Unselected Stroke Research Articles

Prehospital stroke detection scales: A head-to-head comparison of 7 scales in patients with suspected stroke.

Several prehospital scales have been designed to aid paramedics in identifying stroke patients in the ambulance setting. However, external validation and comparison of these scales are largely lacking. To compare all published prehospital stroke detection scales in a large cohort of unselected stroke code patients. We conducted a systematic literature search to identify all stroke detection scales. Scales were reconstructed with prehospital acquired data from two observational cohort studies: the Leiden Prehospital Stroke Study (LPSS) and PREhospital triage of patients with suspected STrOke (PRESTO) study. These included stroke code patients from four ambulance regions in the Netherlands, including 15 hospitals and serving four million people. For each scale, we calculated the accuracy, sensitivity and specificity for a diagnosis of stroke (ischemic, hemorrhagic or TIA). Moreover, we assessed the proportion of stroke patients who received reperfusion treatment with intravenous thrombolysis or endovascular thrombectomy that would have been missed by each scale. We identified 14 scales, of which seven (CPSS, FAST, LAPSS, MASS, MedPACS, OPSS, and sNIHSS-EMS) could be reconstructed. Of 3317 included stroke code patients, 2240 (67.5%) had a stroke (1528 ischemic, 242 hemorrhagic, 470 TIA) and 1077 (32.5%) a stroke mimic. Of ischemic stroke patients, 715 (46.8%) received reperfusion treatment. Accuracies ranged from 0.60 (LAPSS) to 0.66 (MedPACS, OPSS and sNIHSS-EMS), sensitivities from 66% (LAPSS) to 84% (MedPACS and sNIHSS-EMS), and specificities from 28% (sNIHSS-EMS) to 49% (LAPSS). MedPACS, OPSS and sNIHSS-EMS missed the fewest reperfusion-treated patients (10.3-11.2%), whereas LAPSS missed the most (25.5%). Prehospital stroke detection scales generally exhibited high sensitivity but low specificity. While LAPSS performed poorest, MedPACS, sNIHSS-EMS and OPSS demonstrated the highest accuracy and missed the fewest reperfusion-treated stroke patients. Use of the most accurate scale could reduce unnecessary stroke code activations for patients with a stroke mimic by almost a third, but at the cost of missing 16% of strokes and 10% of patients who received reperfusion treatment.

Case management-based post-stroke care for patients with acute stroke and TIA (SOS-Care): a prospective cohort study

BackgroundThe high incidence of stroke recurrence necessitates effective post-stroke care. This study investigates the effectiveness of a case management-based post-stroke care program in patients with acute stroke and TIA.MethodsIn this prospective cohort study, patients with TIA, ischemic stroke or intracerebral hemorrhage were enrolled into a 12-month case management-based program (SOS-Care) along with conventional care. Control patients received only conventional care. The program included home and phone consultations by case managers, focusing on education, medical and social needs and guideline-based secondary prevention. The primary outcome was the composite of stroke recurrence and vascular death after 12 months. Secondary outcomes included vascular risk factor control at 12 months.ResultsFrom 11/2011 to 12/2020, 1109 patients (17.9% TIA, 77.5% ischemic stroke, 4.6% intracerebral hemorrhage) were enrolled. After 85 (7.7%) dropouts, 925 SOS-Care patients remained for comparative analysis with 99 controls. Baseline characteristics were similar, except for fewer males and less frequent history of dyslipidemia in post-stroke care. At 12 months, post-stroke care was associated with a reduction in the composite endpoint compared to controls (4.9 vs. 14.1%; HR 0.30, 95% CI 0.16–0.56, p < 0.001), with consistent results in ischemic stroke patients alone (HR 0.32, 95% CI 0.17–0.61, p < 0.001). Post-stroke care more frequently achieved treatment goals for hypertension, dyslipidemia, diabetes, BMI and adherence to secondary prevention medication (p < 0.05).ConclusionsCase management-based post-stroke care may effectively mitigate the risk of vascular events in unselected stroke patients. These findings could guide future randomized trials investigating the efficacy of case management-based models in post-stroke care.

Risk of stroke in patients with prior VKA or DOAC: A population-based real-world registry analysis.

To date, risk assessment of suffering ischemic and hemorrhagic stroke in individuals under oral anticoagulation (OAC) is limited to hospital-based cohorts and patients with atrial fibrillation. Through the combination of three individual datasets, (1) the population-based Tyrolean Stroke Pathway database, prospectively documenting all (unselected) stroke patients in the entire federal state of the Tyrol and (2) nation-wide prescription data, detailing each reimbursed prescription in Austria as well as (3) the Austrian Stroke Unit Registry, a nation-wide registry comprising data on all patients admitted to any of the 38 stroke units in Austria, we assessed risk of stroke in patients with prior oral anticoagulation and compared characteristics of patients taking direct oral anticoagulants and Vitamin-K-Antagonists. In Austria, oral anticoagulant prescription reimbursements increased from 292,475 in 2015 to 389,407 in 2021. In the Tyrol, prior oral anticoagulation treatment was evident in 586 of 3861 (15.2%) patients with ischemic and 131 of 523 (25.0%) with hemorrhagic stroke, with 20% and 35% of those stroke patients respectively having prior oral anticoagulation due to other indications than non-valvular atrial fibrillation. Considering prescription rates, treatment with direct oral anticoagulants was associated with a reduced stroke risk compared to Vitamin-K-Antagonists, especially in ischemic (1.05% vs 0.62%; RR 0.59, p < 0.001) but also in hemorrhagic stroke, even if less pronounced (0.21% vs 0.14%; RR 0.68, p = 0.06). In Austria, prior intake of direct oral anticoagulants was associated with lower risk of suffering acute large vessel occlusion stroke (RR 0.79, p = 0.003). One in seven patients suffering ischemic and one in four suffering hemorrhagic stroke had prior oral anticoagulation treatment. Both ischemic and hemorrhagic strokes are less frequent in those with direct oral anticoagulant intake compared to those taking Vitamin-K-Antagonists. Establishment of clear standard operating procedures on how to best care for acute stroke patients with oral anticoagulation is essential.

Outcome of endovascular stroke therapy in a large mandatory stroke-registry

BackgroundEndovascular stroke treatment (EST) has become the standard treatment for patients with stroke due to large vessel occlusion, especially in earlier time windows. Only few data from population-based registries on effectiveness of EST have been published.MethodsBaden–Wuerttemberg is the third largest state in Germany in terms of area and population and has a structured stroke concept since 1998 which includes mandatory collection of quality assurance data. In 2018 and 2019, 3820 of 39,168 ischemic stroke patients (9.8%) were treated by EST (age median 78 y, NIHSS median 14). We analyzed the clinical outcome of these patients determined with the modified Rankin Scale (mRS) at discharge from the hospital or with the initiation of palliative therapy using logistic regression analysis with adjustment for the mRS at admission, additive IVT, age, and NIHSS.ResultsThe probability of an excellent clinical outcome (mRS 0 or 1 at discharge) and for a good clinical outcome (mRS 0–2) were significantly higher in EST-patients (odds-ratio (OR) 1.27; 95% confidence interval (95% CI) 1.13–1.43, and OR of 1.15 (95% CI 1.04–1.28). Also, the regression model showed an advantage for EST-patients with less frequent ‘decision for palliative care’ (OR 0.87; 95% CI 0.78–0.98). Sensitivity analysis adjusting for intracranial vessel occlusion as further factor showed similar results.ConclusionOur data suggest that EST can be of benefit also for an area-wide unselected stroke population, in a large German federal state with sometimes long distance to the next thrombectomy center.

Hyperbaric Oxygen in Post-Stroke Patients: A Feasibility Study

Background: Hyperbaric oxygen therapy (HBOT) has been shown to improve the outcomes of certain stroke patients. Our objective was to assess the feasibility of employing HBOT in daily practice in unselected stroke patients with mild-to-moderate residual post-stroke symptoms, considering their ability to commute our center. Methods: This was an exploratory, interventional, prospective monocentric study on post-stroke patients who have completed their in-hospital stroke rehabilitation. We aimed to include 10 participants who were able to complete 40 daily HBOT sessions (2.0 ATA). Effectiveness was assessed using the National Institutes of Health Stroke Score (NIHSS) pre- and post-HBOT. Results: We recruited 13 patients (12 males) with a mean age of 61 years. Three patients dropped out (two never started HBOT and one withdrew after five sessions because of traveling distance). Post-stroke time was 4–251 months. Among the 10 patients completing the HBOT program, 8 improved their NIHSS by a mean of 1,3 (1–4), while 2 patients’ NIHSS remained unchanged. There were no serious adverse events and no side effects. Conclusions: HBOT was shown to be feasible for mobile post-stroke patients who have completed standard rehabilitation. In the absence of major safety concerns, HBOT seems to be an interesting option post-stroke, with the potential to further improve residual stroke severity.

Abstract TP54: Organized Post-stroke Care: Results From A Prospective Cohort Study

Introduction: Pilot data suggests that organized post-stroke care enhances achievement of secondary prevention goals in stroke patients. We aimed to further investigate whether organized post-stroke care favourably affects stroke recurrence and survival. Methods: Prospective, quasi-experimental study of consecutive stroke patients admitted at two tertiary stroke centers in Saxony, Germany. According to health insurance provider status, patients were non-randomly assigned to either 12-months post-stroke pathway plus conventional care or conventional care alone. The organized post-stroke care pathway was facilitated by certified case managers and included pre-scheduled home- and phone visits aiming at educational intervention and achievement of guideline-based secondary prevention treatment goals. Primary outcomes were stroke recurrence and vascular death at 12-months. Further outcomes included favourable functional outcome (i.e. mRS 0-1), health-related quality of life and vascular risk factor control at 12-months. Results: In total, 1109 patients were recruited between 11/2011 and 12/2020. Of these, 1009 patients (91%) were assigned to organized post-stroke care and 100 (9%) to conventional care (mean age 70.6±12.8 years, 54% male, median NIHSS 3 [IQR, 1-5] points, 77.5% AIS, 17.9% TIA and 4.6% ICH). Baseline demographics and clinical characteristics were well balanced between both groups (p≥0.05). At 12-months, recurrent stroke rate was lower in the post-stroke care than in the conventional care group (5.5% vs. 14%; aOR 0.35, 95%CI 0.18-0.66; p=0.001). This association was not modified by stroke severity (TIA/minor stroke versus major stroke). Vascular death occurred in 0.2% in the post-stroke care and 3% in the conventional care group (aOR 0.07, 95%CI 0.01-0.41; p=0.003). Organized post-stroke care more frequently yielded individual treatment goals for hypertension, lipids, HbA1c, body-mass-index and secondary prevention adherence than conventional care (p&lt;0.05). Conclusions: Our results substantiate the effectiveness of case management-based post-stroke care in unselected stroke patients.

Vital real-world experience regarding Naoshuantong capsules for unselected ischemic stroke (VENUS): Rationale, design, and baseline of a prospective, multicenter, observational study.

Background: Naoshuantong capsules (NC) are commonly used for the treatment of ischemic stroke. Experimental research and small-sample clinical trials have demonstrated that NC is effective in improving neurological recovery. Yet, there is a substantial lack of high-quality evidence on the precision treatment population of NC and long-term safety when making real-world clinical decisions. The acquisition of prospective longitudinal data in the real-world setting is essential to fully characterize the effectiveness and safety profile of NC for patients with ischemic stroke. Methods: The Vital real-world Experience regarding Naoshuantong capsules for Unselected ischemic Stroke (VENUS) registry is a prospective, multicenter, observational study aiming to register 5,000 patients. Eligible adult patients diagnosed with ischemic stroke and newly treated with NC within 30 days of symptom onset will be consecutively registered from 84 participating sites across the Chinese mainland. Baseline data will be recorded at the patient registry, and all patients will be regularly followed up at 2, 4, 8, and 12 weeks after the initial patient registry, and 180 days after ischemic stroke onset. The primary outcome is the distribution of scores on the modified Rankin Scale at 12 weeks after initial patient registry. Adverse events will be recorded during the study for NC safety assessment. Results: A total of 4,185 patients with ischemic stroke were enrolled, among which 37.06% patients were female. The average age of all patients was 65.22 years. The proportion of patients whose course of ischemic stroke was less than 14 days accounted for 93.45%. Conclusion: The VENUS registry is designed to comprehensively document medical data regarding NC treatment for ischemic stroke in real-world settings. The findings of this study will provide valuable insights into the clinical management of patients with ischemic stroke and the subsequent outcomes of the use of NC when included in the best clinical practice.Study registration: This study was registered with the Chinese Clinical Trial Registry (URL: http://www.chictr.org.cn/index.aspx, Unique identifier: ChiCTR1900025053).

Reconstruction of pseudonymized patient-trajectories in Austria's stroke cohort using medical record-linkage of in-patient routine documentation to establish a nation-wide acute stroke cohort of 102,107 pseudonymized patients between 2015 and 2019.

Administrative health data are increasingly used for disease surveillance, quality assurance and research purposes. In Austria, reporting of a standardized dataset is mandatory for each patient. Routine documentation includes administrative and medical data, including admission and discharge characteristics, disease-diagnosis using ICD-10, medical procedure codes, and coding of involved hospital departments. Since 2015, a three-step pseudonymization on these data is provided including a pseudonym using secure hash algorithm 256, a non-recalculable record-ID, and age-groups of 5 years, allowing the reconstruction of individual patient-trajectories. We included persons aged ⩾20 years with an in-patient treatment in Austrian hospitals for acute stroke or transient ischemic attack (TIA) between 01.01.2015 and 31.12.2019 using medical record-linkage. This totals 102,107 patients (49.3% women) with 107,055 treatment episodes. An ischemic stroke (IS) occurred in 60.9% (n = 65,133), 27.1% (n = 29,019) had a TIA, 3.3% (n = 3488) a subarachnoid hemorrhage, and 8.8% (n = 9415) an intracerebral hemorrhage (ICH). The study period covers 35.2 million person-years at risk, with a hospitalization rate for acute stroke of 221.8 per 100,000 person-years (95% CI 220.2-223.3), and 185.1 per 100,000 person-years (95% CI 183.7-186.5) for IS. Unscheduled re-admissions within 1 year occurred in 29.2% (95% CI 28.8-29.7) after IS, and 41.7% (95% CI 40.0-43.3) after ICH. Recurrent stroke occurred in 5.3% (95% CI 5.1-5.5) after IS, and 5.6% (95% CI 4.9-6.4) after ICH. We present herein the details of a novel methodology to establish a nation-wide unselected Austrian stroke cohort, and to reconstruct pseudonymized individual longitudinal patient-trajectories on a national level. This approach shows potential applications in epidemiological research, quality assessment and outcome measurement. This novel approach opens new research fields, facilitates international comparison, and is needed for national benchmarking to assess the achievement of goals according to the Stroke Action Plan for Europe and augment the quality of Austria's integrated stroke care.

COVID‐19 did not result in increased hospitalization for stroke and transient ischemic attack: A nationwide study

BackgroundThe risk of thrombosis increases in infectious diseases, yet observational studies from single centers have shown a decrease in admission of acute ischemic stroke patients during the COVID‐19 pandemic. To investigate unselected stroke admission rates we performed a nationwide study in Denmark.MethodsWe extracted information from Danish national health registries. The following mutually exclusive time periods were compared to the year before the lockdown: (1) first national lockdown, (2) gradual reopening, (3) few restrictions, (4) regional lockdown, and (5) second national lockdown.ResultsGenerally, admission rates were unchanged during the pandemic. In the unadjusted data, we observed a small decrease in the admission rate for all strokes under the first lockdown (incidence rate ratio: 0.93, confidence interval [CI]: 0.87–0.99) and a slight increase during the periods with gradual reopening, few restrictions, and the regional lockdown driven by ischemic strokes. We found no change in the rate of severe strokes, mild strokes, or 30‐day mortality. An exception was the higher mortality for all strokes during the first lockdown (risk ratio: crude 1.30 [CI: 1.03–1.59]; adjusted 1.17 [CI: 0.93–1.47]). The quality of care remained unchanged.ConclusionStroke admission rates remained largely unchanged during the pandemic, while an increased short‐term mortality rate in patients admitted with stroke observed during the first lockdown was seen, probably reflecting that the more frail patients constituted a higher proportion of admitted patients at the beginning of the pandemic.

Abstract WMP102: Prevalence Of Genetic Mutations In 15 Mendelian Stroke Genes In Young Stroke Patients

Introduction: Although the heritability of stroke might be higher in young-age stroke population, it is even uncertain how many of them has monogenic causes of stroke. We aimed to estimate the prevalence and clinical characteristics of 15 monogenic disorders associated with stroke in a large, unselected young-age stroke population Methods: From a prospective, nationwide, multicenter, acute stroke registry of consecutive patients admitted to 15 academic or regional stroke centers in Korea, we enrolled all patients aged 55 years or younger except those who refuse to participate in this study. We performed genetic analysis using a customized targeted next-generation sequencing panel ( GLA, NOTCH3, HTRA1, RNF213, ACVRL1, ENG, CBS, TREX1, ABCC6, COL4A1, FBN1, NF1, COL3A1, MT-TL1, and APP ) to find clinically relevant genetic variants, and reviewed clinical information of the patients. Results: Genetic analysis was performed in 1,033 patients (male 70.7%, mean age 45.8±7.9). Twenty-eight clinically relevant genetic variants were identified in 131 (12.7%) patients, and were found most frequently in RNF213 (59, 5.7%) followed by ABCC6 (53, 5.1%) and NOTCH3 (15, 1.5%). Genetic variants were more commonly observed in younger group than older group (17.1% vs. 9.3%, p=0.021), but were not different according to vascular risk factor burden. Patients with premature (&lt;60y) family history of stroke had genetic variants more frequently than those with family history at ≥60y (23.7% vs. 11.4%, p=0.047). Typical neuroimaging abnormalities were observed in only 25% of patients with RNF213 variants and 27% of those with NOTCH3 variants. Variants of uncertain significance were found in 15.4%. Conclusion: Clinically relevant genetic variants were not uncommon than expected. We might have opportunities to improve our daily practice by genetic counseling patients and their families to reduce the future stroke.

Nationwide screening for Fabry disease in unselected stroke patients.

Fabry disease (FD) is a rare X-linked lysosomal storage disorder caused by disease-associated variants in the alpha-galactosidase A gene (GLA). FD is a known cause of stroke in younger patients. There are limited data on prevalence of FD and stroke risk in unselected stroke patients. A prospective nationwide study including 35 (78%) of all 45 stroke centers and all consecutive stroke patients admitted during three months. Clinical data were collected in the RES-Q database. FD was diagnosed using dried blood spots in a stepwise manner: in males-enzymatic activity, globotriaosylsphingosine (lyso-Gb3) quantification, if positive followed by GLA gene sequencing; and in females GLA sequencing followed by lyso-Gb3. 986 consecutive patients (54% men, mean age 70 years) were included. Observed stroke type was ischemic 79%, transient ischemic attack (TIA) 14%, intracerebral hemorrhage (ICH) 7%, subarachnoid hemorrhage 1% and cerebral venous thrombosis 0.1%. Two (0.2%, 95% CI 0.02-0.7) patients had a pathogenic variant associated with the classical FD phenotype (c.1235_1236delCT and p.G325S). Another fourteen (1.4%, 95% CI 0.08-2.4) patients had a variant of GLA gene considered benign (9 with p.D313Y, one p.A143T, one p.R118C, one p.V199A, one p.R30K and one p.R38G). The index stroke in two carriers of disease-associated variant was ischemic lacunar. In 14 carriers of GLA gene variants 11 strokes were ischemic, two TIA, and one ICH. Patients with positive as compared to negative GLA gene screening were younger (mean 60±SD, min, max, vs 70±SD, min, max, P = 0.02), otherwise there were no differences in other baseline variables. The prevalence of FD in unselected adult patients with acute stroke is 0.2%. Both patients who had a pathogenic GLA gene variant were younger than 50 years. Our results support FD screening in patients that had a stroke event before 50 years of age.

Advances in Neurocardiology: Focus on Atrial Fibrillation.

Advances in Neurocardiology: Focus on Atrial Fibrillation.

Rate of, and risk factors for, white matter hyperintensity growth: a systematic review and meta-analysis with implications for clinical trial design

BackgroundWhite matter hyperintensities (WMHs) are a highly prevalent MRI marker of cerebral small vessel disease (SVD), which predict stroke and dementia risk, and are being increasingly used as a surrogate...

Medical complications and outcome after endovascular therapy for acute ischemic stroke.

Endovascular therapy (EVT) in acute stroke is an effective but invasive treatment which is frequently followed by various complications. The aim of the present study was to examine the rate of medical complications and other adverse events following EVT. Retrospective single-center study of 380 consecutive stroke patients who received EVT between the years 2015-2019. A total of 234 (61.6%) patients had at least one recorded medical complication. The most common complication was pneumonia in 154 (40.5%) patients, followed by acute cardiac insufficiency in 134 (35.3%), and myocardial infarction in 22 (5.8%) patients. In multivariate analysis, the need for general anesthesia (OR 3.8 (1.9-7.7)), Charlson Comorbidity Index >3 (OR 1.3 (1.1-1.5)), male gender (1.9 (1.1-1.3)) and high National Institutes of Health Stroke Scale (NIHSS) score at admission (1.1 (1.0-1.2)) were associated with medical complications. Medical complications are common among unselected stroke patients undergoing EVT. Both comorbidity and stroke severity have an influence on medical complications. Early recognition of complications is essential, because vast majority of patients encountering medical complications have a poor short-term outcome.

The Risk of Selection Bias in a Clinical Multi-Center Cohort Study. Results from the Norwegian Cognitive Impairment After Stroke (Nor-COAST) Study.

PurposeThe Norwegian Cognitive Impairment After Stroke (Nor-COAST) study aimed to estimate the prevalence and incidence of neurocognitive disorder in an unselected stroke cohort. The aim of the present study was to investigate whether selection bias occurred by comparing baseline characteristics from participants with non-participants in Nor-COAST.Patients and MethodsNor-COAST is a prospective cohort multi-center study, recruiting participants from five Norwegian hospitals. Patients with the diagnosis of acute stroke were screened for inclusion. Baseline data from the participants recruited between May 2015 and March 2017 were compared to corresponding data from those not participating in Nor-COAST but registered in the Norwegian Stroke Registry. Regression analysis was used to assess whether age, stroke severity, sex and stroke subtype were independently associated with inclusion in the study.ResultsOut of 2505 available patients, 815 (32.5%) were included in Nor-COAST. There were no differences between participants and non-participants with respect to age (mean (SD) age 73.5 (11.7) versus 74.2 (14.5) years) or sex (44.8% versus 46.9% women). A significantly larger proportion of the participants were independent prior to stroke (87% versus 78%), had mild strokes (69% versus 55%) and suffered from cerebral infarction (90% versus 84%). The regression analysis showed decreased odds ratio (OR) of being included for those with higher degree of pre-stroke dependency (OR 0.895, 95% CI 0.825 to 0.971, p=0.007) and a more severe stroke (OR 0.952, 95% CI 0.939 to 0.966, p<0.001).ConclusionThe participants in Nor-COAST had a better pre-stroke health condition and milder strokes compared to non-participants. However, the participants should be regarded as representative of the majority of the stroke population which suffers from mild strokes. Nevertheless, baseline information for non-participants should be available also in future clinical studies to make it easier to identify which part of the stroke population the results can be generalized to.

Impact of pulmonary embolism on in-hospital mortality of patients with ischemic stroke

BackgroundPulmonary embolism (PE) is a frequent complication in immobile stroke patients and an important cause of death in stroke patients. We aimed to investigate predictors of PE and the impact of PE on survival of ischemic stroke patients. MethodsPatients were selected by screening the German nationwide inpatient sample (2005–2017) for ischemic stroke (ICD-code I63) and stratified for occurrence of PE (ICD-code I26). Impact of PE on mortality and predictors for PE in ischemic stroke patients were analysed. ResultsOverall, 2,914,546 patients were hospitalized due to ischemic stroke (50.5% females; 69.3% aged ≥70 years) in Germany 2005–2017. Among these, 0.4% had PE and 7.2% died during hospitalization. In-hospital mortality rate of ischemic stroke patients with PE was substantially higher compared to those patients without PE (28.4% vs. 7.1%, P < 0.001). PE was strongly associated with in-hospital death (OR 5.786, 95%CI 5.515–6.070, P < 0.001). Important predictors of PE were cancer (OR 3.165, 95%CI 2.969–3.374, P < 0.001), coagulation abnormalities (OR 2.672, 95CI 2.481–2.878, P < 0.001), heart failure (OR 1.553, 95%CI 1.472–1.639, P < 0.001) and obesity (OR 1.559, 95%CI 1.453–1.672, P < 0.001).Systemic thrombolysis was not beneficial regarding survival in unselected ischemic stroke patients. In contrast, systemic thrombolysis was beneficial in ischemic stroke patients without PE, who had to undergo cardio-pulmonary resuscitation (OR 0.866, 95%CI 0.782–0.960, P = 0.006). ConclusionsPatients with ischemic stroke revealed still a high in-hospital mortality of 7.2% in Germany. While only a minority of 0.4% of the ischemic stroke patients suffered from occurrence of PE, PE was accompanied by a substantial increase regarding in-hospital mortality. Systemic thrombolysis was beneficial regarding short-term survival in ischemic stroke patients without PE, who had to undergo cardio-pulmonary resuscitation.

Abstract 33: Diagnostic Accuracy, Reperfusion Delay and Triage Scale Comparison: Real-World Paramedic Validation Results From the ACT-FAST Triage Algorithm for Thrombectomy

Background: Severity-based selection tools for large vessel occlusion (LVO) are limited by lack of validation in unselected prehospital stroke patients and concerns regarding delayed thrombolysis (tPA) and comprehensive stroke center (CSC) burdening. We examined these issues in a real-world validation of the two exam step (severe arm motor + speech or neglect) ACT-FAST LVO triage algorithm. Methods: The ACT-FAST statewide validation involved 15 metro and 17 rural hospitals in Victoria, Australia from Nov 2017-July 2019 with training of paramedics using an 8 min video. Prehospital paramedic assessments were correlated with hospital imaging to determine presence of LVO. Data were then examined for diagnostic accuracy, time saving for direct bypass to CSC using a validated Google maps model, rates and magnitude of delayed tPA in false-positive non-LVO infarcts, and extra CSC workload. Results: In 517 completed assessments, 58% involving non-EVT centers and including 114 (22%) LVO, ACT-FAST sensitivity was 81% (92/114) and specificity was 81% (325/403; 89% if ICH are not regarded as false-positive) for LVO. Figure compares to other LVO scales. Bypass to CSC was modelled to save median 71 min for analysis of 29 thrombectomy patients requiring inter-hospital transfer. Of 27 non-LVO infarcts with false positive ACT-FAST, only 4 (15%) received tPA at a non-CSC center, and bypass would have only added median 10 mins in these cases. The increase in CSC presentation using ACT-FAST triage was estimated to be 2-3.3 patients/week using estimated 7,200 suspected stroke cases/year across entire metro Victoria. Conclusion: In comprehensive real-world validation, the simple ACT-FAST algorithm detected LVO or ICH in almost 80% of positive assessments with highly favorable comparison to other scales. Prehospital bypass to CSC substantially reduces thrombectomy delay, and appears to strongly outweigh negatives of bypassing false positive cases on tPA delay and CSC overburdening.

The neuroanatomy of spatial awareness: a large-scale region-of-interest and voxel-based anatomical study.

Lesion-symptom studies of spatial neglect and the attention deficits associated with this disorder draw a complex picture of the brain areas involved in spatial awareness. Several cortical regions and fiber tracts have been identified as predictors of behavioral performance, a pattern reflecting the large degree of methodological variance and modest sample sizes of many studies. Here, we examined the anatomical predictors of deficits of spatial exploration, reading and line bisection in 134 unselected stroke patients with post-acute, right-hemispheric brain injury. In order to neutralize shortcomings of traditional lesion-symptom analyses we used several methodological approaches: voxel-based lesion-symptom mapping focusing on binary groups or continuous performance measures, region-of-interest analyses and a 'minimal-lesion' method, comparing patients with highly selective deficits to specific brain areas. All four approaches converged on the central role of the right temporo-parietal junction and frontoparietal connections conveyed through the superior longitudinal fasciculus for contralateral deployment of attention and detection of task-relevant stimuli.

A Role for the Action Observation Network in Apraxia After Stroke.

Limb apraxia is a syndrome often observed after stroke that affects the ability to perform skilled actions despite intact elementary motor and sensory systems. In a large cohort of unselected stroke patients with lesions to the left, right, and bilateral hemispheres, we used voxel-based lesion-symptom mapping (VLSM) on clinical CT head images to identify the neuroanatomical correlates of the impairment of performance in three tasks investigating praxis skills in patient populations. These included a meaningless gesture imitation task, a gesture production task involving pantomiming transitive and intransitive gestures, and a gesture recognition task involving recognition of these same categories of gestures. Neocortical lesions associated with poor performance in these tasks were all in the left hemisphere. They involved the pre-striate and medial temporal cortices, the superior temporal sulcus, inferior parietal area PGi, the superior longitudinal fasciculus underlying the primary motor cortex, and the uncinate fasciculus, subserving connections between temporal and frontal regions. No significant lesions were identified when language deficits, as indicated via a picture naming task, were controlled for. The implication of the superior temporal sulcus and the anatomically connected prestriate and inferior parietal regions challenges traditional models of the disorder. The network identified has been implicated in studies of action observation, which might share cognitive functions sub-serving praxis and language skills.

What Proportion of Patients Admitted with Stroke or Transient Ischemic Attack May Be Suitable for Newer Cholesterol-Lowering Treatment?

BackgroundProtein convertase subtilisin–kexin type 9 (PCSK9) inhibitors effectively clear low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol (non-HDL-C). We evaluated stroke admissions potentially eligible for more intensive cholesterol treatment. MethodsRetrospective analysis of consecutive admissions to a hyperacute stroke unit over 5 months in 2017. Records were individually searched. Data were collected on diagnosis, risk factors, and stroke work-up. European Society of Cardiology and European Atherosclerosis Society guidelines for the management of dyslipidaemias were used for screening patients eligible for PCSK9 inhibitors. ResultsOf 650 patient admissions: 351 (54%) had acute ischemic stroke or transient ischemic attack (TIA), 80 (12%) hemorrhage, and 219 (34%) mimic syndromes. Patients with hemorrhage (n = 80), mimic syndromes (n = 219), and absent LDL-C, or non-HDL-C testing (n = 27) were subsequently excluded. 324 patients with acute ischemic stroke and TIA were further screened for PCSK9-inhibitor treatment eligibility. Forty-one (13%) patients with LDL-C greater than or equal to 1.8mmol/L (≥70 mg/dL) on maximal tolerated statin dose and with concomitant “very high vascular risk” were identified. “Very high vascular risk” was defined as a documented history of cardiovascular disease and/or peripheral arterial disease. Of 41 patients eligible for PCSK9 inhibitors, median age was 82 years (range 53-96); median vascular risk factors were 2 (range 1-5); 7 (17%) had TIA; 13 (31%) had history of preceding cerebrovascular events, 13 (31%) diabetes mellitus, 17 (42%) cardioembolic events, 9 (22%) lacunar syndrome, 11 (22%) symptomatic internal carotid artery stenosis (n = 9 were >70%), and 4 (10%) undetermined aetiology. Eighty-three percent patients eligible for PCSK9 inhibitors also had non-HDL-C values greater than or equal to 2.6 mmol/L. ConclusionsUp to 13% of unselected acute ischemic stroke or TIA patients admitted to a hyper-acute stroke unit were potentially suitable for more intensive cholesterol treatment. Our data may act as a useful guide for sample size selection in future stroke trials testing PCSK9 inhibitors.