Systematic review and meta-analysis of the effects of menopause hormone therapy on cognition

Introduction

Despite evidence from preclinical studies suggesting estrogen's neuroprotective effects, the use of menopausal hormone therapy (MHT) to support cognitive function remains controversial.

Methods

We used random-effect meta-analysis and multi-level meta-regression to derive pooled standardized mean difference (SMD) and 95% confidence intervals (C.I.) from 34 randomized controlled trials, including 14,914 treated and 12,679 placebo participants.

Results

Associations between MHT and cognitive function in some domains and tests of interest varied by formulation and treatment timing. While MHT had no overall effects on cognitive domain scores, treatment for surgical menopause, mostly estrogen-only therapy, improved global cognition (SMD=1.575, 95% CI 0.228, 2.921; P=0.043) compared to placebo. When initiated specifically in midlife or close to menopause onset, estrogen therapy was associated with improved verbal memory (SMD=0.394, 95% CI 0.014, 0.774; P=0.046), while late-life initiation had no effects. Overall, estrogen-progestogen therapy for spontaneous menopause was associated with a decline in Mini Mental State Exam (MMSE) scores as compared to placebo, with most studies administering treatment in a late-life population (SMD=-1.853, 95% CI -2.974, -0.733; P = 0.030). In analysis of timing of initiation, estrogen-progestogen therapy had no significant effects in midlife but was associated with improved verbal memory in late-life (P = 0.049). Duration of treatment >1 year was associated with worsening in visual memory as compared to shorter duration. Analysis of individual cognitive tests yielded more variable results of positive and negative effects associated with MHT.

Discussion

These findings suggest time-dependent effects of MHT on certain aspects of cognition, with variations based on formulation and timing of initiation, underscoring the need for further research with larger samples and more homogeneous study designs.

Outcomes of patients with pre-existing disability managed by mobile stroke units: A sub-analysis of the BEST-MSU study

BACKGROUND

Few data exist on acute stroke treatment in patients with pre-existing disability (PD) since they are usually excluded from clinical trials. A recent trial of mobile stroke units (MSUs) demonstrated faster treatment and improved outcomes, and included PD patients.

AIM

To determine outcomes with tissue plasminogen activator (tPA), and benefit of MSU versus management by emergency medical services (EMS), for PD patients.

METHODS

Primary outcomes were utility-weighted modified Rankin Scale (uw-mRS). Linear and logistic regression models compared outcomes in patients with versus without PD, and PD patients treated by MSU versus standard management by EMS. Time metrics, safety, quality of life, and health-care utilization were compared.

RESULTS

Of the 1047 tPA-eligible ischemic stroke patients, 254 were with PD (baseline mRS 2-5) and 793 were without PD (baseline mRS 0-1). Although PD patients had worse 90-day uw-mRS, higher mortality, more health-care utilization, and worse quality of life than non-disabled patients, 53% returned to at least their baseline mRS, those treated faster had better outcome, and there was no increased bleeding risk. Comparing PD patients treated by MSU versus EMS, 90-day uw-mRS was 0.42 versus 0.36 (p = 0.07) and 57% versus 46% returned to at least their baseline mRS. There was no interaction between disability status and MSU versus EMS group assignment (p = 0.67) for 90-day uw-mRS.

CONCLUSION

PD did not prevent the benefit of faster treatment with tPA in the BEST-MSU study. Our data support inclusion of PD patients in the MSU management paradigm.

Abstract 161: Racial And Ethnic Differences In The Risk Of Ischemic Stroke After Intracerebral Hemorrhage

Background: Intracerebral hemorrhage (ICH) is associated with an increased risk of ischemic stroke. Whether there are racial and ethnic disparities in the risk of ischemic stroke after ICH is poorly understood.

Hypothesis: Non-Hispanic Black and Hispanic ICH patients have a higher risk of ischemic stroke compared to White ICH patients.

Methods: We retrospectively analyzed data from the Healthcare Cost and Utilization Project on all hospitalizations at all nonfederal hospitals in Florida from 2005 to 2018 and New York from 2006 to 2016. We included patients with an ICH, and without a prior or concomitant diagnosis of ischemic stroke. ICH and ischemic stroke were ascertained using validated ICD-9-CM and ICD-10-CM codes. Using Cox proportional hazard models, we studied the relationship between race and risk of ischemic stroke, after adjustment of demographics and comorbidities.

Results: We included 55,582 patients with ICH- 66% Non-Hispanic White, 19% Non-Hispanic Black, and 13% Hispanic. Black and Hispanic patients were younger and had a higher prevalence of cardiovascular comorbidities; however, atrial fibrillation was more prevalent among White patients. During a median follow up period of 3.6 years (IQR 0.7-7.2), an incident ischemic stroke occurred in 3,361 (9%) Non-Hispanic White, 1,308 (12%) Non-Hispanic Black, and 858 (12%) Hispanic patients (p<.001). In adjusted Cox models, the risk of an ischemic stroke was significantly higher among Non-Hispanic Black patients (HR 1.6; 95% CI,1.4-1.7) and Hispanic patients (HR 1.4; 95% CI,1.2-1.5]), compared to non-Hispanic White patients.

Conclusions: Among patients with ICH, Non-Hispanic Black and Hispanic patients had a significantly higher risk of ischemic stroke compared to Non-Hispanic White patients.

Abstract WP6: Strokes Averted by Intravenous Thrombolysis: A Secondary Analysis of the BEST-MSU Trial

Introduction: While the goal of IV tissue plasminogen activator (TPA) is to prevent infarction, few data exist on averted stroke.

Methods: Secondary analysis of a multicenter trial from 2014-2020 comparing outcomes between patients treated for stroke by mobile stroke unit (MSU) vs standard care (SC). The analytical cohort were patients with suspected stroke treated with IV TPA. The primary outcome was a time-defined averted stroke diagnosis, defined as a final diagnosis of stroke with resolution of presenting symptoms/signs by 24 hours. The secondary outcome was a tissue-defined averted stroke diagnosis, defined as a final diagnosis of stroke with resolution of presenting symptoms/signs by 24 hours and no acute infarction/hemorrhage on imaging. We used multivariable logistic regression to evaluate associations between study exposures (demographics, comorbidities, stroke characteristics) and outcomes.

Results: Among 1009 patients with a median last known well-to-TPA time of 87 minutes, 276 patients (27%) had a time-defined averted stroke (31% MSU, 21% SC) and 159 patients (16%) had a tissue-defined averted stroke (18% MSU, 11% SC). Factors independently associated with time-defined averted stroke were younger age (OR, 0.98; 95% CI, 0.96-0.99), female sex (0R, 0.51; 95% CI, 0.36-0.74), hyperlipidemia (OR, 1.81, 95% CI, 1.24-2.64), normal premorbid function (0R, 2.22; 95% CI, 1.37-3.67), lower glucose (OR, 0.996; 95% CI, 0.993-0.999), lower MAP (OR, 0.991; 95% CI, 0.983-0.998), MSU care (OR, 1.77; 95% CI, 1.21-2.62), lower NIH stroke scale (OR, 0.89; 95% CI, 0.86-0.93), and no large vessel occlusion (LVO) (OR, 0.52; 95% CI, 0.32-0.83). For tissue-based averted stroke, younger age, female sex, hyperlipidemia, lower MAP, MSU treatment, lower NIH stroke scale, and no LVO were significantly associated.

Conclusion: In a modern acute stroke trial, one-in-four patients treated with TPA for stroke recovered within 24 hours and one-in-six had no demonstrable brain injury on imaging. Younger age, female sex, hyperlipidemia, lower MAP, MSU care, lower stroke severity, and no LVO may increase the odds of averting stroke.

Abstract WMP2: Acute Stroke Treatment In Patients With Pre-exiting Disability: A Secondary Analysis Of The BEST-MSU Trial

Background: Few data exists on acute stroke treatment in patients with pre-existing disability (PD) since they are usually excluded from clinical trials.

Methods: A pre-specified subgroup analysis of tPA-eligible patients with PD enrolled in a prospective multicenter trial of Mobile Stroke Units (MSUs) vs standard management by emergency medical services (EMS). All patients had baseline mRS scores. Co-primary outcomes were mean utility-weighted modified Rankin Scale score (uw-mRS) and return to baseline mRS at 90 days. Linear and logistic regression models compared outcomes in patients with vs without PD, and patients with PD treated by MSU vs EMS. Time metrics, safety, quality of life, and health-care utilization were also compared.

Results: Of 1047 patients, 254 had baseline mRS >= 2 (159 MSU, 95 EMS; 31% mRS 2, 52% mRS 3, 17% mRS 4). Compared to patients without disability, patients with PD were older, had higher NIHSS, more comorbidities, less often lived at home, were treated slower, and had less thrombectomy. Patients with PD had worse 90-day uw-mRS (0.39 vs 0.80), higher mortality, more health-care utilization and worse quality of life than patients without PD. However, rates of symptomatic intracranial hemorrhage and final diagnoses of stroke mimics were similar between groups, and 52% of patients with PD returned to their baseline mRS. Patients with PD treated within the first hour had better 90-day uw-mRS than those treated later (0.48 vs 0.36, p=0.01). Comparing patients with PD treated by MSU vs EMS, time from last-known-well to tPA bolus was shorter (82 vs 111 min), and 24% vs 0% were treated in the first hour. Among patients with PD, MSU patients had non-significantly better 90-day uw-mRS (0.41 vs 0.35, p=0.09) and higher rate of returning to baseline mRS (56% vs 44%, p=0.09) than EMS patients. There was no interaction between either time to treatment (p=0.24) or MSU vs EMS group assignment (p= 0.42), 90-day uw-mRS, and PD vs no disability status.

Conclusion: Although outcomes after stroke are less favorable in patients with vs without PD, in a large, controlled trial, we found no interaction between baseline disability and the benefit of MSU treatment. Our data support the earliest treatment of acute stroke patients regardless of premorbid functional status.

Comparing hematoma characteristics in primary intracerebral hemorrhage versus intracerebral hemorrhage caused by structural vascular lesions

Intracerebral hemorrhage (ICH) caused by structural vascular lesions is associated with better outcomes than primary ICH, but this relationship is poorly understood. We tested the hypothesis that ICH from a vascular lesion has more benign hematoma characteristics compared to primary ICH. We performed a retrospective study using data from our medical center. The SMASH-U criteria were used to adjudicate the etiology of ICH. The co-primary outcomes were admission parenchymal hematoma volume and hematoma expansion at 24 h. Linear and logistic regression analyses were performed to test associations. A total of 231 patients were included of whom 42 (18%) had a vascular lesion. Compared to primary ICH patients, those with structural vascular lesions were younger (49 vs. 68 years, p < 0.001), less likely to have hypertension (29% vs. 74%, p < 0.001), had lower mean admission systolic blood pressure (140 ± 23 vs. 164 ± 35, p < 0.001), less frequently had IVH (26% vs. 44%, p = 0.03), and had mostly lobar or infratentorial hemorrhages. The median admission hematoma volume was smaller with vascular lesions (5.9 vs. 9.7 mL, p = 0.01). In regression models, ICH from a vascular lesion was associated with smaller admission hematoma volume (beta, -0.67, 95% CI, -1.29 to -0.05, p = 0.03), but no association with hematoma expansion was detected when assessed as a continuous (OR, 0.93; 95% CI, -4.46 to 6.30, p = 0.73) or dichotomous exposure (OR, 1.86; 95% CI, 0.40 to 8.51, p = 0.42). In a single-center cohort, patients with ICH from vascular lesions had smaller hematoma volumes than patients with primary ICH.

Abstract WP183: Pregnancy-related Factors Associated With Stroke In Mothers And Newborns: Data From The International Maternal Newborn Stroke Registry

Background: Maternal and newborn stroke occur during the same period when physiological and anatomic connections between mother and infant may provide a rationale for common pathogenetic mechanisms. The similarities and differences between maternal and newborn stroke remain poorly understood. We created the International Maternal Newborn Stroke Registry - the first database to explore these relationships.

Methods: Eleven international sites participated; 9 enrolled cases for this analysis. Eligible cases were newborns (from 28 weeks gestation to 28 postnatal days) or mothers (peripartum or within 6 weeks postpartum) diagnosed with stroke (ischemic, hemorrhagic, cerebral sinovenous thrombosis). Preterm infants (< 28 weeks gestation) and neonates with germinal matrix/intraventricular hemorrhage were excluded. Descriptive statistics were performed to compare stroke sub-types, demographic and pregnancy-related risk factors.

Results: We enrolled 103 cases, 69 newborn and 34 maternal. Median maternal age was 29 years (IQR 25-36) for the maternal group and 32 years (IQR 30-36) for the neonatal group. Women with maternal strokes were more likely to have pre-eclampsia (15%) and migraine (44%). Compared to maternal strokes, newborn strokes occurred more often in women from urban locations, were ischemic, and were less likely to be associated with alcohol use and pre-eclampsia during pregnancy (Table).

Conclusion: In this novel registry, we describe factors that impact both maternal and newborn stroke. Urban area of residence and maternal age > 30 were associated with newborn strokes, while migraine and pre-eclampsia were strongly associated with maternal strokes. Differing mechanisms and stroke subtypes may explain these differences. In addition, lack of access to healthcare in certain geographical locations may lead to under-identification. Further research is needed to determine if these results are consistent when applied to a larger sample size.

Abstract WMP81: Association Between Systemic Amyloidosis And Intracranial Hemorrhage

Introduction: Isolated amyloid deposition in the brain is associated with intracranial hemorrhage. Whether systemic amyloidosis also increases the risk of intracranial hemorrhage is unclear.

Methods: We evaluated the association between systemic amyloidosis and intracranial hemorrhage using claims data from a 5% national sample of Medicare beneficiaries from 2008-2015. The primary outcome was non-traumatic intracranial hemorrhage, defined as a composite of intracerebral hemorrhage, subarachnoid hemorrhage, and subdural hemorrhage. Secondary outcome were each hemorrhage type assessed separately. The exposure and outcomes were identified using previously validated ICD-9-CM diagnosis codes. We used Cox regression analysis adjusting for demographics and vascular risk factors to evaluate the association between systemic amyloidosis and intracranial hemorrhage. We also examined the risk of hip fracture (negative control). In sensitivity analyses, we excluded patients with cardiac amyloidosis, a subset most likely to be on antithrombotic therapy.

Results: Among 1.8 million Medicare beneficiaries, 924 were diagnosed with systemic amyloidosis. During a median follow-up of 5.3 years (IQR, 2.8- 6.7), the cumulative incidence of intracranial hemorrhage was 19 per 1,000 patients per year among patients with amyloidosis, and 2 per 1,000 patients per year in those without amyloidosis. In adjusted Cox models, systemic amyloidosis was associated with an increased risk of intracranial hemorrhage (HR, 4.3; 95% CI, 2.9-6.3). The association persisted in a sensitivity analysis after excluding beneficiaries with cardiac amyloidosis (HR, 8.0; 95% CI, 5.0-12.7). In secondary analyses, systemic amyloidosis was associated with intracerebral hemorrhage (HR, 5.6; 95% CI, 3.6-8.7), subarachnoid hemorrhage (HR, 14.7; 95% 9.0-24.0), and subdural hemorrhage (HR, 3.6; 95% 2.0-6.2). There was no association between systemic amyloidosis and hip fracture (HR, 0.9; 95% CI, 0.6-1.4).

Conclusions: In a large, heterogeneous national cohort of elderly patients, a diagnosis of systemic amyloidosis was associated with a 4-fold increased risk of intracranial hemorrhage, including intracerebral, subarachnoid, and subdural hemorrhages.

Evaluation of Transient Ischemic Attack and Minor Stroke: A Rapid Outpatient Model for the COVID-19 Pandemic and Beyond

The grim circumstances of the COVID-19 pandemic have highlighted the need to refine and adapt stroke systems of care. Patients' care-seeking behaviors have changed due to perceived risks of in-hospital treatment during the pandemic. In response to these challenges, we optimized a recently implemented, novel outpatient approach for the evaluation and management of minor stroke and transient ischemic attack, entitled RESCUE-TIA. This modified approach incorporated telemedicine visits and remote testing, and proved valuable during the pandemic. In this review article, we provide the evidence-based rationale for our approach, describe its operationalization, and provide data from our initial experience.

Feasibility of a wearable biosensor device to characterize exercise and sleep in neurology residents

BACKGROUND

Research suggests optimizing sleep, exercise and work-life balance may improve resident physician burnout. Wearable biosensors may allow residents to detect and correct poor sleep and exercise habits before burnout develops. Our objectives were to evaluate the feasibility of a wearable biosensor to characterize exercise/sleep in neurology residents and examine its relationship to self-reported, validated survey measures. We also assessed the device's impact on well-being and barriers to use.

METHODS

This prospective cohort study evaluated the WHOOP Strap 2.0 in neurology residents. Participants completed regular online surveys, including self-reported hours of sleep/exercise, and validated sleep/exercise scales at 3-month intervals. Autonomic, exercise, and sleep measures were obtained from WHOOP. Changes were evaluated over time via linear regression. Survey and WHOOP metrics were compared using Pearson correlations.

RESULTS

Sixteen (72.7%) of 22 eligible participants enrolled. Eleven (68.8%) met the minimum usage requirement (6+ months) and were classified as 'consecutive wearers.' Significant increases were found in sleep duration and exercise intensity. Moderate-to-low correlations were found between survey responses and WHOOP measures. Most (73%) participants reported a positive impact on well-being. Barriers to use included 'Forgetting to wear' (20%) and 'not motivational' (23.3%).

CONCLUSION

Wearable biosensors may be a feasible tool to evaluate sleep/exercise in residents.

Prospective, Multicenter, Controlled Trial of Mobile Stroke Units

BACKGROUND

Mobile stroke units (MSUs) are ambulances with staff and a computed tomographic scanner that may enable faster treatment with tissue plasminogen activator (t-PA) than standard management by emergency medical services (EMS). Whether and how much MSUs alter outcomes has not been extensively studied.

METHODS

In an observational, prospective, multicenter, alternating-week trial, we assessed outcomes from MSU or EMS management within 4.5 hours after onset of acute stroke symptoms. The primary outcome was the score on the utility-weighted modified Rankin scale (range, 0 to 1, with higher scores indicating better outcomes according to a patient value system, derived from scores on the modified Rankin scale of 0 to 6, with higher scores indicating more disability). The main analysis involved dichotomized scores on the utility-weighted modified Rankin scale (≥0.91 or <0.91, approximating scores on the modified Rankin scale of ≤1 or >1) at 90 days in patients eligible for t-PA. Analyses were also performed in all enrolled patients.

RESULTS

We enrolled 1515 patients, of whom 1047 were eligible to receive t-PA; 617 received care by MSU and 430 by EMS. The median time from onset of stroke to administration of t-PA was 72 minutes in the MSU group and 108 minutes in the EMS group. Of patients eligible for t-PA, 97.1% in the MSU group received t-PA, as compared with 79.5% in the EMS group. The mean score on the utility-weighted modified Rankin scale at 90 days in patients eligible for t-PA was 0.72 in the MSU group and 0.66 in the EMS group (adjusted odds ratio for a score of ≥0.91, 2.43; 95% confidence interval [CI], 1.75 to 3.36; P<0.001). Among the patients eligible for t-PA, 55.0% in the MSU group and 44.4% in the EMS group had a score of 0 or 1 on the modified Rankin scale at 90 days. Among all enrolled patients, the mean score on the utility-weighted modified Rankin scale at discharge was 0.57 in the MSU group and 0.51 in the EMS group (adjusted odds ratio for a score of ≥0.91, 1.82; 95% CI, 1.39 to 2.37; P<0.001). Secondary clinical outcomes generally favored MSUs. Mortality at 90 days was 8.9% in the MSU group and 11.9% in the EMS group.

CONCLUSIONS

In patients with acute stroke who were eligible for t-PA, utility-weighted disability outcomes at 90 days were better with MSUs than with EMS. (Funded by the Patient-Centered Outcomes Research Institute; BEST-MSU ClinicalTrials.gov number, NCT02190500.).

Association between Pregnancy and Cervical Artery Dissection

OBJECTIVE

We wanted to determine whether pregnancy is associated with cervical artery dissection.

METHODS

We performed a case-control study using claims data from all nonfederal emergency departments and acute care hospitals in New York and Florida between 2005 and 2015. Cases were women 12-42 years of age hospitalized with cervical artery dissection, defined using validated diagnosis codes for carotid/vertebral artery dissection. Controls were women 12-42 years of age with a primary diagnosis of renal colic. Cases and controls were matched 1:1 on age, race, insurance, income, state, and visit year. The exposure variable was pregnancy, defined as labor and delivery within 90 days before or 6 months after the index visit. Logistic regression was used to compare the odds of pregnancy between cases and controls. We performed a secondary cohort-crossover study comparing the risk of cervical artery dissection during pregnancy versus the same time period 1 year later.

RESULTS

Pregnancy was twice as common among 826 women with cervical artery dissection compared with the 826 matched controls with renal colic (odds ratio, 2.5; 95% confidence interval [CI], 1.3-4.7). In our secondary analysis, pregnancy was associated with a higher risk of cervical artery dissection (incidence rate ratio [IRR], 2.2; 95% CI, 1.3-3.5), with the heightened risk limited to the postpartum period (IRR, 5.5; 95% CI, 2.6-11.7).

INTERPRETATION

Pregnancy, specifically the postpartum period, was associated with hospitalization for cervical artery dissection. Although these findings might in part reflect ascertainment bias, our results suggest that arterial dissection is one mechanism by which pregnancy can lead to stroke. ANN NEUROL 2020;88:596-602.

Risk of Ischemic Stroke in Patients With Coronavirus Disease 2019 (COVID-19) vs Patients With Influenza

IMPORTANCE

It is uncertain whether coronavirus disease 2019 (COVID-19) is associated with a higher risk of ischemic stroke than would be expected from a viral respiratory infection.

OBJECTIVE

To compare the rate of ischemic stroke between patients with COVID-19 and patients with influenza, a respiratory viral illness previously associated with stroke.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study was conducted at 2 academic hospitals in New York City, New York, and included adult patients with emergency department visits or hospitalizations with COVID-19 from March 4, 2020, through May 2, 2020. The comparison cohort included adults with emergency department visits or hospitalizations with influenza A/B from January 1, 2016, through May 31, 2018 (spanning moderate and severe influenza seasons).

EXPOSURES

COVID-19 infection confirmed by evidence of severe acute respiratory syndrome coronavirus 2 in the nasopharynx by polymerase chain reaction and laboratory-confirmed influenza A/B.

MAIN OUTCOMES AND MEASURES

A panel of neurologists adjudicated the primary outcome of acute ischemic stroke and its clinical characteristics, mechanisms, and outcomes. We used logistic regression to compare the proportion of patients with COVID-19 with ischemic stroke vs the proportion among patients with influenza.

RESULTS

Among 1916 patients with emergency department visits or hospitalizations with COVID-19, 31 (1.6%; 95% CI, 1.1%-2.3%) had an acute ischemic stroke. The median age of patients with stroke was 69 years (interquartile range, 66-78 years); 18 (58%) were men. Stroke was the reason for hospital presentation in 8 cases (26%). In comparison, 3 of 1486 patients with influenza (0.2%; 95% CI, 0.0%-0.6%) had an acute ischemic stroke. After adjustment for age, sex, and race, the likelihood of stroke was higher with COVID-19 infection than with influenza infection (odds ratio, 7.6; 95% CI, 2.3-25.2). The association persisted across sensitivity analyses adjusting for vascular risk factors, viral symptomatology, and intensive care unit admission.

CONCLUSIONS AND RELEVANCE

In this retrospective cohort study from 2 New York City academic hospitals, approximately 1.6% of adults with COVID-19 who visited the emergency department or were hospitalized experienced ischemic stroke, a higher rate of stroke compared with a cohort of patients with influenza. Additional studies are needed to confirm these findings and to investigate possible thrombotic mechanisms associated with COVID-19.

Risk of Ischemic Stroke in Patients with Covid-19 versus Patients with Influenza

Importance:

Case series without control groups suggest that Covid-19 may cause ischemic stroke, but whether Covid-19 is associated with a higher risk of ischemic stroke than would be expected from a viral respiratory infection is uncertain.

Objective:

To compare the rate of ischemic stroke between patients with Covid-19 and patients with influenza, a respiratory viral illness previously linked to stroke.

Design:

A retrospective cohort study.

Setting:

Two academic hospitals in New York City.

Participants:

We included adult patients with emergency department visits or hospitalizations with Covid-19 from March 4, 2020 through May 2, 2020. Our comparison cohort included adult patients with emergency department visits or hospitalizations with influenza A or B from January 1, 2016 through May 31, 2018 (calendar years spanning moderate and severe influenza seasons).

Exposures:

Covid-19 infection confirmed by evidence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the nasopharynx by polymerase chain reaction, and laboratory-confirmed influenza A or B.

Main Outcomes and Measures:

A panel of neurologists adjudicated the primary outcome of acute ischemic stroke and its clinical characteristics, etiological mechanisms, and outcomes. We used logistic regression to compare the proportion of Covid-19 patients with ischemic stroke versus the proportion among patients with influenza.

Results:

Among 2,132 patients with emergency department visits or hospitalizations with Covid-19, 31 patients (1.5%; 95% confidence interval [CI], 1.0%-2.1%) had an acute ischemic stroke. The median age of patients with stroke was 69 years (interquartile range, 66-78) and 58% were men. Stroke was the reason for hospital presentation in 8 (26%) cases. For our comparison cohort, we identified 1,516 patients with influenza, of whom 0.2% (95% CI, 0.0-0.6%) had an acute ischemic stroke. After adjustment for age, sex, and race, the likelihood of stroke was significantly higher with Covid-19 than with influenza infection (odds ratio, 7.5; 95% CI, 2.3-24.9).

Conclusions and Relevance:

Approximately 1.5% of patients with emergency department visits or hospitalizations with Covid-19 experienced ischemic stroke, a rate 7.5-fold higher than in patients with influenza. Future studies should investigate the thrombotic mechanisms in Covid-19 in order to determine optimal strategies to prevent disabling complications like ischemic stroke.

Differences in Admission Blood Pressure Among Causes of Intracerebral Hemorrhage

Background and Purpose- It is unknown whether admission systolic blood pressure (SBP) differs among causes of intracerebral hemorrhage (ICH). We sought to elucidate an association between admission BP and ICH cause. Methods- We compared admission SBP across ICH causes among patients in the Cornell Acute Stroke Academic Registry, which includes all adults with ICH at our center from 2011 through 2017. Trained analysts prospectively collected demographics, comorbidities, and admission SBP, defined as the first recorded value in the emergency department or on transfer from another hospital. ICH cause was adjudicated by a panel of neurologists using the SMASH-U criteria. We used ANOVA to compare mean admission SBP among ICH causes. We used multiple linear regression to adjust for age, sex, race, Glasgow Coma Scale score, and hematoma size. In secondary analyses, we compared hourly SBP measurements during the first 72 hours after admission, using mixed-effects linear models adjusted for the covariates above plus antihypertensive agents. Results- Among 484 patients with ICH, admission SBP varied significantly across ICH causes, ranging from 138 (±24) mm Hg in those with structural vascular lesions to 167 (±35) mm Hg in those with hypertensive ICH (P<0.001). The mean admission SBP in hypertensive ICH was 17 (95% CI, 11-24) mm Hg higher than in ICH of all other causes combined. These differences remained significant after adjustment for age, sex, race, Glasgow Coma Scale score, and hematoma size (P<0.001), and this persisted throughout the first 72 hours of hospitalization (P<0.001). Conclusions- In a single-center ICH registry, SBP varied significantly among ICH causes, both on admission and during hospitalization. Our results suggest that BP in the acute post-ICH setting is at least partly associated with ICH cause rather than simply representing a physiological reaction to the ICH itself.

Geographic Analysis of Mobile Stroke Unit Treatment in a Dense Urban Area: The New York City METRONOME Registry

Background Mobile stroke units (MSUs) reduce time to intravenous thrombolysis in acute ischemic stroke. Whether this advantage exists in densely populated urban areas with many proximate hospitals is unclear. Methods and Results We evaluated patients from the METRONOME (Metropolitan New York Mobile Stroke) registry with suspected acute ischemic stroke who were transported by a bi-institutional MSU operating in Manhattan, New York, from October 2016 to September 2017. The comparison group included patients transported to our hospitals via conventional ambulance for acute ischemic stroke during the same hours of MSU operation (Monday to Friday, 9 am to 5 pm). Our exposure was MSU care, and our primary outcome was dispatch-to-thrombolysis time. We estimated mean differences in the primary outcome between both groups, adjusting for clinical, demographic, and geographic factors, including numbers of nearby designated stroke centers and population density. We identified 66 patients treated or transported by MSU and 19 patients transported by conventional ambulance. Patients receiving MSU care had significantly shorter dispatch-to-thrombolysis time than patients receiving conventional care (mean: 61.2 versus 91.6 minutes; P=0.001). Compared with patients receiving conventional care, patients receiving MSU care were significantly more likely to be picked up closer to a higher mean number of designated stroke centers in a 2.0-mile radius (4.8 versus 2.7, P=0.002). In multivariable analysis, MSU care was associated with a mean decrease in dispatch-to-thrombolysis time of 29.7 minutes (95% CI, 6.9-52.5) compared with conventional care. Conclusions In a densely populated urban area with a high number of intermediary stroke centers, MSU care was associated with substantially quicker time to thrombolysis compared with conventional ambulance care.

Abstract WP104: Clinical Characteristics of Stroke Mimics Treated on an Urban Mobile Stroke Unit

Introduction: It is unknown how the clinical characteristics of stroke mimics treated on Mobile Stroke Units (MSUs) compare to confirmed acute strokes treated on these units.

Methods: We retrospectively analyzed all patients transported by the NewYork-Presbyterian MSU in New York City from October 2016-May 2018. A vascular neurologist assigned a final diagnosis after comprehensive medical record review. Clinical data were abstracted, including comorbidities, presenting symptoms, stroke severity, acute treatments, and short-term outcomes. We compared characteristics of patients with a stroke mimic diagnosis versus those with acute ischemic or hemorrhagic stroke using targeted minimum loss-based estimation to adjust for demographics, comorbidities, NIH Stroke Scale (NIHSS) score, and intravenous tPA administration.

Results: Among 92 suspected stroke patients transported by MSU, 56 (61%) had confirmed acute stroke (77% ischemic, 23% hemorrhagic) and 36 (39%) had a stroke mimic. Mimics consisted of seizure (n=8), metabolic encephalopathy (n=6), somatoform disorders (n=4), and others (n=18). The mean NIHSS score was 8 (SD 7) among mimics versus 11 (SD 8) among confirmed strokes (p=0.14). The top presenting symptoms among mimics were unilateral weakness (n=8), aphasia (n=6), confusion (n=6), and decreased consciousness (n=6). Nine mimics (25%) received tPA and none had hemorrhagic conversion; while 30 (53%) confirmed strokes received tPA and 2 (7%) had hemorrhagic conversion. There was no difference in MSU arrival-to-tPA time between groups (46 vs. 44 minutes, p=0.70). In multivariable analyses, compared to patients with confirmed stroke, mimics had significantly lower NIHSS scores, higher initial blood pressures, and shorter lengths-of-stay. Rates of death and discharge disposition were similar between groups.

Conclusions: Among patients transported by a MSU for suspected stroke, two-fifths were stroke mimics. Seizure, metabolic encephalopathy, and somatoform disorders were the most common mimic diagnoses. Patients with stroke mimics had lower NIHSS scores and less often were treated with tPA.

Abstract WP92: Radiologist Inter-rater Reliability of Prehospital Alberta Stroke Program Early CT Scores on a Mobile Stroke Unit

Introduction: The computed tomography (CT) capabilities of mobile stroke units (MSUs) may facilitate prehospital triaging of patients with suspected large-vessel occlusion directly to thrombectomy-capable centers. However, little is known about the reliability of radiological interpretation of early ischemic changes on prehospital CTs.

Methods: We identified all patients transported by the NewYork-Presbyterian MSU to Weill Cornell Medical Center with the diagnosis of acute ischemic stroke, transient ischemic attack, or stroke mimic between October 3, 2016 and December 31, 2017. All patients underwent noncontrast head CT on board the MSU using a CereTom® scanner. As controls, we matched these patients 1:1 by diagnosis to patients who were transported by standard ambulance and underwent noncontrast brain CT in our emergency department (ED) over the same period. Two neuroradiologists, blinded to patients’ characteristics and final diagnosis, independently calculated Alberta Stroke Program Early CT Scores (ASPECTS) on all scans. Weighted percent agreement and Cohen’s κ were used to assess inter-rater reliability, and paired t-tests were used to compare these metrics between MSU and ED scans.

Results: Among 46 MSU patients and 46 ED patients, 52% had a diagnosis of acute ischemic stroke, 46% a diagnosis of stroke mimic, and 2% a diagnosis of transient ischemic attack. For ASPECTS score as a continuous outcome, the weighted inter-rater agreement was 98% for MSU scans versus 96% for ED scans (mean difference, 2%; 95% CI, -1% to 5%) and the weighted κ was 0.49 for MSU scans versus 0.54 for ED scans (mean difference, -0.05; 95% CI, -0.61 to 0.51). For ASPECTS score categorized as 0-4, 5-7, or 8-10, the weighted inter-rater agreement was 99% for MSU scans versus 97% for ED scans (mean difference, 2%; 95% CI, -2% to 7%) and the weighted κ was 0.66 for MSU scans versus 0.55 for ED scans (mean difference, 0.10; 95% CI, -0.87 to 1.08).

Conclusions: In a sample of 96 patients, which limited our power to detect small differences, we found no substantial difference in the inter-rater reliability of ASPECTS scores obtained from MSU CTs versus ED CTs.

Superficial Siderosis of Central Nervous System as Primary Clinical Manifestation Secondary to Intradural Thoracic Disk Herniation

BACKGROUND

Superficial siderosis of the central nervous system is a rare neurologic disorder characterized by the superficial deposition of hemosiderin in the subpial layer resulting in iron-related progressive neurodegeneration.

CASE DESCRIPTION

In this report, we present a case of superficial siderosis of the central nervous system secondary to an intradural thoracic disk herniation causing a cerebrospinal fluid (CSF) leak.

CONCLUSIONS

The patient was successfully treated with T6-T8 transpedicular partial corpectomy, as well as diskectomy with decompression followed by watertight closure of the CSF leak. Intraoperative watertight closure of the CSF leak was achieved.

Clinical Information Systems Integration in New York City's First Mobile Stroke Unit

BACKGROUND

Mobile stroke units (MSUs) reduce time to thrombolytic therapy in acute ischemic stroke. These units are widely used, but the clinical information systems underlying MSU operations are understudied.

OBJECTIVE

The first MSU on the East Coast of the United States was established at New York Presbyterian Hospital (NYP) in October 2016. We describe our program's 7-month pilot, focusing on the integration of our hospital's clinical information systems into our MSU to support patient care and research efforts.

METHODS

NYP's MSU was staffed by two paramedics, one radiology technologist, and a vascular neurologist. The unit was equipped with four laptop computers and networking infrastructure enabling all staff to access the hospital intranet and clinical applications during operating hours. A telephone-based registration procedure registered patients from the field into our admit/discharge/transfer system, which interfaced with the institutional electronic health record (EHR). We developed and implemented a computerized physician order entry set in our EHR with prefilled values to permit quick ordering of medications, imaging, and laboratory testing. We also developed and implemented a structured clinician note to facilitate care documentation and clinical data extraction.

RESULTS

Our MSU began operating on October 3, 2016. As of April 27, 2017, the MSU transported 49 patients, of whom 16 received tissue plasminogen activator (t-PA). Zero technical problems impacting patient care were reported around registration, order entry, or intranet access. Two onboard network failures occurred, resulting in computed tomography scanner malfunctions, although no patients became ineligible for time-sensitive treatment as a result. Thirteen (26.5%) clinical notes contained at least one incomplete time field.

CONCLUSION

The main technical challenges encountered during the integration of our hospital's clinical information systems into our MSU were onboard network failures and incomplete clinical documentation. Future studies are necessary to determine whether such integrative efforts improve MSU care quality, and which enhancements to information systems will optimize clinical care and research efforts.

Modeling the Impact of Interhospital Transfer Network Design on Stroke Outcomes in a Large City

BACKGROUND AND PURPOSE

We sought to model the effects of interhospital transfer network design on endovascular therapy eligibility and clinical outcomes of stroke because of large-vessel occlusion for the residents of a large city.

METHODS

We modeled 3 transfer network designs for New York City. In model A, patients were transferred from spoke hospitals to the closest hub hospitals with endovascular capabilities irrespective of hospital affiliation. In model B, which was considered the base case, patients were transferred to the closest affiliated hub hospitals. In model C, patients were transferred to the closest affiliated hospitals, and transfer times were adjusted to reflect full implementation of streamlined transfer protocols. Using Monte Carlo methods, we simulated the distributions of endovascular therapy eligibility and good functional outcomes (modified Rankin Scale score, 0-2) in these models.

RESULTS

In our models, 200 patients (interquartile range [IQR], 168-227) with a stroke amenable to endovascular therapy present to New York City spoke hospitals each year. Transferring patients to the closest hub hospital irrespective of affiliation (model A) resulted in 4 (IQR, 1-9) additional patients being eligible for endovascular therapy and an additional 1 (IQR, 0-2) patient achieving functional independence. Transferring patients only to affiliated hospitals while simulating full implementation of streamlined transfer protocols (model C) resulted in 17 (IQR, 3-41) additional patients being eligible for endovascular therapy and 3 (IQR, 1-8) additional patients achieving functional independence.

CONCLUSIONS

Optimizing acute stroke transfer networks resulted in clinically small changes in population-level stroke outcomes in a dense, urban area.