Abstract TP129: Factor VIII in Acute Cerebral Ischemia Trial - Biomarker in Patients with Large Vessel Occlusion?

Introduction: Baseline elevated Factor VIII (FVIII) level is a significant independent predictor of stroke occurrence and severity. We conducted a prospective serial laboratory cohort study to assess the correlation of FVIII levels in response to thrombolysis in patients with large vessel occlusion (LVO) and acute ischemic stroke (AIS).

Methods: AIS patients with anterior circulation LVO were enrolled within 4.5 hours from last seen normal. Baseline and serial FVIII levels were obtained to determine whether FVIII serves as a surrogate marker of clot burden and if FVIII levels or changes predict (1) recanalization with intravenous tissue plasminogen activator (IV tPA) or (2) symptomatic intracranial hemorrhage (sICH) following tPA. Linear and logistic regression analyses were used to determine significant predictors.

Results: Patients (n=29) had a mean age of 71years, median NIHSS of 15, 62% were of black race and 48% were female. Baseline pre -tPA FVIII was not significantly correlated with clot burden score (-0.15, p=0.45) or vessel recanalization (-0.13, p=0.50). Median FVIII decreased significantly from baseline to 6hrs post-tPA (282% to 161%, p=0.0024), but delta in FVIII level did not correlate with vessel recanalization (0.01, p=0.95). No patient had sICH. There was no difference between median FVIII level at baseline and 90 days post AIS.

Interpretation: FVIII level decreased significantly after tPA, but baseline FVIII level and early change in FVIII level were not significant predictors of clot burden, vessel recanalization after treatment with IV tPA, or symptomatic hemorrhage. This trial provided no evidence to support the value of acute FVIII level as a biomarker in AIS due to LVO. The physiology behind the decrease in FVIII level after tPA remains unknown.

Abstract TP186: High Hospital Mortality Among Non-black Stroke Patients with Metabolic Syndrome

Introduction: Limited information is available on race based stroke outcomes among patients with metabolic syndrome.

Methods: We conducted a retrospective review of acute ischemic stroke patients between 2008 and 2015 who were admitted to stroke service at a comprehensive stroke center. Patients were categorized to have metabolic syndrome if they have three of the four criteria (history of hypertension or diabetes or triglycerides ≥ 150 mg/dl or high density lipoprotein (HDL) < 50 mg/dl for women or < 40 mg/dl for men). Patients with metabolic syndrome were grouped based on their race. Primary outcome was modified Rankin Scale score at discharge. Secondary outcomes measures were neurological worsening, hospital mortality, in-hospital complications, discharge stroke scale, and length of stay.

Results: Total 659 patients were found to have metabolic syndrome. Among these patients, 206 (31%) were non-black and 453 (69%) were of black race. Compared to non-black patients with metabolic syndrome, black patients were more likely to be women (56% vs. 35%, p<0.0001) and have a prior history of stroke (55% vs. 35%, p<0.0001). Median admission diastolic blood pressure was higher among blacks compared to non-blacks (92 vs. 87mmHg, p = 0.0093). Higher proportion of black patients were on anti-platelets (67% vs. 56%, p = 0.01), statins (83% vs. 71%; p =0.001), and anti-hypertensive medications at home (90% vs. 81%, p = 0.001). Non-blacks had higher triglycerides (188 vs. 132 mg/dl, p<0.0001) and lower HDL levels (36 vs. 44 mg/dl, p< 0.0001). There was no difference in discharge modified Rankin Scale score among the groups. In-hospital myocardial infarction was significantly more frequent among non-blacks (9% vs. 4%, p = 0.03). In-hospital mortality was significantly higher in the non-black group (11% vs. 6%, p = 0.02).

Conclusion: Non-black race was associated with higher in-hospital mortality among patients with metabolic syndrome admitted for stroke. Further exploration of higher mortality among this group of patients is warranted to improve stroke outcomes.

Treatment With Tissue Plasminogen Activator in the Golden Hour and the Shape of the 4.5-Hour Time-Benefit Curve in the National United States Get With The Guidelines-Stroke Population

BACKGROUND

Earlier tissue plasminogen activator treatment improves ischemic stroke outcome, but aspects of the time-benefit relationship still not well delineated are: (1) the degree of additional benefit accrued with treatment in the first 60 minutes after onset, and (2) the shape of the time-benefit curve through 4.5 hours.

METHODS

We analyzed patients who had acute ischemic stroke treated with intravenous tissue plasminogen activator within 4.5 hours of onset from the Get With The Guidelines-Stroke US national program. Onset-to-treatment time was analyzed as a continuous, potentially nonlinear variable and as a categorical variable comparing patients treated within 60 minutes of onset with later epochs.

RESULTS

Among 65 384 tissue plasminogen activator-treated patients, the median onset-to-treatment time was 141 minutes (interquartile range, 110-173) and 878 patients (1.3%) were treated within the first 60 minutes. Treatment within 60 minutes, compared with treatment within 61 to 270 minutes, was associated with increased odds of discharge to home (adjusted odds ratio, 1.25; 95% confidence interval, 1.07-1.45), independent ambulation at discharge (adjusted odds ratio, 1.22; 95% confidence interval, 1.03-1.45), and freedom from disability (modified Rankin Scale 0-1) at discharge (adjusted odds ratio, 1.72; 95% confidence interval, 1.21-2.46), without increased hemorrhagic complications or in-hospital mortality. The pace of decline in benefit of tissue plasminogen activator from onset-to-treatment times of 20 through 270 minutes was mildly nonlinear for discharge to home, with more rapid benefit loss in the first 170 minutes than later, and linear for independent ambulation and in-hospital mortality.

CONCLUSIONS

Thrombolysis started within the first 60 minutes after onset is associated with best outcomes for patients with acute ischemic stroke, and benefit declined more rapidly early after onset for the ability to be discharged home. These findings support intensive efforts to organize stroke systems of care to improve the timeliness of thrombolytic therapy in acute ischemic stroke.

Higher prehospital blood pressure prolongs door to needle thrombolysis times: a target for quality improvement?

BACKGROUND

Per the American Heart Association guidelines, blood pressure (BP) should be less than 185/110 to be eligible for stroke thrombolysis. No studies have focused on prehospital BP and its impact on door to needle (DTN) times. We hypothesized that DTN times would be longer for patients with higher prehospital BP.

METHODS

We conducted a retrospective review of acute ischemic stroke patients who presented between January 2010 and December 2010 to our emergency department (ED) through emergency medical services within 3 hours of symptom onset. Patients were categorized into 2 groups: prehospital BP greater than or equal to 185/110 (group 1) and less than 185/110 (group 2). Blood pressure records were abstracted from emergency medical services run sheets. Primary outcome measure was DTN time, and secondary outcome measures were modified Rankin Score at discharge, symptomatic intracranial hemorrhage, length of stay in stroke unit, and discharge disposition.

RESULTS

A total of 107 consecutive patients were identified. Of these, 75 patients (70%) were thrombolysed. Mean DTN times were significantly higher in group 1 (adjusted mean [95% confidence interval], 86minutes [76-97] vs 56minutes [45-68]; P<.0001). A greater number of patients required antihypertensive medications before thrombolysis in the ED in group 1 compared to group 2 (54% vs 27%; P=.02).

CONCLUSION

Higher prehospital BP is associated with prolonged DTN times and DTN time remains prolonged if prehospital BP greater than or equal to 185/110 is untreated before ED arrival. Prehospital BP control could be a potential area for improvement to reduce DTN times in patients with acute ischemic stroke.

Abstract 161: Safety of Intravenous Thrombolysis in Wake-up Stroke: A Multicenter, Prospective, Open-label Study

Background and Objectives: A significant number of ischemic strokes are noticed upon awakening and are not candidates for intravenous recombinant tissue plasminogen activator (rtPA) due to >3 hours from last seen normal (LSN). We tested the safety of rtPA in a multicenter, single-arm, prospective, open-label study (NCT01183533) of rtPA in patients with wake-up stroke (WUS).

Methods: We aimed to enroll 40 WUS patients with disabling deficits. Patients were 18-80; NIHSS ≤25; and selected only on the appearance of non-contrast CT (i.e., <1/3 MCA territory hypodensity). Standard dose (0.9mg/kg) intravenous rtPA had to be started ≤3 hours of awakening. The primary safety outcome was symptomatic intracerebral hemorrhage (ICH) with pre-planned stopping rules and data safety board oversight. Other endpoints included: asymptomatic ICH, clinical improvement in NIHSS and 90-day modified Rankin Scale score (mRS).

Results: Between 10/2010 and 10/2013, all pre-planned patients were enrolled. Four patients (10%) were subsequently determined to be mimics. Baseline characteristics, treatment and outcome data are shown in the table. No symptomatic ICH or parenchymal hematomas occurred.

Conclusion: Intravenous thrombolysis appears to be safe in WUS patients selected by non-contrast CT. A randomized effectiveness trial appears feasible using a similar, pragmatic design.

Blood pressure management in stroke: Five new things

Hypertension is a major modifiable risk factor for stroke, with an estimated 51% of stroke deaths being attributable to high systolic blood pressure globally.^1,2 The management of hypertension in stroke is determined by timing, the type of stroke, use of thrombolysis, concurrent medical conditions, and pharmacologic variables. We highlight the details of elevated blood pressure management in the hyperacute/acute, subacute, and chronic stages of ischemic stroke and intracerebral hemorrhage.

Progressive leg pain and weakness

A 54-year-old man presented with progressive asymmetric leg pain and weakness. He had a history of invasive squamous cell carcinoma that was fully treated 2 years earlier. His leg symptoms progressed relentlessly during several months. Imaging studies demonstrated enhancement of the cauda equina and leptomeninges of the lower spinal cord. Initial cerebrospinal fluid examination showed an elevated protein concentration and lymphocytic pleocytosis with no malignant cells on cytological analysis. There was short-term improvement in symptoms and cerebrospinal fluid abnormalities with intravenous steroids. Two additional cerebrospinal fluid studies showed normal cytological findings, elevated IgG synthesis, and elevated antibody titers to varicella-zoster virus. Over time, the patient worsened, developed cranial neuropathies, and ultimately died. The pathological diagnosis and the approach to the clinical data are discussed.