bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 104: Golden Hour-Thrombolysis by Starting Treatment Before Hospital Arrival the Pre-Hospital Acute Neurological Treatment and Optimization of Medical Care in Stroke Study (PHANTOM-S)
Authors: Ebinger Martin , Wendt Matthias , Rozanski Michal , Winter Benjamin , Waldschmidt Carolin , Weber Joachim , Villringer Kerstin , Fiebach Jochen , Kunz Alexander , Audebert Heinrich J
Published: July 2021

Objective:
The effectiveness of intravenous thrombolysis in acute ischemic stroke is time dependent. The effects are likely to be highest if onset-to-treatment time (OTT) is < 60 minutes, the so called Golden-Hour. Starting thrombolysis in a specialized ambulance with a CT-scanner plus point-of-care laboratory reduced time from emergency call to treatment in the prospective controlled PHANTOM-S study. We evaluated the rate and effectiveness of Golden-Hour thrombolysis.

Methods:
The stroke emergency mobile (STEMO) is staffed with a neurologist trained in emergency medicine, a paramedic and a technician. The effects of the STEMO implementation were evaluated in a prospective study comparing weeks with and without STEMO-availability. STEMO was deployed when the dispatchers suspected an acute stroke during emergency calls. If STEMO was not available (in operation or maintenance), patients received conventional care. OTT-intervals were dichotomized in either ≤60 (Golden-Hour) or > 60 minutes as well as categorized in 10-minute intervals from 0 to 270 minutes for graphical description.

Results:
Overall, thrombolysis rates in ischemic stroke were 33% (200/614) when STEMO was deployed and 22% (330/1497) in conventional care (p<0.001). The proportion of Golden-Hour treatments (from all thrombolysis) was 6-fold higher after STEMO deployment (31.0%; n= 62 versus 4.9%; n=16; p<0.01). Compared to patients with longer OTT patients with Golden-Hour thrombolysis had no higher risks for 7- or 90-day mortality (adjusted ORs: 0.38, 95%-CI: 0.09-1.70 and 0.69, 95%-CI: 0.32-1.53) but were more likely to be discharged at home (adjusted OR: 1.93 95%CI: 1.09-3.41; p=0.024).

Conclusion:
STEMO increased the percentage of patients treated within the Golden-Hour. This entailed no risk to patients’ safety and was associated with better short-term outcome.
Abstract 110: Age Associated Brain Volume is More Closely Correlated to Periventricular than Deep White Matter Disease
Authors: Nyquist Paul , Bilgel Murat , Yanek Lisa R , Moy Taryn F , Becker Lewis C , Cuzzocreo Jennifer L , Yousem David M , Prince Jerry , Becker Diane M , Kral Brian G , Vaidya Dhananjay
Published: July 2021

Introduction:
The loss of total brain volume (TBV) due to aging is associated with increasing ischemic white matter lesion volume (WMH) and dementia. Lower TBV may be secondary to chronic ischemia and hypoperfusion throughout the periventricular white matter rather than the burden of focal ischemia in the deep white matter. We hypothesized lower TBV would be more closely correlated with increasing periventricular white matter lesion volume (PV) rather than deep white matter lesion volume (DWMH).

Methods:
We enrolled 593 asymptomatic family members of probands with premature coronary artery disease (<60 years). DWMH, PV, and TBV were measured with 3Tesla MRI. Multivariate regression was completed for DWMH, PV, and TBV using volume change per age decade controlling for sex, race, diabetes, smoking currently, hypertension, obesity , and intracranial volume (ICV) for TBV, and a spline incorporated at age 54.

Results:
Participants were 58% women, 37% African-American, 29-74 years old. TBV/ICV was more correlated to PV than DWMH (correlation coefficients -0.26 and -0.11, p=<0.001 and 0.006). The PV was greater with older age 9%/decade until age 54 (95% CI 4-15%) and 24%/decade after age 54 (95% CI 1.6-3.2%). TBV was reduced with older age: 1.1 % smaller/decade until age 54 (95% CI -0.6 to -1.6) and 2.4% smaller/decade after (95% CI -1.6 to -3.1). For PV and TBV their age association changed significantly after age 54 (p=0.012, and 0.014). DWMH age association remained constant regardless of age.

Conclusions:
PV is more strongly correlated to TBV than DWMH and the age associated changes in PV and TBV were more similar to one another than DWMH. The association of increasing PV with lower TBV may help to explain the association of cognitive and motor decline with increasing PV. Future longitudinal studies are needed to verify this association.
Abstract 119: Serial Analysis of Perfusion Angiography in Endovascular Intervention for Acute Stroke With Proximal Middle Cerebral Artery Occlusion
Authors: Tarpley Jason W , Scalzo Fabien , Jovin Tudor , Aghaebrahim Amin , Alger Jeffry R , Duckwiler Gary R , Liebeskind David S
Published: July 2021

Background:
Perfusion imaging is often used to predict tissue fate during acute stroke in clinical practice and in research trials. During endovascular interventions, conventional angiography provides perfusion information at the actual time of reperfusion therapy yet scoring reperfusion remains operator-dependent and limited by scale properties. Here, a quantitative analysis was conducted to evaluate serial changes in perfusion during treatment.

Methods:
Angiography was analyzed from 118 acute MCA occlusion cases with attempted endovascular reperfusion at UPMC or UCLA. Parametric maps for MTT, TTP, Tmax, CBV, and CBF were extracted with perfusion angiography software (PerfAngio) from angiograms acquired at the time of treatment. Delta maps were created representing the serial change in perfusion parameters across treatment. Region of interest analysis (ROI) performed on the MCA distribution quantified the average change in perfusion.

Results:
Delta maps allowed for spatial characterization of the change in perfusion that occurs as a consequence of endovascular therapy as shown in the figure. ROI analysis performed for the first 35 cases demonstrated a wide variance in perfusion change ranging from 52% decrease in CBF to 476% increase in CBF.

Conclusions:
Serial changes extracted using perfusion angiography provide a quantitative, continuous measure of tissue reperfusion resulting from an endovascular therapy. Such perfusion data are more spatially informative and may be more amenable to statistical analysis than the standard categorical scale of reperfusion (TICI) following endovascular intervention.
Abstract 120: Surpass Flow Diverter for Endovascular Treatment of Intracranial Aneurysms - A Multicenter Preliminary Clinical and Angiographic Experience in 161 Patients with 186 Aneurysms
Authors: Wakhloo Ajay K , Lylyk Pedro , de Vries Joost , Gounis Matthew J , Biondi Alexandra , Taschner Christian , Hartmann Marius , Szikora Istvan , Pierot Laurent , Sakai Nobuyuki , Boccardi Edoardo , Turjman Francis , Sourour Nader ,   and The Surpass Study Group
Published: July 2021

Objective:
Validated through experimental studies a new generation of flow diverters (Surpass™ FD) was evaluated for treatment of intracranial aneurysms (IA). We present our multicenter preliminary clinical and angiographic experience.

METHODS:
To achieve the calculated flow disruption between the parent artery and aneurysm for thrombosis, single FDs were placed endovascularly in parent arteries. Implants measured 2.5-5.3mm in diameter with a length of 10-80mm. Patients were enrolled harboring a wide range large and giant wide-neck, fusiform and multiple small and blister-type aneurysm. Clinical and angiographic follow-up were performed at 1-3, 6, and 12 months.

RESULTS:
A total of 186 consecutive IA in 161 patients (mean age 57.1 years) were treated at 33 centers. Fifty-three aneurysms were smaller than 5 mm, 64 were 5-9.9mm in diameter, 47 were 10-20mm in diameter, and 22 were larger than 20mm (10.4±0.7mm, neck size 6.0±0.5mm [mean±SEM]) . The aneurysms originated in 63.4% from the internal carotid artery; 22% and 14.5% of the lesions were located in the anterior circulation distal to Circle of Willis and posterior circulation respectively. Technical success was achieved in 182 aneurysms (98%); average number of devices used per aneurysm was 1.05. Permanent morbidity and mortality during the follow-up period of mean 8.4months (range 1-24 months) including periprocedural complications for patients with aneurysms of the anterior circulation were encountered in 5 (3.7%) and 2 (1.5 %) patients respectively and 1 (3.7%) and 4 (14.8%) respectively for patients with aneurysms of the posterior circulation location. One-hundred-ten patients (70.5%) harboring 127 (70.2%) were available for clinical and angiographic follow-up and showed a complete or near complete aneurysm occlusion in 63 (81.8%) of the ICA. Aneurysms of the ICA≥10mm that were completely covered by FD and not previously stent-treated with a minimum of 6 months follow-up available in 16 patients showed a complete obliteration in 81.3% (n=13) and >90% occlusion in remaining 3 patients.

CONCLUSION:
Preliminary data demonstrate high safety and efficacy of a new generation of FD for a wide range of IA of the anterior and posterior circulation with a single implant.
Abstract 140: Long-term disability after lacunar stroke: Secondary Prevention of Small Subcortical Stroke Study
Authors: Dhamoon Mandip S , McClure Leslie A , White Carole L , Benavente Oscar , Elkind Mitchell S
Published: July 2021

Background:
Long-term disability after lacunar stroke is under-studied. We hypothesized that vascular and demographic risk factors predict worsening disability after recovery from lacunar stroke, even in the absence of recurrent stroke.

Methods:
The Secondary Prevention of Small Subcortical Stroke Study is a clinical trial in lacunar stroke patients with annual assessments of disability with the Older Americans Resources and Survey Instrumental Activities of Daily Living (IADL) scale (range 0-14), measuring 7 IADLs. Generalized estimating equations were used to model the likelihood of disability (IADL score <14) over time, adjusting for demographics, medical risk factors, cognitive and mood factors, and region in univariate and multivariable models. IADL assessments after recurrent stroke were censored. We stratified by study region and age quartile (<55, 55-63, 63-72, ≥72 years), and the final model excluded non-significant terms.

Results:
Among 2820 participants, mean age was 63.4 years (SD 10.8), 63% were male, 51% White, 32% Hispanic, 36% had some college education, 36% had diabetes, 90% had hypertension, and 10% had prior stroke. Mean follow-up was 3.5 years. Mean IADL score at 3 months was 12.5 (SD 2.5), and 43% were disabled. In multivariable models, female sex (OR 1.5, 95% CI 1.3-1.8), diabetes (1.52, 1.30-1.75), current smoking (1.28, 1.06-1.54), non-regular alcohol use (1.6, 1.4-1.9), prior stroke (1.61, 1.28-2.00), cognitive assessment screening instrument score (0.98 per point, 0.97-0.98), and depression (1.79, 1.49-2.17) were associated with disability. The youngest age quartile had decreased odds of disability over time (OR 0.56 per year, 95% CI 0.36-0.91), whereas the oldest age quartile had increased odds (1.33, 0.83-2.22). There was heterogeneity by region (p<0.0001): Americans and Latin Americans had 2.5-fold greater odds of disability per year compared to Spaniards.

Conclusion:
In lacunar stroke patients, older age predicted worsening long-term disability, even without recurrent stroke. Worse long-term function was associated with vascular risk factors and prior stroke, and regional differences may have been due to geographic variations in health care delivery or scale interpretation.
Abstract 145: Transferred Ischemic Stroke Patients Have Worse Outcomes After Endovascular Therapy
Authors: Adil Malik M , Prabhakaran Shyam
Published: July 2021

Background and Objective:
Ischemic stroke (IS) patients may require inter-facility transfer for higher level of care. Endovascular treatment is the main indication for transfer. We aimed to compare patient characteristics and clinical outcomes amongst transferred vs. non-transferred IS patients who undergo endovascular therapy.

Methods:
Patients admitted to US hospitals between 2008 and 2011 with a primary discharge diagnosis of IS were identified by ICD-9 codes (433, 434, 436 and 437.1). Mechanical embolectomy (ME) was identified using the ICD-9 procedure code 39.74 or DRG 543 and cerebral angiography (CA) day 0-1 by 88.41. Using logistic regression, we estimated the odds ratio (OR) and 95% confidence intervals (CI) for intracerebral hemorrhage (ICH), in-hospital mortality, and good outcomes (discharge home or inpatient rehabilitation) among transfer vs. non-transfers, adjusting for potential confounders.

Results:
Of 116,382 patients with IS treated with ME or CA (7.0% of all patients with IS), 10.1% were performed in transferred patients. Atrial fibrillation and hyperlipidemia was significantly higher in IS transfers. In-hospital mortality was higher among IS transfers (9.0% vs. 3.7%; p<0.001) and discharge to home or inpatient rehabilitation was less likely among transferred IS patients (70.2% vs. 80.6%; p<0.001). ICH was higher among IS transfers (4.6% vs. 1.7%; p<0.001). After adjusting for age, gender, race, presence of hypertension, dyslipidemia, atrial fibrillation, renal failure, alcohol abuse, insurance status, and hospital teaching status, transferred patients had higher odds of ICH (OR 2.0, 95% CI 1.5-2.8, p<0.001)] and death (OR 2.0, 95% CI 1.6-2.4, p<0.001) and lower odds of discharge to home/rehabilitation (OR 0.5, 95% CI 0.4-0.7, p<0.001) .

Conclusion:
Endovascular treatment for acute ischemic stroke may be associated with worse outcomes among inter-hospital transfer patients compared to non-transfers. Organized stroke systems of care may need to consider pre-hospital strategies to increase direct referrals to comprehensive stroke centers and inter-hospital strategies to reduce delays to treatment.
Abstract 15: Differential Impact of Comprehensive Stroke Care Capacity on in-Hospital Mortality After Stroke-j-aspect Study
Authors: Iihara Koji , Nishimura Kunihiho , Kada Akiko , Kamitani Satoru , Nakagawara Jyoji , Ogasawara Kuniaki , Aruga Toru , Ono Junichi , Shiokawa Yoshiaki , Miyachi Shigeru , Toyoda Kazunori , Suzuki Akifumi , Nagata Izumi , Matsuda Shinya , Miyamoto Yoshihiro , Ishikawa Koichi , Nakamura Fumiaki , Kataoka HIroharu , Morita Kenichi ,   J-ASPECT Investigators
Published: July 2021

Background:
The effectiveness of comprehensive stroke center (CSC) capacities on stroke mortality remains uncertain. We examined whether specific CSC capacities influenced in-hospital mortality of patients with ischemic and hemorrhagic stroke in a nationwide study.

Methods and Results:
Of 749 certified training institutions in Japan responded to a questionnaire survey regarding CSC capacities, specifically regarding the availability of personnel, diagnostic techniques, specific expertise, infrastructure, and educational components recommended for CSCs, 265 institutions agreed to participate in this study. Data on patients hospitalized for stroke between April 1, 2010 and March 31, 2011 were obtained from the Japanese Diagnosis Procedure Combination database. In-hospital mortality was analyzed using hierarchical logistic regression analysis adjusted for age, sex, level of consciousness on admission, and 25 fulfilled CSC items in each component. Data from 265 institutions and 53,170 emergency-hospitalized patients were analyzed. Mortality rates were 7.8% for patients with ischemic stroke, 16.8% for patients with intracerebral hemorrhage (ICH), and 28.1% for patients with subarachnoid hemorrhage (SAH). Mortality adjusted for age, sex, and level of consciousness was significantly correlated with different items in the five components recommended for CSC depending on stroke types (Table 1 and 2).

Conclusions:
CSC capacities were associated with reduced in-hospital mortality rates, and relevant aspects of care were found to be dependent on the type of stroke.
Abstract 156: Embolization Followed by Radiosurgery for the Treatment of Brain Arteriovenous Malformations (AVMs)
Authors: Marks Michael P , Marcellus Mary L , Santarelli Justin , Dodd Robert L , Do Huy M , Chang Steven D , Adler John R , Steinberg Gary K
Published: July 2021

Purpose:
Multimodality therapy of brain AVMs with embolization followed by radiosurgery is controversial. We present the largest case series to date of AVM patients treated with embolization and radiosurgery.

Methods:
Retrospective review of our institutional AVM database identified 92 patients treated from 1995-2009 with embolization followed by radiosurgery. Patients treated with surgery or radiosurgery prior to embolization were excluded. Pre- and post-embolization AVM volumes were calculated using angiography. The modified Pollock-Flickinger (PF) score was also calculated pre and post-embolization. PF scores from pre-embolization volumes were used to report obliteration rates. Post-radiosurgical obliteration was assessed using angiography or MRI.

Results:
Mean AVM volume went from 19.95 ml (IQR, 10.3 - 32.75) to 10.17 (3.15 - 20.65) following embolization (p<0.001) and mean PF scores decreased from 2.78 (1.77-3.94) to 1.83 (1.07 - 2.79), p<0.001. 2/92 (2.2 %) had new fixed deficits following embolization, however no patient had new disabling deficits (mRS>2). 61/92 (66%) have had ≥3 year follow-up and 35/61 (57%) had excellent outcomes (complete obliteration without neurologic decline). Excellent outcome was seen in 88% of patients with modified PF score <1, 67% of patients with score 1-1.5, 44% patients with score 1.5-2, and 48% of patients with score >2. In addition 16 patients had complete obliteration with further treatment (total 51/61 patients- 84%). Two patients died in the follow-up period due to AVM bleed.

Conclusion:
These data suggest that embolization of brain AVMs can safely and effectively reduce the treatment volume prior to radiosurgery. Combined therapy with embolization and radiosurgery does not adversely affect rates of excellent outcome.
Abstract 159: Exceptional Aggressiveness of CCM3 Phenotype
Authors: Rebeiz Tania J , Mikati Abdul Ghani , Simkhin Darlene , Lee Cornelia , Akers Amy , Awad Issam
Published: July 2021

Introduction:
Familial forms of cerebral cavernous malformations (CCM) account for about 1/3 of cases, involving autosomal dominant inheritance at 1 of 3 gene loci. Few studies have examined any special features of the rarest cases with
CCM3 (PDCD10
) mutation at q3, constituting <15 % of probands genotyped by sequential mutation screening, and <2% of CCM cases at large.

Hypothesis:
We hypothesize that CCM3 cases have unique phenotypic features not recognized in the more common CCM1 and 2 families, or in sporadic cases.

Methods:
Twelve probands including 17 subjects with confirmed
CCM3
mutations were prospectively enrolled through systematic facilitated referral by the patient advocacy group Angioma Alliance. Clinical features were catalogued, including high sensitivity susceptibility weighted imaging (SWI). Rates of overt hemorrhage were determined based on adjudicated criteria. Comparisons were made to systematic literature review of natural history data on non-CCM3 cases.

Results:
The first overt hemorrhage occurred most often in the 1st decade of life (mean age 5.8). Nine of 17 subjects (52%) suffered 30 overt hemorrhages, with an estimated incidence of 6.7 % /patient/year based on exposure risk since birth, and 17% /patient/year based on risk since first symptom onset. Lesion burden on SWI was exceptionally high, >100 lesions in 28%, and > 20 lesions in 72% of cases, respectively. Adjusted bleed rate was <0.5% /lesion/year. New SWI lesions formed at a rate of 2.7/patient/year in prospective follow-up, and 1.8/patient/year based on years since birth. Scoliosis was found in 47% (an association not recognized previously), skin lesions in 29.4%, and brain tumors in 29.4% of cases, respectively. Cognitive disability affected 47% of cases, mostly in association with high lesion burden. Six of 15 cases with parental screening (40%) represented a spontaneous mutation.

Conclusion:
CCM3 is exceptionally aggressive compared to other familial and sporadic CCM. High risks of bleeding and cognitive disability mostly reflect severe lesion burden early in life, rather than a higher risk per lesion. These results will inform the design of clinical trials, urgently needed to address this unique CCM cohort.
Abstract 167: Noninvasive MRI Measurement of Cerebrovascular Reactivity Enables Evaluation of Surgical Revascularization Response in Moyamoya
Authors: Ladner Travis R , Faraco Carlos , Donahue Manus J , Arteaga Daniel , Jordan Lori C , Clemmons Paul , Thompson Lindsey , Mocco J , Singer Robert J , Strother Megan K
Published: July 2021

Introduction:
Frequent dissociation between clinical severity and angiographic grading of moyamoya supports a role for alternative tissue-level hemodynamic measures. Here, angiography is complemented with noninvasive MRI measurements of parenchymal impairment to assess changes in cerebrovascular reactivity (CVR) after extracranial-intracranial bypass in moyamoya.

Hypothesis:
CVR is regionally impaired pre-operatively, yet increases after surgery. This can be visualized noninvasively by assessing blood oxygenation level-dependent (BOLD) MRI changes with safe, mildly hypercarbic gas.

Methods:
Using a block MRI paradigm, carbogen (5% CO
2
; 95% O
2
3 min) was interleaved with atmospheric air (<1% CO
2
; 3 min) administration during BOLD MRI in intracranial stenosis patients (n=70), a subset of which (n=9; age=35.7+/-10.8; 7F/2M) underwent indirect (n=8) or direct (n=1) revascularization for moyamoya. Five patients had both pre-operative and post-operative hemodynamic imaging, with post-operative scans performed after 7.3+/-4.1 months. CVR, calculated as a z-statistic in response to hypercarbia vs. atmospheric air, was compared (two-tailed t-test) for each patient between the two time points to correlate CVR changes with surgery.

Results:
Fig. 1 shows BOLD MRI on a patient scanned before and 2 years after right-sided indirect bypass, with significant (t=79.29, p<0.01) right-sided hemodynamic improvement. Cohort analyses of patients with pre/post-operative scans revealed significant interhemispheric CVR differences prior to surgery (t=3.48, p<0.01), which resolved after bypass (t=0.88, p=0.20). Additionally, CVR increased significantly in the operative hemisphere (t=4.50, p<0.01).

Conclusions:
CVR-weighted hemodynamic MRI can be implemented into routine clinical protocols, corresponds well with revascularization response, and has potential as a noninvasive complement to angiography for serial monitoring of moyamoya patients.
Abstract 179: Racial-ethnic Blood Pressure Differences in Acute Intracerebral Hemorrhage.
Authors: Koch Sebastian , Elkind Mitchell S , Testai Fernando D , Brown Mark W , Martini Sharyl R , Sheth Kevin N , Chong Ji Y , Osborne Jennifer , Moomaw Charles J , Langefeld Carl D , Woo Daniel
Published: July 2021

Background:
Intracerebral hemorrhage (ICH) incidence and hypertension prevalence vary among racial-ethnic groups. Elevated blood pressure (BP) is common following ICH, but there are few racial/ethnic comparisons of acute BP. This study assessed the BP response to acute ICH in a multi-ethnic population.

Methods:
We examined BP in the field (EMS), emergency department (ED) and at 24 hours after ICH in subjects enrolled in the Ethnic Racial Variations of Intracerebral Hemorrhage (ERICH) study. ERICH is a multi-center prospective case-control study of ICH in non-Hispanic whites (whites), non-Hispanic blacks (blacks) and Hispanics. Baseline characteristics and BP recordings by EMS, in the ED and at 24 hours were analyzed for group differences.

Results:
Of 1052 subjects enrolled, BP recordings were available by EMS in 370, ED in 1041 and at 24 hours in 1014 cases of which 24% were white, 42% black and 34% Hispanic. Whites were significantly older 68± 14 years than blacks (58±13 years) and Hispanics (59± 15 years) (p≤0.0001) and had more lobar hemorrhages (39% vs. 23% blacks and 26% Hispanics; p≤0.0001). Baseline differences included larger hematoma volumes, in whites, and more frequent hypertension history and substance use, including cocaine use and smoking, in blacks. Blacks and Hispanics had significantly higher EMS (p=0.0001) and ED (p=0.0001) systolic BPs compared to whites (blacks: 198± 39, 195± 37; Hispanics: 191± 41, 191± 39; whites: 173± 37, 176± 37 mmHg). At 24 hours blacks had a higher systolic BP (144± 25 mmHg; p=0.0014) than Hispanics and whites (139± 21 and 138± 22 mmHg). These differences remained significant after adjustment for baseline group differences, including lobar and deep location. In multivariate analysis, low GCS and being black were associated with a systolic BP> 140mmHg at 24h. Blacks were more likely to receive BP treatment in the ER when compared to whites and Hispanics (76% vs. 52% and 68%).

Conclusion:
We found significant differences in the acute BP response to ICH, with blacks and Hispanics having a higher systolic BP at acute presentation. At 24 hours systolic BP remained elevated in blacks. These findings contribute to our understanding of racial-ethnic differences in BP and identify groups at risk for continued BP elevation.
Abstract 18: Does Quality Improvement Training Add to Audit and Feedback for Inpatient Stroke Care Processes?
Authors: Williams Linda S , Daggett Virginia , Slaven James , Yu Zhangsheng , Sager Danielle , Myers Jennifer , Plue Laura , Woodward-Hagg Heather , Damush Teresa
Published: July 2021

Background:
Despite advances in stroke care, many patients do not receive recommended care processes.

Quality indicator (QI) reporting programs, like GWTG-Stroke, have been shown to improve care. We sought to determine whether training plus QI feedback was more effective than QI feedback alone in improving two stroke QIs.

Methods:
We conducted a cluster randomized trial in 11 VA hospitals. Sites were randomized to a quality improvement training program plus QI feedback vs. QI feedback alone to improve DVT prophylaxis and dysphagia screening. Intervention sites received face-to-face training, developed individualized improvement plans, and had 6 months of post-training facilitation. Both groups received monthly QI feedback. Eligibility and passing for the two stroke QIs, plus nine other stroke QIs, was determined by centralized chart review. We compared pre-intervention (pre-I) to post-intervention (post-I) performance on the two stroke QIs and on defect-free care (DF, a binary patient-level variable including all QIs) in intervention vs. control sites. We constructed logistic models of the two QIs and DF care, adjusting for patient variables, time, intervention group, and time-group interaction.

Results:
The five intervention sites had 1147 admissions and the six control sites had 1017 admissions during the study period. DVT prophylaxis was similar pre-I (85% vs. 90%) and improved in both groups (post-I rates 90% intervention and 94% control, ratio of ORs 0.89, p = 0.75). Dysphagia screening was higher pre-I in intervention sites (51% vs. 37%), and improved more in the control sites (post-I 56% and 52%, ratio of ORs 0.67, p=0.04). In logistic models, DVT, Dysphagia, and DF performance were associated with baseline performance and post-I time. Dysphagia performance was also associated with NIHSS and time-group interaction, and DF care was also associated with the presence of a baseline data collection program.

Conclusion:
Quality improvement training did not add to the impact of data feedback in sites already motivated to participate in QI initiatives. Defect-free stroke care is associated with an ongoing stroke data collection program, emphasizing the importance of audit and feedback to achieve the highest quality stroke care.
Abstract 184: Drivers of Costs Associated With Reperfusion Therapy in Acute Stroke: The IMS III Trial
Authors: Simpson Kit N , Simpson Annie N , Mauldin Patrick D , Hill Michael D , Yeatts Sharon D , Spilker Judith A , Foster Lydia D , Khatri Pooja , Martin Renee , Jauch Edward C , Kleindorfer Dawn , Palesch Yuko Y , Broderick Joseph P
Published: July 2021

Importance:
The annual costs of stroke to the nation have been estimated to be over $38 billion, with nearly $22 billion attributed to direct medical costs.

Objective:
To understand cost drivers during the initial hospitalization for acute ischemic stroke subjects in the IMS III Trial.

Design, Setting and Participants:
Prospective cost analysis of subjects from U.S. centers treated with IV t-PA alone or IV t-PA followed by endovascular therapy in the IMS III trial. Cost of initial hospital admission was estimated from the actual hospital charges on UB04 billing forms provided by the treating hospitals. Cost profiles of the IMS III treatment groups were compared to profiles of a sample of US patients from the HCUP National Inpatient Sample (NIS) for 2010.

Interventions:
IV t-PA alone as compared to IV t-PA followed by endovascular therapy.

Main Outcome Measure:
Costs of hospitalization for acute stroke subjects.

Results:
The adjusted cost of a stroke admission in the study was $35,130 for subjects treated with endovascular therapy following IV t-PA and $25,630 for subjects treated with IV t-PA alone (p<0.0001). The higher cost in the endovascular therapy following IV t-PA treatment arm was largely explained by the costs of the devices. Significant factors related to costs included treatment group (higher costs with endovascular therapy), baseline NIH Stroke Scale (higher costs with higher severity), time from stroke onset to IV t-PA (lower costs with earlier treatment), age (higher costs with older age), stroke location (higher cost with right hemispheric location) and comorbid diabetes (higher costs with diabetes). The mean cost for subjects who had routine use of general anesthesia as part of endovascular therapy was $46,444 as compared to $30,350 for those who did not have general anesthesia. The costs of embolectomy for IMS III subjects and patients from the NIS cohort exceeded the Medicare DRG payment in more than 75% of hospitalized patients.

Conclusions and Relevance:
Changing the processes of acute stroke care, such as minimizing the time to start of IV t-PA and decreasing the use of routine general anesthesia, may improve the cost-effectiveness of medical and endovascular therapy for acute stroke.
Abstract 196: Human Recombinant Peptide (RCP) Sponge Enables Novel Noninvasive Cell Therapy for Ischemic Stroke
Authors: Miyamoto Michiyuki , Kuroda Satoshi , Nakamura Kentaro , Yamauchi Tomohiro , Ito Masaki , Saito Hisayasu , Shichinohe Hideo , Sasaki Tasuku , Houkin Kiyohiro
Published: July 2021

Background:
The bone marrow stromal cells (BMSCs) have the potential to improve neurologic function when transplanted into animal models of ischemic stroke. However, it is unclear through which route the BMSC should be delivered to yield the maximal therapeutic benefits safely. Using genetic engineering technique, the authors have developed the recombinant peptide (RCP) sponge of human collagen. Therefore, this study was aimed to assess whether the RCP sponge of human collagen could act as a noninvasive, valuable scaffold in cell therapy for ischemic stroke.

Methods:
The BMSCs were harvested from GFP-transgenic rats and were cultured in the RCP sponge. The rats were subjected to permanent middle cerebral artery (MCA) occlusion. Vehicle, BMSC suspension, or the BMSC-RCP sponge construct was transplanted onto the ipsilateral intact neocortex at 7 days after the insult. Motor function was serially evaluated throughout the experiments. The distribution and fate of engrafted cells were examined at 6 weeks after BMSC transplantation.

Results:
The BMSCs proliferated in the RCP sponge in vitro. Transplantation of BMSC suspension or the BMSC-RCP sponge construct equally promoted functional recovery, when compared with the vehicle group. RCP sponge provoked no inflammatory reactions in the host brain. Histological analysis revealed that the BMSC migrated and differentiated into the neural cells in the infarct brain when transplanted using the RCP sponge.

Conclusion:
These findings suggest that surgical transplantation of tissue-engineered BMSC onto the infarct neocortex may enhance functional recovery. RCP sponge can be a promising candidate for the animal protein-free scaffolds in cell therapy for ischemic stroke.
Abstract 198: Robotic Telepresence versus Standardly Supervised Stroke Alert Team Assessments
Authors: O'Carroll Cumara B , Hentz Joseph G , Demaerschalk Bart M
Published: July 2021

Background:
The implementation of telemedicine for stroke has played a vital role in creating universal access to emergency stroke care for patients in both rural and urban communities, regardless of location or hospital resources.

Objective:
We evaluated the hypothesis that there is no difference in speed of assessment between vascular neurologist (VN) robotic telepresence and standard VN supervised stroke alert patients in a primary stroke center.

Methods:
A retrospective stroke alert database review was used to identify all robotic telepresence and standardly supervised stroke alert patient assessments at Mayo Clinic Hospital Emergency Department from 2009 to 2012. The robotic telepresence cohort was compared to a random sample of standard stroke alert patients, with an equal number of patients selected from each year. The primary outcome measure was the duration of assessment from stroke alert activation to treatment or downgrade.

Results:
The sample size was 196 subjects. The mean duration of time from stroke alert activation to initiation of IV thrombolytic treatment or downgrade was 8.6 minutes longer in the robotic telepresence group than in the standard group (
P
=0.03). There was a higher percentage of patients diagnosed with acute stroke in the robotic stroke alert group than in the standard stroke alert group (77% vs 60%,
P
=0.01). Controlling for acute stroke, age, and NIHSS did not significantly reduce the time difference between groups. Among the subgroup of acute ischemic stroke patients requiring IV thrombolysis, the mean duration of time from activation to treatment was 18 minutes longer in the robotic group than in the standard group (
P
=0.01). Safety outcomes including thrombolysis protocol violations (0% vs 1%), post-thrombolysis symptomatic intracranial hemorrhagic complications (3% vs 1%), and death during hospitalization (8% vs 6%) were low in the robotic group and not significantly different from that in the standard group.

Conclusion:
Standard VN supervised acute stroke team assessments are swifter than those supervised by robotic telepresence. Safety outcomes of robotic telepresence supervised stroke alerts are excellent, and this modality may be preferred in circumstances when a VN is not immediately available on-site.
Abstract 200: Team of Neurohospitalists, Telestroke, and Nurse Stroke Coordinator Increases the Use of Intravenous Alteplase in a Community Hospital
Authors: Smith H. McCord , Morris C. Van , Nichols Shelley , Lockamy Joanne , Switzer Jeffrey A , Hess David C
Published: July 2021

Background and Purpose:
The FDA approved IV tPA in 1996 for the treatment of AIS. Its safety and efficacy have been demonstrated in community hospitals (CH) and it is now the standard of care; but intravenous Alteplase (IV tPA) remains underemployed. It is used in fewer than 5% of AIS patients. Short supply of neurologic manpower and concern over adverse effect contribute to this underutilization. Our hypothesis was that a combination of onsite neurohospitalists (NH), telestroke (TS), nurse stroke coordinator (NC), and education of staff and community would increase IV tPA use in a mid-sized CH PSC without compromise of safety or outcome.

Methods:
The hospital is a 197 bed nonprofit hospital located 60 miles from Atlanta serving a population of 350,000 in 10 counties. The hospital has been certified as a PSC since August 2004; however, the volume of AIS admissions and use of IV tPA remained low through 2008. The stroke program thus was reorganized in 2009: two full-time NH were hired to provide onsite coverage daily from 8am to 6pm, the REACH™ TS System was installed to provide the remainder of coverage, a NC was hired, and an education plan for staff and community was implemented. Patients treated with IV tPA via TS were admitted to the neuro-ICU by medical hospitalists initially with NH assuming primary care of these patients within hours. AIS admission and IV tPA use data for 2002- 2008 were compared with those for 2009 - 2012. Outcomes, assessed at discharge, 2009 - 2012 were also examined. Favorable outcome was defined as a mRS of 0 or 1.

Results:
From 2002-2008, 25 of 933 AIS were treated with IV tPA: 3.6 per year (2.7%). In contrast, from 2009-2012, 105 of 802 AIS received IV tPA: 26.25 per year (13%) with favorable outcome in 47 (45%). Of 64 patients treated by NH, 28 (44%) achieved favorable outcome as did 19 of 41 (46%) TS patients. These outcomes were not statistically different (p=0.92). There were 5 deaths (3 NH, 2 TS), none attributable to tPA. There were no sICH.

Conclusions:
A model combining NH, TS, NC, and education in a CH PSC significantly increased the use of IV tPA without compromising safety or effectiveness. Such a model may be an option where resources are limited.
Abstract 203: Emergent Brain Imaging for Acute Ischemic Stroke in Veterans Health Administration Hospitals
Authors: Sauser Kori , Bravata Dawn M , Hayward Rodney A , Levine Deborah A
Published: July 2021

Objective:
Tissue plasminogen activator (tPA) is under-utilized in Veterans Health Administration medical centers (VAMCs); delays in brain imaging may be a significant barrier. Our primary objective was to describe door-to-imaging time (DIT) patterns among veterans with acute ischemic stroke (IS). We identified patient-level predictors of faster imaging times and decomposed variation in DIT attributable to hospital and patient-level factors.

Methods:
Detailed medical record reviews were done on 5,000 acute IS patients admitted to any VAMC in 2007; this analysis included those with emergent brain imaging (CT/MRI within 6 hours). We used descriptive statistics to report DIT patterns and a series of random-intercept hierarchical linear regression models to identify predictors of DIT and to decompose variation in DIT.

Results:
Among the 2,681 acute IS patients emergently imaged in a VAMC, median DIT was 67.7 minutes (min) (IQR, 37.1-115.8 min). Among the 83 patients who were eligible for tPA, the median DIT was 45.9 min (IQR, 28.4-72.1 min) and 22% met the DIT<25 min guideline. Arrival from clinic and increased onset-to-arrival time were independently associated with slower DIT, whereas blood pressure on arrival >185/110 mm Hg was associated with faster DIT (Table). In the model without patient-level factors, 7.2% of variation in DIT was attributable to hospital. Adding patient-level predictors to the model explained 18.8% of the variation in DIT, but 6.4% of the variation remained attributable to case-mix-adjusted hospital variation. Despite this clinical substantial hospital variation, the low IS caseload at most hospitals made it impossible to reliably identify high- and low-performing facilities.

Conclusion:
There remains room for improvement in DIT for VAMC acute IS patients. Variation is attributable to patient and hospital factors, however, low case IS loads at most hospitals prevented reliable discrimination between high and low-performing centers.
Abstract 208: Pharmocologic Thromboprophylaxis Reduces the Odds of Venous Thromboembolism in Patients With Hemorrhagic Stroke
Authors: Levy A S , Salottolo Kristin , Coplin William M , Smith Richard , Santos Patricia , Bar-Or David
Published: July 2021

Background:
Current guidelines regarding the use and optimal timing of Pharmacologic Thromboprophylaxis (PTP) are unclear in patients with primary diagnosis of hemorrhagic stroke. We sought to determine the association between PTP and development of venous thromboembolism (VTE) in this population.

Methods:
We reviewed patients with non-traumatic/spontaneous subarachnoid hemorrhage and intracerebral hemorrhage admitted between 1/2010-12/2012 with hospital LOS ≥ 3 d (n=245). Multivariate stepwise logistic regression was used to analyze the association between PTP and development of VTE. PTP was analyzed in regards to: use of PTP (vs. not administered), early administration of PTP (vs. ≥ 72 h) and interruption of PTP (vs. continuous use). The following covariates were considered: primary diagnosis, age, gender, transfer status, pre-event warfarin use, overweight/obese (BMI ≥ 25), ambulation ≥ 100 feet, IVC filter placement, moderate/severe stroke (NIHSS ≥ 8), Glasgow Coma Score (GCS 3-8, 9-12, 13-15), hospital LOS and ICU LOS.

Results:
The overall incidence of VTE was11.4% (28/245). All but 4 patients (98.4%) received mechanical prophylaxis; however, only one-third of patients (n=81) received PTP, and was initiated early in a minority (9.9%, n=8). The incidence of VTE was not significantly different in patients who received PTP (7.3%, 5/69) compared to patients who did not receive PTP (13.1%, 23/176), before adjustment (OR: 0.52, p = 0.20). However, after adjustment for age, gender, pre-event warfarin use, ambulation, and ICU LOS, PTP was associated with significantly reduced odds of VTE (OR: 0.05 (0.01 - 0.31), p = 0.001). Age ≥ 65 (5.73 (1.17 - 28.19), p = 0.03) and prolonged ICU LOS (1.29 (1.16 - 1.44), p < 0.001) were associated with increased odds of VTE. Neither the timing nor the interruption of PTP was associated with development of VTE.

Conclusions:
This study demonstrated that the odds of developing VTE were 95% lower in patients receiving PTP. We recommend the use of PTP in addition to mechanical thromboprophylaxis in patients with stable hemorrhagic stroke. The exact timing of beginning such chemoprophylaxis needs better definition.
Abstract 21: Are Stroke Outcomes Influenced by New Starting Residents? The July Effect: Myth or Reality?
Authors: Park Tai Hwan , Pongmoragot Jitphapa , Li Shudong , Saposnik Gustavo ,   on behalf the RCSN Investigators for the Stroke Outcomes Rsch (SORCan) Working Group
Published: July 2021

Background:
Acute stroke care provided by comprehensive stroke centers usually follows prespecified protocols. However, there are concerns about lower quality of care and poorer stroke outcomes early after new trainnees (e.g.) residents start in July in academic/teaching hospitals. This has been called ‘the July effect’.

Objective:
To evaluate access to specialized care and outcomes among patients admitted with an acute ischemic stroke (AIS) in July and other months.

Hypothesis:
We hypothesized that there were no significant differences in access to stroke care and outcomes for patients admitted in July when new trainees start at academic centers.

Methods:
Patients presenting with an AIS at 11 stroke centers in Ontario, Canada, between 2003 and 2009 were identified from the Registry of the Canadian Stroke Network. We compared performance measures and functional outcomes (death at 30 days, modified Rankin Scale 3 to 5 at discharge) between AIS patients admitted in July of each studied year and those who admitted during other months.

Results:
Of 10,319 eligible patients with an AIS, 882 (8.5%) were admitted in July. There was not difference in age, sex, or baseline stroke severity between patients admitted in July or other months. Among the performance measures analyzed, AIS admitted in July were less likely to receive thrombolysis (12.1% vs. 16.0%, p=0.002), swallowing test (64.4% vs. 67.9%, p=0.033), and admission to stroke unit (61.9% vs. 67.6%, <0.001). There was no difference in death at 30-days (16.4% vs. 16.1%, p=0.823) or poor functional outcome (61.0% vs. 63.5%, p=0.14) between two groups (Table).

Conclusion:
AIS patients admitted in July were less likely to receive thrombolysis and be admitted to stroke units compared to patients admitted on the rest of the year. However, there was no negative effect of “admission on July” on functional outcome or death.
Abstract 3: Collaterals, Not Clots! CT Angiography Predictors of Recanalization, Reperfusion and Clinical Outcomes After Thrombectomy in Pooled Analyses of TREVO EU and TREVO2
Authors: Liebeskind David S , Sanossian Nerses , Scalzo Fabien , Xiang Bin , Johnson Mark S , Gupta Rishi , Jovin Tudor G , Albers Gregory W , Lutsep Helmi L , Smith Wade S , Killer-Oberpfalzer Monika , Macho Juan M , Jansen Olav , Wahlgren Nils , Nogueira Raul G ,   for the TREVO EU and TREVO2 Investigators
Published: July 2021

Background:
CTA is often used to define clot location prior to endovascular therapy yet systematic evaluation may reveal many details about underlying pathophysiology. We tested a battery of CTA measures to identify optimal predictors of response to thrombectomy.

Methods:
CTA datasets of anterior circulation strokes in TREVO EU and TREVO2 with available source images were reconstructed into 3D-curved and 2D-orthogonal maximum-intensity projections by the core lab. Occlusion site, clot length and volume, clot burden score (CBS) and regional leptomeningeal collateral score (rLMC) were scored on CTA. Hyperdense vessels, Hounsfield Unit (HU) indices and location of hyperdensity relative to CTA occlusion site were noted on noncontrast CT.

Results:
111 cases (mean age 68.0 ± 13.8 years; 58.6% women; median baseline NIHSS 18 (8-28)) were analyzed. CTA occlusions were 68.5% M1, 22.5% M2, and 9.0% ICA. CTA clot volumes were mean 49.3 ± 36.3 mm
3
with mean CBS 6.7 ± 1.8 and mean rLMC 15.3 ± 4.2. Noncontrast hyperdensity was noted at M1 in 44.1%, M2 in 27.0%, and ICA 8.1%, with ipsilateral:contralateral HU indices of mean 1.3 ± 0.2. Noncontrast CT hyperdensity relative to CTA opacification revealed hyperdensity proximal to occlusions in 2.7%, just past occlusion in 55.0%, and distal to clot end in 6.2%. Only better collaterals on rLMC predicted AOL 2-3 recanalization (OR 1.26, p=0.058) in multivariate analyses and distal hyperdensity (OR 0.11, p=0.037) predicted worse recanalization. Similarly, only rLMC predicted TICI 2b-3 reperfusion (OR 1.27, p=0.004) and distal hyperdensity (OR 0.12, p=0.071) predicted worse reperfusion. Clots (CBS) and collaterals (rLMC) were moderately correlated with each other (0.44 Spearman) in multivariate models of good clinical outcome (mRS 0-2) at day 90, yet clots were significant only when removing collaterals.

Conclusions:
Collaterals, not clots, are the best CTA predictors of outcomes after thrombectomy. Worse outcomes with hyperdensity distal to clots on CTA likely reflect stasis due to poor retrograde collaterals.