Three-month Outcome Research Articles

Elevated Cerebrospinal Fluid Protein Is Associated with Unfavorable Functional Outcome in Spontaneous Subarachnoid Hemorrhage

Background/objective: Subarachnoid hemorrhage (SAH) is a devastating neurologic event for which markers to assess poor outcome are needed. Elevated cerebrospinal fluid (CSF) protein may result from inflammation and blood-brain barrier (BBB) disruption that occurs during SAH. We sought to determine if CSF protein level is associated with functional outcome after SAH. Methods: We prospectively collected single-center demographic and clinical data for consecutive patients admitted with spontaneous SAH. Inclusion required an external ventricular drain and daily CSF protein and cellular counts starting within 48 hours of symptom onset and extending through 7 days after onset. Seven-day average CSF protein was determined from daily measured values after correcting for contemporaneous CSF red blood cell (RBC) count. Three-month functional outcome was assessed by telephone interview with good outcome defined as modified Rankin score 0-3. Variables univariately associated with outcome at P less than .25 and measures of hemorrhage volume were included for binary logistic regression model development. Results: The study included 130 patients (88% aneurysmal SAH, 69% female, 54.8 ± 14.8 years, Glasgow Coma Scale [GCS] 14 [7-15]). Three-month outcome assessment was complete in 112 (86%) patients with good functional outcome in 74 (66%). CSF protein was lower in good outcome (35.3 [20.4-49.7] versus 80.5 [40.5-115.5] mg/dL; P < .001). CSF protein was not associated with cerebral vasospasm, but delayed radiographic infarction on 3 to 12-month neuroimaging was associated with higher CSF protein (46.3 [32.0-75.0] versus 30.2 [20.4-47.8] mg/dL; P = .023). Good 3-month outcome was independently associated with lower CSF protein (odds ratios [OR] .39 [.23-.70] for 75th versus 25th percentile of protein; P = .001) and higher admission GCS (OR 1.23 [1.10-1.37] for good outcome per GCS point increase; P < .001). Parenchymal hematoma predicted worse outcome (OR 6.31 [1.58-25.25]; P = .009). Results were similar after excluding nonaneurysmal SAH and after including CSF RBC count, CT score, and intraventricular hemorrhage volume in models. Conclusions: Elevated average CSF protein is associated with poor outcome after spontaneous SAH. Further research should investigate if elevated CSF protein identifies patients in whom mechanisms such as BBB disruption contribute to poor outcome.

A cohort study of the effects of dementia and dependence on the three-month outcome of acute stroke

Objective To investigate the effect of pre-stroke dependence and pre-stroke combined dementia on the outcome of 3 months after stroke in patients aged more than 65 years. Methods This study was a retrospective cohort study. A total of 966 patients with acute stroke were enrolled in the Department of Neurology, the First Affiliated Hospital of China Medical University from March 2015 to March 2018, including 168 patients diagnosed with dementia before acute stroke for the dementia group, and the remaining 798 people were treated as the non-dementia group. The demographic differences between the two groups at admission were compared. With the death and independence as the dependent variable within 3 months after the diagnosis of acute stroke, the independent risk of admission and the presence of dementia were used as covariates to make a COX proportional hazard assessment. Results There was significant difference in the number of medications, consistently taken with warfarin, pre-stroke independence, admission status between the dementia group and the non-dementia group (U=3.42, χ2=4.52, 8.96, 8.76, P 0.05). There was significant difference in the number of deaths within 3 months after discharge and dependence within 3 months after stroke between the two groups (χ2=5.69, 6.94, P < 0.01). Patients with pre-stroke dementia died during hospitalization and died within 3 months after discharge, the risk of moderate-to-severe dependence within 3 months after discharge was 1.00, 1.32, 2.56 compared with those who were completely independent before admission; mild dependence before admission patients who died before the stroke were completely dead during hospitalization and died within 3 months after discharge, the risk of moderate-to-severe dependence within 3 months after discharge was 1.42, 1.86, 2.73, respectively. Patients who were moderately dependent before admission were more likely to die from hospitalization than those who were completely independent before stroke, the risk of death within 3 months after discharge was 1.68, 2.42, respectively. Patients who were heavily dependent before admission were more likely to die from hospitalization than those who were completely independent before stroke, the risk of death within 3 months after discharge was 1.89, 3.24, respectively. Conclusions Pre-stroke dementia and activity disorder lead to a high risk of death and high disability within 3 months after stroke. Key words: Stroke; Dementia; Weakness; Function; Mortality

Functional impairment assessed by the Barthel Index influenced outcomes after transcatheter aortic valve implantation

Objective. We investigated the influence of functional impairment assessed by the Barthel index (BI) on the three-month outcomes after transfemoral-transcatheter aortic valve intervention (TF-TAVI) under general anesthesia. Design. We included retrospectively analyzed 336 patients undergoing TAVI between January 2017 and January 2018 in central hospital, Bad Berka, Germany. All patients were followed up at three-month in our center’s outpatient clinic. We stratified the patients according to the BI. Results. At baseline, 76 patients had a BI <80. Patients with a BI <80 were characterized by advanced age (80.6 ± 5.6 vs. 83 ± 4.1 years. p = .027), diabetes mellitus on insulin and higher surgical risk scores. A prior cerebral ischemic event was recorded more in patients with a BI ≥80. Regarding intermediate outcomes, three-month mortality was significantly higher in patients with a BI <80. Patients with a BI <80 developed significantly more postoperative cardiac decompensation, delirium and strokes. Patients with BI <80 had lower hemoglobin level preoperative and needed more blood transfusion postoperative. Other valve academic research consortiums (VARCs) complications were equally distributed in both groups. A BI <80 was associated with prolonged postoperative hospital stay and was an independent predictor of FT protocol failure (OR 4; CI 95% 1.3–11. p .02). Conclusions. A BI <80 is associated with increased mortality and risk of neurological events and cardiac decompensations after TF TAVI. A BI <80 is an independent predictor of failure in fast track TAVI.

Effect of haemoglobin levels on outcome in intravenous thrombolysis-treated stroke patients.

Alterations in haemoglobin levels are frequent in stroke patients. The prognostic meaning of anaemia and polyglobulia on outcomes in patients treated with intravenous thrombolysis is ambiguous. In this prospective multicentre, intravenous thrombolysis register-based study, we compared haemoglobin levels on hospital admission with three-month poor outcome (modified Rankin Scale 3-6), mortality and symptomatic intracranial haemorrhage (European Cooperative Acute Stroke Study II-criteria (ECASS-II-criteria)). Haemoglobin level was used as continuous and categorical variable distinguishing anaemia (female: <12g/dl; male: <13g/dl) and polyglobulia (female: >15.5g/dl; male: >17g/dl). Anaemia was subdivided into mild and moderate/severe (female/male: <11g/dl). Normal haemoglobin level (female: 12.0-15.5g/dl, male: 13.0-17.0g/dl) served as reference group. Unadjusted and adjusted odds ratios with 95% confidence intervals were calculated with logistic regression models. Among 6866 intravenous thrombolysis-treated stroke patients, 5448 (79.3%) had normal haemoglobin level, 1232 (17.9%) anaemia - of those 903 (13.2%) had mild and 329 (4.8%) moderate/severe anaemia - and 186 (2.7%) polyglobulia. Anaemia was associated with poor outcome (ORadjusted 1.25 (1.05-1.48)) and mortality (ORadjusted 1.58 (1.27-1.95)). In anaemia subgroups, both mild and moderate/severe anaemia independently predicted poor outcome (ORadjusted 1.29 (1.07-1.55) and 1.48 (1.09-2.02)) and mortality (ORadjusted 1.45 (1.15-1.84) and ORadjusted 2.00 (1.46-2.75)). Each haemoglobin level decrease by 1 g/dl independently increased the risk of poor outcome (ORadjusted 1.07 (1.02-1.11)) and mortality (ORadjusted 1.08 (1.02-1.15)). Anaemia was not associated with occurrence of symptomatic intracranial haemorrhage. Polyglobulia did not change any outcome. The more severe the anaemia, the higher the probability of poor outcome and death. Severe anaemia might be a target for interventions in hyperacute stroke. Anaemia on admission, but not polyglobulia, is a strong and independent predictor of poor outcome and mortality in intravenous thrombolysis-treated stroke patients.

Impact of intravenous thrombolysis on functional outcome in patients with mild ischemic stroke without large vessel occlusion or rapidly improving symptoms.

Optimal treatment strategy in patients with mild ischemic stroke remains uncertain. While functional dependency or death has been reported in up to one-third of non-thrombolyzed mild ischemic stroke patients, intravenous thrombolysis is currently not recommended in this patient group. Emerging evidence suggests two risk factors-rapid early improvement and large vessel occlusion-as main associates of unfavorable outcome in mild ischemic stroke patients not undergoing intravenous thrombolysis. To analyze natural course as well as safety and three-month outcome of intravenous thrombolysis in mild ischemic stroke without rapid early improvement or large vessel occlusion. Mild ischemic stroke was defined by a National Institute of Health Stroke Scale score ≤6. We used the modified Rankin Scale (mRS) to compare three-month functional outcome in 370 consecutive mild ischemic stroke patients without early rapid improvement and without large vessel occlusion, who either underwent intravenous thrombolysis (n = 108) or received best medical treatment (n = 262). Favorable outcome (mRS ≤ 1) was common in both groups (intravenous thrombolysis: 91%; no intravenous thrombolysis: 90%). Although intravenous thrombolysis use was independently associated with a higher risk of asymptomatic hemorrhagic transformation (OR = 4.62, p = 0.002), intravenous thrombolysis appeared as an independent predictor of mRS = 0 at three months (OR = 3.33, p < 0.0001). Mild ischemic stroke patients without rapidly improving symptoms and without large vessel occlusion have a high chance of favorable three-month outcome, irrespective of treatment type. Patients receiving intravenous thrombolysis, however, more often achieved complete remission of symptoms, which particularly in mild ischemic stroke may constitute a meaningful endpoint.

Hemicraniectomy for Supratentorial Primary Intracerebral Hemorrhage: A Retrospective, Propensity Score Matched Study

Background and Purpose: Spontaneous supratentorial intracerebral hemorrhage (ICH) contributes disproportionately to stroke mortality, and randomized trials of surgical treatments for ICH have not shown benefit. Decompressive hemicraniectomy (DHC) improves functional outcome in patients with malignant middle cerebral artery ischemic stroke, but data in ICH patients is limited. We hypothesized that DHC would reduce in-hospital mortality and poor functional status (defined as modified Rankin scale ≥5) among survivors at 3 months, without increased complications. Methods: We performed a retrospective, case-control, propensity score matched study to determine whether hemicraniectomy affected outcome in patients with spontaneous supratentorial ICH. The propensity score consisted of variables associated with outcome or predictors of hemicraniectomy. Forty-three surgical patients were matched to 43 medically managed patients on ICH location, sex, and nearest neighbor matching. Three-month functional outcomes, in-hospital mortality, and in-hospital complications were measured. Results: In the medical management group, 72.1% of patients had poor outcome at 3 months compared with 37.2% who underwent hemicraniectomy (odds ratio 4.8, confidence interval 1.6-14). In-hospital mortality was 51.2% for medically managed patients and 16.3% for hemicraniectomy patients (odds ratio 8.5, confidence interval 2.0-36.8). There were no statistically significant differences in the occurrence of in-hospital complications. Conclusions: In our retrospective study of selected patients with spontaneous supratentorial ICH, DHC resulted in lower rate of in-hospital mortality and better 3-month functional status compared with medically managed patients. A randomized trial is necessary to evaluate DHC as a treatment for certain patients with spontaneous supratentorial ICH.

Direct Targeting of the Ventral Intermediate Nucleus Using High-Field Proton Density MR Imaging: Functional Outcomes and Comparison to “Indirect” Targeting

Abstract INTRODUCTION The ventral intermediate nucleus is typically considered not to be visible on MRI, However, there have been reports of successful imaging of this structure. In this study, the authors describe their experience incorporating “direct targeting” to surgical planning of DBS surgery. METHODS Between July 2017 and September 2018, 41 patients underwent VIM DBS for essential tremor under general anesthesia using direct targeting methods. Images were acquired on a 3.0-tesla MR system, and a proton density sequence was used to visualize the VIM. Clinical outcomes were prospectively collected at baseline and 3-mo follow-up and compared to patients treated previously using indirect targeting methods. RESULTS A total of 77 leads were placed with 36 patients undergoing bilateral surgery and 5 patients undergoing unilateral surgery (mean age 68.6, M: F 25:16). Relative to the mid-commisural point, the mean target coordinates for these patients was (±14.4, −5.9, 0.1). Comparing this to our previous cohort (213 patients) in whom indirect targeting was used, direct targeting led to a more lateral target (P &lt; .05). Three-month follow-up outcomes for 21 patients were compared to to 33 patients who had undergone asleep VIM DBS surgery using indirect targeting. Accuracy was comparable between groups. Direct and Indirect groups did not differ significantly regarding mean postoperative percentages of functional improvement (direct, 36% vs indirect, 48%) or quality of life (direct 68% vs indirect 75%). Mean voltage was 2.09 for the direct group and 2.14 for the indirect group (P = .7). Fewer postoperative stimulation-related speech side effects were reported among the direct targeting group (direct n = 4 vs indirect n = 9). CONCLUSION VIM targeting based upon direct visualization using proton density MRI resulted in more lateral targeting, equivalent functional outcomes, and fewer stimulation-related speech side effects compared to our historical cohorts.

Association between Blood Urea Nitrogen-to-creatinine Ratio and Three-Month Outcome in Patients with Acute Ischemic Stroke.

Hydration status significantly affects the clinical outcome of acute ischemic stroke (AIS) patients. Blood urea nitrogen-to-creatinine ratio (BUN/Cr) is a biomarker of hydration status. However, it is not known whether there is a relationship between BUN/Cr and three-month outcome as assessed by the modified Rankin Scale (mRS) score in AIS patients. AIS patients admitted to West China Hospital from 2012 to 2016 were prospectively and consecutively enrolled and baseline data were collected. Poor clinical outcome was defined as three-month mRS > 2. Univariate and multivariate logistic regression analyses were performed to determine the relationship between BUN/Cr and three-month outcome. Confounding factors were identified by univariate analysis. Stratified logistic regression analysis was performed to identify effect modifiers. A total of 1738 patients were included in the study. BUN/Cr showed a positive correlation with the three-month outcome (OR 1.02, 95% CI 1.00-1.03, p=0.04). However, after adjusting for potential confounders, the correlation was no longer significant (p=0.95). An interaction between BUN/Cr and high-density lipoprotein (HDL) was discovered (p=0.03), with a significant correlation between BUN/Cr and three-month outcome in patients with higher HDL (OR 1.03, 95% CI 1.00-1.07, p=0.04). Elevated BUN/Cr is associated with poor three-month outcome in AIS patients with high HDL levels.

Treating opioid dependence with extended-release naltrexone (XR-NTX) in Ukraine: Feasibility and three-month outcomes

BackgroundAlthough opioid agonist treatments (OAT) with methadone or buprenorphine are available to treat opioid use disorders (OUD) in Ukraine, OAT acceptability and coverage remains low. Extended-release naltrexone (XR-NTX) that recently became available as another treatment option provides new opportunities for treating OUDs in this region and we aimed to test its feasibility. MethodsPatients with OUD (N=135) and interested in treatment with XR-NTX were initiated on monthly XR-NTX injections and monitored for three months. Correlates of 3-month retention on XR-NTX and drug use at each time-point using self-reports and urine drug testing (UDT) were assessed. ResultsOf the 134 participants initiated XR-NTX, 101 (75%) completed three months, defined as 4 consecutive XR-NTX injections. Independent factors negatively associated with retention in XR-NTX treatment included previous maintenance with OAT (aOR=0.3; 95%CI=0.1-0.9) and extrinsic help-seeking treatment motivation (aOR=0.7; 95%CI=0.5-0.9). Of these 101 participants completing three months of treatment, opioid use markedly reduced using self-report (67%% to 22%; p>0.001) and UDT (77% to 24%; p<0.001) outcomes over time. Alcohol, marijuana and stimulant use, however, remained unchanged. Craving for opioids and symptoms of depression also significantly decreased, while health-related quality of life scores improved over time. No adverse side effects were reported during the period of observation. ConclusionThe first introduction of XR-NTX in Ukraine among persons with OUD resulted in high levels of retention, marked reductions in opioid use and improved quality of life. These descriptive results suggest that XR-NTX treatment is feasible and well-tolerated over a 3-month period in Ukraine.

IER-START nomogram for prediction of three-month unfavorable outcome after thrombectomy for stroke.

The applicability of the current models for predicting functional outcome after thrombectomy in strokes with large vessel occlusion (LVO) is affected by a moderate predictive performance. We aimed to develop and validate a nomogram with pre- and post-treatment factors for prediction of the probability of unfavorable outcome in patients with anterior and posterior LVO who received bridging therapy or direct thrombectomy <6 h of stroke onset. We conducted a cohort study on patients data collected prospectively in the Italian Endovascular Registry (IER). Unfavorable outcome was defined as three-month modified Rankin Scale (mRS) score 3-6. Six predictors, including NIH Stroke Scale (NIHSS) score, age, pre-stroke mRS score, bridging therapy or direct thrombectomy, grade of recanalization according to the thrombolysis in cerebral ischemia (TICI) grading system, and onset-to-end procedure time were identified a priori by three stroke experts. To generate the IER-START, the pre-established predictors were entered into a logistic regression model. The discriminative performance of the model was assessed by using the area under the receiver operating characteristic curve (AUC-ROC). A total of 1802 patients with complete data for generating the IER-START was randomly dichotomized into training (n = 1219) and test (n = 583) sets. The AUC-ROC of IER-START was 0.838 (95% confidence interval [CI]): 0.816-0.869) in the training set, and 0.820 (95% CI: 0.786-0.854) in the test set. The IER-START nomogram is the first prognostic model developed and validated in the largest population of stroke patients currently candidates to thrombectomy which reliably calculates the probability of three-month unfavorable outcome.

A COACHS Nomogram to Predict the Probability of Three-Month Unfavorable Outcome after Acute Ischemic Stroke in Chinese Patients

Background: Accurate prognostication of unfavorable outcome made at the early onset of stroke is important to both the clinician and the patient management. This study was aimed to develop a nomogram based on the integration of parameters to predict the probability of 3-month unfavorable functional outcome in Chinese acute ischemic stroke patients. Methods: We retrospectively collected patients who underwent acute ischemic stroke at Stroke Center of the Nanjing First Hospital (China) between May 2013 and May 2018. After exclusion, the study population includes 1,025 patients for nomogram development. The main outcome measure was 3-month unfavorable outcome (modified Rankin Scale > 2). Multivariable logistic regression analysis was used to develop the predicting model, and stepwise logistic regression with the Akaike information criterion was utilized to find best-fit nomogram model. We incorporated the creatinine, fast blood glucose, age, previous cerebral hemorrhage, previous valvular heart disease, and NHISS score (COACHS), and these factors were presented with a nomogram. We assessed the discriminative performance by using the area under curve (AUC) of receiver-operating characteristic (ROC) and calibration of risk prediction model by using the Hosmer-Lemeshow test. Results: Multivariate analysis of the 1,025 patients for logistic regression helped identify the independent factors as National Institutes of Health Stroke Scale score on admission, age, previous valvular heart disease, fasting blood glucose, creatinine, and previous cerebral hemorrhage, which were included in the COACHS nomogram. The AUC-ROC of nomogram was 0.799. Calibration was good (p = 0.1376 for the Hosmer-Lemeshow test). Conclusions: The COACHS nomogram may be used to predict unfavorable outcome at 3 months after acute ischemic stroke in Chinese population. It may be also a reliable tool that is effective in its clinical utilization to risk-stratify acute stroke patients.

Trajectories of cognitive-affective depressive symptoms in acutely hospitalized older adults: The hospital-ADL study

ObjectiveTo identify trajectories of cognitive-affective depressive symptoms among acutely hospitalized older patients and whether trajectories are related to prognostic baseline factors and three-month outcomes such as functional decline, falls, unplanned readmissions, and mortality. MethodsProspective multicenter cohort of acutely hospitalized patients aged ≥ 70. Depressive trajectories were based on Group Based Trajectory Modeling, using the Geriatric Depression Scale-15. Outcomes were functional decline, falls, unplanned readmission, and mortality within three months post-discharge. ResultsThe analytic sample included 398 patients (mean age = 79.6 years; SD = 6.6). Three distinct depressive symptoms trajectories were identified: minimal (63.6%), mild persistent (25.4%), and severe persistent (11.0%). Unadjusted results showed that, compared to the minimal symptoms group, the mild and severe persistent groups showed a significantly higher risk of functional decline (mild: OR = 3.9, p < .001; severe: OR = 3.0, p = .04), falls (mild: OR = 2.0, p = .02; severe: OR = 6.0, p < .001), and mortality (mild: OR = 2.2, p = .05; severe: OR = 3.4, p = .009). Patients with mild or severe persistent symptoms were more malnourished, anxious, and functionally limited and had more medical comorbidities at admission. ConclusionNearly 40% of the acutely hospitalized older adults exhibited mild to severe levels of cognitive-affective depressive symptoms. In light of the substantially elevated risk of serious complications and the fact that elevated depressive symptoms was not a transient phenomenon identification of these patients is needed. This further emphasizes the need for acute care hospitals, as a point of engagement with older adults, to develop discharge or screening procedures for managing cognitive-affective depressive symptoms.

Abstract WP113: Racial Disparities in Patient Selection for Drip and Ship Thrombolytic Therapy for Acute Ischemic Stroke

Introduction: There is preliminary data indicating potential racial disparities in use of intravenous thrombolysis (IVT) for acute ischemic stroke (AIS). We sought to compare “drip and ship” (DNS) tPA use between African-Americans (AA) and Caucasians (CS) in a high-volume tertiary care stroke center. Methods: AIS patients treated with IVT during a seven-year period were evaluated. Baseline stroke severity and early hypodensity on baseline CT were assessed by NIHSS-score and ASPECTS by certified physicians. All patients who received IVT at an outside facility with subsequent transfer to our center were included in the DNS group. Safety of IVT was evaluated SITS-MOST symptomatic intracranial hemorrhage (sICH) definition. Three-month functional status was assessed using modified Rankin Scale (mRS) scores. Results: Out of total 1339 IVT-treated AIS patients [51% men, 63% AA, mean age 63±15years, median baseline NIHSS-score: 7 pts (IQR: 3-13)], 521 (39%) were treated using the DNS approach. DNS tPA use was less common in AA compared to CS (33% vs. 51%; p &lt; 0.001). AA race was independently associated with lower likelihood of DNS tPA use (OR: 0.46; 95%CI: 0.35-0.62; p&lt;0.001) on multivariable logistic regression models adjusting for multiple potential confounders including demographics, vascular risk factors, onset-to-treatment time, door-to-needle time, baseline stroke severity, serum glucose, BP parameters and ASPECTS. Among DNS patients, the rates of sICH, three-month favorable functional outcome (mRS-scores of 0-1) and mortality did not differ between AA and CS. Using geospatial software, the observed treatment disparity could not be explained by racial zipcode. distribution. Conclusions: Our study uncovers substantial racial disparities in the selection of AIS patients for DNS thrombolytic therapy that cannot be explained by racial geographic proximity to the primary stroke center.

Abstract TP416: Safety and Efficacy Outcomes of Intravenous Thrombolysis (IVT) for In-Hospital Stroke

Introduction: Cross-sectional data suggest that IVT in patients with in-hospital (IHS) acute ischemic stroke (AIS) onset is associated with unfavourable outcomes compared to out-of-hospital (OHS) stroke onset patients. We sought to compare safety and efficacy outcomes between IHS and OHS patients treated with IVT. Methods: Consecutive AIS patients treated with IVT during a five-year period in a tertiary care stroke center were prospectively evaluated. Demographics, vascular risk factors, admission blood pressure and serum glucose levels were documented. Baseline stroke severity and early hypodensity on baseline CT were assessed using NIHSS-score and ASPECTS by certified physicians. Three-month functional outcome was evaluated by mRS-score. We compared the following outcomes between IHS and OHS patients: 1.symptomatic intracranial hemorrhage (sICH) 2.favourable functional outcome (FFO) [3-month mRS scores of 0-1], 3.Functional independence (FI) [3-month mRS scores of 0-2], 4. Mortality at three months. Results: Of 1264 IVT-treated AIS patients, we identified 51 (4%) subjects with IHS. Baseline median NIHSS-score was higher in IHS (10 points; IQR: 6-16 vs. 6 points; IQR: 3-12; p=0.004), while median onset-to-treatment was shorter (75 min; IQR: 37-115 vs. 135 min; IQR: 100-185; p&lt;0.001). In univariable analyses, IHS patients had higher three-month mortality rates (21% vs. 9%; p=0.009). There were no differences (p&gt;0.1) between the two groups in FFO, FI and sICH rates. IHS was associated with higher likelihood three-month mortality (OR: 3.1; 95%CI: 1.2-7.8; p=0.016) on multivariable logistic regression models adjusting for demographics, risk factors, onset-to-treatment time, admission blood pressure and serum glucose levels, baseline NIHSS and ASPECTS. Conclusions: IHS patients treated with IVT have more severe strokes and higher mortality rates compared to OHS patients. IVT for IHS is not associated with higher hemorrhagic complications.

Abstract WP102: Association of Elevated Blood Pressure Levels With Outcomes in Acute Ischemic Stroke Patients Treated With Intravenous Thrombolysis: A Systematic Review and Meta-Analysis

Introduction: Although arbitrary blood pressure (BP) thresholds exist for acute ischemic stroke (AIS) patients eligible for intravenous thrombolysis (IVT), current international recommendations lack clarity on the impact of mean pre- and post-IVT BP levels on clinical outcomes. Methods: We identified eligible studies involving IVT-treated AIS patients that reported the association of mean systolic (SBP) or diastolic BP (DBP) levels before and after IVT with the following outcomes: three-month favorable functional outcome (FFO; mRS-scores of 0-1), three-month functional independence (FI; mRS-scores of 0-2)], three-month mortality and symptomatic intracranial hemorrhage (sICH). Unadjusted analyses of standardized mean differences (SMD) for individual outcomes and adjusted analyses of studies reporting odds ratios (ORadj) per 10mmHg BP increment were performed using the random-effects models. Results: We identified 26 studies comprising 56,513 patients. Higher pre- (SMD: 0.24; 95%CI: 0.04 to 0.43; p=0.02) and post-treatment (SMD: 0.50; 95%CI: 0.14 to 0.86; p=0.006) SBP levels were observed in patients with sICH. Patients with 3-month FI had lower pre- (SMD: -0.18; 95%CI: -0.34 to -0.01; p=0.04) and post-treatment (SMD: -0.19; 95%CI: -0.23 to -0.15; p&lt;0.001) SBP. In adjusted analyses, elevated pre- (ORadj: 1.08; 95%CI: 1.01 to 1.16) and post-treatment (ORadj: 1.13; 95%CI: 1.01 to 1.25) SBP levels were associated with increased likelihood of sICH. Increasing pre- (ORadj: 0.91; 95%CI: 0.84 to 0.98) and post-treatment (ORadj: 0.70; 95%CI: 0.57 to 0.87) SBP values were also related to lower odds of 3-month FI. No association was noted between either mean pre-treatment or post-treatment SBP levels with three-month mortality. Likewise, no associations were observed with either mean pre-treatment or post-treatment DBP levels and three-month FFO, three-month FI, sICH, or three-month mortality. Conclusions: We found that elevated BP levels adversely impact AIS outcomes in patients receiving IVT. Future randomized-controlled clinical trials will provide definitive data regarding the potential association of BP control with improved outcomes of AIS patients treated with IVT.

Regional differences in ischemic stroke in India (north vs. south).

India is a large country with geographically diverse populations and varying risk factors. Identification of regional differences can improve healthcare policy decisions. To study regional differences in stroke between North and South India. We analyzed data from the Indo-US Collaborative Stroke Project, a National Institute of Health-funded multicentre prospective study conducted in five academic centers in India with a US-based coordinating center. Risk factors, severity, mechanisms, management, complications, and outcomes among ischemic stroke patients were compared between North and South Indian centers. Of the 2066 patients enrolled from North (n = 1060) and South India (n = 1006), North Indian patients were significantly older with fewer men and had lower rates of diabetes (32.8% vs. 38.7%, p < 0.01), dyslipidemia (3.5% vs. 25.7%, p < 0.01), tobacco use (27% vs. 38%, p < 0.001), and alcohol use (30.1% vs. 38.6%, p < 0.01). North Indian patients had higher median National Institute of Health stroke scale scores (10 vs. 9, p < 0.01), more frequent large-artery atherosclerosis mechanism (34% vs. 25.6%, p < 0.001), intravenous thrombolysis (14.0% vs. 6.1%, p < 0.001), and lower rates of pneumonia (10.5% vs. 15.1%, p = 0.02). The three-month outcome (modified Rankin Scale score 0-2, 45.8% vs. 50.3%, p = 0.08) did not differ; however, North Indian patients had higher 90-day mortality (23.5% vs. 13.5%, p < 0.0001). The substantial regional differences in stroke risk factors and mechanisms may be partly explained by factors such as differing dietary habits and lifestyle, which can be addressed at a national level. Differences in acute and inpatient stroke care suggest a need for better adoption of national stroke management guidelines.

Antiplatelets versus Anticoagulants in the Treatment of Extracranial Carotid and Vertebral Artery Dissection.

Very few studies have compared the safety and efficacy of antiplatelets and anticoagulants in the treatment of extracranial carotid and vertebral artery dissection. Our study was aimed at comparing the two types of antithrombotic treatment in extracranial dissection and to study the predictors of outcome in these patients. Prospective data of 200 consecutive patients with a confirmed diagnosis of extracranial carotid (n = 132) or vertebral (n = 68) artery dissection (76% males; mean age, 43.5 ± 13 years) treated with antiplatelets (n = 136) or anticoagulants (n = 64) were analyzed retrospectively. The presenting symptom was stroke in 74.5%, transient ischemic attack (TIA) in 18.5%, and local symptoms in 7% of the patients. Follow-up was done at three and six months. Primary outcome measures were TIA or stroke and symptomatic intracerebral hemorrhage (SICH) at three months. At the three-month follow-up, 106 (53%) patients had an excellent outcome. Recurrent ischemic events occurred in 7 (3.5%) and SICH in 11 (5.55%) patients. Six (4.41%) patients in the antiplatelet group and 1 patient (1.56%) in the anticoagulant group had recurrent ischemic events (P = 0.434); SICH was more frequent in the anticoagulant group (9.4% vs 3.7%, P = 0.185). On multivariate analysis, significant predictors of a poor three-month outcome were stroke as the presenting event and severity of stroke at onset. The risk of recurrent ischemic events in carotid and vertebral artery dissection is low and is irrespective of the type of antithrombotic treatment. Stroke as the presenting event and severity of stroke at onset were significant predictors of a poor three-month outcome.

Tapered arteriovenous grafts do not provide significant advantage over nontapered grafts in upper extremity dialysis access

ObjectiveAlthough tapered dialysis access grafts are often used in an effort to prevent ischemic steal, their efficacy is uncertain. Our goal was to use real-world data to assess the performance of these grafts with respect to primary patency and ischemic steal. MethodsThe Vascular Quality Initiative database was queried from 2010 to 2017 for all patients undergoing tapered dialysis grafts in the upper arm. Multivariable analysis was performed to analyze primary patency, ischemic steal, and reinterventions. ResultsWe identified 3608 patients who received dialysis access grafts, 1473 tapered grafts and 2135 nontapered grafts. The mean age was 64.8 years, and 43.4% of the patients were male. Tapered grafts were used more often in female patients (60.5% vs 54%), nonwhite patients (53.3% vs 47.7%), patients with no previous access (28% vs 26.3%), grafts with an antecubital brachial artery origin (50% vs 44.4%), and grafts with an antecubital cephalic vein target (7.4% vs 3.7%; P < .05). Three-month outcomes between tapered and nontapered grafts were similar for wound infection (1.4% vs 2%; P = .31), ischemic steal (4.1% vs 4.6%; P = .58), and arm swelling (3.5% vs 2.9%; P = .38). Multivariable analyses revealed that in comparison to nontapered grafts, tapered grafts did not affect primary patency rates (hazard ratio [HR], 1.17; 95% confidence interval [CI], 0.96-1.42; P = .11), ischemic steal (HR, 1.03; 95% CI, 0.64-1.65; P = .92), difference in endovascular reintervention (HR, 1.08; 95% CI, 0.74-1.16; P = .5), or operative reintervention (HR, 1.25; 95% CI, 0.86-1.82; P = .24). ConclusionsTapered grafts for upper extremity arteriovenous access do not affect primary patency, development of steal, or endovascular reintervention in comparison to nontapered grafts. Our findings do not support the routine use of these grafts in dialysis access to improve outcomes.

Hemoglobin level and three-month clinical outcomes among ischemic stroke patients with elevated systolic blood pressure

BackgroundPrevious studies have reported that extreme low and high hemoglobin levels are positively associated with the risk of ischemic stroke. However, there are few reports on the relationship between hemoglobin at acute phase and clinical outcomes after ischemic stroke and the results of their association to date are inconsistent. We aimed to investigate the association between them in a large prospective cohort of ischemic stroke patients. MethodsBaseline hemoglobin levels were measured in 3881 patients with acute ischemic stroke. The primary outcome was defined as composite outcome of major disability and death (modified Rankin Scale score ≥ 3) at 3 months after stroke onset. Secondary outcomes were separately those of major disability and death. ResultsCompared with the lowest quartile of hemoglobin, the multivariate adjusted odds ratios (95% confidence intervals) associated with the highest quartile were 1.38 (1.03–1.86), 1.49 (1.11–1.99), 0.79 (0.41–1.52) for primary outcome, major disability and death, respectively. Multiple-adjusted spline regression model showed linear associations of hemoglobin levels with primary outcome (P for linearity =0.037) and major disability (P for linearity =0.004). Subgroup analyses further confirmed the positive association between high hemoglobin and poor prognosis of ischemic stroke. ConclusionsElevated hemoglobin levels in the acute phase were associated with poor prognosis at 3 months after ischemic stroke. Further prospective studies from other samples of ischemic stroke patients are needed to validate our findings.

Multimodal Predictions of Super-Refractory Status Epilepticus and Outcome in Status Epilepticus Due to Acute Encephalitis.

Objective: Status epilepticus (SE) is one of the most critical symptoms of encephalitis. Studies on early predictions of progression to super-refractory status epilepticus (SRSE) and poor outcome in SE due to acute encephalitis are scarce. We aimed to investigate the values of neuroimaging and continuous electroencephalogram (EEG) in the multimodal prediction.Methods: Consecutive patients with convulsive SE due to acute encephalitis were included in this study. Demographics, clinical features, neuro-imaging characteristics, medical interventions, and anti-epileptic treatment responses were collected. All the patients had EEG monitoring for at least 24 h. We determined the early predictors of SRSE and prognostic factors of 3-month outcome using multivariate logistic regression analyses.Results: From March 2008 to February 2018, 570 patients with acute encephalitis were admitted to neurological intensive care unit (N-ICU) of Xijing hospital. Among them, a total of 94 patients with SE were included in this study. The percentage of non-SRSE and SRSE were 76.6 and 23.4%. Cortical or hippocampal abnormality on neuroimaging (p = 0.002, OR 20.55, 95% CI 3.16–133.46) and END-IT score (p < 0.001, OR 4.07, 95% CI 1.91–8.67) were independent predictors of the progression to SRSE. At 3 months after N-ICU discharge, 56 (59.6%) patients attained good outcomes, and 38 (40.4%) patients had poor outcomes. The recurrence of clinical or EEG seizures within 2 h after the infusion rate of a single anesthetic drug >50% proposed maximal dose (p = 0.044, OR 4.52, 95% CI 1.04–19.68), tracheal intubation (p = 0.011, OR 4.99, 95% CI 1.37–11.69) and emergency resuscitation (p = 0.040, OR 9.80, 95% 1.11–86.47) predicted poor functional outcome.Interpretation: Initial neuro-imaging findings assist early identification of the progression to SRSE. Continuous EEG monitoring contributes to outcome prediction in SE due to acute encephalitis.