Poor haemorrhagic stroke outcomes during the COVID-19 pandemic are driven by socioeconomic disparities: analysis of nationally representative data

Background

Nationally representative studies evaluating the impact of the COVID-19 pandemic on haemorrhagic stroke outcomes are lacking.

Methods

In this pooled cross-sectional analysis, we identified adults (≥18 years) with primary intracerebral haemorrhage (ICH) or subarachnoid haemorrhage (SAH) from the National Inpatient Sample (2016-2020). We evaluated differences in rates of in-hospital outcomes between the prepandemic (January 2016-February 2020) and pandemic (March-December 2020) periods using segmented logistic regression models. We used multivariable logistic regression to evaluate differences in mortality between patients admitted from April to December 2020, with and without COVID-19, and those admitted from April to December 2019. Stratified analyses were conducted among patients residing in low-income and high-income zip codes, as well as among patients with extreme loss of function (E-LoF) and those with minor to major loss of function (MM-LoF).

Results

Overall, 309 965 patients with ICH (47% female, 56% low income) and 112 210 patients with SAH (62% female, 55% low income) were analysed. Prepandemic, ICH mortality decreased by ~1% per month (adjusted OR, 95% CI: 0.99 (0.99 to 1.00); p<0.001). However, during the pandemic, the overall ICH mortality rate increased, relative to prepandemic, by ~2% per month (1.02 (1.00 to 1.04), p<0.05) and ~4% per month (1.04 (1.01 to 1.07), p<0.001) among low-income patients. There was no significant change in trend among high-income patients with ICH (1.00 (0.97 to 1.03)). Patients with comorbid COVID-19 in 2020 had higher odds of mortality (versus 2019 cohort) only among patients with MM-LoF (ICH, 2.15 (1.12 to 4.16), and SAH, 5.77 (1.57 to 21.17)), but not among patients with E-LoF.

Conclusion

Sustained efforts are needed to address socioeconomic disparities in healthcare access, quality and outcomes during public health emergencies.

Minimally Invasive Surgery With Thrombolysis for Intracerebral Hemorrhage Evacuation: Bayesian Reanalysis of a Randomized Controlled Trial

BACKGROUND AND OBJECTIVES

Bayesian analysis of randomized controlled trials (RCTs) can extend the value of trial data beyond interpretations based on conventional p value-based binary cutoffs. We conducted an exploratory post hoc Bayesian reanalysis of the minimally invasive surgery with thrombolysis for intracerebral hemorrhage (ICH) evacuation (MISTIE-3) trial and derived probabilities of potential intervention effect on functional and survival outcomes.

METHODS

MISTIE-3 was a multicenter phase 3 RCT designed to evaluate the efficacy and safety of the MISTIE intervention. Five hundred and six adults (18 years or older) with spontaneous, nontraumatic, supratentorial ICH of ≥30 mL were randomized to receive either the MISTIE intervention (n = 255) or standard medical care (n = 251). We provide Bayesian-derived estimates of the effect of the MISTIE intervention on achieving a good 365-day modified Rankin Scale score (mRS score 0-3) as relative risk (RR) and absolute risk difference (ARD), and the probabilities that these treatment effects are greater than prespecified thresholds. We used 2 sets of prior distributions: (1) reference priors, including minimally informative, enthusiastic, and skeptical priors, and (2) data-derived prior distribution, using a hierarchical random effects model. We additionally evaluated the potential effects of the MISTIE intervention on 180-day and 30-day mRS and 365-, 180-, and 30-day mortality using data-derived priors.

RESULTS

The Bayesian-derived probability that MISTIE intervention has any beneficial effect (RR >1) on achieving a good 365-day mRS score was 70% using minimally informative prior, 87% with enthusiastic prior, 68% with skeptical prior, and 73% with data-derived prior. However, these probabilities were ≤55% for RR >1.10 and 0% for RR >1.52 across a range of priors. The probabilities of achieving RR >1 for 180- and 30-day mRS scores are 65% and 80%, respectively. Furthermore, the probabilities of achieving RR <1 for 365-, 180-, and 30-day mortality are 93%, 98%, and 99%, respectively.

DISCUSSION

Our exploratory analyses indicate that across a range of priors, the Bayesian-derived probability of MISTIE intervention having any beneficial effect on 365-day mRS for patients with ICH is between 68% and 87%. These analyses do not change the frequentist-based interpretation of the trial. However, unlike the frequentist p values, which indirectly evaluate treatment effects and only provide an arbitrary binary cutoff (such as 0.05), the Bayesian framework directly estimates the probabilities of potential treatment effects.

TRIAL REGISTRATION INFORMATION

ClinicalTrials.gov/ct2/show/NCT01827046.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that minimally invasive surgery (MIS) + recombinant tissue plasminogen activator (rt-PA) does not significantly improve functional outcome in patients with ICH. However, this study lacks the precision to exclude a potential benefit of MIS + rt-PA.

A Neuro-Informatics Pipeline for Cerebrovascular Disease: Research Registry Development

BACKGROUND

Although stroke is well recognized as a critical disease, treatment options are often limited. Inpatient stroke encounters carry critical information regarding the mechanisms of stroke and patient outcomes; however, these data are typically formatted to support administrative functions instead of research. To support improvements in the care of patients with stroke, a substantive research data platform is needed.

OBJECTIVE

To advance a stroke-oriented learning health care system, we sought to establish a comprehensive research repository of stroke data using the Houston Methodist electronic health record (EHR) system.

METHODS

Dedicated processes were developed to import EHR data of patients with primary acute ischemic stroke, intracerebral hemorrhage (ICH), transient ischemic attack, and subarachnoid hemorrhage under a review board-approved protocol. Relevant patients were identified from discharge diagnosis codes and assigned registry patient identification numbers. For identified patients, extract, transform, and load processes imported EHR data of primary cerebrovascular disease admissions and available data from any previous or subsequent admissions. Data were loaded into patient-focused SQL objects to enable cross-sectional and longitudinal analyses. Primary data domains (admission details, comorbidities, laboratory data, medications, imaging data, and discharge characteristics) were loaded into separate relational tables unified by patient and encounter identification numbers. Computed tomography, magnetic resonance, and angiography images were retrieved. Imaging data from patients with ICH were assessed for hemorrhage characteristics and cerebral small vessel disease markers. Patient information needed to interface with other local and national databases was retained. Prospective patient outreach was established, with patients contacted via telephone to assess functional outcomes 30, 90, 180, and 365 days after discharge. Dashboards were constructed to provide investigators with data summaries to support access.

RESULTS

The Registry of Neurological Endpoint Assessments among Patients with Ischemic and Hemorrhagic Stroke (REINAH) database was constructed as a series of relational category-specific SQL objects. Encounter summaries and dashboards were constructed to draw from these objects, providing visual data summaries for investigators seeking to build studies based on REINAH data. As of June 2022, the database contains 18,061 total patients, including 1809 (10.02%) with ICH, 13,444 (74.43%) with acute ischemic stroke, 1221 (6.76%) with subarachnoid hemorrhage, and 3165 (17.52%) with transient ischemic attack. Depending on the cohort, imaging data from computed tomography are available for 85.83% (1048/1221) to 98.4% (1780/1809) of patients, with magnetic resonance imaging available for 27.85% (340/1221) to 85.54% (11,500/13,444) of patients. Outcome assessment has successfully contacted 56.1% (240/428) of patients after ICH, with 71.3% (171/240) of responders providing consent for assessment. Responders reported a median modified Rankin Scale score of 3 at 90 days after discharge.

CONCLUSIONS

A highly curated and clinically focused research platform for stroke data will establish a foundation for future research that may fundamentally improve poststroke patient care and outcomes.

Lifelong cerebrovascular disease burden among CADASIL patients: analysis from a global health research network

Introduction

Data reporting on patients with Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) within the United States population is limited. We sought to evaluate the overt cerebrovascular disease burden among patients with CADASIL.

Methods

Harmonized electronic medical records were extracted from the TriNetX global health research network. CADASIL patients were identified using diagnostic codes and those with/without history of documented stroke sub-types (ischemic stroke [IS], intracerebral hemorrhage [ICH], subarachnoid hemorrhage [SAH] and transient ischemic attack [TIA]) were compared. Adjusted odds ratios (OR) and 95% confidence intervals (CI) of stroke incidence and mortality associated with sex were computed.

Results

Between September 2018 and April 2020, 914 CADASIL patients were identified (median [IQR] age: 60 [50-69], 61.3% females); of whom 596 (65.2%) had documented cerebrovascular events (i.e., CADASIL-Stroke patients). Among CADASIL-Stroke patients, 89.4% experienced an IS, co-existing with TIAs in 27.7% and hemorrhagic strokes in 6.2%; initial stroke events occurred ≤65 years of age in 71% of patients. CADASIL-Stroke patients (vs. CADASIL-non-Stroke) had higher cardiovascular and neurological (migraines, cognitive impairment, epilepsy/seizures, mood disorders) burden. In age- and comorbidity-adjusted models, males had higher associated risk of stroke onset (OR: 1.37, CI: 1.01-1.86). Mortality risk was higher for males (OR: 2.72, CI: 1.53-4.84).

Discussion

Early screening and targeted treatment strategies are warranted to help CADASIL patients with symptom management and risk mitigation.

Seasonal variation in the incidence of primary intracerebral hemorrhage: a 16-year nationwide analysis

Introduction

Data on nationwide trends and seasonal variations in the incidence of Intracerebral Hemorrhage (ICH) in the United States (US) are lacking.

Methods

We used the Nationwide Inpatient Sample (2004-2019) and Census Bureau data to calculate the quarterly (Q1:January-March; Q2:April-June; Q3:July-September; Q4:October-December) incidence rates (IR) of adult (≥18 years) ICH hospitalizations, aggregated across Q1-Q4 and Q2-Q3. We report adjusted incidence rate ratios (aIRR) and 95% confidence intervals (CI) for differences in the quarterly incidence of ICH, as compared to acute ischemic stroke (AIS), between Q1Q4 and Q2Q3 using a multivariable Poisson regression model. We additionally performed stratified analyses across the four US regions.

Results

Among 822,143 (49.0% female) ICH and 6,266,234 (51.9% female) AIS hospitalizations, the average quarterly crude IR of ICH was consistently higher in Q1Q4 compared to Q2Q3 (5.6 vs. 5.2 per 100,000) (aIRR, CI: 1.09, 1.08-1.11)-this pattern was similar across all four US regions. However, a similar variation pattern was not observed for AIS incidence. The incidence (aIRR, CI) of both ICH (1.01, 1.00-1.02) and AIS (1.03, 1.02-1.03) is rising.

Conclusion

Unlike AIS, ICH incidence is consistently higher in colder quarters, underscoring the need for evaluation and prevention of factors driving seasonal variations in ICH incidence.

Stroke severity mediates the effect of socioeconomic disadvantage on poor outcomes among patients with intracerebral hemorrhage

Background

Socioeconomic deprivation drives poor functional outcomes after intracerebral hemorrhage (ICH). Stroke severity and background cerebral small vessel disease (CSVD) burden have each been linked to socioeconomic status and independently contribute to worse outcomes after ICH, providing distinct, plausible pathways for the effects of deprivation. We investigate whether admission stroke severity or cerebral small vessel disease (CSVD) mediates the effect of socioeconomic deprivation on 90-day functional outcomes.

Methods

Electronic medical record data, including demographics, treatments, comorbidities, and physiological data, were analyzed. CSVD burden was graded from 0 to 4, with severe CSVD categorized as ≥3. High deprivation was assessed for patients in the top 30% of state-level area deprivation index scores. Severe disability or death was defined as a 90-day modified Rankin Scale score of 4-6. Stroke severity (NIH stroke scale (NIHSS)) was classified as: none (0), minor (1-4), moderate (5-15), moderate-severe (16-20), and severe (21+). Univariate and multivariate associations with severe disability or death were determined, with mediation evaluated through structural equation modelling.

Results

A total of 677 patients were included (46.8% female; 43.9% White, 27.0% Black, 20.7% Hispanic, 6.1% Asian, 2.4% Other). In univariable modelling, high deprivation (odds ratio: 1.54; 95% confidence interval: [1.06-2.23]; p = 0.024), severe CSVD (2.14 [1.42-3.21]; p < 0.001), moderate (8.03 [2.76-17.15]; p < 0.001), moderate-severe (32.79 [11.52-93.29]; p < 0.001), and severe stroke (104.19 [37.66-288.12]; p < 0.001) were associated with severe disability or death. In multivariable modelling, severe CSVD (3.42 [1.75-6.69]; p < 0.001) and moderate (5.84 [2.27-15.01], p < 0.001), moderate-severe (27.59 [7.34-103.69], p < 0.001), and severe stroke (36.41 [9.90-133.85]; p < 0.001) independently increased odds of severe disability or death; high deprivation did not. Stroke severity mediated 94.1% of deprivation's effect on severe disability or death (p = 0.005), while CSVD accounted for 4.9% (p = 0.524).

Conclusion

CSVD contributed to poor functional outcome independent of socioeconomic deprivation, while stroke severity mediated the effects of deprivation. Improving awareness and trust among disadvantaged communities may reduce admission stroke severity and improve outcomes.

Geographic Disparities in Case Fatality and Discharge Disposition Among Patients With Primary Intracerebral Hemorrhage

Background We evaluate nationwide trends and urban-rural disparities in case fatality (in-hospital mortality) and discharge dispositions among patients with primary intracerebral hemorrhage (ICH). Methods and Results In this repeated cross-sectional study, we identified adult patients (≥18 years of age) with primary ICH from the National Inpatient Sample (2004-2018). Using a series of survey design Poisson regression models, with hospital location-time interaction, we report the adjusted risk ratio (aRR), 95% CI, and average marginal effect (AME) for factors associated with ICH case fatality and discharge dispositions. We performed a stratified analysis of each model among patients with extreme loss of function and minor to major loss of function. We identified 908 557 primary ICH hospitalizations (overall mean age [SD], 69.0 [15.0] years; 445 301 [49.0%] women; 49 884 [5.5%] rural ICH hospitalizations). The crude ICH case fatality rate was 25.3% (urban hospitals: 24.9%, rural hospitals:32.5%). Urban (versus rural) hospital patients had a lower likelihood of ICH case fatality (aRR, 0.86 [95% CI, 0.83-0.89]). ICH case fatality is declining over time; however, it is declining faster in urban hospitals (AME, -0.049 [95% CI, -0.051 to -0.047]) compared with rural hospitals (AME, -0.034 [95% CI, -0.040 to -0.027]). Conversely, home discharge is increasing significantly among urban hospitals (AME, 0.011 [95% CI, 0.008-0.014]) but not significantly changing in rural hospitals (AME, -0.001 [95% CI, -0.010 to 0.007]). Among patients with extreme loss of function, hospital location was not significantly associated with ICH case fatality or home discharge. Conclusions Improving access to neurocritical care resources, particularly in resource-limited communities, may reduce the ICH outcomes disparity gap.

Reducing psychiatric illness in the perinatal period: A review and commentary

This brief overview highlights the global crisis of perinatal psychiatric illness (PPI). PPI is a major contributor to many adverse pregnancy, childbirth, and childhood development outcomes. It contributes to billions of dollars in spending worldwide each year and has a significant impact on the individual, their family, and their community. It is also highly preventable. Current recommendations for intervention and management of PPI are limited and vary considerably from country to country. Furthermore, there are several significant challenges asso-ciated with implementation of these recommendations. These challenges are magnified in number and consequence among women of color and/or minority populations, who experience persistent and negative health disparities during pregnancy and the postpartum period. This paper aims to provide a broad overview of the current state of recommendations and implementation challenges for PPI and layout a framework for overcoming these challenges. An equity-informed model of care that provides universal intervention for pregnant women may be one solution to address the preventable consequences of PPI on child and maternal health. Uniquely, this model emphasizes the importance of managing and eliminating known barriers to traditional health care models. Culturally and contextually specific challenges must be overcome to fully realize the impact of improved management of PPI.

Real-world effectiveness of COVID-19 vaccines and anti-SARS-CoV-2 monoclonal antibodies against postacute sequelae of SARS-CoV-2: analysis of a COVID-19 observational registry for a diverse US metropolitan population

OBJECTIVES

We evaluated the effectiveness of COVID-19 vaccines and monoclonal antibodies (mAbs) against postacute sequelae of SARS-CoV-2 infection (PASC).

DESIGN AND SETTING

A retrospective cohort study using a COVID-19 specific, electronic medical record-based surveillance and outcomes registry from an eight-hospital tertiary hospital system in the Houston metropolitan area. Analyses were replicated across a global research network database.

PARTICIPANTS

We identified adult (≥18) patients with PASC. PASC was defined as experiencing constitutional (palpitations, malaise/fatigue, headache) or systemic (sleep disorder, shortness of breath, mood/anxiety disorders, cough and cognitive impairment) symptoms beyond the 28-day postinfection period.

STATISTICAL ANALYSIS

We fit multivariable logistic regression models and report estimated likelihood of PASC associated with vaccination or mAb treatment as adjusted ORs with 95% CIs.

RESULTS

Primary analyses included 53 239 subjects (54.9% female), of whom 5929, 11.1% (95% CI 10.9% to 11.4%), experienced PASC. Both vaccinated breakthrough cases (vs unvaccinated) and mAb-treated patients (vs untreated) had lower likelihoods for developing PASC, aOR (95% CI): 0.58 (0.52-0.66), and 0.77 (0.69-0.86), respectively. Vaccination was associated with decreased odds of developing all constitutional and systemic symptoms except for taste and smell changes. For all symptoms, vaccination was associated with lower likelihood of experiencing PASC compared with mAb treatment. Replication analysis found identical frequency of PASC (11.2%, 95% CI 11.1 to 11.3) and similar protective effects against PASC for the COVID-19 vaccine: 0.25 (0.21-0.30) and mAb treatment: 0.62 (0.59-0.66).

CONCLUSION

Although both COVID-19 vaccines and mAbs decreased the likelihood of PASC, vaccination remains the most effective tool for the prevention of long-term consequences of COVID-19.

Abstract WP117: Effectiveness Of Minimally Invasive Surgery With Thrombolysis For Evacuation Of Intracerebral Hemorrhage: Post Hoc Bayesian Analysis Of A Phase 3 Randomized Controlled Trial

Introduction: Bayesian analyses provide meaningful interpretations of clinical trial data in terms of probabilities of treatment effect. This extends the value of results beyond that obtained from traditional binary cut offs. Such interpretations provide actionable information for conditions with high mortality and no proven treatments, such as intracerebral hemorrhage (ICH).

Methods: The minimally invasive surgery with thrombolysis in ICH evacuation (MISTIE 3) trial randomized 506 adults with spontaneous, supratentorial ICH of ≥ 30mL to receive either MISTIE intervention or standard medical care. Using reference priors (minimally informative, enthusiastic, skeptical) and a MISTIE 2-derived prior, we estimated probabilities that the effect of MISTIE intervention exceeds pre-specified thresholds of relative risks (RR) for achieving a 365-day Modified Rankin Scale (mRS) score of 0-3. We also computed the effects of MISTIE intervention on 180 and 30-day mRS and 365, 180 and 30-day mortality.

Results: Using a minimally informative prior, the posterior probability of MISTIE intervention having any beneficial effect (RR > 1) on 365-day mRS was 70%. The probabilities of observing RR > 1.02 and > 1.10 were 63% and 34%, respectively. The probabilities of observing RR > 1, 1.02 and 1.10, with other priors are: 87%, 82% and 55% (enthusiastic); 68%, 60% and 30% (skeptical); and 73%, 66% and 38% (MISTIE 2-derived). The probabilities that MISTIE intervention has any beneficial effect on 180 and 30-day mRS, and 365, 180, and 30-day mortality are 65%,80%, 93%, 98% and 99%, respectively. RR, 95% credible intervals across various priors are shown in Figure.

Conclusions: The probability that the MISTIE intervention has a favorable functional outcome at 365-days among ICH patients is 68 to 87%. Bayesian-derived probabilities of treatment effect may facilitate shared decision making in ICH management, above and beyond p-value-based frequentist interpretation of trial results.

Abstract HUP7: Contemporary Nationwide Estimates For Outcomes Associated With Craniotomy Among Patients With Intracerebral Hemorrhage

Introduction: Contemporary nationwide estimates of outcomes associated with craniotomy procedures (CP) among patients with primary intracerebral hemorrhage (ICH) are lacking.

Methods: From the nationwide inpatient sample (2016 - 2019), we identified adults discharged with primary ICH diagnosis and those who received CP. We fit a series of multivariable logistic regression models to report the adjusted odds ratios (aOR) and 95% confidence interval (CI) for factors associated with receiving CP and the association of CP with in-hospital mortality, home discharge, and development of major complication (MCC): brain abscess, sepsis, deep vein thrombosis, urinary tract infection, and pneumonia. We also fit generalized linear model (γ family) to report the adjusted mean ratio (aMR) and CI for the association of craniotomy with length of stay (LOS) and cost of care.

Results: Among 271 840 ICH hospitalizations (mean age [SD] 68.2 [14.9] years; 48% females), 15.3% received CP. Utilization of CP increased from 14.6% in 2016 to 15.8% in 2019 (aOR, CI: 1.10, 1.00 -1.21). Factors independently associated with lower odds of receiving CP (aOR, CI) are older age (0.97, 0.97 - 0.97); Hispanic ethnicity (0.87, 0.78 - 0.97) and Asian race (0.84, 0.73 - 0.96) (vs. Non-Hispanic White); congestive heart failure (0.86, 0.79 - 0.95); diabetes (0.79, 0.72 - 0.87) and renal failure (0.68, 0.62 - 0.74). Private (vs. Medicare) insurance (1.23, 1.13 - 1.34); and residence in large metropolitan (vs. non-metropolitan) counties (1.14, 1.03 - 1.25) is associated with higher odds of receiving a CP. CP is associated with significantly lower odds of in-hospital mortality (aOR, CI: 0.66, 0.61 - 0.72) and home discharge (0.51, 0.45 - 0.57). However, CP ICH patients had longer LOS (aMR, CI: 1.79. 1.75 - 1.84) and higher cost of care (1.82, 1.79 - 1.85). CP is not associated with MCC (aOR, CI: 0.99, 0.92 - 1.07).

Conclusions: Modern-day craniotomy procedures likely improve ICH in-patient survival and are not associated with major complications. Large, pragmatic clinical trials for ICH patients are needed to evaluate effectiveness of craniotomy, particularly minimally invasive procedures, on longer term mortality and functional outcomes.

Abstract TP122: Systolic Blood Pressure Variability Increases During The Initial 24 Hours After Intravenous Nicardipine Administration Among Patients With Primary Intracerebral Hemorrhage

Background: Systolic blood pressure variability (SBPV) has been associated with poor outcomes among patients with intracerebral hemorrhage (ICH). Intravenous nicardipine (IVN) is frequently used for blood pressure management among hospitalized ICH patients, however SBPV in response to IVN has not been characterized.

Methods: Data for primary ICH patients who received IVN were retrieved from a stroke-specific bioinformatics pipeline. SBPV was quantified as the coefficient of variation (CV) of cuff-measured systolic blood pressure, and CV was calculated over the time periods 0-24 hrs prior to (Pre24), 0-24 hrs after (Post24), and 24-48 hrs after (Post48) initial IVN administration. Group differences were assessed using Friedman’s Test and Bonferroni-corrected Wilcoxon Signed-rank tests. Contributions of SBPV at each timepoint to poor in-hospital mortality or discharge to hospice (poor outcome) were assessed in separate multivariable logistic regression models adjusted for patient characteristics. Adjusted Odds ratios (aOR) and 95% confidence intervals (CI) are reported.

Results: Data included 370 ICH patients with a median [interquartile range] age of 65 [54 - 76]. Patients included were 46.0% female, 41.1% Non-Hispanic White, 25.1% Non-Hispanic Black, 23.8% Hispanic, 8.1% Asian, and 1.9% other. Patients had a median CV of 9.2 [6.1-13.6] in the Pre24 period, 11.6 [9.46 - 13.9] in Post24, and 9.5 [7.6 - 12.1] in Post48. SPBV showed significant differences across timepoints (p=0.000), with Post24 showing elevated SBPV (vs. Pre24 (p=0.000) or Post48 (p=0.000), Figure 1A, B). In multivariable modelling, patients in the highest quartile of SPBV during the Post24 period showed increased risk of poor outcome: aOR (CI) 2.91 (1.06-8.01), Figure 1C.

Conclusions: SBPV increases over the first 24 hours of IVN administration and patients with higher SPBV during this time are at higher risk for in-hospital mortality. SPBV management protocols need to be evaluated.

Abstract 165: Nationwide Seasonal Variations And Increases In Incidence Of Intracerebral Hemorrhage And Acute Ischemic Stroke: An Analysis Of Pre-pandemic 16-year National Data

Introduction: There is paucity of evidence on long-term nationwide trends and seasonal variation in incidence of Intracerebral Hemorrhage (ICH) and Acute Ischemic Stroke (AIS).

Methods: Using the Nationwide Inpatient Sample (2004 - 2019), we identified adults (≥ 18 years) discharged with primary diagnosis of ICH and AIS. We aggregated hospitalizations across quarters: Jan - Mar (Q1); Apr - Jun (Q2); Jul - Sep (Q3) and Oct - Dec (Q4). We used survey weights to calculate nationally representative estimates of quarter-specific incidence across age, sex, and race/ethnicity sub-cohorts and obtained time-specific denominators from the US Census Bureau. We calculated per quarter incidence rate (IR) across Q1-Q4 and Q2-Q3. We used multivariable Poisson regression model to report the adjusted incidence rate ratio (aIRR) and 95% confidence interval (CI) for the differences in quarterly incidence between Q1Q4 and Q2Q3.

Results: Across 16 years, 985 959 ICH and 7 067 178 AIS hospitalizations were evaluated. The average quarterly crude IR of ICH in Q1Q4 of 6 per 100 000 was higher than the average rate of 5.4 per 100 000 observed in Q2Q3 (aIRR, CI: 1.10, 1.09 - 1.10). However, for AIS the average quarterly IR of ICH in Q1Q4 (41.2 per 100 000) was similar to the incidence rate in Q2Q3 (41.2 per 100 000) (aIRR, CI: 1.00, 1.00 - 1.00). Furthermore, we observed that average quarterly incidence is increasing overtime (aIRR, CI) for both ICH (1.01, 1.01 - 1.01) and AIS (1.03, 1.03 -1.03). The aIRR and CI for age, race, and sex are provided in the figure.

Conclusion: Both stroke phenotypes demonstrate an increasing nationwide incidence. However, unlike AIS, ICH incidence is consistently and significantly higher in the months of October to March. Additional evaluation of factors such as holiday stress, seasonal variations in health behaviors (diet, physical activity, medication adherence) and physiological parameters (blood pressure, blood viscosity, fibrinogen, and cholesterol levels) is warranted.

Abstract TMP84: Contemporary Nationwide Estimates For Outcomes Associated With Craniotomy Among Patients With Intracerebral Hemorrhage

Introduction: Contemporary nationwide estimates of outcomes associated with craniotomy procedures (CP) among patients with primary intracerebral hemorrhage (ICH) are lacking.

Methods: From the nationwide inpatient sample (2016 - 2019), we identified adults discharged with primary ICH diagnosis and those who received CP. We fit a series of multivariable logistic regression models to report the adjusted odds ratios (aOR) and 95% confidence interval (CI) for factors associated with receiving CP and the association of CP with in-hospital mortality, home discharge, and development of major complication (MCC): brain abscess, sepsis, deep vein thrombosis, urinary tract infection, and pneumonia. We also fit generalized linear model (γ family) to report the adjusted mean ratio (aMR) and CI for the association of craniotomy with length of stay (LOS) and cost of care.

Results: Among 271 840 ICH hospitalizations (mean age [SD] 68.2 [14.9] years; 48% females), 15.3% received CP. Utilization of CP increased from 14.6% in 2016 to 15.8% in 2019 (aOR, CI: 1.10, 1.00 -1.21). Factors independently associated with lower odds of receiving CP (aOR, CI) are older age (0.97, 0.97 - 0.97); Hispanic ethnicity (0.87, 0.78 - 0.97) and Asian race (0.84, 0.73 - 0.96) (vs. Non-Hispanic White); congestive heart failure (0.86, 0.79 - 0.95); diabetes (0.79, 0.72 - 0.87) and renal failure (0.68, 0.62 - 0.74). Private (vs. Medicare) insurance (1.23, 1.13 - 1.34); and residence in large metropolitan (vs. non-metropolitan) counties (1.14, 1.03 - 1.25) is associated with higher odds of receiving a CP. CP is associated with significantly lower odds of in-hospital mortality (aOR, CI: 0.66, 0.61 - 0.72) and home discharge (0.51, 0.45 - 0.57). However, CP ICH patients had longer LOS (aMR, CI: 1.79. 1.75 - 1.84) and higher cost of care (1.82, 1.79 - 1.85). CP is not associated with MCC (aOR, CI: 0.99, 0.92 - 1.07).

Conclusions: Modern-day craniotomy procedures likely improve ICH in-patient survival and are not associated with major complications. Large, pragmatic clinical trials for ICH patients are needed to evaluate effectiveness of craniotomy, particularly minimally invasive procedures, on longer term mortality and functional outcomes.

Abstract TP94: Optimizing The Utilization Of Cardiac Computed Tomography Angiography Among Patients With Ischemic Stroke

Background: The current AHA guidelines recommend (class IIb) advanced cardiac imaging in embolic stroke of unknown source (ESUS). We aim to better characterize the role of cardiac CTA (cCTA) in the evaluation of stroke patients.

Method: A retrospective review of stroke patients at a comprehensive stroke center, who had cCTA between 12/2016 and 11/2020 was conducted using institutional registries. Ischemic stroke patients with ESUS, cryptogenic (with ESUS as a competing etiology) and cardio-embolic etiologies were included. Only cardioembolic etiologies in which a suspicion of intracardiac thrombus with either a known diagnosis of atrial fibrillation or presence of LVAD were included. Cases with TIA, large vessel disease, small vessel disease, dissection or hemodynamic etiologies were excluded. TTE and cCTA results from all cases were reviewed for remarkable findings, most notably intracardiac thrombus, and analyzed if a change in anti-thrombotic therapy was directly attributable to cCTA results.

Results: As per our criteria, 96 cases (Female 42.7%, Black 37.5%, Age mean: 63.7 years) were included, of whom 45 (46.9%) were ESUS, 21 (21.9%) were cryptogenic, and 30 (31.2%) were cardioembolic. cCTA revealed intracardiac thrombus in 5 (5.2%) cases, all with LA thrombus. Of these, 3 (60%) had escalation of anti-thrombotic therapy. Interestingly, in one patient who had both cMRI and cCTA imaging, the cMRI revealed an apical LV thrombus which was not detected on cCTA.

Conclusion: In this retrospective analysis of 96 select stroke cases, escalation of anti-thrombotic therapy from anti-platelets to full dose anti-coagulation was indicated in 3 patients (3.1%) with addition of cCTA. Compared to a similar cohort of patients from the same institutional registry using cMRI as the advanced cardiac imaging modality, cCTA did not reveal any LV thrombi and even missed a case of LV thrombus seen on cMRI suggesting lower sensitivity for cCTA to detect LV thrombus. Further analysis of data is in process to determine the subset of stroke patients who would benefit the most from cCTA.

Chronic neuropsychiatric sequelae of SARS-CoV-2: Protocol and methods from the Alzheimer's Association Global Consortium

Introduction

Coronavirus disease 2019 (COVID-19) has caused >3.5 million deaths worldwide and affected >160 million people. At least twice as many have been infected but remained asymptomatic or minimally symptomatic. COVID-19 includes central nervous system manifestations mediated by inflammation and cerebrovascular, anoxic, and/or viral neurotoxicity mechanisms. More than one third of patients with COVID-19 develop neurologic problems during the acute phase of the illness, including loss of sense of smell or taste, seizures, and stroke. Damage or functional changes to the brain may result in chronic sequelae. The risk of incident cognitive and neuropsychiatric complications appears independent from the severity of the original pulmonary illness. It behooves the scientific and medical community to attempt to understand the molecular and/or systemic factors linking COVID-19 to neurologic illness, both short and long term.

Methods

This article describes what is known so far in terms of links among COVID-19, the brain, neurological symptoms, and Alzheimer's disease (AD) and related dementias. We focus on risk factors and possible molecular, inflammatory, and viral mechanisms underlying neurological injury. We also provide a comprehensive description of the Alzheimer's Association Consortium on Chronic Neuropsychiatric Sequelae of SARS-CoV-2 infection (CNS SC2) harmonized methodology to address these questions using a worldwide network of researchers and institutions.

Results

Successful harmonization of designs and methods was achieved through a consensus process initially fragmented by specific interest groups (epidemiology, clinical assessments, cognitive evaluation, biomarkers, and neuroimaging). Conclusions from subcommittees were presented to the whole group and discussed extensively. Presently data collection is ongoing at 19 sites in 12 countries representing Asia, Africa, the Americas, and Europe.

Discussion

The Alzheimer's Association Global Consortium harmonized methodology is proposed as a model to study long-term neurocognitive sequelae of SARS-CoV-2 infection.

Key Points

The following review describes what is known so far in terms of molecular and epidemiological links among COVID-19, the brain, neurological symptoms, and AD and related dementias (ADRD)The primary objective of this large-scale collaboration is to clarify the pathogenesis of ADRD and to advance our understanding of the impact of a neurotropic virus on the long-term risk of cognitive decline and other CNS sequelae. No available evidence supports the notion that cognitive impairment after SARS-CoV-2 infection is a form of dementia (ADRD or otherwise). The longitudinal methodologies espoused by the consortium are intended to provide data to answer this question as clearly as possible controlling for possible confounders. Our specific hypothesis is that SARS-CoV-2 triggers ADRD-like pathology following the extended olfactory cortical network (EOCN) in older individuals with specific genetic susceptibility.The proposed harmonization strategies and flexible study designs offer the possibility to include large samples of under-represented racial and ethnic groups, creating a rich set of harmonized cohorts for future studies of the pathophysiology, determinants, long-term consequences, and trends in cognitive aging, ADRD, and vascular disease.We provide a framework for current and future studies to be carried out within the Consortium. and offers a "green paper" to the research community with a very broad, global base of support, on tools suitable for low- and middle-income countries aimed to compare and combine future longitudinal data on the topic.The Consortium proposes a combination of design and statistical methods as a means of approaching causal inference of the COVID-19 neuropsychiatric sequelae. We expect that deep phenotyping of neuropsychiatric sequelae may provide a series of candidate syndromes with phenomenological and biological characterization that can be further explored. By generating high-quality harmonized data across sites we aim to capture both descriptive and, where possible, causal associations.

SARS-CoV-2 and the central nervous system: Emerging insights into hemorrhage-associated neurological consequences and therapeutic considerations

Coronavirus disease 2019 (COVID-19), caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) continues to impact our lives by causing widespread illness and death and poses a threat due to the possibility of emerging strains. SARS-CoV-2 targets angiotensin-converting enzyme 2 (ACE2) before entering vital organs of the body, including the brain. Studies have shown systemic inflammation, cellular senescence, and viral toxicity-mediated multi-organ failure occur during infectious periods. However, prognostic investigations suggest that both acute and long-term neurological complications, including predisposition to irreversible neurodegenerative diseases, can be a serious concern for COVID-19 survivors, especially the elderly population. As emerging studies reveal sites of SARS-CoV-2 infection in different parts of the brain, potential causes of chronic lesions including cerebral and deep-brain microbleeds and the likelihood of developing stroke-like pathologies increases, with critical long-term consequences, particularly for individuals with neuropathological and/or age-associated comorbid conditions. Our recent studies linking the blood degradation products to genome instability, leading to cellular senescence and ferroptosis, raise the possibility of similar neurovascular events as a result of SARS-CoV-2 infection. In this review, we discuss the neuropathological consequences of SARS-CoV-2 infection in COVID survivors, focusing on possible hemorrhagic damage in brain cells, its association to aging, and the future directions in developing mechanism-guided therapeutic strategies.

Sex differences in post-stroke cognitive decline: A population-based longitudinal study of nationally representative data

Background

Sex differences in post-stroke cognitive decline have not been systematically evaluated in a nationally representative cohort. We use a quasi-experimental design to investigate sex differences in rate of post-stroke cognitive decline.

Methods

Utilizing the event study design, we use the Health and Retirement Study (HRS) data (1996–2016) to evaluate the differences (percentage points [95% Confidence interval]) in the rate of change in cognitive function, measured using the modified version of the Telephone Interview for Cognitive Status (TICS-m) score, before and after incident stroke, and among patients with and without incident stroke. We estimated this event study model for the overall study population and separately fit the same model for male and female participants.

Results

Of 25,872 HRS participants included in our study, 14,459 (55.9%) were females with an overall mean age (SD) of 61.2 (9.3) years. Overall, 2,911 (11.3%) participants reported experiencing incident stroke. Participants with incident stroke (vs. no stroke) had lower baseline TICS-m score (15.6 vs. 16.1). Among participants with incident stroke, the mean pre-stroke TICS-m score was higher than the mean post-stroke TICS-m score (14.9 vs. 12.7). Event study revealed a significant short-term acceleration of cognitive decline for the overall population (4.2 [1.7–6.6] percentage points, p value = 0.001) and among female participants (5.0 [1.7–8.3] percentage points, p value = 0.003). We, however, found no evidence of long-term acceleration of cognitive decline after stroke. Moreover, among males, incident stroke was not associated with significant changes in rate of post-stroke cognitive decline.

Conclusion

Females, in contrast to males, experience post-stroke cognitive deficits, particularly during early post-stroke period. Identifying the sex-specific stroke characteristics contributing to differences in post stroke cognitive decline may inform future strategies for reducing the burden of post-stroke cognitive impairment and dementia.

Clinical and Economic Profile of Homeless Young Adults with Stroke in the United States, 2002 - 2017

INTRODUCTION

. Homelessness is a major social determinant of health. We studied the clinical and economic profile of homeless young adults hospitalized with stroke.

METHODS

. We studied the National Inpatient Sample database (2002-2017) to evaluate trends of stroke hospitalization, clinical outcomes, and health expenditure in homeless vs. non-homeless young adults (<45 years).

RESULTS

. We identified 3,134 homeless individuals out of 648,944 young adults. Homeless patients were more likely to be men, Black adults and had a higher prevalence of cardiometabolic risk factors and psychiatric disorders than non-homeless adults. Both homeless and non-homeless adults had a similar prevalence of ischemic and hemorrhagic stroke. Between 2002 and 2017, hospitalization rates per million increased for both non-homeless (295.8 to 416.8) and homeless adults (0.5 to 3.6) (P≤0.01). Between 2003 and 2017, the decline in in-hospital mortality was limited to non-homeless adults (11% to 9%), while it has increased in homeless adults (3% to 11%) (P<0.01). The prevalence of acute myocardial infarction (6.8% vs. 3.3%, P<0.01), and acute kidney injury (13.1% vs. 9.4%, P<0.01) was also higher in homeless vs. non-homeless adults. The length of stay and inflation-adjusted care cost were comparable between both study groups. Finally, a higher proportion of homeless patients left the hospital against medical advice than non-homeless adults.

CONCLUSIONS

. Homeless young stroke patients had significant comorbidities, increased hospitalization rates, and adverse clinical outcomes. Therefore, public health interventions should focus on multidisciplinary care to reduce health care disparities among young homeless adults.

Contemporary Trends in the Nationwide Incidence of Primary Intracerebral Hemorrhage

BACKGROUND

We report contemporary trends in nationwide incidence of intracerebral hemorrhage (ICH) across demographic and regional strata over a 15-year period.

METHODS

Utilizing the Nationwide Inpatient Sample (2004-2018) and US Census Bureau data, we calculated ICH incidence rates for age, race/ethnicity, sex, and hospital region sub-cohorts across 5 consecutive 3-year periods (2004-2006 to 2016-2018). We fit Poisson and log binomial regression models to evaluate demographic and regional differences in ICH incidence and trends in prevalence of hypertension and past/current anticoagulant use among hospitalized ICH patients.

RESULTS

Overall, the annual incidence rate (95% CI) of ICH per 100 000 was 23.15 (23.10-23.20). The 3-year incidence of ICH (per 100 000) increased from 62.79 in 2004 to 2006 to 78.86 in 2016 to 2018 (adjusted incidence rate ratio, CI: 1.11 [1.02-1.20]), coinciding with increased 3-year prevalence of hypertension and anticoagulant use among hospitalized ICH patients (adjusted risk ratio, CI: hypertension-1.16 [1.15-1.17]; anticoagulant use-2.30 [2.14-2.47]). We found a significant age-time interaction, whereby ICH incidence increased significantly faster among those aged 18 to 44 years (adjusted incidence rate ratio, CI: 1.10 [1.05-1.14]) and 45 to 64 years (adjusted incidence rate ratio, CI: 1.08 [1.03-1.13]), relative to those aged ≥75 years.

CONCLUSIONS

Rising ICH incidence among young and middle-aged Americans warrants ICH prevention strategies targeting these economically productive age groups.

Abstract WP180: Lifelong Cerebrovascular And Neurological Disease Burden Among Patients With Cerebral Autosomal Dominant Arteriopathy With Subcortical Infarcts And Leukoencephalopathy (cadasil): Analysis Of 914 Cadasil Patients From A Global Research Network

Background: We evaluated the cerebrovascular and neurological disease (CVND) burden among patients with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL).

Methods: Harmonized electronic medical record data from a global research network were utilized to identify diagnosed CADASIL patients. We compared demographics, risk factors, co-existing conditions, and outcomes for CADASIL patients with and without stroke sub-types (ischemic stroke [IS], intracerebral hemorrhage [ICH], subarachnoid hemorrhage [SAH] and transient ischemic attack [TIA]). Likelihood of stroke incidence and overall mortality associated with sex were computed. Odds ratios (OR) and 95% confidence intervals (CI) are reported.

Results: Between 2018 and 2020, 914 CADASIL patients were identified (Median (IQR) age: 60 (50 - 69) years, 61.3% females); of whom 596 (65.2%) had a stroke diagnosis. Among all CADASIL-Stroke patients, 89.4% had IS, which co-existed with TIAs in 27.7% and ICH / SAH in 6.2% (Figure). Among 30% and 71% of CADASIL-Stroke patients, the initial stroke event occurred before 50 and 65 years of age, respectively. In addition to a higher burden of hypertension, atrial fibrillation, hyperlipidemia, and diabetes; a higher proportion of CADASIL-Stroke patients (vs CADASIL-non-Stroke) had other co-existing neurological conditions, including migraines (36.7% vs 29.9%), cognitive impairment (38.8% vs 24.2%), epilepsy / seizures (18.6% vs 11.6%), and mood disorders (52.9% vs 40.9%). Adjusted for age and commodities, males had a higher risk of stroke (OR, CI: 1.37, 1.01 - 1.86) and also demonstrated higher overall mortality in a separate model additionally adjusted for stroke diagnoses (OR, CI: 2.72, 1.53 - 4.84).

Conclusion: Given the high CVND burden; early genetic screening and targeted preventive strategies are warranted among patients with suspected CADASIL and other hereditary cerebral small vessel diseases.

Abstract WMP104: Race And Regional Disparities In Prevalence Of Poor Metabolic Health Among Community Dwelling Adults With Stroke: Nationwide Analysis Of 2019 BRFSS Data

Introduction: High burden of Metabolic Syndrome (MS) results in incident stroke and poor outcomes. We report contemporary national estimates of stroke prevalence and quantify MS burden and its socio-demographic associates among stroke individuals.

Methods: We analyzed 2019 Behavioral Risk Factor Surveillance System data; a nationally representative survey of health-related conditions and behaviors among community dwelling adults. We identified individuals with self-reported stroke and flagged 4 MS indicators (diabetes, hypertension, BMI ≥ 25 kg/m 2 , hypercholesterolemia). Individuals with ≥ 2 features were categorized as High MS (HMS). We compared socio-demographic characteristics (age, sex, race, education, income, marital and employment status, stroke belt residence) and healthcare utilization (insurance status and frequency of healthcare visits) among HMS and no-HMS groups. We fit survey design logistic regression models with appropriate sampling weights and report national estimates of stroke prevalence and HMS associates.

Results: In 2019, there were 8,570,876 adults (≥ 18 years) with stroke in the US; translating into a nationwide prevalence of 3.4% (7.9% among ≥ 65 years). Overall, 94.4% had at least one MS feature; 77.4% had HMS. Advanced age, male sex, non-Hispanic Black (NHB) race and residence in stroke belt region were associated with HMS. Participants with high income (≥ $75,000) and health insurance coverage were less likely to have HMS. In the fully adjusted model, advanced age; Asian American / Pacific Islander race and Hispanic ethnicity (vs. Non-Hispanic White) and residence in the US stroke belt had higher likelihood of HMS (Figure). Healthcare utilization patterns and sex were not significantly associated with HMS. Updated 2020 BRFSS data will be presented.

Conclusion: Racial and regional disparities exist in HMS burden among stroke individuals. Targeted MS prevention and management measures are needed for high-risk populations.

Abstract WMP98: Association Between Serotonin Receptor Antidepressant Use And 90-day Mortality After Acute Ischemic Stroke: Propensity Score Analysis Of 10-year Real-world Data

Introduction: Post-stroke depression is associated with higher mortality. Unfortunately, the use of antidepressants (AD) as stroke treatment adjuvants has not been established due to a lack of placebo controls and concerns that selective serotonin reuptake inhibitor (SSRI) initiation after stroke may increase mortality.

Methods: Using ICD-10 diagnosis/procedure, procedural terminology codes and medications, we identified index ischemic strokes (IS) with and without AD use (SSRIs, Serotonin Antagonist Reuptake Inhibitors, Serotonin Norepinephrine Reuptake Inhibitors) 1 year pre and post event, using deidentified pooled data from a 50 healthcare organization network (8/2011-7/2021). Non adult (<18 yrs) and intracerebral hemorrhage were excluded. AD and no AD patients were propensity score (PS) matched for demographic, comorbidity and clinical variables. Standardized mean difference (SMD) assessed match adequacy. Absolute Risk Difference (RD) and Risk Ratios (RR) with 95% Confidence Intervals (CI) were reported for 90-day mortality in the PS-matched sample. Kaplan-Meier (KM) analysis with log rank test (LRT) was performed.

Results: Among 910,749 patients with an index IS, 634,599 met the inclusion criteria, of whom 136,219 (21.5%) had AD use before and after IS. Significant pre-match differences in demographic and clinical parameters were observed between the AD and no-AD groups (table). PS algorithm generated a 1:1 optimally matched sample (95% SMD reduction) of 78,815 AD and no AD IS patients each, with significant covariate differences for female sex, mood disorder diagnosis, systolic blood pressure and cardiovascular medication use (table). In the matched sample, the 90-day mortality risk post-IS was significantly lower in the AD group. RD: -3.4%, RR(CI) 0.54(0.52-0.56). LRT P<0.0001, KM curve shown in the graphic.

Conclusion: AD utilization before and after IS demonstrates significantly lower 90-day mortality in real world multicenter data.

Abstract WMP84: High Morbidity And Mortality Associated With Anticoagulation Prior To Intracerebral Hemorrhage: Propensity Score Analysis Of 10-year Real-world Data

Introduction: Anticoagulation for prevention of cardioembolic stroke is safe and effective. However, there is a paucity of data on morbidity and mortality among non-traumatic intracerebral hemorrhage (ICH) patients with history of anticoagulant (AC) use.

Methods: Using ICD-10 diagnosis/procedure, procedural terminology codes and medications, we identified index ICH events with and without prior AC use from deidentified pooled data; in a network of 50 healthcare organizations (Aug 2011-July 2021). Non adult (<18 years) and the presence of a prosthetic heart valve were excluded. AC and no-AC patients were propensity score (PS) matched for demographic, comorbidity and clinical variables. Match adequacy was assessed by standardized mean difference (SMD). Absolute Risk Difference (RD) and Risk Ratios (RR) with 95% Confidence Intervals (CI) are reported for morbidity [seizure, sepsis, intraventricular hemorrhage or external ventricular drain(IVH/EVD)] and mortality at 5 years post index ICH event in the PS-matched sample.

Results: Among 193,600 patients with an index ICH event, 171,561 met the inclusion criteria, of whom, 62,578 (36.5%) had prior AC use. Significant pre-match differences in demographic and clinical parameters were observed between the AC and no AC groups (table). PS algorithm generated a 1:1 optimally matched sample (95% SMD reduction) of 21,808 AC and no AC ICH patients each, without significant covariate differences. In the matched sample, the risk of post-ICH seizure, sepsis, IVH/EVD, and mortality were significantly higher in the AC group. RR (CI) for seizure: 1.27(1.22-1.32), sepsis: 1.56(1.46-1.67), IVH/EVD: 1.78(1.66-1.92), mortality: RR (CI) 1.05 (1.02 - 1.09). RD of 5-year death between AC and no-AC groups was 1.3%, compared to a 4.1% RD of seizure, 3.2% RD of sepsis and a 3.7% RD of IVH/EVD.

Conclusion: In Real World multicenter data, utilization of AC prior to ICH demonstrates significantly high long-term morbidity and mortality.

Abstract 92: Delirium In-hospital Leads To Poor Short And Long-term Outcomes Among Treated And Non-treated Patients With Acute Ischemic Stroke

Background: Delirium in-hospital (DIH) is common among the critically ill. However, DIH incidence and outcomes are not well characterized among ischemic stroke (IS) patients, particularly those treated with intravenous tissue plasminogen activator (tPA) and / or mechanical thrombectomy (MT).

Methods: Utilizing data from a healthcare system with standardized delirium screening protocols, DIH was determined by a positive 4AT / CAM-ICU screen or diagnosis codes. IS patients with tPA or MT were flagged and a subset with available 90-day modified Rankin Scale (mRS) were analyzed for shifts in mRS scores associated with DIH, via ordinal logistic regression models adjusted for age, stroke severity, tPA or MT, Charlson Comorbidity Index [CCI], prior stroke and sepsis / infections. Common odds ratios (OR) and 95% confidence intervals (CI) are reported.

Results: Between May 2016 and June 2021, IS was the primary discharge diagnosis in 12,415 encounters (10,878 unique patients). DIH was documented in 41.6% of IS encounters, compared to 20.0% of non-IS encounters. Stroke-DIH patients (vs no-DIH Stroke) were older (median: 75 vs 65 years), more frequently female (53.3% vs 48.7%), with higher comorbidity burden (median CCI: 7 vs 5), longer hospital stays (median: 6 vs 3 days), higher in-hospital mortality (3.1% vs 0.5%), and fewer home discharges (36.2% vs 75.2%). Among a sub-cohort of 2,785 IS patients with 90-day mRS, fully adjusted model indicated lower mRS (OR, CI: 0.48, 0.41-0.57) for those with tPA or MT, and worse outcomes for DIH patients (OR, CI: 2.70, 2.26-3.23). Among 948 treated IS patients, DIH remained a significant risk for worse outcomes (OR, CI: 2.54, 1.89-3.43).

Conclusion: Delirium was twice as common in IS patients and was a negative prognostic indicator of short and long-term outcomes among non-treated and treated IS patients. Active screening and management of DIH is critically important to improve stroke outcomes.

Social Determinants of Health Among Non-Elderly Adults With Stroke in the United States

OBJECTIVE

To examine the association of social determinants of health (SDOH) on prevalence of stroke in non-elderly adults (<65 years of age).

METHODS

We used the National Health Interview Survey (2013-2017) database. The study population was stratified into younger (<45 years of age) and middle age (45 to 64 years of age) adults. For each individual, an SDOH aggregate score was calculated representing the cumulative number of individual unfavorable SDOH (present vs absent), identified from 39 subcomponents across five domains (economic stability, neighborhood, community and social context, food, education, and health care system access) and divided into quartiles (quartile 1, most favorable; quartile 4, most unfavorable). Multivariable models tested the association between SDOH score quartiles and stroke.

RESULTS

The age-adjusted prevalence of stroke was 1.4% in the study population (n=123,631; 58.2% (n=71,956) in patients <45 years of age). Young adults reported approximately 20% of all strokes. Participants with stroke had unfavorable responses to 36 of 39 SDOH; nearly half (48%) of all strokes were reported by participants in the highest SDOH score quartile. A stepwise increase in age-adjusted stroke prevalence was observed across increasing quartiles of SDOH (first, 0.6%; second, 0.9%; third, 1.4%; and fourth, 2.9%). After accounting for demographics and cardiovascular disease risk factors, participants in the fourth vs first quartile had higher odds of stroke (odds ratio, 2.78; 95% CI, 2.25 to 3.45).

CONCLUSION

Nearly half of all non-elderly individuals with stroke have an unfavorable SDOH profile. Standardized assessment of SDOH risk burden may inform targeted strategies to mitigate disparities in stroke burden and outcomes in this population.

Abstract WP128: Race Heterogeneity Potentially Drives The Association Between Hypercholesterolemia And In-hospital Mortality Among Patients With Primary Intracerebral Hemorrhage: Analysis Of 15-year Nationwide Data

Background: The evidence of association between Intracerebral Hemorrhage (ICH) outcomes and hypercholesterolemia (HC) is equivocal. We provide nationwide estimates of ICH in-hospital mortality (IHM) among patients with HC, across race/ethnicity subgroups.

Methods: In a pooled cross-sectional analysis of adult (≥ 18 years) primary ICH patients in the National Inpatient Sample (2004 - 2018), we used ICD 9 / 10 codes to identify patients with HC. We fit survey design multivariable logistic regression models to provide nationwide estimates of the association between IHM and HC as adjusted odds ratio (aOR) and 95% confidence interval (CI).

Results: Among a total of 803,230 ICH hospitalizations, we identified 56,635 HC ICH patients. HC patients, compared to patients with no hypercholesterolemia (NHC), were older (72.3 vs. 68.7 years), had higher proportional (%) burden of diabetes (35.8 vs. 26.4), hypertension (90.0 vs. 80.9), obesity (9.2 vs. 8.0), atrial fibrillation (22.1 vs. 19.3) and past / current use of anticoagulation (11.9 vs. 9.8). However, HC patients (vs. NHC) were less likely to have extreme loss of function (21.4 vs. 28.7) or receive invasive treatment, including extra-ventricular drain (5.2 vs. 7.6), invasive ventilation (5.7 vs. 7.9), tracheostomy (2.4 vs. 4.2) and gastric tube placement (6.0 vs. 8.5). Overall, and non-Hispanic whites (NHW), non-Hispanic black and Hispanic, HC patients (vs. NHC) had lower IHM (aOR, CI for overall effect: 0.85, 0.81 - 0.90) (Figure 1). The HC - IHM association was significantly modified by age among NHW, whereby the likelihood of IHM among HC (vs. NHC) significantly increased with advancing age (aOR, CI: 1.01, 1.00 - 1.02) (Figure 2).

Conclusion: HC is associated with lower ICH severity and IHM, albeit with significant race/ethnic variations. Further evaluation of potential role of genetic, environmental and treatment factors, across race/ethnicity sub-groups, in the relationship between HC and ICH outcomes is warranted.

Abstract WP138: Delirium Is Associated With Higher Rates Of 90-day Hospital Readmission Among Patients With Primary Intracerebral Hemorrhage

Background: Delirium in-hospital (DIH) results in poor in-patient outcomes. However, it’s longer-term effects among intracerebral hemorrhage (ICH) patients are not well characterized. We sought to evaluate the association between DIH and 90-day readmission (RA) among primary ICH patients.

Method: Clinical, imaging and outcomes data, from May 2016 to June 2021, were obtained from the Neurological Outcomes Registry for ICH (NEURO-RICH) ; an informatics pipeline across 7 comprehensive and primary stroke centers which implement protocolized delirium assessments via 4AT / CAM-ICU scales. Demographic (age, sex, race, ethnicity, marital status), Glasgow Coma Scale (GCS), systolic and diastolic blood pressure (S/DBP), sepsis, systemic inflammatory response syndrome, and comorbidity data were analyzed. Survival analysis for time-to-90-Day RA was performed with death modeled as a competing risk. Sub hazard ratios (SHR) and 95% confidence intervals (CI) are reported. Subgroup with imaging data (ICH score and cerebral small vessel disease) was analyzed.

Results: Final analyses included 1,434 ICH patients (mean age: 66.0 years, 47.2% female, 24.8% non-Hispanic Black, 19.9% Hispanic, median GCS: 13.2, SBP: 163 mmHg). In the fully adjusted model, DIH was significantly associated with higher rates of 90-Day RA (SHR, CI: 2.24, 1.04 - 4.81) (Figure 1A). Anticoagulant therapy (1.36, 1.03 - 1.80), hypertension (1.95, 1.38 - 2.74), diabetes (1.13, 1.09 - 1.17), and Charlson Comorbidity Index (1.08, 1.04 - 1.13) were also independently associated with 90-Day RA (SHR, CI reported). In the imaging subgroup of 523 patients, DIH retained independent association with 90-Day RA (SHR: 3.94 [1.37 - 11.36]) (Figure 1B).

Discussion: In addition to traditional predictors of poor outcomes among ICH patients, DIH demonstrated strong and independent association with 90-day RA. Screening, identification, and active management of DIH is critical to reduce long-term disease burden of ICH.

Abstract TP105: Optimizing The Utilization Of Cardiac Magnetic Resonance Imaging Among Patients With Ischemic Stroke

Background: The current AHA guidelines recommend (class IIb) advanced cardiac imaging in an embolic stroke of unknown source (ESUS). We aim to better characterize the role of cardiac MRI (cMRI) in the evaluation of stroke patients and determine patient characteristics that may increase the positive predictive value of cMRI.

Method: A retrospective review of stroke patients at a comprehensive stroke center, who had cMRI between 12/2016 and 11/2020 was conducted using institutional registries. Ischemic stroke patients with ESUS, cryptogenic (with ESUS as a competing etiology), and cardioembolic etiologies were included. Cases with TIA, large vessel, small vessel, or hemodynamic etiologies were excluded. Cardioembolic etiology was defined as newly diagnosed Afib patients with TTE abnormalities including wall motion abnormalities and/or reduced LVEF <50%, stroke while compliant with anticoagulation for known Afib, or among whom the timing of restarting anticoagulation was in question. TTE and cMRI results from all cases were reviewed for remarkable findings, most notably intracardiac thrombus, and analyzed if a change in anti-thrombotic therapy was directly attributable to cMRI results.

Results: As per our criteria, 250 cases (Female 44.4%, Black 29.6%, Age mean: 65.2 years) were included, of whom 146 (58.4%) were ESUS, 86 (34.4%) were cryptogenic, and 18 (7.2%) were cardioembolic. Sixteen (6.4%) revealed intracardiac thrombus, of which 10 had LV thrombus, 5 had LA thrombus, and 1 had RA thrombus along with questionable PFO on cMRI. Of these, 14 (87.5%) had an escalation of anti-thrombotic therapy. For the other 2 cases, despite cMRI obtained due to low LVEF and revealing LA thrombus, antithrombotic regimen was not changed. Eight (3.2%) additional patients were placed on anticoagulation secondary to incidental findings.

Conclusion: In this large retrospective analysis of 250 select stroke cases, escalation of anti-thrombotic therapy from anti-platelets to full dose anti-coagulation was indicated in 14 patients (5.6%) with addition of cMRI. Further analysis of data is in process to determine the subset of stroke patients who would benefit the most from cMRI.

Abstract TP164: Diaschisis As A Possible Predictive Factor On 90-day MRS Outcomes In Extended Window Lvos

Objective: To determine whether the presence of diaschisis on CT perfusion (CTP) scans is predictive of 90-day functional outcomes in stroke patients with extended window large vessel occlusion (EWLVO) treated with mechanical thrombectomy (MT).

Background: Diaschisis is a neurophysiological phenomenon that indicates functional/metabolic depression in the cerebellar hemisphere contralateral to supratentorial cortex following focal ischemic injury. Typically seen on PET or Perfusion-MR/-CT imaging, it is thought to reflect depressed Purkinje Cell activity secondary to disruptions of excitatory cortico-ponto-cerebellar afferent projections. Despite its reported incidence of 20%, its prognostic value and clinical significance remain unclear. Given the underlying pathophysiology, we hypothesized that presence of contralateral cerebellar diaschisis would be associated with worse 90 day mRS outcomes in patients with intracranial EWLVO treated with MT.

Methods: A retrospective review was performed evaluating all EWLVO patients who presented from 2016 to July 2021. The presence of contralateral cerebellar diaschisis was determined by visual review of CTP imaging. EWLVO patients were categorized into those with and without daichisis. The 90 day mRS outcomes were compared between the two groups while controlling for age, gender, race, medical co-morbidities, NIHSS, and reperfusion outcomes.

Results: 83 LVO patients with CTP imaging were identified by chart review. Of these, 32 (38.5%) demonstrated contralateral cerebellar diaschisis. There no statistically significant differences among all studied variables. Using logistic regression analysis, no statistical association was found between the presence of contralateral cerebellar diaschisis on EWLVO patients and their 90 day outcomes.

Conclusions: For patients with acute EWLVO treated with thrombectomy, the presence of diaschisis on CTP is not predictive of 90 day functional outcomes.

Abstract 33: Stroke Severity Mediates The Association Between Socioeconomic Disadvantage And Poor Outcomes Among Patients With Acute Ischemic Stroke

Background: Impact of socioeconomic disadvantage on outcomes among acute ischemic stroke (AIS) patients has not been well characterized.

Methods: Clinical data on AIS patients were extracted from electronic medical records and 90-day modified Rankin Scale (mRS) scores were collected as a part of prospective stroke registry. Exact patient addresses were geocoded, and state-level Area Deprivation Index (ADI) ranks were categorized as low, medium, high. Patients with a 90-day mRS score ≥ 4 were categorized as severe disability or death (SDD). Logistic regression models (adjusted for treatment with intravenous tissue plasminogen activator or mechanical thrombectomy, age, sex, race/ethnicity, insurance, prior stroke, vascular risk factors) were fitted to compute odds ratios (OR) and 95% confidence intervals (CI) for total effect of high ADI on SDD. Structural equation modeling was used to assess mediation effects of stroke severity as measured by National Institutes of Health Stroke Scale (NIHSS).

Results: Between May 2016 and Apr 2021, a total of 2,900 AIS patients (mean age: 68.5 years; 50.1% male; 28.4% non-Hispanic Black; 12.9% Hispanic) with complete outcomes data were included. In an adjusted model, high ADI was significantly associated with SDD (OR, CI: 1.14, 1.02-1.28). In the mediation analysis, patients in higher ADI neighborhoods had a 28% increased likelihood of having higher NIHSS (OR: 1.28, CI: 1.15-1.44). Likewise, higher NIHSS was associated with SDD (OR: 7.10, CI: 5.96-8.51). The effect of neighborhood disadvantage on SDD was fully mediated by NIHSS (average causal mediation effect of ADI on SDD: P=0.002), with 77% of the total effect pathway mediated through NIHSS. The proportions of 90-day mRS by ADI categories are reported (Figure).

Conclusion: Neighborhood disadvantage leads to poor stroke outcomes mediated via stroke severity. Tracking social determinants of health may identify opportunities for reducing stroke related disability.

Abstract 140: Real-world Efficacy Of Left Atrial Appendage Closure Versus Anticoagulation Therapy For Long-term Prevention Of Ischemic Stroke And All-cause Mortality Among Patients With Atrial Fibrillation

Introduction: There is limited data on real-world efficacy of left atrial appendage closure (LAAC) procedures compared to anticoagulants (AC) for stroke prevention among patients with atrial fibrillation (AF).

Methods: We utilized a retrospective cohort of over 63 million patients from 51 healthcare organizations across 6 countries via a harmonized electronic medical record-based research data platform. Utilizing international classification of disease version 10 and current procedural terminology codes, adult (≥ 18 years) patients with AF (I48) were identified and grouped by treatment type (LAAC (33340, 02L73DK) vs AC (1015112, Z79.0, BL110)). Patients with a history of stroke prior to AC initiation or LAAC procedure were excluded. Subjects were followed for 5 years for incident ischemic stroke (I63), intracerebral hemorrhage (I61), and all-cause mortality. Treatment groups were propensity score matched by age, sex, race, ethnicity, and comorbidities. Risk ratio(RR) and 95% confidence intervals(CI) among unmatched and matched populations are reported.

Results: Among a total of 1,980,130 AF patients; 1,374,013 were flagged for AC use and 8,004 were treated via LAAC. Treatment cohorts were propensity score matched by age, race, sex, hyperlipidemia, and hypertension resulting in an exact 1:1 matched cohort of 8,004 subjects, across all co-variates. In the matched population the mean (SD) age was 75.2 (8.05) years, 63.2% were male; 86.6% were white, 4.4% black, 0.89% Asian, and 3.5% Hispanic; with 64.4% hyperlipidemic and 79.2% hypertensive. Prior to matching, AC (vs. LAAC) was significantly associated with a higher 5-year risk of ischemic stroke, intracerebral hemorrhage, and all-cause mortality. The protective effect of LAAC (vs. AC) was maintained for 5-year risk of ischemic stroke (RR, CI: 0.68, 0.58 - 0.79) and all-cause mortality (RR, CI: 0.42, 0.39 - 0.45). However, the difference in 5-year risk for intracerebral hemorrhage for LAAC (vs. AC) was not statistically lower (RR, CI: 0.72, 0.50 - 1.05).

Conclusion: Notwithstanding the possibility of residual confounding in our analyses, LAAC seems to be associated with a lower long-term risk of ischemic stroke and all-cause mortality as compared to AC treated AF patients in large real-world data.

Abstract WP143: Stroke Severity Mediates The Association Between Neighborhood Socioeconomic Deprivation And Poor Outcomes Among Patients With Intracerebral Hemorrhage

Background: Relationships between neighborhood socioeconomic deprivation (NSD) and Intracerebral hemorrhage (ICH) outcomes are not well characterized. We sought to evaluate the impact of NSD on ICH outcomes and assessed mediating pathways for association between NSD and poor outcomes.

Methods: Clinical data were extracted from the electronic medical records and 90-day modified Rankin Scale (mRS) scores were obtained from a prospectively collected stroke registry at a large healthcare system. Presentation NIHSS score was used to assess ICH severity. Exact patient addresses were geocoded, and state-level Area Deprivation Index (ADI) was calculated, with high NSD (H-NSD) categorized as top 15% of ADI scores. The outcome was severe disability or death (SDD) (mRS ≥ 4). Age-adjusted logistic regression models were fitted, and mediation analyses were performed utilizing structured equation modeling. Odds ratios (OR) and 95% Confidence Intervals (CI) are reported.

Results: Final analyses included 486 patients with complete data (mean age: 65.6 years, 45.9 % female, 28.8% non-Hispanic Black, 20.2% Hispanic, median presentation NIHSS: 10, and median 90-day mRS 4). In separate age-adjusted models, both high NIHSS scores (OR, CI: 1.24, 1.20 - 1.29) and H-NSD (OR, CI: 1.59, 1.02 - 2.46) were associated with SDD. In a mediation analysis, H-NSD significantly contributed to higher NIHSS scores (OR, CI: 14.30, 1.44 - 141.61) and in turn higher NIHSS scores were significantly associated with SDD (OR, CI: 1.03, 1.03 - 1.04). In this analysis, H-NSD did not retain a significant direct effect on SDD (OR, CI: 1.38, 0.96 - 1.12) and was instead fully mediated by high NIHSS scores (Figure 1).

Discussion: Our analyses uniquely identify higher stroke severity as a potential causal pathway between NSD and poor ICH outcomes. These findings warrant comprehensive understanding of factors that may predispose the disadvantaged to experience higher ICH severity and greater neurological deficit.

Abstract WP140: Environment Matters: Neighborhood Socioeconomic Disadvantage And Cerebral Small Vessel Disease Are Associated With Poor Outcomes Among Patients With Intracerebral Hemorrhage

Background: Only 20-30% of Intracerebral Hemorrhage (ICH) survivors achieve functional independence. We investigated if neighborhood socioeconomic disadvantage (NSD) mediated by cerebral small vessel disease (CSVD) is associated with post-ICH functional outcomes.

Methods: Clinical and imaging data were extracted from electronic medical records and 90-day modified Rankin Score (mRS) was obtained from prospectively collected stroke registry at a large hospital system. CSVD was assessed based on MRI markers from 1-year before to 30 days after the ICH event and was scored from 0-4 with severe CSVD (S-CSVD) ≥ 2. Exact patient addresses were geocoded, and state-level Area Deprivation Index (ADI) was calculated, with high NSD (H-NSD) categorized as the top 15% of ADI scores. The outcome was severe disability or death (SDD) categorized as 90-day mRS score ≥4. Multivariate logistic regression models were fitted, and mediation was evaluated by structural equation modeling. Odds ratios (OR) and 95% confidence intervals (CI) are reported.

Results: Final analysis included 367 patients (mean age: 65 years, 49.7% female, median presentation ICH Score: 1) with complete data. We found significant associations between older age, Black race, S-CSVD, H-NSD, hematoma volume, presence of ventricular hemorrhage, presentation systolic blood pressure (SBP), and ICH score with SDD (P<0.05). In a multivariate model adjusted for age, SBP, ICH score and other important clinical co-variates, SDD was significantly and independently associated with both H-NSD (OR, CI: 2.03, 1.05 - 4.23) and S-CSVD (OR, CI: 1.93, 1.12 - 3.35). Our data did not demonstrate an association between CSVD and NSD; and S-CSVD did not mediate the relationship between H-NSD and SDD.

Discussion: In addition to known clinical factors, NSD, as measured by the ADI, and CSVD were independently associated with poor ICH outcomes. Potential causal pathways between H-NSD and poor ICH outcomes need to be further evaluated.

Abstract TP187: Contemporary Estimates Of Poor Cardiovascular Health Among Individuals With Stroke: Nationwide Analysis Of The American Heart Association’s Simple 7

Introduction: The American Heart Association’s (AHA) “Simple 7” are lifestyle behaviors for maintenance of ideal cardiovascular health (CVH).

Methods: We analyzed 2019 Behavioral Risk Factor Surveillance System (BRFSS) data (nationally representative, annual, health-related survey of community dwelling US adults), and flagged individuals with a stroke diagnosis. Among stroke individuals (SI), we identified validated CVH features (diabetes, hypertension, BMI ≥ 25 kg/m 2 , hypercholesterolemia, smoking, poor eating habits, and lack of exercise) based on AHA’s simple 7. SI with ≥ 5 CVH features were categorized as ‘Poor CVH’ (PCVH). We evaluated socio-demographic, regional and healthcare utilization factors associated with PCVH. We fit survey design logistic regression models, and report nationally representative estimates as adjusted Odds Ratios (aOR) and 95% confidence intervals (CI).

Results: The 2019 estimated national count of SI is 8,570,876 translating into a nationwide stroke prevalence of 3.4% among US adults (7.9% among ≥ 65 years). SI who were divorced/separated (vs. married), non-Hispanic Black or Native American (vs. Non-Hispanic White - NHW), had lower income, resided in the stroke belt had higher likelihood of PCVH. In our adjusted model (Figure), males had a significantly higher PCVH aOR (CI) 1.26 (1.00 - 1.59). Moreover, Asian American and Pacific Islanders vs. NHW demonstrated higher PCVH, aOR (CI) 4.74 (1.25 - 17.95). Compared to the New England region, residence in following divisions was associated with higher PCVH; aOR (CI) for West South-Central: 1.73 (1.05 -2.85), East North Central: 1.64 (1.11 - 2.43), East South Central: 2.29 (1.37 - 3.83), South Atlantic: 1.74 (1.18 - 2.57). Analyses for 2020 BRFSS data will be presented.

Conclusion: National stroke prevalence rates are provided. Poor CVH among stroke individuals continues to be disparately high. These analyses are important to identify and target high-risk population sub-groups.

Abstract TP10: Inflammatory And Neurodegenerative Gene Expression Changes Occur Long-term After ICH

Objective: There is a high prevalence of progressive cognitive impairment in intracerebral hemorrhage (ICH) survivors. We sought to identify gene expression changes, in association with long-term neurodegeneration, among patients 12-24 months post-ICH.

Methods: The Recovery and Outcomes from StrokE (ROSE) study prospectively recruits patients with spontaneous, supratentorial ICH, collecting baseline peripheral blood samples and MRI with diffusion tract imaging (DTI). The Recovery of StrokE-Longitudinal Assessment with Neuroimaging (ROSE-LAWN) study performs long term follow-up at 12-24 months on cases enrolled in ROSE. We report on the first five cases enrolled in the ROSE-LAWN study from December 2020 to March 2021. Controls were matched to an overall ICH population by age, sex, and race. RNA-sequencing, aligned to human genome assembly GRCh38, was tested for differential gene expression. Canonical pathway enrichment and network analyses were computed for differentially expressed genes using Ingenuity Pathway Analysis, STRING and MCODE.

Results: RNA-seq analysis of 5 ICH cases [male, 80%; median age, 61 (45 - 73); black, 40%; ICH volume, 14.88cc ± 13.07] and 13 controls [male, 54%; median age, 74 (69 - 79); black, 15%] identified 554 differentially expressed genes (genomic control adjusted p < 0.01), of which 24 met the false discovery rate correction for multiple comparisons (FDR < 0.05). The most significant difference was observed in hypoxia up-regulated 1 ( HYOU1), a heat shock protein related gene (p = 2.64E-11). Pathway analysis identified enrichment of dopamine and serotonin receptor signaling (p = 8.74E-03, 2.23E-02), cell cycle regulation (p = 1.75E-02) and agranulocyte adhesion pathways (p = 2.18E-02). Comparison of baseline and follow-up MRI DTI demonstrated extensive cortical tract degeneration, beyond the initial injury.

Conclusion: These results provide novel evidence of significant gene expression changes occurring years after the initial ICH. Despite resolution of the ICH, persistent inflammation may correlate with progressive neurodegeneration and subsequent cognitive impairment in ICH survivors. Future studies with greater sample sizes are supported by this work.

Abstract TMP18: Global Estimates Of Frequency And Outcomes Of Coronavirus Disease 2019 Associated Stroke And Myocardial Infarction

Background: We evaluated the frequency and outcomes of Coronavirus Disease 2019 (COVID-19) associated stroke (ischemic and hemorrhagic) and myocardial infarction (MI) in a global research network.

Methods: All adult (≥ 18 years) patients with ICD-10 diagnoses of COVID-19 were included and those with a stroke (ischemic stroke, intracerebral hemorrhage [ICH], transient ischemic attach [TIA] or subarachnoid hemorrhage [SAH]) or myocardial infarction (MI) ± 28 days from COVID-19 diagnosis were flagged. Individuals with a prior history of stroke / MI were excluded. COVID-19 associated stroke (CAS) and MI (CAM) frequencies were compared to prior AHA-reported population-based incidences. Severe COVID-19 disease (use of ventilator, intubation, or life support) and 90-day mortality were evaluated among no-stroke/MI and stroke/MI subgroups utilizing general linear models adjusted for age, sex, race/ethnicity, and Charlson Comorbidity Index scores. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) are reported.

Results: Between Jan 2020 and Jul 2021, we identified 637,820 COVID-19 patients of whom 4,559 (0.71%) had a CAS and 6,972 (1.09%) had a CAM. COVID-19 was associated with significantly higher stroke/MI rates compared to population based reported incidence (ORs, CI for CAS 1.99, 1.93 - 2.05 and CAM 3.09, 3.01 - 3.16). Severe COVID disease was observed among 1.07% of COVID-19 only patients, 11.25% of CAS patients (aOR, CI: 4.82, 4.35 - 5.34), and 14.81% of CAM patients (aOR, CI: 5.77, 5.34 - 5.22). 90-Day mortality was 1.92% for COVID-19 only patients, 14.35% for CAS patients (aOR, CI: 3.16, 2.87 - 3.46), and 20.52% for CAM patients (aOR, CI: 4.12, 3.85 - 4.41). Group specific demographic and outcome proportions are reported (Figure).

Conclusion: The COVID-19 pandemic has tremendously exacerbated the burden of cerebrovascular and cardiovascular disease globally. Continued work is needed to understand drivers of poor outcomes among COVID-19 patients.

COVID‐19 associated disruptions in routine health care of people with mild cognitive impairment or dementia

Introduction

We report the COVID‐19 pandemic's impact on health‐care use disruption among people with mild cognitive impairment or Alzheimer's disease and related dementia (MCI/ADRD).

Methods

We compared the pandemic‐period health‐care use between MCI/ADRD and matched non‐MCI/ADRD patients. Using 4‐year pre‐pandemic data, we modeled three health‐care use types (inpatient, outpatient, emergency encounters) to predict pandemic‐period use, disaggregated for lockdown and post‐lockdown periods. Observed health‐care use was compared to the predicted. Proportional differences (confidence intervals) are reported.

Results

Both MCI/ADRD and non‐MCI/ADRD patients (n = 5479 each) experienced pandemic‐related health‐care use disruptions, which were significantly larger for the MCI/ADRD group for outpatient, –13.2% (–16.2%, –10.2%), and inpatient encounters, –12.8% (–18.4%, –7.3%). Large health‐care disruptions during lockdown were similar for both groups. However, post‐lockdown outpatient, –14.4% (–17.3%, –11.5%), and inpatient, –15.2% (–21.0%, –9.5%), disruptions were significantly greater for MCI/ADRD patients.

Conclusion

MCI/ADRD patients experienced greater and sustained pandemic‐related health‐care use disruptions, highlighting the need for robust strategies to sustain their essential health care during pandemic‐like catastrophes.

572. Real-world Effectiveness of COVID-19 mRNA Vaccines against Hospitalizations and Deaths in a Retrospective Cohort

Background

The effectiveness of Severe Acute Respiratory Syndrome Coronavirus 2 vaccines after two doses needs to be demonstrated beyond clinical trials.

Methods

In a retrospective cohort assembled from a cross-institution comprehensive data repository, established patients of the health care system were categorized as having received no doses, one dose or two doses of SARS-CoV-2 mRNA vaccine through April 4, 2021. Outcomes were COVID-19 related hospitalization and death.

Results

Of 94,018 patients 27.7% had completed two doses and 3.1% had completed one dose of a COVID-19 mRNA vaccine. The two dose group was older with more comorbidities. 1.0% of the two dose group had a COVID-19 hospitalization, compared to 4.0% and 2.7% in the one dose and no dose groups respectively. The adjusted Cox proportional-hazards model based vaccine effectiveness after two doses (vs. no dose) was 96%(95% confidence interval(CI):95–97), compared to 78%(95%CI:76–82) after one dose. After two doses, vaccine effectiveness for COVID-19 mortality was 97.9%(95%CI:91.7–99.5), and 53.5%(95%CI:0.28–80.8) after one dose. Vaccine effectiveness at preventing hospitalization was conserved across age, race, ethnicity, Area Deprivation Index and Charlson Comorbidity Indices.

Cohort Enrollment and Distribution by Immunization Status and Vaccine effectiveness against mortality

Cohort members are described by their immunization status and hospitalization at the end of the study period ending April 4th, 2021. Percentages compare this population to the total established patients. Each group is then divided into when hospitalized events occurred across immunization status. These percentages compare the number of events to the population in the immunization status at the end of the analysis period. Odds ratios for mortality were calculated and vaccine effectiveness calculated as 1 minus odds ratio times 100%.

Conclusion

In a large, diverse US cohort, receipt of two doses of an mRNA vaccine was highly effective in the real-world at preventing COVID-19 related hospitalizations and deaths with a substantive difference in effectiveness between one and two doses.

Disclosures

All Authors: No reported disclosures

Demographic Characteristics and Clinical Outcomes of Asian American and Pacific Islander Patients With Primary Intracerebral Hemorrhage

This cross-sectional study analyzes the 15-year demographic, incidence, hospitalization, and case fatality data of Asian American and Pacific Islander adults with intracerebral hemorrhage.

A contemporary review of therapeutic and regenerative management of intracerebral hemorrhage

Intracerebral hemorrhage (ICH) remains a common and debilitating form of stroke. This neurological emergency must be diagnosed and treated rapidly yet effectively. In this article, we review the medical, surgical, repair, and regenerative treatment options for managing ICH. Topics of focus include the management of blood pressure, intracranial pressure, coagulopathy, and intraventricular hemorrhage, as well as the role of surgery, regeneration, rehabilitation, and secondary prevention. Results of various phase II and III trials are incorporated. In summary, ICH patients should undergo rapid evaluation with neuroimaging, and early interventions should include systolic blood pressure control in the range of 140 mmHg, correction of coagulopathy if indicated, and assessment for surgical intervention. ICH patients should be managed in dedicated neurosurgical intensive care or stroke units where continuous monitoring of neurological status and evaluation for neurological deterioration is rapidly possible. Extravasation of hematoma may be helpful in patients with intraventricular extension of ICH. The goal of care is to reduce mortality and enable multimodal rehabilitative therapy.

Impact of mRNA vaccines in curtailing SARS-CoV-2 infection and disability leave utilisation among healthcare workers during the COVID-19 pandemic: cross-sectional analysis from a tertiary healthcare system in the Greater Houston metropolitan area

OBJECTIVES

We provide an account of real-world effectiveness of COVID-19 vaccines among healthcare workers (HCWs) at a tertiary healthcare system and report trends in SARS-CoV-2 infections and subsequent utilisation of COVID-19-specific short-term disability leave (STDL).

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

Summary data on 27 291 employees at a tertiary healthcare system in the Greater Houston metropolitan area between 15 December 2020 and 5 June 2021. The initial 12-week vaccination programme period (15 December 2020 to 6 March 2021) was defined as a rapid roll-out phase.

MAIN OUTCOMES AND MEASURES

At the pandemic onset, HCW testing and surveillance was conducted where SARS-CoV-2-positive HCWs were offered STDL. Deidentified summary data of SARS-CoV-2 infections and STDL utilisation among HCWs were analysed. Prevaccination and postvaccination trends in SARS-CoV-2 positivity and STDL utilisation rates were evaluated.

RESULTS

Updated for 5 June 2021, 98.2% (n=26 791) of employees received a full or partial dose of one of the approved mRNA COVID-19 vaccines. The vaccination rate during the rapid roll-out phase was approximately 3700 doses/7 days. The overall mean weekly SARS-CoV-2 positivity rates among HCWs were significantly lower following vaccine roll-out (2.4%), compared with prevaccination period (11.8%, p<0.001). An accompanying 69.8% decline in STDL utilisation was also observed (315 to 95 weekly leaves). During the rapid roll-out phase, SARS-CoV-2 positivity rate among Houston Methodist HCWs declined by 84.3% (8.9% to 1.4% positivity rate), compared with a 54.7% (12.8% to 5.8% positivity rate) decline in the Houston metropolitan area.

CONCLUSION

Despite limited generalisability of regional hospital-based studies-where factors such as the emergence of viral variants and population-level vaccine penetrance may differ-accounts of robust HCW vaccination programmes provide important guidance for sustaining a critical resource to provide safe and effective care for patients with and without COVID-19 across healthcare systems.

National Trends in Transfer of Patients with Primary Intracerebral Hemorrhage: An Analysis of 12-Year Nationwide Data

OBJECTIVES

The guidelines of the American Hospital Association encourage transferring intracerebral hemorrhage patients from community hospitals to centers with stroke expertise. However, research on the differences in outcomes between transferred intracerebral hemorrhage hospitalizations and directly admitted hospitalizations have been largely limited to small single-center studies. In this study, we explored the national trends in transferred intracerebral hemorrhage hospitalizations, as well as evaluated the differences, in terms of demographic characteristics, co-morbidity, resource utilization, and outcomes, between transferred intracerebral hemorrhage hospitalizations and directly admitted hospitalizations.

MATERIALS AND METHODS

From the National Inpatient Sample (2004 - 2016), we assessed the linear trends in the proportion of interhospital transfers for intracerebral hemorrhage hospitalizations. We constructed a series of multivariate logistic regression models to explore the association of transfer status with inpatient mortality and discharge disposition, controlling for demographic, clinical, and hospital characteristics. We used survey design variables to report nationally weighted estimates.

RESULTS

Among 786,999 hospitalizations, 137,340 (17.5%, 95% CI: 16.4-18.6) were transferred. Overall, interhospital transfers for intracerebral hemorrhage has been increasing over the 12-year period of this study. Patients in transferred hospitalizations were younger, more likely to be white, and more likely to have private insurance. Transferred hospitalizations were associated with significantly lower adjusted odds of inpatient mortality, compared to directly admitted hospitalizations.

CONCLUSIONS

As the US healthcare system continues shifting towards value-based care, evidence on the short- and long-term outcomes of transfer of intracerebral hemorrhage patients will inform optimal management of intracerebral hemorrhage patients.

Association Between 2010 Medicare Reform and Inpatient Rehabilitation Access in People With Intracerebral Hemorrhage

Background

Evidence suggests intracerebral hemorrhage survivors have earlier recovery compared with ischemic stroke survivors. The Centers for Medicare and Medicaid Services prospective payment system instituted documentation rules for inpatient rehabilitation facilities (IRFs) in 2010, with the goal of optimizing patient selection. We investigated whether these requirements limited IRF and increased skilled nursing facility (SNF) use compared with home discharge.

Methods and Results

Intracerebral hemorrhage discharges to IRF, SNF, or home were estimated using GWTG (Get With The Guidelines) Stroke registry data between January 1, 2008, and December 31, 2015 (n=265 444). Binary hierarchical models determined associations between the 2010 Rule and discharge setting; subgroup analyses evaluated age, geographic region, and hospital type. From January 1, 2008, to December 31, 2009, 45.5% of patients with intracerebral hemorrhage had home discharge, 22.2% went to SNF, and 32.3% went to IRF. After January 1, 2010, there was a 1.06% absolute increase in home discharge, a 0.46% increase in SNF, and a 1.52% decline in IRF. The adjusted odds of IRF versus home discharge decreased 3% after 2010 (adjusted odds ratio [aOR], 0.97; 95% CI, 0.95–1.00). Lower odds of IRF versus home discharge were observed in people aged <65 years (aOR, 0.92; 95% CI, 0.89–0.96), Western states (aOR, 0.89; 95% CI, 0.84–0.95), and nonteaching hospitals (aOR, 0.90; 95% CI, 0.86–0.95). Adjusted odds of SNF versus home discharge increased 14% after 2010 (aOR, 1.14; 95% CI, 1.11–1.18); there were significant associations in all age groups, the Northeast, the South, the Midwest, and teaching hospitals.

Conclusions

The Centers for Medicare and Medicaid Services 2010 IRF prospective payment system Rule resulted in fewer discharges to IRF and more discharges to SNF in patients with intracerebral hemorrhage. Health policy changes potentially affect access to intensive postacute rehabilitation.

Risk factors for severity of COVID-19 in hospital patients age 18-29 years

BACKGROUND

Since February 2020, over 2.5 million Texans have been diagnosed with COVID-19, and 20% are young adults at risk for SARS-CoV-2 exposure at work, academic, and social settings. This study investigated demographic and clinical risk factors for severe disease and readmission among young adults 18-29 years old, who were diagnosed at a hospital encounter in Houston, Texas, USA.

METHODS AND FINDINGS

A retrospective registry-based chart review was conducted investigating demographic and clinical risk factors for severe COVID-19 among patients aged 18-29 with positive SARS-CoV-2 tests within a large metropolitan healthcare system in Houston, Texas, USA. In the cohort of 1,853 young adult patients diagnosed with COVID-19 infection at a hospital encounter, including 226 pregnant women, 1,438 (78%) scored 0 on the Charlson Comorbidity Index, and 833 (45%) were obese (≥30 kg/m2). Within 30 days of their diagnostic encounter, 316 (17%) patients were diagnosed with pneumonia, 148 (8%) received other severe disease diagnoses, and 268 (14%) returned to the hospital after being discharged home. In multivariable logistic regression analyses, increasing age (adjusted odds ratio [aOR] 1.1, 95% confidence interval [CI] 1.1-1.2, p<0.001), male gender (aOR 1.8, 95% CI 1.2-2.7, p = 0.002), Hispanic ethnicity (aOR 1.9, 95% CI 1.2-3.1, p = 0.01), obesity (3.1, 95% CI 1.9-5.1, p<0.001), asthma history (aOR 2.3, 95% CI 1.3-4.0, p = 0.003), congestive heart failure (aOR 6.0, 95% CI 1.5-25.1, p = 0.01), cerebrovascular disease (aOR 4.9, 95% CI 1.7-14.7, p = 0.004), and diabetes (aOR 3.4, 95% CI 1.9-6.2, p<0.001) were predictive of severe disease diagnoses within 30 days. Non-Hispanic Black race (aOR 1.6, 95% CI 1.0-2.4, p = 0.04), obesity (aOR 1.7, 95% CI 1.0-2.9, p = 0.046), asthma history (aOR 1.7, 95% CI 1.0-2.7, p = 0.03), myocardial infarction history (aOR 6.2, 95% CI 1.7-23.3, p = 0.01), and household exposure (aOR 1.5, 95% CI 1.1-2.2, p = 0.02) were predictive of 30-day readmission.

CONCLUSIONS

This investigation demonstrated the significant risk of severe disease and readmission among young adult populations, especially marginalized communities and people with comorbidities, including obesity, asthma, cardiovascular disease, and diabetes. Health authorities must emphasize COVID-19 awareness and prevention in young adults and continue investigating risk factors for severe disease, readmission and long-term sequalae.

SARS-CoV-2 Susceptibility and COVID-19 Mortality Among Older Adults With Cognitive Impairment: Cross-Sectional Analysis From Hospital Records in a Diverse US Metropolitan Area

Introduction: Persistent knowledge gaps exist as to the extent that preexisting cognitive impairment is a risk factor for susceptibility to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and mortality from the coronavirus disease 2019 (COVID-19). Methods: We conducted a cross-sectional analysis of adults tested for SARS-CoV-2 at a tertiary healthcare system. Cognitive impairment was identified utilizing diagnosis codes (mild cognitive impairment, Alzheimer's disease, vascular, and other dementias) or cognitive impairment-specific medication use. Propensity score (PS) matched analyses were utilized to report odds ratios (OR) and 95% confidence intervals (CI) for association of cognitive impairment with SARS-CoV-2 susceptibility and COVID-19 mortality. Results: Between March-3rd and December-11th, 2020, 179,979 adults were tested, of whom 21,607 (12.0%) tested positive. We identified 6,364 individuals with preexisting cognitive impairment (mean age: 78.5 years, 56.8% females), among whom 843 (13.2%) tested positive and 139 (19.5%) of those hospitalized died. In the pre-PS matched cohort, cognitive impairment was significantly associated with increased SARS-CoV-2 susceptibility (OR, CI: 1.12, 1.04-1.21) and COVID-19 mortality (OR, CI: 2.54, 2.07-3.12). One-to-one matches were identified for 6,192 of 6,364 (97.3%) individuals with prior cognitive impairment and 687 of 712 (96.5%) hospitalized patients with prior cognitive impairment. In the fully balanced post-matched cohort, preexisting cognitive impairment was significantly associated with higher likelihood of SARS-CoV-2 infection (OR, CI: 1.51, 1.35-1.70); however, cognitive impairment did not confer higher risk of COVID-19 mortality (OR, CI: 0.96, 0.73-1.25). Discussion: To mitigate the effects of healthcare catastrophes such as the COVID-19 pandemic, strategies for targeted prevention and risk-stratified comorbidity management are warranted among the vulnerable sub-population living with cognitive impairment.

Disparities in COVID-19 hospitalizations and mortality among black and Hispanic patients: cross-sectional analysis from the greater Houston metropolitan area

BACKGROUND

Disparate racial/ethnic burdens of the Coronavirus Disease 2019 (COVID-19) pandemic may be attributable to higher susceptibility to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) or to factors such as differences in hospitalization and care provision.

METHODS

In our cross-sectional analysis of lab-confirmed COVID-19 cases from a tertiary, eight-hospital healthcare system across greater Houston, multivariable logistic regression models were fitted to evaluate hospitalization and mortality odds for non-Hispanic Blacks (NHBs) vs. non-Hispanic Whites (NHWs) and Hispanics vs. non-Hispanics.

RESULTS

Between March 3rd and July 18th, 2020, 70,496 individuals were tested for SARS-CoV-2; 12,084 (17.1%) tested positive, of whom 3536 (29.3%) were hospitalized. Among positive cases, NHBs and Hispanics were significantly younger than NHWs and Hispanics, respectively (mean age NHBs vs. NHWs: 46.0 vs. 51.7 years; p < 0.001 and Hispanic vs. non-Hispanic: 44.0 vs. 48.7 years; p < 0.001). Despite younger age, NHBs (vs. NHWs) had a higher prevalence of diabetes (25.2% vs. 17.6%; p < 0.001), hypertension (47.7% vs. 43.1%; p < 0.001), and chronic kidney disease (5.0% vs. 3.3%; p = 0.001). Both minority groups resided in lower median income (median income [USD]; NHBs vs. NHWs: 63,489 vs. 75,793; p < 0.001, Hispanic vs. non-Hispanic: 59,104 vs. 68,318; p < 0.001) and higher population density areas (median population density [per square mile]; NHBs vs. NHWs: 3257 vs. 2742; p < 0.001, Hispanic vs. non-Hispanic: 3381 vs. 2884; p < 0.001). In fully adjusted models, NHBs (vs. NHWs) and Hispanics (vs. non-Hispanic) had higher likelihoods of hospitalization, aOR (95% CI): 1.42 (1.24-1.63) and 1.61 (1.46-1.78), respectively. No differences were observed in intensive care unit (ICU) utilization or treatment parameters. Models adjusted for demographics, vital signs, laboratory parameters, hospital complications, and ICU admission vital signs demonstrated non-significantly lower likelihoods of in-hospital mortality among NHBs and Hispanic patients, aOR (95% CI): 0.65 (0.40-1.03) and 0.89 (0.59-1.31), respectively.

CONCLUSIONS

Our data did not demonstrate racial and ethnic differences in care provision and hospital outcomes. Higher susceptibility of racial and ethnic minorities to SARS-CoV-2 and subsequent hospitalization may be driven primarily by social determinants.

COVID-19-related state-wise racial and ethnic disparities across the USA: an observational study based on publicly available data from The COVID Tracking Project

OBJECTIVE

To evaluate COVID-19 infection and mortality disparities in ethnic and racial subgroups in a state-wise manner across the USA.

METHODS

Publicly available data from The COVID Tracking Project at The Atlantic were accessed between 9 September 2020 and 14 September 2020. For each state and the District of Columbia, % infection, % death, and % population proportion for subgroups of race (African American/black (AA/black), Asian, American Indian or Alaska Native (AI/AN), and white) and ethnicity (Hispanic/Latino, non-Hispanic) were recorded. Crude and normalised disparity estimates were generated for COVID-19 infection (CDI and NDI) and mortality (CDM and NDM), computed as absolute and relative difference between % infection or % mortality and % population proportion per state. Choropleth map display was created as thematic representation proportionate to CDI, NDI, CDM and NDM.

RESULTS

The Hispanic population had a median of 158% higher COVID-19 infection relative to their % population proportion (median 158%, IQR 100%-200%). This was followed by AA, with 50% higher COVID-19 infection relative to their % population proportion (median 50%, IQR 25%-100%). The AA population had the most disproportionate mortality, with a median of 46% higher mortality than the % population proportion (median 46%, IQR 18%-66%). Disproportionate impact of COVID-19 was also seen in AI/AN and Asian populations, with 100% excess infections than the % population proportion seen in nine states for AI/AN and seven states for Asian populations. There was no disproportionate impact in the white population in any state.

CONCLUSIONS

There are racial/ethnic disparities in COVID-19 infection/mortality, with distinct state-wise patterns across the USA based on racial/ethnic composition. There were missing and inconsistently reported racial/ethnic data in many states. This underscores the need for standardised reporting, attention to specific regional patterns, adequate resource allocation and addressing the underlying social determinants of health adversely affecting chronically marginalised groups.