Hospice decision time was determined by chart review for documentation of goals of care discussions. Results: Of 530 transfers to the hub, there were 32 (6%) patients who expired or went on to hospice within 48 hours. Compared to those who did not, these patients had increased age (OR 1.08; 95% CI 1.05-1.12), higher incidence of atrial fibrillation (OR 2.24; 95% CI 1.02-4.90) or cancer (OR 3.04; 95% CI 1.17-7.87), higher pre-morbid mRS (OR 5.14; 95% CI 1.57-16.88), and higher NIHSS (OR 1.23; 95% CI 1.16-1.31). Interestingly, the same characteristics were also significantly different in those who expired or went on to hospice beyond 48 hours. There was no significant difference in demographic characteristics of sex and race/ethnicity. There was also no significant difference in the frequency of treatment with tPA or IAT; of the 32 patients who expired or went on to hospice within 48 hours, 21 (66%) had received tPA and 3 (9%) had undergone IAT. Palliative care was consulted for 31 (97%) of those patients. Conclusions: A relatively small but significant proportion of TS transfers to our hub expired or went on to hospice within 48 hours. These patients were characterized by increased age, poorer pre-stroke functional status and high stroke severity. In light of the current strain on resources with the pandemic, telepalliative services may help to better serve certain patients, in particular those who are elderly or debilitated, at spoke hospitals without the need for transfer to hub.

Abstract P855: Importance of Compliance in Dysphagia Screening in Acute Stroke Care

Introduction: Dysphagia occurs in up to two thirds of stroke patients and can lead to serious complications such as aspiration pneumonia, which is also linked to increased morbidity and mortality. Evidence-based guidelines recommend a bedside dysphagia assessment before oral intake in stroke patients regardless of initial stroke severity. Several studies have described registered nurses’ competency in terms of knowledge and skills regarding dysphagia screening. We aimed to examine the rate of aspiration pneumonia compared to the rate of dysphagia screening. Methods: A retrospective analysis of prospectively collected data at a single tertiary stroke center was carried out between January 2017 and June 2020. Data comparison was completed utilizing ICD-10 diagnosis codes to identify aspiration pneumonia in ischemic and hemorrhagic stroke patients. The data was reviewed to compare the compliance of a completed dysphagia screen prior to any oral intake to rate of aspiration pneumonia. Chi square tests were used to assess proportion differences in completed dysphagia screen and proportion of aspiration pneumonia diagnosis in the ischemic and hemorrhagic stroke patients. Results: We identified 3320 patient that met inclusion criteria. 67% were ischemic strokes, 22% were intracerebral hemorrhages and 11% were subarachnoid hemorrhages. Compliance with dysphagia screening decreased from 94.2% (n=1555/1650) in 2017-2018 to 74.0% (n=1236/1670) in 2019-2020, OR=0.17 (95%CI 0.14 - 0.22), p &lt; 0.0001. Aspiration pneumonias increased from 58 (3.5%) in 2017-2018 to 77 (4.6%) in 2019-2020, but this difference was not statistically significant, OR=0.75 (95%CI 0.53 - 1.07), p = 0.11. Conclusion: We noted that the decrease in compliance with completing a dysphagia screen in patients with acute stroke prior to any oral intake was associated with a higher trend of aspiration pneumonia.

Impact of National Lockdown on the Hyperacute Stroke Care and Rapid Transient Ischaemic Attack Outpatient Service in a Comprehensive Tertiary Stroke Centre During the COVID-19 Pandemic.

Background: The COVID-19 pandemic is having major implications for stroke services worldwide. We aimed to study the impact of the national lockdown period during the COVID-19 outbreak on stroke and transient ischemic attack (TIA) care in London, UK.Methods: We retrospectively analyzed data from a quality improvement registry of consecutive patients presenting with acute ischemic stroke and TIA to the Stroke Department, Imperial College Health Care Trust London during the national lockdown period (between March 23rd and 30th June 2020). As controls, we evaluated the clinical reports and stroke quality metrics of patients presenting with stroke or TIA in the same period of 2019.Results: Between March 23rd and 30th June 2020, we documented a fall in the number of stroke admissions by 31.33% and of TIA outpatient referrals by 24.44% compared to the same period in 2019. During the lockdown, we observed a significant increase in symptom onset-to-door time in patients presenting with stroke (median = 240 vs. 160 min, p = 0.020) and TIA (median = 3 vs. 0 days, p = 0.002) and a significant reduction in the total number of patients thrombolysed [27 (11.49%) vs. 46 (16.25%, p = 0.030)]. Patients in the 2020 cohort presented with a lower median pre-stroke mRS (p = 0.015), but an increased NIHSS (p = 0.002). We registered a marked decrease in mimic diagnoses compared to the same period of 2019. Statistically significant differences were found between the COVID and pre-COVID cohorts in the time from onset to door (median 99 vs. 88 min, p = 0.026) and from onset to needle (median 148 vs. 126 min, p = 0.036) for thrombolysis whilst we did not observe any significant delay to reperfusion therapies (door-to-needle and door-to-groin puncture time).Conclusions: National lockdown in the UK due to the COVID-19 pandemic was associated with a significant decrease in acute stroke admission and TIA evaluations at our stroke center. Moreover, a lower proportion of acute stroke patients in the pandemic cohort benefited from reperfusion therapy. Further research is needed to evaluate the long-term effects of the pandemic on stroke care.

Delivering telemedicine consultations for patients with transient ischaemic attack during the COVID-19 pandemic in a comprehensive tertiary stroke centre in the United Kingdom.

Background and purposeThe global COVID‐19 pandemic led many stroke centres worldwide to shift from in‐person to telemedicine consultations to assess patients with transient ischaemic attacks (TIAs). We aimed to investigate the impact of telemedicine during the COVID‐19 pandemic on the management and outcome of the patients with TIA.MethodsWe retrospectively analysed data from a registry of consecutive TIA patients assessed at the Stroke Department, Imperial College Health Care Trust, London, during the national lockdown period (between March 23 2020 and 30 June 2020). As controls, we evaluated the clinical reports and stroke quality metrics of patients presenting to the TIA clinic in the same period of 2019.ResultsBetween 23 March 2020 and 30 June 2020, 136 patients were assessed using the telemedicine TIA clinic, compared to 180 patients evaluated with face‐to‐face consultation in the same period in 2019. Patients’ characteristics were similar in both groups. At 3 months after the TIA, there were no significant differences in the proportion of patients admitted to the hospital for recurrent TIA/stroke or any other cardiovascular cause from the 2020 period compared to the same period in 2019.ConclusionsOur analysis showed that during the pandemic, our telemedicine consultations of TIA patients were not associated with an increased 3‐month rate of recurrent TIA/stroke or cardiovascular hospital admissions. More robust studies looking at this model of care will be needed to assess its long‐term effects on patients and health care systems.

Mitigating the impact of coronavirus disease 2019 on emergency stroke care: an original study and meta-analysis.

The coronavirus disease 2019 is still continuing and may affect stroke emergency care. We aim to investigate the impact of pandemic on stroke treatment in tertiary stroke centers in western China, and to quantitatively evaluate the worldwide influence with a meta-analysis. The original part was conducted in three tertiary stroke centers in Sichuan province. We compared emergency visits and efficiency of stroke treatment pre-, early, peak and late pandemic. Single-center analysis was further conducted in the largest local hospital and one hospital located close to the epicenter respectively. Relevant studies were searched in PubMed, Ovid Embase and Cochrane Library for English publications from December 2019 to July 2020 for systematic review. Fixed-and random-effect meta-analysis was performed to calculate the overall rates.Totally current original study showed fewer time of hospital admission and significantly higher rates of mechanical thrombectomy during the early and peak epidemic periods, compared with pre-epidemic time. The largest local hospital had significantly higher mechanical thrombectomy rates during the whole crisis and less daily admission during early and peak epidemic periods. The hospital located close to the epicenter presented higher proportions of intravenous thrombolysis since outbreak, and more favorable outcomes after reperfusion therapies than later (all P values <0.05). In meta-analysis, studies reported differences in reperfusion therapies and stroke severity but pooled results were non-significant. Overall, comprehensive measures should be implemented to keep hospital's capacity to deliver high-quality stroke emergency care during the global pandemic. Some key messages were provided for medical practice in the crisis.

Real-world comparative safety and efficacy of tenecteplase versus alteplase in acute ischemic stroke patients with large vessel occlusion.

Background and aims:Tenecteplase has recently emerged as an alternative thrombolytic agent in acute ischemic stroke (AIS) patients with large vessel occlusion (LVO), possibly superior in achieving early reperfusion compared with alteplase. We aimed to compare the safety and efficacy of intravenous tenecteplase with intravenous alteplase for AIS patients with LVO in everyday clinical practice settings.Methods:We prospectively evaluated patients with AIS due to LVO, treated with intravenous thrombolysis (IVT) with or without mechanical thrombectomy in two tertiary stroke centers. Patients were treated with standard-dose alteplase (0.9 mg/kg) or 0.25 mg/kg tenecteplase. Safety outcomes included prevalence of symptomatic intracranial hemorrhage (sICH) and mortality. Efficacy outcomes included averted thrombectomy, major neurological improvement at 24 h (defined as decrease in baseline NIHSS score of 8 points or greater) and functional status on discharge and on 3 months assessed by modified Rankin Scale (mRS).Results:Nineteen AIS patients with LVO received tenecteplase and 39 received alteplase. We observed a non-significant higher rate of averted thrombectomies (32% versus 18%, p = 0.243) and a non-significant higher rate of sICH (16% versus 5%, p = 0.201) in the tenecteplase group. The rate of 24 h major neurological improvement was higher in the tenecteplase group (64% versus 33%, p = 0.046) but this was marginally attenuated in multivariable analyses (adjusted OR 10.22, 95% CI: 0.73–142.98; p = 0.084). Discharge mRS, 3-months mRS, and 3-month functional independence (mRS scores of 0–2) did not differ (p > 0.2) between the two groups. The rates of 3-month mortality (11% versus 18%, p = 0.703) were similar in the two groups. No independent association between thrombolytic agent and safety or efficacy outcomes emerged in multivariable regression analyses.Conclusion:The present pilot observational study highlights that AIS patients with LVO treated with 0.25 mg/kg bolus administration of tenecteplase had increased likelihood to achieve early neurological improvement compared with AIS patients treated with alteplase, but this association was attenuated after adjustment for potential confounders. There were no significant differences in 3-month functional or safety outcomes between the two groups. This preliminary real-world observation requires independent confirmation in larger, multicenter studies.

Gaze Deviation and Paresis Score (GPS) Sufficiently Predicts Emergent Large Vessel Occluding Strokes

ObjectivesThe prognosis of patients with acute ischemic stroke (AIS) essentially depends on both prompt diagnosis and appropriate treatment. Endovascular stroke therapy (EST) proved to be highly efficient in the treatment of emergent large vessel occluding (ELVO) strokes in the anterior circulation. To achieve a timely diagnosis, a robust combination of few and simple signs to identify ELVOs in AIS patients applicable by paramedics in the prehospital triage is worthwhile. Materials and MethodsThis retrospective single-center study included 904 AIS patients (324 ELVO, 580 non-ELVO) admitted between 2010 and 2015 in a tertiary stroke center. We re-evaluated two symptoms based on NIHSS items, gaze deviation and hemiparesis of the limbs (“Gaze deviation and Paresis Score, GPS”) for the pre-hospital prediction of ELVO. ResultsA positive GPS AIS in patients predicted ELVO with a sensitivity of 0.89, specificity = 0.97, positive predictive value (PPV) = 0.95, negative predictive value (NPV) = 0.94 and diagnostic odds ratio (DOR) = 34.25 (CI: 20.75–56.53). The positive Likelihood-ratio (LR+) was 29.67, the negative Likelihood ratio (LR−) 0.11. NIHSS of patients with positive GPS (gaze palsy NIHSS ≥ 0, Motor arm NIHSS ≥2 and Motor leg NIHSS ≥2) was markedly higher compared to negative GPS patients (p < 0.001). ConclusionsThe GPS proved to be similarly accurate in detecting ELVO in the anterior circulation of AIS patients and even more specific than other published clinical scores. Its simplicity and clarity might enable non-neurological medical staff to identify ELVO AIS patients with high certainty in a preclinical setting.