202: Best “Better Early Stroke Treatment”: Implementation of Nursing Questionnaire Aids in Triage of Acute Ischemic Stroke Patients

Objective: Most acute stroke treatment trials exclude patients above the age of 80. Given the clear benefit of revascularization with intravenous tissue plasminogen activator (IV tPA) and mechanical thrombectomy (MT), we sought to assess functional outcomes in patients treated above the age of 80. Methods: We conducted a review of all patients admitted to Houston Methodist Hospital between January 2019 and August 2020 with an acute ischemic stroke (AIS) presentation[MOU1] for whom premorbid, discharge, and 90 day modified Rankin Scale scores were available. Patients were categorized by acute stroke treatment (IV tPA, MT, both or none[MOU2] ). mRS values were assessed during admission prior to discharge and at 90 days post stroke event. A delta mRS (Discharge vs. 90-day [MOU3] ) was defined and grouped as no change, improved, or worsened to assess overall functional disability in regards to the index stroke presentation. Results: A total of 865 patients with AIS presentation were included, of whom 651 (75.3%) were <80 years and 214 (24.7%) were > 80 years of age at presentation. A total of 208 patients received IV tPA, 176 underwent revascularization with MT only, 71 had both treatments, and 552 had no acute intervention. In patients >80 yrs who had no acute stroke intervention. mRS improvement was noted in 71.4% compared to 54.1% observed in those patients <80 years. Among patients who received IV tPA, 81.5% of > 80 years improved vs. 61.6% in the younger cohort. A similar trend was noted in the MT and combined treatment groups (76.2% vs. 71.2% and 78.6% vs. 79.3%, respectively). Conclusion: Based on our cohort of acute stroke patients, there was no significant difference in outcomes (as measured by delta mRS) for octogenarians and nonagenarians when compared to younger patients. There was a trend towards improvement in the elderly patients. Chronological age by itself may be an insufficient predictor of functional outcome among stroke patients and age cutoffs for enrollment of patients in acute stroke trials may need additional considerations.

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Abstract TP52: Endovascular Therapy in Patients Over 80 Years of Age With Acute Ischemic Stroke

Stroke ◽

10.1161/str.51.suppl_1.tp52 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Janhavi M Modak ◽

Syed Daniyal Asad ◽

Jussie Lima ◽

Amre Nouh ◽

Ilene Staff ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Symptom Onset ◽

Time Window ◽

Extended Time ◽

Stroke Patients ◽

Stroke Outcomes ◽

Stroke Treatment ◽

Group A ◽

Group B

Introduction: Acute ischemic stroke treatment has undergone a paradigm shift, with patients being treated in the extended time window (6-24 hours post symptom onset). The purpose of this study is to assess outcomes in stroke patients above 80 years of age undergoing endovascular treatment (EVT) in the extended time window. Methods: Acute ischemic stroke patients presenting to Hartford Hospital between January 2017 to June 2019 were considered for the study. Stroke outcomes in patients above 80 years of age with anterior circulation ischemic strokes presenting in the extended time window (Group A, n=30) were compared to a younger cohort of patients below 80 years (Group B, n=31). Patients over 80 years treated in the traditional time window (within 6 hours of symptom onset) served as a second set of controls (Group C, n=40). Statistical analysis was performed with a significance level of 0.05 Results: For angiographic results, there were no statistically significant differences in terms of good outcomes (TICI 2b-3) among patients of Group A, when compared to Groups B or C (p>0.05). For the endovascular procedures, no significant differences were noted in the total fluoroscopy time (Median Group A 44.05, Group B 38.1, Group C 35.25 min), total intra-procedure time (Median Group A 144, Group B 143, Group C 126 min) or total radiation exposure (Median Group A 8308, Group B 8960, Group C 8318 uGy-m 2 ). For stroke outcomes, a good clinical outcome was defined as modified Rankin score of 0-2 at discharge. Significantly better outcomes were noted in the younger patients in Group B - 35.4%, when compared to 13.3% in Group A (p=0.03). Comparative outcomes differed in the elderly patients above 80 years, Group A -13.3% vs Group C - 25%, although not statistically significant (p=0.23). There was a significant difference in mortality in patients of Group A - 40% as compared to 12% in the younger cohort, Group B (p= 0.01). Conclusions: In the extended time window, patients above 80 years of age were noted to have a higher mortality, morbidity compared to the younger cohort of patients. No significant differences were noted in the stroke outcomes in patients above 80 years of age when comparing the traditional and the extended time window for stroke treatment.

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Role of the Neurosurgeon in Acute Ischemic Stroke Treatment From Triage to Intensive Care Unit

Neurosurgery ◽

10.1093/neuros/nyz013 ◽

2019 ◽

Vol 85 (suppl_1) ◽

pp. S47-S51

Author(s):

Kimberly P Kicielinski ◽

Christopher S Ogilvy

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Stroke Care ◽

Stroke Patients ◽

Acute Setting ◽

Stroke Treatment

Abstract As ischemic stroke care advances with more patients eligible for mechanical thrombectomy, so too does the role of the neurosurgeon in these patients. Neurosurgeons are an important member of the team from triage through the intensive care unit. This paper explores current research and insights on the contributions of neurosurgeons in care of acute ischemic stroke patients in the acute setting.

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Abstract T P187: Regionalization of Endovascular Therapy for Acute Ischemic Stroke in California, 2009-2010

Stroke ◽

10.1161/str.45.suppl_1.tp187 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Jay Chol Choi ◽

Renee Y Hsia ◽

Anthony S Kim

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Health Planning ◽

Stroke Therapy ◽

Stroke Patients ◽

Stroke Treatment ◽

Transport Distance ◽

Procedural Volume ◽

Endovascular Stroke Therapy

Background: The regional availability of hospitals with expertise in applying endovascular therapy for acute ischemic stroke is critical to ongoing efforts to develop effective interventions for this time-sensitive indication. We sought to assess the geographic proximity of stroke patients in California to centers that perform endovascular stroke therapy. Methods: We identified all hospitalizations for ischemic stroke at all 366 non-federal acute care hospitals in California from 2009 to 2010, including the subset where endovascular stroke therapy was employed, using data from the Office of Statewide Health Planning and Development. ZIP code centroids were used to estimate the geographic distance between a treating hospital and the patient’s residence. Using these distances, we estimated the proportion of stroke patients that lived within 2-hour (65 mile) transport distance to a hospital that performed certain threshold volumes of endovascular stroke cases each year. Results: From 2009-10, endovascular stroke treatment was used in 643 of 104,350 (0.6%) hospital discharges for ischemic stroke in California. A majority (60%) of these procedures were performed at hospitals that performed at least 12 procedures per year, and 83% of these procedures were performed at hospitals that performed at least 6 procedures per year. Of the 366 hospitals, 54 (15%) performed at least one endovascular stroke procedure per year. The median number of procedures per hospital per year was 3.5 (IQR 1-9). In-hospital mortality for endovascular stroke therapy was 21%, and a higher procedural volume at the hospital level was not associated with lower mortality. Most (86%) stroke patients lived within 65 miles of a center that performed at least 6 procedures per year (median with IQR, 9.5[7-17]), and 97% were within 65 miles of a center that performed at least 1 procedure per year. Conclusion: In 2009-10, less than 1% of ischemic stroke hospitalizations in California involved the use of endovascular stroke therapy. Most patients lived within a 2-hour transport distance from a center that performed at least one endovascular procedure per year.

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Abstract W MP7: Predictors and Implications of Capacity to Provide Informed Consent for Acute Ischemic Stroke Treatment Trials

Stroke ◽

10.1161/str.45.suppl_1.wmp7 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Hari Kishan R Indupuru ◽

Loren Shen ◽

Amber N Jacobs ◽

Chunyan Cai ◽

James C Grotta ◽

...

Keyword(s):

Clinical Trials ◽

Ischemic Stroke ◽

Informed Consent ◽

Acute Ischemic Stroke ◽

Stroke Patients ◽

Stroke Treatment ◽

Capacity To Consent ◽

Decision Making Capacity ◽

The Right ◽

Study Designs

Background and objectives: Enrollment into AIS trials has always been limited by the ability of the patient to give informed consent or the availability of a Legally Authorized Representative (LAR) in decision making capacity on behalf of the patient. In this analysis we try to identify the factors contributing to an acute ischemic stroke (AIS) patient’s inability to give informed consent. We hypothesized that clinical features and demographics would differ between those patients with and without capacity to consent. Methods: This analysis includes patients who enrolled into the coordinating center of the prospective, randomized ARTSS-2 clinical trial (Argatroban + TPA for acute ischemic stroke) and also screen failures due to inability to consent. Data is collected prospectively in the study screening log. The data collected included age, gender, race, NIHSS, lesion location, ER arrival time and mode of consent (self-consent, LAR-consent and unable to consent). Results: Between 12/11 and 06/13, a total of 33 acute ischemic stroke patients received IV-tPA and were eligible for the ARTSS-2 study. While 19 were enrolled, 14/33 (42.4%) were otherwise eligible, but not enrolled due to inability to self-consent and no LAR present. Patients not enrolled due to lack of capacity to consent and without LAR present tended to have higher median NIHSS scores and greater proportions of drowsiness and aphasia compared to the other groups (see table). Conclusion: Approximately 2 in 5 AIS patients are not eligible for AIS clinical trials based solely on their lack of capacity for informed consent. It is remains ethically imperative that current clinical trials as well as future study designs address this disregarded group of patients who deserve the right to be able to participate in research. Addressing this group of patients through exception from informed consent (EFIC) will both extend research to all stroke patients, but also greatly enhance AIS research.

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Abstract P85: Impact of Covid-19 Pandemic on Hospitalizations and Outcomes of Acute Ischemic Stroke Patients, Paul Coverdell National Acute Stroke Program (pcnasp)

Stroke ◽

10.1161/str.52.suppl_1.p85 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Xin Tong ◽

Sallyann Coleman King ◽

Erika Odom ◽

Quanhe Yang

Keyword(s):

Ischemic Stroke ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Reperfusion Therapy ◽

The United States ◽

Emergency Department Visits ◽

National Institutes Of Health ◽

Hospital Death ◽

Stroke Patients ◽

Stroke Treatment

Introduction: Studies suggest a significant reduction in emergency department visits and hospitalizations for acute ischemic stroke (AIS) during the COVID-19 pandemic in the United States. Few studies have examined AIS hospitalizations, treatments, and outcomes during the pandemic period. The present study compared the demographic and clinical characteristics of patients hospitalized with AIS before and during the COVID-19 pandemic (weeks 11-24 in 2019 vs. 2020). Method: We identified 42,371 admissions with a clinical diagnosis of AIS, from 370 participating hospitals who contributed data during weeks 11-24 in both 2019 and 2020 to the Paul Coverdell National Acute Stroke Program (PCNASP). Results: During weeks 11-24 of the COVID-19 period, AIS hospitalizations declined by 24.5% compared to the same period in 2019 (18,233 in 2020 vs. 24,138 in 2019). In 2020, the percentage of individuals aged <65 years who were hospitalized with AIS was higher compared with the same period in 2019 (34.6% vs. 32.7%, p<0.001); arriving by EMS were higher in 2020 compared with 2019 (47.7% vs. 44.8%, p<0.001). Individuals admitted with AIS in 2020 had a higher mean National Institutes of Health Stroke Scale (NIHSS) score compared with 2019 (6.7 vs. 6.3, p<0.001). In 2020, the in-hospital death rates increased by 16% compared to 2019 (5.0% vs. 4.3%, p<0.001). However, there were no differences in rates of alteplase use, achievement of door to needle in 60 minutes, or complications from reperfusion therapy between the two time periods. Conclusion: A higher percentage of younger (<65 years) individuals and more severe AIS cases were admitted to the participating hospitals during weeks 11 to 24 of the COVID-19 pandemic in 2020 compared to the same period in 2019. The AIS in-hospital death rate increased 16% during the pandemic weeks as compared to the same weeks in 2019. Additional studies are needed to examine the impacts of the COVID-19 pandemic on stroke treatment and outcomes.

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In-Hospital Delays for Acute Stroke Treatment Delivery During the COVID-19 Pandemic

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2020.170 ◽

2020 ◽

pp. 1-7

Author(s):

Aristeidis H. Katsanos ◽

Danielle de Sa Boasquevisque ◽

Mustafa Ahmed Al-Qarni ◽

Mays Shawawrah ◽

Rhonda McNicoll-Whiteman ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Stroke Patients ◽

State Of Emergency ◽

Treatment Delivery ◽

Stroke Treatment ◽

Intravenous Tissue Plasminogen Activator ◽

Before And After ◽

The Impact ◽

Central South

ABSTRACT: Background: We investigated the impact of regionally imposed social and healthcare restrictions due to coronavirus disease 2019 (COVID-19) to the time metrics in the management of acute ischemic stroke patients admitted at the regional stroke referral site for Central South Ontario, Canada. Methods: We compared relevant time metrics between patients with acute ischemic stroke receiving intravenous tissue plasminogen activator (tPA) and/or endovascular thrombectomy (EVT) before and after the declared restrictions and state of emergency imposed in our region (March 17, 2020). Results: We identified a significant increase in the median door-to-CT times for patients receiving intravenous tPA (19 min, interquartile range (IQR): 14–27 min vs. 13 min, IQR: 9–17 min, p = 0.008) and/or EVT (20 min, IQR: 15–33 min vs. 11 min, IQR: 5–20 min, p = 0.035) after the start of social and healthcare restrictions in our region compared to the previous 12 months. For patients receiving intravenous tPA treatment, we also found a significant increase (p = 0.005) in the median door-to-needle time (61 min, IQR: 46–72 min vs. 37 min, IQR: 30–50 min). No delays in the time from symptom onset to hospital presentation were uncovered for patients receiving tPA and/or endovascular reperfusion treatments in the first 1.5 months after the establishment of regional and institutional restrictions due to the COVID-19 pandemic. Conclusion: We detected an increase in our institutional time to treatment metrics for acute ischemic stroke patients receiving tPA and/or endovascular reperfusion therapies, related to delays from hospital presentation to the acquisition of cranial CT imaging for both tPA- and EVT-treated patients, and an added delay to treatment with tPA.

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Effects of Glycemic Gap on Post-Stroke Cognitive Impairment in Acute Ischemic Stroke Patients

Brain Sciences ◽

10.3390/brainsci11050612 ◽

2021 ◽

Vol 11 (5) ◽

pp. 612

Author(s):

Minwoo Lee ◽

Jae-Sung Lim ◽

Yerim Kim ◽

Ju Hun Lee ◽

Chul-Ho Kim ◽

...

Keyword(s):

Ischemic Stroke ◽

Cognitive Impairment ◽

Acute Ischemic Stroke ◽

Sex Education ◽

Cognitive Domain ◽

P Value ◽

Stroke Severity ◽

Stroke Patients ◽

Stroke Treatment ◽

Post Stroke

Background: Post-stroke hyperglycemia is a frequent finding in acute ischemic stroke patients and is associated with poor functional and cognitive outcomes. However, it is unclear as to whether the glycemic gap between the admission glucose and HbA1c-derived estimated average glucose (eAG) is associated with post-stroke cognitive impairment (PSCI). Methods: We enrolled acute ischemic stroke patients whose cognitive functions were evaluated three months after a stroke using the Korean version of the vascular cognitive impairment harmonization standards neuropsychological protocol (K-VCIHS-NP). The development of PSCI was defined as having z-scores of less than −2 standard deviations in at least one cognitive domain. The participants were categorized into three groups according to the glycemic gap status: non-elevated (initial glucose − eAG ≤ 0 mg/dL), mildly elevated (0 mg/dL < initial glucose − eAG < 50 mg/dL), and severely elevated (50 mg/dL ≤ initial glucose − eAG). Results: A total of 301 patients were enrolled. The mean age was 63.1 years, and the median National Institute of Health Stroke Scale (NIHSS) score was two (IQR: 1–4). In total, 65 patients (21.6%) developed PSCI. In multiple logistic regression analyses, the severely elevated glycemic gap was a significant predictor for PSCI after adjusting for age, sex, education level, initial stroke severity, Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification, and left hemispheric lesion (aOR: 3.65, p-value = 0.001). Patients in the severely elevated glycemic gap group showed significantly worse performance in the frontal and memory domains. Conclusions: In conclusion, our study demonstrated that an elevated glycemic gap was significantly associated with PSCI three months after a stroke, with preferential involvement of frontal and memory domain dysfunctions.

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Influence of Renal Function on Treatment Results after Stroke Thrombectomy

Cerebrovascular Diseases ◽

10.1159/000481147 ◽

2017 ◽

Vol 44 (5-6) ◽

pp. 351-358 ◽

Cited By ~ 8

Author(s):

Mona Laible ◽

Markus Alfred Möhlenbruch ◽

Johannes Pfaff ◽

Ekkehart Jenetzky ◽

Peter Arthur Ringleb ◽

...

Keyword(s):

Ischemic Stroke ◽

Clinical Outcome ◽

Acute Ischemic Stroke ◽

Multivariate Regression ◽

Stroke Severity ◽

Stroke Patients ◽

Anterior Circulation ◽

Stroke Treatment ◽

Poor Outcome ◽

Increased Risk

Background: Renal dysfunction (RD) may be associated with poor outcome in ischemic stroke patients treated with mechanical thrombectomy (MT), but data concerning this important and emerging comorbidity do not exist so far. Here, we investigated the influence of RD on postprocedural intracerebral hemorrhage (ICH), clinical outcome, and mortality in a large prospectively collected cohort of acute ischemic stroke patients treated with MT. Methods: Consecutive patients with anterior-circulation stroke treated with MT between October 2010 and January 2016 were included. RD was defined as glomerular filtration rate (GFR) <60 mL/min/1.73 m2. In a prospective database, clinical characteristics were recorded and brain images were analyzed for the presence of ICH after treatment in all patients. Clinical outcome was assessed by the modified Rankin Scale (mRS) after 3 months. To evaluate associations between clinical factors and outcomes uni- and multivariate regression analyses were conducted. Results: In total, 505 patients fulfilled all inclusion criteria (female: 49.7%, mean age: 71.0 years). RD at admission was present in 20.2%. RD patients were older and had cardiovascular risk factors more often. Multivariate regression analysis after adjustment for age, stroke severity, diabetes, hypertension, GFR, previous stroke, MT alone, or additional thrombolysis and recanalization results revealed that lower GFR was not independently associated with poor outcome (mRS 3-6; OR 1.13, 95% CI 0.99-1.28; p = 0.072) or ICH. However, lower GFR at admission was associated with a higher risk of mortality (OR 1.15, 95% CI 1.01-1.31; p = 0.038). Compared to admission, GFR values were higher at discharge (mean: 77.9 vs. 80.8 mL/min/1.73 m2; p = 0.046). Conclusions: We did not find evidence for an association of lower GFR with an increased risk of poor outcome and ICH, but lower GFR was a determinant of 90-day mortality after endovascular stroke treatment. Our findings encourage also performing MT in this relevant subgroup of acute ischemic stroke patients.

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Sex Differences in the Risk of 30-Day Death After Acute Ischemic Stroke

Neurology Clinical Practice ◽

10.1212/cpj.0000000000001087 ◽

2021 ◽

pp. 10.1212/CPJ.0000000000001087

Author(s):

Fumi Irie ◽

Ryu Matsuo ◽

Kuniyuki Nakamura ◽

Yoshinobu Wakisaka ◽

Tetsuro Ago ◽

...

Keyword(s):

Sex Differences ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Lower Risk ◽

Stroke Patients ◽

Risk Models ◽

Risk Of Death ◽

Acute Infections ◽

Competing Risk Models ◽

Early Stroke

AbstractObjective:To examine sex differences in early stroke deaths according to cause of death.Methods:We investigated 30-day deaths in acute ischemic stroke patients enrolled in a multicenter stroke registry between 2007 and 2019 in Fukuoka, Japan. We estimated the multivariable-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of cause-specific deaths for women vs. men using Cox proportional hazards models and competing risk models. The risk of acute infections during hospitalization and the associated case fatality rates were also compared between the sexes.Results:Among 17,956 acute ischemic stroke patients (women: 41.3%), the crude 30-day death rate after stroke was higher in women than men. However, adjusting for age and stroke severity resulted in a lower risk of death among women (HR [95% CI]: 0.76 [0.62–0.92]). Analyses using competing risk models revealed that women were less likely to die from acute infections (subdistribution HR [95% CI]: 0.33 [0.20–0.54]). Further analyses showed that women were associated with a lower risk of acute infections during hospitalization (odds ratio [95% CI]: 0.62 [0.52–0.74]), and a lower risk of death due to these infections (subdistribution HR [95% CI]: 052 [0.33–0.83]).Conclusions:When adjusting for confounders, the female sex was associated with a lower risk of 30-day death after stroke, which could be explained by a female survival advantage in poststroke infections. Sex-specific strategies are needed to reduce early stroke deaths.Classification of Evidence:This is a Class I prognostic study because it is a prospective population based cohort with objective outcomes. Female gender appears to be protective for 30 mortality and post stroke infections.

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