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Background and ObjectivesEarly consciousness disorder (ECD) after acute ischemic stroke (AIS) is understudied. ECD may influence outcomes and the decision to withhold or withdraw life-sustaining treatment.MethodsWe studied patients with AIS from 2010 to 2019 across 122 hospitals participating in the Florida Stroke Registry. We studied the effect of ECD on in-hospital mortality, withholding or withdrawal of life-sustaining treatment (WLST), ambulation status on discharge, hospital length of stay, and discharge disposition.ResultsOf 238,989 patients with AIS, 32,861 (14%) had ECD at stroke presentation. Overall, average age was 72 years (Q1 61, Q3 82), 49% were women, 63% were White, 18% were Black, and 14% were Hispanic. Compared to patients without ECD, patients with ECD were older (77 vs 72 years), were more often female (54% vs 48%), had more comorbidities, had greater stroke severity as assessed by the National Institutes of Health Stroke Scale (score ≥5 49% vs 27%), had higher WLST rates (21% vs 6%), and had greater in-hospital mortality (9% vs 3%). Using adjusted models accounting for basic characteristics, patients with ECD had greater in-hospital mortality (odds ratio [OR] 2.23, 95% CI 1.98–2.51), had longer hospitalization (OR 1.37, 95% CI 1.33–1.44), were less likely to be discharged home or to rehabilitation (OR 0.54, 95% CI 0.52–0.57), and were less likely to ambulate independently (OR 0.61, 95% CI 0.57–0.64). WLST significantly mediated the effect of ECD on mortality (mediation effect 265; 95% CI 217–314). In temporal trend analysis, we found a significant decrease in early WLST (2 0.7, p = 0.002) and an increase in late WLST (≥2 days) (R2 0.7, p = 0.004).DiscussionIn this large prospective multicenter stroke registry, patients with AIS presenting with ECD had greater mortality and worse discharge outcomes. Mortality was largely influenced by the WLST decision.

Background and Purpose: Impaired level of consciousness (LOC) on presentation at hospital admission in patients with intracerebral hemorrhage (ICH) may affect outcomes and the decision to withhold or withdraw life-sustaining treatment (WOLST). Methods: Patients with ICH were included across 121 Florida hospitals participating in the Florida Stroke Registry from 2010 to 2019. We studied the effect of LOC on presentation on in-hospital mortality (primary outcome), WOLST, ambulation status on discharge, hospital length of stay, and discharge disposition. Results: Among 37 613 cases with ICH (mean age 71, 46% women, 61% White, 20% Black, 15% Hispanic), 12 272 (33%) had impaired LOC at onset. Compared with cases with preserved LOC, patients with impaired LOC were older (72 versus 70 years), more women (49% versus 45%), more likely to have aphasia (38% versus 16%), had greater ICH score (3 versus 1), greater risk of WOLST (41% versus 18%), and had an increased in-hospital mortality (32% versus 12%). In the multivariable-logistic regression with generalized estimating equations accounting for basic demographics, comorbidities, ICH severity, hospital size and teaching status, impaired LOC was associated with greater mortality (odds ratio, 3.7 [95% CI, 3.1–4.3], P P P Conclusions: In this large multicenter stroke registry, a third of ICH cases presented with impaired LOC. Impaired LOC was associated with greater in-hospital mortality and worse disposition at discharge, largely influenced by early decision to withhold or WOLST.

Background: Impaired level of consciousness (LOC) on presentation after intracerebral hemorrhage (ICH) may affect outcomes and the decision to withdraw life-sustaining treatment (WLST). We aim to investigate the outcomes and trends after ICH by the LOC status on presentation. Methods: We studied 37,613 cases with ICH in the Florida Stroke Registry from 2010-2019. Pearson chi-squared and Kruskall-Wallis tests were used to compare descriptive statistics. A multivariable-logistic regression with GEE accounted for basic demographics, comorbidities, ICH severity, hospital size and teaching status. Results: At stroke presentation, 12,272 (33%) cases had impaired LOC (mean age 72, 49% women, 61 white%, 20% Black, 14% Hispanic). Compared to cases with preserved LOC, LOC case were older (72 vs. 70 years old), more women (49% vs. 45%), more likely to have aphasia (38% vs. 16%), had lower GCS score (9 vs. 15), had greater ICH score (3 vs. 1), greater WLST rates (41% vs. 18%), and had greater in-hospital mortality rates (32% vs. 12%). In our adjusted model, no association was found between impaired LOC and in-hospital mortality, or length of stay. Those with preserved LOC were more likely discharged home/rehab (OR 0.4, 95%CI 0.2-0.9, p=0.03) and more likely to ambulate independently (OR 1.6, 95%CI 1.1-2.4, p=0.02). Trend analysis (2010-2019) showed decreased mortality, increased length of stay, and increased rates of discharge to home/rehab in all, regardless of the LOC status. Conclusion: In this large multi-center registry, a third of ICH cases presents with impaired LOC. Although LOC was not associated with significantly more in-hospital morality, LOC was associated with had higher rates of WLST and more disability at discharge. Future efforts should focus on biomarkers of LOC that detect early recovery and reduced disability in ICH patients with impaired LOC.

Background: Impaired level of consciousness (LOC) on presentation after acute ischemic stroke (AIS) may affect outcomes and the decision to withdraw life-sustaining treatment (WLST). We aim to investigate the outcomes and their trends after AISby the LOC on stroke presentation. Methods: We studied 238,989 cases with AIS in the Florida Stroke Registry from 2010-2019. Pearson chi-squared and Kruskall-Wallis tests were used to compare descriptive statistics. A multivariable-logistic regression with GEE accounted for basic demographics, comorbidities, stroke severity, location, hospital size and teaching status. Results: At stroke presentation, 32,861 (14%) cases had impaired LOC (mean age 77, 54% women, 60 white%, 19% Black, 16% Hispanic). Compared to cases with preserved LOC, impaired cases were older (77 vs. 72 years old), more women (54% vs. 48%), had more comorbidities, greater stroke severity on NIHSS ≥ 5 (49% vs. 27%), higher WLST rates (3% vs. 0.6%), and greater in-hospital mortality rates (9% vs. 3%). In our adjusted model however, no significant association was found between impaired LOC and in-hospital mortality, or length of stay. Those with preserved LOC were more likely discharged home/rehab (OR 0.7, 95%CI 0.6-0.8, p Conclusion: In this large multicenter registry, AIS cases presenting with impaired LOC had more severe strokes at presentation. Although LOC was not associated with significantly worse in-hospital morality, it was associated with higher rates of WLST and more disability among survivors. Future efforts should focus on biomarkers of LOC that discriminates the potential for early recovery and reduced disability in acute stroke patients with impaired LOC.

Background: To estimate the frequency of post-sudden cardiac arrest survivorship (PSCAS) problems (i.e., cognitive impairment, disability in activities of daily living, depression and posttraumatic stress disorder (PTSD)). Methods: We prospectively enrolled adults with return of spontaneous circulation after in-hospital or out-of-hospital CA between 9/2015-8/2018 at a high-volume, major academic center. A consecutive sample of survivors at hospital discharge and at one-year follow-up able to engage in the Repeatable Battery for Neuropsychological Status (RBANS) or Telephone Interview for Cognitive Status (TICS), Barthel Index (BI) as a measure of disability, Center for Epidemiological Studies Depression Scale (CES-D), and PTSD Checklist - Specific (PCL-S) were included. Results: Of 159 patients included, average age was 54±15 years, 41% were women, 30% identified themselves as Latinos and 18% as African-American. There were 14 deaths and 13 lost to follow-up at one-year. As shown in table 1, 1 out of 2 patients at discharge, and 1 out of 4 at one-year had global cognition scores similar to scores for patients with moderate traumatic brain injury and patients with mild Alzheimer’s disease, respectively. The majority had physical disability at hospital discharge, which showed improvement within one-year. A significant proportion of patients experienced depressive and PTSD symptoms at hospital discharge and the symptoms persisted at one-year. Conclusions: In a racial and ethnically diverse cohort in a major academic center in the US, one or more PSCAS problems were present and persisted in the majority of CA survivors, and co-occurring problems were present in one out of four at one-year. Future studies are needed to understand better the heterogeneous subtypes of PCAS and to identify modifiable risk factors and potential ameliorating factors. Table 1. Estimates of post-sudden cardiac arrest survivorship problems at discharge and one-year

Introduction: To determine the association of depressive and posttraumatic stress disorder symptoms with cardiac arrest (CA) survivors’ long-term recovery perceptions, after accounting for cognitive status, functional independence, and medical comorbidities. Hypothesis: We recently demonstrated that posttraumatic stress and depressive symptoms, not cognitive or functional impairment, were associated with cardiac arrest survivors’ negative recovery perceptions at hospital discharge. Current study aims to extend this work by examining the correlates of perceived recovery in these CA survivors at 6 months after their hospital discharge. Methods: Perceived recovery of 78 prospectively enrolled CA survivors at 6-months post-discharge was assessed through the question, “Do you feel that you have made a complete recovery from your arrest?” Psychological symptoms were measured using the Center for Epidemiological Studies-Depression scale (CES-D) and the PTSD Checklist-Specific (PCL-S). Logistic regression was utilized to assess the association between depression and PTSD symptoms with positive and negative recovery perceptions, adjusting for demographics, cognitive impairment (Repeatable Battery for Assessment of Neuropsychological Status or Telephone Interview for Cognitive Status), functional dependence (Modified Lawton Instrumental Activities of Daily Living), and medical comorbidities (Charlson Comorbidity Index). Results: At 6 months, 53% of patients (n=41) had a negative recovery perception. 32.1% (n = 25) of patients screened for depression and 28.2% (n = 22) for PTSD. Patients with higher CES-D scores were significantly more likely to have a negative recovery perception in both unadjusted (Odds Ratio (OR): 1.10, 95% Confidence Interval (CI) [1.4, 1.16], p Conclusions: In contrast with cognitive and functional measures, psychological symptoms were strongly associated with cardiac arrest survivors’ negative recovery perceptions at 6-months post-discharge.

Background: Overall survival and functional status is poor in patients that undergo a tracheostomy after respiratory failure. Little data exists on cardiac arrest (CA) patients’ in-hospital and long-term survival, and neurological status after tracheostomy. Methods: We retrospectively reviewed 509 consecutive patients that were more than 18 years of age, admitted to one of the intensive care units between 12/2007 and 12/2015, resuscitated following either in-hospital or out-of-hospital CA, and considered for targeted temperature management. Tracheostomy and other data was collected via chart review. Chi-square and Wilcoxon rank sum tests were used for analysis. Survival and Cerebral Performance Category score (CPC) at discharge and one year were compared between patients with and without tracheostomy. Results: Of 509 patients, 389 (76.4%) did not undergo a tracheostomy, 83 (16.3%) had new tracheostomies placed during the hospitalization, and 37 (7.3%) had pre-existing tracheostomy before the index cardiac event. In comparison to the non-tracheostomy group, the new tracheostomies patients had a greater number of in-hospital arrests with shorter duration of median return of spontaneous circulation, while the pre-existing tracheostomy group was older, worse CPC on admission, were mostly living in a subacute nursing facility, had lower rates of ventricular tachycardia/fibrillation as initial rhythm, and lower rates of therapeutic hypothermia. At the time of hospital discharge, there were 64/83 (77%) survivors in the new tracheostomy group, 104/389 (26.7%) in the non-tracheostomy, and 7/37 (19%) in the pre-existing tracheostomy group. Available one year data on 53 patients in the new tracheostomy group showed a 55% (n=29) survival rate, with neurological status as follows: {CPC 1: 7 (24%), CPC 2: 6 (21%), CPC 3: 8 (27.5%), CPC 4: 8 (27.5%)} compared to 66/81 (81%), {(CPC 1: 34 (51%), CPC 2: 15 (23%), CPC 3: 16 (24%), CPC 4: 1 (0.01%)} in the non-tracheostomy group (p=0.005). Conclusions: Cardiac arrest survivors that undergo a tracheostomy have reduced survival and poor neurological status at one year compared to those discharged without receiving a tracheostomy. Pre-existing tracheostomy patients suffer from high rates of in-hospital mortality.