bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP185: Cryptogenic Stroke and Patent Foramen Ovale: Posterior Circulation Strokes Are More Common In Men Than In Women
Authors: Thaler David E , Ruthazer Robin , Di Angelantonio Emanuele , Di Tullio Marco R , Donovan Jennifer S , Elkind, M Mitchell S , Griffith John , Homma Shunichi , Jaigobin Cheryl , Mas Jean-Louis , Mattle Heinrich P , Michel Patrik , Mono Marie-Luise , Nedeltchev Krassen , Papetti Federica , Serena Joaquín , Weimar Christian , Kent David M
Published: March 2022

Background
Stroke databanks have consistently found a high ratio of anterior circulation (AC) to posterior circulation (PC) strokes without significant differences when compared for vascular risk factors, stroke etiology, treatments and outcome. One study suggested that there was a deviation from this consistent observation when comparing men and women with cryptogenic stroke (CS) and patent foramen ovale (PFO). We tested these associations using the RoPE database.

Methods
The Risk of Paradoxical Embolism (RoPE) Study is an international collaboration of 12 merged cohort studies of patients with CS and known PFO status (n=3674). This analysis was restricted to those subjects in the RoPE database with index strokes in the AC or PC (excluding both or unknown) from the 7 databases that had data for CS with, and without, PFO. We compared the effect of sex on infarct location among patients with versus without PFO. We used generalized linear mixed models to examine whether PFO status modified the gender effect on infarct location adjusting for study cohort as a random effect.

Results
Among cryptogenic stroke patients both with and without PFO, AC strokes were more common (61%) than PC overall (n=1535). Among patients with PFO, PC stroke was higher in men than in women (50% vs. 33%, OR 2.23, 95% CI: 1.58-3.13). This gender effect was attenuated in those without PFO (38% vs. 31%; OR 1.32, 95% CI: 0.98-1.77). The gender-by-PFO-status interaction was significant (p= 0.0224) and was highly consistent across study cohorts.

Conclusions
These data confirm that males with CS and PFO contravene the otherwise consistent pattern that AC strokes are more commonly observed than PC strokes in stroke populations. The potential mechanisms underlying this interaction between gender and PFO-status remain to be elucidated.
Abstract WP188: Cardiac Diastolic Dysfunction Is Associated With Poor Functional Outcome In Ischemic Stroke Patients
Authors: Matsuki Takayuki , Fujimoto Shigeru , Mezuki Satomi , Jinnouchi Juro , Inoue Takuya , Suzuki Satoshi , Tsuchimochi Ryosuke , Ishitsuka Takao
Published: March 2022

Background and Purpose:
Some studies reported that cardiac diastolic dysfunction was related to poor prognosis in heart failure, however, its relationship with acute stroke has not yet been clear. We assessed the hypothesis that cardiac diastolic dysfunction may affect the outcome in acute ischemic stroke patients.

Methods:
Among 938 consecutive acute stroke patients admitted to Steel Memorial Yawata Hospital, Kitakyushu, Japan within 7 days after the symptom onset from January 2008 to March 2012, 460 patients with ischemic lesions on the initial diffusion-weighted image, prior modified Rankin scale (mRS) of 0 or 1, and available E/E’ values (one of the parameters of cardiac diastolic function in transthoracic echocardiography) evaluated after admission were included into the final statistical analysis. Patients were divided into quartiles according to E/E’ values; Q1 (less than 10), Q2 (10-13), Q3 (14-15), Q4 (more than 15). A NIH stroke scale score worsening of ≥1-point during the first 21 hospital days was defined as an acute neurological deterioration. A modified Rankin scale (mRS) of 2 or more was defined as a poor outcome. We also observed stroke recurrence or any death during one year from the onset.

Results:
Age (p<0.0001), frequency of female (p<0.0001), initial NIH stroke scale score (p=0.0184), and frequency of diabetes mellitus (p=0.0304), hypertension (p=0.0344), and severe valvular heart diseases (p=0.0008) showed a stepwise increase in Q1-Q4 in order. A poor outcome 3 months after the onset was observed in 15%, 27%, 24%, and 49% in the Q1-4 patients respectively. A stroke recurrence or any death occurred in 6%, 11%, 11%, and 17% in the Q1-4 patients respectively. On the multivariate logistic regression analysis, the worst E/E’ grade (Q4) was independently associated with a poor outcome 3 months after the onset (Odds Ratio 2.7; 95% CI 1.01-7.14; p=0.0463) and stroke recurrence or any death (Odds Ratio 5.2; 95% CI 1.59-18.9; p=0.0058), however, it was not associated with an acute neurological deterioration and a poor outcome on the discharge.

Conclusions:
Severe cardiac diastolic dysfunction might be associated with a poor outcome and long-term stroke recurrence in ischemic stroke patients.
Abstract WP198: Trends of Racial Disparity in Stroke Hospitalization Rate and Hospital Charges in the Buckle of Stroke Belt In the Past Decade (2001-2010)
Authors: Boan Andrea D , Lackland Daniel T , Bachman David L , Adams Robert J , Feng Wuwei
Published: March 2022

Background:
Racial disparities in stroke patients have been well documented but trends of disparity in the past decade are not clear. This study aims to determine whether racial disparities changed in South Carolina between African Americans (AAs) and Caucasian Americans (CAs) in stroke hospitalization rates and hospital charges from 2001 to 2010.

Methods:
From the state uniform billing hospital discharge database, patients discharged with a primary diagnosis of stroke from 2001 to 2010 were identified. Age, race, stroke subtype, group-specific stroke hospitalization rates, and hospital charges were compared over the 10 years period.

Results:
There were 89,357 stroke hospitalizations from 2001 to 2010. Stroke hospitalization rates decreased in all age-race groups but less significant in younger groups. Rates were persistently higher for AAs in all age groups, but the racial disparity was more pronounced in the younger group across all stroke subtypes. The highest disparity exists in the 35-45 year old group with intracerebral hemorrhage. Ten year hospital charges totaled $3.0 billion; 39.0% ($1171.0 million) of this total were attributable to racial disparities, 88.6% ($1037.9 million) is from the < 65 years old group.

Conclusions:
Racial disparities in stroke hospitalization rates are more severe in the younger age groups and result in significant economic consequences for the state.
Abstract WP20: Procedure Time and Degree of Collateral Flow Determines Outcome in Acute Endovascular Stroke Therapy
Authors: Khawaja Zeshaun S , Wisco Dolora , Cardona Luzma , Man Shu-Mei , Cheng Ching Esteban , Burgess Richard , Gomes Joao , Toth Gabor , Ferdinand Hui , Uchino Ken , Hussain Muhammad S
Published: March 2022

BACKGROUND AND PURPOSE:
Treatment options for acute ischemic stroke remain limited. There is a clear time dependant nature to this condition, though more evidence is accumulating that degree of collateral flow is a powerful modulator of the effect of time in acute ischemic stroke. In addition, longer procedural times have been associated with worse outcome. We sought to study the relationship between procedure times, collateral flow, recanalization, and clinical outcomes.

MATERIALS AND METHODS:
A retrospective review of prospectively collected database of 152 patients with anterior circulation strokes treated with endovascular stroke therapy within 8 hours of symptom onset from August 2006 to December 2011. General demographics, clinical features, imaging findings, and outcomes were collected. Univariate and multivariate analysis was performed using JMP statistical analysis software.

RESULTS:
152 patients [71 (46.7%) male, mean age: 68±15 years;] were included in the analysis. Complete or partial revascularization occurred in 121 (81%) patients. Collateral circulation was assessed on CTA with 7 (0.6%) having no significant collateral flow, 22 (20.7%) having low collateral flow (50% of affected territory), and 28 (26.4%) having full collateral flow. Overall, there was no significant difference in the baseline clinical and radiographic features between the groups. Analysis of procedural times showed significantly reduced chance of good outcome with procedure times >90 minutes. This effect was more pronounced based on collaterals; in those with good collaterals, good outcome (mRS ≤3) was significantly higher in procedures < 90 minutes (56% vs. 24%; p=0.02); in those with poor collaterals, no good outcomes were seen after 90 minutes of procedure time (39% vs. 0%; p=0.02).

CONCLUSION:
Procedure time and the degree of collateralization play a significant role in determining outcome in patients who undergo endovascular therapy in acute ischemic stroke, with significantly worse outcomes seen in patients with procedure times >90 minutes, particularly in those with poor collaterals. Treating physicians should keep these factors in mind during the treatment of acute stroke patients.
Abstract WP200: Racial Disparities In Stroke Mortality In Brazil
Authors: Bensenor Isabela M , Lotufo Paulo A
Published: March 2022

Background:
Racial disparities in stroke mortality are well known, but most of the studies were performed in United States. We aimed to analyze stroke mortality rates in Brazil that has a racial distribution including white, brown, and black people.

Methods:
Mortality data were obtained from the official statistics health bureau. All deaths were classified according to the 10th revision of International Classification of Diseases (ICD10). Data about stroke (ICD10:I60-69), acute stroke (ICD10:I60-68), sequels of stroke (ICD10:I69), ischemic stroke (ICD10:I63-64), intracerebral hemorrhage (ICD10:I61-62, cardiovascular disease (ICD10: Chapter I) and hypertension (ICD10:I10-15) in the years of 2010 was analyzed according to gender and age-strata. Population was based on the National Census Data (2010).

Results:
There is a consistent gradient of stroke mortality rates with higher risk of stroke deaths in black, an intermediate in brown and a lower risk in white in all categories except for sequels of stroke, and for both gender.

Conclusion:
mortality rates associated to stroke and its subtypes is race dependent with the burden concentrated in black and brown people. Hypertension plays a very influential role in this scenario
Abstract WP202: The Metabolic Syndrome Significantly Increases the Risk of Ischemic Stroke in the Mexican Hispanic Population
Authors: Osborn Michael F , Badr Ahmed , Miller Charles C , Zhang Jun
Published: March 2022

Background and Purpose:
Stroke is a major health burden in the United States in both morbidity and mortality. Evidence showed that the Hispanic population is disproportionately affected by this condition, while the prevalence of diabetes, hypertension, dyslipidemia and obesity is coincidently on the rise in the same group. We hypothesized that these factors, known as the Metabolic Syndrome, significantly increase the risk of ischemic stroke in Hispanic population.

Methods:
To test our hypothesis, we used data from
ElPasoStroke
(n=505) which were created in a retrospective study conducted in El Paso, TX, USA, and matching subjective data from the
NHANES
database (n=1010) to assess the effects of Metabolic Syndrome risk factors on the pathogenesis of ischemic stroke among the Mexican Hispanic population. Subjects were classified as obese if BMI ≥ 30, and as having the metabolic syndrome if they had three or more of: obesity, diabetes, hypertension, and dyslipidemia. Odds ratios (OR) and 95% confidence interval (CI) between different groups and age stratified groups were calculated for the evaluation of pathogenic effects of individual components of metabolic syndrome, as well as other risk factors for stroke.

Results and Conclusion:
Our results show that the metabolic syndrome substantially increases the odds of suffering ischemic stroke among the Mexican Hispanic population, with the risk being greatest in the younger age groups. Hypertension alone has the most significant impact, putting Hispanics at nearly forty times the risk of suffering stroke (Table 1). In conclusion, the metabolic syndrome significantly increases the risk of ischemic stroke in the Mexican Hispanic population, and efforts to prevent stroke incidence ought to be directed at reducing the prevalence of the metabolic syndrome in this population.
Abstract WP208: Albuminuria, But Not eGFR, Predicts Stroke Risk In Patients With Chronic Kidney Disease
Authors: Sandsmark Danielle K , Messe Steven R , Zhang Xiaoming , Roy Jason , Kasner Scott E ,   CRIC Study Investigators
Published: March 2022

Background and Objectives:
Chronic kidney disease (CKD) is associated with cardiovascular morbidity and mortality independent of common vascular risk factors. The Chronic Renal Insufficiency Cohort (CRIC) study is a large, multicenter, longitudinal study of patients with CKD. Using this cohort, we aimed to better understand how CKD influences stroke risk. We hypothesized that worsened renal function would be associated with an increased risk of stroke and that this would be independent of other vascular risk factors.

Methods:
Baseline measures of renal function were collected 3 months after an initial screening visit for each CRIC participant who were then contacted every 6 months to identify possible stroke events. Medical records were reviewed by 2 independent vascular neurologists. Univariate and multivariate Cox proportional hazards regression analysis was performed to identify risk factors for future stroke events in patients with CKD. The study had 80% power to detect a hazard ratio (HR) of 1.87 for a 50% prevalent binary predictor.

Results:
Among 3939 subjects followed for a median of 4.0 years, there were 101 stroke events. Decreased estimated glomerular filtration rate (eGFR), a common marker of renal dysfunction, was not associated with a risk of stroke (eGFR 30-60 mL/min/m
2
: HR 1.3 (95%CI 0.6-2.7); 15-29 mL/min/m
2
: HR 1.08 (0.5-2.5), <15 mL/min/m2: no stroke events occurred). Albuminuria >30 mg/day, another marker of kidney dysfunction, was associated with an increased risk of stroke. As albuminuria worsened, the risk of stroke increased. In a multivariate analysis, albuminuria was a predictor of future stroke (30-299 mg/day: HR 1.9 (95% CI 1.03-3.4); 300-999 mg/day: 2.4(1.3-4.6); >1000 mg/day: HR 2.9 (1.6-5.5) independent of Framingham risk score (HR 1.01 (1.0-1.03)), a composite marker of cardiovascular disease risk, or diabetes (HR 1.3 (0.8-2.0)).

Conclusions:
Albuminuria is a strong predictor of stroke in patients with CKD. Albuminuria may be a modifiable risk factor with important implications for long-term stroke risk in this population.
Abstract WP212: Opportunities for Prevention of Oral Contraceptive-Associated Ischemic Stroke:The Stroke Prevention in Young Women Study
Authors: Saslow Keely , Mitchell Braxton , McArdle Patrick , Cheng Yuching , Cole John , Kittner Steven J
Published: March 2022

Background and Purpose:
Current use of oral contraceptives (OCs) has been associated with increased risk of ischemic stroke. We sought to determine whether elevated stroke risk in women using OCs was restricted to women with other concurrent high risk conditions (risk modifiers), whether patients with these conditions recalled being advised not to use or to stop using OCs, and whether this advice resulted in behavioral change.

Methods:
59 hospitals in the Baltimore-Washington area participated in a population based case-control study of stroke in young women ages 15 to 49 (228 cases/348 controls). Data on OC use was gathered through standardized interview. Potential risk modifiers to OC use included hypertension, smoking, headache, chest pain or heart attack, and blood clots in the legs or lungs.

Results:
Overall the unadjusted odds ratio for OC use and stroke was 1.5 (95% CI: 1.0-2.3). Participants who had one or more potential risk modifiers to OC use while using OCs had an OR of 2.4 (95% CI: 1.3-4.3), while participants without any of these conditions had an OR of 1.1 (95% CI: 0.6-1.9). The most common conditions cited were smoking and headache. Thirty-eight women with ≥1 high risk conditions recalled being advised not to start OCs; however 9 (24%) of these women were taking OCs at the time of stroke or interview. There were 93 women with ≥1 high risk conditions who recalled being told to discontinue OCs, of whom 14 (15%) were still taking OCs at the time of stroke or interview.

Conclusions:
Our data are consistent with prior studies suggesting that increased the risk of stroke associated with OC use is restricted primarily to women with concurrent high risk conditions, such as headache or smoking. Improved physician and patient education about the medical conditions associated with higher stroke risk among OC users and a better understanding of the dynamics of the physician-patient encounter could further reduce risk.
Abstract WP222: Non-invasive Monitoring Of Cortical Activity Post-reperfusion. A Powerful Tool To Improve The Prediction Of Early Clinical Improvement Immediately After Recanalization
Authors: Flores Alan , Ribó Marc , Rubiera Marta , Pagola Jorge , Rodriguez-Luna David , Muchada Maria Angeles , Kallas Julia , Meler Pilar , Sanjuan Estela , Montaner Joan , Alvarez-Sabín Jose , Molina Carlos A.
Published: March 2022

Background
Although baseline stroke severity is a powerful outcome predictor, in some patients the NIHSS score does not reflect the degree of reperfusion (stunning brain) or it is simply unreliable. Currently the use of BIS(bispectral index) is restricted to monitoring level of consciousness in critical care patients and patients under anaesthesia. Real-time assessment of cortical activity after reperfusion may refine the predictive accuracy of stroke severity on patients outcome and be useful as surrogate of reperfusion success. We aimed to evaluate the impact of BIS monitoring before and shortly after reperfusion on stroke outcome.

Methods
Consecutive patients with anterior acute ischemic stroke who received reperfusion therapy were monitored with bicortical BIS in the first 6 hours of the admission. We registered the initial and final BIS number on the affected and contralateral side and determined asymmetry and changes in relation with recanalization and other clinical variables. We defined clinical improvement as an decrease of > or = 4 points between NIHSS baseline and the NIHSS at discharge or 5 day.

Results
28 patients were monitored by bicortical BIS.

The median age was 72 years, baseline NIHSS 16.

In all patients, median BIS number in the affected side varied baseline 83 and 85 final (p=0.34). The final BIS number was associated inversely with the NIHSS at discharge or 5 day (p=0,013) and the infarct volume (p= 0.031). Patients with clinical improvement had higher final number BIS (88,4 vs 78,9 p=0,007). A ROC curve identified a Final BIS number of >82 as the better predictor of further clinical improvement with a Sensitivity 88% and Specificity 89% p=0.02. After adjusting for recanalization, post recanalization NIHSS and age, a logistic regression showed that final BIS emerged as the only independent predictive factor of clinical improvement(p=0.024 OR1.41 IC95%: 1.01-1.28)

Conclusion
Our study demonstrates that some parameters of BIS are related to clinical and radiological variables in acute stroke patients. The final BIS number emerged a powerful independent predictor of further clinical improvements. Larger studies are needed to assessment of post reperfusion cortical activity measured by BIS
Abstract WP229: Clinical Significance Of Fluid-attenuated Inversion Recovery Vascular Hyperintensities In Transient Ischemic Attack
Authors: Kobayashi Junpei , Uehara Toshiyuki , Toyoda Kazunori , Endo Kaoru , Ohara Tomoyuki , Minematsu Kazuo
Published: March 2022

BACKGROUND AND PURPOSE:
Fluid-attenuated inversion recovery vascular hyperintensities (FVH) is often seen in patients with acute ischemic stroke attributable to arterial stenosis or occlusion. However, clinical significance of FVH in patients with transient ischemic attack (TIA) remains understudied.

METHODS:
Consecutive patients with TIA who underwent brain MRI within 24 hours of onset were studied. The frequency, relative factors, and time course of FVH were determined. Large artery atherosclerosis (LAA) was defined as more than 50 % stenosis or occlusion of the cervicocranial artery presumably due to atherosclerosis.

RESULTS:
Of 202 patients enrolled (76 women, 69.0±13.2 years old, median onset-to-arrival time 98 min [IQR 60-200], none undergoing thrombolysis), FVH was identified in 41 (20%). Atrial fibrillation (AF, 49% vs. 19%, P<0.001), LAA (56% vs. 25%, P<0.001), and positive findings on diffusion weighted image were more common (32% vs. 14%, P=0.020) in FVH-positive patients than in FVH-negative patients. Multivariate analysis showed that AF (OR 7.50 ; 95% CI 2.85-16.8) and LAA (OR 6.60; 95% CI 3.18-16.8) were independently associated with FVH. Within 90 days after the onset, 13 patients developed recurrent TIA or ischemic stroke (17% in FVH-positive vs. 4% in FVH-negative, P=0.010); 9 did within a week, 1 did between 2-4 weeks, and 3 did later. After multivariate analysis, LAA was independently associated (OR 6.38; 95% CI 1.59-33.0) and FVH tended to be associated (OR 3.30; 95% CI 0.89-12.6) with the recurrent episode. Of 36 recurrence-free FVH-positive patients, 23 underwent follow-up MRI median 7 days (IQR 6-11) after onset. FVH was no longer positive in 15 patients (65%). In these 15 patients, AF was more common (67% vs 13%, P=0.027) and LAA was less common (13% vs 88%, P=0.001) than the other 8 patients with persistent FVH.

CONCLUSION:
FVH was identified in 20% of acute TIA patients. AF and LAA were positively associated with FVH; AF seems to be associated with transient FVH and LAA does with persistent FVH.
Abstract WP236: The Acute Ischemic Stroke Process in the Emergency Department: Improving Door to Needle Times and Advancing Best Practice
Authors: Kimbrell Misty D , Johnson Corrina , Lege Jaimee R , Valadi Nojan
Published: March 2022

Background
The Acute Ischemic Stroke (AIS) process of care in the emergency department (ED) continues to evolve with interventions that help expedite administration of tPA and decrease “Door-to-Needle” (DTN) time and the burden associated with AIS. We hypothesized that redesigning the ED stroke process using selected best practice strategies would increase the percentage of patients receiving tPA in under 60 minutes, increase the percentage of patients treated with tPA within 4.5 hours, decrease the mean DTN time, and increase the percentage of stroke code activations (Code S) that occur in under 15 minutes. The variables implemented in the AIS process were analyzed for correlation of impact on decreasing DTN time.

Methods
The team mapped current AIS processes and developed an initiative to redesign the process including developing an AIS treatment room, a “stroke clot box” for storing and mixing tPA at bedside, and NIHSS certification of leadership staff. Multiple regression analysis of the correlation of these strategies as well as the presence of an in-house neurologist and EMS pre-notification on DTN time was performed.

Results
The initiatives increased the percentage of AIS patients treated with tPA within 4.5 hours from 67% to 100%. AIS patients treated under 60 minutes increased from 50% to 65%. The mean DTN time has decreased from 88.4 to 54.1 minutes. Of patients treated with tPA under 60 minutes (n=11) the mean DTN time was 40.6 minutes (lowest DTN time of 24 minutes). Code S activations within 15 minutes increased by 14 % to 47.8%. Multiple Regression analysis revealed that the presence of an in-house neurologist had the highest correlation (β=0.810, p=0.001) with lower DTN times, followed by using a "stroke clot box" (β=0.631, p=0.008) and a dedicated AIS treatment room (β=0.244, p=0.03). EMS pre-notification was done for nearly every tPA treated patient and its impact was therefore negligible (β=0.05, p=0.2).

Conclusions
These initiatives increased the number of patients treated, decreased mean DTN time, and increased the percentage of tPA eligible AIS patients within 60 minutes. An in-house neurologist, tPA at bedside, and a dedicated treatment room correlate with lower DTN times and therefore advance best practice for acute stroke care.
Abstract WP240: A US National Emergency Teleneurology Delivery System: Hospital Characteristics and Frequency of Thrombolytic Therapy.
Authors: Dimitri DaSilva Leonard
Published: March 2022

A National Emergency Teleneurology System: Hospital Characteristics and Frequency of IV rTPA.

Authors:
Leonard D. DaSilva, MD; Chris Teprow, David Gigas; Robert Ritchie; Evan Allen; MD; Mason Gasper, DO, ; Christina Burch, MD; Mitch Rubin, MD, Todd Samuels, MD; Jean R. Schneider, MD; Suman Kalanathi, MD; Carlos Villar, MD; Heather Linn, MD; Jeanine Turner, PhD; James D. Robinson, PhD; James Grotta, MD (UT-Houston); Michael Katsnelson, MD (U. Miami); Karen Deli, MS.

Background
—Literature demonstrates the value of telestroke for hospitals with no specialist coverage. We describe clinical and hospital characteristics of Specialists On Call (SOC); a national telemedicine service providing emergency neurological evaluation to 170 hospitals across 17 states.

Methods:
Retrospective review of SOC’s data was analyzed for IV tPA usage and hospital demographics.

Results:
From 2006 thru 07/12; 37 neurologists have performed 48,414 emergency teleneurology evaluations: 31,783 (65.6%) for neurovascular and 16,631 (34.4%) for non-neurovascular cases. Vascular / non-vascular emergency consult ratio has been stable for the past 5 years (59/41% - 2008, 61.2%/38.8% - 2009, 66%/34% - 2010, 67.7%/32.3% - 2011 and 63.2%/36/8% - 2012). IV TPA usage has increased from 3.4 %( 22) in 2006; 4.7% (72) 2007; 4.9% (175) 2008; 9.2% (380) 2009; 8.2% (610) 2010; 8.6% (797) 2011 to 11% (752) until 07/12 (8.8% (2808) overall). Increase in consultations and IV TPA coincides with adoption of emergency teleneurology in lieu of telestroke only; and multistate coverage by dedicated “teleneurologists”. Post-tPA follow up CT images reviewed a 4.5% PH2 ICH (25) in 556 cases reviewed. Hospital demographics: 5.3% have less than 25 adult beds; 3.5% (6):26-50; 18.8% (32) 51-100; 27% (46): 101-200; 21.2% (36): 201-300; 13.5% (23): 301-400; 6.5 %( 11) 401-500 and 4.1% (7) have more than 501 beds. IV TPA is available in the ER in 79.4% (135) and in the pharmacy in 20.6% (35). Seventy (42%) hospitals have at least one staff neurologist, but 58.2% (99) have none.

Conclusion:
A national teleneurology service is able to provide emergency of consultations to hospitals of different demographics, maximizing available neurological expertise, increasing IV TPA utilization within standard ICH complication rates.
Abstract WP243: Identification of Common Confounders in the Prehospital Identification of Stroke in Urban, Underserved Minorities
Authors: Brandler Ethan S , Sharma Mohit , Khandelwal Priyank , Kinraich David , Freese John P , Braun James , Ben-Eli David , Gropen Toby , Kaufman Bradley , Levine Steven R
Published: March 2022

Background:
Pre-hospital providers report positive predictive values (PPV) of 40-85% for the diagnosis of stroke, typically using the Cincinnati Pre-hospital Stroke Scale. In New York City 911, both emergency medical technicians [Basic Life Support (BLS)] and paramedics [Advanced Life Support (ALS)] care for/transport stroke patients.

Hypotheses:
(1) In an urban, underserved, minority population, ALS would have greater PPV than BLS for the confirmed diagnosis of stroke, and (2) Hypoglycemia and seizures would be frequent confounders, particularly for BLS providers.

Methods:
After IRB approval, medical records were reviewed of patients (85% Carribean Blacks) transported by EMS to participating Brooklyn facilities from 1/1/10-12/31/11. We compared EMS impressions of the presenting problem with AHA/ASA “Get with the Guidelines” (GWTG) databases - serving as the gold standard for diagnosis of stroke/TIA. Medical records of patients thought to have stroke by EMS but without a GWTG stroke diagnosis were queried for confounders (e.g. hypoglycemia, seizures). Patients who were not transported by EMS were excluded. Differences in confounders between ALS and BLS were analyzed using chi squared and Fisher’s exact test.

Results:
Of 671 patients suspected of having stroke by EMS, 628 patients (94%) had complete records (n=445 BLS, 183 ALS) available for review; 392 were confirmed strokes (275 ischemic, 46 TIA, 66 ICH, 5 SAH). There was no difference in PPV between ALS 59% (95% CI, 52% to 66%) and BLS 64% (95% CI, 59% to 68%) (P=0.277). Of the remaining 236 who did not have confirmed strokes, seizure was the greatest single confounder (n=72, 31%) followed in frequency by syncope (n=24, 10%), infections (n=23, 10%) and hypoglycemia (n=18, 8%). ALS more frequency diagnosed confounders than BLS (chi squared 8.64, df=3, p = 0.034), driven by seizure (2 tailed p < 0.0001).

Conclusions:
Our data suggest EMS called seizures a stroke more commonly than the other 3 leading confounders (hypoglycemia, syncope, and infection) combined and this was true more frequent for ALS than BLS, suggesting an area for focused EMS education. There was no difference between ALS and BLS in PPV. Further study is planned to determine the accuracy of ALS vs. BLS providers for the diagnosis of stroke.
Abstract WP250: Hospital System Collaborative has Positive Impact on Door to Needle Times
Authors: Motz Deb , Moore Tracy , Miesen Douglas , Huey Dicky , Freemyer Byron , Grnach Gina , Austin Tommye
Published: March 2022

Background:
Target Stroke is a National quality initiative to increase administration of IV rtPA to within 60 minutes from arrival on at least 50% of eligible ischemic stroke patients. Historically, the National statistic was approximately 25%. The Baptist Health System (BHS) benchmark in January 2010 was at 16.9%. This statistic is for a five hospital system with 1,674 licensed beds and one provider number. BHS has one Stroke Medical Director and follows the same standard of care and stroke order sets at all locations. We will describe the process applied across BHS to decrease door to needle times.

Methods:
One hospital Emergency Department’s (ED) Physician Champion, Director and nursing staff used LEAN methodology to outline present state and streamline the process to eliminate wasted time. Our process already consisted of pre-notification from Emergency Medical Services (EMS) with the estimated time of arrival and a stroke alert page. In our new process, the ED Physician (EDP) and RN1 meet EMS in ambulance bay for a quick assessment. The patient is taken directly to CT scan by RN1 and EMS1. Concurrently, EMS2 reports off to RN2 while assembling the equipment and contacting Specialists On Call (SOC) for the neurology consult. The CT technician notifies the Radiologist of the stroke alert and sends the films to SOC. Upon patient return from CT, the SOC video consultation begins. If a high probability of IV rtPA administration exists per EDP, the rtPA is reconstituted awaiting SOC recommendations. This process was piloted before being duplicated at the other four hospitals.

Results:
BHS achieved Target Stroke Honor Roll status for third quarter 2010 with 71.4% (n = 20/24) of eligible patients treated with door to needle time of 60 minutes or less. Median time was 48.5 minutes. BHS sustained Target Stroke Honor Roll status for July 2010 through June 2011, at 56.6% (n = 56/99) with a median time of 56 minutes.

Conclusion:
BHS was the first hospital in Texas to be awarded the Target Stroke Honor Roll. Incorporating LEAN methodology to eliminate waste, develop guidelines, actions, time durations, and collaboration across the hospital system is an effective means to decrease door to needle time.
Abstract WP255: The Novel C-Jun N-terminal Kinase Inhibitor IQ-1S Protects Against Cerebral Ischemia-reperfusion Injury In Mice
Authors: Atochin Dmitriy N , Schepetkin Igor A , Swanson Helen , Kirpotina Lilia N , Patel Nikitaben B , Quinn Mark T , Huang Paul L
Published: March 2022

The c-Jun N-terminal kinase (JNK) has been shown to be an important regulator of neuronal cell death. Recently, we synthesized the sodium salt of 11H-indeno[1,2-b]quinoxalin-11-one (IQ-1S) and demonstrated it was a high-affinity inhibitor of the JNK family, with preference for JNK3. We hypothesized that IQ-S1 could decrease stroke vulnerability in vivo by altering JNK activity, apoptosis, and inflammation. To test our hypothesis, we subjected wild-type (C57BL6, male, 8-12 weeks old) mice to a stroke model of temporal focal ischemia (30 minutes) with subsequent reperfusion (48 hours). The mice were anesthetized with 1.5 % of aerrane in 30% oxygen/70% nitrous oxide, and body temperature was maintained at 36.5-37.0° C. Mice were treated intraperitoneally with IQ-1S (25 mg/kg) suspended in 10% solutol (100 μl) or with vehicle alone (10% solutol, 100 μl) 30 minutes before and 12 and 24 hours after middle cerebral artery occlusion (MCAO). Using laser-Doppler flowmetry, we monitored cerebral blood flow (CBF) above the middle cerebral artery during 30 minutes of MCAO provoked by a filament and during the first 30 minutes of subsequent reperfusion. In mice treated with IQ-S1, ischemic and reperfusion values of CBF were not different from vehicle-treated mice. However, IQ-S1 treated mice demonstrated markedly reduced infarct volumes (35 ± 23 mm3, n=6; Mean ± SD, standard tetrazolium staining) when compared with vehicle-treated mice (68 ± 23 mm3, n=5, p< 0.05) after 48 hours of reperfusion. Neurological deficit after 48 hours of reperfusion was improved in IQ-S1 treated mice (1.0 point deficit on a 5 point scale) as compared with vehicle treated mice (1.8 point deficit). Our results indicate that the novel JNK inhibitor improved stroke outcome in a mouse model of cerebral reperfusion. We conclude that IQ-S1 can serve as specific small-molecule modulator for mechanistic studies of JNK function in cerebral ischemia and reperfusion injury.
Abstract WP259: CaMKII Inhibitor tatCN21 Decreases Neuronal Damage Following Cardiac Arrest and Cardiopulmonary Resuscitation in Mice
Authors: Deng Guiying , Vest Rebekah S , Grewal Himmat S , Quillinan Nidia , Bayer Karl U , Traystman Richard J , Herson Paco S
Published: March 2022

INTRODUCTION:
Glutamate excitotoxicity is considered an important mechanism of ischemic neuronal damage. However, directly inhibiting glutamate receptors can cause severe side effects due to their key physiological functions in the central nervous system (CNS). Ca2+/calmodulin (CaM)-dependent protein kinase II (CaMKII) is a major downstream target of glutamate-induced Ca2+ signaling. The aim of this study is to examine the neuroprotective potential of the CaMKII inhibitor tatCN21 on experimental cardiac arrest and cardiopulmonary resuscitation (CA/CPR).

Methods:
Global cerebral ischemia was induced with 8 min of cardiac arrest followed by CPR in C57BL/6 male mice. The mice were randomly administered either tatCN21 (1 mg/kg, n=14) or vehicle (saline, n=13) 2 minutes after resuscitation (intravenous). Hippocampal neuronal damage was analyzed three days after resuscitation by H&E staining. Primary hippocampal neurons were insulted with 400 μm glutamate for 5 min and treated with tatCN21 (5 μm), the scrambled CN peptide (tatRev, 5 μm) or KN93 (10 μm) 1 hr after removal of glutamate, cell viability was measure by LDH release 24 hrs later. Statistical analyses were performed using ANOVA and t tests, with P<0.05 considered statistically significant.

Results:
Analysis of histological damage 72 hrs after resuscitation revealed that tatCN21 significantly reduces hippocampal CA1 neuronal injury compared to vehicle-treated mice, reducing damage from 72.9±4.5% (n=13) for vehicle to 54.1±7.6% (n=14, P<0.05) for tatCN21 treated mice. tatCN21 significantly reduced glutamate-induced neuronal cell death, but not the classical CaMKII inhibitor KN93 (P<0.05). No difference in body weight, cardiac arrest parameters and survival rates were observed between each groups.

Conclusions:
Our data showed that the novel CaMKII inhibitor tatCN21 decreases neuronal damage both in vivo and in vitro. Therefore, this study indicated that CaMKII may have an important role in glutamate excititoxicity and that tatCN21 may serve as a potential therapeutic strategy for minimizing brain injury following cardiac arrest.
Abstract WP267: Adipose Stem Cells Restore Alveolar Macrophage and Monocyte Dynamics after Ischemic Stroke
Authors: Migliati Elton R , Parsha Kaushik , Karmouty-Quintana Harry , Blackburn Michael R , Savitz Sean I
Published: March 2022

Background:
Pneumonia is a complication in stroke patients. Resident alveolar macrophages (AMΦs) are the predominant cell type in the alveolar space with a slow turn-over rate maintained by monocytes (Mo). Distinct macrophage (MΦ) populations have protective (tissue homeostasis) or pathogenic roles (inflammation), the balance of which might predispose to pneumonia. The lungs are the first pass filter for the intravenous administration of various cell therapies but the effects of cell therapies within the lungs are largely unknown. The objective of this study was to determine the dynamics of AMΦs subpopulations and Mo in ischemic stroke and investigate the effects of acute adipose stem cells (ASC) on these alveolar cell populations.

Methods:
C57 mice were subjected to 60 min ischemia by the intraluminal filament model. ASCs, harvested from donor mice adipose tissue, were injected IV 4h after ischemia. BAL was collected 72h after ischemia and processed for flow cytometry. Macrophages and monocyte cells were assessed based on CD45, CD11b and CD11c expression. For lung inflammation, BAL cytospin slides and slides stained for HE and Toluidine blue were processed at 24h, 48h, and 72h.

Results:
There were no significant differences in lung pathology and in BAL cell differentiation between sham and stroke animals. Total AMΦ cell count in BAL did not change acutely (days 1 to 3) after stroke when compared with sham or naïve animals. Compared to naive animals, vehicle group had a significant decrease in the Mo population (CD45
pos
/ CD 11b
high
/CD 11c
neg/low
; 11.29% ± 9.5; 1.5% ± 0.9; 4.47% ± 4.0) and a decreasing trend in activated AMΦs subpopulation (CD45
pos
/ CD 11b
pos
/CD 11c
high
). These changes appeared to be driven by CD86 rather than CD206 AMΦ and were not observed in ASC treated animals.

Conclusion:
We identified heterogeneity and differential responses in AMΦ/monocyte populations in the lung after ischemic stroke. Our results suggest that ASC treatment might prevent the decrease in lung monocyte/activated AMΦ populations, thus preserving the beneficial host defense mechanisms against post stroke pneumonia. This study suggests new target candidates within the lung to attenuate post stroke pneumonia and possible new mechanisms for cell therapy in stroke.
Abstract WP274: Novel Platelet-Activating Factor Receptor Antagonists are Highly Neuroprotective in Focal Cerebral Ischemia
Authors: Bazan Nicolas G , Eady Tiffany N , Khoutorova Larissa , Atkins Kristal D , Alvarez-Builla Julio , Belayev Ludmila
Published: March 2022

INTRODUCTION:
Platelet-activating factor (PAF) is a bioactive phospholipid that regulates synaptic activity and when overproduced is a potent mediator of leukocyte functions, including platelet aggregation and inflammation. PAF concentration increases during ischemia-reperfusion and is a mediator of neurotoxicity. The inhibition of this process plays a critical role in neuronal survival. We synthesized various analogues and identified them as PAF receptor antagonists, which were then selected for
in vivo
experiments to evaluate anti-ischemic activity.

METHODS:
Physiologically controlled Sprague-Dawley rats received 2 h MCAo by poly-L-lysine-coated intraluminal suture. LAU compounds (LAU-0901, LAU-09015, LAU-09018, LAU-09019, LAU-09020 or LAU-09023; 30 mg/kg) or vehicle (45% cyclodextran) was administered IP at 2 h from onset of MCAo. Neurological status was evaluated during occlusion (at 60 min) and on day 1, 2, 3 and 7. Histopathology was carried out on day 7.

RESULTS:
Physiological variables were stable and showed no significant differences between groups. All LAU compounds significantly reduced the neurobehavioral deficit compared to the vehicle group, beginning from day 1 and persisting through the 7 day survival period. Histologically, the vehicle group showed large hemispheric infarcts with pan-necrosis. By contrast, LAU-treated rats showed preserved hemispheric structure and small subcortical infarcts. Treatment with LAU (LAU-0901, LAU-09015, LAU-09018, LAU-09019, or LAU-09023) significantly reduced total infarct volume compared to the vehicle group by 68%, 52%, 40%, 51% and 54%, respectively.

CONCLUSION:
Our results clearly indicate that novel LAU PAF receptor antagonists are highly neuroprotective on behavior and reduction of brain infarction in experimental stroke. These compounds may provide the basis for future therapeutics in patients suffering ischemic stroke.

This study was supported by NIH, NINDS grant R01 NS046741 (NGB).
Abstract WP279: Can We Reduce Door-to-Needle Times and Improve Outcome by Giving tPA on the CT Suite?
Authors: Kallas Julia A , Rodriguez-Luna David , Muchada Marian , Flores Alan , Pagola Jorge , Sanjuan Estela , Meler Pilar , Ribo Marc , Rubiera Marta , Molina Carlos A
Published: March 2022

Objectives:
The time to administration of intravenous (iv) tPA has a relevant impact on patients outcome. Our treatment protocol has been modified in order to improve our latency times by starting iv tPA bolus in the computed tomography room (CT-tPA). We aimed to evaluate the impact of CT-tPA on door-to-needle times and functional outcome in patients with acute ischemic stroke.

Material and methods:
We consecutively evaluated 70 patients treated in accordance with the CT-tPA protocol from June 2011 to June 2012. Those patients were compared to 130 patients from the previous year who received iv tPA bolus in the Stroke Unit (conventional protocol). Demographic data, baseline stroke severity, and inpatient latency times were evaluated. The primary outcome was the modified Rankin scale (mRS) at 3 months. Functional independency was considered when mRS≤2.

Results:
Two-hundred patients were evaluated, with mean age of 74.4±11.5 years and median NIHSS of 13 (IQR 11). There was no difference in baseline clinical characteristics at admission between CT-tPA and conventional protocol. The door-to-CT times were similar in both groups.

Mean door-to-needle time was 57.1 min in the conventional protocol, and was reduced to 53.4 after CT-tPA protocol implantation. We analyzed the number of patients who received iv tPA bolus bellow 30 and 50 minutes in each group. The CT-tPA group had 9% more patients treated in <30 min (16% vs. 25%) and 11% more treated in <50 min-window (50% vs. 61%) after arrival to the emergency department.

Clinically, there was a trend toward a better functional outcome in the CT-tPA protocol, with an increase of 10.7% of patients with mRS≤ 2 at 3 months compared with the conventional protocol (56.9% vs 46.2%). We also observed a reduction of 3-months mortality in patients treated according to the CT-tPA protocol (19% vs. 23%).

The application of CT-tPA was not associated with the increase of ICH nor with tPA protocol violations.

Conclusions:
The CT-tPA protocol reduces door-to-needle times, increasing the number of patients treated bellow the <50 and <30 minutes time-window. We hypothesized that this time-reduction would improve functional outcome in a larger number of patients.
Abstract WP284: Telestroke Coverage Improves Stroke Care In The Urban Hospital Setting
Authors: Scott Jonathan W , Hulbert Jill , Fanale Chris V
Published: March 2022

Introduction:
Telestroke consultation has been promoted as a way to improve stroke care in the remote hospital setting where neurology coverage is not available. The question remains if there is a benefit of telestroke consultation in the urban hospital setting where neurology coverage already exists.

Hypothesis:
We hypothesize that the use of telestroke consultation will improve patient treatment times in the urban hospital setting while maintaining patient satisfaction.

Methods:
In May 2011 our hospital, a Joint Commission certified Primary Stroke Center hospital located in a metropolitan area implemented telestroke coverage to aid with the rapid evaluation and treatment of patients with acute stroke. Telestroke coverage did not replace 24 hour neurologist call coverage but assisted in the acute evaluation when a neurologist was not present at the bedside. We performed a retrospective data comparison on stroke care for one year before and one year after implementing telestroke coverage. A total of 632 stroke alerts were reviewed for the following: percentage of patients treated with intravenous thrombolytics, Door-to-CT scan time, Door-to-treatment time, patient satisfaction.

Results:
There was a 14% increase in stroke alerts following telestroke implementation. Treatment rates were similar, 10.8% verses 11.3% with telestroke. There was a decrease from 83 minutes to 66 minutes for door-to-treatment time with telestroke. Treatment times were identical for patients treated with telestroke versus bedside neurologist during the first year of telestroke coverage. Patient satisfaction results remained high with telestroke.

Conclusions:
In conclusion telestroke consultation can be an effective tool for improving patient treatment times while maintaining high patient satisfaction in the urban hospital setting.
Abstract WP286: Emergency vs. In House Code Stoke: Differences and Similarities
Authors: Jones Robin R , Buckner Amy M , Taylor Reid
Published: March 2022

Background and Purpose:
The Joint Commission requires consistent evaluation, treatment and services for acute ischemic stroke patients. In house code strokes are an important subset of stroke patients that present outside of the carefully managed environment of the emergency room. We hypothesized a difference in treatment rates, interventions (intravenous thrombolyis IVT vs. intra-arterial thrombolysis with or without mechanical thrombectomy IAT) and mortality for in house code strokes compared to emergency room code strokes.

Methods:
This report is a single center review of code strokes from 1/1/09 to 12/31/11. We classified the total code strokes (TCS) as emergency department codes strokes (EDCS) or in house code strokes (IHCS). We then compared demographics, acute stroke interventions, and mortality. Patients who expired in hospital or were discharged to hospice were counted as mortality. We determined the location within the hospital where the in house code stroke occurred.

Results:
There were 1207 TCS during the study period. There were 1082 EDCS and 125 IHCS. Baseline demographics for age, gender and ethnicity were similar. TCS acute intervention rate was 30% (360/1207), EDCS acute intervention rate was 32% (341/1082) and IHCS acute intervention rate was 15% (19/125). IVT was the only treatment modality in 75%(262/360) of EDCS with acute intervention. IAT was used as acute intervention in 58%(11/19) of IHCS treated acutely. Mortality for TCS treated with acute intervention was 22% (79/360). EDCS treated with acute intervention had a mortality of 21% (71/341) and IHCS treated with acute intervention had a mortality of 42% (8/19). The IHCS patients had geographically widespread locations within the hospital.

Conclusions:
EDCS are more numerous and more likely to get acute intervention with lower mortality compared to IHCS. IHCS are less likely to be candidates for acute intervention, more likely to have IAT, and the IHCS patients treated with acute intervention have a higher mortality rate. Educating staff to recognize IHCS is difficult because of the wide range of locations of IHCS within the hospital.