bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP347: The Stroke Transitions Education and Prevention (STEP) Clinic: A Learning Healthcare Model for Post-Stroke Care
Authors: Hinojosa Evelyn , Okpala Munachi N , Cooksey Gail , Denny M C , Savitz Sean I , Sharrief Anjail Z
Published: January 2019

Background and Purpose:
The STEP clinic was established to provide post-acute care for stroke patients. In this learning healthcare model, optimization of processes is enriched by evaluation of patient outcomes and patient and provider feedback. Trainee education and clinical trial recruitment are key. We describe the approach, patient population, and outcomes.

Methods:
STEP patients are assessed by a multidisciplinary care team within 6 weeks post-hospitalization. Patients complete depression, fatigue, and sleep apnea questionnaires. The team develops a personalized treatment and follow-up plan and provides risk factor counseling and education. We obtained data from the STEP clinical registry for patients enrolled from 10/2014 to 05/2017.

Results:
Among 605 enrolled patients following up at median of 47 days, 55% were male, mean age was 62.2 (SD 14.3), and stroke types included 76% ischemic/transient ischemic attack and 20% intracerebral hemorrhage. By race, 45% were non-Hispanic white, 27% non-Hispanic black, 19% Hispanic, and 3% Asian. Initial blood pressure (BP) was controlled for 66% (<140/90 mmHg) with medications adjusted for 9%. BP control was maintained at 67% among assessed patients. Of 91% completing a depression screen, 24% had at least moderate depression, and 22% were maintained or initiated on an antidepressant. Of 92% patients completing an epworth sleepiness scale, 36% scored >9 (abnormal), and 27% were sent for a sleep study. A total of 38 trainees rotated through the clinic and 91 patients were enrolled in studies. Four novel trials, 3 randomized clinical trials and 1 observational study, were derived from the clinic.

Conclusions:
The STEP clinic represents a learning healthcare model for post-stroke care. Learning healthcare models for post-stroke care are feasible and may be an effective approach to secondary and tertiary prevention.
Abstract TP355: Rate of Deep Vein Thrombosis in Patients When Pharmacological DVT Prophylaxis is Delayed Due to IV tPA Use
Authors: Ali Syed F , Hemmen Thomas , Nalleballe Krishna , Onteddu Sanjeeva , Schwamm Lee H
Published: January 2019

Introduction:
Deep vein thrombosis (DVT) is associated with pulmonary embolism and reduced post stroke recovery. After thrombolysis, current US guidelines recommend a delay of 24 hours before initiation of pharmacological DVT prophylaxis. We sought to determine the rate of DVT in post-tPA patients with delayed pharmacological prophylaxis.

Methods:
Using GWTG stroke registry data from three large comprehensive stroke centers in the Northeast, South and West, we analyzed 13,420 consecutive stroke admissions from 02/2002 - 06/2018. Rates of DVT were compared between those with delayed prophylaxis due to post-tPA vs. all others. Chi-square was used for categorial data, T-Test for parametric continuous and Wilcoxon for non-parametric continuous variables. Multiple regression analysis (MV) was used to identify associations.

Results:
Of the 13,420 patients, 2974 (22.2%) received IV-tPA, 772 (5.8%) underwent EVT, 252 (1.9%) only EVT and 3279 (24.4%) received IV-tPA and/or EVT. There was a total of 536 (4.0%) patients with a documented DVT during the in-hospital stay. The rate of DVT in patients who received IV-tPA was significantly higher than in those who did not (4.6% vs 3.8%, p=0.036). Rates of DVT were 3.8% in patients not receiving tPA or EVT, 4.6% in IV tPA only group, 4.0% in EVT only group and 4.4% in IV tPA and/or EVT group. On univariate analysis Caucasian race, atrial fibrillation, smoking, weakness on presentation and use of IV tPA was significantly associated with DVT. On MV, only age, Caucasian race and a history of smoking was remained significantly associated with DVT.

Conclusion:
Although the NINDS tPA trial delayed DVT ppx initiation to 24 hrs, ECASS 3 allowed DVT ppx in post tPA patients without delay. Our analysis shows that post-thrombolysis patients with delayed DVT ppx had higher rates of DVT, although this effect did not remain significant on MV analysis. Larger studies to assess the safety of delaying DVT ppx in post tPA patients are warranted.
Abstract TP363: Early Changes in Stroke Severity: Characterization and Impact on Patient-Centered Stroke Outcomes
Authors: Regenhardt Robert W , Lin David J , Snider Samuel , Cloutier Alison , Giatsidis Fabio , Ranford Jessica A , Parlman Kristin , Clark Judy , Macdonald Kiera S , Finklestein Seth P , Rosand Jonathan , Hochberg Leigh R
Published: January 2019

Introduction:
Early changes in NIH stroke scale (NIHSS) within the first days after ischemic stroke have been associated with clinical outcomes, however association with patient-centered outcomes is unknown. Predicting outcomes is important for decisions after the acute period. We sought to characterize the magnitude of early NIHSS change and identify its impact on 90-day Stroke Impact Scale-16 (SIS).

Methods:
Data were collected as part of an ongoing single-center study of recovery for patients with upper extremity weakness. NIHSS at time of presentation (presentation NIHSS) was obtained by chart review and NIHSS at time of enrollment (enrollment NIHSS) was assessed prior to acute hospital discharge. We collected demographic, treatment, imaging, and 90-day outcomes. We used a linear regression to determine the relationship of early NIHSS improvement (presentation-enrollment NIHSS) with 90-day SIS and dichotomized the dataset (early NIHSS improvement ≥3 vs not) to compare predefined clinical variables hypothesized to be early improvement predictors.

Results:
Study participants (n=72) had median presentation NIHSS of 6 (IQR4-13) and median enrollment NIHSS of 6 (IQR4-10) with a mean of 2.7+/-2.5 days between timepoints. Seventeen subjects improved by ≥3 and 16 worsened by ≥3. Acute treatments were endovascular therapy (ET, n=10) and thrombolysis (tPA, n=16). Early NIHSS improvement was associated with better 90-day SIS (p=0.012). This association remained when subjects who underwent ET or tPA were excluded (p=0.046). Subjects with early NIHSS improvement ≥3 were less likely to have hypertension (15 vs 85%, p=0.039) and more likely to have undergone ET (60 vs 40%, p=0.010), but there were no differences in tPA treatment, infarct volume, days between timepoints, age, or other medical history.

Conclusion:
This analysis confirms that there are substantial changes in NIHSS in the first days after stroke. Early NIHSS improvement was associated with better 90-day SIS, even when excluding subjects who underwent treatment with ET or tPA suggesting this association also exists for subjects with spontaneous improvement. Early NIHSS improvement may be a useful prognostic tool for patient-centered outcomes after stroke.
Abstract TP371: Adopting a Patient-centered Approach in Acute Stroke Trials With Utility-weighted Modified Rankin Scale Scores
Authors: Wang Xia , Moullaali Tom , Sandset Else C , Berge Eivind , Robinson Thompson , Lindley Richard , Zheng Danni , Delcourt Candice , Arima Hisatomi , Song Lili , Chalmers John , Anderson Craig
Published: January 2019

Background and Purpose:
Patient beliefs/values over illness/wellbeing are important considerations in health care delivery. We aimed to map function with health-related quality of life (HRQoL) to derive utility-weighted outcomes to test the efficacy of acute stroke trial interventions.

Methods:
Physical function and HRQoL were defined by modified Rankin scale (mRS) and EuroQol 5-dimensional questionnaire (EQ-5D) scores, respectively, for calculating utility-weighted mRS (UW-mRS) scores in pooled data from 5 international trials and externally validated in another trial database. UW-mRS was derived using ordinary least squares regression with mRS as a discrete ordinal explanatory dummy variable and EQ-5D as a continuous response variable. Linear regression was used to assess mean UW-mRS scores between intervention groups.

Results:
UW-mRS scores derived from 19338 acute stroke patients were 0.96, 0.92, 0.75, 0.58, 0.32, -0.093 for mRS scores 0, 1, 2, 3, 4 and 5, respectively. Both UW-mRS and ordinal mRS were statistically significant in INTERACT (P=0.04 and P=0.02 for UW-mRS and ordinal mRS, respectively) and ENCHANTED (0.04, P<0.0001). For HeadPoST (0.84, 0.41), SCAST (0.12, 0.22), ATTEND (0.42, 0.29) and COSSACS (0.77, 0.95), both UW-mRS and ordinal mRS scores captured divergent treatment effects in showing neutral results.

Conclusions:
UW-mRS as an outcome measure provides comparable statistical efficiency to ordinal analysis of mRS, but may better reflect patient and societal views on recovery. Greater HRQoL occurs where there is a large favourable shift away from high disability (mRS scores 3-5); interventions that achieve this provide the greatest benefit to patients.
Abstract TP372: Intra-Procedural Back Pain is an Under-Recognized Event in Patients Undergoing Neuroendovascular Procedures in Awake State-Results of a Prospective Study
Authors: Qureshi Adnan I , Singh Baljinder , Jahngir Muhammad U , Belton Patrick , French Brandi R
Published: January 2019

Background:
A high proportion of patients undergo neuroendovascular procedures in the awake state. The prevalence and characteristics of intra-procedural back pain are not well studied despite high-risk settings of prolonged immobility on the firm angiographic table with external restrictions.

Methods:
We performed a prospective study as part of a quality improvement initiative in which all patients who underwent neuroendovascular procedures in the awake state were inquired regarding presence and location of back pain immediately after the procedure. The severity of pain was classified using a numeric rating scale score ranging from 0 (no pain) to 10 (worst pain) and location was identified by the patient on an anatomical chart. The primary endpoint was the proportion of patients with moderate to severe pain (score of ≥3).

Results:
The procedure was performed in an awake state in 111 (79.3%) of 140 patients who underwent neuroendovascular procedures. The mean age was 56.6 ± 16.3 years. The mean duration of the procedure was 76.6 min (range 30-190 min); 44 (39.6%) of 111 patients reported intra-procedural back pain with a median severity of 5/10 (range 1-10). The pain was classified as moderate to severe in 39 of 44 patients. The location of pain was identified in lumbar (n=40), thoracic (n=4), and cervical (n=8) regions. Patients with moderate to severe pain had higher body mass index (mean value±SD, 28.8 ± 7.3 kg/m2 versus 31.4 ± 6.7 kg/m2, p = 0.42) and longer procedure times (mean value±SD, 75 ± 42.4 mins versus 83.3 ± 34.8 mins, p = 0.63).

Conclusions:
The relatively high prevalence of intra-procedural back pain in patients undergoing neuro-endovascular procedures in the awake state must be recognized and strategies to reduce the occurrence need to be identified.
Abstract TP386: The Risk Score to Predict Functional Outcome Following Acute Ischemic Stroke Based on the Linked Big Data between theClinical Research Center for Stroke Data and the Health Insurance Review and Assessment Service Data
Authors: Kim Tae Jung , Lee Ji Sung , Oh Mi-Sun , Kim Ji-Woo , Lim Jae-Sung , Lee Chan-Hyuk , Mo Heejung , Jeong Han-Yeong , Kim Yerim , Lee Sang-hwa , Jung Keun-Hwa , Ko Sang-Bae , Yu Kyung-Ho , Lee Byung-Chul , Yoon Byung-Woo
Published: January 2019

Introduction:
Prediction of outcome after stroke may help clinicians provide effective stroke management and plan long-term care for patients.

Hypothesis:
We aimed to develop and validate a risk score for predicting functional outcome available at hospital after ischemic stroke using linked big data.

Methods:
A total of 24,907 cases with acute ischemic stroke (within 7 days after onset) were enrolled, who were registered in the Clinical Research Center for Stroke (CRCS) registry from 2006 to 2014 and successfully linked the Health Insurance Review and Assessment Service (HIRA) database. Among them, 22,005 cases were derivation and internal validation group, and 2,902 cases were external validation group. We assessed the functional outcome using a modified Rankin Scale (mRS) at 3-month after onset ischemic stroke. We evaluated the predictive value of variables associated with the favorable 3-month outcome (mRS ≤ 2) and developed the score using the logistic regression coefficients. The prediction model performance was assessed by the area under the receiver-operating characteristic curve (AUC).

Results:
Proportion of cases with favorable outcome were 67.0% (n=14,748) in the derivation and internal validation group, and 68.4% (n=1,986) in the external validation group. Multivariable predictors of functional outcome at 3-month included age, gender, stroke severity, body mass index, stroke subtype, previous functional status, recanalization treatment, pre-stroke antiplatelet or anticoagulation therapy, fasting glucose level, history of stroke, hyperlipidemia, diabetes mellitus, hypertension, congestive heart failure, kidney disease on dialysis, cancer before the stroke. The AUC of the prediction model was 0.855 (0.850 - 0.860) in the derivation group and 0.854 (0.849 - 0.860) in the internal validation group for 3-month functional outcome. In addition, the AUC of the model was 0.860 (0.846 - 0.874) in the external validation group for outcome at 3-month.

Conclusions:
This prediction of functional outcome model is a valid clinical tool to predict functional outcome following ischemic stroke and reliable externally. This prediction model may assist to estimate functional outcome after stroke and to decide the care plan after stroke.
Abstract TP390: Clinical Characteristics and Outcomes in Nonagenarian and Centenarian Patients With Acute Cerebrovascular Syndrome
Authors: Abe Yuko , Mima Yohei , Wadayama Tomoya , Tanaka Aimi , Ueda Naoko
Published: January 2019

Background and Purpose:
The number of elderly patients with acute cerebrovascular syndrome (ACVS) is increasing. The management of ACVS is difficult especially in very elderly patients such as nonagenarians and centenarians. Therefore, we aimed to clarify the clinical characteristics, treatments, and complications of these patients.

Methods:
We enrolled 80 patients aged over 90 in a group of 1,420 patients with ACVS who were admitted to our hospital between July 2013 and June 2018. We assessed clinical data and conducted brain MRI/MRA scans, carotid ultrasonograms, echocardiograms, 24hr Holter electrocardiograms and chest-abdominal CT scans to evaluate the severity of atherosclerotic change, stroke subtype, and cardiovascular status in these patients. We categorized them as follows: atherothrombotic brain embolism (ATBE: n=11, 14%), atherothrombotic brain infarction (ATBI: n=9, 11%), cardioembolic infarction (CEI: n=25, n=31%), lacunar infarction (LI: n=15, 19%), transient ischemic attack (TIA: n=6, 8%), and embolic stroke of undetermined source (ESUS: n=14, 18%).

Results:
Patient age was 92±3 years and 19% were male. Median baseline NIHSS was 9 and median baseline modify Rankin Scale (mRS) was 3. The brain natriuretic peptide (BNP) level was significantly higher in the CEI group (358±206pg/ml) compared to the ATBI group (104±48pg/ml, p<0.001), the ESUS group (130±82pg/ml, p<0.001), the LI group (85±42pg/ml, p<0.001), and the ATBE group (62±49pg/ml, p<0.001). The D-dimer level was correlated to the baseline NIHSS (r=0.44, p<0.01). There were no significant differences of D-dimer level among the stroke subgroups. Anticoagulation for the initial therapy was done in 62 patients (77%) including 2 patients who received thrombolysis. Major complications were aspiration pneumonia (11%), urinary tract infection (10%), bleeding in other organs (6%), and congestive heart failure (5%). The median mRS at discharge was 4 and in-hospital mortality rate was 3.8%.

Conclusion:
The BNP level was useful to identify the CEI group. Although the ACVS treatment of nonagenarians and centenarians are thought to be high risk for bleeding, the clinical and neurological outcomes were acceptable despite many complications.
Abstract TP399: Complications from IV Alteplase in Mild Stroke Patients in a Multi-state Health System
Authors: Yanase Lisa R , Lucas Lindsay , Corless Leslie , Baraban Elizabeth
Published: January 2019

Introduction:
The rate of complications from IV alteplase (tPA) for acute ischemic stroke is necessary for discussing risk and benefit when deciding whether to treat. Symptomatic intracerebral hemorrhage (sICH) rate is often quoted as 6.4% based on the NINDS trials. This risk often makes patients and physicians wary of tPA treatment for mild ischemic stroke (MIS). However, NINDS excluded these patients, so risk in MIS is not clear. The Objective of this study was to examine rates of tPA-related complications in MIS compared to moderate-to-severe stroke using real-world data.

Methods:
Data from a multi-state hospital system included tPA-treated patients discharged between January 2011 and May 2018. Patients who were <18 years old, received thrombectomy, transferred to another hospital, or had inpatient stroke were excluded. Outcomes included percentage of patients who experienced any complication, sICH, life-threatening systemic hemorrhage, other serious complication, or in-hospital mortality or discharge to hospice. Chi-squared and Fisher’s exact tests and generalized linear models were used to compare outcomes between patients with mild (NIHSS ≤ 5) and moderate-to-severe (NIHSS >5) strokes.

Results:
A total of 3,067 patients met inclusion criteria with 36% (1,111) having a mild stroke. When compared to MIS patients, moderate-to-severe stroke patients were more likely to have sICH (4.4% vs. 1.3%; p<.001), life-threatening systemic hemorrhage (0.8% vs. 0%; p<.001), and other serious complication (2.1% vs. 0.5%; p<.001). In multivariate analysis, patients with moderate-to-severe stroke were 3.69 (95% CI: 2.26, 6.01) times more likely to have any complication and 7.66 (95% CI: 4.82, 12.16) times more likely to die or be discharged to hospice after adjusting for age, sex, hospital, and history of atrial fibrillation, hypertension, diabetes, and coronary artery disease or prior myocardial infarction.

Conclusion:
Patients with mild strokes that received IV-alteplase had fewer treatment-related complications and were less likely to experience in-hospital mortality or discharge to hospice compared to those with moderate-to-severe strokes. This may inform decision-making in treatment of mild ischemic strokes.
Abstract TP400: Intravenous Glibenclamide Reduces Water Uptake and Mass Effect in Large Hemispheric Infarction (GAMES-RP Study)
Authors: Vorasayan Pongpat , Bevers Matthew B , Beslow Lauren , Sze Gordon , Molyneaux Bradley J , Hinson Holly , Simard J. M , Kummer Rüdiger v , Sheth Kevin N , Kimberly W. T
Published: January 2019

Introduction:
Prior studies have shown a linear relationship between CT-derived density and brain water uptake. We sought to determine whether intravenous (IV) glibenclamide (glyburide; BIIB093) would reduce water uptake and mass effect on serial CT scans from patients enrolled in the phase 2 GAMES-RP trial.

Methods:
Non-contrast CT scans performed between admission and day 7 (n=263) were analyzed in patients in the GAMES-RP modified intention-to-treat sample. Midline shift (MLS) was measured at the level of maximal lateral displacement of the septum pellucidum. CT-derived radiodensity was measured in pre-defined regions of interest (ROI) within the infarct. The same ROIs were mirrored to the contralateral hemisphere. The change in CT radiodensity (change in water uptake) was averaged among gray and white matter regions separately, and across both regions together. Repeated measures mixed effects models were used to assess the effect of IV glibenclamide on MLS or CT-measured water uptake.

Results:
There was a median of 3 CT scans [IQR 2-5] per patient during the first 7 days after stroke. Greater change in water uptake was associated with more MLS (β=0.17, 95% CI 0.15 to 0.20,
p
<0.0001). Using repeated measures models, treatment with IV glibenclamide was associated with reduced water uptake (β= -2.25, 95% CI -4.37 to -0.13,
p
=0.037) and reduced MLS (β= -1.78, 95% CI -2.87 to -0.67,
p
=0.002), and adjusted for time. Treatment with IV glibenclamide reduced both gray and white matter water uptake independently. In mediation analysis, gray matter edema (β=0.10, 95% CI 0.05 to 0.16,
p
<0.001) mediated a greater proportion of MLS when compared to white matter (β=0.02, 95% CI -0.03 to 0.08,
p
=0.427).

Conclusions:
IV glibenclamide reduced water uptake and MLS after large hemispheric infarction. A phase 3 study is underway to determine whether IV glibenclamide treatment improves clinical outcome.
Abstract TP402: Inpatient versus Emergency Department Code Stroke via Telemedicine
Authors: Malazarte Rene M , Zhu Liang , Ankrom Christy M , Bambhroliya Arvind B , Astudillo Cesar , Trevino Alyssa D , Cossey Tiffany D , Jagolino-Cole Amanda , Savitz Sean I , Wu Tzu-Ching
Published: January 2019

Introduction:
Inpatient (IP) code strokes have been noted to have worse time metrics than code strokes in the Emergency Department (ED). Telemedicine (TM) has alleviated some disparities in management of acute ischemic stroke (AIS). We compared tPA time metrics between inpatient and ED code strokes via TM.

Methods:
We identified 681 AIS patients who received tPA in our Lone Star Stroke Consortium Telestroke Registry (LeSTER) from 1/2016-12/2017. There were 52 IP and 629 ED patients who underwent code strokes. We compared demographics and time metrics including TM page time to tPA (TPT) and CT scan time to tPA treatment (CTT), camera to tPA time (CAT), as well as post-tPA outcomes among the two groups using Wilcoxon rank sum test, Chi-square test, Fisher’s exact test, or logistic regression.

Results:
Inpatient strokes had delayed TPT compared to ED code strokes (44.5 vs. 38 minutes; p=0.007), longer CTT (56 vs. 46 minutes; p=0.003), longer CAT (34 vs. 29 minutes; p=0.010), but has a shorter time from last known well (LKW) to TPT (47 vs. 95.5 minutes; p<0.0001). Inpatient strokes were more severe (NIHSS 10 vs. 7; p=0.011). Pre-hospitalized patients were older (72 vs. 62; p<0.001). More inpatient stroke patients were sent to hospice or expired by discharge (17.3% vs. 7.3%; p=0.011) and less likely to be sent home (46% vs. 60.5%; p=0.044). Furthermore, inpatient strokes presented a higher mortality rate (28.2% vs. 12.7%; p=0.009) in the 90 day follow up. After adjusted for age and initial NIHSS, all the differences in the disposition and mortality rate are no longer significant.

Conclusions:
We found a significant delay in tPA metrics for inpatient code strokes as well as poorer clinical outcomes compared to patients who presented directly to the ED. Further investigation is needed to address gaps in the delivery of care to inpatients with suspected AIS via TM.
Abstract TP405: Dual Antiplatelet Therapy Reduced Stroke Risk in High-risk Transient Ischemic Attack Patients Assessed by ABCD3-I Score
Authors: Song Bo , Pei Lu L , Liu Kai , Cao Yuan , Ning Ming M , Buonanno Ferdinando , Xu Yu M
Published: January 2019

Introduction:
Studies showed dual antiplatelet therapy (DAPT) benefited TIA patients with an ABCD2 score ≥4. The present study aims to investigate whether the ABCD3-I score could be a more appropriate tool for TIA patients’ selection to use DAPT in the real-world experience.

Methods:
We derived data from the TIA database of the First Affiliated Hospital of Zhengzhou University. The predictive outcome was ischemic stroke at 90-day. Cox proportional hazards regression was used to examine the interaction effect between risk score and antiplatelet treatment. The Kaplan-Meier curves were plotted to present cumulative stroke rates in different risk patients with monotherapy and DAPT.

Results:
Among 785 patients, the mean (SD) age was 56.95 (12.73) years and 38.3% were female (n =301). A percentage of 36.9% patients used DAPT during hospitalization, and 77 patients (9.8%) had an ischemic stroke at 90-day. The Kaplan-Meier curves showed a significant difference between patients with monotherapy and DAPT in high-risk TIA patients (p= 0.021, Figure 1). After adjustment for confounding factors, DAPT only reduced 90-day stroke risk in high-risk TIA patients assessed by ABCD3-I score (HR= 0.402, 95%CI 0.189-0.859, p= 0.019, Table 1 and 2).

Conclusions:
High-risk TIA patients assessed by ABCD3-I score received the most pronounced clinical benefit from DAPT in the real-clinical experience.
Abstract TP408: Alcohol Withdrawal is Associated With Poorer Outcome in Ischemic Stroke
Authors: Otite Fadar Oliver O , Akano Emmanuel , Chaturvedi Seemant
Published: January 2019

Objective:
Prevalence of alcohol abuse (AA) in the United States (US) is on the increase. AA patients may develop alcohol withdrawal (AW) during hospitalization, but it remains unknown how AW influences acute ischemic stroke (AIS) outcome.

Methods:
All adult AIS admissions in the US from 2004–2014 were identified from the National Inpatient Sample (NIS) (weighted N=4,438,968). Multivariable-adjusted models were used to evaluate the association of AW with in-hospital medical complications, mortality, cost, and length-of-stay in patients with AIS.

Results:
During this period, 3.9% of all AIS admissions had comorbid codes for AA but prevalence differed significantly by age; 10.6% of AA patients, representing 0.4% of all AIS, developed AW. Prevalence of AA and AW in AIS increased by 45.2% and 40.0%, respectively, over time (p-value for trend <0.001). AA patients were predominantly men (80.2%), white (65.9%), and in the 40–59-year (44.6%) and 60–79-year (45.6%) age groups. After multivariable adjustment, AIS patients with AW had >50% increased odds of urinary tract infection, pneumonia, sepsis, gastrointestinal bleeding, deep venous thrombosis, and acute renal failure compared to those without AW. Patients with AW were also 32% more likely to die during their AIS hospitalization compared to those without AW (OR 1.32, 95% CI 1.11–1.58). AW was associated with 15-day increase in length-of-stay and $5,000 increase in hospitalization cost (p-values <0.001).

Conclusions:
AW is associated with increased cost, longer hospitalizations, and higher odds of medical complications and in-hospital mortality following AIS. Proactive surveillance and management of AW may be important in improving outcomes in these patients.
Abstract TP409: Prevalence and Predictors of Stroke in Patients With Short-Term Mechanical Circulatory Support Devices: A Single-Center Study
Authors: Topiwala Karan , Tarasaria Karan , Staff Ilene , Gluck Jason , Nouh Amre
Published: January 2019

Introduction:
Short-term mechanical circulatory support devices (ST-MCS) include intra-aortic balloon-pump (IABP), extracorporeal membrane oxygenation (ECMO) and the CentriMag® and Impella® ventricular assist systems (VAS). Despite an exponential increase in their use, data regarding stroke prevalence and predictors are lacking.

Objective:
To identify the prevalence and predictors of stroke in ST-MCS.

Methods:
Data was collected prospectively into a database from January 2016 to June 2018 and retrospectively extracted and analyzed. Primary analysis was performed between acute-stroke vs. non-stroke diagnoses. Dichotomous and continuous variables were analyzed using Chi-Square test of proportions and Wilcoxon Ranked Sum test respectively.

Results:
Out of 203 ST-MCS-patients [IABP 31.5% (n=64), Impella 24.6% (n=50), ECMO 31% (n=63) and CentriMag®VAS 12.8% (n=26)], 8.4% (n=17) had an acute stroke. Among them 6.4% (n=13) had ischemic stroke and 1% (n=2) had hemorrhagic stroke, with 1% (n=2) having both. CentriMag®VAS had a higher stroke rate than the other devices (23.1% [n=6] vs. 6.2% [n=11]; p=0.011, OR 4.53). Predictors of stroke in all patients were central cannulation (p=0.044, OR 3.08), duration >4 days (p=0.025, OR 3.21) and use of another ST-MCS device before primary device (p=0.043, OR 1.45). Flow-rate (p=0.86) and catheter size (p=0.15) did not predict stroke. Only 1 patient was eligible for thrombolytic therapy and received IV tPA, with the most common reasons to hold treatment being unknown last-seen-normal (n=8), coagulopathy (n=2) and established infarct on head CT (n=2). A large vessel occlusion was present in 20% (n=3), but none underwent a mechanical thrombectomy due of established infarction. All hemorrhagic strokes and 47% (n=7) ischemic strokes led to withdrawal of care.

Conclusion:
About 1 in 12 patients placed on a ST-MCS device may have an acute stroke, but this can be as high as 1 in 5 with the use of the CentriMag®VAS. Factors such as central cannulation, duration >4 days and use of another ST-MCS device before the primary device may be predictive of acute stroke in these patients. Further research in the identification of such predictors, in conjunction with early symptom recognition could help improve treatment rates.
Abstract TP41: The Importance of First Pass Substantial Reperfusion in the ARISE II Study
Authors: Yoo Albert J , Andersson Tommy , Ribo Marc , Bozorgchami Hormozd , Liebeskind David , Jadhav Ashutosh , Saver Jeffrey L , Mattle Heinrich P , Zaidat Osama O
Published: January 2019

Background:
Recent studies report an approximately 90% rate of TICI 2b-3 reperfusion. With little room for further improvement, the resulting ceiling effect will limit the utility of this angiographic endpoint in future studies. We aimed to identify a more optimal definition of angiographic success along two dimensions: 1) the extent of tissue reperfusion and 2) the speed of revascularization.

Methods:
Data from the ARISE II study was used for this analysis. Core-lab adjudicated TICI scores (inclusive of 2c) after the first pass of EmboTrap and the final TICI scores after all interventions were collected. Receiver-operating characteristic (ROC) analyses were used to compare first pass and final TICI 2b-3, TICI 2c-3, and TICI 3 endpoints for the optimal prediction of 90-day mRS 0-2, 24-hour NIHSS improvement of ≥8 points, and 90-day mortality. The optimal procedural time from groin puncture to substantial reperfusion (TICI ≥2b) was also determined using ROC analysis.

Results:
Of 218 ARISE II subjects with anterior circulation occlusions, 201 (92.2%) had substantial reperfusion at the end of the procedure (final TICI 2b-3): 38 (17.4%) final TICI 2b, 52 (23.9%) final TICI 2c, and 111 (50.9%) final TICI 3. Substantial reperfusion after the first pass (first pass TICI 2b-3) was seen in 109 (50%) subjects. In 101 of these 109 (92.7%) cases, the first pass TICI score matched the final TICI score. The median procedural time from groin puncture to achieving TICI ≥2b was 29 minutes (interquartile range [IQR] 22.75-45 minutes) in the subjects who had first pass TICI 2b-3 versus 60 minutes (IQR 44.5-85 minutes) in those who did not (P<0.0001). In ROC analysis, first pass TICI 2b-3 had the highest c-statistic for predicting 90-day mRS 0-2 (0.644), ≥8-point improvement in NIHSS (0.625) and 90-day mortality (0.634). Among subjects with final TICI 2b-3, the subgroup with first pass TICI 2b-3 had lower median 90-day mRS (1 [IQR 0-2] vs. 2 [IQR 1-4], P<0.0001), lower mortality (4.8% vs. 13.2%, P=0.04), and lower rate of symptomatic intracranial hemorrhage (1.8% vs. 7.6%, P<0.05). The optimal procedural time to substantial reperfusion was ≤59 minutes.

Conclusion:
First pass TICI 2b-3 is the optimal angiographic endpoint for predicting clinical and safety outcomes in ARISE II.
Abstract TP417: Advanced Cardiac Imaging in Patients With Ischemic Stroke: When to Scan?
Authors: Orabi Yser , Girotra Tarun , Ajinkya Shaun , Suh Jimmy , Banerjee Chirantan
Published: January 2019

Background:
Advanced cardiac imaging(ACI) with cardiac CT (CCT) and cardiac MR (CMR) are valuable noninvasive investigative tools to assess cardiac structure in cryptogenic stroke assessment. In this study, we examine patient, electrocardiographic (EKG), and TTE variables associated with subsequent detection of intracardiac thrombus using CCT and CMR in patients with cryptogenic stroke.

Methods:
The Medical University of South Carolina Comprehensive stroke center database was used to identify acute ischemic stroke patients who received inpatient CCT or CMR between January 2017 to May 2018. Patient demographics, past medical history, EKG, and TTE related variables were abstracted by 2 physicians. Univariate and multivariable logistic regression was used to identify factors associated with detection of intracardiac thrombus on CCT/CMR. Negative and positive predictive value (NPV and PPV) were calculated for TTE, with CCT/CMR considered as gold standard.

Results:
256 subjects received CCT/CMR after TTE during the study period; with 25 (9.7%) found to have an intracardiac thrombus [12 (4.7%) LV thrombus, 6 (2.3%) LA thrombus, 7 (2.8%) Others including myxoma,valve aortic arch thrombus]. The PPV and NPV of TTE were 57% and 93% respectively. Mild-Modertely Reduced (30-50% EF was associated with subsequent detection of intracardiac thrombus onCCT/CMR in univariate model, but did not reach significance after adjusting for other variables. Atrial fibrillation, P wave abnormality on EKG, ST changes on EKG, Left Ventricle wall motion akinesia on TTE were associated with intracardiac thrombus on CCT/CMR in both models.

Conclusion:
Advanced cardiac imaging is a useful noninvasive tool to identify cardiac source of ischemic stroke. Although small sample size and inadequate power may limit generalizability, patients with atrial fibrillation, P wave and ST changes on EKG, and LV wall motion akinesis should be considered for advanced cardiac.
Abstract TP418: Asymptomatic Hemorrhagic Infarction on 24-Hour CT Post Intravenous Recombinant Tissue Plasminogen Activator for Acute Ischemic Stroke Predicts Symptomatic Intracerebral Hemorrhage After Initiation of Antiplatelet Therapy
Authors: Ricci Brittany , Mac Grory Brian , Chang Andrew , Cutting Shawna , Burton Tina , Dakay Katarina , McTaggart Ryan , Jayaraman Mahesh , Reznik Michael , Thompson Bradford , Wendell Linda , Mahta Ali , Rao Shyam , Potter Stevenson , Sheth Kevin N , Willey Joshua , Khatri Pooja , Furie Karen , Yaghi Shadi
Published: January 2019

Background and Purpose:
Predictors of symptomatic intracerebral hemorrhage (sICH) after intravenous alteplase in acute ischemic stroke (AIS) are well established however there is limited data on predictors of delayed sICH (d-sICH) (occurring > 36 hours from alteplase) after initiation of antithrombotic therapy in these patients. We hypothesize that asymptomatic hemorrhagic infarction (HI) on 24-hour brain imaging predicts delayed sICH after initiation of antiplatelet therapy.

Methods:
We included consecutive patients who received intravenous alteplase for AIS over a 12-month period. All patients received brain imaging, either CT or MRI, approximately 24-hours post alteplase. Patients who were deceased or made comfort measures only or with lack of at least 48 hour follow-up, or those with parenchymal hematoma (PH) or sICH prior to antithrombotic therapy initiation were excluded. The primary outcome was delayed sICH defined using the modified SITS-MOST criteria. We compared demographic data, clinical risk factors, NIHSS score, pre-admission antithrombotic usage, and 24-hour imaging characteristics between the two groups (d-sICH vs. no d-sICH) using univariate and multivariable analyses (including variables with p<0.1 on univariable models). Analysis was done using SPSS version 20.0 and p<0.05 was considered significant.

Results:
We identified 263 patients who met the inclusion criteria; 51.3% were men and the mean age was70.9 years, 8 patients (3.0%) had d-sICH and 60 patients (22.8%) had asymptomatic HI on 24-hour brain imaging (CT or MRI). On univariate analyses, predictors of d-sICH were diabetes [50.0% (4/8) vs. 23.1% (59/255), p = 0.097} and asymptomatic HI on CT [50.0% (4/8) vs. 13.1 (31/236), p=0.016] and a trend for asymptomatic hemorrhage on MRI [60.0% (3/5) vs. 25.0% (42/168), p = 0.11]. In a multivariable model, both diabetes (OR 5.1 95% CI 1.1 - 23.3, p=0.037) and asymptomatic hemorrhage on CT (OR 8.9 95% CI 1.9 - 41.7 p = 0.005) predicted d-sICH.

Conclusion:
In AIS patient receiving alteplase, asymptomatic HI on 24-hour brain imaging predicts d-sICH after antithrombotic treatment. Future studies are needed to confirm our findings and investigate best timing of initiating antiplatelet therapy and other measures to reduce d-sICH risk.
Abstract TP431: Primary Occipital Lobar Hemorrhages Associated With Lower 1-Year Case-Fatality
Authors: Pan Rachel , Blatsioris Ashley D , Moser Elizabeth A , Carter Ravan J , Saha Chandan , Cohen-Gadol Aaron A , Leipzig Thomas J , Williams Linda S , Mackey Jason
Published: January 2019

Introduction:
Intracerebral hemorrhage (ICH) has a high rate of morbidity and mortality and is typically classified as “lobar“ or “deep.“ While these terms describe ICH location, a more detailed examination of the relationship between supratentorial ICH location and clinical outcomes may guide clinician treatment plans and potentially predict survival rates.

Methods:
In this retrospective, single-center cohort study we identified patients with primary lobar ICH from 2009-2013. ICH due to trauma and structural etiologies were excluded. For patients with multiple ICHs, symptomatic location was determined via chart review. We compared demographic data, risk factors, ICH location and volume (ABC/2), clinical outcomes, and case-fatality rates and performed Cox regression analyses stratified by lobar location.

Results:
We identified 294 ICH patients, of which 94 were frontal (median volume 21.2 mL; IQR 10, 45), 65 temporal (21 mL; 8, 45), 75 parietal (17.2 mL; 7.5, 49), and 60 occipital (17.2 mL; 3.8, 26.3). There were no differences among locations in age (p=0.90), sex (p=0.87), IVH (p=0.22), anticoagulant use (p=0.41), or Charlson (p=0.43). There were significant differences in NIHSS across locations (p<0.0001), with medians from 3 (occipital) to 10 (frontal). Frontal ICH was associated with more SAH (p=0.006); temporal ICH with more seizures (p=0.007). Occipital ICH was associated with better survival rates than frontal, temporal, and parietal ICH over 1 year after adjustment for ICH volume (p=0.039; see Figure).

Conclusions:
We found that occipital ICH was associated with lower 1-year case-fatality rates than ICH in other lobar locations independent of volume. While occipital ICH may be less likely to cause deficits associated with potentially life-threatening complications, these data suggest it may be important to separate lobar ICH mortality analyses by location to discern other characteristics of these hemorrhages and their relationships to outcomes.
Abstract TP433: Structural, Molecular and Physiologic Alterations in Patients with Lobar Microbleeds
Authors: Gokcal Elif , Fotiadis Panagiotis , Becker J. Alex , Schwab Kristin , Goldstein Joshua , Rosand Jonathan , Viswanathan Anand , Greenberg Steven M. , Gurol M. Edip
Published: January 2019

Background:
Cerebral amyloid angiopathy (CAA) is diagnosed after a lobar intracerebral hemorrhage (L-ICH) but lobar microbleeds (LMB) are increasingly detected on MRIs of patients without L-ICH. We aimed to compare advanced imaging measures of structural brain damage, amyloid load, and cerebrovascular reactivity between CAA patients with L-ICH (CAA-ICH) and those with LMB (LMB-only).

Methods:
Standard MRI markers (LMB counts, cortical superficial siderosis [cSS], enlarged perivascular spaces [EPVS], white matter hyperintensity [WMH] patterns) and FreeSurfer based advanced volumetric analyses (calculated as percent of total intracranial volume) were obtained in 115 non-demented patients with either CAA-ICH or LMB-only. Pittsburgh compound B PET measures of amyloid deposition and fMRI measures of vascular reactivity (amplitude, time-to-peak, time-to-baseline) were also compared between the 2 groups.

Results:
LMB-only patients (n=37) presented with transient neurological symptoms or cognitive/gait complaints and stroke/neurodegenerative conditions were ruled out. Age, vascular risk factors, LMB counts, presence of cSS, EPVS counts and WMH patterns were not different between CAA-ICH and LMB-only (Table). Volume of WMH was significantly higher in CAA-ICH as compared to LMB-only patients in univariable and multivariable models (p=0.026). There was no difference in cortical thickness, WM volume, amyloid load/distribution and finally functional MRI markers of vascular reactivity between the two groups (Table).

Conclusions:
Our results indicate that measures of vascular physiology and amyloid load as well as structural damage of LMB-only patients are not different from CAA-ICH, except a lower WMH load. These data support the view that LMB-only patients represent a non-hemorrhagic stage of the disease and that they can be enrolled in clinical trials aimed at modifying the molecular/physiologic changes to reverse/prevent CAA progression.
Abstract TP434: Intracerebral Hemorrhage in Orange County: Who Gets Tested for Methamphetamines and Why Might It Matter?
Authors: Osman Sahar , Zhu Zhu , Farag Mark , Groysman Leonid , Dastur Cyrus K , Akbari Yama , Stern-Nezer Sara , Stradling Dana , Yu Wengui
Published: January 2019

Background/Objective:
Methamphetamine use is associated with intracerebral hemorrhage (ICH) and is a major public health issue. The urine drug screen (UDS) is an essential test to identify and potentially control this risk factor. This study aims to analyze how an academic comprehensive stroke center uses this tool to identify methamphetamine associated ICH.

Methods:
Retrospective chart review of consecutive patients hospitalized with ICH from January 2013 to December 2017 was performed. Patients were divided based on presence or absence of UDS for methamphetamines. Methamphetamine associated ICH was identified per positive UDS or reported history of use. Features of patients with versus without UDS were compared using chi-square or t-test where appropriate.

Results:
A total of 596 consecutive patients with ICH were included in this study. UDS was performed in 357 patients (60%), and positive for methamphetamines in 44 patients (12.3%, 44/357). Among the 239 patients without UDS, 12 had self-reported history of methamphetamine abuse (5%, 12/239), resulting in a total of 56 patients with methamphetamine associated ICH (9.4%). Patients with UDS were more likely to be younger than 45 (OR=2.24; 95% CI 0.26-0.78; p=0.004), male (OR=1.65; 95% CI 0.44-0.84; p =0.003), smokers (OR=1.74; 95% CI 1.09-2.77; p<0.001), not on anticoagulant therapy (OR 2.20; 95% CI 0.26-0.78; p=0.004), with NIHSS >4 (OR=1.92; 95% CI 1.34-2.75; p<0.001), without diabetes (OR=1.47; 95% CI 0.471-0.975; p=0.036), requiring EVD (OR=1.63; 95% CI 1.07-2.47; p=0.021) or having a history of methamphetamine use (OR 10.48; 95% CI 2.48-44.34; p<0.001). There was no significant difference in race (p=0.319).

Conclusion:
At a comprehensive stroke center in Orange County, 9.4% of patients with ICH were methamphetamine related per UDS and history. UDS identified most of the cases (78.6%, 44/56) and was performed in only 60% of the cohort, more often in patients that were younger, male, smokers, with no anticoagulant use or history of diabetes. Methamphetamine associated ICH is common, likely underestimated, and potentially preventable. UDS may be indicated in all patients presenting with ICH and in routine health screening to reduce the risk of methamphetamine associated ICH.
Abstract TP435: Development of Outcome Models for Intracerebral Hemorrhage Using Patient Level Data From ATACH-II and Information Theory to Identify the Best Predictors
Authors: Mandava Pitchaiah , Saeed Omar , Qureshi Adnan I , Kent Thomas A
Published: January 2019

Background:
A predictive outcome model for intracranial hemorrhage (ICH) from patient level data would be of interest in planning clinical trials. Despite decades of effort and several different types of models attempted, there is no universally accepted model. Here, we sought to apply Information Theory precepts to select the optimum set of baseline variables that can predict outcomes using data from the control arm of ATACH-II, a recently concluded ICH trial that tested the effects of control of systolic BP (SBP).

Methods:
Sixty-three logistic regression models of mortality and good outcome (modified Rankin Score of 0-3 at 90 days) were generated based on all possible combination of 6 baseline variables: NIH Stroke Scale (NIHSS), Glasgow Coma Scale (GCS), age, hematoma volume (Hem Vol), intraventricular hematoma volume (IVH Vol), and SBP. Akaike Information Criterion (AIC) a measure of information content in a model was calculated. Those with the lowest AIC are considered best.

Results:
ATACH-II had 405 subjects with non-lobar hemorrhages that reported all six baseline variables and long-term outcomes. The best model of good outcome was based on NIHSS, age, Hem Vol, IVH Vol (R
2
= 0.33; p <<0.0001; AIC:421.28). The best mortality model was based on NIHSS, age, IVH Vol, and SBP (R
2
= 0.18; p <<0.0001; AIC:-59.50).

Conclusion:
We show that Information Theory constructs can be used to select the best set of variables to model outcomes in ICH. While we found generally better predictive ability for good outcome compared to mortality, the best model predicted only 57% of the outcome variance. While additional types of data fitting might yield additional predictive value, the relatively modest results seen here suggest that there remain additional factors related to outcome not typically measured in ICH trials. Additional data points from other trails are being pooled to see if predictive ability improves.
Abstract TP44: First Pass Effect in Mechanical Thrombectomy for Emergent Large Vessel Occlusion Outside Clinical Trials: Combined Report From a University and a Community Hospital
Authors: Memon Muhammad Z , Grewal Manjot K , Daniel David , Majidi Shahram , Leon Guerrero Christopher , Burger Kathleen , Olan Wayne , Sigounas Dimitri , Putman Christopher , Greenberg Edward
Published: January 2019

Background:
First pass effect (FPE) is defined as achieving a TICI 3 recanalization with a single pass with no use of rescue therapy. We aimed to compare the clinical and radiological outcomes of patient who had FPE versus those who didn’t outside a clinical trial or registry in a community setting.

Methods:
Patients were identified from two prospectively collected stroke databases from Jan 2015 to March 2018. We compared clinical and radiological outcomes of all endovascular treated who had FPE to those who didn’t. Primary outcomes were favorable functional outcome at hospital discharge (modified Rankin Scale (mRS) score of 0-3), and the rate of intracranial hemorrhage (ICH). Early neurological improvement, angiographic recanalization, time to recanalization, and mortality at 30 days were used as secondary outcomes.

Results:
We identified 238 patients who underwent thrombectomy [mean age 68 ± 14 years, 121 (51%) were women]. FPE was achieved in 91(38%) patients. More middle cerebral artery occlusions (59% versus 41%) were present in the FPE group. Mean time from symptoms onset to revascularization was significantly shorter in the FPE group (336 ± 288 minutes vs 438± 364 minutes; P=0.003). Since the general protocol of both institutions was to use ADAPT technique for the first thrombectomy attempt when feasible, 75% of the cases with first pass success were performed with aspiration alone. FPE was an independent predictor of good clinical outcome (mRS score ≤3 56 % in FPE versus 35 % in non-FPE cohort; P=2.601 [odds ratio 2.60 (95% confidence interval 1.25-4.99)]. Similarly lower rate of ICH was observed among FPE group (23% versus 46%; P= 0.40 [(odds ratio 0.4 (95% confidence interval 0.20 -0.79)].

Conclusion:
In this analysis from a community setting outside of clinical trials or registries, FPE was associated with significantly improved functional outcomes and lower ICH rates and was more frequently achieved in MCA occlusions. More studies are required in order to determine the most efficient technique to achieve FPE.