Tertiary Stroke Center Research Articles

Abstract 43: Is Dual Antiplatelet Therapy Underutilized Following TIA And Minor Stroke?

Background: Initiation of dual antiplatelet therapy (DAPT) with aspirin and clopidogrel plays a significant role in the secondary prevention of recurrent acute ischemic events following high risk transient ischemic attack (TIA) and minor acute ischemic stroke (AIS). However, some patients do not receive the same targeted therapy on discharge and are only maintained on single antiplatelet therapy. Our aim was to identify the variations in single vs dual antiplatelet prescribing practices at the time of discharge within a Stroke Clinical Network consisting of nine stroke centers located in rural, suburban, and urban geographical regions. Methods: The GWTG registry was queried for all patients >18 years old with a TIA or a minor AIS (admission NIHSS ≤5), who were admitted to a single hospital network between January 2018 and December 2021. Demographics collected including age, race, gender, and BMI. Patients on concurrent anticoagulation were excluded. We evaluated antiplatelet discharge practices at the tertiary stroke center vs the entire network, among men vs. women, African Americans (AA) vs whites, age 18-70 vs >70 years, and across BMI. Chi squared and generalized linear models were used to test significant relationships between subgroups. Results: Among 2953 patients with a TIA or minor AIS, the mean age was 67.3 (SD +/- 13.8 years), with 42% >70 years of age. 47.8% were women; 37% were AA and 60% were white. DAPT was prescribed at the time of discharge to 40% of patients overall. Gender was a significant factor with men (43%) more likely to get prescribed DAPT than females (37%) (p=.002). While BMI did not have a lone effect on number of antiplatelets (AP) prescribed, when it was included as a covariate, there was a significant effect on the number of AP prescribed; with the higher the BMI, the less likely patients were to receive DAPT. Differences according to age, race, and effect of whether the patient was discharged from a tertiary center were not significant. Conclusion: We identified underutilization of DAPT following TIA and minor stroke across a health system, especially in women. Targeted intervention to increase DAPT use could lead to reduced rate of short-term stroke recurrence.

Abstract WMP85: Mobile Stroke Unit: Direct To Angio Or Some Stops Along The Way?

Introduction: Reducing the time from last known well to recanalization are associated with better functional outcomes and lower mortality in ischemic stroke. Recent data suggests that a “direct to angio” approach might improve the outcome of stroke patients with suspected emergent large vessel occlusion (ELVO). In this study, we aim to describe our direct-to-angiography vs those taken for additional imaging-first experience in our mobile stroke unit (MSU). Methods: Retrospective chart review from 2014 until 2022 was done. Patients with acute ischemic stroke due to ELVO arriving via MSU to our tertiary care comprehensive stroke center were included. We compared outcomes of those who went directly to the angiography suite versus those who underwent additional imaging studies first. Results: 14 patients with ELVO went directly to angio (DTA group) compared to 52 patients who underwent additional imaging (CTA group). There were no differences in age, gender, pre-morbid vascular risk factors or presenting symptoms. The DTA group had a higher median initial NIHSS and a higher interquartile range when compared to the CTA group but not significant. The DTA group received more thrombolytic therapy compared to the CTA group (p = 0.03). The DTA group had better door-to-groin times (median 39 minutes) compared to the CTA group (median 51.5 minutes) (p = 0.02). TICI 0 - 2a was more frequently seen in the DTA group (35.7%) compared to the CTA group (9.6%) (p = 0.03). Mortality was significantly higher in the DTA group compared to the CTA group (35% vs. 9%; p = 0.028) but there was no difference in functional outcomes amongst groups (mRS 0 - 2 28% vs 17%; p = 0.45). There was a non-significantly higher incidence of tandem occlusions in the DTA group (28.5%) compared to the CTA group (28.5% vs. 15%; p = 0.43). Conclusions: In our analysis, those going direct to angiography from the MSU had less successful recanalization and increased mortality. These findings could also be related to the higher rate of tandem occlusions in the DTA group. Due to head only scanning being available on MSU, additional information from in-hospital scanning may offer other information which may influence selection of patients for the procedure. Further analysis of these paradigms, particularly on MSUs, are warranted.

Clinical and Imaging Phenotypes and Outcomes in a Costa Rican Cohort of Acute Ischemic Stroke Survivors: A Retrospective Study.

We characterized clinical and imaging phenotypes and their association with clinical outcomes in acute ischemic stroke (AIS) survivors in the understudied region of Costa Rica. We conducted a retrospective cohort study in AIS patients treated at a tertiary stroke center in Costa Rica from 2011-2015. Participants underwent detailed phenotyping for cardiovascular risk factors and stroke etiology. We assessed the association of ischemic brain lesion features and clinical outcomes using the Oxfordshire Community Stroke Project (OCSP) classification. We included 684 AIS survivors (60.2% males, aged 68.1 ± 13.6 years, mean ± SD). While the cardiovascular risk profiles and mortality rates of our patients were similar to populations in European and North American countries, only 20.2% of patients with atrial fibrillation (AF) received anticoagulation. On multivariable analysis, patients with total anterior circulation infarct (TACI) displayed an increased risk of complications (OR: 4.2; 95% CI: 2.2-7.8; p < 0.001), higher mortality (OR: 6.9; 95% CI: 2.9-16.1; p < 0.001) and lower chance of functional independence at discharge (OR: 8.9; 95% CI: 4.1-19; p < 0.001) compared to non-TACI. The comorbidity of bronchopneumonia increased the probability of death by 14.5 times. Our observations in a Costa Rican cohort of AIS survivors might help improve local measures for preventing and managing AIS.

Comparative Analysis of Tertiary Stroke Center: Factors Affecting the 3&lt;sup&gt;rd&lt;/sup&gt; Month Clinical Outcome of Patients Treated with Thrombolytic Treatment

Comparative Analysis of Tertiary Stroke Center: Factors Affecting the 3&lt;sup&gt;rd&lt;/sup&gt; Month Clinical Outcome of Patients Treated with Thrombolytic Treatment

Multilesion Segmentations in Patients with Intracerebral Hemorrhage: Reliability of ICH, IVH and PHE Masks.

Background and Purpose: Fully automated methods for segmentation and volume quantification of intraparenchymal hemorrhage (ICH), intraventricular hemorrhage extension (IVH), and perihematomal edema (PHE) are gaining increasing interest. Yet, reliabilities demonstrate considerable variances amongst each other. Our aim was therefore to evaluate both the intra- and interrater reliability of ICH, IVH and PHE on ground-truth segmentation masks. Methods: Patients with primary spontaneous ICH were retrospectively included from a German tertiary stroke center (Charité Berlin; January 2016−June 2020). Baseline and follow-up non-contrast Computed Tomography (NCCT) scans were analyzed for ICH, IVH, and PHE volume quantification by two radiology residents. Raters were blinded to all demographic and outcome data. Inter- and intrarater agreements were determined by calculating the Intraclass Correlation Coefficient (ICC) for a randomly selected set of patients with ICH, IVH, and PHE. Results: 100 out of 670 patients were included in the analysis. Interrater agreements ranged from an ICC of 0.998 for ICH (95% CI [0.993; 0.997]), to an ICC of 0.979 for IVH (95% CI [0.984; 0.993]), and an ICC of 0.886 for PHE (95% CI [0.760; 0.938]), all p-values < 0.001. Intrarater agreements ranged from an ICC of 0.997 for ICH (95% CI [0.996; 0.998]), to an ICC of 0.995 for IVH (95% CI [0.992; 0.996]), and an ICC of 0.980 for PHE (95% CI [0.971; 0.987]), all p-values < 0.001. Conclusion Manual segmentations of ICH, IVH, and PHE demonstrate good-to-excellent inter- and intrarater reliabilities, with the highest agreement for ICH and IVH and lowest for PHE. Therefore, the degree of variances reported in fully automated quantification methods might be related amongst others to variances in ground-truth masks.

Thrombectomy with or without Bridging Thrombolysis for Anterior Circulation Stroke.

Currently, there is still no clear consensus on bridging thrombolysis (BT) before mechanical thrombectomy (MT). In this study, we aimed to compare clinical and procedural outcomes and complication rates of BT versus direct mechanical thrombectomy (d-MT) in anterior circulation stroke. A total of 359 consecutive anterior circulation stroke patients who received d-MT or BT in our tertiary stroke center between January 2018 and December 2020 were retrospectively analyzed. The patients were divided into two groups as Group d-MT (n = 210) and Group BT (n = 149). The primary outcome was the impact of BT on clinical and procedural outcomes, whereas the secondary outcome was the safety of BT. The incidence of atrial fibrillation was higher in the d-MT group (p = 0.010). The median duration of the procedure was significantly higher in Group d-MT than in Group BT (35 vs 27 min, respectively; P = 0.044). The number of patients achieving good and excellent outcomes was significantly higher in Group BT (p = 0.006 and P = 0.03). The edema/malign infarction rate was higher in the d-MT group (p = 0.003). Successful reperfusion, first-pass effects, symptomatic intra-cranial hemorrhage, and mortality rates were similar between the groups (p > 0.05). In this study, BT seems to yield better clinical and procedural outcomes with lower complication rates than d-MT. These findings may support the additional value of intravenous alteplase in anterior system strokes. Further large-scale, prospective, randomized-controlled studies will clarify the gray lines in this consensus, but this paper is important for reflecting the real-world data in developing countries.

Predicting Factors for Seizures after Cerebral Venous Thrombosis: A Retrospective Single Center Cohort Study.

Seizures are a common complication of cerebral venous thrombosis. In this study, we intended to define clinical and neuroradiological factors associated with early and late seizures and predictors for seizure recurrence. The database of our high-volume tertiary stroke center was screened for patients diagnosed with cerebral venous thrombosis between April 2006 and July 2021. Demographics, clinical, imaging, and instrumental data were collected. Out of a total of 80 patients, 30 had seizures, either within the first week after onset (22 patients) or after (8 patients). Speech impairment and intracerebral bleeding were statistically associated with seizures in univariate analysis, but in a logistic regression model, only brain damage with hemorrhagic infarct and/or presence of brain hematoma [OR 6.051; 95% CI 1.881-19.468] (p = 0.003) were predicting factors for seizures. Late seizures were significantly more frequent in younger age [OR 0.864; 95% CI 0.763-0.978] (p = 0.020). Early seizures resulted as protective factors for recurrence; an altered state of consciousness at baseline and late seizures resulted as predictive factors for relapses (0.0% vs. 81.0%, p = 0.005, and 100.0% vs. 19.0%, p &lt; 0.005, respectively). Our study confirms brain bleeding as the strongest risk factor for seizures after cerebral venous thrombosis. Recurrence is unusual after early seizures, while the presence of late seizures seems to raise the risk of recurrence.

Exact Basilar Artery Occlusion Location Indicates Stroke Etiology and Recanalization Success in Patients Eligible for Endovascular Stroke Treatment

IntroductionEndovascular stroke treatment (EST) is commonly performed for acute basilar artery occlusion (BAO). We aimed to identify the role of the exact location of BAO in patients receiving EST regarding the stroke etiology, recanalization success and prediction of favorable clinical outcome.MethodsRetrospective analysis of 191 consecutive patients treated for BAO with EST from 01/2013 until 06/2021 in a tertiary stroke center. Groups were defined according to exact location of BAO in I: proximal third, II: middle third, III: distal third and IV: tip of the basilar artery. Univariate and multivariate analyses were performed for BAO location comparing stroke etiology, recanalization result and favorable clinical outcome according to mRS 0–3 90 days after stroke onset.ResultsOcclusion sides types I–IV were evenly distributed (37, 36, 60 and 58 patients). Types I and II were more often associated with large artery atherosclerosis (50 vs. 10 patients, p < 0.001). Distal/tip occlusion (types III/IV) occurred mostly in cardiac embolism or embolic stroke of unknown source (89 vs. 12 in types I/II, p < 0.001). Occlusion site correlated with the underlying stroke etiology (AUC [Area under the curve] 0.89, p < 0.0001, OR [odds ratio] for embolism in type IV: 245). Recanalization rates were higher in patients with distal occlusions (type III/IV OR 3.76, CI [95% confidence interval] 1.51–9.53, p = 0.0076). The BAO site is not predicting favorable clinical outcome.ConclusionThe exact basilar artery occlusion site in patients eligible for endovascular stroke treatment reflects the stroke etiology and is associated with differing recanalization success but does not predict favorable clinical outcome.

Potential Embolic Sources in Embolic Stroke of Undetermined Source Patients with Patent Foramen Ovale

Introduction: A patent foramen ovale (PFO) may coexist with other potential embolic sources (PESs) in patients with embolic stroke of undetermined source (ESUS), leading to difficulty in attributing the stroke to either the PFO or other PESs. We aimed to investigate the prevalence and predictors of concomitant PESs in ESUS patients with PFOs. Methods: A retrospective cohort study was conducted in a tertiary stroke centre. Consecutive patients with ESUS and a concomitant PFO admitted between 2012 and 2021 were included in the study. Baseline characteristics and investigations as a part of stroke workup including echocardiographic and neuroimaging data were collected. PESs were adjudicated by 2 independent neurologists after reviewing the relevant workup. Results: Out of 1,487 ESUS patients, a total of 309 patients who had a concomitant PFO with mean age of 48.8 ± 13.2 years were identified during the study period. The median Risk of Paradoxical Embolism (RoPE) score for the study cohort was 6 (IQR 5–7.5). Of the 309 patients, 154 (49.8%) only had PFO, 105 (34.0%) patients had 1 other PES, 34 (11.0%) had 2 PES, and 16 (5.2%) had 3 or more PES. The most common PESs were atrial cardiopathy (23.9%), left ventricular dysfunction (22.0%), and cardiac valve disease (12.9%). The presence of additional PESs was associated with age ≥60 years (p < 0.001), RoPE score ≤6 (p ≤0.001), and the presence of comorbidities including diabetes mellitus (p = 0.004), hypertension (p≤ 0.001), and ischaemic heart disease (p = 0.011). Conclusion: A large proportion of ESUS patients with PFOs had concomitant PESs. The presence of concomitant PESs was associated with older age and a lower RoPE score. Further, large cohort studies are warranted to investigate the significance of the PES and their overlap with PFOs in ESUS.

In-hospital predictors of post-stroke depression for targeted initiation of Selective Serotonin Reuptake Inhibitors (SSRIs)

BackgroundAlthough SSRIs are no longer widely prescribed for post-stroke motor recovery, fluoxetine demonstrated beneficial effects on post-stroke depression (PSD). Given the potential side effects of SSRIs, targeted initiation among individuals at highest risk for PSD warrants consideration. While previous studies have identified stroke severity and psychiatric history as factors associated with PSD, its predictability remains unknown. In this study, we investigate inpatient predictive factors to better identify individuals who might derive the most benefit from targeted initiation of SSRIs.MethodsWe performed a retrospective analysis of a prospectively-collected registry of adult patients presenting with acute ischemic stroke to a tertiary referral urban academic comprehensive stroke center between 2016–2020. Patients were seen 4–6 weeks post-discharge and administered the PHQ-9 (Patient Health Questionnaire-9) to screen for PSD (PHQ-9 ≥ 5). Demographics, history of depression, stroke severity, and inpatient PHQ-9 scores were abstracted. Logistic regression was used to determine factors associated with PSD and an ROC analysis determined the predictability of PSD in the inpatient setting.ResultsThree hundred seven individuals were administered the PHQ-9 at follow-up (mean age 65.5 years, 52% female). History of depression (OR = 4.11, 95% CI: 1.65–10.26) and inpatient PHQ-9 score (OR = 1.17, 95% CI: 1.06–1.30) were significantly associated with PSD. Stroke severity, marital status, living alone, employment, and outpatient therapy were not associated with PSD. The ROC curve using a positive inpatient PHQ-9 achieved an area under the curve (AUC) of 0.65 (95% CI: 0.60–0.70), while the AUC was 0.72 (95% CI: 0.66–0.77) after adding history of depression.ConclusionsHistory of depression and a positive inpatient PHQ-9 appear to be most strongly predictive of long-term PSD. Initiating SSRIs only in those individuals at highest risk for PSD may help reduce the burden of stroke recovery in this targeted population while minimizing adverse side effects.

In-Hospital Symptoms of Depression and Anxiety are Strong Risk Factors for Post-Stroke Depression 90 Days After Ischemic Stroke.

Acute ischemic stroke (AIS) and depression are the major causes of disability and decreased quality of life worldwide. Psychiatric disorders are common after stroke, especially post-stroke depression (PSD), which affects one-third of survivors. Although frequent, little is known about the real complexity of the pathophysiology and the factors associated with PSD. This research aimed to provide data about risk factors and predictors of PSD 90days after AIS. A cohort study was conducted in a tertiary stroke center located in southern Brazil. We interviewed 148 patients with AIS who were consecutively hospitalized between January 2020 and January 2021. The Hospital Anxiety and Depression Scale (HADS) was applied during hospitalization and at follow-up 90days after AIS. Furthermore, sociodemographic, clinical, and radiological variables were investigated. Predictive factors were assessed using univariate and multivariate linear regression. The impact of the COVID-19 pandemic on the data was also evaluated. The frequency of PSD 90days after AIS was 33.9%. In-hospital symptoms of depression and anxiety each represented a 2-fold risk for PSD at follow-up. Furthermore, the HADS - anxiety score 90days after AIS was strongly associated with the HADS - depression value 90days after stroke (R: .71; B: .56; P < .01). The present study highlighted a noteworthy frequency of PSD 90days after AIS. Psychiatric variables during hospitalization and in the follow-up appeared to be the leading associated factors with PSD. These data might support the determination of which patients require more psychiatric management.

Thrombus migration in ischemic stroke due to large vessel occlusion: a question of time

BackgroundThrombus migration (TM) is frequently observed in large vessel occlusion (LVO) ischemic stroke to be treated by endovascular thrombectomy (EVT). TM may impede complete recanalization and hereby worsen clinical outcomes....

Point-of-Care Assessment of Direct Oral Anticoagulation in Acute Ischemic Stroke: Protocol for a Prospective Observational Diagnostic Accuracy Study.

Treatment of ischemic stroke with recombinant tissue plasminogen activator for intravenous thrombolysis (IVT) must be delivered within a narrow time window after symptom onset. This effective hyperacute treatment can be administered after ruling out active anticoagulation with direct oral anticoagulants (DOACs). Whenever this is impractical, e.g., due to aphasia, plasmatic DOAC levels are measured with a consequent delay in the IVT decision-making process ranging from 30 to 60 minutes of time. This study will test the hypothesis that hyperacute point-of-care assessment of clotting time in the patient's whole blood has sufficient diagnostic accuracy to determine immediately whether stroke patients are pretreated with DOAC. This will be a prospective single-center diagnostic accuracy study in 1,850 consecutive acute ischemic stroke patients at a tertiary stroke center in Saxony, Germany. Presence of active anticoagulation with DOAC will be determined by point-of-care quantification of clotting time via whole blood viscoelastic testing (ClotPro) using Russell venom viper and ecarin assay compared with high-performance liquid chromatography-tandem mass spectrometry as the reference standard. Viscoelastic point-of-care assessment of clotting time in whole blood might improve swift delivery of time-sensitive hyperacute treatment with IVT in stroke patients.

Simplified Assessment of Lesion Water Uptake for Identification of Patients within 4.5 Hours of Stroke Onset: An Analysis of the MissPerfeCT Study.

Background and Purpose Many patients with stroke cannot receive intravenous thrombolysis because the time of symptom onset is unknown. We tested whether a simple method of computed tomography (CT)-based quantification of water uptake in the ischemic tissue can identify patients with stroke onset within 4.5 hours. Methods This retrospective analysis of the MissPerfeCT study (August 2009 to November 2017) includes consecutive patients with known onset of symptoms from seven tertiary stroke centers. We developed a simplified algorithm based on region of interest (ROI) measurements to quantify water uptake of the ischemic lesion and thereby quantify time of symptom onset within and beyond 4.5 hours. Perfusion CT was used to identify ischemic brain tissue, and its density was measured in non-contrast CT and related to the density of the corresponding area of the contralateral hemisphere to quantify lesion water uptake. Results Of 263 patients, 204 (77.6%) had CT within 4.5 hours. Water uptake was significantly lower in patients with stroke onset within (6.7%; 95% confidence interval [CI], 6.0% to 7.4%) compared to beyond 4.5 hours (12.7%; 95% CI, 10.7% to 14.7%). The area under the curve for distinguishing these patient groups according to percentage water uptake was 0.744 with an optimal cut-off value of 9.5%. According to this cut-off the positive predictive value was 88.8%, sensitivity was 73.5%, specificity 67.8%, negative predictive value was 42.6%. Conclusions Ischemic stroke patients with unknown time of symptom onset can be identified as being within a timeframe of 4.5 hours using a ROI-based method to assess water uptake on admission non-contrast head CT.

Outcomes Following Mechanical Thrombectomy in Different Etiological Subtypes of Acute Basilar Artery Occlusion : Stroke Etiology and Outcome after EVT in BAO.

Vertebrobasilar occlusion stroke (VBOS) is innately associated with high morbimortality despite advances in endovascular thrombectomy (EVT). Nonetheless, notable outcome dissimilarities exist between angiographically categorized stroke subtypes. We aim to evaluate potential differences concerning clinical angiographic outcomes among etiological subtypes of VBOS based on the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria. We retrospectively reviewed prospective EVT databases at two tertiary care stroke centers for consecutive patients with VBOS who had preinterventional MRI and underwent EVT from January 2015 to December 2019. We identified three groups: large artery atherosclerosis (LAA), cardioembolic stroke (CES), and embolic stroke of undetermined source (ESUS). The primary endpoints were the rates of poor outcome (identified as 90-day modified Rankin scale score of 3-6) and mortality, while the secondary endpoint included the rates of incomplete reperfusion (identified as modified treatment in cerebral infarction scale mTICI 0-2b), and periprocedural symptomatic intracranial hemorrhage. We evaluated the association between the etiology and clinical angiographic outcomes through stepwise logistic regression analysis. Out of 1823 patients, 139 (91men; median age, 69 (61-76) years) with VBOS were qualified for the final analysis with incidence as follows: LAA (41%, n = 57), CES (35%, n = 48), and ESUS (24%, n = 34). Overall, incomplete reperfusion was realized in 41% (57/139) of the patients, apoor outcome in 65% (90/139), and mortality in 40% (55/139). Longer puncture to reperfusion interval (aOR 1.0182 [95% CI: 1.008-1.029]; p < 0.001) and utilization of combined aspiration-retriever technique (aOR 0.1998 [95% CI: 0.066-0.604]; p = 0.004) were associated with agreater likelihood of incomplete reperfusion (mTICI 0-2b) irrespective of the stroke etiology. After adjustment for confounding factors in the regression analysis, ESUS was an independent predictor of poor outcome (aOR 5.315 [95% CI: 1.646-17.163]; p = 0.005) and mortality (aOR 4.667 [95% CI: 1.883-11.564]; p < 0.001) at 90days following EVT. The functional outcome following EVT for VBOS might depend on stroke etiology. According to our results, ESUS seems to be associated with the worst outcome, which needs further investigation to tailor the appropriate therapeutic plan.

Prevalence of stroke in acute vertigo presentations: A UK tertiary stroke centre perspective

The reported prevalence of stroke amongst patients presenting to hospital with acute vertigo and/or imbalance is c. 5%, leading to the pervasive notion amongst emergency and stroke physicians, that stroke is uncommon in this cohort.To interrogate the veracity of this notion, we systematically and retrospectively screened the electronic care records in our institution of patients referred as suspected stroke, to a hyperacute stroke service at a large tertiary referral centre.We screened 24,310 consecutive patients' electronic case records presenting to our hospital as an emergency over a 4-month period, 332 of whom were referred as suspected stroke whose case records were assessed via structured review. Of these 332 cases, 61 presented with a vestibular syndrome, i.e. having at least one of imbalance, dizziness or vertigo. Of the 61 vestibular cases, 38 (62%) were diagnosed as stroke confirmed by imaging in 25/38 or upon clinical grounds only (13/38). None of the 38 vestibular stroke cases received thrombolysis or thrombectomy treatment.In a UK urban population (2.5mn), acute vestibular syndrome cases referred to stroke services have a 50% stroke prevalence. None of the vestibular stroke cases received hyperacute stroke treatment e.g., thrombolysis, due to delay in diagnosis. The high stroke prevalence in our cohort may indicate an excessively high threshold for referring acute vestibular cases for stroke, implying a high number of missed stroke cases. We suggest that early access to vestibular neurologists in acute vestibular cases should improve the proportion of vestibular stroke cases receiving definitive stroke treatment.

The Impact of COVID-19 Pandemic on Ischemic Stroke Patients in a Comprehensive Hospital.

PurposeThis study aimed to investigate the impact of characteristic ischemic stroke and outcomes during the first COVID-19 pandemic lockdown.Patients and MethodsA retrospective, observational cohort study of a comprehensive tertiary stroke center was conducted. Patients with ischemic stroke were divided into pre-COVID-19 lockdown (11/1/2019 to 1/30/2020) and COVID-19 lockdown (1/31/2020 to 4/30/2020) period groups. Patient data on stroke admission, thrombolysis, endovascular treatment, and 3-month routine follow-up were recorded. Data analysis was performed using SPSS according to values following a Gaussian distribution.ResultsThe pre-COVID-19 lockdown period group comprised 230 patients compared to 215 patients in the COVID-19 lockdown period group. Atrial fibrillation was more predominant in the COVID-19 lockdown period group (11.68% vs 5.65%, p=0.02) alongside patients who were currently smoking (38.8% vs 28.7%, p=0.02) and drinking alcohol (30.37% vs 20.00%, p=0.012) compared with that of the pre-COVID-19 lockdown period group. For patients receiving thrombolysis, the median door-to-CT time was longer in the COVID-19 lockdown period group (17.0 min (13.0, 24.0) vs 12.0 min (8.0, 17.3), p=0.012), median door to needle time was 48.0 minutes (35.5, 73.0) vs 43.5 minutes (38.0, 53.3), p=0.50, compared with that of the pre-COVID-19 lockdown period group. There were no differences for patients receiving mechanical thrombectomy. The median length of hospitalization (IQR) was no different. Discharge mRS scores (IQR) were higher in the COVID-19 lockdown period group (1.0 (1.0, 3.0) vs 1.0 (1.0, 2.0), p=0.022). Compared with the pre-COVID-19 lockdown period, hospitalization cost (Chinese Yuan) in the COVID-19 period group was higher (13,445.7 (11,009.7, 20,030.5) vs 10,799.2 (8692.4, 16,381.7), p=0.000). There was no difference observed in 3-month mRS scores.ConclusionPatients presenting with ischemic stroke during the COVID-19 pandemic lockdown period had longer median door-to-CT time and higher hospitalization costs. There were no significant differences in 3-month outcomes. Multidisciplinary collaboration and continuous workflow optimization may maintain stroke care during the COVID-19 pandemic lockdown.

Locked-in syndrome responding to endovascular treatment

BackgroundLocked-in syndrome (LiS) is a rare and devastating condition in patients with acute basilar artery occlusion. However, the benefits of endovascular treatment (EVT) for LiS remain unclear.ObjectiveTo assess the outcomes...

Pre-Hospital Delay in Acute Ischemic Stroke Care: Current Findings and Future Perspectives in a Tertiary Stroke Center from Romania-A Cross-Sectional Study.

Background and objectives: The time interval between stroke onset and hospital arrival is a major barrier for reperfusion therapies in acute ischemic stroke and usually accounts for most of the onset-to-treatment delay. The present study aimed to analyze the pre-hospital delays for patients with acute ischemic stroke admitted to a tertiary stroke center in Romania and to identify the factors associated with a late hospital arrival. Material and methods: The study population consisted of 770 patients hospitalized with the diagnosis of acute ischemic stroke in the University Emergency Hospital Bucharest during a 6-month period, between 1 January and 30 June 2018. Data regarding pre-hospital delays were prospectively collected and analyzed together with the demographic and clinical characteristics of the patients. Results: In total, 31.6% of patients arrived at the hospital within 4.5 h from stroke onset and 4.4% in time intervals between 4.5 and 6 h from the onset, and 28.7% of the patients reached the hospital more than 24 h after onset of symptoms. Transport to hospital by own means was the only factor positively associated with arrival to hospital > 4.5 h from stroke onset and more than doubled the odds of late arrival. Factors negatively associated with hospital arrival > 4.5 h after stroke onset were prior diagnosis of atrial fibrillation, initial National Institute of Health Stroke Scale (NIHSS) score ≥ 16 points, presence of hemianopsia, facial palsy and sensory disturbance. Factors increasing the odds of hospital arrival after 24 h from stroke onset were living alone and living in rural areas. Conclusions: Almost one in three ischemic stroke patients presenting to our center reaches hospital more than 24 h after onset of symptoms. These findings highlight the need for urgent measures to improve not only stroke awareness but also pre-hospital protocols in order to provide timely and appropriate care for our stroke patients.

Diabetes, Hypertension, Atrial Fibrillation and Subsequent Stroke-Shift towards Young Ages in Brunei Darussalam.

Southeast Asia harbors a young population of more than 600 million people. Socioeconomic transition within the last decades, driven by globalization and rapid economic growth, has led to significant changes in lifestyle and nutrition in many countries of this region. Hence, an increase in the number of non-communicable diseases is seen in most populations of Southeast Asia. Brunei Darussalam is the smallest country in this region, with a population of around 400,000 inhabitants. Vast hydrocarbon resources have transformed Brunei into a wealthy industrialized country within the last few decades. We compared the age distribution and prevalence of cardiovascular risk factors in ischemic stroke patients between the only stroke unit in Brunei Darussalam and a tertiary stroke center from Frankfurt/Germany. Between 2011 and 2016, a total number of 3877 ischemic stroke patients were treated in both institutions. Even after adjusting for age due to different population demographics, stroke patients in Brunei were younger compared to their German counterparts. The prevalence of hypertension and diabetes mellitus was significantly higher in young age groups in Brunei, whereas no difference was observed for older patients. The rapid socioeconomic transition might be a significant risk factor for the development of non-communicable diseases, including stroke.