Safety of Intraventricular rt-PA for Pan-Ventricular IVH Caused by a Ruptured AVM: A Case Report

Intraventricular recombinant tissue plasminogen activator (IVT rt-PA) has improved outcomes for intraventricular hemorrhage (IVH). Patients with suspected or untreated arteriovenous malformations (AVMs) have been excluded from clinical trials. We present a patient with IVH secondary to a ruptured AVM safely treated with IVT rt-PA. A 48-year-old Hispanic male with a history of dermatomyositis presented to the emergency department with sudden left-sided weakness. En route to computed tomography (CT), he became lethargic. Computed tomography revealed extensive IVH with acute hydrocephalus, which was treated with the placement of external ventricular drain with clinical improvement. Computed tomography angiogram performed did not reveal AVM. Cerebral digital subtraction angiogram (DSA) was planned due to suspicion of AVM. Prior to DSA, patient became acutely lethargic. Computed tomography imaging revealed worsening hydrocephalus. External ventricular drain was noted to be draining. Repeat CT revealed improved hydrocephalus but with left lateral ventricle dilatation. Risks and benefits of IVT rt-PA were discussed with the family and a decision was made to treat. Three doses of 1 mg IVT rt-PA were administered with resolution of midline blood and lateral ventricular dilatation with clinical improvement. Digital subtraction angiogram revealed early draining vein on right internal carotid artery injection draining into the inferior sagittal sinus representing ruptured AVM without clear nidus. Repeat DSA with possible embolization was planned after discharge. In spite of additional in-hospital complications, the patient gradually improved and was ultimately discharged home. Our case supports the idea that the use of IVT rt-PA following an IVH caused by an underlying AVM could be further explored in carefully designed clinical trials

Abstract TMP71: Increasing Prevalence of Secondary Intracerebral Hemorrhage in Acute Ischemic Stroke

Background: Temporal data on secondary intracerebral hemorrhage (SICH) risk in acute ischemic stroke (AIS) patients (pts) is sparse since implementation of current measures to lessen times to intravenous thrombolysis (tPA) and/or endovascular reperfusion. Aims: (1) Evaluate trends in SICH prevalence in AIS pts in the United States from 2004-2013 and to compare SICH risk following tPA and mechanical thrombectomy (MT) from 2011-2013 to risk in earlier periods. (2) Assess the magnitude of the current association of SICH with in-hospital morbidities and mortality in AIS. Methods: All adults with a primary diagnosis of AIS (n=4,355,140) were identified from the 2004-2013 Nationwide Inpatient Sample. We computed weighted risk of SICH in AIS according to age, sex and intervention received (tPA, MT or no-intervention). Multivariate models were used to compare SICH risks in the period 2004-2007 to periods 2008-2010 and 2011-2013, respectively, and to evaluate association of SICH with in-hospital morbidity, mortality, length-of-stay (LOS) and cost. Results: SICH risk increased over the study period but most of the increase occurred after 2010 (figure 1). From the period 2004-2007 to period 2011-2013, SICH risk increased by 75% in IV tPA pts (4.8%-8.4%), 164% in MT pts (8.1%-21.4%) and by 367.8% in no-intervention pts (0.5%-2.3%). Risks increased with age but only in tPA pts and did not vary by sex in both tPA and MT pts after multivariate adjustment. SICH was associated with >200% increased odds of ventilator use, pneumonia, sepsis, acute renal failure, deep venous thrombosis, pulmonary embolism and 67% reduced odds of home disposition compared to non-SICH. Mortality in SICH decreased from 26% to 18.3% compared to 6.1% to 4.0% in the non-SICH patients over the entire period. SICH was associated with >$8,000 increase in cost and >3-day increase in mean LOS. Conclusion: The burden of SICH in AIS is growing. Innovative strategies are needed to prevent SICH and/or alleviate its sequelae

Conjugate Eye Deviation on CT Associated With Worse Outcomes Despite IV Thrombolysis

INTRODUCTION: Rapid stroke management has significant implications in patient outcomes. Ipsilateral computed tomography conjugate eye deviation (CT-CED) has been associated with worse outcomes but has never been evaluated as predictive of vascular occlusion. To test the hypothesis that CT-CED is a marker for vascular occlusion, we evaluated patients treated with intravenous tissue plasminogen activator (IV tPA). METHODS: We performed a retrospective analysis of patients with acute ischemic stroke treated with IV tPA at a large tertiary care hospital over an 18-month period. A waiver of informed consent was granted. Two examiners evaluated baseline brain CTs blinded to the location of infarct to assess the presence of CT-CED and follow-up imaging for the location of infarct and the presence of intracranial large vessel occlusion. Demographics, initial National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scales (mRSs), and hospital length of stay (LOS) were collected. RESULTS: Among 104 patients treated with IV tPA, 36 had CT-CED. Inter-rater reliability for CT-CED was excellent (κ = 0.97; 95% confidence interval: 0.98-1.0). The CT-CED group was older (69.8 vs 64 years; P = .038), had higher initial NIHSS (14.6 vs 11; P = .01), worse mRS (3.2 vs 2.4; P = .03), and longer LOS (8.4 vs 6.4; P = .05) compared with those without CT-CED. A vascular occlusion in the territory of the infarct was seen in 58% of patients with CT-CED versus 32% without CT-CED (P < .01). Atrial fibrillation (AF) was diagnosed in 61% patients with CT-CED versus 22% without (P < .01). CONCLUSION: The CT-CED is associated with higher initial NIHSS, large vessel occlusion, and AF. Prospective studies are needed to ascertain whether CT-CED may be utilized part of a screen for endovascular therapy

Utilizing CT with Maximum Intensity Projection Reconstruction Bypassing CTA Improves Time to Groin Puncture in Large Vessel Occlusion Stroke Thrombectomy

Prior to thrombectomy for proximal anterior circulation large vessel occlusion (LVO) stroke, recent trials have utilized CT angiography (CTA) for vascular imaging immediately following noncontrast CT (NCCT) for decision-making, but thin-section NCCT with automated maximum intensity projection (MIP) reconstruction also has high accuracy in demonstrating the site of an occluding thrombus. We hypothesized that performing thin-section NCCT with MIP alone prior to thrombectomy improves the time to groin puncture (GP) compared to performing CTA after NCCT. We performed a retrospective cohort study of anterior circulation LVO thrombectomy at our tertiary care academic medical center. All stroke patients evaluated with thin-section NCCT (0.625 mm) with automated MIP reconstructions alone and those who had additional CTA were included. We excluded transfer patients, in-hospital strokes, posterior circulation strokes, and patients that were evaluated with stroke imaging other than NCCT or CTA prior to thrombectomy. The study groups were compared for duration from NCCT to GP and total stroke imaging duration. From March 2008 through August 2015, 34 thrombectomy patients met the inclusion/exclusion criteria - 13 in the NCCT and 20 in the NCCT+CTA group. The total stroke imaging duration was shorter in the NCCT group than in the NCCT+CTA group (2 min [1-6] vs. 28 min [23-65]; < 0.001). The NCCT-only group had a shorter time from NCCT to GP (68 min [32-99] vs. 104 min [79-128]; = 0.030). Avoiding advanced imaging for patients with anterior circulation LVO in whom thin-section NCCT with MIPs reveals a hyperdense sign significantly shortens the imaging-to-GP time

Abstract Number ‐ 203: #BEFASTChallenge: Social Media Dance Campaign for Stroke Symptoms Awareness

Introduction Public stroke education campaigns have traditionally utilized mass media. We hypothesized that a worldwide stroke awareness social media campaign, utilizing dance videos to express the BE‐FAST acronym for stroke signs and symptoms, could reach a large audience at a low cost. Methods Mission Thrombectomy 2020+ officially launched the #BEFASTChallenge, a Social Media (SoMe) public stroke educational campaign, on May 15, 2022, World Stroke Thrombectomy Day, after an internal “lead‐in” phase starting the first week of May 2022. The campaign was volunteer designed and implemented. The public and their followers were encouraged to post a video of their dance depicting each letter of BE‐FAST, tag the post with #BEFASTChallenge, and nominate others to participate. We tracked the SoMe posts from May 4th through July 13, 2022, on Facebook (FB), Twitter (TW), and Instagram (IG) platforms by searching #BEFASTChallenge on each SoMe site. We ascertained campaign adoption, public reach, and interaction by measuring original posts, views, likes, retweets, shares, and comments. Results There were 4 countries represented in the original posts on SoMe with the vast majority being from the US. The first post was on May 4, and the last was on July 13 (71 days), resulting in a daily average of 0.55 posts. The largest number of posts occurred on the launch date (16 posts). There were 39 original posts, which accumulated 170 retweets, 44 quote tweets, 755 likes, 32 comments, and 14 shares. The videos had 13,821views (Table 1). Conclusions We report that the preliminary analysis of a volunteer‐driven SoMe public stroke campaign utilizing dance to express stroke symptoms demonstrates feasibility, reaching a modest audience directly with good interaction. A similar professionally implemented SoMe campaign could lead to increased and more sustained user engagement to raise public stroke symptom awareness

Abstract Number ‐ 203: #BEFASTChallenge: Social Media Dance Campaign for Stroke Symptoms Awareness

Introduction Public stroke education campaigns have traditionally utilized mass media. We hypothesized that a worldwide stroke awareness social media campaign, utilizing dance videos to express the BE‐FAST acronym for stroke signs and symptoms, could reach a large audience at a low cost. Methods Mission Thrombectomy 2020+ officially launched the #BEFASTChallenge, a Social Media (SoMe) public stroke educational campaign, on May 15, 2022, World Stroke Thrombectomy Day, after an internal “lead‐in” phase starting the first week of May 2022. The campaign was volunteer designed and implemented. The public and their followers were encouraged to post a video of their dance depicting each letter of BE‐FAST, tag the post with #BEFASTChallenge, and nominate others to participate. We tracked the SoMe posts from May 4th through July 13, 2022, on Facebook (FB), Twitter (TW), and Instagram (IG) platforms by searching #BEFASTChallenge on each SoMe site. We ascertained campaign adoption, public reach, and interaction by measuring original posts, views, likes, retweets, shares, and comments. Results There were 4 countries represented in the original posts on SoMe with the vast majority being from the US. The first post was on May 4, and the last was on July 13 (71 days), resulting in a daily average of 0.55 posts. The largest number of posts occurred on the launch date (16 posts). There were 39 original posts, which accumulated 170 retweets, 44 quote tweets, 755 likes, 32 comments, and 14 shares. The videos had 13,821views (Table 1). Conclusions We report that the preliminary analysis of a volunteer‐driven SoMe public stroke campaign utilizing dance to express stroke symptoms demonstrates feasibility, reaching a modest audience directly with good interaction. A similar professionally implemented SoMe campaign could lead to increased and more sustained user engagement to raise public stroke symptom awareness