Therapy For Acute Stroke Research Articles

Type of anesthesia for endovascular therapy in acute ischemic stroke: A literature review and meta-analysis.

Endovascular thrombectomy (EVT) has been proven as the standard treatment for acute ischemic stroke (AIS) patients due to large vessel occlusion (LVO). However, the ideal anesthetic strategy during EVT still remains unclear. Therefore, this systematic review and meta-analysis aimed to determine the optimal anesthetic modality for patients with AIS undergoing EVT based on current randomized controlled trials (RCTs). The databases Medline (via PubMed), EMBASE, Web of Science, and the Cochrane Library were searched for RCTs comparing general anesthesia (GA) and conscious sedation (CS) in AIS patients undergoing EVT. The primary outcome was a favorable functional outcome at 90 days postintervention. Data analysis was conducted using the Review Manager software (RevMan V.5.3). Eight RCTs involving 1199 patients were included. There was no significant difference between GA and CS group in the rate of functional independence (risk ratio (RR) = 1.10, 95% confidence interval (CI) = 0.96 to 1.25; p = 0.17; I2 = 30%). Compared with the CS group, the GA group attained a higher successful recanalization rate (RR = 1.14, 95% CI = 1.08 to 1.20; p < 0.00001; I2 = 17%). In addition, patients in the GA were associated with a higher rate of hypotension (RR = 1.87, 95% CI = 1.44 to 2.41; p < 0.00001; I2 = 66%) and a higher incidence of pneumonia (RR = 1.38, 95% CI = 1.05 to 1.8; p = 0.02; I2 = 37%). For AIS patients receiving EVT, the choice of anesthetic modality did not influence the 3-month neurological outcome while GA is superior to CS in terms of successful reperfusion rate. Moreover, the patients in the GA group were at a higher risk of developing hypotension and pneumonia. Further studies are required to provide more sufficient evidence.

Efficacy and safety of hyperbaric oxygen therapy in acute ischaemic stroke: a systematic review and meta-analysis

ObjectiveThis study aims to evaluate the efficacy and safety of adjunctive hyperbaric oxygen therapy (HBOT) in acute ischaemic stroke (AIS) based on existing evidence.MethodsWe conducted a comprehensive search through April 15, 2023, of seven major databases for randomized controlled trials (RCTs) comparing adjunctive hyperbaric HBOT with non-HBOT (no HBOT or sham HBOT) treatments for AIS. Data extraction and assessment were independently performed by two researchers. The quality of included studies was evaluated using the tool provided by the Cochrane Collaboration. Meta-analysis was conducted using Rev Man 5.3.ResultsA total of 8 studies involving 493 patients were included. The meta-analysis showed no statistically significant differences between HBOT and the control group in terms of NIHSS score (MD = -1.41, 95%CI = -7.41 to 4.58), Barthel index (MD = 8.85, 95%CI = -5.84 to 23.54), TNF-α (MD = -5.78, 95%CI = -19.93 to 8.36), sICAM (MD = -308.47, 95%CI = -844.13 to 13227.19), sVCAM (MD = -122.84, 95%CI = -728.26 to 482.58), sE-selectin (MD = 0.11, 95%CI = -21.86 to 22.08), CRP (MD = -5.76, 95%CI = -15.02 to 3.51), adverse event incidence within ≤ 6 months of follow-up (OR = 0.98, 95%CI = 0.25 to 3.79). However, HBOT showed significant improvement in modified Rankin score (MD = 0.10, 95%CI = 0.03 to 0.17), and adverse event incidence at the end of treatment (OR = 0.42, 95%CI = 0.19 to 0.94) compared to the control group.ConclusionWhile our findings do not support the routine use of HBOT for improving clinical outcomes in AIS, further research is needed to explore its potential efficacy within specific therapeutic windows and for different cerebral occlusion scenarios. Therefore, the possibility of HBOT offering clinical benefits for AIS cannot be entirely ruled out.

Abstract 84: Efficacy of Endovascular Therapy in Acute Ischemic Stroke by Alberta Stroke Program Early Computed Tomography Score and National Institutes of Health Stroke Scale-A Secondary Analysis of a Randomized Controlled Trial

Introduction and Aims: The ANGEL-ASPECT trial demonstrated the effectiveness of endovascular therapy (EVT) in acute ischemic stroke (AIS) patients with large infarct. We did a secondary analysis to explore the efficacy of EVT according to Alberta Stroke Program Early Computed Tomography Score (ASPECT) and National Institutes of Health Stroke Scale (NIHSS). Methods: ANGEL-ASPECT trial was a randomized clinical trial involving patients with acute anterior-circulation large-vessel occlusion and an ASPECT score of 3-5 or an infarct-core volume of 70-100ml. Patients were randomly assigned to EVT or standard medical treatment (SMT) alone. We categorized patients based on the combination of ASPECT (≤3 or 4-5) and NIHSS (&lt;20 or ≥20) into four groups: low ASPECT &amp; low NIHSS; low ASPECT &amp; high NIHSS; high ASPECT &amp; low NIHSS and high ASPECT &amp; high NIHSS. We assessed the efficacy of EVT using ordinal shift analysis of 90-day modified Rankin Scale (mRS). Results: Among 455 patients, the prevalence of the four groups were 190 (41.8%), 70 (15.4%), 157 (34.5%) and 38 (8.4%), respectively. A significant shift in the distribution of 90-days mRS toward better outcomes in favor of EVT was observed in patients with low ASPECT &amp; low NIHSS (common OR [cOR], 2.25; 95% CI, 1.34-3.76; P=0.002), and high ASPECT &amp; low NIHSS (cOR, 2.30; 95% CI, 1.31-4.05; P=0.004), but not in other two groups with high NIHSS (all P &gt;0.05). Conclusions: EVT was associated with better outcomes in AIS patients with large infarct and mild-to-moderate stroke severity (NIHSS &lt;20), but not in those with severe stroke severity (NIHSS ≥20). Stroke severity should be considered when planning EVT for AIS patients with large infarcts.

Abstract WP203: Prediction of Outcome After Endovascular Therapy for Acute Ischemic Stroke: A Machine Learning Approach From Japan Stroke Data Bank

Introduction: Previous studies have demonstrated the predictive capabilities of machine learning (ML) models using clinical, imaging, and angiographic characteristics in determining the clinical outcome of patients undergoing endovascular treatment for acute ischemic stroke. We aimed to analyze a large-scale stroke registry and develop an ML model that solely utilizes clinical characteristics, without the need for imaging or angiographic data, to predict the outcome of patients treated with endovascular therapy for acute ischemic stroke. Methods: We conducted our analysis using data from the Japan Stroke Data Bank, a nationwide acute stroke registry containing individual patient data. A total of 4353 patients who underwent endovascular treatment for acute ischemic stroke between January 2016 and December 2020 were included in the study. Patient data from 2016 to 2019 were used as the derivation cohort, while data from 2020 were used as the validation cohort. An ML models were trained on 70% of the patients randomly selected from the derivation cohort and tested on the remaining 30%. The input variables for the ML models consisted of 138 clinical characteristics including neurological examination findings. Imaging, angiographic, and laboratory data were not utilized in the ML process. The primary outcome measure was good outcome at discharge, defined as a modified Rankin Scale score of 0-2. Results: Of the 4353 patients included in the study, 1520 patients (34.9%) achieved good outcome. The area under the curve for predicting good outcome was 0.76 for the test set in the derivation cohort and 0.78 for the validation cohort. The SHAP summary plot revealed that the top five major predictive contributors for good outcomes were pre-stroke modified Rankin Scale score, level of consciousness, age, stroke classification, and NIHSS score. Conclusions: Our findings demonstrate that an ML model utilizing solely clinical characteristics, without the inclusion of imaging or angiographic data, can accurately predict good outcomes at discharge for acute stroke patients treated with endovascular therapy. This approach has the potential to provide an aid in clinical decision-making before imaging examination.

Abstract WP146: Critical Care After Thrombolytic Therapy in Acute Stroke: Who Really Needs the ICU?

Introduction: Intravenous thrombolytic therapy remains the cornerstone of management in acute ischemic stroke (AIS) patients. Given the potential adverse effects of thrombolysis, patients are admitted to an intensive care unit (ICU) for close monitoring following administration. Alternative post-thrombolytic pathways may provide for safe cost-effective care in certain populations. We aimed to determine the proportion of patients treated with thrombolytics who required ICU care for reasons other than frequent neurologic monitoring and define their characteristics. Methods: We retrospectively reviewed patients ≥ 18 years of age who received TNK/ tPA for AIS at our community-based stroke center between May 2020 and August 2022. Patients were classified as requiring ICU care if they required intubation within 24 hours of admission or neurosurgical intervention, had symptomatic hemorrhagic conversion or brain compression, required a continuous infusion for hemodynamic management, or were in status epilepticus. Univariate and multivariate statistical analysis was performed. The study protocol was deemed exempt by our institutional IRB. Results: 262 patients met inclusion criteria. 54 (20.6%) required ICU level of care. Characteristics of those requiring ICU level of care are described in Table 1. Multivariate analysis showed that patients on antiplatelet or anticoagulant therapies prior to arrival (AOR: 2.205, p= 0.021) or who presented with higher initial NIH stroke scale (AOR: 1.108, p &lt; 0.001) had significantly higher likelihood of requiring ICU level of care. Conclusions: In our cohort, approximately 21% of patients required critical care. Anticoagulant or antiplatelet therapy prior to admission and greater NIH stroke scale on arrival were associated with an increased likelihood of requiring ICU level of care. Further prospective studies are indicated to assess the efficacy of alternative settings for post-thrombolytic care in selected AIS patients.

Abstract 60: Utilization, Workflow, and Outcomes of Endovascular Thrombectomy in Patients With versus Without Pre-Morbid Disability in a National Stroke Registry

Background: Given the paucity of high-quality data on acute stroke therapies in patients with pre-morbid disability, they risk being routinely excluded from such therapies. We examined utilization of endovascular thrombectomy (EVT), workflow, and outcomes among ischemic stroke patients with vs without pre-morbid disability in a national registry. Methods: We used data for the Czech Republic from 1-January-2016 to 31-December-2020. Pre-morbid disability was defined as pre-stroke modified Rankin Scale score (mRS) &gt;2. We compared receipt of EVT, workflow times, ΔmRS (change from pre-stroke to 3-months), intracerebral hemorrhage (ICH), mortality, and discharge NIHSS among patients with vs without pre-morbid disability, adjusting for age, sex, baseline NIHSS, and comorbidities, and verified using propensity score-weighting (PSW) for differences in treatment assignment. Results: Among 22,405 patients, 1,712 (7.6%) had pre-stroke mRS &gt;2. Patients with pre-morbid disability were less likely to receive EVT (10.1% vs 20.7%, aOR:0.30, 95%CI:0.24-0.36) and had longer door-to-puncture times (median:75-minutes, IQR:58-100 vs 54, IQR:27-77, adjusted-difference:12.5, 95%CI:2.68-22.3), worse ΔmRS (adjusted rate-ratio, aIRR on PSW:1.57, 1.43-1.72), rates of 3-month mRS 5-6, discharge NIHSS, and mortality (aOR-PSW[mortality]:2.54, 1.92-3.34); ICH rates did not differ. Among those with pre-morbid disability, 32.1% returned to pre-stroke state; this ranged from 19.6% for those &gt;85-years to 66.0% for &lt;65-years. EVT was associated with better outcomes including lower ΔmRS (aIRR-PSW:0.87, 0.83-0.91) and mortality, with no interaction of treatment effect by pre-morbid disability (e.g. mortality p interaction =0.73). EVT recipients with pre-morbid disability did not differ significantly for several key outcomes including ΔmRS (aIRR:0.99, 0.84-1.17), but were more likely to have mRS 5-6 (70.1% vs 39.5%, aOR:1.85, 1.12-3.04). Conclusions: Patients with pre-morbid disability were less likely to receive EVT and had slower treatment and worse outcomes than those without disability. However, patients fared better with EVT versus medical care, and one-third with pre-stroke disability returned to their pre-stroke state.

Intravenous thrombolysis in acute ischemic stroke patients with pre-stroke disability: A systematic review and meta-analysis.

Intravenous thrombolysis (IVT), which is safe and effective, is the first-line therapy for acute ischemic stroke (AIS). However, its benefit for AIS patients with pre-stroke disability (PSD) is controversial. We determined the association of PSD with the safety and efficacy of IVT among patients with AIS. We searched PubMed, Embase, and the Cochrane Library from inception to May 23, 2022. The articles focusing on outcomes of AIS patients with PSD receiving IVT were retrieved. We used the random-effects model to pool outcomes including mortality, 24h NIHSS improvement, symptomatic intracerebral hemorrhage (sICH), favorable functional outcome (FFO), the favorable outcome, and mortality prevalence. Ten studies (including 245,773 participants) that reported the outcomes of AIS patients with PSD undergoing IVT were included. In unadjusted analyses, PSD was associated with mortality (10 studies; odds ratio [OR] 1.739, 95% confidence interval [CI], 1.336-2.407), FFO (7 studies; OR 1.057, 95% CI, 1.015-1.100), 24h NIHSS improvement (5 studies; OR .840, 95% CI, .819-.917, p=.000), and sICH (9 studies; OR .773, 95% CI, .481-1.243). In adjusted analyses, PSD was associated with mortality (seven studies; ORadj 1.789, 95% CI, 1.413-2.264), FFO (five studies; ORadj 1.087, 95% CI, 1.002-1.179), 24h NIHSS improvement (five studies; ORadj .837, 95% CI, .799-.876), and sICH (five studies; ORadj .857, 95% CI, .725-1.012). The prevalence of FFO and mortality in patients with pre-stroke modified Rankin Scale scores of 2-5 were 49% (0.42-0.56) and 37% (0.21-0.53), respectively. Patients with PSD undergoing IVT had a higher mortality rate than those without PSD. Meanwhile, PSD was associated with FFO, and there was no significant difference in sICH and 24h NIHSS improvement. High-quality data are needed to clarify the benefits of administering IVT in these patients.

Risk Factors and Prognosis of Early Neurological Deterioration after Bridging Therapy.

Early neurological deterioration (END) after bridging therapy (BT) of acute ischemic stroke (AIS) patients is associated with poor outcomes. We aimed to study the incidence, risk factors and prognosis of END after BT. From January to December 2021, the clinical data of AIS patients treated by BT (intravenous thrombolysis with alteplase prior to mechanical thrombectomy) from three comprehensive stroke centers were analyzed. Patients were divided into non-END group and END group according to whether they developed END within 72 hours of symptom onset. Modified Rankin scale (mRS) was used to assess the patient's prognosis at 90 days, and favorable outcomes were defined as mRS≤2. The incidence of END was investigated, and binary logistic regression analysis was used to explore its associated factors. The incidence of END after BT was 33.67%. The eligible 90 patients included 29 cases in the END group and 61 cases in the non-END group. Multivariate Logistic regression analysis showed that increase of systolic blood pressure (SBP) (OR=1.026, 95%CI:1.001-1.051, p =0.043), higher level of blood glucose at admission (OR=1.389, 95%CI:1.092-1.176, p =0.007) and large artery atherosclerosis (LAA) subtype (OR=8.009, 95%CI:2.357-27.223, p =0.001) were independent risk factors of END. Compared with the non-END group, the END group had significantly lower rates of good outcomes (6.90% versus 65.57%, p =0.001) while higher rates of mortality (44.83% versus 4.92%, p =0.001). It was found that the incidence of END after BT in AIS patients was 33.67%. An increase in SBP, higher glucose levels at admission, and LAA were independent risk factors of END that predicted a poor prognosis.

Abstract WP202: Thrombectomy versus Combined Thrombolysis and Thrombectomy for Primary Medium and Distal Intracranial Occlusions: A Propensity-Score Matched Multicenter Analysis

Background: Mechanical thrombectomy (MT) has demonstrated superiority over medical therapy for acute ischemic stroke (AIS) with large vessel occlusion (LVO). The role of adjunctive intravenous thrombolysis, such as intravenous tissue plasminogen activator (IVtPA), with MT remains unclear, especially for medium vessel occlusion (MeVO). This multicenter study aimed to compare outcomes between MT alone and MT+IVtPA in patients with MeVO. Methods: Data from 827 patients treated at 37 academic centers in North America, Asia, and Europe were collected between September 2017 and July 2021. Propensity score matching was performed to create two well-balanced groups: MT alone and MT+IVtPA. Baseline characteristics, procedural details, and clinical outcomes were analyzed. Results: After propensity score matching, 577 patients (315 in the MT alone group and 262 in the MT+IVtPA group) were included in the analysis. The two groups had comparable baseline characteristics, except for longer onset-to-puncture and onset-to-recanalization times in the MT alone group. In univariable regression, all outcomes were comparable between the two groups, except for higher mRS 0-2 rates in the MT+IVtPA group. Multivariable regression analysis showed no significant differences in first pass effect (FPE), number of passes, Thrombolysis in Cerebral Infarction (TICI) scores, rates of mRS 0-1, mRS 0-2, mortality, or intracranial hemorrhage between the groups. Conclusion: In patients with primary medium and distal intracranial occlusions, MT alone and MT+IVtPA yielded similar clinical outcomes. These findings suggest that adding IVtPA to MT may not confer additional benefit in this population. Further research is needed to determine the optimal treatment approach for MeVO.

Abstract 152: Endovascular Therapy versus Medical Management for Acute Ischemic Stroke With Large Infarct: A Time-Benefit Relationship Analysis

Objective: Recent randomized trials demonstrated the benefit of endovascular thrombectomy for acute ischemic stroke with large infarct. We aimed to characterize the effect of time to treatment on the benefit of endovascular therapy compared to medical management among patients with acute large ischemic stroke. Methods: Analysis the Endovascular Therapy in Acute Anterior Circulation Large Vessel Occlusive Patients with a Large Infarct Core trial (ANGEL-ASPECT), which was a multicenter, randomized trial at 46 comprehensive stroke centers in China from August 2020 to October 2022. Onset to arterial puncture time (OPT) associated with outcomes of endovascular therapy were analyzed as a category and continuous variable. The primary outcome was favorable outcome (modified Rankin scale 0-3) at 90 days. Secondary outcomes included degree of disability (modified Rankin scale range), symptomatic intracranial hemorrhage, any intracranial hemorrhage, and mortality. Results: Among 455 eligible patients, the median age was 68 years, and median Alberta Stroke Program Early Computed Tomography Score was 3 (interquartile range 3-4). Compared with medical management alone, endovascular therapy plus medical management was associated with higher rates of favorable outcome with OPT within 6 hours (44.4% vs 29.9%, adjusted odds ratio[aOR] 2.78 [95% confidence interval [CI] 1.22-6.32]), 6-12 hours (45.7% vs 29.6%, aOR 2.39 [95% CI 1.21-4.71]), but not in OPT beyond 12 hours (51.6% vs 41.4%, aOR 2.05 [95% CI, 0.88-4.77]). The benefit in favorable outcome became nonsignificant after OPT of 13 hours and 22 minutes. In three OPT intervals, the odds of better disability outcome with endovascular therapy plus medical management than medical management alone were observed; the rates of symptomatic intracranial hemorrhage and mortality were similar, though the rates of any intracranial hemorrhage increased. Conclusion: In patients with large cerebral infarction, endovascular therapy plus medical management was efficacious in improving functional outcomes with acceptable safety in a broad time window of 0 to 24 hours, but greater benefit was observed with earlier treatment. A pooled analysis with larger sample size is needed.

Prognostic Significance of Plasma VEGFA and VEGFR2 in Acute Ischemic Stroke-a Prospective Cohort Study.

Enhancement of vascular remodeling in affected brain tissue is a novel therapy for acute ischemic stroke (AIS). However, conclusions regarding angiogenesis after AIS remain ambiguous. Vascular endothelial growth factor A (VEGFA) and VEGF receptor 2 (VEGFR2) are potent regulators of angiogenesis and vascular permeability. We aimed to investigate the association between VEGFA/VEGFR2 expression in the acute stage of stroke and prognosis of patients with AIS. We enrolled 120 patients with AIS within 24h of stroke onset and 26 healthy controls. Plasma levels of VEGFA and VEGFR2 were measured by enzyme-linked immunosorbent assay (ELISA). The primary endpoint was an unfavorable outcome defined as a modified Rankin Scale (mRS) score > 2 at 3months after AIS. Univariate and multivariate logistic regression analyses were used to identify risk factors affecting prognosis. Plasma VEGFA and VEGFR2 were significantly higher in patients with AIS than in health controls, and also significantly higher in patients with unfavorable than those with favorable outcomes. Moreover, both VEGFA and VEGFR2 showed a significantly positive correlation with mRS at 3months. Univariate and multivariate analyses showed VEGFA and VEGFR2 remained associated with unfavorable outcomes, and adding VEGFA and VEGFR2 to the clinical model significantly improved risk reclassification (continuous net reclassification improvement, 105.71%; integrated discrimination improvement, 23.45%). The new risk model curve exhibited a good fit with an area under the receiver operating characteristic curve (ROC) curve of 0.9166 (0.8658-0.9674). Plasma VEGFA and VEGFR2 are potential markers for predicting prognosis; thus these two plasma biomarkers may improve risk stratification in patients with AIS.

Abstract TMP16: Impact of Door-to-Imaging and Imaging-to-Door Times on Door-in-Door-out Times in Interhospital Transfers of Patients With Stroke

Introduction: Urgent inter-hospital transfer ensures timely access to therapies for acute ischemic stroke. Door-in-door-out (DIDO) represents the total amount of time a patient spends in the transferring emergency department (ED) before transfer. DIDO time is an important quality metric for the care of acute stroke; however, little is known about the influence of process steps on DIDO times and which steps most often cause delays. Methods: This was a retrospective cohort study of patients in the American Heart Association Get With The Guidelines®-Stroke registry with ischemic stroke presenting January 2019 to December 2021 transferred from the ED at the presenting hospital to another acute care hospital for evaluation of thrombolytics, endovascular therapy or post-thrombolytic care. The primary independent variables were door-to-imaging and imaging-to-door times, and the primary outcome was DIDO time. Multivariate GEE regression models were performed to assess the comparative contributions of interval process times to variation in DIDO time, controlling for patient and hospital-level characteristics. Results: Among 24,662 patients (50.5% male, mean age 68.3 years, 73.2% White), mean DIDO time was 171.4 min (SD: 149.5), mean door-to-imaging time was 18.3 min (SD: 34.1) and mean imaging-to-door time was 153.1 min (SD: 141.5). A 1 min increase in door-to-imaging time was associated with a 1.33 min increase in the mean DIDO time, while a 1 min increase in imaging-to-door time was associated with a 1.02 min increase in mean DIDO time. The baseline model (without door-to-imaging or imaging-to-door included) had an R2 of 0.03. With door-to-imaging included in the GEE model, R2 was 0.13; whereas the model with imaging-to-door included had an R2 of 0.95. Conclusion: Imaging-to-door time accounts for a greater proportion of the variance in DIDO times than door-to-imaging time. Though the opportunity for improvement in DIDO is greater through reduction of imaging-to-door time, door-to-imaging time has greater per-minute effect on DIDO. While existing guidelines and care resources heavily focus on reducing door-to-imaging times, further attention is warranted to reduce imaging-to-door times in the management of acute ischemic stroke.

Abstract TP181: Endovascular Therapy for Acute Ischemic Stroke With Large Infarct: A Meta Analysis of Randomized Controlled Trials

Background: The efficacy of endovascular thrombectomy (EVT) in patients with large infarct among acute ischemic stroke patients has not been exclusively studied, with conflicting results till date. Objective: We sought to evaluate the outcomes comparing EVT and medical therapy among stroke patients with large infarcts. Methods: We performed a systematic literature search on PubMed, EMBASE, and Clinicaltrial.gov for relevant randomized controlled trials (RCTs) from inception until August 30th, 2023. Odds ratios (OR) were pooled using a random-effect model, and a p-value of &lt;0.05 was considered statistically significant. Results: A total of 3 randomized controlled trials with 1010 patients (509 in EVT and 501 in MT) were included in the analysis. Pooled analysis of primary and secondary endpoints showed that ET was associated with a significantly greater rate of MRS 0-2 (OR, 2.53(95%CI: 1.76-3.64), P&lt;0.001), MRS 0-3 (OR, 1.75(95%CI: 1.28-2.39), P&lt;0.001). ET group of patients were having a significantly higher risk of any intracranial hemorrhage (OR, 2.34(95%CI: 1.53-3.58), P&gt;0.001), and a trend of higher risk of incidence of symptomatic intracranial hemorrhage (OR, 1.83(95%CI: 0.90-3.70), P=0.09) compared to medical therapy. However, the risk of incidence of 90 days mortality (OR, 0.95(95%CI: 0.73-1.24), P=0.71), hemi craniotomy (OR, 0.97(95%CI: 0.45-2.12), P=0.95), and adverse cardiovascular event (OR, 1.68(95%CI: 0.50-5.59), P=0.40) was comparable between ET and MT group. Conclusion: Patients with large infarcts had better functional outcomes with ET than with MT alone. However, intracranial hemorrhage was higher among ET compared with MT group, while 90 days mortality being comparable between both groups of patients.

Abstract WP78: Large Vessel Occlusion Triage and Routing Utilized for Long-Distance Stroke Transports by Emergency Medical Services (LVO TRUST EMS)

Introduction: Endovascular treatment (EVT) is the most effective therapy in acute ischemic stroke (AIS) with large vessel occlusion (LVO) but its practice is limited to comprehensive stroke centers (CSC). Previous studies have suggested that trained Emergency Medical Services (EMS) professionals can successfully detect LVO cases using a validated screening tool. For these cases, direct transfer to CSC bypassing community hospitals could lead to better outcomes. Methods: This is a retrospective cohort study from 01/01/2018-12/31/2022 of patients with suspected stroke transported by EMS providers from 14 community agencies (primarily fire paramedics) in Southeastern Massachusetts (EMS Region V). When stroke was suspected, EMS providers applied the Field Assessment Stroke Triage for Emergency Destination (FAST-ED) score to assess severity. Bypass of local community hospitals for direct transport to CSC was generally considered for patients with FAST-ED ≥4 and approval of the Region V EMS Medical Director, with the goal of early intervention for severe strokes. In addition to standard education on the use of the FAST-ED score, the EMS agencies received annual aggregate performance feedback and individual case feedback (when requested) from the CSC. Data were collected from the Electronic Health Record (EHR) on demographics, comorbidities, final diagnoses, FAST-ED scores, NIHSS and acute treatments. Descriptive statistics were performed to describe the accuracy of diagnosis and rates of treatment. Results: Among 166 triaged patients to go directly to CSC, 57.6% (95/166) were diagnosed with AIS, and 61.1% (58/95) of them were found to have LVO. There was a higher proportion of AIS or intracranial hemorrhage (ICH) in cases with higher FAST-ED scores. Only 23.4% (39/166) of the cases were diagnosed with stroke mimics, primarily related to lower FAST-ED scores. In total, 36.9% of patients with AIS received EVT: thrombectomy with standard window tPA (21.1%) or late presenter tPA (LKW ≥ 4.5 h, 1.1%), and without tPA (14.7%). Conclusions: A diverse group of community-based EMS services in Southeastern Massachusetts using a prehospital tool can identify patients with severe stroke, i.e. AIS due to LVO or ICH, with acceptable diagnostic accuracy.

Abstract WP179: Clinical Outcomes in Acute Stroke in Patients Undergoing Emergency Intracranial Stenting Receiving IV Thrombolysis

Background: Stent-retriever thrombectomy is the first-line therapy for acute stroke with intracranial large vessel occlusion. In cases of stent-retriever thrombectomy failure, rescue stent angioplasty might be the sole option for achieving permanent recanalization. This study aims to evaluate the safety of combined intracranial vessel stent placement and thrombolysis. Methods: We conducted a retrospective analysis of patients with large vessel occlusion who underwent rescue stent angioplasty after stent-retriever thrombectomy between 2012 and 2023 in 8 neurovascular centers. We defined two binary outcomes: (1) functional clinical outcome (modified Rankin Scale 0-2) and (2) early symptomatic intracerebral hemorrhage (sICH). Clinical outcomes were assessed using uni- and multivariable logistic regression models. Results: A total of 216 patients were included, with target vessels located within the anterior circulation (133; 63.4%) and posterior circulation (79; 36.6%). Among patients who underwent emergency intracranial stenting, 66 (30.6%) received intravenous thrombolytic treatment. In multivariate logistic regression analysis, adjusted for age, gender, baseline NIHSS, target vessel, time to recanalization, number of passes including, and type of antiplatelet therapy, intravenous thrombolytic therapy was not associated with symptomatic ICH (odds ratio (OR) 1.05, 95% confidence interval (CI) 0.27-4.14, p=0.9502), but it was associated with a functional clinical outcome at 90 days (OR 3.39, 95% CI 1.11-10.43, p=0.0325). Conclusions: The use of rescue stent angioplasty can be considered after unsuccessful stent-retriever thrombectomy, along with intravenous thrombolytic therapy. Patients receiving intravenous thrombolytic therapy before the procedure exhibited higher rates of good functional outcomes.

Abstract 79: Twelve-Year Trends in Ninety-Day Stroke Outcomes and Ethnic Differences From a Population-Based Study

Background: Stroke outcomes may be changing over time with improved acute stroke therapy, secondary prevention, and post-acute care. At the same time, stroke mortality has declined suggesting more people are living with stroke disability. No US population-based data exists on trends in outcomes. The objective was to investigate trends and ethnic differences in 90-day stroke outcomes in a population-based study. Methods: First-ever ischemic strokes in the population-based Brain Attack Surveillance in Corpus Christi Project (2009-2020, n=1,449) were included. 90-day outcomes included function (activities of daily living (ADL)/instrumental ADL), cognition (modified mini-mental state exam), NIHSS, and quality of life (Stroke-Specific Quality of Life (SS-QoL)). Linear regression with multiple imputation and inverse probability weighting was used to model adjusted associations between time, ethnicity, the interaction of time and ethnicity and outcomes. Results: Median age was 66; 61% Mexican American (MA). Trends in 90-day function overtime were roughly quadratic (Figure) and the change in the ethnic difference was significant among reference groups (p-value&amp;lt0.01). Trends in NIHSS were linear with no change in the ethnic difference (p-value=0.51). Trends in cognition were approximately cubic and the change in the ethnic difference was significant within reference groups (p-value=0.03). Trends in QOL were stable with no change in the ethnic difference. Conclusion: Recent improvements in 90-day post-stroke functional and cognitive outcomes in MAs have resulted in reduced disparities. Factors contributing to favorable trends in outcomes in this group should be further studied.

Patient’s understanding of and satisfaction with acute stroke treatment

ObjectiveWe aimed to assess patient and surrogate understanding of and satisfaction with communication regarding acute stroke treatments of intravenous thrombolysis (IVT) and endovascular therapy (EVT). MethodsIn this single health-system prospective observational study, patients or their surrogates were interviewed within 72 h of acute stroke therapy. Respondent’s satisfaction and self-reported understanding were rated on a Likert scale. Responses to open-ended questions were evaluated for recall of purpose and risks of treatment. ResultsOf 56 completed interviews (24 patients and 32 surrogates), 33 patients received IVT alone, 11 IVT and EVT, 12 EVT alone. Forty participants (71%) reported being extremely satisfied with their acute stroke care, 46 (82%) reported no difficulty understanding the purpose of treatment, while 36 (64%) reported no difficulty understanding risks. Two or more risks were verbalized by 8 (24%) participants for IVT, 2 (17%) for EVT, and 7 (64%) for both IVT and EVT. Brain bleeding was the most recalled risk for IVT and “lack of benefit” for EVT. ConclusionsMajority of the participants were extremely satisfied and reported no difficulty understanding purpose and risks of acute stroke treatment, however only 30% were able to verbalize two or more risks associated with the treatment.

Development and validation of outcome prediction model for reperfusion therapy in acute ischemic stroke using nomogram and machine learning.

To develop logistic regression nomogram and machine learning (ML)-based models to predict 3-month unfavorable functional outcome for acute ischemic stroke (AIS) patients undergoing reperfusion therapy. Patients undergoing reperfusion therapy (intravenous thrombolysis and/or endovascular treatment) were prospectively recruited. Unfavorable outcome was defined as 3-month modified Rankin Scale (mRS) score 3-6. The independent risk factors associated with unfavorable outcome were obtained by regression analysis and included in the prediction model. The performance of nomogram was assessed by the area under the curve (AUC), calibration curve, and decision curve analysis (DCA). ML models were compared with nomogram using AUC; the generalizability of all models was ascertained in an external cohort. A total of 505 patients were enrolled, with 256 in the model construction, and 249 in the external validation. Five variables were identified as prognostic factors: baseline NIHSS, D-dimer level, random blood glucose (RBG), blood urea nitrogen (BUN), and systolic blood pressure (SBP) before reperfusion. The AUC values of nomogram were 0.865, 0.818, and 0.779 in the training set, test set, and external validation, respectively. The calibration curve and DCA indicated appreciable reliability and good net benefits. The best three ML models were extra trees (ET), CatBoost, and random forest (RF) models; all of them showed favorable discrimination in the training cohort, and confirmed in the test and external sets. Baseline NIHSS, D-dimer, RBG, BUN, and SBP before reperfusion were independent predictors for 3-month unfavorable outcome after reperfusion therapy in AIS patients. Both nomogram and ML models showed good discrimination and generalizability.

Multicenter exploration of tenecteplase transition factors: A quantitative analysis

BackgroundTenecteplase (TNK) is gaining recognition as a novel therapy for acute ischemic stroke (AIS). Despite TNK offering a longer half-life, time and cost saving benefits and comparable treatment and safety profiles to Alteplase (ALT), the adoption of TNK as a treatment for AIS presents challenges for hospital systems. ObjectiveIdentify barriers and facilitators of TNK implementation at acute care hospitals in Texas. MethodsThis prospective survey used open-ended questions and Likert statements generated from content experts and informed by qualitative research. Stroke clinicians and nurses working at 40 different hospitals in Texas were surveyed using a virtual platform. ResultsThe 40 hospitals had a median of 34 (IQR 24.5–49) emergency department beds and 42.5 (IQR 23.5–64.5) inpatient stroke beds with 506.5 (IQR 350–797.5) annual stroke admissions. Fifty percent of the hospitals were Comprehensive Stroke Centers, and 18 (45 %) were solely using ALT for treatment of eligible AIS patients. Primary facilitators to TNK transition were team buy-in and a willingness of stroke physicians, nurses, and pharmacists to adopt TNK. Leading barriers were lack of clinical evidence supporting TNK safety profile inadequate evidence supporting TNK use and a lack of American Heart Association guidelines support for TNK administration in all AIS cases. ConclusionUnderstanding common barriers and facilitators to TNK adoption can assist acute care hospitals deciding to implement TNK as a treatment for AIS. These findings will be used to design a TNK adoption Toolkit, utilizing implementation science techniques, to address identified obstacles and to leverage facilitators.

Safety Profile of Intra-Arterial Tirofiban as a Rescue Therapy during Mechanical Thrombectomy in Acute Ischemic Stroke

Abstract Purpose This article studies the safety profile and role of intra-arterial (IA) tirofiban as a rescue therapy in acute ischemic stroke (AIS) patients undergoing mechanical thrombectomy. Methods This is a retrospective observational study conducted among AIS patients with large vessel occlusion (LVO) eligible for endovascular revascularization and in whom IA tirofiban is given as rescue therapy. If the target vessel shows reocclusion following initial recanalization, flow limiting or significant residual stenosis after thrombectomy, or requires balloon angioplasty or stenting, IA tirofiban at a dose of 0.4 μg/kg/min was administered through the microcatheter in the target vessel followed by intravenous infusion of 0.1 μg/kg/min. The primary safety measure of the study was the incidence of symptomatic hemorrhage. Results The total number of patients in the study group was 82, 36 were in the tirofiban group and 46 were in the non-tirofiban group. Immediate successful reperfusion was achieved in 31 patients (86.1%) and 41 patients (89%) in the tirofiban and non-tirofiban groups, respectively. Note that 19.4 and 25% of patients in the tirofiban group required adjunct techniques of angioplasty and stenting, respectively. Also, 2.7% patient in the tirofiban group had a symptomatic hemorrhage, while 8.7% in the non-tirofiban group had symptomatic intracranial hemorrhage. On multinomial logistic regression, history of transient ischemic attack, truncal occlusion and watershed infarct pattern predicted the usage of IA tirofiban during mechanical thrombectomy. Conclusion Usage of IA tirofiban with or without adjunct techniques as a rescue therapy during mechanical thrombectomy in LVO improved recanalization rates without increasing the risk of symptomatic hemorrhage.