bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP33: Early Lessons Learned From the WEB Device: Feasibility, Technique and Complications—A Real Life Experience
Authors: Mouchtouris Nikolaos , Hasan David , Al Saiegh Fadi , Sweid Ahmad , Zanaty Mario , Khanna Omaditya , Chalouhi Nohra , Tjoumakaris Stavropoula , Gooch Michael R , Rosenwasser Robert H , Jabbour Pascal M
Published: June 2021

Introduction:
Wide-neck bifurcation cerebral aneurysms have always posed a treatment challenge and have historically required either clip ligation, or stent vs. balloon-assisted coil embolization. This predicament led to the development of the newly FDA-approved Woven EndoBridge (WEB) aneurysm embolization system (Sequent Medical Inc, Aliso Viejo, CA) Which is a self-expanding mesh that achieves intrasaccular flow disruption and does not require antithrombotic medications. In this study, we report our experience with the first 64 consecutive aneurysms treated via WEB embolization at two high-volume institutions.

Methods:
We reviewed our first 61 consecutive patients with 64 cerebral aneurysms who underwent WEB embolization from February-August 2019. We collected data on patient demographics and clinical presentation, aneurysm characteristics, device and procedural details, and functional outcomes.

Results:
A total of 64 aneurysms were included in our study. Fifteen patients (24.1%) presented with acutely ruptured aneurysm while the rest were unruptured. The majority of patients (82.8%) required only one attempt for successful device deployment, while a stent was necessary as an adjunct treatment in 4 patients (6.3%) due to WEB herniation. Two patients had residual aneurysm that had to undergo additional treatment; one of them underwent second WEB embolization and one underwent clip ligation. One patient with a PICA aneurysm had device dislodgment with injury to the parent vessel—Onyx and coils were used to deconstruct the vertebral artery.

Conclusions:
The advent of the WEB device has significantly impacted the surgical decision-making for the treatment of bifurcation, wide-neck aneurysms. We discuss in detail the lessons learned from patient selection, device size selection, technique, and complications from two institutions with high-volume endovascular and microsurgical aneurysm treatment experience.
Abstract WP334: Stroke Case Volume After Implementation of the 24 Hour Extended Intra-Arterial Thrombectomy Window
Authors: Glenn Jessica , Heaton Sharon , Powers Ciarán , Nimjee Shahid , Youssef Patrick , Lee Vivien H
Published: June 2021

Introduction:
The results of the DAWN and DEFUSE 3 trials demonstrated improved functional outcome with mechanical thrombectomy (MT) in stroke patients who present with anterior circulation large vessel occlusion (LVO) up to a 24 hours after last known well. The AHA guidelines were updated to include this recommendation in 2018, but the impact of the increase in number of patients treated in clinical practice remains unknown.

Methods:
We reviewed ischemic stroke MT patients admitted to a comprehensive stroke center (DEFUSE 3 trial participating site), from July 2015- July 2019. Our center instituted a 24 hour IAT window protocol in March 2018 (Figure 1). Eligibility for MT in the 24 hour window followed the DEFUSE 3 criteria including the presence of LVO, National Institute of Health Stroke Scale (NIHSS)
>
6, and favorable CT perfusion imaging.

Results:
During this 4-year period, 290 stroke patients with LVO received MT at our institution. MT volumes increased in each subsequent year in this study as follows: July 2015 (44), July 2016 (58), July 2017 (73) and July 2018 (115). An increase in MT volume was observed after the expansion of the treatment window to 24 hours (Figure 2). In the period prior to the expanded 24 hour treatment window, MT volumes were 25-33 per 6 month period. After the 24 hour treatment window was started, MT volumes were 58-60 per 6 month period.

Conclusions:
Expanding the MT window to 24 hours has nearly doubled the MT case volume at our single center. This dramatic increase in IAT clinical utilization observed with expansion to the 24 hour window has implications for systems of care and resource optimization of the stroke patient.
Abstract WP335: An Intervention to Facilitate the Informed Consent Process for tPA
Authors: Mendelson Scott J , Weaver Bradley , Leena Thomas , Gordon Elisa , Holl Jane , Prabhakaran Shyam
Published: June 2021

Introduction:
The informed consent process delays or results in a refusal of therapy in up to 10% of eligible patients. Our prior work identified preferences, content, framing, sequencing of the informed consent process for tPA based on patient, physician, caregiver, and layperson input. These data were used by design teams in an iterative process with both patients and clinicians through an AHRQ-funded project to develop patient-facing decision aids (
S
tandardized
C
onsent
R
edesign and
I
mplementation
P
rotocol for
t
PA in
S
troke: SCRIPtS).

Hypothesis:
We hypothesized that the SCRIPtS intervention would improve patient knowledge, and reduce decisional conflict and regret without impacting door to needle (DTN) time.

Methods:
Patients or their proxies who provided informed consent for tPA at a single academic medical center were approached from July 1, 2017 to June 30, 2019. All neurology residents who obtain informed consent for tPA were trained on the SCRIPtS intervention on July 2, 2018. Prospective data captured included: DTN time and qualitative data in the form of: patient or proxy decisional conflict (6-items) within 48h of tPA treatment, and patient or proxy decision regret (5-items) at 14 days and 90 days post-treatment. Mann-Whitney U and t-test statistics were used to compare pre-intervention (before July 2, 2018) to post-intervention results. Internal consistency of survey responses was measured using Cronbach’s α.

Results:
During pre-intervention, 32 patients received tPA with a median DTN of 41.7m (
+
8.8). Twenty patients received tPA post-intervention with a median DTN of 48.0m (+/- 16.3, p=0.11). Eight (63% female, 25% black) pre- and 14 (57% female, 36% black) post-SCRIPtS stroke patients or their proxies provided qualitative data. We observed a significant improvement in patient reported understanding of the side effects of tPA post-SCRIPtS (3.25
+
0.54 vs 4.14
+
0.14; p=0.02). There was no difference in measures of decisional conflict or of decision regret between groups (Cronbach’s α = 0.75).

Conclusions:
The small pilot study suggests that an intervention to improve patient and family understanding of risks and benefits of tPA can be successfully implemented without prolonging DTN time.
Abstract WP336: Global Variation in the Representation of Women in Contemporary Acute Stroke Trials
Authors: Strong Brent , Howard Virginia , Reeves Mathew J
Published: June 2021

Introduction:
Women have historically been underrepresented in RCTs of cardiovascular disease. We undertook a review of acute stroke RCTs to determine whether women were equitably represented and whether any sex disparity varied across geographic region.

Methods:
We searched for papers describing primary results of acute stroke RCTs published 2013-2018 in 9 major journals and abstracted the proportion of trial participants that were women (PPW). We then searched for incidence studies from the geographic regions in which trial enrollment took place and estimated the proportion of incident strokes occurring in women (PSW) in each region (i.e., North America, Europe, Asia Pacific, Multiple Regions). We quantified the representation of women using the enrollment disparity difference (EDD) calculated as the absolute difference between the two proportions (i.e., PSW - PPW). An EDD greater than 0 indicated a disparity in favor of men. We pooled EDDs from individual RCTs using random effects meta-analysis to estimate overall and region-specific disparities.

Results:
Among 60 trials the PPW ranged from 33.8% to 56.9% (median 44.7%). The overall pooled EDD was 0.07 (95% CI=0.06-0.08, Q p<0.001, I
2
=85.8%) (Figure), indicating that 7% more men were included in the trials, relative to the underlying incidence. A statistically significant EDD existed in all regions; the magnitude was largest for RCTs with enrollment from Asia Pacific (EDD=0.11, 95% CI=0.10-0.13) and Multiple Regions (EDD=0.10, 95% CI=0.08-0.12) and smallest among North American and European trials (EDD 0.04 and 0.06, respectively). All region-specific summary estimates showed significant between study heterogeneity apart from Asia (Q p=0.102, I
2
=38.4%).

Conclusions:
Women were underrepresented globally in contemporary acute stroke RCTs; the magnitude of the disparity differed between regions. Future research should focus on trial eligibility criteria that may contribute to this disparity.
Abstract WP337: Age and Race Disparities in Statin Prescribing Persist Following Discharge for Stroke or Transient Ischemic Attack
Authors: Cummings Doyle M , Jones Sara , Bushnell Cheryl , Halladay Jacquie , Kinlaw Alan , Wen Molly , Sissine Mysha , Duncan Pamela
Published: June 2021

Introduction:
Prescribing of high intensity statins (atorvastatin 40-80mg/d, rosuvastatin 20-40mg/d) following acute stroke and anti-coagulants in the subgroup with atrial fibrillation (AF) result in reduced risk for a second stroke. Recent data suggests that high intensity statins are less often prescribed for older patients and real-world data are limited for direct-acting oral anti-coagulants (DOAC). The present study examines discharge prescribing patterns for these medications by age and race from a prospective trial in 41 hospitals in North Carolina.

Methods:
Data are from the Comprehensive Post-Acute Stroke Services Study, a cluster-randomized trial of transitional care for adult stroke or TIA patients discharged directly home after hospital discharge. Analyses included 3787 patients [mean age 66 yrs., 47% female; 30% non-white] linked to the Get-with-the-Guidelines (GWTG) database. Prescribing of intensive statin therapy as well as rivaroxaban or apixaban vs. warfarin in those with a history of AF was abstracted, and was compared by age (< 65 vs. ≥ 65yr.), race (white vs. non-white) and gender. Odds ratios were obtained from logistic mixed models with a random intercept for hospital.

Results:
Among 3096 patients prescribed statin therapy at discharge, 61% were prescribed intensive statin therapy. Patients who were ≥ 65yr. had significantly lower odds of intensive statin therapy prescription than younger patients (OR=0.54, 95% CI 0.45-0.65); results were similar across all sex-race subgroups. Among 366 patients with a history of AF who were prescribed an anti-coagulant at discharge, 72% were prescribed rivaroxaban or apixaban. Among 254 patients ≥ 65yr., 26 of 39 non-white patients (67%) vs. 156 of 215 white patients (73%) were prescribed rivaroxaban or apixaban [p=0.29].

Conclusion:
Intensive statin therapy following mild stroke or TIA is significantly less common in older patients compared with those under age 65. Among patients ≥65yr. with a history of AF and acute stroke, there was minimal difference by race in rivaroxaban or apixaban prescribing. Prescription fills/refills and adherence should be further explored in these patients.
Abstract WP342: Linking the Coverdell Clinical Stroke Program Inpatient Registry to Commercial Claims Data to Assess Post-Discharge Medication Adherence
Authors: Patorno Elisabetta , Schneeweiss Sebastian , Pawar Ajinkya , Mogun Helen , Schwamm Lee
Published: June 2021

Background:
Non-interventional large-scale research on patients with stroke requires the use of data sources ensuring access to large populations with clinically detailed and longitudinally available real-world healthcare information. We linked the Paul Coverdell National Acute Stroke Program registry (PCNASP) to commercial longitudinal claims data to assess long-term medication adherence post discharge.

Methods:
All ischemic stroke (IS) admissions in PCNASP between 2008-2015 were considered for linkage to longitudinal patient claims records from a commercial health insurer using a probabilistic algorithm. We assessed the linkage quality via the percentage of unique records among the linked subset, evaluated the representativeness of the linked population via standardized differences (SD), and described medical history, stroke severity and disability, and patterns of medication use before and after the stroke hospitalization among linked patients.

Results:
The linkage produced uniqueness equal to 99.1%. Overall, we linked 5,644 out of 104,540 patients with an IS hospitalization in claims data. Linked patients were similar to unlinked except for mean age (69.7 vs 72.5 yr, SD 0.23) and % home discharge (59.8 vs. 52.2, SD 0.14) with mild strokes (median NIHSS 3). Medication information from the PCNASP registry often differed from claims-based out-of-hospital drug utilization patterns, particularly after discharge, with prescriptions at discharge largely overestimating the real-world use of medications as measured by filled prescriptions. (Table)

Conclusions:
In a large cohort of hospitalized IS patients, high-quality probabilistic linkage between the PCNASP stroke registry and commercial claims data is feasible. Differences between predicted and actual post discharge medication utilization highlight the challenges of assuming long-term medication adherence based on discharge prescriptions. Further research is warranted.
Abstract WP345: Feasibility of Monitoring Door in Door Out Times Across a 14 Hospital Telemedicine Supported Stroke System of Care
Authors: Rho Howard J , Sangha Navdeep S
Published: June 2021

Background:
Door-in-door-out time (DIDO) is an established driver of outcome in ischemic stroke patients who initially present to a Primay Stroke Center (PSC) and require transfer for endovascular intervention. In 2019, the Joint Commission required monitoring of DIDO as part of its STK-OP measure. Given the importance of rapidly transferring ischemic stroke patients, we embarked to create a monitoring tool to help assess the areas of delay in a 14 hospital telemedicine supported stroke system.

Methods:
A monitoring system was designed using PowerBI™ and Microsoft Suite™ products that models various data sources for consumption and action. Separate data queries from various sources were entered into one report using the Office365™ suite and Power Query Editor™ in PowerBI™. The resulting data model was then reorganized and programmed into a PowerBI™ report that can be shared throughout the organization.

Results:
The report allowed region-wide or hospital specific evaluation of several time based transfer metrics, including: door to initial call to transfer center, transfer center contact to neurointerventional physician accept time, accept time to ambulance arrival, ambulance arrival to ambulance departure and travel time to thrombectomy center. The largest areas of delays identified were door to initial call to transfer center and time of ambulance arrival to spoke to departure from spoke. The tool also allowed the separation of the STK-OP measure into ischemic stroke, intracerebral hemorrhage or sub-arachnoid hemorrhage. The assessment of these time metrics at a regional and individual hospital level permitted us to create a plan to focus on the greatest areas of delay to further decrease our transfer times.

Conclusion:
Modern data software may be leveraged by stroke programs to help assess the specific time metrics causing delay in DIDO, which could then further assist in focused quality improvement of these metrics.
Abstract WP35: Thrombectomy Techniques and Patient Characteristics Associated With Complete TICI 3 Reperfusion After Stroke Thrombectomy
Authors: Baraban Elizabeth , Stuchiner Tamela , Ovando Renee , Darflinger Rob , Hou Samuel , Kelly Dan , Teitelbaum George , Tiwari Ambooj , Tarpley Jason W
Published: June 2021

Introduction:
Prior randomized trials have defined substantial reperfusion for stroke thrombectomy as TICI 2b or TICI 3. However, recent data suggest that complete TICI 3 reperfusion results in more favorable patient outcomes than partial reperfusion with TICI 2b. We have multiple effective techniques for thrombectomy, but it is not clear which are most likely to achieve TICI 3 rather than TICI 2b reperfuson.

Methods:
Retrospective data from 15 hospitals were used for patients age 18 or over discharged from January 2014 to May 2019 with a primary or secondary diagnosis of ischemic stroke who received a thrombectomy and achieved TICI reperfusion grade of 2b or 3. Primary outcome was TICI grade 3, defined as complete reperfusion, versus TICI 2b. Multivariate logistic regression was conducted to determine if procedure technique (retrievable stent only, distal aspiration only or a combination approach with both) was associated with achieving TICI 3 versus 2b adjusting for sex, age ≥70 vs ≤69, race/ethnicity, history of chronic renal insufficiency or diabetes, history or newly diagnosed atrial fibrillation or flutter, previous anticoagulation medication. Interaction effects between technique and clinical variables were also tested.

Results:
The analysis included 787 patients, 67.9% (n=534) TICI 3 and 32.1% (n=253) TICI 2b. While, main effect of procedure technique was not a significant predictor of achieving TICI 3 (p=.451), interaction effects showed superiority of the combination approach in several patient populations. Specifically, the combined approach increased the likelihood of TICI 3 compared to stent retrieval alone for older patients (Adjusted Odds Ratio (AOR) =1.79, p=.007), those with a history of diabetes (AOR=1.56, p=.045) and Asian patients (AOR=4.41, p=.010). Among AFIB/flutter patients, the combined approach also increased the odds of complete reperfusion compared to stent retriever alone (AOR=1.76, p=.005) or distal aspiration alone (AOR=1.38, p=.034).

Conclusion:
The combined approach of retrievable stent and distal aspiration was a significant predictor of achieving TICI 3 in certain patient subgroups including patients who were older, Asian, had a history of diabetes or history of or current AFIB/flutter.
Abstract WP353: Assessing the Accuracy of ICD-10 Codes for Ruptured Intracranial Aneurysm Location
Authors: Roark Christopher , Kubes Sheila , Mayer David , Wiley Laura K
Published: June 2021

The adoption of ICD10 in October 2015 offers important opportunities for administrative database and EHR-based aneurysm research as it includes more than twenty distinct codes for subarachnoid hemorrhage (SAH), for the first time labeling the specific location for common sites of aneurysm rupture. Aneurysm location is a significant risk factor for rupture, but was not specified in any previous ICD classification. This has limited the value of “big-data” research for aneurysm risk modeling. Currently, it is not clear how frequently - or accurately - the codes are being used in practice. This study reviewed three years of records (10/2015-9/2018) from the UCHealth system in Colorado to assess the accuracy and utility of these codes for stroke research. Over this time, ICD10 codes for SAH (I60.x) were used a total of 5,090 times in 1,842 patients. After removing non-aneurysmal SAH (I60.8), the majority (92.7%) of the codes had no location specified (I60.7, I60.9). Of the codes with a location (I60.00-I60.6), upon review of the clinical record 9 (2.5%) did not have any evidence of subarachnoid hemorrhage, 3 (0.8%) did not have an aneurysm, and 5 (1.4%) had a pseudoaneurysm. Of the 338 verified instances of aneurysmal subarachnoid hemorrhage, 82 (24%) had multiple aneurysms and were excluded from further analysis. Within those records that had only a single aneurysm 197/256 (77%) had the location coded correctly. Of the 23% that were incorrectly coded, 1 was coded as the correct artery on the wrong side, all remaining (n=58) were the wrong artery. Although ICD10 codes offers the possibility of more advanced analysis due to the inclusion of aneurysm location, based on these data, we found that codes specifying location are frequently incorrect. Future studies are needed to validate these findings in other settings. However, researchers should be cautious about their ability to detect aneurysm location from administrative billing data using ICD10 location mapping.
Abstract WP359: Microembolic Signals Are Associated With Stroke Readmission in Patients With Ischemic Stroke
Authors: Fakhri Nasir , Mahinrad Simin , Srivastava Arth , Liotta Eric , Bernstein Richard , Gorelick Philip , Sorond Farzaneh
Published: June 2021

Background:
Microembolic signals (MES) identified by transcranial Doppler (TCD) are strong predictors of recurrent stroke in patients with carotid disease. In this study, we investigated the association of MES with transient ischemic attack (TIA) or stroke readmission among ischemic stroke patients.

Methods:
We included a total of 789 patients (mean age 62±17 years, 55% male) who were consecutively admitted to Northwestern Memorial hospital with a diagnosis of stroke. All patients who underwent TCD studies within the first 48 hours of admission were included. Using an electronic database warehouse, patients were followed during 12 months for any hospital readmission due to ischemic stroke or TIA. Risk of stroke readmission was estimated using multivariate Cox proportional hazard models.

Results:
MES were detected in 95 patients on admission. During 12 months of follow-up, incidence rates for stroke and TIA readmission, and stroke readmission alone were 23.0 and 7.0 per 100 person-years across the entire cohort, respectively. In multivariate adjusted models, patients with MES, as compared to patients without MES, had 1.80-fold (95% CI=1.07, 2.53;
p
=0.008) higher risk of stroke and TIA readmission, and 2.30-fold (95% CI=1.13, 4.67,
p
=0.021) higher risk of readmission due to stroke alone.

Conclusion:
We showed that the presence of MES early after stroke admission is associated with higher risk of stroke and TIA readmission in stroke patients. This not only highlights the importance of identifying MES in the stroke population upon first admission, but also the need to further identify and implement therapeutic strategies to reduce stroke burden and prevent readmission in this high-risk population.
Abstract WP36: National Trends in Utilization and Outcome of Endovascular Thrombectomy for Acute Ischemic Stroke in Elderly
Authors: Majidi Shahram , Mehta Amol , Singh Inder P , Shoirah Hazem , Shigematsu Tomoyoshi , Kellner Christopher P , De Leacy Reade , Mocco J , Fifi Johanna
Published: June 2021

Background:
The efficacy of endovascular thrombectomy (EVT) for large vessel occlusion in elderly is controversial as this age group is often excluded or under-represented in major randomized clinical trials. We evaluated the real-world trends in utilization and outcome of EVT in patients ≥80 years in a nationally representative database.

Methods:
Using nationwide inpatient sample (2014-2016), we identified patients admitted to hospitals in the United States with acute ischemic stroke who underwent EVT. Baseline demographics and clinical outcome were assessed among patients with age ≥80 years and those with age <80 years. The primary endpoint was favorable outcome defined as discharge to home or acute rehabilitation center. Hemorrhage and in-hospital mortality rates were assessed as secondary outcome measures. Multivariate analysis was performed to identify independent predictors of favorable clinical outcome in elderly.

Results:
A total of 6,230 patients were identified and 1,547 (24.83%) of them were ≥80. The number of patients ≥80 years who underwent EVT increased from 323 (22%) in 2014 to 695 (28%) in 2016. The rate of favorable outcome in elderly was 9% which was significantly lower than in younger patients (22%). In-hospital mortality was 19% in patients ≥80 years compared to 13% in their younger counterpart. There was no difference in the rate of hemorrhagic transformation between octogenarians and younger patients (3.2% vs 2.6%). Among patient ≥80, decreasing baseline comorbidity burden (Elixhauser Comorbidity Index) [OR; (95% CI): 1.24; (1.04-1.47)] was an independent predictor of favorable outcome.

Conclusions:
Two-fold increase in the number of EVT was seen from 2014 to 2016 among patients ≥80 years old. Although the rate of favorable outcome is lower in this age group, comparison to a historical control group suggests significant outcome benefit from EVT in these patients. Future prospectively designed studies are warranted for further characterization of the risks and benefit of EVT in elderly.
Abstract WP366: Exploring the Association Between Physician Trust and Recurrent Stroke and Transient Ischemic Attack (TIA)
Authors: Venkatesan Anita , Boden-Albala Bernadette , Parikh Nina , Goldmann Emily
Published: June 2021

Purpose:
More positive health behaviors, fewer symptoms, higher quality of life, and greater treatment satisfaction have been reported among those with greater physician trust. This study assessed the relationship between physician trust and recurrent stroke/TIA within 1 year of discharge among stroke survivors in Northern Manhattan.

Methods:
This study used data from the Stroke Warning Information and Faster Treatment (SWIFT) study, a randomized controlled trial conducted from 2005-2012 in a multiethnic cohort of 1,193 mild/moderate ischemic stroke and TIA survivors. The goal was to assess the impact of a stroke preparedness educational intervention on emergency department arrival time after subsequent stroke symptom onset. Physician trust, assessed at baseline, was measured with one item: “What percentage of the time do you trust doctors?”. For the analysis, it was dichotomized with the cutoff at 80%. Recurrent stroke/TIA was assessed at 1 month and 1 year. The association between recurrent stroke/TIA and patient trust was evaluated using multivariate logistic regression adjusted for sociodemographics and comorbidities.

Results:
In the analytic sample (n=1108), those who answered both exposure and outcome, the prevalence of recurrent stroke/TIA and lack of physician trust was 10.75% and 36.46%, respectively. Consistent with the literature, Hispanics compared to whites had a higher prevalence of lack of physician trust (42.71% vs. 34.11%, p<0.001). Adjusting for race/ethnicity, intervention status, age, sex, education, marital status, smoking, insurance, hypertension, diabetes, body mass index, physical activity, and depression, those who lacked trust had greater odds of recurrent stroke/TIA (OR=1.36, 95% CI:0.86-2.18) than those who had trust. When observing the association among Hispanics and Blacks, those who lacked trust had (OR=1.27, 95% CI: 0.66-2.42) and (OR=1.26, 95% CI: 0.36-4.38) respectively, greater odds of a recurrent episode than those who had trust.

Conclusion:
Despite insignificant findings, a national study with a greater range of stroke severity and additional measures such as medication compliance may be warranted to provide greater insight on the effects of physician trust on stroke outcomes.
Abstract WP369: Fractures at Stroke Presentation: Attributes and Outcomes
Authors: McVey Courtney M , Marchina Sarah , Kumar Sandeep
Published: June 2021

Background:
Many studies have shown that stroke survivors are at increased risk for fractures, however systematic investigations of acute strokes that present with concomitant acute fractures are lacking. We hypothesize that such fractures are more likely in women, with embolic infarcts, and in strokes causing leg weakness or seizures and adversely affect outcomes.

Methods:
We retrospectively analyzed a cohort of 7411 acute stroke patients identified by ICD codes from 2014-2017. We performed univariate analyses to compare the frequencies of women, stroke subtype, seizure and leg weakness in our cohort to their expected binomial probabilities derived from established acute stroke cohorts in literature. We performed multivariate regression analyses to examine the association of fractures with ICU admission, length of hospital stay, discharge to home and in-hospital mortality after adjusting for age, stroke subtype, hypertension, diabetes, coronary artery disease, heart failure, chronic obstructive pulmonary disease, atrial fibrillation, kidney disease and cancer.

Results:
Review of medical records confirmed 61 patients with acute stroke and acute fracture. The median NIHSS was 12, 48 (79%) of patients fell or were found down and 7 (12%) of patients’ fractures were missed on admission. The proportion of patients with acute ischemic stroke (AIS) was 80% vs. an expected 75% (p<0.0001); 44% were women vs. an expected 50% (p=0.44); 28% had cardioembolic etiology vs. an expected 16% (p<0.0001); 77% of patients had leg weakness vs. an expected 10% (p=0.0041); 10% of patients had seizure at onset vs. 6% expected (p<0.001). Multivariate analysis showed that fracture was independently associated with ICU admission (OR 3.60 [2.08-6.25] p<0.0001), longer hospitalization (p<0.0001), reduced likelihood of discharge home (OR 0.15 [0.05-0.45], p=0.0006), but not with in-hospital mortality.

Conclusion:
Acute fractures are more frequent in cardioembolic AIS, and in strokes causing leg weakness or seizure. Stroke patients with acute fracture are more likely to require ICU care, have longer length of stay, and are less likely to be discharged home. Our findings highlight stroke characteristics associated with acute fracture and the need for diagnostic vigilance.
Abstract WP374: High Frequency Blood Pressure Monitoring in the Acute Phase of Large Vessel Occlusion Ischemic Stroke
Authors: Peshwe Krithika Umesh , Nguyen Cindy Khanh , Kimmel Alexandra C , Kodali Sreeja , Silverman Andrew , Strander Sumita , Wang Anson , Wira Charles , Sansing Lauren , Matouk Charles , Sheth Kevin , Petersen Nils
Published: June 2021

Introduction:
Decreases in blood pressure (BP) during endovascular therapy (EVT) have been associated with infarct progression and worse outcome after large vessel occlusion (LVO) stroke. However, BP trajectories in the acute phase prior to EVT have not been well characterized. We thus used high-frequency BP and hemodynamic monitoring to create a continuous BP time trend and to determine timing of BP reductions.

Methods:
We prospectively enrolled patients with LVO stroke undergoing EVT. BP and cardiac hemodynamic variables were recorded every 20 seconds from emergency room admission until end of EVT using non-invasive finger plethysmography. Time trends of BP recordings were categorized into 4 windows: admission to imaging; imaging to EVT; EVT to groin puncture and groin puncture to recanalization. Episodes of hypotension (mean arterial pressure ≤ 70 mmHg) were correlated with administered medications and other potentially related interventions. Time trends in hemodynamic variables were analyzed using generalized estimating equations.

Results:
25 patients underwent continuous BP monitoring (age 74±18; 68% female; mean NIHSS 12, monitoring time 8.34±2 hrs). Aggregated time series data revealed a marked BP reduction around time of imaging from which patients recovered (mean SBP 33 mmHg, duration 18 min, Fig A). A sustained decrease in BP was observed after groin puncture without return to baseline BP levels. In 62% of cases, reductions in BP were associated with BP lowering medications. A significant reduction in cardiac output (p=0.003) and increase in stroke volume variation (p=0.022) was seen across predetermined time points (Fig B & C).

Conclusion:
In patients with LVO, marked and frequently iatrogenic BP reductions occur around time of initial imaging and may present a potential target for intervention. Changes in cardiac hemodynamic variables throughout acute stroke period suggest a potential role for fluid resuscitation for hemodynamic optimization.
Abstract WP376: Candidates for Long Term Anticoagulation Among Hospitalized Patients With Atrial Fibrillation in United States
Authors: Kumar Nitish , Huang Wei , Lobanova Iryna , Balasetti Vamshi , Bhagavan Sachin , Siddiq Farhan , French Brandi R , Gomez Camilo R , Qureshi Adnan I
Published: June 2021

Context:
Long-term anticoagulation has been consistently shown to reduce the rate of ischemic stroke among selected patients with atrial fibrillation (AFib). There is paucity of data regarding number of eligible patients with AFib in United States who could benefit from long-term anticoagulation.

Objective:
To provide national estimate of eligible hospitalized patients with AFib who could benefit from long-term anticoagulation.

Methods:
We analyzed data from Nationwide Inpatient Sample (NIS) for the year 2016. NIS represents the largest all payer nationally representative dataset of hospitalizations in United States. We identified patients with primary or secondary diagnosis of AFib who were aged 75 years or greater, women aged 65-74 years, men aged 65-74 years with history of ischemic stroke/transient cerebral ischemia( TIAs), and patients aged 18-64 years with AF and ischemic stroke/TIAs (CHA2DS2-VASc score of 2 or greater) who were hospitalized and discharged alive to provide national estimates.

Results:
A total of 871,391 patients (163,236 aged between 18-64 years, 216,645 aged between 65-74 years, and 491,107 aged 75 years or greater) were admitted with a diagnosis of AFib in 2016. The number of patients with atrial fibrillation who also had history of ischemic stroke/TIAs was 38,051 (4.37%). Of the Afib patients, aged 75 years or greater, 25,050 (2.87 %) had a history of ischemic stroke/TIAs. Of the patients aged 65-74 years, 3,534 women (0.41%) and 4,341 men (0.50%) had history of ischemic stroke/TIAs. Also, there were 91,364 (10.48%) women between age 65-74 years who had AFib but did not have stroke.5,117 (=n,0.59%) patients between age 18-64 years had AFib and history of ischemic stroke/TIAs. The total number of potentially eligible patients with AFib who could benefit from the anticoagulation (based on CHA2DS2-VASc) was 564,030(65% of all patients admitted with AFib).

Conclusions:
Over half a million hospitalized patients with atrial fibrillation who are under medical care can benefit from long-term anticoagulation. Most are stroke free at time of hospitalization in United States and thus associated death and disability from new strokes can be prevented by timely initiation of long-term anticoagulation.
Abstract WP379: Sex-specific Effects of Comorbid Diabetes and Depression on Post-stroke Mortality in Individuals With Atrial Fibrillation
Authors: Edwards Jodi , Colby-Milley Jessica , Fang Jiming , Zhou Limei , Shah Baiju R , Herrmann Nathan , Linkewich Elizabeth , Law Marcus , Swartz Richard , Kapral Moira , MacIntosh Bradley , Swardfager Walter
Published: June 2021

Background:
Comorbid diabetes and depression are highly prevalent in atrial fibrillation (AF) and increase the risk of stroke. Women with AF show higher mortality rates and have worse functional outcomes post-stroke. However, the sex-specific effects of comorbid diabetes and depression on mortality and other adverse outcomes in stroke patients with a history of AF is unclear.

Methods:
Prospectively collected consecutive patients with ischemic stroke and known AF presenting to designated stroke centres in Ontario (2003-2013). Multinomial regression was used to determine sex-specific associations between diabetes and depression and in-hospital mortality post-stroke in individuals with AF. Cox proportional hazards regression was used to estimate the adjusted hazard of long-term mortality post-stroke and competing risks models to estimate hazards of recurrent stroke/TIA, admission to long-term care, and incident dementia post-discharge.

Results:
Among 5082 stroke patients with known AF (median age=80, IQR:73-85), female patients were more likely to have comorbid depression than males (63.5% vs. 36.5%) and those with comorbid diabetes and depression were younger (77 yrs) and had more vascular history (HTN, CAD, hyperlipidemia) than those with AF only. For males, comorbid diabetes increased the likelihood of in-hospital mortality post-stroke by 53% (OR=1.53, 95% CI=1.16-2.02), after adjustment for stroke severity, demographic and clinical factors, while comorbid depression did not significantly impact in-hospital mortality and neither diabetes or depression affected in-hospital mortality post-stroke for females. However, diabetes was independently associated with increased hazard of long-term mortality for both female (HR=1.15, 95%CI=1.02-1.29) and male AF stroke patients (HR=1.35, 95%CI=1.19-1.53). No associations with recurrent stroke/TIA, institutionalization or dementia post-stroke were observed for either females or males.

Conclusion:
In stroke patients with known AF, comorbid diabetes but not depression was independently associated with increased in-hospital mortality for males and increased long-term mortality post-stroke for both females and males.
Abstract WP388: Inpatient Teleneurology Follow-Up Has Similar Outcomes to In-Person Neurology and Provides an Alternative to Transfer
Authors: Trevino Alyssa D , Zha Alicia M , Ankrom Christy M , Chu Kristie M , Joseph Michele M , Zhu Liang , Malazarte Rene M , Cossey TC , Savitz Sean I , Wu Tzu-Ching , Jagolino-Cole Amanda L
Published: June 2021

Introduction:
Community emergency departments (EDs) often transfer ischemic stroke (IS) patients for lack of neurology coverage, burdening patients and accepting facilities. Telestroke (TS) improves acute stroke care access, but data lack on inpatient teleneurology follow-up (TNF) care. We hypothesized that IS patients evaluated in the ED via TS, then admitted and managed by TNF, have similar outcomes to those seen by in-person neurology follow-up (IPF) after admission.

Methods:
In our spoke EDs, 4069 IS patients were seen via TS (9/2015-12/2018). Figure 1 demonstrates hospital stroke designations and patient triage patterns. Transfer was at ED discretion. We compared baseline demographics, clinical characteristics, and hospital outcomes in patients with TNF vs IPF.

Results:
There were 447 (23%) patients with TNF and 1459 (77%) IPF. Both groups presented with similar stroke severity (Table 1). In multivariate analysis, there were no significant differences in discharge disposition, stroke readmission rates, or 90-day mRS; length of stay was shorter with TNF. tPA-only patients showed no differences in outcomes and similar complication rates. TNF patients less likely received tPA or endovascular therapy. TNF resulted in a 3% transfer rate for higher level of care. There remained no difference in outcomes in a sub-analysis without CSCs. A higher proportion of non-Hispanic Black patients and lower proportion of Hispanic patients in the TNF group were possibly due to spoke demographics.

Conclusion:
TNF resulted in comparable outcomes to IPF and few transfers after admission. For select IS patients, TNF provides an alternative to transfer for hospitals lacking neurology coverage.
Abstract WP39: Intraprocedural Systolic Blood Pressure Mean and Variability During Endovascular Thrombectomy Not Associated With Neurologic Outcome
Authors: Anadani Mohammad , De Havenon Adam , Baki Linda M , Spiotta Alejandro M
Published: June 2021

Background:
Prior research has shown that increased systolic blood pressure variability (BPV) is associated with worse neurologic outcome after endovascular thrombectomy (EVT). Those studies have typically included BPV from 24-72 hours after stroke onset, but none have focused specifically on the BPV during EVT.

Methods:
We included acute ischemic stroke patients who underwent EVT for anterior circulation large vessel occlusion from 2 stroke centers. All patients had a minimum of 10 blood pressure readings during EVT. The primary outcome is mRS 0-2 (good outcome) and the secondary outcome is death, both as close to 90 days as possible. We fit adjusted logistic regression models to our outcomes with the predictors of intraprocedural systolic mean, standard (SD), and coefficient of variation (CV).

Results:
We included 303 patients with a mean (SD) age of 65.7 years and 53.5% were female. The primary outcome of mRS 0-2 was met by 39.9% and 27.4% died. Systolic mean, SD, and CV did not differ in patients with mRS 0-2 versus 3-6 (Table 1) nor for patients who died versus were alive (all p>0.5). In the adjusted logistic regression models, systolic mean, SD, and CV were not associated with either mRS 0-2 or death at follow-up (Tables 2 & 3).

Conclusions:
Blood pressure variation during endovascular thrombectomy was not associated with the functional outcome or death in patients with anterior circulation strokes.
Abstract WP4: Efficacy of EVT in Patients Presenting Very Late (>16 Hours) From Last Known Well
Authors: Kim Beom Joon , Menon Bijoy , Kim Jun Yup , Kim Hyeran , Baik Sung Hyun , Jung Chulkyu , Han Moon-Ku , Demchuk Andrew , Bae Hee-Joon
Published: June 2021

Background:
Recent endovascular treatment (EVT) trials suggest the presence of target mismatch profiles up until 24 hours after stroke symptom onset. We aim to a) demonstrate the presence of target mismatch in patients presenting beyond these recent time thresholds and b) potential benefit with EVT in these patients.

Methods:
Between 01/2012 and 12/2018, patients with AIS with ICA or MCA occlusion and baseline NIHSS score ≥6 arriving ≥16 hours from last known well were identified. CT or MR perfusion images at presentation were evaluated using RAPID software; ischemic core was defined as rCBF <30% (CTP) or ADC <620 (MRI). Clinical information and outcome events were collected prospectively.

Results:
Of 154 patients [55% male, mean age 70 ± 13 years, median baseline NIHSS 13 [IQR 8 - 18], 76 (49%) had unwitnessed onset. Median last known well to arrival in hospital time was 42.2 [22.8 - 76.9]. CTP or MR perfusion were obtained in 115 (75%). Median ischemic core volume i.e., 11.0 ml [iqr 0 - 40 ml], and penumbra volume (Tmax >6 s) i.e., 57 ml [16 - 133 ml] and a median mismatch ratio 4.0 [iqr 0.9 - 18.0] were noted. When inclusion criteria of the following trials, namely, ESCAPE, DAWN and DEFUSE3 trial were applied, DAWN-eligible patients were n=45 (29%), DEFUSE3 n= 61 (40%) and ESCAPE n=59 (43%). Figure 1a shows trial eligibility by time from last known well. 24 (16%) patients had EVT. EVT was associated with better functional recovery at 3 months (Figure 1b) for 90-day mRS 0-2 (adjusted OR [95% CI], 8.11 [2.49 - 30.44]) and 90-day mRS shift (common adjusted OR 5.50 [2.33 - 13.29]). Treatment effect with EVT was seen from 16 to 240 hours since last known well (Figure 1c). Parenchymal Hemorrhage type 2 was seen in 13 % offered EVT vs. 3% (adjusted OR 4.11 [0.73 - 21.72]).

Conclusions:
Patients with anterior circulation LVO presenting very late, even days from last known well, may potentially benefit from EVT.
Abstract WP413: Portable, Bedside, Point of Care Magnetic Resonance Imaging in an Intensive Care Setting for Intracranial Hemorrhage
Authors: Cahn Bradley A , Shah Jill T , By Samantha , Welch E. B , Sacolick Laura , Yuen Matthew M , Mazurek Mercy H , Wira Charles , Leasure Audrey C , Matouk Charles , Ward Adrienne , Payabvash Sam , Beekman Rachel , Brown Stacy C , Falcone Guido , Gobeske Kevin , Petersen Nils , Jasne Adam , Sharma Richa , Schindler Joseph , Sansing Lauren , Gilmore Emily , Sze Gordon , Rosen Matthew , Kimberly W. T , Sheth Kevin N
Published: June 2021

Background:
Radiographic diagnosis of intracranial hemorrhage (ICH) is a critical determinant of stroke care pathways requiring patient transport to a neuroimaging suite. Advances in low-field MRI have made it possible to obtain clinically useful imaging at the point of care (POC).

Aim:
The aim of this study was to obtain preliminary data regarding the ability of a bedside POC MRI scanner to detect ICH.

Methods:
We studied 36 patients with a diagnosis of ICH (n=18) or ischemic stroke (n=18). Five blinded readers independently evaluated T2W and FLAIR exams acquired prospectively on a 64 mT, portable bedside MRI system (Hyperfine Research, Inc). Kappa coefficients (κ) were calculated to determine inter-rater agreement. Ground truth was obtained from the clinical report of the closest conventional imaging study (17.9 ± 10.4 hours) and verified by a core reader. For each exam, majority consensus among raters was used to determine sensitivity.

Results:
ICH volume ranged from 4 to 101 cc (median of 13 cc). Exams were acquired within 7 days of symptom onset (51.1 ± 28.8 hours). A pathologic lesion was identified on every exam with 100% sensitivity. Sensitivity for distinguishing any hemorrhage was 89% and specificity was 83%. The mean sensitivity and specificity for individual raters was 79% and 69%, respectively. When limited to supratentorial hemorrhage, consensus sensitivity was 94%. For ICH cases detected by all raters (n=9), there was 100% accuracy for localizing the bleed (lobar vs. non-lobar) with perfect agreement among raters (κ = 1, p <0.0001). There was substantial agreement for identifying intraventricular hemorrhage (IVH) (κ = 0.72, p < 0.0001). Sensitivity for IVH was 100% based on rater consensus. Figure 1 shows a POC exam with an ICH and IVH.

Conclusions:
These data suggest that low-field, POC MRI may be used to detect hemorrhagic stroke at the bedside. Further work is needed to evaluate this approach in the hyperacute setting and across a wide range of ICH characteristics.
Abstract WP42: Stroke Severity and Size Modify the Association Between IV Thrombolysis and Outcomes Following Endovascular Thrombectomy
Authors: Sarraj Amrou , Grotta James C , Lansberg Maarten , Abraham Michael , Sitton Clark , Chen Peng R , Cai Chunyan , Pujara Deep , Blackburn Spiros , Reddy Sujan , Vora Nirav , Haussen Diogo , Parsha Kaushik , Kamal Haris , Imam Bita , Shaker Faris , Gupta Rishi , Martin-Schild Sheryl , Hicks William J , Arora Ashish , Barreto Andrew D , Riascos Roy F , Hassan Ameer , Savitz Sean I , Albers Gregory W
Published: June 2021

Background:
Whether IV tPA has adjunctive benefit to endovascular thrombectomy (EVT) is unclear.

Methods:
In a prospective multicenter cohort study of imaging selection for EVT (SELECT), patients who received IV tPA vs. no IV tPA were compared stratified by stroke severity and ischemic core size (rCBF<30%).

Results:
Of 361 enrolled, 285 received EVT; 226 presented within 4.5 hrs, 162 (72%) received IV tPA. IV tPA patients had lower median ASPECTS (8 vs 9, p=0.007) and larger ischemic core size (11.4 (1.5-37) vs 3.9 (0-32.15), p=0.042, otherwise similar at baseline. There were no delays in EVT delivery associated with tPA: median time (IQR) from arrival to groin puncture 95.0 min (66.0, 118.0) tPA vs 81.5 (63.5, 107.5) no tPA, p=0.21. IV tPA use was associated with higher mRS 0-2 rates (57% vs 44%), aOR 2.02 (95% CI 1.01-4.03, p=0.046) after adjustment for baseline differences with a shift towards better outcomes on all mRS levels (cOR 2.06, 95% CI 1.18-3.59, p=0.01) with lower mortality (11% vs 22%, p=0.026) and similar sICH rates (and 6% vs 6%, p=1.0). In patients with NIHSS <15, IV tPA was associated with higher mRS 0-2 (tPA 83% vs no tPA 50%, aOR 4.53, 95%CI 1.48-13.80, p=0.008) with a shift towards better outcomes (adj cOR 5.44, 95% CI 2.16-13.70, p<0.001) while with NIHSS≥15 there was no adjunctive benefit of IV tPA (tPA 42% vs no tPA 38%, aOR 1.05, 95%CI 0.40-2.74, p=0.92) or shift (adj cOR: 1.32, 95% CI 0.61-2.86, p=0.48) with an interaction between IV tPA effect on EVT outcome with NIHSS (p=0.04) Fig A. Similarly, in ischemic core < 50 cc (62% vs. 46%, aOR 1.96, 95%CI 0.96-3.99, p=0.06; adj cOR 2.03, 95% CI 1.13-3.66, p=0.018) as compared to core ≥ 50cc (tPA 26% vs no tPA 25% P=1.0) with an interaction between IV tPA effect on EVT outcome with core size (p=0.037) Fig B.

Conclusion:
IV tPA did not result in thrombectomy delivery delays and may result in better outcomes. Patients with less severe strokes and smaller infarct size had a stronger association between the use of IV tPA and favorable outcomes.