Association of Dental Infections with Intracranial Atherosclerotic Stenosis

INTRODUCTION

Periodontal disease (PD) and dental caries are oral infections leading to tooth loss that are associated with atherosclerosis and cerebrovascular disease. We assessed the hypothesis that PD and caries are associated with asymptomatic intracranial atherosclerosis (ICAS) in the Atherosclerosis Risk in Communities (ARIC) study.

METHODS

Full-mouth clinical periodontal measurements (7 indices) collected at 6 sites per tooth from 6,155 subjects from the Dental Atherosclerosis Risk in Communities Study (DARIC) without prior stroke were used to differentiate seven PD stages (Periodontal Profile Class [PPC]-I to -VII) and dental caries on coronal dental surface (DS) and dental root surface (DRS). A stratified subset underwent 3D time-of-flight MR angiogram and 3D high isotropic-resolution black blood MRI. ICAS was graded according to the criteria established by the Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) trial. We evaluated the relationship between PD stage and dental caries with asymptomatic ICAS, graded as no ICAS, <50% ICAS, and ≥50% ICAS.

RESULTS

Among dentate subjects who underwent vascular imaging, 801 (70%) had no ICAS, 232 (20%) had <50% ICAS, and 112 (10%) had ≥50% ICAS. Compared to participants without gum disease (PPC-I), participants with mild-moderate tooth loss (PPC-VI), severe tooth loss (PPC-VII), and severe PD (PPC-IV) had higher odds of having <50% ICAS. Participants with extensive gingivitis (PPC-V) had significantly higher odds of having ≥50% ICAS. This association remained significant after adjusting for confounding variables: age, gender, race, hypertension, diabetes, dyslipidemia, 3-level education, and smoking status. There was no association between dental caries (DS and DRS) and ICAS <50% and ≥50%.

CONCLUSION

We report significant associations between mild-moderate tooth loss, severe tooth loss, and severe PD with <50% ICAS as well as an association between extensive gingivitis and ≥50% ICAS. We did not find an association between dental caries and ICAS.

Abstract 135: Adiponectin: Potential Mediator Between Central Obesity And Intracranial Atherosclerosis?

Introduction: Prior studies have identified a significant association between Waist-to-Hip Ratio (WHR) and intracranial atherosclerosis (ICAS). Adiponectin, a hormone that improves insulin sensitivity, has been hypothesized to have a protective effect against atherosclerosis. We assessed the association between central obesity-ICAS, and its potential mediation by Adiponectin.

Methods: In the ARIC cohort a stratified subset of subjects were assessed for adiposity, adiponectin level and ICAS during visit 5 (2011-2013). Adiposity was assessed by body mass index (BMI) and waist to hip ratio (WHR). Central obesity was defined as WHR ≥0.90 for men and ≥0.85 for women. Plasma total and total adiponectin were measured by ELISA. ICAS was assessed for by 3D time-of-flight magnetic resonance angiogram (MRA). Subjects were stratified as those with any ICAS and those without. Multivariable analysis was conducted using multiple logistic regression to test the central obesity-ICAS association.

Results: A total of 1641 subjects underwent evaluations (age 76.3±5.3, 41% Male, 71% white). Of these subjects 506 (31%) had ICAS detected on MRA. Those with ICAS were older (77±5 vs. 76±5, p<0.001), likely to be male (47% vs. 39%, p=0.001), African American (33% vs. 27%, p=0.006) and hypertensive (72% vs. 64%, p=0.004). Those with ICAS had similar BMI (28.5±5.7 vs. 28.1±5.3, p=0.26) although the WHR was higher (0.94±0.08 vs. 0.92±0.08, p<0.001). Adiponectin levels were lower (10.6±6.7 vs. 12.0±7.5, p<0.001) compared with those without ICAS. Those with central obesity had a lower level of Adiponectin (10.6±6.5 vs. 15.3±8.7, p<0.001). Central obesity was significantly (p=0.01) associated with ICAS (Odds Ratio 1.43, 95%) CI 1.08-1.91) adjusted for age, race, gender, and hypertension, however lost its significance (p=0.06) when Adiponectin is added to the model (Odds Ratio 1.33, 95% CI 0.99-1.80).

Conclusion: We report a significant inverse association between central obesity, as well as ICAS, with Adiponectin levels. We also report a significant association between central obesity with ICAS that loses its significance after adding Adiponectin to the multivariate model. This result suggests that central obesity effect on ICAS may possibly be mediated by Adiponectin.

Abstract TMP76: Association Of Adiposity With Intracranial Atherosclerosis

Introduction: Adiposity, as measured by Body Mass Index (BMI) and Waist-to-Hip Ratio (WHR), is associated with ischemic stroke. However, association with Intercranial Atherosclerosis has not been well-established in the United States. We assessed the hypothesis that adiposity is associated with asymptomatic intracranial atherosclerosis (ICAS).

Methods: BMI was calculated as weight (kg)/height (m) 2 . The ratio of waist (umbilical level) to hip (maximum buttocks) circumference (WHR) was calculated as a measure of fat distribution. In the ARIC cohort, a stratified subset (N=1145) underwent 3D time-of-flight MR angiogram and 3D high-isotropic resolution black blood MRI. ICAS was graded according to the criteria established by the Warfarin-Aspirin Symptomatic Intracranial Disease trial. In this study, we evaluated the relationship between BMI as well as WHR, and significant asymptomatic ICAS, defined as ≥50% stenosis. Student t-tests were performed to test continuous variables, and X 2 test was used to compare categorical variables. Analysis of covariance (ANCOVA) was used for multivariate testing.

Results: Among subjects who underwent vascular imaging, 1033 (90%) had <50% ICAS and 112 (10%) had ≥50% ICAS. At the time of assessment, those with ≥50% ICAS were older (age 79±5 vs. 76±5, p<0.001), and had higher systolic blood pressure or SBP (134±19 vs. 130±18, p=0.02), compared with those with <50% ICAS. The BMI was higher (29.1±6.7 vs. 28.1±5.2), although the difference was statistically borderline significant (p=0.06). The WHR was higher (0.95±0.07 vs. 0.93±0,08), the difference being statistically significant (p=0.01). The difference remained significant after adjustment for age and SBP (p=0.02).

Conclusion: We report a significant association between WHR, a measure of central adiposity, and ≥50% ICAS. This may be one of the first reported associations between central adiposity and ICAS. These results emphasize the importance of adiposity distribution in addition to overall adiposity, as a risk factor for significant asymptomatic ICAS.

Abstract MP43: Paradoxical Response to Antibodies in Periodontal Microbes in Subjects With Intracranial Atherosclerotic Stenosis

Introduction: Previously we have shown that periodontal disease and systemic inflammation are related to intracranial atherosclerosis (ICAS) in Atherosclerosis Risk In Communities study (ARIC). In this study we evaluated the relationship between serum antibodies against periodontal pathogens and ICAS.

Methods: In this ongoing, prospective, longitudinal community-based cohort study, participants were assessed for antibodies to periodontal organisms including Porphyrmonas gingivalis (PG), Prevotella intermedia (PI), Prevotella nigrescens (PN), Bacteriodes forsythensis (BF), Treponema denticola (TD), Actinobacillus actinomycetemcomitans (AA), Campylobacter rectus (CR), Eikenella corrodens (EC), Fusobacterium nucleatum (FN), Peptostreptococcus micros (PM), Selenomonas noxia (SN), Capnocytophaga ochracea (CO), Veillonella parvula (VP), Streptococcus sanguinis (SS), Streptococcus intermedius (SI), Streptococcus oralis (SO), Actinomycosis viscosis (AV) and Helicobacter pylori (HP). These participants underwent 3D time-of-flight magnetic resonance angiography (MRA) to evaluate ICAS. Log mean antibody (IgG), CRP and IL-6 levels were compared using t-test between groups with and without ≥50% ICAS.

Results: In this ARIC cohort, 1066 participants were assessed by MRA for ICAS. Serum CRP and IL-6 data were available for all and IgG levels were available for 772 participants. The log mean IgG level was significantly lower for patients with ≥50% ICAS versus patients with <50% ICAS in four organisms: PN (1.69 vs 1.80, p= 0.03 ), BF (1.30 vs 1.38, p=0.05 ), CO (1.23 vs 1.33, p= 0.04 ), FN (0.87 vs 1.01, p=0.02 ). The log mean IgG was also lower for CR, EC, SN, VP, SI, SO and AV though not significant. Log mean CRP was higher in the ≥50% ICAS group versus the <50% ICAS group (0.58 vs. 0.47, p < 0.001 ). Log mean IL-6 levels were also higher but not significant (0. 17 vs. 0.11, p= 0.07 ).

Conclusion: Higher levels of systemic inflammatory markers (CRP, IL-6) are associated with significant ICAS, but we report a significantly lower level of IgG antibodies to specific periodontal pathogens (PN, BF, CO and FN) in patients with ≥50% ICAS. This paradoxical finding may represent the effect of systemic inflammation and oxidative stress on IgG levels to periodontal bacteria.

Abstract 136: Role of Periodontal Disease on Intracranial Atherosclerosis

Introduction: Periodontal disease (PD) is a chronic inflammatory process that affects gum and teeth. Due to the role of inflammation on atherosclerosis, we assessed the hypothesis that PD is associated with asymptomatic intracranial atherosclerosis (ICAS) in the Atherosclerosis Risk In Communities (ARIC) study.

Methods: Full-mouth clinical periodontal measurements (7-indices) collected at 6 sites per tooth from 6155 subjects from the Dental Atherosclerosis in Communities Study (DARIC) without prior stroke were used to differentiate seven periodontal profile classes (PPCs). Of this cohort, a stratified subset underwent 3D time-of-flight MR angiogram and 3D high-isotropic resolution black blood MRI. ICAS was graded according to the criteria established by the Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) trial. In this study, we evaluated the relationship between PD status and severe asymptomatic ICAS, defined as ≥50% stenosis.

Results: Among dentate subjects who underwent vascular imaging, 1033 (90%) had 0-50% ICAS and 112 (10%) had ≥50% ICAS. Compared to participants without gum disease (PPC-A), participants with gingivitis (PPC-C) had significantly higher odds of having ≥50% ICAS (Figure 1; Crude OR 2.1, 95% CI 1.2-3.8, p=0.015). This association strengthened after adjusting for the significant confounding variables: age, hypertension, and LDL cholesterol (Adjusted OR 2.4, 95% CI 1.3-4.5, p=0.006).

Conclusion: We report a significant association between inflammatory PD class and ≥50% asymptomatic ICAS. Because gingivitis is reversible, future studies are needed to determine if treatment of gingivitis can prevent the development and progression of ICAS, thus reducing the risk of stroke.

Abstract W P310: Contemporary Trends In The Ischemic Stroke “Weekend Effect” On IV Thrombolytic Use, In-hospital Mortality, Discharge Disposition, Hospital Charges, And Length Of Stay - A National Perspective

Background: We sought to check current stutus of weekend effect (differences in acute ischemic stroke (AIS) outcomes between patients admitted at the weekend versus weekday) which is the basis of many change in health policy to deal with disparities.

Objective: To evaluate the influence of admission on a perticular day of the week (DOW) on outcomes in AIS pts.

Methods: We reviewed the HCUP's Nationwide Inpatient Sample (NIS) database from 2008 - 11 for all emergency room (ER) admissions for AIS using ICD 9-CM code. NIS represents 20% of all US hospital. Pts aged < 18 years were excluded. After adjusting for age, gender, median income level, primary payer, hospital region, teaching status, and bed size, a Survey Logistic and Linear regression models were used to compare weekend versus weekday stroke admissions in terms of: incidence of IV thrombolytic (IVT) use, in-hospital mortality and discharge disposition. Length of stay (LOS) was calculated only in pts who survived. Cost to charge ratio files were merged with NIS to calculate cost of care. The cost of care was adjusted for inflation with reference to 2011. Chi-square was utilized for univariate analysis for categorical variable.

Results: A total 390,401 (weighted: 1,933,243) ER admissions were studied, of which 99,968 (weighted: 494,863) were admitted on weekends. The average age of the cohort was 71 years, 53.4 % females, and 60.8% were whites. In univariate analysis, admission on weekend was associated with higher mortality (7.28% vs. 7.13%, p<0.001), higher utilization of IVT (4.10% vs. 3.72%, p<0.001) and higher discharge to long term facility (44.7% vs. 42.9%, p<0.001). After adjusting for confounders, weekend admission was associated with higher utilization of IVT (OR/days/cost, 95% CI, P-value) (OR 1.10, 1.06 - 1.14; p<0.001); increased discharge to long term facility (OR 1.08, 1.06 - 1.10; p<0.001) and have statistically shorter LOS (-0.08 days, -0.14 - -0.02; p = 0.007). There was no difference in in-hospital mortality (OR: 1.02, 0.99 - 1.05; p = 0.17) or cost of care (142$, - 5 - 288; p=0.06) for weekend admission.

Conclusion: Admission on a weekend is a predictor of higher utilization of IVT and discharge to a long-term facility , but there was no difference in in-hospital mortality or cost of care.

Abstract W MP118: Influence of Do-Not-Resuscitate Orders on Length of Stay and Cost of care after Intracerebral Hemorrhage after Charlson's Comorbidity Index adjustment in United States

Background: The trends in utilization of Do-Not-Resuscitate Orders (DNR) and its effect upon outcomes among patients with intracerebral hemorrhage (ICH) is not studied within a national representative population.

Objective: To identify the contemporary rate of utilization impact of DNR status on length of stay (LOS) and cost of care among patients (pts) admitted with ICH.

Methods: We reviewed the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample (NIS) database from 2011 for ICH using ICD 9-CM code (431) as a primary diagnosis. We defined patients’ DNR status with ICD CM code - V49.86 as a secondary diagnosis. Comorbid conditions were defined by Charlson's Comorbidity Index (CCI). Cost to charge ratio files were merged with NIS to calculate cost of care. LOS was calculated only in pts who were alive. T test was utilized for univariate analysis for continuous variable. Hierarchical multilevel regression models were generated to determine independent predictors of LOS and cost of care.

Results: Total of 13440 pts (weighted: 64617) with ICH were analyzed, out of which 2029 pts (weighted: 9713) had DNR orders. Average LOS and cost of care for all ICH pts were 8.76 ± 0.12 days and $ 19386 ± 261, respectively. In univariate analysis, LOS and cost of care were lower in DNR pts (LOS: 5.76 ± 0.34 vs. 9.04± 0.13, p <0.001; Cost: $11020 ± 400 vs. $20916 ± 298, P <0.001). In multivariate analysis, the results were (days/cost, 95% CI, P-value) (LOS: -1.30 days, -2.26 - -0.35, p<0.001; cost: $ -5509, -6851 - -4168, p<0.001). Elective admission was associated with decrease in cost (Cost: $ -2439, -4506 - -372, p=0.02). Pts with private insurance were more likely to have decrease LOS and cost of care (LOS: -1.62, -2.35 - -0.90, p<0.001; Cost: -1439, -2745 - -132, p=0.03) as compared with Medicare/Medicaid. Hospital teaching status was associated increase in cost of care while self pay/others was associated with decrease in cost of care. CCI >= 3 was associated with increase in both cost of care and LOS as compared to CCI= 1.

Conclusions: DNR status in patient with ICH is a predictor of a significantly lower LOS and cost of care. Appropriate use of DNR status may reduce LOS and cost of care in ICH patients and decrease inappropriate resource utilization.

Abstract T P108: MRI Measurements of Intracranial Atherosclerosis in the ARIC Neurocognitive Study: Methods, Reliability and Descriptive Statistics

Introduction: A 3D high resolution MRI (HRMRI) vascular protocol was designed to measure intracranial atherosclerosis in a biracial population from the multicenter ARIC Neurocognitive (ARIC-NCS) study.

Hypothesis: HRMRI provides reliable intracranial vessel wall measurements in a population-based study.

Methods: 1980 ARIC-NCS participants (mean age, 77.2±5.3 years; 40% male; 71% white, 28% black) underwent a brain HRMRI protocol designed to identify atherosclerosis in major intracranial arteries, that included 3D time-of-flight MRA and 3D black blood MRI (both acquired at 0.5-mm 3 resolution). Among 1980 participants, 102 were recruited for repeat MRI exams to estimate scan and reader variability. Participants were selected based on identification of at least one intracranial plaque on the baseline MRI scan with adequate or excellent image quality. Exam pairs were read by the same reader to exclude inter-reader variation. Presence of plaque by vessel segment was recorded. Quantitative MRI measurements included lumen size and stenosis, wall/plaque thickness, area, and volume, normalized wall index over each vessel segment, and the largest plaque identified for each vascular territory (Table 1). Reliability was assessed by percent of agreement, kappa statistics and intraclass correlations (ICC).

Results: There were 272 pairs of repeated interpretations. Percent agreement, of plaque identification per participant was 87.0% (inter-reader), 89.2% (intra-reader), and 89.9% (between scans). The reliability for plaque identification was not impacted by the vessel segment. Repeat scan and repeat reader reliability (ICC) for quantitative measurements ranged from 0.69 to 0.98 (Table 1).

Conclusion: HRMRI provides reliable MRI measurements of intracranial vessels, and reliability was not impacted by plaque location.

Abstract W MP109: Variation In Utilization Of Do-not-resuscitate Orders Between Hospitals In Patients With Intracerebral Hemorrhage: A National Perspective

Background: An unfavorable clinical course and limited treatment for intracerebral hemorrhage (ICH) leads to frequent do not resuscitate (DNR) orders. Data on inter-hospital variability of DNR utilization in patients (pts) with ICH is limited.

Hypothesis: To analyze the between hospital variation in the utilization of DNR in ICH among low volume and high volume hospitals.

Methods: We reviewed the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample (NIS) database from 2011-2012 for ICH admissions in patients >18 years using the ICD 9-CM code 431. We defined DNR status with ICD9CM code V49.86 entered during the same admission as a secondary diagnosis and estimated severity of illness by the 3M™ All Patient Refined DRG (APR DRG) classification System. We calculated ICH annual hospital volume and ranked them into four quartiles. 1st quartile hospitals were defined as low volume and rest as high volume. We generated hierarchical two level multivariate models and calculated Inter class correlation (ICC) and Median Odds Ratio (MOR).

Results: We analyzed 25768 patients (weighted estimate126254) with ICH out of which 4620 (18%) patients (weighted estimate 22668) had DNR orders placed. Low volume hospitals accounted for total of 6575 pts (weighted: 32849), out of which 1504 pts (weighted: 7508) had DNR orders. Of the variation in DNR utilization between low volume hospitals, 63.0 % (ICC of 0.63; C statistics: 0.9) was attributable to individual hospital behavior of as compared to 29% in high volume (ICC=0.29; C statistics: 0.8), Also, the MOR was 9.3 for low volume hospitals indicating that a randomly selected patient at a particular hospital would have approximately nine times the chance of having a DNR order placed than an identically matched patient at another. This was three times as high as that for high volume hospitals (MOR=3). All models were adjusted for patient level, hospital level characteristics, APR DRG severity scale and other clinical characteristics.

Conclusion: In conclusion, there is significant individual variation between hospitals in DNR utilization. Variation is three times higher in low volume hospitals as compared to high volume hospitals. Further attempts should be made to understand this inter-hospital difference.

Abstract T P22: Intra-procedural Heparin Increases Mortality and Reduces Rates of Favorable Outcome in Acute Ischemic Stroke Patients Undergoing Endovascular Treatment

Background: Heparin is thought to provide an anticoagulant effect preventing catheter related thrombosis duting acute intra-arterial thrombolytics in acute ischemic stroke patients undergoing endovascular procedures.

Objective: To perform a systematic review to determine the effect of intra-procedural heparin (and intensity) on rates of symptomatic intracerebral hemorrhage (ICH), mortality, and favorable outcome (mRS of 0-2) at 1-3 months.

Methods: All published trials until 2012 evaluating endovascular treatment were identified from Pubmed using searches with keywords “Catheter based therapy AND Stroke,” “Intra-arterial acute stroke,” “Intra-arterial thrombolysis,”. Studies that reported their treatment time window, baseline median NIH Stroke Scale (NIHSS) score, mean age, and 3-month outcomes were selected. The studies were divided into two groups; endovascular treatment performed with or without intra-procedural heparin. Among those who received heparin, patients were divided into high and low dose heparin. Low dose of heparin was defined as less than 2500 U/hr, and high dose heparin was defined as more than 2500 U/hr.

Results: A total of 957 (patients in both arms were analyzed) from 33 trials. Intra-procedural heparin was used in 485 of 957 patients (51%); 228 and 257 patients were treated with low dose and high dose heparin, respectively. The rate of symptomatic ICH was not different in patients who received or did not receive intra-procedural heparin (80 of 485 versus 60 of 472, p=0.09). However, trial defined mortality was significantly lower in those who did not receive heparin (107 of 472 versus 141 of 485, p=0.02). There was a significantly higher rate of favorable outcomes at 1 to 3 months in patients who did not receive heparin compared with those who received heparin (305 of 472 versus 264 of 485, p=0.001). . Among patients who received intra-procedural heparin, the rate of symptomatic ICH was significantly higher in those who received high dose heparin as compared to low (dose (55 of 257 versus 25 of 228, p=0.001).

Conclusion: Intra-procedural use of heparin during endovascular treatment among acute ischemic stroke patients was associated with higher rates of mortality and lower rates of favorable outcomes at 1-3 months.

Cost-effectiveness analysis of intracranial stent placement versus contemporary medical management in patients with symptomatic intracranial artery stenosis

BACKGROUND

Intracranial angioplasty and stent placement has been increasingly evaluated as a new method for treatment of symptomatic intracranial stenosis in select patients. The Food and Drug Administration (FDA) has approved intracranial stent treatment of symptomatic atherosclerotic intracranial lesions.

PURPOSE

To determine the cost-effectiveness of intracranial artery stent placement compared with contemporary medical management for secondary stroke prevention among patients with symptomatic intracranial stenosis.

METHODS

Clinical outcome data were obtained from the aspirin treatment arm of the Comparison of Warfarin and Aspirin for Symptomatic Intracranial Disease (WASID) trial (n = 280) and 12 case series (n = 216) of patients who underwent stent placement of symptomatic intracranial stenosis with comparable characteristics. Total cost of procedure and medical management-only was calculated using the rates of major stroke, minor stroke, or death in each group. All costs are expressed in 2010 US$. The quality-adjusted life-year (QALY) of each intervention strategy was estimated using the frequency of the outcomes of major and minor stroke, death, and baseline health. An incremental cost-effectiveness ratio (ICER) was formulated for a 1-year period.

RESULTS

The total rate of stroke at one year was 10.2% (6.1-14.2%) and the rate of all-cause mortality was 3.7% (1.2-6.2%) in the stent group. The corresponding annualized rates of stroke and all-cause mortality in the medical management-only group were 15% (10.8-19.2%) and 2.4% (0.6-4.2%), respectively. The calculated net costs at one year for intracranial stent placement and contemporary medical management were US$16,898 and US$3,468, respectively. Overall, QALYs for the two groups were 0.82 and 0.81 (in a range of 0 to 0.89 corresponding to death and baseline health), respectively. The cost per QALY gained after intracranial stent placement and contemporary medical therapy was US$20,542 and US$4,265, respectively. The corresponding ICER for stent versus medical treatment alone was US$1,416,268.

CONCLUSION

The reduced risk of stroke following intracranial stent placement is offset by significantly higher procedure-associated net costs. Select procedures in patients with symptomatic stenosis of 70% or greater are more likely to be cost-effective.

Abstract 3158: Presence of Underlying Metastatic Malignancy Increases the Risk of Intracerebal Hemorrhage after Endovascular Treatment of Acute Ischemic Stroke

Background: The effect of pre-existing malignancy with or without metastasis on angiographic and clinical success of endovascular treatment in acute ischemic stroke patients has not been previously studied. The procoagulant states in patients with pre-existing malignancy may lead to suboptimal results after endovascular treatment.

Objective: To determine the effect of underlying malignancy with or without metastasis on angiographic recanalization and clinical outcomes among acute ischemic stroke patients undergoing endovascular treatment.

Methods: We reviewed consecutive acute ischemic stroke patients treated with endovascular treatment over a 5-year period. Demographics characteristics, NIHSS score before and after the procedure, and discharge modified Rankin scale (mRS) were collected. An improvement of 1 point or more on the Qureshi grading scale was used to define angiographic recanallization. Primary malignancy and evidence of metastasis was obtained by individual chart review. We analyzed whether the presence of malignancy with or without metastasis was associated with angiographic recanalization, favorable clinical outcome, intra-cerebral hemorrhage (ICH), and length of stay (LOS) after age and NIHSS score adjustment.

Results: We analyzed 186 patients undergoing endovascular treatment, mean age + SD: 65+16 years, 100(54%) men, and mean admission NIHSS score ± SD: 15.3+8. Of these, 34 patients (18%) had underlying malignancy [20 were men] with 16 patients with documented metastatic disease. The mean age was higher in the malignancy group (72 versus 64 years, p=0.014). LOS was similar (11 days versus 9, p=NS). Adjusting for age and admission NIHSS score, regression analysis showed no impact from malignancy with or without metastatic disease on recanalization rate (odds ratio [OR]=0.5, p=NS) or discharge mRS (p=NS). A total of 37 patients developed ICH after endovascular therapy (38% and 18% in patients with or without underlying malignant disease, respectively). The presence of malignancy wih or without metastatic disease was associated with significantly higher ICH rates (OR=3, p=0.05) after endovascular treatment.

Conclusion: Underlying malignancy with or without metastasis in patients undergoing endovascular procedure for acute ischemic stroke is not associated with lower rates of angiographic recanalization or poor outcomes but increases the rates of post-procedural ICH by 3 fold.

Abstract 3946: Determinants and Outcomes Associated with Withdrawal of Care following Endovascular Treatment in Acute Ischemic Stroke Patients

Background: Withdrawal of care although frequently used may prematurely reduce the odds of recovery in patients with acute ischemic stroke. We performed this study to provide a better understanding of physician practices in withdrawal of care following endovascular treatment in acute ischemic stroke patients.

Objective: Our goal was to identify frequency and factors associated with endovascular treatment that increase the odds of withdrawal of care in consecutive series of acute ischemic stroke patients.

Methods: We reviewed consecutive acute ischemic stroke patients treated with endovascular treatment over a 5-year period. Demographics characteristics, National Institute of Health Stroke Scale (NIHSS) score before and after the procedure, and modified Rankin scale (mRS) at discharge were collected. The Qureshi grading scale was used to evaluate angiographic recanalization. We analyzed whether the presence of successful recanalization, or post-procedure intracerebral hemorrhage (ICH), was associated with withdrawal of care after age and 24 hr NIHSS score adjustment. The effect of withdrawal of care on poor outcome (mRS 3-6) at discharge was determined after adjusting for age and admission NIHSS score.

Results: A total of 186 patients underwent endovascular treatment, mean age + SD: 65 (±17) years, 100 (54%) men, and mean NIHSS score ± SD: 15.5+ 7. Sixty four patients received intra-arterial thrombolytic only, 28 mechanical thrombectomy only, and 75 combined lytic/mechanical thrombectomy. Among all, 142 patients (77%) had vessel recanalization. Of these, 17 (9%) underwent withdrawal of care. 14% of the patients with recanalization versus 8% without recanalization underwent withdrawal of care (p=NS). Overall there were 37 patients who developed post-procedure ICH, but this occurrence was not associated with withdrawal of care status (p=NS). After adjusting for age and admission NIHSSS, there was no relationship between angiographic recanalization with withdrawal of care (OR=0.5, p=0.3). Patients who underwent mechanical thrombectomy during endovascular treatment had significant correlation with withdrawal of care compared to intra-arterial thrombolytic therapy alone (OR=10, p=0.02).

Conclusion: Withdrawal of care, although infrequent, contributes to poor outcome at discharge in patients undergoing endovascular procedure for acute ischemic stroke. However, the choice of withdrawal of care is not related to angiographic recanalization or post-procedural ICH.

Abstract 140: National Trends in Utilization and Outcomes of Endovascular Treatment in Acute Ischemic Stroke Patients

Background: With the availability of several new devices for mechanical thrombectomy after recent approvals by the Food and Drug Administration, the outcomes of patients undergoing endovascular treatment for acute ischemic stroke are expected to improve in United States.

Objective: To evaluate trends in utilization of endovascular treatment and associated rates of death and disability among acute ischemic stroke patients over six years.

Methods: We obtained data for patients admitted to hospitals in the United States between 2004 to 2009 with a primary diagnosis of ischemic stroke using a large national database. We determined the rate of utilization of endovascular treatment. Outcomes were classified as minimal disability, moderate to severe disability, and death based on discharge disposition.

Results: Of the 670,069 patients with ischemic stroke, 72,342 (10.8%) received intravenous thrombolytic treatment, 18,229 (2.72%) had endovascular thrombolysis. Patients with endovascular treatment comprised 0.35% of ischemic strokes in 2004 vs 4.95% in 2009 (p < 0.001). The estimated number of patients undergoing endovascular treatment increased by 1,519% (362 to 5502) despite a 324% increase in patients receiving intravenous thrombolytic. The rates of intracranial hemorrhage remained unchanged throughout the 6 years. There was no significant difference in all age groups. The interaction between endovascular treatment among all ischemic stroke patients for predicting in-hospital mortality significantly improved (p <0.02).

Conclusion: There has been a significant increase in proportion of acute ischemic stroke patients receiving endovascular treatment over the last 6 years with significant reduction in in-hospital mortality.