bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP43: Successful Reperfusion in Patients With Concomitant Bi-territorial Anterior Circulation Strokes is Associated With Favorable Outcome and Decreased Symptomatic Hemorrhage and Mortality
Authors: Escalard Simon , Khameneh Bagheri Arash , Desilles Jean-Philippe , Redjem Hocine , Ciccio Gabriele , Smajda Stanislas , Fahed Robert , Labreuche Julien , Mazighi Mikaël , Blanc Raphaël , Piotin Michel
Published: January 2019

Background and Purpose:
Mechanical thrombectomy is now the gold standard treatment for patients presenting with acute ischemic stroke and proximal middle cerebral artery occlusion. The impact of mechanical thrombectomy in patients with concomitant anterior and middle cerebral arteries occlusions has not been evaluated.

Methods:
We analyzed data collected between January 2012 and june 2018 in a prospective clinical registry of consecutive acute ischemic stroke patients treated with mechanical thrombectomy. Every patient with concomitant anterior and middle cerebral arteries occlusions documented on initial imaging and angiographic first run were included. The primary study outcome was the percentage of patients who achieved a 90-day favorable outcome, defined as an mRS score of 0-2 or equal to the prestroke value.

Results:
Among 1242 strokes with anterior circulation occlusion treated by thrombectomy, 80 (6.4%) had biterritorial occlusions, defined as ischemic lesions in both anterior and middle cerebral artery territories and occlusions in both territories or carotid occlusion confirmed on first angiographic run. Among them, 67.5% had successful reperfusion of middle cerebral artery defined as mTICI 2B or 3. Patients with successful reperfusion had an increased rate of favorable outcome (28.6% versus 4.2%; P=0.043), decreased risk of symptomatic intracerebral hemorrhage (11.5% versus 45%; P=0.004) and decreased mortality (30.6% versus 66.7%; P=0.006), respectively.

Conclusion:
In patients with concomitant occlusions of anterior and middle cerebral arteries territories, successful reperfusion is associated with an increased rate of favorable outcome, a decreased risk of symptomatic intracerebral hemorrhage and a decreased mortality.
Abstract WP440: Pre-existing Cerebral Atrophy is Associated With Diminished Intracerebral Hemorrhage Severity
Authors: Uniken Venema Simone M , Marini Sandro , Brouwers Bart , Morotti Andrea , Woo Daniel , Anderson Christopher D , Rosand Jonathan
Published: January 2019

Background and Objective:
Cerebral small vessel disease (CSVD) is a chronic, cumulative cerebrovascular disease and is the most common cause of intracerebral hemorrhage (ICH). The effects of pre-existing CSVD on the severity of acute ICH are incompletely understood. We aim to clarify associations between computed tomography (CT) markers of CSVD and 1) acute ICH volume and 2) presence and severity of concomitant intraventricular hemorrhage (IVH).

Methods:
Baseline CT scans of patients from the Ethnic and Racial Variations of Intracerebral Hemorrhage (ERICH) study were evaluated for the extent of leukoaraiosis and cerebral atrophy using visual rating scales and for the Graeb Score, as a measure of IVH severity. ICH volume was measured on baseline CT scans using semi-automated software. The associations of leukoaraiosis and atrophy and ICH volume, IVH presence and the Graeb Score were tested using multivariable linear, ordinal and binary logistic regression models. Secondary analyses were stratified by hemorrhage location (lobar versus non-lobar). Bonferroni correction was applied.

Results:
The study included 2579 patients, 774 (30.0%) with a lobar ICH and 1805 (70.0%) with a non-lobar ICH. Median ICH volume was higher for lobar ICH and non-lobar ICH was more frequently associated with IVH. Increasing grades of central, cortical and total atrophy were inversely and dose-dependently associated with baseline ICH volume (P for trend <0.001). Leukoaraiosis was not significantly associated with ICH volume in multivariable analysis. Leukoaraiosis was associated with increased risk of IVH in a dose-dependent manner (P for trend <0.001), while global atrophy was inversely associated with IVH presence and severity (both P for trend <0.001). Analyses stratified by ICH location revealed largely similar associations for non-lobar and lobar ICH.

Conclusions:
In this study, increasing grades of cerebral atrophy were associated with smaller ICH volume and decreased risk of IVH presence and severity, while increasing extent of leukoaraiosis was associated with higher risk of IVH. These findings suggest that cerebral atrophy might be protective in the setting of acute ICH. Future studies are needed to confirm our findings and identify the underlying mechanisms.
Abstract WP447: Race, Socioeconomic Status and Care Decisions After Intracerebral Hemorrhage
Authors: Garcia Roxanna M , Naidech Andrew M , Prabhakaran Shyam , Maas Matthew B
Published: January 2019

Introduction:
Spontaneous intracerebral hemorrhage (ICH) is a leading cause of disability. Incidence of dysphagia is similar across racial subgroups, but studies have shown increased odds of percutaneous endoscopic gastrostomy (PEG) placement among minorities, Medicaid enrollees, and those with low household income. Socioeconomic status (SES) indicators such as education or occupation have not been fully investigated as predictors of maximal care after ICH among minorities.

Hypothesis:
SES is associated with maximal care post-ICH in non-white patients.

Methods:
Patients with spontaneous ICH without underlying pathology were enrolled into a single center, observational cohort study. SES was imputed using neighborhood socioeconomic characteristics by patient’s zip code, according to an established method which calculates an index from six SES indicators: median household income, median home value, percent >25 years old who completed high school, percent >25 who completed college, percent with income from passive sources (investments, rents), and percent working in management, executive, or professional careers. Neighborhood SES data was obtained from the United States Census Bureau’s 2012-2016 American Community Survey. We used PEG placement as a surrogate for maximal care. Based on a single regression model with an interaction term for SES and race, models were created by racial-ethnic subgroups.

Results:
Among 607 patients comprised of 245 blacks, 56 Hispanics and 306 non-Hispanic whites, the SES index differed across subgroups (p < 0.001). White patients had the highest index and black patients had the lowest. After adjustment for age, gender, premorbid modified Rankin Scale score, and ICH Score, no association was observed between SES index and PEG placement in black (odds ratio 0.99, 95% confidence interval [0.90, 1.09], p= 0.87) or white patients (OR 0.94, 95%CI [0.84, 1.04], p=0.24). However, higher SES index was associated with reduced likelihood of PEG in Hispanic patients (OR 0.69, 95%CI [0.45, 0.95], p=0.041).

Conclusions:
A reduced likelihood of maximal care as measured by PEG placement was observed only among Hispanic patients with higher SES index. Further study into culturally-bound decisional factors after ICH is warranted.
Abstract WP45: Subarachnoid Hemorrhage After Mechanical Thrombectomy With a Direct Aspiration First Pass Technique
Authors: Orabi Yser , Anadani Mohamad , Alawieh Ali , M.Spiotta Alejandro
Published: January 2019

Introduction:
The incidence and clinical significance of subarachnoid hemorrhage post mechanical thrombectomy (MT) has been evaluated after stent retriever use in limited studies. The goal of this study is to report the incidence, identify predictors of SAH, and explore the effect of SAH on outcome after MT with ADAPT technique.

Method:
We interrogated our prospectively collected ADAPT database to identify patients who developed SAH post MT. All patients were treated using ADAPT technique. Collected variables included demographics, comorbidities, admission NIHSS, procedural variables and outcome variables. Post procedural CT scans were reviewed by independent Neuroneuro-surgeon to identify SAH. Successful recanalization was defined as mTICI≥ 2b. Outcome measures included 90 days modified Rankin scale (mRS) and mortality. Logistic regression was used to identify the predictors of SAH and explore the effect of SAH on outcome.

Results:
A total of 510 patients were included in the study. Thirty-three patients (6.4%) had evidence of SAH on the post thrombectomy CT scan. There were more patients with HTN in the SAH group (90.9% vs 73.2%; p=0.024). Adjunctive stent retriever was used more in SAH group (57.6% vs 29.6%; p=0.001). More patients in SAH group required two or more attempts to achieve recanalization (93.9% vs 62.8%; p<0.001). Successful recanalization was achieved in higher proportion of patients in the non-SAH group (93.5% vs 81.8% p=0.012). On multivariate analysis, only HTN (OR 0.29: 95% CI 0.086-0.983) and higher number of aspiration attempts (OR 6.124: 95% CI 1.32-28.25) were associated with SAH .With respect to functional outcome, patients with SAH had worse outcome (mRS 3-6) comparing to non SAH (75.8% vs 55.6%; p= 0.023). However, SAH did not predict poor functional outcome on multivariate analysis.

Conclusion:
SAH after mechanical thrombectomy is not uncommon. HTN and higher number of attempts were associated with SAH when ADAPT technique was used. The presence of SAH does not appear to predict worse outcome.
Abstract WP452: Matrix Metalloproteinase Expression as Sex-specific Biomarker of Secondary Injury and Functional Outcomes After Spontaneous Hypertensive Intracerebral Hemorrhage
Authors: Furr Joseph W , Howe Mathew D , Zhu Liang , Edwards Nancy J ,   UTHealth BRAINS Rsch Laboratory, McCullough Louise D , Gonzales Nicole R
Published: January 2019

Introduction:
Intracerebral hemorrhage (ICH) affects approximately 2 million individuals per year. Incidence of ICH is roughly equal in men and women, but few studies have examined the influence of sex on long-term outcomes after ICH and secondary injury. Previous studies have shown that women in the post-partum period and post-menopausal women are especially susceptible to poor functional outcomes after ICH. Matrix metalloproteinases (MMPs) promote vessel rupture during ICH and may lead to poorer outcomes in female patients due to blood-brain barrier breakdown. We hypothesized that MMP isoform levels would be predictive of injury severity, secondary injury and long-term functional outcomes after ICH in males and females.

Methods and Results:
Patients from our prospectively collected ICH database were included. We included patients with deep hypertensive ICH, and excluded secondary ICH. Baseline clinical, radiographic and laboratory data were collected. Neurologic deterioration was defined as increase in NIHSS score and/or reduction in GCS score. Functional outcomes were assessed by modified Rankin Scale (mRS) and EuroQol at 90 DPI. Discharge disposition was recorded. With a total of 55 patients (n = 39 male, 16 female) we demonstrated a significantly higher risk of IVH (p = 0.012) and neurologic deterioration (p = 0.005) in females compared to males. We found that MMP levels in serum reliably predict injury severity in males, and secondary injury in females. Using multiplex ELISA we demonstrated that serum MMP-2 levels are negatively correlated with IVH severity (p = 0.028) in females. Additionally, serum levels of MMP-3 (p= 0.011) in males and MMP-10 (p= 0.044) in females predicted long-term functional outcomes in a sex-specific manner.

Conclusion:
Our work demonstrates the importance of studying sex-specific factors in ICH outcomes. We have found that there is a potential use of serum MMP expression as a sex-specific diagnostic tool for physicians treating patients after ICH. To our knowledge, this is the first sex-specific study to examine serum MMP levels and their correlation with clinicoradiologic measures after ICH. Further research to confirm these findings is necessary.
Abstract WP459: The Impact of Patient Demographics and Comorbidities on Inpatient Mortality After Intracerebral Hemorrhage
Authors: Kuybu Okkes , Davis Debra E , Javalkar Vijayakumar
Published: January 2019

Objective:
To observe for trends in the inpatient mortality rate following nontraumatic intracerebral hemorrhage (ICH) and to determine the effect of pertinent comorbidities on inpatient mortality using the US National Inpatient Sample (NIS) database.

Method:
Using the NIS (2012-first three quarter of 2015) database, patient records of adults with ICH were analyzed. We extracted data with a principal diagnosis of ICH using the diagnostic code 431 (ICD-9-CM) and clinical classifications software code 109 (acute cerebrovascular disease) so that traumatic ICH cases were eliminated.

Results:
A total number of 47,700 patients were included in this study. The mean age was 68 years. The majority of the patients ranged in age from 51 to 75 years (49%), were male (52%) and Caucasian (60%). Weekend admissions made up 27% of cases. Pertinent comorbidities noted in this cohort include coagulopathy (8%), diabetes (28%), hypertension (84%), liver disease (3%), renal failure (14%) and obesity (9%). The overall inpatient mortality rate was 24%. The mortality rate was high in females (25%) vs males (23%, p< 0.001); underlying coagulopathy (29% vs 24% without, p< 0.001) and liver disease (27% vs 24% without, p=0.019). Mortality rate was also elevated in patients >75 years old (28%, p< 0.001). There was no association between inpatient mortality rate and median household income, or the presence of diabetes or renal failure. It was significantly low with hypertension (23% vs 29%, p< 0.001) and obesity (17% vs 25%, p< 0.001). When the group of ICH patients without hypertension was compared with the hypertensive group we found a significantly higher proportion of patients with coagulopathy (11% vs 8%) and liver disease (5% vs 3%). However obesity did not confer a significant risk of comorbid coagulopathy (8% vs 8%) or liver disease (2.9% vs 3.1%).

Conclusion:
The overall observed inpatient mortality rate in this study of patients admitted for nontraumatic ICH was 24%. Comorbidities which increased the mortality rate significantly were female gender, age greater than 75 years, coagulopathy and liver disease. It was significantly low in hypertension and in obesity. The paradoxical effect of hypertension and obesity on inpatient mortality needs to be further assessed in prospective studies.
Abstract WP468: Nurse Role Expedites Triage during Stroke Alert to Improve IV Alteplase Door to Needle Times
Authors: Patterson Michele , Moore Tracy , Cline Beth , Sharp Johanna
Published: January 2019

Background:
Comprehensive Stroke Center strives to meet IV Alteplase Door to Needle Times (DTNt) of less than (<) 45 minutes. In addition, a new electronic medical record (EMR) was expected to slow the stroke alert (SA) process. An action plan focusing on the Registered Nurse (RN) role to expedite triage and impact response times to improve DTNt was implemented while transitioning to a new EMR.

Purpose:
Improve DTNt through focused education on the RN role to expedite triage and impact response times in the Emergency Department (ED) while transitioning to a new EMR.

Methods:
RNs participated in classroom education regarding required SA time goals to include time last known well, NIHSS, door to CT, door to lab, door to physician, and door to needle. An audit tool was created to include these categories to document times during the SA process. A focus was placed on the role of the RN to expedite triage in order to meet door to needle time goals. After classroom education RNs completed the audit tool on each SA for a 6 month period that also included transition to the new EMR (phase 1). To evaluate impact of the new EMR on the SA process and continued compliance following education, DTNt were evaluated for an additional 6 month period (phase 2).

Results:
Prior to RN education, creation of the audit tool and new EMR implementation, the DTNt were 31% (4/13) < 45 minutes and 54% (7/13) < 60 minutes. During phase 1 there was a slight decline in DTNt < 45 minutes to 20% (3/15), with an increase in DTNt < 60 minutes to 73% (11/15). Phase 2 showed continued improvement with an increase in DTNt < 45 minutes to 67% (6/9) and DTNt < 60 minutes to 89% (8/9).

Conclusions:
RNs play a pivotal role in the hyper acute phase of stroke care. Classroom education focusing on the RN role to expedite triage and the utilization of an audit tool focusing on required SA time goals impacted response in the ED and improved DTNt during transition to a new EMR. Completion of the audit tool assisted the RN to meet door to needle goals during the learning phase of a new EMR and continued to improve performance after the change.
Abstract WP496: Early Mobility in the Neurosurgical Intensive Care Unit: A Quality Improvement Project
Authors: Mathews Essie P , Huffman Allison , Aiyagari Venkatesh , Olson Daiwai
Published: January 2019

Bed rest is prevalent among patients in neurosurgical intensive care units (NSICU). The most common conditions that contribute to bed rest are acute ischemic or hemorrhagic strokes, neuromuscular weaknesses, spinal instability, post endovascular interventions, neurobehavioral disturbances, and mechanical ventilation. The immobility of bed rest causes numerous complications including critical illness myopathy, deep venous thrombosis (DVT), pressure ulcers, pulmonary dysfunction, bone demineralization, alterations in peripheral muscle mass, joint contractures, and general deconditioning. The purpose of this evidence-based quality improvement (QI) project was to evaluate the effectiveness of a practice change, which was the implementation of an early mobility program in the NSICU. The study design for this project was a retrospective analysis of a previous practice change. The algorithm for the practice change was specially designed for patients with neurological illnesses in the ICU. The number of days during which patients had mobility interventions, the frequency of mobility interventions, Functional Status Score for ICU (FSS-ICU), NSICU Length of Stay (LOS), the incidence of ICU delirium, and ventilator days were compared pre and post intervention. This QI project was conducted in an academic neuroscience hospital with 146 beds and receives referral patients from all over the nation. The principal investigator (PI) anticipated an increase in the physical activity, thereby improving the functional and cognitive outcomes of critically ill patients admitted to the NSICU through this QI project. The outcomes of this QI project were assessed and the results revealed a statistically significant improvement in the frequency of out of bed mobility activities (number of days patients had mobility interventions,
p
= 0.03; frequency of mobility steps,
p
= 0.002). The difference in mean LOS (
p
= 0.5), FSS-ICU (
p
= 0.7), and ICU delirium (
p
= 0.99) did not prove any statistical significance. The intervention of early mobilization in the NSICU is safe and feasible to implement, providing a structured plan for increasing the activity level of neurologically injured patients.
Abstract WP499: Effective Communication Between Nurses and Physicians Leads to Better Patient Outcomes!
Authors: Sostand Shanequa , Allen-Mcbride Enedra , Gonzales Nicole , Smith Kim , Lightford Mallory Lightford , Navarro Arianne
Published: January 2019

Background:
Open lines of communication are essential amongst multidisciplinary team members to ensure that patients are receiving quality care. Lack of communication can lead to poor patient outcomes, low morale, and create mistrusting relationships. A review of evidence has shown that when nursing staff and physician staff communication is seamless there is an increase in patient outcomes. Patient satisfaction, outcomes, and length of stay are expectations in our Comprehensive Stroke Center. The quality of care that patients receive can be determined by the relationship between physicians and nursing staff.

Purpose:
The purpose of this study is to improve nurse-physician communication during a 6 month period and to identify areas of need with goals to increase patient satisfaction scores and decrease the length of stay of Stroke patients.

Action:
Daily physician and nursing staff rounds with patients were reconstructed in order to classify responses for patients discharged from Comprehensive Stroke Center from January 2018 to June 2018 based off scores from our Hospital Consumer Assessment of Healthcare Providers (HCAHP) Survey. The questions posed concerning physicians and nursing staff are parallel, and it is imperative that they are both on the same page. Stroke unit nurses were trained and given an in -service by the unit educator in Plan Do Act Check format and rounding tool was implemented. A Stroke Capacity Notification System was continued and fortified to communicate with physician staff and nursing leadership pertaining information on census, transfer, and discharge status of patients via text message every four hours.

Results:
Communication between physician and nursing staff revealed that engagement scores increased by 11% based on Press Ganey engagement survey. HCAHP Scores increased by 85%. There was a 12% overall decrease in length of stay of stroke population due to collaborative initiative.

Practice Implication:
Implementation of the daily interactive team rounds and texting will decrease the length of stay, improve physician- nursing communication, and improve patient satisfaction as well as quality of care.
Abstract WP503: Your House or Mine: Where to Do Stroke Imaging for Thrombectomy Decision?
Authors: Richardson Alicia M , Velasco Cesar , Seifert Autumn , Dimemmo Gabrielle
Published: January 2019

Introduction:
Thrombectomy is a standard of care for eligible patients, yet there are many systems of care challenges associated with where the advanced imaging is done. The goal is to always select the right patient for treatment, get them to the right center, in the right amount of time. Some experts suggest that EMS providers with a positively screened large vessel occlusion (LVO) patient by-pass Primary Stroke Centers (PSCs) to save time since performing advanced imaging at PSCs can add significant delay. But this by-pass can add travel time and the imaging might not support thrombectomy after all. Comprehensive Stroke Centers (CSCs) have the responsibility to provide guidance to PSCs, but when the hospitals are local competitors this can be a challenge.

Methods:
In 2017, the CSC and PSC Stroke Coordinators from competing hospitals collaborated on a CT Angiogram protocol to be implemented at the PSC. The protocol included expanding the stroke alert window to 24 hours.

Results:
At baseline, the PSC’s DIDO average was 2 hours and 8 minutes, 0% had a CTA prior to arrival to the CSC, and the average Door to Puncture (DTP) was 1 hour 27 minutes. Post-implementation of the CTA protocol, the PSC had a 28% reduction in Door-in Door-out (DIDO) time (average 1 hour 46 minutes) while the CSC noted a 41% decrease in the DTP time (average 51 minutes). 100% of transferring PSC cases had a CTA prior to CSC arrival.

Conclusion:
Collaboration between a CSC and PSC in standardization and visualization of a process facilitates awareness and supports rapid implementation in the emergency department. CTA completion at the PSC does not hinder DIDO times and contributes to appropriate patient selection, thus eliminating costly transport. The result is optimal, individualized stroke care that saves more than time... it saves brain.
Abstract WP513: Pioglitazone for Secondary Prevention After Stroke in Asian Real World Data
Authors: Woo Min-Hee , Kim Jinkwon
Published: January 2019

Introduction:
Pioglitazone is anti-diabetic drug class known as thiazolidinediones. It has been established that pioglitazone has cardiovascular prevention effect in the patients with ischemic stroke or transient ischemic attack. However, the benefits for secondary prevention after stroke was not well-established, especially in Asian patients.

Methods:
This was a retrospective cohort study using the nationwide population-based sample cohort data based by the National Health Insurance Service in South Korea (NHIS-NSC). We included acute ischemic stroke patients with diabetes mellitus admitted for primary diagnosis code of ‘I63’ (ICD-10 code) between 2002 and 2013. Primary outcome was defined as the admission for recurrent stroke (I60-63), myocardial infarction (I21) or all-cause death. On every day of the follow-up period, exposure to pioglitazone was determined by accessing the prescription data in NHIS-NSC. Patients were followed until development of primary outcome or Dec 2013. We performed Cox regression model that included use of pioglitazone during follow-up period as time-dependent variable. Adjustments were performed for sex, age, hypertension, atrial fibrillation, myocardial infarction and use of other anti-diabetic medication.

Results:
We included 6391 diabetic patients who admitted with acute ischemic stroke and followed up > 3 months. During the mean follow-up period of 3.03 ± 2.48 years, 2276 patients had primary outcome. Use of pioglitazone during follow-up period was significantly associated with lower risk for primary outcome (Figure, unadjusted HR [95%CI], 0.50 [0.30-0.85],
p
<0.001). The cardiovascular benefit of pioglitazone remained significant even in multivariate model (adjusted HR, 0.57 [0.33-0.96],
p
=0.034).

Conclusions:
In this cohort study based on nation-wide health claim data, use of pioglitazone after acute ischemic stroke had significant cardiovascular benefits for secondary prevention.
Abstract WP521: Health Beliefs and Blood Pressure Reduction in the Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) Study
Authors: Jacoby Rachelle , Goldmann Emily , Parikh Nina S , Roberts Eric T , Appleton Noa , Boden-Albala Bernadette
Published: January 2019

Introduction:
Hypertension is a leading risk factor for stroke recurrence. Previous studies have found that patients’ health attitudes and beliefs play a critical role in shaping health behaviors. The aim of this analysis is to investigate the relationship between specific health beliefs and blood pressure reduction following stroke.

Methods:
DESERVE is an RCT of a skills-based educational intervention vs. standard care in a multi-ethnic cohort of mild/moderate stroke and TIA survivors. The relationship between participants’ baseline health beliefs and systolic blood pressure (SBP) reduction from baseline to one-year follow-up was assessed. Health beliefs were measured by asking participants to agree or disagree with five health belief questions such as, ‘I worry about having a stroke,’ ‘I can protect myself against having a stroke,’ and ‘Some people are more likely to have a stroke than others.’ Multivariable linear regression models were used to assess the relationship between each health belief and SBP reduction.

Results:
A total of 434 patients were included in the analysis (50.2% female; mean age 64.2; 29.7% non-Hispanic white, 32.0% non-Hispanic black, 32.5% Hispanic, 5.8% other). Of those participants, 77.9% agreed with the statement, “I can protect myself against having a stroke” and had a significantly greater mean SBP reduction compared to those who disagreed (6.29 vs. 1.57 mmHg, p=0.02). No other health belief questions were found to be significantly associated with SBP reduction. In the multivariable model, adjusting for age, gender, race, education, intervention status, stroke history, and marital status, agreeing that you can protect yourself against having a stroke was associated with a 6.44 mmHg greater mean SBP reduction compared to disagreeing (p=0.02).

Conclusion:
In this cohort of stroke/TIA patients, participants who agreed that they could protect themselves against having a stroke had an average mean SBP reduction of more than two times that of participants who disagreed with that statement. Certain health beliefs, such as those related to patient empowerment, may play an important role in secondary stroke prevention.
Abstract WP522: Catheter Ablation of Atrial Fibrillation and Long-Term Cardiovascular Outcomes
Authors: Bhave Prashant D , Soliman Elsayed Z , Okin Peter M , Cheung Jim , Kim Luke K , Weinsaft Jonathan W , Goyal Parag , Safford Monika M , Iadecola Costantino , Kamel Hooman
Published: January 2019

Introduction:
Catheter ablation is increasingly used in older patients with atrial fibrillation (AF) but the long-term effects on vascular outcomes in this population remain unclear.

Methods:
We used inpatient and outpatient claims between 2008-2015 from a nationally representative 5% sample of Medicare beneficiaries. Patients ≥66 years old who underwent AF ablation and control AF patients were matched in a 1:1 ratio based on a propensity score calculated from their age, sex, race, a socioeconomic status score, visit date, date of first AF diagnosis, history of vascular events, CHA
2
DS
2
-VASc score, and Charlson comorbidity index. Outcomes were ischemic stroke, myocardial infarction, heart failure hospitalization, major bleeding, number of AF hospitalizations, and all-cause mortality. Variables were ascertained using previously validated code algorithms. Survival statistics, Cox proportional hazards analysis, and Poisson regression were used to compare groups with adjustment for warfarin use during follow-up.

Results:
The 2,119 patients who underwent ablation and 2,119 controls were well matched, including on age (72.8 ±5.6 years), sex (39.5% female), race (92.5% white), CHA
2
DS
2
-VASc score (4.4 ±1.5), Charlson comorbidities (2.4 ±2.0), and duration since AF diagnosis (1.2 ±1.4 years). During 2.8 (±1.9) years of follow-up, ablation was associated with a lower risk of death (5.9% vs 10.8% per year) (HR, 0.55; 95% CI, 0.48-0.63) or heart failure hospitalization (5.9% vs 10.7% per year) (HR, 0.57; 95% CI, 0.47-0.70) and fewer AF hospitalizations (incidence rate ratio, 0.85; 95% CI, 0.81-0.89). There was no difference in the risk of ischemic stroke (0.9% vs 1.2% per year) (HR, 0.77; 95% CI, 0.54-1.12), myocardial infarction (0.8% vs 1.0% per year) (HR, 0.75; 95% CI, 0.50-1.11), or major bleeding (3.0% vs 3.4% per year) (HR, 0.90; 95% CI, 0.72-1.11).

Conclusions:
In a propensity-matched cohort of elderly AF patients, catheter AF ablation was associated with lower mortality and fewer hospitalizations for AF or heart failure, but ablation was not associated with a long-term reduction in thromboembolic or bleeding events.
Abstract WP527: Chronic Environmental Circadian Disruption Accelerates Stroke Onset in Spontaneously Hypertensive Stroke Prone Rats
Authors: Ramsey Anne M , Hill Atlantis , Stowie Adam , Ellis Ivory , Namura Shobu , Davidson Alec
Published: January 2019

Shift work is associated with a higher risk of stroke, but the mechanisms of this relationship are unknown. Photic cues to the suprachiasmatic nucleus (SCN) are the primary source of environmental regulation for circadian rhythms, but non-photic cues such as food intake can synchronize peripheral clocks involved in metabolic functions. Abrupt changes in the timing of such environmental time cues cause environmental circadian disruption (ECD) that may be responsible for chronic and acute diseases in shift workers such as hypertension and stroke. In this study, we used a spontaneously hypertensive stroke-prone rat model to determine whether ECD accelerates stroke onset. We also test the hypothesis that scheduled mealtimes can rescue such effects of ECD. Adult male rats were exposed to either a fixed or shifted (6hr weekly advance shifted) light-dark (LD) 12:12 cycle. Rats were given a high salt diet and 1% NaCl drinking water to increase hypertension onset and establish the conditions for spontaneous hemorrhagic stroke. A second cohort exposed to the same two lighting conditions received 5h scheduled daily mealtimes. Food and water intake were measured to estimate salt load. Neurological assessment scoring was used to determine stroke onset. Circadian activity rhythms stably entrained to the fixed LD cycle but were disrupted in shifted LD rats, causing chronic misalignment as occurs in shift workers. In contrast to the stroke onset in fixed LD conditions, the survival rate was shortened in shifted LD rats with a median survival time of 46.5 days versus 58.5 days, respectively (Log-rank Mantel-Cox test p<0.05). While fixed meals substantially prolonged lifespan in this model in a fixed LD cycle, this feeding schedule did not prevent the effects of ECD. These results suggest that the environmental circadian disruption may accelerate hypertension and the onset of hemorrhagic stroke, even in the presence of the potent protective factor of fixed restricted mealtimes. This model will afford the opportunity to probe the mechanistic connections between chronic circadian misalignment and disease onset and progression. Supported by NIH U54NS083932 to Peter R. MacLeish and SC1GM112567 Alec Davidson
Abstract WP530: A Machine Learning Approach in Prediction of Recurrent Stroke
Authors: Park Moon Ho , Kwon Do-Young , Jung Jin-Man
Published: January 2019

Introduction:
Although recurrent stroke is clinically important, prediction of recurrent stroke is less well known. Machine learning encompasses a body of statistical approaches that can detect complex interaction patterns from multi-dimensional data. ML is gradually being adopted in medical science. The purpose of this study was to illustrate the possibility of using machine learning as an aid in prediction of recurrent stroke.

Methods:
We obtained clinical data from a consecutively registered, hospital-based acute stroke registry. Using a dataset of 4,766 acute ischemic stroke patients, predictive models were built using 1) linear 2) non-linear/non-parametric machine learning algorithms. The accuracy obtained was compared to that of the baseline model built without the clinical data.

Results:
There were 810 patients with recurrent stroke after ischemic stroke or transient ischemic attack (median follow-up, 365 days). The performances of the various machine learning models were compared. The accuracy of the baseline model was 31.4%, but the best non-linear model showed an accuracy of 64.6%, which was significantly higher than that of non-informative random guessing (p=0.002). Overall, the models using the nonlinear algorithms showed better accuracy than the linear ones.

Conclusions:
The high performance of the developed models demonstrated the predictive capacity of recurrent stroke and justified the application of machine learning algorithms. However, the practical application of machine learning models may need refinement and larger-scale data collection.
Abstract WP540: Acid Base and Electrolyte Alterations in Acute Large Vessel Occlusion Stroke
Authors: Martha Sarah R , Collier Lisa A , Davis Stephanie M , Alhajeri Abdulnasser , Grupke Stephen , Pennypacker Keith R , Fraser Justin F
Published: January 2019

Background and Purpose:
In the setting of mechanical thrombectomy for emergent large vessel occlusion (ELVO), we have developed a protocol to collect and evaluate blood immediately distal and proximal from the removed intracranial thrombus. These samples provide a unique resource in evaluating acute changes in acid/base and electrolyte concentrations at the time of ischemic stroke. The purpose of this study is to compare acid/base and electrolyte differences obtained proximal and distal to the occluded intracranial thrombus in acute ischemic stroke patients.

Methods:
We developed the Blood and Clot Thrombectomy Registry and Collaboration (BACTRAC) protocol: an IRB-approved tissue banking strategy for ELVO (clinicaltrials.gov NCT03153683). We compared arterial blood gases (ABG) of blood distal versus proximal to the thrombus during thrombectomy. Comparisons were evaluated by Paired Samples T-Tests (p < 0.05).

Results:
We analyzed the first 46 subjects (age = 67 ± 14.23, 20 males) in the BACTRAC registry. Preliminary results demonstrate that, while pH is nonsignificant (p = 0.513), distal blood in relation to proximal blood showed significantly lower oxygen (p < 0.001), carbon dioxide (p < 0.001), bicarbonate (p < 0.001), ionized calcium (p < 0.001), and potassium (p < 0.001). Sodium concentration was significantly higher (p < 0.001) in distal blood. These results suggest alterations occurring intravascularly during ischemia.

Conclusions:
These preliminary findings provide a novel insight into the pathology of large vessel stroke in humans, particularly in regard to identifying acute changes in acid/base balance and electrolyte concentrations that occur during stroke.
Abstract WP550: Pathophysiology of Acute, Subacute and Chronic Lesions in Stroke: A Radiological-Pathological Analysis
Authors: Griffin Allison , Ray-Chaudhury Abhik , Edwards Nancy , Maric Dragan , Lynch John , Leigh Richard , De Vis Jill , Latour Lawrence
Published: January 2019

Introduction:
The imaging characteristics of ischemic lesions seen on MRI aid in the interpretation of the lesion pathogenesis. Early ischemic lesions are seen on diffusion weighted imaging (DWI) with low apparent diffusion coefficient (ADC), later evolve on T2-FLAIR, develop elevated ADC, then disappear on DWI. Chronic white matter lesions (WML) seen on T2-FLAIR but not DWI may or may not be of ischemic origin. Here we present an MRI targeted pathology approach to better describe in-vivo MRI based on cellular changes.

Methods:
The brain of a patient was obtained for pathological evaluation early after stroke recurrence. As part of clinical care and study procedures, 3T MRI was obtained at baseline (within 2-hours), multiple follow-up visits, and during second admission. Radiological-pathological methods previously validated in trauma was employed. Whole brain 7T MRI was performed after formalin fixation, and MRI targeted pathology was performed, co-localizing three lesions of different ages based on history and presumed imaging characteristics; i) acute, ii) subacute, and iii) chronic vs WML. Homologous contralateral tissue was used as control.

Results:
Lesions seen in-vivo were observed in post mortem MRI, and reconfirmed in histology. An example of in-vivo and post-mortem MRI, along with corresponding tissue sections and H&E are shown in figure. Qualitative delineation of the boundaries of the chronic lesion on H&E was challenging. A large number of small vessels with enlarged perivascular spaces dominated. The subacute lesion, was characterized by loss of white mater, infiltration of macrophages, and astrocytosis. The acute lesion had a text-book appearance.

Conclusion:
Dramatic differences are seen in the volume fraction of free water, which likely a major contributor to the appearance on DWI/ADC and T2 FLAIR. Work continues with immunohistochemistry to better delineate the boundaries of the lesions and cellular morphology relevant to in-vivo MRI.
Abstract WP551: Senescence-Induced Methylation Changes in Global DNA and Atherosclerosis-Related Genes in Human Vascular Endothelial Cells
Authors: Kim Jee Yeon , Jelinek Jaroslav , Hwang Junha , Shin Jong Wook , Jeong Hye Seon , Choi Bong Geun , Issa Jean-Pierre , Kim Jei
Published: January 2019

Background:
Endothelial senescence has been known as a pathophysiological alteration related to atherosclerosis development. We investigated whether methylation changes in global DNA and atherosclerosis-related genes are developed in in-vitro senescence of human vascular endothelial cells.

Methods:
We induced in-vitro replicative senescence by subculturing 5 human umbilical vein endothelial cell (HUVEC) lines from three to fifteen passages. Using DNA extracted from the 5th, 10th, and 15th passages of the 5 HUVECs, we evaluated LINE1 methylation for global methylation status as well as promoter methylation status for 5 genes (
AIRE1, ALOX12, FANK1, NETO1
, and
SERHL2
) profiled from carotid endarterectomy plaques for gene-specific methylation evaluations. Differences in LINE1 methylations and promoter methylations of the 5 genes were evaluated using pyrosequencing and compared among the 5th, 10th, and 15th passages of the 5 HUVECs using analysis of variance (ANOVA) tests.

Results:
LINE1 global methylation subsequently decreased as passages were advanced from 5 to 15 (p<0.001). On gene-specific promoter methylation analysis,
ALOX12
(p<0.001) and
SERHL2
(p<0.001) showed significant passage-dependent increase of promoter methylation.
AIRE1
and
NETO1
also showed an increase of promoter methylation as passages increased, but without statistical significance.
FANK1
exhibited an increase-decrease pattern of methylation changes showing an increase of methylation at passage 10 compared to passage 5, but showing a decrease in passage 15 (p=0.005).

Conclusion:
After replicative senescence for vascular endothelial cells, global methylation subsequently decreased. However, atherosclerosis-related genes showed either a increase or an increase-decrease of promoter methylations. In particular, the increase of
ALOX12
methylation showed as a possible epigenetic marker related to vascular endothelial cell senescence.
Abstract WP60: Later Imaging More Accurately Captures Infarct Growth in DEFUSE 3
Authors: Tate William J , Polding Laura C , Christensen Soren , Mlynash Michael , Heit Jeremy J , Marks Michael M , Albers Gregory W , Lansberg Maarten G
Published: January 2019

Background:
DEFUSE 3 assessed thrombectomy in patients with evidence of salvageable tissue on brain imaging in the 6 to 16 hour treatment window. Despite substantially better functional outcomes as measured by the modified Rankin Scale at day 90, the study did not find a significant reduction in infarct growth between baseline and 24-hour follow up with endovascular therapy. The aim of this study was to determine if infarct growth captured with scans performed at later timepoints could demonstrate differences between treatment groups.

Methods:
We included DEFUSE 3 patients in whom infarct volume could be measured at baseline, at 24-hour follow up, and at one additional later time point using either CT or MRI. Early infarct growth (increase in lesion volume between baseline imaging and 24 hours) and late infarct growth (increase in lesion volume between 24 hours and a later time point) were calculated. Differences in infarct growth between the medical and endovascular groups were assessed using Wilcoxon rank-sum tests.

Results:
For the 70 patients who met inclusion criteria, the average age was 69 ± 14 years, average NIHSS 17 ± 6, and the average time of late imaging was 5.3 ± 3.1 days. There were no significant differences in these variables between the medical (n=43) and endovascular (n=27) cohorts. Median early infarct growth was not different between the medical 32 mL (IQR: 24 - 79) and the endovascular groups 24 mL (IQR: 15 - 91; p = 0.359). Median late infarct growth was greater in the medical group 11 mL (IQR: 2 - 29) compared to the endovascular group 2 mL (IQR: -10 - 9; p = 0.003) (see figure).

Discussion:
Imaging performed at a mean of 5 days post-stroke demonstrates continued infarct growth in the medical arm and minimal additional growth in the endovascular arm. These data correspond to the clinical benefit of endovascular therapy observed in DEFUSE 3 and suggest that imaging beyond 24 hours is preferred for assessing final infarct volume in endovascular therapy trials.
Abstract WP64: The Effect of Leukoaraiosis on Functional Outcome After Thrombectomy
Authors: Mikati Abdul Ghani , Mandelbaum Max , Sapnar Shweta , Puri Ajit , Silver Brian , Goddeau Richard P , Haussen Diogo , moonis Majaz , Jun-O'Connell Adalia , Henninger Nils
Published: January 2019

Introduction:
The chance for a favorable outcome after mechanical thrombectomy (MT) for large vessel occlusion stroke decreases with the symptom onset-to-reperfusion time (OTR). Patients with severe leukoaraiosis are at increased risk for a poor outcome after MT. However, whether leukoaraiosis modulates to the association between OTR and 90-day functional outcome is uncertain.

Methods:
We retrospectively analyzed 144 consecutive patients with successful (TICI ≥2b/3) MT for anterior circulation LVO within 24 hours form OTR between January 2012 to November 2016. Leukoaraiosis was dichotomized to absent-to-mild (van Swieten scale score 0-2) versus moderate-to-severe (3-4) as assessed on admission head CT. Multiple linear, logistic, and ordinal regression analyses were used to determine the association between leukoaraiosis, OTR and 90-day modified Rankin Scale (mRS) score, after adjustment for pertinent covariates.

Results:
Leukoaraiosis was independently associated with OTR on multivariable linear regression (
p
=0.003). The association between OTR and 90-day outcome depended on the degree of preexisting leukoaraiosis burden as shown by a significant leukoaraiosis-by-OTR interaction on multivariable logistic regression (OR 0.76, 95%-CI 0.58-0.98,
p
=0.037) and multivariable ordinal regression (OR 0.87, 95%-CI 0.78-0.97,
p
=0.011).

Conclusions:
The severity of pre-existing leukoaraiosis is associated with 90-day functional outcome and modulates the association between the OTR and 90-day mRS among patients undergoing MT within 24 hours from last known well. If confirmed, our results may have important implications for optimizing patient selection for acute stroke therapies.
Abstract WP76: Automated Detection of Hyperdense MCA Sign and Automated Notification of Large Vessel Occlusion Using Artificial Intelligence
Authors: Chung Charlotte Y , Rodrigues Gabriel M , Haussen Diogo C , Barreira Clara M , Grossberg Jonathan , Frankel Michael R , Nogueira Raul G
Published: January 2019

Introduction:
The hyperdense vessel sign (HDVS) on non-contrast computed tomography (NCCT) is one of the earliest findings in patients with acute ischemic stroke. Further, the HDVS has been associated with poor outcomes. Recognition of the HDVS, which indicates the presence and location of a red blood cell-rich intra-arterial thrombus, aids the diagnosis of large vessel occlusions (LVOs) and helps the triage to endovascular reperfusion. An efficient workflow to identify patients eligible for reperfusion therapy is essential to achieve the best patient outcome, and an artificial intelligence technology that can automatically detect HDVS and notify specialists may streamline this process. We present the first results using artificial intelligence to accurately identify HDVS for LVO detection.

Methods:
A convolutional neural network (Viz HDVS) was developed to detect hyperdense middle cerebral artery (MCA) sign of the M1 segment on NCCT. A single center retrospective analysis of NCCT in consecutive acute ischemic stroke patients from January 2014 to May 2015 with angiography-proven LVO was performed. Results of the Viz HDVS algorithm were compared to findings reported by expert neuroradiologists in the electronic medical record database, which were independently reassessed for congruence by a separate radiologist. Patients were excluded if a pre-angiography NCCT or the radiology report was unavailable for review, or if the presence of hyperdense MCA M1 sign was indeterminate.

Results:
A total of 223 patients were reviewed. The Viz HDVS algorithm identified hyperdense MCA M1 sign with a sensitivity of 70%, a specificity of 96%, and an AUC of 0.85 in 117 NCCT scans from acute ischemic stroke patients with LVO. The mean algorithm run time was 1 minute 30 seconds, with a maximum run time of 3 minutes. Projected mean time to specialist notification using Viz HDVS was 5 minutes.

Conclusions:
The novel Viz HDVS algorithm demonstrated remarkable feasibility and speed of applying artificial intelligence in the automated detection of HDVS and notification of specialists. This algorithm may aid in earlier identification and treatment of acute ischemic stroke patients with LVOs.