Apixaban to Prevent Recurrence After Cryptogenic Stroke in Patients With Atrial Cardiopathy: The ARCADIA Randomized Clinical Trial

Importance

Atrial cardiopathy is associated with stroke in the absence of clinically apparent atrial fibrillation. It is unknown whether anticoagulation, which has proven benefit in atrial fibrillation, prevents stroke in patients with atrial cardiopathy and no atrial fibrillation.

Objective

To compare anticoagulation vs antiplatelet therapy for secondary stroke prevention in patients with cryptogenic stroke and evidence of atrial cardiopathy.

Design, Setting, and Participants

Multicenter, double-blind, phase 3 randomized clinical trial of 1015 participants with cryptogenic stroke and evidence of atrial cardiopathy, defined as P-wave terminal force greater than 5000 μV × ms in electrocardiogram lead V1, serum N-terminal pro-B-type natriuretic peptide level greater than 250 pg/mL, or left atrial diameter index of 3 cm/m2 or greater on echocardiogram. Participants had no evidence of atrial fibrillation at the time of randomization. Enrollment and follow-up occurred from February 1, 2018, through February 28, 2023, at 185 sites in the National Institutes of Health StrokeNet and the Canadian Stroke Consortium.

Interventions

Apixaban, 5 mg or 2.5 mg, twice daily (n = 507) vs aspirin, 81 mg, once daily (n = 508).

Main Outcomes and Measures

The primary efficacy outcome in a time-to-event analysis was recurrent stroke. All participants, including those diagnosed with atrial fibrillation after randomization, were analyzed according to the groups to which they were randomized. The primary safety outcomes were symptomatic intracranial hemorrhage and other major hemorrhage.

Results

With 1015 of the target 1100 participants enrolled and mean follow-up of 1.8 years, the trial was stopped for futility after a planned interim analysis. The mean (SD) age of participants was 68.0 (11.0) years, 54.3% were female, and 87.5% completed the full duration of follow-up. Recurrent stroke occurred in 40 patients in the apixaban group (annualized rate, 4.4%) and 40 patients in the aspirin group (annualized rate, 4.4%) (hazard ratio, 1.00 [95% CI, 0.64-1.55]). Symptomatic intracranial hemorrhage occurred in 0 patients taking apixaban and 7 patients taking aspirin (annualized rate, 1.1%). Other major hemorrhages occurred in 5 patients taking apixaban (annualized rate, 0.7%) and 5 patients taking aspirin (annualized rate, 0.8%) (hazard ratio, 1.02 [95% CI, 0.29-3.52]).

Conclusions and Relevance

In patients with cryptogenic stroke and evidence of atrial cardiopathy without atrial fibrillation, apixaban did not significantly reduce recurrent stroke risk compared with aspirin.

Trial Registration

ClinicalTrials.gov Identifier: NCT03192215.

Antithrombotic Treatment for Stroke Prevention in Cervical Artery Dissection: The STOP-CAD Study

Background: Small, randomized trials of cervical artery dissection (CAD) patients showed conflicting results regarding optimal stroke prevention strategies. We aimed to compare outcomes in patients with CAD treated with antiplatelets versus anticoagulation. Methods: This is a multi-center observational retrospective international study (16 countries, 63 sites) that included CAD patients without major trauma. The exposure was antithrombotic treatment type (anticoagulation vs. antiplatelets) and outcomes were subsequent ischemic stroke and major hemorrhage (intracranial or extracranial hemorrhage). We used adjusted Cox regression with Inverse Probability of Treatment Weighting (IPTW) to determine associations between anticoagulation and study outcomes within 30 and 180 days. The main analysis used an "as treated" cross-over approach and only included outcomes occurring on the above treatments. Results: The study included 3,636 patients [402 (11.1%) received exclusively anticoagulation and 2,453 (67.5%) received exclusively antiplatelets]. By day 180, there were 162 new ischemic strokes (4.4%) and 28 major hemorrhages (0.8%); 87.0% of ischemic strokes occurred by day 30. In adjusted Cox regression with IPTW, compared to antiplatelet therapy, anticoagulation was associated with a non-significantly lower risk of subsequent ischemic stroke by day 30 (adjusted HR 0.71 95% CI 0.45-1.12, p=0.145) and by day 180 (adjusted HR 0.80 95% CI 0.28-2.24, p=0.670). Anticoagulation therapy was not associated with a higher risk of major hemorrhage by day 30 (adjusted HR 1.39 95% CI 0.35-5.45, p=0.637) but was by day 180 (adjusted HR 5.56 95% CI 1.53-20.13, p=0.009). In interaction analyses, patients with occlusive dissection had significantly lower ischemic stroke risk with anticoagulation (adjusted HR 0.40 95% CI 0.18-0.88) (Pinteraction=0.009). Conclusions: Our study does not rule out a benefit of anticoagulation in reducing ischemic stroke risk, particularly in patients with occlusive dissection. If anticoagulation is chosen, it seems reasonable to switch to antiplatelet therapy before 180 days to lower the risk of major bleeding. Large prospective studies are needed to validate our findings.

Adding a chapter to the literature: A rare encounter of unilateral Moyamoya disease with ipsilateral persistent trigeminal artery

Background

The coexistence of persistent trigeminal artery (PTA) and Moyamoya disease (MMD) has been reported. If their pathogenesis is related and if PTA is protective or harmful in MMD remains unknown as these are rare cerebrovascular anomalies.

Case presentation

A 35-year-old woman with sudden global aphasia whose CT head and CT angiography of head and neck showed a hypodensity in the left posterior middle cerebral artery (MCA), a possible left proximal internal carotid artery occlusion, and a left PTA with hypoplasia of vertebral and basilar arteries. Digital subtraction angiography showed chronic MMD in the left MCA with extensive pial collateralization from anterior cerebral artery (ACA). The patient was initiated on single antiplatelet therapy and later she underwent direct bypass surgical intervention and rehabilitation.

Discussion

Our case report brings attention to the infrequent coexistence of ipsilateral MMD and PTA suggesting a potential congenital pathogenesis based on embryologic development and hemodynamics. Also, we propose a protective role of PTA in MMD in case of large anterior vessel occlusion. This case contributes to the scarce literature on the intriguing relationship between MMD and PTA.

Association of Endovascular Thrombectomy vs Medical Management With Functional and Safety Outcomes in Patients Treated Beyond 24 Hours of Last Known Well: The SELECT Late Study

Importance

The role of endovascular thrombectomy is uncertain for patients presenting beyond 24 hours of the time they were last known well.

Objective

To evaluate functional and safety outcomes for endovascular thrombectomy (EVT) vs medical management in patients with large-vessel occlusion beyond 24 hours of last known well.

Design, Setting, and Participants

This retrospective observational cohort study enrolled patients between July 2012 and December 2021 at 17 centers across the United States, Spain, Australia, and New Zealand. Eligible patients had occlusions in the internal carotid artery or middle cerebral artery (M1 or M2 segment) and were treated with EVT or medical management beyond 24 hours of last known well.

Interventions

Endovascular thrombectomy or medical management (control).

Main Outcomes and Measures

Primary outcome was functional independence (modified Rankin Scale score 0-2). Mortality and symptomatic intracranial hemorrhage (sICH) were safety outcomes. Propensity score (PS)-weighted multivariable logistic regression analyses were adjusted for prespecified clinical characteristics, perfusion parameters, and/or Alberta Stroke Program Early CT Score (ASPECTS) and were repeated in subsequent 1:1 PS-matched cohorts.

Results

Of 301 patients (median [IQR] age, 69 years [59-81]; 149 female), 185 patients (61%) received EVT and 116 (39%) received medical management. In adjusted analyses, EVT was associated with better functional independence (38% vs control, 10%; inverse probability treatment weighting adjusted odds ratio [IPTW aOR], 4.56; 95% CI, 2.28-9.09; P < .001) despite increased odds of sICH (10.1% for EVT vs 1.7% for control; IPTW aOR, 10.65; 95% CI, 2.19-51.69; P = .003). This association persisted after PS-based matching on (1) clinical characteristics and ASPECTS (EVT, 35%, vs control, 19%; aOR, 3.14; 95% CI, 1.02-9.72; P = .047); (2) clinical characteristics and perfusion parameters (EVT, 35%, vs control, 17%; aOR, 4.17; 95% CI, 1.15-15.17; P = .03); and (3) clinical characteristics, ASPECTS, and perfusion parameters (EVT, 45%, vs control, 21%; aOR, 4.39; 95% CI, 1.04-18.53; P = .04). Patients receiving EVT had lower odds of mortality (26%) compared with those in the control group (41%; IPTW aOR, 0.49; 95% CI, 0.27-0.89; P = .02).

Conclusions and Relevance

In this study of treatment beyond 24 hours of last known well, EVT was associated with higher odds of functional independence compared with medical management, with consistent results obtained in PS-matched subpopulations and patients with presence of mismatch, despite increased odds of sICH. Our findings support EVT feasibility in selected patients beyond 24 hours. Prospective studies are warranted for confirmation.

Yield of ASPECTS and collateral CTA Selection for mechanical thrombectomy within 6-24 hours from symptom onset in a hub and spoke system

BACKGROUND

Recent extended window trials support the benefit of mechanical thrombectomy in anterior circulation large vessel occlusions with clinical-radiographic dissociation. Using trial imaging criteria, 6% were found eligible for MT in the EW in a hub-and-spoke system. We examined the eligibility and outcomes in consecutive extended window-mechanical thrombectomy patients using more pragmatic selection criteria.

METHODS

We retrospectively analyzed single-institution data of anterior circulation large vessel occlusions patients presenting between 6-24 h who underwent mechanical thrombectomy based on a priori determined criteria including non-contrast CT head ASPECTS ≥ 6 and/or CTA collateral scores ASITN/SIR 2-4. Primary outcomes consisted of post-mechanical thrombectomy TICI 2b-3 and 3-month modified Rankin scores; safety outcomes consisted of in-hospital mortality and symptomatic intracerebral hemorrhage.

RESULTS

767 consecutive acute ischemic strokes patients presented within the 6-24 hour window, and of these 48 (6%) anterior circulation large vessel occlusions patients underwent mechanical thrombectomy. In this cohort the mean age was 63±17 years, 56% were male, the median NIHSS was 16 [IQR 10-19], the median ASPECTS was 9 (IQR 8-10), and 79% (n=38) had good CTA collaterals. Occlusions were primarily M1 MCA (46%), with 29% tandem occlusions. Successful recanalization (mTICI 2b or 3) was achieved in 73% (n=35), while 6% (n=3) of patients developed symptomatic intracerebral hemorrhage. In-hospital mortality was 25% (n=12) while 40% (n=19) achieved 3-month modified Rankin Scores 0-2.

CONCLUSIONS

Our data suggest the use of pragmatic imaging approach of ASPECTS ≥6 with CTA collateral grade in extended time window which is already established in most hospitals.

Abstract 36: Endovascular Thrombectomy Beyond 24 Hours From Last Known Well: A Pooled Multicenter International Cohort

Background: Limited data are available on endovascular thrombectomy (EVT) efficacy and safety in large vessel occlusion (LVO) patients presenting >24hr from last known well (LKW). We compared outcomes between patients receiving EVT and best medical management (MM) in a multicenter international cohort.

Methods: Consecutive patients with anterior circulation LVO presenting >24h after LKW from 13 centers from 7/2012-4/2021 were analyzed. Multivariable models for 90d mRS distribution and symptomatic ICH were adjusted for age, NIHSS, glucose, IV tPA, transfer status, clot location, time from LKW, CT ASPECTS and ischemic core (rCBF<30%) and Tmax >6s volumes.

Results: Of 240 patients with a median (IQR) LKW to presentation 28.3h (24.9-38.2), 153 (64%) received EVT. Baseline characteristics were similar except for NIHSS (EVT: 13 (8-20) vs MM: 17 (10-22), p=0.005), CT ASPECTS (EVT: 8(6-9) vs MM: 4(3-6), p<0.001) and ischemic core 2.5(0-13) vs 15(0-71) mL, p<0.001. EVT was associated with a better shift in 90d mRS (acOR: 2.45, 95% CI=1.42-4.22, p=0.001), higher functional independence (42% vs 10%, aOR: 4.84, 95% CI=2.02-11.64, p<0.001) and numerically lower mortality (22% vs 42%, aOR: 0.50, 95% CI=0.23-1.06, p=0.071), Fig 1A. However, EVT was associated with numerically higher sICH (5.5% vs 0%, p=0.10). Following EVT, 82% achieved successful reperfusion (mTICI 2b-3), which was associated with better shift in 90d mRS (acOR: 5.82, 95% CI: 1.77-19.10, p=0.004), higher functional independence (44% vs 22%, aOR: 5.03, 95% CI: 0.87-29.12, p=0.07) and lower mortality (20% vs 52%, aOR: 0.08, 95% CI: 0.01-0.57, p=0.01), Fig 1B.

Conclusions: EVT may be associated with better functional outcomes, despite numerically increased risk of sICH in patients presenting with anterior circulation LVO beyond 24 hours. Further prospective studies are warranted.

Recognizing Aphemia and How to Differentiate From Aphasia in the Era of Telemedicine

Background

Aphemia, or pure motor mutism, is a phenomenon that has been reported previously in the literature and typically is associated with small infarcts in the inferior dominant precentral gyrus, pars opercularis, or inferior perirolandic gyrus. Clinically, it is important to distinguish aphemia from aphasia syndromes. Telemedicine is becoming more prevalent and involving neurologists across the country. This is an important consideration when addressing aphemic patients as many mistakes can be made during a virtual exam clouding a patient's clinical picture.

Case Presentation

Our patient is a 61-year-old female with a past medical history of hypertension, diabetes, and an old right frontoparietal stroke without any residual deficits. She presented after her family stated that she "quit speaking" for about seven hours. Initial neurological evaluation was done via telemedicine due to the COVID-19 pandemic and was pertinent for decreased consciousness, inability to answer either orientation question, a right facial droop, and aphasia. Later it was found that the patient exhibited a pure motor mutism rather than aphasia and had an MRI lesion in the left inferior precentral gyrus.

Conclusion

Differentiating aphemia from aphasia is an important clinical skill for a neurologist to foster especially in the era of telemedicine. An intimate knowledge of the parts of a speech exam are vital in directing emergency staff during stroke evaluation. Additionally, distinguishing these clinical syndromes has implications with respect to prognosis and long-term rehabilitation.

High-resolution CT with arch/neck/head CT angiography on a mobile stroke unit

BACKGROUND

Mobile stroke units (MSUs) performance dependability and diagnostic yield of 16-slice, ultra-fast CT with auto-injection angiography (CTA) of the aortic arch/neck/circle of Willis has not been previously reported.

METHODS

We performed a prospective observational study of the first-of-its kind MSU equipped with high resolution, 16-slice CT with multiphasic CTA. Field CT/CTA was performed on all suspected stroke patients regardless of symptom severity or resolution. Performance dependability, efficiency and diagnostic yield over 365 days was quantified.

RESULTS

1031 MSU emergency activations occurred; of these, 629 (61%) were disregarded with unrelated diagnoses, and 402 patients transported: 245 (61%) ischemic or hemorrhagic stroke, 17 (4%) transient ischemic attack, 140 (35%) other neurologic emergencies. Total time from non-contrast CT/CTA start to images ready for viewing was 4.0 (IQR 3.5-4.5) min. Hemorrhagic stroke totaled 24 (10%): aneurysmal subarachnoid hemorrhage 3, hemorrhagic infarct 1, and 20 intraparenchymal hemorrhages (median intracerebral hemorrhage score was 2 (IQR 1-3), 4 (20%) spot sign positive). In 221 patients with ischemic stroke, 73 (33%) received alteplase with 31.5% treated within 60 min of onset. CTA revealed large vessel occlusion in 66 patients (30%) of which 9 (14%) were extracranial; 27 (41%) underwent thrombectomy with onset to puncture time averaging 141±90 min (median 112 (IQR 90-139) min) with full emergency department (ED) bypass. No imaging needed to be repeated for image quality; all patients were triaged correctly with no inter-hospital transfer required.

CONCLUSIONS

MSU use of advanced imaging including multiphasic head/neck CTA is feasible, offers high LVO yield and enables full ED bypass.

Abstract P274: Evaluation of Glycemic Variability and Discharge Outcomes in Patients Presenting With Ischemic Stroke Following Intravenous Thrombolysis

Presentation Objective: Does glycemic variability worsen Modified Rankin Score (mRS) following ischemic stroke in patients treated with thrombolytics (tPA)?

Background/Purpose: Acute hyperglycemia and strict glucose control have been identified as predictors of hemorrhage, increased length of stay and hypoglycemia following ischemic stroke. However, the role of glucose variability in patients with ischemic stroke treated with tPA is largely unknown. The aim of this study was to evaluate the role of glycemic variability on discharge outcomes in patients treated with tPA for ischemic stroke.

Methodology: A retrospective review of adults with ischemic stroke who received tPA was completed. Patients hospitalized for at least 48 hours with image-confirmed ischemic stroke and symptom onset within 4.5 hours of presentation were included. Glycemic variability was measured using the J-index calculation and groups were defined as patients with normal or abnormal J-indices. Logistic regression models were developed to determine odds ratios for defined outcomes including NIHSS score, mRS and disposition at discharge. Statistical significance was a p-value of <0.05.

Results: Of the 229 patients included, 132 (58%) had a normal J-index (4.7 – 23.6). In the univariate analysis, abnormal J-index was associated with higher rates of hypertension (94% vs 73%), type 2 diabetes mellitus (74% vs 12%), chronic kidney disease (34% vs 11%), higher initial blood glucose values (220 ±172 vs 111 ±20) and HbA1c, and worse outcomes in terms of NIHSS score, mRS and disposition at discharge. In the multivariate analysis, patients with an abnormal J-index had higher odds of unfavorable outcomes in terms of discharge mRS (OR 2.1; 95% CI 1.0 – 4.3, p=0.045) and hemorrhagic transformation (OR 4.1; 95% CI 1.7 – 10.2, p=0.002). There was no difference in discharge disposition (OR 1.4; 95% CI 0.7 – 3.0 p=0.4).

Conclusion: Glycemic variability, following ischemic stroke, may result in unfavorable patient outcomes in patients treated with tPA. Additional studies are needed to determine the appropriate glucose management strategy.

Abstract WP196: Selective Serotonin Reuptake Inhibitors (SSRI) for Depression and Functional Recovery After Stroke: A Meta-Analysis

Background: Post-stroke depression is common and it impedes rehabilitation and function recovery after stroke, and numerous trials evaluated SSRI’s for depression prophylaxis. The objective of this study is to assess the use of SSRI for prevention of poststroke depression and the potential effect on functional recovery after stroke.

Methods: We searched electronic databases up to July 2019 for randomized controlled trials of SSRI’s for patients with stroke versus placebo. We calculated pooled odds ratios and 95% CIs by using random-effects models. The primary end points were depression and good functional outcome (modified Rankin Scale score of 0-2) at 90 days post-randomization. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Results: Twelve randomized control trials assessing 4,887 patients have been included in the meta-analysis. SSRI treatment after stroke decreased the odds of depression compared to control group (OR = 0.48, 95% CI - 0.30 to 0.78, p=0.003). There was no heterogeneity between the trials (Cochran’s Q statistic 4.623, df 5; P = .337, I 2 =5.626%). The proportion of subjects who achieved mRS 0-2 at 90 days was similar between SSRI and control groups (OR= 3.471, 95% CI - 0.59 to 20.38, p=0.168).

Conclusion: SSRI treatment for the stroke patients reduces the incidence of depression but it does not increase the odds of good functional recovery.

Abstract WP394: Compliance With Statin Therapy and Risk of Recurrent Adverse Events in Intracerebral Hemorrhage: Analysis of the ATACH II Trial

Background: Hypercholesterolemia is associated with increased risk of ischemic strokes. Statin therapy has been shown to reduce risk of cardiovascular mortality including ischemic strokes. Despite these benefits there still exists a debatable effect of statin use in outcome of patients with intracerebral hemorrhage.

Methods: Retrospective analysis was performed using data from the Antihypertensive treatment of acute cerebral hemorrhage II (ATACH-2) trial to determine effect of baseline compliant statin use on occurrence of adverse events, mortality and death and disability at 90 days. We compared demographic, clinical characteristics and outcomes of subjects dichotomized into those on statin therapy at baseline versus those who were not. We performed a multivariate analysis using binary logistic regression model after adjusting for all potential confounders for binary variables as well as linear regression model for continuous variables.

Results: Of the total 1000 participants in the ATACH-2 trial total of 931 responded and were included. Of the 931 there were 271 (29.1%) who were complaint with baseline statin use, with mean age 61.6 SD± 13.0 and 60.9% were males. Those were complaint with statin use had significantly higher rates of previous stroke (13.9% vs 19.7%), coronary artery disease (2.3% vs 7.7%), hyperlipidemia (15.7% vs 42.0%), and type 2 diabetes mellitus (14.2% vs 25.2%). In the multivariate analysis after adjusting for age, race, hypertension, and smoking those who were compliant with baseline statin use had significant lower odds of recurrent hemorrhagic adverse events (OR 0.4, 95% CI 0.21- 0.89; p-value .023) and lower odds of requiring surgical evacuation (OR 0.3, 95% CI 0.12 - 0.91; p-value .032). In a linear regression model those who were compliant with statin use had lower 24hr NIHSS score ( β -1.2, S.E 0.5; p-value .031) and higher baseline GCS score ( β 0.3, S.E 0.1; p-value .02). There was no difference in favorable outcome mRS 0-2 or death in the multivariate analysis.

Conclusion: Patient who are compliant with statin use seem to have higher GCS score at baseline and improved NIHSS scores at 24hrs. They were at lower odds of having recurrent hemorrhagic bleeds after discharge and required less surgical evacuations.

Abstract TP63: Risk of Contrast Induced Nephropathy After Emergency CTA in Stroke Patients: A Meta-Analysis

Background: Contrast agents for computed tomographic angiography (CTA) and perfusion (CTP) are presumed to be nephrotoxic prompting many hospitals to require serum creatinine values prior to imaging likely causing delays in door to needle times. The objective of this study is to assess the risk of developing contrast induced acute kidney injury (AKI) in patients who are undergoing CTA and CTP.

Materials and Methods: We have searched the electronic databases up to July 2019 for studies that reported incidence of AKI in patients who have undergone CTA and CTP. We calculated pooled odds ratios and 95% CIs by using random-effects models for the primary end point being AKI due to contrast induced nephropathy. We followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines for systematic reviews and meta-analyses.

Results: Eight case control studies assessing 4,449 patients have been included in the study. The odds of AKI in CTA/CTP patients versus non-contrast CT was not statistically significant (odds ratio = 0.53, 95% CI = 0.20-1.39, p=0.199). There was no significant heterogeneity between the studies (Cochran’s Q statistic 3.632, df 4; P = .461, I2=2.514%). Overall, no AKI patient required hemodialysis due to contrast induced nephropathy. The absolute number of patients who developed AKI among CTA/CTP patients was lower than among patients who underwent just non-contrast CT (67 versus 87, NS).

Conclusion: The use of contrast agents for CTA/CTP in acute stroke is not associated with an increased risk of developing contrast induced nephropathy nor AKI requiring dialysis.

Abstract WP160: Conivaptan (Combined Vasopressin Receptor Antagonism) Attenuates Cerebral Edema Following Ischemic Stroke in Rodent Model

Objective: To study the potential role of Conivaptan on cerebral edema, infarct volume, neurological deficit and survival.

Introduction: Although vasopressin has a significant detrimental role in stroke-related cerebral edema, the effect of mixed vasopressin antagonism in stroke has not been well studied. We studied the effects of conivaptan on the course of cerebral edema, severity of neurological deficit, infarct volume, aquaporin-4 (AQP4) protein levels and survival after experimental stroke.

Methods: Animals were randomized to receive either conivaptan or vehicle after reperfusion of experimental middle cerebral artery occlusion. The severity of neurological deficit, edema, and infarct volume assessments were performed by an investigator blinded to group assignment. All assessments were performed at either 12h or 24h and Western blot was subsequently used to investigate AQP4 levels.

Results: At 12h, conivaptan-treated mice (n=16) had 6.64±6.50% ipsilateral hemispheric enlargement compared to 16.55±7.05% in control mice (n=16, p=0.0003). Similarly, at 24h, conivaptan-treated mice (n=12) had 6.81±4.63% ipsilateral hemispheric enlargement in comparison to 13.93±5.43% in control mice (n=12, p=0.0023). At 24h, the conivaptan-treated mice had lower neurological deficits in comparison to control (p=0.04). There was no significant effect of conivaptan on infarct size or AQP4 levels in comparison to vehicle, naïve and sham group.

Conclusions: The present study highlights the role of mixed vasopressin receptor antagonism in reducing cerebral edema secondary to brain ischemia. This data suggests the possibility of developing vasopressin antagonism as a new adjuvant in treatment of stroke-related brain edema.

Developmental Venous Anomaly Presenting with Spontaneous Intracerebral Hemorrhage, Acute Ischemic Stroke, and Seizure

Developmental venous anomaly (DVA) is the most common, benign, congenital vascular malformation of the brain and mostly an incidental finding on imaging. The exact etiology of DVA is unknown but thought to be due to medullary vein thrombosis during embryonic venous development. DVA is generally asymptomatic although associated neurologic deficits and seizures have been described. Several reports of DVA causing neurovascular compression, obstructive hydrocephalus, venous infarction, and intracerebral hemorrhage (ICH) have been described. In this report, we discuss a patient with fluctuating neurological symptoms found to have multiple DVA, predominantly draining into the deep venous system. To the best of our knowledge, DVAs leading to simultaneous ischemic stroke, intracerebral hemorrhage, and seizures are not reported in the literature. We reviewed the relevant literature and discussed the epidemiology and clinical and radiological characteristics of DVA.

Impact of pretreatment with intravenous thrombolysis on reperfusion status in acute strokes treated with mechanical thrombectomy

Introduction

We sought to evaluate the impact of pretreatment with intravenous thrombolysis (IVT) on the rate and speed of successful reperfusion (SR) in patients with emergent large vessel occlusion (ELVO) treated with mechanical thrombectomy (MT) in a high-volume tertiary care stroke center.

Methods

Consecutive patients with ELVO treated with MT were evaluated. Outcomes were compared between patients who underwent combined IVT and MT (IVT+MT) and those treated with direct MT (dMT). The elapsed time between groin puncture to beginning of reperfusion (GPTBRT) and the numbers of device passes required to achieve SR were also documented.

Results

A total of 287 and 132 patients were treated with IVT+MT and dMT, respectively. The IVT+MT group had higher SR (73.8% vs 62.9%; p=0.023) and 3-month functional independence (modified Rankin Scale score 0–2;51.6% vs 38.2%; p=0.008) rates. The median GPTBRT was shorter in the IVT+MT group (48 (IQR 33–70) vs 70 (IQR 44–98) min; p<0.001). Among patients who achieved SR (n=292), the median number of required device passes was lower in the IVT+MT subgroup (1 (IQR 1–1) vs 2 (IQR 1–2); p<0.001), while the rate of patients requiring ≤2 device passes was higher (98% vs 77%; p<0.001). IVT+MT was independently related to higher odds of SR (OR 1.64; 95% CI 1.03 to 2.61; p=0.036) and shorter GPTBRT (unstandardized linear regression coefficient −20.39; 95% CI −27.56 to –13.22; p<0.001) on multivariable analyses adjusting for potential confounders. Among patients with SR, IVT+MT was independently associated with a higher likelihood of ≤2 device passes (OR 14.63; 95% CI 4.46 to 48.00; p<0.001).

Conclusions

IVT pretreatment appears to increase the rates of SR and shortens the duration of the endovascular procedure by requiring fewer device passes in patients with ELVO treated with MT.

Abstract TP24: Impact of Pretreatment With Intravenous Thrombolysis on Reperfusion Status in Emergent Large Vessel Occlusion (ELVO) Patients Treated With Mechanical Thrombectomy (MT)

Introduction: It currently remains unclear whether pre-treatment with intravenous thrombolysis (IVT) provides any additional benefits to emergent large vessel occlusion (ELVO) patients undergoing mechanical thrombectomy (MT). We sought to evaluate the impact of pretreatment with IVT on the rate and the speed of complete reperfusion (CR) in LVO patients treated with MT in a high-volume tertiary care stroke center.

Methods: Consecutive ELVO patients treated with MT during a five-year period were evaluated. Baseline stroke severity was assessed by NIHSS-score. Standard safety [symptomatic Intracranial Hemorrhage (sICH) by SITS-MOST definition] and efficacy outcomes [CR (modified Thrombolysis in Cerebral Infarction IIb/III), 3-month functional independence (FI; modified Rankin Scale scores of 0-2)] were compared between patients who underwent combined IVT and MT (IVT+MT) vs. direct MT (dMT). The elapsed time between groin puncture to beginning of reperfusion (GPTBRT) and the numbers of device passes (DP) required to achieve CR were also documented.

Results: A total of 287 and 132 patients were treated with IVT+MT and dMT respectively. The IVT+MT group had higher CR (74% vs. 63%; p=0.023) and FI (52% vs.38%; p=0.008) rates and shorter median GPTBRT (48 vs. 70 min; p<0.001). The two groups did not differ in sICH rates (7% vs. 9%; p=0.368). Among patients who achieved CR, the median number of required DP was lower in the IVT+MT subgroup (1 vs. 2; p<0.001) and the rate of patients requiring ≤2 DP was higher (98% vs. 77%; p<0.001). IVT+MT was independently related to higher odds of CR (OR:1.64; 95%:1.03-2.61; p=0.036) and shorter GPTBRT (unstandardized linear regression coefficient: -20; 95%CI: -12, -27; p<0.001) on multivariable analyses adjusting for potential confounders including demographics, vascular risk factors, collateral status, stroke severity, location of occlusion and onset to groin puncture time. Among patients with CR, IVT+MT was independently associated with higher likelihood of ≤2 DP (OR:14.75; 95%:4.72-46.04; p<0.001).

Conclusions: IVT pretreatment increases the rates of CR and shortens the duration of endovascular procedure by requiring fewer DP in ELVO patients treated with MT.

Abstract TP416: Safety and Efficacy Outcomes of Intravenous Thrombolysis (IVT) for In-Hospital Stroke

Introduction: Cross-sectional data suggest that IVT in patients with in-hospital (IHS) acute ischemic stroke (AIS) onset is associated with unfavourable outcomes compared to out-of-hospital (OHS) stroke onset patients. We sought to compare safety and efficacy outcomes between IHS and OHS patients treated with IVT.

Methods: Consecutive AIS patients treated with IVT during a five-year period in a tertiary care stroke center were prospectively evaluated. Demographics, vascular risk factors, admission blood pressure and serum glucose levels were documented. Baseline stroke severity and early hypodensity on baseline CT were assessed using NIHSS-score and ASPECTS by certified physicians. Three-month functional outcome was evaluated by mRS-score. We compared the following outcomes between IHS and OHS patients: 1.symptomatic intracranial hemorrhage (sICH) 2.favourable functional outcome (FFO) [3-month mRS scores of 0-1], 3.Functional independence (FI) [3-month mRS scores of 0-2], 4. Mortality at three months.

Results: Of 1264 IVT-treated AIS patients, we identified 51 (4%) subjects with IHS. Baseline median NIHSS-score was higher in IHS (10 points; IQR: 6-16 vs. 6 points; IQR: 3-12; p=0.004), while median onset-to-treatment was shorter (75 min; IQR: 37-115 vs. 135 min; IQR: 100-185; p<0.001). In univariable analyses, IHS patients had higher three-month mortality rates (21% vs. 9%; p=0.009). There were no differences (p>0.1) between the two groups in FFO, FI and sICH rates. IHS was associated with higher likelihood three-month mortality (OR: 3.1; 95%CI: 1.2-7.8; p=0.016) on multivariable logistic regression models adjusting for demographics, risk factors, onset-to-treatment time, admission blood pressure and serum glucose levels, baseline NIHSS and ASPECTS.

Conclusions: IHS patients treated with IVT have more severe strokes and higher mortality rates compared to OHS patients. IVT for IHS is not associated with higher hemorrhagic complications.

Abstract WP113: Racial Disparities in Patient Selection for Drip and Ship Thrombolytic Therapy for Acute Ischemic Stroke

Introduction: There is preliminary data indicating potential racial disparities in use of intravenous thrombolysis (IVT) for acute ischemic stroke (AIS). We sought to compare “drip and ship” (DNS) tPA use between African-Americans (AA) and Caucasians (CS) in a high-volume tertiary care stroke center.

Methods: AIS patients treated with IVT during a seven-year period were evaluated. Baseline stroke severity and early hypodensity on baseline CT were assessed by NIHSS-score and ASPECTS by certified physicians. All patients who received IVT at an outside facility with subsequent transfer to our center were included in the DNS group. Safety of IVT was evaluated SITS-MOST symptomatic intracranial hemorrhage (sICH) definition. Three-month functional status was assessed using modified Rankin Scale (mRS) scores.

Results: Out of total 1339 IVT-treated AIS patients [51% men, 63% AA, mean age 63±15years, median baseline NIHSS-score: 7 pts (IQR: 3-13)], 521 (39%) were treated using the DNS approach. DNS tPA use was less common in AA compared to CS (33% vs. 51%; p < 0.001). AA race was independently associated with lower likelihood of DNS tPA use (OR: 0.46; 95%CI: 0.35-0.62; p<0.001) on multivariable logistic regression models adjusting for multiple potential confounders including demographics, vascular risk factors, onset-to-treatment time, door-to-needle time, baseline stroke severity, serum glucose, BP parameters and ASPECTS. Among DNS patients, the rates of sICH, three-month favorable functional outcome (mRS-scores of 0-1) and mortality did not differ between AA and CS. Using geospatial software, the observed treatment disparity could not be explained by racial zipcode. distribution.

Conclusions: Our study uncovers substantial racial disparities in the selection of AIS patients for DNS thrombolytic therapy that cannot be explained by racial geographic proximity to the primary stroke center.

Abstract TP19: Impact of Single-Pass Complete Reperfusion on Clinical Outcomes in Emergent Large Vessel Occlusion (ELVO) Patients Treated With Mechanical Thrombectomy (MT)

Introduction: There is mounting evidence indicating that first pass (FP) complete reperfusion (CR) may reduce peri-procedural complications for emergent large vessel occlusion (ELVO) patients treated with mechanical thrombectomy (MT). We investigated the impact of device passes (DP) on the clinical outcomes of ELVO patients who achieved CR following treatment with MT in a high-volume tertiary care stroke center.

Methods: Consecutive ELVO patients with CR (modified Thrombolysis in Cerebral Infarction grades IIb/III) at the end of MT were evaluated during a five-year period. Baseline stroke severity was assessed by NIHSS-score. The numbers of DP during the procedure were documented. Standard safety outcomes included symptomatic Intracranial Hemorrhage (sICH) by SITS-MOST criteria and three-month mortality. Standard efficacy outcomes included neurological improvement at 24 hours (determined by the relative reduction in NIHSS-score compared to baseline) and functional improvement at three months [determined as the shift in modified Rankin Scale (mRS) scores].

Results: Among 258 ELVO patients achieving CR during MT the rate of FPCR was 67% (n=173). Patients with FPCR had greater median relative NIHSS-reduction at 24 hours (46% vs. 33%; p=0.033), lower median mRS-scores at three months (2 vs. 3; p=0.034) and lower three-month mortality rates (12% vs. 26%; p=0.005) compared to the rest. The two groups did not differ in sICH rates (5% vs. 10%; p=0.200). FPCR was associated with lower odds of three-month mortality (OR:1.64; 95%:1.03-2.61; p=0.036) on multivariable logistic regression models adjusting for potential confounders (demographics, risk factors, occlusion site, collateral status, stroke severity, onset to groin puncture time, baseline blood pressure and serum glucose values).

Conclusions: FPCR appears to impact favourably clinical outcomes in ELVO patients treated with MT. CR following FP results in greater neurological and functional improvement at 24 hours and 3 months respectively.

Abstract WP15: Safety of Dual Antiplatelet Treatment in Emergent Large Vessel Occlusion (ELVO) Patients Treated With Mechanical Thrombectomy (MT) and Extracranial Internal Carotid Artery Stenting

Introduction: Extracranial Internal carotid artery (ExICA) stenting may be required during mechanical thrombectomy (MT) for anterior circulation large vessel occlusions (ACLVO) with coexisting ExICA steno-occlusive disease. We sought to evaluate the safety of acute dual antiplatelet therapy (DAP) in this high-risk MT subgroup.

Methods: Consecutive ACLVO patients treated with MT were evaluated during a five-year period. All patients receiving ExICA stenting during MT were also acutely treated with DAP coupled with heparin or eptifibatide drips. Baseline stroke severity and early hypodensity on baseline CT were assessed using NIHSS-score and ASPECTS. Complete reperfusion (CR) was defined as modified Thrombolysis in Cerebral Infarction grades IIb/III) at the end of MT. Final infarct volume (FIV) on brain MRI was assessed at 24-48 hours using standardized methodology. Safety outcomes included symptomatic Intracranial Hemorrhage (sICH) documented by SITS-MOST criteria, infarct in new unaffected territory (INT) determined according to ESCAPE trial methodology and three-month mortality. We also assessed 3-month functional outcomes using modified Rankin Scale (mRS) scores.

Results: Among 309 ACLVO patients treated with MT, 24 received additional ExICA stenting. Eptifibatide and heparin drips were administered in 15 (65% of stenting subgroup: 9 patients: aspirin + clopidogrel, 6 patients: aspirin + ticagrelor) and 8 (35% of stenting subgroup: 6 patients: aspirin + clopidogrel, 2 patients: aspirin + ticagrelor) cases respectively. Patients with and without ExICA stenting had similar (p>0.1) median baseline NIHSS-scores (15 vs. 16 points) and ASPECTS (10 vs. 10 points). The two groups did not differ (p>0.1) in terms of median FIV (20 vs. 15 cm 3 ) and median 3-month mRS-scores (2 vs. 2). Patients with ExICA stenting had similar (p>0.1) rates of sICH (5% vs. 8%), INT (0% vs. 9%), CR (74% vs. 70%) and 3-month mRS-scores of 0-2 (55% vs. 51%) compared to the rest.

Conclusions: DAP coupled with eptifibatide or heparin drips does not appear to increase peri-procedural complications or to worsen clinical outcome of ELVO patients treated with MT and ExICA stenting.

Abstract TP158: Risk prediction for symptomatic Intracranial Hemorrhage (sICH) in Acute Ischemic Stroke (AIS) Patients Treated With Intravenous Thrombolysis (IVT): Does Infarct Location Matter?

Introduction: There are mounting data supporting a substantially lower risk of sICH in AIS patients with posterior circulation stroke (PCS) following treatment with IVT. However, stroke location is not included in any of the numerous risk prediction scores for sICH complicating IVT in AIS. We sought to compare the safety and efficacy of IVT for AIS with respect to the location of acute cerebral ischemia in a high-volume tertiary care stroke center.

Methods: Consecutive AIS patients treated with IVT during a five-year period were evaluated. Baseline stroke severity and early hypodensity on baseline CT were assessed by NIHSS-score and ASPECTS by certified physicians. Stroke location was classified as posterior (PCS) vs. anterior circulation (ACS), and supratentorial (STN) vs. infraterorial (ITN) infarction. Safety of IVT was evaluated using the SITS-MOST sICH definition. Three-month functional status was assessed using modified Rankin Scale (mRS) scores.

Results: Out of total 1008 IVT-treated AIS patients [52% men, mean age 64±15years, median baseline NIHSS-score: 8 pts (IQR: 4-4)], 181 (18%) had PC and 88 (9%) had STN location. The rates of sICH were lower in patients with PCS [2.8% vs. 6.9%; p=0.039 by Fisher’s exact test (FET)] and ITN infarction (0% vs. 6.7%; p=0.005 by FET). PCS and ITN strokes (OR computed using Firth’s penalized likelihood method for rare events: 0.11; 95%CI: 0.01-1.82) were not independently associated with lower likelihood of sICH on multivariable logistic regression models adjusting for multiple potential confounders including demographics, vascular risk factors, onset-to-treatment time, baseline stroke severity, serum glucose, BP parameters and ASPECTS, pretreatment with antiplatelets (single or dual), statins and oral anticoagulants.

Conclusions: Our study indicates that infarct location appears not to be independently related to the risk of sICH in AIS patients treated with IVT.

Abstract WP110: Does Paradoxical Embolism Impart Different Outcomes After IVT Treatment?

Introduction: There are pilot data indicating that patients with acute ischemic stroke (AIS) due to paradoxical embolism (PxE) via patent foramen ovale (PFO) may respond better to intravenous thrombolysis compared to other stroke subtypes. We sought to compare the safety and efficacy of IVT in AIS patients with and without PxE as their stroke etiopathogenic mechanism in a high-volume tertiary care stroke center.

Methods: Consecutive AIS patients treated with IVT during a five-year period were evaluated. Baseline stroke severity and early hypodensity on baseline CT were assessed by NIHSS-score and ASPECTS by certified physicians. Presence of PFO was diagnosed by echocardiography, while PxE was determined using the TOAST criteria. Safety of IVT was evaluated using SITS-MOST sICH definition. Three-month functional status was assessed using modified Rankin Scale (mRS) scores.

Results: Out of total 1301 IVT-treated AIS patients, we identified 51 cases (4%) with PxE due to PFO. Patients with PxE were younger (mean age 52±15 vs. 63±15 years; p<0.001), but had similar baseline and 24-hour NIHSS-scores compared to the others. The rates of sICH (4% vs. 5%), 3-month functional independence (mRS-scores 0-2; 77% vs. 68%) and 3-month favourable functional outcome (mRS-scores 0-1; 64% vs. 53%) did not differ (p>0.1) between the two groups. Three-month mortality was lower in the PxE group (0% vs. 9% by Fisher exact test). PxE due to PFO (OR computed using Firth’s penalized likelihood method for rare events: 0.11; 95%CI: 0.01-1.74) was not independently associated with 3-month mortality on multivariable logistic regression models adjusting for potential confounders.

Conclusions: Our study indicates that AIS patients with PxE due to PFO have similar response to IVT compared to AIS patients with other underlying mechanisms.

Abstract WP28: Yield of ASPECTS and CTA-Based Selection Criteria for Mechanical Thrombectomy in Patients Treated Within 6-24 Hours From Symptom Onset

Background: Recent extended window (EW) trials support the benefit of mechanical thrombectomy (MT) in anterior circulation emergent large vessel occlusions (ELVO). However, only up to 1.7% of consecutive acute ischemic strokes (AIS) were eligible for EW-MT using clinical trial selection criteria. We examined eligibility and outcomes of EW-MT in consecutive ELVOs using pragmatic selection criteria.

Methods: We prospectively evaluated consecutive patients presenting between 6-24 hours that underwent MT using selection criteria consisting of only non-contrast CT (ASPECTS > 6), CTA occlusion + good collateral scores (JNIS 2016;8:559-562). Effectiveness outcomes included TICI 2b-3 and 3-month modified Rankin Scores (mRS); safety outcomes included in-hospital mortality and symptomatic intracerebral hemorrhage (sICH).

Results: 767 consecutive AIS patients presented within 6-24 hour window, and of these 48 (6%) anterior circulation ELVOs underwent MT (mean age 63±17 years; 56% men; median NIHSS 16 [IQR 10-19]; median groin puncture to recanalization 53 minutes [IQR 41-85]). Median ASPECTS was 9 (IQR 8-10), and 79% (n=38) of patients had good CTA collateral grade. Occlusions were primarily M1 MCA (46%), with 29% tandem occlusions. Successful recanalization (mTICI 2b or 3) was achieved in 73% (n=35), while 6% (n=3) of patients developed sICH. In-hospital mortality was 25% (n=12), however 40% (n=19) achieved 3-month mRS 0-2.

Conclusions: The use of standard of care CT/CTA yields an acceptable rate of MT eligibility, allowing a group of patients facing likely death or severe disability to obtain reasonable safety and effectiveness outcomes.

Abstract WP30: Does Pretreatment With Intravenous Thrombolysis Prevent Infarct in a New Previously Unaffected Territory (INT) in Emergent Large Vessel Occlusion (ELVO) Patients Treated With Mechanical Thrombectomy (MT)?

Introduction: There are contradictory data concerning the preventive role of intravenous thrombolysis (IVT) in preventing infarct in a new previously unaffected territory (INT) in emergent large vessel occlusion (ELVO) patients treated with mechanical thrombectomy (MT). We sought to evaluate the potential association of IVT pretreatment with the likelihood of INT complicating MT in a high-volume tertiary care stroke center.

Methods: Consecutive ELVO patients reated with MT during a five-year period were evaluated. Baseline stroke severity was assessed by NIHSS-score. INT was defined using standardized methodology proposed by ESCAPE investigators. Collateral status was graded using ASITN/SIR criteria. The association of INT with 3-month functional independence (FI) defined as modified Rankin Scale scores of 0-2 was also investigated.

Results: A total of 419 consecutive ELVO patients received MT [mean age 64±15 years, 50% men, median NIHSS-score 16 points (IQR:11-20), 69% IVT pretreatment). The incidence of INT was lower in patients treated with combination therapy (IVT & MT) than in patients treated with direct MT respectively (10% vs. 20%; p=0.011). INT occurred more frequently in patients with posterior circulation occlusion (28% vs. 10%; p<0.001). Patients with good collaterals tended to have lower rates of INT (11% vs. 18%; p=0.072). The rates of 3-month FI were lower in patients with INT (30% vs. 50%; p=0.007). IVT pretreatment was not independently related to INT (OR: 0.79; 95%CI: 0.34-1.83) on multivariable logistic regression models adjusting for location of occlusion, collateral status and onset to groin puncture time. INT did not emerge as anindependent predictor of 3-month FI (OR: 0.69; 95%CI: 0.29-1.62) on multivariable analyses.

Conclusions: IVT pretreatment is not independently associated with lower likelihood of INT in LVO patients treated with MT. INT does not appear to independently affect 3-month functional outcomes.

Subpial transection surgery for epilepsy

BACKGROUND

Nearly 30% of patients with epilepsy continue to have seizures despite using several antiepileptic drugs (AEDs). Such patients are regarded as having refractory, or uncontrolled, epilepsy. While there is no universally accepted definition of uncontrolled, or medically refractory, epilepsy, for the purposes of this review we will consider seizures as drug resistant if they have failed to respond to a minimum of two AEDs. Specialists consider that early surgical intervention may prevent seizures at a younger age, which in turn may improve the intellectual and social status of children. Many types of surgery are available for treating refractory epilepsy; one such procedure is known as subpial transection.

OBJECTIVES

To assess the effects of subpial transection for focal-onset seizures and generalised tonic-clonic seizures in children and adults.

SEARCH METHODS

For the latest update we searched the following databases on 7 August 2018: the Cochrane Register of Studies (CRS Web), which includes the Cochrane Epilepsy Group Specialized Register and the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid, 1946 to August 06, 2018), ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP). We imposed no language restrictions.

SELECTION CRITERIA

We considered all randomised and quasi-randomised parallel-group studies, whether blinded or non-blinded.

DATA COLLECTION AND ANALYSIS

Two review authors (BK and SR) independently screened trials identified by the search. The same two review authors planned to independently assess the methodological quality of studies. Had we identified studies for inclusion, one review author would have extracted the data, and the other would have verified the data.

MAIN RESULTS

We found no relevant studies.

AUTHORS' CONCLUSIONS

We found no evidence to support or refute the use of subpial transection surgery for patients with medically refractory epilepsy. Well-designed randomised controlled trials are needed to guide clinical practice.

Abstract TP357: BP Management on the Mobile Stroke Unit for Ultra-Early Treatment of ICH and Acute Ischemic Stroke

Background: Lowering of blood pressure (BP) is discouraged in current ASA guidelines for emergency medical service (EMS) personnel. However, ultra-early treatment with IVtPA and BP lowering in ICH are possible on mobile stroke units (MSU). We examined the effectiveness and safety of two antihypertensive agents for MSU treatment.

Methods: Consecutive MSU patients were treated with target ICH BP parameters less than 140/90, and IVtPA BP parameters by current guidelines. BP was measured by noninvasive oscillometric cuff, and cycled every 5 minutes per EMS MSU protocol. Available agents were labetalol IV 10-20mg and/or nicardipine double-strength premix infusion started at 5mg/hour and titrated. Preference in usage, and effect were recorded and analyzed for the first year of MSU operation.

Results: During 168 service days, 127 acute stroke patients were transported (68±16, range 23-96 years; 58% women; 65% African American, 34% White; 1% Hispanic). Fifteen (12%) had hemorrhage on CT (1 aneurysmal SAH, 1 SDH, 1 subacute AIS with HT-2; 12 HTN ICH [median ICH score 2, IQR 1-3] of which 1 had a positive spot sign on CTA). AIS cases (n=100) had median NIHSS 9 (IQR 7-17); 38% were treated with IVtPA at a median 13 (IQR 11-16) minutes from scene arrival, one of these by IO route, with 1 angioedema and 0 sICH. Labetalol was used for 9 patients, with all but one (89%) requiring the addition of nicardipine infusion. In 24 patients nicardipine was the first agent selected, with 100% achieving target BP control prior to hospital arrival.

Conclusions: MSU use of nicardipine double-strength premix infusions provides rapid, reliable, and safe BP control. When time is of the essence, elimination of labetalol, in favor of a dihydropyridine calcium channel blocker infusion may provide the most rapid achievement of prescribed BP parameters.

Abstract 94: Ultra-Fast Performance and Yield of a High-Resolution CT With Head and Neck CT Angiography on a Mobile Stroke Unit

Background: MSU’s are capable of ultra-early treatment of acute stroke patients in the field. We tested field use of a high-resolution CT and CT-angiography on our MSU.

Methods: We designed and implemented the first of its kind MSU equipped with a 16 slice CT scanner (24-row adaptive detector array, fixed 70 cm gantry, auto-injection system, Somatom Scope, Siemens), led by stroke fellowship trained MDs or ANVP-board certified nurse practitioners without telemedicine support. Head/neck CTA was performed on all suspected stroke patients immediately following noncontrast CT. The MSU is embedded within local Fire/EMS and is activated by 911, or by on-scene medics 14 days/month. Transport and drug re-stock agreements were developed with Comprehensive, Primary, and CSC-Capable (CSC-cap) competing stroke centers.

Results: Of 420 activations in the first year, our MSU transported a total 206 patients: 127 (62%) strokes and 79 (38%) stroke mimics. In all 127 acute stroke patients (68±16 years, 58% women, 65% African American, 34% White, 1% Hispanic), median CT/CTA completion time, from start of scan, to images ready for diagnostic viewing, was 3.5 minutes (IQR 3-4). Diagnosis was 15 (12%) hemorrhages, 12 (9%) suspected TIA, 100 (79%) acute ischemic stroke (AIS). AIS median NIHSS was 9, IQR 7-17. IV-tPA treatment rate was 38% with median scene arrival to bolus time of 13 min, IQR 11-16. Large vessel occlusion (LVO) was found in 30% of ischemic strokes. No patients required repeat imaging on arrival due to image quality, and 100% were accurately triaged to CSC, PSC, or CSC-cap hospitals without the need for subsequent transfer.

Conclusions: MSUs can effectively operate a high-resolution automated CT similar to in-hospital radiology settings. The addition of head/neck CTA in the field yields a high rate of LVO detection supporting definitive prehospital triage to Comprehensive Stroke Centers.

Abstract TP363: Can Intravenous Alteplase tPA Be Given Safely in the CT Scan Suite?

Background: In an effort to shorten door to needle times, stroke teams have moved towards injection of alteplase tPA (IVtPA) in the CT scan suite immediately after completion of the noncontrast CT, and before completion of the CTA. However, many stroke programs are prevented from initiating IVtPA in CT due to concerns about patient deterioration. We sought to determine the safety of this practice.

Methods: 12 months of prospectively treated IVtPA cases from 2 comprehensive stroke centers were assembled for analysis. Cases were carefully examined to determine treatment location, and those treated inside the CT suite were selected for final review. Safety incidents were defined as those in which an IVtPA treated patient developed any condition requiring urgent or emergent management in the CT suite. sICH was defined as parenchymal hematoma type 2 in combination with a 4 or more point worsening on the NIHSS.

Results: A total of 589 acute ischemic stroke patients were treated with IVtPA in calendar year 2016; of these 562 (95%) received their tPA bolus and start of infusion in the CT scan immediately after completion of the noncontrast CT, and prior to CTA. Zero safety incidents occurred in these cases. Additionally, there were no renal insults in the sample, despite not waiting for lab results prior to performing CTA. Median door to needle time was 22 minutes, and overall the sICH rate was 3% for the sample.

Conclusions: Administration of IVtPA in the CT scan suite is safe and allows for faster administration of IVtPA. Use of this method should be adopted in a widespread manner to facilitate rapid early treatment of acute ischemic stroke.

Blood pressure levels post mechanical thrombectomy and outcomes in non-recanalized large vessel occlusion patients

Objective

Permissive hypertension may benefit patients with non-recanalized large vessel occlusion (nrLVO) post mechanical thrombectomy (MT) by maintaining brain perfusion. Data evaluating the impact of post-MT blood pressure (BP) levels on outcomes in nrLVO patients are scarce. We investigated the association of the post-MT BP course with safety and efficacy outcomes in nrLVO.

Methods

Hourly systolic BP (SBP) and diastolic BP (DBP) values were prospectively recorded for 24 hours following MT in consecutive nrLVO patients. Maximum, minimum, and mean BP levels were documented. Three-month functional independence (FI) was defined as modified Rankin Scale (mRS) scores of 0–2.

Results

A total of 88 nrLVO patients were evaluated post MT. Patients with FI had lower maximum SBP (160±19 mmHg vs 179±23 mmHg; P=0.001) and higher minimum SBP levels (119±12 mmHg vs 108±25 mmHg; P=0.008). Maximum SBP (183±20 mmHg vs 169±23 mmHg; P=0.008) and DBP levels (105±20 mmHg vs 89±18 mmHg; P=0.001) were higher in patients who died at 3 months while minimum SBP values were lower (102±28 mmHg vs 115±16 mmHg; P=0.007). On multivariable analyses, both maximum SBP (OR per 10 mmHg increase: 0.55, 95% CI 0.39 to 0.79; P=0.001) and minimum SBP (OR per 10 mmHg increase: 1.64, 95% CI 1.04 to 2.60; P=0.033) levels were independently associated with the odds of FI. Maximum DBP (OR per 10 mmHg increase: 1.61; 95% CI 1.10 to 2.36; P=0.014) and minimum SBP (OR per 10 mmHg increase: 0.65, 95% CI 0.47 to 0.90; P=0.009) values were independent predictors of 3-month mortality.

Conclusions

Our study demonstrates that wide BP excursions from the mean during the first 24 hours post MT are associated with worse outcomes in patients with nrLVO.

Abstract WP397: Multidisciplinary Simulation of Stroke Alerts in Resident Education Leads to a 20% Decrease in Door to Needle Times

Introduction: Neurology residents are primarily responsible for responding to stroke alerts within our institution. It is imperative that first year residents understand the process and role expectations are clearly defined. Historically, residents were expected to run a stroke alert without having formal education on the stroke alert process.

Hypothesis: Giving residents timely education of the stroke alert process will lead to decreased door to needle times.

Methods: In July 2015, the Clinical Nurse Specialist (CNS) identified that simulation based learning (SBL) would close this gap. Scenarios were developed in collaboration with a Vascular attending and fellow. Emergency department nurses, EMS, chaplains, and pharmacist all participated in the scenario to make it as realistic as possible. A mannequin was utilized and controlled by simulation lab personnel while participants were videotaped as they performed the scenario. Incorporated into the debriefing of the scenario was education of door to needle goals, stroke alert process, and a discussion of role expectations.

Results: In FY2014, the average door to needle was 49.5 minutes. After providing simulation education to residents, the door to needle (DTN) average decreased to 39.8 minutes with a p-value of 0.0794. Before the education we met the goal of administering Alteplase in less than 60 minutes, 80% of the time. Following the education we met the goal 89% of the time. Improvement also occurred with the DTN goal of less than 45 minutes from FY2014 to FY2015, 51.5% and 59.2% respectively.

Conclusion: Education of residents in a SBL environment prior to their stroke rotation led to a 20% decrease in door to needle times. Although results did not meet statistical significance, this reduction in DTN time is clinically significant as evidence has shown shorter DTN association with improved outcomes. Anecdotally, residents expressed increased confidence in running a stroke alert and understood the DTN goals.

Knowledge, attitude, and practice of people toward epilepsy in a South Indian village

Introduction:

People living with epilepsy continue to suffer from enacted or perceived stigma that is based on myths, misconceptions, and misunderstandings that have persisted for many years. In the last decade, there has been an increase in individual literacy rate and increased access to technology in rural population. However, it is unclear if this has any effect on knowledge, attitude, and practice (KAP) attitude toward epilepsy.

Objective:

Our primary aim is to evaluate KAP toward epilepsy. In addition, we also estimated the prevalence of stroke and epilepsy in rural South India.

Materials and Methods:

Using a 14-item questionnaire, we assessed KAP toward epilepsy and identified determinants of inappropriate attitudes toward people with epilepsy and 10-item questionnaires to assess the prevalence of epilepsy and stroke among 500 randomly selected populations in a Pattaravakkam village (Tamil Nadu, India).

Results:

About 87.7% of the people had heard or read about epilepsy. Negative attitudes appeared to be reinforced by beliefs that epilepsy is hereditary (23.1%), kind of insanity (22.6%), or as contagious (12.0%). The knowledge about the clinical characteristics and first aid to a person during a seizure was 25.8%. About 36.5% of people think that society discriminates people with epilepsy. Moreover, our prevalence study showed that 8.7% people are suffering from epilepsy and 3.7% had stroke previously and at the day of survey, the stroke prevalence is 3.3%.

Conclusion:

Even with increased literacy, technology, and communication devices, the KAP of people toward epilepsy is relatively low. General public education campaigns and specific school education campaigns children should be encouraged to increase the KAP toward epilepsy. The prevalence and pattern of epilepsy and stroke is on the higher side in the village of Pattaravakkam. Future research regarding the value of targeted education in improving KAP will be worthwhile.

Young girl presenting with exercise-induced myoglobinuria

INTRODUCTION

The sarcoglycanopathies are a heterogeneous group of autosomal recessive limb-girdle muscular dystrophies that cause varying degrees of progressive proximal muscle weakness.

METHODS

We describe the case of a Caucasian girl who presented with exercise intolerance, myalgia, and dark urine. Onset of symptoms was at age 4, and she had myalgia with physical activity throughout childhood. Creatine kinase levels were as high as 18,000.

RESULTS

Immunostaining of a muscle biopsy showed mildly diminished alpha sarcoglycan staining, and SGCA gene sequencing revealed n.C229T; p.Arg77Cys (R77C) and n.C850T; p.Arg284Cys (R284C), which is associated with alpha sarcoglycanopathy.

CONCLUSIONS

This patient presented with exercise intolerance, myoglobinuria, and almost normal muscle strength into adolescence, which is uncommon in sarcoglycanopathies. This uncommon presentation should be kept in mind, so that early recognition and intervention may prevent future comorbidities and help preserve the quality of life. Muscle Nerve 54: 161-164, 2016.

Subpial transection surgery for epilepsy

BACKGROUND

Nearly 30% of patients with epilepsy continue to have seizures in spite of using several antiepileptic drug (AED) regimens. Such patients are regarded as having refractory, or uncontrolled, epilepsy. No definition of uncontrolled, or medically refractory, epilepsy has been universally accepted, but for the purposes of this review, we will consider seizures as drug resistant if they have failed to respond to a minimum of two AEDs. It is believed that early surgical intervention may prevent seizures at a younger age, which, in turn, may improve the intellectual and social status of children. Many types of surgery are available for treatment of refractory epilepsy; one such procedure is known as subpial transection.

OBJECTIVES

To determine the benefits and adverse effects of subpial transection for partial-onset seizures and generalised tonic-clonic seizures in children and adults.

SEARCH METHODS

We searched the Cochrane Epilepsy Group Specialised Register (29 June 2015), the Cochrane Central Register of Controlled Trials (CENTRAL; May 2015, Issue 5) and MEDLINE (1946 to 29 June 2015). We imposed no language restrictions.

SELECTION CRITERIA

We considered all randomised and quasi-randomised parallel-group studies, whether blinded or non-blinded.

DATA COLLECTION AND ANALYSIS

Two review authors (BK and SR) independently screened trials identified by the search. The same two review authors planned to independently assess the methodological quality of studies. When studies were identified for inclusion, one review author would have extracted the data, and the other would have verified the data.

MAIN RESULTS

We found no relevant studies.

AUTHORS' CONCLUSIONS

We found no evidence to support or refute use of subpial transection surgery for patients with medically refractory epilepsy. Well-designed randomised controlled trials are needed to guide clinical practice.

Subpial transection surgery for epilepsy

BACKGROUND

Nearly 30% of patients with epilepsy continue to have seizures in spite of several antiepileptic drug (AED) regimens. In such cases they are regarded as having refractory, or uncontrolled epilepsy.There is no universally accepted definition for uncontrolled or medically refractory epilepsy, but for the purpose of this review, we will consider seizures to be drug resistant if they failed to respond to a minimum of two AEDs. It is believed that early surgical intervention may prevent seizures at a younger age and improve the intellectual and social status of children. There are many types of surgery for refractory epilepsy with subpial transection being one.

OBJECTIVES

Our main aim is to determine the benefits and adverse effects of subpial transection for partial-onset seizures and generalised tonic-clonic seizures in children and adults.

SEARCH METHODS

We searched the Cochrane Epilepsy Group Specialised Register (8 August 2013), The Cochrane Central Register of Controlled Trials (CENTRAL Issue 7 of 12, The Cochrane Library July 2013), and MEDLINE (1946 to 8 August 2013). We did not impose any language restrictions.

SELECTION CRITERIA

We considered all randomised and quasi-randomised parallel group studies either blinded or non-blinded.

DATA COLLECTION AND ANALYSIS

Two review authors (BK and SR) independently screened the trials identified by the search. The same two authors planned to independently assess the methodological quality of studies. If studies had been identified for inclusion, one author would have extracted the data and the other would have verified it.

MAIN RESULTS

No relevant studies were found.

AUTHORS' CONCLUSIONS

There is no evidence to support or refute the use of subpial transection surgery for medically refractory cases of epilepsy. Well designed randomised controlled trials are needed in future to guide clinical practice.