bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract T P170: Carotid Artery Intima-Media Thickness and Ankle-Brachial Index are Strong Predictors of Complicated Aortic Arch Plaque in Acute Cerebral Embolism Patients
Authors: Kaneko Kazuyoshi , Saito Hiroki , Tsunoda Yuichi , Sugawara Shigeo , Akasaka Masahiro , Kanaya Tohru , Kubota Isao
Published: July 2021

Background:
Complicated aortic arch plaque (CAP) detected by transesophageal echocardiography (TEE) provides prognostic information regarding cerebrovascular disease risk. Coexistence of peripheral atherosclerotic disease worsens the prognosis in ischemic stroke patients.

Methods:
We examined TEE, carotid artery intima-media thickness (CIMT, calculated from carotid echograms), and ankle-brachial index (ABI, calculated from ankle/brachial blood pressure ratios) in 100 consecutive cerebral embolism patients within 2 weeks of onset of symptoms. CAP was defined as atherosclerotic plaque (≥4mm) or presence of ulcerated plaque assessed by TEE. Patients were classified into those with CAP (n=36, Group A) or without CAP (n=64, Group B).

Results:
Comparing patients in the two groups, significantly higher values were seen in Group A for age (69±8 vs. 63±11 years, p<0.01), prevalence of hypertension (75% vs. 50%, p<0.05) and ischemic heart disease (19% vs. 3%, p<0.01), and CIMT (1.9±0.8 vs. 1.2±0.5 mm, p<0.0001). Significantly lower values were seen in Group B for ABI (0.93±0.22 vs. 1.11±0.11, p<0.0001). Defining arteriosclerosis obliterans (ASO) as ABI <0.9 and CIMT thickening as CIMT ≥1.1mm, CAP was predicted by ASO with 39% sensitivity and 97% specificity, and by CIMT thickening with 78% sensitivity and 48% specificity. Combined ASO and CIMT thickening predicted CAP with 83% sensitivity and 81% positive predictive value, and with 97% specificity and 83% negative predictive value in all of the subjects. Furthermore, aortic arch intima-media thickness was significantly correlated with CIMT and ABI (r=0.441, p<0.0001 and r=-0.384, p<0.0001, respectively).

Conclusions:
For non-invasive evaluation of patients with acute cerebral embolism, the combination of both ABI and CIMT predicts CAP more strongly than either ABI or CIMT considered alone, with higher figures for sensitivity, specificity, and positive and negative predictive value.
Abstract T P174: Intra-Arterial Signal on Arterial Spin Labeling Perfusion MRI Can Identify Stagnant Flow in Patients with Acute Middle Cerebral Artery Occlusion
Authors: Satomi Junichiro , Tada Yoshiteru , Abe Takashi , Kuwayama Kazuyuki , Sogabe Shu , Fujita Koji , Yamamoto Nobuaki , Kaji Ryuji , Harada Masafumi , Nagahiro Shinji
Published: July 2021

Introduction:
T2*-weighted imaging (T2*WI) can detect acute endovascular clots by the susceptibility vessel sign (SVS). Stagnant flow in front of middle cerebral artery (MCA) occlusion sites may contribute to intra-arterial high-intensity signal on arterial spin labeling (ASL) magnetic resonance imaging (MRI), making it another potential marker of MCA occlusion. We compared intra-arterial high-intensity signal and SVS in patients with symptomatic and asymptomatic MCA occlusion and patients without major vessel occlusion.

Methods:
We identified transient ischemic attack or ischemic stroke patients by (a) 3-T MRI, diffusion-weighted imaging, ASL, T2*WI, and magnetic resonance angiography (MRA) performed within 24 h after stroke onset and (b) the presence of MCA occlusion (n=34 patients) or the absence of major vessel occlusion (n=24 patients). We included asymptomatic patients with MCA occlusion (n=6). The presence or absence of intra-arterial high-intensity signal and SVS was recorded as was its coincidence with the presence of MCA occlusion on MRA.

Results:
In patients with acute ischemic stroke the sensitivity of intra-arterial high-intensity signal was significantly higher than of the SVS (88% vs 50%; p<0.05). The accuracy of intra-arterial high-intensity signal was also higher than of the SVS (93% vs 71%; p<0.05). Neither the intra-arterial high-intensity signal nor the SVS was observed in patients without major vessel occlusion. The presence or absence of intra-arterial high-intensity signal was highly consistent with the presence or absence of MCA occlusion on MRA (κ=0.74). Positivity for the intra-arterial high signal was higher in symptomatic than asymptomatic patients with MCA occlusion (88% vs 17%; p<0.05), suggesting that acute rather than chronic arterial occlusion contributes to the visibility of the intra-arterial high-intensity signal.

Conclusions:
The intra-arterial high-intensity signal on ASL could identify stagnant flow in front of occlusion sites due to acute arterial occlusion.
Abstract T P200: Feasibility of Telemedicine on a Mobile Stroke Treatment Unit
Authors: Cho Sung , Cejero Russell , Taqui Ather , Itrat Ahmed , Donohue Megan M , Briggs Farren , Buttrick Maureen , Winners Stacey , Rasmussen Peter , Hussain Muhammad S , Uchino Ken
Published: July 2021

Background:
Mobile stroke treatment unit (MTSU) with on-site treatment team that includes a stroke physician can provide thrombolysis successfully in pre-hospital setting more quickly than traditional treatment in hospital. We report our initial experience of mobile stroke unit with remote physician presence by telemedicine.

Methods:
We implemented a MSTU at our institution starting July 18
th
, 2014. The unit includes a registered nurse, paramedic, emergency medical personnel, CT technologist. Stroke physician evaluated patient via telemedicine (InTouch RP-Lite) and neuroradioloigst remotely assessed images obtained by Ceretom mobile CT. Data were entered in medical records and a prospective registry. The evaluation and treatment in the first 3 weeks of implementation of MSTU was compared to a control group of patients brought to emergency department (ED) via a traditional ambulance in the preceding 2 months. Times were measured from patient arrival entering the “door” of MSTU or emergency department (ED).

Results:
Twenty three patients were evaluated by MSTU. All patients were evaluated successfully with CT scan, IV placement, neurologic exam and NIH Stroke scale evaluation over telemedicine, and CT interpretation. Duration of telemedicine evaluation was median 21 minutes (IQR: 17-34 minutes). There was a single 44 second interruption of telemedicine connection that did not affect clinical care. The Median NIHS Stroke Scale was 7 (IQR 2 to 11) and was successfully completed in all 23 patients with assistance of a registered nurse by patient side. The time from door to CT scan completion was similar between MSTU and ED (median 21 minutes and 20 minutes, p=0.70). The time from CT completion to radiologist report to stroke physician was similar between MSTU and ED (median 6 minutes and 4.5 minutes, p=0.18).

Conclusion:
Mobile stroke unit using telemedicine is feasible and as time efficient as traditional ED evaluation.
Abstract T P213: An Interactive Video Improves the Understanding of a Hypothetical Adaptive Acute Stroke Trial
Authors: McEvoy Brendan , Tehranisa Jason , Meurer William J
Published: July 2021

BACKGROUND AND PURPOSE:
The communication of adaptive clinical trials can be more difficult due to the increased complexity of the design itself, especially in an emergent, time-sensitive setting such as with acute stroke patients. We hypothesized that introducing brief, comprehension questions into a video explaining a hypothetical acute stroke trial would improve the understanding of the trial allocation procedure and increase patient participation.

METHODS:
We conducted a cross-sectional survey of adult patients presenting to the emergency department. After obtaining verbal consent, patients were randomized to one of four groups: They watched a video with either an RAR or a standard hypothetical acute stroke trial, with or without the addition of interactive comprehension questions. These questions addressed research procedures relevant to the consent process and operation of the trial. Subjects were asked whether they would consent to the trial and if they could identify the method of randomization and allocation used.

RESULTS:
A total of 720 patients were enrolled. A significantly higher proportion of individuals in the RAR interactive video group (85.9%) correctly identified the trial allocation method assigned versus the RAR uninterrupted video group (60.4%), absolute increase: 25.5% (95% confidence interval, 17-33%). Additionally, there was significantly higher trial participation in the RAR interactive video group (table).

CONCLUSIONS:
Integrating structured comprehension questions into the consent process of a hypothetical acute stroke trial increased understanding of the RAR trial design and further attracted more research participation. Improving the communication of the trial procedures within a simulated situation that mimics the rapid discussion regarding an emergency research trial is beneficial and should be incorporated into future acute stroke trials
Abstract T P239: Therapeutic Efficacy and Pharmacological Mechanisms of SP-8203 for Treatment of Cerebral Ischemia
Authors: Kim Won-Ki , Ju Chung , Jalin Angela M. A. A , Ryu Jei-Man , Cho Il-Hwan , Kim Won-Seok , Kim Byung-Su , Lee Yong-Hyun , Lee Eun-Bang
Published: July 2021

In cerebral ischemia, neurons and glia are deteriorated by various mechanisms including excitotoxicity, oxidative stress and inflammatory responses. Thus, pharmacological blockade of multiple cytotoxic pathways would be a therapeutic strategy for the treatment of ischemic injury. We recently identified a novel multi-potent neuroprotectant SP-8203. Pharmacological efficacy and action mechanism of SP-8203 were evaluated in rat transient middle cerebral artery occlusion (MCAO). Post-ischemic treatment (i.v.) of SP-8203 reduced cerebral ischemic injury in a dose-dependent manner (0.03 ~ 10 mg/kg) and at clinically relevant therapeutic time window (up to 12 h after ischemia onset). Similar efficacy was also obtained in beagle dogs subjected to permanent MCAO. Although it did not ameliorate the excitotoxicity, SP-8203 markedly reduced ischemia-evoked oxidative stress via up-regulation of anti-oxidant enzymes, specifically Mn-SOD and Cu/Zn-SOD, but not catalase and glutathione reductase. SP-8203 also reduced the infiltration of ED-1-immunopositive monocytes and MPO-positive neutrophils into ischemic brain lesions of rats. Moreover, SP-8203 significantly reduced the release of pro-inflammatory cytokines/chemokines (e.g. IL-1beta, TNF-alpha, MCP-1) and also the expression of iNOS and resultant formation of nitrotyrosine. Early (3 h) thrombolysis with tPA restored perfusion and reduced infarction in embolic rat models. However, late 6-h tPA did not decrease infarction, but instead increased intracerebral hemorrhage and mortality. Interestingly, SP-8203 treatment at 1.5 h before late (6 h) tPA infusion markedly reduced tPA-evoked cerebral hemorrhage and mortality. Blood levels of MMPs were significantly correlated with the changes of hemorrhage and mortality. Taken together, SP-8203 has multiple neuroprotective activities in cerebral ischemia: up-regulation of anti-oxidant enzymes, reduction of inflammatory cells recruitment, and suppression of anti-inflammatory cytokines/chemokines and MMP expression. Thanks to the multiple neuroprotective mechanisms, SP-8203 could be a promising drug candidate for stroke treatment, especially in combination of tPA by extending therapeutic time window.
Abstract T P30: Logarithmic Growth of Ischemic Lesions in Major Anterior Circulation Ischemic Strokes
Authors: Gonzalez Ramon G , Silva Gisele , He Julian , Sadaghiani Saloomeh , Wu Ona , Singhal Aneesh B
Published: July 2021

Purpose:
To analyze the dynamics of diffusion lesion volumes within the first 48 hours after stroke onset in patients with major anterior circulation occlusions (ACOs).

Methods:
Diffusion ischemic lesion volumes were serially measured in 50 patients that had MRI performed at baseline (~4 hours post ictus) and 2 or 3 additional MRI exams (~12, ~24, ~48 hours post ictus). Thirty eight of these patients had documented major ACOs (terminal internal carotid or proximal middle cerebral artery). Average rate of lesion growth was calculated at each time interval. Functional outcomes (3-month modified Rankin Scale) were correlated to admission NIHSS, DWI volumes and initial lesion growth rates.

Results:
DWI lesion growth in ACOs was nonlinear over 48 hours and exhibited a logarithmic pattern. The lesion growth rates were highest during earliest period (11.4 ml/hr) and declined during at the 5-12 (0.8 ml/hr ), 12-24 (1.9 ml/hr) and 24-48 hour (0.9 ml/hr) periods. In 23/38 patients there was little or no growth during 5-12 hours period despite continued presence of occlusion in over half of these patients. However, 12/38 experienced >30% growth of lesion during this period, with nearly all patients having persistent occlusions. Functional outcomes correlated with baseline NIHSS and DWI lesion size, as well as initial average growth rate, but only the latter was an independent predictor

Conclusions:
The growth of ischemic DWI lesions caused by occlusion of major anterior circulation arteries is nonlinear and typically logarithmic. The rate of growth at the earliest time period is a strong predictor of functional outcomes. There is high variability in growth rates due to site of occlusion and most likely the quality of collateral flow. Our results have implications for "Time is Brain."
Abstract T P333: Impact of Tele-Stroke Network on Door to Needle Times and TPA Use in Rural and Urban Community Hospitals
Authors: Greene Erin A , Braunlin Jeri , Neff Julie , Walker Tari , Thoman Ivy , Kitchener Jacob
Published: July 2021

Background:
This project describes one healthcare system’s journey to expand the outreach of the Primary Stroke Center. Premier Health (PH) is a hospital system based in Dayton Ohio that provides services for over 2,200 stroke patients annually. Premier Health consists of 5 community hospitals 3 of which are Joint Commission certified Primary Stroke Centers. The requirement for Stroke Specialized Physicians on-call 24 hours a day had become more difficult with expansion of services to respond to community needs. With a limited number of Stroke Physicians within system, it was not feasible for available Physician’s to cover the 50 mile radius. A Tele-Stroke Network was developed to provide lifesaving services as well as 24/7 coverage for stroke call. Program results include synergistic unity of best practices and improved patient outcomes with the majority of patients remaining in their community.

Purpose:
Implement a Tele-Stroke System to provide specialty coverage and favorable patient outcomes for a Primary Stroke Center that provides coverage for a large region in the Midwest.

Methods:
In 2013 a stroke telehealtlh Clinical Nurse Specialist role was added and became pivotal in facilitating the following outcomes:

1) Restructuring of the Stroke Alert Call Schedules across the system.

2) Streamlining Stroke Alert Process across the system and redesign of work flows

3) Development of standard system order sets to streamline care delivery.

4) Providing IT training to end users and physicians at five hospitals.

Results:

• 304 Tele-Stroke consults conducted since implementation.

• 33% increase in the volume of patient’s receiving T-PA

• Average of 20 minutes reduction in Door to Needle for 2 of the 5 hospitals

• Post telemedicine implementation there was a reduction in transfers from spoke hospitals to hub. On average, 83 % of the PH Tele-Stroke patients were able to stay in their respective communities while receiving Primary Stroke Center Care via telemedicine.

Conclusion:
Telemedicine implementation with standardization of stroke alert processes and order sets, restructuring of physician scheduling and IT training for the Primary Stroke Team resulted in improved t-PA use, lower door to needle time and reduction in unnecessary transfers of patients.
Abstract T P338: Time is of the Essence: A Nurse-Based Intervention to Improve Door to Needle Times
Authors: Lawrence Erin , Merbach Dawn , Thorpe Sherry , Llinas Rafael H , Marsh Elisabeth B
Published: July 2021

Background:
For acute ischemic stroke, the chance of improved recovery is directly impacted by the length of time from symptom onset to administration of intravenous tissue plasminogen activator (IV t-PA). Despite the importance of rapid treatment, stroke centers struggle with achieving consistent door to needle times of less than 60 minutes. In an effort to improve efficiency, we implemented a change in our response to the acute stroke patient by adding a dedicated stroke nurse and Nursing Flow Sheet that focuses on critical benchmarks (e.g., door to CT time) prior to treatment. We collected data on patients treated with IV t-PA pre- and post-intervention to determine if our process increased the number of patients receiving t-PA in less than 60 minutes.

Methods:
137 patients (n=77 pre, 60 post) who were treated with IV t-PA between 2009-2013 were included in analysis. Student’s t-tests and Fisher’s exact tests were used to compare door to needle times pre- and post-intervention. Additional data were collected regarding: patient demographics, admission characteristics (e.g., day of the week), stroke severity, medical comorbidities, and other barriers to t-PA administration (e.g., need for antihypertensives or additional imaging).

Results:
With implementation, the mean time to treatment only decreased from 82 to 78 minutes (p=0.58); however, the percentage of patients successfully treated within 60 minutes of arrival improved from 26% to 58% (p=0.003). NIH Stroke Scale severity and need for additional imaging (i.e., CTA of the chest) were associated with increased time to treatment.

Conclusion:
The use of a dedicated stroke nurse and Nursing Flow Sheet as part of the acute stroke assessment reduces door to needle times and significantly increases the proportion of patients treated with IV tPA within 60 minutes from hospital arrival.
Abstract T P356: Functional Outcomes of the Acute Ischemic Stroke Patient Population
Authors: Paletz Laurie , Roberts Pam , Steiner Nili , Robertson Betty , Wolber Nicole , Guerra Sonia
Published: July 2021

Background:
Stroke is the leading cause of long-term disability and affects 795,000 in the U.S. each year. This study is conducted to enhance knowledge ofoutcomes after an acute ischemic stroke (AIS).Comprehensive Stroke Certification tasks hospitals with expanding knowledge of functional and quality of life outcomes for AIS patients through the early acute and post-acute phase of recovery and examining the effects of stroke severity, functional impairment,discharge destinations, functional independence, and quality of life post discharge.

Researchable question:
What are most common setbacks after AIS affetcing functional outcome & readmission?

Methods:
Looked at AIS patients from 12/2012 -12/ 2013 at Cedars-Sina. Of total of 709 patients 318 were contacted by phone. Measures collected by MedTel Outcomes LLC on all AIS patients one month after discharge. This included the Functional Independence Measure and standardized quality of life and participation measures.The median age was 65 years at the time of the stroke.

Results:
Most common setbacks were recurrent strokes, pneumonia, falls& heart failure.All caused re-hospitalization after stroke. Discharge destinations 30 days post stroke hospitalization were: home independent 144 (43.3%). No significant disability 49 (14.7%), Slight disability 21 (6.3%) Moderate disability 44 ( 13.2%), moderate to severe disability 43 ( 12.9%) and finally severe disability 31( 9.3%). 83.7 % were home without assistance and 1.3 % were in board and care, 15 patients, (4.7 %) had been readmitted for recurrent stroke, 48 patients had fallen since discharge

Conclusions:
Over 83.7 % of AIS patients were back living in the community at home with over 60 % having slight disability.The long-term outcomes have implications for late secondary and tertiary prevention and creating a model for predictors of these At follow-up, in terms of physical functioning measures,mostpatients were independent in toileting and self-care activities,half were independent in mobility excluding stairs.Data from this study can be used to understand the functional trajectory of recovery based on severity of stroke, discharge destination and other factors. It is important to understand patients’ characteristics to help prevent readmissions.
Abstract T P382: Urgent Primary Care Physician Follow up is Associated with Reduced Stroke Readmission after Acute Ischemic Stroke Hospitalization
Authors: Neil William , Rosete Jane , Seibel Jennifer , Buccigrossi David , Forde Kerry , Cory William
Published: July 2021

Introduction:
Readmission after acute ischemic stroke is common and costly, with an average rate of 14.8% within 30 days of discharge1. In 2010, as part of a hospital performance improvement strategy, ischemic stroke patients who were discharged to home had an urgent (within 7 days) appointment with Primary Care Physician (PCP) scheduled. We compared 30-day readmission rates for those who kept and did not keep their appointment.

Methods:
Data from an electronic medical record system was retrospectively evaluated.

The cohort included all patients with hospital admission for ICD 9 diagnosis of ischemic stroke (433, 434, 435) during the years 2010 - 2013. Only those with a discharge disposition of home were included. Group 1 included patients discharged to home who kept follow up appointment. Group 2 included those who did not keep their scheduled appointment. Significant predictors of readmission such as age, heart failure, diabetes, LACE score were compared. Fisher’s Exact test was used for categorical variables.

Results:
A total of 349 ischemic stroke patients were discharged to home during the study period. Of these, 250 had appointments scheduled, and 167 (66.8%) kept these appointments (Group 1). The average age was 69.2 and 68.3 with average LACE of 9.7 and 9.5 for groups 1 and 2 respectively. There was no significant difference in rates of diabetes or heart failure between groups. There were 7 (3.6%) readmissions in group 1 and 19 of 83 (22.9%) in group 2. Five patients were readmitted prior to appointment time in group 2, so were not entered into final calculation; this left readmission rate of 14/83 (16%); p =0.004.

Conclusion:
Urgent follow up with PCP may prevent hospital readmission in those with mild strokes. Reverse causation, from missing appointment due to hospital readmission did not account for these results. Although NIHSS was not compared, our cohort consisted of those with mild symptoms, given home disposition. Further study is needed to determine which elements of the PCP follow up visit are most effective in reducing hospital readmission.

Reference:

1. Lichtman, JH. Leifheit-Limson, EC. Predictors of Hospital Readmission after Stroke: A Systematic Review Stroke. 2010; 41(11): 2525-2533.
Abstract T P390: Baseline Stroke Knowledge of 4th-6th Grade Children in New York City Public Schools Has No Appreciable Trend from 2005-2014
Authors: Noble James M , Simmons Cailey , Hecht Mindy F , Williams Olajide
Published: July 2021

Background and Purpose:
To examine whether the baseline stroke knowledge of children in schools participating in our Hip Hop Stroke program has changed since its inception in late 2005.

Methods:
We gathered baseline stroke knowledge surveys from 2,839 students enrolled in the Hip Hop Stroke program from November 2005 through April 2014 with median annual enrollment of 344 (range 55 to 582). All students were enrolled in New York City public schools, in 4th through 6th grade. Students who left ≥3 questions blank were discarded; other blank answers were treated as missing. Data were analyzed using binomial, Chi-Square and regression analysis (SPSS v22.0).

Results:
Overall there was no consistent trend in baseline stroke knowledge by academic year. Overall, 28.4% of students recognized stroke occurred in the brain (expected value 25% [p<0.001], range from 13.8-61.2% for any given year). With stroke diagnosis provided, 85.5% of 1436 students knew to call 911, whereas only 59.6% of 1243 students knew to call 911 when given a hypothetical real-world stroke symptom scenario without stroke diagnosis included, p<0.001. For a composite assessment of knowledge including 4 stroke symptoms (blurred vision, facial droop, sudden headache, slurred speech), 1 distractor (chest pain), and urgent action plan (call 911), asked consistently since 2006, overall students scored a mean 2.86 (95% CI: 2.80-2.92; possible range 0-6, expected value 2.75), with annual scores ranging from 2.54-3.56.

Conclusion:
Stroke knowledge among elementary school students remains low and has not appreciably changed during the last 9 years. The use of hypothetical real-world stroke symptom scenarios may more accurately reflect intent to call 911 for stroke than the use of questions in which stroke diagnosis is given.
Abstract T P391: Stroke Knowledge Among Children Is Associated With Measures Of Economic Need
Authors: Noble James M , Simmons Cailey , Hecht Mindy F , Williams Olajide
Published: July 2021

Background and Purpose:
To identify potential community- and school-level quality measures which may influence trends in baseline stroke knowledge of children participating in the Hip Hop Stroke program from 2005-2014.

Methods:
We gathered baseline stroke knowledge surveys from 2,839 available surveys of 4th, 5th, and 6th grade students enrolled in the Hip Hop Stroke program from November 2005-April 2014. We explored several objective standardized factors assessed city-wide, including performance grade (letter categories A-F, as measured via standardized testing) and economic need index (incorporates subsidized housing and meals; range 0-2 and higher scores indicate higher needs; example: a value of 2 indicates 100% students requiring food and housing subsidies or support). Students who left ≥3 questions blank were discarded; other blank answers were treated as missing. Data were analyzed using Chi-Square and regression analysis (SPSS v22.0).

Results:
Schools studied included those with performance grades B (n=196), C (n=1590), and D (n=1053) and mean economic need index of 0.85 (SD 0.23). For a composite assessment of knowledge including 4 stroke symptoms (blurred vision, facial droop, sudden headache, and slurred speech), 1 distractor (chest pain), and urgent action plan (call 911), asked consistently since 2006, overall students scored a mean 2.86 (95% CI: 2.80-2.92; possible range 0-6, expected value 2.75). For quartiles of economic need, means scores ranged from Q1: 2.89 (95% CI: 2.79-2.99), Q2: 3.08 (95% CI: 2.96-3.20), Q3: 2.77 (95% CI: 2.66-2.89), and Q4: 2.57 (95% CI: 2.43-2.71), p-trend <0.001. Students at B schools scored 2.96 (95% CI: 2.72-3.20), C: 2.93 (95% CI 2.85-3.01), D: 2.71 (95% CI: 2.63-2.81), p-trend=0.001.

Conclusion:
Lower student knowledge of stroke is strongly associated with measures of greater economic need and lower school performance. Consideration should be given to focus implementation of stroke education campaigns in schools and communities with higher needs.
Abstract T P396: Endothelial Inflammation Correlates with Severity of Bleed and Outcome in SAH Patients
Authors: Lee James , Gordon Errol L , Bederson Joshua B , Sobotka Stanislaw , Mayer Stephan A , Sehba Fatima A
Published: July 2021

Introduction:
Subarachnoid hemorrhage (SAH) is a devastating disease that portends a high rate of morbidity and early mortality in its patients. Although brain injury that is assumed in the early phases of SAH is an important prognosticator of functional outcome, the underlying mechanism behind the acute phase of the disease is still poorly understood. The aim of this study is to investigate endothelial inflammation in the early phases of SAH, and to determine its association with severity of bleed, mortality risk, and functional outcome.

Hypothesis:
We hypothesize that endothelial inflammation will be higher in SAH patients with severe bleed and poor functional outcome.

Methods:
Patients (n=15) admitted to our neurosurgical intensive care unit within 24 hours of bleed onset (day 1) and angiographic evidence of aneurysmal SAH were identified. Endothelial inflammation was studied as intracellular adhesion marker-1 (ICAM-1) levels in blood samples drawn at admission and on days 3 and 7 post-SAH (ICAM-1 ELISA; R&D Systems). Severity of bleed and patient status at admission was studied via Hunt Hess (HH) (1-5) grade and modified Fisher (mF) score (0-4), and 7-day outcome was assessed via Rankin functional and NIHSS score. ANOVA and Pearson correlation analyses (SAS) were used to assess the data.

Results:
ELISA analysis demonstrated that levels of ICAM-1/CD54 were significantly greater in high grade (grade 4) mF score (p=0.025, ANOVA), and correlated to higher Rankin score (p=0.0097, Pearson). HH scores when grouped as 1,2 vs 3 vs 4,5 showed a positive trend in relation to increased ICAM-1/CD54 (p=0.087, ANOVA). No correlation between ICAM-1 level and NIHSS score was found.

Conclusion:
Endothelial inflammation (ICAM-1/CD54 levels) associates with severity of bleed and poor 7 day outcome, and hence may serve as a useful biomarker for assessment of clinical severity of bleed in SAH patients.
Abstract T P399: Patient Characteristics and Outcomes in Pregnancy-Related Subarachnoid Hemorrhage
Authors: Leffert Lisa , Clancy Caitlin , Bateman Brian , Cox Margueritte , Schulte Phillip , Smith Eric , Fonarow Gregg , Schwamm Lee , George Mary , Kuklina Elena
Published: July 2021

Background:
Subarachnoid hemorrhage (SAH) accounts for up to 4.1% of all pregnancy-related in-hospital deaths, but is less often aneurysmal and is associated with better short term outcomes than in non-pregnant patients. We sought to describe the risk factors, management and outcomes of pregnant vs. non-pregnant patients with SAH in the Get With The Guidelines (GWTG) Stroke Registry.

Methods:
Using medical history or ICD-9 codes, we identified 152 pregnant and 5745 non-pregnant SAH female patients aged 18-44 with SAH in GWTG from 2008-2013. Differences in characteristics were compared by Chi-square tests for categorical and Wilcoxon Rank-Sum tests for continuous variables. Stratified logistic regression assessed the effect of pregnancy on outcomes conditional on age and adjusted for patient and hospital characteristics.

Results:
Pregnant SAH patients were younger, more often black and insured with Medicaid. They had higher initial blood pressure (BP) and were less likely to report prior hypertension. Arrival delays from stroke onset were common in both groups (median 340 vs. 277 min), but pregnant SAH patients were more often already hospitalized at stroke onset (16% vs. 10%). Fewer pregnant vs. non-pregnant SAH patients had initial neurologic exam findings recorded (Table). Pregnant SAH patients had lower in-hospital death than non-pregnant patients (aOR 0.17, 95% CI 0.06-0.45) and were more likely at discharge to ambulate independently (aOR 2.40, 95% CI 1.56-3.69) and return home (aOR 2.60, 95% CI 1.67-4.06).

Conclusions:
Several differences exist between pregnant and non-pregnant women with SAH. Many present with BP well below the threshold for hypertensive disorders of pregnancy, making prompt recognition and prevention of brain hemorrhage challenging. Overall, pregnancy-related SAH is associated with less morbidity and mortality than non-pregnancy related disease.
Abstract T P413: Early Executive Dysfunction Predicts Poor Stroke Outcomes One Year Following Mild Ischemic Stroke
Authors: Chen Hui-Chun , Dromerick Alexander W , Kidwell Chelsea S , Edwards Dorothy F
Published: July 2021

Background:
Cognitive dysfunction has been considered a primary deficit to be addressed after mild stroke. Higher order cognitive deficits immediately after mild stroke may lead to poor longitudinal outcomes. However, existing stroke outcome studies tend to focus on physical capacity and mood rather than cognitive function.

Aim:
To examine contribution of acute impairment of executive function(EF) and verbal memory (VM) after mild stroke to one year outcomes on Stroke Impact Scale (SIS, health-related quality of life), Activity Card Sort (ACS, activity participation), and Reintegration to Normal Living (RNL, life satisfaction), independent of demographics, ADL and depression.

Methods:
Patients with ischemic stroke and initial NIHSS ≤ 5 enrolled in PROTECT-DC trial were included. Multiple linear regression analyses identified baseline variables significantly associated with each outcome of interest for all patients completing both baseline and one-year assessments. For each outcome, Model 1 included covariates: age, sex, race, education, lesion side, NIHSS, Barthel Index, Lawton IADL, and depression. In Model 2, all Model 1 variables and dichotomized cognitive variables (impaired versus not impaired) were entered into the equation. Examination of R2 change between Models 1 & 2 identified unique contributions of impaired EF or VM to each one-year outcome beyond Model 1 variables.

Results:
A total of 86 participants completed baseline assessment and one-year SIS were included for analyses. Our results show that EF was significantly and independently associated with the SIS total score beyond other baseline variables. Participants with acute EF deficits at baseline had poorer SIS outcome at one year: mean 7.47 lower SIS score compared to patients without EF deficits (p = .021). Similar results were found for ACS and RNL.

Conclusion:
Analyses suggest impact of EF deficits on activity participation, health-related quality of life, and life satisfaction one year after mild stroke. The findings highlight importance of assessment of EF deficits after mild stroke. We suggest that rehabilitation interventions aimed at improving long-term outcomes require careful consideration of assessing and treating EF deficits during the acute phase of mild stroke.
Abstract T P59: Brain Atrophy Rates Not Affected By Stroke Thrombolysis
Authors: Brodtmann Amy
Published: July 2021

Introduction:
Despite clear outcome benefits, some physicians remain concerned about theoretical deleterious effects of intravenous thrombolysis. In the CANVAS study (Cognition and Neocortical Volume After Stroke) we have reported brain volume changes in patients following stroke. We sought here to compare brain atrophy rates of 3 groups of patients presenting with MCA stroke, versus a group of healthy control participants.

Hypothesis:
We hypothesized that IV thrombolysis would not affect brain atrophy rates following stroke.

Methods:
Three groups of patients with acute ischemic MCA stroke were included, 2 of whom received thrombolysis: 10 patients were imaged at 2 hours and at 3 months (Copenhagen cohort) and 9 patients imaged within 30 days of symptom onset and at 3 months (Melbourne CANVAS cohort). We compared regional and global brain volume and atrophy rates with 10 patients who did not receive thrombolysis and a group of 10 healthy control participants were also imaged at these timepoints. 3D MPRAGE images were acquired on a Siemens Trio 3T MRI scanner. Images were processed using Freesurfer V 5.1 with default settings. We compared baseline and 3 month average regional cortical thickness. Ipsilesional and contralesional results were analyzed separately. Paired sample t-tests were used to assess significant change.

Results:
There was no significant difference in brain volume between the 2 timepoints in our control participants. Ipsilesional white matter (WM) and gray matter (GM) volume declined over the 3 month period in all 3 stroke groups. There was no significant difference in brain atrophy rates between stroke patients who received IV thrombolysis and those who didn’t.

Conclusions:
In this pilot study, we found that thrombolysis did not affect brain atrophy rates in the stroke patients studied.
Abstract W MP73: EMS Triage of Stroke Patients by Stroke Severity: Estimated Impact and Call to Action
Authors: Broderick Joseph P , Sucharew Heidi , Alwell Kathleen A , Kissela Brett M , Khoury Jane , Woo Daniel , Adeoye Opeolu , Flaherty Matthew L , Khatri Pooja , Ferioli Simona , Moomaw Charles J , Kleindorfer Dawn
Published: July 2021

Background:
Severely affected stroke patients in most U.S. communities are often brought to the nearest or requested community hospital rather than to a comprehensive stroke center. We hypothesized that the additional time to transport these severely affected stroke patients directly to a comprehensive stroke center rather than to a nearby community hospital within the Greater Cincinnati/Northern Kentucky (GCNK) Region would be less than a mean of 15 minutes.

Methods:
We included all stroke subjects in the GCNK region during 2005 who were >= age 20, had a documented time of symptom onset, were transported by EMS, lived at home, and had their stroke at home. Pt home addresses and hospitals were geocoded and travel time estimated using road class speed limits for the route with the shortest driving time to the presenting hospital as well as the comprehensive stroke center. The estimated baseline NIHSS was abstracted from hospital medical records and severe strokes were defined as an estimated NIHSS >=15.

Results:
Of 2628 hospitalized stroke subjects during 2005, 1019 arrived by EMS of which 469 had a clearly documented time of stroke onset. Of these, 348 occurred at home. Of the 348, 8 could not be geocoded. Of the remaining 340 subjects, 90 (26%) had an NIHSS >=15. The types of strokes and estimated travel times for these 340 subjects are listed in the Table below.

Conclusions:
Within the GCNK region, triage of severe stroke patients by EMS personnel from a patient’s home to a comprehensive stroke center, rather than to a nearby or requested community hospital, would add only an average of 6 additional minutes in travel time and would have little effect upon start of IV t-PA therapy. Such triage of stroke patients transported by EMS would facilitate rapid interventional therapy for severe ischemic strokes and assessment, treatment, and neurocritical critical care for ICH and SAH
Abstract W MP76: Diagnostic Accuracy and Characteristics of Missed Ischemic Strokes in the Emergency Department
Authors: Arch Allison E , Nystrom Karin V , Coca Steven , Wira Charles R , Schindler Joseph L
Published: July 2021

Objectives:
The failure to recognize an acute stroke in the ED represents a missed opportunity for potential thrombolytic therapy and for prompt treatment for secondary prevention. The aim of this study was to examine the diagnostic accuracy of acute ischemic strokes at a large academic center and to identify common characteristics of these missed strokes.

Methods:
A retrospective review was performed on a random sample of patients >18 years old with a discharge diagnosis of ischemic stroke in 2013. All acute strokes were confirmed on CT or MRI. A stroke was “missed” if practitioners in the ED did not initially consider stroke in the differential, or the diagnosis was delayed causing the patient to miss the therapeutic window for thrombolytic therapy.

Results:
Two hundred ischemic stroke patients were included in the study. The mean patient age was 72 years, and the mean initial NIHSS was 7. There were 36 “missed” strokes (18%) in this population. Of the strokes that were initially misdiagnosed, 20 of 36 (56%) presented in the time window for thrombolytic therapy and potentially could have received intervention. Posterior circulation strokes were more likely to be missed overall (20/58 posterior, 34%, vs 16/142 anterior, 11%, p < 0.001). Seventy-six percent of patients with posterior stroke had stroke in the original differential compared with 96% in those with anterior circulation stroke (p < 0.001). Symptoms independently associated with posterior circulation strokes included nausea/vomiting (OR=6.9, 95% CI: 2.0-23), headache (OR=6.4, 95% CI: 1.5-27) and difficulty walking (OR=3.5, 95% CI: 1.3-9.5). Anterior circulation patients more commonly presented with focal weakness (OR=0.11, 95% CI: 0.05-0.25) and aphasia (OR=0.17, 95% CI: 0.06-0.45).

Conclusions:
Despite having a certified stroke program in a large academic medical center, 18% of acute ischemic strokes were missed in the ED. Posterior circulation strokes were 3 times more likely than anterior strokes to be missed. Posterior stroke patients were more likely to present with nausea/vomiting, headache and difficulty walking, and these symptoms should serve as triggers to consider ischemic stroke in the ED.
Abstract W MP86: Microrna-146a Modulates Neurogenesis And Oligodendrogenesis After Stroke
Authors: Liu Xianshuang , Michael Chopp , Wang Xinli , Zhang Li , Cui Yisheng , Zhang Yi , Zhang Ruilan , Zhang Zhenggang
Published: July 2021

Background:
Neurogenesis and oligodendrogenesis are associated with functional recovery after stroke. However, the molecules that regulate the generation of new neurons and oligodendrocytes have not been fully investigated. MicroRNAs (miRNAs) post-transcriptionally regulate gene expression. MiR-146a has been reported to regulate the immune response in cells, but the role of miR-146a in neural (NPCs) and oligodendrocyte progenitor cells (OPCs) remains unexplored. Methods and Results: Adult Wistar rats were subjected to right middle cerebral artery occlusion (MCAo). In situ hybridization using locked nucleic acid (LNA)probes against miR-146a showed that stroke considerably increased miR-146a density in the subventricular zone (SVZ, 19 ± 1 vs 6 ± 0.1 area/mm2 in non-MCAo group, p<0.05, n=4/group) and corpus callosum (24 ± 3 vs 8±1 area/mm2 in non-MCAo group) of the ischemic hemisphere. Quantitative RT-PCR also demonstrated a marked upregulation of miR-146a transcript in ischemic NPCs (8.5 fold), suggesting an important role in stroke-induced neurogenesis and oligodendrogenesis. To test its biological function, we over-expressed miR-146a in neural progenitor cells by transfection of miR-146a mimics using nucleofector and found that elevation of miR-146a significantly increased the percentage of Tuj1+ neuroblasts (5 ± 0.3 vs 1 ± 0.2%, p<0.05, n=6/group) and O4+ OPCs (10 ± 1 vs 4 ± 0.4%, p<0.05). Moreover, over-expression of miR-146a in primary cultured OPCs significantly increased several myelin proteins including MBP and PLP, and decreased levels of OPC marker proteins including PDGFRα and NG2, whereas attenuation of miR-146a by siRNA against miR-146a suppressed myelin proteins and augmented OPC marker proteins. Furthermore, miR-146a levels in the OPCs were inversely related to IRAK1 proteins, one of miR-146a target genes. Attenuation of IRAK1 in OPCs substantially increased myelin proteins, indicating that miR-146a mediates oligodendrocyte maturation via targeting IRAK1. Conclusion: Our data provide new insight into molecular mechanisms underlying stroke-induced neurogenesis and oligodendrogenesis by revealing a novel role of miR-146a in NPCs and OPCs, which has potential to be used as a new therapy for neurorecovery after stroke.
Abstract W P128: The Effect of Obesity on K-Modified Barthel Index at 6 Months after Stroke: A Prospective Multicenter Study
Authors: Jang Shin Yi , Kim Yun-Hee , Sohn Min Kyun , Lee Jongmin , Kim Deog Young , Lee Sam-Gyu , Shin Yong-Il , Oh Gyung-Jae , Lee Yang-Soo , Joo Min Cheol , Han Eun Young , Lim Young Shil , Chang Won Hyuk , Lee Ahee , Kim Jeong Hyun
Published: July 2021

Introduction:
Previously, association between body mass index (BMI) and K-Modified Barthel Index (KMBI) score was reported. However, few studies investigated the value of obesity as a predictive factor of 6 months functional outcome after stroke.

Aims:
The aim of this study is to examine whether BMI predicts the 6-month KMBI after stroke onset with adjustment for cardiovascular disease risk factors socioeconomic position and health behavior factors in stroke patients.

Methods:
This is an interim report of the Korean Stroke Cohort for Functioning and Rehabilitation (KosCo). The sample included 1,299 stroke patients, both ischemic and hemorrhagic, aged 18-92 years. FIM score was assessed at 6 months after stroke onset. Subjects were classified into three groups based on their baseline BMI categories at admission: normal (18.5 ≤ BMI < 23), overweight (23 ≤ BMI < 25), or obese (BMI ≥ 25) groups.

Results:
The mean age was 64.1 (±12.8) years. The distribution of overweight and obese groups was 28.5 % and 36.3 %, respectively. The mean 6-month KMBI was 85.6 (±27.6) and 88.0 (±26.0), respectively. The 6-month KMBI significantly increased in obese group compared to the normal BMI group after adjustment for confounding factors. In the ischemic stroke, the 6-month KMBI was increased in the obese group (p<0.05), but not in the hemorrhagic stroke.

Conclusions:
This hospital-based cohort study showed that obesity measured by BMI may predict good 6 months functional outcome, especially, for the ischemic stroke patients (Supported by Korea Centers for Disease Control and Prevention (2013E3301701)).
Abstract W P141: Anti-Gravity Treadmill Training Leads to Superior Walking Ability Compared to Conventional Physical Therapy in Chronic Community Dwelling Stroke Survivors
Authors: Popp Heather , Breen Joan , Ferlito Tom , Kiley Sandy
Published: July 2021

The Anti-gravity (AG) treadmill is a new modality, initially used by athletes and astronauts allowing precise unweighting up to 80% of body weight. Patients are enclosed in a cockpit which unweights by filling with air, allowing patients to be safely progressed at higher speed and longer durations than the conventional treadmill. Only a few case studies report outcomes of stroke patients using this system.

Methods:
We trialled the AG system on 9 (5 men, 4 women) community dwelling, chronic stroke patients between 6/2014 and 8/2014 as part of an outpatient physical therapy (PT) program. 7/9 patients received AG treatment following conventional treadmill training, while 2 began new PT treatments with the AG system. Endurance was measured with the standardized 6 minute walk test before initiation and after completion of AG system treatments. Various other PT and stroke outcomes were measured.

Results:
8 ischemic and 1 hemorrhage stroke patients with average age 63 (49-79); average NIHSS of 7.9 (range 3-15) and Modified Rankin Scores of 4 for 5 patients and 3 for 4 were treated an average of 21.4(range 11-86) months post stroke. Patients received an average of 5 sessions (2-8) over an average of 2.8 weeks ((1-4). Blood Pressures monitored pre and post each treatment were stable. No adverse complications or pain occurred. All patients reported subjectively experiencing improvement in gait quality with AG system use. 89% (8/9) patients had improved 6" walk test scores following AG treatments. 7/9 patients had received conventional treadmill training during skilled PT prior to initiation of AG treatments. In the 1 month prior to AG treatment, 3/7 of these patients had worsening of 6" walk scores; 2/7 improved, and 2/7 had no change. Of the 7/9 patients receiving AG treatment following usual treadmill training, 6/7 had improved 6" walk scores (range 2-17%). 6 minute walk scores improved by 81% and 1% in 2 patients initiating AG training without preceding treadmill training. All patients had improved walking duration and speed on AG compared to traditional treadmill.

Conclusions:
AG treadmill treatment was reported to be positive and led to improved walking and endurance compared to conventional treadmill training in this pilot group of chronic community dwelling stroke patients.