Intravenous tPA for Acute Ischemic Stroke in Patients with COVID-19

BACKGROUND/PURPOSE: Coronavirus disease 2019 (COVID-19) is associated with increased risk of acute ischemic stroke (AIS), however, there is a paucity of data regarding outcomes after administration of intravenous tissue plasminogen activator (IV tPA) for stroke in patients with COVID-19. METHODS: We present a multicenter case series from 9 centers in the United States of patients with acute neurological deficits consistent with AIS and COVID-19 who were treated with IV tPA. RESULTS: We identified 13 patients (mean age 62 (±9.8) years, 9 (69.2%) male). All received IV tPA and 3 cases also underwent mechanical thrombectomy. All patients had systemic symptoms consistent with COVID-19 at the time of admission: fever (5 patients), cough (7 patients), and dyspnea (8 patients). The median admission NIH stroke scale (NIHSS) score was 14.5 (range 3-26) and most patients (61.5%) improved at follow up (median NIHSS score 7.5, range 0-25). No systemic or symptomatic intracranial hemorrhages were seen. Stroke mechanisms included cardioembolic (3 patients), large artery atherosclerosis (2 patients), small vessel disease (1 patient), embolic stroke of undetermined source (3 patients), and cryptogenic with incomplete investigation (1 patient). Three patients were determined to have transient ischemic attacks or aborted strokes. Two out of 12 (16.6%) patients had elevated fibrinogen levels on admission (mean 262.2 ± 87.5 mg/dl), and 7 out of 11 (63.6%) patients had an elevated D-dimer level (mean 4284.6 ±3368.9 ng/ml). CONCLUSIONS: IV tPA may be safe and efficacious in COVID-19, but larger studies are needed to validate these results

Abstract TP244: Predictive Scoring System to Differentiate Acute Ischemic Stroke From Stroke Mimic During Code Stroke Evaluation

Background: Migraine, seizure and toxic metabolic encephalopathy are common stroke mimics (SM) during code stroke (CS) evaluation and up to 30% of patients treated with IV tPA are found to have SM. An ideal way to differentiate SM from acute ischemic stroke (AIS) is through history and clinical examination in conjunction with MRI brain. Quick identification of a set of clinical characteristics predictive of SM may be helpful to prevent unnecessary IV thrombolysis. This study aimed to develop and evaluate effectiveness of a predictive scoring system to differentiate AIS from SM. Methods: The study population included 508 patients who received IV tPA from Jan 2013-Dec 2016 at a large comprehensive stroke center. Sixty clinical characteristics were reviewed and 27 were chosen for prediction analysis based on univariate ANOVA F-test. A prediction model is proposed by multivariate logistic regression with step wise selection of variables with the variable entry and stay threshold of p value 0.2 and 0.05 respectively to develop a predictive score. Results: Our scoring system consists of 7 clinical characteristics which are easily assessable during “CS” with yes and no answers. Each clinical variable has score weightage based on strength of statistical association with final diagnosis AIS Vs SM. Score is composed of : seizure at onset (score yes: -1.8, no:0), headache (yes: -2.3, no:0), history of migraine (yes: -1.7, no:0) , encephalopathy (yes: -1.2, no:0), atrial-fibrillation (yes: 1.3, no:0), NIHSS (0.1 per unit) and localizable symptoms (yes : 3.3, no: 0). Area under receiver operative characteristic (ROC) curve was 0.91 and a score >3.4 identified AIS with a sensitivity of 88.3% and specificity of 82.1%. Conclusion: Our study found that clinical characteristics of acute presentation were more helpful than conventional vascular risk factors history to differentiate AIS from SM. Our predictive score is reliable to differentiate AIS from SM and is intended to help clinicians identify SM using quick and simple clinical characteristics. Prospective validation of the score is needed

American Academy of Neurology Anti-racism Education Pilot Program: A Single Academic Center Experience (P9-7.005)

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Optimizing the “Stroke Alert” Activation Protocol for Hospitalized Patients (P1-1.Virtual)

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Confidence in a Crisis: A Pilot Multi-disciplinary Stroke Alert Simulation for First-year Neurology Residents (P8-7.006)

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Direct Bypass Surgery for Moyamoya and Steno-occlusive Vasculopathy: Clinical Outcomes, Intraoperative Blood Flow Analysis, Long-term Follow-up, and Long-term Bypass Patency in a Single Surgeon Case Series of 162 Procedures

Cerebral extracranial-intracranial (EC-IC) direct bypass is a commonly used procedure for the treatment of cerebral hypoperfusion secondary to chronic steno-occlusive vasculopathy. We sought to determine clinical outcomes, intraoperative blood flow analysis, long term follow up, and long term patency rates from a single surgeon’s series of direct cerebral bypass for moyamoya disease, moyamoya syndrome, and steno-occlusive disease. We reviewed clinical, demographic, operative and neuroimaging records for all patients who underwent a direct EC-IC bypass by the senior author between August 1999 and November 2020. Primary outcomes analyzed were functional long-term outcomes (by modified Rankin score [mRS]), surgical complications, and short-term and long-term bypass patency. A total of 162 revascularization procedures in 124 patients were performed. Mean clinical follow up time was 2 years 11 months. The combined immediate and long term postoperative stroke and/or intracerebral hemorrhage rate was 6.2%. There were 17 bypasses (10%) that were found to be occluded at long-term follow-up, all but one were asymptomatic. Long-term graft occlusion was correlated with presence of complete collateralization on preoperative angiography but not cut flow index (CFI). Overall, patients had a significant clinical improvement with a mean mRS score 1.8 preoperatively and 1.2 postoperatively. In our consecutive series of patients treated with direct EC-IC cerebral bypass, there was significant improvement in functional outcome as measured by the mRS. The long term patency rate was 90%. There was a statistically significant correlation between complete or incomplete angiographic collateralization patterns and long-term bypass occlusion. There was no correlation between bypass type, clinical syndrome, or CFI and long-term occlusions. The role of bypass surgery and the need for surgical expertise remain strong in the treatment of moyamoya variants and a select group of atherosclerotic steno-occlusive patients

Abstract WP112: Neighborhood Level Characteristics Associated With Adequate Transition of Stroke Care: The Transition of Care Stroke Disparities Study

Abstract only Objective: Transition of Care Stroke Disparities Study is an observational prospective cohort aimed to investigate disparities in the transition of stroke care (TOSC) post-hospitalization to home and to identify factors associated with adequate TOSC and stroke outcomes. we have demonstrated that higher individual socioeconomic status is associated with adequate TOSC. The present study explores the association between neighborhood-level characteristics (NLC) and adequate TOSC in ischemic stroke patients 1 month after discharge. Methods: Data from 925 ischemic stroke patients discharged from 10 Comprehensive Stroke Centers (CSCs) was obtained from three sources: a. NLC: demographic composition, level of education, and median household income from publicly available data using participants’ Zip codes (independent variables); b. 30-day post-discharge data for 6 categories of TOSC-related behaviors (dependent variables) including medication adherence, weekly exercise, medical follow-up, rehabilitation attendance, toxic habit cessation, diet modification. c. Clinical characteristics from Get with the Guidelines-Stroke (covariates). The primary outcome was 100% adequate transition of care (ATOC), a combined index of ideal adherence to all applicable behavior modifications. Results: The sample included 46% Women, 23% Non-Hispanic Black and 22% Hispanic, the average age was 64 years. NLC ranged as follows: % Black (0-93.9, median 9.1), %Hispanic (3-99.9, median 82.3), % bachelor’s degree (6.3-77.3, median 26.2), and median household income ($18,920-159,914, median$48,816). Almost a third (34%) of participants achieved 100% ATOC. In the adjusted analysis of NLC variables, higher %Hispanic (OR=1.45, 95% CI=1.03-2.04), higher %bachelor's degree recipients (OR=1.62, 95% CI=1.21-2.18), and higher median income (OR=1.12, 95%CI=1.04-1.21) were significantly associated with achieving 100% ATOC. Conclusions: Results suggest that NLC plays a crucial role in adherence to care transition instructions, underscoring the importance of interventions targeted at lower socioeconomic status populations. Future work will determine the impacts of NLC on stroke recurrence and readmission

Reducing neurodisparity Recommendations of the 2017 AAN Diversity Leadership Program

Many advances in prevention, diagnosis, and treatment of neurologic disease have emerged in the last few decades, resulting in reduced mortality and decreased disability. However, these advances have not benefitted all populations equally. A growing body of evidence indicates that barriers to care fall along racial and ethnic lines, with persons from minority groups frequently having lower rates of evaluation, diagnosis, and intervention, and consequently experiencing worse neurologic outcomes than their white counterparts. The American Academy of Neurology (AAN) challenged its 2017 Diversity Leadership Program cohort to determine what the AAN can do to improve quality of care for racially and ethnically diverse patients with neurologic disorders. Developing a fuller understanding of the effect of disparities in neurologic care (neurodisparity) on patients is an important prerequisite for creating meaningful change. Clear insight into how bias and trust affect the doctor-patient relationship is also crucial to grasp the complexity of this issue. We propose that the AAN take a vital step toward achieving equity in neurologic care by enhancing health literacy, patient education, and shared decision-making with a focus on internet and social media. Moreover, by further strengthening its focus on health disparities research and training, the AAN can continue to inform the field and aid in the development of current and future leaders who will address neurodisparity. Ultimately, the goal of tackling neurodisparity is perfectly aligned with the mission of the AAN: to promote the highest-quality patient-centered neurologic care and enhance member career satisfaction

Developing the Neurology Diversity Officer A Roadmap for Academic Neurology Departments

Academic neurology departments must confront the challenges of developing a diverse workforce, reducing inequity and discrimination within academia, and providing neurologic care for an increasingly diverse society. A neurology diversity officer should have a specific role and associated title within a neurology department as well as a mandate to focus their efforts on issues of equity, diversity, and inclusion that affect staff, trainees, and faculty. This role is expansive and works across departmental missions, but it has many challenges related to structural intolerance and cultural gaps. In this review, we describe the many challenges that diversity officers face and how they might confront them. We delineate the role and duties of the neurology diversity officer and provide a guide to departmental leaders on how to assess qualifications and evaluate progress. Finally, we describe the elements necessary for success. A neurology diversity officer should have the financial, administrative, and emotional support of leadership in order for them to carry out their mission and to truly have a positive influence

Living with Children Improved Functional Recovery Post-Stroke (P16-10.001)

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