Lack of Racial, Ethnic, and Sex Disparities in Ischemic Stroke Care Metrics within a Tele-Stroke Network

INTRODUCTION

Differences in access to stroke care and compliance with standard of care stroke management among patients of varying racial and ethnic backgrounds and sex are well-characterized. However, little is known on the impact of telestroke in addressing disparities in acute ischemic stroke care.

METHODS

We conducted a retrospective review of acute ischemic stroke patients evaluated over our 17-hospital telestroke network in Texas from 2015-2018. Patients were described as Non-Hispanic White (NHW) male or female, Non-Hispanic Black (NHB) male or female, or Hispanic (HIS) male or female. We compared frequency of tPA and mechanical thrombectomy (MT) utilization, door-to-consultation times, door-to-tPA times, and time-to-transfer for patients who went on to MT evaluation at the hub after having been screened for suspected large vessel occlusion at the spoke.

RESULTS

Among 3873 patients (including 1146 NHW male (30%) and 1134 NHW female (29%), 405 NHB male (10%) and 491 NHB female (13%), and 358 HIS male (9%) and 339 HIS female (9%) patients), we did not find any differences in door-to consultation time, door-to-tPA time, time-to-transfer, frequency of tPA administration, or incidence of MT utilization.

CONCLUSION

We did not find racial, ethnic, and sex disparities in ischemic stroke care metrics within our telestroke network. In order to fully understand how telestroke alleviates disparities in stroke care, collaboration among networks is needed to formulate a multicenter telestroke database similar to the Get-With-The Guidelines.

Hypertension-Related Cerebral Microbleeds

Hypertension and cerebral amyloid angiopathy are the most common causes of cerebral microbleeds. The pattern of microbleeds on T2*-weighted gradient echo sequence of magnetic resonance imaging of the brain can be indicative of the etiology of intracerebral hemorrhage. We describe a case of cerebellar hemorrhage with cerebral microbleeds secondary to chronic hypertension.

Impact of Initial Imaging Protocol on Likelihood of Endovascular Stroke Therapy

Background and Purpose:

Noncontrast head CT and CT perfusion (CTP) are both used to screen for endovascular stroke therapy (EST), but the impact of imaging strategy on likelihood of EST is undetermined. Here, we examine the influence of CTP utilization on likelihood of EST in patients with large vessel occlusion (LVO).

Methods:

We identified patients with acute ischemic stroke at 4 comprehensive stroke centers. All 4 hospitals had 24/7 CTP and EST capability and were covered by a single physician group (Neurology, NeuroIntervention, NeuroICU). All centers performed noncontrast head CT and CT angiography in the initial evaluation. One center also performed CTP routinely with high CTP utilization (CTP-H), and the others performed CTP optionally with lower utilization (CTP-L). Primary outcome was likelihood of EST. Multivariable logistic regression was used to determine whether facility type (CTP-H versus CTP-L) was associated with EST adjusting for age, prestroke mRS, National Institutes of Health Stroke Scale, Alberta Stroke Program Early CT Score, LVO location, time window, and intravenous tPA (tissue-type plasminogen activator).

Results:

Among 3107 patients with acute ischemic stroke, 715 had LVO, of which 403 (56%) presented to CTP-H and 312 (44%) presented to CTP-L. CTP utilization among LVO patients was greater at CTP-H centers (72% versus 18%, CTP-H versus CTP-L, P <0.01). In univariable analysis, EST rates for patients with LVO were similar between CTP-H versus CTP-L (46% versus 49%). In multivariable analysis, patients with LVO were less likely to undergo EST at CTP-H (odds ratio, 0.59 [0.41–0.85]). This finding was maintained in multiple patient subsets including late time window, anterior circulation LVO, and direct presentation patients. Ninety-day functional independence (odds ratio, 1.04 [0.70–1.54]) was not different, nor were rates of post-EST PH-2 hemorrhage (1% versus 1%).

Conclusions:

We identified an increased likelihood for undergoing EST in centers with lower CTP utilization, which was not associated with worse clinical outcomes or increased hemorrhage. These findings suggest under-treatment bias with routine CTP.

Different strokes: differences in the characteristics and outcomes of BCVI and non-BCVI strokes in trauma patients

Background

Although strokes are rare in trauma patients, they are associated with worse functional and cognitive outcomes and decreased mobility. Blunt cerebrovascular injury (BCVI)–related strokes and mortality have decreased, likely due to refined screening and treatment algorithms in trauma literature; however, there is a paucity of research addressing non-BCVI strokes in trauma. The purpose of this study is to evaluate the incidence, etiology, and risk factors of stroke in our trauma population in order to identify preventive strategies.

Methods

This study was a retrospective review of all adult trauma patients admitted to a level 1 trauma hospital who suffered a stroke during trauma admission from 2010 to 2017. Data were collected from the prospectively maintained trauma and stroke databases. Stroke etiology was determined by a vascular neurologist.

Results

Of the 43 674 adult trauma patients admitted during the study period, 99 (0.2%) were diagnosed with a stroke during the index admission. Twenty-one (21%) strokes were due to BCVI. Seventy-eight (79%) strokes were due to non-BCVI etiologies. Patients with non-BCVI strokes were older, less severely injured, and had more medical comorbidities compared with patients with a BCVI stroke. While patients with a BCVI stroke were more likely to suffer multiple traumatic injuries from MVC (76% vs 28%, p<0.001), non-BCVI strokes had more isolated extremity injuries from fall mechanism (55% vs 10%, p<0.001). Over the study period, the age and incidence of stroke and BCVI (p<0.001) increased. However, the rate of BCVI strokes decreased while the rate of non-BCVI strokes increased.

Discussion

The incidence of stroke has increased despite aggressive screening and treatment of BCVI. This increase is primarily due to non-BCVI strokes which are associated with advanced age and medical comorbidities after low mechanism traumatic injury. Medical optimization of comorbid conditions during trauma hospitalization will become increasingly important for stroke prevention as the population ages.

Level of evidence: Level III

Patients transferred within a telestroke network for large-vessel occlusion

INTRODUCTION

In a telestroke network, patients at a referring hospital (RH) with large-vessel occlusion (LVO) are transferred to a comprehensive stroke centre (CSC) for endovascular thrombectomy (EVT). However, a significant number of patients do not ultimately undergo thrombectomy after CSC arrival.

METHODS

Within a 17-hospital telestroke network, we retrospectively analysed patients with suspected or confirmed LVO transferred to a CSC, and characterized the reasons why these patients did not undergo EVT based on the 2019 American Heart Association guidelines.

RESULTS

Of 400 patients transferred to our hub, 68 (17%) were based on vascular imaging at RH. Time from RH arrival to neuroimaging was significantly longer in patients that underwent both computed tomography (CT) and CT angiography of the brain and neck compared to only CT of the brain (53 vs 13 minutes, p < 0.05). Accuracy of anterior circulation LVO (ACLVO) detection based on clinical suspicion was 62% (205 of 332 patients). Among 234 ACLVO patients, overall, 175 (74%) (early window group: 123 (73%) patients and late window group: 52 (80%) patients) met at least one EVT ineligibility criterion. The reasons for EVT ineligibility varied from large core infarct (aspects <6 or core volume >70 cc on perfusion imaging in late window), low National Institutes of Health Stroke Scale (<6), distal occlusion, and poor baseline modified Rankin Scale score (>1).

DISCUSSION

Instituting rapid acquisition and interpretation of vascular imaging at RHs for LVO detection and establishing benchmarks for door to vascular imaging is urgently needed for RHs.

Rapid Infarct Progression in Anterior Circulation Large Vessel Occlusion Ischemic Stroke Patients During Inter-Facility Transfer

INTRODUCTION

We aimed to identify factors associated with rapid infarct progression during inter-facility transfer for endovascular thrombectomy evaluation and its impact on clinical outcomes.

METHODS

Patients with anterior circulation large artery occlusion within 24 h of onset transferred within our 17 hospital tele-stroke network were retrospectively analyzed. Patients were divided into fast progressors and slow progressors. Fast progressors were defined as CT ASPECTS score of ≥6 at the referring hospital (RH) and <6 at the hub hospital. Good clinical outcomes were defined as modified Rankin Scale score (mRS) 0-2 at 90 days. Demographic, clinical and radiologic variables associated with fast progressors and good clinical outcomes were identified using multivariable regression models.

RESULTS

Among the 190 patients, 44 (23%) patients underwent rapid infarct progression. Higher stroke severity at presentation [aOR, 1.096, 95% CI,1.023, 1.174; p = 0.009], presence of early ischemic changes (CT ASPECT 6-9) at the RH [aOR, 2.721, 95% CI, 1.22, 6.071; p = 0.014] were positively associated, whereas prior ischemic stroke [aOR, 0.272, 95% CI, 0.078, 0.948; p = 0.04] and higher collateral score (2,3,4) [aOR, 0.138, 95%CI, 0.059, 0.324, p=<0.0001] were negatively associated with rapid infarct progression. Fifty-eight (31%) transferred patients had good outcomes. After adjusting for reperfusion status, age [aOR, 0.96, 95% CI, 0.93, 0.98; p=<0.001], initial stroke severity [aOR, 0.87, 95% CI, 0.81, 0.93; p=<0.001], absolute rate of decrease in CT ASPECTS [aOR, 0.38, 95% CI, 0.19, 0.77; p = 0.007] and internal carotid artery (ICA) occlusion [aOR, 0.34, 95 %CI, 0.12, 0.94; p = 0.038] were negatively associated with good outcome.

CONCLUSION

Higher stroke severity, presence of early ischemic changes at the referring facility, absence of prior stroke, and poor collateral scores (CS 0-1) are the factors associated with rapid infarct progression in the telemedicine transfer cohort. Increasing age, higher stroke severity, higher absolute decrease in CT ASPECTS and ICA occlusion determine poor clinical outcomes.

Recent Advances in Cell-Based Therapies for Ischemic Stroke

Stroke is the most prevalent cardiovascular disease worldwide, and is still one of the leading causes of death and disability. Stem cell-based therapy is actively being investigated as a new potential treatment for certain neurological disorders, including stroke. Various types of cells, including bone marrow mononuclear cells, bone marrow mesenchymal stem cells, dental pulp stem cells, neural stem cells, inducible pluripotent stem cells, and genetically modified stem cells have been found to improve neurological outcomes in animal models of stroke, and there are some ongoing clinical trials assessing their efficacy in humans. In this review, we aim to summarize the recent advances in cell-based therapies to treat stroke.

Racial disparities in post-stroke functional outcomes in young patients with ischemic stroke

BACKGROUND AND PURPOSE

Recent studies show rising incidence of stroke in the young, for which risk factors are not well characterized. There is evidence of increased risk in certain racial and ethnic groups. We assessed racial differences in risk factors, stroke etiology, and outcomes among young stroke patients.

METHODS

Using data from our inpatient registry for ischemic stroke, we reviewed patients aged 18-50 who were admitted 01/2013 to 04/2018. Race/ethnicity were characterized as non-Hispanic White (NHW), non-Hispanic Black (NHB), Hispanic (HIS). For univariate comparisons Chi-square and Kruskal-Wallis tests were performed as appropriate. Multivariable logistic regression was used to assess impact of race on day seven modified Rankin score (mRS).

RESULTS

Among 810 patients with race and outcome data who were admitted in the study period, median age was 43, 57.1% were male, and 36.5% NHW, 43.2% NHB, 20.2% HIS. History of hypertension (HTN), type II diabetes (DM II), smoking, heart failure (CHF), prior stroke, and end-stage renal disease varied significantly by race. Compared to NHW, NHB had higher odds of HTN (OR 2.28, 1.65-3.15), CHF (OR 2.17, 1.06-4.46), and DM II 1.92 (1.25-2.94) while HIS had higher odds of DM II (OR 2.52, 1.55-4.10) and lower odds of smoking (OR 0.56, 0.35-0.90). Arrival NIHSS was higher in NHB, but etiology and rates of tpA treatment and thrombectomy did not vary by race. Compared to NHW patients, NHB (OR 0.50 CI (0.31-0.78)) and HIS (OR 0.37 CI (0.21-0.67)) were less likely to have good functional outcome (mRS <2) at day 7 in adjusted analyses.

CONCLUSIONS

In this study, there was a higher prevalence of several modifiable risk factors in NHB and HIS young stroke patients and early functional outcome was worse in these groups. Our study suggests a need for targeted prevention efforts for younger populations at highest risk for stroke.

Cerebrovascular Disease in Patients with COVID-19: A Review of the Literature and Case Series

COVID-19 has been associated with a hypercoagulable state causing cardiovascular and neurovascular complications. To further characterize cerebrovascular disease (CVD) in COVID-19, we review the current literature of published cases and additionally report the clinical presentation, laboratory and diagnostic testing results of 12 cases with COVID-19 infection and concurrent CVD from two academic medical centers in Houston, TX, USA, between March 1 and May 10, 2020. To date, there are 12 case studies reporting 47 cases of CVD in COVID-19. However, only 4 small case series have described the clinical and laboratory findings in patients with COVID-19 and concurrent stroke. Viral neurotropism, endothelial dysfunction, coagulopathy and inflammation are plausible proposed mechanisms of CVD in COVID-19 patients. In our case series of 12 patients, 10 patients had an ischemic stroke, of which 1 suffered hemorrhagic transformation and two had intracerebral hemorrhage. Etiology was determined to be embolic without a clear cause identified in 6 ischemic stroke patients, while the remaining had an identifiable source of stroke. The majority of the patients had elevated inflammatory markers such as D-dimer and interleukin-6. In patients with embolic stroke of unclear etiology, COVID-19 may have played a direct or indirect role in the processes that eventually led to the strokes while in the remaining cases, it is unclear if infection contributed partially or was an incidental finding.

Use of a Smartphone-Based Mobile App for Weight Management in Obese Minority Stroke Survivors: Pilot Randomized Controlled Trial With Open Blinded End Point

Background

Minorities have an increased incidence of early-onset, obesity-related cerebrovascular disease. Unfortunately, effective weight management in this vulnerable population has significant barriers.

Objective

Our objective was to determine the feasibility and preliminary treatment effects of a smartphone-based weight loss intervention versus food journals to monitor dietary patterns in minority stroke patients.

Methods

Swipe out Stroke was a pilot prospective randomized controlled trial with open blinded end point. Minority stroke patients and their caregivers were screened for participation using cluster enrollment. We used adaptive randomization for assignment to a behavior intervention with (1) smartphone-based self-monitoring or (2) food journal self-monitoring. The smartphone group used Lose it! to record meals and communicate with us. Reminder messages (first 30 days), weekly summaries plus reminder messages on missed days (days 31-90), and weekly summaries only (days 91-180) were sent via push notifications. The food journal group used paper diaries. Both groups received 4 in-person visits (baseline and 30, 90, and 180 days), culturally competent counseling, and educational materials. The primary outcome was reduced total body weight.

Results

We enrolled 36 stroke patients (n=23, 64% African American; n=13, 36% Hispanic), 17 in the smartphone group, and 19 in the food journal group. Mean age was 54 (SD 9) years; mean body mass index was 35.7 (SD 5.7) kg/m2; education, employment status, and family history of stroke or obesity did not differ between the groups. Baseline rates of depression (Patient Health Questionnaire-9 [PHQ-9] score median 5.5, IQR 3.0-9.5), cognitive impairment (Montreal Cognitive Assessment score median 23.5, IQR 21-26), and inability to ambulate (5/36, 14% with modified Rankin Scale score 3) were similar. In total, 25 (69%) stroke survivors completed Swipe out Stroke (13/17 in the smartphone group, 12/19 in the food journal group); 1 participant in the smartphone group died. Median weight change at 180 days was 5.7 lb (IQR –2.4 to 8.0) in the smartphone group versus 6.4 lb (IQR –2.2 to 12.5; P=.77) in the food journal group. Depression was significantly lower at 30 days in the smartphone group than in the food journal group (PHQ-9 score 2 vs 8; P=.03). Clinically relevant depression rates remained in the zero to minimal range for the smartphone group compared with mild to moderate range in the food journal group at day 90 (PHQ-9 score 3.5 vs 4.5; P=.39) and day 180 (PHQ-9 score 3 vs 6; P=.12).

Conclusions

In a population of obese minority stroke survivors, the use of a smartphone did not lead to a significant difference in weight change compared with keeping a food journal. The presence of baseline depression (19/36, 53%) was a confounding variable, which improved with app engagement. Future studies that include treatment of poststroke depression may positively influence intervention efficacy.

Trial Registration

ClinicalTrials.gov NCT02531074; https://www.clinicaltrials.gov/ct2/show/NCT02531074

Association of Primary Intracerebral Hemorrhage With Pregnancy and the Postpartum Period

IMPORTANCE

Intracerebral hemorrhage (ICH) during pregnancy and the postpartum period results in catastrophic maternal outcomes. There is a paucity of population-based estimates of pregnancy-related ICH risk, including risk during the extended postpartum period.

OBJECTIVE

To evaluate ICH risk during pregnancy and an extended 24-week postpartum period in a population-level cohort and to determine fetal and maternal outcomes as well as demographic and comorbidity factors associated with ICH during pregnancy and post partum.

DESIGN, SETTING, AND PARTICIPANTS

This study used a cohort-crossover design in which patients serve as their own controls when no longer exposed (pregnant or post partum). Administrative data were obtained from all hospital admissions for New York, California, and Florida for a 7- to 10-year period. Participants included all women admitted for labor and delivery who were older than 12 years and did not have a prior diagnosis of ICH. Conditional Poisson regression models were used to evaluate ICH risk, and data were reported as rate ratios and 95% CIs. Data analysis was performed from August 2018 to February 2020.

EXPOSURES

Women were tracked using hospitalization records for the duration of pregnancy (40 weeks), for 24 weeks post partum, and for an additional 64 weeks when no longer exposed.

MAIN OUTCOMES AND MEASURES

Diagnosis of ICH during both 64-week observation periods was determined using validated International Classification of Diseases, Ninth Revision codes.

RESULTS

A total of 3 314 945 pregnant women were included (mean [SD] age, 28.17 [6.47] years; 1 451 780 white [43.79%], 474 808 black [14.32%], 246 789 Asian [7.44%], and 835 917 Hispanic [25.22%]). The risk of ICH was significantly higher during the third trimester (2.9 vs 0.7 cases per 100 000 pregnancies; rate ratio, 4.16; 95% CI, 2.52-6.86) and remained elevated during the first 12 weeks post partum (4.4 vs 0.5 cases per 100 000 pregnancies; rate ratio, 9.15; 95% CI, 5.16-16.23). Advanced maternal age (adjusted odds ratio [OR], 1.08; 95% CI, 1.05-1.10), nonwhite race (adjusted ORs, 2.44 [95% CI, 1.73-3.44] for black patients, 2.12 [95% CI, 1.34-3.35] for Asian patients, and 1.59 [95% CI, 1.12-2.26] for Hispanic patients), hypertension (adjusted OR, 2.02; 95% CI, 1.19-3.42), coagulopathy (adjusted OR, 14.17; 95% CI, 9.17-21.89), preeclampsia or eclampsia (adjusted OR, 9.23; 95% CI, 6.99-12.19), and tobacco use (adjusted OR, 2.83; 95% CI, 1.53-5.23) were independently associated with ICH during pregnancy and the postpartum period. Pregnancy-related ICH was associated with a higher risk of maternal (relative risk difference, 792.6; absolute risk difference, 0.18) and fetal (relative risk difference, 5.3; absolute risk difference, 0.03) death, compared with pregnancies without ICH.

CONCLUSIONS AND RELEVANCE

These findings suggest that the risk of ICH is significantly higher during the third trimester of pregnancy and the first 12 weeks post partum. There are age and race disparities in ICH risk that are associated with devastating maternal and fetal outcomes. These data illustrate the critical need for continuous monitoring and aggressive management of ICH-associated risk factors. These findings suggest that extended postpartum monitoring of high-risk women may be warranted.

Outcomes of Thrombectomy in Transferred Patients With Ischemic Stroke in the Late Window: A Subanalysis From the DEFUSE 3 Trial

Importance

Although thrombectomy benefit was maintained in transfer patients with ischemic stroke in early-window trials, overall functional independence rates were lower in thrombectomy and medical management-only groups.

Objective

To evaluate whether the imaging-based selection criteria used in the Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3 (DEFUSE 3) trial would lead to comparable outcome rates and treatment benefits in transfer vs direct-admission patients.

Design, Setting, and Participants

Subgroup analysis of DEFUSE 3, a prospective, randomized, multicenter, blinded-end point trial. Patients were enrolled between May 2016 and May 2017 and were followed up for 90 days. The trial comprised 38 stroke centers in the United States and 182 patients with stroke with a large-vessel anterior circulation occlusion and initial infarct volume of less than 70 mL, mismatch ratio of at least 1.8, and mismatch volume of at least 15 mL, treated within 6 to 16 hours from last known well. Patients were stratified based on whether they presented directly to the study site or were transferred from a primary center. Data were analyzed between July 2018 and October 2018.

Interventions or Exposures

Endovascular thrombectomy plus standard medical therapy vs standard medical therapy alone.

Main Outcomes and Measures

The primary outcome was the distribution of 90-day modified Rankin Scale scores.

Results

Of the 296 patients who consented, 182 patients were randomized (66% were transfer patients and 34% directly presented to a study site). Median age was 71 years (interquartile range [IQR], 60-79 years) vs 70 years (IQR, 59-80 years); 69 transfer patients were women (57%) and 23 of the direct group were women (37%). Transfer patients had longer median times from last known well to study site arrival (9.43 vs 9 hours) and more favorable collateral profiles (based on hypoperfusion intensity ratio): median for transfer, 0.35 (IQR, 0.18-0.47) vs 0.42 (IQR, 0.25-0.56) for direct (P = .05). The primary outcome (90-day modified Rankin Scale score shift) did not differ in the direct vs transfer groups (direct OR, 2.9; 95% CI, 1.2-7.2; P = .01; transfer OR, 2.6; 95% CI, 1.3-4.8; P = .009). The overall functional independence rate (90-day modified Rankin Scale score 0-2) in the thrombectomy group did not differ (direct 44% vs transfer 45%) nor did the treatment effect (direct OR, 2.0; 95% CI, 0.9-4.4 vs transfer OR, 3.1; 95% CI, 1.6-6.1). Thrombectomy reperfusion rates, mortality, and symptomatic intracranial hemorrhage rates did not differ.

Conclusions and Relevance

In late-window patients selected by penumbral mismatch criteria, both the favorable outcome rate and treatment effect did not decline in transfer patients. These results have health care implications indicating transferring potential candidates for late-window thrombectomy is associated with substantial clinical benefits and should be encouraged.

Trial Registration

ClinicalTrials.gov identifier: NCT02586415.

Abstract WMP86: Persistent Gender and Racial Disparities Among Neurology Residents and Vascular Neurology Fellows Over the Past 10 Years

Introduction: Women and minorities are underrepresented in academic medicine. There is little in the literature about gender and racial disparities among neurology or vascular neurology trainees. At the International Stroke Conference, women overall and women physicians have been underrepresented as invited speakers and abstract first authors, and there is recent momentum for improvement.

Methods: Data were collected from the Accreditation Council for Graduate Medical Education public website. Dataset included neurology resident and vascular neurology fellow gender data from 2007 to 2017 and race data from 2011 to 2017. Data were analyzed by chi-square test and one-sample proportion test.

Results: From 2007-2017, women represented 45% of all neurology trainees and only 33% of all vascular neurology fellows, both significantly lower than 50% (p<0.0001). There was no trend in the proportion of gender by year for vascular fellows (p=0.11) or neurology trainees (p=0.39). However, each year, except for 2012-2013 and 2015-2016 for vascular fellows, varied significantly by gender where men represented the largest proportion. Race varied by year for vascular fellows (p=0.03) and neurology trainees (p=0.017). Blacks and Hispanics represented the lowest proportions and Whites represented the highest proportion of both vascular and neurology trainees. When comparing Whites vs Non-Whites for both fellows (43% vs 57%; p=0.76) and residents (50% vs 50%; p=0.14), there was no trend in the proportions by year.

Conclusions: Women, Black and Hispanic physicians remain underrepresented as vascular neurology trainees. The low representation of women and underrepresented minorities has not changed in the last decade. Addressing gender and racial disparities among trainees should be a high national priority for future medical and scientific contributions from these groups.

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 TP146: Rate of Functional Improvement for Stroke Patients Plateaus During Inpatient Rehabilitation

Introduction: Functional outcomes and length of stay (LOS) are common outcome measures in stroke patients at Inpatient Rehabilitation Facilities (IRF).

Aim: To examine trends in functional outcomes among patients with hemorrhagic versus ischemic stroke in IRF.

Methods: Using a prospectively collected database of stroke patients admitted in our health system of 5 IRFs in Houston, we reviewed patients with either ischemic or hemorrhagic stroke between 1/18 to 6/19. The main outcome measure was the FIM scores. The relationship between LOS and FIM score improvement were analyzed using a third order polynomial regression model.

Results: Among 88 patients, 43% were female and 60% had an ischemic stroke. The median LOS was 21 days (IQR14, 26) for all patients; 22 (IQR16, 30) in patients with hemorrhagic stroke; 20.5 (IQR14, 25) in patients with ischemic stroke (P: 0.24). Based on change in FIM, stroke patients benefited the most from IRF in the first 17 days (P<.0001) while the improvement rate declined significantly afterwards with the highest FIM score change of 32. The FIM score changes were not significantly different when adjusting for CMI. There were no significant differences in FIM changes and extent of temporal benefit between ischemic and hemorrhagic strokes. Moreover, bathing, dressing, tub transfer and walking were the areas of greatest improvement (Median change: 2 for all variables).

Conclusion: Stroke patients in our IRF network benefit the most on FIM in the first 17 days. Further studies are needed to identify factors that could maximize functional gains in IRF.

Abstract WP15: Correlation of 24-Hour Infarct Volumes and Imaging Reperfusion With Functional Independence in DEFUSE 3

Background: In DEFUSE 3, infarct volumes 24 hours after randomization did not significantly differ in EVT vs. medical management only (MM) groups. We hypothesized that this lack of difference was due underestimation of the final infarct volume among patients who had persistent penumbral tissue 24 hours after randomization that subsequently progressed to infarction. In this substudy, we evaluated if the 24 hr post-randomization DWI volumes correlated with functional independence.

Methods: We correlated the 24-hr post-randomization DWI volumes and penumbral profiles with 90-day functional independence.

Results: 182 patients, 92 were randomized to EVT, 90 to MM. 24 hr post-randomization Tmax and DWI volume were assessable for 75 EVT and 69 MM. Infarct volumes at 24 hr follow-up did not differ between EVT and MM median (IQR) ml 35.0 (17.6-81.6) vs 41.0(25.4-106.2), P=0.185. Still, 24 hr infarct volumes independently correlated with 90 day functional independence: median (IQR) 30.3 ml (9.0-55.6) vs. 47.5 ml (25.4-132.3), aOR=0.93 (95%CI=0.89-0.98, P=0.004) for achieving functional independence vs. disability for each additional 5 ml of infarct volume after adjustment for baseline NIHSS, age, glucose, and treatment, figure 1. EVT resulted in higher rates of reperfusion (>90% reduction in Tmax>6 seconds at 24 hrs in 79% of EVT vs. 18% of MM, P<0.001). Patients who achieved successful reperfusion with no evidence of remaining penumbra had smaller 24- hr infarct volumes: 32.9 (17.6-67.0) vs. 59.3 (24.7-126.3), P=0.007), figure 2 and a higher odds of functional independence aOR=10.9, 95%CI 3.6-39.8, P<0.001, compared to those who had remaining penumbral tissue, figure 3.

Conclusion: 24 hr- post randomization infarct volumes independently correlated with functional independence in DEFUSE 3. Patients who had complete reperfusion had smaller follow-up infarct volumes and a higher odds of functional independence as compared to those with persistent penumbral mismatch.

Abstract TP94: White Matter Tract Integrity After Vascular Insult: Longitudinal Analysis of Hemorrhagic vs Ischemic Lesions

Introduction: White matter tract (WMT) injury occurs in patients with acute cerebrovascular disorders. In this study, we elucidate longitudinal differences in mechanism of injury and repair between ischemic stroke (ISC) and intracerebral hemorrhage (ICH).

Methods: Twenty patients (10 ISC and ICH) were prospectively imaged at 1, 3, and 12 months of onset on a 3T MRI. 3D anatomical and DTI images were obtained and integrity of the corticospinal tract (CST) assessed at the ipsi and contralesional posterior limb of internal capsule (PLIC). Fractional anisotropy (FA), mean diffusivity (MD) and pixel volume were recorded. A linear regression model was applied for statistical analysis.

Results: ISC group had 4 men, 6 women whereas ICH group had 7 men, 3 women, both with average age 52. Baseline NIHSS in ISC was 11 (IQR=4.5-20) and ICH 6 (IQR=2-13). All lesions were unilateral, hemispheric, completely subcortical or with a significant subcortical component. The average lesion and hematoma volume at 1 month was 37 and 39 cc in ISC and ICH, respectively. The MD in the PLIC of the ISC increased from 1 to 3m (P <0.05) then plateaued, whereas it decreased in ICH over the entire 12m (Fig 1A). The rFA showed a similar pattern of initial injury and then improvement over time in both ISC and ICH (Fig 1B). The ISC group showed 12% WM atrophy in the PLIC at 12m, wheras 13% expansion (P < 0.05) in ICH over this period, after an initial contraction of 14% at 1m (fig 1C-D). Structural changes of the PLIC correlated with changes in mRS/NIHSS (p<0.05).

Conclusions: ISC and ICH display unique patterns of WMT changes over one year in which ICH injury reflects a compression of the CST that resolves over time, while in ISC our data show degeneration and microstructural injury. These changes reflect different mechanisms of injury and remodeling on a cellular level. A better understanding of these changes could improve recovery therapies. Larger studies are needed to better characterize long term WMT changes in IS and ICH.

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 WMP88: Shorter Door-to-Needle Times of Intravenous Alteplase Improve “Efficiency” of Care and Moderately Affect “Quality” of Care: Study Based on a Large Comprehensive Stroke Center

Introduction: The American Heart Association (AHA) recently raised the bar on timely treatment of acute ischemic stroke (AIS) with intravenous (IV) alteplase, by recommending door-to-needle times of 30 minutes or less for 50% or more of the AIS patients. Our study looks at the effectiveness of this new standard, by examining the effect of varying door-to-needle times on efficiency and quality of care, and clinical outcomes.

Methods: Our study examined 762 AIS patients treated with IV alteplase in a large academic health system from 2015-2018, and compared their outcomes after treatment within 30, 45 and 60 minutes of arrival. The outcomes compared were: 1) Efficiency of care outcome - Length of stay (LOS); 2) Quality of care outcomes - Inpatient mortality and Disability at discharge; 3) Clinical outcomes - Discharge and 90-day modified Rankin Scale (mRS), and Post-alteplase (24 hr) NIH Stroke Scale (NIHSS). Adjusted logistic and linear regression analyses were used, after controlling for baseline patient socio-demographic and clinical characteristics.

Results: Based on the adjusted regression analyses (Table 1), being treated within 30 minutes of arrival reduced the average LOS by 1.3 days (p-value: 0.02), but did not affect the quality of care outcomes. Similarly, being treated within 45 minutes of arrival reduced LOS by 0.9 days (p-value: 0.04). Being treated within 60 minutes of arrival did not affect LOS, but reduced the odds of inpatient mortality by 68% (p-value: 0.00), and disability at discharge by 29% (p-value: 0.08). Being treated within 30 minutes of arrival was associated with better mRS and NIHSS scores as compared with being treated within 45 or 60 minutes.

Conclusion: Quicker IV alteplase treatment significantly improved efficiency of care and clinical outcomes. Quality of care outcomes did not improve beyond the 60 minute door-to-needle threshold. This study provides evidence supporting AHA’s new recommendation of 30 minutes or less door-to-needle time.

Abstract WP358: Comprehensive Integrated Stroke System: A Novel Approach to Optimizing Cerebrovascular Disease Care

Introduction: There is a need to deliver endovascular stroke therapy (EST) locally and rapidly, due to the time sensitivity of acute ischemic stroke (AIS). However, the optimal distribution of resources, and means to maintain quality outcomes in patients with diseases that benefit from concentrated care at specialized centers, including subarachnoid hemorrhage (SAH), is unknown.

Methods: We performed a multicenter, observational cohort study across our 11-hospital network from Jan 2017 - Feb 2019, identifying AIS patients who received EST. From Jan 2017 - Aug 2017, there was one CSC in the system. Starting in Aug 2017, we implemented an Integrated Stroke System (ISS), in which 3 additional centers became CSCs, practices were standardized across a single physician group covering all 4 CSCs, and SAH care was centered at the original CSC, while EST was performed at 3 new CSCs. Logistic regression adjusted for age, sex, NIHSS, direct vs. transfer arrival, and time from onset to recanalization was used to assess likelihood of good outcome, defined as discharge to home or rehabilitation. Results are given as median [IQR] and OR [95% CI].

Results: Among 478 patients who received EST, median age was 68 [57-78], 47% were female, and 37% were white. Over the course of the study (Fig. 1), the number of monthly EST cases increased; EST volume at our original CSC remained stable, and an increasing EST was performed at the new CSCs (p<0.01). Monthly SAH case volume remained unchanged at the original CSC (29 cases vs. 30 cases, p=0.68). After implementation of our ISS, there was a decrease in the time from arrival to groin puncture (107 min [88-125] vs 92 min [67-120]; p<0.01). Among patients presenting 0-6 hours, there was a significant improvement in likelihood of good outcome after ISS (OR 2.59 [1.06-6.35]; p<0.05).

Conclusions: By restructuring our stroke system of care and extending EST capability, we observed increased EST utilization and improvement in quality of care for AIS patients.

Abstract WMP12: Benefits of Thrombectomy Among Patients Who Did Not Achieve Functional Independence in DEFUSE 3

Background: While endovascular thrombectomy (EVT) patients may not achieve functional independence, they may avoid devastating outcomes as in profound disability/death.

Methods: DEFUSE 3 patients who did not achieve mRS 0-2 were assessed for a shift towards reductions in severe (mRS 4-6) and profound (mRS 5-6) disability, mortality, length of stay (LOS) and increased rates of home/rehabilitation discharges.

Results: 126 of the 182 randomized in DEFUSE 3 did not achieve mRS 0-2 (EVT 51, MM 75). Baseline characteristics were similar. EVT was associated with a higher mRS 3 rate (28% vs 18%) and lower rates of severe (72% vs 82%) and profound disability (39% vs. 50%), EVT vs MM respectively, with a trend for a shift towards less disability aOR=1.6 (95%CI=0.9-3.2, P=0.138), figure 1. Mortality rates were numerically lower with EVT (25% vs 31, p=0.528). EVT patients had a trend for shorter LOS (8.6 (6.5-13.7) vs 9.3 (7.1-16.3) days, p=0.156) and increased rates of home/rehabilitation discharges 51% vs. 40%, p=0.224. Older age correlated independently with severe disability aOR=1.04 per year/age, (95%CI=1.01-1.07, p=0.023) as did more severe strokes, aOR per NIHSS point=1.07, 95%CI=0.99-1.15, P=0.096). Larger final infarct volumes had a trend towards severe disability in EVT aOR=1.005, 95%CI=0.996-1.013, p=0.257, but not in MM aOR=1.0 (95% CI 0.993-1.007, p=0.966). Lack of reperfusion (>90% Tmax>6 reduction) had a strong trend for severe disability in MM (83% in non-reperfusers vs. 50% for reperfusers), p=0.056, but not in EVT: 77% vs. 63%, p=0.484.

Conclusion: In patients who did not achieve functional independence, EVT resulted in reduced rates of severe and profound disability, decreased length of stay and increased home and rehabilitation discharges. Older patients, more severe strokes and those who did not achieve reperfusion were more likely to have severe disability especially if not treated with EVT. EVT may result in avoiding severe disability in elderly patients.

Abstract TMP95: Structured Screening for Post-Stroke Cognitive Impairment in the Outpatient Stroke Clinic

Introduction: Cognitive impairment (CI) affects 30% of stroke survivors and impacts ability to return to work, drive and perform ADLs. However, there is no standardized screening for post-stroke CI. We implemented CI screening in the STEP (Stroke Transitions, Education and Prevention) clinic. We sought to identify demographic and clinical factors associated with early post-stroke CI.

Methods: Eligible pts had ischemic stroke, ICH or TIA, were seen in the STEP clinic from March 2017 to June 2018, and included in the prospective outpatient clinical registry. Screening for post-stroke CI was performed with a Brief Neurocognitive Screen (BNS), a validated 5-minute subset of the Montreal Cognitive Assessment. BNS 0-8 was defined as abnormal (CI present) and 9-12 was defined as normal. Continuous variables were analyzed with student t-tests or Wilcoxon rank-sum tests and categorical variables with Fisher’s exact test. Logistic regression was performed with the significant variables in the univariate analyses.

Results: Of 256 patients, 116 completed a BNS at a median of 35 days after hospital discharge. Median NIHSS was 3 (IQR 0.5,6) and follow-up modified Rankin scale (mRS) was 1 (IQR 1,2). Median BNS was 10 (IQR 9,11). Abnormal BNS, was present in 17.2% of pts screened. Of the 20 pts with abnormal BNS, 17 had neuropsychological testing ordered. In the univariate analysis, age, education, admission NIHSS, poor mRS (<2) at follow-up, and atrial fibrillation were significantly associated with early post-stroke CI (Table 1). In the multivariable analysis, only age and follow-up mRS remained significant.

Conclusion: Early post-stroke CI is common in stroke pts, even with low NIHSS, and associated with older age and worse mRS. The BNS is a post-stroke CI screening tool than can be performed in stroke clinics. Future studies are needed to assess the feasibility of implementing the BNS across multiple sites and outcomes associated with early identification of post-stroke CI.

Abstract 29: Optimization Methodologies to Enhance Endovascular Thrombectomy Access in the United States

Background: Timely access to endovascular thrombectomy (EVT) centers is vital for best stroke outcome. We map current EVT access in the US then utilize modeling to optimize it.

Methods: US designated stroke centers were mapped utilizing geo-mapping and stratified into EVT or non-EVT if they reported ≥1 thrombectomy code for acute ischemic stroke in 2017 to CMS. Direct EVT access, defined as the population with the closest facility to EVT centers, was calculated from validated trauma models adapted for stroke. Current 15 and 30 min access were described nationwide and in 4 states (TX, NY, CA, IL).

Two optimization models were utilized. Model A used a greedy algorithm to capture the largest population with direct access when flipping 10 non-EVT to EVT centers to maximize access. Model B used bypassing methodology to directly transport patients to EVT centers within 15 min from the closest non-EVT center.

Results: Of 1941 stroke centers, 714 were EVT. Approximately 99 million/32% Americans have direct EVT access within 15 min while 111 million (36.0%) within 30 minutes (Fig 1).

There were 65 (43%) EVT centers in TX with 22% current 15 min access. Flipping the top 10 population density hospitals improved access to 32%, while bypassing resulted in 46% having direct access to EVT centers (fig 2 A-B). Direct access in CA was 26% which improved to 35% with flipping and 54% by 15 min bypassing from the closest non-EVT to EVT centers. Similar results were found in NY (current 21%, flipping 39%, bypassing 50%) and IL (15%, 27% and 35%, respectively), Tab 1.

Conclusion: EVT access within 15 min is limited to less than 1/3 of the US population. Optimization methodology that increase EVT centers or bypass non-EVT to the closest EVT center both showed enhanced access. Results varied by states based on the population size and density. However, bypass showed more potential for maximizing direct EVT access. National and state efforts should focus on identifying gaps and tailoring solutions to improve EVT access.