bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP341: Experimental Internal Carotid Artery Stenosis Models Pathogenic Features of Moyamoya Syndrome
Authors: Wodrich Andrew P , Roberts Jill M , Fraser Justin F , Bix Gregory J
Published: January 2019

Introduction:
Moyamoya is an arteriopathy defined by the progressive stenosis of the intracranial internal carotid arteries accompanied by the formation of abnormal vascular networks. To address the paucity of research on the adult-onset Moyamoya Syndrome, which completely lacks any animal model for evaluation, our lab created a novel surgical technique, termed internal carotid artery stenosis (ICAS), that attempts to model the cerebrovascular changes seen in the human Moyamoya Syndrome. We hypothesized that the ICAS model would mimic the key proposed pathogenic features of Moyamoya Syndrome; namely, intimal hyperplasia of the major vessels of the cerebrovasculature leading to vessel stenosis and the formation of small, compensatory collateral arteries.

Methods:
ICAS (n=9) and sham (n=6) surgeries were performed in a randomized fashion on male C57Bl/6 mice (age=16 weeks). Brain tissue sections and RNA were collected 28-days post-surgery. Intimal hyperplasia was assessed with a modified Verhoeff-van Gieson stain. Expression of genes associated with human Moyamoya Syndrome (VEGF, SDF-1α, MMP-9, bFGF, VCAM-1, and MCP-1) was quantified by qPCR. MatLab and PRISM software were used for data analysis.

Results:
ICAS induces intimal hyperplasia of the cerebrovasculature (
p
=0.033). ICAS increases genetic expression of VEGF in the whole brain (fold change=0.60,
p
=0.050) and SDF-1α in the striatum (fold change=0.59,
p
=0.016), and decreases genetic expression of MMP-9 in the ipsilateral cortex (fold change=0.39,
p
=0.044). Furthermore, a trend indicates that ICAS may increase genetic expression of VCAM-1 in the ipsilateral striatum (fold change=0.33,
p
=0.109).

Conclusions:
The present finding that ICAS induces intimal hyperplasia and alters genetic expression supports ICAS as a relevant model of the proposed pathology of Moyamoya Syndrome. The upregulation of VEGF, SDF-1α, and VCAM-1 is indicative of angiogenesis, hypoxia-induced vasculogenesis, and ischemia-induced inflammation, while the downregulation of MMP-9 may indicate decreased extracellular remodeling in the cortex. While investigation of the long-term effects of coil-placement is needed, ICAS may provide a crucial model for development of therapies for Moyamoya Syndrome.
Abstract WP344: Abdullah Al mamun
Authors: Mamun Abdullah Al , Sharmeen Romana , McCullough Louise D , Liu Fudong
Published: January 2019

Introduction:
Ischemic stroke is becoming increasingly recognized as a sexually dimorphic disease. However, the mechanisms underlying the sex dichotomy are complicated and remain elusive. We have reported that the sex chromosome complement contributes to the stroke sensitivity in aged animals.
Kdm6a
and
Kdm5c,
two genes escaping from X chromosome inactivation (XCI), are demethylases of H3K27me3 and H3K4me3 respectively. The two genes have higher expression in XX vs. XY cardiac tissue and are implicated in mediating expression of inflammatory mediators. We hypothesize that
Kdm6a
and
Kdm5c
are also differently expressed in brains of mice with two vs. one copy of X chromosome, and lead to sex differences in post-stroke inflammation and stroke outcomes in aged mice.

Methods:
Aged (18-22 months) WT C57BL/6 and FCG mice (XXF, XYF, XXM, and XYM) were subjected to a 60-minute middle cerebral artery occlusion (MCAO). Stroke outcomes including infarct size and behavior deficits were evaluated at 3d of MCAO. Initial screening of X-escapee genes was performed by RNAseq. Microglial activation and peripheral immune cell infiltration were determined by flow cytometry (FC). Expression of Kdm6a and kdm5c was evaluated by RT-PCR and IHC. Epigenetic markers (H3K27me1/3 and H3K4me1/3) downstream to Kdm6a and kdm5c were examined by Western blot.

Results:
RNAseq data revealed a significantly higher mRNA levels of
Kdm6a
and
Kdm5c
in WT female vs. male microglia. WT female brains had dramatic increase of both kdm6a and kdm5c expression after MCAO compared to male brains, corresponding to higher levels of H3K27me1 and H3K4me1 in females. Brain mRNA levels of Kdm6a and Kdm5c were also significantly increased in XXF/XXM compared to XYF/XYM FCG mice. Importantly, microglia from XXF/XXM mice express more Kdm6a and kdm5c than XYF/XYM microglia, accompanied by higher expression of H3K27me1 and H3K4me1 in XXF and XXM mice brains. XXF/XXM microglia had higher levels of intracellular pro-inflammatory cytokines (TNFα, IL1β, iNOS, IL6) after stroke.

Conclusion:
Mice with two X chromosomes have robust expression of kdm6a and kdm5c in microglia that leads to high epigenetic modification of inflammatory gene expression. XCI escaping may be critical in mediating stroke sensitivity in aged mice.
Abstract WP345: Impaired Platelet Function After Combination Treatment With Aspirin and Clopidogrel Contributes to tPA Associated Hemorrhagic Transformation Following Experimental Stroke
Authors: Lieschke Franziska , Zheng Yi , Schaefer Jan Hendrik , Foerch Christian , Wang Xiaoying , Lo Eng H , van Leyen Klaus
Published: January 2019

Introduction:
Thrombolytic treatment under dual antiplatelet therapy (DAPT) is usually performed with great restrictions due to an increased risk of hemorrhagic transformation (HT). This translational study aimed to explore the risk of tPA-associated HT under DAPT with Aspirin and Clopidogrel (ASA+CPG), particularly focusing on the evaluation of recently developed clinical strategies to reduce HT. To monitor DAPT efficiency and to further investigate tPA effects on platelets, we successfully established a flow cytometry based test of platelet function.

Hypothesis:
The impaired platelet function after DAPT contributes to tPA associated HT following ischemic stroke.

Methods:
Male C57/BL6 mice were fed with ASA+CPG or placebo via drinking water for 3 days. Platelet function was assessed in vitro using flow cytometry. Animals were subjected to 2h MCAO, followed by tPA treatment when indicated. 24h later standard tail bleeding tests were conducted and HT was quantified by measuring hemorrhaged areas on the brain surface and in brain sections using ImageJ. Sample sizes varied between 8 to 15 mice per group.

Results:
In ASA+CPG treated mice, platelet function (indicated by the expression of CD62P) was significantly reduced by 40.55±4.23% (p<0.0001) compared to controls. The decreased CD62P expression rate correlates inversely with increased HT and prolonged tail bleeding tests (r=-0.8, p=0.0033, n=12). ASA+CPG led to significant HT after 2h MCAO and tPA treatment (increased by 90.25±26.57% compared to controls following 2h MCAO and tPA, p=0.0055), which persisted when low-dose tPA was used instead of the standard dose (HT increased by 85.24±27.48% in ASA+CPG treated mice compared to low dose tPA in controls, p=0.01). In the absence of tPA, ASA+CPG treatment increased HT non-significantly. In 2h MCAO mice, tPA did not by itself result in HT in this model.

Conclusions:
Using our flow cytometry-based platelet function assay, we demonstrated that ASA+CPG treatment reduces CD62P expression rates, which is a reliable indicator of impaired platelet function. Investigating the in vivo effects of this impairment, we found that, ASA+CPG results in significant hemorrhage in mice given 2h MCAO and tPA administration, when using both low- or high-dose tPA.
Abstract WP346: A Cost-effective and Reproducible Mouse Model of Intracranial Aneurysm: Renal Hypertension and Local Hemodynamic Change Combined With Elastase Infusion
Authors: Jin Jinghua , Zhang Junhao , Wang Yaqi , Xu Jing
Published: January 2019

Introduction:
The study of animal models of intracranial aneurysms (IA) can improve our understanding of the IA pathogenesis and identify the potential pharmaceutical targets. Although a variety of mouse models of IA have been described, all the models have their limitations. We here modified the current models and established a cost-effective and reproducible mouse model that recapitulates the key features of human IA.

Methods:
In adult C57black/6 male mice, the left common carotid arteries and the left renal arteries were ligated with high salt diet. One week later, 35 mU elastase was stereotactically injected into the right basal cistern. The animals were closely monitored each day for any neurological symptoms until the end of the study. All asymptomatic mice were euthanized 4 weeks after stereotactic injection and the circle of Willis (COW) was inspected under microscope for the presence of aneurysm and/or signs of rupture. Histological analyses were then performed to evaluate the pathological features of IA. Quantitative real-time PCR was employed on COW tissue to compare the expression of IA-pathogenesis associated genes between IA-inducing group and sham operative controls group.

Results:
All of the mice in the IA-inducing group were developed various aneurysmal changes within COW (n=40). A total of 67.5% (27/40) of the mice were successfully induced saccular IA (sIA) and 11% (3/27) had ruptured aneurysms. The average sIA number for each mouse is 1.4 (38/27). Histologically, aneurysms observed in this model closely resembled human IA including fragmentation of internal elastic lamina, thinning or discontinuities of the smooth muscle cell layer, and F4/80 positive macrophage infiltration within the aneurysm wall. Gene expression assay revealed that IA induction significantly increased expression of inflammation (
NF-κBp65, TNF-α,
IL-1β, IL-8
), matrix remodeling (
MMP-2, TIMP-3
), EC marker (
Vinculin
) and VSMC marker (
KIF5
) genes.

Conclusion:
This model can serve as a useful tool for future studies that utilize various inhibitors, knockout mice, or transgenic mice to test how specific molecules and pathways influence IA development.
Abstract WP35: A Comparison of Transradial versus Transfemoral Access in Anterior Circulation Mechanical Thrombectomy
Authors: Chen Stephanie H , Snelling Brian , Sur Samir , Shah Sumedh , McCarthy David , Luther Evan , Yavagal Dileep , Starke Robert M , Peterson Eric C
Published: January 2019

Background:
The transradial approach (TRA) to endovascular procedures decreases access site morbidity and mortality when compared to the traditional transfemoral technique (TFA). Despite its improved safety profile, there remains concerns that performing mechanical thrombectomy (MT) via TRA may lead to longer revascularization times and thus worse outcomes. However, TRA may confer an added benefit in mechanical thrombectomy (MT) where navigation of challenging aortic arch and carotid anatomy is often facilitated by a right radial artery trajectory. In this study, we compare technical and clinical outcomes in patients who underwent MT via TRA versus TFA.

Methods:
We performed a retrospective review of our institutional database to identify 51 patients with challenging vascular anatomy who underwent MT for anterior circulation large vessel occlusion between February 2015 and February 2017. Patient characteristics, procedural techniques, and outcomes were recorded and TFA and TRA cohorts were compared.

Results:
Of the 51 patients, 35% of patients (n=18) underwent MT via TRA. There were no significant differences between the cohorts in patient characteristics, clot location, or aortic arch type and presence of ICA tortuosity. There were no significant differences in technical or clinical outcomes between the 2 cohorts, including rates of single-pass recanalization (54.6% vs. 55.6%, p=0.949) and average number of passes (1.9 vs. 1.7, p=0.453). Mean time from vascular access to reperfusion (61.9 vs. 61.1 mins, p=0.920), rates of successful revascularization (>= TICI2b; 87.9% vs. 88.9%, p=1.0) and functional outcomes (mRS >=2, 39.4% vs. 33.3%, p=0.669) were also similar between the TFA and TRA cohorts, respectively.

Conclusions:
Our results demonstrate equivalence in efficacy and efficiency between transradial and transfemoral access for MT in acute large vessel occlusion in the anterior circulation in patients with challenging vascular anatomy. Given the established advantage in access-site morbidity, our data suggests that the transradial approach may be superior to the transfemoral approach in well-selected patients undergoing MT.
Abstract WP350: Detecting Endogenous Neurogenesis After Ischemic Stroke: A F-18-fluorothymidine PET Study
Authors: Tsai Hsin-Hsi , Yen Ruoh-Fang , Tsai Yi-Chieh , Tsai Li-Kai
Published: January 2019

Background and Purpose:
Adult neural stem cells (NSCs) can be activated after stroke, but currently noninvasive imaging technique to visualize cerebral neurogenesis is lacking. F-18-fluorothymidine (FLT) has been used as a PET tracer to image cell proliferation and could detect endogenous NSCs
in vivo
. In this study, we assessed the change in cerebral FLT uptake in a rat model of ischemic stroke.

Methods:
Cerebral FLT PET was performed in rats subjected to transient middle cerebral artery occlusion (MCAO). PET data were semiquantitatively analyzed and expressed as average mean standardized uptake value ratios (SUVRs) of regions of interest using cerebellar cortex as the reference region. Neurological function was assessed via modified Neurological Severity Score (mNSS) 1 day after MCAO, and infarct volume was analyzed by 2,3,5-Triphenyltetrazolium chloride staining method 7 days after MCAO.

Results:
Seven days after MCAO, rats exhibited a higher number of Ki67 immunoreactive cells at the subventricular zone, striatum, frontal and temporal cortices in the infarcted brain, indicating promotion of neurogenesis (Figure 1A). The FLT PET showed higher SUVR in the infarcted brain compared to the unaffected side (Figure 1B; Striatum: 1.03±0.36 vs 0.74±0.16, p=0.001; Frontal: 1.14±0.27 vs 0.96±0.13, p=0.004; Temporal: 1.16±0.26 vs 1.00±0.15, p=0.01). The cerebral FLT binding activity gradually declined from post MCAO day 7 to day 28 in the infarcted brain (Figure 1C and D). The FLT binding ratio (global SUVR in the infarcted brain divided by that in the contralateral side) was positively correlated to the severity of stroke, including mNSS (r=0.70, p<0.001) and infarct volume (r=0.90, p<0.001).

Conclusion:
In vivo
FLT PET can detect NSCs in a rat model of ischemic stroke. The promising results of FLT PET suggest that it can be potentially applied in clinical studies as noninvasive longitudinal monitoring and quantification of endogenous NSC activation in the human brain.
Abstract WP351: Lung-Specific Extracellular Superoxide Dismutase Blocks Neutrophil-Mediated Toxicity in Brain Ischemia-Reperfusion
Authors: Mai Nguyen , Gates Kathleen , Prifti Landa , Lim Kihong , O'Reilly Michael , Kim Minsoo , Halterman Marc W
Published: January 2019

Introduction:
Tissue damage and neuroinflammatory responses associated with cerebral ischemia trigger a systemic immune response that exacerbates brain injury during reperfusion and adversely influences functional recovery. Polymorphonuclear neutrophils (PMNs) are the first-line response to inflammation following acute brain injury, and evidence implicates lung-dependent PMN depriming as a critical endogenous protective mechanism against reperfusion injury.

Methods:
We explored mechanisms of PMN priming and neurotoxicity with
in vivo
modeling of systemic inflammation after brain ischemia-reperfusion as well as cellular culture experiments. Using transgenic mice overexpressing the human antioxidant gene superoxide dismutase 3 in the lung (TgSOD3), we tested the hypothesis that manipulation of the lung’s redox environment could mitigate PMN activation and post-ischemic brain injury. Injury was induced by occlusion of the common carotid and basilar arteries followed by reperfusion and lipopolysaccharide-induced systemic inflammation. To assess cell interactions using live microscopy, we cultured primary cortical neurons after oxygen-glucose deprivation (OGD) with primed PMNs from wild-type or TgSOD3 mice.

Results:
Our results show that pulmonary SOD3 protects against peripheral PMN activation, lung injury, brain injury, and neuroinflammation after ischemia/reperfusion with systemic inflammation. We also found that PMNs from TgSOD3 mice are less toxic to post-OGD cultures compared to wild-type PMNs. Our data indicate that direct cell-cell contact is required for PMN-dependent neurotoxicity in mixed cellular cultures and that pre-exposure of neurons to OGD amplifies this response. Analyses reveal that PMNs effect a considerable degree of neuritic damage
in vitro
, while
in vivo
modeling demonstrates cortical injury, blood-brain barrier compromise, PMN activation, and lung injury after reperfusion.

Conclusion:
Collectively, these studies expand our understanding of PMN-dependent mechanisms in post-ischemic toxicity, both directly on neurons and via effects on CNS inflammation, and argue that the inflammatory milieu within the lung may modulate CNS reperfusion injury via manipulation of peripheral PMN priming.
Abstract WP353: Inter-alpha Inhibitor Proteins (IAIPs) Reduce Astrocyte Activation and Gliosis in the Neonatal Brain After Hypoxic-ischemic (HI) Brain Injury
Authors: Barrios-Anderson Adriel , Chen Xiaodi , Nakada Sakura , Lim Yow-Pin , Stonestreet Barbara S
Published: January 2019

Background:
IAIPs are serine protease inhibitors that exert anti-inflammatory effects after HI brain injury. We have previously shown that IAIP administration after HI attenuates histopathological brain injury, apoptosis, and microglial activation and improves neurobehavioral outcomes in neonatal rats. Astrocytes are known to form glial scars, increase neuroinflammation, and exacerbate brain injury after stroke.

Objective:
To determine the effect of IAIPs on astrocytic GFAP expression in the neonatal rat brain after HI.

Methods:
HI was induced using the Rice-Vannucci method with right carotid ligation and exposure to 8% O
2
for 90 min. Post-natal day 7 rats were assigned to one of three groups: non-ischemic sham-control (Sham, n=12), HI exposed placebo-treated (HI-PL, n=13), or HI exposed IAIP-treated (HI-IAIP, n=14). Intraperitoneal injections of 30 mg/kg of IAIP or saline were given at 15 min, 24, and 48 h after HI. We recorded the sex of the rats. 72 h after HI, brains were collected, paraffin embedded, and sectioned. We performed immunohistochemical analysis by staining slides with GFAP, a marker of astrocyte activation. We performed stereological analysis by capturing images of the whole damaged hemisphere, cerebral cortex, hippocampus, and corpus callosum with the StereoInvestgator 10.0 Probe. We quantified GFAP expression levels using Image J software without knowledge of the group assignments.

Results:
Sham rats had significantly lower GFAP expression compared with the HI-PL group in the hemisphere (P<0.001), cortex (P<0.005), and hippocampus (P<0.005). IAIP treatment significantly reduced GFAP expression after HI in the hemisphere (P<0.05) compared with the HI-PL group. We also examined GFAP expression separately in male and female rats and found no differences in GFAP expression among the groups in females. However, we found that the Sham males had significantly lower GFAP expression compared to HI-PL in the hemisphere (P<0.005), cortex (P<0.005), and hippocampus (P<0.005), and that the IAIP treated HI exposed males had lower GFAP expression compared with the HI-PL group in the hemisphere (P<0.05) and cortex (P<0.05).

Conclusion:
IAIPs attenuate HI related astrogliosis in some brain regions particularly in male neonatal rats.
Abstract WP355: Quality of Stroke Care Between 2008 and 2014 in Korea: Analysis of the Nationwide Acute Stroke Quality Assessment Program
Authors: Park Hong-Kyun , Cho Yong-Jin , Hong Keun-Sik , Kim Seong-Eun , Kim Jun Yup , Kim Beom Joon , Park Jong-Moo , Park Kwang-Yeol , Lee Kyung Bok , Lee Soo Joo , Lee Ji Sung , Lee Juneyoung , Yang Ki Hwa , Choi Ah Rum , Kang Mi Yeon , Gorelick Philip B
Published: January 2019

Introduction:
Higher quality of stroke care based on guideline recommendations is associated with better clinical outcomes. However, there is limited information about contemporary status of quality of stroke care and its association with improvements in clinical outcomes in Korea.

Methods:
This retrospective observational study was performed by analyzing the data of the patients admitted to 258 acute stroke care hospitals covering an entire country from the Acute Stroke Quality Assessment Program, which was carried out by the Health Insurance Review and Assessment Service from 2008 to 2014. Six GWTG-Stroke performance measures (except prophylaxis for venous thromboembolism) were applied to evaluate quality of stroke care in Korea. The primary outcome variable was defect-free care, which is defined as the proportion of patients who received all of the performance measure interventions for which they were eligible. Multivariable analysis was performed to evaluate the association between defect-free care and clinical outcomes. Temporal trends and hospital variations of performance measures were evaluated.

Results:
Among 43 793 patients (mean age, 67±14 years; male, 55%) with acute stroke during the study period, 31 915 (72.9%) patients were hospitalized due to ischemic stroke or transient ischemic attack. The proportion of defect-free care for stroke steadily increased throughout the study period: from 80.2% in 2008 to 92.1% in 2014. Defect-free care was given more frequently in patients admitted to hospitals with a higher volume of stroke cases or intravenous thrombolysis administration, and stroke units. Patients who received defect-free care were associated with discharge to home (adjusted odds ratio 1.96; 95% CI 1.78-2.16) and 1-year survival (adjusted odds ratio 0.41; 95% CI 0.37-0.46). Only 60% of stroke patients were managed in hospitals with a certified stroke unit, and the distribution of certified stroke units showed an urban-to-rural gradient.

Conclusions:
The quality of stroke care in Korea has improved over time, and defect-free care was associated with discharge to home and 1-year mortality. There are still opportunities to improve the quality of stroke care in Korea by development of stroke networks in Korea.
Abstract WP357: Implementation of Stroke Templates and Enhanced Trainee Education in an Academic Hospital Improved Data Capture of Risk Variables and Reduced Hospital Costs
Authors: Toumbs Randi , Dao Thanh , McCullough Louise , Zhu Liang , Savitz Sean , Cossey TC
Published: January 2019

Background:
Effective medical record documentation is required to support accurate capture of diagnoses and reflect true patient acuity (case mix index [CMI]) related to resource utilization for healthcare reimbursement. Increasing complexity and expansion in billing codes combined with the lack of a documentation education component in provider training programs has created a need for academic medical centers to incorporate training for new residents and nurse practitioners. We hypothesized that standardized stroke templates combined with formal education of trainees and feedback from chart audits would improve costs and documentation accuracy (increase expected length of stay (LOS), CMI).

Purpose:
To design and implement ischemic and hemorrhagic stroke templates with high frequency complication and comorbidity diagnoses that have the greatest impact on stroke populations, combined with trainee education and real-time chart audits, to improve the capture and accuracy of Vizient risk variables (LOS, CMI).

Methods:
Descriptive statistics were used to analyze outcomes before and after implementation of the templates. The outcomes include expected (E) LOS and observed (O) LOS. The O/E ratio and variance days (O-E) were calculated. Cost avoidance was calculated by multiplying the terminal day total cost by the variance days. The Wilcoxon rank sum test was used to compare groups with significance set at p<0.05. Analyses were performed using SAS 9.4.

Results:
The post-template group demonstrated significant improvement in all outcomes. The ELOS showed the most improvement contributing to the reduction in the O/E LOS. Cost avoidance increased from $24.49 to $1,897.01 per patient, yielding a net cost avoidance of $1,252,373.02.

Conclusions:
Stroke-specific templates, combined with trainee education and chart audits, significantly improves the accuracy of documentation and addresses the importance of quality and efficiency in healthcare reform.
Abstract WP359: Changes in Risk Factors and Hospital Cost of Stroke Care Among California Elderly Over 4 Years, 2007-2010
Authors: Moonis Majaz , Levine Robert , Husaini Baqar A
Published: January 2019

Objective:
We examine risk factors and healthcare costs of stroke among patients discharged for four years, 2007-2010.

Methods:
We used OSHPD’s administrative files of discharged patients (HDDS) from 2007-2010 with a diagnosis of stroke (ICD-9 codes, 430-438) along with their demographics, secondary diagnoses, number of admissions, length of hospital stay, and hospital charges (costs) for each discharge. We computed stroke rates per CDC methodology, and analyzed data with multivariate logistic models, along with Pearson Chi Square, Fisher’s Exact test and ANOVA.

Results:
Total number of stroke admissions by year were as follows (2007:13027,2008:12676, 2009: 11521, 2010:7845). Stroke rate in 2007 was 235 per 100,000 population and has gradually declined each year from 218 in 2008 per 100K, to 200 in 2009, to 201 in 2010. Similarly, the number of patients admitted for acute stroke continue to decline over these 4 years (2007:13027 to 7845in2010).Regression models revealed that five risk factors (HTN, DM, dyslipidemia, CHD, AFib) had significant (p<.001) Odd ratios for stroke each year. Further, while Dementia and Depression was associated with stroke, obesity also emerged as a significant factor only in 2007 and 2010. Similar changes were noted in the total costs for the year which increased from $141,290 in 2007 to $178,010 in 2008 to $195,420 in 2009. The cost, however, declined to $130,860 in 2010. The higher costs during 2007-2009 were largely due to longer hospitalization (23.2 days in 2007, 21.9 days in 2008, 21.2 days in 2009) compared to relatively fewer days (6.0 days) in 2010.

Conclusions:
Stroke rates as well as the number of patients hospitalized per year have declined over the years in California and so has the hospital costs associated with shorter period of hospitalization. These findings point to continued utilization of proven preventive programs and possibly improved acute interventions in acute ischemic stroke to reduce stroke morbidity, length of stay and healthcare costs.
Abstract WP36: Thrombus Composition and Success of Thrombectomy in Acute Ischemic Stroke Patients: A Histopathological Analysis
Authors: Gurkas Erdem , Asif Ahmer , Akpinar Cetin K , Shoukat Maryum , Aytac Emrah , Aydin Makbule C , Naseem Nishath , Qureshi Adnan I
Published: January 2019

Background:
Thrombus composition may vary among acute ischemic stroke patients. Thrombus composition is a key factor in determining susceptibility to mechanical and pharmacological thrombus disruption and thus the degree of successful recanalization. Many studies have reported the correlation between thrombus components and parameters such as stroke etiology, treatment outcome but there is still a lack of information due to a small sample size. We determined the relationship of thrombus composition on the success of thrombectomy in this multicenter study.

Methods:
We analyzed the data on 111 acute stroke patients, treated with mechanical thrombectomy, taken from 3 different stroke centers. Retrieved clots underwent semiquantitative proportion analysis by pathologists blinded to patient characteristics and imaging findings. Thrombus type was classified as erythrocyte rich, fibrin-rich and mixed type. Primary outcome assessment was the effect of clot composition on recanalization attempts. Multivariate analysis was performed to identify predictors of attempt number. Successful recanalization is defined as thrombolysis in cerebral infarction (TICI) scale 2b and 3. The good functional outcome is defined as modified Rankin Scale (mRS) 0-2 at 3 months.

Results:
Successful recanalization was achieved in 86 of 111 patients who underwent acute thrombectomy. Pathological characteristics did not differ significantly when compared to the number of attempts for recanalization (p = 0.469). Symptom recanalization time was shorter for patients recanalized with fewer attempts (p=0.0027). National Institute of Health Stroke Scale (NIHSS) or Stroke Etiologic Subtype was not correlated significantly with thrombectomy attempts ( p=0.76 and 0.22, respectively) as well. There was a no significant trend for good functional outcome with fewer attempts (p=0.10). There was no predictor of the number of attempts in multivariate analysis.

Conclusions:
In our study, histological thrombus composition had no impact on the number of attempts of thrombectomy done in acute ischemic stroke patients.
Abstract WP361: Temporal Variation in Facility Performance of Process Measures After Transient Ischemic Attack in the Veterans Health Administration: Predictors and Association With Ischemic Stroke Incidence
Authors: Levine Deborah A , Perkins Anthony J , Sico Jason J , Myers Laura , Phipps Michael S , Zhang Ying , Ferguson Jared B , Bravata Dawn M
Published: January 2019

Background:
Little is known about facility factors that contribute to change in facility performance and how temporal variation in facility performance of transient ischemic attack (TIA) process measures contributes to variation in facility-level ischemic stroke incidence.

Methods:
Prospective study of 7760 veterans (mean age, 70; 95% male) with TIA presenting to 53 VA facilities in 2014-2018. We examined process measures (high/moderate potency statin and anti-thrombotics </=7 days; hypertension control [<140/90 mmHg] at 90 days) and facility-level characteristics (percentage of TIA patients admitted, number of TIA patients per year, percentage of TIA patients getting Neurology consultation, and VA facility complexity level). We used multi-level hierarchical linear mixed-effects models with random effects for intercept and slope to measure the association between time-varying facility characteristics, changes in facility performance of process measures over time, and 90-day stroke incidence adjusting for patient factors.

Results:
Facilities significantly increased statin use and anti-thrombotic use, but not hypertension control over the 4-year study period (Table). Facilities who admitted more TIA patients had significantly greater use of statins and anti-thrombotics. Facilities with higher facility complexity had significantly greater use of statins. Facilities with higher rates of Neurology consultation had significantly lower stroke incidence.

Conclusion:
Facility characteristics, namely percentage of TIA patients admitted, are independently associated with changes in performance of process measures for TIA. Neurology consultations were associated with lower 90-day stroke incidence over time.
Abstract WP363: Females are Significantly Less Likely to be Invited as Speakers to the International Stroke Conference: Time’s Up to Address Sex Disparity
Authors: Fournier Lauren E , Zhu Liang , Perez-Pinzon Miguel A , Ovbiagele Bruce , McCullough Louise D , Sharrief Anjail Z
Published: January 2019

Introduction:
Females are underrepresented as speakers at major scientific conferences. Furthermore, in neurology, males outnumber females in academic positions, rank and number of publications, which may influence this inequality.

Objective:
To evaluate trends in invited speakers by sex at the International Stroke Conference (ISC).

Methods:
Data were obtained (years 2014-2018) for invited speakers to the ISC from the American Heart Association. Variables included sex, degree, race, speaker institution country, and speaker category. Data were analyzed by chi-square test, Fisher’s exact test, or logistic regression.

Results:
Over 5 years, 1086 individuals with 1283 presentations were invited for invited symposia (83%), pre-conference (11%), debate (5%), and case theater (1%). Females represented a mean of 29% of speakers, which did not vary by year (p=0.99), so years were combined. The highest and lowest proportions of females were in invited symposia (30.4%) and case theater (5.6%). All mid-levels and nurses, but only 17.7% of physician speakers were female. Females were 32.7% of Caucasian speakers and only 16.7% and 12.0% of Black and Hispanic speakers, respectively. The highest and lowest proportions of female speakers were from institutions in South America (50%) and Africa (0%). The proportion of female speakers was highest in nursing (86.4%) and pediatric stroke (45.2%) and lowest in neurocritical care and aneurysm (0%). Grouped, the highest proportion of female speakers was in recovery and rehabilitation (33.5%), and the lowest was in acute care (19%). Males were more likely invited as speakers more than once (p=0.01).

Conclusions:
Females are less likely invited speakers to the ISC compared to males, especially in fields like critical care, with a smaller female pool. Moreover, females in underrepresented racial groups and female physicians are less often speakers. Increased efforts are warranted to improve sex differences among speakers at the ISC.
Abstract WP364: Lower Revascularization Rates for Stroke Due to Carotid Stenosis at Ethnic Minority Serving US Hospitals
Authors: Faigle Roland , Cooper Lisa A , Gottesman Rebecca F
Published: January 2019

Background:
Revascularization with either carotid endarterectomy (CEA) or carotid artery stenting (CAS) has been shown to decrease future stroke risk in eligible patients with ischemic stroke due to carotid artery stenosis. We sought to determine whether the use of carotid revascularization procedures after ischemic stroke due to carotid stenosis differs between minority-serving hospitals and hospitals serving predominantly white patients.

Methods:
We identified ischemic stroke cases due to carotid artery disease, identified by ICD9-CM codes, from 2007-2011 in the Nationwide Inpatient Sample. The use of carotid revascularization procedures, i.e. CEA and CAS, was recorded. Hospitals with ≥40% ethnic minority patients (minority-serving hospitals) were compared to hospitals with <40% minority patients (white hospitals). Logistic regression was used to evaluate the use of CEA/CAS among minority-serving and white hospitals.

Results:
Of the 21,135 ischemic stroke cases meeting inclusion criteria, 16,256 (76.9%) were treated at 827 white hospitals, and 4,879 (23.1%) received care at 284 minority-serving hospitals. Compared to patients in white hospitals, patients in minority hospitals were less likely to undergo CEA or CAS (18.3%, 95% CI 16.7%-19.9%, in minority vs. 21.6%, 95% CI 20.5%-22.8%, in white hospitals, p<0.001). In fully adjusted logistic regression models, the odds of CEA/CAS were lower in minority compared to white hospitals (OR 0.82, 95% CI 0.71-0.95), independent of individual patient race and other measured hospital characteristics. Patient-level racial differences in the use of carotid revascularization procedures remained within each hospital stratum.

Conclusions:
The odds of receiving carotid revascularization after stroke is lower in minority-serving compared to white hospitals, suggesting system-level factors as a major contributor to explain race disparities in the use of carotid revascularization.
Abstract WP365: Utility of Hyperdense Middle Cerebral Artery Sign for Earlier Activation of Endovascular Team
Authors: Hafen Heidi , Malmberg Elisabeth , Martinez Julie , Chatwin Stephen , McLean Logan , Herrod H.C. , Donohue Megan
Published: January 2019

Introduction:
The hyperdense MCA sign has been used as a marker of an underlying large vessel occlusion (LVO)/thrombus in the non-contrast head CT of acute stroke patients. However, due its low sensitivity, it has not been used routinely for definitive diagnosis of LVO. Furthermore, clinicians also have the ability to obtain further imaging with CT angiography to better visualize the vessels in most patients. However, this further imaging can take on average up to an additional 30 minutes due to delays in acquisition, patient cooperation, processing and image transmission time. We wanted to look for a simple sign on the early imaging (non-contrast HCT) to determine if we could activate the neuro interventional suite faster.

Hypothesis:
When present, the hyperdense MCA sign can accurately predict presence of a LVO and identify patients eligible for endovascular therapy sooner than vessel imaging.

Methods:
We retrospectively looked at all initial non-contrast head CTs for all consecutive stroke patients presenting to our facility in 2017 (n=86), with a last known well time (LKW) < 6 hours and NIHSS > 4, for the presence of a hyperdense MCA sign. We then reviewed subsequent imaging (CTA) to determine if LVO was actually present.

Results:
The hyperdense MCA sign was present in 17 (out of 86) cases, all of which had an LVO on CTA. The positive predictive value (PPV) was 100% indicating that there was a high probability that subjects with a positive hyperdense MCA sign will have a LVO. There were 12 cases with an LVO on CTA did not have a hyperdense MCA sign showing a sensitivity of 58.6%, thus the absence of a hyperdense MCA sign does not exclude LVO.

Conclusion:
Quick delivery of appropriate treatments for acute stroke patients have been linked to better outcomes. Given our analysis of cases with NIHSS > 4 and LKW < 6 hours, it seems that presence of a hyperdense MCA sign on the initial non-contrast HCT leads to a high level of certainty that an LVO is present. Perhaps this sign, in combination of LKW and NIHSS, can be used to activate the neuro interventional team while additional imaging is being obtained.
Abstract WP366: Readmission for an Infection After a Stroke Admission: The Role of Hospital Acquired Infections
Authors: Boehme Amelia K , Oka Maitreyi , Cohen Bevin , Mathema Barun , Larson Elaine
Published: January 2019

Background and Purpose:
Stroke patients are at increased risk for acquiring infections in the hospital. This study aimed to examine whether an infection acquired during the initial stroke admission contributes to increased risk of readmission and infection during readmission.

Methods:
Electronic data were collected retrospectively for all adult ischemic stroke patients admitted to three New York City hospitals from 2006-2016. A validated computer algorithm defined infections based on laboratory culture data. Multivariable logistic regression was used to evaluate the crude and adjusted association of infections present on admission (IPOA) and healthcare-associated infections (HAI) with 60-day readmissions, and infection during readmission.

Results:
Among the 10436 stroke patients, 17% had infections during initial admission of which 52% were IPOA and 48% were HAI. The risk of readmission (Table) was significantly higher for those with HAIs (OR=1.20; 95% CI: 1.02-1.42) but not IPOA (OR=1.07; 95% CI: 0.91- 1.25) after adjusting for covariates. The presence of infection during the 60-day readmission was also independently predicted by HAI (OR=2.20; 95% CI: 1.79-2.71), and IPOA (OR=1.70; 95% CI: 1.32-2.17).

Conclusion:
Among stroke patients, HAI and IPOA were predictors of readmission within 60 days and infection during readmission. Patients who had an HAI or IPOA during their stroke stay were at increased risk to have an infection during their readmission hospitalization. The findings also indicate that the HAI-associated poor prognosis makes patients more susceptible to new infections during their readmission, or worsening of their current infection.
Abstract WP370: DESTINE: Interactive Software Modeling Best Transport Option for Ischemic Stroke Patients to Access EVT Using a Novel 2-Dimensional Temporal Spatial Visualization
Authors: Francis Michael J , Kamal Noreen , Lau Maria , Zhu Luke , Malik Fizzah , Goyal Mayank , Holodinksy Jessalyn K
Published: January 2019

Introduction:
There is uncertainty regarding the best transport strategy for ischemic stroke patients with a suspected large vessel occlusion since endovascular therapy (EVT) has become standard of care. Patients can be transported directly to an EVT hospital (mothership), or first to a closer hospital for alteplase and then transferred to the EVT hospital (drip-and-ship). Based on mathematical models, we have developed DESTINE (DEcision Support Tool IN Endovascular therapy), a cloud-based interactive software, which produces visualizations depicting whether drip-and-ship or mothership results in the greatest probability of good outcome. The results are customizable to each system (travel time between treatment centres, treatment efficiency, field population). A novel visualization technique (2-D temporal-spatial visualization) is used to display the model results to the user (Figure).

Methods:
A usability study was performed with a group of healthcare administrators and clinicians. Users were introduced to the software and asked to perform several tasks and then interpret the results. Users were also asked open-ended questions to help better understand their experience with using a 2-D temporal-spatial diagram. Sessions were screen and audio recorded, audio was transcribed verbatim and analyzed using inductive thematic analysis.

Results:
67% of participants were physicians and 33% paramedics, 67% were female and the average age was 40.0 years (SD: 10.54). Some users remarked that once familiarized with the software it was simple to use and the visualizations was clear. Although others felt a video tutorial or reference image would have been helpful. Users also thought the ability to compare two visualizations was beneficial. Several suggestions for improvements were also made.

Conclusion:
The study results have illuminated that 2-D temporal-spatial visualizations can be used to display the results of a stroke transportation model to end users.
Abstract WP371: Effects of VA National Telestroke Program Implementation Training
Authors: Anderson Jane A , Schlamb LeeAnn , Martini Sharyl , Plue Laurie , Williams Linda , Martin Holly , Dhaliwal Navdeep , Lyerly Michael , Graham Glenn
Published: January 2019

Background:
In July 2017, the VA initiated implementation “Go-Live” Training to support the VA National TeleStroke Program (NTSP). NTSP Go-Live Training incorporates systems redesign methods with iterative interprofessional whole-hospital medical simulations.

Methods:
A qualitative questionnaire with 4 open-ended questions was developed based on Kirkpatrick’s learning hierarchy. Participants’ responses were analyzed using direct content analysis to identify themes related to “reaction & satisfaction” with the training and “knowledge or skills acquired”. To determine learning transfer to practice, process measures (telestroke activation time and door-to-needle time) were collected in “live” facilities.

Results:
A total of 12 VA facilities participated in NTSP Go-Live trainings and 8 were live by 3/31/18. Of the 296 employees who participated in Go-Live training, 178 (60%) completed the questionnaire. Participants identified “process mapping”, “simulations” and “debrief sessions” as the most valuable aspect of the training. Three themes emerged based on participants’ reactions: 1) reinforced “time-is-brain”, 2) telestroke provides “opportunity to help veterans” and 3) the “hands-on experience tied it all together”. Participants’ indicated that the training “created confidence”, “instilled motivation” and stimulated “recognized value” for the NTSP. Participants indicated acquiring new knowledge and skill in how to “trouble-shoot the telestroke process”, “communicate while using tele-technology” and that “teamwork is key”. In the first 2 quarters, 93 telestroke consults were completed and 92% of all eligible patients (N=12) received thrombolytic therapy. The percent of patients with a telestroke consult initiated within 10 minutes of arrival increased from 13.5% in Quarter 1 to 31.6 % in Quarter 2, with median door to activation decreasing from 32 to 19 minutes. Median door to needle times also decreased, from 72 to 62 minutes.

Conclusions:
The VA’s NTSP Go-Live Training is a novel approach for implementation of telestroke care in facilities without experience administering alteplase. Moreover, the training improves provider skills/confidence as well as improving quality of acute stroke care.
Abstract WP377: A Stroke and Cardiovascular Disease Risk Alert in the Electronic Health Record Increased Prescriptions for Smoking Cessation in Women
Authors: Felton Warren L , Kornstein Susan G , Huynh Christine , Masho Saba W , Gondwe Tamala , Wallenborn Jordyn T , Henry Jeneane
Published: January 2019

Introduction:
The purpose of the study was to determine if incorporating a risk stratification alert in the electronic health record (EHR) improved screening of women for stroke and cardiovascular disease (CVD) risk and the treatment of modifiable conditions in primary care clinics.

Methods:
Primary care faculty physicians were by cluster randomization divided into an intervention group who received a stroke and CVD risk alert in the EHR for their patients and a control group who used the EHR in the usual manner. Validated risk scores for stroke, treatment of cholesterol, atrial fibrillation, and bleeding risk were calculated from data extracted from the EHR and automatically displayed in the alert for intervention group physicians, who were also provided evidence-based order sets. Baseline data for study physician patients were evaluated. Electronic prescriptions by study physicians were compared by group and patient gender for 1) statin, 2) antihypertensive, 3) anticoagulant, 4) aspirin/statin in patients with diabetes mellitus, 5) anticoagulant/warfarin/aspirin and 6) smoking cessation.

Results:
There were 7190 consecutive study physician patient encounters, of whom 19% were 40-50 years, 32% 51-60 years, 27% 61-70 years, and 22% 71 years or older. Patients included 65% women, 35% men, 63% African Americans, 33% white and 5% other ethnicity. Of these patients, 41% had hypertension, 37% diabetes mellitus, 27% cardiovascular disease, 5% congestive heart failure, 4% atrial fibrillation, 1% prior stroke, TIA, or thromboembolism, and 33% were cigarette smokers. For 860 patients with cholesterol data, 42% had abnormal cholesterol. Physicians in the intervention group generated smoking cessation prescriptions for women at a rate more than double that of control group physicians (OR 2.38, 95% CI 1.20-4.74, aOR 2.37, 95% CI 1.23-4.57); men showed no significant difference. No significant differences were found for the other five prescription categories.

Conclusion:
In conclusion, primary care physicians in this study provided with a pre-calculated stroke and CVD risk alert in the EHR for their patients were significantly more likely to provide smoking cessation prescriptions for women compared to primary care physicians who were not provided the alert.