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OBJECTIVE: Patients referred to stroke centers from community hospitals for intra-arterial stroke treatment (IAT) may experience significant delay during the transfer process. We sought to determine the difference in clinical outcomes amongst patients presenting directly to stroke centers (PD) versus those transferred from outside community hospitals (TR). METHODS: We reviewed records of patients who underwent IAT at our center from July 2012 – July 2014. All patients had intracranial large vessel occlusion and a baseline ASPECT score of ≥ 6. Patients demographics, risk factors, admission clinical and neuroimaging findings, treatment times and methods, procedure related complications and modified Rankin score (mRS) at 90 days were analyzed. For patients who are not yet at 90 days post-treatment, mRS at hospital discharge was used in the final analysis. A favorable outcome was defined as mRS 2 or less at 90 days. RESULTS: Overall 141 consecutively treated patients were identified. Of these, 89 (63.1%) were transferred from community hospitals for IAT. Median time from last known well to stroke center arrival was 50 mins for PD and 245 mins for TR group (T-test p<0.01). Despite this difference final infarct volume, favorable outcome and mortality rates were comparable between the groups (see table). Multivariate logistic regression model identified lower final DWI infarct volume (OR 0.97, 95%CI 0.95-0.99, p<0.01) and low presentation NIHSS (OR 0.85, 95% CI 0.73-0.99, p=0.04) as predictors of favorable outcome. CONCLUSION: Our results indicate that patients with favorable baseline head CT, referred from outlying facilities, may achieve similar clinical outcomes following IAT when compared to those presenting directly to a designated stroke center. Further randomized studies on an intent to treat design are needed to corroborate these findings.

<b><i>Objective:</i></b> To describe the impact of COVID-19 on acute cerebrovascular disease care across 9 comprehensive stroke centers throughout Los Angeles County (LAC). <b><i>Methods:</i></b> Volume of emergency stroke code activations, patient characteristics, stroke severity, reperfusion rates, treatment times, and outcomes from February 1 to April 30, 2020, were compared against the same time period in 2019. Demographic data were provided by each participating institution. <b><i>Results:</i></b> There was a 17.3% decrease in stroke code activations across LAC in 2020 compared to 2019 (1,786 vs. 2,159, respectively, χ² goodness of fit test <i>p</i> &#x3c; 0.0001) across 9 participating comprehensive stroke centers. Patients who did not receive any reperfusion therapy decreased by 16.6% in 2020 (1,527) compared to 2019 (1,832). Patients who received only intravenous thrombolytic (IVT) therapy decreased by 31.8% (107 vs. 157). Patients who received only mechanical thrombectomy (MT) increased by 3% (102 vs. 99). Patients who received both IVT and MT decreased by 31.8% (45 vs. 66). Recanalization treatment times in 2020 were comparable to 2019. CSCs serving a higher proportion of Latinx populations in the eastern parts of LAC experienced a higher incidence of MT in 2020 compared to 2019. Mild increase in stroke severity was seen in 2020 compared to 2019 (8.95 vs. 8.23, <i>p</i> = 0.046). A higher percentage of patients were discharged home in 2020 compared to 2019 (59.5 vs. 56.1%, <i>p</i> = 0.034), a lower percentage of patients were discharged to skilled nursing facility (16.1 vs. 20.7%, <i>p</i> = 0.0004), and a higher percentage of patients expired (8.6 vs. 6.3%, <i>p</i> = 0.008). <b><i>Conclusion:</i></b> LAC saw a decrease in overall stroke code activations in 2020 compared to 2019. Reperfusion treatment times remained comparable to prepandemic metrics. There has been an increase in severe stroke incidence and higher volume of thrombectomy treatments in Latinx communities within LAC during the pandemic of 2020. More patients were discharged home, less patients discharged to skilled nursing facilities, and more patients expired in 2020, compared to the same time frame in 2019.

Background: Agonism of protease-activated receptor 1 (PAR1) potently protects neurons and vasculature in the central nervous system during stroke. We evaluated the effects of 3K3A-APC, a recombinant variant of activated protein C active at PAR1, in acute ischemic stroke patients during conventional recanalization with thrombolysis or thrombectomy or both. We hypothesized that 3K3A-APC would reduce post-treatment hemorrhage and symptomatic neurologic deterioration. Methods: Using the NeuroNEXT trial NN104 (RHAPSODY) database, susceptibility weighted and gradient echo images were graded for intracerebral hemorrhage size according to radiographic criteria described in ECASS (Hemorrhagic infarction type 1 and 2 and parenchymal hematoma type 1 and 2) at four time points (0, 7, 30, and 90 days after treatment). Of 110 participants enrolled, 101 had appropriate imaging for analysis. Images were evaluated and graded by two blinded, independent raters with an expert providing consensus reads. Utilizing NIHSS following drug treatment, neurological worsening was defined as an increase in NIHSS ≥ 4 points. We compared placebo versus drug administration using multi-variate regression. Results: Of 101 participants evaluated, those receiving placebo (n=41) were significantly more likely to have hemorrhage at any time compared with those receiving any amount of drug (n=60) (p = 0.04; CI: 1.080 - 7.544; OR = 2.73). Age was found to be the only significant variable leading independently to increased neurological worsening (p = 0.038; CI: 1.015-1.193; OR = 1.086). Conclusion: The neuroprotectant 3K3A-APC showed significant reduction in hemorrhagic transformation when co-administered with conventional recanalization therapy. Further studies are underway for determining the effect of 3K3A-APC on functional outcome.

OBJECTIVE: Previous studies have shown age and recanalization as principal variables influencing clinical outcome following intra-arterial stroke treatment (IAT). We sought to study the impact of final DWI infarct volume on patient outcomes following IAT. METHODS: We reviewed records of stroke patients who underwent IAT at our center from Jul 2012 – Jul 2014. Patients demographics, risk factors, admission clinical and neuroimaging findings, treatment times and methods, procedure related complications and modified Rankin score (mRS) at 90 days were analyzed. For patients who are not yet at 90 days post-treatment, mRS at hospital discharge was used in the final analysis. A favorable outcome was defined as mRS 2 or less at 90 days. Infarct volume was calculated using the MIM Maestro automated software on post IAT MR DWI sequences. RESULTS: Overall, 144 consecutively treated patients were identified. Eighty-eight subjects underwent post treatment MRI and are included in this analysis. Patients who achieved successful recanalization (TICI 2b &3) had lower mean infarct burden (53.2 mL) than the cohort with persistent occlusion (95.1 mL), p=0.01. Also, patients with favorable outcomes had significantly lower mean infarct volumes (see table). Multivariate logistic regression model identified lower final DWI infarct volume (OR 0.97, 95% CI 0.95-0.99, p<0.01) and low presentation NIHSS (OR 0.85, 95% CI 0.73-0.99, p=0.04) as predictors of favorable outcome. CONCLUSION: Our study results indicate that final DWI infarct volume is an independent predictor of outcome in patients undergoing IAT. Infarct volume may be utilized as a surrogate for clinical outcome. Larger prospective studies are warranted to corroborate these findings.