bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract T P241: Glial Responses in a Pediatric Model of Ischemic Stroke
Authors: Ahrendsen Jared T , Hickey Sean P , Grewal Himmat , Herson Paco S , Traystman Richard J , Macklin Wendy B
Published: March 2022

Pediatric arterial ischemic stroke affects hundreds of children in the United States each year, with a majority of surviving children suffering long-term neurologic deficit. Initial studies suggest that recovery from stroke is greater among juveniles compared to neonates or adults. We have developed a middle cerebral artery occlusion (MCAO) mouse model of pediatric stroke in order to understand the cellular responses unique to the juvenile developmental time period. One strikingly understudied aspect of stroke, especially in juvenile subjects, is its impact on glia, in particular myelinating glia. Therefore, the glial responses following experimentally-induced stroke in juvenile mice were investigated.

Methods:
P20-25 mice were subjected to 45 min MCAO with an intraluminal filament. Animals were analyzed at 24 hr, 3, 7 and 30 days of recovery.

Results:
Due to the high metabolic activity of myelinating oligodendrocytes during pediatric development, we hypothesized that oligodendrocytes would be particularly sensitive to ischemia. Surprisingly, mature oligodendrocytes and gross myelin production were unaffected during the acute (24 hr and 3 d post MCAO) and subacute (7 d) recovery phases. However, during the chronic (30 d) phase, some myelin debris and signs of mild axon pathology were detected in the lateral striatum, where gliosis was most severe. GFAP immunoreactivity steadily increased in the lesioned striatum from 24 hr to 30 d following MCAO. Similarly, Iba1-positive microglia and NG2-positive cells proliferated in the lesioned area 24 hr after stroke, and remained increased after 30 d. Adult mice subject to identical ischemic insult resulted in decreased numbers of oligodendrocytes, severe axon pathology, and significantly greater tissue loss.

Conclusions:
Together, these results suggest that myelinating oligodendrocytes in the pediatric brain are resistant to the initial ischemic insult. Furthermore, retaining healthy oligodendrocytes after stroke could serve an important role in maintaining axon integrity and limiting long-term tissue loss after stroke. Understanding the unique cellular responses in the juvenile brain could yield valuable insight into enhancing cellular resistance and promoting recovery after ischemia.
Abstract T P262: Lower Thrombolysis Rates in Women with Acute Ischemic Stroke in the Florida-Puerto Rico Collaboration to Reduce Stroke Disparities Study - The NINDS Stroke Prevention Intervention Research Program
Authors: Asdaghi Negar , Wang Kefeng , Gardener Hannah , Dong Chuanhui , Ciliberti-Vargas Maria A , Rose David Z , Santiago Fernando L , Romano Jose G , Burgin W S , Carrasquillo Olveen , Garcia-Rivera Enid J , Koch Sebastian , Meschia James F , Nelson Joe A , Nobo Ulises , Robichaux Mary , Waters Michael F , Zevallos Juan C , Sacco Ralph L , Rundek Tatjana ,   for the FL-PR CReSD Investigators and Collaborators
Published: March 2022

Background:
Higher prevalence of stroke in women and sex-specific disparities in stroke care are reported. We sought to determine sex-specific differences in stroke performance metrics in a large quality improvement registry of Florida and Puerto Rico based on Get With The Guidelines-Stroke (GWTG-S).

Methods:
38,684 (49% women) acute ischemic stroke patients were included from 63 sites (54 FL; 9 PR) from 2010 to 2013. Logistic regression was used to evaluate sex-specific differences in defect-free care (IV tPA therapy, in-hospital antithrombotic therapy, DVT prophylaxis, antithrombotic therapy at discharge, anticoagulation therapy, statin medication at discharge, smoking cessation counseling) adjusting for age and race-ethnicity.

Results:
As compared to men, women were older (73±15 vs. 69±14 years; p<0.0001), less likely Hispanic (17% vs. 18%; p=0.0001), with lower age- and race-ethnic-adjusted rates of hypertension (34% vs. 37%; p=0.0009) and smoking (13% vs. 21%; p<0.0001), but higher rates of atrial fibrillation (18% vs. 16%; p=0.02). Overall, 9% of patients received thrombolysis. Women were less likely to receive thrombolysis (OR 0.92, 95% CI 0.86-0.99) and less likely to have door-to-needle time <1 hour (OR 0.84, 95% CI 0.73-0.97). Overall, defect-free care was 75% in women and 76% in men (lower early antithrombotic therapy [OR 0.86, 95% CI 0.77-0.96], less antithrombotic at discharge [OR 0.87, 95% CI 0.77-0.99], less statin therapy at discharge [OR 0.81, 95% CI 0.74-0.88] and less smoking cessation counseling [OR 0.74, 95% CI 0.56-0.98]). Defect- free care improved over the study period; it was significantly lower in women vs. men in 2010 (58.2% vs. 60.7%, p=0.005), but similar in 2013 (90.2% vs 90.0%; p=0.64).

Conclusions:
Women eligible to receive IV tPA for acute ischemic stroke were less likely to be treated and received less defect-free care compared to men, but these measures improved over time. These findings suggest that the adoption of GWTG-S quality improvement program helps reduce sex disparities in quality of care for acute ischemic stroke patients.
Abstract T P297: Arterial Spin Labeled MRI Quantifies Cerebral Blood Flow Changes with Blood Pressure from Acute to Subacute Stroke
Authors: Liebeskind David S , Ichwan Daniel J , Yu Songlin , Scalzo Fabien , Johnson Mark S , Qiao Joe X , Alger Jeffry R , Ali Latisha K , Kim Doojin , Hinman Jason D , Rao Neal M , Saver Jeffrey L , Yoo Bryan , Vespa Paul M , Sanossian Nerses , Blanco Manuel B , Wang Danny J ,   on behalf of the UCLA Stroke Investigators
Published: March 2022

Background:
Hemodynamic interventions, such as blood pressure (BP) manipulation, are often utilized to optimize perfusion of the ischemic territory. Scant data support theoretical effects of permissive hypertension or BP reduction, yet arterial-spin labeled (ASL) MRI may chronicle quantitative cerebral blood flow (CBF) changes. We used serial ASL to measure CBF changes associated with hemodynamic interventions, based on arterial occlusion site and collaterals.

Methods:
Serial ASL acquired in 148 consecutive cases of acute ischemic stroke at a single center during a 3-year period. A pseudo-continuous ASL pulse sequence with background suppressed 3D GRASE (gradient and spin echo) readout with 4 post-labeling delays was used, with normalization of quantitative CBF on a standard neurovascular template. CBF values and relative changes were measured in the affected hemisphere and in discrete regions of infarct core and collateral territories.

Results:
148 cases (median age 68 years (IQR 62-82), 73 women) were studied. Overall, CBF (ml/100g/min) was related to age (r=-0.40, p<0.001) but not gender (male: 39±9.7, female: 40.6±8.2; r=.05, p=NS). Serial studies were obtained in 126 cases, including 2 studies in 91, 3 in 32, and 4 in 3. Median time to 1
st
, 2
nd
, 3
rd
, and 4
th
ASL study was 11.3, 39.7, 140.7, and 121.3 hrs and median CBF at these timepoints was 39.9 (IQR 28-48); 42.2 (IQR 29-52); 47.1 (IQR 36-56); and 35.6 (IQR 34-41). Average changes in CBF from study 1 to 2, 2 to 3, 3 to 4 were +2.2; +3.4; -14.8. Average CBF ratio between leptomeningeal and perforating MCA regions was 1.1. The correlation of initial delta CBF (study 1 to 2) with initial delta BP (1 to 2) was r=-0.1, p=NS. Average delta CBF/delta mmHg SBP was 0.25. At studies 1 and 2, lower BP was related to higher CBF (r=-0.148, p=0.102). Overall, delta BP was not linked with CBF (r=0.002, p=NS) or delta CBF (r=-0.108, p=NS). For those with low initial CBF (<40), positive delta BP was strongly associated with lower CBF at study 2 (r=-0.552, p=0.006).

Conclusions:
Blood pressure modification, permissive or interventional, may differentially affect CBF in the ischemic core and collateral regions. ASL provides a novel method for non-invasive mapping of serial changes in absolute CBF quantification in the ICU and beyond.
Abstract T P300: Hospital Characteristics, Distribution, and Site Reviews of Certified Comprehensive Stroke Centers
Authors: Alberts Mark J , Hampel MJ , Cantwell Vicki , Range Jean , Eggen Nancy , Kolbusz Karen , Watt Ann
Published: March 2022

Objectives:
In 2012 The Joint Commission (TJC) began an advanced certification program for Comprehensive Stroke Centers (CSC) using criteria defined by the Brain Attack Coalition and several Technical Advisory Panels. We now report the results from organizations who successfully achieved this certification. Our hypothesis was that, compared to Primary Stroke Centers (PSCs), the CSCs would be larger urban teaching hospitals, and that their distribution would be uneven and would not match population density.

Methods:
We obtained data from TJC about the 73 hospitals that were successful in achieving CSC certification from 2012 through July 2014. These data were compared to the 1036 organizations that achieved PSC designation from 2004 through July 2014. Data on hospital type, location, bed size, and distribution by population were analyzed. Analyses were done using Chi-square comparisons. The number of Requirements for Improvement (RFI) were tabulated and analyzed for the CSCs.

Results:
More than 94% of PSCs and 100% of CSCs were in urban locations (p=0.026.) More than 92% of CSCs were teaching hospitals compared to 50% of PSCs (p< 0.0001). CSCs were larger facilities than PSCs, with 64.4% of CSCs having 500 or more beds compared to only 21.7% of PSCs (p< 0.001). Among the 10 largest states by population, the percent of certified CSCs as a percent to total JC certified stroke centers varied from a high of 11.3% (OH) to a low of 0% (FL ) and 2% (TX). The most common RFIs were 1) time parameters for stroke work-up (74% non-compliant), 2) assessments consistent with clinical practice guidelines (69% non-compliant), and 3-5) documenting care/treatments, monitoring complications, and defined accountability of leaders (each 57% non-compliant). Our data do not reflect CSCs certified by other agencies and organizations.

Conclusions:
Compared to PSCs, hospitals certified as CSCs are large teaching facilities in urban areas. The current distribution of CSCs is uneven. Many CSCs were not initially compliant with several standards.
Abstract T P305: Long-term Analysis of an RN-Developed Stroke Bedside Swallow Screening Tool
Authors: Yanase Lisa R , Stuchiner Tamela , Baraban Elizabeth , Dancer Sandy
Published: March 2022

Purpose:
To assess performance of the Providence Bedside Swallow Screening Tool (BSS) by reviewing pre- and post-implementation hospital-acquired pneumonia rates, length of stay (LOS), disposition and mortality of our stroke patient population.

Background:
Lack of appropriate swallow screening is a leading contributor to hospital-acquired pneumonia. To address this problem, Providence Health and Services Oregon Region Stroke Program developed and implemented a BSS in 2005. This tool was designed by a multidisciplinary team to ensure the best evidence-based practice.

Methods:
Data from the Providence Stroke Registry collected via Get With The Guidelines were analyzed to determine whether the BSS improved outcomes after implementation in July 2005. Data include all stroke patients admitted to two affiliated Primary Stroke Centers (PSCs) between 2004 and 2013. Hospital-acquired pneumonia rates (HAP) per 100 patient discharges and LOS in days were compared pre (2004- June 2005) and post (July 2005-2013) implementation of the BSS tool using Analysis of Variance Tests. Pre- and post-implementation discharge disposition was compared using Pearson’s chi-square.

Results:
Between 2004 and 2013, 10,989 stroke patients were discharged from two PSCs, 1,385 pre-, and 9,604 post- implementation of the BSS. Comparing pre- and post-data, there was a significant decrease in HAP per 100 patient discharges, 7.2 (±25.9) vs 1.9 (±13.6) (p<0.01), and in LOS, 5.1 days (±5.9) vs. 4.4 days (±5.6) (p<0.01). In addition, more patients were discharged home (26.6% vs 19.6%), fewer went to a skilled nursing facility (26.6% vs 19.6%), and fewer expired or went to hospice (15.7% vs. 12.9%) (p<.01).

Conclusion:
The Providence Stroke Program Bedside Swallow Screening Tool has provided excellent safety and outcomes for our stroke patients, including lowering risk of HAP. This effect has been sustained over 9 years in over 9600 patients. This is the longest documented ongoing use of a tool for bedside swallow screen. Further studies are needed to determine the relationship between the BSS and other outcomes.
Abstract T P317: Sepsis in Intracranial Hemorrhage: Does Stroke-Induced Systemic Immunosuppression Play a Role?
Authors: Rajagopalan Swarna , Ronca Richard , Azizi Ausim
Published: March 2022

INTRODUCTION:
Infection is a significant cause of mortality in patients with both ischemic and hemorrhagic stroke. This is thought to occur as a result of stroke-induced systemic immunosuppression (SIIS). The role of cerebral damage pre-disposing to sepsis has only been addressed in a few studies for ischemic stroke, and literature is sparse in Spontaneous Intracerebral Hemorrhage (SICH) patients who have higher mortality, greater disability and require more intensive medical care. We sought to determine identify predictors of SIIS and sepsis, so we may be able to recognize and intervene early.

METHODOLOGY:
We retrospectively analyzed 40 patients with SICH admitted to the NICU between January 2012 and January 30, 2014. We included patients with SICH. We excluded patients with multi-compartmental hemorrhage and patients lacking outcome data. Patient demographics including age, gender, location, volume of SICH, GCS, and total lymphocyte counts from days one to five of hospitalization was recorded. Data was divided into a non-infection group, where patients lacked any clinical or laboratory evidence of infections, and an infection group. Statistical analysis was performed to compare lymphocyte depletion over time between patients that developed an infection and those that did not.

RESULTS:
From the cohort of 40 patients with SICH, 20 developed an infection during their hospital course. Total lymphocyte counts were lower on all five days in the infection group compared to the non-infection group and became significant on day four of hospitalization (1 in the infection group vs. 2.1 in the non-infection group, p<0.01. Lymphopenia preceded clinical signs and symptoms of infection, which occurred in average on day 5.8 of hospitalization. Patients in the infection group had greater hemorrhage volume (32.5 ml vs. 15.5 ml) and poorer GCS scores on admission (12.7 vs. 11.8) although these differences did not reach statistical significance.

CONCLUSION:
The incidence of sepsis is high in SICH patients, and these patients have worse prognostic parameters. Our data suggests identification of lymphopenia may be a significant predictor of development of clinical infection in these patients. Future studies with larger sample sizes are warranted.
Abstract T P342: Clot Busting: Enhancing Nursing Documentation
Authors: Tieri Patience , Scott Nancy , McKoy Cedric , Wahome Ashley , Vincent Catherine
Published: March 2022

Background:
Stroke is the leading cause of death and disability in the United States. The only FDA-approved treatment of ischemic stroke is tissue plasminogen activator (rt-PA) which dissolves the clot and improves blood flow to the compromised brain area(s). According to the National Institute of Neurological Disorders and Stroke rt-PA Study Group, 6.4% of patients treated with rt-PA experienced a hemorrhagic conversion. Thus, it is critical to closely monitor neurologic status (neurologic exam and vital signs) during treatment. During the Joint Commission Comprehensive Stroke Certification (CSC), we identified opportunities for improvement in our documentation of neurological status for our patients receiving rt-PA.

Purpose:
Following the Iowa Model of EBP to promote quality patient care, our purpose was to develop a standardized guideline for neurological assessment and documentation for patients following administration of rt-PA. Our goal was to attain a 90% compliance rate for appropriate neurological assessment documentation.

Methods:
Based on research, the American Heart Association clinical guidelines, and consultation with a CSC and our Regulatory Compliance department, we developed the standardized documentation guideline. The project included strategies addressing the four process phases required to implement and integrate EBP. Strategies included: 1) education on standards utilizing information sessions at staff meetings, tip sheets, and badge cards, 2) standardization of neurological assessment in EMR, 3) utilization of the stroke page system for patient identification, and 4) audit and feedback loops with just-in time in-servicing.

Results:
Prior to the implementation of this standardized guideline, of the 14 patients who received rt-PA, 14% met the threshold goal; of the 10 patients who received rt-PA after our implementation, all patients met the threshold.

Conclusions:
Through the implementation of our standardized protocol for neurological assessment and documentation of patients following administration of rt-PA, we were able to improve the quality of neurological assessments, meet Joint Commission requirements, and improve the quality of patient care.
Abstract T P347: "Changing How We've Always Done it" Utilizing Lean Six-Sigma to Improve Door to IV-tPA times
Authors: Finley Heather , Leonhardt Ann M , Gervase Joe , Hazarie Roopnarine , Jahromi Babak S , Benesch Curtis G
Published: March 2022

Background & Purpose:
Changing procedures in a large academic hospital is a difficult process. Our institution sought to improve IV-tPA administration times for patients with acute stroke. The purpose of this Kaizen event was to break down this process and rebuild it with the goal of safely administering IV-tPA consistently within the 60- minute window.

Methods:
Utilizing the expertise of a lean Six-Sigma trained professional, a team was carefully selected comprising multiple disciplines. After receiving lean Six-Sigma training, this team deconstructed the process of IV-tPA administration, using a mock patient experience, external consultants, and direct observation of other institutions. Delays in treatment were attributed to obtaining multi-modal imaging on arrival and performing multiple examinations by different providers. Data were analyzed using reports from the GWTG national registry.

Results:
With support from all stakeholders, the group developed a new pathway: ED triage◊CT scan (non-contrast only)◊ED Critical Care Bay. By postponing multi-modal CT imaging until after determining IV-tPA eligibility and treatment, door-to IV-tPA times improved significantly (see Fig. 1).

Conclusions:
Effecting change in a large academic hospital requires buy-in from multiple departments and administrative levels. Resistance to change was a barrier overcome by enlisting the assistance of nurses, radiology techs, and providers. The lean Six-Sigma process was instrumental in streamlining our process in evaluating and treating patients with acute stroke. This one simple change has improved all of our “door-to” metrics and has allowed us to treat acute ischemic stroke patients more quickly. As a result of this process, other potential projects have been identified, such as improving door to groin puncture times for patients undergoing endovascular treatment.
Abstract T P36: DWI Lesion Size but Not FLAIR Status Alone is Associated With Early Clinical Outcome in Stroke Patients Undergoing MRI Prior to Systemic Thrombolysis
Authors: Hobohm Carsten , Budig Sarah , Fritzsch Dominik , Michalski Dominik
Published: March 2022

Objectives:
Treatment of ischemic stroke holds the risk of intracerebral hemorrhage (ICH) due to systemic thrombolysis, often associated with poor functional outcome. Hence, parameters allowing prediction from deleterious courses are of increasing interest. We have recently shown that fluid-attenuated inversion recovery (FLAIR)-positive lesions seen on baseline magnetic resonance imaging (MRI) are associated with an increased rate on ICH. This study asked for the relationship between findings originating from baseline MRI and the clinical course.

Methods:
Using a multi-parameter hospital-based registry, the diffusion-weighted imaging (DWI) and FLAIR on baseline MRI of 122 ischemic stroke patients were analyzed for DWI lesion size and FLAIR-positive lesions within diffusion-restricted areas. These data originated from MRI that had been done prior to treatment with tissue plasminogen activator (tPA) within 3 hours from symptom onset, whereas computed tomography performed within 24 hours post-treatment served for detection of ICH. The early clinical outcome was assessed at hospital discharge using Barthel index (BI), modified Rankin scale (mRS) and National Institutes of Health Stroke Scale (NIHSS).

Results:
Out of 97 patients providing sufficient imaging quality, FLAIR-positive lesions were present in 25 patients (25.8 %) and ICH occurred in 32 patients (33.0 %). Remarkably, patients with or without FLAIR-positive lesions did not differ concerning the clinical outcome (BI,
P
=0.055; mRS,
P
=0.106; NIHSS,
P
=0.295). Patients exhibiting an initial DWI lesion size of at least 1/3 of vascular territory demonstrated an increased NIHSS (
P
=0.031), increased mRS (
P
=0.011) and decreased BI (
P
=0.004) when compared to patients with smaller lesion sizes. As expected, more severe clinical affection was found in patients suffering from ICH (BI,
P
=0.013; mRS,
P
=0.001; NIHSS,
P
=0.016).
Conclusions:
In ischemic stroke patients treated with tPA, initial DWI lesion size was found to be closely associated with early clinical outcome, which was, however, not seen for FLAIR positivity. Therefore, a combination of both DWI lesion size and FLAIR status might represent an addition tool to enhance safety for stroke patients undergoing systemic thrombolysis.
Abstract T P363: A Pilot Study: Parents Show Evidence of PTSD while Children Display Anxiety following Childhood Stroke
Authors: Lehman Laura L , Maletsky Kristin , Islam Fareesa , Rivkin Michael J , Mrakotsky Christine
Published: March 2022

Objectives:
Post-traumatic stress disorder (PTSD) is commonly found in parents and child following life-threatening pediatric illness or injury including cancer, organ transplant, traumatic brain injury, and admission to the pediatric intensive care unit. It can be diagnosed months to years after the event. The prevalence and significance of PTSD in parents and children following a childhood stroke are unknown. We examine the emotional outcomes of a cohort of 33 parents and 10 children following recent stroke in the child.

Methods:
We prospectively enrolled children with stroke of ages 7-18 years and parents of children with stroke ages 0-18 years whose stroke occurred in 2013 or 2014. Parents were screened for PTSD using the PTSD checklist and children with stroke ≥ 7 years of age were screened with the University of California Los Angeles PTSD Reaction Index. Emotional outcome of the child was examined with the Behavior Assessment System for Children (BASC-2). Parents were surveyed on their child’s stroke outcome with the Recurrence and Recovery Questionnaire (RRQ).

Results:
Of the 33 parents (10 fathers, 23 mothers) 18 (55%) met one or more of the 3 PTSD criteria and 8 (24%) met all criteria for PTSD. Although not yet reaching significance, RRQ is higher in the group of parents with PTSD (RRQ M= 1.2, SD=1.4) compared to parents without PTSD (M=0.6, SD=1.0). The subsample of children enrolled ranged in age from 7 to 17 years old at time of stroke. Although preliminary, of the children who were surveyed none met criteria for PTSD while 2 of the 9 (22%) had clinically significant levels of anxiety.

Conclusion:
Preliminary findings reveal a rate of PTSD in parents of children with childhood stroke similar to that found in parents of other critically ill children. We did not yet detect PTSD in our small sample of children. However, emotional ratings revealed that over 20% experience anxiety. The children of parents with PTSD had higher RRQ scores reflecting increased disability which may be related to the parent’s PTSD. PTSD in parents of a child with stroke and children with anxiety following stroke could impede compliance with therapeutic interventions and, consequently, lead to poorer functional outcome in the child.
Abstract T P383: The Stroke East Saxony Pilot Project For Organized Post-Stroke Care: A Case-Control Study
Authors: Kepplinger Jessica , Barlinn Kristian , Helbig Uwe , Siepmann Timo , Haase Kathrin , Zerna Charlotte , Pallesen Lars-Peder , Reichmann Heinz , Puetz Volker , Bodechtel Ulf
Published: March 2022

Background:
Currently there is no standardized guidance on post-stroke management and adherence to secondary stroke prevention guidelines is modest in stroke survivors. We aimed to determine the feasibility of a self-developed evidence-based post-stroke pathway and its impact on secondary stroke prevention and long-term functional outcome.

Methods:
Acute ischemic stroke patients were prospectively included in a standardized poststroke pathway facilitated by a single certified case manager (CM). The one-year pathway comprised educational discussions on stroke as well as quarterly check-ups for vascular risk factors, life-style changes and adherence to antithrombotic/anticoagulant therapy. The CM intervened when deviations from stroke prevention guidelines were present and if judged necessary. At 12 months, we compared achieved target goals for secondary prevention, functional outcome, stroke recurrence and vascular death with age- and gender-matched controls that received usual post-stroke care.

Results:
We included 45 cases and 45 controls. At 12 months, the following target goals were more frequently achieved in patients with CM than in controls: blood pressure (100% vs. 46%, p<.001), cholesterol (100% vs. 74%, p<.001) and body-mass-index (67% vs. 46%, p=.053). No differences were found in nicotine abstinence (p=n.s.), HbA1c (p=n.s.) and adherence to antithrombotics/anticoagulants (p=n.s.). CM emerged as an independent predictor of favorable functional outcome (mRS≤2) at 12 months after adjusting for baseline stroke severity and IV thrombolysis (OR: 4.27; 95%CI: 1.2-15.21; p=.025). As opposed to the controls, none of the cases experienced a recurrent stroke (0% versus 13%; p=.003) or suffered from vascular death (0% versus 7%; p=.242) during the follow-up period.

Conclusions:
Our pilot data suggest that organized post-stroke care may enhance achievement of secondary prevention goals. Its possible effect on stroke recurrence, long-term disability and quality of life is currently investigated in a prospective cohort study.
Abstract T P402: Acute Microemboli and Clinical Outcome after Subarachnoid Hemorrhage: Magnetic Resonance Diffusion-Weighted Imaging Study
Authors: Mansur Ann , Manoel Airton Leonardo de Oliveira , Bonares Michael , Macdonald R. Loch , Schweizer Tom A
Published: March 2022

Introduction:
Aneurysmal subarachnoid hemorrhage (aSAH) is a life-threatening stroke that can be treated with endovascular coiling. Coiling can be associated with microemboli, although the extent to which they are due to aSAH versus the coiling procedure has seldom been investigated. We investigated the implications of these microemboli on clinical outcome.

Hypothesis:
We hypothesized that the presence, number, location and volume of microemboli would correlate with clinical outcome.

Methods:
We retrospectively analyzed diffusion-weighted imaging (DWI) scans and apparent diffusion coefficient maps obtained within 7 days of aneurysm rupture in 140 patients. We analyzed the DWI scans of 80 patients with unruptured intracranial aneurysms (UIA) who underwent coiling at our institution as a control group. We assessed the presence and location of microemboli, quantified their volume and number, and correlated these factors with clinical variables and intervention details.

Results:
The aSAH and UIA groups did not differ in the presence of microemboli. The location of the lesions significantly correlated with the aneurysm location (p<0.05), suggesting they are catheter-induced and not attributed to early brain injury after aSAH. The presence of microemboli correlated with the development of cerebral infarction. Left-sided microemboli were associated with angiographic vasospasm and anterior microemboli were associated with infarcts.

Conclusions:
Microemboli commonly occur in coiled aSAH patients and have implications on clinical outcome. They are secondary to the coiling procedure and were not increased by presence of aSAH. Catheter-induced microemboli may initiate an early ischemic burden that contributes to angiographic vasospasm and cerebral infarction. That left-sided microemboli contribute to angiographic vasospasm is consistent with prior studies suggesting a left-sided approach significantly contributes to procedure-related microembolism. This suggests that improvements in endovascular practices are required to lower the risk of ischemic damage, especially when employing a left-sided approach.
Abstract T P49: Diagnosis of Carotid Artery Near-Occlusion in Computed Tomography Angiography Compared to Catheter Angiography - Validation of Criteria and Implications for Clinical Practice
Authors: Macharzina Roland R , Jochum Elena S , Rutkowski Thomas , Reuter Björn , Rastan Aljoscha , Vach Werner , Neumann Franz-Josef , Zeller Thomas
Published: March 2022

BACKGROUND/PURPOSE:
Patients with near-occlusion (NO) of the internal carotid artery (ICA) are suggested to benefit from an exclusive therapeutic stratification. We intended to verify computertomography angiography (CTA) criteria for NO-detection by the catheter angiography (CA) reference and to investigate the impact of NO upon diagnosis of 70%-NASCET stenosis. We hypothesized, that selected CTA-criteria are non-inferior to detect NO compared to CA.

METHODS:
Two independend observers analysed DICOM-images of 115 ICA stenoses obtained by multislice CTA and selective CA. Reference-NO’s were identified in CA by applying established criteria. Lumen measures and indizes previously applied to CTA , the minimal luminal diameter (MLD), the distal ipsilateral ICA (diICA) and the ratios between diICA and distal contralateral ICA (diICA : dcICA) and the diICA and ipsilateral external carotid artery (diICA : iECA) were validated against the CA-defined NO by receiver operator characteristic analysis (ROC).

RESULTS:
The ROC-curves showed AUC for criteria MLD, dICA, dICA:dcICA and dICA:dICE of 0.867, 0.952, 0.919 and 0.957 at cutpoints of ≤1.1mm, ≤2.7mm, ≤0.64 and ≤0.90 for detecting CA defined NO. For the CTA-detection of NO a sensitivity and specificity of ≥93% was achieved with dICA and dICA:dcICA criteria. PPV values could be augmented by a combination of two criteria. Correlation of CTA with CA %-NASCET-degree of stenosis revealed a relevant amount of false negatively categorized stenosis <70% in part due to underestimation of NO stenoses by CTA.

CONCLUSIONS:
CTA is an accurate modality for the detection of NO compared to CA. The detection of NO in CTA is important for correctly diagnosing severe stenosis.
Abstract T P62: Safety Scans after Intravenous Thrombolytic Therapy Fail to Alter Course or Management
Authors: Nezhad Mani K , Eskenazi Jonathan , Le Duy , Schlick Konrad H , Shafie Mohammad , Paletz Laurie , Guerra Sonia , Song Shlee S , Lyden Patrick D
Published: March 2022

Introduction:
The risk of intracranial hemorrhage (ICH) following IV-rtPA is 20%, and symptomatic ICH is 6%. Due to this concern, many practitioners obtain a 24-hour safety image after administration of t-PA for acute ischemic stroke (AIS). We sought to determine whether 24-hour safety imaging influenced clinical management or outcomes

Methods:
We conducted a retrospective analysis of suspected AIS patients treated with IV t-PA at our medical center between January 2012 and February 2014. Medical records were reviewed for clinical decision-making, neurologic deterioration, and ICH. All patients were examined on admission by NIHSS-certified neurologists. Baseline characteristics were captured from a department database. A stepwise linear regression was used to identify variables predicting change in management and discharge modified Rankin scores (mRS).

Results:
Our study included 172 patients who received IV t-PA. After exclusion for endovascular treatment, clinical research trials that required follow-up imaging, and missing demographics, 116 patients were included in the final analysis. Neurologic deterioration was seen in 20 (17.2%) patients, intracranial hemorrhage was seen in 19 (16.3%) patients, and clinical management changed in 11 (9.4%) patients. Clinical deterioration was the only variable that predicted a change in management (logistic regression p<0.05). After adjusting for deterioration, neither 24-hour imaging nor presence of ICH predicted a change in management. Using a linear regression model, baseline NIHSS and clinical deterioration predicted mRS at discharge, whereas 24-hour imaging and change in clinical management did not (r
2
=0.43, p<0.001).

Conclusion:
Our data suggests frequent examination for neurologic deterioration is superior to 24-hour imaging in guiding clinical decision making. These findings should be investigated prospectively.
Abstract T P64: Change in UCSD Stroke Center IV tPA Treatment Patterns Over the Last Decade
Authors: Ali Maysun N , Raman Rema , Enstrom Karin , Ramani Hami , Meyer Dawn M , Modir Royya , Rapp Karen S , Meyer Brett C , Hemmen Thomas M
Published: March 2022

Background:
IV tPA has been approved since 1995, and treatment practices have changed over time. Especially in the last decade, the treatment has become more widely adopted and is offered to more patients. We explored the UCSD stroke center database specifically to assess changes in treatment patterns over time. These could affect clinical trial design, performance and outcomes as the prediction of such is often based on historical information.

Methods:
We included all patients with acute ischemic stroke (AIS) from the UCSD Stroke Center Database between 2004 and 2014 (comparing 2004-2009 - Group 1 vs. 2010-2014 - Group 2). We assessed age, sex, race/ethnicity, pre-stroke disability, frequency of IV tPA use (<3 hours between 2004 and 2009; 25 stroke. Good outcomes were defined as discharge to home or acute rehabilitation.

Results:
We identified 1,816 patients with AIS from 2004 to 2014 (Group 1: 988, Group 2: 828) and found no difference in age, sex, diabetes, pre-stroke mRS and outcomes between the groups. Mean±SD NIHSS was lower in Group 2 (11.6±8.2 versus 3.6±13.3; p=0.0005) and overall IV tPA use more frequent (332/828 (36.3%) versus 328/988 (33.2%) - p=0.0024). More patients with mild (22.1% versus 12.3%; p=0.0009) and moderate (45.6% versus 41.3%; p=0.02) receive IV tPA. There was no difference in tPA use for patients with NIHSS >14.

Discussion:
IV tPA use increased over time, especially in mild and moderate stroke. This may in part be a function of increased treatment times (4.5 hours) or overall increased acceptance of this therapy. It is important to consider these treatment changes over time when planning for research protocols and use caution when comparing current data to historical controls.
Abstract T P8: Outcomes of Endovascular Treatment Using Solitaire Devices in Acute Ischemic Stroke With Favorable Penumbral Imaging Pattern
Authors: Kim CK Chi Kyung , Kang Jongsoo , Kim Yerim , Jung Keun-Hwa , Yoon Byung-Woo , Choi Dae Seob , Yoon Woong , Cho Young Dae , Han Moon Hee , Sohn Chul-Ho
Published: March 2022

Introduction:
Through emerging of novel devices and elaborated patient selection, endovascular treatment against acute ischemic stroke is gaining popularity. We investigated factors influencing outcomes after endovascular treatment in highly applicable patients.

Methods:
We enrolled consecutive 72 patients with favorable penumbral pattern, who underwent endovascular treatment with Solitaire from 2010 through 2013 in three hospitals of Korea. Inclusion criteria were these: the NIHSS and age were between 6 and 29, and 18 and 85, respectively, and endovascular procedures could begin within 8 h from onset. A favorable penumbral pattern was defined as a mismatch ratio ≥ 1.43 between hypoperfusion by Tmax > 6 s and infarction core by DWI which should be < 90 mL. The good outcome was defined as mRS ≤ 2 at 3 Mo. The recanalization was evaluated by TICI grading and successful recanalization was defined as grade 2b or 3.

Results:
Among 72 patients, 44 (61%) underwent combined treatment with intravenous (IV) and endovascular treatments, and 28 (39%) were treated by endovascular thrombectomy only. The overall recanalization rate was 82%, and the proportion of good outcome was 55.6%. Younger age and recanalization were associated with good outcome, but onset to treatment time and the combined IV thrombolysis was not related to good outcome. After propensity score matching to balance possible confounders between combined and endovascular-only treatment groups, combined treatment did not have beneficial effects than endovascular-only (OR, 0.8; 95% CI, 0.1-2.6). The successful recanalization after endovascular treatment was an independent predictor for good outcome (adjusted OR, 6.8; 95% CI, 1.3-34.5), after controlling age, sex, stroke severity, onset to treatment time, the combined IV therapy, and risk factors.

Conclusion:
In patients with discrete diffusion-perfusion mismatch, the recanalization after thrombectomy is the most important predictor for good outcomes.
Abstract T P97: CCL17-deficiency Leads to Worsened Functional Outcome and Increased Lesion Size in Experimental Stroke
Authors: Strecker Jan-Kolja , Diederich Kai , Schmidt Antje , Förster Irmgard , Alferink Judith , Minnerup Jens
Published: March 2022

Introduction:
Progression of post-stroke tissue damage is partially driven by an inflammatory response involving different subsets of innate and adaptive immune cells. Functionally diverse T-cell subsets have been associated with beneficial and deleterious effects in lesion development. The role of dendritic cells (DCs), which are crucial for T-cell activation, remains undetermined so far. DCs, which express the CC-chemokine CCL17 are key regulators of Treg- and Th17-cell function. The role of DC-dependent immunomodulation as well as the impact of CCL17 in the pathogenesis of cerebral ischemia has not yet been defined.

Methods:
Transient middle cerebral ischemia was induced by middle cerebral artery occlusion (MCAO, 30 min) in CCL17-deficient (CCL17E/E), heterozygous (CCL17E/+) and wildtype (WT) adult mice. Following MCAO, mice were tested for functional outcome, infarct volume, CCL17 expression and presence of immune cells by immunofluorescence analysis and flow cytometry.

Results:
Cerebral ischemia led to worsened functional outcome (p<0.001) and increased infarct lesion size (p<0.05) in CCL17-deficient mice. Immunofluorescence analysis of brain tissues revealed expression of CCL17 within the lesion and the ipsilateral hippocampus. CCL17-deficient brains showed enhanced neutrophil immigration, but decreased monocyte recruitment and microglial activation.

Conclusion:
Altogether, these results suggest a neuroprotective role of CCL17 in the pathogenesis of ischemia/reperfusion damage.
Abstract W MP108: Identifying Factors Predictive of Good Outcome among Patients with Severe Ischemic Stroke: the BASIC Project
Authors: Garcia Nelda , Lisabeth Lynda D , Sanchez Brisa N , Zahuranec Darin B , Skolarus Lesli E , Morgenstern Lewis B
Published: March 2022

Background:
Utilizing a population-based stroke surveillance study, our objective was to identify possible socio-demographic, cultural and psychological factors that influence outcome among patients with severe stroke who survive at least 3 months.

Methods:
Ischemic strokes (IS) were identified utilizing the Brain Attack Surveillance in Corpus Christi (BASIC) Project. Severe stroke was defined as the highest quartile of the initial NIH Stroke Scale (NIHSS ≥ 8). Functional outcome was assessed at 90 days using the ADL/IADL score (0-4, higher worse). Good outcome was defined as ADL/IADL <3. Single predictor logistic regression models were used to identify predictors of good outcome among those with severe stroke. Backward elimination was then used to select a final set of predictors. Next, models including selected predictors and pre-stroke social support or pre-stroke depression (PHQ-9) were used to evaluate their association with good outcome among a subset of patients who were asked about these factors. Only patients who were able to answer their own questions were asked about depression and social support.

Results:
From Feb 2009 to Jun 2012, 646 IS patients completed a baseline interview and subsequent 90-day outcome interview. Of 168 with severe stroke, 68 had a good outcome at 3 months (ADL/IADL <3). One year older age (OR=0.94, 95% confidence interval (CI) 0.91, 0.97), Mexican American ethnicity (OR 0.30, 95%CI: 0.13, 0.68), stroke history (OR 0.27, 95%CI: 0.11, 0.66) and higher pre-stroke modified Rankin of 4-5 (OR 0.28, 95%CI: 0.08, 0.93) were associated with lower odds of good outcome. Among the subset of severe stroke patients (N=93) asked about pre-stroke depression and social support, higher pre-stroke depression score was associated with lower odds of good outcome (OR: 0.89, 95%CI 0.79, 0.99) while greater pre-stroke social support was associated with higher odds of good outcome (OR: 1.45, 95% CI 1.13, 1.86).

Conclusion:
Among IS survivors with severe stroke, pre-stroke depression and social support are important predictors of good outcome. These factors should be considered in crafting interventions to improve stroke outcome. Mexican American ethnicity and history of prior stroke are strongly negatively associated with good stroke outcome.
Abstract W MP112: Hematoma Contraction In Primary Intracerebral Hemorrhage Is Associated With Short-term Functional Outcome
Authors: Kate Mahesh , Boyko Mathew , Gioia Laura , Kosior Jayme , McCourt Rebecca , Butcher Kenneth
Published: March 2022

Introduction:
Although blood clot retraction is a normal part of wound healing, this process has never been documented in intracerebral hemorrhage (ICH). Using a serial imaging approach, we aimed to assess the frequency of hematoma contraction in ICH patients. We also tested the hypothesis that hematoma contraction is associated with increased perihematoma edema volumes.

Methods:
We conducted a retrospective imaging study in primary ICH patients with a non-contrast CT (NCCT) study within 24h of symptom onset. All patients had a follow-up NCCT within 48h of the baseline scan. Patients who underwent any surgical intervention were excluded. Two blinded assessors, planimetrically measured hematoma and perihematoma edema volumes. Hematoma contraction was defined a priori as ≥10% reduction in ICH volume from baseline.

Results:
A total of 202 patients with a mean±SD age of 67.9±15.1 years were included. The mean baseline ICH volume was 22.5±23.8ml. The mean difference in ICH volume between the two raters was 0.2±0.8ml (Intraclass correlation coefficient-0.93; 95% Limits of Agreement=0.82-0.95). Hematoma contraction of at least 10% from baseline was seen in 22 (10.9%) patients. The mean absolute change in volume in these patients was -3.9±4.2ml. Hematoma expansion occurred in 51 (25.2%) patients. There is no difference in mean interscan interval between patients with ICH contraction (26.1±11.7h), expansion (20.7±11.8h) or stability (24.2±10.6h, p=0.96). Baseline perihematoma edema volumes were larger in patients with subsequent hematoma contraction (8.9±9.7ml) than those with stable (2.6±2.8 ml) or expanding ICH (3.5±4.4 ml, p<0.0001). Perihematoma edema volume growth was greater in patients with hematoma expansion (7.8±12.11ml) than those with contracting (3.4±4.7ml), or stable ICH (1.6±3.2ml, p=0.004). Median (IQR) modified Rankin scale scores were lower in patients with hematoma contraction (3(2)) or stable hematomas (3(3)) than those with expansion (6(2), p<0.0001).

Conclusions:
Hematoma contraction is evident in approximately 10% of ICH patients. Baseline perihematoma edema volume in patients with subsequent hematoma contraction is larger, which is consistent with the hypothesis that acute edema represents successful hemostasis.
Abstract W MP15: Use of Multimodal Imaging for Thrombolysis-Eligible Stroke Patients Presenting to Hospitals in a Large Urban Region
Authors: Sanossian Nerses , Fu Katherine , Liebeskind David S , Starkman Sidney , Villablanca J P , Hamilton Scott , Eckstein Marc , Stratton Samuel , Pratt Franklin D , Conwit Robin , Saver Jeffrey L ,   FAST-MAG Investigators and Coordinators
Published: March 2022

Introduction:
Advances in diagnostic imaging of stroke include the use of multimodal techniques, including noninvasive angiography to evaluate the intracranial and cervical vasculature as well as perfusion imaging. Despite increased adoption of these imaging techniques in academic medical centers, the current practice of multimodal imaging utilization among stroke patients in the community has remained largely uncharacterized.

Methods:
We quantified neuroimaging utilization in the ED among 1700 hyperacute stroke patients participating in the NIH Field Administration of Stroke Therapy Magnesium (FAST-MAG) study throughout Los Angeles and Orange Counties. Subjects were enrolled in the field <2 hours from symptom onset and transported to their usual care hospital, one of 58 centers throughout a single urban region. There was no recommendation as to what type of imaging should be utilized.

Results:
Of 1700 cases 1699 were imaged a median (IQR) of 92 (74-120) minutes after last known well time and 28 (19-40.75) minutes after ED arrival. The mean age was 71 (SD13) years old and the final diagnosis was cerebral ischemia in 73%, intracerebral hemorrhage in 23%, and mimic in 4%. Initial imaging scanner used in the ED was CT in a preponderance of cases (N=1612, 95%), with MRI in 88 cases (5%). Parenchymal CT scan was almost always performed without contrast and most commonly as the only study. However, CT angiography was obtained in 192 (11%) and perfusion CT in 91 (5.4%) cases in the first 24 hours. MRI imaging was universally obtained using diffusion-weighted images, 60% with MR angiography and 33% included perfusion imaging. Rates of multimodal (CTA and/or CTP) CT imaging utilization increased in the later years of the study from 4% in 2005-2006, 2% in 2007-2008, 8% in 2009-2010 and 26% in 2011-2012 (p for trend <0.001). There was no change in rates of multimodal MRI imaging as one academic medical center accounted for >80% of all studies.

Conclusions:
Among acute stroke patients presenting in the time window for TPA use, noncontrast CT was the most common initial imaging strategy in clinical practice in the 2005-2012 time period, though use of concomitant CTA grew to one-quarter of cases.