Abstract WP390: Misdiagnosis of Cervicocephalic Artery Dissection in the Emergency Department

Introduction: Cervicocephalic artery dissection is an important cause of stroke, particularly in the young. The initial presentation of cervicocephalic artery dissection can resemble benign neurological conditions resulting in delayed or incorrect diagnosis. We therefore sought to quantify the rate of possible cervicocephalic artery dissection misdiagnosis and to assess the impact of misdiagnosis on patient outcomes in a large heterogeneous cohort.

Methods: We performed a retrospective cohort study using administrative claims data from all ED visits and nonfederal hospitalizations in New York, California, and Florida from 2005-2015. Using previously validated ICD-9-CM codes, we identified patients hospitalized with a diagnosis of cervicocephalic artery dissection and no prior stroke diagnosis. Possible misdiagnosis of cervicocephalic artery dissection was defined as having a treat-and-release ED visit for headache, facial pain, neck pain, or Horner syndrome in the 14 days prior to a hospitalization for cervicocephalic artery dissection. Multivariable logistic regression was used to compare adverse clinical outcomes (stroke or death at the time of cervicocephalic artery dissection diagnosis) in patients with and without a possible misdiagnosis.

Results: Among 8,874 patients diagnosed with cervicocephalic artery dissection (mean age 52.7 years, 44.1% women), 300 (3.4%; 95% CI, 3.0-3.8%) had a possible ED misdiagnosis. Patients with a possible misdiagnosis of cervicocephalic artery dissection were younger and more often women than those not misdiagnosed. Stroke occurred in 128 (42.7%; 95% CI, 37.0-48.5%) patients with a possible misdiagnosis of dissection and in 3,908 (44.0%; 95% CI, 43.0-45.1%, P =0.63) patients without a possible misdiagnosis of cervicocephalic artery dissection. After adjustment for demographics and vascular risk factors, there were no differences in rates of hospital death (OR 0.48; 95% CI, 0.20-1.9) or stroke (OR 0.94; 95% CI, 0.74-1.2).

Conclusion: We found a low rate of possible misdiagnosis of cervicocephalic artery dissection in the ED. Possible misdiagnosis was not associated with stroke or death at the time of subsequent hospitalization for cervicocephalic artery dissection.

Abstract 126: A Simple Classification of the Left Atrial Appendage Morphology Based on Stroke Risk: The LAA H/L Classification System

Introduction: The left atrial appendage (LAA) morphology is classified into 4 categories: chicken wing (CW), windsock, cactus, and cauliflower (cLAA-CS) (Figure) without established inter and intra-rater agreements. We aim to determine intra-rater and inter-rater agreements and relationship with embolic stroke subtypes using a new classification system vs. cLAA-CS.

Methods: Consecutive patients with ischemic stroke from a prospective stroke registry who previously underwent a clinically-indicated chest CT were included. Stroke subtype was determined and LAA morphology were classified using the cLAA-CS (CW=low risk) and the new LAA-H/L system [Low risk morphology (LAA-L) defined an acute angle bend or fold from the proximal/middle portion of the LAA and LAA-H defined as all others]. We determined intra and inter-rater agreements for the two classification systems and the association between non-CW and LAA-H morphologies with embolic subtypes in our cohort and stroke in previous studies.

Results: We identified 329 patients with a qualifying chest CT performed (126 cardioembolic subtype, 116 ESUS, and 87 non-cardioembolic subtypes). Intra and inter-rater agreements improved using the LAA-H/L (0.95 and 0.85) vs. cLAA-CS (0.4 and 0.5). Using the LAA-H/L led to classifying 50 LAA morphologies that met criteria for CW as LAA-H (Figure). In fully adjusted models, LAA-H was associated with cardioembolic stroke (OR 5.4, 95%CI 2.1-13.7) and ESUS (OR 2.8 95% CI 1.2-6.4). Non-CW morphology was also associated with embolic stroke subtypes, but the effect size was much less pronounced. Studies using the cLAA-CS yielded mixed results for inter and intrarater agreements but most showed an association between a non-CW morphology and stroke with no difference among the three non-CW subtypes (Table).

Conclusion: The LAA-H/L classification system is simple, has excellent intra and inter-rater agreements, and may help risk stratify patients at risk for cardioembolic stroke.

Abstract TP212: Stroke Risk Following Takotsubo Cardiomyopathy

Introduction: Takotsubo cardiomyopathy, also known as stress cardiomyopathy, is an increasingly recognized cause of left ventricular dysfunction after acute brain injury. Previously considered a benign disease, recent small, single-center case series suggest that Takotusubo cardiomyopathy may be a risk factor for ischemic stroke. The strength and temporal profile of this association remain uncertain.

Methods: We performed a cohort-crossover study using administrative claims data on all emergency department visits and acute care hospitalizations from 2005-2015 in California New York, and Florida. We identified patients with Takotsubo cardiomyopathy using a previously validated International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code. We excluded patients with a prior or concomitant stroke diagnosis. We compared the risk of ischemic stroke in the first year after Takotsubo cardiomyopathy to the risk of ischemic stroke in the second year after. The absolute risk increase and odds ratio (OR) were calculated using McNemar’s test for matched data.

Results: Among 5,283 patients with Takotsubo cardiomyopathy (mean age, 67 years; 92% female), we identified 49 ischemic strokes during the year after Takotsubo cardiomyopathy versus 19 ischemic strokes in the control period 2 years later. The risk of stroke was significantly higher in the year after Takotsubo cardiomyopathy (absolute increase, 0.6%; 95% CI, 0.2%-0.9%) (OR, 2.6; 95% CI, 1.5-4.6) as compared to the control period.

Conclusion: We found a heightened risk of ischemic stroke in the year after a diagnosis of Takotsubo cardiomyopathy, although the absolute risk increase was small.

Abstract WP265: Racial Differences in Left Atrial Size Among Patients With Ischemic Stroke

Introduction: Blacks in the U.S. face twice the risk of ischemic stroke as whites, and this disparity is not fully explained by established stroke risk factors. Although atrial fibrillation (AF) is a major risk factor for stroke, blacks are less often diagnosed with AF than whites. It is unclear whether this paradox exists because AF is less thoroughly ascertained in blacks compared to whites or because blacks have less predisposing substrate and thus a truly lower risk of AF.

Hypothesis: Based on our prior work, we hypothesized that black patients with ischemic stroke less often have left atrial enlargement, a major predisposing factor for AF.

Methods: We compared left atrial size in black versus white patients in the Greater Cincinnati/Northern Kentucky Stroke Study, a study of racial disparities in stroke incidence in a nationally representative population of 1.3 million. We obtained reports of echocardiograms performed for stroke evaluation among patients in the 2010 and 2015 study periods. Patients with known AF or atrial flutter were excluded. Investigators blinded to patients’ characteristics abstracted left atrial diameter from echocardiogram reports. Linear regression was used to examine the association between race and left atrial diameter after adjustment for demographics, body mass index, and comorbidities.

Results: Among 2,980 cases of ischemic stroke without AF, the median age was 66 years, 52% were female, and 30% were black. The overall mean left atrial diameter was 3.65 (±0.69) cm. Despite a higher burden of vascular risk factors and comorbidities, blacks had significantly smaller left atrial diameters (mean difference, -0.10 cm; 95% CI, -0.04 to -0.17 cm). This difference persisted after adjustment for demographics, comorbidities, and body mass index (adjusted mean difference, -0.15 cm; 95% CI, -0.09 to -0.21 cm).

Conclusions: In a population-based sample, we found that black patients with ischemic stroke had smaller left atrial size than white patients. Our results suggest that the paradox of greater stroke risk but lower AF risk in blacks compared with whites at least partly stems from a lesser degree of AF substrate in blacks.

Abstract 77: Perihematomal Edema Expansion Rate is Associated With Poor Functional Outcomes in Basal Ganglia Intracerebral Hemorrhage

Background: Perihematomal edema (PHE) has been associated with poor outcomes in deep spontaneous intracerebral hemorrhage (ICH). However, it is unknown if specific deep location (thalamus versus basal ganglia) modifies the effect of PHE on functional outcome.

Methods: We used data from the Antihypertensive Treatment of Acute Cerebral Hemorrhage 2 (ATACH-2) trial. We included patients who had deep ICH and available neuroimaging and 3-month functional outcome data. We calculated the 24-hour PHE expansion rate as the difference in PHE volume between baseline and 24-hour CT scan divided by hours between scans. We used logistic regression models to evaluate the relationship between PHE expansion rate (natural-log transformed) and poor outcome (3-month modified Rankin Scale [mRS] score 4-6), with subgroup analyses to determine the effect of thalamic vs basal ganglia location on this association.

Results: Out of 1000 subjects enrolled in ATACH-2, 870 (87%) had supratentorial, deep ICH. Of these, 754 (87%) had complete neuroimaging and outcome data (thalamus n=324, basal ganglia n=430). Overall, PHE expansion rate was associated with poor outcome in univariable (OR 1.3, 1.2-1.5, p<0.001) but not multivariable models (OR 1.1, 0.9-1.3, p=0.24). Median PHE expansion rate was faster in basal ganglia versus thalamic ICH (0.03 [0.09] mL/hr vs 0.01 [0.04] mL/hr, p<0.001). In basal ganglia ICH, PHE expansion rate was associated with poor outcome (OR 1.4, 1.1-1.8, p=0.01) in a multivariable model including age, sex, race, admission GCS, ICH volume (natural log-transformed), presence of intraventricular hemorrhage (IVH), hematoma expansion, time to baseline scan, and treatment group. In thalamic ICH, PHE expansion rate was not associated with poor outcome in multivariable analysis (OR 0.9, 0.7-1.2, p=0.44).

Conclusions: In the ATACH-2 trial population, 24-hour PHE expansion rate was associated with poor functional outcome among basal ganglia, but not thalamic, bleeds. These results provide further evidence that PHE is associated with functional outcomes and supports the existence of effect modification by the specific deep location involved.

Abstract WMP100: Prior Antiplatelet Use and Outcomes After Lobar, Deep, and Intraventricular Hemorrhage

Introduction: We examined the association between prior antiplatelet therapy and outcomes in patients with lobar versus deep intracerebral hemorrhage (ICH) versus intraventricular hemorrhage (IVH).

Methods: We performed a retrospective cohort study using data from patients with lobar and deep ICH registered in the Virtual International Stroke Trials Archive (VISTA-ICH), and patients with IVH enrolled in the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage (CLEAR) III trial. We excluded patients in the intervention arms of the trials, and those on prior anticoagulation therapy. The exposure was antiplatelet therapy prior to ICH/IVH. Primary outcomes were hematoma expansion and death/major disability in the VISTA-ICH cohort, and ventriculostomy tract hemorrhage, hematoma expansion, and death/major disability in the CLEAR III cohort. We used separate sets of logistic regression models in each group—lobar ICH, deep ICH, and IVH—to examine the association between antiplatelet therapy and our outcomes.

Results: Among 548 ICH patients in the VISTA-ICH cohort, there were 416 (75.9%) lobar and 121 (22.1%) deep hematomas. Median baseline ICH volumes were 19 ml (IQR, 11-26) in lobar and 8 ml (IQR, 4-13) in deep bleeds. Prior antiplatelet therapy was reported in 92 patients with lobar (22.1%) and 26 patients (20.8%) patients with deep ICH. After adjustment for demographics, comorbidities, and hematoma characteristics, antiplatelet therapy was not associated with hematoma expansion or poor functional outcomes after lobar (OR, 0.8; 95% CI, 0.5-1.8) or deep (OR, 1.3; 95% CI, 0.4-3.8) ICH. In the CLEAR cohort, the 62 of 222 IVH patients (27.9%) with prior antiplatelet therapy had similar odds of hematoma expansion (OR, 0.6; 95% CI, 0.2-1.7) or poor functional outcomes (OR, 0.9; 95% CI, 0.4-2.1), but higher odds of ventriculostomy tract hemorrhage (OR, 3.2; 95% CI, 1.3-7.7).

Conclusions: Prior antiplatelet therapy was not associated with hematoma expansion or functional outcomes after lobar or deep ICH or IVH, but was associated with ventriculostomy tract hemorrhage.

Abstract 47: Incidence of Cervical Artery Dissection Across Age Groups

Introduction: Dissection of a cervical artery has been well described as a cause of ischemic stroke in the young. The role of dissection as a cause of stroke among older adults is less clear, but there are no obvious reasons why older patients would have less of a predisposition to dissection than younger patients.

Hypothesis: We hypothesized that the incidence of dissection-related ischemic stroke would remain constant across age.

Methods: We used inpatient discharge data included in the 2012-2015 releases of the National Inpatient Survey (NIS). We used previously validated ICD-9-CM codes to identify adults who were hospitalized with ischemic stroke and a concomitant diagnosis of either carotid- or vertebral-artery dissection. We compared the prevalence of concomitant dissection among stroke hospitalizations across patient subgroups defined by age. Survey weights provided by the NIS were used to calculate nationally representative estimates. Population estimates from the U.S. census were used to calculate the incidence of hospitalization with stroke and concomitant dissection per million person-years.

Results: From 2012-2015, there were 17,325 hospitalizations with ischemic stroke and a concomitant dissection in the US. The prevalence of cervical-artery dissection among stroke hospitalizations was highest among those under 40 years of age and gradually decreased across increasing 10-year age intervals (Figure 1A). On the other hand, the overall incidence of hospitalization for stroke and concomitant dissection increased with increasing age (Figure 1B).

Conclusions: In a nationally representative sample, we found that cervical-artery dissection accounts for a greater proportion of ischemic strokes among younger patients, but the absolute incidence of dissection-related stroke increases with age.

Abstract WP263: Wall Motion Abnormalities on Transthoracic Echocardiography in the Setting of Ischemic Stroke Reflect Underlying Cardiac Disease and May Warrant an Ischemic Cardiac Evaluation

Background and Purpose: Patients with acute ischemic stroke (AIS) are at a heightened risk of cardiovascular events. We hypothesize that wall motion abnormalities (WMA) on transthoracic echocardiography (TTE) in the setting of AIS reflect underlying heart disease rather than reversible cardiac strain caused by the stroke.

Methods: Data was abstracted from a single center prospective AIS database over 18 months and included all patients with acute ischemic stroke who underwent a TTE. The presence of WMA was abstracted from the TTE report. Univariate analyses and predefined multivariable models were performed to determine factors associated with WMA, including demographic factors (age and sex), risk factors (hypertension, diabetes, hyperlipidemia, history of stroke, atrial fibrillation, congestive heart failure, coronary heart disease, and smoking), NIHSS score, cardiac markers (positive troponin, ECG evidence of prior myocardial infarction, ejection fraction), and insular location of infarct.

Results: We identified 1044 patients who met the inclusion criteria; 139 (13.3%) had evidence of WMA, of which only 23 patients had no history of heart disease or ECG evidence of prior myocardial infarction. Among these 23 patients, 12 had a follow up TTE after the stroke and WMA persisted in 92.7% (11/12) of patients. On fully adjusted models, factors associated with WMA are older age (OR per SD 1.03, 95% CI 1.001-1.05; p=0.009), congestive heart failure (OR 4.44, 95% CI 2.39-8.33, p<0.001), history of coronary artery disease or ECG evidence prior myocardial infarction (OR 27.03, 95% CI 14.93-50.0, p<0.001), and elevated serum troponin levels (OR 2.00, 95% CI 1.06-3.75, p=0.031).

Conclusion: In AIS patients, WMA on TTE may reflect underlying cardiac disease and warrant further cardiovascular evaluation particularly in those without known history of cardiac disease. Future studies are needed to investigate the cost-effectiveness of this approach.

Abstract 117: Relationship Between Presence of Visceral Infarction and Functional Outcome Among Patients with Acute Ischemic Stroke

Background: Evidence of visceral infarction is often found in patients with acute ischemic stroke, and appears to be more common among patients with embolic stroke subtypes. It remains uncertain whether there exists a relationship between visceral infarction and functional outcomes among patients with stroke.

Methods: Among patients with acute ischemic stroke enrolled in the Cornell AcutE Stroke Academic Registry (CAESAR) from 2011 through 2016, we included those with a contrast-enhanced abdominal computed tomographic scan within 1 year of admission. Our outcome was ambulatory status at discharge from the acute stroke hospitalization, defined as walking without assistance, walking with assistance, and unable to walk. We used ordinal logistic regression to examine the association between visceral infarction and discharge ambulatory status after adjustment for demographics, stroke risk factors, stroke severity (NIH Stroke Scale score) and stroke subtype.

Results: Among 2,116 ischemic stroke patients registered in CAESAR from 2011-2016, 228 had contrast-enhanced abdominopelvic computed tomographic imaging, of whom 40 (18%) had evidence of visceral infarction. Among the 188 patients without visceral infarction, 125 (66%) patients were discharged walking without assistance, 34 (18%) patients could walk with assistance, and 29 (15%) patients could not walk. In comparison, among the 40 patients with visceral infarction, 18 (45%) patients were discharged walking without assistance, 9 (23%) patients could walk with assistance, and 13 (33%) patients could not walk. After adjustment for demographics, stroke risk factors, stroke severity and stroke subtype, the presence of visceral infarction was associated with a worse ambulatory status (global OR for better ambulatory status, 0.3; 95% CI, 0.1-0.8).

Conclusions: We found that the presence of visceral infarction, which is often incidentally detected on imaging among stroke patients, was associated with poor functional outcomes at the time of hospital discharge. These findings suggest that such incidental findings are not benign and are at the least a marker of poor outcomes.

Abstract WMP72: High Risk Left Atrial Appendage Morphology (LAA-H) is Associated With Cardioembolic and Embolic Stroke of Unknown Source Subtypes

Background: The left atrial appendage (LAA) is the main source of thrombus in atrial fibrillation (AF); biomarkers of LAA dysfunction are associated with ischemic stroke (IS) risk in patients with AF. We hypothesized that high risk LAA features [High risk morphology (LAA-H), LAA volume (LAAV), and LAA orifice surface area (LAAOSA)] would be more prevalent among patients with cardioembolic (CE) stroke and embolic stroke of undetermined source (ESUS) than among those with non-cardioembolic stroke (NCS).

Methods: Consecutive patients with IS from a prospective comprehensive stroke center registry who previously underwent a clinically-indicated qualifying chest CT were included. Patients underwent inpatient diagnostic evaluation for ischemic stroke, and stroke subtype was determined based on ESUS criteria. LAA morphology [Low risk morphology was defined as two lobes with an acute angle between them or chicken wing morphology and LAA-H defined as all others], LAAOSA (measured in a plane parallel to the left atrium), and LAAV (measured using a volumetric analysis software) were determined using contrast enhanced thin-slice chest CT (≤2.5 mm thickness) by investigators blinded to stroke subtype.

Results: Of 1234 patients with ischemic stroke, 329 (26.7%) patients had a qualifying chest CT performed (126 CE, 116 ESUS, and 87 NCS). The baseline characteristics of patients with and without chest CT were similar. When compared to NCS, LAA-H was more prevalent in ESUS (86.4% vs. 70.1%, p=0.018) and CE stroke (82.5% vs. 70.1%, p=0.042). The LAAOSA and volume did not significantly differ between the 3 groups (Table).

Conclusion: LAA characteristics associated with cardioembolic stroke are also more prevalent in patients with ESUS. Larger studies are needed to confirm that LAA features are a risk factor for stroke among patients without AF, and whether anticoagulation is effective in patients with high-risk LAA features.

Abstract 76: Intensive Blood Pressure Reduction is Associated With Reduced Hematoma Expansion in Deep Intracerebral Hemorrhage: A Secondary Analysis of ATACH-2

Introduction: Hypertension is the strongest risk factor for spontaneous intracerebral hemorrhage (ICH) involving deep brain regions. We tested the hypothesis that intensive blood pressure (BP) treatment reduces hematoma expansion and improves functional outcomes in deep ICH, and evaluated whether this effect is modified by the specific deep structure involved (thalamus versus basal ganglia).

Methods: We performed a secondary analysis of data from the Antihypertensive Treatment of Acute Cerebral Hemorrhage 2 (ATACH-2) trial, which randomly assigned ICH patients with symptom onset within 4.5 hours and hematoma volume <60mL to either intensive treatment (systolic BP target 110-139 mm Hg) or standard treatment (target 140-179 mm Hg). Significant hematoma expansion was defined as a >33% increase in volume between baseline and 24-hour CT. We used chi-square and Mann–Whitney U tests and logistic and ordinal logistic regression models as appropriate.

Results: Of 1000 trial subjects, 870 (87%) had deep ICH, of whom 780 (90%) had complete neuroimaging/outcome data (thalamus n=336, basal ganglia n=444) and 405 (52%) were randomized to intensive treatment. Significant hematoma expansion was less frequent in the intensive vs standard arm (17% vs 26%, p=0.008). Intensive treatment was associated with a lower risk of significant hematoma expansion (OR 0.6, 95% CI 0.4-0.9; p=0.01) even in multivariable models (OR 0.6, 95% CI 0.4-0.9; p=0.01) including age, sex, baseline INR and time to scan. This treatment effect was modified by the specific deep location of the ICH (interaction p=0.02): there was less hematoma expansion with intensive versus standard treatment among basal ganglia bleeds (0.4 [IQR 2] mL vs 0.9 [IQR 6] mL, p=0.002) but not among thalamic bleeds (0.3 [IQR 2] mL vs 0.4 [IQR 2] mL, p=0.48). Intensive treatment was not associated with a shift in the distribution of 3-month modified Rankin Scale scores (overall p=0.9, basal ganglia p=0.9, thalamus p=0.8).

Conclusions: Compared to standard treatment, intensive BP reduction was associated with less hematoma expansion in deep ICH, specifically among hemorrhages located in the basal ganglia. In this underpowered subgroup analysis, intensive BP reduction was not associated with improved outcomes.

Abstract WP92: Radiologist Inter-rater Reliability of Prehospital Alberta Stroke Program Early CT Scores on a Mobile Stroke Unit

Introduction: The computed tomography (CT) capabilities of mobile stroke units (MSUs) may facilitate prehospital triaging of patients with suspected large-vessel occlusion directly to thrombectomy-capable centers. However, little is known about the reliability of radiological interpretation of early ischemic changes on prehospital CTs.

Methods: We identified all patients transported by the NewYork-Presbyterian MSU to Weill Cornell Medical Center with the diagnosis of acute ischemic stroke, transient ischemic attack, or stroke mimic between October 3, 2016 and December 31, 2017. All patients underwent noncontrast head CT on board the MSU using a CereTom® scanner. As controls, we matched these patients 1:1 by diagnosis to patients who were transported by standard ambulance and underwent noncontrast brain CT in our emergency department (ED) over the same period. Two neuroradiologists, blinded to patients’ characteristics and final diagnosis, independently calculated Alberta Stroke Program Early CT Scores (ASPECTS) on all scans. Weighted percent agreement and Cohen’s κ were used to assess inter-rater reliability, and paired t-tests were used to compare these metrics between MSU and ED scans.

Results: Among 46 MSU patients and 46 ED patients, 52% had a diagnosis of acute ischemic stroke, 46% a diagnosis of stroke mimic, and 2% a diagnosis of transient ischemic attack. For ASPECTS score as a continuous outcome, the weighted inter-rater agreement was 98% for MSU scans versus 96% for ED scans (mean difference, 2%; 95% CI, -1% to 5%) and the weighted κ was 0.49 for MSU scans versus 0.54 for ED scans (mean difference, -0.05; 95% CI, -0.61 to 0.51). For ASPECTS score categorized as 0-4, 5-7, or 8-10, the weighted inter-rater agreement was 99% for MSU scans versus 97% for ED scans (mean difference, 2%; 95% CI, -2% to 7%) and the weighted κ was 0.66 for MSU scans versus 0.55 for ED scans (mean difference, 0.10; 95% CI, -0.87 to 1.08).

Conclusions: In a sample of 96 patients, which limited our power to detect small differences, we found no substantial difference in the inter-rater reliability of ASPECTS scores obtained from MSU CTs versus ED CTs.

Abstract TMP20: Association Between Intravenous Thrombolysis and Anaphylaxis Among Medicare Beneficiaries With Acute Ischemic Stroke

Introduction: Anaphylaxis has been reported as a potential adverse event after intravenous thrombolysis in patients with acute ischemic stroke, but the magnitude of risk remains unclear.

Methods: We performed a retrospective cohort study using inpatient and outpatient claims between 2008-2015 from a nationally representative 5% sample of Medicare beneficiaries. We included patients who were ≥65 years old and hospitalized with ischemic stroke, defined by validated ICD-9-CM diagnosis codes. Our exposure was treatment with an intravenous thrombolytic agent during the index hospitalization ( ICD-9-CM code 99.10). Our primary outcome was anaphylaxis, defined using an accepted ICD-9-CM code algorithm (989.5, 995.0-4, 995.6x, E905, E905.3, E905.5, or E905.8-9). Our secondary outcome was anaphylactic shock (995.0 or 995.6x). Multiple logistic regression was used to evaluate the association between intravenous thrombolysis and anaphylaxis after adjustment for demographics, vascular risk factors, the Charlson comorbidity index, exposure to intravenous contrast dye, treatment with mechanical thrombectomy, and history of allergic reactions.

Results: Among 66,989 patients with acute ischemic stroke, the 3,176 (4.7%) who underwent intravenous thrombolysis more often had atrial fibrillation (47.7% vs 37.4%) and more often received intravenous contrast dye (44.3% vs 21.9%), but were otherwise similar in terms of demographics and comorbidities. Anaphylaxis developed in 17 (0.54%; 95% CI, 0.31-0.86%) patients who received intravenous thrombolysis versus 45 (0.07%; 95% CI, 0.05-0.09%) who did not. After adjustment for demographics, comorbidities, contrast dye, mechanical thrombectomy, and history of allergies, there was a significant association between receipt of intravenous thrombolysis and anaphylaxis (OR, 7.3; 95% CI, 4.1-13.0). We found a similar association for anaphylactic shock.

Conclusions: Although a rare occurrence, the risk of anaphylaxis among patients with acute ischemic stroke was significantly higher among those who received intravenous thrombolysis.

The AtRial Cardiopathy and Antithrombotic Drugs In prevention After cryptogenic stroke randomized trial: Rationale and methods

RATIONALE

Recent data suggest that a thrombogenic atrial substrate can cause stroke in the absence of atrial fibrillation. Such an atrial cardiopathy may explain some proportion of cryptogenic strokes.

AIMS

The aim of the ARCADIA trial is to test the hypothesis that apixaban is superior to aspirin for the prevention of recurrent stroke in subjects with cryptogenic ischemic stroke and atrial cardiopathy.

SAMPLE SIZE ESTIMATE

1100 participants.

METHODS AND DESIGN

Biomarker-driven, randomized, double-blind, active-control, phase 3 clinical trial conducted at 120 U.S. centers participating in NIH StrokeNet.

POPULATION STUDIED

Patients ≥ 45 years of age with embolic stroke of undetermined source and evidence of atrial cardiopathy, defined as ≥ 1 of the following markers: P-wave terminal force >5000 µV × ms in ECG lead V1, serum NT-proBNP > 250 pg/mL, and left atrial diameter index ≥ 3 cm/m2 on echocardiogram. Exclusion criteria include any atrial fibrillation, a definite indication or contraindication to antiplatelet or anticoagulant therapy, or a clinically significant bleeding diathesis. Intervention: Apixaban 5 mg twice daily versus aspirin 81 mg once daily. Analysis: Survival analysis and the log-rank test will be used to compare treatment groups according to the intention-to-treat principle, including participants who require open-label anticoagulation for newly detected atrial fibrillation.

STUDY OUTCOMES

The primary efficacy outcome is recurrent stroke of any type. The primary safety outcomes are symptomatic intracranial hemorrhage and major hemorrhage other than intracranial hemorrhage.

DISCUSSION

ARCADIA is the first trial to test whether anticoagulant therapy reduces stroke recurrence in patients with atrial cardiopathy but no known atrial fibrillation.

Abstract 121: Machine Learning Prediction of Stroke Mechanism in Embolic Strokes of Undetermined Source

Introduction: Embolic strokes of undetermined source (ESUS) are thought to arise mostly from occult cardiac sources or large-artery atherosclerotic lesions and, less frequently, other causes. The proportions of such mechanisms remains unclear.

Methods: We trained a machine learning algorithm to distinguish non-lacunar strokes caused by cardiac embolism versus large-artery atherosclerosis or other known causes (e.g., dissection), then applied the algorithm to ESUS cases to determine the predicted prevalence of cardiac embolism, which we focused on since it is plausibly a potential target for anticoagulation. We used data from the Cornell Acute Stroke Academic Registry (CAESAR), which includes all acute strokes at our hospital from 2011-2016. All variables measured during echocardiography were pulled directly from our image server (Xcelera, Philips Healthcare) and used as features to train the algorithm. Stroke etiologies were adjudicated by a panel of neurologists using TOAST and ESUS criteria. We excluded patients with an ejection fraction <35% because it was highly collinear with a cardioembolic etiology. A gradient-boosted decision tree ensemble (XGBoost) was trained on a 90% random sample of patients with a known non-lacunar etiology. Random search and cross-validation were used to tune hyperparameters. Model performance was assessed in the 10% sample of held-out non-lacunar cases not used for model training. We then applied the final algorithm to the ESUS cases in our registry to determine the predicted label (cardioembolic or not).

Results: Among 1,758 patients with echocardiograms and an ejection fraction 35% or greater, 497 had a cardioembolic etiology, 240 a large-vessel etiology, and 78 another known etiology. Our XGBoost algorithm had an area under the curve of 0.83 (± 0.06) for classifying these non-lacunar strokes as cardioembolic versus non-cardioembolic. When applied to our 520 ESUS cases, the algorithm classified 16% as cardioembolic.

Conclusions: An echocardiogram-based prediction algorithm that accurately distinguished known cardioembolic versus non-cardioembolic strokes predicted that about one-sixth of our ESUS cases were cardioembolic.

Abstract WP404: Cost-Effectiveness of Plaque Echolucency on Ultrasound as a Stroke Risk Stratification Tool in Asymptomatic Carotid Artery Stenosis

Imaging may play an important role in identifying high-risk plaques in patient with carotid disease who could benefit from surgical revascularization. We sought to evaluate the cost-effectiveness of a decision-making rule based on the ultrasound (US) imaging assessment of plaque echolucency (PE) in patients with asymptomatic carotid stenosis. We developed a decision-analytic model to project lifetime quality-adjusted life years (QALYs) and costs for five stroke prevention strategies: 1) medical therapy only; 2) revascularization if both PE and stenosis progression to >90% is present; 3) revascularization only if PE is present; 4) revascularization only if stenosis progression >90% is present; or 5) either PE or stenosis progression is present. Risks of clinical events, costs, and quality-of-life values were estimated based on published sources and the analysis was conducted from a health care system perspective for asymptomatic patients with 70-89% carotid stenosis at presentation. Patients who did not undergo revascularization had the highest stroke events (16.9%) and lowest life-years, while those who underwent revascularization on the basis of either presence of PE on US or progression of carotid stenosis had the lowest stroke events (10.0%) and longest life-years (13.67). The either PE or progression-based revascularization group had an incremental cost effectiveness ratio of $43,000/QALY compared with those with revascularization based on having both PE and stenosis progression. Plaque echolucency on US can be a cost-effective tool to identify patients with asymptomatic carotid artery stenosis most likely to benefit from carotid endarterectomy.

Abstract WMP53: New Diagnosis of Cancer and the Risk of Subsequent Arterial Thromboembolic Events

Background: Retrospective studies have reported an association between cancer and arterial thromboembolism risk. We sought to confirm this in a prospective cohort with adjudicated cardiovascular outcomes.

Methods: We analyzed data from participants enrolled in the REasons for Geographic and Racial Differences in Stroke (REGARDS) study who had Medicare coverage for 365 days before their baseline study visit in 2003-2007. Participants with prevalent cancer, coronary heart disease, or cerebrovascular disease were excluded. Medicare claims were used to identify new cancer diagnoses during follow-up. Using incidence-density sampling, participants who developed cancer were matched by age, sex, race, and education level 1:4 to participants who hadn’t developed cancer. Participants were prospectively followed through September 30, 2015 for an adjudicated arterial thromboembolic event, defined as fatal or nonfatal acute myocardial infarction or ischemic stroke. Cox regression was performed to evaluate the association between incident cancer and subsequent arterial thromboembolic events. To fulfill the proportional hazard assumption, follow-up time was modeled in discrete time periods.

Results: In this analysis, 836 REGARDS participants with incident cancer were matched to 3,339 participants without cancer. During median follow-up of 3 years, 63 (7.5%) participants with cancer and 216 (6.5%) participants without cancer had an arterial thromboembolic event. Compared to non-cancer controls, participants with incident cancer had an increased risk of arterial thromboembolic events in the first 30 days after diagnosis (HR, 5.2; 95% CI, 2.1-12.7). This association persisted after adjustment for demographics, region of residence, and cardiovascular risk factors (HR, 5.8; 95% CI, 2.1-15.9). Cancers with known metastases and types considered high-risk for venous thromboembolism had the strongest associations with arterial thromboembolic events. There was no association between cancer diagnosis and arterial thromboembolic event risk beyond 30 days.

Conclusions: Incident cancer, particularly when metastatic, is associated with an increased short-term risk of arterial thromboembolic events independent of vascular risk factors.

Abstract WP522: Catheter Ablation of Atrial Fibrillation and Long-Term Cardiovascular Outcomes

Introduction: Catheter ablation is increasingly used in older patients with atrial fibrillation (AF) but the long-term effects on vascular outcomes in this population remain unclear.

Methods: We used inpatient and outpatient claims between 2008-2015 from a nationally representative 5% sample of Medicare beneficiaries. Patients ≥66 years old who underwent AF ablation and control AF patients were matched in a 1:1 ratio based on a propensity score calculated from their age, sex, race, a socioeconomic status score, visit date, date of first AF diagnosis, history of vascular events, CHA 2 DS 2 -VASc score, and Charlson comorbidity index. Outcomes were ischemic stroke, myocardial infarction, heart failure hospitalization, major bleeding, number of AF hospitalizations, and all-cause mortality. Variables were ascertained using previously validated code algorithms. Survival statistics, Cox proportional hazards analysis, and Poisson regression were used to compare groups with adjustment for warfarin use during follow-up.

Results: The 2,119 patients who underwent ablation and 2,119 controls were well matched, including on age (72.8 ±5.6 years), sex (39.5% female), race (92.5% white), CHA 2 DS 2 -VASc score (4.4 ±1.5), Charlson comorbidities (2.4 ±2.0), and duration since AF diagnosis (1.2 ±1.4 years). During 2.8 (±1.9) years of follow-up, ablation was associated with a lower risk of death (5.9% vs 10.8% per year) (HR, 0.55; 95% CI, 0.48-0.63) or heart failure hospitalization (5.9% vs 10.7% per year) (HR, 0.57; 95% CI, 0.47-0.70) and fewer AF hospitalizations (incidence rate ratio, 0.85; 95% CI, 0.81-0.89). There was no difference in the risk of ischemic stroke (0.9% vs 1.2% per year) (HR, 0.77; 95% CI, 0.54-1.12), myocardial infarction (0.8% vs 1.0% per year) (HR, 0.75; 95% CI, 0.50-1.11), or major bleeding (3.0% vs 3.4% per year) (HR, 0.90; 95% CI, 0.72-1.11).

Conclusions: In a propensity-matched cohort of elderly AF patients, catheter AF ablation was associated with lower mortality and fewer hospitalizations for AF or heart failure, but ablation was not associated with a long-term reduction in thromboembolic or bleeding events.

Abstract WMP71: Atrial Fibrillation and Atrial Flutter After Ischemic Stroke in Black versus White Medicare Beneficiaries

Introduction: Several studies suggest that black U.S. residents have a lower risk of atrial fibrillation (AF) and a similar risk of atrial flutter (AFL) compared to whites. It remains unclear whether these differences reflect screening practices or true differences in risk. Because individuals with ischemic stroke are usually screened for AF as part of standard care, this population may provide insights into racial differences in the risk of AF and AFL.

Methods: We performed a retrospective cohort study using inpatient and outpatient claims between 2008-2015 from a nationally representative 5% sample of Medicare beneficiaries. We included patients of black or white race who were ≥65 years old and hospitalized with ischemic stroke, defined by validated ICD-9-CM diagnosis codes. Validated codes were used to identify the outcomes of AF and AFL. We excluded patients with AF or AFL before discharge from their first documented stroke hospitalization. We adjusted for post-stroke heart-rhythm monitoring, classified as Holter monitors, external loop recorders, implanted loop recorders, or interrogations of implanted pacemakers/defibrillators. We calculated AF and AFL incidence rates and hazard ratios (HR) using Cox proportional hazards models.

Results: Among 36,624 patients with ischemic stroke and no prior AF/AFL, the 5,095 black patients were slightly younger (mean age, 76.7 versus 78.9 years) but had more hypertension, diabetes, heart failure, and chronic kidney disease. During a mean follow-up of 2.0 years, the incidence of AF was 4.5 per 100 person-years and that of AFL was 0.5 per 100 person-years. Black race was associated with a lower risk of post-stroke AF (HR, 0.86; 95% CI, 0.77-0.96) including after adjustment for demographics, vascular risk factors, and post-stroke heart-rhythm monitoring (HR, 0.88; 95% CI, 0.79-0.98). There was no association between black race and post-stroke AFL in the unadjusted model (HR, 1.04; 95% CI, 0.78-1.39) or adjusted model (HR, 1.06; 95% CI, 0.79-1.44).

Conclusions: We found that black patients with ischemic stroke had a lower rate of post-stroke AF and a similar rate of post-stroke AFL compared to whites.

Abstract WP246: Long Term Risk of Hip Fracture After Ischemic Stroke

Introduction: The recent Insulin Resistance Intervention after Stroke trial found that pioglitazone decreased the risk of stroke and myocardial infarction in patients with insulin resistance and a recent cerebrovascular event. However, by 5 years, patients receiving pioglitazone had a significantly increased risk of bone fracture requiring surgery or hospitalization compared to patients who received placebo (5.1% versus 3.2%). Data is lacking on the long-term real-world risk of bone fracture among patients with ischemic stroke.

Methods: We performed a retrospective cohort study using inpatient and outpatient claims data between 2008-2015 from a nationally representative 5% sample of Medicare beneficiaries. We included patients who were ≥65 years old and hospitalized with ischemic stroke, defined by validated International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. We excluded patients who had a prior or concurrent hip fracture diagnosis at the time of ischemic stroke. The primary outcome was hip fracture requiring hospitalization. Survival statistics were used to calculate incidence rates and Kaplan-Meier statistics were used to calculate cumulative rates of hip fracture.

Results: Among the 1,952,305 beneficiaries in our sample, 60,099 patients developed an ischemic stroke in the absence of a prior or concomitant hip fracture. During 4.5 (±2.2) years of follow-up, the incidence of hip fracture was 1.6 (95% CI, 1.5-1.6) per 100 person-years in the patients with ischemic stroke versus 0.6 (95% CI, 0.6-0.6) per 100 person-years in patients without ischemic stroke. The cumulative 5-year rate of hip fracture was 7.6% (95% CI, 7.2-8.0%) among patients with ischemic stroke compared to 2.8% (95% CI, 2.8-2.9%) among the remaining Medicare beneficiaries.

Conclusions: We found that the 5-year cumulative risk of hip fracture in the overall population of Medicare beneficiaries with ischemic stroke was approximately 7.5%.

Abstract WP14: Association Between Socioeconomic Status and Endovascular Therapy Among Medicare Beneficiaries With Acute Ischemic Stroke

Introduction: Mechanical thrombectomy has recently been proven to improve outcomes in selected patients with acute ischemic stroke, prompting concerns about equitable access to this treatment.

Methods: We performed a retrospective cohort study using inpatient and outpatient claims between 2008-2015 from a nationally representative 5% sample of Medicare beneficiaries. We included patients who were ≥65 years old and hospitalized with ischemic stroke, defined by validated ICD-9-CM diagnosis codes. Our exposure variable was county-level socioeconomic advantage, defined by a validated summary score of income, wealth, education, and occupation data from the U.S. Census Bureau’s American Community Survey. Our outcome was mechanical thrombectomy, ascertained using CPT codes. Multiple logistic regression was used to evaluate the association between socioeconomic status and thrombectomy while adjusting for demographics, vascular risk factors, Charlson comorbidities, calendar year, intravenous thrombolysis, and mechanical ventilation (included as proxy for stroke severity).

Results: Among 66,989 patients with acute ischemic stroke, the 459 (0.69%; 95% CI 0.62-0.75%) patients who underwent thrombectomy during their index hospitalization were younger (77.7 versus 79.9 years), more often had atrial fibrillation (65.1% versus 37.7%), and more often received intravenous thrombolysis (43.7% versus 4.5%). The likelihood of thrombectomy increased across increasing quartiles of the county-based socioeconomic advantage score: 0.46%, 0.59%, 0.70%, and 0.97% ( P <0.001) (Figure). In an adjusted model, socioeconomic advantage was associated with thrombectomy (OR per SD, 1.05; 95% CI 1.02-1.07).

Conclusions: We found an association between increasing socioeconomic status and higher odds of thrombectomy for acute ischemic stroke.

Abstract WMP61: Recurrent Stroke Rates in Short versus Long Term Cardiac Monitoring in Patients With Embolic Stroke of Unknown Source

Background: Outpatient cardiac monitoring for 30 days or longer increases detection rates of paroxysmal atrial fibrillation (AF) after cryptogenic stroke, but the ideal duration of monitoring remains unclear. Two commonly used methods of prolonged outpatient cardiac monitoring are 30-day continuous telemetry and insertable cardiac monitors (ICM). We aim to compare rates of AF detection and recurrent stroke between patients with Embolic Stroke of Unknown Source (ESUS) monitored for approximately 30 days (short term) vs. beyond 30 days with ICM (long term).

Methods: We analyzed a single center retrospective cohort of patients discharged with a diagnosis of ESUS over a two-year period. Patients were divided into two groups based on implemented cardiac monitoring method: short-term (30-day non-invasive monitor) and long-term (ICM

Results: We identified 117 ESUS patients; 71 patients underwent short-term monitoring and 46 patients underwent long-term monitoring. After a median follow-up of 259 days (IQR 166-468 days), AF was detected in 11.2% (8/71) of patients undergoing short-term cardiac monitoring and 19.6% (9/46) of patients on long-term monitoring; 77.8% of AF was detected beyond 30 days. Recurrent stroke occurred in 12.8% (15/117) of patients. Rates of recurrent stroke were lower in patients undergoing long-term cardiac monitoring vs. only short-term monitoring [adjusted hazard ratio 0.12, 95% confidence interval 0.02-0.89, p = 0.038].

Conclusion: In a real world ESUS patient cohort, long term monitoring was associated with increased detection of AF and reduced risk of recurrent stroke. Large multicenter prospective studies are needed to confirm our findings.

Abstract WP279: Cardiac Biomarkers Predict Large Vessel Occlusion in Patients With Ischemic Stroke

Background and Purpose: Cardiac biomarkers may help identify stroke mechanisms and may aid in improving stroke prevention strategies. There is limited data on the association between these biomarkers and large vessel occlusion (LVO) in patients with acute ischemic stroke (AIS). We aim to determine the association between cardiac biomarkers [cardiac troponin and left atrial diameter (LAD)] and the presence of large vessel occlusion.

Methods: Data was abstracted from a single center prospective AIS database over 18 months and included all patients with AIS with intracranial vascular imaging (CT angiogram or MR angiography). The presence of large vessel occlusion was defined as proximal LVO of the internal carotid artery terminus, middle cerebral artery (M1 or proximal M2), or basilar artery. Univariate analyses and predefined multivariable models were performed to determine the association between cardiac biomarkers [positive troponin (troponin > 0.1) and LAD on transthoracic echocardiogram] and LVO adjusting for demographic factors (age and sex), risk factors (hypertension, diabetes, hyperlipidemia, history of stroke, congestive heart failure, coronary heart disease, and smoking), and atrial fibrillation (AF).

Results: We identified 1234 patients admitted with AIS; 886 patients (71.8%) had intracranial MRA or CTA. Of those with imaging available, 398 patients (44.9%) had LVO and 232 patients (26.2%) underwent thrombectomy. There was an association between positive troponin and LVO after adjusting for age and sex and other risk factors [adjusted OR 1.97 (1.29-3.00), P=0.002)] and this association persisted after including AF in the model [adjusted OR 1.90 (1.24-2.93), p=0.003]. There was an association between LAD and LVO after adjusting for age, sex, and risk factors [adjusted OR per mm 1.04 (1.01-1.06), p = 0.002] but this association was not present when AF was added to the model [adjusted OR 1.01 (0.99-1.04), p = 0.323]. Sensitivity analyses using thrombectomy as an outcome yielded similar findings.

Conclusion: Cardiac biomarkers predict acute LVO in patients with ischemic stroke. Prospective studies are ongoing to confirm this association and to test whether anticoagulation reduces the risk of recurrent embolism in this patient population.

Abstract WMP66: Differences in Diagnostic Evaluation in Women and Men After Acute Ischemic Stroke

Introduction: Sex differences have been found in stroke risk factors, incidence, treatment, and outcomes. There are conflicting data on whether diagnostic evaluation for stroke may differ between men and women.

Methods: We performed a retrospective cohort study using inpatient and outpatient claims between 2008-2015 from a nationally representative 5% sample of Medicare beneficiaries. We included patients who were ≥65 years old and hospitalized with ischemic stroke, defined by validated ICD-9-CM diagnosis codes. Medicare providers’ specialty codes, National Provider Identifier numbers, and data from the American Board of Psychiatry and Neurology were used to determine which patients were evaluated by a neurologist or vascular neurologist during their index stroke hospitalization or within 90 days of discharge. CPT codes were used to ascertain whether intracranial vessel imaging, cervical vessel imaging, echocardiography, and heart-rhythm monitoring were performed during the same period. Logistic regression was used to determine the association between female sex and the odds of diagnostic testing and specialist evaluation after adjustment for age, race, and number of Charlson comorbidities.

Results: Of 66,989 patients with ischemic stroke, 58.4% (95% CI, 58.1-58.8%) were female. After adjustment for age, race, and comorbidities, female sex was associated with decreased odds of intracranial vessel imaging (OR, 0.94; 95% CI, 0.91-0.97), cervical vessel imaging (OR, 0.90; 95% CI, 0.87-0.93), heart-rhythm monitoring (OR, 0.92; 95% CI, 0.86-0.98), echocardiography (OR, 0.92; 95% CI, 0.89-0.95), evaluation by a non-vascular neurologist (OR, 0.95; 95% CI, 0.92-0.99), and evaluation by a vascular neurologist (OR, 0.94; 95% CI, 0.90-0.98). Our findings were unchanged in sensitivity analyses excluding patients who died during the index hospitalization or patients discharged to hospice.

Conclusions: In a nationally representative cohort of Medicare beneficiaries, we found that women with ischemic stroke were less likely to be evaluated by stroke specialists and less likely to undergo standard diagnostic testing compared to men.

Abstract TP444: Liver Fibrosis is Associated With Hematoma Expansion and 90-Day Mortality in Primary Intracerebral Hemorrhage

Introduction: Liver disease is associated with inflammation and coagulopathy. We hypothesized that liver fibrosis, a frequently subclinical precursor of cirrhosis, is associated with outcomes in intracerebral hemorrhage (ICH).

Methods: We performed a retrospective cohort study using the Virtual International Stroke Trials Archive - ICH database. We included adult patients with primary ICH who presented within 24 hours of symptom onset. Patients with alcohol abuse and known liver disease were excluded. The exposure variables were three validated fibrosis indices calculated at the time of admission: the Aspartate aminotransferase Platelet Ratio Index (APRI), the Non-alcoholic Fatty Liver Disease Fibrosis Score (NFS), and the Fibrosis-4 (Fib-4) score. Our outcomes were hematoma expansion (HE) over 96 hours, perihematomal edema expansion, 90-day mortality, and 90-day disability (modified Rankin Scale scores 4-6). Multiple logistic regression models assessing the relationship between each 1.0 unit change in fibrosis indices and outcomes were adjusted for age, baseline ICH volume, Glasgow Coma Scale, location, intraventricular hemorrhage, and use of antithrombotic drugs. Patients with antithrombotic use and thrombocytopenia were excluded in sensitivity analyses.

Results: Of 588 patients with ICH, mean age was 66 years (SD, 12), and mean baseline hematoma volume was 22.8 milliliters (SD, 21.6). Antithrombotic use was noted in 165 patients (28%). The mean APRI, NFS, and FIB-4 values were 0.4 (SD, 0.4), -0.8 (SD, 1.3), and 1.9 (SD, 1.4), respectively; the means reflect intermediate probabilities of fibrosis. HE was seen in 212 patients (36%). After adjusting, APRI was associated with HE (OR 2.00; 95% CI 1.09-3.67) and 90-day mortality (OR 1.75; 95% CI 1.04-2.97). NFS was also associated with HE (OR 1.20; 95% CI 1.04-1.46) and mortality (OR 1.34; 95% CI 1.02-1.75). Similarly, FIB-4 was associated with HE (OR 1.28; 95% CI 1.05-1.56) and mortality (OR 1.9; 95% CI 1.04-1.60). Indices were not associated with perihematomal edema expansion or 90-day disability. Sensitivity analysis results were similar.

Conclusion: Liver fibrosis may be associated with HE and 90-day mortality after ICH. The implications of liver fibrosis for ICH warrant further investigation.