Cerebral blood flow and neurocognition in patients undergoing transcatheter aortic valve replacement for severe aortic stenosis

Aims

Aortic valve stenosis (AS) results in higher systolic pressure to overcome resistance from the stenotic valve, leading to heart failure and decline in cardiac output. There has been no assessment of cerebral blood flow (CBF) association with neurocognition in AS or the effects of valve replacement. The goal was to determine if AS is associated with altered cerebral haemodynamics and impaired neurocognition, and whether transcatheter aortic valve replacement (TAVR) improves haemodynamics and cognition.

Methods and results

In 42 patients with planned TAVR, transcranial Doppler (TCD) assessed bilateral middle cerebral artery (MCA) mean flow velocities (MFVs); abnormality was <34.45 cm/s. The neurocognitive battery assessed memory, language, attention, visual-spatial skills, and executive function, yielding a composite Z-score. Impairment was <1.5 SDs below the normative mean. The mean age was 78 years, 59% Male, and the mean valve gradient was 46.87 mm/Hg. Mean follow-up was 36 days post-TAVR (range 27-55). Pre-TAVR, the mean MFV was 42.36 cm/s (SD = 10.17), and the mean cognitive Z-score was -0.22 SDs (range -1.99 to 1.08) below the normative mean. Among the 34 patients who returned after TAVR, the MFV was 41.59 cm/s (SD = 10.42), not different from baseline (P = 0.66, 2.28-3.67). Post-TAVR, average Z-scores were 0.17 SDs above the normative mean, not meeting the pre-specified threshold for a clinically significant 0.5 SD change.

Conclusion

Among patients with severe AS, there was little impairment of MFV on TCD and no correlation with cognition. Transcatheter aortic valve replacement did not affect MFV or cognition. Assumptions about diminished CBF and improvement after TAVR were not supported.

Educational Intervention in the Emergency Department to Address Disparities in Stroke Knowledge

OBJECTIVES

In the United States, Black individuals have higher stroke incidence and mortality when compared to white individuals and are also at risk of having lower stroke knowledge and awareness. With the need to implement focused interventions to decrease stroke disparities, the objective of this study is to evaluate the feasibility and efficacy of an emergency department-based educational intervention aimed at increasing stroke awareness and preparedness among a disproportionately high-risk group.

MATERIALS AND METHODS

Over a three-month timeframe, an emergency department-based, prospective educational intervention was implemented for Black patients in an urban, academic emergency department. All participants received stroke education in the forms of a video, written brochure and verbal counseling.  Stroke knowledge was assessed pre-intervention, immediately post-intervention, and at one-month post-intervention.

RESULTS

One hundred eighty-five patients were approached for enrollment, of whom 100 participants completed the educational intervention as well as the pre- and immediate post- intervention knowledge assessments. Participants demonstrated increased stroke knowledge from baseline knowledge assessment (5.35 ± 1.97) at both immediate post-intervention (7.66 ± 2.42, p < .0001) and one-month post-intervention assessment (7.21 ± 2.21, p < .0001).

CONCLUSIONS

Emergency department-based stroke education can result in improved knowledge among this focused demographic. The emergency department represents a potential site for educational interventions to address disparities in stroke knowledge.

Trauma Communications Center Coordinated Severity-Based Stroke Triage: Protocol of a Hybrid Type 1 Effectiveness-Implementation Study

Background: Mechanical thrombectomy (MT) can improve the outcomes of patients with large vessel occlusion (LVO), but a minority of patients with LVO are treated and there are disparities in timely access to MT. In part, this is because in most regions, including Alabama, the emergency medical service (EMS) transports all patients with suspected stroke, regardless of severity, to the nearest stroke center. Consequently, patients with LVO may experience delayed arrival at stroke centers with MT capability and worse outcomes. Alabama's trauma communications center (TCC) coordinates EMS transport of trauma patients by trauma severity and regional hospital capability. Our aims are to develop a severity-based stroke triage (SBST) care model based on Alabama's trauma system, compare the effectiveness of this care pathway to current stroke triage in Alabama for improving broad, equitable, and timely access to MT, and explore stakeholder perceptions of the intervention's feasibility, appropriateness, and acceptability.

Methods: This is a hybrid type 1 effectiveness-implementation study with a multi-phase mixed methods sequential design and an embedded observational stepped wedge cluster trial. We will extend TCC guided stroke severity assessment to all EMS regions in Alabama; conduct stakeholder interviews and focus groups to aid in development of region and hospital specific prehospital and inter-facility stroke triage plans for patients with suspected LVO; implement a phased rollout of TCC Coordinated SBST across Alabama's six EMS regions; and conduct stakeholder surveys and interviews to assess context-specific perceptions of the intervention. The primary outcome is the change in proportion of prehospital stroke system patients with suspected LVO who are treated with MT before and after implementation of TCC Coordinated SBST. Secondary outcomes include change in broad public health impact before and after implementation and stakeholder perceptions of the intervention's feasibility, appropriateness, and acceptability using a mixed methods approach. With 1200 to 1300 total observations over 36 months, we have 80% power to detect a 15% improvement in the primary endpoint.

Discussion: This project, if successful, can demonstrate how the trauma system infrastructure can serve as the basis for a more integrated and effective system of emergency stroke care.

A Novel Combination of Blood Biomarkers and Clinical Stroke Scales Facilitates Detection of Large Vessel Occlusion Ischemic Strokes

Acute ischemic stroke caused by large vessel occlusions (LVOs) is a major contributor to stroke deaths and disabilities; however, identification for emergency treatment is challenging. We recruited two separate cohorts of suspected stroke patients and screened a panel of blood-derived protein biomarkers for LVO detection. Diagnostic performance was estimated by using blood biomarkers in combination with NIHSS-derived stroke severity scales. Multivariable analysis demonstrated that D-dimer (OR 16, 95% CI 5–60; p-value < 0.001) and GFAP (OR 0.002, 95% CI 0–0.68; p-value < 0.05) comprised the optimal panel for LVO detection. Combinations of D-dimer and GFAP with a number of stroke severity scales increased the number of true positives, while reducing false positives due to hemorrhage, as compared to stroke scales alone (p-value < 0.001). A combination of the biomarkers with FAST-ED resulted in the highest accuracy at 95% (95% CI: 87–99%), with sensitivity of 91% (95% CI: 72–99%), and specificity of 96% (95% CI: 90–99%). Diagnostic accuracy was confirmed in an independent cohort, in which accuracy was again shown to be 95% (95% CI: 87–99%), with a sensitivity of 82% (95% CI: 57–96%), and specificity of 98% (95% CI: 92–100%). Accordingly, the combination of D-dimer and GFAP with stroke scales may provide a simple and highly accurate tool for identifying LVO patients, with a potential impact on time to treatment.

Restoration of CTSD (cathepsin D) and lysosomal function in stroke is neuroprotective

Stroke is a leading cause of death and disability. The pathophysiological mechanisms associated with stroke are very complex and not fully understood. Lysosomal function has a vital physiological function in the maintenance of cellular homeostasis. In neurons, CTSD (cathepsin D) is an essential protease involved in the regulation of proteolytic activity of the lysosomes. Loss of CTSD leads to lysosomal dysfunction and accumulation of different cellular proteins implicated in neurodegenerative diseases. In cerebral ischemia, the role of CTSD and lysosomal function is not clearly defined. We used oxygen-glucose deprivation (OGD) in mouse cortical neurons and the middle cerebral artery occlusion (MCAO) model of stroke to assess the role of CTSD in stroke pathophysiology. Our results show a time-dependent decrease in CTSD protein levels and activity in the mouse brain after stroke and neurons following OGD, with concurrent defects in lysosomal function. We found that shRNA-mediated knockdown of CTSD in neurons is sufficient to cause lysosomal dysfunction. CTSD knockdown further aggravates lysosomal dysfunction and cell death in OGD-exposed neurons. Restoration of CTSD protein levels via lentiviral transduction increases CTSD activity in neurons and, thus, renders resistance to OGD-mediated defects in lysosomal function and cell death. This study indicates that CTSD-dependent lysosomal function is critical for maintaining neuronal survival in cerebral ischemia; thus, strategies focused on maintaining CTSD function in neurons are potentially novel therapeutic approaches to prevent neuronal death in stroke.Abbreviations: 3-MA: 3-methyladenine; ACTB: actin beta; AD: Alzheimer disease; ALS: amyotrophic lateral sclerosis; CQ: chloroquine; CTSB: cathepsin B; CTSD: cathepsin D; CTSL: cathepsin L; FTD: frontotemporal dementia, HD: Huntington disease; LAMP1: lysosomal associated membrane protein 1; LSD: lysosomal storage disease; MCAO: middle cerebral artery occlusion; OGD: oxygen glucose deprivation; OGR: oxygen glucose resupply; PD: Parkinson disease; SQSMT1: sequestosome 1; TCA: trichloroacetic acid; TTC: triphenyl tetrazolium chloride.

Abstract WP354: The Rural Health Care Penalty: Urban-rural Disparities in Stroke Center Performance

Goal: To determine hospital and stroke system characteristics associated with higher levels of stroke center performance.

Methods: We included all Centers for Medicare and Medicaid Services designated Acute Care Hospitals and Critical Access Centers (ACH/CAC) from January 1, 2005 to December 31, 2014. Higher stroke center performance was defined as earning a performance achievement award (PAA) on a predefined set of 7 evidence-based measures in a national quality program, Get-With-The-Guidelines-Stroke (GWTG-S). Generalized Estimating Equations were used to model characteristics associated with attaining a PAA over nine years of data. Hospital variables included total, ischemic and hemorrhagic stroke discharge volumes; medicaid discharge volume; patient race/ethnicity; ownership; rurality (Truven Health MarketScan); and state and/or national stroke center certification. Stroke system variables included emergency medical service (EMS) stroke routing protocol; stroke center directives (legislation, regulation, or department of health initiatives); and location in a region with a stroke consortium.

Results: As a percentage of all ACH/CACs, GWTG-S hospitals with PAA increased significantly over time from 0.001% (5/4530) in 2005 to 24% (1086/4526) in 2014 (linear and nonlinear p’s<0.0001). Variables associated with PAA status at the p<0.05 level were included in the combined analysis. Significant independent predictors of PAA status included urban location (p<0.0001); total (p=0.0016) and ischemic stroke (p<0.0048) discharge volumes; national stroke center designation (p<0.0001); and presence of state stroke center directives (p=0.0012). EMS routing was not statistically significant but there was an EMS-by-time interaction; hospitals with EMS routing had a significantly increased rate of earning PAA (p = 0.0463).

Conclusions: There has been rapid improvement in stroke center performance from 2005 to 2014. Urban location, higher hospital discharge volume, national stroke center designation, and state stroke directives are independently associated with better stroke center performance. After controlling for hospital and stroke system factors, there are significant urban-rural disparities in stroke center performance.

Abstract TP483: Transcatheter Aortic Valve Replacement (TAVR) Does Not Improve Cerebral Hemodynamics or Neurocognition in Patients With Severe Aortic Stenosis

Objective: To determine if aortic stenosis (AS) is associated with altered cerebral hemodynamics and impaired neurocognition, and whether TAVR improves hemodynamics and cognition.

Background: AS results in higher systolic pressure to overcome resistance from the stenotic valve, leading to heart failure and decline in cardiac output. There has been no baseline assessment of CBF with neurocognition in AS, or the effects of valve replacement.

Methods: In 40 patients with planned TAVR, transcranial Doppler (TCD) assessed bilateral MCA mean flow velocity (MFV); abnormality was < 30cc/sec. The neurocognitive battery assessed memory, language, attention, visual-spatial skills, and executive function, yielding an average Z-score. Impairment was < 1.5 SD’s below the normative mean.

Results: The mean age was 78 years, 59% male, and the mean valve gradient was 46.87%. Mean follow-up was 36 days post-TAVR (range 27 - 55). Before TAVR, the average MFV was 42 cc/sec (SD=10.22), and the mean cognitive score was -0.22 SD’s (range -1.99 to 1.08) below the normative mean. Of the 5 with abnormal MFV’s, none had abnormal cognition (average=0.19 SD’s above the normative mean). After TAVR, the MFV was 43 cc/sec, not different from baseline (p=0.56). The post-TAVR average Z-score was 0.01 SD’s above the normative mean, also not different from baseline (p=0.29). There was no correlation between the change scores in MFV and in neurocognition (r = 0.08, p= 0.69).

Conclusions: Among patients with severe AS, there was no correlation at baseline between abnormal MFV’s on TCD and abnormal neurocognition. It was therefore unsurprising that there was little impact of valve replacement on these measures of cerebral blood flow and brain function. Prior assumptions about diminished CBF and the relationship to cognitive function may not be supported.

Abstract TP237: Can We Improve Clinical Detection of Right Hemisphere Large Vessel Occlusion?

Introduction: The Emergency Medical Stroke Assessment (EMSA) is a six point stroke severity scale with one point each for gaze preference, facial droop, arm drift, leg drift, abnormal naming, and abnormal repetition that was developed to help emergency medical services (EMS) providers identify acute ischemic stroke (AIS) patients with large vessel occlusion (LVO). We hypothesized that the EMSA would detect left hemisphere LVO with a higher sensitivity than right hemisphere LVO.

Methods: We trained 24 trauma system-based emergency communication center (ECC) paramedics in the EMSA. ECC-guided EMS in performance of the EMSA on patients with suspected stroke. We compared the sensitivity, specificity, area under the curve (AUC), and 95% confidence interval (CI) of ECC-guided prehospital EMSA for right versus left hemisphere ICA or M1 occlusion.

Results: We enrolled 569 patients from September 2016 through February 2018, out of which 236 had a discharge diagnosis of stroke and 173 had a diagnosis of AIS. We excluded patients with bilateral (n=21) and brainstem (n=21) AIS. There were 64 patients with left hemisphere AIS including 19 with LVO. There were 67 patients with right hemisphere AIS including 22 with LVO. A score of ≥ 4 points yielded a sensitivity of 84.2 (95% CI = 60.4-96.6) and specificity of 66.7 (51.1-80.0) for left hemisphere LVO compared to a sensitivity of 68.2 (45.1-86.1) and specificity of 73.9 (58.9-85.7) for right hemisphere LVO. For predicting a left hemisphere LVO, the AUC was 0.77 (0.65-0.90) compared to 0.66 (0.50-0.82) for right-sided LVO. Assigning 2 points for abnormal gaze yielded an AUC of 0.78 (0.66-0.91) versus 0.67 (0.52-0.83) for left and right hemisphere LVO, respectively.

Conclusions: The EMSA, like the National Institutes of Health Stroke Scale (NIHSS) upon which it is based, is more sensitive to left compared to right hemisphere LVO. More heavily weighting abnormal gaze did not improve the sensitivity of the EMSA for right hemisphere LVO. There is no comparable data on the right versus left hemisphere performance of other prehospital scales. There is a need to develop sensitive tests of right hemisphere dysfunction that are suitable for use in the field.

Centrally Guided Identification of Patients With Large Vessel Occlusion: Lessons From Trauma Systems

OBJECTIVE

Improve prehospital identification of acute ischemic stroke patients with large vessel occlusion (LVO) by using a trauma system-based emergency communication center (ECC) to guide the emergency medical service (EMS).

METHODS

We trained 24 ECC paramedics in the Emergency Medical Stroke Assessment (EMSA). ECC-guided EMS in performance of the EMSA on patients with suspected stroke. During the second half of the study, we provided focused feedback to ECC after reviewing recorded ECC-EMS interactions. We compared the sensitivity, specificity, and area under the receiver operator characteristics curve (AUC) and 95% confidence interval of ECC-guided EMSA to the NIH Stroke Scale (NIHSS) for predicting a discharge diagnosis of LVO.

RESULTS

We enrolled 569 patients from September 2016 through February 2018. Of 463 patients analyzed, 236 (51%) had a discharge diagnosis of stroke and 227 (49%) had a nonstroke diagnosis. There were 45 (19%) stroke patients with LVO. For predicting LVO, there was no significant difference between the EMSA AUC = .68 (.59-.77) and the NIHSS AUC = .73 (.65-.81). An EMSA score greater than or equal to 4 had sensitivity = 75.6 (60.5-87.1) and specificity = 62.4 (57.6-67.1) for LVO. During the first 9 months of the study, the EMSA AUC = .61 (.44-.77) compared to an AUC = .74 (.64-.84) during the second 9 months.

CONCLUSIONS

ECC-guided prehospital EMSA is feasible, has similar ability to predict LVO compared to the NIHSS, and has sustained performance over time.

Abstract WP298: Communication Center Guided Prehospital Stroke Assessment Scoring has High Inter-rater Agreement

Introduction: We are prospectively validating a model of communication center guided prehospital identification of stroke patients with large vessel occlusion (LVO).

Goal: Assess the inter-rater agreement between a Vascular Neurologist and Alabama Trauma Communication Center (ATCC) personnel in diagnostic classification of stroke patients.

Methods: The ATCC is staffed by paramedic-trained dispatchers who field calls from Emergency Medical Service (EMS) responders and maintain up-to-the-minute status of hospitals and resources 24/7. We trained ATCC personnel in stroke pathology, pathophysiology, appropriate patient selection for thrombolytic and endovascular therapies; and the previously derived 6 point Emergency Medical Stroke Assessment (EMSA). ATCC personnel guided EMS responders in the Birmingham Regional Emergency Medical Services System (BREMSS), and paged-out a hospital stroke prenotification that included specific EMSA scale items (gaze, facial droop, arm drift, leg drift, naming, and repetition). All interactions between the ATCC and EMS responders were recorded, allowing review of audio files and ongoing quality improvement. ATCC personnel and a vascular neurologist separately reviewed recordings and assigned scores to each patient according to the deficit stated by the EMS. To determine inter-rater reliability we utilized the Kappa statistic with a significance level of 0.05, and 95% confidence intervals (CI).

Results: We sampled a total of 146 patients. We observed statistically significant agreement between the raters for all EMSA components, with 71% (CI=45-97%, p<0.0001) agreement in rating the gaze component, 54% (CI=26-82%, p=0.002) for the face, 57% (CI=29-85%, p=0.001) for the arm, 60% (CI=33-86%, p<0.0006) for the leg, 56% (CI=30-81%, p<0.001) for naming, and 34% (CI=6-61%, p<0.04) for repetition.

Conclusion: We conclude that there is moderate to substantial agreement in most stroke assessment items by a paramedic staffed communication center and a vascular neurologist. There was only fair inter-rater agreement for repetition. Paramedic-trained dispatchers can reliably guide EMS responders and score the Emergency Medical Stroke Assessment.

Abstract WP300: Characteristics and Prognosis of Transfer Patients to a Comprehensive Stroke Center in the Stroke Belt

Background: The stroke belt has a higher stroke mortality rate compared to other regions of the United States with Alabama recording about 3,000 deaths yearly. The University of Alabama at Birmingham (UAB) is the only comprehensive stroke center (CSC) in Alabama equipped to manage the most complex stroke patients.

Objective: The purpose of this study was to determine the characteristics and prognosis of patients transferred to a comprehensive stroke center in the stroke belt.

Methods: Data was abstracted from the electronic health records of patients admitted to the stroke service between 2016 and 2018. We assessed differences between transfer and non-transfer patients in terms of demographics, stroke severity, insurance, administration of alteplase (t-PA) and thrombectomy (IA). We also evaluated the relationship between the Alabama state stroke designation of the originating hospital including non-stroke centers (level 0), acute stroke ready hospitals, ASRH (level 3), primary stroke centers, PSC (level 2) and direct admissions to UAB (level 1) and characteristics and prognosis of patients.

Results: 1107 patients were assessed for the study with 402(36%) being transfers. Race, NIHSS,TPA and IA use, discharge disposition were associated with the level of stroke center, as shown in the table. Level 2 centers transferred patients with more severe strokes, and a higher proportion of TPA and IA use. Non-transfer patients had the best outcome with Home as their primary discharge location compared to patients transferred from level 2 stroke centers.

Conclusion: About 36% of our stroke discharge volume is a result of patients transferred to UAB from outside hospitals. We conclude that Level 2 stroke centers are appropriately transferring patients with more severe stroke to CSCs compared to transfers from non-stroke centers and acute stroke ready hospitals. Some of the patients transferred to a CSC from non-stroke centers and ASRHs could be managed at PSCs.

Derivation and Validation of the Emergency Medical Stroke Assessment and Comparison of Large Vessel Occlusion Scales

BACKGROUND

This study aims to develop a simple scale to identify patients with prehospital stroke with large vessel occlusion (LVO), without losing sensitivity for other stroke types.

METHODS

The Emergency Medical Stroke Assessment (EMSA) was derived from the National Institutes of Health Stroke Scale (NIHSS) items and validated for prediction of LVO in a separate cohort. We compared the EMSA with the 3-item stroke scale (3I-SS), Cincinnati Prehospital Stroke Severity Scale (C-STAT), Rapid Arterial oCclusion Evaluation (RACE) scale, and Field Assessment Stroke Triage for Emergency Destination (FAST-ED) for prediction of LVO and stroke. We surveyed paramedics to assess ease of use and interpretation of scales.

RESULTS

The combination of gaze preference, facial asymmetry, asymmetrical arm and leg drift, and abnormal speech or language yielded the EMSA. An EMSA less than 3, 75% sensitivity, and 50% specificity significantly reduced the likelihood of LVO (LR- = .489, 95% confidence interval .366-0.637) versus 3I-SS less than 4 (.866, .798-0.926). A normal EMSA, 93% sensitivity, and 47% specificity significantly reduced the likelihood of stroke (LR- = .142, .068-0.299) versus 3I-SS (.476, .330-0.688) and C-STAT (.858, .717-1.028). EMSA was rated easy to perform by 72% (13 of 18) of paramedics versus 67% (12 of 18) for FAST-ED and 6% (1 of 18) for RACE (χ² = 27.25, P < .0001), and easy to interpret by 94% (17 of 18) versus 56% (10 of 18) for FAST-ED and 11% (2 of 18) for RACE (χ² = 21.13, P < .0001).

CONCLUSIONS

The EMSA has superior abilities to identify LVO versus 3I-SS and stroke versus 3I-SS and C-STAT. The EMSA has similar ability to triage patients with stroke compared with the FAST-ED and RACE, but is simpler to perform and interpret.

Abstract WP365: Radiographic Predictors of Prognosis in Intracerebral Hemorrhage: "If It Ain’t Broke, Don’t Fix It"

Background/Purpose: The ICH score (ICHS) is commonly used to predict 30-day mortality in spontaneous ICH. Several investigators have evaluated additional factors in an attempt to refine this score, though none of these modifications have been incorporated into routine practice. We sought to determine whether incorporating additional radiographic features, specifically herniation and/or the degree of midline shift (MLS), improved the performance of the ICH score.

Methods: We retrospectively reviewed 180 consecutive ICH patients admitted to a single comprehensive stroke center between September 2014 and November 2015. The outcome of interest was poor prognosis, defined as mRS of 4-6, at time of discharge. Admission head CTs were evaluated by a vascular neurologist to determine whether uncal, tonsillar or subfalcine herniation were present, and to quantify the degree of midline shift. Midline shift was treated as a categorical variable determined by measuring the shift of the septum pellucidum from midline at the level of the basal ganglia.

Results: Patients with radiographic herniation present on admission had a much higher odds of poor outcome; however, this measure was specific (98%) but not sensitive (23%). Degree of midline shift performed similarly, with a specificity of 86% and a sensitivity of 36%. In our population, the ICH score was a better predictor of poor outcome than any of the combinations shown in the Table. For each unit increase in ICH score, the odds of a poor outcome increased by a factor of 2.6.

Conclusion: Although clinicians often view radiographic evidence of herniation and midline shift as indicators of dire prognosis, incorporation of these features into a modification of the ICH score failed to improve upon the original scale.

Abstract 148: Age Disparities in Acute Stroke Treatment: An Analysis of Six Years of US Hospital Discharges

Introduction: For each decade beyond age 55, the risk of ischemic stroke more than doubles; however, studies suggest that the elderly may receive acute treatments less frequently. Recently, several trials have shown benefit for endovascular thrombectomy (IA). Many of these trials included elderly patients. It remains unclear if previously described age disparities will continue to be seen as strategies for acute stroke therapy evolve. The purpose of this analysis was to establish the proportion of older adults that received acute revascularization treatment prior to the publication of these new endovascular trials.

Methods: We used the National Inpatient Sample to obtain data on primary ischemic stroke diagnosis discharges from US hospitals between 2006 to 2011. Among these discharges, utilization of IV tPA or endovascular thrombectomy was identified using procedure codes. Discharges were further classified by age ≥75 and year.

Results: Over the 6 year period, nearly half (47%) of the 2,592,269 ischemic stroke discharges were age 75 or older. Despite this, they represented only 27% of tPA administrations and 34% of endovascular procedures (Figure 1). For all ischemic stroke discharges during this period, tPA was administered in a lower proportion of patients ≥75 years compared to those <75 (3.7% [95% CI 3.5-4.0] vs. 4.5% [95% CI 4.3-4.8%]). Both tPA utilization and endovascular procedures increased each year for all age groups (p<0.001, Figure 1).

Conclusions: Despite the fact that approximately half of stroke discharges were age 75 or older, they account for only about 30% of those receiving acute stroke therapies. As the US population ages, these findings raise concern that fewer older patients will receive the only acute therapies shown to improve functional outcome in ischemic stroke. Providers should be cognizant of potential age biases when selecting candidates for acute therapy and should continue to enroll the elderly in therapeutic trials.

Abstract 306: Regional Differences in Stroke Center Designation and Get with The Guidelines (GWTG-S) Participation and Performance: Results From The NorthEast Cerebrovascular Consortium (NECC)

Introduction: The NorthEast Cerebrovascular Consortium (NECC) was created in 2006 to unite health care providers, public health officials, legislators and advocacy organizations in an 8-state region to implement and assess a Stroke Systems of Care Model.

Objectives: To examine differences in Primary Stroke Center (PSC) designation, participation in GWTG-S and performance of acute care hospitals (ACH) and critical access centers (CAC) in the NECC region compared to non-NECC regions.

Methods: We compared percentages of ACHs/CACs with State versus National PSC Designation, GWTG-S participation and Performance Achievement award trends over time in the pre- (2005) and post- NECC (2006-13) time periods. State designation refers to states conducting designation themselves or a combination of their own designation/national designation (Joint Commission, DNV or HFAP). US census data regions were stratified as The NECC region (CT, MA, ME, NH, NJ, NY, RI, VT) vs. Non-NECC regions (PA, South, Midwest, West). ACH/CACs were obtained from CMS. GWTG-S data were used for GWTG-S participation and awards (silver or higher for >1 year).

Results: Over the study time period (2005-13) the ACH/CACs per year in The NECC and non-NECC regions were 433 + 10 and 4420 + 172. State PSC designation occurred in CT, MA, FL, MD, NJ, and NYS. OK State designation was excluded due to lack of data. In the NECC region, State PSC designation increased over time from 29.3% in 2005 to 63.2% in 2013, compared to 0.1% in 2005 to 3.6% in 2013 in non-NECC regions (both analyses p<0.0001, Cochran Armitage Trend (CAT)). In the NECC region, National PSC designation increased over time from 2.8% in 2005 to 17.1% in 2013, compared to 35.5% in 2005 to 77.3% in 2013 in non-NECC regions (both analyses p<0.0001, CAT). In the NECC region, GWTG-S participation increased over time from 21.2% in 2005 to 61.5% in 2013 compared to 9.2% in 2005 to 32.4% in 2013 in non-NECC regions (both analyses p<0.0001, CAT), and GWTG-S awards increased over time in the NECC region from 0.5% in 2005 to 42.5% in 2013 compared to 0.1% in 2005 to 16.6% in 2013 in non-NECC regions (both analyses p<0.0001, CAT). After adjusting for year, significantly more NECC ACH/CACs received State PSC designation and significantly more non-NECC ACH/CACs received National PSC designation (both analyses p<0.0001, Cochran-Mantel-Haenszel (CMH)). Significantly more NECC ACH/CACs participated in GWTG-S and received GWTG-S awards than non-NECC ACH/CACs (both analyses p<0.0001, CMH).

Conclusions: There has been more rapid growth of State in lieu of National PSC certification, and participation and achievement in GWTG-S in the Northeast from 2006 through 2013 compared to other regions in the U.S. The NECC may compliment and enhance existing regulatory and advocacy initiatives. Further investigation is merited to evaluate the influence of regional networks and State versus National PSC designation.

Abstract 3301: Clinical Outcomes and Rates of Symptomatic ICH May be Better Among Patients Receiving only IA tPA in the 4.5 Hour Window

BACKGROUND: Intravenous tissue plasminogen activator (IV tPA) has established benefit in the treatment of acute ischemic stroke (AIS) among selected patients. Intra-arterial (IA) thrombolysis, though still of unproven efficacy, is postulated to have greater success in recanalizing large artery occlusion (LAO), and also offers an alternative treatment for patients disqualified from IV tPA. Combination therapy delivers the standard of care with potentially higher recanalization rates, but the safety of this is unknown.

OBJECTIVE: To evaluate hemorrhage, recanalization, and outcome for different modes of thrombolysis in AIS.

METHODS: We retrospectively selected consecutive patients with LAO presenting to 2 medical centers within three-4.5 hours between August 2006 and July 2011 and divided them into three groups based on the mode of thrombolysis: group 1) IV-IA, group 2) IA, and group 3) IV. Patients who received IV tPA and underwent mechanical thrombolysis without additional IA tPA were excluded. We compared age, baseline and one week/discharge National Institutes of Health stroke scale scores (NIHSSS), pre/post intervention thrombolysis in myocardial infarction (TIMI) scores, one to three month modified Rankin Scale (mRS) and rates of symptomatic hemorrhage (sICH) using chi-square tests and analysis of variance.

RESULTS: A total of 116 patients were included as follows: group 1, n=71; group 2, n=31; group 3, n=14. The mean age was 67+/-15 years, and initial NIHSSS 16+/-8, with minor inter-group differences. Times to IV tPA were 104+/- 42 (group 1) versus 140 +/-48 minutes (group 2, p=0.012). One week NIHSSS among survivors were 14+/-14 (group 1), 10+/-9 (group 2), and 12+/-12 (group 3). Initial angiographic data was retrievable for 52, among whom 71% had initial TIMI 0 scores in groups 1 and 2 (mean 0+/-1). Final TIMI scores were available in 39 patients with mode scores of 2 in 59% patients in group 1 (mean 2 +/-1) versus 71% in group 2 (mean 2+/-1). Long term outcomes were available for 42 patients, with median mRS of 4 in groups 1 and 3 versus 3 in group 2. There were 2 sICH in groups 1 and 3, and none in group 2.

CONCLUSIONS: Though there was a trend towards better outcomes with lower rates of hemorrhage in group 2 patients, the above findings did not reach statistical significance in this analysis. As ongoing trials compare outcomes between patients receiving IV versus IV and IA tPA, additional studies evaluating groups receiving only IA tPA are needed.

Abstract P24: Ethnic Disparities in Acute Stroke Care in New York State

Background: There is a greater burden of disease, mortality, and severity of strokes for Blacks and other ethnic minorities. Evidence for disparities in acute stroke care is less conclusive. Our goal was to assess whether significant ethnic disparities in acute stroke care exist in New York State (NYS).

Methods: NYS Statewide Planning and Research Cooperative System (SPARCS) data was used to identify all patients from NYS with a principal diagnosis of acute ischemic stroke (AIS, ICD-9 Diagnosis code of 433.01, 433.11, 433.21, 433.31, 433.91, 434.01, 434.11, or 434.91) from 1-1-2007 through 12-31-2008. Data were analyzed by chi square with respect to race/ethnicity (White, Black, or Hispanic), discharge from a NYS designated Primary Stroke Center (PSC), and use of intravenous t-PA. Get With The Guidelines preliminary data was used to examine the relationship between ethnicity and percent of AIS patients arriving < 2 hours, and percent arriving < 2 hours who were eligible for t-PA for whom t-PA was initiated < 3 hours.

Results: There were 47,037 patients with AIS, including 28,628 Whites, 4,166 Hispanics, and 9,001 Blacks. Whites were treated at PSCs 75% (21,489 of 28,628) of the time, compared to 91% (3,786 of 4,166) of Hispanics (p < 0.0001) and 85% (7,620 of 9,001) of Blacks (p < 0.0001). Overall, 4.7% (1,737 of 37,162) of AIS patients at PSCs were treated with t-PA compared to 1.4% (143 of 9,875) of patients treated elsewhere (p < 0.0001). Whites at PSCs received t-PA 5.2% (1,119 of 21,489) of the time, compared to 4.2% (160 of 3,786) of Hispanics (p = 0.01 vs. Whites), and 3.5% (267 of 7,620) of Blacks (p < 0.0001 vs. Whites). Whites arrived within 2 hours 48% (5,762 of 12,016) of the time, compared to 45% (815 of 1,792) of Hispanics (p < 0.001) and 44% (1,096 of 2,479) of Blacks (p <0.001). Eligible White patients were treated with t-PA 71% (864 of 1,216) of the time, compared to 70% (133 of 191) of Hispanics (p = NS) and 62% (164 of 265) of Blacks (p = 0.03).

Conclusions: Access to care does not guarantee utilization, particularly for Blacks. Black and Hispanic AIS patients were more often treated at PSCs compared to Whites. Yet, a lower percent of Blacks and Hispanics were treated with t-PA, reflecting both lower rates of timely hospital arrival and less frequent treatment of eligible patients.

Quality improvement in acute stroke: The New York State Stroke Center Designation Project

BACKGROUND

Many hospitals lack the infrastructure required to treat patients with acute stroke. The Brain Attack Coalition (BAC) published guidelines for the establishment of primary stroke centers.

OBJECTIVE

To determine if stroke center designation and selective triage of acute stroke patients improve quality of care.

METHODS

Baseline chart abstraction was performed on all stroke patients admitted to 32 hospitals serving Brooklyn and Queens, NY, from March to May 2002. Hospitals were invited to meet BAC guideline-based criteria. Adherence was verified by on-site visits. After designation, acute stroke patients were selectively triaged. Remeasurement data were collected from August to October 2003.

RESULTS

The authors abstracted 1,598 charts at baseline and 1,442 charts at remeasurement. From baseline to remeasurement, median times decreased for door to physician contact (25 vs 15 minutes, p = 0.001), CT performance for potential tissue plasminogen activator (t-PA) candidates (68 vs 32 minutes, p < 0.001), and t-PA administration (109 vs 98 minutes (p = NS). IV t-PA utilization increased from 2.4 to 5.2% (p < 0.005), select t-PA protocol violations decreased from 11.1 to 7.9% (p = NS), and the stroke unit admission rate increased from 16 to 39% (p < 0.001). In stroke centers (n = 14) vs nondesignated hospitals (n = 18), there were shorter median times from door to physician contact (10 vs 25 minutes, p < 0.001), CT performance for potential t-PA candidates (31 vs 40 minutes, p = NS), and t-PA administration (95 vs 115 minutes, p < 0.05). Stroke centers, compared with nondesignated centers, admitted acute stroke patients to stroke units more often (55.9 vs 10.9%, p < 0.001).

CONCLUSIONS

Stroke center designation and selective triage of acute stroke patients improved the quality of care, including access to timely thrombolytic therapy and stroke units.

Cardiac papillary fibroelastoma originating from pulmonary vein--a case report

Cardiac papillary fibroelastoma is a primary cardiac neoplasm that typically affects the cardiac valves, mainly the aortic and mitral valves, and very rarely the endocardium of cardiac chambers. Cardiac papillary fibroelastoma is rarely diagnosed during life, as the majority are incidental findings at autopsy, but with the advent of echocardiography, it is being increasingly recognized. Although the tumor is usually small and histologically benign, it may have a malignant propensity for life-threatening complications, such as a cerebrovascular accident, myocardial ischemia or infarction, or sudden death. The patient reported here presented with an embolic stroke from a thrombus on the surface of a left atrial papillary fibroelastoma. The papillary fibroelastoma was originating from the lower portion of the left inferior pulmonary vein and was protruding into the left atrial cavity. Papillary fibroelastoma originating from the pulmonary veins has not been reported before. The tumor was successfully removed by intraoperative transesophageal echocardiography-guided cardiac surgery. Grossly, the surface of the tumor was smooth and translucent. The gelatinous membrane on the surface tore easily, and soft papillary tumor with multiple fronds was visible. Histology confirmed the mass was a papillary fibroelastoma. Postoperative recovery was uneventful. Follow-up transthoracic echocardiogram revealed no residual or recurrence of tumor. The patient was in excellent health at 2-year follow-up. The case is described and the clinical characteristics of cardiac papillary fibroelastoma are reviewed.

Disorientation following stroke: frequency, course, and clinical correlates

To investigate the frequency, course, and clinical correlates of disorientation following stroke, we administered the Mini-Mental State Examination orientation subtest to 177 alert patients 7-10 days and 3 months after stroke and 240 stroke-free nondemented subjects. Disorientation was defined as a score < or = 8/10. Seventy-two (40.7%) of the patients were disoriented 7-10 days after stroke and 39 patients (22.0% of the sample) remained disoriented 3 months later. A logistic regression analysis determined that persistent disorientation was significantly related to stroke status [odds ratio (OR) = 5.8], after adjusting for memory and attentional deficits and demographic variables. Among stroke patients, disorientation was associated with severe hemispheral stroke syndromes (OR = 7.7), but not infarct location or vascular risk factor history, after adjusting for memory and attentional deficits and demographic variables. Sensitivity and specificity analyses determined that disorientation was an inaccurate marker for dementia or deficits in memory or attention, while intact orientation was associated with a low probability of dementia or memory dysfunction in most patients but not preserved attention. We conclude that disorientation is common and persistent following stroke and associated with severe hemispheral stroke syndromes but not infarct location. While disorientation is a poor marker for dementia or deficits in memory or attention, intact orientation should suggest that cognitive functions are likely to be preserved.

Cerebral hyperemia in MELAS

BACKGROUND

The pathophysiology of stroke-like episodes in MELAS (mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes) is uncertain.

CASE DESCRIPTION

We studied a 24-year-old man with MELAS who had fluent aphasia and right hemianopia. Magnetic resonance imaging and computed tomography showed a large infarction in the parietal, temporal, and occipital lobes. We performed serial planar 133Xe regional cerebral blood flow studies and single-photon emission computed tomography. Fifteen and 26 days after the stroke-like episode, there was generalized hyperperfusion, highest in infarcted areas. Four and 8 months after the stroke-like episode, the brain was still hyperemic, with highest flow in noninfarcted tissue. Reactivity to CO2 was less than normal within the infarct at 26 days but improved thereafter. In the noninfarcted region, vasomotor reactivity was impared at 4 months, when resting flows were at their peak.

CONCLUSIONS

We observed generalized cerebral hyperemia and fluctuating CO2 reactivity in MELAS, possibly a consequence of local lactic acid production. In addition, this case suggests that nonquantitative functional imaging may be misleading in MELAS.

Clinical determinants of dementia related to stroke

Among 251 patients examined 3 months after the onset of acute ischemic stroke, we diagnosed dementia in 66 (26.3%) by using modified DSM-III-R criteria based on neuropsychological, neurological, functional, and psychiatric examinations. We used a logistic regression model to derive odds ratios (ORs) for clinical factors independently related to dementia in this cross-sectional sample. Dementia was significantly associated with age, education, and race. A history of prior stroke (OR = 2.7) and diabetes mellitus (OR = 2.6) was also independently related to dementia, but hypertension and cardiac disease were not. Stroke features associated with dementia included lacunar infarction compared with all other subtypes combined (OR = 2.7) and hemispheric laterality in relation to brainstem or cerebellar location. There was a predominance of dementia in patients with left-sided lesions (OR = 4.7), an effect not explained by aphasia. Dementia was especially common with infarctions in the left posterior cerebral and anterior cerebral artery territories. A major dominant hemispheral syndrome (reflecting size and laterality) was also independently associated with dementia (OR = 3.9). We suggest that dementia after ischemic stroke is a result of multiple independent factors, including both small subcortical and large cortical infarcts especially involving the left medial frontal and temporal regions, with additional contributions by demographic and vascular risk factors.

Confusion and memory loss from capsular genu infarction: a thalamocortical disconnection syndrome?

We examined six patients with an abrupt change in behavior after infarction involving the inferior genu of the internal capsule. The acute syndrome featured fluctuating alertness, inattention, memory loss, apathy, abulia, and psychomotor retardation, suggesting frontal lobe dysfunction. Contralateral hemiparesis and dysarthria were generally mild, except when the infarct extended into the posterior limb. Neuropsychological testing in five patients with left-sided infarcts revealed severe verbal memory loss. Additional cognitive deficits consistent with dementia occurred in four patients. A right-sided infarct caused transient impairment in visuospatial memory. Functional brain imaging in three patients showed a focal reduction in hemispheric perfusion most prominent in the ipsilateral inferior and medial frontal cortex. We infer that the capsular genu infarct interrupted the inferior and anterior thalamic peduncles, resulting in functional deactivation of the ipsilateral frontal cortex. These observations suggest that one mechanism for cognitive deterioration from a lacunar infarct is thalamocortical disconnection of white-matter tracts, in some instances leading to "strategic-infarct dementia."

Evaluation of lithium as an inhibitory agent of herpes simplex virus in cell cultures and during reactivation of latent infection in rabbits

Lithium carbonate inhibited plaque formation of herpes simplex virus types 1 and 2 in rabbit kidney and Vero cells (50% effective dose, 435.5 to 490 micrograms/ml). Plasma lithium levels of 67 to 134 micrograms/ml were achieved by oral therapy in rabbits. However, neither ocular virus shedding nor virus-positive trigeminal ganglia were reduced after intentional reactivation of latent herpes simplex virus infection.