Addressing Disparities in Acute Stroke Management and Prognosis

There are now abundant data demonstrating disparities in acute stroke management and prognosis; however, interventions to reduce these disparities remain limited. This special report aims to provide a critical review of the current landscape of disparities in acute stroke care and highlight opportunities to use implementation science to reduce disparities throughout the early care continuum. In the prehospital setting, stroke symptom recognition campaigns that have been successful in reducing prehospital delays used a multilevel approach to education, including mass media, culturally tailored community education, and professional education. The mobile stroke unit is an organizational intervention that has the potential to provide more equitable access to timely thrombolysis and thrombectomy treatments. In the hospital setting, interventions to address implicit biases among health care providers in acute stroke care decision-making are urgently needed as part of a multifaceted approach to advance stroke equity. Implementing stroke systems of care interventions, such as evidence-based stroke care protocols at designated stroke centers, can have a broader public health impact and may help reduce geographic, racial, and ethnic disparities in stroke care, although further research is needed. The long-term impact of disparities in acute stroke care cannot be underestimated. The consistent trend of longer time to treatment for Black and Hispanic people experiencing stroke has direct implications on long-term disability and independence after stroke. A learning health system model may help expedite the translation of evidence-based interventions into clinical practice to reduce disparities in stroke care.

Healthcare Worker With Large Vessel Acute Ischemic Stroke Likely Related to Mild SARS-CoV-2 Infection

We report the case of a healthcare worker who presented with a large vessel acute ischemic stroke in setting of a mild SARS-CoV-2 infection and provide a review of the emerging literature on COVID-related stroke. A 43-year-old female presented with right-sided hemiparesis, aphasia and dysarthria. She had a nonproductive of cough for 1 week without fever, fatigue or dyspnea. A CT Head, CT angiography and CT perfusion imaging revealed a M1 segment occlusion of the left middle cerebral artery requiring transfer from a primary to a comprehensive stroke center. A nasopharyngeal swab confirmed SARS-CoV-2 infection prior to arrival at the accepting center. During the thrombectomy a 3 cm thrombus was removed. Thrombus was also evident in the 8 French short sheath during closure device placement so a hypercoagulable state was suspected. Stroke work-up revealed a glycosylated hemoglobin of 8.7%, elevation of inflammatory markers and an indeterminate level of lupus anticoagulant IgM. On discharge home, she had near complete neurological recovery. This case highlights suspected mechanisms of hypercoagulability in SARS-CoV-2 infection and the importance of optimizing stroke care systems during the COVID-19 pandemic.

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

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

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

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

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

Abstract WP468: Follow Up After Stroke, Screening and Treatment Clinic: Advancing Post-Stroke Care

Objective: To assess feasibility and replicability of a multidisciplinary, specialized clinic in optimization of secondary stroke prevention and stroke related complications.

Background: Recommendations exist for secondary stroke prevention, but it is unclear which outpatient model of care optimizes vascular risk factor control and decreases post-stroke complications most effectively. Designed after the Stroke Transitions, Education, and Prevention clinic in Houston, TX, the Follow up After Stroke, Screening and Treatment (FASST) clinic is an integrated, multidisciplinary, specialized clinic designed to optimize secondary stroke prevention. It provides post discharge stroke education and medication adherence counseling by Pharmacists, as well risk factor and complications management by Vascular Neurologists. Validated patient reported surveys screen for complications: depression, anxiety, sleep disorders, cognitive impairment, disability, social support, quality of life and functional status. Our approach and the characteristics of patients enrolled in the clinic is described.

Methods: Patients attending one FASST clinic visit are included. Institutional Board Review approved consent is obtained. Demographic and clinical data are recorded including risk factors, surveys and outcome scores. Data is entered in Redcap and analyzed through the Statistical Analysis Software (SAS) program.

Results: Of the 25 patients enrolled in the clinic, 83.3% are African American. A high prevalence of hyperlipidemia (100%) and hypertension (100%) exists, with 44% of patients having concomitant diabetes mellitus. Overall 26.7% screened positive for depression with PHQ-9, and 20% screened positive for anxiety with GAD-7. These patients were started on medications and referred for psychotherapy. Abnormal ESS scores were noted in 31.3% and directed for sleep apnea evaluation. Eighteen medical and pharmacy trainees rotated through the clinic.

Conclusion: The FASST clinic represents a reproducible model for an integrated approach to post-stroke care. Adapted to academic centers across the country, a collaborative network would provide best practices, and measure patient reported outcomes to optimize stroke care.

Abstract WP500: Stroke Transitions of Care Coordination Program is Feasible and May Reduce 30-day Readmissions

Introduction: Transitions of care from the acute hospital to other medical facilities and home is a national health care priority. We designed a randomized pilot study to assess the feasibility of a Transitions of Care Coordinator (TOCC) program led by a nurse navigator. We hypothesized that the navigator would complete all portions of TOCC program in at least 75% of acute ischemic stroke (AIS) pts.

Methods: Consecutive AIS patients admitted from April to July 2018 were randomized to TOCC group or usual care group. Pts discharged to subacute rehab, nursing home and hospice or died during hospitalization were excluded. In TOCC, the navigator met patient/caregiver on admission, followed up discharge pending diagnostics, attended multi-disciplinary rounds, facilitated rehab referrals, provided stroke education, and arranged clinic follow-up. Demographics, NIHSS, mRS and discharge disposition were collected. Hospital length of stay (LOS) was calculated from date/time of patient registration to discharge. Patient satisfaction questionnaire and readmission rate was assessed at 30 days by phone. Continuous variables were analyzed using Wilcoxon rank-sum and categorical variables using Fisher’s exact test.

Results: TOCC pts were older, but other demographics were well matched (table 1). The navigator completed all portions of the TOCC program in 80% of pts. The mean time spent by the navigator per TOCC pt was 111 minutes (SD 23). There was no difference in distribution of LOS between the TOCC and usual care groups (5.7 vs. 5.1 days, p=0.51). There was no difference in the mean patient satisfaction scores between TOCC and usual care groups (30.3 vs. 29.6, p=0.66). There were no 30-day readmissions or ER visits in TOCC group vs. 3 and 2 in the usual care (p=0.25, p=0.50).

Conclusion: A nurse navigator-led TOCC program is feasible and may be associated with decreased 30-day readmissions. The ongoing TOCC study will assess any association with LOS and patient satisfaction.

Abstract TP458: Stroke Disparities: Longer Lengths of Stay in Acute Stroke Patients With Medicaid

Introduction: Prolonged hospital stays expose stroke patients to hospital-acquired infections, increase overall cost of care, and delay the initiation of rehabilitation therapies. We sought to examine the factors associated with length of stay (LOS) in acute ischemic stroke (AIS) patients at a comprehensive stroke center (CSC) in an urban center. We hypothesized that patients being discharged to subacute rehabilitation (SAR) or nursing home facilities would have longer LOS.

Methods: Consecutive patients admitted to our stroke service from April to July 2018 with a principal diagnosis of AIS were included. Patients with transient ischemic attack, intracerebral hemorrhage or subarachnoid hemorrhage were excluded. Demographics, admission NIHSS, baseline modified Rankin Scale (mRS), discharge mRS, and discharge disposition were collected. LOS was calculated from date/time of patient registration to discharge.

Results: Baseline characteristics are shown in table 1. LOS and NIHSS were significantly correlated ( r s 0.745, p <0.001). Medicaid as primary insurance on admission was associated with longer LOS (21.9 days) as compared to Medicare (6.5 days) or commercial insurance (2.6 days) [p=0.017]. Higher discharge mRS was associated with longer LOS [p=0.002]. Discharge to SAR was associated with longer LOS (22.9 days) as compared to acute rehab (8.8 days), home with home health (3.2 days), or home (2.6 days) [p = 0.001]. There was no difference in LOS according to baseline mRS, age, gender, or race.

Conclusions: Higher admission NIHSS, Medicaid insurance on admission, discharge to SAR, and discharge mRs &gt4 were significantly associated with longer LOS in AIS patients. Systems of care interventions are needed to address disparity in LOS for Medicaid patients.

Abstract TP347: The Stroke Transitions Education and Prevention (STEP) Clinic: A Learning Healthcare Model for Post-Stroke Care

Background and Purpose: The STEP clinic was established to provide post-acute care for stroke patients. In this learning healthcare model, optimization of processes is enriched by evaluation of patient outcomes and patient and provider feedback. Trainee education and clinical trial recruitment are key. We describe the approach, patient population, and outcomes.

Methods: STEP patients are assessed by a multidisciplinary care team within 6 weeks post-hospitalization. Patients complete depression, fatigue, and sleep apnea questionnaires. The team develops a personalized treatment and follow-up plan and provides risk factor counseling and education. We obtained data from the STEP clinical registry for patients enrolled from 10/2014 to 05/2017.

Results: Among 605 enrolled patients following up at median of 47 days, 55% were male, mean age was 62.2 (SD 14.3), and stroke types included 76% ischemic/transient ischemic attack and 20% intracerebral hemorrhage. By race, 45% were non-Hispanic white, 27% non-Hispanic black, 19% Hispanic, and 3% Asian. Initial blood pressure (BP) was controlled for 66% (<140/90 mmHg) with medications adjusted for 9%. BP control was maintained at 67% among assessed patients. Of 91% completing a depression screen, 24% had at least moderate depression, and 22% were maintained or initiated on an antidepressant. Of 92% patients completing an epworth sleepiness scale, 36% scored >9 (abnormal), and 27% were sent for a sleep study. A total of 38 trainees rotated through the clinic and 91 patients were enrolled in studies. Four novel trials, 3 randomized clinical trials and 1 observational study, were derived from the clinic.

Conclusions: The STEP clinic represents a learning healthcare model for post-stroke care. Learning healthcare models for post-stroke care are feasible and may be an effective approach to secondary and tertiary prevention.

Abstract WP405: Minimizing Delayed Length of Stay by Utilizing Stroke Transitions of Care Coordination Program

Introduction: Delay in discharge of acute stroke patients considered medically ready for discharge increases costs and exposure to nosocomial infections, and is frustrating for patients. We evaluated factors associated with delays in discharge in acute ischemic stroke (AIS) patients in a Transitions of Care Coordination (TOCC) study.

Methods: From April to July 2018, 29 AIS patients (pts) were randomized to TOCC (n=13) or usual care (n=16) groups. Intracerebral hemorrhage, transient ischemic attack and subarachnoid hemorrhage pts were excluded. In TOCC, a nurse navigator met patient/family, identified barriers to discharge, checked status of diagnostics, attended multi-disciplinary rounds to facilitate rehab referrals, provided stroke education, and coordinated clinic follow-up. Delayed length of stay (dLOS) was defined as the difference between date/time medically ready for discharge and date/time of actual discharge. Demographic variables, NIHSS, mRS and discharge disposition were collected. Continuous variables were analyzed with Wilcoxon rank-sum or Kruskal-Wallis test, and categorical variables with Fisher’s exact test.

Results: Pts in the TOCC group were older, but other baseline characteristics were well matched (Table 1). dLOS was significantly correlated with NIHSS ( r s 0.65, p=0.00037. There was a difference in dLOS by insurance type (Medicare 4.05 d vs. Medicaid 17.7 d vs. Commercial 3.0 days, p=0.0250). There was a difference in mean dLOS by discharge disposition (acute rehab 6.5 d, home 1 d, home with home health 1.4 d, subacute rehab 17 d, (and patient death 9 d), p=0.007. There was a difference in distribution of dLOS by distance from home zip code to hospital but no difference was found in the post-hoc analysis. There was no difference in mean dLOS between TOCC and usual care groups (6.5 vs. 4.5 days, p=0.256).

Conclusion: Higher NIHSS, Medicaid insurance, and discharge to acute rehab were significantly associated with dLOS in AIS patients.

Abstract TP462: Recruitment of African Americans in Blood Pressure Reduction Trials for Secondary Stroke Prevention

Background and Purpose: Reductions in blood pressure (BP) after stroke are associated with dramatic reductions in stroke risk. African Americans (AA) have higher risk of recurrent stroke than Whites and higher rates of uncontrolled BP after stroke. Prior studies have shown under-representation of minorities in secondary prevention trials. We identified studies of BP control for secondary stroke prevention and explored minority representation in the trials.

Methods: Relevant MeSH headings were used to conduct a PubMed search of randomized trials for secondary prevention of ischemic and hemorrhagic stroke and TIA, focused on BP reduction. We included studies published 1998 to 2018 that included participants from the US. We categorized articles according to timing post stroke, stroke type, intervention type, race/ethnic distribution, and mentioned efforts to increase minority proportions.

Results: Of 703 abstracts identified from PubMed, 42 studies were retained, and 8 met criteria after manuscript review. Six were US based and 2 international. All included ischemic stroke and/ or TIA patients. None focused on hemorrhagic stroke. Six trials included behavioral modification as a component of the intervention. Enrollment period ranged from 0 to 180 days post-stroke. For US based studies, 5 reported AA race (race reporting complete for 3 studies). The proportion of AA participants ranged from 8.4% to 41.5% Three studies recruited from diverse populations. There was no specific mention of oversampling of AAs in any trial.

Conclusion: Despite strong data to support BP reduction after stroke, there is a lack of US-based studies for secondary stroke prevention. More studies of BP control interventions to test medications and behavioral strategies for secondary stroke prevention in diverse patient populations are urgently needed.

Abstract NS1: Blood Pressure Medications at Hospital Discharge

Introduction: Recurrent strokes carry a higher risk of disability and mortality than first-ever acute ischemic stroke (AIS). Several studies have demonstrated that controlling blood pressure (BP) reduces the risk of recurrent stroke. National guidelines suggest diuretics and ACE inhibitors (ACE-i) may be preferred for BP control in stroke survivors.

Hypothesis: We hypothesized that there would be a wide variation in the classes of blood pressure medications prescribed to adult AIS patients at the time of hospital discharge.

Methods: We reviewed 483 consecutive adult AIS patients admitted to our institution from January 2015 to April 2017. ICH, SAH and TIA patients were excluded. BP medications were categorized by type according to the Get with the Guidelines (GWTG) database. Hypertension was defined as a known past medical history of hypertension on admission. Exploratory and descriptive analyses were performed.

Results: Baseline characteristics and discharge disposition are in shown in table 1. Of the 483 AIS patients, 373 (77.2%) had a known history of hypertension. Among the patients, 335 (90%) were prescribed BP medications at discharge, 135 (40%) received an ACE-i , 69 (21%) an angiotensin receptor blocker (ARB), 121 (36%) a diuretic, 182 (54%) a beta blocker, 134 (40%) a calcium channel blocker, and 10% other BP medications.

Conclusions: There is wide variation in classes of BP medications prescribed at hospital discharge after AIS. Although ACE-i and diuretics are recommended in the AHA/ASA guidelines for BP treatment after AIS, they were not prescribed to the majority of AIS patients. Further studies are needed to evaluate in-hospital antihypertensive medication prescribing patterns in a national multi-center study.

Endovascular Therapy for Acute Ischemic Stroke With Occlusion of the Middle Cerebral Artery M2 Segment

IMPORTANCE

Randomized clinical trials have shown the superiority of endovascular therapy (EVT) compared with best medical management for acute ischemic strokes with large vessel occlusion (LVO) in the anterior circulation. However, of 1287 patients enrolled in 5 trials, 94 with isolated second (M2) segment occlusions were randomized and 51 of these received EVT, thereby limiting evidence for treating isolated M2 segment occlusions as reflected in American Heart Association guidelines.

OBJECTIVE

To evaluate EVT safety and effectiveness in M2 occlusions in a cohort of patients with acute ischemic stroke.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter retrospective cohort study pooled patients with acute ischemic strokes and LVO isolated to M2 segments from 10 US centers. Patients with acute ischemic strokes and LVO in M2 segments presenting within 8 hours from their last known normal clinical status (LKN) from January 1, 2012, to April 30, 2015, were divided based on their treatment into EVT and medical management groups. Logistic regression was used to compare the 2 groups. Univariate and multivariate analyses evaluated associations with good outcome in the EVT group.

MAIN OUTCOMES AND MEASURES

The primary outcome was the 90-day modified Rankin Scale score (range, 0-6; scores of 0-2 indicate a good outcome); the secondary outcome was symptomatic intracerebral hemorrhage.

RESULTS

A total of 522 patients (256 men [49%]; 266 women [51%]; mean [SD] age, 68 [14.3] years) were identified, of whom 288 received EVT and 234 received best medical management. Patients in the medical management group were older (median [interquartile range] age, 73 [60-81] vs 68 [56-78] years) and had higher rates of intravenous tissue plasminogen activator treatment (174 [74.4%] vs 172 [59.7%]); otherwise the 2 groups were balanced. The rate of good outcomes was higher for EVT (181 [62.8%]) than for medical management (83 [35.4%]). The EVT group had 3 times the odds of a good outcome as the medical management group (odds ratio [OR], 3.1; 95% CI, 2.1-4.4; P < .001) even after adjustment for age, National Institute of Health Stroke Scale (NIHSS) score, Alberta Stroke Program Early Computed Tomographic Score (ASPECTS), intravenous tissue plasminogen activator treatment, and time from LKN to arrival in the emergency department (OR, 3.2; 95% CI, 2-5.2; P < .001). No statistical difference in symptomatic intracerebral hemorrhage was found (5.6% vs 2.1% for the EVT group vs the medical management group; P = .10). The treatment effect did not change after adjusting for center (OR, 3.3; 95% CI, 1.9-5.8; P < .001). Age, NIHSS score, ASPECTS, time from LKN to reperfusion, and successful reperfusion score of at least 2b (range, 0 [no perfusion] to 3 [full perfusion with filling of all distal branches]) were independently associated with good outcome of EVT. A linear association was found between good outcome and time from LKN to reperfusion.

CONCLUSIONS AND RELEVANCE

Although a randomized clinical trial is needed to confirm these findings, available data suggest that EVT is reasonable, safe, and effective for LVO of the M2 segment relative to best medical management.

Abstract TP424: Acute Stroke Education Video Associated With Improved Stroke Literacy

Introduction: Interventions are needed to improve stroke literacy and secondary prevention. We developed a video to educate patients hospitalized with acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH).

Hypothesis: In a prospective trial, we hypothesized that a stroke video would improve stroke literacy in AIS and ICH patients.

Methods: A 5-minute stroke education video was shown to AIS and ICH patients admitted to our service from 3/15 to 6/15. Demographics and a cognitive screen (5-min MoCA) were collected. Questions, related to stroke knowledge (n=8), self-efficacy (n=1) and patient satisfaction (n=1), were answered before, after, and 30 days after the video.

Results: Among 295 screened, 102 patients were enrolled (Table 1). There was a significant difference between pre-video median knowledge score of 6 (IQR 4-7) and the post-video score of 7 (IQR 6-8; p<0.001) and between pre-video and the 30 day score of 7 (IQR 5-8; p=.04). There was a significant difference between the proportion of patients who were “very certain” in recognizing symptoms of a stroke pre- and post-video, which was maintained at 30-days (36% vs. 53%, p=0.001; 36% vs. 56%, p=0.08). The proportion who were “very satisfied” with their stroke education post-video (74%) was significantly higher than pre-video (49%, p=0.001), and this was maintained at 30 days (75%, p=0.004). There was no association between 5-min MoCA scores and stroke knowledge acquisition pre- and post-video scores, p=0.53) or stroke knowledge retention post-video and 30-day scores, p=0.95). MoCA scores correlated with pre-, post- and 30-day knowledge scores (r=0.41, p<0.001; r=0.47, p<0.001; r=0.40, p=0.003). Potential associations between stroke knowledge and behavioral changes will be reported.

Conclusion: A stroke educational video was associated with improved stroke knowledge, certainty in recognizing stroke symptoms and satisfaction with stroke education. A randomized trial is planned.

Abstract 202: Endovascular Therapy for Acute Ischemic Stroke With Distal Large Vessel Occlusion in the Anterior Circulation

Introduction: Five RCTs demonstrated the superiority of endovascular therapy (EVT) over best medical management (MM) for acute ischemic strokes (AIS) with large vessel occlusion (LVO) in the anterior circulation. Patients with M2 occlusions, however, were underrepresented (95 randomized; 51 EVT treated). Evidence from RCTs of the benefit of EVT for M2 occlusions is lacking, as reflected in the recent AHA guidelines.

Methods: A retrospective cohort was pooled from 10 academic centers from 1/12 to 4/15 of AIS patients with LVO isolated to M2 presenting within 8 hours from last known normal (LKN). Patients were divided into EVT and MM groups. Primary outcome was 90 day mRS (good outcome 0-2); secondary outcome was sICH. Logistic regression compared the 2 groups. Univariate and multivariate analyses evaluated predictors of good outcome in the EVT group.

Results: Figure 1 shows participating centers, 522 patients (288 EVT and 234 MM) were identified. Table (1) shows baseline characteristics. MM treated patients were older and had higher IV tPA treatment rates, otherwise the 2 groups were balanced. 62.7 % EVT patients had mRS 0-2 at 90 days compared to 35.4 % MM (figure 2). EVT patients had 3 times the odds of good outcome as compared to MM patients (OR: 3.1, 95% CI:2.1-4.4, P <0.001) even after adjustment for age, NIHSS, ASPECTS, IV tPA and LKN to door time (OR: 3.2, 95%CI: 2-5.2, P<0.001). sICH rate was 5.6 %, which was not statistically different than the MM group (table 1, P=0.1). Age, NIHSS, good ASPECTS, LKN to reperfusion time and successful reperfusion mTICI ≥ 2b were independent predictors of good outcome in EVT patients. There was a linear relationship between good outcome and time LKN to reperfusion (Figure 3).

Conclusion: Despite inherent limitations of its retrospective design, our study suggests that EVT may be effective and safe for distal LVO (M2) relative to best MM. A trial randomizing M2 occlusions to EVT vs. MM is warranted to confirm these findings.

Abstract T P307: Similar Rates of Early Cognitive Dysfunction after Intracerebral Hemorrhage and Acute Ischemic Stroke

Introduction: Post-stroke cognitive dysfunction (CD) affects at least 1/3 of acute ischemic stroke (AIS) patients when assessed at 3 months. Limited data exists on CD in intracerebral hemorrhage (ICH). The role of early, in-hospital cognitive screening using the brief Montreal Cognitive Assessment (mini MoCA) is being investigated at our center.

Hypothesis: We assessed the rates of early CD in ICH and AIS and hypothesized that even minor deficits from these disorders causes significant CD.

Methods: 1218 consecutive stroke patients admitted from 2/13 to 12/13 were reviewed; 610, 442 with AIS and 168 with ICH, with admission NIHSS and mini MoCAs were included in the final analyses. CD was defined as mini MoCA <9 (max 12). Poor outcome was defined as discharge mRS 4-6. Stroke severity was stratified by NIHSS score of 0-5, 6-10, 11-15, 16-20, 21-42 as in ECASS-I . Chi-squared tests and univariate logistic regression analyses were performed.

Results: Baseline characteristics are shown in table 1. AIS and ICH groups were similar with regard to race, gender and stroke severity. ICH patients were younger, had longer stroke service lengths of stay and poorer outcomes than AIS patients (p=0.03, p<0.001, p<0.001). No difference was seen in rates of CD between AIS and ICH patients (60% vs. 57%, p=0.36, OR 1.2 (CI 0.8-1.7)). CD rates ranged from 36% for NIHSS 0-5 to 96% for 21-42 (figure 1). Older patients were twice as likely to have CD (p<0.001, OR 2.2 (CI 1.6 - 3.0)). Patients with CD had five times the odds of having a poor outcome compared to the cognitively intact (p<0.001, OR 5.2 (CI 3.4-7.7)). In univariate logistic regression analyses, age was a significant predictor of CD in AIS, but not in ICH (p= <0.001, p=0.06).

Conclusion: Post-stroke CD is common across all severities and occurs at similar rates in AIS and ICH. More than 1/3 of patients with minor deficits (NIHSS 0-5) had CD in the acute hospital setting. Whether early CD is predictive of long term cognitive outcomes deserves further study.

Wake-up Strokes Are Similar to Known-Onset Morning Strokes in Severity and Outcome

BACKGROUND

Stroke symptoms noticed upon waking, wake-up stroke, account for up to a quarter of all acute ischemic strokes. Patients with wake-up stroke, however, are often excluded from thrombolytic therapy.

METHODS

Using our prospectively collected stroke registry, wake-up stroke and known-onset morning strokes were identified. Wakeup stroke was defined as a patient who was asleep >3 hours and first noted stroke symptoms upon awakening between 0100 and 1100. Known-onset morning stroke was defined as a patient who had symptom onset while awake during the same time interval. We compared wake-up stoke to known-onset morning stroke with respect to patient demographics, stroke severity, etiology and outcomes.

RESULTS

One-quarter of patients with acute ischemic strokes (391/1415) had documented time between 0100 and 1100 of symptom onset: 141 (36%) wake-up strokes and 250 (64%) known-onset morning strokes. No difference in baseline characteristics, stroke severity, stroke etiology, neurologic deterioration, discharge disposition or functional outcome was detected. Known-onset morning stroke patients were significantly more likely to get thrombolytic therapy and have higher risk of in-hospital mortality. Wake-up stroke patients tended to be older, have higher diastolic blood pressure and have longer length of hospital stay.

DISCUSSION

While patients with wake-up stroke were similar to patients with known-onset morning stroke in many respects, patients with known onset morning stroke were significantly more likely to get treated with thrombolytic therapy and have higher in-hospital mortality.

The Heerfordt-Waldenström syndrome as an initial presentation of sarcoidosis

Sarcoidosis is a granulomatous disease of unclear etiology, which commonly presents with cough, dyspnea, chest pain, fever, weight loss, arthralgias, and erythema nodosum. Heerfordt-Waldenström syndrome, a rare presentation of sarcoidosis, is characterized by the presence of parotid gland enlargement, facial palsy, anterior uveitis, and fever. Here we present a case of a 59-year-old nonsmoking African American woman who presented with 3 days of progressively worsening left facial droop, difficulty swallowing, and blurred vision. Over the prior 4 months, she had had a productive cough, fevers, night sweats, and an unintentional 30-pound weight loss. Physical examination revealed a left facial droop involving the forehead, cheek, and chin with an inability to close the left eyelid. Her serum angiotensin-converting enzyme level was twice the upper limit of normal. Prominent hilar markings were identified on chest x-ray, but no focal opacity was seen. Fine-needle aspiration of a preauricular lymph node revealed noncaseating granulomas consistent with granulomatous lymphangitis. The patient was given a diagnosis of Heerfordt-Waldenström syndrome, or uveoparotid fever. Treatment with a high-dose steroid improved her parotid gland enlargement, facial palsy, and anterior uveitis.

Abstract 3563: Ischemic Stroke with Early AM Onset is More Severe but Less Frequent

Background: Diurnal fluctuations in clotting factors, occurrence of thrombosis, and stroke have been reported. We sought to evaluate the distribution of stroke occurrence and differences in stroke characteristics and outcomes in a biracial population.

Methods: Patients presenting to our center with acute ischemic stroke of known symptom onset were identified by retrospective chart review. Patients were grouped into one of four onset periods: 00:01-06:00, 06:01-12:00, 12:01-18:00, and 18:01-00:00. We compared demographics, baseline stroke severity, blood pressure and glucose levels, IV tPA treatment rates, stroke etiology, complications, and early clinical outcomes.

Results: The 244 patients with a known time of onset were included in analyses; the distribution of stroke onset and comparison of other collected variables are demonstrated in the figure and table , respectively. Stroke onset 00:01-06:00 was less frequent, but associated with significantly higher median NIHSS score (p=0.005). Patients with stroke onset 00:01-06:00 were more often African-American, had atherothrombotic mechanisms (large artery or small artery infarctions), received IV tPA, and had reduced frequency of good mRS, though statistical significance was not achieved. Time interval of stroke onset was not an independent predictor of death, good outcome (mRS 0-2), or favorable discharge disposition (home or inpatient rehabilitation).

Discussion: The most severe ischemic strokes occurred in early AM hours, but were less common than stroke onset during other time intervals. A larger sample is required to determine why ischemic stroke is more severe with early AM onset, if blacks are more susceptible to early AM stroke, and if early AM stroke is less responsive to tPA.

Abstract 3793: Wake-up Strokes Similar to Known-Onset Morning Strokes in Severity and Outcomes

Background: Stroke symptoms first noticed upon waking (wake-up strokes) account for 15-30% of all acute ischemic strokes. Whether or not the onset of ischemic stroke wakes people from sleep is not known. We sought to compare patient demographics, stroke characteristics and outcomes among people with wake-up strokes to those with known-onset morning strokes.

Methods: Using retrospective chart review, we identified patients with wake-up strokes (WUS). WUS was defined as asleep for >3 hours and symptoms noted on wakening from 01:00-11:00. We then identified patients with known-onset morning stroke, defined as symptoms noted when patient already awake, during same time interval. We compared WUS to known-onset morning strokes with respect to patient demographics, stroke severity, etiology and outcomes.

Results: 112 patients with documented time of 01:00-11:00 when symptoms were first noted were included in the analysis; 33 (29.5%) wake-up strokes and 79 (70.5%) known-onset morning strokes. Patients with WUS were significantly more likely to be female (p=0.009). WUS patients demonstrated a trend toward lower IV tPA treatment rate (p=0.079), higher atherosclerotic burden with greater proportion having carotid artery stenosis (p=0.109), and large vessel mechanism (40.6% vs. 24%). A higher proportion of cortical involvement was also observed among wake-up strokes (p=0.07). Wake-up stroke and known-onset morning strokes were similar with respect to stroke severity (as measured by NIHSS score) at presentation, 24 hours and discharge. WUS was not an independent significant predictor of favorable functional status (mRS 0-2, p=0.371), good disposition (home or inpatient rehab, p=0.909) or mortality (p=0.303). Discussion: While wake-up strokes were similar to known-onset strokes that occurred in the same time interval in stroke severity, functional outcomes, disposition and mortality, WUS patients tended to be older, to be female, and to have large vessel disease. A larger sample size is needed to discern whether large artery atherosclerosis is more likely to cause ischemic stroke while a patient in sleeping and if IV tPA alters the natural history of wake-up strokes.

Do antidepressant medications relieve chronic low back pain?

BACKGROUND

Antidepressant medications are commonly prescribed for patients with chronic low back pain. A literature synthesis was performed to determine whether antidepressants are more effective than placebos in decreasing pain, disability, depression, and analgesic medication use in such patients.

METHODS

English-language journal articles were identified from MEDLINE and PsycLIT databases, bibliographies, and inquiries to researchers and drug companies. Articles were included if they reported data from placebo-controlled or drug comparison trials of antidepressants for patients with low back pain. Six articles met these criteria.

RESULTS

Three studies compared the effects of antidepressants and placebos on pain; two found no difference and one found a trend toward superiority of imipramine for patient-rated symptoms but no difference in investigator ratings. Effects on functional disability were examined in three antidepressant-placebo comparisons; only one found the antidepressant to be more effective. Antidepressant effects of an antidepressant vs placebo were compared in three studies; none found a significant difference. Effects on analgesic medication use were compared in three studies; one found amitriptyline to be superior and the others found no difference. Serious methodologic flaws characterized all six studies, and insufficient reporting of data precluded meta-analysis.

CONCLUSIONS

The literature has not demonstrated that antidepressants are superior to placebos in improving low back pain or related problems. However, further randomized controlled trials are needed to determine whether antidepressants are useful for low back pain.