Risultati per: Sindromi coronariche acute

Stroke, Volume 53, Issue Suppl_1, Page A151-A151, February 1, 2022. Background:Published data suggests tenecteplase (TNKase) is non-inferior to alteplase for acute ischemic stroke treatment. TNKase has certain advantages over alteplase including single-bolus administration. We evaluated TNKase performance in all acute stroke patients in a large integrated healthcare system.Methods:In 2016, we launched a standardized telestroke program for 21 certified stroke centers to include immediate video evaluation by a teleneurologist. In November 2020, we transitioned all centers to use TNKase for qualifying stroke patients presenting within 4.5 hours of last time known well. Selection criteria were the same as those for alteplase. Our study cohort included all potential acute stroke patients evaluated by telestroke. We compared the TNKase cohort treated during 12/1/20 – 3/31/21 to the alteplase cohort during 5/1/20 – 8/31/20. Assessment included demographics, mode of arrival, initial NIHSS, neuroimaging results, large vessel occlusion, rate of intracranial hemorrhage (ICH), discharge outcomes, percent with mRS (0-2) and mortality at 90 days with 95% CI.Results:Study cohort had 301 patients treated with TNKase and 248 patients with alteplase. Average age was about 70 years. Compared to alteplase, TNKase was associated significantly with faster door-to-needle (DTN) and door-in-door-out (DIDO) times [Table]. TNKase cohort had a larger percentage of stroke mimics. There was a trend of less symptomatic hemorrhage seen with TNKase. Multivariate model revealed that TNKase treatment was less likely to have 90-day mortality (OR=0.56, 95% CI 0.33-0.96, p=0.04). Percent 90-day favorable mRS score (0-2) was no different between the cohorts.Conclusions:We have successfully and safely transitioned to using TNKase for acute stroke treatment in our community setting. Compared to alteplase, TNKase cohort achieved faster DTN and DIDO times and less 90-day mortality. Further evaluation is needed to examine 90-day mRS in larger cohorts.

Stroke, Volume 53, Issue Suppl_1, Page AWMP3-AWMP3, February 1, 2022. Background and Purpose:Hyperglycemia has been associated with higher rates of death or disability in acute ischemic stroke patients undergoing endovascular treatment. However, it remains unclear whether intensive serum glucose reduction can reduce the rates of death or disability in patients undergoing endovascular treatment.Methods:We analyzed the effect of intensive (serum glucose

Stroke, Volume 53, Issue Suppl_1, Page ATP74-ATP74, February 1, 2022. Introduction:Acute stroke (AS) is a high-harm, high-cost condition that affects nearly 800,000 people/year in the US. Proven, time-sensitive treatments can reduce disability. However, to deliver an AS treatment, a timely and accurate diagnosis is first needed. Yet, diagnostic error is the most common type of error in AS, occurring in ~10% of AS patients, and higher in patients with mild or atypical presentations.Hypothesis:The identification, characterization, and ranking of failures of the AS diagnostic process, by clinicians who provide AS care in the ED, is an essential step prior to designing feasible, robust, and effective solutions to reduce AS diagnostic error.Methods:A Learning Collaborative (LC) of clinicians involved in the AS diagnostic process at 3 health systems in Chicago, IL participated in a Failure Modes, Effects, and Criticality Analysis (FMECA) to identify the steps in the AS diagnostic process, failures of each step and their underlying causes, and to characterize each failure’s frequency (F), impact (I) on making a timely and accurate AS diagnosis, and any existing safeguards (S), using standardized scores. A risk priority index (RPN=FxIxS) and a criticality number (CN=FxI) was calculated for each failure and rank ordered.Results:In a series (N=7) of 60-90 minute virtual sessions, the LC, comprised of Emergency Medicine (N=9), Neurology (N=10), and Radiology (N=1) clinicians of all professions (MD, RN, Technician) and levels (resident, attending, coordinator), created an AS diagnostic process map and risk table. The process map included 27 specific steps. The highest risk steps were failure to use a severe stroke/large vessel occlusion scale (RPN=432; CN=72); inability to establish patients’ last known well (RPN=384; CN=48); failure to use an AS screening scale (RPN=384; CN=54); lack of a “witness” of the event to confirm information (RPN=378; CN=42); and failure to recognize potential stroke and activate a stroke code at triage (RPN=288; CN=48).Conclusion:This study, for the 1sttime, reveals specific targets, particularly in the early phase of the AS diagnostic process, for which solutions should be designed (e.g., standardized process to use a severe stroke/LVO tool) to reduce AS diagnostic error.

Stroke, Volume 53, Issue Suppl_1, Page AWP114-AWP114, February 1, 2022. Introduction:Stroke is the fifth leading cause of death in the US and a major cause of disability. Atrial fibrillation (AF) increases the risk of ischemic stroke fivefold. Cardioembolic stroke in patients with AF is associated with high mortality. The association of elevated cardiac troponin with mortality in patients with acute ischemic stroke has been studied previously; however, there is limited data in subgroups of ischemic stroke etiology. We sought to determine the association of troponin elevation at presentation with 90-day all-cause mortality in patients with acute ischemic stroke and AF.Methods:TheInitiation ofAnticoagulation afterCardioembolic Stroke (IAC) study is a multicenter cohort drawn from eight US Stroke Centers. We included consecutive patients hospitalized with acute ischemic stroke and AF between 2015-2018, who had an initial baseline cardiac troponin I (bcTnI) obtained at presentation. The primary outcome was all-cause mortality at 90 days from stroke onset. We undertook multivariable logistic regression to determine the association between elevated bcTnl (≥0.1 ng/mL) and 90-day mortality.Results:Of the 2084 patients enrolled in IAC, 1889 patients had 90-day follow-up of which 1461 patients had bcTnI available. 239 of the included patients (16.4%) had an elevated bcTnl, and death within 90-days occurred in 323 patients (22.1%). Elevated bcTnI was associated with 90-day mortality in univariable analysis (49.4% vs 24.9%; OR 1.71, 95% CI 1.17-2.50, p

Stroke, Volume 53, Issue Suppl_1, Page ATMP23-ATMP23, February 1, 2022. Background and Purpose:We sought to investigate the impact of COVID-19 pandemic on number of acute stroke patients admitted to Japanese primary stroke centers (PSCs).Methods:The Japan Stroke Society and the MHLW registry of mechanical thrombectomy for acute ischemic stroke conducted a national annual survey of hospitalization volumes for acute ischemic stroke, intracranial cerebral hemorrhage, and subarachnoid hemorrhage in PSCs. Number of acute stroke patients was defined as sum of three stroke subtypes admitted within 7 days after the onset. Monthly acute stroke volumes were compared between 2019 and 2020, among COVID-19 waves, and regional infectious rates.Results:The stroke volume data was completed in 530 PSCs. The annual acute stroke volume was declined 2.5% from 179,893 in 2019 to 174,385 in 2020. Number of acute stoke patients was declined during COVID-19 expanding periods (1stwave, Mar-May; 2ndwave Jul-Aug; 3rdwave Nov-Dec), whereas it was increased in the other months. The mean decline rate of stroke volumes from 2019 to 2020 was greater in 125 PSCs located in prefectures with high estimated SARS-CoV 2 infected rate (more than 2,300 per million people) than in 405 PSCs of the other regions (-4.6±15.4% vs -0.1±20.0%, P=0.008), especially during COVID-19 expanding periods (-8.2±17.9% vs -3.1±21.3%, P=0.009).Conclusions:Acute stroke volumes were declined in 2020 from 2019 in Japanese PSCs, especially during COVID-19 expanding periods and in highly infected regions. The overwhelmed health care system and infection control practices may have associated with decline of number of acute stroke patients during COVID-19 pandemic.

Stroke, Volume 53, Issue Suppl_1, Page AWP112-AWP112, February 1, 2022. Introduction:Transthoracic echocardiography (TTE) is valuable in evaluating stroke etiology. A left ventricular (LV) thrombus, the identification of which can immediately impact clinical management, is rarely seen unless the ejection fraction (EF) is less than 50%. A clinical prediction score to identify stroke patients with EF less than 50% may help guide the timing of TTE after stroke.Methods:The CAESAR registry includes all patients with ischemic stroke at our medical center. We derived a clinical prediction score using CAESAR data from calendar years 2011-2016. We included all patients who underwent TTE and had a quantitative EF measurement. We selected clinical factors, laboratory values, and vital signs based on biological plausibility and the results of multiple logistical regression with backward selection.Results:Of 2,116 patients with ischemic stroke from 2011-2016, 1,045 patients had an EF measurement. The mean age was 63 (SD, 15), 49% were women, and the mean EF was 63% (SD, 14%). Reduced EF was identified in 171 patients (16%). Our final model comprised historical variables (coronary disease, heart failure, and chronic kidney disease) and clinical parameters from the time of admission (NIHSS score, heart rate, serum potassium, and serum creatinine). The model AUC was 0.80 (95% CI, 0.76-0.85) and model calibration was good (Figure). At a predicted probability threshold of 0.1, the score’s sensitivity for reduced EF was 80% with a specificity of 62%. In a sensitivity analysis excluding patients with atrial fibrillation, the AUC was 0.77 (95% CI 0.70-0.83) and calibration remained good.Conclusions:We derived a clinical score with good performance for predicting reduced EF in acute ischemic stroke patients. If externally validated, such a score may help identify which patients are most likely to benefit from an expedited inpatient TTE.

Stroke, Volume 53, Issue Suppl_1, Page ATMP50-ATMP50, February 1, 2022. Background:Prior research has shown that increased blood pressure variability (BPV) after ischemic stroke is associated with lower odds of good functional outcome, but the number, intervals between, and epochs of blood pressure measurements have not been standardized.Methods:We include patients enrolled in the FAST-MAG trial with a final diagnosis of ischemic stroke, premorbid modified Rankin Scale (mRS) of 0, 4 “early” blood pressure measurements (prehospital and 3 in the hour after arrival), and 9 “later” measurements (q4 hours from hours 4-24 and q8 hours from hours 24-48). The primary outcome was 90-day mRS of 0-1 (good outcome). The BPV exposure was the top tertile (highest level) of systolic standard deviation (SD). We fit logistic regression models adjusted for patient age, race, sex, baseline NIH Stroke Scale, tPA, endovascular therapy, mean systolic blood pressure, smoking, atrial fibrillation, hypertension, and diabetes.Results:We included 455 patients, with a mean age of 70.8 years, 46.8% female, 50.8% had tPA, 6.4% had endovascular therapy, the median baseline NIH Stroke Scale was 12 (5-19) and good outcome occurred in 152/455 (33.4%). The mean early SD was not significantly lower in patients with good outcome (p=0.12), but later SD was lower in patients with good outcome (13.5±5.6 vs. 15.1±5.6, p

Stroke, Volume 53, Issue Suppl_1, Page AWP259-AWP259, February 1, 2022. Introduction:RNS60 is an experimental therapy comprised of stable oxygenated nanobubbles in a sodium chloride solution with an oxygen content of 55+/-5 ppm. Phase I/II clinical trials established a safety profile for RNS60 in patients with ALS and MS. In-vitro assays in neurons have demonstrated mitochondrial biogenesis with RNS60. Therefore, we hypothesized that RNS60 would protect the ischemic penumbra and delay stroke evolution. In this study, we assessed RNS60 in a cynomolgus macaque (CM) model of transient middle cerebral artery occlusion (MCAO).Methods:Experimenters were blinded and CMs randomly allocated to treatment. In the first experiment, 22 male CMs (2.6+/-0.55 kg) were anesthetized with physiologic monitoring and MCAO followed by immediate MRI imaging to define perfusion deficit. RNS60 (5cc/kg/h IV over 1h followed by 2.5cc/kg/h for 48h) or drug vehicle were administered starting 1h following MCAO. MCA was reperfused 90min after MCAO. CMs underwent MRI diffusion-weighted (DWI) and T2 imaging at 48h and 30d after MCAO. Serial Non-Human Primate Stroke Scale (NHPSS) assessments were collected over 30 days following MCAO. In the second experiment, 10 male CMs (4.95+/-0.18 kg) underwent permanent MCAO. RNS60 or drug vehicle were infused starting 5 minutes after MCAO (5cc/kg/h IV for 1 hour followed by 2.5cc/kg/h until sacrifice). Perfusion and DWI MRI images were obtained serially over 6 hours to measure the evolution of the penumbra. CMs were sacrificed at the completion of the experiment.Results:DWI stroke volume was significantly reduced 4.3+/-1.1mL vs. 9.1+/-0.92mL (P=0.0036) at 48 hours post MCAO in RNS60 vs. placebo treated CMs. This result was conserved on T2 imaging at 30 days where stroke volume was 3.5+/-0.86mL vs. 7.3+/-0.79mL (P=0.004). RNS60 significantly improved NHPSS scores over 30 days compared to controls after removing three outlier CMs (2 mortalities and one non-reperfused MCA). The results of the second experiment demonstrated a 6h DWI volume of 5.9cc in RNS60 treated CMs compared to 10.6cc in controls.Conclusion:RNS60 administered during acute ischemic stroke significantly reduces stroke volume and improves functional outcomes in male CMs. The evolution of penumbra to stroke is slowed following RNS60 administration.

Stroke, Volume 53, Issue Suppl_1, Page ATP96-ATP96, February 1, 2022. Introduction:Neurologic deterioration (ND) occurs in a quarter of acute lacunar infarcts and may lead to severe disability, but underlying pathophysiology of ND remains poorly understood. We sought to identify risk factors and clinical characteristics associated with ND.Methods:This retrospective observational study included consecutive patients with acute lacunar stroke admitted to New York University Langone Health and Brown University (NYU/Brown). Lacunar stroke was defined as a subcortical infarct

Stroke, Volume 53, Issue Suppl_1, Page ATMP52-ATMP52, February 1, 2022. Introduction:Obstructive sleep apnea (OSA) is a known ischemic stroke risk factor. We analyzed OSA prevalence trends in hospitalized acute ischemic stroke (AIS) patients and treatment utilization and outcomes among AIS patients with and without OSA.Methods:Hospitalized adults 18 and over with a primary diagnosis of AIS per ICD-9 and 10 codes recorded in the Nationwide Inpatient Sample from 2005-2017 were identified. The diagnosis of OSA was identified by ICD-9 and 10 codes. National estimates were generated using discharge weights. Temporal trends in OSA prevalence were analyzed by logistic regression. Links between OSA and IV-tPA and endovascular thrombectomy (EVT) use, mechanical ventilation, discharge disposition, and in-hospital mortality were assessed by adjusted logistic regression models.Results:Of 5,864,798 AIS patients, 234,339 (4.0%) had OSA (intravenous tPA (n=18,421; 7.9%), EVT (n=3,787; 1.6%), in-hospital deaths (n=10,422; 4.5%)). OSA rates in AIS increased from 0.16% in 2005 to 6.3% in 2017 (p-value < .001). OSA AIS patients were younger (mean age 66 vs. 73 years, p

Stroke, Volume 53, Issue Suppl_1, Page ATP68-ATP68, February 1, 2022. Introduction:Nebraska Mission: Lifeline Stroke is a 4-year initiative to increase guideline-based treatment of acute stroke across the continuum of care. Guidelines advise post-stroke assessment by a multi-disciplinary team to guide discharge process and select ideal rehab setting.Purpose:To develop resources to facilitate the transition of Nebraskans with stroke to the most appropriate level of post-acute care.Methods:Healthcare Providers (HCPs) from various settings completed two surveys: hospital stroke rehab referral strategies and practices (N=23), and individual experiences related to stroke rehab (N=260). In addition, a literature review was conducted to find published guidelines and research on clinical decision making. Lastly, a focus group consisting of social worker/case managers was held to provide input on resources developed.Results:Hospitals (N=23) believe higher numbers of stroke patients should be referred to IRFs (42%) and stated that patients’ “health status” (91%), “opinions from hospital team members” (87%), and “opinions from patient, family, or caregivers” (78%) are most relevant in the decision process. Factors that impact referral process include: HCPs may not be familiar with all options for post-acute rehab care (17%) and patient or family/caregivers are not educated about options (30%). Most (57%) of HCPs surveyed and all focus group participants indicated discharge referral process could be improved with a standardized decision-making tool. Based on this input, two discharge planning guides were developed. The first assists HCPs in determining appropriate level of post-acute stroke care by comparing various types and settings in an easy-to-read format. The second is patient/caregiver focused and includes information to assist in decision-making process and a table comparing rehab settings. These guides have been disseminated through conference presentations, direct mailings, and web-based resources.Conclusions:Discharge tools with clear descriptions of options are necessary to assist HCPs and patients/caregivers in matching appropriate care with patient’s rehab needs. These care choices are key to patients achieving their highest level of independence.

Stroke, Volume 53, Issue Suppl_1, Page AWP90-AWP90, February 1, 2022. Introduction:Given the impact of endovascular therapy (EVT) on clinical outcomes and usage of pre-hospital bypass protocols to route acute ischemic stroke (AIS) patients with suspected large vessel occlusion (LVO) to EVT-performing hospitals (EPH), there is substantial interest in upgrading stroke center certification to become comprehensive centers. Here, we assess the effect of becoming EPH on total AIS and non-LVO AIS admissions in four hospitals in a large urban area.Methods:From our prospectively collected multi-institutional registry, we identified all consecutive patients with AIS at four EPHs between Nov 2017 – May 2019. Three of the EPHs (named EPH 1, EPH 2, EPH 3) became EPHs in early 2017, which allowed for preferential routing and pre-hospital bypassing of other non-EPH hospitals by regional emergency medical services protocols. Another EPH (named original EPH) had been an EPH for many years. The primary outcome was the volume of AIS admissions after upgrading to a EPH over time and was determined by linear regression.Results:Among 3,727 patients with AIS presenting to 4 hospitals across the Houston area, median age was 67 [IQR 57-78], 48% were female, median NIHSS was 5 [IQR 2-12], 21% had LVO, 11% underwent EST. AIS admissions increased at EPH 1 at a rate of 15 AIS per quarter (95% CI 5.5-25.3, p=0.012); EPH 2 increased at a rate of 8 AIS per quarter (95% CI 3.18 – 13.44, p=0.011); EPH 3 increased at a rate of 10 AIS per quarter (95% CI 2.4-18.6, p=0.023) AIS admissions at the original EPH did not change significantly during the study period (CI 0-11.9, p=0.47). Increases in AIS admissions were predominantly in non-LVO AIS (Figure A).Conclusions:In this observational cohort study, upgrading to EPH status resulted in continuously increasing AIS admissions over time, particularly for non-LVO patients; this growth was not observed in established EPH. These findings demonstrate and quantify the effect of upgrading stroke center certification on inpatient AIS volumes.

Stroke, Volume 53, Issue Suppl_1, Page AWMP92-AWMP92, February 1, 2022. Background:In patients with ischemic stroke undergoing endovascular treatment (EVT), time to treatment and collateral status are important prognostic factors. We assessed the relation between time to CT angiography (CTA) and collateral status. Furthermore, we assessed whether collateral status modifies the relationship between onset to recanalization time (ORT) and functional outcome.Methods:From the prospective, multicenter MR CLEAN Registry, we included patients with acute ischemic stroke, who had a carotid terminus or M1 occlusion and were treated with EVT in the Netherlands within 6.5 hours of symptom onset. A quantitative collateral score (qCS) was assessed from baseline CTA using an automated image analysis algorithm (Strokeviewer; Nico.lab). Multivariable regression models were used to assess the relationship between time to imaging and the qCS and between ORT and functional outcome (90-day modified Rankin Scale score). An interaction term (ORT * qCS) was introduced in the latter model to test whether qCS modifies this relation.Results:We analysed 1813 patients. The median time from symptom onset to CTA was 91 minutes [IQR: 56-150] and the median qCS was 49% [IQR: 25-79]. Longer time to CTA was not associated with qCS (β per 30 minutes, 0.001 [-0.008 – 0.010]). Both a higher qCS (acOR per 10% increase, 1.07 [1.03-1.10], p

Stroke, Volume 53, Issue Suppl_1, Page A108-A108, February 1, 2022. Introduction:Hypertension is the most important modifiable risk factor for recurrent stroke. However, it remains poorly controlled after stroke, especially among Black and Hispanic patients. Black and Hispanics have a higher prevalence of uncontrolled BP and limited access to care. Interventions that promote equitable access are needed to improve outcomes.Aim:We tested whether a randomized trial of post-acute stroke care that integrates nurse-supported home BP telemonitoring, tailored infographics, and video visits with a multidisciplinary team including pharmacy (Telehealth After Stroke Care (TASC intervention) was feasible.Methods:Acute stroke patients with hypertension were randomized prior to discharge to usual care or TASC. Usual care patients received a video visit with primary care at 1-2 weeks and stroke specialist at 6 and 12 weeks after discharge. TASC patients received a tablet that wirelessly transmits BP data to the electronic health record, supported by remote telehealth nurse monitoring along with BP infographics, developed through community participatory design, at first visit and pharmacist visits. Outcomes included recruitment feasibility, visit adherence, and retention. Generalized linear modeling was used to evaluate within-patient home BP change.Results:Of 67 eligible patients, 6 were discharged before recruitment, 8 refused and 3 engaged in other studies. Fifty enrolled patients included 44% Hispanic, 32% Black and 36% women with mean age 64.3 (±14.0) yrs. About half had ≤ a high school education and 30% had commercial insurance. Baseline SBP was similar in TASC (140 ± 19 mmHg) vs. usual care (142 ± 19 mmHg). Retention rate was higher in TASC vs. usual care (84% vs 64%, p=0.11). Adherence to video visits was also higher in TASC (91% vs 75%, p=0.14). SBP control was better in TASC (76% vs. 25%, p

Stroke, Volume 53, Issue Suppl_1, Page ATP25-ATP25, February 1, 2022. Hypothesis:Hospital presentation for acute stroke may have been delayed during COVID-19. We hypothesize that stroke patients with mild symptoms (NIHSS

Stroke, Volume 53, Issue Suppl_1, Page ATP223-ATP223, February 1, 2022. Introduction:Cardiac troponins are often elevated in patients with acute stroke and have been associated poor outcomes. Whether the elevation in cardiac troponins, a marker of acute myocardial injury, is due to neurogenic mechanisms or the underlying cardiac risk factors is unknown. We evaluated the association between stroke severity and serum cardiac troponin levels in people with acute stroke.Methods:We conducted a retrospective study of adults (≥ 40 years) with a discharge diagnosis of imaging confirmed stroke admitted to a quaternary stroke centre in Toronto, Canada between January 1, 2018 and December 31, 2018. We collected demographic and clinical information, including stroke severity using the National Institutes of Health Stroke Scale [NIHSS], modelled as a continuous variable. We recorded serum cardiac troponin levels on admission. We modelled serum troponin level both as a continuous and a categorical variable (normal vs. high, ≥ 15 ng/L). We evaluated the association between admission NIHSS and serum troponin level using multivariable negative binomial models and logistic regression models, adjusting for demographics (age and sex) and comorbidities [history of congestive heart failure or stroke, stroke type (ischemic vs. hemorrhagic), ST elevation on ECG, and creatinine levels].Results:We included 218 patients with acute stroke (median age 76 years, 48.6% women), of whom 190 (87.2%) had an ischemic stroke. Median NIHSS was 6 (Q1-Q3, 2-14), and median cardiac troponin level was 17 ng/L (Q1-Q3, 9-30), with 108 (53.2%) patients having higher than normal levels. A one-point increase in NIHSS (stroke severity) was associated with a higher serum troponin level in age- and sex- (RR 1.03; 1.00-1.05) and multivariable- (RR 1.03; 1.01-1.05) adjusted models. However, stroke severity was not associated with the odds of having high troponin levels in adjusted models (OR 1.03; 0.98-1.08).Conclusions:The modest, yet independent, association between greater stroke severity and higher cardiac troponins in patients with acute stroke could suggest a neurogenic basis for mild cardiac injury in patients with acute stroke. Future work on the association between elevated troponin and poor stroke outcomes should account for stroke severity on admission.