Cost-Effectiveness of Increased Use of Dual Antiplatelet Therapy After High-Risk Transient Ischemic Attack or Minor Stroke

BACKGROUND

Rates of dual antiplatelet therapy (DAPT) after high-risk transient ischemic attack or minor ischemic stroke (TIAMIS) are suboptimal. We performed a cost-effectiveness analysis to characterize the parameters of a quality improvement (QI) intervention designed to increase DAPT use after TIAMIS.

METHODS AND RESULTS

We constructed a decision tree model that compared current national rates of DAPT use after TIAMIS with rates after implementing a theoretical QI intervention designed to increase appropriate DAPT use. The base case assumed that a QI intervention increased the rate of DAPT use to 65% from 45%. Costs (payer and societal) and outcomes (stroke, myocardial infarction, major bleed, or death) were modeled using a lifetime horizon. An incremental cost-effectiveness ratio <$100 000 per quality-adjusted life year was considered cost-effective. Deterministic and probabilistic sensitivity analyses were performed. From the payer perspective, a QI intervention was associated with $9657 in lifetime cost savings and 0.18 more quality-adjusted life years compared with current national treatment rates. A QI intervention was cost-effective in 73% of probabilistic sensitivity analysis iterations. Results were similar from the societal perspective. The maximum acceptable, initial, 1-time payer cost of a QI intervention was $28 032 per patient. A QI intervention that increased DAPT use to at least 51% was cost-effective in the base case.

CONCLUSIONS

Increasing DAPT use after TIAMIS with a QI intervention is cost-effective over a wide range of costs and proportion of patients with TIAMIS treated with DAPT after implementation of a QI intervention. Our results support the development of future interventions focused on increasing DAPT use after TIAMIS.

Impact of tobacco smoking on disease-specific outcomes in common neurological disorders: A scoping review

Although the association of smoking with the risk of incident neurological disorders is well established, less is known about the impact of smoking and smoking cessation on outcomes of these conditions. The objective of this scoping review was to synthesize what is known about the impact of smoking and smoking cessation on disease-specific outcomes for seven common neurological disorders. We included 67 studies on the association of smoking and smoking cessation on disease-specific outcomes. For multiple sclerosis, smoking was associated with greater clinical and radiological disease progression, relapses, risk for disease-related death, cognitive decline, and mood symptoms, in addition to reduced treatment effectiveness. For stroke and transient ischemic attack, smoking was associated with greater rates of stroke recurrence, post-stroke cardiovascular outcomes, post-stroke mortality, post-stroke cognitive impairment, and functional impairment. In patients with cognitive impairment and dementia, smoking was associated with faster cognitive decline, and smoking was also associated with greater cognitive decline in Parkinson's disease, but not motor symptom worsening. Patients with amyotrophic lateral sclerosis who smoked faced increased mortality. Last, in patients with cluster headache, smoking was associated with more frequent and longer cluster attack periods. Conversely, for multiple sclerosis and stroke, smoking cessation was associated with improved disease-specific outcomes. In summary, whereas smoking is detrimentally associated with disease-specific outcomes in common neurological conditions, there is growing evidence that smoking cessation may improve outcomes. Effective smoking cessation interventions should be leveraged in the management of common neurological disorders to improve patient outcomes.

Cognitive impairment and liver fibrosis in non-alcoholic fatty liver disease

Background

Data regarding the prevalence and phenotype of cognitive impairment in non-alcoholic fatty liver disease (NAFLD) are limited.

Objective

We assessed the prevalence and nature of cognitive deficits in people with NAFLD and assessed whether liver fibrosis, an important determinant of outcomes in NAFLD, is associated with worse cognitive performance.

Methods

We performed a prospective cross-sectional study. Patients with NAFLD underwent liver fibrosis assessment with transient elastography and the following assessments: Cognitive Change Index, Eight-Item Informant Interview to Differentiate Aging and Dementia Questionnaire (AD8), Montreal Cognitive Assessment (MoCA), EncephalApp minimal hepatic encephalopathy test and a limited National Institutes of Health Toolbox battery (Flanker Inhibitory Control and Attention Test, Pattern Comparison Test and Auditory Verbal Learning Test). We used multiple linear regression models to examine the association between liver fibrosis and cognitive measures while adjusting for relevant covariates.

Results

We included 69 participants with mean age 50.4 years (SD 14.4); 62% were women. The median liver stiffness was 5.0 kilopascals (IQR 4.0-6.9), and 25% had liver fibrosis (≥7.0 kilopascals). Cognitive deficits were common in people with NAFLD; 41% had subjective cognitive impairment, 13% had an AD8 >2, 32% had MoCA <26 and 12% had encephalopathy detected on the EncephalApp test. In adjusted models, people with liver fibrosis had modestly worse performance only on the Flanker Inhibitory Control and Attention Task (β=-0.3; 95% CI -0.6 to -0.1).

Conclusion

Cognitive deficits are common in people with NAFLD, among whom liver fibrosis was modestly associated with worse inhibitory control and attention.

Association of liver fibrosis with cognitive decline in Parkinson's disease

BACKGROUND

Cognitive decline is a common but variable non-motor manifestation of Parkinson's disease. Chronic liver disease contributes to dementia, but its impact on cognitive performance in Parkinson's disease is unknown. We assessed the effect of liver fibrosis on cognition in Parkinson's disease.

METHODS

We conducted a retrospective cohort study using data from the Parkinson's Progression Markers Initiative. Our exposure was liver fibrosis at baseline, based on the validated Fibrosis-4 score. Our primary outcome was the Montreal Cognitive Assessment, and additional outcome measures were the Symbol Digit Modalities Test, the Benton Judgement of Line Orientation, the Letter-Number Sequencing Test, and the Modified Semantic Fluency Test. We used linear regression models to assess the relationship between liver fibrosis and scores on cognitive assessments at baseline and linear mixed models to evaluate the association between baseline Fibrosis-4 score with changes in each cognitive test over five years. Models were adjusted for demographics, comorbidities, and alcohol use.

RESULTS

We included 409 participants (mean age 61, 40 % women). There was no significant association between liver fibrosis and baseline performance on any of the cognitive assessments in adjusted models. However, over the subsequent five year period, liver fibrosis was associated with more rapid decline in scores on the Montreal Cognitive Assessment (interaction coefficient, -0.07; 95 % CI, -0.12, -0.02), the Symbol Digit Modalities Test, the Benton Judgement of Line Orientation, and the Modified Semantic Fluency Test.

CONCLUSION

In people with Parkinson's disease, the presence of comorbid liver fibrosis was associated with more rapid decline across multiple cognitive domains.

Misdiagnosis of Posterior Reversible Encephalopathy Syndrome and Reversible Cerebral Vasoconstriction Syndrome in the Emergency Department

Background Cerebrovascular dysregulation syndromes, posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS), are challenging to diagnose because they are rare and require advanced neuroimaging for confirmation. We sought to estimate PRES/RCVS misdiagnosis in the emergency department and its associated factors. Methods and Results We conducted a retrospective cohort study of PRES/RCVS patients using administrative claims data from 11 states (2016-2018). We defined patients with a probable PRES/RCVS misdiagnosis as those with an emergency department visit for a neurological symptom resulting in discharge to home that occurred ≤14 days before PRES/RCVS hospitalization. Proportions of patients with probable misdiagnosis were calculated, characteristics of patients with and without probable misdiagnosis were compared, and regression analyses adjusted for demographics and comorbidities were performed to identify factors affecting probable misdiagnosis. We identified 4633 patients with PRES/RCVS. A total of 210 patients (4.53% [95% CI, 3.97-5.17]) had a probable preceding emergency department misdiagnosis; these patients were younger (mean age, 48 versus 54 years; P<0.001) and more often female (80.4% versus 69.3%; P<0.001). Misdiagnosed patients had fewer vascular risk factors except prior stroke (36.3% versus 24.2%; P<0.001) and more often had comorbid headache (84% versus 21.4%; P<0.001) and substance use disorder (48.8% versus 37.9%; P<0.001). Facility-level factors associated with probable misdiagnosis included smaller facility, lacking a residency program (62.2% versus 73.7%; P<0.001), and not having on-site neurological services (75.7% versus 84.3%; P<0.001). Probable misdiagnosis was not associated with higher likelihood of stroke or subarachnoid hemorrhage during PRES/RCVS hospitalization. Conclusions Probable emergency department misdiagnosis occurred in ≈1 of every 20 patients with PRES/RCVS in a large, multistate cohort.

Management of Stroke in Patients With Chronic Liver Disease: A Practical Review

Chronic liver disease (CLD) is a highly prevalent condition. There is burgeoning recognition that there are many people with subclinical liver disease that may nonetheless be clinically significant. CLD has a variety of systemic aberrations relevant to stroke, including thrombocytopenia, coagulopathy, elevated liver enzymes, and altered drug metabolism. There is a growing body of literature on the intersection of CLD and stroke. Despite this, there have been few efforts to synthesize these data, and stroke guidelines provide scant guidance on this topic. To fill this gap, this multidisciplinary review provides a contemporary overview of CLD for the vascular neurologist while appraising data regarding the impact of CLD on stroke risk, mechanisms, and outcomes. Finally, the review addresses acute and chronic treatment considerations for patients with stroke-ischemic and hemorrhagic-and CLD.

Timing and Predictors of Recanalization After Anticoagulation in Cerebral Venous Thrombosis

BACKGROUND AND PURPOSE

Vessel recanalization after cerebral venous thrombosis (CVT) is associated with favorable outcomes and lower mortality. Several studies examined the timing and predictors of recanalization after CVT with mixed results. We aimed to investigate predictors and timing of recanalization after CVT.

METHODS

We used data from the multicenter, international AntiCoagulaTION in the Treatment of Cerebral Venous Thrombosis (ACTION-CVT) study of consecutive patients with CVT from January 2015 to December 2020. Our analysis included patients that had undergone repeat venous neuroimaging more than 30 days after initiation of anticoagulation treatment. Prespecified variables were included in univariate and multivariable analyses to identify independent predictors of failure to recanalize.

RESULTS

Among the 551 patients (mean age, 44.4±16.2 years, 66.2% women) that met inclusion criteria, 486 (88.2%) had complete or partial, and 65 (11.8%) had no recanalization. The median time to first follow-up imaging study was 110 days (interquartile range, 60-187). In multivariable analysis, older age (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.03-1.07), male sex (OR, 0.44; 95% CI, 0.24-0.80), and lack of parenchymal changes on baseline imaging (OR, 0.53; 95% CI, 0.29-0.96) were associated with no recanalization. The majority of improvement in recanalization (71.1%) occurred before 3 months from initial diagnosis. A high percentage of complete recanalization (59.0%) took place within the first 3 months after CVT diagnosis.

CONCLUSION

Older age, male sex, and lack of parenchymal changes were associated with no recanalization after CVT. The majority recanalization occurred early in the disease course suggesting limited further recanalization with anticoagulation beyond 3 months. Large prospective studies are needed to confirm our findings.

Association of liver fibrosis with cognitive test performance and brain imaging parameters in the UK Biobank study

INTRODUCTION

We hypothesized that liver fibrosis is associated with worse cognitive performance and corresponding brain imaging changes.

METHODS

We examined the association of liver fibrosis with cognition and brain imaging parameters in the UK Biobank study. Liver fibrosis was assessed using the Fibrosis-4 (FIB-4) score. The primary cognitive outcome was the digit symbol substitution test (DSST); secondary outcomes were additional executive function/processing speed and memory tests. Imaging outcomes were hippocampal, total brain, and white matter hyperintensity (WMH) volumes.

RESULTS

We included 105,313 participants with cognitive test data, and 41,982 with magnetic resonance imaging (MRI). In adjusted models, liver fibrosis was associated with worse performance on the DSST and tests of executive function but not memory. Liver fibrosis was associated with lower hippocampal and total brain volumes, without compelling association with WMH volume.

DISCUSSION

Liver fibrosis is associated with worse performance on select cognitive tests and lower hippocampal and total brain volumes.

HIGHLIGHTS

It is increasingly recognized that chronic liver conditions impact brain health. We performed an analysis of data from the UK Biobank prospective cohort study. Liver fibrosis was associated with worse performance on executive function tests. Liver fibrosis was not associated with memory impairment. Liver fibrosis was associated with lower hippocampal and total brain volumes.

Cost-Effectiveness of Smoking Cessation Interventions in Patients With Ischemic Stroke and Transient Ischemic Attack

BACKGROUND

Smoking cessation rates after stroke and transient ischemic attack are suboptimal, and smoking cessation interventions are underutilized. We performed a cost-effectiveness analysis of smoking cessation interventions in this population.

METHODS

We constructed a decision tree and used Markov models that aimed to assess the cost-effectiveness of varenicline, any pharmacotherapy with intensive counseling, and monetary incentives, compared with brief counseling alone in the secondary stroke prevention setting. Payer and societal costs of interventions and outcomes were modeled. The outcomes were recurrent stroke, myocardial infarction, and death using a lifetime horizon. Estimates and variance for the base case (35% cessation), costs and effectiveness of interventions, and outcome rates were imputed from the stroke literature. We calculated incremental cost-effectiveness ratios and incremental net monetary benefits. An intervention was considered cost-effective if the incremental cost-effectiveness ratio was less than the willingness-to-pay threshold of $100 000 per quality-adjusted life-year (QALY) or when the incremental net monetary benefit was positive. Probabilistic Monte Carlo simulations modeled the impact of parameter uncertainty.

RESULTS

From the payer perspective, varenicline and pharmacotherapy with intensive counseling were associated with more QALYs (0.67 and 1.00, respectively) at less total lifetime costs compared with brief counseling alone. Monetary incentives were associated with 0.71 more QALYs at an additional cost of $120 compared with brief counseling alone, yielding an incremental cost-effectiveness ratio of $168/QALY. From the societal perspective, all 3 interventions provided more QALYs at less total costs compared with brief counseling alone. In 10 000 Monte Carlo simulations, all 3 smoking cessation interventions were cost-effective in >89% of runs.

CONCLUSIONS

For secondary stroke prevention, it is cost-effective and potentially cost-saving to deliver smoking cessation therapy beyond brief counseling alone.

Duration of Heightened Risk of Acute Ischemic Stroke After Hospitalization for Acute Systolic Heart Failure

Background The duration and magnitude of increased stroke risk after a hospitalization for acute systolic heart failure (HF) remains uncertain. Methods and Results The authors performed a retrospective cohort study using claims (2008-2018) from a nationally representative 5% sample of Medicare beneficiaries aged ≥66 years. Cox regression models were fitted separately for the groups with and without acute systolic HF to examine its association with the incidence of ischemic stroke after adjustment for demographics, stroke risk factors, and Charlson comorbidities. Corresponding survival probabilities were used to compute the hazard ratio (HR) in each 30-day interval after discharge. The authors stratified patients by the presence of atrial fibrillation (AF) before or during the hospitalization for acute systolic HF. Among 2 077 501 eligible beneficiaries, 94 641 were hospitalized with acute systolic HF. After adjusting for demographics, stroke risk factors, and Charlson comorbidities, the risk of ischemic stroke was highest in the first 30 days after discharge from an acute systolic HF hospitalization for patients with AF (HR, 2.4 [95% CI, 2.1-2.7]) and without AF (HR, 4.6 [95% CI, 4.0-5.3]). The risk of stroke remained elevated for 60 days in patients with AF (HR, 1.4 [95% CI, 1.2-1.6]) and was not significantly elevated afterward. The risk of stroke remained significantly elevated through 330 days in patients without AF (HR, 2.1 [95% CI, 1.7-2.7]) and was no longer significantly elevated afterward. Conclusions A hospitalization for acute systolic HF is associated with an increased risk of ischemic stroke up to 330 days in patients without concomitant AF.

Validation of the International Classification of Diseases, Tenth Revision Code for the National Institutes of Health Stroke Scale Score

BACKGROUND

Administrative data can be useful for stroke research but have historically lacked data on stroke severity. Hospitals increasingly report the National Institutes of Health Stroke Scale (NIHSS) score using an International Classification of Diseases, Tenth Revision (ICD-10) diagnosis code, but this code's validity remains unclear.

METHODS

We examined the concordance of ICD-10 NIHSS scores versus NIHSS scores recorded in CAESAR (Cornell Acute Stroke Academic Registry). We included all patients with acute ischemic stroke from October 1, 2015, when US hospitals transitioned to ICD-10, through 2018, the latest year in our registry. The NIHSS score (range, 0-42) recorded in our registry served as the reference gold standard. ICD-10 NIHSS scores were derived from hospital discharge diagnosis code R29.7xx, with the latter 2 digits representing the NIHSS score. Multiple logistic regression was used to explore factors associated with availability of ICD-10 NIHSS scores. We used ANOVA to examine the proportion of variation (R2) in the true (registry) NIHSS score that was explained by the ICD-10 NIHSS score.

RESULTS

Among 1357 patients, 395 (29.1%) had an ICD-10 NIHSS score recorded. This proportion increased from 0% in 2015 to 46.5% in 2018. In a logistic regression model, only higher registry NIHSS score (odds ratio per point, 1.05 [95% CI, 1.03-1.07]) and cardioembolic stroke (odds ratio, 1.4 [95% CI, 1.0-2.0]) were associated with availability of the ICD-10 NIHSS score. In an ANOVA model, the ICD-10 NIHSS score explained almost all the variation in the registry NIHSS score (R2=0.88). Fewer than 10% of patients had a large discordance (≥4 points) between their ICD-10 and registry NIHSS scores.

CONCLUSIONS

When present, ICD-10 codes representing NIHSS scores had excellent agreement with NIHSS scores recorded in our stroke registry. However, ICD-10 NIHSS scores were often missing, especially in less severe strokes, limiting the reliability of these codes for risk adjustment.

Long-term risk of seizure after posterior reversible encephalopathy syndrome

OBJECTIVE

Patients with posterior reversible encephalopathy syndrome (PRES) can develop seizures during the acute phase. We sought to determine the long-term risk of seizure after PRES.

METHODS

We performed a retrospective cohort study using statewide all-payer claims data from 2016-2018 from nonfederal hospitals in 11 US states. Adults admitted with PRES were compared to adults admitted with stroke, an acute cerebrovascular disorder associated with long-term risk of seizure. The primary outcome was seizure diagnosed during an emergency room visit or hospital admission after the index hospitalization. The secondary outcome was status epilepticus. Diagnoses were determined using previously validated ICD-10-CM codes. Patients with seizure diagnoses before or during the index admission were excluded. We used Cox regression to evaluate the association of PRES with seizure, adjusting for demographics and potential confounders.

RESULTS

We identified 2095 patients hospitalized with PRES and 341,809 with stroke. Median follow-up was 0.9 years (IQR, 0.3-1.7) in the PRES group and 1.0 years (IQR, 0.4-1.8) in the stroke group. Crude seizure incidence per 100 person-years was 9.5 after PRES and 2.5 after stroke. After adjustment for demographics and comorbidities, patients with PRES had a higher risk of seizure than patients with stroke (HR, 2.9; 95% CI, 2.6-3.4). Results were unchanged in a sensitivity analysis that applied a two-week washout period to mitigate detection bias. A similar relationship was observed for the secondary outcome of status epilepticus.

INTERPRETATION

PRES was associated with an increased long-term risk of subsequent acute care utilization for seizure compared to stroke.

Abstract 34: Liver Fibrosis, Apolipoprotein E, And Hemorrhagic Stroke Risk: A Cohort Analysis

Introduction: Cirrhosis is associated with an increased risk of hemorrhagic stroke (HS). Liver fibrosis, typically a silent condition, is antecedent to cirrhosis. We hypothesized that liver fibrosis is associated with an increased risk of HS. Further, because apolipoprotein E2 (ApoE2) and E4 (ApoE4) are associated with HS, and because liver-derived peripheral ApoE4 may disrupt endothelial integrity, we evaluated for effect modification by these isoforms.

Methods: We performed a cohort analysis using the UK Biobank Study, which prospectively enrolled adults in 2007, with continuous follow-up. We excluded participants with prevalent HS or thrombocytopenia. Liver fibrosis was defined using the validated Fibrosis-4 score. The primary outcome, incident HS (intracerebral or subarachnoid hemorrhage), was captured in UK Biobank based on hospitalization and death registry data. We used Cox proportional hazards models to evaluate the association of liver fibrosis with HS while adjusting for HS risk factors (demographics, systolic blood pressure, hemoglobin A1c, total cholesterol, BMI, tobacco and alcohol use, antithrombotic use). Effect modification by ApoE2 and ApoE4 were evaluated using interaction terms and stratified analyses.

Results: Among 453,251 included participants, the mean age was 57 years and 54% were women. Approximately 2% had liver fibrosis, 16% used antithrombotic agents, 29% were ApoE4 carriers, and 15% were ApoE2 carriers. In adjusted Cox models, liver fibrosis was associated with an increased risk of HS (HR, 2.17; 95% CI, 1.51-3.12) (Figure). This relationship appeared stronger in ApoE4 homozygotes (HR, 8.27; 95% CI, 2.30-29.73) than in others (HR, 2.18; 95% CI, 1.47-3.24) (P=0.05, interaction). ApoE4 carrier status, ApoE2 carrier status, and ApoE2 homozygosity did not modify this relationship (P>0.20, interactions).

Conclusions: Liver fibrosis was associated with an increased risk of HS, possibly more so in ApoE4 homozygous persons.

Abstract WP70: Emergency Department Visits For Hypertensive Urgency And Risk Of Subsequent Stroke

Introduction: Chronic hypertension is an established long-term risk factor for stroke. However, little is known about short-term stroke risk after an episode of acute severe hypertension without evidence of target organ damage (i.e., hypertensive urgency [HU]). We evaluated the short-term risk of stroke after an ED visit with HU resulting in discharge home (treat-and-release).

Methods: We performed a case-crossover study using deidentified administrative claims from all nonfederal EDs and hospitals across 11 states. The study cohort comprised patients diagnosed with any stroke (ischemic stroke, intracerebral hemorrhage, or subarachnoid hemorrhage), defined using validated ICD-10 codes, between 2016-2018. We tabulated and compared incident ED visits for HU during case periods (2-week intervals from 0-24 weeks before the index stroke) to control periods (equivalent time periods exactly 1 year earlier). ED visits with HU were ascertained using the ICD-10 code I16.0, which we validated through detailed chart review of 50 patients at our center resulting in a code sensitivity and specificity of 100% and 96%, respectively. We used McNemar’s test for matched data to calculate risk ratios (RRs) for an ED HU visit occurring before stroke.

Results: Among 45,063 patients with stroke, 22,417 (50%) were female and 37,577 (83%) had a prior diagnosis of hypertension. There were 201 patients with stroke who had at least one ED visit for HU during the preceding 24 weeks. An ED visit for HU was significantly more common in the 2 weeks before stroke compared to the 2-week control period 1 year earlier (RR, 5.1; 95% CI, 2.4-12.7; p<0.0001). The association between stroke and preceding ED visit for HU decreased in magnitude with increasing temporal distance from stroke and was no longer significant by the 7-8 week period before stroke (Figure 1).

Conclusion: Treat-and-release ED visits for HU are associated with a significantly increased short-term risk of stroke.

Prevalence of neurological complaints among emergency department patients with severe hypertension

OBJECTIVE

Severe hypertension can accompany neurological symptoms without obvious signs of target organ damage. However, acute cerebrovascular events can also be a cause and consequence of severe hypertension. We therefore use US population-level data to determine prevalence and clinical characteristics of patients with severe hypertension and neurological complaints.

METHODS

We used nationally representative data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) collected in 2016-2019 to identify adult ED patients with severely elevated blood pressure (BP) defined as systolic BP ≥ 180 mmHg and/or diastolic BP ≥120 mmHg. We used ED reason for visit data fields to define neurological complaints and used diagnosis data fields to define acute target organ damage. We applied survey visit weights to obtain national estimates.

RESULTS

Based on 5083 observations, an estimated 40.4 million patients (95% CI: 37.5-43.0 million) in EDs nationwide from 2016 to 2019 had severe hypertension, equating to 6.1% (95% CI: 5.7-6.5%) of all ED visits. Only 2.8% (95% CI: 2.0-3.9%) of ED patients with severe hypertension were diagnosed with acute cerebrovascular disease; hypertensive urgency was diagnosed in 92.0% (95% CI: 90.3-93.4%). Neurological complaints were frequent in both patients with (75.6%) and without (19.9%) cerebrovascular diagnoses. Hypertensive urgency patients with neurological complaints were more often older, female, had prior stroke/TIA, and had neuroimaging than patients without these complaints. Non-migraine headache and vertigo were the most common neurological complaints recorded.

CONCLUSION

In a nationally representative survey, one-in-sixteen ED patients had severely elevated BP and one-fifth of those patients had neurological complaints.

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

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

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

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

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

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

Practice Current: Variability in Smoking Cessation Intervention Practice Patterns After Ischemic Stroke and Transient Ischemic Attack

People who continue to smoke after ischemic stroke and transient ischemic attack (TIA) are at increased risk for subsequent stroke and cardiovascular events. Although effective smoking cessation strategies exist, smoking rates after stroke remain high. Through case-based discussions with 3 international vascular neurology panelists, this article seeks to explore practice patterns and barriers to smoking cessation for patients with stroke/TIA. We sought to answer these questions: What are the barriers to using smoking cessation interventions for patients with stroke/TIA? Which interventions are most used for hospitalized patients with stroke/TIA? Which interventions are most used for patients who continue smoking during follow-up? Our synthesis of panelists' commentaries is complemented by the preliminary results of an online survey posed to global readership. Together, the interviews and survey results identify practice variability and barriers to smoking cessation after stroke/TIA, suggesting that there is substantial need for research and standardization.

Abstract WP77: Cost-effectiveness Analysis Of Increasing Dual Antiplatelet Therapy Treatment After High-risk Transient Ischemic Attack Or Minor Ischemic Stroke

Background: Use of guideline recommended dual antiplatelet therapy (DAPT) after high-risk TIA or minor ischemic stroke is suboptimal. We performed a cost-effectiveness analysis of current DAPT treatment patterns and modeled optimal parameters for future healthcare delivery quality improvement (QI) interventions designed to increase DAPT use.

Methods: We constructed two decision tree models. Our first model compared DAPT (90 days of aspirin and clopidogrel) to aspirin alone at current national treatment rates (45% of eligible patients receive DAPT). Our second model compared current DAPT treatment patterns to a theoretical QI intervention that increases DAPT use at an initial cost of $20,000 per institution, in keeping with costs of published stroke QI interventions, with variable annual maintenance costs. Healthcare costs and outcomes (stroke, MI, major bleed, death) were modeled using 90-day and lifetime horizons. We calculated incremental cost-effectiveness ratios (ICER) and considered an ICER<$100,000 per quality-adjusted life year (QALY) to be cost-effective. Sensitivity analyses varying key inputs, including QI costs, were performed using Monte Carlo simulations.

Results: Compared to aspirin alone, DAPT use was not cost-effective at 90 days (ICER $173,003/QALY) but was cost saving ($3,030) and more effective (0.31 more QALYs) over a lifetime at current treatment rates. Increasing the use of DAPT by 20% with a QI intervention was not cost-effective at 90 days (ICER $474,467/QALY) but was cost-effective over a lifetime (ICER $29,217/QALY). Increasing DAPT use with a QI intervention was the preferred strategy in 89% of Monte Carlo runs (lifetime horizon). QI interventions to increase DAPT use were cost-effective over a range of annual costs (Figure).

Conclusion: In a modeling study, current rates of DAPT use after TIA/minor stroke are cost-effective over a lifetime, but a QI intervention to increase DAPT use is preferred in nearly all simulations.

Abstract TMP60: Misdiagnosis Of Posterior Reversible Encephalopathy Syndrome And Reversible Cerebral Vasoconstriction Syndrome In The Emergency Department

Introduction: Syndromes of cerebrovascular dysregulation such as posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS) can be challenging to diagnose given their rarity and the need for advanced neuroimaging to diagnose them. We sought to measure the rate of potential PRES/RCVS misdiagnosis in the ED and identify features associated with misdiagnosis.

Methods: We conducted a retrospective cohort study of patients with PRES/RCVS using deidentified administrative claims data from all nonfederal EDs and hospitals across 11 states from 2016-2018. To identify patients with PRES/RCVS, we used the previously validated ICD-10-CM codes I67.841 and I67.83. We defined patients with a probable misdiagnosis of PRES/RCVS as those with an ED visit resulting in discharge to home that occurred within the 14 days prior to their PRES/RCVS hospitalization. Only preceding ED visits where a non-specific neurological condition (e.g., headache, dizziness, numbness) was diagnosed were considered instances of probable ED misdiagnosis. Standard tests of comparison between patients with versus without probable misdiagnosis were used to identify patient-level and ED facility-level features associated with misdiagnosis.

Results: We identified 4,633 patients hospitalized for PRES/RCVS; the majority (4,169; 90.0%) had PRES. A total of 210 patients (4.5%, 95% CI: 3.95-5.17) had at least one preceding ED visit with a probable misdiagnosis; these patients were younger (mean age 47.7 vs. 53.8 years; P<0.001) and more often female (80.4% vs. 69.7%: P<0.001). Misdiagnosed patients generally had fewer vascular risk factors including hypertension (46.3% vs. 84.9%; P<0.001) and more often had a history of headache (81.1% vs. 22.6%; P<0.001) and psychiatric disease (48.6% vs. 34.9%; P<0.001) as compared to patients without an ED misdiagnosis. Facility factors inversely associated with probable misdiagnosis included an ACGME-approved residency (63.4% vs. 75.3%; P<0.001) and on-site neurological services (74.9% vs. 84.7%; P<0.001).

Conclusion: Probable ED misdiagnosis occurred in nearly 1 of 20 cases of PRES/RCVS in a large, multistate cohort.

Abstract WP132: Cerebral Amyloid Angiopathy And Risk Of Ischemic And Hemorrhagic Stroke

Introduction: Cerebral amyloid angiopathy (CAA), a condition characterized by beta amyloid deposition in the cerebral vasculature, is a common cause of intracerebral hemorrhage (ICH) in elderly patients. Radiographic features of CAA such as white matter hyperintensities and cerebral microbleeds are also associated with an increased risk of ischemic stroke. However, there are limited population-based data regarding the risk of incident ischemic and hemorrhagic stroke associated with clinically diagnosed CAA.

Methods: We performed a retrospective cohort study using inpatient and outpatient claims from 2016 to 2018 from a nationally representative 5% sample of Medicare beneficiaries. The study exposure was a diagnosis of CAA identified using ICD-10-CM code I68.0. Participants with prevalent stroke were excluded. The primary outcome was any stroke (ischemic or hemorrhagic), and secondary outcomes were ICH, subarachnoid hemorrhage (SAH), and ischemic stroke, assessed separately. These outcomes were identified using validated ICD-10-CM diagnosis codes. Cox proportional hazards regression was used to determine the association between CAA and outcomes after adjustment for demographics and vascular comorbidities.

Results: Of the 1.3 million Medicare beneficiaries included, 436 had clinically documented CAA without a prior or concurrent stroke. During a median follow-up of 3.0 years (IQR, 2.3-3.0), incident ischemic stroke occurred in 29,545 patients (2.28%), SAH in 3,340 (0.26%), and ICH in 4,338 (0.34%). In adjusted Cox models, CAA was significantly associated with an increased risk of any stroke (HR, 3.4; 95% CI, 2.5-4.7), ICH (HR, 17.1; 95% CI, 11.1-26.3), and SAH (HR, 6.2; 95% CI, 2.7-13.9). There was a nonsignificant association with ischemic stroke (HR, 1.4; 95% CI, 0.8-2.4).

Conclusions: In a nationally representative cohort of Medicare beneficiaries, CAA was associated with a significantly increased risk of future ICH and SAH, but was not significantly associated with an increased risk of future ischemic stroke.

Abstract 2: Timing And Predictors Of Recanalization After Cerebral Venous Thrombosis

Background and Purpose: Recanalization after cerebral venous thrombosis (CVT) is poorly understood. We aimed to investigate predictors and timing of recanalization in a large, international cohort of patients with CVT.

Materials and Methods: We used data from the multicenter, international, AntiCoagulaTION in the Treatment of Cerebral Venous Thrombosis (ACTION-CVT) study of consecutive patients with confirmed CVT from 01/2015 to 12/2020. Our analysis included patients that had undergone repeat venous neuroimaging more than 30 days after initiation of anticoagulation treatment. Pre-specified variables were included in univariate and multivariable analyses to identify independent predictors of failure to recanalize. We also examined improvement in recanalization at clinically-relevant time points ( <75 days, 3 months ± 15 days, 6 months ± 30 days, and 12 month ± 30 days) after the initial CVT hospital admission.

Results: Among the 551 patients (mean age, 44.4 ± 16.2 years, 66% women) that met inclusion criteria, 486 (88.2%) had complete or partial, and 65 (11.8%) had no recanalization. In multivariable analysis, older age (OR, 1.05; 95% CI, 1.03 - 1.07), male sex (OR, 0.44; 95% CI, 0.24 - 0.80), and lack of parenchymal changes on baseline imaging (OR, 0.53; 95% CI, 0.29 - 0.96) were associated with no recanalization. The majority of improvement in recanalization (71.1%) occurred before 3 months from initial diagnosis. A high percentage of complete recanalization (59.0%) took place within the first 3 months after diagnosis.

Discussion: Older age, male sex, and lack of parenchymal changes were associated with no recanalization after CVT. The majority of improvement in recanalization and complete recanalization occurred early in the disease course.

Risk of Stroke After Posterior Reversible Encephalopathy Syndrome

BACKGROUND

Posterior reversible encephalopathy syndrome (PRES) can cause short-term cerebrovascular complications, such as brain infarction and hemorrhage. We hypothesized that PRES is also associated with an increased long-term risk of stroke.

METHODS

We performed a retrospective cohort study in the United States using statewide all-payer claims data from 2016 to 2018 on all admissions to nonfederal hospitals in 11 states. Adults with PRES were compared with adults with renal colic (negative control) and transient ischemic attack (TIA; positive control). Any stroke and the secondary outcomes of ischemic and hemorrhagic stroke were ascertained using International Classification of Diseases, Tenth Revision, Clinical Modification codes. We excluded prevalent stroke. We used time-to-event statistics to calculate incidence rates and Cox proportional hazards analyses to evaluate the association between PRES and stroke, adjusting for demographics and stroke risk factors. In a sensitivity analysis, outcomes within 2 weeks of index admission were excluded.

RESULTS

We identified 1606 patients with PRES, 1192 with renal colic, and 38 216 with TIA. Patients with PRES had a mean age of 56±17 years; 72% were women. Over a median follow-up of 0.9 years, the stroke incidence per 100 person-years was 6.1 (95% CI, 5.0-7.4) after PRES, 1.0 (95% CI, 0.62-1.8) after renal colic, and 9.7 (95% CI, 9.4-10.0) after TIA. After statistical adjustment for patient characteristics and risk factors, patients with PRES had an elevated risk of stroke compared with renal colic (hazard ratio [HR], 2.3 [95% CI, 1.7-3.0]), but lower risk than patients with TIA (HR, 0.67 [95% CI, 0.54-0.82]). In secondary analyses, compared with TIA, PRES was associated with hemorrhagic stroke (HR, 2.0 [95% CI, 1.4-2.9]). PRES was associated with ischemic stroke when compared with renal colic (HR, 1.9 [95% CI, 1.4-2.7]) but not when compared with TIA (HR, 0.49 [95% CI, 0.38-0.63]). Results were similar with 2-week washout.

CONCLUSIONS

Patients with PRES had an elevated risk of incident stroke.

Short-term stroke risk after emergency department treat-and-release headache visit

OBJECTIVE

To evaluate whether patients discharged to home after an emergency department (ED) visit for headache face a heightened short-term risk of stroke.

BACKGROUND

Stroke hospitalizations that occur soon after ED visits for headache complaints may reflect diagnostic error.

METHODS

We conducted a retrospective cohort study using statewide administrative claims data for all ED visits and admissions at nonfederal hospitals in Florida 2005-2018 and New York 2005-2016. Using standard International Classification of Diseases (ICD) codes, we identified adult patients discharged to home from the ED (treat-and-release visit) with a benign headache diagnosis (cohort of interest) as well as those with a diagnosis of renal colic or back pain (negative controls). The primary study outcome was hospitalization within 30 days for stroke (ischemic or hemorrhagic) defined using validated ICD codes. We assess the relationship between index ED visit discharge diagnosis and stroke hospitalization adjusting for patient demographics and vascular comorbidities.

RESULTS

We identified 1,502,831 patients with an ED treat-and-release headache visit; mean age was 41 (standard deviation: 17) years and 1,044,520 (70%) were female. A total of 2150 (0.14%) patients with headache were hospitalized for stroke within 30 days. In adjusted analysis, stroke risk was higher after headache compared to renal colic (hazard ratio [HR]: 2.69; 95% confidence interval [CI]: 2.29-3.16) or back pain (HR: 4.0; 95% CI: 3.74-4.3). In the subgroup of 26,714 (1.78%) patients with headache who received brain magnetic resonance imaging at index ED visit, stroke risk was only slightly elevated compared to renal colic (HR: 1.47; 95% CI: 1.22-1.78) or back pain (HR: 1.49; 95% CI: 1.24-1.80).

CONCLUSION

Approximately 1 in 700 patients discharged to home from the ED with a headache diagnosis had a stroke in the following month. Stroke risk was three to four times higher after an ED visit for headache compared to renal colic or back pain.

Association between liver fibrosis and incident dementia in the UK Biobank study

BACKGROUND AND PURPOSE

There is growing recognition that chronic liver conditions influence brain health. The impact of liver fibrosis on dementia risk was unclear. We evaluated the association between liver fibrosis and incident dementia in a cohort study.

METHODS

We performed a cohort analysis using data from the UK Biobank study, which prospectively enrolled adults starting in 2007, and continues to follow them. People with a Fibrosis-4 (FIB-4) liver fibrosis score >2.67 were categorized as at high risk of advanced fibrosis. The primary outcome was incident dementia, ascertained using a validated approach. We excluded participants with prevalent dementia at baseline. We used Cox proportional hazards models to evaluate the association between liver fibrosis and dementia while adjusting for potential confounders.

RESULTS

Among 455,226 participants included in this analysis, the mean age was 56.5 years and 54% were women. Approximately 2.17% (95% confidence interval [CI] 2.13%-2.22%) had liver fibrosis. The rate of dementia per 1000 person-years was 1.76 (95% CI 1.50-2.07) in participants with liver fibrosis and 0.52 (95% CI 0.50-0.54) in those without. After adjusting for demographics, socioeconomic deprivation, educational attainment, metabolic syndrome, hypertension, diabetes, dyslipidemia, and tobacco and alcohol use, liver fibrosis was associated with an increased risk of dementia (hazard ratio 1.52, 95% CI 1.22-1.90). Results were robust to sensitivity analyses. Effect modification by sex, metabolic syndrome, and apolipoprotein E4 carrier status was not observed.

CONCLUSION

Liver fibrosis in middle age was associated with an increased risk of incident dementia, independent of shared risk factors. Liver fibrosis may be an underrecognized risk factor for dementia.

Sex differences in the risk of recurrent ischemic stroke after ischemic stroke and transient ischemic attack

Background

Sex differences in stroke outcomes have been noted, but whether this extends to stroke recurrence is unclear. We examined sex differences in recurrent stroke using data from the Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) trial.

Patients and methods

We assessed the risk of recurrent stroke in women compared to men using data from the POINT trial. Adults >18 years old were randomized within 12 hours of onset of minor ischemic stroke or transient ischemic attack (TIA), and followed for up to 90 days for ischemic stroke, our primary outcome. We used Cox proportional hazards model adjusted for demographics and stroke risk factors to evaluate the association between sex and stroke recurrence. We used interaction term testing and prespecified subgroup analyses to determine if the association between sex and recurrent stroke differed by age (<60 versus >60 years old), locale (US versus non-US), and index event type (stroke versus TIA). Last, we evaluated whether sex modified the effect of common stroke risk factors on stroke recurrence.

Results

Of 4,881 POINT trial participants with minor stroke or high-risk TIA, 2,195 (45%) were women. During the 90-day follow-up period, 267 ischemic strokes occurred; 121 were in women and 146 in men. The cumulative risk of recurrent ischemic stroke was not significantly different among women (5.76%; 95% CI, 4.84%-6.85%) compared to men (5.67%; 95% CI, 4.83%-6.63%). Women were not at a different risk of recurrent ischemic stroke compared to men (hazard ratio [HR], 1.02; 95% CI, 0.80-1.30) in unadjusted models or after adjusting for covariates. However, there was a significant interaction of age with sex (P=0.04). Among patients <60 years old, there was a non-significantly lower risk of recurrent stroke in women compared to men (HR 0.66; 95% CI 0.42-1.05). Last, sex did not modify the association between common stroke risk factors and recurrent stroke risk.

Discussion and Conclusion

Among patients with minor stroke or TIA, the risk of recurrent ischemic stroke and the impact of common stroke risk factors did not differ between men and women.

Association of chronic liver disease with cognition and brain volumes in two randomized controlled trial populations

BACKGROUND AND PURPOSE

We examined the association of chronic liver disease with cognition and brain imaging markers of cognitive impairment using data from two large randomized controlled trials that included participants based on diabetes and hypertension, two common systemic risk factors for cognitive impairment and dementia.

METHODS

We performed post hoc analyses using data from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) and Systolic Blood Pressure Intervention Trial (SPRINT) studies, which included participants with diabetes and hypertension, respectively. Data were from the NHLBI Biologic Specimen and Data Repository Information Coordinating Center. In ACCORD, our measure of chronic liver disease was the Dallas Steatosis Index (DSI). In SPRINT, we used self-reported chronic liver disease. We used linear regression to evaluate the association between the measure of chronic liver disease and both baseline and longitudinal cognitive test performance and brain magnetic resonance imaging volume measurements.

RESULTS

Among 2969 diabetic participants in ACCORD, the mean age of participants was 62 years, 47% were women. The median DSI was 1.0 (IQR, 0.2-1.8); a DSI of 1.0 corresponds to approximately a > 70% probability of having NAFLD. Among 2890 hypertensive participants in SPRINT, the mean age was 68 years, and 37% were women, and 60 (2.1%) had chronic liver disease. There were no consistent associations between liver disease and cognitive performance or brain volumes at baseline or longitudinally after adjustment.

CONCLUSION

Markers of chronic liver disease were not associated with cognitive impairment or related brain imaging markers among individuals with diabetes and hypertension.

Abstract TP72: Cost Effectiveness Of Smoking-Cessation Interventions Following Ischemic Stroke And Transient Ischemic Attack

Introduction: The cost effectiveness of smoking-cessation interventions after ischemic stroke and TIA has not been evaluated. We performed a cost-effectiveness analysis of smoking-cessation interventions in this population.

Methods: We constructed a decision tree model to compare brief counseling alone to 3 interventions: varenicline, any pharmacotherapy with intensive counseling, and monetary incentives. Direct health care costs of interventions and outcomes were modeled. The outcomes were recurrent stroke, myocardial infarction, and death using a 5-year horizon. Estimates and variance for the base case (42% cessation), costs and effectiveness of interventions, and outcome rates were imputed from the stroke literature. Using standard techniques, we calculated incremental cost-effectiveness ratios (ICER) and net-monetary benefits (NMB). An intervention was considered cost effective if the ICER was less than the standard willingness-to-pay threshold of $100,000 per quality-adjusted life year (QALY) or when the NMB was maximized. Sensitivity analyses and a probabilistic Monte Carlo simulation modeled the impact of parameter uncertainty, including for the base case cessation rate and costs and effectiveness of interventions (TreeAge Pro).

Results: All three interventions were cost effective based on the ICER: varenicline - $7,422/QALY, pharmacotherapy with counseling - $14,550/QALY, and monetary incentives - $23,280/QALY. In one-way sensitivity analyses, interventions costing up to $1,729 remained cost-effective. In a two-way sensitivity analysis varying the cost and effectiveness of smoking-cessation interventions, all three interventions were cost effective based on NMB (Figure). In 10,000 Monte Carlo simulations, smoking-cessation interventions were cost effective 90% of the time, as compared to brief counseling alone.

Conclusion: Smoking-cessation strategies are cost effective in secondary prevention after stroke and TIA.

Abstract WMP55: Short-term Stroke Risk After Emergency Department Treat-and-release Headache Visit

Introduction: When a stroke hospitalization follows soon after an Emergency Department (ED) treat-and-release visit for non-specific neurological complaints, a diagnostic error may have occurred. In this study, we sought to evaluate potential stroke misdiagnoses after ED treat-and-release headache visits.

Methods: We conducted a retrospective cohort study using state-wide administrative claims data for all ED visits and admissions at nonfederal hospitals in Florida 2005-2018 and New York 2005-2016. Using standard ICD codes, we identified adult patients discharged home from the ED with a benign headache diagnosis (cohort of interest) as well as those with a diagnosis of back pain or renal colic (negative control cohorts). The primary study outcome was hospitalization within 30 days for stroke (ischemic or hemorrhagic), defined using validated ICD codes. We used Cox proportional hazards modeling to assess the relationship between the index ED visit reason and stroke hospitalization adjusting for demographics and vascular risk factors.

Results: We identified 1,458,904 patients with an ED treat-and-release headache visit; mean age was 41 (SD: 17) and 70% were female. A total of 2,636 (0.18%) headache patients were hospitalized for stroke within 30 days. Stroke risk was higher among headache patients compared to patients diagnosed with renal colic (HR: 2.7; 95% CI, 2.3-3.1) or back pain (HR: 3.8; 95% CI, 3.6-4.1; Figure). Among patients <40 years of age, stroke risk was even higher among headache as compared to back pain (HR: 10; 95% CI, 7.7-13.1); no strokes occurred in renal colic patients <40 years of age.

Conclusion: Approximately 1 in 500 patients discharged home from the ED with a headache diagnosis had a stroke in the following month. Stroke risk was 3-4 times higher after an ED visit for headache compared to back pain or renal colic. There may be opportunities to reduce diagnostic error among patients with ED visits for headache, particularly for those <40 years of age.

Abstract TMP101: Preoperative Atrial Fibrillation And Risk Of Stroke After Noncardiac Surgery

Objective: To assess rates of postoperative stroke after elective noncardiac surgery in patients with atrial fibrillation (AF).

Methods: We conducted a retrospective cohort study using all-payer administrative claims data on all non-federal hospitalizations and emergency department visits in 11 states between 2016 and 2018. We included patients hospitalized for elective noncardiac surgery, as defined by a surgical diagnosis related group and major diagnostic category codes. The exposure variable was preoperative AF. The outcome variable was ischemic stroke within 30 days of surgery. We performed survival analyses using Kaplan-Meier cumulative rates and Cox proportional hazards models. We stratified AF patients by their CHA 2 DS 2 -VASc score and tested its discrimination using the c-statistic.

Results: We identified 1,301,709 patients undergoing elective noncardiac surgery, of whom 94,363 (7.3%) had preoperative AF. Patients with AF were older (mean age, 73 versus 62 years) and had higher CHA 2 DS 2 -VASc scores (mean score, 3.2 vs 2.2). We identified 2,893 patients with postoperative stroke. The cumulative rate of postoperative stroke was 0.65% (95% CI, 0.60-0.70%) in patients with AF vs 0.19% (95% CI, 0.18-0.20%) in patients without AF. After adjustment for demographics and vascular risk factors, AF was associated with a higher risk of postoperative stroke (HR, 1.7; 95% CI, 1.5-1.8). Among AF patients, the CHA 2 DS 2 -VASc score was a good predictor of postoperative stroke (AUC, 0.81; 95% CI, 0.79-0.83). Rates of postoperative stroke among AF patients ranged from <0.1% in those with a CHA 2 DS 2 -VASc score of 0-2 to 14% in those with a score of 8 (Figure).

Conclusions: Patients with AF faced a heightened risk of postoperative stroke and this risk varied in proportion to the CHA 2 DS 2 -VASc score.

Abstract 153: Long-Term Risk Of Stroke After Posterior Reversible Encephalopathy Syndrome

Introduction: Posterior reversible encephalopathy syndrome (PRES) can cause brain infarction and hemorrhage in the acute phase. We hypothesized that PRES is also associated with an increased long-term risk of stroke.

Methods: We performed a retrospective cohort study using statewide all-payer claims data from 2016-2018 for all admissions to nonfederal hospitals in 11 states. Adult patients with PRES were compared to patients with TIA (positive control) and renal colic (negative control), as done in prior studies. The primary outcome was any stroke, and secondary outcomes were ischemic and hemorrhagic stroke. Diagnoses were ascertained using ICD-10-CM codes. We excluded patients with stroke before and during index admissions for PRES and controls. We used Cox proportional hazards analyses to evaluate associations between PRES and stroke, adjusting for demographics, stroke risk factors, and factors associated with PRES (cancer, kidney disease, rheumatological disease). In a sensitivity analysis, stroke events within 4 weeks of index admissions were excluded.

Results: We identified 3,086 patients with PRES, 85,189 with TIA, and 3,094 with renal colic. Patients with PRES (55±17 years) and renal colic (54±18 years) were younger than those with TIA (72±14 years). Median follow-up was 1.1 years and similar between groups. Stroke incidence was 3.2 per 100 person-years after PRES, 3.8 per 100 person-years after TIA, and 0.4 per 100 person-years after renal colic (Figure). After adjustment, patients with PRES had a similar stroke risk as patients with TIA (HR, 0.9; 95% CI, 0.8-1.2), and a higher stroke risk than patients with renal colic (HR, 2.6; 95% CI, 2.0-3.5). Compared to TIA, PRES had a higher risk of hemorrhagic stroke (HR, 2.9; 95% CI, 2.2-3.9) and a lower risk of ischemic stroke (HR, 0.7; 95% CI, 0.6-0.9). Results were similar with a 4-week washout period.

Conclusions: PRES is associated with an increased risk of future stroke, specifically hemorrhagic stroke.

Abstract TP183: Risk And Predictors Of Relapse After Smoking Cessation In Patients With Ischemic Stroke And Transient Ischemic Attack

Introduction: Smoking cessation is an integral part of secondary prevention after stroke and TIA. Relapse after successful smoking cessation in this population is poorly understood.

Methods: This is a retrospective cohort analysis of patients enrolled in the international Insulin Resistance Intervention After Stroke (IRIS) trial, which included 3,876 nondiabetic patients with ischemic stroke or TIA. In IRIS, patients were asked about smoking status at the time of the index event, at randomization, and annually thereafter for 5 years. For this analysis, we included patients who quit smoking by randomization. Patients with active smoking at any follow-up visit were categorized as relapsed. We used time-to-event analysis to estimate cumulative relapse rates. We used univariate Cox proportional hazards regression to assess possible predictors of relapse: demographics, index event type (stroke vs TIA), country of origin, cardiovascular comorbidities, and duration/intensity of smoking.

Results: At the time of stroke/TIA, 1,072 patients were active smokers. By randomization, a median of 3 (IQR, 2-5) months later, 450 (42%) had quit smoking. The mean age of the 450 quitters was 58 years, and 35% were women. They had smoked a median of 20 (IQR, 10-25) cigarettes/day for a median of 40 (IQR, 34-46) years. Over a mean follow-up of 3.8 years, 156 patients relapsed. The 5-year cumulative relapse rate was 38% (95% CI, 34-43%), with 21% (95% CI, 18-25%) relapsing within 1 year (Figure). Age, sex, index event type, duration and intensity of smoking were not associated with relapse. However, patients at US sites (vs non-US sites) were more likely to relapse (HR, 1.46; 95% CI, 1.01-2.10), as were patients with more cardiovascular comorbidities (HR, 1.28; 95% CI, 1.05-1.55; for each additional condition).

Conclusion: Stroke/TIA survivors with early smoking cessation have a high rate of relapse, highlighting a need to engage this at-risk population in sustained cessation interventions.

Fatty liver and cerebrovascular disease: plausible association and possible mechanisms

PURPOSE OF REVIEW

Nonalcoholic fatty liver disease (NAFLD) is a common comorbidity and has wide ranging extrahepatic manifestations, including through cardiometabolic pathways. As such, there is growing interest in the impact of NAFLD on cerebrovascular disease and brain health more broadly. In this review, we assess recent research into understanding the association between NAFLD and brain health while highlighting potential clinical implications.

RECENT FINDINGS

Mechanistically, NAFLD is characterized by both a proinflammatory and proatherogenic state, which results in vascular inflammation and neurodegeneration, potentially leading to clinical and subclinical cerebrovascular disease. Mounting epidemiological evidence suggests an association between NAFLD and an increased risk and severity of stroke, independent of other vascular risk factors. Studies also implicate NAFLD in subclinical cerebrovascular disease, such as carotid atherosclerosis and microvascular disease. In contrast, there does not appear to be an independent association between NAFLD and cognitive impairment.

SUMMARY

The current literature supports the formulation of NAFLD as a multisystem disease that may also have implications for cerebrovascular disease and brain health. Further prospective studies are needed to better assess a temporal relationship between the two diseases, confirm these early findings, and decipher mechanistic links.

Abstract WP17: Impact Of Cigarette Smoking And Its Interaction With Hypertension And Diabetes On Cognitive Function

Introduction: We evaluated the association of a cigarette-smoking biomarker with cognitive function, and tested whether smoking acts synergistically with hypertension and diabetes to influence cognition.

Methods: We performed a cross-sectional analysis of nationally representative data from the US National Health and Nutrition Examination Survey. From 2011-2014, participants ≥60 years old were given 4 standardized cognitive tests by trained examiners: immediate word recall, delayed word recall, Animal Fluency Test (AFT), and Digit Symbol Substitution Test (DSST) - a multidomain cognitive test. Participants also had 3 consecutive standardized blood pressure measurements and hemoglobin A1c and serum cotinine tests, the latter an accurate biomarker of cigarette smoking/exposure. We used linear regression to evaluate the association of cotinine with cognitive performance. Where an association was found, interaction term testing evaluated effect modification by systolic blood pressure and hemoglobin A1c as continuous measures, and hypertension and diabetes as categorical variables. Models were adjusted for demographics, socioeconomic factors, education, cardiovascular risk factors/disease, alcohol use, and depression.

Results: The mean age of 3,244 participants was 69 years and 54% were women. Self-reported current smoking was present in 23%, 77% had hypertension, and 24% had diabetes. In adjusted linear regression models, higher serum cotinine levels were associated with worse performance on the DSST (β, -0.02; 95% CI, -0.03, -0.01; P=0.001), and non-significantly on the AFT (β, -0.003; 95% CI, -0.006, 0.0003; P=0.07), but not immediate or delayed recall. For the DSST, effect modification by systolic blood pressure (P=0.14) and hemoglobin A1c (P=0.39) was not observed. There was also no evidence of effect modification when testing interactions for hypertension and diabetes.

Conclusions: Higher levels of a smoking biomarker were associated with worse performance on a multidomain cognitive test at the population level, regardless of hypertension or diabetes. These data demonstrate the detrimental impact of smoking on cognition and underscore the broad importance of promoting smoking cessation to preserve cognitive health.

Abstract TMP13: Risk Stratification Models For Stroke In Patients Hospitalized With Covid-19 Infection: An American Heart Association Covid-19 CVD Registry Study

Introduction: Coronavirus Disease 2019 (COVID-19) is associated with an increased risk of stroke and worse stroke outcomes. A clinical score that can identify high-risk patients could enable closer monitoring and targeted preventative strategies.

Methods: We used data from the AHA’s COVID-19 CVD Registry to create a clinical score to predict the risk of stroke among patients hospitalized with COVID-19. We included patients aged >18 years who were hospitalized with COVID-19 at 122 centers from March 2020-March 2021. To build our score, we used demographics, preexisting comorbidities, home medications, and vital sign and lab values at admission. The outcome was a cerebrovascular event, defined as any ischemic or hemorrhagic stroke, TIA, or cerebral vein thrombosis. We used two separate analytical approaches to build the score. First, we used Cox regression with cross validation techniques to identify factors associated with the outcome in both univariable (p<0.10) and multivariable analyses (p<0.05), then assigned points for each variable based on corresponding coefficients. Second, we used regularized Cox regression, XGBoost, and Random Forest machine learning techniques to create an estimator using all available covariates. We used Harrel’s C-statistic to measure discriminatory performance.

Results: Among 21,420 patients hospitalized with COVID-19 (mean age 61 years, 54% men), 312 (1.5%) had a cerebrovascular event. Using traditional Cox regression, we created and internally validated a risk stratification score (CANDLE) (Fig) with a C-statistic of 0.66 (95% CI, 0.60-0.72). The machine learning estimator had similar discriminatory performance, with a C-statistic of 0.69 (95% CI, 0.65-0.72). For ischemic stroke or TIA, CANDLE’s C-statistic was 0.67 (95% 0.59-0.76).

Conclusion: We developed an easy-to-use clinical score, with similar performance to a machine learning estimator, to help stratify stroke risk among patients hospitalized with COVID-19.

Abstract WP112: A Clinical Score To Predict Reduced Ejection Fraction In Acute Ischemic Stroke

Introduction: Transthoracic echocardiography (TTE) is valuable in evaluating stroke etiology. A left ventricular (LV) thrombus, the identification of which can immediately impact clinical management, is rarely seen unless the ejection fraction (EF) is less than 50%. A clinical prediction score to identify stroke patients with EF less than 50% may help guide the timing of TTE after stroke.

Methods: The CAESAR registry includes all patients with ischemic stroke at our medical center. We derived a clinical prediction score using CAESAR data from calendar years 2011-2016. We included all patients who underwent TTE and had a quantitative EF measurement. We selected clinical factors, laboratory values, and vital signs based on biological plausibility and the results of multiple logistical regression with backward selection.

Results: Of 2,116 patients with ischemic stroke from 2011-2016, 1,045 patients had an EF measurement. The mean age was 63 (SD, 15), 49% were women, and the mean EF was 63% (SD, 14%). Reduced EF was identified in 171 patients (16%). Our final model comprised historical variables (coronary disease, heart failure, and chronic kidney disease) and clinical parameters from the time of admission (NIHSS score, heart rate, serum potassium, and serum creatinine). The model AUC was 0.80 (95% CI, 0.76-0.85) and model calibration was good (Figure). At a predicted probability threshold of 0.1, the score’s sensitivity for reduced EF was 80% with a specificity of 62%. In a sensitivity analysis excluding patients with atrial fibrillation, the AUC was 0.77 (95% CI 0.70-0.83) and calibration remained good.

Conclusions: We derived a clinical score with good performance for predicting reduced EF in acute ischemic stroke patients. If externally validated, such a score may help identify which patients are most likely to benefit from an expedited inpatient TTE.

Abstract WMP81: Association Between Systemic Amyloidosis And Intracranial Hemorrhage

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

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

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

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

Abstract WMP85: Postpartum Risk Of Cerebral Venous Thrombosis

Background: The postpartum state is associated with a heightened risk of thrombosis. The duration of heightened risk for postpartum cerebral venous thrombosis (CVT) is uncertain.

Methods: Using claims data from the Healthcare Cost and Utilization Project (HCUP) from all emergency departments and acute care hospitalizations in Florida from 2005-2015 and New York from 2006-2015, we identified women aged ≥18 years old who were hospitalized for labor and delivery. CVT was ascertained using previously validated International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), diagnosis codes. For women with multiple labor-related hospitalizations during a single 40-week period, we excluded cases of false labor by identifying delivery as the latest hospitalization during that time. Patients with claims for CVT before their first recorded delivery, and women with a second delivery during the follow-up period were also excluded. We compared the likelihood of a first-ever recorded CVT during postpartum days 0-41 compared with the same period 1 year later. We repeated this crossover-cohort analysis for consecutive 6-weeks periods after delivery, as compared with the corresponding 6-week period 1 year later. We used McNemar's to calculate odds ratios for each 6-week interval.

Results: Among the 1,406,447 women with a first recorded delivery, the risk of CVT was markedly higher within the 6 weeks after delivery than in the same period 1 year later (22 versus 3 CVTs per million deliveries). This corresponded to an absolute risk difference of 19 events per million (95% confidence interval [CI], 11-27) and an odds ratio of 10.0 (95% CI, 3.1-51.2). There was no significant increase in the risk of CVT during the period of 7 to 12 weeks after delivery as compared with the same period 1 year later with an absolute risk difference of 6.0 events (95% CI, 0-11) per million deliveries and an odds ratio of 3.0 (95% CI, 0.9-12.8).

Conclusion: There appears to be a heightened risk of CVT for 6 weeks after delivery.

Abstract WP57: Association Between Stroke Presentation During Off-hours And Mechanical Thrombectomy

Background: Access to mechanical thrombectomy in the US remains limited, in part due to a relative lack of trained interventionalists. Given potential staffing challenges, we hypothesized that access to thrombectomy would be worse on nights and weekends.

Methods: We used 2016-2018 all-payer claims data from all nonfederal emergency departments and acute care hospitals across 11 US states encompassing 80 million residents. Using recorded arrival times, hospital presentation was classified as on-hours if it fell between 8:00 a.m. and 6:00 p.m. on weekdays and as off-hours otherwise. For patients who underwent interhospital transfer, we used the arrival time at the initial hospital. We examined the association between off-hours arrival and mechanical thrombectomy using multiple logistic regression adjusted for age, sex, race/ethnicity, insurance type, socioeconomic status, urban-rural location of residence, the Charlson comorbidity index, initial presentation to a thrombectomy hub, and treatment with intravenous thrombolysis. We performed a sensitivity analysis limited to patients who presented with a probable large-vessel occlusion, defined as a documented NIHSS score ≥12, to a thrombectomy hub and underwent intravenous thrombolysis.

Results: Among 169,199 patients with ischemic strokes, the 82,784 (48.9%) who presented during off-hours had higher NIHSS scores (4 [IQR, 2-10] vs 2 [IQR, 1-9], P <0.001) and underwent thrombolysis more often (9.3% vs 8.5%, P <0.001). There were no differences between groups in rates of mechanical thrombectomy (3.4% on-hours vs 3.5% off-hours, P = 0.25). In adjusted models, off-hours presentation was not significantly associated with lower odds of mechanical thrombectomy (OR, 0.94; 95% CI, 0.85-1.03). Our findings were similar in a sensitivity analysis limited to patients with a probable large-vessel occlusion who initially presented to a thrombectomy hub and underwent intravenous thrombolysis (OR, 0.87; 0.69-1.09).

Conclusions: In a large population-based sample of ischemic stroke patients across the US, the odds of mechanical thrombectomy did not vary by time of presentation.

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

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

Long-Term Risk of Ischemic Stroke among Elderly Survivors of Non-Traumatic Subarachnoid Hemorrhage

INTRODUCTION

Non-traumatic subarachnoid hemorrhage (SAH) is associated with poor long-term functional outcomes, but the risk of ischemic stroke among SAH survivors is poorly understood.

OBJECTIVES

The aim of this study was to evaluate the risk of ischemic stroke among survivors of SAH.

METHODS

We performed a retrospective cohort study using claims data from Medicare beneficiaries from 2008 to 2015. The exposure was a diagnosis of SAH, while the outcome was an acute ischemic stroke, both identified using previously validated ICD-9-CM diagnosis codes. We used Cox regression analysis adjusting for demographics and stroke risk factors to evaluate the association between SAH and long-term risk of ischemic stroke.

RESULTS

Among 1.7 million Medicare beneficiaries, 912 were hospitalized with non-traumatic SAH. During a median follow-up of 5.2 years (IQR, 2.7-6.7), the cumulative incidence of ischemic stroke was 22 per 1,000 patients per year among patients with SAH, and 7 per 1,000 patients per year in those without SAH. In adjusted Cox models, SAH was associated with an increased risk of ischemic stroke (HR, 2.0; 95% confidence interval, 1.4-2.8) as compared to beneficiaries without SAH. Similar results were obtained in sensitivity analyses, when treating death as a competing risk (sub HR, 3.0; 95% CI, 2.8-3.3) and after excluding ischemic stroke within 30 days of SAH discharge (HR, 1.5; 95% CI, 1.1-2.3).

CONCLUSIONS

In a large, heterogeneous national cohort of elderly patients, survivors of SAH had double the long-term risk of ischemic stroke. SAH survivors should be closely monitored and risk stratified for ischemic stroke.

Impact of Cigarette Smoking and Its Interaction with Hypertension and Diabetes on Cognitive Function in Older Americans

BACKGROUND

The detrimental impact of tobacco smoking on brain health is well recognized.

OBJECTIVE

To evaluate whether smoking acts synergistically with hypertension and diabetes to influence cognitive performance.

METHODS

We performed a cross-sectional analysis using the US National Health and Nutrition Examination Survey. Participants were tested for serum cotinine, a validated cigarette smoking/exposure biomarker, and had standardized blood pressure and hemoglobin A1c measurements. Participants were administered four cognitive tests: Digit Symbol Substitution (DSST), Animal Fluency, Immediate Recall, and Delayed Recall. Multivariable linear regression models adjusted for demographics and confounders evaluated the association of cotinine with cognition. Interaction testing evaluated effect modification by hypertension, diabetes, and their continuous measures (systolic blood pressure and hemoglobin A1c).

RESULTS

For 3,007 participants, mean age was 69.4 years; 54% were women. Using cotinine levels, 14.9% of participants were categorized as active smokers. Higher cotinine levels were associated with worse DSST performance when modeling cotinine as a continuous variable (β, -0.70; 95% CI, -1.11, -0.29; p < 0.01) and when categorizing participants as active smokers (β, -5.63; 95% CI, -9.70, -1.56; p < 0.01). Cotinine was not associated with fluency or memory. Effect modification by hypertension and diabetes were absent, except that cotinine was associated with worse Immediate Recall at lower blood pressures.

CONCLUSION

Higher levels of a smoking and secondhand exposure biomarker were associated with worse cognitive performance on a multidomain test. Overall, the relationship of cotinine with cognition was not contingent on or amplified by hypertension or diabetes; smoking is detrimental for brain health irrespective of these comorbidities.

Risk of Mortality After an Arterial Ischemic Event Among Intracerebral Hemorrhage Survivors

BACKGROUND AND PURPOSE

The impact of arterial ischemic events after intracerebral hemorrhage (ICH) on outcomes is unclear. This study aimed to evaluate the risk of death among ICH survivors with and without an incident arterial ischemic event.

METHODS

We performed a retrospective cohort study using claims data from Medicare beneficiaries with a non-traumatic ICH from January 2008 to October 2015. Our exposure was an arterial ischemic event, a composite of acute ischemic stroke or myocardial infarction (MI), identified using validated ICD-9-CM diagnosis codes. The outcome was mortality. We used marginal structural models to analyze the risk of death among ICH patients with and without an arterial ischemic event, after adjusting for confounders as time-varying covariates.

RESULTS

Among 8,804 Medicare beneficiaries with ICH, 2,371 (26.9%) had an arterial ischemic event. During a median follow-up time of 1.9 years (interquartile range, 0.7-3.9), ICH patients with an arterial ischemic event had a mortality rate of 21.7 (95% confidence interval [CI], 20.4-23.0) per 100 person-years compared to a rate of 15.0 (95% CI, 14.4-15.6) per 100 person-years in those without. In the marginal structural model, an arterial ischemic event was associated with an increased risk of death (hazard ratio [HR], 1.8; 95% confidence interval [CI], 1.6-1.9). In secondary analyses, the mortality risk was elevated after an ischemic stroke (HR, 1.7; 95% CI, 1.5-1.8), and MI (HR, 3.0; 95% CI, 2.4-3.8).

CONCLUSIONS

We found that elderly patients who survived an ICH had an increased risk of death after a subsequent ischemic stroke or MI.

Cognitive Function, Sarcopenia, and Inflammation Are Strongly Associated with Frailty: A Framingham Cohort Study

BACKGROUND

Frailty is an important contributor to morbidity and mortality in chronic liver disease. Understanding the contributors to frailty has the potential to identify individuals at risk for frailty and may potentially provide targets for frailty-modifying interventions. We evaluated the relationship among cognitive function, inflammation, and sarcopenia and frailty.

METHODS

Using cohorts from the Framingham Heart Study (2011-2014), we evaluated for factors associated with frailty. Exposures included cognitive tests (combined Trails A/B test, Animal Naming Test, and combined Digit Span Forward/Backward test), inflammation (interleukin-6 and tumor necrosis factor receptor II), and sarcopenia (creatinine-to-cystatin C ratio). We performed linear and logistic regression to identify the relationship between these exposures and the Liver Frailty Index (LFI).

RESULTS

The study population (N = 1208) had a median age of 70 years, was 56% female, and 48.5% had evidence of liver disease. The combined Trails A/B test (β 0.05, P < .001), creatinine-to-cystatin C (β -0.17, P = .006), and both inflammatory markers, interleukin-6 levels (β 0.16, P = .002) and tumor necrosis factor receptor II (β 0.21, P = .04), were independently associated with the LFI. Using an LFI cutoff of ≥4.5 to define frailty, Trails A/B (odds ratio [OR] 1.21, 95% confidence interval [CI] 1.07-1.37), Animal Naming Test (OR 0.64, 95% CI 0.42-0.97), sarcopenia (OR 0.10, 95% CI 0.01-0.73), and interleukin-6 (OR 4.99, 95% CI 1.03-15.53) were all associated with frailty. Although liver disease did not modify the relationship between the LFI and the Trails A/B test, interleukin-6 was significantly associated with the LFI only in the presence of liver disease.

CONCLUSIONS

Cognitive performance, inflammation, and sarcopenia, each highly prevalent in cirrhosis, are associated with the LFI in this population-based study of persons without cirrhosis. Further research is warranted for interventions aiming to prevent frailty by tailoring their approach to the patient's underlying risk factors.

Impingement of the Thyroid Cartilage on the Carotid Causing Clicking Larynx Syndrome and Stroke

We present the case of a patient with a recent history of ischemic stroke who presented with clicking larynx syndrome, a condition in which clicking noises in the larynx can be provoked by movement of the head and neck. Diagnostic imaging revealed unusual development and posterior angulation of the superior horn of the thyroid cartilage that potentially was causing trauma to the left common carotid artery. We deduced that symptomatic impingement of the carotid artery by the thyroid cartilage was not only the cause of the patient's clicking larynx syndrome, but also suspected to be the cause of her prior strokes due to repetitive trauma resulting in thrombus. The patient was managed surgically with thyroplasty and transcervical resection of the left greater cornu of the thyroid cartilage with resolution of her symptoms. Anatomical displacement of the thyroid cartilage can manifest as clicking larynx syndrome as well as cause mechanical injury to the carotid artery, resulting in turbulent flow, possible thrombosis, and stroke. Laryngoscope, 2021.

Smoking Cessation in Stroke Survivors in the United States: A Nationwide Analysis

BACKGROUND AND PURPOSE

Continued smoking after stroke is associated with a high risk of stroke recurrence and other cardiovascular disease. We sought to comprehensively understand the epidemiology of smoking cessation in stroke survivors in the United States. Furthermore, we compared smoking cessation in stroke and cancer survivors because cancer is another smoking-related condition in which smoking cessation is prioritized.

METHODS

We performed a cross-sectional analysis of data from the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System, an annual, nationally representative health survey. Using pooled data from 2013 to 2019, we identified stroke and cancer survivors with a history of smoking. We used survey procedures to estimate frequencies and summarize quit ratios with attention to demographic and geographic (state-wise and rural-urban) factors for stroke survivors. The quit ratio is conventionally defined as the proportion of ever smokers who have quit. Then, we used multivariable logistic regression to compare quit ratios in stroke and cancer survivors while adjusting for demographics and smoking-related comorbidities.

RESULTS

Among 4 434 604 Americans with a history of stroke and smoking, the median age was 68 years (interquartile range, 59-76), and 45.4% were women. The overall quit ratio was 60.8% (95% CI, 60.1%-61.6%). Quit ratios varied by age group, sex, race and ethnicity, and several geographic factors. There was marked geographic variation in quit ratios, ranging from 48.3% in Kentucky to 71.5% in California. Furthermore, compared with cancer survivors, stroke survivors were less likely to have quit smoking (odds ratio, 0.72 [95% CI, 0.67-0.79]) after accounting for differences in demographics and smoking-related comorbidities.

CONCLUSIONS

There were considerable demographic and geographic disparities in smoking quit ratios in stroke survivors, who were less likely to have quit smoking than cancer survivors. A targeted initiative is needed to improve smoking cessation for stroke survivors.