Early Infarct Growth Rate Correlation With Endovascular Thrombectomy Clinical Outcomes: Analysis From the SELECT Study

BACKGROUND AND PURPOSE

Time elapsed from last-known well (LKW) and baseline imaging results are influential on endovascular thrombectomy (EVT) outcomes.

METHODS

In a prospective multicenter cohort study of imaging selection for endovascular thrombectomy (SELECT [Optimizing Patient's Selection for Endovascular Treatment in Acute Ischemic Stroke], the early infarct growth rate (EIGR) was defined as ischemic core volume on perfusion imaging (relative cerebral blood flow<30%) divided by the time from LKW to imaging. The optimal EIGR cutoff was identified by maximizing the sum of the sensitivity and specificity to correlate best with favorable outcome and to improve its the predictability. Patients were stratified into slow progressors if EIGR<cutoff and fast progressors if EIGR≥the optimal cutoff. Good collaterals were defined on computed tomography perfusion as a hypoperfusion intensity ratio <0.4 and on computed tomography angiography as collateral score >2. The primary outcome was 90-day functional independence (modified Rankin Scale score =0-2).

RESULTS

Of 445 consented, 361 (285 EVT, 76 medical management only) patients met the study inclusion criteria. The optimal EIGR was <10 mL/h; 200 EVT patients were slow and 85 fast progressors. Fast progressors had a higher median National Institutes of Health Stroke Scale (19 versus 15, P<0.001), shorter time from LKW to groin puncture (180 versus 266 minutes, P<0.001). Slow progressors had better collaterals on computed tomography perfusion: hypoperfusion intensity ratio (adjusted odds ratio [aOR]: 5.11 [2.43-10.76], P<0.001) and computed tomography angiography: collaterals-score (aOR: 4.43 [1.83-10.73], P=0.001). EIGR independently correlated with functional independence after EVT, adjusting for age, National Institutes of Health Stroke Scale, time LKW to groin puncture, reperfusion (modified Thrombolysis in Cerebral Infarction score of ≥2b), IV-tPA (intravenous tissue-type plasminogen activator), and transfer status (aOR: 0.78 [0.65-0.94], P=0.01). Slow progressors had higher functional independence rates (121 [61%] versus 30 [35%], P<0.001) and had 3.5 times the likelihood of achieving modified Rankin Scale score =0-2 with EVT (aOR=2.94 [95% CI, 1.53-5.61], P=0.001) as compared to fast progressors, who had substantially worse clinical outcomes both in early and late time window. The odds of good outcome decreased by 14% for each 5 mL/h increase in EIGR (aOR, 0.87 [0.80-0.94], P<0.001) and declined more rapidly in fast progressors.

CONCLUSIONS

The EIGR strongly correlates with both collateral status and clinical outcomes after EVT. Fast progressors demonstrated worse outcomes when receiving EVT beyond 6 hours of stroke onset as compared to those who received EVT within 6 hours. Registration: URL: https://clinicaltrials.gov. Unique identifier: NCT02446587.

Safety and outcomes of percutaneous tracheostomy in coronavirus disease 2019 pneumonitis patients requiring prolonged mechanical ventilation

OBJECTIVES

Tracheostomy for coronavirus disease 2019 pneumonitis patients requiring prolonged invasive mechanical ventilation remains a matter of debate. This study analysed the timing and outcomes of percutaneous tracheostomy, and reports our experience of a dedicated ENT-anaesthetics department led tracheostomy team.

METHOD

A prospective single-centre observational study was conducted of patients undergoing tracheostomy, who had been diagnosed with coronavirus disease 2019 pneumonitis, between 21st March and 20th May 2020.

RESULTS

Eighty-one patients underwent tracheostomy after a median (interquartile range) of 16 (13-20) days of invasive mechanical ventilation. Median follow-up duration was 32 (23-40) days. Of patients, 86.7 per cent were successfully liberated from invasive mechanical ventilation in a median (interquartile range) of 12 (7-16) days. Moreover, 68.7 per cent were subsequently discharged from hospital. On univariate analysis, there was no difference in outcomes between early (before day 14) and late (day 14 or later) tracheostomy. The mortality rate was 8.6 per cent and no deaths were tracheostomy related.

CONCLUSION

Outcomes appear favourable when patients are carefully selected. Percutaneous tracheostomy performed via a multidisciplinary approach, with appropriate training, was safe and optimised healthcare resource utilisation.

Impact of a Positive Viral Polymerase Chain Reaction on Outcomes of Chronic Obstructive Pulmonary Disease (COPD) Exacerbations

Introduction: More than 15 million adults in the USA have chronic obstructive pulmonary disease. Chronic obstructive pulmonary disease (COPD) places a high burden on the healthcare system. Many hospital admissions are due to an exacerbation, which is suspected to be from a viral cause. The purpose of this analysis was to compare the outcomes of patients with a positive and negative respiratory virus panel who were admitted to the hospital with COPD exacerbations. Methods: This retrospective cohort study was conducted in the Geisinger Healthcare System. The dataset included 2729 patient encounters between 1 January 2006 and 30 November 2017. Hospital length of stay was calculated as the discrete number of calendar days a patient was in the hospital. Patient encounters with a positive and negative respiratory virus panel were compared using Pearson’s chi-square or Fisher’s exact test for categorical variables and Student’s t-test or Wilcoxon rank-sum tests for continuous variables. Results: There were 1626 patients with a total of 2729 chronic obstructive pulmonary disease exacerbation encounters. Nineteen percent of those encounters (n = 524) had a respiratory virus panel performed during their admission. Among these encounters, 161 (30.7%) had positive results, and 363 (69.3%) had negative results. For encounters with the respiratory virus panel, the mean age was 64.5, 59.5% were female, 98.9% were white, and the mean body mass index was 26.6. Those with a negative respiratory virus panel had a higher median white blood cell count (11.1 vs. 9.9, p = 0.0076). There were no other statistically significant differences in characteristics between the two groups. Respiratory virus panel positive patients had a statistically significant longer hospital length of stay. There were no significant differences with respect to being on mechanical ventilation or ventilation-free days. Conclusion: This study shows that a positive respiratory virus panel is associated with increased length of hospital stay. Early diagnosis of chronic obstructive pulmonary disease exacerbation patients with positive viral panel would help identify patients with a longer length of stay.

Crystal structure of the GDP-bound GTPase domain of Rab5a from Leishmania donovani

Eukaryotic Rab5s are highly conserved small GTPase-family proteins that are involved in the regulation of early endocytosis. Leishmania donovani Rab5a regulates the sorting of early endosomes that are involved in the uptake of essential nutrients through fluid-phase endocytosis. Here, the 1.80 Å resolution crystal structure of the N-terminal GTPase domain of L. donovani Rab5a in complex with GDP is presented. The crystal structure determination was enabled by the design of specific single-site mutations and two deletions that were made to stabilize the protein for previous NMR studies. The structure of LdRab5a shows the canonical GTPase fold, with a six-stranded central mixed β-sheet surrounded by five α-helices. The positions of the Switch I and Switch II loops confirm an open conformation, as expected in the absence of the γ-phosphate. However, in comparison to other GTP-bound and GDP-bound homologous proteins, the Switch I region traces a unique disposition in LdRab5a. One magnesium ion is bound to the protein at the GTP-binding site. Molecular-dynamics simulations indicate that the GDP-bound structure exhibits higher stability than the apo structure. The GDP-bound LdRab5a structure presented here will aid in efforts to unravel its interactions with its regulators, including the guanine nucleotide-exchange factor, and will lay the foundation for a structure-based search for specific inhibitors.

Strain tuning of the Stokes shift in atomically thin semiconductors

Atomically thin layers of transition metal dichalcogenides (TMDC) have exceptional optical properties, exhibiting a characteristic absorption and emission at excitonic resonances. Due to their extreme flexibility, strain can be used to alter the fundamental exciton energies and line widths of TMDCs. Here, we report on the Stokes shift, i.e. the energetic difference of light absorption and emission, of the A exciton in TMDC mono- and bilayers. We demonstrate that mechanical strain can be used to tune the Stokes shift. We perform optical transmission and photoluminescence (PL) experiments on mono- and bilayers and apply uniaxial tensile strain of up to 1.2% in MoSe2 and WS2 bilayers. An A exciton red shift of -38 meV/% and -70 meV/% is found in transmission in MoSe2 and WS2, while smaller values of -27 meV/% and -62 meV/% are measured in PL, respectively. Therefore, a reduction of the Stokes shift is observed under increasing tensile strain. At the same time, the A exciton PL line widths narrow significantly with -14 meV/% (MoSe2) and -21 meV/% (WS2), demonstrating a drastic change in the exciton-phonon interaction. By comparison with ab initio calculations, we can trace back the observed shifts of the excitons to changes in the electronic band structure of the materials. Variations of the relative energetic positions of the different excitons lead to a decrease of the exciton-phonon coupling. Furthermore, we identify the indirect exciton emission in bilayer WS2 as the ΓK transition by comparing the experimental and theoretical gauge factors.

Structural and functional characterization of peptidyl-tRNA hydrolase from Klebsiella pneumoniae

Klebsiella pneumoniae is a member of the ESKAPE panel of pathogens that are top priority to tackle AMR. Bacterial peptidyl tRNA hydrolase (Pth), an essential, ubiquitous enzyme, hydrolyzes the peptidyl-tRNAs that accumulate in the cytoplasm because of premature termination of translation. Pth cleaves the ester bond between 2' or 3' hydroxyl of the ribose in the tRNA and C-terminal carboxylate of the peptide, thereby making free tRNA available for repeated cycles of protein synthesis and preventing cell death by alleviating tRNA starvation. Pth structures have been determined in peptide-bound or peptide-free states. In peptide-bound state, highly conserved residues F67, N69 and N115 adopt a conformation that is conducive to their interaction with peptide moiety of the substrate. While, in peptide-free state, these residues move away from the catalytic center, perhaps, in order to facilitate release of hydrolysed peptide. Here, we present a novel X-ray crystal structure of Pth from Klebsiella pneumoniae (KpPth), at 1.89 Å resolution, in which out of the two molecules in the asymmetric unit, one reflects the peptide-bound while the other reflects peptide-free conformation of the conserved catalytic site residues. Each molecule of the protein has canonical structure with seven stranded β-sheet structure surrounded by six α-helices. MD simulations indicate that both the forms converge over 500 ns simulation to structures with wider opening of the crevice at peptide-binding end. In solution, KpPth is monomeric and its 2D-HSQC spectrum displays a single set of well dispersed peaks. Further, KpPth was demonstrated to be enzymatically active on BODIPY-Lys-tRNA^Lys3.

Resonance assignments and secondary structure prediction of secretory protein Rv0603 from Mycobacterium tuberculosis H37Rv

We report the NMR resonance assignments of N-terminal signal sequence deleted secretory protein Rv0603 (∆_1-28-Rv0603) from Mycobacterium tuberculosis H37Rv. ∆_1-28-Rv0603 displayed good peak yield and signal dispersion in 2D [¹⁵N-¹H] HSQC spectrum, which prompted us to proceed for resonance assignments on this construct. Standard triple-resonance experiments for resonance assignments were recorded on [U-¹⁵N]-∆Rv0603 and [U-¹⁵N, ¹³C]-∆Rv0603 samples. We obtained 97% of backbone ¹H^N, 98% of ¹³C^α, 98% of ¹H^α, 96% of ¹³C´, 100% of ¹³C^β, 100% of ¹H^β and 98% of side-chain ¹H chemical shifts. This protein does not show any sequence similarity to any other protein of known structure. Determination of its solution structure would facilitate understanding of its biological function.

The role of transoral fine needle aspiration in expediting diagnosis and reducing risk in head and neck cancer patients in the coronavirus disease 2019 (COVID-19) era: a single-institution experience

OBJECTIVE

The global coronavirus disease 2019 (COVID-19) pandemic has necessitated rapid alterations to diagnostic pathways for head and neck cancer patients that aim to reduce risk to patients (exposure to the hospital environment) and staff (aerosol-generating procedures). Transoral fine needle aspiration cytology offers a low-risk means of rapidly diagnosing patients with oral cavity or oropharyngeal lesions. The technique was utilised in selected patients at our institution during the pandemic. The outcomes are considered in this study.

METHOD

Diagnostic outcomes were retrospectively evaluated for a series of patients undergoing transoral fine needle aspiration cytology of oral cavity and oropharyngeal lesions during the COVID-19 pandemic.

RESULTS

Five patients underwent transoral fine needle aspiration cytology, yielding lesional material in 100 per cent, with cell blocks providing additional information. In one case, excision biopsy of a lymphoproliferative lesion was required for final diagnosis.

CONCLUSION

Transoral fine needle aspiration cytology can provide rapid diagnosis in patients with oral cavity and oropharyngeal lesions. Whilst limitations exist (including tolerability and lesion location), the technique offers significant advantages pertinent to the COVID-19 era, and could be employed in the future to obviate diagnostic surgery in selected patients.

Oral health care among patients with diabetes in Australia: A snapshot

Background

Diabetes increases the risk of periodontal disease, which in turn negatively impact on diabetes control and complications. Therefore, awareness about the diabetes-oral health link and dental problems is important for people with diabetes. This study aimed to assess self-reported oral health status and knowledge of people living with diabetes.

Methods

A survey was conducted among patients who attended four public diabetes clinics in Sydney, Australia. The questionnaire included 10 knowledge items and a validated Oral Health Impact Profile (OHIP-14) scale. A convenience sample of 200 patients were recruited. The data were analysed using SPSS software with descriptive and Pearson's Chi-Squared tests reported.

Results

The mean age of participants was 62.4(±13.5) years. More than half were males (54.5%), born overseas (64%), not working (73%) and had type 2 diabetes (88%). More than half (55.1%) of the patients reported having one or more dental problems and this was negatively associated with their oral health-related quality of life (p &lt; 0.001). The most common dental problems were: gaps between teeth, pain in teeth and dry mouth. Only 46.2% of the participants had adequate oral health knowledge (&gt; the mean correct score 5.2 (±2.6). The main areas with poor knowledge were around the impact of gum disease on blood glucose levels (29.6%), effects of dry mouth on tooth decay (33.8%) and the link between diabetes and teeth and gums (44.5%). Only 13% of the patients reported receiving oral health information from diabetes care providers (diabetes educator, general practitioner/diabetes specialist and dietitian/nutritionist). Receiving oral health information was found to be significantly associated with higher oral health knowledge scores (p &lt; 0.05).

Conclusions

Considering that a majority of patients with diabetes have dental problems and inadequate oral health knowledge, diabetes care providers should take the opportunity to educate patients about oral health risks.

Key messages

People living with diabetes found to have dental problems and inadequate oral health knowledge. Considering that diabetes and dental problems adversely affect each other, it is crucial to educate patients about good oral hygiene and regular dental visit.

Haploinsufficiency of X-linked intellectual disability gene CASK induces post-transcriptional changes in synaptic and cellular metabolic pathways

Heterozygous mutations in the X-linked gene CASK are associated with intellectual disability, microcephaly, pontocerebellar hypoplasia, optic nerve hypoplasia and partially penetrant seizures in girls. The Cask^+/- heterozygous knockout female mouse phenocopies the human disorder and exhibits postnatal microencephaly, cerebellar hypoplasia and optic nerve hypoplasia. It is not known if Cask^+/- mice also display seizures, nor is known the molecular mechanism by which CASK haploinsufficiency produces the numerous documented phenotypes. 24-h video electroencephalography demonstrates that despite sporadic seizure activity, the overall electrographic patterns remain unaltered in Cask^+/- mice. Additionally, seizure threshold to the commonly used kindling agent, pentylenetetrazol, remains unaltered in Cask^+/- mice, indicating that even in mice the seizure phenotype is only partially penetrant and may have an indirect mechanism. RNA sequencing experiments on Cask^+/- mouse brain uncovers a very limited number of changes, with most differences arising in the transcripts of extracellular matrix proteins and the transcripts of a group of nuclear proteins. In contrast to limited changes at the transcript level, quantitative whole-brain proteomics using iTRAQ quantitative mass-spectrometry reveals major changes in synaptic, metabolic/mitochondrial, cytoskeletal, and protein metabolic pathways. Unbiased protein-protein interaction mapping using affinity chromatography demonstrates that CASK may form complexes with proteins belonging to the same functional groups in which altered protein levels are observed. We discuss the mechanism of the observed changes in the context of known molecular function/s of CASK. Overall, our data indicate that the phenotypic spectrum of female Cask^+/- mice includes sporadic seizures and thus closely parallels that of CASK haploinsufficient girls; the Cask^+/- mouse is thus a face-validated model for CASK-related pathologies. We therefore surmise that CASK haploinsufficiency is likely to affect brain structure and function due to dysregulation of several cellular pathways including synaptic signaling and cellular metabolism.

Global, Regional, and National Levels and Trends in Burden of Oral Conditions from 1990 to 2017: A Systematic Analysis for the Global Burden of Disease 2017 Study

Government and nongovernmental organizations need national and global estimates on the descriptive epidemiology of common oral conditions for policy planning and evaluation. The aim of this component of the Global Burden of Disease study was to produce estimates on prevalence, incidence, and years lived with disability for oral conditions from 1990 to 2017 by sex, age, and countries. In addition, this study reports the global socioeconomic pattern in burden of oral conditions by the standard World Bank classification of economies as well as the Global Burden of Disease Socio-demographic Index. The findings show that oral conditions remain a substantial population health challenge. Globally, there were 3.5 billion cases (95% uncertainty interval [95% UI], 3.2 to 3.7 billion) of oral conditions, of which 2.3 billion (95% UI, 2.1 to 2.5 billion) had untreated caries in permanent teeth, 796 million (95% UI, 671 to 930 million) had severe periodontitis, 532 million (95% UI, 443 to 622 million) had untreated caries in deciduous teeth, 267 million (95% UI, 235 to 300 million) had total tooth loss, and 139 million (95% UI, 133 to 146 million) had other oral conditions in 2017. Several patterns emerged when the World Bank’s classification of economies and the Socio-demographic Index were used as indicators of economic development. In general, more economically developed countries have the lowest burden of untreated dental caries and severe periodontitis and the highest burden of total tooth loss. The findings offer an opportunity for policy makers to identify successful oral health strategies and strengthen them; introduce and monitor different approaches where oral diseases are increasing; plan integration of oral health in the agenda for prevention of noncommunicable diseases; and estimate the cost of providing universal coverage for dental care.

A199 BLACK ESOPHAGUS: AN UNDER-RECOGNIZED CAUSE OF UPPER GASTROINTESTINAL BLEEEDING

Background

“Black esophagus” is a term that refers to the endoscopic manifestation of acute esophageal necrosis (AEN), a rare but potentially under-recognized cause of upper gastrointestinal bleeding, characterized by the presence of strikingly black necrotic esophagus on upper endoscopy. The etiology is unclear although ischemic insults and caustic injury from gastric acid exposure are thought to play prominent roles. This condition is often seen in patients who are systemically unwell and have underlying comorbidities such as diabetes mellitus and vascular diseases.

Aims

We present a case of an elderly woman with diabetes and poor glycemic control who developed coffee ground emesis with her upper endoscopy revealing evidence of acute esophageal necrosis. AEN is an important diagnosis to consider in diabetic patients, as it generally carries a poor prognosis with mortality rates as high as 32% reported in the literature.

Methods

Case report and review of the literature

Results

A 61-year-old woman with medical history significant for poorly controlled insulin dependent diabetes (hemoglobin A1c, 11%) developed coffee ground emesis (confirmed via insertion of nasogastric tube) three days after initial admission to hospital for left tibial plateau fracture. Her bloodwork did not reveal any underlying diabetic ketoacidosis or hyperosomlar hyperglycemic state. Her esophagogastroduodenoscopy (EGD) showed black, necrotic-appearing discoloration of the esophageal mucosa circumferentially within the mid to distal part of the esophagus with a sharp transition point towards normal appearing mucosa at the gastroesophageal junction. Biopsies were deferred due to high risk of bleeding and perforation, and the previously placed nasogastric tube was not removed.

After endoscopy, conservative management was advised with restricted oral intake, intravenous proton pump inhibitor (PPI) inhibitor therapy for 72 hours and aggressive treatment of ongoing hyperglycemia. There were no signs or symptoms of esophageal rupture. The patient gradually recovered and in fact had her orthopedic surgery within a week of EGD. Furthermore, three days into the post operative period she developed venous thromboembolism and was placed on full dose oral anticoagulation and tolerated this without any further gastrointestinal bleeding.

Conclusions

AEN is an important diagnostic consideration in elderly diabetic patients presenting with acute upper gastrointestinal bleeding, particularly as timely recognition and management can significantly lower the unfavorable mortality associated with this condition.

Funding Agencies

None

Abstract 171: Endovascular Thrombectomy May Be Cost-Effective for Patients With Large Core Ischemic Strokes: A Cost-Utility Analysis From the SELECT Study

Background: Whether Endovascular Thrombectomy (EVT) is cost-effective in large ischemic core infarcts is unknown.

Methods: In the prospective multicenter cohort study of imaging selection study (SELECT), large core was defined as CT ASPECTS < 6 or CTP ischemic core volume (rCBF<30%) ≥ 50 cc. A Markov model estimated costs, quality-adjusted life years (QALYs) and the Incremental Cost-effectiveness Ratio (ICER) of EVT compared to Medical Management (MM) over 20 years life expectancy. The lower and upper willingness to pay (WTP) per QALY were set at $50000 and $100000 and the Net Monetary Benefit (NMB) for EVT were calculated. A probabilistic sensitivity analysis (PSA) and cost-effectiveness acceptability curves (CEAC) assessed EVT cost-effective probability at WTP range values.

Results: Of 361 enrolled, 105 had large core on CT or CTP (EVT 62, MM 43). 19 (31%) EVT patients achieved mRS 0-2 vs 6 (14%) MM (aOR: 3.27, 95% CI: 1.11-9.62; P = .03) with a shift towards better mRS (adj cOR: 2.12, 95% CI: 1.05-4.31, P = .04). Over 20 years EVT was associated with $26589 (C.I. $8672- $43978) incremental costs and a gain of 1.18 QALYs (C.I. 0.091- 2.2) per patient.

EVT could avert 75 deaths over a theoretical cohort of 1000 patients (MM 861 vs EVT 786) thus the ICER of EVT compared to MM was $22400 per QALY (CI. $10109 - $66140), which is <$50000/QALY, Tab 1.

EVT has a higher NMB compared to MM at the lower and upper WTP thresholds (EVT $86,3 and 271,4 million vs MM $53,6-$179,3 million), Tab 2.

The PSA confirmed the results (fig 1). The CEAC showed 94% and 97% cost-effectiveness probability of EVT at the lower and upper values respectively of the maximum WTP, fig 2.

EVT ICER in SELECT large core ($22400/QALY) was higher but still comparable to those in HERMES ($16882/QALY), DAWN ($7335/QALY) and DEFUSE3 ($14673/QALY), Tab 3.

Conclusion: EVT may result in better outcomes and more lives saved in large core patients with higher QALYs, NMB and an acceptable ICER. The results were comparable to other EVT RCTs.

Abstract 129: Endovascular Thrombectomy Potential Benefits in Isolated M2 Occlusions Are Related to Stroke Severity and Penumbral Mismatch Deficit: A Secondary Analysis From the SELECT Study

Background: The efficacy of endovascular thrombectomy (EVT) in M2 occlusions is uncertain.

Methods: In a prospective multicenter cohort study of imaging selection (SELECT), EVT outcomes were compared to medical managment (MM) in M2 occlusions. Further, we assessed for potential treatment benefit in patients with higher stroke severity (NIHSS) and a larger perfusion deficit on CTP (Tmax > 6 sec - ischemic core volume)The primary outcome was excellent outcome (mRS 0-1).

Results: of 361 patients enrolled in SELECT, 87 had isolated M2 occlusion (EVT 59, MM 28). Baseline NIHSS median (IQR) (EVT 14 (10-20), MM 15 (9.5-19.5), p=0.72) and infarct volume rCBF<30% (EVT 7 (0-21) vs MM 18.5 (0-41.25), P=0.10). EVT was associated with higher rates of excellent outcomes (53% vs 21%, aOR:6.94, 95% CI=1.86-25.90, p=0.004) with a shift towards better mRS outcomes (adj cOR: 3.49, 95% CI=1.39-8.80, p=0.008), smaller final infarct volume (15.9 (2.7-48.0) vs 58 (24.3-141.9), P<0.001), and a reduction of neurological worsening (3% vs 22%, p=0.011), sICH (2% vs 21%, p=0.004), and mortality (5% vs 25%, p=0.011). Assessing outcomes in NIHSS strata; there was no significant increase in excellent outcomes rates in NIHSS ≤10 (EVT 65% vs MM 50%, aOR=1.59, 95% CI=0.21-12.01, p=0.65). In contrast, patients with NIHSS>10 had better outcomes with EVT (46%) vs MM (10%), aOR=11.39, 95% CI=1.80-72.11, p=0.01 as shown in figure 1. As perfusion deficit lesion size increased, the odds of achieving excellent outcomes was reduced (for each 10cc by 11%, aOR: 0.89, 95% CI=0.79-1.00, p=0.05). Excellent outcomes declined in patients with MM as perfusion deficit lesion size increased, yet in the EVT they were maintained as shown in figure 2. Similar results were obtained for mRS 0-2.

Conclusion: EVT may result in better rates of excellent outcomes in isolated M2 occlusions, especially those with more severe strokes and larger perfusion deficits who are more likely to have worse outcomes without emergent reperfusion.

Abstract WP42: Stroke Severity and Size Modify the Association Between IV Thrombolysis and Outcomes Following Endovascular Thrombectomy

Background: Whether IV tPA has adjunctive benefit to endovascular thrombectomy (EVT) is unclear.

Methods: In a prospective multicenter cohort study of imaging selection for EVT (SELECT), patients who received IV tPA vs. no IV tPA were compared stratified by stroke severity and ischemic core size (rCBF<30%).

Results: Of 361 enrolled, 285 received EVT; 226 presented within 4.5 hrs, 162 (72%) received IV tPA. IV tPA patients had lower median ASPECTS (8 vs 9, p=0.007) and larger ischemic core size (11.4 (1.5-37) vs 3.9 (0-32.15), p=0.042, otherwise similar at baseline. There were no delays in EVT delivery associated with tPA: median time (IQR) from arrival to groin puncture 95.0 min (66.0, 118.0) tPA vs 81.5 (63.5, 107.5) no tPA, p=0.21. IV tPA use was associated with higher mRS 0-2 rates (57% vs 44%), aOR 2.02 (95% CI 1.01-4.03, p=0.046) after adjustment for baseline differences with a shift towards better outcomes on all mRS levels (cOR 2.06, 95% CI 1.18-3.59, p=0.01) with lower mortality (11% vs 22%, p=0.026) and similar sICH rates (and 6% vs 6%, p=1.0). In patients with NIHSS <15, IV tPA was associated with higher mRS 0-2 (tPA 83% vs no tPA 50%, aOR 4.53, 95%CI 1.48-13.80, p=0.008) with a shift towards better outcomes (adj cOR 5.44, 95% CI 2.16-13.70, p<0.001) while with NIHSS≥15 there was no adjunctive benefit of IV tPA (tPA 42% vs no tPA 38%, aOR 1.05, 95%CI 0.40-2.74, p=0.92) or shift (adj cOR: 1.32, 95% CI 0.61-2.86, p=0.48) with an interaction between IV tPA effect on EVT outcome with NIHSS (p=0.04) Fig A. Similarly, in ischemic core < 50 cc (62% vs. 46%, aOR 1.96, 95%CI 0.96-3.99, p=0.06; adj cOR 2.03, 95% CI 1.13-3.66, p=0.018) as compared to core ≥ 50cc (tPA 26% vs no tPA 25% P=1.0) with an interaction between IV tPA effect on EVT outcome with core size (p=0.037) Fig B.

Conclusion: IV tPA did not result in thrombectomy delivery delays and may result in better outcomes. Patients with less severe strokes and smaller infarct size had a stronger association between the use of IV tPA and favorable outcomes.

Abstract TMP12: The Effect of Anesthesia Type on Endovascular Thrombectomy Outcomes is Modified by Stroke Size: A Secondary Analysis From the SELECT Study

Background: The effect of anesthesia choice on endovascular thrombectomy (EVT) outcomes is unclear.

Methods: In the prospective multicenter cohort study of imaging selection for EVT (SELECT), patients were stratified based on their anesthesia type into general anesthesia (GA) and conscious sedation (CS). EVT times and outcomes were compared. Further we assessed the impact of ischemic core size (rCBF<30%) on the correlation between anesthesia type and EVT outcomes.

Results: Of 361 enrolled, 285 received EVT. 129 (45%%) received GA and 156 (54%) CS. The baseline characteristics were similar, except for presentation NIHSS (GA 17(13-21), CS 15(11-20), p=0.027) and ischemic core volume (GA 14.1 cc (0-38) vs CS 6.3(0-26.1), p=0.034). GA was associated with numerically longer arrival to GP times 92 (68—115) vs. 85(60-117) mins, p=0.58. After adjustment for baseline imbalances, patients who received CS had a shift toward better outcome (adj cOR 1.72, 95% CI=1.08-2.75, p=0.022) with higher functional independence rates 56.8% vs 48.8%, p=0.75. Furthermore, GA was associated with higher mortality rates (19% vs 9%, p=0.017), figure 1A.

In patients with core volume ≥ 50 cc, there was a trend for a shift towards better outcomes (adj cOR=5.84, 95%CI= 0.90-38.00, P=0.065), figure 1B while there was no difference in patients with core volume < 50 cc (adj cOR=1.01 (95%CI 0.53-1.94, P=0.96), figure 1C. There was an interaction between core volume size and anesthesia type on functional outcome (p=0.042). For every 10cc increase in the core volume, the odds of attaining better functional outcome decreased by 29% (adjusted cOR: 0.71, 95% CI=0.61-0.83, p<0.001) with GA as compared to only 16% (adjusted cOR: 0.84, 95% CI=0.73-0.96, p=0.01) with CS.

Conclusion: Conscious sedation was associated with a shift towards better EVT outcomes. This effect was driven by patients with larger ischemic core volumes and has implications for randomized trials of conscious sedation vs general anesthesia.

Optimizing Patient Selection for Endovascular Treatment in Acute Ischemic Stroke (SELECT): A Prospective, Multicenter Cohort Study of Imaging Selection

OBJECTIVE

The primary imaging modalities used to select patients for endovascular thrombectomy (EVT) are noncontrast computed tomography (CT) and CT perfusion (CTP). However, their relative utility is uncertain. We prospectively assessed CT and CTP concordance/discordance and correlated the imaging profiles on both with EVT treatment decisions and clinical outcomes.

METHODS

A phase 2, multicenter, prospective cohort study of large-vessel occlusions presented up to 24 hours from last known well was conducted. Patients received a unified prespecified imaging evaluation (CT, CT angiography, and CTP with Rapid Processing of Perfusion and Diffusion software mismatch determination). The treatment decision, EVT versus medical management, was nonrandomized and at the treating physicians' discretion. An independent, blinded, neuroimaging core laboratory adjudicated favorable profiles based on predefined criteria (CT:Alberta Stroke Program Early CT Score ≥ 6, CTP:regional cerebral blood flow (<30%) < 70ml with mismatch ratio ≥ 1.2 and mismatch volume ≥ 10ml).

RESULTS

Of 4,722 patients screened from January 2016 to February 2018, 361 patients were included. Two hundred eighty-five (79%) received EVT, of whom 87.0% had favorable CTs, 91% favorable CTPs, 81% both favorable profiles, 16% discordant, and 3% both unfavorable. Favorable profiles on the 2 modalities correlated similarly with 90-day functional independence rates (favorable CT = 56% vs favorable CTP = 57%, adjusted odds ratio [aOR] = 1.91, 95% confidence interval [CI] = 0.40-9.01, p = 0.41). Having a favorable profile on both modalities significantly increased the odds of receiving thrombectomy as compared to discordant profiles (aOR = 3.97, 95% CI = 1.97-8.01, p < 0.001). Fifty-eight percent of the patients with favorable profiles on both modalities achieved functional independence as compared to 38% in discordant profiles and 0% when both were unfavorable (p < 0.001 for trend). In favorable CT/unfavorable CTP profiles, EVT was associated with high symptomatic intracranial hemorrhage (sICH) (24%) and mortality (53%) rates.

INTERPRETATION

Patients with favorable imaging profiles on both modalities had higher odds of receiving EVT and high functional independence rates. Patients with discordant profiles achieved reasonable functional independence rates, but those with an unfavorable CTP had higher adverse outcomes. Ann Neurol 2020;87:419-433.

Determination of Isoflavones in Soy and Selected Foods Containing Soy by Extraction, Saponification, and Liquid Chromatography: Collaborative Study

Isoflavones are biologically active compounds occurring naturally in a variety of plants, with relatively high levels found in soybeans. Twelve laboratories participated in a collaborative study to determine the aglycon isoflavone content of 8 test samples of soy and foods containing soy. The analytical method for the determination of isoflavones incorporates a mild saponification step that reduces the number of analytes measured and permits quantitation versus commercially available, stable reference standards. Test samples were extracted at 65°C with methanol–water (80 + 20), saponified with dilute sodium hydroxide solution, and analyzed by reversed-phase liquid chromatography with UV detection at 260 nm. Isoflavone results were reported as μg/aglycon/g or μg aglycon equivalents/g. The 8 test samples included 2 blind duplicates and 4 single test samples with total isoflavone concentrations ranging from approximately 50 to 3000 μg/g. Test samples of soy ingredients and products made with soy were distributed to collaborators with appropriate reference standards. Collaborators were asked to analyze test samples in duplicate on 2 separate days. The data were analyzed for individual isoflavone components, subtotals of daidzin–daidzein, glycitin–glycitein, and genistin–genistein, and total isoflavones. The relative standard deviation (RSD) for repeatability was 1.8–7.1%, and the RSD for reproducibility was 3.2–16.1% for total isoflavone values of 47–3099 μg/g.