Trimethylamine-N-Oxide Levels Are Similar in Asymptomatic vs. Symptomatic Cerebrovascular Atherosclerosis

Introduction: Trimethylamine-N-oxide (TMAO) is correlated with atherosclerosis and vascular diseases such as coronary heart disease and ischemic stroke. The aim of the study was to investigate whether TMAO levels are different in symptomatic vs. asymptomatic cerebrovascular atherosclerosis.Methods: This was a prospective, case–control study, conducted at a tertiary care university hospital. Patients were included if they had large-artery atherosclerosis (TOAST criteria). Symptomatic patients with ischemic stroke were compared with asymptomatic patients. As primary endpoint, TMAO levels on admission were compared between symptomatic and asymptomatic patients. Univariable analysis was performed using Mann–Whitney U test and multivariable analysis using binary logistic regression. TMAO values were adjusted for glomerular filtration rate (GFR), age, and smoking.Results: Between 2018 and 2020, 82 symptomatic and asymptomatic patients were recruited. Median age was 70 years; 65% were male. Comparing symptomatic (n = 42) and asymptomatic (n = 40) patients, no significant differences were found in univariable analysis in TMAO [3.96 (IQR 2.30–6.73) vs. 5.36 (3.59–8.68) μmol/L; p = 0.055], GFR [87 (72–97) vs. 82 (71–90) ml/min*1.73 m2; p = 0.189] and age [71 (60–79) vs. 69 (67–75) years; p = 0.756]. In multivariable analysis, TMAO was not a predictor of symptomatic cerebrovascular disease after adjusting for age and GFR [OR 1.003 (95% CI: 0.941–1.070); p = 0.920]. In a sensitivity analysis, we only analyzed patients with symptomatic stenosis and excluded patients with occlusion of brain-supplying arteries. Again, TMAO was not a significant predictor of symptomatic stenosis [OR 1.039 (0.965–1.120), p = 0.311].Conclusion: TMAO levels could not be used to differentiate between symptomatic and asymptomatic cerebrovascular disease in our study.

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Endovascular stroke therapy may be safe in patients with elevated international normalized ratio

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2016-012757 ◽

2016 ◽

Vol 9 (12) ◽

pp. 1187-1190 ◽

Cited By ~ 14

Author(s):

Sibu Mundiyanapurath ◽

Anne Tillmann ◽

Markus Alfred Möhlenbruch ◽

Martin Bendszus ◽

Peter Arthur Ringleb

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Tertiary Care ◽

Multivariable Analysis ◽

International Normalized Ratio ◽

Unfavorable Outcome ◽

Favorable Outcome ◽

University Hospital ◽

Increased Risk

IntroductionEndovascular therapy in acute ischemic stroke is safe and efficient. However, patients receiving oral anticoagulation were excluded in the larger trials.ObjectiveTo analyze the safety of endovascular therapy in patients with acute ischemic stroke and elevated international normalized ratio (INR) values.MethodsRetrospective database review of a tertiary care university hospital for patients with anterior circulation stroke treated with endovascular therapy. Patients with anticoagulation other than vitamin K antagonists were excluded. The primary safety endpoint was defined as symptomatic intracranial hemorrhage (sICH; ECASS II definition). The efficacy endpoint was the modified Rankin scale (mRS) score after 3 months, dichotomized into favorable outcome (mRS 0–2) and unfavorable outcome (mRS 3–6).Results435 patients were included. 90% were treated with stent retriever. 27 (6.2%) patients with an INR of 1.2–1.7 and 21 (4.8%) with an INR >1.7. 33 (7.6%) had sICH and 149 patients (34.3%) had a favorable outcome. Patients with an elevated INR did not have an increased risk for sICH or unfavorable outcome in multivariable analysis. The additional use of IV thrombolysis in patients with an INR of 1.2–1.7 did not increase the risk of sICH or unfavorable outcome. These results were replicated in a sensitivity analysis introducing an error of the INR of ±5%. They were also confirmed using other sICH definitions (Safe Implementation of Thrombolysis in Stroke (SITS), National Institute of neurological Disorders and Stroke (NINDS), Heidelberg bleeding classification).ConclusionsEndovascular therapy in patients with an elevated INR is safe and efficient. Patients with an INR of 1.2–1.7 may be treated with combined IV thrombolysis and endovascular therapy.

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Prevalence, Persistence, and Factors Associated with SARS-CoV-2 IgG Seropositivity in a Large Cohort of Healthcare Workers in a Tertiary Care University Hospital in Northern Italy

Viruses ◽

10.3390/v13061064 ◽

2021 ◽

Vol 13 (6) ◽

pp. 1064

Author(s):

Gitana Scozzari ◽

Cristina Costa ◽

Enrica Migliore ◽

Maurizio Coggiola ◽

Giovannino Ciccone ◽

...

Keyword(s):

Tertiary Care ◽

Multivariable Analysis ◽

Northern Italy ◽

University Hospital ◽

Care Workers ◽

Increased Risk ◽

Never Smokers ◽

The University ◽

Job Profile ◽

Pandemic Wave

This observational study evaluated SARS-CoV-2 IgG seroprevalence and related clinical, demographic, and occupational factors among workers at the largest tertiary care University-Hospital of Northwestern Italy and the University of Turin after the first pandemic wave of March–April 2020. Overall, about 10,000 individuals were tested; seropositive subjects were retested after 5 months to evaluate antibodies waning. Among 8769 hospital workers, seroprevalence was 7.6%, without significant differences related to job profile; among 1185 University workers, 3.3%. Self-reporting of COVID-19 suspected symptoms was significantly associated with positivity (Odds Ratio (OR) 2.07, 95%CI: 1.76–2.44), although 27% of seropositive subjects reported no previous symptom. At multivariable analysis, contacts at work resulted in an increased risk of 69%, or 24% for working in a COVID ward; contacts in the household evidenced the highest risk, up to more than five-fold (OR 5.31, 95%CI: 4.12–6.85). Compared to never smokers, being active smokers was inversely associated with seroprevalence (OR 0.60, 95%CI: 0.48–0.76). After 5 months, 85% of previously positive subjects still tested positive. The frequency of SARS-COV-2 infection among Health Care Workers was comparable with that observed in surveys performed in Northern Italy and Europe after the first pandemic wave. This study confirms that infection frequently occurred as asymptomatic and underlines the importance of household exposure, seroprevalence (OR 0.60, 95%CI: 0.48–0.76).

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Association of Carotid Artery Endothelial Signal Intensity Gradient with Unilateral Large Artery Ischemic Stroke

Cerebrovascular Diseases ◽

10.1159/000514141 ◽

2021 ◽

Vol 50 (3) ◽

pp. 270-278

Author(s):

Chan-Hyuk Lee ◽

Sang Hyuk Lee ◽

Young I. Cho ◽

Seul-Ki Jeong

Keyword(s):

Ischemic Stroke ◽

Carotid Artery ◽

Signal Intensity ◽

Internal Carotid ◽

University Hospital ◽

Large Artery ◽

Intensity Gradient ◽

National University ◽

Endothelial Shear Stress ◽

Stroke Center

Background: Common carotid artery (CCA) and internal carotid artery (ICA) are aligned linearly, but their hemodynamic role in ischemic stroke has not been studied in depth. Objectives: We aimed to investigate whether CCA and ICA endothelial shear stress (ESS) could be associated with the ischemic stroke of large artery atherosclerosis (LAA). Methods: We enrolled consecutive patients with unilateral ischemic stroke of LAA and healthy controls aged >60 years in the stroke center of Jeonbuk National University Hospital. All patients and controls were examined with carotid artery time-of-flight magnetic resonance angiography, and their endothelial signal intensity gradients (SIGs) were determined, as a measure of ESS. The effect of right or left unilateral stroke on the association between carotid artery endothelial SIG and ischemic stroke of LAA was assessed. Results: In total, the results from 132 patients with ischemic stroke of LAA and 121 controls were analyzed. ICA endothelial SIG showed significant and independent associations with the same-sided unilateral ischemic stroke of LAA, even after adjusting for the potential confounders including carotid stenosis, whereas CCA endothelial SIG showed a significant association with the presence of the ischemic stroke of LAA. Conclusion: Although CCA and ICA are located with continuity, the hemodynamics and their roles in large artery ischemic stroke should be considered separately. Further studies are needed to delineate the pathophysiologic roles of ESS in CCA and ICA for large artery ischemic stroke.

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Analysis of microRNA signatures in ischemic stroke thrombus

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2021-017597 ◽

2021 ◽

pp. neurintsurg-2021-017597

Author(s):

Jeong-Min Kim ◽

Jun-Soo Byun ◽

Jiah Kim ◽

Moo-Seok Park ◽

Soon Auck Hong ◽

...

Keyword(s):

Ischemic Stroke ◽

Expression Pattern ◽

Microarray Analysis ◽

Laboratory Data ◽

Microrna Expression ◽

University Hospital ◽

Large Artery ◽

Stroke Patients ◽

Qrt Pcr ◽

Functional Relevance

BackgroundWe investigated the microRNA expression pattern from thrombus retrieved by mechanical thrombectomy in acute stroke patients to understand the stroke mechanism.MethodsThis study included acute ischemic stroke patients who had undergone intra-arterial thrombectomy at Chung-Ang University Hospital in Seoul, Korea between February 2016 and March 2019. The thrombus was retrieved and stored at −70℃ after obtaining informed consent. MicroRNA microarray analysis was performed for the patients with identified stroke mechanisms including (1) large artery atherosclerosis, (2) cardioembolism with atrial fibrillation, and (3) cardioembolism with valvular heart disease. The microRNAs derived from microarray analysis were validated by quantitative real-time polymerase chain reaction (qRT-PCR) from different patient populations. The correlation analysis was performed between microRNA levels and laboratory data to understand the functional relevance of the altered microRNA.ResultsIn total, 55 thrombi were obtained from 74 patients, and the microRNAs were analyzed in 45 samples. Microarray analysis of 2578 microRNAs revealed that 50 microRNAs were significantly altered among the three groups. Validation using qRT-PCR showed that miR-378f and miR-450b-5p were significantly elevated among the cardioembolic thrombi; both microRNAs were inversely correlated with the ejection fraction from echocardiography. Thrombi from patients with early neurological deterioration exhibited higher levels of miR-93-5p and lower levels of miR-629-5p than those from neurologically stable patients.ConclusionsThe microRNA expression pattern can provide information regarding the mechanism of stroke by reflecting the underlying pathological status of the organ from which the thrombus was derived.

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Abstract WP22: Reperfusion Therapy After Neurological Deterioration in Acute Ischemic Stroke

Stroke ◽

10.1161/str.51.suppl_1.wp22 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Mooseok Park ◽

Tai Hwan Park ◽

Sang-Soon Park ◽

Jong-Moo Park ◽

Yong-Jin Cho ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Clinical Features ◽

Statistical Significance ◽

Multivariable Analysis ◽

Reperfusion Therapy ◽

Neurological Deterioration ◽

Large Artery ◽

Good Outcome ◽

Intravenous Tissue Plasminogen Activator

Background: Guidelines do not recommend reperfusion therapy in acute ischemic stroke patients with mild symptoms considering low gain compared to the risk. However, some patients with mild first symptoms experience neurological deterioration (ND) after hospitalization. We aimed to analyze clinical features and outcomes of patient who received reperfusion therapy after ND occurred. Methods: We enrolled patients who were admitted within 7 days after acute ischemic stroke or TIA between January 2012 and July 2018 from a multicenter stroke registry database in Korea (CRCS-K). Patients who 1) admitted via emergency room, and 2) received reperfusion therapy including intravenous tissue plasminogen activator and/or endovascular treatment were included. Clinical features and outcomes such as modified Rankin Scale (mRS) score distribution at 3 months after stroke were compared between patients received reperfusion therapy after ND and those without ND before the treatment. Results: Among 51325 patients, 6577 (12.8%) received reperfusion therapy were identified. Reperfusion therapy was performed after ND in 136 patients (2.1%). Mean time of onset to needle is 342.1 and 167.2, and onset to perfusion is 1351.6 and 422.0 in patients treated after ND, and those without, respectively. TIA history was more frequent and atrial fibrillation history was less frequent in patients treated after ND. Initial median (IQR) National Institute of Health Stroke Scale (NIHSS) score was 8 (5 - 12), 10 (6 - 16) in patients treated after ND, and those without, respectively. Large artery atherosclerosis was more frequent in patients treated after ND (42.9 % vs. 26.7%). There was higher rate of good outcome at 90 days in patients treated after ND (84 [61.8%]) compared with those without ND before treatment (3359 [52.2%]; OR, 1.38 [95% CI, 1.02-1.87]). In multivariable analysis, good outcome at 90 days in patients treated after ND lacked statistical significance (OR, 1.06 [95% CI, 0.71-1.62]). There is no significant statistical difference of death at 90 days (13.2% vs. 10.4%, p = 0.364). Conclusion: Reperfusion therapy could apply patients with mild first symptoms experience ND after hospitalization and expect similar prognosis compared to those without ND before the treatment.

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Characteristics of Pediatric Stroke and Association of Delayed Diagnosis with Mortality in a Mexican Tertiary Care Hospital

Neuropediatrics ◽

10.1055/s-0041-1731802 ◽

2021 ◽

Author(s):

Gerardo Garza-Alatorre ◽

Ana Luisa Carrion-Garcia ◽

Alfredo Falcon-Delgado ◽

Elda Carolina Garza-Davila ◽

Angel R Martinez-Ponce de Leon ◽

...

Keyword(s):

Ischemic Stroke ◽

Hemorrhagic Stroke ◽

Early Recognition ◽

Tertiary Care ◽

Delayed Diagnosis ◽

University Hospital ◽

Pediatric Stroke ◽

Care Hospital ◽

Continuous Increase ◽

Common Risk Factors

Abstract Background and objectives Pediatric cerebrovascular disease carries significant morbidity and mortality. Early recognition of a pediatric stroke as well and its most common risk factors are important, but that diagnosis is often delayed. It is believed that the incidence in our center is higher than it appears. This study aims to assess the incidence and characteristics of the pediatric stroke in our university hospital. Likewise, this study seeks to evaluate if a longer symptoms-to-diagnosis time is associated with mortality in patients with ischemic stroke. Methods A retrospective study including children with stroke admitted to the UANL University Hospital from January 2013 to December 2016. Results A total of 41 patients and 46 stroke episodes were admitted. About 45.7% had an ischemic stroke and 54.3% had a hemorrhagic stroke. A mortality of 24.4% and a morbidity of 60.9% were recorded. Regarding ischemic and hemorrhagic stroke, an increased symptoms-to-diagnosis time and a higher mortality were obtained with a relative risk of 2.667 (95% confidence interval [CI]: 1.09–6.524, p = 0.013) and 8.0 (95% CI: 2.18–29.24, p = < 0.0001), respectively. A continuous increase in the incidence rate, ranging from 4.57 to 13.21 per 1,000 admissions comparing the first period (2013) versus the last period (2016), p = 0.02, was found in our center. Conclusions Pediatric stroke is a rare disease; however, its incidence shows a continuous increase. More awareness toward pediatric stroke is needed.

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Abstract TMP45: Usefulness of Susceptibility Vessel Sign With Bright Vessel Appearance in Acute Ischemic Stroke

Stroke ◽

10.1161/str.47.suppl_1.tmp45 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Han-Gil Jeong ◽

Beom-Joon Kim ◽

Chi Kyung Kim ◽

Jun Yup Kim ◽

Dong-Wan Kang ◽

...

Keyword(s):

Ischemic Stroke ◽

Arterial Occlusion ◽

University Hospital ◽

Large Artery ◽

Peripheral Arteries ◽

Inclusion Criteria ◽

Arterial Segment ◽

Susceptibility Effect ◽

National University ◽

Seoul National University

Background: Red thrombi, composed of fibrin and trapped erythrocytes, have magnetic susceptibility effect. Susceptibility vessel sign (SVS) is visualized more sensitively using susceptibility weighted imaging (SWI) than T2*-weighted imaging. Bright vessel appearance (BVA) on arterial spin labeling (ASL) imaging can visualize occluded arterial segment by arterial transit artifact, more sensitively in small and peripheral branches. We investigated the usefulness of SWI-SVS with BVA to visualize different thrombus and predict stroke mechanisms. Methods: From a total of 564 stroke cases who admitted to Seoul National University Hospital in 2014, the authors collected eligible cases with the following inclusion criteria; (1) Lesion-documented ischemic stroke (N=425); (2) SWI and ASL MRI performed (N=407); (3) Symptomatic arterial occlusion with BVA (N=141). All images were analyzed for the presence and location of SWI-SVS and BVA. The location of SWI-SVS and BVA were classified into (1) proximal, large arteries; distal ICA, M1/2, A1, P1, basilar artery, V4 and (2) peripheral, small arteries; M3/4, P2/3, A2/3, lenticulostriate arteries, three cerebellar arteries. The relationships between SWI-SVS in the presence of BVA and stroke etiologies are explored. Results: Male was 58.2% (n=82) and mean age was 65.7±14.3. Thirty-four percent (n=48/141) of BVA and 30.3% (n=30/99) of SVS was located within small, peripheral arteries. SWI-SVS was more commonly associated with other determined etiology (20.2% vs. 4.8%) and cardioembolism (39.4% vs. 14.3%), but less with large artery atherosclerosis (26.3% vs. 69.0%, P <0.01) compared to the patients without SWI-SVS. Cancer-related hypercoagulability (60%, n=12/20) was most common in other determined cases with SWI-SVS. Multivariate analysis showed that SWI-SVS was an independent predictor of other determined etiology (adjusted OR, 7.20; 95% CI, 1.48-34.99) and cardioembolism (adjusted OR, 5.76; 95% CI, 1.27-26.02) Conclusions: SWI-SVS with BVA may predict ischemic stroke of cardioembolism and other determined etiology. Occlusions of small, peripheral arteries are well visualized with BVA and composition of thrombus can be identified by SWI-SVS.

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Optimizing Patient Selection for Interhospital Transfer and Endovascular Therapy in Acute Ischemic Stroke: Real-World Data From a Supraregional, Hub-and-Spoke Neurovascular Network in Germany

Frontiers in Neurology ◽

10.3389/fneur.2020.600917 ◽

2020 ◽

Vol 11 ◽

Author(s):

Maria-Ioanna Stefanou ◽

Vera Stadler ◽

Dominik Baku ◽

Florian Hennersdorf ◽

Ulrike Ernemann ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Patient Selection ◽

Real World ◽

University Hospital ◽

Large Artery ◽

Hub And Spoke ◽

Interhospital Transfer ◽

Selection For ◽

Transferred Patients

Background: Interhospital transfer for endovascular treatment (EVT) within neurovascular networks might result in transfer of patients who will not undergo EVT (futile transfer). Limited evidence exists on factors associated with the primary patient selection for interhospital transfer from primary stroke centers (PSCs) to comprehensive stroke centers (CSCs), or EVT-workflow parameters that may render a transfer futile.Methods: A prospective, registry-based study was performed between July 1, 2017 and June 30, 2018, at a hub-and-spoke neurovascular network in southwest Germany, comprising 12 referring PSCs and one designated CSC providing round-the-clock EVT at the University Hospital Tübingen. Patients with acute ischemic stroke due to suspected large artery occlusion (LAO) were included upon emergency interhospital transfer inquiry (ITI).Results: ITI was made for 154 patients, 91 (59%) of whom were transferred to the CSC. Non-transferred patients (41%) had significantly higher premorbid modified Rankin scale scores (mRS) compared to transferred patients [median (IQR): 2 (1–3) vs. 0 (0–1), p < 0.001]. Interhospital transfer was denied due to: distal vessel occlusion (44.4%), or non-verifiable LAO (33.3%) in computed tomography angiography (CTA) upon teleconsultation by CSC neuroradiologists; limited Stroke-Unit or ventilation capacity (9.5%), or limited neuroradiological capacity at the CSC (12.7%). The CT-to-ITI interval was significantly longer in patients denied interhospital transfer [median (IQR): 43 (29–56) min] compared to transferred patients [29 (15–55), p = 0.029]. No further differences in EVT-workflow, and no differences in the 3-month mRS outcomes were noted between non-transferred and transferred patients [median (IQR): 2 (0–5) vs. 3 (1–4), p = 0.189]. After transfer to the CSC, 44 (48%) patients underwent EVT. The Alberta stroke program early CT score [ORadj (95% CI): 1.786 (1.573–2.028), p < 0.001] and the CT-to-ITI interval [0.994 (0.991–0.998), p = 0.001] were significant predictors of the likelihood of EVT performance.Conclusion: Our findings show that hub-and-spoke neurovascular network infrastructures efficiently enable access to EVT to patients with AIS due to LAO, who are primarily admitted to PSCs without on-site EVT availability. As in real-world settings optimal allocation of EVT resources is warranted, teleconsultation by experienced endovascular interventionists and prompt interhospital-transfer-inquiries are crucial to reduce the futile transfer rates and optimize patient selection for EVT within neurovascular networks.

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Use of Systemic Corticosteroids for Reasons Other than Asthma in Subjects with Asthma

Respiration ◽

10.1159/000518461 ◽

2021 ◽

pp. 1-7

Author(s):

Keisuke Watanabe ◽

Nobuyuki Horita ◽

Yu Hara ◽

Nobuaki Kobayashi ◽

Takeshi Kaneko

Keyword(s):

Adverse Events ◽

Systemic Corticosteroid ◽

Multivariable Analysis ◽

Vascular Diseases ◽

University Hospital ◽

Eosinophilic Granulomatosis With Polyangiitis ◽

Collagen Vascular Diseases ◽

Systemic Corticosteroids ◽

Asthma Patients

Backgrounds: Recent studies have reported increased risks of adverse events from systemic corticosteroids even with only low-dose or short-term use. Some patients with asthma experience complications requiring systemic corticosteroids. However, few studies have examined issues associated with administration of systemic corticosteroids for reasons other than asthma among subjects with asthma. Objectives: We investigated patterns of systemic corticosteroid exposure for reasons other than asthma in subjects with asthma. Method: We retrospectively reviewed the records of adult subjects with asthma followed up for >1 year at Yokohama City University Hospital from January 1, 2010, to December 31, 2019. We investigated patterns and reasons for systemic corticosteroid use during follow-up. In addition, factors related to systemic corticosteroid use for reasons likely other than asthma were investigated. Results: Among the 568 subjects with asthma analyzed, 326 (57.4%) had received systemic corticosteroids for some reason. Among those 326 patients, 120 (36.8%) had received systemic corticosteroids for reasons likely other than asthma. Multivariable analysis revealed rheumatoid arthritis, eosinophilic granulomatosis with polyangiitis, other collagen vascular diseases, chronic rhinosinusitis, and malignancy as positively associated with systemic corticosteroid exposure for reasons likely other than asthma in subjects with asthma. Conclusions: About 40% of systemic corticosteroid use in subjects with asthma was for reasons likely other than asthma. Clinicians should be aware of their asthma patients’ exposures to systemic corticosteroids for nonasthma reasons, to avoid missing adverse events or underestimating the severity of asthma, and to reduce systemic corticosteroid use.

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Abstract P287: Delays in the Identification and Assessment of In-Hospital Stroke Patients

Stroke ◽

10.1161/str.52.suppl_1.p287 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Stephanie Cummings ◽

Andrew Olsen ◽

Steven Messe

Keyword(s):

Acute Stroke ◽

Tertiary Care ◽

Multivariable Analysis ◽

Vascular Imaging ◽

Care Hospital ◽

Univariable Analysis ◽

Vessel Occlusion ◽

Stroke Treatment ◽

Stroke Team ◽

Get With The Guidelines

Introduction: In-hospital stroke is associated with worse outcomes and fewer stroke interventions compared to patients with community-acquired stroke. We assessed factors associated with delays in symptom identification and stroke team alerting, and use of acute interventions for in-hospital strokes. Methods: The local Get With The Guidelines-Stroke and an in-hospital quality improvement database at our tertiary care hospital were screened over a 26-month period ending 10/2019, yielding 98 in-hospital strokes. Results: Strokes were more common on surgery services (70%), were predominantly ischemic (83%), and were moderate-to-severe (median NIHSS 16; interquartile range [IQR] 6-24). There were long delays from the time of last known normal (LKN) until stroke symptom identification (SxID) (median 5.1 hours, IQR 1.0-19.7 hours) and from SxID to stroke alert (median 2.1 hours, IQR 0.5-9.9 hours). In univariable analysis, being in an ICU, being intubated, being on a surgical service, having no lateralized weakness or neglect, and higher NIHSS were associated with delays; in multivariable analysis only intubation was associated with being above median from LKN to SxID (OR 4.3, 95% CI 1.2-16.2, p=0.03) and above median for SxID to stroke alert (OR 8.5, 95% CI 2.0-36.4). Acute stroke interventions were given to 15 patients (15%), including 3 (3%) who received IV tPA and 12 (12%) who underwent IA thrombectomy. Patients who received stroke interventions had shorter times from last normal to SxID (median 0.7 vs 8.2 hours, p=0.002) and times from SxID to stroke alert (median 0.2 vs 3.4 hours, p=0.006). Urgent vascular imaging occurred in 68/98 (69%) of patients and 23/68 (34%) had a large vessel occlusion (LVO). Of those patients with an LVO, 78% had lateralizing arm weakness or neglect on exam. Conclusions: There are long delays from LKN to SxID and from SxID to stroke alert in hospitalized patients leading to low rates of acute stroke treatment. Intubation was a robust risk factor for delays and protocols should be established to monitor these patients more carefully. Despite these delays, 1/3 of patients who had vascular imaging had an LVO identified that might have been eligible for intervention.

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