Components of interprofessional education programs in neonatal medicine: A focused BEME review: BEME Guide No. 73

BACKGROUND

Care delivery in neonatology is dependent on an interprofessional team. Collaborative learning and education amongst professionals can lead to successful management of critically ill patients. This focused BEME review synthesized the components, outcomes, and impact of such interprofessional education (IPE) programs in neonatal medicine.

METHODS

The authors systematically searched four online databases and hand-searched MedEdPublish up to 10 September 2020. Two authors independently screened titles, abstracts, full-texts, performed data extraction and risk of bias assessment related to study methodology and reporting. Discrepancies were resolved by a third author. We reported our findings based on BEME guidance and the STORIES (STructured apprOach to the Reporting in health education of Evidence Synthesis) statement.

RESULTS

We included 17 studies on IPE in neonatal medicine. Most studies were from North America with varying learners, objectives, instruction, and observed outcomes. Learners represented nurses, respiratory therapists, neonatal nurse practitioners, patient care technicians, parents, early interventionists, physicians, and medical trainees amongst others. Risk of bias assessment in reporting revealed poor reporting of resources and instructor training. Bias assessment for study methodology noted moderate quality evidence with validity evidence as the weakest domain. IPE instruction strategies included simulation with debriefing, didactics, and online instruction. Most studies reported level 1 Kirkpatrick outcomes (76%) and few reported level 3 or 4 outcomes (23%). Challenges include buy-in from leadership and the negative influence of hierarchy amongst learners.

CONCLUSIONS

This review highlights IPE program components within neonatal medicine and exemplary practices including a multimodal instructional approach, asynchronous instruction, an emphasis on teamwork, and elimination of hierarchy amongst learners. We identified a lack of reporting on program development and instructor training. Future work should address long term knowledge and skill retention and impact on patient outcomes and organizations.

Abstract TP332: Intracerebral Hemorrhage Volume to Edema Volume Ratio Predicts Poor Functional Outcome in Young Patients with Non-Lobar Primary Intracerebral Hemorrhage

Background and Purpose: Cerebral edema is known to contribute to clinical decline in patients with spontaneous ICH. We sought to evaluate the significance of cerebral edema on outcome in young patients with primary ICH.

Methods: We performed a retrospective review of patients presenting to our CSC center from 2014-2015 with primary ICH, excluding patients with lobar ICH and age 55 and above. Patients were grouped according to functional outcome at discharge (mRS 0-3 vs. 4-6). Imaging characteristics of those with poor short-term functional outcome (mRS 4-6) were compared to those with mRS 0-3. Receiver Operating Characteristics curves were used to evaluate the discriminatory ability of imaging characteristics with regards to poor functional outcome.

Results: A total of 38 patients met inclusion criteria (mean age 47, 42% black, 55% male). On presentation, patients with poor functional outcome had larger mean ICH volume (26 vs 9cc; p=0.020), higher ICH volume to edema volume ratios (2.0 vs. 0.7, p=0.010), more evidence of midline shift (38% vs. 6%, p=0.026), and IVH (52% vs. 17%, p=0.043). Groups did not differ in terms of edema volume, amount of midline shift, evidence of hydrocephalus, or herniation. ICH volume to edema volume ratio was a better discriminator of poor outcome (AUC=0.813, p=0.006) than ICH volume (AUC=0.802, p=0.008, Figure 1a). Further, ICH volume to edema volume ratio was a better discriminator of poor outcome (AUC=0.801, p=0.009) than ICH score (AUC=0.724, p=0.051, Figure 1b).

Discussion: Among young patients with non-lobar primary ICH we observed that the ICH to edema ratio was a better predictor of poor functional status at discharge than ICH volume or ICH score.

Abstract TP344: Seizure is an Independent Predictor of Poor Outcome in Ischemic Stroke

Background and purpose: Occasionally, seizures can be an early complication of ischemic stroke. Recent studies have shown that hemorrhagic transformation is a predictive factor for early seizures as a complication of AIS (acute ischemic stroke). Our research looked as early seizures as a complication of AIS (either seizures on presentation in the emergency department or seizures while admitted for acute stroke), correlation with hemorrhagic transformation (HT), and the implication with poor functional discharge outcomes.

Methods: We evaluated consecutive AIS patients from March 2014-April 2015 admitted to our comprehensive stroke center. The primary endpoint was the modified rankin scale (mRS) on discharge (“poor outcome” defined as a score of 3-6), and association with hemorrhagic transformation (defined as hemorrhagic transformation seen on repeat imaging - either CT or MRI). Seizures were defined as clinical seizures - we did not require EEG data for diagnosis of seizure.

Results: A total of 773 patients met inclusion criteria with a mean age 64, 49.3% female, and 36.6% black. Of these patients, 29 (3.7%) presented with seizures at onset or as an early complication of stroke while in the hospital. In our population, 15.5% of all AIS patients had HT, and 47.5% of all AIS patients had poor functional outcomes. In our patient population, seizures were not an independent risk factor for HT as a complication of AIS (after adjusting for SBP on presentation, age and NIHSS, OR 0.64, 95% CI: 0.18-2.28, P 0.493). We found that early seizures as a complication of AIS was an independent risk factor for poor functional outcome on discharge (after adjusting for SBP on presentation, age and NIHSS, OR 13.3, 95% CI 2.69-65.9, P 0.0015).

Conclusion: In our patient population, we did not find that seizure was an independent risk factor for HT as a complication for AIS. We did find that early seizures as a complication of AIS was an independent risk factor for poor functional outcome.

Abstract TP78: When Non-revascularized Transfer Patients Come A-Knocking at a Stroke Center

Background: Guidelines recommend acute ischemic stroke (AIS) patients be transported rapidly to the closest certified stroke center (SC). The impact of SC care on transfer patients who do not receive acute revascularization therapy is not well understood. We sought to compare patient characteristics, adverse events (AEs), and short term functional outcomes in patients directly presenting to and transferred into a comprehensive stroke center (CSC).

Methods: We conducted a retrospective review of consecutive AIS patients transferred to our CSC from March 2014-April 2015. We excluded patients who received tPA or endovascular therapy. Demographic and clinical data were collected. We compared AEs (hemorrhagic transformation [HT], DVT, PE, urinary tract infection [UTI], pneumonia [PNA], bacteremia) and poor short term functional outcome, as defined by modified Rankin scale (mRS) score 3-6, among patients directly admitted to our CSC and patients transferred to our CSC.

Results: Of 589 patients who did not receive revascularization therapy, 24.4% were transfers. Transfers were disproportionately white (76.4 vs 57.8%, p<0.001), had higher median NIHSS (5 vs 4, p=0.028), were less often privately insured (40.1 vs 46.4%), and had less desirable ASPECTS scores on initial head CT (8-10; 22.9 vs 44.0, p<0.001). Transfers had higher odds of having AEs (crude OR 2.134, 95% 1.353-3.365). This association remained after adjusting for age, stroke severity, and admission glucose (OR 2.103, 95% CI 1.276-3.466.004). Transfers more frequently developed HT on repeat imaging (17.5 vs 7.0%, p<0.001), clinical seizure during inpatient stay (4.9 vs 1.6%, p=0.024), and PNA (7.6 vs 3.8%, p=0.061). However, transfer status was not associated with poor short-term functional outcome (crude OR 1.453, 95% CI 0.986-2.141; adjusted OR 1.200, 95% CI 0.703-2.046).

Conclusion: Despite having more severe strokes and higher frequency of adverse events, patients transferred into our CSC for a higher level of care did not have worse short term functional outcomes. This highlights the importance of specialized inpatient care provided in NICUs and stroke units by experienced multidisciplinary teams.

Abstract TP56: The Impact of Early Ischemic Changes on Head CT on Hemorrhagic Conversion and Outcomes in Patients With Acute Ischemic Stroke

Background: Early ischemic changes (EIC) on head CT are associated with increased hemorrhagic transformation (HT) following treatment with TPA. We examined the associations between EIC, HT, and outcomes in patients treated and not treated with IV TPA.

Methods: We conducted a retrospective review of consecutive acute ischemic stroke (AIS) patients presenting to our CSC from April 2014 to March 2015. Demographic and clinical data, including initial head CT findings (parenchymal hypodensity, loss of gray-white differentiation, sulcal effacement, hyperdense vessel) were collected. HT on repeat neuroimaging, poor functional outcome, as measured by a modified Rankin Scale (mRS) of 3-6, and in-hospital mortality were assessed.

Results: A total of 679 patients were included (50.4% men). One hundred and eight patients (15.9%) received IV TPA. EIC were observed in 38.5% of untreated patients and 17.6% in IV TPA treated patients (p<0.0001). For patients treated with IV TPA, EIC was seen more frequently in patients with pre-stroke anticoagulant use (26.3% vs. 6.7%, p=0.010) and less frequently in patients with pre-stroke statin use (15.8% vs. 43.3%, p=0.025). A higher proportion of HT was observed in patients with EIC (12.8% vs. 6.8%, p=0.016 untreated, 36.8% vs. 14.6%, p=0.024 IV TPA) and with hyperdense artery sign (8.2% vs. 3.7%, p=0.022 untreated, 36.8% vs. 15.7%, p=0.035 IV TPA). For untreated patients, EIC was observed in a larger proportion of patients with an NIHSS>14 (14.8% vs. 9.6%, p=0.016), and discharge mRS 3-6 (53.6% vs. 44.5%, p=0.040). For patients treated with IV TPA, in-hospital mortality was more common in patients with EIC (31.6% vs. 10.0%, p=0.013).

Conclusions: In untreated patients, EIC may serve as a harbinger for HT on repeat imaging and poor functional outcome at discharge, whereas in patients treated with IV TPA, it is associated with HT and in-hospital mortality. Patients with EIC may be at increased risk of HT and poor outcomes even without thrombolytics.

Abstract WP346: HIAT2 Predicts Poor Functional Outcome, Palliative Care Involvement, and In-hospital Mortality in tPA Treated and Untreated Ischemic Stroke Patients

Introduction: The HIAT2 (Houston Intra Arterial Therapy-2) score has been used to predict poor functional outcome in acute ischemic stroke (AIS) patients undergoing endovascular therapy (ET). Little is known about HIAT2’s ability to predict other outcomes in non-ET samples.

Aim: To test the ability of HIAT2 to predict poor functional outcome (mRS 4-6), in-hospital mortality, and inpatient palliative care (PC) consult in (1) ET, (2) IV tPA, and (3) untreated patients.

Methods: A retrospective review of consecutive AIS patients presenting to our comprehensive stroke center (CSC) from March 2014 to April 2015. Demographic and clinical data were collected. HIAT2 was calculated as follows: age (≤59=0, 60-79=2, ≥80=4), glucose (<150=0, ≥150=1), NIHSS (≤10=0, 11-20=1, ≥21=2), ASPECTS Score (8-10=0, ≤7=3). We used AUC to measure the ability of the HIAT2 score to predict our three outcomes of interest.

Results: Among the 776 AIS patients admitted to our CSC, 6.6% received acute ET, 14.6% received IV tPA, and 79.8% received neither. For ET patients HIAT2 had an AUC of 0.592 for mRS 4-6, AUC 0.569 for PC, and AUC 0.656 for death. For tPA patients HIAT2 had an AUC of 0.686 for mRS 4-6, AUC 0.798 for PC, and AUC 0.825 for death. For untreated patients HIAT2 had an AUC of 0.629 for mRS 4-6, AUC 0.649 for PC, and AUC 0.641 for death. In the tPA treated sample, a HIAT2 score ≥4 had a sensitivity and specificity of 0.436 and 0.819 in predicting mRS 4-6, sensitivity and specificity of 0.667 and 0.782 for PC, and sensitivity and specificity of 0.733 and 0.806 for death.

Discussion: Our results suggest that the variables used to create the HIAT2 score are useful in predicting poor outcomes in untreated, tPA treated, and ET patients. Despite its ability to predict poor outcome in these samples, treatment should not be withheld from patients that otherwise qualify.

Abstract TMP8: The New Alteplase Package Insert: What is the Potential Impact?

Background: Alteplase (tPA) contraindications for acute ischemic stroke (AIS) were originally derived from the 1995 NINDS trial. Recently, a history of intracranial hemorrhage (ICH) and recent stroke (within 3 months) were removed as contraindications from the drug package insert, which could increase the number of patients eligible for IV thrombolysis. We sought to define the potential impact on outcomes and health care costs in this newly eligible population.

Methods: Consecutive patients (March 2014 - April 2015) who presented with AIS to our Comprehensive Stroke Center (CSC) were retrospectively analyzed. Demographics and tPA exclusions were recorded. The annual number of discharges with primary diagnosis of ischemic stroke in the U.S. was estimated from the National Inpatient Sample (2006 - 2011). A previously reported value of $25,000/patient was utilized to calculate lifetime cost savings in patients receiving tPA.

Results: During the study period, 776 AIS were admitted to our CSC (median age 64; 55,74, 51% men, 62% white). Seventy-six percent of our patients (n=590) had ≥1 tPA exclusions according to the NINDS trial. Among these patients, 11 excluded had history of ICH, 15 with recent strokes, and 1 both. Following the new package insert, the proportion of patients with ≥1 tPA exclusion fell to 73% (n=563). Given the 432,000 ischemic stroke discharges annually, a 3% increase in patients eligible for tPA could translate to treatment of 12,960 more patients annually and a lifetime cost savings of $324,000,000. Furthermore, we estimate that 1,685 of these newly eligible patients will experience a favorable functional outcome based on the results of the NINDS trial (13% shift analysis for mRS 0-1).

Conclusions: Our results suggest that the new tPA package insert has the potential to increase national tPA treatment rates, decrease U.S. health care costs, and improve functional outcomes in eligible AIS patients. National guidelines need to be updated to reflect these changes.

Abstract TP30: Risks and Benefits of Bypassing the Emergency Department for Ischemic Stroke Transferred in for Acute Endovascular Therapy

Background and Purpose: Minimizing time from symptom onset to recanalization is crucial to maximizing outcome. Approaches to save time in ET cases including processes to reduce door-to-recanalization times need to be explored.

Methods: We performed a retrospective review of consecutive ischemic stroke patients transferred to our comprehensive stroke center (CSC) from March 2014 to April 2015. Demographic and clinical data were collected. We compared adverse events (hemorrhagic transformation [HT], DVT, PE, urinary tract infection [UTI], pneumonia [PNA], bacteremia), door-to-recanalization time, and short-term outcomes in patients that were evaluated in the emergency department (ED) prior to ET and patients that were transferred directly to the endovascular suite, bypassing the ED.

Results: Among the 776 consecutive ischemic stroke patients admitted to our center during the 14-month period, 7% (n=49) received acute ET. Twenty-six of these patients (53%) were transferred to our CSC for ET. Among transfers, 58% (n=15) bypassed the ED. Patients that bypassed the ED had a higher frequency of adverse events (53% vs. 27%, p=0.246), but shorter arrival to recanalization times when compared to patients that did not skip the ED (median 89 vs. 109 minutes p=0.637). Poor functional outcome, as measured by modified Rankin scale (mRS) score of 4-6, was similar between groups (67% vs. 64%, p=1.000), but in-hospital mortality was more frequent in the ED bypass group (33% vs. 18%, p=0.658).

Conclusions: In our sample of acute ischemic patients transferred for acute ET, nearly 60% of patients bypassed the ED, reducing time to recanalization. This time savings was associated with a clinically higher proportion of adverse events. Standardized protocols for patients transferred to acute ET are needed to reduce time to recanalization without increasing adverse event rates.

Abstract WP198: Is There a "Smoker's Paradox" in Acute Reperfusion Therapies?

Background & Purpose: Recent studies have suggested a “smoker’s paradox,” referring to higher recanalization rates and better outcomes after IV thrombolytic therapy for ischemic stroke in smokers compared to nonsmokers. Our goal was to evaluate whether this paradox exists for both IV and endovascular therapies (ET) in our population.

Methods: We retrospectively evaluated consecutive AIS patients (March 2014-April 2015) admitted to our comprehensive stroke center. Patients were stratified by treatment: IV tPA, ET, or neither. The primary endpoint was the modified Rankin scale (mRS) at discharge (“favorable outcome” score 0- 2) analyzed by logistic regression adjusted for demographic factors and admission NIHSS score. Successful reperfusion after ET was classified as Thrombolysis in Cerebral Infarction (TICI) scores of 2b or greater on immediate angiographic imaging.

Results: Of 765 patients, 29 % were smokers (n= 222) including 63 % white (Table). Among smokers, 15% received tPA and 3% of patients received ET. Among nonsmokers 14% received tPA and 6% received ET. There was no difference in favorable outcome between smokers and nonsmokers in patients treated with tPA (60.6% vs. 52.6%; P= 0.43) or ET (26% vs. 40.0%; P= 0.325). There was no difference between smokers and nonsmokers in re-canalization after ET (70.6 % vs. 70.0%; P= 0.62). In patients without tPA or ET treatment, favorable outcome was more frequent in smokers compared to nonsmokers (66.5% vs. 47.8 %; P< 0.001). In a regression model adjusted for admission NIHSS, age, gender, and race, the prevalence of good outcome in smokers was 18% more than nonsmokers. (PR 1.177; 95% CI: 1.021 - 1.409).

Conclusions: Our study did not support presence of the “Smoker’s Paradox” in AIS patients who receive IV or ET therapy. A rigorous adjustment for risk factors is likely to eliminate the paradoxical finding of more frequent favorable outcome in smokers who have not received tPA or ET.

Abstract WMP74: Admission Volume Depletion is Associated With Poor Outcome in Acute Ischemic Stroke

Background: Few large studies exist on volume depletion and its association with outcomes in acute ischemic stroke (AIS) patients. A common marker of volume status is the calculated blood urea nitrogen (BUN) to serum creatinine (SCr) ratio. We examined the association between admission volume depletion (BUN/SCr > 15) and discharge outcome in AIS patients.

Methods: Consecutive patients (March 2014 - April 2015) who presented with AIS to our Comprehensive Stroke Center (CSC) were retrospectively analyzed. Demographics, medical history, imaging, initial lab values, stroke severity (NIHSS), and discharge disposition were recorded. Patients with BUN/SCr <= 15 and > 15 were compared and good outcome defined as discharge home. We performed logistic regression adjusting for admission NIHSS and age.

Results: We identified 776 patients who met inclusion criteria. Patients with BUN/SCr >15, were older (median 61 vs. 68, p<0.001), more often female (43.5 vs. 59.6%, p<0.001), and had atrial fibrillation (9 vs. 16%, p=0.004). Greater proportions presented with a hyperdense artery sign (7.1 vs. 12.9%, p=0.010) and developed an in-hospital UTI (2.8 vs. 5.9%, p=0.034). Volume depleted patients had increased LOS (3 vs. 4 days, p=0.049) and higher in-hospital mortality (6.2 vs. 12.6%, p=0.003) with fewer discharged home (57.7 vs. 44.9%, p=0.001). A BUN/SCr >15 was associated with lower odds of good outcome at discharge (OR=0.57, 0.42 - 0.78; p< 0.001), this relationship persisted after adjusting for known predictors (OR=0.70, 0.49 -1.00; p=0.055).

Conclusions: After controlling for age and NIHSS, volume depletion in AIS patients estimated by BUN/SCr ratio was associated with poor discharge outcome, complicated hospital course, increased LOS, and in-hospital mortality. This simple ratio can be used in the early evaluation and treatment of AIS. However, multi-center prospective studies are needed to determine if volume correction is confounding this association.

Abstract WP348: Palliative Care is Underutilized in Ischemic Stroke Patients With Poor Functional Outcome

Background and Purpose: Palliative care (PC) should be an essential component of stroke care, particularly in patients with severe strokes given their poor prognosis and symptom burden. Despite the potential benefits of PC, a recent AHA scientific statement found that PC use in stroke was understudied and poorly understood.

Methods: We performed a retrospective review of consecutive ischemic stroke patients presenting to our comprehensive stroke center (CSC) from 3/14-4/15. Demographic and clinical data were collected. We compared the proportion of patients that received an inpatient PC consult to the proportion of patients with a discharge modified Rankin scale (mRS) score of 4-6 (unable to walk without assistance and unable to attend to own bodily needs without assistance) by NIHSS score on admission.

Results: Of the 776 ischemic stroke patients admitted to our CSC, only 6% received a palliative care consult. Even among the 254 patients discharged with a mRS of 4-6, only 16% received an PC consult. Figure 1 displays discharge mRS 4-6 and PC consult proportions by NIHSS severity. Patients that received a PC consult were older (median age 75 vs. 65, p<0.001), had more severe strokes (median NIHSS score 17 vs. 5, p<0.001), and more inpatient complications (56.5% vs. 21.8%, p<0.001). On average, PC consults occurred 3.5 days after admission (IQR 2,9). Of the 43 patients who received a PC consult, 78.3% had “do not resuscitate/do not intubate” (DNR/DNI) orders prior to the PC consult as compared to 95.7% after. Before the PC consult, 30.4% had “comfort care” (CC) orders. After the consult, the proportion with CC orders nearly doubled (58.7%).

Conclusions: Our observations suggest that PC may be underutilized in ischemic stroke patients, particularly in those who may benefit from it the most. PC has great potential to diminish suffering through physical and psychological symptom management. Providers should at least consider PC consults for hospitalized stroke patients.

Abstract TMP7: The Effect of Admission Systolic Blood Pressure on Mortality in Patients With Acute Ischemic Stroke

Background: It is unknown what significance different initial Systolic Blood Pressure (SBP) values have for patients presenting with acute ischemic stroke (AIS). We investigated factors associated with admission SBP, including hemorrhagic transformation (HT) and discharge outcome.

Methods: This is a retrospective study of consecutive AIS patients presenting from April 2014 to March 2015. Demographic and clinical data were collected, including admission SBP divided into three tiers: <140, 140-165 and >165. Primary measure of outcome was in-hospital mortality.

Results: A total of 776 patients were included with mean age 64, 49.2% females and 36.5% Black Race. Most patients with Black Race, hypertension (HTN) and hyperlipidemia (HLD) had SBP between 140-165 and >165, whereas most patients with heart failure had lower SBP (<140) (Table 1). The median SPB was 123 (113-133) in the <140 group, 152 (146-158) in the 140-165 group, and 188 (177-201) in the >165 group. A similar number of patients amongst the three groups were on BP medications (63.5% vs. 69.3% vs. 64.1%), and there were no differences in proportion of HT (15.7% vs. 18.7% vs.12.6%). Although the proportion of patients treated with IV TPA were evenly distributed among tiers (14.4% vs. 13.6% vs. 15.7%), more patients with blood pressure <166 were treated with endovascular therapy (7.8% vs. 8.9% vs. 3.7%; p=0.0321). In comparison to SBP<140, SBP>165 was associated with lower odds of in-hospital mortality (OR 0.536, 95%CI 0.295-0.975, p=0.041). This was significant after adjusting for age and NIHSS (OR 0.431, 95%CI 0.193-0.962, p=0.0399).

Conclusions: Normal presenting SBP in patients with AIS was associated with in-hospital mortality. This may be related to heart failure. Further research is needed to define the ideal range to maintain SBP after AIS.

Abstract TP345: The Association Between Stress Hyperglycemia, Hemorrhagic Transformation (HT), and Functional Outcomes in Diabetics and Non-diabetics

Introduction: Nearly 40% of stroke patients present with hyperglycemia, yet little is known about the mechanism by which hyperglycemia affects hemorrhagic transformation (HT) and functional outcome in diabetics as compared to non-diabetics.

Methods: We performed a retrospective review of consecutive ischemic stroke patients presenting to our comprehensive stroke center (CSC) from March 2014 to April 2015. Demographic, clinical, and neuroimaging data were collected. Patients were divided into four groups: (1) no type II diabetes (DM) with glucose on admission <180 [reference group], (2) No DM with glucose >180, (3) DM with glucose <180, and (4) DM with glucose >180. Hemorrhagic transformation (HT) and poor functional outcome at discharge, as measured by modified Rankin scale (mRS) score 3-6, were compared amongst groups.

Results: A total of 773 consecutive patients were admitted during the 14-month period (mean age 64, 49.3% women, and 36.6% Black). When compared to the reference group (n=467), patients without DM, but with glucose >180 (n=50) had higher odds of developing HT (OR 10.6, 95%CI 5.47-20.4, p<0.0001). This association persisted even after adjusting for age, stroke severity, IV tPA use, and endovascular therapy (NIHSS, OR 3.65, 95%CI 1.34-9.97, p=0.011). When compared to the reference group (n=467), patients with DM and glucose >180 (n=104) had higher odds of poor functional outcome even after adjusting for age, stroke severity, IV tPA use, and endovascular therapy (NIHSS, OR 1.88, CI 1.04-3.42, p=0.037).

Conclusions: We observed that hyperglycemia on admission was associated with HT in non-diabetics and associated with poor functional outcome in diabetics. Reasons that diabetics with hyperglycemia do not experience HT remain unclear. A better understanding of the pathophysiology of acute hyperglycemia in patients with and without DM is needed in order to minimize the risk of HT and its adverse effects.

Patient Selection for Drip and Ship Thrombolysis in Acute Ischemic Stroke

OBJECTIVES

The drip and ship model is a method used to deliver thrombolysis to acute stroke patients in facilities lacking onsite neurology coverage. We sought to determine whether our drip and ship population differs from patients treated directly at our stroke center (direct presenters).

METHODS

We retrospectively reviewed consecutive patients who received thrombolysis at an outside facility with subsequent transfer to our center between 2009 and 2011. Patients received thrombolysis after telephone consultation with a stroke specialist. We examined demographics, vascular risk factors, laboratory values, and stroke severity in drip and ship patients compared with direct presenters.

RESULTS

Ninety-six patients were identified who received thrombolysis by drip and ship compared with 212 direct presenters. The two groups did not differ with respect to sex, ethnicity, vascular risk factors, or admission glucose. The odds ratio (OR) of arriving at our hospital as a drip and ship for someone 80 years or older was 0.31 (95% confidence interval [CI] 0.15-0.61, P < 0.001). Only 21% of drip and ship patients were black versus 38% of direct presenters (OR 0.434, 95% CI 0.25-0.76, P = 0.004). Even after stratifying by age (<80 vs ≥80), a smaller proportion of drip and ship patients were black (OR 0.44, 95% CI 0.24-0.81, P = 0.008). Furthermore, we found that fewer black patients with severe strokes arrived by drip and ship (OR 0.33, 95% CI 0.11-0.98, P = 0.0028).

CONCLUSIONS

Our study showed that a smaller proportion of blacks and older adults arrived at our center by the drip and ship model. This may reflect differences in how patients are selected for thrombolysis and transfer to a higher level of care.

Abstract 68: Palliative Care Is Underutilized in Patients with Severe Intracerebral Hemorrhage

Background and Purpose: Palliative care is an essential part of ICH care, particularly in patients with high ICH scores given their poor prognosis. Palliative care involves consultation by the Palliative Care Service and includes de-escalation of care, changing code status, and making pain and symptom relief the central goal of management.

Methods: We performed a retrospective review of consecutive patients presenting to our tertiary care center from 2008-2013 with primary ICH. Demographic and clinical data were collected. Our sample included only patients who died or were transferred to hospice. We examined the proportion of patients that received an inpatient palliative care consult and compared this group to patients who did not receive an inpatient palliative care consult. Patients were categorized by ICH score.

Results: Of the 99 ICH patients who died or were discharged to hospice, only 23% received a palliative care consult. Figure 1 displays death, predicted death, and palliative care consult proportions by ICH score. Patients that received a Palliative Care consult were older (mean age 65 vs. 73, p=0.018) and more frequently had evidence of infection (32% vs. 13%, p=0.038); no other significant differences were found between groups.

Conclusions: In our sample of ICH patients, 23% of patients received a palliative care consult. In those with high ICH scores utilization was only 28%, despite 30 day expected mortality of 97% or greater. This raises concern that palliative care may be underutilized in patients who may benefit from it the most.

Abstract W P309: Serum Albumin Predicts Outcome In Primary Intracerebral Hemorrhage

Background&Purpose: Low serum albumin is associated with poor outcomes in ischemic stroke. Albumin levels are a marker of nutritional status; albumin also has neuro-protective effects. The role of serum albumin in outcomes in patients with ICH has not been investigated. We examined the association between initial admission albumin and functional outcome at discharge.

Subjects&Methods: Consecutive patients (2008 - 2013) diagnosed with primary ICH at our academic stroke center in the Southeast US were retrospectively analyzed. Demographics, initial lab values, and ICH scores were recorded. A poor outcome was defined as mRS 4-6 at discharge. Eligible patients were divided into two groups based on ICH score (0-2 and 3-6). Statistical significance was determined using logistic regression.

Results: A total of 103 patients met inclusion criteria (mean age 63, 45% women, 49% black). In patients with an ICH score of 0-2 (n=85), higher albumin was associated with lower odds of poor functional outcome at discharge (OR=0.40, 0.18 - 0.89; p=0.026). For every 1g/dL increase in albumin, the odds of poor outcome were reduced by 60%. This relationship was not observed in patients with an ICH score of 3-6 (n=18, OR=2.41, 0.06 - 99.5; NS).

Conclusions: Serum albumin on admission predicts outcome at discharge. Patients with low ICH severity seem to be most sensitive to lower serum albumin levels. Early nutritional support may translate into better clinical outcomes in ICH patients. Future studies incorporating other measures of nutritional status are needed to better delineate optimal serum albumin levels and to understand this effect.

Abstract W P328: Elevated Systolic Blood Pressure on Arrival is Not Associated with Higher Early Mortality in Intracerebral Hemorrhage Patients

Background and Purpose: The role of blood pressure control in the initial management of patients with intracerebral hemorrhage (ICH) is an active area of clinical investigation. Although ICH score is a validated predictor of in-hospital mortality in patients with ICH, it is not known whether elevated systolic blood pressure (SBP) on arrival is predictive of early mortality. We hypothesized that elevated SBP on arrival would be associated with in-hospital mortality in primary ICH patients.

Methods: We retrospectively analyzed consecutive spontaneous ICH patients at our institution from 2008-2013. Patients were excluded if they were under the care of a palliative physician. We examined demographics, vascular risk factors, stroke severity (NIHSS), ICH score, and laboratory values.

Results: A total of 361 spontaneous ICH patients (median age 63, 43% black, 42% female) met inclusion criteria. Over half of ICH patients were transferred into our facility (54%). Sixty-four percent of patients arrived with SBP >160. The association of SBP on arrival and in-hospital mortality is depicted in Figure 1.

Conclusions: After adjusting for ICH score, SBP was not a significant independent predictor of death during the hospitalization. This finding suggests that clinical trials of blood pressure management of patients with ICH should stratify patients according to ICH score.

Abstract W P332: Ratio of Blood Urea Nitrogen to Serum Creatinine Predicts Primary Intracerebral Hemorrhage Volume

Background&Purpose: Dehydration is associated with poor outcomes in stroke patients. A common marker of hydration status is the calculated blood urea nitrogen (BUN) to serum creatinine (SCr) ratio. Few studies in primary ICH patients have focused on intravascular volume depletion and ICH volume. We examined if dehydration (BUN/SCr > 15) predicted admission ICH volume.

Subjects&Methods: Consecutive patients (2008 – 2013) who presented with a spontaneous ICH to our academic stroke center in the Southeast US were retrospectively analyzed. Demographics, initial lab values, ICH volumes, and ICH scores were recorded. Patients with INR <= 1.5 were divided into two groups: BUN/SCr <= 15 and > 15. ICH volumes were compared between groups. Statistical significance was determined using linear regression adjusting for admission systolic blood pressure (SBP) and ICH score. Results: We identified 326 patients who met inclusion criteria (mean age 63; SD=15, 43% women, 45% black). Patients with ratio >15 were older (68 vs.60 years, p<0.001). In addition, a higher proportion were white (63% vs.40%, p <0.001) and female (56% vs. 36%, p<0.001). The average SBP on arrival was similar between groups (176 vs.181 mmHg, p=0.159). The average initial ICH volumes for those with BUN/SCr > 15 were higher than patients with BUN/SCr <= 15 (29.6 mL vs. 20.6 mL, p = 0.022). After adjusting for SBP and ICH score, patients with elevated BUN/SCr had an average of 9 mL larger ICH volumes on admission.

Conclusions: Elevated BUN/SCr ratio is linked to larger initial ICH volumes even after controlling for ICH score and SBP. This simple ratio is an independent predictor of ICH volume, may reflect poor hydration status, and can potentially be used in the early evaluation and treatment of ICH patients. Future studies to determine if correction impacts functional outcomes are warranted.

Investigating the utility of previously developed prediction scores in acute ischemic stroke patients in the stroke belt

BACKGROUND

To assess the utility of previously developed scoring systems, we compared SEDAN, named after the components of the score (baseline blood Sugar, Early infarct signs and (hyper) Dense cerebral artery sign on admission computed tomography scan, Age, and National Institutes of Health Stroke Scale on admission), Totaled Health Risks in Vascular Events (THRIVE), Houston Intra-arterial Therapy (HIAT), and HIAT-2 scoring systems among patients receiving systemic (intravenous [IV] tissue plasminogen activator [tPA]) and endovascular (intra-arterial [IA]) treatments.

METHODS

We retrospectively reviewed all IV tPA and IA patients presenting to our center from 2008-2011. The scores were assessed in patients who were treated with IV tPA only, IA only, and a combination of IV tPA and IA (IV-IA). We tested the ability of THRIVE to predict discharge modified Rankin scale (mRS) 3-6, HIAT and HIAT-2 discharge mRS 4-6, and SEDAN symptomatic intracerebral hemorrhage (sICH).

RESULTS

Of the 366 patients who were included in this study, 243 had IV tPA only, 89 had IA only, and 34 had IV-IA. THRIVE was predictive of mRS 3-6 in the IV-IA (odds ratio [OR], 1.95; 95% confidence interval [CI], 1.30-2.91) and the IV group (OR, 1.71; 95% CI, 1.43-2.04), but not in the IA group. HIAT was predictive of mRS 4-6 in the IA (OR, 3.55; 95% CI, 1.65-7.25), IV (OR, 3.47; 95% CI, 2.26-5.33), and IV-IA group (OR, 6.48; 95% CI, 1.41-29.71). HIAT-2 was predictive of mRS 4-6 in the IA (OR, 1.39; 95% CI, 1.03-1.87) and IV group (OR, 1.36; 95% CI, 1.18-1.57), but not in the IV-IA group. SEDAN was not predictive of sICH in the IA or the IV-IA group, but was predictive in the IV group (OR, 1.54; 95% CI, 1.01-2.36).

CONCLUSIONS

Our study demonstrated that although highly predictive of outcome in the original study design treatment groups, prediction scores may not generalize to all patient samples, highlighting the importance of validating prediction scores in diverse samples.

Abstract T P133: Hot and Humid in Alabama: Atmospheric Parameters and Stroke Admissions

Background&Purpose: evidence is conflicting on the effects of atmospheric conditions on the incidence of acute ischemic stroke (AIS). Since acute stroke patients are often brought to hospitals in clusters, we sought to examine the correlation of local weather parameters with AIS admission rates in a region of the United States affected by wide fluctuations in temperature and humidity.

Subjects&Methods: Basic patient demographics, stroke severity and admission dates were collected from our prospectively collected registry of consecutive acute ischemic strokes at our tertiary center. Atmospheric temperature (°F) and humidity (%) levels were obtained for each month for 3 consecutive years (2010-2012) using http://weatherspark.com/averages publicly available data.

Results: A total of 2014 consecutive AIS patients were admitted (47% women, mean age 63±15 years, median NIHSS 5, IQR 8). Ischemic stroke admissions increased linearly with both minimum (r=0.52; p=0.001) and maximum (r=0.51; p=0.001) temperature increases. Maximum humidity levels were negatively correlated with AIS admissions throughout the year (r= - 0.39; p=0.010) while minimum humidity levels yield opposite correlation with IS admissions (r=0.43; p=0.007). There was no effect of age, gender or race on these correlations. When the different seasons were evaluated separately, the strongest correlation between lower humidity levels and IS admissions was noted during summer (r=0.474; p=0.197), while higher humidity levels appeared to correlate more strongly with hospital admissions during autumn (r= - 0.596; p=0.090).

Conclusions: our study showed that humidity levels and temperature rises may affect the number of acute ischemic stroke admissions in a humid subtropical climate. Non-random clustering of IS admissions during the year underscores a potential role for atmopsheric parameters in determining allocaton of resources to treat stroke.

Abstract T P51: Tolerability and Safety of External Counterpulsation (ECP) in Acute Ischemic Stroke: Final Results of the Counterpulsation to Upgrade Forward Flow in Stroke (CUFFS) Trial

Background/Purpose: External counterpulsation (ECP) has been cited as a method that may improve brain perfusion and functional outcome in ischemic stroke. We sought to understand the tolerability and safety of ECP within 48 hours of ischemic stroke.

Methods: A randomized, patient-blinded design was used in MCA strokes ineligible for reperfusion arriving within 46 hours of stroke onset at 3 CSCs. A 1-hour ECP session (ViaCare, Scottcare Inc.) was provided with 200-300 mm Hg pressures in treatment group patients, and the lowest device pressure with air-leak cuffs in shams. TCD and NIHSS measures were collected before, during and after ECP; patients were followed for 30-days post-treatment.

Results: 23 patients were randomized (13 treatment; 10 sham); age (mean 58+12), race (78% White; 74% non-Hispanic) and gender (65% male) were similar between groups, baseline NIHSS was 6 in treatment cases and 6.5 in sham patients (p=ns), and all other baseline measures were similar between groups. There was no difference in time to ECP between groups. During ECP, an unexpected increase in sham group PSV, EDV, MFV, and proportional velocity change (PVC) was observed, with very little augmentation of MFV or PVC observed in the treatment group (Table). Tolerability was 100% in shams vs. 92% in the treatment group, with 54% sustained tolerance during high pressure. A >2 point NIHSS decrease during ECP occurred in 70% of shams vs. 38% of treatment group patients, and persisted at 30 days; mRS and Barthel indices at 30-days were similar between groups (Figure). One adverse event (AE) occurred in each group, and 1 treatment group patient had 3 serious AEs. No sICH, new ischemic strokes, or deaths occurred.

Conclusions: ECP is safe in acute ischemic stroke, although 60-minute sustained tolerance of higher pressures remains questionable. The ViaCare device did not augment MFV compared to our experience with other ECPs. Sham arms should be cautiously undertaken in the future designs of ECP studies.

Abstract W P30: Middle Cerebral Artery (MCA) Mid-to-distal M1 Segment Occlusion Masquerading as Isolated Central Facial Palsy (I-CFP)

Background & Purpose: Acute MCA occlusions produce well-known syndromes. Historically, I-CFP was largely attributed to lacunar syndromes affecting the corona radiata region or pons. With an advent of multimodal early vascular imaging, we sought to revisit lesion localization with I-CFP.

Subjects & Methods: Consecutive patients with symptoms of acute cerebral ischemia admitted to the inpatient service from January 2008 to December 2012 had NIHSS scores obtained by a certified neurologist unaware of the purposes of this study. All patients with I-CFP with or without dysarthria and without weakness (total NIHSS scores less than 3) underwent routine multimodal neurovascular imaging consisting of at least two of the following: CT-angiography, MRA, or standardized TCD. All ischemic lesions were localized by MRI within 72 hours from symptom onset.

Results: Of the 2202 consecutive patients, 879 (35%) had an NIHSS <3 (mean age 63±15 years, 46% women): 9 stroke patients (0.4%) presented with an I-CFP ± dysarthria. Of these, only 1 had a lesion in corona radiata and patent MCA, and 1 had pontine lesion without a proximal vessel occlusion (2/9, or 22%). The remaining 7 patients (78%) had mid-to-distal M1 MCA occlusions (artery-to-artery or cardioembolic stroke mechanism) with 6/7 (86%) having a prominent early anterior temporal artery on imaging or flow diversion on TCD. Corresponding ischemic lesions affecting cortical areas in the frontal lobe are shown in Figure.

Conclusions: Contrary to the current teaching of lesion localization for I-CFP, the majority of our acute patients had mid-to-distal MCA obstruction and cortical rather than lacunar lesions. This underscores the role of early vascular imaging in patients presenting with mild symptoms that could radically change management. Favorable anatomy and collateralization of flow can explain sparing of the rest of the MCA territory.

Figure

Abstract T MP28: High Rate of Symptomatic Intracranial Stenosis (sICS) in Patients Treated with Systemic Thrombolysis at a United States Stroke Belt Tertiary Care Center

Background & Purpose: sICS is a common mechanism for acute ischemic stroke (AIS), believed to preferentially affect Asians and Blacks compared to Whites. In the U.S., the reported rates of sICS for regions other than the Stroke Belt are 17% among hospitalized Blacks and 9% among Whites with AIS. We aimed to determine the rate of sICS among stroke patients treated at our Southeastern U.S. center.

Subjects & Methods: Consecutive AIS patients receiving IV tPA admitted to our tertiary center were routinely evaluated for the presence of intracranial stenosis (≥50% diameter reduction in the intracranial vessel supplying the affected territory) using either CT-angiography, catheter angiography, contrasted MRA or standardized transcranial Doppler (TCD). All imaging studies were performed following reperfusion therapy within 48 hours from symptom onset. Our published TCD criteria were previously validated against WASID measurements. Persisting arterial occlusions (TIMI 0-1 flow) and patients with cardioembolism as the only suspected stroke mechanism were not considered as having sICS.

Results: We examined 318 patients who received IV tPA at our center in 2010-12 (52% men, mean age 62±16 years, median NIHSS 5, IQR 8, 36% Blacks, 63% Whites, 1% Other) who underwent multi-modal vascular imaging with at least 2 of the 4 abovementioned modalities post treatment. Symptomatic ICS was found in 84 (26%) patients (63% men, 65±17 years, 37% Blacks, 62% Whites, 1% Other). Multiple intracranial stenoses were identified in 26% of patients with sICS (95% CI, adjusted Wald method:17.9%-36.5%). The most common locations of sICS included MCA (34.5%), intracranial ICA (15.5%), and vertebral artery (12%). Only basilar artery stenosis was more common in Blacks (16.1%) than Whites (1.9%; p=0.024).

Conclusions: Our study showed that approximately 1 out of every 4 AIS patients treated with tPA had sICS as the underlying mechanism of acute cerebral ischemia. Whether the persisting lesions represent partial recanalization of a thrombus or an underlying atheromatous stenosis deserve further investigation in a prospective multicenter study. Furthermore, this is the first report showing that sICS may be more common among Whites in the Stroke Belt of the U.S. than previously thought.

Predictors of systemic inflammatory response syndrome in ischemic stroke undergoing systemic thrombolysis with intravenous tissue plasminogen activator

BACKGROUND

Systemic inflammatory response syndrome (SIRS) is an inflammatory process associated with poor outcomes in acute ischemic stroke (AIS) patients. However, no study to date has investigated predictors of SIRS in AIS patients treated with intravenous (IV) tissue plasminogen activator (tPA).

METHODS

Consecutive patients were retrospectively reviewed for evidence of SIRS during their acute hospitalization. SIRS was defined as the presence of 2 or more of the following: (1) body temperature less than 36°C or greater than 38°C, (2) heart rate greater than 90, (3) respiratory rate greater than 20, or (4) white blood cell count less than 4000/mm or greater than 12,000/mm or more than 10% bands for more than 24 hours. Those diagnosed with an infection were excluded. A scoring system was created to predict SIRS based on patient characteristics available at the time of admission. Logistic regression was used to evaluate potential predictors of SIRS using a sensitivity cutoff of ≥65% or area under the curve of .6 or more.

RESULTS

Of 212 patients, 44 had evidence of SIRS (21%). Patients with SIRS were more likely to be black (61% versus 54%; P = .011), have lower median total cholesterol at baseline (143 versus 167 mg/dL; P = .0207), and have history of previous stroke (51% versus 35%; P = .0810). Ranging from 0 to 6, the SIRS prediction score consists of African American (2 points), history of hypertension (1 point), history of previous stroke (1 point), and admission total cholesterol less than 200 (2 points). Patients with an SIRS score of 4 or more were 3 times as likely to develop SIRS when compared with patients with a score of ≤3 (odds ratio = 2.815, 95% confidence interval 1.43-5.56, P = .0029).

CONCLUSIONS

In our sample of IV tPA-treated AIS patients, clinical and laboratory characteristics available on presentation were able to identify patients likely to develop SIRS during their acute hospitalization. Validation is required in other populations. If validated, this score could assist providers in predicting who will develop SIRS after treatment with IV tPA.

The Potential Impact of Maintaining a 3-Hour IV Thrombolysis Window: How Many More Patients can we Safely Treat?

BACKGROUND

In 2008, the European Cooperative Acute Stroke Study-3 (ECASS-3) demonstrated that intravenous-tissue plasminogen activator could be safely administered for acute stroke patients presenting between 3 and 4.5 hours from symptom onset. Recently, the Food and Drug Administration rejected expansion of this time window in the United States. We sought to determine how many fewer patients would be treated by maintaining this restricted time window.

METHODS

We reviewed charts from patients who received intravenous thrombolysis at the University of Alabama at Birmingham between January 2009 and December 2011. Patients were divided into two groups (treated within 3 hours of onset, treated between 3 and 4.5 hours from onset). Demographics, stroke severity and protocol deviations according to the ECASS-3 trial were collected. Our safety measures were any hemorrhagic transformation, symptomatic intracerebral hemorrhage and systemic hemorrhage.

RESULTS

Two hundred and twelve patients were identified, of whom 192 were included in our analysis. A total of 36 patients (19%) were treated between 3 and 4.5 hours. No statistical differences were seen between age (p=0.633), gender (p=0.677), race (p=0.207) or admission stroke severity (p=0.737). Protocol deviations from the ECASS-3 criteria were found in 20 patients (56%). These were primarily age > 80 and aggressive blood pressure management. Despite these deviations, we did not see significant increases in the rates of adverse events in patients treated in the extended time window.

CONCLUSIONS

Our data are consistent with previously reported international data that IV thrombolysis can safely be used up to 4.5 hours from symptom onset. Restricting the time window to 3 hours would have resulted in almost one-fifth fewer patients treated at our center.

Safety of protocol violations in acute stroke tPA administration

BACKGROUND

Intravenous (IV) tissue plasminogen activator remains the only approved therapy for acute ischemic stroke (AIS) in the United States; however, less than 10% of patients receive treatment. This is partially because of the large number of contraindications, narrow treatment window, and physician reluctance to deviate from these criteria.

METHODS

We retrospectively analyzed consecutive patients who received IV thrombolysis at our stroke center for National Institute of Neurological Disorders and Stroke (NINDS) protocol violations and rates of symptomatic intracerebral hemorrhage (sICH). Other outcome variables included systemic hemorrhage, modified Rankin Scale at discharge, and discharge disposition.

RESULTS

A total of 212 patients were identified in our stroke registry between 2009 and 2011 and included in the analysis. Protocol violations occurred in 76 patients (36%). The most common violations were thrombolysis beyond 3 hours (26%), aggressive blood pressure management (15%), elevated prothrombin time (PT) or partial thromboplastin time (PTT) (6.6%), minor or resolving deficits (4.2%), unclear time of onset (3.9%), and stroke within 3 months (3%). There were no significant differences in any of the safety outcomes or discharge disposition between patients with or without protocol violations. Controlling for age, National Institutes of Health Stroke Scale on admission, and glucose on admission, there was no significant increase in sICH (odds ratio: 3.8; 95% confidence interval: .37-38.72) in the patients who had protocol violations.

CONCLUSIONS

Despite more than one third of patients receiving thrombolysis with protocol violations, overall rates of hemorrhage remained low and did not differ from those who did not have violations. Our data support the need to expand access to thrombolysis in AIS patients.

Reversal of the neurological deficit in acute stroke with the signal of efficacy trial of auto-BPAP to limit damage from suspected sleep apnea (Reverse-STEAL): study protocol for a randomized controlled trial

Background

Although the negative impact of sleep apnea on the clinical course of acute ischemic stroke (AIS) is well known, data regarding non-invasive ventilation in acute patients are scarce. Several studies have shown its tolerability and safety, yet no controlled randomized sequential phase studies exist that aim to establish the efficacy of early non-invasive ventilation in AIS patients.

Methods/design

We decided to examine our hypothesis that early non-invasive ventilation with auto-titrating bilevel positive airway pressure (auto-BPAP) positively affects short-term clinical outcomes in AIS patients. We perform a multicenter, prospective, randomized, controlled, third rater- blinded, parallel-group trial. Patients with AIS with proximal arterial obstruction and clinically suspected sleep apnea will be randomized to standard stroke care alone or standard stroke care plus auto-BPAP. Auto-BPAP will be initiated within 24 hours of stroke onset and performed for a maximum of 48 hours during diurnal and nocturnal sleep. Patients will undergo unattended cardiorespiratory polygraphy between days three and five to assess sleep apnea. Our primary endpoint will be any early neurological improvement on the NIHSS at 72 hours from randomization. Safety, tolerability, short-term and three-months functional outcomes will be assessed as secondary endpoints by un-blinded and blinded observers respectively.

Discussion

We expect that this study will advance our understanding of how early treatment with non-invasive ventilation can counterbalance, or possibly reverse, the deleterious effects of sleep apnea in the acute phase of ischemic stroke. The study will provide preliminary data to power a subsequent phase III study.

Trial registration

Clinicaltrials.gov Identifier: NCT01812993

CLOTBUST-hands free: initial safety testing of a novel operator-independent ultrasound device in stroke-free volunteers

BACKGROUND AND PURPOSE

We aimed to evaluate safety and tolerability of a novel operator-independent ultrasound device among stroke-free volunteers.

METHODS

A headframe containing 18 ultrasound transducers (each operating at 2 MHz, pulsed-wave) was used to expose both temporal windows and the suboccipital window. The transmission characteristics were set to emulate the acoustic characteristics of the exposure levels in the Combined Lysis of Thrombus in Brain Ischemia using Transcranial Ultrasound and Systemic tPA (CLOTBUST) trial and to never exceed Food and Drug Administration mandated diagnostic ultrasound exposure limits. Volunteers underwent 2 hours of insonation with transducer activation one at a time. Safety was captured using serial neurological examinations and pre- and postinsonation MRI for detection of the blood brain barrier permeability.

RESULTS

A total of 15 volunteers (40% men; 49 ± 16 years; 27% black; all pre-exposure National Institutes of Health Stroke Scale scores 0) were enrolled. Five volunteers received pulsed-wave ultrasound via the best pair temporal transducers, 5 via sequential activation of the suboccipital transducers, and 5 via sequential activation of all bilateral temporal and suboccipital transducers. All subjects were safely insonated with no adverse effects as indicated by the neurological examinations during, immediately after the exposure, and at 24 hours, and no abnormality of the blood brain barrier was found on any of the MRIs.

CONCLUSIONS

Our novel device was well tolerated by stroke-free volunteers and did not cause any neurological dysfunction nor did it affect blood brain barrier integrity. The safety and efficacy of the device are now being tested in stroke patients receiving intravenous tissue-type plasminogen activator in phase II-III clinical trials.

Systemic inflammatory response syndrome in tissue-type plasminogen activator-treated patients is associated with worse short-term functional outcome

BACKGROUND AND PURPOSE

Systemic inflammatory response syndrome (SIRS) is a generalized inflammatory state. The primary goal of the study was to determine whether differences exist in outcomes in SIRS and non-SIRS intravenous tissue-type plasminogen activator-treated patients.

METHODS

Consecutive patients were retrospectively reviewed for the evidence of SIRS during their admission. SIRS was defined as the presence of ≥2 of the following: body temperature<36°C or >38°C, heart rate>90, respiratory rate>20, and white blood cells<4000/mm or >12 000 mm, or >10% bands. Patients diagnosed with infection (via positive culture) were excluded.

RESULTS

Of the 241 patients, 44 had evidence of SIRS (18%). Adjusting for pre-tissue-type plasminogen activator National Institutes of Health Stroke Scale, age, and race, SIRS remained a predictor of poor functional outcome at discharge (odds ratio [OR], 2.58; 95% confidence interval [CI], 1.16-5.73; P=0.0197).

CONCLUSIONS

In our sample of tissue-type plasminogen activator-treated (tPA) patients, ~1 in 5 patients developed SIRS. Furthermore, we found the presence of SIRS to be associated with poor short-term functional outcomes and prolonged length of stay.

Abstract WP72: Safety of Label- and Protocol Violations in Acute Stroke tPA Administration

Background: IV-tPA remains the only FDA approved therapy for acute ischemic stroke, however less than 10% of patients receive treatment. This is partially due to the large number of contraindications on the drug label and continued use of NINDS trial criteria for patient selection.

Methods: We retrospectively analyzed consecutive patients who received IV-tPA at our stroke center for label or NINDS protocol violations, as well as safety according to the NINDS t-PA Stroke Study definition of sICH. Other outcome variables included systemic hemorrhage, mRS at discharge and disposition.

Results: A total of 308 patients were identified in our tPA registry between 2009 and 2011. Ninety six patients were excluded because they received tPA at an outside facility prior to transfer, leaving 212 patients for analysis. Median patient age was 68 (IQR 55, 82), median pretreatment NIHSS score was 8 (IQR 5, 14). Protocol violations occurred in 103 patients (49%). The most common violations were tPA delivery beyond 3 hours (26%), aggressive blood pressure management with nicardipine (15%), elevated PT/PTT (6.6%), minor or resolving deficits (4.2%), unclear time of onset (3.9%) and stroke within 3 months (3%). Three patients had a history of ICH. There were no significant differences in any of the safety outcomes between patients with or without protocol violations (Table). Furthermore, after controlling for age, admission NIHSS and glucose, there was no significant increase in the rate of any hemorrhagic transformation (OR 1.046, p= 0.905) or sICH (OR 0.569, p= 0.613) in patients with protocol violations.

Conclusions: Despite nearly half of patients receiving tPA off label or in violation of the NINDS protocol, overall rates of hemorrhage remained low and did not differ from those who did not have violations. Our data support the need to mitigate restrictions for IV-tPA in patients presenting with acute ischemic stroke.

Abstract WP277: Aggressive Blood Pressure Management: A Perceived Contraindication to IV-tPA

Background: Our recent poll of US Primary Stroke Centers demonstrated that 23% of practitioners perceived the need for blood pressure (BP) management by means of a continuous dihydropyridine calcium channel blocker infusion (i.e. nicardipine) as a contraindication to IV-tPA. While the NINDS study originally excluded patients who required "aggressive" BP management, the Activase® label is silent on this criterion. In view of this persistent belief, we sought to examine the safety of IV tPA administered with nicardipine.

Methods: A retrospective cohort study was performed over a period of 36 months examining consecutive patients treated with IV-tPA at our comprehensive stroke center who received nicardipine vs. intermittent IV labetalol or those requiring no BP medications. Patient demographics, past medical history, and stroke severity were compared. Safety was assessed by (1) symptomatic intracerebral hemorrhage (sICH) within 36 hours, defined as parenchymal hemorrhage in combination with ≥ 4 points increase in NIHSS, and (2) the presence of any hemorrhagic transformation (HT) on repeat CT or MRI.

Results: A total of 212 patients were treated with IV-tPA, median age 68 (range 24-99), median pre-tPA bolus NIHSS 8 (range 0-32) with no differences between nicardipine treated (n=32, 15%) vs. others (n=180). Patients treated with nicardipine were more frequently female (63%; p=0.0337). Past medical history was similar except for CHF (nicardipine 0, other 15%, p=0.0087) and previous stroke (nicardipine 59%, other 36%, p=0.0132). Despite these imbalances, nicardipine patients vs. others had similar rates of sICH (0 vs. 3.3%; p=NS), or any HT (3.1% vs. 9.5%; p=NS). No telephone-assisted tPA drip-n-ship patients (n=96) received nicardipine prior to or during tPA infusion due to non-formulary status at transferring hospitals; sICH rate in this group was 4% vs. 2% (p=NS) in non-transfers with or without nicardipine.

Conclusions: IV thrombolysis in patients requiring continuous nicardipine infusion is safe compared to those requiring less intensive BP management. The need for continuous nicardipine infusion should not be construed as rationale for withholding IV tPA in acute ischemic stroke patients.

Abstract 5: Management Of Intravenous tPA In Non-ICU Environments: Safety, Clinical Outcome, And Cost Savings

Background: Administration of IV tPA has traditionally necessitated admission to an ICU solely for monitoring, with relatively no need for extensive critical care services. Stroke Units that are capable of monitoring IV tPA patients have been proposed to reduce ICU use, but limited data exist that demonstrate safety. We report the largest series of non-ICU managed tPA cases in relation to safety and discharge outcomes.

Methods: Consecutive cases admitted to our intermediate-level Stroke Unit spanning 2009-2011 were assembled. Unit capabilities include IV tPA management with nicardipine infusion for blood pressure control as needed, non-invasive or direct central/arterial line and cardiac monitoring, and BiPAP ventilation. Stroke Unit nurses underwent extensive orientation and participate in NET SMART Junior for continuing education. Overall sICH, and drip/ship sICH (parenchymal hemorrhage in combination with > 4 point increase on the NIHSS), systemic hemorrhage, and tPA related death rates were calculated, along with discharge mRS and total ICU cost savings per day.

Results: A total of 302 Stroke Unit admissions for intravenous tPA occurred over the 3 year period, while another 31 (10%) were excluded due to critical care admission for systemic hemodynamic or pulmonary instability. Nicardipine infusions were used in 9 (10.5%) Stroke Unit tPA cases in 2009, 10 (9%) in 2010, and 14 (13%) in 2011. Overall sICH rate was 3.3% (n=10) and systemic hemorrhage rate was 2.9% (n=9) with 5 of these (56%) requiring transfusion. Estimated cost savings in total for this 3 year period was $362,400 for “avoided” ICU days.

Conclusions: Intravenous tPA patients may be safely managed on non-ICU Stroke Units when nurses undergo extensive education to ensure clinical competence. Use of the ICU solely for management of tPA monitoring needs may constitute significant overuse of system resources at an expense that is not associated with additional safety benefit.

Abstract WMP76: Predictors of Systemic Inflammatory Response in Acute Ischemic Stroke Patients Treated with IV tPA

Background: Systemic Inflammatory Response Syndrome (SIRS) is a generalized inflammatory state in which cytokines are elevated. SIRS in the setting of AIS has been associated with poor outcomes. However, no study to date has investigated what predicts SIRS in AIS patients treated with tPA.

Methods: Consecutive patients were retrospectively reviewed for evidence of SIRS during their admission. SIRS was defined as the presence of two or more: fever >38° C, HR >90, respiratory rate >20 and WBC <4 or >12. Patients diagnosed with infection (via positive culture) were excluded as well as those with evidence of pneumonia or UTI on admission. A scoring system was created to predict SIRS based on patient characteristics available at the time of admission. Logistic regression was used to evaluate potential predictors of SIRS using a sensitivity cut-off of ≥65% or area under the curve (AUC) ≥0.6.

Results: Out of 212 patients, 44 had evidence of SIRS (21%). Patients with SIRS were more likely to be Black (61% vs 54%; p=0.011), had lower median total cholesterol at baseline (143 vs.167 mg/dL; p=0.0207), and had a nonsignificant difference on prior history of stroke (51% vs. 35%; p=0.0810). Ranging from 0-6, the SIRS prediction score consists of Black race (2 points), history of hypertension (1 point), history of prior stroke (1 point) and admission total cholesterol < 200 (2 points). As shown in Figure 1, 80% of patients with a SIRS score ≥4 have SIRS. Patients with a SIRS score ≥ 4 were 3 times as likely to develop SIRS when compared to patients with a score of ≤ 3 (OR=2.815, 95% CI 1.43-5.56, p=0.0029).

Conclusion: In our sample of IV tPA treated patients, clinical and laboratory characteristics available on presentation were able to identify patients likely to develop SIRS during their acute hospitalization. Validation is required in other populations. If validated, this score could assist providers in predicting who will develop SIRS after treatment with IV tPA.

Abstract WP71: Recanalization Leads To Early Clinical Improvement In Patients Treated With Argatroban And Intravenous TPA A Subanalysis Of The Argatroban Tpa Stroke Study

Background and Objectives: Early neurological improvement (ENI) at 2-hours post thrombolysis has recently been proposed to most accurately predict recanalization when repeat vascular imaging is not available. However, these studies analyzed recanalization at a delayed time point (≥24 hours). The Argatroban tPA Stroke Study (ARTSS-1), is a recently completed NIH sponsored, Phase IIa, prospective, open-label, safety and activity study of Argatroban and rtPA in patients with ischemic stroke ( NCT00268762 ). We hypothesized 2-hour recanalization correlates with ENI (NIHSS improvement of 20% or greater from baseline).

Methods: A total of 65 patients with intracranial large vessel occlusive disease were given standard dose (0.9mg/kg) tPA and a 100 μg/kg bolus of argatroban followed by infusion of 1 μg/kg per minute for 48 hours adjusted to a PTT of 1.75 times baseline. Pre-tPA vessel imaging using TCD or CTA confirmed intracranial occlusions. A multivariate logistic regression tested whether recanalization at 2 hours was associated with ENI after controlling for age, NIHSS, clot location (ICA, MCA or vertebrobasilar). We analyzed whether patients with ENI had statistically significant greater odds of an excellent mRS (0 or 1) at day 7.

Results: Recanalization data was available for 47 patients at 2-hours. ENI occurred at 2-hours in 46% patients. Patients with any recanalization (complete or partial) at 2-hours were more likely to experience ENI (OR 3.4; 95% CI 0.71-16.6, p=0.124). This association strengthened when 2-hour complete recanalization was analyzed (OR 5.4; 95% CI 0.98-29.2, p=0.053). In an unadjusted analysis, patients with ENI at 2-hours were five times more likely to have excellent mRS outcomes at day 7 (OR 4.7; 95% CI 1.4-15.6, p=0.01). In the adjusted model, the association remained significant (OR 3.8; 95%CI 1.1-13.4, p=0.041).

Conclusion: Two-hour recanalization is predictive of early neurological improvement and better early clinical outcomes in patients treated with combination Argatroban and tPA. A randomized, controlled clinical trial of this promising adjunctive therapy is warranted and ongoing (ARTSS-2 trial, NCT01464788 ).

Abstract TP278: Prevalence Of Systemic Inflammatory Response Syndrome and its Impact On Outcome In Acute Ischemic Stroke Patients Receiving IV tPA Therapy

Background: Systemic Inflammatory Response Syndrome (SIRS) is a generalized inflammatory state linked to a release of various pro- and anti-inflammatory cytokines and associated with fibrin deposition, platelet aggregation, and coagulopathies. Although SIRS is associated with various inflammatory and ischemic conditions, its prevalence and impact on patients with acute ischemic stroke (AIS) has not been extensively studied.

Methods: A retrospective cross sectional study was used to look at the prevalence of SIRS and its impact on outcome in AIS patients treated with IV tPA between 2009-2011 at our tertiary care center. SIRS was diagnosed if two or more of the following were present: temperature < 36°C or > 38°C, heart rate > 90/min, respiratory rate >20/min or PaCO 2 <32 mmHg and WBC count <4000/mm 3 or >12000/mm 3 or 10% bands. Patients meeting the SIRS criteria for at least 24h were included in the study. Patients with signs of active infection such as pneumonia, UTI, bacteremia, and sinusitis or deep venous thrombosis were excluded from the study. The discharge modified Rankin score (mRS) was used to compare the short-term outcomes between patients with and without SIRS. An mRS of 4-6 was used to define poor functional outcome.

Results: Out of the 212 patients screened, 44 met the SIRS criteria (21%). The median NIHSS for SIRS patients was 9 (range 0-32). SIRS patients were more likely to have a longer length of stay than non-SIRS patients (5 vs. 3 days; p<0.0001). Patients with SIRS had worse functional outcomes compared to patients without SIRS (OR=2.824, 95% CI, 1.358 - 5.871, p=0.0054). Adjusting for pre-tPA NIHSS, age and race, SIRS remained a predictor of poor outcome (OR= 2.581, 95% CI, 1.163 - 5.727, p=0.0197). Presence of SIRS did not have a significant effect upon in-hospital mortality (OR=1.978, 95% CI, 0.774 - 5.057, p=0.1545).

Conclusions: One out of five AIS patients treated with IV tPA developed SIRS. The presence of SIRS is associated with poor short-term functional outcomes and prolonged length of stay.

Abstract WP129: The Potential Impact of Maintaining a 3-Hour IV tPA Window

Background: In 2008, the ECASS-3 trial demonstrated that IV-tPA could be safely administered for acute stroke patients presenting between 3 and 4.5 hours from symptom onset. Recently, the FDA rejected expansion of the 3 hour time window. We sought to determine the safety of the ECASS protocol at our center and assess how many fewer patients would be treated by restricting treatment to 3 hours.

Methods: We reviewed charts from patients who received IV tPA at our comprehensive stroke center and excluded patients who were drip and ship. Patients were divided into two groups (receiving tPA within 3 hours of onset, receiving tPA between 3 and 4.5 hours from onset). Demographics, admission NIHSS and protocol deviations (NINDS and ECASS-3) were collected. Safety was assessed using any hemorrhagic transformation (MRI or CT), symptomatic ICH and systemic hemorrhage.

Results: Two hundred and twelve patients were identified in our tPA registry between 2009 and 2011, of whom 36 received tPA between 3 and 4.5 hours. No statistical differences were seen between age (p=0.633), gender (p=0.677), race (p=0.207) or admission NIHSS (0.737). Protocol deviations from the ECASS 3 criteria were found in 20 patients (56%). The most common deviations were age > 80 (8/36, 22%) and aggressive blood pressure management (5/20, 25%). Safety outcomes were not different between the two groups (Table).

Conclusions: Our data are consistent with previously reported international data that IV thrombolysis can safely be used up to 4.5 hours from symptom onset. By expanding the three hour time window, we were able to treat an additional 17% over three years at our stroke center without an increase in adverse outcomes. Physicians should not withhold thrombolytic therapy based solely on a three hour time window as this unnecessarily restricts the population of patients who could potentially benefit from treatment.

Abstract WP58: Early Recanalization Rates Do Not Differ among Stroke Subtypes when treated with Argatroban and intravenous tPA: a Subanalysis of the Argatroban TPA Stroke Study

Background and Objectives: Argatroban is a direct thrombin inhibitor that safely augments the benefit of tPA in animal stroke models. The Argatroban tPA Stroke Study (ARTSS-1), was a recently completed NIH sponsored, Phase IIa, prospective, open-label, safety and activity study of Argatroban and tPA in patients with ischemic stroke ( NCT00268762 ). Symptomatic hemorrhage occurred in 4.6% and rates of complete recanalization were 30% and 63% at 2 and 24 hours, respectively. We hypothesized that stroke subtypes might respond differently to the treatment combination.

Methods: A total of 65 patients with intracranial large vessel occlusive disease were given standard dose (0.9mg/kg) tPA and a 100 μg/kg bolus of argatroban followed by infusion of 1 μg/kg per minute for 48 hours adjusted to a PTT of 1.75 times baseline. Pre-tPA vessel imaging using TCD or CTA confirmed intracranial occlusions. A multivariate logistic regression was performed to test whether stroke subtype independently influenced recanalization after controlling for: NIHSS, antithrombotic use, diabetes, age and clot location (ICA, MCA, Vertebrobasilar).

Results: Recanalization data was available for 47 patients at 2-hours. Baseline characteristics are displayed in the table. After adjusting for age, NIHSS, diabetes, clot location and previous antithrombotic use, there was no difference between any recanalization at 2-hours in the different stroke etiologies. Interestingly, M1 clots were more likely to recanalize compared with M2 (OR 6.2; 95% CI 1.3-25, p=0.019). Results were similar when only analyzing 2-hours complete recanalization.

Conclusion: Although all large vessel stroke subtypes recanalize at similar rates when treated with combination Argatroban and rtPA, larger thrombi may benefit to a greater degree. A randomized, controlled clinical trial of this promising adjunctive therapy is warranted and ongoing (ARTSS-2 trial, NCT01464788 ).

Abstract TP70: Safety of IV tPA Administration with CT Evidence of Prior Infarction

Background: Prior stroke within 3 months excludes patients from thrombolysis, however patients may have CT evidence of prior infarct often of unknown time of origin. We aimed to determine if the presence of a previous infarct on pre-treatment head CT is a predictor of hemorrhagic complications following administration of IV tPA.

Methods: We retrospectively analyzed the database of consecutive patients treated with IV tPA at our institution from 2009-2011. Pre-treatment CTs were reviewed without knowledge of subsequent hemorrhagic transformation (HT) for evidence of any prior infarct. Further independent review determined if any HT was present on repeat CT or MRI. Symptomatic ICH (sICH) was defined as the presence of parenchymal hematoma (PH-1 or PH-2) and neurological deterioration by ≥ 4 points within 36 hours.

Results: Of 212 IV tPA treated patients, 72 (34%) had evidence of prior infarct on pre-treatment CT. Any HT was found in 16%, sICH occurred in 2.4% of the total population, and both events never occurred in the areas of prior infarcts. Patients with prior infarcts on CT were older (median age 72 vs 65; p=0.001), were more likely to have a history of hypertension (85% vs 71%; p=0.024), were on antiplatelet agents prior to admission (49% vs 31%; p=0.007) and had higher pre-treatment NIHSS scores (median 10 vs 7; p=0.023). Patients with prior infarcts on CT did not experience more HT (p=0.3956) nor sICH (p=0.2207), even after stratifying for prior lacunar or cortical stroke appearances (p=0.301). More patients with prior infarcts on CT had microbleeds on follow-up MRI (25% vs 11%; p=0.033), and patients with prior infarcts and microbleeds experienced more HT (63% vs. 10%; p<0.0001) but did not have more sICH (p=0.4784).

Conclusions: Visualization of prior infarcts on pre-treatment CT does not predict an increased risk of sICH and should not be viewed as a contraindication for systemic tPA treatment after clinically evident strokes within 3 months were excluded. A subgroup of patients with prior infarcts and subsequently discovered cerebral microbleeds show a propensity to develop asymptomatic HT.

Abstract TP138: SITS Symptomatic Intracerebral Hemorrhage Risk Score in the Stroke Belt

Background: sICH remains the most feared complication of IV tPA treatment. SITS investigators developed a clinical score to predict sICH in European stroke patients. We aimed to investigate the how this score would perform in IV tPA treated patients at two centers in the US Stroke Belt.

Methods: We retrospectively reviewed IV tPA treated consecutive patients from two centers in the Stroke Belt (2008-2011). The SITS Symptomatic Intracerebral Hemorrhage Risk Score was calculated using published criteria . sICH was defined as a type 2 parenchymal hemorrhage with deterioration in NIHSS score of 4 points or death. Only patients with all 9 variables needed to calculate the SITS sICH scores were included. Logistic regression was used to investigate the predictive ability of the score.

Results: During the study period, 457 patients were treated with IV tPA (sICH 4.2%). Among the 220 patients with all 9 variables, 19 (8.6%) had sICH. The SITS sICH scores and other variables are shown in the Table. SITS score was not a predictor of sICH in overall patient sample (OR=1.16, 95% CI 0.856-1.57, p=0.3387). The score performed poorly in Blacks (OR 1.18, 95% CI 0.79-1.77, p=0.417) as compared to Whites (OR 1.19, 95% CI 0.77-1.82, p=0.438) for prediction of sICH, Figure. However, SITS score was predictive of mRS 4-6 at discharge (OR=1.34, 95% CI 1.16-1.55, p<0.001).

Conclusions: SITS sICH score was not predictive of sICH in Stroke Belt patients, particularly among Blacks. The specific components of the 9 variable score needs to be re-evaluated individually for point estimates specific for the Stroke Belt population.

The argatroban and tissue-type plasminogen activator stroke study: final results of a pilot safety study

BACKGROUND AND PURPOSE

Argatroban is a direct thrombin inhibitor that safely augments recanalization achieved by tissue-type plasminogen activator (tPA) in animal stroke models. The Argatroban tPA Stroke Study was an open-label, pilot safety study of tPA plus Argatroban in patients with ischemic stroke due to proximal intracranial occlusion.

METHODS

During standard-dose intravenous tPA, a 100-μg/kg bolus of Argatroban and infusion for 48 hours was adjusted to a target partial thromboplastin time of 1.75× baseline. The primary outcome was incidence of significant intracerebral hemorrhage defined as either symptomatic intracerebral hemorrhage or Parenchymal Hematoma Type 2. Recanalization was measured at 2 and 24 hours by transcranial Doppler or CT angiography.

RESULTS

Sixty-five patients were enrolled (45% men, mean age 63±14 years, median National Institutes of Health Stroke Scale=13). The median (interquartile range) time tPA to Argatroban bolus was 51 (38-60) minutes. Target anticoagulation was reached at a median (interquartile range) of 3 (2-7) hours. Significant intracerebral hemorrhage occurred in 4 patients (6.2%; 95% CI, 1.7-15.0). Of these, 3 were symptomatic (4.6%; 95% CI, 0.9-12.9). Seven patients (10%) died in the first 7 days. Within the 2-hour monitoring period, transcranial Doppler recanalization (n=47) occurred in 29 (61%) patients: complete in 19 (40%) and partial in another 10 (21%).

CONCLUSIONS

The combination of Argatroban and intravenous tPA is potentially safe in patients with moderate neurological deficits due to proximal intracranial arterial occlusions and may produce more complete recanalization than tPA alone. Continued evaluation of this treatment combination is warranted.

CLINICAL TRIAL REGISTRATION

URL: www.clinicaltrials.gov. Unique identifier: NCT00268762.

Abstract NS 4: Non-Invasive Oscillometric Blood Pressure Monitoring in tPA Treated Patients: Is Mean Arterial Pressure Associated with Patient Outcomes?

Background: Blood pressure (BP) parameters for management of tPA treated patients are well known among experienced stroke clinicians, and violation of systolic and diastolic BP limits have previously been shown to be associated with symptomatic intracerebral hemorrhage (sICH) in tPA treated patients. Non-invasive oscillometric BP monitoring measures a “true” mean arterial pressure (MAP), and then algorithmically defines what systolic and diastolic pressure "might" be. Because this form of BP monitoring has become the national standard, we examined the occurrence of MAP BP elevations to determine their association with sICH and treatment outcome in acute ischemic stroke patients that received systemic tPA.

Methods: Two-years of consecutive systemic tPA cases were retrieved from our Stroke Center database and arterial blood pressures for the first 24 hours from time of bolus were entered from auto-recordings in our electronic medical records. Protocol violations in MAP were defined as greater than 120 mm Hg at any point in the first 24 hours from time of bolus. Off-label treatment with intravenous tPA beyond 4.5 hours from symptom onset was identified a priori as a potential counfounder to stroke outcome. Symptomatic intracerebral hemorrhage was defined as an increase in the NIHSS of ≥ 4 points. Spearman’s correlation was used to assess the relationship between MAP and post-tPA NIHSS score.

Results: 191 tPA cases were identified for inclusion in the analysis with 150 (79%) receiving their tPA at our Comprehensive Stroke Center and another 41 (21%) administered as a telephone-consult supported drip and ship. Patients were 65.5±16 years of age with median admission NIHSS scores of 12 (IQR=7-17). All patients had normal CT scans or minor changes consistent with acute stroke without hypo-attenuation. A total of 77 (40%) patients experienced a MAP violation overall. There were 11 isolated systolic BP violations, 4 isolated diastolic BP violations, and 21 isolated MAP violations that were otherwise not detectable by a violation in systolic or diastolic parameters, averaging 123.3±2 mm Hg. A total of 2 (1%) sICHs occurred in the sample, and of these 1 was associated with on-label peri-treatment BP protocol violations affecting systolic, diastolic and MAP parameters. An increased reduction in post-tPA NIHSS points was significantly associated with higher MAPs (r=.92; p=.008).

Conclusions: Evidence-based guidelines are silent on MAP limits, and MAP is rarely monitored clinically in tPA treated patients despite dependence on the MAP for assignment of systolic and diastolic pressures in oscillometric BP monitoring. Our findings suggest that an improved understanding of the contribution of MAP-dependent oscillometric methods to BP monitoring in acute stroke patients is warranted.

Safety and tolerability of early noninvasive ventilatory correction using bilevel positive airway pressure in acute ischemic stroke

BACKGROUND AND PURPOSE

Hypercapnia can induce intracranial blood-flow steal from ischemic brain tissues, and early initiation of noninvasive ventilator correction (NIVC) may improve cerebral hemodynamics in acute ischemic stroke. We sought to determine safety and tolerability of NIVC initiated on hospital admission without polysomnography study.

SUBJECTS AND METHODS

Consecutive acute ischemic stroke patients were evaluated for the presence of a proximal arterial occlusion, daytime sleepiness, or history of obstructive sleep apnea, and acceptable pulse oximetry readings while awake (96%-100% on 2 to 4 L supplemental oxygen delivered by nasal cannula). NIVC was started on hospital admission as standard of care when considered necessary by treating physicians. NIVC was initiated using bilevel positive airway pressure at 10 cmH(2)O inspiratory positive airway pressure and 5 cmH(2)O expiratory positive airway pressure in combination with 40% fraction of inspired oxygen. All potential adverse events were prospectively documented.

RESULTS

Among 356 acute ischemic stroke patients (median NIHSS score, 5; interquartile range, 2-13), 64 cases (18%) received NIVC (median NIHSS score, 12; interquartile range, 6-17). Baseline stroke severity was higher and proximal arterial occlusions were more frequent in NIVC patients compared to the rest (P<0.001). NIVC was not tolerated by 4 patients (7%). Adverse events in NIVC included vomiting (n=1), aspiration pneumonia (n=1), respiratory failure/intubation (n=1), hypotension requiring pressors (n=1), and facial skin breakdown (n=3). The in-hospital mortality rate was 13% in NIVC patients and 8% in the rest (P=0.195). Neurological improvement during hospitalization tended to be greater in the NIVC group (median NIHSS score decrease, 2 points; interquartile range, 0-4) compared to the rest (median NIHSS score decrease, 1; interquartile range, 0-2; P=0.078).

CONCLUSIONS

In acute ischemic stroke patients with proximal arterial occlusion and excessive sleepiness or obstructive sleep apnea, NIVC can be initiated early with good tolerability and a relatively small risk of serious complications.

Noninvasive ventilatory correction as an adjunct to an experimental systemic reperfusion therapy in acute ischemic stroke

Background. Obstructive sleep apnea (OSA) is a common condition in patients with acute ischemic stroke and associated with early clinical deterioration and poor functional outcome. However, noninvasive ventilatory correction is hardly considered as a complementary treatment option during the treatment phase of acute ischemic stroke. Summary of Case. A 55-year-old woman with an acute middle cerebral artery (MCA) occlusion received intravenous tissue plasminogen activator (tPA) and enrolled into a thrombolytic research study. During tPA infusion, she became drowsy, developed apnea episodes, desaturated and neurologically deteriorated without recanalization, re-occlusion or intracerebral hemorrhage. Urgent noninvasive ventilatory correction with biphasic positive airway pressure (BiPAP) reversed neurological fluctuation. Her MCA completely recanalized 24 hours later. Conclusions. Noninvasive ventilatory correction should be considered more aggressively as a complementary treatment option in selected acute stroke patients. Early initiation of BiPAP can stabilize cerebral hemodynamics and may unmask the true potential of other therapies.