bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TMP45: Constrained-Induced Movement Therapy Transfer the Function Gained by Upper Arm Robotic Therapy Into Daily Activities
Authors: Takahashi Kayoko , Takebayashi Takashi , Amano Satoru , Uchiyama Yuki , Domen Kazuhisa , Hachisuka Kenji
Published: June 2021

Introduction:
Robotic Therapy (RT) is shown to improve upper extremity (UE) function, but not the use of affected arm in daily activities. Constraint-Induced Movement Therapy (CIMT), on the other hand, is the most well-established intervention for improving the use of the affected arm.

Hypothesis:
(1) RT as self-training would improve UE function better than usual self-training. (2) Combination of RT and modified CIMT would improve daily use of affected arm as compared to the combination of RT with usual therapy.

Methods:
This study was a prospective, single-blinded, randomized, multicenter clinical trial conducted at 24 rehabilitation clinics in Japan. Participants were 129 individuals with hemiplegia (FM<44) at least over 6 months post stroke. They were randomized to one of three interventions for ten weeks (3 days a week): (a) 40 minutes RT as self-training(ReoGo®-J, Teijin Pharma, Japan) with usual therapy (RT group), (b) 40 minutes RT as self-training with 20 minutes modified CIMT (Combination group), and (c) 40 minutes usual self-training with 20 minutes usual therapy (Control group). UE function (Fugl-Meyer Assessment: FM), and arm usage (Motor Activity Log: MAL) was measured. Sub-analysis was conducted divided by the onset period (14 months) and age (65 year).

Results:
Proximal FM improved significantly in RT group than Control group (p=0.04), especially for age under 65. MAL significantly improved in Combination group than Control group (p=0.05), especially for age over 65. RT group significantly improved on Proximal FM than Combination (p=0.05) and Control (p=0.03) groups, for patients less than 14 months onset. For over 14 months onset, Combination group improved Wrist/Finger FM (p=0.06) and arm usage (p=0.09) than RT group.

Conclusions:
This study indicate robotic self-training improve UE function of chronic stroke patients than usual self-training. In addition, arm usage only exceeded MCID by the combination therapy of robotic self-training with modified CIMT, and more effective for older patients (age over 65) at chronic stage (over 14 months onset).
Abstract TMP49: Social Network Simulation Identifies Persistent Racial Disparities of Delay to Hospital in Acute Ischemic Stroke Patients
Authors: Greben Rachel , Sheth Kevin , Dhand Amar
Published: June 2021

Introduction:
Delayed arrival to the hospital remains the major reason for non-use of stroke therapies. Minority patients have longer delays that have not been adequately understood nor acted upon. Social context plays a key role, because most strokes occur in front of witnesses who influence decision-making. We created a social network simulation to understand the interpersonal factors that influence decision-making, particularly in minority patients.

Methods:
We developed an agent-based computer simulation of individual traits and social contextual factors that contribute to decision-making. The inputs into this parsimonious model were based on the largest empirical studies (e.g., Get With The Guidelines) and included: stroke severity, use of Emergency Medical Services (EMS), race, and social network size. The model outputs were the number of stroke patients who arrived at the hospital early (≤3 hours) and late (>3 hours). For each run of the model, 1,000 stroke patients decided to go to the hospital early or late based on individual and social contextual factors. Two sample t-tests were used to compare means between white and non-white patients.

Results:
In 1.03 million simulations, the model reproduced observed population trends of delay. The overall mean percent of early arrivers was 25.2% (SD 0.02), which matched national metrics showing good calibration of the model. Race predicted delay and modified the relationship of the main effects. 17.9% of non-white patients arrived early compared to 28.3% white patients (p<0.0001) (Fig 1-A). 17.6% of non-white patients with moderate strokes arrived early compared to 39.8% of white patients (p<0.0001) (Fig 1-B). 18.8% of non-white patients with a social network size of 10 arrived early compared to 31.5% of white patients (p<0.0001) (Fig 1-C).

Conclusion:
A social network simulation reproduced persistent racial disparities of delayed arrival allowing for novel interventions to be tested on this platform.
Abstract TMP51: A VA Observational Study Examining the Mortality Benefit of Various Post-ischemic Stroke/tia Hypertension Goals - Is There a Too Low?
Authors: Sico Jason J , Hu Xin , Arling Greg , Myers Laura , Bravata Dawn
Published: June 2021

Introduction:
Joint National Committee (JNC)-8 goal blood pressure (BP) recommendation of < 140/90 mmHg has been supplanted by 2017 ACC/AHA goal of < 130/80 mmHg for patients with ischemic stroke/TIA. Understanding potential mortality benefit for patients reaching ACC/AHA goal is needed.

Hypothesis:
Stroke/TIA patients reaching ACC/AHA goal BP will experience lower 1-year all-cause mortality compared to those reaching JNC-8 BP goals.

Methods:
This is a retrospective cohort of Veterans with stroke/TIA (N=39,053) who received their longitudinal outpatient primary care within a Veterans Administration Medical Center between 10/2014 and 9/2018. Patients were excluded (n=25,381) if they had missing or physiologically improbable BP values, died, or had less than 1 year of follow-up for analysis of 1-year mortality. We calculated average SBP during 90 days after discharge and assessed it in categorical form (≤115 mmHg, 106-115 mmHg, 116-130, mmHg, 131-140 mmHg, and >140 mmHg) and continuous form. Multivariate COX proportional hazard regression was used to examine the relationship between average SBP groups and time to mortality 90 days after discharge up to 1 year. In multivariate logistic regression, we used continuous SBP along with its quadratic term to predict 1-year mortality.

Results:
A total of 12,337 eligible patients were included in the final analysis. COX proportional regression demonstrated a statistically significant higher risk of death among patients with SBP lower than 105 mmHg as compared to those with > 140 mmHg (HR = 1.79, 95% CI= 1.37-2.34), but no statistical differences were found in other SBP groups. Predicted probability of 1-year mortality generated from the logistic regression was plotted and showed a “U” shaped relationship between SBP and mortality, whereas SBP ranges encompassing both AHA/ACC and JNC-8 goal BP recommendations are found on the “flat” part of the curve.

Conclusions:
In considering BP reached by 90-days, there was no differential 1-year all-cause mortality benefit between JNC-8 and ACC/AHA BP recommendations, whereas patients experiencing low SBPs were at increased risk for higher mortality. Providers should be aware of the association between lower SBP and higher mortality when treating BP.
Abstract TMP6: Optimal Early Clinical Endpoints for Long-Term Functional Outcome Prediction After Thrombectomy
Authors: Mistry Eva A , Yeatts Sharon , Mistry Akshitkumar , Mehta Tapan , Arora Niraj , De Los Rios La Rosa Felipe , Starosciak Amy , Siegler James , Dakay Katarina , Chitale Rohan , Yaghi Shadi , Khatri Pooja
Published: June 2021

Background:
Early neurological recovery (ENR) is an attractive surrogate marker for long-term functional outcome of endovascularly-treated stroke patients. However, the optimal definition of 24-hour ENR that best predicts 90-day functional independence (modified Rankin Scale, mRS, 0-2) has not been established. We sought to determine ENR measure that best predicts 90-day mRS 0-2.

Methods:
The prospective BEST cohort study includes consecutive adult patients treated with endovascular therapy at 12 comprehensive stroke centers. In this post-hoc analysis, we measured the ability of various thresholds of both 24-hour NIHSS and αNIHSS (baseline minus 24-hour) to predict 90-day mRS 0-2 using Youden’s index. The strength of the associations were assessed using logistic regression adjusted for age, glucose, hypertension, ASPECT score, time to recanalization, recanalization status, and thrombolytic treatment.

Results:
Of 485 patients in the BEST cohort, 447 with 90-day follow-up were included in this study (228 females, mean age 68.05 ±15 years). The optimal Youden’s Index was achieved at 24 hour NIHSS of ≤7 (sensitivity 80.1%, specificity 80.4%, area under the curve [AUC] 0.855 [0.819-0.887], p<0.001; Figure). The optimal for αNIHSS cut point was ≥4 points (sensitivity 79%, specificity 58.5%, AUC 0.73 [0.685-0.77], p<0.001; Figure), which performed less well at outcome prediction than 24 hour NIHSS (difference between the AUCs 0.126, p<0.001; Figure). Strength of association between other common early clinical endpoints and outcome in this cohort are listed in the Table.

Conclusions:
A 24-hour NIHSS ≤7 was the optimal measure to predict functional independence at 90 days in our multicenter, prospective cohort. Among αNIHSS thresholds, ≥4 points was optimal but performed less well. These findings should be validated in independent endovascular cohorts to establish a standard short-term outcome measure for both clinical and research scenarios.
Abstract TMP66: Eight-year Trends in Ambulance Use in a National Sample of Medicare Beneficiaries With Stroke
Authors: Meng Tong , Trickey Amber W , Govindarajan Prasanthi
Published: June 2021

Thrombolysis for acute stroke must be administered within a short time after stroke onset. Since ambulance use has been shown to ensure timely arrival leading to higher use of thrombolysis, we evaluated the trend in ambulance use among all Medicare beneficiaries with stroke and compared the utilization of ambulance transport among subgroups of patients.

Method:
The study analyzed the first hospitalization of aged 66+ patients where the primary diagnosis was ischemic stroke from Medicare claims (2007-2014). We excluded patients without continuous enrollment in Parts A+B in the year prior to stroke hospitalization. The primary outcome measure was ambulance arrival among stroke patients who were treated in the emergency department. Ambulance transport was identified from Medicare carrier and outpatient claims (HCPCS A0425-A0436). We calculated Cochran-Armitage trend tests to assess changes in utilization over time and chi-square tests to compare utilization by patient and hospital characteristics.

Results:
Among 240,486 patients, the ambulation utilization rate increased from 61.2% in 2007 to 63.5% in 2014 (p<0.001). Small but significant increasing trends were observed among most age, racial, and area subgroups, but was not observed among Hispanic patients. Patient and hospital characteristics were associated with the ambulance utilization (all p 0.002). Older patients were much more likely to arrive by ambulance (age 86+ 72.4%, 76-85 62.1%, 66-75 52.4%, Figure). Higher utilization rates were also observed for Non-Hispanic White patients (63.1%, Hispanic 58.5%, Black 57.6%, Asian 54.3%) and patients in rural areas (63.1%, urban 62.1%).

Conclusion:
Although ambulance use has increased, more than one-third of Medicare beneficiaries with stroke use other forms of transportation. In this ongoing multi-year study, we will assess thrombolysis use by transport modality and estimate the impact of prehospital care on thrombolysis and functional outcomes.
Abstract TMP67: Prehospital Cath Lab Activation Based on EMS Large Vessel Occlusion Screen Cancelled
Authors: Fuller Megan , Cathel Danise , Gizzi Martin
Published: June 2021

Background:
Current guidelines indicate reduced time to reperfusion with thrombectomy is strongly associated with better outcomes. Validated screening tools for large vessel occlusions are available for the prehospital setting.

Objective:
To reduce door to access times for patients arriving by EMS to an urban 487 bed quaternary hospital.

Methods:
Starting in January of 2016, EMS crews screened all stroke patients with the Cincinnati - Stroke Triage Assessment Tool (C-STAT) and communicated results to the ED prior to arrival (PTA). In 2017, a team consisting of Neurology, ED, Cath Lab, Neuro Interventional leadership and stroke coordinator agreed to a 6-month pilot project of activating the Cath Lab when EMS radioed a patient was C-STAT positive. Any ED staff who might take EMS radio report were educated on the new process. Instructions were added to the existing Stroke Patient Checklist. Cath Lab and EMS staff were notified of the pilot project. During the pilot period, feedback was provided to EMS and ED leadership if an issue was identified for a specific case and trends were discussed.

Results:
During the pilot period, median door to access time for C-STAT positive patients who had Cath Lab activated PTA was 66 minutes compared to the 104 minutes the previous year (37% reduction). Unexpectedly, the median door to needle time for these patients also improved from 45 minutes the previous year to 28 minutes (38% reduction). The Cath Lab was activated PTA 16 times for patients EMS reported as C-STAT positive; Only 5 went on to have a thrombectomy. Overcalls were due to lack of C-STAT specificity (n=6) or C-STAT not scored correctly (n=5). In practice as well as when cases associated with assessment errors are removed, C-STAT demonstrated a low specificity for LVO (37.5% and 40% respectively). Lastly, internal process issues lead to 5 additional PTA Cath Lab activations for patients EMS did not report as being C-STAT positive.

Conclusions:
It was felt additional education would not be enough to make this initiative sustainable given the low specificity. In conclusion, despite marked improvement in door to access and door to needle times, the overactivation of Cath Lab lead to the initiative being cancelled.
Abstract TMP70: Simulation Modeling Predicts Actual Patient Transport Rates Following the Implementation of a Prehospital Comprehensive Stroke Center Direct Transport Protocol
Authors: Richards Christopher T , Holl Jane L , Khorzad Rebeca , Prabhakaran Shyam
Published: June 2021

Introduction:
Implementing emergency medical services (EMS) protocols that incorporate severe stroke screening and direct transport to comprehensive stroke centers (CSCs) has been advocated as a strategy to improve timely stroke care for patients with large vessel occlusion and hemorrhage, but such screening can have important unintended effects on stroke systems of care. Mathematical modeling can estimate the impact of prehospital CSC direct transport protocols, but few models have been evaluated after protocol implementation.

Hypothesis:
The proportion of patients transported to CSCs versus primary stroke centers (PSCs) in a mathematical model will approximate actual transport rates following implementation of a prehospital CSC direct transport protocol.

Methods:
A previously reported discrete event data simulation was used to model the proportion of patients with suspected stroke transported directly to CSCs in a large, urban EMS system with 8 CSCs, 24 PSCs, and a single municipal fire-based EMS agency responding to all 9-1-1 calls prior to implementation of a prehospital CSC direct transport protocol in late 2018. Electronic patient care records in which paramedics documented “suspected stroke” were included for analysis. The proportion of patients transported to CSCs versus PSCs in the 3 months (92 days) prior to and following protocol implementation were compared using Fisher’s exact test in Stata 12.1 (College Station, TX).

Results:
The simulation predicted that the proportion of patients transported to CSCs would increase by 8.3% following implementation of a prehospital CSC direct transport protocol. In the 3 months prior to protocol implementation, 247 of 872 (28.3%) suspected stroke patients were transported to CSCs, and 265 of 701 (37.8%) were transported to CSCs in the 3 months following implementation, a difference of 9.5% (p<0.001). The model underestimated the proportion of patients transported to CSCs by 1.2%.

Conclusions:
A mathematical model simulating the proportion of patients transported to CSCs differed by only 1.2% compared to actual rates after implementation of a prehospital CSC direct transport protocol. Simulation modeling holds promise for estimating system-level effects prior to EMS protocol implementation.
Abstract TMP72: Auto-Launching of Interfacility Transport for Presumed Emergent Large Vessel Occlusion Strokes Decreases Door-In-Door-Out (DIDO) Times and May Improve Outcomes
Authors: Zammit Christopher , Gallagher Sarah , Proper Diana , George Benjamin , Halpert David , Emmons Jerry , Talbott Matthew , Lux Jeremy , Teeter Mary Ann , Bose-Kolanu Anjali , Holloway Robert , Pilcher Webster , Benesch Curtis , Mattingly Thomas , Bhalla Tarun
Published: June 2021

Introduction:
Mechanical thrombectomy (MT) is effective for select acute ischemic strokes due to large vessel occlusion (LVO-AIS). Systems of care need to expeditiously identify, transfer, and treat qualifying LVO-AIS. Data are needed to define which ingredients are most effective when engineering LVO-AIS regional systems of care.

Methods:
Strong Memorial Hospital (SMH) is a Comprehensive Stroke Center in Rochester, NY serving twenty-two New York State designed stroke centers (NYS-DSC). Arnot Ogden Medical Center (AOMC), Cayuga Medical Center (CMC), and Geneva General Hospital (GGH) are NYS-DSCs located 115, 91, and 50 miles from SMH, respectively. Clinical leaders at each site collaborated to implement an integrated regional system of care for LVO-AIS, dubbed “Code LVO”, which includes the auto-launching of an interfacility transport to the referring hospital for presumed strokes with an NIHSS of >/= 10 and last known well time (LKWT) of </=24 hours. We retrospectively reviewed a QA database for transfer patients with an ASPECTS of >/= 6 and proximal anterior circulation LVO on a CTA at the referring hospital to identify the door-in-door-out (DIDO) times, thrombectomy attempt rate, and mortality of patients before and after Code LVO implementation. Wilcoxon Rank-Sum was used to analyze median DIDO times and Fisher’s exact was used to analyze the proportion of DIDO times of < 90 minutes, < 60 minutes, thrombectomy attempt rate, and mortality.

Results:
There were 51 pre- Code LVO versus 12 post Code-LVO transfers. The median DIDO times were significantly reduced post-Code LVO (80 vs 127 minutes, p=0.001). The proportion of DIDO times < 90 minutes and < 60 minutes were significantly improved (58% vs 16%, p=0.005 and 17% vs 0%, p=0.034, respectively). Mortality was numerically, but not significantly, reduced (17% vs 22%). Median DIDO times were significantly shorter in those undergoing thrombectomy (97 vs 136 minutes, p=0.008) and numerically longer in those who died (138 vs 112 minutes, p=0.24).

Conclusions:
Auto-launching of interfacility transport within an integrated regional system care for LVO-AIS decreases DIDO times and may improve outcomes. Further study is needed to outline its value, in terms of patient outcomes, resource utilization, and safety.
Abstract TMP74: Telepresence and Provider Communication Predict Satisfaction With Telestroke
Authors: Selch Griffin T , Lyerly Michael J , Martin Holly , Graham Glenn , Martini Sharyl , Anderson Jane , Damush Teresa , LaPradd Michelle , Ofner Susan , Williams Linda
Published: June 2021

Background:
In 2016 the Veterans Health Administration implemented the first nationwide Telestroke program; 800 consults were completed in the first 18 months. Preliminary analysis showed Veterans reported high satisfaction and acceptance of the program. This study sought to understand patient, provider, and hospital-level factors associated with patient satisfaction.

Methods:
Patients who received a Telestroke consultation were eligible for a phone interview two weeks later, including standard questions about technology quality, telepresence (how much the encounter felt like face-to-face), Telestroke provider communication, and overall satisfaction. Satisfaction scores ranged from 1-7, (higher = more satisfied), and for analyses were dichotomized as 6-7 indicating high satisfaction vs. < 6. Patient variables including stroke severity (NIH Stroke Scale) were obtained from study records. We used Student’s t-tests and Chi-square tests to compare variables related to patient-reported satisfaction, and used a logistic regression model to determine factors independently associated with high satisfaction.

Results:
Over 18 months, 208 interviews were completed and 156 (75%) reported high satisfaction with Telestroke. Patients with more severe stroke were less likely to recall the consultation (p = 0.01). Factors significantly associated with patient satisfaction were higher ratings of the technology (p < 0.0001), telepresence (p < 0.0001), provider communication ratings (p < 0.0001) and overall VA satisfaction (p = 0.01). Among 13 providers with at least 10 consultations, there was no difference in mean patient satisfaction scores. In the multivariate model, telepresence (OR 3.10, 95% CI 1.81-5.31) and provider communication scores (OR 2.37, 95% CI 1.20-4.68) were independently associated with satisfaction.

Conclusion and Potential Impact:
Provider qualities, including telepresence and provider ratings, were associated with overall Veteran satisfaction with Telestroke. Technology quality may be necessary but not sufficient to impact patient experience. Training providers to improve telepresence and communication skills could improve patient experience with Telestroke consultation.
Abstract TMP76: Ischemic Stroke Location and Vascular Risk in Dizziness Visits and The Follow-up Period: A Population-based Study
Authors: Kerber Kevin A , Burke James , Morgenstern Lewis , Brown Devin , McLaughlin Thomas , Sharp Adam , Meurer William
Published: June 2021

Objective:
Prior studies found a concerning frequency of missed ischemic stroke among Emergency Department (ED) dizziness visits. We aim to describe details about the location of infarction (identified at ED dizziness visits or in the follow-up time period) and vascular risk. These data could inform opportunities to identify index strokes or reduce the risk of subsequent events.

Methods:
From October 2016 to April 2018, ED visits for dizziness, vertigo, or imbalance were identified in Nueces County, Texas. Validated index or subsequent 90-day ischemic stroke events were identified by linkage to the Brain Attack Surveillance in Corpus Christi (BASIC) project. Infarct locations were classified using imaging reports. The proportion of the events associated with Atherosclerotic cardiovascular disease (ASCVD) score ≥0.10, a common trigger for preventive therapy, was summarized.

Results:
There were 55 ischemic strokes identified at the time of the ED dizziness visit and 33 ischemic strokes identified in the subsequent 90-days. The Figure displays infarct location, days since ED visit, and ASCVD score. Posterior fossa infarction comprised 47% (26/55) (17 cerebellar, 9 brainstem) of the strokes identified at the dizziness visit and 39% (13/33) (11 cerebellar, 5 brainstem) of the strokes in the follow-up period. Baseline ACSVD scores were ≥0.10 in 78% (43/55) of patients with stroke identified at the dizziness visit and 79% (26/33) of patients with stroke identified in the subsequent 90-days.

Conclusions:
Posterior fossa lesions account a minority of the ischemic strokes that present to the ED with dizziness or occur in the subsequent 90-days. A substantial majority of these strokes have ASCVD scores higher than a common threshold for preventative therapies. Vascular risk assessment during ED dizziness visits might help providers to both diagnose acute strokes and to prompt preventative strategies in presumed non-stroke cases at increased risk for short-term stroke.
Abstract TMP79: Pre-Stroke Sleep Apnea and Post-Stroke Depression
Authors: Dong Liming , Brown Devin , Chervin Ronald , Case Erin , Morgenstern Lewis , Lisabeth Lynda
Published: June 2021

Introduction:
Sleep apnea is an independent risk factor for stroke and strongly associated with depression; however, little is known about its role in predicting depression after stroke among stroke survivors. This study examined the association between pre-stroke sleep apnea risk and depression at 90 days post-stroke in a population-based sample.

Methods:
Data were obtained from the Brain Attack Surveillance in Corpus Christi (BASIC) project, a population-based stroke study in south Texas. The study sample consisted of 1,383 participants who had ischemic or hemorrhagic stroke between August 2010 and December 2016. Depression after stroke was measured by the 8-item Patient Health Questionnaire (range: 0-24). Participants scoring 10 or above were classified as having depression. Pre-stroke sleep apnea risk assessed at stroke onset was classified as high or low based on Berlin Questionnaire scores (high risk: 2 or more categories with a positive score; low risk: 0-1 category with a positive score). Inverse probability weighting and multiple imputation were used to deal with attrition and missing covariate data. Weighted logistic regression models were used to examine the association between pre-stroke sleep apnea risk and post-stroke depression.

Results:
Mean age of participants was 68.1 years (SD=12.3), men and women were evenly distributed, 59.4% were Mexican American, and 59.2% were at high risk for sleep apnea before stroke. High-risk participants were significantly more likely to be men, Mexican American, obese and on medication for depression at the time of stroke. Pre-stroke sleep apnea risk was associated with post-stroke depression (Odds Ratio [OR]=1.78, 95% Confidence Interval [CI]=1.38-2.29), even after adjustment for sociodemographic characteristics, smoking, obesity, pre-stroke depression status and stroke severity (OR=1.60, 95% CI=1.19-2.14).

Conclusions:
Pre-stroke sleep apnea may be an independent risk factor for post-stroke depression. Treatment of sleep apnea before or perhaps even after stroke may reduce risk for depression after stroke.
Abstract TMP81: Artificial Intelligence Beats Conventional Regression Analysis in Predicting Short and Long Term Risk of Stroke in Patients Undergoing Percutaneous Coronary Interventions
Authors: Agasthi Pradyumna , Chao Chieh-Ju , Wu Han Lun , Mookadam Farouk , Venepally Nithin , Eleid Mackram , Beohar Nirat , Forutin Floyd D , Yang Eric H , Holmes David R , Arsanjani Reza
Published: June 2021

Introduction:
Ischemic stroke (IS) causes substantial morbidity and mortality in patients undergoing percutaneous coronary intervention (PCI) with a 5 yr incidence ~ 3%. We sought the test the accuracy of Machine learning (ML) algorithms in predicting IS in patients undergoing PCI.

Methods:
Mayo Clinic CathPCI registry data were retrospectively analyzed from Jan 2003 - June 2018 including 21,872 patients who underwent PCI. The cohort was randomly divided into a training sample (75%, n=16404) and a unique test sample (25%, n=5468) prior to model generation. The risk prediction model was generated utilizing a random forest algorithm (RF model) on 188 unique variables to predict the risk of IS at 6-month, 1, 2, and 5-year post PCI. Conventional risk factors for stroke were used for logistic regression. The receiver operating characteristic (ROC) curve and area under the curve for the RF and logistic regression models were compared for the test cohort.

Results:
The mean age was 66.9 ± 12.4 years, and 71% were male. Patient demographics and outcomes are shown in
Table 1
.

The ROC area under the curve for the RF model was superior compared to the logistic regression model in predicting IS at 6 months, 1,2 and 5 yrs for the test cohort (
Figure 1
.)

Conclusions:
The RF model accurately predicts short and long term risk of IS and outperforms logistic regression analysis in patients undergoing PCI.
Abstract TMP82: Young Stroke Questionnaire (YSQ): A Patient Centered Stroke Outcome Measure
Authors: Kodumuri Nishanth , Edmunds Amy , McMillian Brittiny , Grant Alyson , Fleming Phil , Vezzetti Alexandra , Kothari Ravish , Sen Souvik
Published: June 2021

Introduction:
Stroke is a leading cause of disability affecting patients and their caregivers. Current outcome measures inadequately quantify the impact of stroke in young patients (≤65) in terms of managing education, career, and family.

Methods:
This study assessed the reliability and discriminate validity of the Young Stroke Questionnaire (YSQ) to further build upon the knowledge and understanding of young stroke patients and the specific needs for management and long-term outcomes relevant to young stroke survivors. The initial questionnaire evolved from a focus group comprised of 6 young stroke survivors and 6 stroke neurologists centralized around 4 patient-centered domains: work and leisure, relationships, wellbeing, and healthcare resources. To determine the reliability and discriminate validity of YSQ, 100 young stroke survivors were consented at the Neurology clinic. Standardized clinical assessments completed included the modified Rankin Scale (mRS). Additionally, all patients were asked to complete the patient-centered questionnaire, YSQ.

Results:
We enrolled 100 patients (Mean age ± SD = 49.2 ± 11.7, 42 Males, 53% African-American, 44% White) into the YSQ validation study. Cronbach’s α coefficients for the four domains and the total scale were calculated to measure the internal consistency of the YSQ. The α coefficients were found to be high (work & leisure α = 0.88, relationships α = 0.82, wellbeing α= 0.84, healthcare resources α= 0.75), indicating the scale with 4 subdomains is internally consistent and reproducible. The discriminant validity of the scale was assessed by comparing the means of each subdomain of YSQ among healthy subjects to the groups of stroke patients as defined by the mRS. YSQ was able to differentiate healthy subjects from subjects with varying degree of disability, as defined by the modified Rankin scale ( work and leisure p< 0.0001, relationships p< 0.0001, wellbeing p< 0.0001, Healthcare resources p= 0.017)

Conclusions:
Standardized clinical assessments are not sensitive to disabilities in young stroke survivors. When compared to standardized clinical assessments, the YSQ is significantly capable of differentiating the young survivor perspective of the impact of stroke in all the four subdomains.
Abstract TMP83: Association Between Hospital Procedural Volumes and Clinical Outcomes For Patients With Non-Traumatic Subarachnoid Hemorrhage
Authors: Leifer Dana , Fonarow Gregg , Hellkamp Anne , Baker David , Hoh Brian , Prabhakaran Shyam , Schoeberl Mark , Suter Robert , Washington Chad , Williams Scott , Xian Ying , Schwamm Lee
Published: June 2021

Introduction:
Previous studies of patients with non-traumatic subarachnoid hemorrhage (SAH) suggest better outcomes at hospitals with higher case and procedural volumes, but the shape of the volume-outcome curve has not been defined. We sought to establish minimum volume criteria for SAH and aneurysm obliteration procedures that could be used for comprehensive stroke centers (CSC) certification.

Methods:
The 8,512 SAH discharges in the National Inpatient Sample (NIS) from 2010-11 were analyzed. Logistic regression models were used to evaluate the association between clinical outcomes (in-hospital mortality and the NIS-SAH Outcome Measure (NIS-SOM)) and 3 measures of hospital annual case volume (ACV) (nontraumatic SAH discharges, coiling, and clipping procedures). Sensitivity and specificity analyses for the association of desirable clinical outcomes with different volume thresholds were performed.

Results:
28.7% of cases underwent clipping and 20.1% underwent coiling with rates of 21.2%for in-hospital mortality and 38.6% for poor outcome on the NIS-SOM. The mean (range) of SAH ACV, coiling ACV, and clipping ACV were 30.9 (1-195), 8.7 (0-94), and 6.1 (0-69). Logistic regression demonstrated improved outcomes with increasing ACVs of SAH discharges and procedures for aneurysm obliteration, with attenuation of the benefit beyond 35 SAH cases/yr. Sensitivity and specificity analyses with different ACV thresholds confirmed the results. Analysis of previously proposed ACV thresholds, including those used as minimum standards for CSC certification, showed that hospitals with more than 35 SAH cases annually had better outcomes compared to hospitals with fewer cases, but some hospitals below this threshold had similar outcomes to those with more cases. The adjusted odds ratio favoring better outcomes with SAH ACV ≥ 35 compared to SAH 20 to 34 was 0.82 for the NIS-SOM (p=0.0054) and 0.80 (p=0.0055) for in-hospital mortality.

Conclusions:
Outcomes for SAH patients improve with increasing hospital case volumes and procedure volumes, with consistently better outcomes for hospitals with more than 35 SAH cases per year.
Abstract TMP85: Predictive Score of Hemorrhagic Transformation in Patients Not Submitted to Reperfusion Therapies - PROpHET
Authors: Andrade Joao B , Silva Gisele S , Mohr Jay P , Carvalho Joao J , Franciscatto Luisa , Oliveira Filho Jamary , Pontes-Neto Octavio , Pires Matheus M , Modolo Gabriel P , Bazan Rodrigo , Lima Fabricio O
Published: June 2021

Objective:
To create an accurate and user-friendly

pr

edictive sc

o

re for

he

morrhagic

t

ransformation in patients not submitted to reperfusion therapies (PROpHET).

Methods:
We created a multivariable logistic regression model to assess the prediction of Hemorrhage Transformation (HT) for acute ischemic strokes not treated with reperfusion therapy. One point was assigned for each of gender, cardio-aortic embolism, hyperdense middle cerebral artery sign, leukoaraiosis, hyperglycemia, 2 points for ASPECTS ≤7, and -3 points for lacunar syndrome. Acute ischemic stroke patients admitted to the Fortaleza Comprehensive Stroke Center in Brazil from 2015 to 2017 were randomly selected to the derivation cohort. The validation cohort included similar, but not randomized, cases from 5 Brazilian and one American Comprehensive Stroke Centers. Symptomatic cases were defined as NIHSS ≥4 at 24 hours after the event. Results from the derivation and validation cohorts were assessed with the area under the receiver operating characteristic curve (AUC-ROC).

Results:
From 2,432 of acute ischemic stroke screened in Fortaleza, 448 were prospectively selected for the derivation cohort and a 7-day follow-up. From 1,847 not selected, 577 underwent reperfusion therapy, 734 were excluded due to inadequate imaging or refusal of consent, and 538 whose data were obtained retrospectively and were selected only for the validation cohort. A score ≥3 had 78% sensitivity and 75% specificity, AUC-ROC 0.82 for all cases of HT, Hosmer-Lemeshow 0.85, Brier Score 0.1, and AUC-ROC 0.83 for those with symptomatic HT. An AUC-ROC of 0.84 was found for the validation cohort of 1,910 from all 6 centers, and a score ≥3 was found in 65% of patients with HT against 11.3% of those without HT. In comparison with 8 published predictive scores of HT, PROpHET was the most accurate (p < 0.01).

Conclusions:
PROpHET offers a tool simple, quick and easy-to-perform to estimate risk stratification of HT in patients not submitted to RT. A digital version of PROpHET is available in www.score-prophet.com

Classification of evidence:
This study provides Class I evidence from prospective data acquisition.
Abstract TMP88: Blood Pressure Variability Within 24 Hours After Recanalization Worsens Functional Outcome Among Patients Who Underwent Endovascular Treatment
Authors: Campos Daniel , Requena Manuel , Carvalho Mariana , Saraiva Marlene , Garcia-Tornel Alvaro , Olive-Gadea Marta , Rodriguez-Villatoro Noelia , Juega Jesus , Deck Matias , Boned Sandra , Muchada Marian , Ballve Alejandro , Llaurado Arnau , Hernandez David , Coscojuela Pilar , Pagola Jorge , Rodriguez-Luna David , Tomasello Alejandro , Ribo Marc , Rubiera Marta
Published: June 2021

Introduction:
Systemic blood pressure (BP) should be strictly monitored and adjusted during the initial stages of stroke. Due to the impairment of cerebral autoregulation, cerebral blood flow is directly affected by systemic BP and some degree of permissive hypertension might be beneficial prior to reperfusion treatments to ensure an adequate perfusion in the ischemic tissue. However, after generalization of endovascular treatment (EVT) the rate of successful recanalization has skyrocketed and it is not well established if, once achieved, BP control should be stricter given its potential risks. We aim to explore the relation between BP and outcome among patients who underwent EVT.

Methods:
This is a retrospective study of a prospectively acquired unicentric database that includes patients who underwent EVT with successful recanalization measured by a mTICI ≥2b. Hourly measuring of systolic and diastolic BP was conducted during the first 24 hours post-procedure. BP variation was measured using standard deviation (SD) and range. We explored the effects of BP on functional outcome at 3 months and safety variables.

Results:
The study included 351 subjects with a mean age of 72.7+/-13.1 and 51.6% were men. The 3-months mRS was ≤2 in 50.4% of patients, 66 subjects (19.2%) presented hemorrhagic transformation and 67 (19.1%) were dead in the 3-months follow-up period. Both systolic BP SD (15.6+/-9.9 vs. 12.9+/-4.3; p<0.01) and range (55.6+/-18.4 vs. 48.7+/-16.4; p<0.01) were higher among patients with bad functional outcome (mRS>2). Subjects with hemorrhagic transformation presented higher range of DBP (35.7+/-12.4 vs. 32.0+/-11.9; p=0.03) and SBP (56.8+/-17.0 vs. 51.4+/-18.1; p=0.03) and higher diastolic DBP SD (9.3+/-4.1 vs. 8.2+/-2.7; p<0.01). In a logistic regression analysis DBP SD predicted ICH (OR 1.11, CI 1.02-1.22, p=0.01) and SBP range emerged as a predictor of poor functional outcome (OR 0.97, CI 0.96-0.99, p<0.01). No differences were detected in regard to admission BP, maximal and minimal BP or mean arterial pressure.

Conclusions:
Major fluctuations in systolic and diastolic BP predict increased risk of hemorrhagic complications and poor functional outcome. Minimizing BP fluctuations may improve outcome of EVT patients after recanalization.
Abstract TMP9: Use of Immediate Dual Antiplatelet Therapy in Carotid Stenting for Tandem Occlusion Stroke is Associated With Acceptable Symptomatic Intracranial Haemorrhage Rates
Authors: Lau Fiona S , Mitchelle Amer , Cheung Andrew , Wenderoth Jason , Cappelen-Smith Cecilia , Cordato Dennis , Hodgkinson Suzanne , McDougall Alan , Zagami Alessandro S , Manning Nathan W
Published: June 2021

Introduction:
Observational studies have shown conflicting data on safety and efficacy of carotid stenting in the setting of acute ischemic stroke. We evaluated our stent patency, functional outcomes and symptomatic intracranial haemorrhage rates in acute strokes with tandem occlusions treated with endovascular thrombectomy and concurrent carotid stenting.

Methods:
Prospectively maintained EVT databases at two comprehensive stroke centres were interrogated for patients with anterior circulation tandem occlusion stroke who were treated with EVT and extracranial carotid artery stenting. Intracranial haemorrhage on post-operative CT & MRI brain was assessed on European Cooperative Acute Stroke Study II criteria. Stent patency was assessed on CTA 12-24 hours post-operatively. Clinical and neuroimaging endpoints were modified treatment in cerebral ischaemia (mTICI) score, stent patency, any intracranial haemorrhage, symptomatic intracranial haemorrhage (sICH), and 90-day modified Rankin Scale (mRS).

Results:
Between 2016 and 2019, 105 patients were identified (mean age 70 years, 78% male, median NIHSS 15). Median time to reperfusion was 9.26 hours, with 97.1% achieving mTICI 2b/3. Immediate dual antiplatelet therapy was used in 102 (97.1%) patients. Good functional outcomes (mRS 0-2) were achieved in 53 (51%) patients. Acute stent thrombosis occurred in 12 (11.4%) patients with 7 (58.3%) still achieving good functional outcomes. Any intracranial haemorrhage occurred in 46 (44%) of all patients. Symptomatic intracranial haemorrhage occurred in 8 (7.6%). All sICH patients had 90-day mRS of 3-6.

Conclusion:
Acute tandem occlusion stroke patients present complex management challenges. Despite immediate dual antiplatelet therapy, acute stent occlusions may still occur. Symptomatic intracranial haemorrhage rates are acceptable in these complex patients, however, all patients with sICH had poorer outcomes.
Abstract TMP91: Pre-Sepsis P-wave Terminal Force in Lead V1 (PTFV1) as a Predictor of Atrial Fibrillation, In-Hospital Mortality, and Cognition in Sepsis Patients
Authors: Elfasi Aisha , Mankowski Robert T , Moore Frederick A , Ghita Gabriela L , Villani Katelyn , Anton Stephen D , Brackenridge Scott C , Brumback Babette , Efron Philip , Leeuwenburgh Christiaan , Moldawer Lyle L , Simpkins Alexis N
Published: June 2021

Introduction:
Enlarged P-wave terminal force in lead V1 (PTFV1) >5000 μV*ms is a long-term predictor of the left atrial abnormality such as atrial fibrillation (AF), cognitive dysfunction, and stroke at age ≤ 60. Sepsis patients are at high risk of cardiac dysfunction, AF, stroke, and impaired cognition acutely and longitudinally, but predictive value pre-sepsis PTFV1 has not been studied.

Hypothesis:
Higher PTFV1 before sepsis onset is associated with AF events, left atrial enlargement, mortality, and 1-year cognitive impairment in patients who developed sepsis.

Methods:
Patients with acute sepsis were prospectively screened and enrolled in an observational study years 2015-2019. Of the 360 consented, 287 had pre-sepsis electrocardiograms (ECG), and 272 were evaluable. PTFV1 was measured using the Mitutoyo 500-195-30CAL Absolute Digimatic Caliper. Left atrial diameter index (LADI) pre-sepsis and post enrollment were recorded (median of 2 days [interquartile range (IQR) 1-13]). Occurrence of AF was assessed on the next available ECG, 3 days [IQR 1-11] post-enrollment. Cognitive function at 1-year follow-up was assessed by the mini-mental state examination (MMSE) and the Hopkins Verbal Learning test (HVLT). Statistical significance was evaluated using linear and logistic univariate regression.

Results:
In this cohort, the median age was 63 years [IQR 53-71], 44% women. The median PTVF1, LADI at pre-sepsis and follow up were 3219 μV*ms [IQR 0 - 5487], 1.86 cm/mm
2
[IQR 1.58 - 2.14], and 1.89 cm/mm
2
[IQR 1.59 - 2.17], respectively. Pre-sepsis PTFV1 was > 5,000 μV*ms in 32%. Elevated PTFV1 at age ≥ 60 was not associated with AF (p=0.06) or in-hospital mortality (p=0.17). Similarly, high PTFV1 at age < 60 was not associated in-hospital mortality (p=0.50), and only 3 in this cohort had AF. There was no association with pre-sepsis LADI (p=0.55), follow-up LADI (p=0.70), MMSE (p=0.35), or HVLT (p=0.78) and PTFV1.

Conclusions:
Here, PTFV1 values were not associated with AF or measures of cognitive impairment. While our findings differ from other longitudinal studies, the early time interval and setting of sepsis in our study is unique. Future studies will include multivariate analysis and evaluation of long term outcome measures linked to PTFV1 such as stroke.
Abstract TMP93: Carotid Stiffness and Parahippocampal Volume Over a 20-Year Period: A Secondary Analysis of the ARIC Study
Authors: Baradaran Hediyeh , Majersik Jennifer , Mcnally Scott , de Havenon Adam
Published: June 2021

Introduction:
Arterial stiffness is associated with dementia, however, the relationship between carotid stiffness and parahippocampal volume (PHV) is less established. Decreased PHV is a validated early biomarker of Alzheimer’s disease.

Hypothesis:
Carotid artery stiffness will be associated with lower PHV on MRI performed over 20 years later in the Atherosclerosis Risk in the Community (ARIC) study.

Methods:
We included ARIC patients with common carotid stiffness measurements on ultrasound at Visit 1 (1987-1989) and volumetric brain MRI at Visit 5 (2011-2013). The primary outcome is pooled bilateral PHV in mL.

Results:
We included 664 participants with a mean (SD) age of 75.7 (5.4) at the follow-up MRI (42% female). The mean (SD) PHV was 3.9 (0.6) mL. Carotid stiffness was correlated with lower PHV (R=-0.142, p <0.001) and compliance was correlated with higher PHV (R =0.220, p<0.001) (Table 1). The associations were linear (Figure 1) and significant after adjusting for confounders (Table 2). At the follow-up MRI, 32 patients had an adjudicated diagnosis of dementia and lower PHV than patients without dementia (4.0 vs. 3.4 mL, p<0.001), further validating the significance of PHV in this cohort.

Conclusion:
Carotid stiffness is associated with decreased PHV when measured 20 years later, further supporting the link between large artery atherosclerosis and cognitive decline.
Abstract TMP99: White Matter Hyperintensity Progression and Subsequent Incident Stroke: A Secondary Analysis of the ACCORD Trial
Authors: de Havenon Adam H , Yeatts Sharon , Gottesman Rebecca , Turan Tanya , Rost Natalia , Prabhakaran Shyam
Published: June 2021

Introduction:
Studies have shown that the volume of white matter hyperintensity (WMH) is a risk factor for stroke, but there are scarce data exploring the relationship between WMH progression on serial MRIs and subsequent risk of stroke.

Hypothesis:
We hypothesize that WMH progression in the ACCORD trial increases the risk of subsequent incident stroke.

Methods:
The exposure period was from baseline to month 40, during which an MRI was performed at both baseline and month 40. The primary outcome was incident ischemic stroke after the month 40 MRI until study completion. We fit Cox models to the primary outcome and included both the baseline and month 40 WMH volume as covariates, with the hazard ratio for the month 40 WMH volume of primary interest because it represents WMH progression in this model.

Results:
We included 497 patients, of whom 53.3% were male and the mean (SD) age was 62.7 (5.7) years at enrollment. Mean (SD) follow-up after the month 40 MRI was 5.2 (1.8) years. Incident stroke occurred in 17 (3.4%) patients, in whom 2 were recurrent strokes and 15 were first-ever strokes. WMH progression was associated with subsequent stroke in the Cox model (HR 1.27, 95% CI 1.03-1.57, p=0.024) and remained significant after adjusting for patient age, history of prior stroke, and cigarette smoking (HR 1.33, 95% CI 1.07-1.65, p=0.010).

Conclusions:
Although this preliminary analysis is underpowered, WMH progression, independent of absolute WMH burden, may be a risk factor for future stroke in diabetic patients. This novel finding could have translational implications - specifically that interventions which reduce the progression of WMH could, in turn, reduce future risk of stroke.