Pretreatment parameters associated with hemorrhagic transformation among successfully recanalized medium vessel occlusions

Although pretreatment radiographic biomarkers are well established for hemorrhagic transformation (HT) following successful mechanical thrombectomy (MT) in large vessel occlusion (LVO) strokes, they are yet to be explored for medium vessel occlusion (MeVO) acute ischemic strokes. We aim to investigate pretreatment imaging biomarkers representative of collateral status, namely the hypoperfusion intensity ratio (HIR) and cerebral blood volume (CBV) index, and their association with HT in successfully recanalized MeVOs. A prospectively collected registry of acute ischemic stroke patients with MeVOs successfully recanalized with MT between 2019 and 2023 was retrospectively reviewed. A multivariate logistic regression for HT of any subtype was derived by combining significant univariate predictors into a forward stepwise regression with minimization of Akaike information criterion. Of 60 MeVO patients successfully recanalized with MT, HT occurred in 28.3% of patients. Independent factors for HT included: diabetes mellitus history (p = 0.0005), CBV index (p = 0.0071), and proximal versus distal occlusion location (p = 0.0062). A multivariate model with these factors had strong diagnostic performance for predicting HT (area under curve [AUC] 0.93, p < 0.001). Lower CBV indexes, distal occlusion location, and diabetes history are significantly associated with HT in MeVOs successfully recanalized with MT. Of note, HIR was not found to be significantly associated with HT.

Prolonged venous transit on perfusion imaging is associated with higher odds of mortality in successfully reperfused patients with large vessel occlusion stroke

BACKGROUND

Poor venous outflow (VO) profiles are associated with unfavorable outcomes in patients with acute ischemic stroke caused by large vessel occlusion (AIS-LVO), despite achieving successful reperfusion. The objective of this study is to assess the association between mortality and prolonged venous transit (PVT), a novel visual qualitative VO marker on CT perfusion (CTP) time to maximum (Tmax) maps.

METHODS

We performed a retrospective analysis of prospectively collected data from consecutive adult patients with AIS-LVO with successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b/2c/3). PVT+ was defined as Tmax ≥10 s timing on CTP Tmax maps in at least one of the following: superior sagittal sinus (proximal venous drainage) and/or torcula (deep venous drainage). PVT- was defined as lacking this in both regions. The primary outcome was mortality at 90 days. In a 1:1 propensity score-matched cohort, regressions were performed to determine the effect of PVT on 90-day mortality.

RESULTS

In 127 patients of median (IQR) age 71 (64-81) years, mortality occurred in a significantly greater proportion of PVT+ patients than PVT- patients (32.5% vs 12.6%, P=0.01). This significant difference persisted after matching (P=0.03). PVT+ was associated with a significantly increased likelihood of 90-day mortality (OR 1.22 (95% CI 1.02 to 1.46), P=0.03) in the matched cohort.

CONCLUSIONS

PVT+ was significantly associated with 90-day mortality despite successful reperfusion therapy in patients with AIS-LVO. PVT is a simple VO profile marker with potential as an adjunctive metric during acute evaluation of AIS-LVO patients. Future studies will expand our understanding of using PVT in the evaluation of patients with AIS-LVO.

Redefining CT perfusion-based ischemic core estimates for the ghost core in early time window stroke

BACKGROUND AND PURPOSE

In large vessel occlusion (LVO) stroke patients, relative cerebral blood flow (rCBF)<30% volume thresholds are commonly used in treatment decisions. In the early time window, nearly infarcted but salvageable tissue volumes may lead to pretreatment overestimates of infarct volume, and thus potentially exclude patients who may otherwise benefit from intervention. Our multisite analysis aims to explore the strength of relationships between widely used pretreatment CT parameters and clinical outcomes for early window stroke patients.

METHODS

Patients from two sites in a prospective registry were analyzed. Patients with LVOs, presenting within 3 hours of last known well, and who were successfully reperfused were included. Primary short-term neurological outcome was percent National Institutes of Health Stroke Scale (NIHSS) change from admission to discharge. Secondary long-term outcome was 90-day modified Rankin score. Spearman's correlations were performed. Significance was attributed to p-value ≤.05.

RESULTS

Among 73 patients, median age was 66 (interquartile range 54-76) years. Among all pretreatment imaging parameters, rCBF<30%, rCBF<34%, and rCBF<38% volumes were significantly, inversely correlated with percentage NIHSS change (p<.048). No other parameters significantly correlated with outcomes.

CONCLUSIONS

Our multisite analysis shows that favorable short-term neurological recovery was significantly correlated with rCBF volumes in the early time window. However, modest strength of correlations provides supportive evidence that the applicability of general ischemic core estimate thresholds in this subpopulation is limited. Our results support future larger-scale efforts to liberalize or reevaluate current rCBF parameter thresholds guiding treatment decisions for early time window stroke patients.

Recognizing and Responding to the Needs of Future Child and Adult Neurology Care Through the Evolution of Residency Training

Recent insights into the frequency of occurrence and the genetic and mechanistic basis of nervous system disease have demonstrated that neurologic disorders occur as a spectrum across all ages. To meet future needs of patients with neurologic disease of all ages and prepare for increasing implementaton of precision therapies, greater integration of child and adult neurology residency training is needed. ANN NEUROL 2023;94:1005-1007.

Neuro-11: a new questionnaire for the assessment of somatic symptom disorder in general hospitals

Background

Somatic symptom disorder (SSD) commonly presents in general hospital settings, posing challenges for healthcare professionals lacking specialised psychiatric training. The Neuro-11 Neurosis Scale (Neuro-11) offers promise in screening and evaluating psychosomatic symptoms, comprising 11 concise items across three dimensions: somatic symptoms, negative emotions and adverse events. Prior research has validated the scale's reliability, validity and theoretical framework in somatoform disorders, indicating its potential as a valuable tool for SSD screening in general hospitals.

Aims

This study aimed to establish the reliability, validity and threshold of the Neuro-11 by comparing it with standard questionnaires commonly used in general hospitals for assessing SSD. Through this comparative analysis, we aimed to validate the effectiveness and precision of the Neuro-11, enhancing its utility in clinical settings.

Methods

Between November 2020 and December 2021, data were collected from 731 patients receiving outpatient and inpatient care at Shenzhen People's Hospital in China for various physical discomforts. The patients completed multiple questionnaires, including the Neuro-11, Short Form 36 Health Survey, Patient Health Questionnaire 15 items, Hamilton Anxiety Scale and Hamilton Depression Scale. Psychiatry-trained clinicians conducted structured interviews and clinical examinations to establish a gold standard diagnosis of SSD.

Results

The Neuro-11 demonstrated strong content reliability and structural consistency, correlating significantly with internationally recognised and widely used questionnaires. Despite its brevity, the Neuro-11 exhibited significant correlations with other questionnaires. A test-retest analysis yielded a correlation coefficient of 1.00, Spearman-Brown coefficient of 0.64 and Cronbach's α coefficient of 0.72, indicating robust content reliability and internal consistency. Confirmatory factor analysis confirmed the validity of the three-dimensional structure (p<0.001, comparative fit index=0.94, Tucker-Lewis index=0.92, root mean square error of approximation=0.06, standardised root mean square residual=0.04). The threshold of the Neuro-11 is set at 10 points based on the maximum Youden's index from the receiver operating characteristic curve analysis. In terms of diagnostic efficacy, the Neuro-11 has an area under the curve of 0.67.

Conclusions

(1) The Neuro-11 demonstrates robust associations with standard questionnaires, supporting its validity. It is applicable in general hospital settings, assessing somatic symptoms, negative emotions and adverse events. (2) The Neuro-11 exhibits strong content reliability and validity, accurately capturing the intended constructs. The three-dimensional structure demonstrates robust construct validity. (3) The threshold of the Neuro-11 is set at 10 points.

Multidomain cognitive dysfunction after minor stroke suggests generalized disruption of cognitive networks

OBJECTIVE

Although small strokes typically result in "good" functional outcomes, significant cognitive impairment can occur. This longitudinal study examined a cohort of patients with minor stroke to determine the pattern of deficits, evolution over time, and factors associated with outcome.

METHODS

Patients admitted to the hospital with their first clinical minor stroke (NIH Stroke Scale [NIHSS] ≤ 10, absence of severe hemiparesis, aphasia, or neglect) were assessed at 1 month post-infarct, and a subset were followed over time (with 6- and 12-month evaluations). Composite scores at each time point were generated for global cognition, verbal memory, spatial memory, motor speed, processing speed, and executive function. Paired t-tests evaluated change in scores over time. Regression models identified factors associated with initial performance and better recovery.

RESULTS

Eighty patients were enrolled, evaluated at 1 month, and prospectively followed. The average age of the participants was 62.3 years, and mean education was 13.5 years. The average stroke volume was 6.6 cc; mean NIHSS score was 2.8. At 1 month, cognitive scores were below the normative range and > 1 standard deviation below the patient's peak ("recovery") score for every cognitive domain, strongly suggesting that they were well below patients' prestroke baselines. Forty-eight patients followed up at 6 months, and 39 at 12 months. Nearly all (98%) patients significantly improved in global cognition (averaged across domains) between 1 and 6 months. Between 6 and 12 months, recovery was variable. Higher education, occupational class, and Caucasian race were associated with higher recovery scores for most domains.

CONCLUSIONS

Cognitive impairment across multiple domains is common following minor stroke regardless of infarct location, suggesting a global process such as network dysfunction that improves over 6 months. Degree of recovery can be predicted using baseline factors.

The telemedicine experience: using principles of clinical excellence to identify disparities and optimize care

The use of telemedicine has increased significantly during the Corona virus disease 2019 pandemic. This manuscript serves to identify the underlying principles of clinical excellence in telemedicine and to determine whether effective care practices can be generalized as a one-size-fits-all model or must instead be tailored to individual patient populations.A survey assessing care quality and patient satisfaction for patients using telemedicine was created and administered via email to 2 urban cohorts of varying demographics and socioeconomic backgrounds: a population of patients with prior stroke and cerebrovascular disease, and a cohort of patients followed for interstitial lung disease. Results were compared across groups to determine the generalizability of effective practices across populations.Individuals taking part in telemedicine were more likely to be White, more affluent, and woman, regardless of clinical diagnosis compared with a similar cohort of patients seen in-person the year prior. A lower-than-expected number of patients who were Black and of lower socioeconomic status followed up virtually, indicating potential barriers to access. Overall, patients who participated in televisits were satisfied with the experience and felt that the care met their medical needs; however, those who were older were more likely to experience technical difficulties and prefer in-person visits, while those with less education were less likely to feel that their questions were addressed in an understandable way.When thoughtfully designed, telemedicine practices can be an effective model for patient care, though implementation must consider population characteristics including age, education, and socioeconomic status, and strategies such as ease of access versus optimization of communication strategies should be tailored to meet individual patient needs.

Early Post-stroke Cognition: In-hospital Predictors and the Association With Functional Outcome

Purpose: To characterize and predict early post-stroke cognitive impairment by describing cognitive changes in stroke patients 4-8 weeks post-infarct, determining the relationship between cognitive ability and functional status at this early time point, and identifying the in-hospital risk factors associated with early dysfunction. Materials and Methods: Data were collected for 214 patients with ischemic stroke and 39 non-stroke controls. Montreal Cognitive Assessment (MoCA) exams were administered at post-hospitalization clinic visits approximately 4-8 weeks after infarct. MoCA scores were compared for patients with: no stroke, minor stroke [NIH Stroke Scale (NIHSS) < 5], and major stroke. Ordinal logistic regression was performed to assess the relationship between MoCA score and functional status [modified Rankin Scale score (mRS)] at follow-up. Predictors of MoCA < 26 and < 19 (cutoffs for mild and severe cognitive impairment, respectively) at follow-up were identified by multivariable logistic regression using variables available during hospitalization. Results: Post stroke cognitive impairment was common, with 66.8% of patients scoring < 26 on the MoCA and 22.9% < 19. The average total MoCA score at follow-up was 18.7 (SD 7.0) among major strokes, 23.6 (SD 4.8) among minor strokes, and 27.2 (SD 13.0) among non-strokes (p = <0.0001). The follow-up MoCA score was associated with the follow-up mRS in adjusted analysis (OR 0.69; 95% C.I. 0.59-0.82). Among patients with no prior cognitive impairment (N = 201), a lack of pre-stroke employment, admission NIHSS > 6, and left-sided infarct predicted a follow-up MoCA < 26 (c-statistic 0.75); while admission NIHSS > 6 and infarct volume > 17 cc predicted a MoCA < 19 (c-statistic 0.75) at follow-up. Conclusion: Many patients experience early post-stroke cognitive dysfunction that significantly impacts function during a critical time period for decision-making regarding return to work and future independence. Dysfunction measured at 4-8 weeks can be predicted during the inpatient hospitalization. These high-risk individuals should be identified for targeted rehabilitation and counseling to improve longer-term post-stroke outcomes.

The Post-Pipeline Headache: New Headaches Following Flow Diversion for Intracranial Aneurysm

OBJECTIVE

Flow diversion using devices such as the "pipeline" stent is now a common treatment for unruptured intracranial aneurysms. Though much is known about the efficacy of the device, less is reported regarding potential side effects. In this study, we report the frequency and characteristics of the "post-pipeline headache."

METHODS

We prospectively enrolled a cohort of 222 patients who underwent pipeline stenting for the treatment of intracranial aneurysm between 2015 and 2018. A follow-up telephone survey was conducted with a mean 21.6 months postprocedure evaluating postprocedure headaches and previous headache history. A post-pipeline headache was defined as a new headache or pain distinct from their prior headache syndrome. Information was collected regarding patient demographics, headache characteristics, headache history, and whether symptoms were ongoing. Logistic regression was used to determine factors associated with post-pipeline headache and the risk of long-term headache persistence.

RESULTS

Eighty-eight individuals were reached by phone for follow-up; 48 (55%) of whom reported a new headache postprocedure. Patients experiencing post-pipeline headache were more likely to be young (OR 0.9; 95% CI: 0.85-0.94) and have a history of prior headaches (OR 2.4, 95% CI: 1.02-5.81). Associated motor (OR 6.1; 95% CI: 1.19-31.47), cognitive (OR 7.0; 95% CI: 081-60.33), visual (OR 5.4; 95% CI: 1.05-27.89), and vestibular (OR 4.8; 95% CI: 1.14-20.23) symptoms were associated with ongoing headache.

CONCLUSIONS

Post-pipeline headache is common, particularly in younger individuals with prior headache history, and has distinctive features. Symptoms can remit over time; however, two-thirds experience ongoing headaches, particularly those with associated migrainous features.

Safety of intravenous alteplase within 4.5 hours for patients awakening with stroke symptoms

Background

Up to 25% of acute stroke patients first note symptoms upon awakening. We hypothesized that patients awaking with stroke symptoms may be safely treated with intravenous alteplase (IV tPA) using non-contrast head CT (NCHCT), if they meet all other standard criteria.

Methods

The SAfety of Intravenous thromboLytics in stroke ON awakening (SAIL ON) was a prospective, open-label, single treatment arm, pilot safety trial of standard dose IV tPA in patients who presented with stroke symptoms within 0–4.5 hours of awakening. From January 30, 2013, to September 1, 2015, twenty consecutive wakeup stroke patients selected by NCHCT were enrolled. The primary outcome was symptomatic intracerebral hemorrhage (sICH) in the first 36 hours. Secondary outcomes included NIH stroke scale (NIHSS) at 24 hours; and modified Rankin Score (mRS), NIHSS, and Barthel index at 90 days.

Results

The average age was 65 years (range 47–83); 40% were women; 50% were African American. The average NIHSS was 6 (range 4–11). The average time from wake-up to IV tPA was 205 minutes (range 114–270). The average time from last known well to IV tPA was 580 minutes (range 353–876). The median mRS at 90 days was 1 (range 0–5). No patients had sICH; two of 20 (10%) had asymptomatic ICH on routine post IV tPA brain imaging.

Conclusions

Administration of IV tPA was feasible and may be safe in wakeup stroke patients presenting within 4.5 hours from awakening, screened with NCHCT. An adequately powered randomized clinical trial is needed.

Clinical trial registration

ClinicalTrials.gov NCT01643902.

Cerebral microbleeds shouldn't dictate treatment of acute stroke: a retrospective cohort study evaluating risk of intracerebral hemorrhage

Background

Intravenous tissue plasminogen activator (IV tPA) after acute ischemic stroke carries the risk of symptomatic intracerebral hemorrhage (sICH). Cerebral microbleeds (CMBs) may indicate increased risk of hemorrhage and can be seen on magnetic resonance imaging (MRI). In this study, we examined the association between CMBs and sICH, focusing on the predictive value of their presence, burden, and location.

Methods

Records from all patients presenting to two academic stroke centers with acute ischemic stroke treated with IV tPA over a 5-year period were retrospectively reviewed. Demographic, medical, and imaging variables were evaluated. The presence, number, and location (lobar vs nonlobar) of CMBs were noted on gradient echo MRI sequences obtained during the admission. Univariable and multivariable statistical models were used to determine the relationship between CMBs and hemorrhagic (symptomatic and asymptomatic) transformation.

Results

Of 292 patients (mean age 62.8 years (SD 15.3), 49% African-American, 52% women), 21% (n = 62) had at least one CMB, 1% (n = 3) had > 10 CMBs, and 1% (n = 3) were diagnosed with probable cerebral amyloid angiopathy. After treatment, 16% (n = 46) developed hemorrhagic transformation, of which 6 (2%) were sICH. There was no association between CMB presence (p = .135) or location (p = .325) with sICH; however, those with a high CMB burden (> 10 CMB) were more likely to develop sICH (OR 37.8; 95% CI: 2.7–539.3; p = .007).

Conclusions

Our findings support prior findings that a high CMB burden (> 10) in patients with acute stroke treated with IV tPA are associated with a higher risk of sICH. However, the overall rate of sICH in the presence of CMB is very low, indicating that the presence of CMBs by itself should not dictate the decision to treat with thrombolytics.

Abstract WMP7: Cost-Effectiveness of Combined Thrombectomy with Intravenous Thrombolysis vs Thrombectomy Alone for Acute Ischemic Stroke

Introduction: Meta-analysis of 13 studies suggested that combined mechanical thrombectomy (MT) with intravenous thrombolysis (IV-tPA) is more effective than MT alone. Limited economic analyses have explored this topic. We aimed to determine the cost-effectiveness of combined vs MT alone therapy in patients with large-vessel occlusive stroke.

Hypothesis: Combined MT with IV-tPA is more cost-effective than MT alone.

Methods: Markov model was constructed to simulate health outcomes and costs of two therapies (combined MT with IV-tPA, MT alone) over a 20 years lifetime horizon. The model incorporated an acute phase (0-90 days) and a rest of life phase (>90 days) with modified Rankin categories at 90days as the primary health states. Probabilities, utilities, and cost data were obtained from published sources. Incremental costs, quality-adjusted life-year (QALY), net monetary benefits, incremental cost-effectiveness ratio (ICER) were derived from the models. The willingness-to-pay was set to ICER $50,000/QALY.

Results: Table 1 summarizes the base-case values and cost-effectiveness outcomes. Combined MT and IV-tPA led to improved quality-of-life and increased life expectancy; however, it was at slightly higher costs compared to MT alone. Combined MT with IV-tPA yielded 13.5 QALYs and accrued $220,227 in lifetime costs, whereas MT alone yielded 12.5 QALYs and accrued $185,714 in lifetime costs. Combined MT with IV-tPA costs $1,468 per QALY higher than MT alone group. The higher costs in combined therapy were driven by the costs of long-term care in stroke survivors with severe disability. Net monetary benefit was higher in the combined therapy by 14,988 points suggesting that combined MT with IV-tPA was more cost-effective than MT alone.

Conclusions: Combined MT with IV-tPA is more cost effective than MT alone in patients with large vessel occlusive stroke. Randomized clinical trials to directly compare between combined MT with IVT vs MT alone seem warranted.

Collaterals Predict Outcome Regardless of Time Last Known Normal

BACKGROUND AND PURPOSE

Recent studies suggest that patients with large-vessel ischemic strokes (large-vessel occlusion [LVO]) with favorable imaging may benefit from mechanical thrombolysis even when treated outside the standard 6-hour window. However, many patients in these studies presented with unknown times of onset. We compare outcomes in thrombectomy patients treated at less than versus greater than 6 hours from last known well (LKN), and evaluate whether "unknown time of onset" alters prognosis.

METHODS

We retrospectively reviewed patients at 2 comprehensive stroke centers. Student's t and chi-square tests evaluated the association between predetermined clinical and radiographic variables, including unknown time of onset, and outcome (discharge and follow-up National Institutes of Health Stroke Scale score and modified Rankin Scale [mRS] score) for LVOs treated after greater than 6 hours versus 6 hours or less from LKN. Multivariable logistic regression was used to determine the odds of good outcome (mRS score 0-2).

RESULTS

A total of 113 patients were treated over 2 years; 31 were treated at greater than 6 hours. Those who were treated at greater than 6 hours and experienced poor outcomes were more likely to have large-artery atherosclerosis (P = .033). There was no difference in outcome for patients outside the window with known (39.1%) versus unknown (60.9%) time of onset. mRS scores at discharge were higher among those outside the window (odds ratio 3.78; 95% confidence interval 1.20-11.89) but not at follow-up. After multivariable regression, favorable collaterals alone were associated with a mRS score of 0-2.

CONCLUSIONS

When imaging is favorable, the mRS score at follow-up is comparable regardless of time LKN. Functional outcomes appear to be driven most significantly by the presence of collaterals.

Isolated aphasia in the emergency department: The likelihood of ischemia is low

OBJECTIVE

Aphasia is a common presentation of ischemic stroke, often diagnosed in the acute setting using tools such as the NIH Stroke Scale (NIHSS). Due to the vascular distribution of the middle cerebral artery, it is often accompanied by other symptoms such as weakness, sensory loss, or visual changes. Isolated aphasia due to ischemia is possible, but language problems mimicking aphasia syndromes can also be seen with other diagnoses such as metabolic abnormalities or dementia. In this study, we determine the incidence of aphasia-only strokes using the NIHSS, and factors associated with a higher likelihood of ischemia.

PATIENTS AND METHODS

Over a 2year period, 788 patients presented to our Emergency Department with symptoms of acute stroke. Data were collected regarding patient demographics, medical history, presenting symptoms (based on NIHSS), work-up results, and final diagnosis. The incidence of aphasia-only stroke was calculated. Student's t-tests and chi square analysis were used to determine factors associated with ischemia.

RESULTS

Of 788 patients, 21 (3%) presented with isolated "aphasia". None of the 21 had infarcts on neuroimaging. Three (14%) were diagnosed with possible transient ischemic attacks and the rest with stroke mimics. Toxic/metabolic disturbances were the most common mimics (39%). Prior history of stroke or transient ischemic attack was associated with ischemia over mimic (p=0.023).

CONCLUSIONS

Strokes affecting language without motor or sensory deficits are uncommon. In the acute setting, isolated "aphasia" is most often due to a stroke mimic; however can occur rarely, particularly in those with prior history of ischemia.

In Potential Stroke Patients on Warfarin, the International Normalized Ratio Predicts Ischemia

BACKGROUND

Stroke can occur in patients on warfarin despite anticoagulation. Patients with a low international normalized ratio (INR) should theoretically be at greater risk for ischemia than those who are therapeutic. Therefore, INR may be able to indicate whether new neurological deficits are more likely strokes or stroke mimics in patients on warfarin. This study evaluates the association and predictive value of INR in determining the likelihood of ischemia.

METHODS

Patients were identified using the acute stroke registry at a Primary Stroke Center from January 2013 through December 2014. All adult patients undergoing evaluation for acute stroke with prior documented use of warfarin and an INR level at presentation were included. Data were collected regarding patient demographics, medical comorbidities, stroke severity, reason for anticoagulation, and laboratory studies including INR. Student t tests and χ2 analysis were used to evaluate factors associated with increased likelihood of ischemia (stroke or transient ischemic attack) versus mimic. Significant results were entered into a multivariable regression analysis. Sensitivity and specificity analyses were conducted to determine the predictive value of INR for ischemic risk.

RESULTS

116 patients were included; 46 were diagnosed with ischemia, 70 were diagnosed as mimics. 75% of patients were on warfarin for atrial fibrillation versus 25% for venous thrombosis. A statistically significant difference in mean INR for patients with ischemia (n = 46) versus mimics (n = 70) was observed (1.7 vs. 2.8; p < 0.001). In multivariable analysis, both sub-therapeutic INR (p < 0.001) and atrial fibrillation (p = 0.014) were predictors of ischemia. In patients with an INR ≥2, the predictive value of having a non-ischemic etiology was 79%. No patient with an INR of ≥3.6 was found to have ischemia.

CONCLUSIONS

Sub-therapeutic INR and atrial fibrillation are strongly associated with ischemia in patients on warfarin presenting with acute neurologic symptoms. Ischemia is far less likely in patients with an INR of ≥2 and rare in those with an INR ≥3.6. This study shows that the INR value of a patient on warfarin can help stratify patients' risk for acute ischemic stroke and guide further neurologic imaging and workup.

Abstract WMP4: Thrombectomy-only versus Combined Intravenous Alteplase and Thrombectomy: Meta-analysis

Introduction: Contraindications for intravenous thrombolysis are not infrequent (eg. anticoagulation, recent surgery, unclear last known well). With overwhelming recent evidence supporting the use of endovascular thrombectomy for large-vessel occlusive stroke, we conducted a metaanalysis to compare long-term functional outcome between thrombectomy-alone versus combined IV-tPA and thrombectomy.

Hypothesis: Patients with acute ischemic stroke ineligible for IV-tPA treated with thrombectomy-alone have equally favorable long-term functional outcomes to patients treated with combined IV-tPA and thrombectomy

Methods: Searched PubMed from 2014-2016 using pre-specified terms for studies that report odds ratio of improvement in mRS score at 90 days comparing thrombectomy vs IV-tPA stratified by whether patients had received IV-tPA. Multivariate adjusted odds ratios were used for the metaanalysis. Pooled odds ratio estimates across trials were synthesized by using a random-effects model based on Mantel-Haenszel methods. The pooled estimates were compared between thrombectomy-alone and combined IV-tPA and thrombectomy. Forest plots constructed.

Results: Of the 920 studies, 3 studies reported subgroup analysis with 822 participants, 19.5% (N=160) received thrombectomy-alone, 80.5% (N=662) received combined IV-tPA and thrombectomy. Among patients who received thrombectomy-alone, the pooled odds ratio of good functional outcome at 3 months was 2.48 (1.43-4.30), in the combined IV-tPA and thrombectomy group the pooled odds ratio was 1.85 (1.37-2.49).

Conclusions: Endovascular therapy was an effective therapy for patients ineligible for IV-tPA presenting with acute ischemic stroke caused by large vessel occlusive disease. While IV-tPA should not be withheld before thrombectomy in IV-tPA eligible patients, prospective studies are needed to select those who may benefit more from thrombectomy-only treatment.

Keep it simple: vascular risk factors and focal exam findings correctly identify posterior circulation ischemia in "dizzy" patients

BACKGROUND

Dizziness is a common chief complaint of patients presenting to the Emergency Department (ED). Physicians must quickly and accurately identify patients whose etiology is most likely ischemia. Additional tools are available, but often require further training (vestibular testing) or are costly and not always readily available (magnetic resonance imaging (MRI)). This study evaluates the ability of a routine history and simple physical examination to correctly identify dizzy patients with posterior circulation ischemia, and the added utility of CT angiography (CTA).

METHODS

We performed a retrospective analysis of all individuals presenting to the ED with a reported chief complaint of dizziness. Neurology was consulted and CTA ordered at the discretion of the ED provider. Demographic, medical, and radiographic variables were evaluated along with final diagnosis. Multivariable logistic regression and ROC analysis were used to determine factors associated with ischemia, the sensitivity of vascular risk factors and focal exam findings in predicting ischemia, and the additional benefit, if any, of CTA.

RESULTS

One thousand two-hundred sixteen individuals meeting inclusion criteria presented to the ED over a 2 year period and were included in analysis. One hundred (8.2 %) were diagnosed with posterior circulation ischemia. For the entire cohort, age (OR 1.4 per 10 years, p < 0.0001), systolic blood pressure (OR 1.3 per 10 mmHg, p < 0.0001), and focal exam findings (OR 28.69, p < 0.0001) were most significantly associated with ischemia in multivariable modeling. When age, race, sex, presence of vascular risk factors, and focal neurologic findings were entered into ROC analysis, the AUC for correctly identifying posterior circulation ischemia was 0.90. In the subset of patients who underwent CTA (n = 87), the AUC did not improve (0.78 with and without CTA in ROC analysis, p = 0.52).

CONCLUSIONS

A vascular risk assessment and neurological examination are adequate for risk stratification of ischemia in the dizzy patient and should remain the standard evaluation.

Race-Specific Predictors of Mortality in Intracerebral Hemorrhage: Differential Impacts of Intraventricular Hemorrhage and Age Among Blacks and Whites

Background

Intracerebral hemorrhage (ICH) carries high risk for short‐term mortality. We sought to identify race‐specific predictors of mortality in ICH patients.

Methods and Results

We used 2 databases, the Johns Hopkins clinical stroke database and the Nationwide Inpatient Sample (NIS). We included 226 patients with the primary diagnosis of spontaneous ICH from our stroke database between 2010 and 2013; in the NIS, 42 077 patients met inclusion criteria. Logistic regression was used to assess differences in predictors of mortality in blacks compared to whites. In our clinical stroke database, Glasgow Coma Scale (GCS; P=0.016), ICH volume (P=0.013), intraventricular haemorrhage (IVH; P=0.023), and diabetes mellitus (P=0.037) were predictors of mortality in blacks, whereas GCS (P=0.007), ICH volume (P=0.005), age (P=0.002), chronic kidney disease (P=0.003), and smoking (P=0.010) predicted mortality in whites. Among patients with IVH, blacks had over 7 times higher odds of mortality compared to whites (odds ratio [OR], 7.27; P value for interaction, 0.017) and were more likely to present with hydrocephalus (OR, 2.76; P=0.026). In the NIS, black ICH patients had higher rates of external ventricular drain (EVD) placement compared to whites (9.7% vs 5.0%; P<0.001) and were more likely to develop hydrocephalus (OR, 1.32; 95% CI, 1.20–1.46). Comparison of a race‐specific ICH score to the original ICH score showed that the various ICH score components have differential relevance for ICH score performance by race.

Conclusions

IVH and age differentially predict mortality among blacks and whites. Blacks have higher rates of obstructive hydrocephalus and more frequently require EVD placement compared to their white counterparts.

The Need for a Rational Approach to Vasoconstrictive Syndromes: Transcranial Doppler and Calcium Channel Blockade in Reversible Cerebral Vasoconstriction Syndrome

INTRODUCTION

Reversible cerebral vasoconstriction syndrome (RCVS) typically affects young patients and left untreated can result in hemorrhage or ischemic stroke. Though the disorder has been well characterized in the literature, the most appropriate way to diagnose, treat, and evaluate therapeutic response remains unclear. In previous studies, transcranial Doppler ultrasound (TCD) has shown elevated velocities indicative of vasospasm. This imaging modality is noninvasive and inexpensive; an attractive option for diagnosis and therapeutic monitoring if it is sensitive enough to detect changes in the acute setting given that RCVS often affects the distal vessels early in the course of disease. There is also limited data that calcium channel blockade may be effective in treating vasospasm secondary to RCVS, though the agent of choice, formulation, and dose are unclear.

METHODS

We report a small cohort of seven patients presenting with thunderclap headache whose vascular imaging was consistent with RCVS. All were treated with calcium channel blockade and monitored with TCD performed every 1-2 days.

RESULTS

On presentation, TCD correlated with standard neuroimaging findings of vasospasm (on MR, CT, and conventional angiography). TCD was also able to detect improvement in velocities in the acute setting that correlated well with initiation of calcium channel blockade. Long-acting verapamil appeared to have the greatest effect on velocities compared to nimodipine and shorter-acting calcium channel blockers.

CONCLUSION

Though small, our cohort demonstrates potential utility of TCD to monitor RCVS, and relative superiority of extended-release verapamil over other calcium channel blockers, illustrating the need for larger randomized trials.

ICAT: a simple score predicting critical care needs after thrombolysis in stroke patients

Background

Patients receiving intravenous thrombolysis (IVT) for acute ischemic stroke are at risk of developing complications, commonly necessitating admission to an intensive care unit (ICU). At present, most IVT is administered in the Emergency Department or in dedicated stroke units, but no evidence-based criteria exist that allow for early identification of patients at increased risk of developing ICU needs. The present study describes a novel prediction score aiming to identify a subpopulation of post-IVT patients at high risk for critical care interventions.

Methods

We retrospectively analyzed data from 301 patients undergoing IVT at our institutions during a 5-year period. Two hundred and ninety patients met inclusion criteria. The sample was randomly divided into a development and a validation cohort. Logistic regression was used to develop a risk score by weighting predictors of critical care needs based on strength of association.

Results

Seventy-two patients (24.8 %) required critical care interventions. Black race (odds ratio [OR] 3.81, p =0.006), male sex (OR 3.79, p =0.008), systolic blood pressure (SBP; OR 1.45 per 10 mm Hg increase in SBP, p <0.001), and NIH stroke scale (NIHSS; OR 1.09 per 1 point increase in NIHSS, p =0.071) were independent predictors of critical care needs. The optimal model for score development, predicting critical care needs, achieved an AUC of 0.782 in the validation group. The score was named the ICAT (Intensive Care After Thrombolysis) score, assigning the following points: black race (1 point), male sex (1 point), SBP (2 points if 160–200 mm Hg; 4 points if >200 mm Hg), and NIHSS (1 point if 7–12; 2 points if >12). Each 1-point increase in the score was associated with 2.22-fold increased odds for critical care needs (95 % CI 1.78–2.76, p <0.001). A score ≥2 was associated with over 13 times higher odds of critical care needs compared to a score <2 (OR 13.60, 95 % CI 3.23–57.19), predicting critical care with 97.2 % sensitivity and 28.0 % specificity.

Conclusion

The ICAT score, combining information about race, sex, SBP, and NIHSS, predicts critical care needs in post-IVT patients and may be helpful when triaging post-IVT patients to the appropriate monitoring environment.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-016-1195-7) contains supplementary material, which is available to authorized users.

Predicting Hemorrhagic Transformation of Acute Ischemic Stroke: Prospective Validation of the HeRS Score

Hemorrhagic transformation (HT) increases the morbidity and mortality of ischemic stroke. Anticoagulation is often indicated in patients with atrial fibrillation, low ejection fraction, or mechanical valves who are hospitalized with acute stroke, but increases the risk of HT. Risk quantification would be useful. Prior studies have investigated risk of systemic hemorrhage in anticoagulated patients, but none looked specifically at HT. In our previously published work, age, infarct volume, and estimated glomerular filtration rate (eGFR) significantly predicted HT. We created the hemorrhage risk stratification (HeRS) score based on regression coefficients in multivariable modeling and now determine its validity in a prospectively followed inpatient cohort.A total of 241 consecutive patients presenting to 2 academic stroke centers with acute ischemic stroke and an indication for anticoagulation over a 2.75-year period were included. Neuroimaging was evaluated for infarct volume and HT. Hemorrhages were classified as symptomatic versus asymptomatic, and by severity. HeRS scores were calculated for each patient and compared to actual hemorrhage status using receiver operating curve analysis.Area under the curve (AUC) comparing predicted odds of hemorrhage (HeRS score) to actual hemorrhage status was 0.701. Serum glucose (P < 0.001), white blood cell count (P < 0.001), and warfarin use prior to admission (P = 0.002) were also associated with HT in the validation cohort. With these variables, AUC improved to 0.854. Anticoagulation did not significantly increase HT; but with higher intensity anticoagulation, hemorrhages were more likely to be symptomatic and more severe.The HeRS score is a valid predictor of HT in patients with ischemic stroke and indication for anticoagulation.

The NIH Stroke Scale Has Limited Utility in Accurate Daily Monitoring of Neurologic Status

BACKGROUND AND PURPOSE

The National Institute of Health Stroke Scale (NIHSS) is rapid and reproducible, a seemingly attractive metric for the documentation of clinical progress in patients presenting with ischemic stroke. Many institutions have adopted it into daily clinical practice. Unfortunately, the scale may not adequately capture all forms of functional change. We evaluate its utility as a measure of recovery in patients treated with intravenous tissue plasminogen activator (IV tPA) for ischemic stroke.

METHODS

We prospectively evaluated the difference in the rate of improvement based on NIHSS (a ≥4 point change based on previous trials) versus physician-documented subjective and objective measures in 41 patients' status post IV tPA treatment. The NIHSS 24 hours posttreatment, on discharge, and at follow-up were compared to NIHSS on admission using tests of proportions and McNemar tests of paired data. Secondary analyses were performed defining significant improvement as NIHSS changes of 1 to 3 points.

RESULTS

The mean NIHSS improved from 9 to 6, 24 hours post-tPA. Of the 41 patients, 29 improved by physician documentation, although only 11 of the 29 met the NIHSS criteria (P < .001; McNemar P < .001). On discharge, 20 of the 41 patients met the NIHSS criteria; however, the proportion "better" by physician documentation (71%) remained significantly higher (P = .04; McNemar P = .004). The mean postdischarge follow-up NIHSS was 2. Twenty of the 21 patients improved by documentation versus 16 of the 21 by NIHSS (P = .08, McNemar P = .125). Using NIHSS changes of 1 to 3 increased sensitivity for detecting improvement but remained lower than physician documentation.

CONCLUSION

The NIHSS has many advantages; however, it may miss functional changes when used in place of a comprehensive neurological examination to measure improvement poststroke.

Troponin elevation predicts critical care needs and in-hospital mortality after thrombolysis in white but not black stroke patients

INTRODUCTION

Stroke patients undergoing intravenous thrombolysis (IVT) are at increased risk for critical care interventions and mortality. Cardiac troponin elevation is common in stroke patients; however, its prognostic significance is unclear. The present study evaluates troponin elevation as a predictor of critical care needs and mortality in post-IVT patients and describes racial differences in its predictive accuracy.

METHODS

Logistic regression and receiver operating characteristics (ROC) analysis were used to determine racial differences in the predictive accuracy of troponin elevation for critical care needs and mortality in post-IVT patients.

RESULTS

Troponin elevation predicted critical care needs in white (odds ratio [OR] 29.40, 95% confidence interval [CI] 4.86-177.81) but not black patients (OR 0.50, 95% CI 0.14-1.78; P value for interaction < .001). Adding troponin elevation to a prediction model for critical care needs in whites improved the area under the curve from 0.670 to 0.844 (P = .006); however, addition of troponin elevation did not improve the model in blacks (area under the curve 0.843 vs 0.851, P = .54). Troponin elevation was associated with in-hospital mortality in whites (OR 21.94, 95% CI 3.51-137.11) but not blacks (OR 1.10, 95% CI 0.19-6.32, P value for interaction .022).

CONCLUSION

Troponin is a useful predictor of poor outcome in white but not black post-IVT stroke patients.

Critical Care Needs in Patients with Diffusion-Weighted Imaging Negative MRI after tPA--Does One Size Fit All?

Background and Purpose

Patients who receive intravenous (IV) tissue plasminogen activator (tPA) for ischemic stroke are currently monitored in an intensive care unit (ICU) or a comparable stroke unit for at least 24 hours due to the high frequency of neurological exams and vital sign checks. The present study evaluates ICU needs in patients with diffusion-weighted imaging (DWI) negative MRI after IV tPA.

Methods

A retrospective chart review was performed for 209 patients who received IV tPA for acute stroke. Data on stroke risk factors, physiologic parameters, stroke severity, MRI characteristics, and final diagnosis were collected. The timing and nature of ICU interventions, if needed, was recorded. Multivariable logistic regression was used to determine factors associated with subsequent ICU needs.

Results

Patients with cerebral infarct on MRI after tPA had over 9 times higher odds of requiring ICU care compared to patients with DWI negative MRI (OR 9.2, 95% CI 2.49–34.15). All DWI negative patients requiring ICU care did so by the end of tPA infusion (p = 0.006). Among patients with DWI negative MRI, need for ICU interventions was associated with higher NIH Stroke Scale (NIHSS) scores (p<0.001), uncontrolled hypertension (p<0.001), seizure at onset (p = 0.002), and reduced estimated glomerular filtration rate (eGFR) (p = 0.010).

Conclusions

Only a small number of DWI negative patients required ICU care. In patients without critical care needs by the end of thrombolysis, post-tPA MRI may be considered for triaging DWI negative patients to a less resource intense monitoring environment.

Abstract 202: The NIH Stroke Scale Can Miss Improvement After IV tPA For Acute Ischemic Stroke

Background and Objective: The National Institute of Health Stroke Scale (NIHSS) is the most commonly used metric to evaluate stroke severity and improvement following intervention. Despite its advantages as a rapid, reproducible screening tool, it may be too insensitive to adequately capture functional improvement following treatment. We evaluated the difference in rate of improvement by previously accepted criteria (change of ≥4 NIHSS points) versus physician documentation in patients receiving IV tissue plasminogen activator (tPA) for acute ischemic stroke.

Methods: Prospectively collected data on all patients receiving IV tPA over a 15 month period were retrospectively reviewed. NIHSS 24 hours post-treatment and on discharge were extrapolated based on examination and compared to NIHSS on presentation. NIHSS scores at post-discharge follow-up were also recorded. Two reviewers evaluated the medical record and determined improvement based on physician documentation. Using tests of proportion, ‘significant improvement’ by NIHSS was compared to physician documentation at each time point.

Results: Forty-one patients were treated with IV tPA. The mean admission NIHSS was 8.6 and improved to 6.4 24 hours post-tPA. Twenty-nine of 41 patients (79%) were “better” by documentation; however only 11/41 (27%) met NIHSS criteria for improvement (p compared to documentation <0.001). On discharge, 20/41 patients (49%) met NIHSS criteria for improvement; however a significant difference between physician documentation remained (p=0.04). The mean post-discharge follow-up NIHSS score was 2.0. 20/21 patients (95%) were “better” compared to 16/21 (76%) meeting NIHSS criteria (p=0.08).

Conclusion: The NIHSS may inadequately capture functional improvement post-treatment, especially in the days immediately following intervention.

Abstract T P340: The Electronic Medical Record: Are the Times Accurate?

Background: The Electronic Medical Record (EMR) was designed to improve patient outcomes, eliminate unnecessary costs, and provide continuity of care. Intravenous tissue plasminogen activator (IV t-PA) is most effective when administered early. In order to effectively decrease door to needle times, a stroke center must be able to correctly identify the steps within their pathway where there is room for improvement. A reliable way to measure and record time is therefore crucial. In our experience, the EMR has been extremely helpful with data collection; however, there are limitations, particularly with respect to the automatic time stamp for electronic documentation. We sought to determine the accuracy of the EMR time stamp versus real-time paper charting in our assessment of the acute stroke patient.

Methods: 33 patients treated with IV t-PA between July 2013 and July 2014 were included in analysis. Specific time points were documented on a Nursing Flow Sheet by a dedicated stroke nurse who is part of each acute stroke assessment and were compared to the time points documented in the EMR. The average discrepancy between the Nursing Flow Sheet and EMR for each time point was calculated. Arrival time to the Emergency Department (ED), time to CT scanner, lab collection time, and t-PA bolus time were evaluated.

Results: The average discrepancy on arrival time to the ED was 7 minutes. The Nursing Flowsheet documented earlier arrival times in all but 2 cases. The arrival time obtained from the EMR required extrapolation- either from the point of comprehensive triage where vital signs were obtained (n=24) or from the code sheet scanned into the electronic record (n=9). Times documented on the code sheet were only 3 minutes different from the Nursing Flow Sheet versus 9 minutes for those with vital signs charted. The average discrepancy between time to the CT scanner on the Nursing Flow Sheet and the order time in the EMR was 13 minutes. The majority of patients (88%) had imaging completed prior to the order being placed. The discrepancies for lab collection time and t-PA bolus time were smaller (4 minutes and 0 minutes respectively).

Conclusion: Automatic time stamps provided by an EMR may not accurately reflect true time points, making improvement of door to needle times more difficult.

Abstract T P341: Transitions of Care: Increasing Follow-up and Decreasing Readmission Rates After Hospitalization for Acute Ischemic Stroke

Background: Acute ischemic stroke accounts for nearly 800,000 inpatient hospitalizations annually in the United States. Post-discharge disposition varies greatly among stroke survivors. The transition to home or nursing facilities post-hospitalization provides an opportunity to improve quality of life; but also increases the potential for miscommunication between patients, care givers, and health care providers. This may result in the need for hospital readmission, which further complicates patient care. A timely post-discharge neurology clinic visit would be the ideal forum to address miscommunication and reduce readmission. Without dedicated infrastructure, it is difficult to see patients quickly, resulting in a poor follow-up rate. Our Stroke Center sought to improve transitions for stroke survivors with the addition of a neurology nurse case manager, creation of a targeted post-discharge plan, and implementation of the Bayview Stroke Intervention Clinic (BaSIC).

Methods: Beginning in September 2013, all patients admitted with acute ischemic stroke were assessed by our case manager prior to discharge and a specific post-discharge plan was developed including a plan for follow-up within 4-6 weeks. This was achieved with the implementation of a weekly neurology clinic dedicated to post-stroke care, staffed by two cerebrovascular neurologists. To gauge the effectiveness of our intervention to improve follow-up rates and decrease hospital readmissions, we retrospectively compared stroke patients discharged in fiscal year 2013 (prior to implementation) to those discharged in 2014. Annual readmission rates as well as follow-up rates in neurology clinic at 30, 60 and 90 day post-discharge intervals were assessed.

Results: With implementation of targeted post-discharge planning and BaSIC clinic, the 30 day follow-up rate (2.6% pre versus 8.4% post; p=0.01), 60 day follow-up rate (8.3% pre versus 16% post; p=0.01), and 90 day follow-up rate (14.4% pre versus 20.6% post; p=0.10) all improved. Hospital readmissions fell from 10.5% to 8.7% (p=0.63).

Conclusion: Implementation of a targeted post-discharge plan and specialized stroke follow-up clinic decreases readmissions and increases follow-up visits with neurology.

Abstract T P338: Time is of the Essence: A Nurse-Based Intervention to Improve Door to Needle Times

Background: For acute ischemic stroke, the chance of improved recovery is directly impacted by the length of time from symptom onset to administration of intravenous tissue plasminogen activator (IV t-PA). Despite the importance of rapid treatment, stroke centers struggle with achieving consistent door to needle times of less than 60 minutes. In an effort to improve efficiency, we implemented a change in our response to the acute stroke patient by adding a dedicated stroke nurse and Nursing Flow Sheet that focuses on critical benchmarks (e.g., door to CT time) prior to treatment. We collected data on patients treated with IV t-PA pre- and post-intervention to determine if our process increased the number of patients receiving t-PA in less than 60 minutes.

Methods: 137 patients (n=77 pre, 60 post) who were treated with IV t-PA between 2009-2013 were included in analysis. Student’s t-tests and Fisher’s exact tests were used to compare door to needle times pre- and post-intervention. Additional data were collected regarding: patient demographics, admission characteristics (e.g., day of the week), stroke severity, medical comorbidities, and other barriers to t-PA administration (e.g., need for antihypertensives or additional imaging).

Results: With implementation, the mean time to treatment only decreased from 82 to 78 minutes (p=0.58); however, the percentage of patients successfully treated within 60 minutes of arrival improved from 26% to 58% (p=0.003). NIH Stroke Scale severity and need for additional imaging (i.e., CTA of the chest) were associated with increased time to treatment.

Conclusion: The use of a dedicated stroke nurse and Nursing Flow Sheet as part of the acute stroke assessment reduces door to needle times and significantly increases the proportion of patients treated with IV tPA within 60 minutes from hospital arrival.

Novel score predicting gastrostomy tube placement in intracerebral hemorrhage

BACKGROUND AND PURPOSE

Dysphagia after intracerebral hemorrhage (ICH) contributes significantly to morbidity, often necessitating placement of a percutaneous endoscopic gastrostomy (PEG) tube. This study describes a novel risk prediction score for PEG placement after ICH.

METHODS

We retrospectively analyzed data from 234 patients with ICH presenting during a 4-year period. One hundred eighty-nine patients met inclusion criteria. The sample was randomly divided into a development and a validation cohort. Logistic regression was used to develop a risk score by weighting predictors of PEG placement based on strength of association.

RESULTS

Age (odds ratio [OR], 1.64 per 10-year increase in age; 95% confidence interval [CI], 1.02-2.65), black race (OR, 3.26; 95% CI, 0.96-11.05), Glasgow Coma Scale (OR, 0.80; 95% CI, 0.62-1.03), and ICH volume (OR, 1.38 per 10-mL increase in ICH volume) were independent predictors of PEG placement. The final model for score development achieved an area under the curve of 0.7911 (95% CI, 0.6931-0.8892) in the validation group. The score was named the GRAVo score: Glasgow Coma Scale ≤12 (2 points), Race (1 point for black), Age >50 years (2 points), and ICH Volume >30 mL (1 point). A score >4 was associated with ≈12× higher odds of PEG placement when compared with a score ≤4 (OR, 11.81; 95% CI, 5.04-27.66), predicting PEG placement with 46.55% sensitivity and 93.13% specificity.

CONCLUSIONS

The GRAVo score, combining information about Glasgow Coma Scale, race, age, and ICH volume, may be a useful predictor of PEG placement in ICH patients.

Infarct volume predicts critical care needs in stroke patients treated with intravenous thrombolysis

INTRODUCTION

Patients receiving intravenous thrombolysis with recombinant tissue plasminogen activator (IVT) for ischemic stroke are monitored in an intensive care unit (ICU) or a comparable unit capable of ICU interventions due to the high frequency of standardized neurological exams and vital sign checks. The present study evaluates quantitative infarct volume on early post-IVT MRI as a predictor of critical care needs and aims to identify patients who may not require resource intense monitoring.

METHODS

We identified 46 patients who underwent MRI within 6 h of IVT. Infarct volume was measured using semiautomated software. Logistic regression and receiver operating characteristics (ROC) analysis were used to determine factors associated with ICU needs.

RESULTS

Infarct volume was an independent predictor of ICU need after adjusting for age, sex, race, systolic blood pressure, NIH Stroke Scale (NIHSS), and coronary artery disease (odds ratio 1.031 per cm(3) increase in volume, 95% confidence interval [CI] 1.004-1.058, p = 0.024). The ROC curve with infarct volume alone achieved an area under the curve (AUC) of 0.766 (95% CI 0.605-0.927), while the AUC was 0.906 (95% CI 0.814-0.998) after adjusting for race, systolic blood pressure, and NIHSS. Maximum Youden index calculations identified an optimal infarct volume cut point of 6.8 cm(3) (sensitivity 75.0%, specificity 76.7%). Infarct volume greater than 3 cm(3) predicted need for critical care interventions with 81.3% sensitivity and 66.7% specificity.

CONCLUSION

Infarct volume may predict needs for ICU monitoring and interventions in stroke patients treated with IVT.

Collaterals: an important determinant of prolonged ischemic penumbra versus rapid cerebral infarction?

Intravenous tissue plasminogen activator is the mainstay for the treatment of acute ischemic stroke in patients presenting within 4.5 h of symptom onset. Studies have demonstrated that treating patients early leads to improved long-term outcomes. MR imaging currently allows quantification of the ischemic penumbra in order to better identify individuals most likely to benefit from intervention, irrespective of “time last seen normal.” Its increasing use in clinical practice has demonstrated individual differences in rate of infarction. One explanation for this variability is a difference in collateral blood flow. We report two cases that highlight the individual variability of infarction rate, and discuss potential underlying mechanisms that may influence treatment decisions and outcomes.

The Association between Specific Substances of Abuse and Subcortical Intracerebral Hemorrhage Versus Ischemic Lacunar Infarction

Background: Hypertension damages small vessels, resulting in both lacunar infarction and subcortical intracerebral hemorrhage (ICH). Substance abuse has also been linked to small vessel pathology. This study explores whether the use of specific substances (e.g., cocaine, tobacco) is associated with subcortical ICH over ischemia in hypertensive individuals.

Methods: Patients with hypertension, admitted with lacunar infarcts (measuring <2.0 cm) or subcortical ICH, were included in analysis. Brain MRIs and head CTs were retrospectively reviewed along with medical records. Demographic information and history of substance use (illicit/controlled: cocaine, heroin, marijuana, benzodiazepines, and methadone; alcohol; and tobacco) was obtained. “Current use” and “history of use” were determined from patient history or a positive toxicology screen. “Heavy use” was defined as: smoking- ≥0.5 packs per day or 10 pack-years; alcohol- average of >1 drink per day (women), >2 drinks per day (men). Logistic regression was performed with ICH as the dependent variable comparing those presenting with ICH to those presenting with ischemia.

Results: Of the 580 patients included in analysis, 217 (37%) presented with ICH. The average age was similar between the two groups (64.7 versus 66.3 years). Illicit/controlled drug use was associated with a significantly increased risk of ICH over stroke in unadjusted models (25 versus 15%, p = 0.02), with the largest effect seen in users ≥65 years old (not statistically significant). Smoking was associated with ischemia over ICH in a dose-dependent manner: any history of smoking OR 1.84, CI 1.19–2.84; current use OR 2.23, CI 1.37–3.62; heavy use OR 2.48, CI 1.50–4.13. Alcohol use was not preferentially associated with either outcome (p = 0.29).

Conclusion: In hypertensive patients, tobacco use is associated with an increased risk of subcortical ischemia compared to ICH, while use of illicit/controlled substances appears to be predictive of hemorrhage.

A comparison of two methods for MRI classification of at-risk tissue and core infarction

Objective: To compare how at-risk tissue and core infarction were defined in two major trials that tested the use of MRI in selecting acute stroke patients for endovascular recanalization therapy.

Methods: MRIs from 12 patients evaluated for possible endovascular therapy were processed using the methods published from two major trials, MR RESCUE and DEFUSE 2. Specifically, volumes of at-risk tissue and core infarction were generated from each patient’s MRI. MRIs were then classified as whether or not they met criteria for salvageable tissue: “penumbral pattern” for MR RESCUE and/or “target profile” for DEFUSE 2 as defined by each trial.

Results: Volumes of at-risk tissue measured by the two definitions were correlated (p = 0.017) while the volumes of core infarct were not (p = 0.059). The volume of at-risk tissue was consistently larger when defined by the penumbral pattern than the target profile while the volume of core infarct was consistently larger when defined by the target profile than the penumbral pattern. When these volumes were used to classify the MRI scans, 9 out of 12 patients (75%) were classified as having a penumbral pattern, while only 4 out of 12 patients (33%) were classified as having a target profile. Of the 9 patients classified as penumbral pattern, 5 (55%) were classified differently by the target profile.

Interpretation: Our analysis found that the MR RESCUE trial defined salvageable tissue in a way that made it more likely for patients be labeled as favorable for treatment. For the cohort of patients examined in this study, had they been enrolled in both trials, most of the patients identified as having salvageable tissue by the MR RESCUE trial would not have been considered to have salvageable tissue in the DEFUSE 2 trial. Caution should be taken in concluding that MRI selection for endovascular therapy is not effective as imaging selection criteria were substantially different between the two trials.

Predicting symptomatic intracerebral hemorrhage versus lacunar disease in patients with longstanding hypertension

BACKGROUND AND PURPOSE

Hypertension results in a spectrum of subcortical cerebrovascular disease. It is unclear why some individuals develop ischemia and others develop hemorrhage. Risk factors may differ for each population. We identify factors that predispose an individual to subcortical symptomatic intracerebral hemorrhage (sICH) compared with ischemia.

METHODS

Demographic and laboratory data were prospectively collected for hypertensive patients presenting with ischemic stroke or sICH during an 8.5-year period. Neuroimaging was retrospectively reviewed for acute (subcortical lacunes [<2.0 cm] versus subcortical sICH) and chronic (periventricular white matter disease and cerebral microbleeds) findings. We evaluated the impact of age, race, sex, serum creatinine, erythrocyte sedimentation rate, low-density lipoprotein, presence of periventricular white matter disease or cerebral microbleeds, and other factors on the risk of sICH versus acute lacune using multivariate logistic regression.

RESULTS

Five hundred seventy-one patients had subcortical pathology. The presence of cerebral microbleeds (adjusted odds ratio [OR], 3.39; confidence interval [CI], 2.09-5.50) was a strong predictor of sICH, whereas severe periventricular white matter disease predicted ischemia (OR, 0.56 risk of sICH; CI, 0.32-0.98). This association was strengthened when the number of microbleeds was evaluated; subjects with >5 microbleeds had an increased risk of sICH (OR, 4.11; CI, 1.96-8.59). It remained significant when individuals with only cortical microbleeds were removed (OR, 1.77, CI, 1.13-2.76). An elevated erythrocyte sedimentation rate (OR, 1.19 per 10 mm/h increase; CI, 1.06-1.34) was significantly associated with sICH, whereas low-density lipoprotein was associated with ischemic infarct (OR, 0.93 risk of sICH per 10 mg/dL increase; CI, 0.86-0.99).

CONCLUSIONS

Subclinical pathology is the strongest predictor of the nature of subsequent symptomatic event. Low-density lipoprotein and erythrocyte sedimentation rate may also have a role in risk stratification.

Predictors of critical care needs after IV thrombolysis for acute ischemic stroke

BACKGROUND AND PURPOSE

Intravenous (IV) tissue plasminogen activator (tPA) is the only Food and Drug Administration (FDA)-approved treatment for acute ischemic stroke. Post tPA patients are typically monitored in an intensive care unit (ICU) for at least 24 hours. However, rigorous evidence to support this practice is lacking. This study evaluates factors that predict ICU needs after IV thrombolysis.

METHODS

A retrospective chart review was performed for 153 patients who received intravenous tPA for acute ischemic stroke. Data on stroke risk factors, physiologic parameters on presentation, and stroke severity were collected. The timing and nature of an intensive care intervention, if needed, was recorded. Using multivariable logistic regression, we determined factors associated with requiring ICU care.

RESULTS

African American race (Odds Ratio [OR] 8.05, 95% Confidence Interval [CI] 2.65-24.48), systolic blood pressure, and National Institutes of Health Stroke Scale (NIHSS) (OR 1.20 per point increase, 95% CI 1.09-1.31) were predictors of utilization of ICU resources. Patients with an NIHSS≥10 had a 7.7 times higher risk of requiring ICU resources compared to patients who presented with an NIHSS<10 (p<0.001). Most patients with ICU needs developed them prior to the end of tPA infusion (81.0%, 95% CI 68.8-93.1). Only 7% of patients without ICU needs by the end of the tPA infusion went on to require ICU care later on. These patients were more likely to have diabetes mellitus and had significantly higher NIHSS compared to patients without further ICU needs (mean NIHSS 17.3, 95% CI 11.5-22.9 vs. 9.2, 95% CI 7.7-9.6).

CONCLUSION

Race, NIHSS, and systolic blood pressure predict ICU needs following tPA for acute ischemic stroke. We propose that patients without ICU needs by the end of the tPA infusion might be safely monitored in a non-ICU setting if NIHSS at presentation is low.

Cerebral Amyloid Angiopathy: A Hidden Risk for IV Thrombolysis?

Recombinant tissue plasminogen activator (t-PA) is the only FDA approved therapy for acute ischemic stroke. Cerebral microbleeds (CMBs) or cerebral amyloid angiopathy (CAA) are currently not contraindications, however, data regarding this complex issue are limited. We report 2 cases of fatal intracerebral hemorrhage (sICH) after IV t-PA, each with evidence of CAA. Patients with CAA may have increased risk for IV thrombolysis-associated sICH. We highlight the severe and catastrophic pattern of ICH, which may be a defining characteristic, and discuss the limitations of our current understanding of the risk of thrombolysis-associated ICH in patients with CAA and/or CMBs.

Stuttering Lacunes: An Acute Role for Clopidogrel?

INTRODUCTION

Intravenous tissue plasminogen activator (IV tPA) has revolutionized the treatment of acute ischemic stroke. However, there remain situations when administration is relatively contraindicated (eg. , arrival outside the accepted treatment window, mild or rapidly improving symptoms). Optimal treatment in these situations is less clear.

CASE SERIES

We describe a small case series of 7 patients presenting with fluctuating symptoms concerning for a capsular warning syndrome (acute isolated motor and/or sensory deficits without cortical signs, usually attributed to small vessel pathology), often referred to as a "stuttering lacune", who were orally loaded with 300mg of clopidogrel. Four of the 7 patients had complete resolution of their symptoms following the load. The others experienced stabilization of their deficits, but were discharged with mild persistent symptoms. Four patients had evidence of diffusion bright lesions on MRI, while the others had no evidence of infarction. None of the patients experienced hemorrhagic conversion of their infarct or other bleeding complications.

CONCLUSION

Our experience suggests that acutely loading with clopidogrel may be both effective and well tolerated in the treatment of stuttering lacunes.

Serum creatinine may indicate risk of symptomatic intracranial hemorrhage after intravenous tissue plasminogen activator (IV tPA)

Symptomatic intracranial hemorrhage (sICH) is a known complication following administration of intravenous tissue plasminogen activator (IV tPA) for acute ischemic stroke. sICH results in high rates of death or long-term disability. Our ability to predict its occurrence is important in clinical decision making and when counseling families. The initial National Institute of Neurological Disorders and Stroke (NINDS) investigators developed a list of relative contraindications to IV tPA meant to decrease the risk of subsequent sICH. To date, the impact of renal impairment has not been well studied. In the current study we evaluate the potential association between renal impairment and post-tPA intracranial hemorrhage (ICH). Admission serum creatinine and estimated glomerular filtration rate (eGFR) were recorded in 224 patients presenting within 4.5 hours from symptom onset and treated with IV tPA based on NINDS criteria. Neuroimaging was obtained 1 day post-tPA and for any change in neurologic status to evaluate for ICH. Images were retrospectively evaluated for hemorrhage by a board-certified neuroradiologist and 2 reviewers blinded to the patient's neurologic status. Medical records were reviewed retrospectively for evidence of neurologic decline indicating a "symptomatic" hemorrhage. sICH was defined as subjective clinical deterioration (documented by the primary neurology team) and hemorrhage on neuroimaging that was felt to be the most likely cause. Renal impairment was evaluated using both serum creatinine and eGFR in a number of ways: 1) continuous creatinine; 2) any renal impairment by creatinine (serum creatinine >1.0 mg/dL); 3) continuous eGFR; and 4) any renal impairment by eGFR (eGFR <60 mL/min per 1.73 m²). Student paired t tests, Fisher exact tests, and multivariable logistic regression (adjusted for demographics and vascular risk factors) were used to evaluate the relationship between renal impairment and ICH. Fifty-seven (25%) of the 224 patients had some evidence of hemorrhage on neuroimaging. The majority of patients were asymptomatic. Renal impairment (defined by serum creatinine >1.0 mg/dL) was not associated with combined symptomatic and asymptomatic intracranial bleeding (p = 0.359); however, there was an adjusted 5.5-fold increased odds of sICH when creatinine was >1.0 mg/dL (95% confidence interval, 1.08-28.39), and the frequency of sICH for patients with elevated serum creatinine was 10.6% (12/113), versus 1.8% (2/111) in those with normal renal function (p = 0.010). Our study suggests that renal impairment is associated with higher risk of sICH after administration of IV tPA. As IV tPA is an important and effective treatment for acute ischemic stroke, a multicenter study is needed to determine whether the observation that renal dysfunction is associated with sICH from this retrospective study holds true in a larger prospective trial.

Hemorrhagic transformation in patients with acute ischaemic stroke and an indication for anticoagulation

BACKGROUND AND PURPOSE

Intracerebral hemorrhage (ICH) can occur in patients following acute ischaemic stroke in the form of hemorrhagic transformation, and results in significant long-term morbidity and mortality. Anticoagulation theoretically increases risk. We evaluated stroke patients with an indication for anticoagulation to determine the factors associated with hemorrhagic transformation.

METHODS

Three-hundred and forty-five patients with ICD-9 codes indicating: (i) acute ischaemic stroke; and (ii) an indication for anticoagulation were screened. One-hundred and twenty-three met inclusion criteria. Data were collected retrospectively. Neuroimaging was reviewed for infarct volume and evidence of ICH. Hemorrhages were classified as: hemorrhagic conversion (petechiae) versus intracerebral hematoma (a space occupying lesion); symptomatic versus asymptomatic. Using multivariable logistic regression, we determined the hypothesized factors associated with intracerebral bleeding.

RESULTS

Age [odds ratio (OR) = 1.50 per 10-year increment, 95% confidence interval (CI) 1.07-2.08], infarct volume (OR = 1.10 per 10 ccs, 95% CI 1.06-1.18) and worsening category of renal impairment by estimated glomerular filtration rate (eGFR; OR = 1.95, 95% CI 1.04-3.66) were predictors of hemorrhagic transformation. Ninety- nine out of 123 patients were anticoagulated. Hemorrhage rates of patients on and off anticoagulation did not differ (25.3% vs. 20.8%; P = 0.79); however, all intracerebral hematomas (n = 7) and symptomatic bleeds (n = 8) occurred in the anticoagulated group.

CONCLUSIONS

The risk of hemorrhagic transformation in patients with acute ischaemic stroke and an indication for anticoagulation is multifactorial, and most closely associated with an individual's age, infarct volume and eGFR.

Differentiation of transverse sinus thrombosis from congenitally atretic cerebral transverse sinus with CT

BACKGROUND AND PURPOSE

Transverse sinus thrombosis can have nonspecific clinical and radiographic signs. We hypothesized that the novel "sigmoid notch sign" (on head CT) can help differentiate transverse sinus thrombosis from a congenitally atretic sinus among individuals with absent signal in 1 transverse sinus by MR venography.

METHODS

We retrospectively evaluated 53 subjects with a unilaterally absent transverse sinus signal on MR venography. Eleven had true transverse sinus thrombosis and 42 had an atretic transverse sinus. Reviewers were trained in the sigmoid notch sign: "positive" if 1 of the sigmoid notches was asymmetrically smaller than the other, consistent with a congenitally absent transverse sinus on that side. This sign was scored on CT scans by 2 blinded reviewers to determine if signal dropout was clot or atretic sinus. A consensus rating was reached when the reviewers disagreed. Characteristics of the sigmoid notch sign as a diagnostic test were compared with a gold standard of full chart review by an independent reviewer.

RESULTS

Each reviewer had a sensitivity of 91% (detecting 10 of 11 clots based on a negative sigmoid notch sign) and specificity of 71% to 81%; consensus specificity increased to 86% (36 of 42 individuals with an atretic sinus had a positive notch sign, detecting atretic sinuses based on presence of the sign).

CONCLUSIONS

Asymmetries of the sigmoid notches on noncontrast brain CT is a very sensitive and specific measure of differentiating transverse sinus thrombosis from an atretic transverse sinus when absence of transverse sinus flow is visualized on MR venography.

Abstract 2424: Who Bleeds? Predicting Intracranial Bleeding in Patients with Acute Ischemic Stroke and an Indication for Anticoagulation

Introduction: Many patients with acute ischemic stroke also have an indication for anticoagulation. A major concern in these patients is whether they are at increased risk for intracranial bleeding, and if so, what factors further increase their risk. We evaluated stroke patients with an indication for anticoagulation to determine what factors are associated with increased risk of intracranial bleeding.

Methods: Patients presenting with acute ischemic stroke and an indication for anticoagulation were included in analysis. Data were collected in the following categories: demographics (age, race, gender), medical profile (blood pressure, glycemic control, statin use/LDL, renal function [divided into GFR categories- 0: GFR ≥60, 1: GFR 30-59, or 2: GFR <30], antiplatelet use, anticoagulation status), and stroke characteristics (type of stroke, time from onset of symptoms to anticoagulation, NIH Stroke Scale). Stroke volume, gradient echo positivity, and evidence of intracranial bleeding on head CT and MRI were also assessed. Hemorrhages were classified as: hemorrhagic conversion (petechiae) versus intracranial hemorrhage (a space occupying lesion), and symptomatic versus asymptomatic (based on subjective clinical worsening noted by the primary neurology team). Using stepwise regression analysis we determined which factors were associated with increased risk of intracranial bleeding (with any intracranial bleeding as the primary outcome).

Results: 143 patients (mean age 63.5 years) met criteria and were included in analysis. 117 were placed on anticoagulation. The most common indications for anticoagulation were atrial fibrillation (35.6%), deep vein thrombosis (27.3%), presence of a hypercoagulable state (18.2%), and pulmonary embolism (17.5%). The difference in bleeding rates between those placed on anticoagulation and those treated with an antiplatelet agent was not statistically significant (25.6% versus 23.1%, χ2=0.785), but all of the intracranial hemorrhages (n=8) and symptomatic bleeds (n=9) occurred in the anticoagulated group. Age (OR= 1.31 per 10 year increment, 95% CI 0.98-1.74), volume (OR= 1.13 per 10 cc’s, 95% CI 1.05-1.21), and worsening GFR category (OR= 1.81, 95% CI 1.01-3.26) were predictors of intracranial bleeding. Odds of hemorrhage was predicted by exponentiating the equation: -3.823563 + (0.0120706)*(Volume) + (0.5939482)*(GFR Category) + (0.0266442)*(Age). Probability of hemorrhage can then be calculated.

Conclusions: Probability of intracranial bleeding in patients with acute ischemic stroke and an indication for anticoagulation can be calculated based on an individual’s age, stroke volume, and GFR. This score can be used to assist with prognosis and clinical management. While anticoagulation does not appear to increase risk of bleeding, it does tend to result in larger, more symptomatic bleeds.

Deferiprone reduces hemosiderin deposits in the brain of a patient with superficial siderosis

A man with superficial siderosis showed improvement in symptoms and reduction in hemosiderin by MR imaging following treatment with deferiprone, a lipid-soluble iron chelator.