bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TMP66: Sustainably High Thrombolysis Rates Through SMART Criteria Training of Emergency Physicians: 10 Year Results
Authors: Barazangi Nobl , McDermott Dan , Chen Charlene , Wong Christine , Yee Alan , Ke Michael , Gao Billy , Rose Jack , Bedenk Ann , Patel Susila , Fernandes Julia , Grosvenor David , Tong David
Published: October 2018

Introduction:
Thrombolysis rates remain low. One important factor is emergency physician (EP) participation. We routinely trained EPs to use SMART (Simplified Management of Acute Stroke Using Revised Treatment) criteria with real time feedback, resulting in high thrombolysis rates. The goal of this study was to determine the sustainability of this approach.

Methods:
Retrospective analysis of all consecutively treated IV rt-PA treated patients from 1/2006-6/2017, presenting to the ED at a large tertiary/quaternary stroke referral center. All EPs are trained using SMART criteria, which greatly lessen the contraindications to thrombolytic treatment. In addition the protocol requires response by the stroke neurologist ≤10min, and continuous real time feedback to the EP to maximize physician training. Formal in-service training is de-emphasized. Data regarding thrombolysis rates, and patient characteristics were routinely collected, including outcomes, safety and mortality.

Results:
From 1/06 to 6/17, 524 patients received thrombolysis . The IV rt-PA rate increased from 7% in 2004 prior the inception of the stroke program, to 24% in 2006. From 1/06 to 6/17, the annual rt-PA rate was sustained at an average of 30% (range 16-52%). The mean age was 72 (range 16-103), 54% were female. Mean pretreatment NIHSS score was 8.9 ± 7.9. 412 patients had discharge mRS recorded. Of these, favorable outcome (mRS ≤ 1) was observed in 43% (n=176). sICH rate was 1.1%, and mortality was 7.8%.

Conclusions:
A comprehensive acute ischemic stroke treatment protocol integrating EPs with real time education using SMART criteria is safe and highly effective, resulting in sustained high thrombolysis rates, excellent outcomes and low complication rates. This approach may also reduce unnecessary in-service training without reducing quality of care or thrombolysis rates.
Abstract TMP68: ACT-FAST Algorithm: Paramedic Validation Of A 3-Step Algorithmic Approach to Large Vessel Occlusion Identification
Authors: Zhao Henry , Pesavento Lauren , Rodrigues Edrich , Churilov Leonid , Smith Karen , Bernard Stephen , Yassi Nawaf , Davis Stephen M , Campbell Bruce C
Published: October 2018

Introduction:
Large vessel occlusion (LVO) triage scales facilitate prehospital bypass to endovascular centers, avoiding time consuming inter-hospital transfers. However, there are concerns that current scales lack specificity when used by paramedics, leading to erroneous bypass. The 3-step ACT-FAST Algorithm was designed for high specificity and reliability. First, arm fall to stretcher <10s is assessed, followed by severe aphasia (if right arm weak) or abnormal shoulder tap response for gaze/neglect (if left arm weak), followed then by questions regarding endovascular eligibility. We prospectively validated the new algorithm with paramedics.

Methods:
Over 8 months, paramedics bringing suspected stroke or endovascular transfers to the Royal Melbourne Hospital assessed deficits contemporaneously with stroke doctors. For the first 100 patients (Phase 1), paramedics completed an assessment allowing derivation of several scales: ACT-FAST (exam steps), RACE, LAMS and FAST-ED. For remaining patients (Phase 2) paramedics scored only the ACT-FAST Algorithm with eligibility questions. LVO was defined as ICA/M1 occlusion on CTA with NIHSS ≥6 (AHA guidelines).

Results:
A total of 142 patients (29 LVO) were included. Table 1 compares scales in Phase 1. ACT-FAST showed a trend towards highest accuracy compared with other scales. In Phase 2, the full ACT-FAST Algorithm had 83.3% sensitivity and 100% specificity in identifying LVO accepted for endovascular treatment. Agreement on ACT-FAST classification between paramedics and doctors was excellent (kappa = 0.93).

Conclusion:
ACT-FAST combines the simplicity of a 3-step algorithm with items optimized for paramedic usability to create a simple LVO identification tool. Initial prospective validation shows excellent reliability and trends towards increased accuracy for LVO recognition compared to other scales. Future research will focus on implementing ACT-FAST in Victoria to determine efficacy of LVO bypass.
Abstract TMP69: Educating Paramedics on the “Finger-to-Nose’ Test Improves Recognition of Posterior Stroke
Authors: Oostema John A , Chassee Todd , Edberg Allison , Baer William , Reeves Mathew
Published: October 2018

Background:
Emergency medical services (EMS) stroke recognition is critical for appropriate triage and rapid activation of stroke systems. Posterior strokes represent up to 25% of acute stroke admissions. Prehospital stroke screening tools such as the Cincinnati Prehospital Stroke Scale (CPSS) rely on stroke signs that may not be present in patients with posterior stroke, resulting in delays in diagnosis and treatment. We hypothesized that addition of the finger to nose test (FNT) to the standard CPSS would improve EMS recognition of posterior stroke.

Methods:
Over a 21-month period consecutive ischemic stroke cases transported by 3 EMS agencies in a single county in southwestern Michigan were identified and classified as anterior, posterior, or indeterminate based upon the final hospital discharge diagnoses. Following a 12-month baseline data collection period, all paramedics in the county completed a 30-minute on-line training module targeting recognition of stroke symptoms. Additionally, paramedics in 1 of the 3 EMS agencies also received in-person training in the performance of the finger to nose test (FNT group). We calculated the change in EMS posterior stroke recognition between the 12-month preintervention period and the 9-month postintervention period in the agency that received FNT training, and compared this to the change in the 2 control agencies that did not received FNT education intervention.

Results:
Over 21 months, 798 ischemic stroke cases were transported by EMS; 114 (14%) were posterior circulation strokes. Before training, 9/26 (38%) of posterior strokes were recognized by paramedics in the intervention agency and 10/36 (28%) in the 2 control agencies. Following training, the FTN group recognized 12/16 (75%, p=0.02 compared to 38% baseline) posterior strokes while the control group recognized 13/23 (46%, p=0.2 compared to 28% baseline). The net increase in posterior stroke recognition was therefore greater in the CPSS-A group than in the control agencies (37% vs. 18%, p=0.03).

Conclusion:
Posterior strokes were more likely to be recognized by paramedics when the finger to nose test was added to the CPSS. These encouraging initial results demonstrate the potential value of incorporating this simple test into EMS training.
Abstract TMP70: The Need for Speed: Consistently Achieving Arrival to Recanalization Times in 90 Minutes or Less for Large Vessel Occlusion
Authors: McTaggart Ryan A , Paolucci Gino , Quinn Katherine , Hemendinger Morgan , Baird Grayson , Haas Richard , Saad Ali , Jayaraman Mahesh
Published: October 2018

Introduction:
Since the treatment effect of mechanical thrombectomy (MT) is profoundly time-dependent, we created an optimized Comprehensive Stroke Center-Large Vessel Occlusion (CSC-LVO) protocol focusing on three key steps: early vessel imaging on all code stroke patients, standardizing the MT procedure, and integrating a team of stroke-dedicated advanced practice clinicians (APCs) to manage patients across the continuum of initial hospital care.

Methods:
All direct to CSC (“mothership”) LVO patients treated during the following time periods (Epochs) were retrospectively reviewed: 1/1/2015 to 6/30/2015 (Pre-optimization); 1/1/2016 to 6/30/2016 (Early Vessel Imaging and MT standardization) and 1/1/2017 to 6/30/2017 (Early Vessel Imaging, MT standardization, APC integration). Epochs were separated by 6 months to minimize any “ramp-up” effect. We included all patients who presented with large vessel occlusion stroke (ICA, M1, Basilar), within six hours from symptom onset, and with an NIHSS of 6 or higher. During Epoch 3, APCs were available for 12h/day and 7 days a week. For all cases, the neurointerventional team was activated only after the CTA confirmed large vessel occlusion. To measure efficiency of initial hospital processes, we compared CSC door to CT, door to CTA, door to IV t-PA, door to groin puncture, and door to recanalization across time Epochs.

Results:
All results are summarized in the table below and there was a marked decrease in median time from CSC arrival to recanalization from 186 to 100 minutes. Within Epoch 3, when APCs were in-house (n=29/44 or 70% of cases), the median [IQR] Door to t-PA, door to groin puncture, and door to recanalization times were lowest 27 [23-31], 53 [42-73], and 86 [72-118] minutes, respectively.

Conclusions:
A CSC-LVO protocol including early vessel imaging, procedural standardization, and integrating a team of stroke-dedicated APCs enables CSCs to achieve median door to recanalization times in less than 90 minutes.
Abstract TMP71: Non-Enhanced Computed Tomography to Computed Tomography Angiogram Performance Times: Telestroke versus Bedside Neurologists
Authors: Asimos Andrew W , Rhoten Jeremy B , Singh Sam J , Raheem Enayetur , Karamchandani Rahul R
Published: October 2018

Introduction:
The 2015 AHA/ASA Stroke Management Guidelines strongly recommend that if endovascular therapy is contemplated, a Computed Tomography Angiogram (CTA) be included in the initial imaging evaluation. Telestroke neurologists evaluating patients at Non-endovascular Stroke Centers (NESCs) are mostly focused on achieving quick door-to-needle (DTN) intravenous (IV) tPA times, not prompt CTA performance times to facilitate expeditious endovascular treatment for large vessel occlusion (LVO) acute ischemic stroke (AIS) patients.

Hypothesis:
The Non-Enhanced Computed Tomography (NECT) to CTA time interval for LVO patients evaluated by telestroke neurologists at NESCs is significantly longer than for LVO patients initially evaluated at Endovascular Stroke Centers (ESCs).

Methods:
From a large healthcare system’s stroke network database, we conducted a retrospective analysis comparing the NECT to CTA time performance interval for consecutive patients initially presenting to any one of 23 different hospitals or freestanding emergency departments who were identified as having an LVO AIS and met candidacy for ESC transfer.

Results:
Over 7 months, we identified 71 LVO cases initially presenting to one of 21 NESCs covered by teleneurologists and 62 cases from one of 2 ESCs covered by bedside neurologists. After removing the outliers (>95th percentile for ESC cases and >90th percentile for NESC cases), we retained 64 cases from NESCs and 59 from ESCs for our analysis. NECT to CTA times were significantly longer at the NESCs than at the ESCs, with NECT to CTA means of 27.94 minutes (SD: 24.93, IQR: 41.5) for NESC cases versus 10 minutes (SD: 3.29, IQR:4) for ESC cases (Kolmogorov-Smirnov test asymptotic p-value 0.0001),

Conclusion:
The NECT to CTA performance time interval for LVO AIS patients evaluated at NESCs by telestroke neurologists is significantly longer than for LVO AIS patients evaluated at ESCs. These data suggest that steps should be taken to ensure that NECT to CTA time intervals receive the same attention as DTN IV tPA times in assessing overall telestroke neurologist process performance.
Abstract TMP72: Technological Innovation in a Mobile Stroke Treatment Unit
Authors: Schimpf Brandi , Deanda Kathy , Severenuk David A , Montgomery Tara M , Cooley Gregory D , Kowalski Robert G , Vela Duarte Daniel , Jones William J
Published: October 2018

Background:
University of Colorado Hospital, under the UCHealth system, developed a Mobile Stroke Unit (UCHealth MSU) which began clinical operation in January 2016 and added a second operational location in August 2016. As one of the first centers to institute ambulance-mounted brain imaging and neurologic evaluation and treatment in the field for acute stroke in the U.S., it was necessary to design unique, dynamic IT systems for operationalizing the MSU. These include high speed cellular, HIPAA-compliant cloud based environments and remote access to patient electronic medical records (EMR) and a reliable means for rapid image transfer. Here we describe novel technologies engineered and incorporated into the UCHealth MSU.

Methods:
Technological data-handling aspects of the UCHealth MSU were reviewed. Functions evaluated included wireless connectivity while in transit, EMR capability in the field, computed tomography (CT) scanning and image transfer, and communications for tele-stroke neurologic assessment.

Results:
The UCHealth MSU began clinical operation in January 2016, Wireless communications were designed with redundancy to avoid dropped signals during data transfer. Two IP destinations were assigned for videoconferencing and EMR data transfer, with split-tunnel architecture to direct traffic to each. Placement of the MSU antenna inside the unit reduced interference from home and business Wi-Fi routers encountered. Brain imaging acquired in the ambulance CT scanner is transferred initially to an onboard laptop, then via Citrix Receiver to a hospital-based server and can be visualized by the stroke neurologist, neuroradiologist and all other care providers. Picture Archiving Communications System (PACS) and Radiology Information System (RIS) are two of the XenApps used by CT technologists.

Conclusions:
Technological hurdles associated with remote imaging, assessment, and treatment, are critical to overcome if time-saving benefits of mobile stroke protocols are to be recognized. Innovative and unique techniques developed to accommodate wireless communication and image transfer from the field in the UCHealth MSU may aid start-up of similar units elsewhere and serve as a framework to further improve this technology.
Abstract TMP73: Rehabilitation for Patients With Primary Intracerebral Hemorrhage is Associated With Reduced 30-Day Hospital Readmissions
Authors: Bambhroliya Arvind B , Meyer Ellie G , Meeks Jennifer R , Slaughter Kristen B , Bowry Ritvij , Ahmed Wamda O , Gealogo Gretchel A , Warach Steven , McCullough Louise D , Wu Tzu-Ching , Begley Charles E , Tyson Jon E , Miller Charles C , Savitz Sean I , Vahidy Farhaan S
Published: October 2018

Introduction:
Readmission (RA) after stroke is an established quality of care metric and is tied to reimbursements. Administrative databases lack stroke-specific severity indicators and information on post-discharge mortality. We report the cumulative incidence of 30-day RA for patients with primary intracerebral hemorrhage (ICH) from a statewide prospective cohort.

Methods:
Eligible ICH patients are consented to participate in the cohort to assess the impact of level of care on patient-centered outcomes across Texas. Patients undergo inpatient evaluation, followed by 30- and 90-day assessments for functional, cognitive, quality of life, dependency, and resource utilization outcomes. We defined 30-day RA as any RA that was assessed 30 days post-acute care hospitalization for the index ICH event. We used survival analyses to provide hazard ratios (HR) and 95% confidence interval (CI), while modeling post-discharge mortality as a competing risk.

Results:
Thus far, 158 patients have been enrolled with RA information available for 104. The overall RA rate is 5.1 / 1000 person-days (CI: 3.1-8.3). Among the various factors evaluated (Table 1), 30-day RA is significantly higher for patients with a higher ICH score (HR: 5.67, CI: 1.45-22.19), whereas post-discharge rehabilitation (as compared to discharge to home) appears to reduce the risk of RA, even after accounting for institution-free period of observation (HR: 0.11, CI: 0.01-0.86). Among patients with a high ICH score, those discharged home had significantly higher risk of RA as compared to those who received rehabilitation (Figure 1). Enrollment is continuing; updated analyses will be presented.

Conclusion:
Stroke-specific disease severity factors are important to identify to develop effective preventive strategies against RA, and need to be controlled for when comparing RA metrics across patient populations. Influence of post-stroke rehab on curtailing RA for ICH patients needs to be explored further.
Abstract TMP75: Clinical Care and Outcomes of Asian Acute Ischemic Stroke Patients
Authors: Song Sarah Y , Liang Li , Fonarow Gregg , Smith Eric E , Bhatt Deepak L , Matsouaka Roland , Xian Ying , Schwamm Lee , Saver Jeffrey L
Published: October 2018

Introduction:
Though overall stroke incidence and mortality in U.S. is improving, little is known about the state of stroke care and trends over time in Asian-Americans.

Methods:
We abstracted clinical characteristics, treatment patterns, and outcomes from acute ischemic stroke admissions for Asian-American and White patients from 4/1/04-7/31/16 from 2,171 hospitals in Get With The Guidelines-Stroke. Multivariable regression models assessed association of Asian ethnicity and outcomes that adjusted for patient and hospital characteristics and NIHSS.

Results:
Study population (N=1,772,299) had 64,337 Asian-American patients (3.6%) and 1,707,962 White patients; mean age 72.4, 51.3% female. Asians had greater stroke severity than Whites (Table). After adjustment, Asians had greater stroke severity, higher in-hospital mortality, poorer functional recovery, received IVtPA less but had more serious and hemorrhagic complications, despite being more likely to receive IV tPA<60 min. After NIHSS adjustment, Asians had lower in-hospital mortality than Whites. Adjusted analyses of time trends revealed statistically significant increasing trend on IVtPA usage, decreased symptomatic ICH post-TPA, decreased in-hospital mortality, and improved QOC measures in both Asians and Whites. Both Asians and Whites had an increasing trend on IVtPA within 60 min, and Asians had significant larger increasing trend compared to Whites. Trend analyses also showed only Whites had decreasing trend on stroke severity and increasing trend on discharge home.

Conclusions:
This is the largest analysis of clinical and functional outcomes for Asian-American acute ischemic stroke patients. Asian-Americans have more severe ischemic strokes, worse functional outcomes, and receive less IVtPA than White patients. These findings warrant additional research, and more dedicated interventions towards improving clinical outcomes for Asian-American patients with acute ischemic stroke.
Abstract TMP77: To Treat or Not to Treat? A Survey Exploring Factors Influencing rt-PA Treatment Decisions for Minor Stroke
Authors: Balucani Clotilde , Weingast Sarah Z , Weedon Jeremy , Stefanov Dimitre G , Katz Patricia , Hurley Dana , Khatri Pooja , Broderick Joseph P , Kasner Scott E , Grotta James C , Feldmann Edward , Panagos Peter D , Romano Jose G , Bianchi Riccardo , Meyer Brett C , Scott Phillip A , Kim Doojin , Levine Steven R
Published: October 2018

Introduction:
The 2015 updated US FDA package insert for rt-PA allows for a greater degree of clinical judgment regarding contraindications; thus there is flexibility in the decision to treat or not to treat.

Hypothesis:
Identifiable clinical factors influence rt-PA treatment decisions for patients with minor stroke.

Methods:
An Expert Panel (N=10) selected 7 factors from which to build a series of survey vignettes: NIHSS (1-5), NIHSS area of primary deficit (visual, language, weakness), baseline functional status (fully independent, mild-moderate disability), previous ischemic stroke (IS) (Yes < 6 wks, Yes ≥ 6 wks or No), previous ICH (Yes < 6 mos, Yes ≥ 6 mos, No), recent use of anticoagulation (AC) (Yes < 48 hrs, Yes ≥ 48 hrs, No), and temporal pattern of symptoms in 1
st
hr of care (stable, improving). We used a fractional factorial design (150 vignettes) to provide unconfounded estimates of the effect of all 7 main factors, plus first-order interactions for NIHSS. Surveys were emailed to 5 national organizations of neurologists and/or emergency physicians and investigator colleagues. Physicians were randomized to 1 of 10 sets of 15 vignettes, presented in random order. Physicians reported the subjective likelihood of giving rt-PA on a 0-5 scale; scale categories were anchored to probabilities 0, 20, 40, 60, 80, and 100%. A conjoint statistical analysis was applied.

Results:
Responses from 194 US physicians yielded 156 with complete vignette data: 74% male, mean age 46 (range 27-76), 80% neurologists. Treatment mean probabilities for individual vignettes ranged from 5-95%. Treatment probability increased from 24% for NIHSS=1 to 41% for NIHSS=5. The conjoint model accounted for 25% of total observed response variance. In contrast, a model accounting for all possible interactions accounted for 30% variance. Four of the 7 factors accounted jointly for 58% of total relative importance within the conjoint model: previous ICH (18%), recent AC (17%), NIHSS (13%), and previous IS (10%).

Conclusions:
Four main variables jointly account for only a small fraction (< 15%) of the total variance related to deciding to treat with IV rtPA, reflecting high variability and complexity. Future studies should consider other variables, including physician characteristics.
Abstract TMP78: Burden of Cerebrovascular Disease among Adults Aged 35+, United States 2006-2014
Authors: Tong Xin , Ritchey Matthew , Yang Quanhe , George Mary G , Jackson Sandra L , Gillespie Cathleen , Merritt Robert
Published: October 2018

Introduction:
Cerebrovascular disease is a leading cause of death and disability in the United States. Little is known about the overall burden of cerebrovascular disease across the healthcare system combined with mortality in the United States.

Methods:
We used data on adults aged 35+ in the 2006 through 2014 Nationwide Emergency Department Sample (NEDS), National Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project (HCUP), and the National Vital Statistics System (NVSS). Cerebrovascular disease was identified using the underlying cause of death in NVSS, and principal diagnoses in NEDS and NIS. The overall burden was estimated by obtaining mutually exclusive events with the total number of treat-and-release ED visits, non-fatal hospitalizations, and deaths. We calculated age-standardized cerebrovascular disease event rates using the year 2010 US Census population and relative percent change (RPC) to assess changes from 2006 to 2014.

Results:
A total of 685,278 cerebrovascular disease events occurred in 2014 (Table). The age-standardized treat-and-release ED visit rate increased from 10.2 to 15.1/100,000 persons from 2006 to 2014 (RPC of 47%), while death rates decreased 18%. The total cerebrovascular disease event rate increased 12% among persons aged 35-54 from 2006 to 2014 and 2% among persons aged 55-64, while the rate decreased by about 12% among persons aged 65+. Among men aged 35-54, the rates increased from 104.5/100,000 in 2006 to 121.0/100,000 in 2014 (RPC 16%), increased 8% for women 35-54, and 6% for men 55-64 years old.

Conclusions:
Our findings have important implications regarding rising cerebrovascular disease burden among adults aged 35-64 years. Focused prevention strategies should be implemented, especially among younger adults.
Abstract TMP86: Safety of Thombolysis for Acute Stroke in Patients With Diabetes and Prior Stroke
Authors: Pishanidar Sammy D , Merkler Alexander E , Navi Babak B , Gialdini Gino , Bernardini Gary L , Yaghi Shadi , Roh David , Lerario Michael P
Published: October 2018

Background:
It is uncertain whether history of prior ischemic stroke is associated with an increased risk of adverse outcomes in diabetic patients treated with intravenous tissue plasminogen activator (IV-tPA) for acute ischemic stroke.

Methods:
Using administrative claims data, we identified all diabetic adults with acute ischemic stroke who received IV-tPA at California, New York, or Florida hospitals between 2005-2013. Our exposure of interest was prior ischemic stroke. Our primary outcome was intracerebral hemorrhage (ICH) and our secondary outcomes were inpatient mortality and unfavorable discharge disposition (skilled nursing facility, subacute care center, chronic rehabilitation center, hospice, or death). We used multivariable logistic regression to compare the rate of outcomes in diabetic patients with and without a history of prior ischemic stroke.

Results:
We identified 12,786 diabetic patients (mean age 70.7 [±13.1] years) who received IV-tPA for AIS, of whom 1,112 (8.6%) had a history of prior ischemic stroke. Among all patients, 699 (5.5%; 95% confidence interval [CI] 5.1-5.9%) developed ICH and in-hospital death occurred in 11.9% (95% CI, 11.3-12.5%). After adjusting for demographics, stroke risk factors, and the Elixhauser comorbidity index, history of prior ischemic stroke was not associated with an increased risk of ICH (OR, 0.8; 95% CI, 0.6-1.1,
P =
0.26), inpatient mortality (OR, 0.9; 95% CI, 0.7-1.1,
P
=0.22), or unfavorable discharge disposition (OR, 1.1; 95% CI, 0.9-1.2,
P=
0.57).

Conclusion:
Among diabetic patients who received IV-tPA for acute ischemic stroke at three large states in the U.S., history of prior ischemic stroke was not associated with an increased risk of ICH, inpatient death, or unfavorable discharge disposition. Further evaluation is necessary to assess whether administration of IV-tPA within the extended 3-4.5 hour window for acute ischemic stroke is safe for diabetic patients with prior stroke.
Abstract TMP88: High Accuracy of Auto-CPAP for Obstructive Sleep Apnea in Acute Stroke Patients
Authors: Camilo Millene , Eckeli Alan , Barreira Clara , Machado Luis , Sander Heidi , Leite João , Fernandes Regina , Pontes-Neto Octavio M
Published: October 2018

Background:
Obstructive sleep apnea (OSA) is very common in acute stroke patients and has been associated with a poor short-term and long-term outcome. Polysomnography (PSG) is the gold standard diagnostic method for OSA, but it is not feasible as a routine for all acute stroke patients. Therefore, it is essential to validade alternative methods to accurately diagnose OSA in acute stroke patients. The newest generation of automatic continuous positive airway pressure (auto-CPAP) devices innovates by the possibility of detecting the different types of respiratory events. However, the accuracy of auto-CPAP devices for OSA diagnosis has never been tested in comparison to PSG in the acute stroke setting. The main objective of this study was to evaluate the accuracy of an auto-CPAP device to diagnose OSA and to validate its algorithm of respiratory events detection to diagnose OSA in patients during the acute phase of stroke.

Methods:
A sleep study was performed with PSG and auto-CPAP device, simultaneously, within the first 48 hours after the acute stroke onset. The Receiver Operating Characteristic Curve (ROC), C-statistics, Spearman correlation coefficient, and intraclass correlation coefficient were analyzed.

Results:
We prospectively evaluated 31 adult patients with acute stroke. The mean age was 59.7 ± 12 years and 60% were males. All patients used auto-CPAP for longer than 4 hours. The PSG revealed an apnea-hypopnea index (AHI) mean of 34 ± 41 events/h, and the auto-CPAP showed an AHI of 18 ± 16 events/h. The area under the ROC curve for OSA diagnosis by the auto-CPAP was above 0.90, with sensitivity and specificity above 80% for each AHI value. The Spearman correlation coefficients (rs) of the AHI, of the hypopnea index, of the obstructive apnea index and of the central apnea index were 0.92; 0.89; 0.63 and 0.62, respectively. The intraclass correlation coefficients between device-detected and PSG manually scored events were 0.60 for AHI, 0.64 for hypopnea index, and 0.45 for apnea index.

Conclusion:
The auto-CPAP showed an excellent accuracy for the diagnosis of OSA and it was well tolerated by acute stroke patients. Our results suggest that auto-CPAP should be considered as the preferred diagnostic tool for OSA diagnosis during the acute phase of stroke.
Abstract TMP90: Prevention of Stroke in Traumatic Cerebrovascular Injury With Aspirin Carries an Increased Risk of Transfusion
Authors: Harrigan Mark , Falatko Stephanie R , Griffin Russell L , Aslibekyan Stella , Marques Marisa , Strickland Virginia
Published: October 2018

Introduction:
Traumatic extracranial carotid or vertebral artery injury (TCVI) occurs in about 1% of all blunt trauma admissions, carries a 10% risk of thromboembolic ischemic stroke, and accounts for up to 2,400 strokes annually in the U.S. Screening CT angiography (CTA) of trauma patients is ubiquitous, and patients with initially asymptomatic TCVI are commonly treated with antiplatelet agents to prevent stroke. Although prophylaxis with these agents is thought to be safer than anticoagulation, which carries a sgnificant risk of hemorrhage in trauma patients, their risk of hemorrhagic complications is unknown.

Methods:
Single-center retrospective cohort study of patients with a screening CTA after admission for blunt trauma. Patients with CTA indicating TCVI were treated routinely with aspirin 325 mg daily. Risk of transfusion ≥1 unit of packed red blood cells (PRBC) >24 hours after admission (excluding transfusions during injury-related blood loss) was assessed according to CTA findings (CTA+ or CTA-) and whether the patient was treated with aspirin (ASA+ or ASA-). Cox proportional hazards regression assuming equal time at risk was used to estimate risk ratios (RRs) and the relative excess risk due to interaction (RERI) for comparing risk of transfusion among the CTA/ASA groups.

Results:
The mean overall number of units of PRBC was 0.9±2.1 for CTA+/ASA+ patients (n=196) and 0.3±1.60 for CTA-/ASA- patients (n=2290) (<0.0001). When adjusting for age, ISS, and INR ≥1.2 at admission, the overall RR of transfusion was 1.81 (95% CI 1.40-2.35) for CTA+/ASA+ patients compared to CTA-/ASA- patients. Among age groups, CTA+/ASA+ patients ages 50-69 years had the greatest RR (1.91 CI [1.21-3.03]) compared to CTA-/ASA- patients.

Conclusion:
Use of aspirin to prevent stroke in patients with TCVI carries a significantly increased risk of PRBC transfusion. Future studies are needed to determine if this increased risk of transfusion is offset by a reduced risk of ischemic stroke.
Abstract TMP92: Keep On Working. Occupational Status Before and After Stroke Protects the Brain, General Health and Cognitive Status
Authors: Hallevi Hen , Molad Jeremy , Korczyn Amos , Kliper Efrat , Shopin Ludmila , Auriel Eitan , Shenhar-Tsarfaty Shani , Volfson Victoria , Bornstein Natan M , Ben Assayag Einor
Published: October 2018

Background:
Stroke considerably increases the risk of dementia, while occupational status may influence physically and mentally long-term outcome after the event. We aimed to evaluate the interrelationship between occupational status, brain pathology on imaging and cognitive decline in a longitudinal post-stroke cohort.

Methods:
Data from 252 persons at working age (<65 years), with first-ever stroke from the TABASCO study was available. All patients underwent 3T MRI, inflammatory markers and cognitive assessment during the acute phase, 12 and 24 months thereafter.

Results:
The working rate before stroke was 68.7%, and 60.4% 12 months later. Pre-stroke unemployment was associated with reduced cortical thickness and white matter volume, severity of the neurological deficit, poorer cognitive scores at 12 and 24 months, higher depression scores, and elevated inflammation (p=0.002, p=0.049, p=0.001, p=0.002, p<0.001, p=0.011, p<0.001, p=0.02, respectively). Unemployed subjects suffered also from higher prevalence of Type 2 diabetes mellitus (T2DM) and hypertension compared to employed subjects (p=0.016, p=0.006, respectively). During the follow-up, 4.4% of the participants died and 8.9% developed cognitive decline. Mortality and cognitive decline were higher among unemployed compared to employed participants (p<0.001, p=0.001, respectively). Multiple regression, controlling for age, sex, education, vascular risk factors, and ApoE4, revealed that T2DM, stroke severity and pre-stroke unemployment were independent predictors of this decline (OR=3.2, 5.2, 3.2, respectively); while gender and pre-stroke unemployment predicted mortality (OR=11.4,16.2, respectively). Return to work after the event was also associated with decreased prevalence of cognitive decline.

Conclusions:
Pre-stroke unemployment was independently associated with brain atrophy, depression, higher mortality, and poorer performance in cognitive evaluation 2 years post-stroke. T2DM, stroke severity and pre-stroke unemployment were independent predictors of this decline, as well as early retirement after the stroke. These results emphasizing the advantage of employment versus early retirement in an attempt to reserve health and cognitive abilities.
Abstract TMP94: Dietary Salt Impairs Cognitive Function Through Suppression of Endothelial Nitric Oxide Synthesis and Hippocampal BDNF Signaling
Authors: Faraco Giuseppe , Wang Gang , Santisteban Monica M , Chang Haejoo , Segarra Steven , Anrather Josef , Iadecola Costantino
Published: October 2018

High sodium diet (HSD) is a risk factor for stroke and dementia independent of hypertension, but it remains unclear if dietary salt impairs cognition. To address this question, we fed HSD (8% NaCl) or normal diet (ND; 0.5% NaCl) to males C57BL/6 mice for 12 weeks (n=10/group) and assessed cognitive function. At a novel object recognition task (non-spatial memory) HSD mice failed to identify a new object from a familiar one (ND: 72.4±2%, HSD: 56.4±2%, p<0.05). At the Barnes maze test, HSD mice took longer to locate the escape hole (ND: 26±5sec, HSD: 64±12sec, p<0.05), suggesting impaired spatial memory. Nesting behavior, akin to activities of daily living in humans, was also impaired (ND: 4.6±0.1, HSD: 4.1±0.1, Deacon scale, p<0.05). Since HSD alters endothelial function (Compr Physiol, 6:215, 2015) and endothelial nitric oxide (NO) plays a role in cognition (J Neurosc, 26:11513, 2006), we assessed NO production in isolated brain microvessels using DAF-FM as a marker. In HSD mice, NO levels were markedly reduced (ND: 0.33±0.04, HSD: 0.19±0.02 RFU/μm2, p<0.05) and the NO increase produced by the endothelium-dependent agonist acetylcholine (ACh) was suppressed (ND, Veh: 0.33±0.04, ACh: 0.54±0.05 RFU, p<0.05; HSD, Veh: 0.19±0.02, ACh: 0.25±0.05 RFU/μm2, p>0.05). Endothelial NO participates in synaptic plasticity by contributing to maintain normal levels of the neurotrophic factor BDNF (Eur J Neurosc, 44:2226, 2016). Hippocampal BDNF levels were reduced in HSD mice (-52±3%, p<0.05). Consistent with attenuated BDNF signaling, we also observed reductions in the phosphorylation of the BDNF receptor TrkB (-31±0.1%), and of related signaling molecules (ERK1/2: -36±1%; CREB: -45±1%; p<0.05). Arc, a protein involved in memory formation and dependent on BDNF, was also reduced (-41±1%; p<0.05). The data suggest that HSD-induced endothelial dysfunction leads to reduced NO, which, in turn, suppresses hippocampal BDNF and attendant signaling pathways, resulting in impaired synaptic plasticity and cognitive deficits. The finding that dietary salt has a profound impact of on cognition highlights the harmful effects of endothelial dysfunction on brain health and supports public health efforts to curb salt intake especially in individuals at high vascular risk.
Abstract TMP96: Determining the Relationship Between Cognitive Function and ex-vivo Leptomeningeal Arteriole Function: A Study in Rapid Autopsy Brain Donors
Authors: Madrigal Calvin , Truran Seth , Karamanova Nina , Serrano Geidy E , Beach Thomas G , Migrino Raymond Q
Published: October 2018

Impaired cerebrovascular function can lead to cognitive dysfunction and is implicated as a potential mechanism by which vascular stressors (Aβ, saturated fatty acids such as palmitic acid PA or high glucose HG) contribute to dementia. We aim to test the hypothesis that cognitive function score correlates significantly with baseline ex-vivo cerebrovascular function and dilator response to vascular stressors.

Methods:
Under a Brain Donation Rapid Autopsy Program, leptomeningeal arterioles were isolated from 59 donors (87.4±1.1 years, 13 cognitively normal, 46 with various neuropathologies), cannulated, pressurized and endothelium-dependent dilation (EDD, acetylcholine max 10
-4
M) and smooth muscle dilation (SMD, papaverine or DETA-Nonoate) were measured at baseline and following exposure to Aβ42 (0.5 or 2 μM, n=40), PA 150 μM (n=13) or high glucose 33 mM (n=11). Correlation analyses were performed between cognitive function score (last mini mental state examination MMSE) and baseline and post-exposure arteriole function.

Results:
There was no correlation between MMSE score and baseline EDD and SMD (Fig. A-B). Exposure of arterioles to Aβ and PA significantly impaired EDD (-29.1±4.6% and -27.6±9.1% vs. baseline, p<0.05) but not HG (-2.7±6.6%). Aβ and PA impaired SMD (-7.4±3 and -7.4±6.7% vs. baseline, p<0.05) but not HG (0.1±4.4%). There was no significant correlation between MMSE score and arteriole EDD and SMD response to Aβ and PA. However, there was significant correlation between MMSE score and arteriole SMD response to HG (Fig. C).

Conclusions:
Contrary to our hypothesis, there was no correlation between cognitive function score and baseline ex-vivo leptomeningeal arteriole function. There was significant correlation between cognitive function score and SMD response to HG (but not Aβ or PA). The role of cerebrovascular smooth muscle reserve against hyperglycemic insult in the pathophysiology of cognitive dysfunction needs to be further explored.
Abstract TMP99: Assessment of Management and Outcomes of a First Hemorrhage in Patients With Untreated Arteriovenous Malformations
Authors: Maruyama Daisuke , Satow Tetsu , Kataoka Hiroharu , Mori Hisae , Ito Yoshiro , Hamano Eika , Ishiguro Taichi , Chikuie Hidekazu , Takahashi Jun C
Published: October 2018

Introduction:
Invasive interventions are commonly used to prevent re-rupture of ruptured arteriovenous malformations (AVMs), but are controversial for managing unruptured AVMs. This study uses a retrospective design to identify influential factors and outcomes in our multimodal treatment program for AVMs following a first rupture.

Methods:
We reviewed data from a single institution for 89 patients aged 18 years or older, with a first intracranial hemorrhage due to untreated AVMs between 2002 and 2015. We analyzed patient-specific variables and initial modified Rankin Scale (mRS) score groups (A, 0-2; B, 3-5) to compare group differences. Group outcomes were also assessed via multivariate regression.

Results:
Locations of Hemorrhage were as follows: 43 (48.3%) intraparenchymal, 16 (18.0%) intraventricular, 6 (6.7%) subarachnoid, and 24 (27.0%) combined. Spetzler-Martin grades included 50 grade I/II, 26 grade III, and 13 grade IV/V AVMs. Interventions were utilized in 79 patients (20 surgical resection, 28 Gamma Knife surgery [GKS], and 31 combined with embolization), and conservative management in 10. Mean follow-up was 77.2±45.4 months. Peri-interventional morbidity was 5.1% and the mortality rate was zero. Re-bleeding was observed in 2 patients before intervention and 3 patients after GKS. The group A (N=69) was significantly younger (44.1±16.7 vs. 53.3±13.1, P=0.02), more likely to have a nidus fed by a perforator (30.4% vs. 5.3%, P=0.02), and more likely to undergo GKS with or without embolization (56.5% vs. 25.5%, P=0.01) than the group B (N=19). Significantly more patients in the group A had final mRS scores ≤2 than the group B (95.5% vs. 36.8%, P<0.0001). Multivariate analyses indicated that a nidus fed by a perforator was the only independent pre-hemorrhagic factor for an initial mRS 0-2, which was the only independent pre-treatment factor for a good outcome.

Conclusion:
Although our treatment results seemed favorable, initial severity influenced the outcome after an untreated AVM-related first intracranial hemorrhage. Further analyses of the factors associated with severe hemorrhage of AVMs may improve both the outcome of ruptured AVMs and the management of unruptured AVMs.
Abstract TP101: Chronic Cerebral Hypoperfusion Induces Post-Stroke Dementia Following Acute Ischemic Stroke In Rats
Authors: Kim Hahn Young , Back Dong Bin , Kwon Kyoung Ja , Choi Dong-Hee , Shin Chan Young , Lee Jongmin , Han Seol-Heui
Published: October 2018

Background and purpose:
Post-stroke dementia (PSD) is one of the major consequences after stroke. Chronic cerebral hypoperfusion (CCH) can induce vascular cognitive impairment and potentiate amyloid pathology. We investigated how CCH contributes to the development of PSD after stroke in the context of neuroinflammation and amyloid pathology.

Methods:
We designed a unique animal model for PSD. We performed middle cerebral artery occlusion (MCAO) surgery in rats mimicking acute territorial infarct, which was followed by bilateral common carotid artery occlusion (BCCAo) surgery mimicking CCH. We performed behavioral tests including neurologic function test and water maze task and histological investigations including neuroinflammation, neuronal cell death, amyloid pathology, and glymphatic pathway-related aquaporin 4 (AQP4) distribution.

Results:
Spatial memory was synergistically impaired when BCCAo was superimposed on MCAO. Neuroinflammation with astroglial or microglial activation and amyloid pathology were enhanced in the ipsilateral cortex, thalamus, and hippocampus when BCCAo was superimposed on MCAO. Glymphatic pathway-related AQP4 distribution changed from perivascular to parenchymal pattern.

Conclusions:
Our experimental results suggest that CCH may contribute to the development of PSD by interfering with amyloid clearance through the glymphatic pathway. Therapeutic strategy to clear brain metabolic waste through the glymphatic pathway may be a promising approach to prevent PSD after stroke.
Abstract TP103: Cholesterol Transporters Abca1 and Apoe Mediate Grey/White Matter Remodeling and Neurogenesis/Oligodendrogenesis After Stroke
Authors: Li Rongwen
Published: October 2018

The ATP-binding cassette transporter-A1 (ABCA1) and apolipoprotein-E (ApoE) are major cholesterol transporters in the brain. ABCA1 effluxes cholesterol and phospholipids to extra-cellular, and ApoE transport cholesterol and lipid back into cells. Brain-specific ABCA1-deficient (ABCA1
-B/-B
) mice exhibit reduced ApoE level in brain and cerebrospinal-fluid (CSF), and increased white matter damage and neurological deficits after stroke.

Hypothesis:
ApoE-treatment increases grey/white matter remodeling and neurogenesis/oligodendrogenesis in the ischemic brain in ABCA1
-B/-B
-stroke mice.

Methods:
Adult ABCA1
-B/-B
mice were subjected to distal middle cerebral artery occlusion (dMCAo) and were intraventricularly-infused with recombinant human ApoE2 (rhApoE2, 25μg in artificial-CSF) or artificial-CSF as vehicle-control by transplanting a micro-osmotic pump into the right lateral-ventricle starting 24h after dMCAo until sacrifice 14 days after dMCAo. Primary cultured cortical neurons (PCNs) and oligodendrocyte progenitor cells (OPCs) derived from ABCA1
-B/-B
and ABCA1-floxed control (ABCA1
fl/fl
) mice were employed, and the PCN-axonal outgrowth and OPC proliferation/death were investigated.

Results:
No changes in the lesion volume between ABCA1
-B/-B
+CSF and ABCA1
-B/-B
+rhApoE2 mice were found. Compared with ABCA1
-B/-B
+CSF mice, the ABCA1
-B/-B
+rhApoE2 mice exhibit: 1) increased CSF ApoE level and improved functional outcome 7 and 14 days after dMCAo; 2) increased grey matter and white matter density in the ischemic boundary zone; 3) increased neurogenesis in the subventricular zone and oligodendrogenesis in the corpus collosum in the ischemic brain (p<0.05, n=11/group). In vitro data show that: 1) ABCA1
-B/-B
decreased axonal-outgrowth and ApoE-treatment (2, 4 and 8 μg/ml) significantly attenuated ABCA1
-B/-B
-induced reduction in axonal-outgrowth; 2) ABCA1
-B/-B
decreased OPC proliferation and survival compared with ABCA1
fl/fl
-OPCs and ApoE treatment increased OPC proliferation and OPC survival in primary cultured ABCA1
-B/-B
-OPCs.

Conclusion:
ABCA1/ApoE contributes to grey and white matter remodeling, increases neurogenesis and oligodendrogenesis as well as improves functional recovery after stroke.
Abstract TP108: Ischemia-Induced Multipotent Stem Cells in Human Cerebral Infarction
Authors: Tatebayashi Kotaro , Takagi Toshinori , Nakano-Doi Akiko , Sakuma Rika , Tanaka Yasue , Kamachi Saeko , Shirakawa Manabu , Uchida Kazutaka , Kageyama Hiroto , Nakagomi Takayuki , Matsuyama Tomohiro , Yoshimura Shinichi
Published: October 2018

We have previously demonstrated that brain pericytes near cerebral vessels acquired multipotency following cerebral ischemia in mice, and these ischemia-induced multipotent stem cells (iSCs) could contribute to neurogenesis (Nakagomi et al. Eur J Neurosci. 2009, Stem Cells. 2009, 2015). However, it remains unclear whether pericytes can also revert to multipotency in the human brain following stroke. The study protocol was approved by the Ethics Committee of Hyogo College of Medicine. Brain samples were obtained from post-stroke areas in patients requiring both decompressive craniectomy and partial lobectomy for diffuse cerebral infarction (Fig.1). Histological findings of post-stroke human brain tissue sections showed that nestin-positive cells localized near von Willebrand factor-positive endothelial cells and coexpressed pericytic markers (Figs. 2, 3). Then, post-stroke human brain tissue sections were dissociated and cells were incubated under adherent culture conditions. Polymerase chain reaction (PCR) analysis indicated that putative iSCs did not express astrocytic and endothelial lineage markers, but expressed pericytic and neural crest lineage markers. PCR analysis showed that iSCs maintained expression of stem cell and undifferentiated cell markers even after several passages (Fig.4). Immunohistochemistry showed that iSCs differentiated into multiple cells in vitro, including neurons (Fig.5). We demonstrated that iSCs are present within the post-stroke human brain. iSCs can differentiate into neuronal cells and, therefore, might play an important role in central nervous system repair following ischemic stroke.