Abstract TP222: Prevalence of Carotid Web in Patients With Cryptogenic Stroke

Introduction: Carotid web is a putative mechanism of cryptogenic ischemic stroke. We aimed to determine the prevalence of carotid web based on assigned stroke mechanism, and hypothesized that carotid webs would be found more frequently in younger cryptogenic stroke patients.

Methods: We performed a single-center retrospective cohort study using institutional registry data from consecutive patients with confirmed anterior circulation ischemic stroke between July 2015-September 2017. We reviewed all available computed tomography angiogram (CTA) studies of the neck, and excluded patients who did not have a high-quality CTA of the neck performed. Carotid web was defined as a thin shelf of non-calcified tissue protruding into the lumen of the internal carotid artery immediately distal to the bifurcation, best visualized on sagittal oblique imaging and evident as a small septum on axial imaging. Stroke subtype was adjudicated a priori using validated methods, and we compared relevant risk factors in patients with cryptogenic stroke with and without carotid web.

Results: We identified 882 patients with anterior circulation stroke who had a CTA neck available for review (49.3% male, 30% cryptogenic). A total of 7 patients (0.8%) were found to have carotid webs, of which 4 were ipsilateral to a patient’s stroke; all patients with ipsilateral carotid webs were adjudicated to have cryptogenic stroke. Patients with carotid web were younger than other patients in our cohort (age 49.0±14.6 vs. 72.2±14.9 years, p=0.003), and none of them had a history of hypertension (0% vs. 72%, p=0.04). In patients with cryptogenic stroke, overall prevalence of carotid webs was 1.5%, but the prevalence was significantly higher in younger cryptogenic stroke patients (age <60: 4.8%; age ≥60: 0.5%; p=0.01). Imaging findings that mimicked carotid webs, including non-calcified atherosclerosis and small protruding lesions, were prevalent in 8.3% of all patients.

Discussion: Carotid web may represent an under-recognized occult mechanism of cryptogenic stroke, particularly amongst younger patients.

12 versus 24 h bed rest after acute ischemic stroke thrombolysis: a preliminary experience

BACKGROUND

The practice of ≥24 h of bed rest after acute ischemic stroke thrombolysis is common among hospitals, but its value compared to shorter periods of bed rest is unknown.

METHODS

Consecutive adult patients with a diagnosis of ischemic stroke who had received intravenous thrombolysis treatment from 1/1/2010 until 4/13/2016, identified from the local ischemic stroke registry, were included. Standard practice bed rest for ≥24 h, the protocol prior to 1/27/2014, was retrospectively compared with standard practice bed rest for ≥12 h, the protocol after that date. The primary outcome was favorable discharge location (defined as home, home with services, or acute rehabilitation). Secondary outcome measures included incidence of pneumonia, NIHSS at discharge, and length of stay.

RESULTS

392 patients were identified (203 in the ≥24 h group, 189 in the ≥12 h group). There was no significant difference in favorable discharge outcome in the ≥24 h bed rest protocol compared with the ≥12 h bed rest protocol in multivariable logistic regression analysis (76.2% vs. 70.9%, adjusted OR 1.20 CI 0.71-2.03). Compared with the ≥24 h bed rest group, pneumonia rates (8.3% versus 1.6%, adjusted OR 0.12 CI 0.03-0.55), median discharge NIHSS (3 versus 2, adjusted p = .034), and mean length of stay (5.4 versus 3.5 days, adjusted p = .006) were lower in the ≥12 h bed rest group.

CONCLUSION

Compared with ≥24 h bed rest, ≥12 h bed rest after acute ischemic stroke reperfusion therapy appeared to be similar. A non-inferiority randomized trial is needed to verify these findings.

Abstract TP39: 12 versus 24 Hour Bed Rest After Acute Ischemic Stroke Thrombectomy

Background: The practice of 24 hours of bed rest after acute ischemic stroke thrombectomy is common among hospitals, but its value compared to shorter periods of bed rest is unknown. We sought to compare discharge outcomes and in-hospital complications of shorter (12 hour) and 24 hour bed rest protocols following reperfusion therapy.

Methods: Consecutive adult patients with a diagnosis of ischemic stroke who underwent thrombectomy treatment between 1/1/2010 until 4/13/2016 identified from the local ischemic stroke registry were included. Standard practice bed rest for 24 hours, the protocol prior to 1/27/2014, was retrospectively compared with standard practice bed rest for 12 hours, the protocol after that date. The primary outcome was favorable discharge location (defined as home, home with services, or acute rehabilitation). Secondary outcome measures included incidence of pneumonia, readmission within 30 days, NIHSS at discharge, and hospital length of stay.

Results: 193 patients were identified, 59 patients in the 24 hour and 134 in the 12 hour bed rest groups. There was no significant difference in favorable discharge outcome in the 24 hour bed rest protocol compared with the 12 hour bed rest protocol in multivariable logistic regression analysis (54.2% vs. 68.7%, p=0.14, OR 1.73 CI 0.84-3.56). Compared with the 24 hour bed rest group, the incidence rates of pneumonia (13.6% versus 3.7%, p=0.03, OR 0.27 CI 0.08-0.88), median discharge NIHSS (8 versus 4, p=0.036, mean length of stay (7.5 versus 3.9 days, p<0.0001), and 30-day readmission rates (10.2% versus 3.2%, p=0.017, adjusted OR 0.16 CI 0.04-0.72) were lower in the 12 hour bed rest group.

Conclusion: Compared with 24 hour bed rest, 12 hour bed rest after acute ischemic stroke thrombectomy therapy appeared to be safe and may be associated with reduced neurological deficit at discharge, shorter length-of-stay, and reduced rates of readmission within 30 days. A randomized trial is needed to verify these findings.

Hospital-directed feedback to Emergency Medical Services improves prehospital performance

BACKGROUND AND PURPOSE

A potential way to improve prehospital stroke care and patient handoff is hospital-directed feedback for emergency medical service (EMS) providers. We evaluated whether a hospital-directed EMS stroke follow-up tool improved documentation of adherence to the Rhode Island state prehospital stroke protocol for EMS providers.

METHODS

A standardized, 10-item feedback tool was developed in 2012 and sent to EMS directors for every transported patient with a discharge diagnosis of ischemic stroke. We reviewed patient charts meeting these criteria between January 2008 and December 2013. Performance on the tool was compared between the preintervention (January 2008 through January 2012) and postintervention (February 2012 through December 2013) periods.

RESULTS

We identified 1176 patients with ischemic stroke who arrived by EMS in the study period: 668 in the preintervention period and 508 in the postintervention period. The overall score for the preintervention group was 5.31 and for the postintervention group 6.42 (P<0.001). Each of the 10 items, except checking blood glucose, showed statistically significant improvement in the postintervention period compared with the preintervention period.

CONCLUSIONS

Hospital-directed feedback to EMS was associated with improved overall compliance with state protocols and documentation of 9 out of 10 individual items. Future confirmatory studies in different locales and studies on the impact of this intervention on actual tissue-type plasminogen activator administration rates and EMS personnel knowledge and behavior are needed.