bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract T P212: One Year Experience Of An Urban Primary Stroke Center With An Integrated Internal Telestroke System
Authors: Diep Elizabeth , Bronstein Yuri , Danesh Mitchell , Ajani Zahra , Sangha Navdeep , Balkian Garo , Petrovic Marko
Published: March 2022

Background:
Telestroke systems have offered expert stroke care to underserved communities across the United States. Usually, the telestroke service is provided by external consultants, from other institutions with limited access to patients’ medical charts and prior imaging. Here, we report on our one-year experience of an internal telestroke system at a community Primary Stroke Center. Methodology: Prior to August 2013, assessment of thrombolytics was provided by in-house neurologists through bedside consultation during the day and telephone consultation after hours. However, starting August 2013 acute stroke care is provided by neurologists using a telemedicine device via an integrated internal telestroke program. Given the integrated nature of our hospital system, these physicians have immediate access to medical charts, history, laboratory, and prior as well as current imaging. In order to prove the viability of this program, we compared outcomes between the two acute stroke care processes. We determined thrombolytic utilization rate, door-to-needle time (DNT), rate of stroke mimics, and discharge destination of those patients who received thrombolytics 12 month before and after telestroke implementation. Results: We noted improvement in the percentage of eligible stroke patients receiving thrombolytics (8% vs 18.2%). Our DNT decreased by 23 minutes (mean 93.4 vs 69.7 minutes, P<0.005). Thrombolytics administered to stroke mimics was reduced from 16.7% to 8.6%. Patients discharged to a non-home facility (acute rehabilitation or skilled nursing facilities) decreased from 16.6% to 8.6%. Conclusion: Compared to our previous local acute stroke management, stroke care was not inferior. In fact, as a result of an internal telestroke system implementation, our thrombolytic utilization rate increased, our DNT improved, our stroke mimic rate decreased, and non-home discharge disposition decreased. Although not specifically assessed in our study, we suspect that internal telestroke systems also offer obvious advantages for patient care compared to external systems. Further studies evaluating stroke outcomes in these distinct systems are needed.
Abstract T P214: Early Identification Of Cerebrovascular Events In Patients Presenting With Vertigo Or Dizziness
Authors: Bai Harrison , Xiao Yanqiao , Zhao Xin , Zou Yingjie , Yang Na , Jiang Yiqun , Xiang Jun , Shu Yi , Qiu Dongxu , Yang Li
Published: March 2022

Patients with posterior circulation strokes can present with dizziness symptoms. We aimed to identify risk factors associated with cerebrovascular events (CVE) for a subset of patients who presented with a chief complaint of vertigo or dizziness

Methods:
We reviewed records of 883 consecutive patients whose admission diagnosis was coded as vertebrobasilar artery syndrome (ICD-9 code 435.3). Isolation was defined as vertigo or dizziness with no other stroke screening terms or accompanying neurologic signs or symptoms

Results:
19 were excluded because the primary complaint was not vertigo or dizziness. Among the remaining 864, the diagnosis was changed to stroke in 25 (20 posterior, 5 anterior), TIA in 11, ICH in 4 and others in 22. Comparing patients whose diagnosis was later changed to a CVE (stroke, TIA or ICH) vs. those whose diagnosis was either not changed or changed to a non-cerebrovascular one(40 vs. 824), we found that CVE was associated with acute onset (75% vs. 48%, p=0.001), dysarthria (13% vs. 2%, p=0.001), gait instability (60% vs. 39%, p=0.008), Babinski’s sign (10% vs. 3%, p=0.025), numbness (20% vs. 7%, p=0.008), consciousness disturbance (13% vs. 3%, p=0.015) and previous TIA (10% vs. 2%, p=0.011). No CVE was associated with isolation (55% vs. 28%, p=0.001) and intermittent frequency (67% vs. 53%, p=0.059). On multivariate analysis, isolation (p=0.044), acute onset (p=0.011), dysarthria (p=0.017), and previous TIA (p=0.029) remained significant. The c-statistic of the ABCD score was 0.60 (95% CI, 0.52-0.69) and that of the Framingham risk score was 0.59 (0.50-0.69). For patients with isolated vertigo or dizziness (11 vs. 455), acute onset of the chief complaint (91% vs. 46%, p=0.003), dysmetria (27% vs. 3%, p=0.004), Romberg sign (46% vs. 13%, p=0.01) and SBP at presentation (155 vs. 135, p=0.034) were associated with a CVE. On multivariate analysis, acute onset (p=0.034) and dysmetria (p=0.049) remained significant

Conclusion:
clinical characteristics could be more important than cardiovascular risk factors in identifying a cerebrovascular cause in patients presenting with dizziness symptoms. For those with isolated vertigo or dizziness, acute onset and dysmetria should raise concern for a CVE that may benefit from early intervention
Abstract T P224: The Effect of Hyperbaric Oxygen Therapy Following an Ischemic Stroke
Authors: Rosario Emily R , Kaplan Stephanie
Published: March 2022

Hyperbaric oxygen therapy (HBOT) has been approved and is widely used for several conditions such as decompression sickness, gas embolism, wound repair, carbon monoxide poisoning, and burns. There are other reported applications of HBOT including cerebral palsy, autism, migraines, traumatic brain injury, and stroke. While experimental and observational studies suggest a benefit of HBOT for these conditions, controlled clinical trials have not been able to clearly define the benefits. Therefore, future research in these areas is essential to identify and fully understand the therapeutic potential of HBOT. In this study we propose to investigate the effects of HBOT on physical and cognitive impairments resulting from an ischemic stroke. A single case study design was utilized for 8 subjects. Subjects (male or female, 18 - 90yrs of age) were included in this study if they had suffered an ischemic stroke approximately 12-month ago and exhibited some functional impairments. A constant baseline was established which was defined as no functional improvement over a 3 month period. During the study each subject received two 4-week periods of HBOT for a total of 40 treatments of hyperbaric oxygen over a 12-week period. Each participant completed a battery of cognitive, physical, speech, and quality of life measures six times over 9 months, and had blood drawn for biochemical analysis 6 times throughout the study. We found improvements in cognition and executive function as well as physical abilities specifically, gait. Participants reported improved quality of life and decreased following HBOT treatment. We also saw changes in serum levels of biomarkers for inflammation and neural recovery, which appear to correlate with functional changes. In most domains improvement occurred during HBOT treatment but after 3 months following the last treatment, the observed changes were decreased similar to baseline levels. Findings from this study support the idea of HBOT as a potential intervention following stroke however, the timing of this treatment needs to be further examined. Further, the mechanism through which HBOT is eliciting functional changes has yet to be fully determined.
Abstract T P225: Loss of Pregnane X Receptor Impairs Stroke Recovery
Authors: Grenier Jeremy , Koellhoffer Edward , Townshend Courtney , McCullough Louise , Khanna Kamal
Published: March 2022

Introduction:
Inflammation plays an important role in exacerbating injury following stroke, but current understanding of the factors regulating this inflammation is incomplete. Pregnane X Receptor (PXR) is a nuclear receptor which binds many xenobiotic targets including many commonly prescribed medications. Recent work has shown that PXR is crucial for maintaining the integrity of the intestinal epithelial barrier as well repressing inflammatory responses mediated by NFκB. Since both these pathways can modify the peripheral immune response, we hypothesized that PXR would play an important role in limiting inflammation following stroke. Using PXR knockout mice, we show that loss of PXR is detrimental for stroke recovery.

Materials & Methods:
Male PXR knockout mice and littermate controls underwent sham surgery or 60min middle cerebral artery occlusion (MCAO). Weight loss was monitored post-stroke and mice were sacrificed after 7 days for splenic weights, infarct analysis by cresyl violet staining, and bacterial translocation as assessed by culture of homogenized mesenteric lymph nodes on blood agar plates.

Results:
Following MCAO, PXR-/- mice lost significantly more weight than wild type littermate controls (n=6 vs. 4 respectively; p<0.05) and also showed greater splenic atrophy 7 days following MCAO (2.14mg/g body weight vs. 3.40mg/g body weight; p<0.05). However, preliminary studies suggest PXR-/- mice do not have larger infarcts (n=3 vs. 2) and did not exhibit more bacterial translocation 7 days following MCAO (5.4 vs. 7 CFU).

Discussion:
PXR is known to negatively regulate NFκB signaling and maintain intestinal barrier integrity. Both of these mechanisms may contribute to delayed recovery following stroke with PXR acting as a master switch. In summary, this early work begins to explore the importance of a xenobiotic sensor, PXR, in stroke recovery.
Abstract T P226: Cilostazol Can Attenuate Oxidative Stress by Suppressing Nox2 on Neurons in Mice Permanent Focal Ischemia
Authors: Shichinohe Hideo , Kuroda Satoshi , Tan Chengbo , Abumiya Takeo , Nakayama Naoki , Kazumata Ken , Hokari Masaaki , Houkin Kiyohiro
Published: March 2022

It has been reported that phosphodiesterase (PDE) 3 inhibitor cilostazol, which is used as an antiplatelet drug, could ameliorate ischemic brain injury. We aimed to investigate how cilostazol affected permanent focal ischemia. Male Balb/c mice were subjected to permanent middle cerebral artery occlusion. They were treated with cilostazol (10- mg/kg or 20-mg/kg) or vehicle 30 min and 24 h post-ischemia, and the infarct volume was assessed 48 h post-ischemia. The animals treated with 20-mg/kg cilostazol or vehicle were sacrificed 6 h or 24 h post-ischemia, and then the immunohistochemistry was performed to the brain sections. We demonstrated that the treatment with 20- mg/kg cilostazol significantly reduced infarct volume (70.1% vs. vehicle group). Immunohistochemistry against 8-hydroxydeoxyguanosine (OHdG) showed that some neurons suffered from oxidative stress in peri-infarct 6 h post-ischemia. The treatment with cilostazol reduced the number of 8-OHdG-positive neurons significantly (65.8 ± 33.5% in vehicle group and 21.3 ± 9.9% in cilostazol group). Moreover, the number of NADPH oxidase (NOX) 2-positive neurons was also reduced significantly (57.0 ± 13.6% in vehicle group and 26.5 ± 16.7% in cilostazol group). On the other hand, immunohistochemistry against phosphorylated cyclic-AMP response element binding protein (pCREB) showed that the number of the pCREB-positive neurons in peri-infarct of the cilostazol-treated animals was significantly higher than in vehicle-treated ones 24 h post-ischemia. These findings suggested that cilostazol could have multi-mechanisms to ameliorate the tissue damage, one was to attenuate oxidative stress by suppressing NOX2 on ischemic neurons, and another was anti-apoptotic effect through the pathway of Akt/pCREB.
Abstract T P231: B- Cell Depletion Decreases Lesion Burden in a Murine Model of Cerebral Cavernous Malformation Disease
Authors: Shi Changbin , Rorrer Autumn , Zhang Lingjiao , Cecilia Austin , Gallione Carol , Shenkar Robert , Duggan Ryan , Marchuk Douglas A , Awad Issam A
Published: March 2022

Introduction:
The cerebral cavernous malformation (CCM), a common cerebrovascular anomaly, predisposes patients to a lifetime risk of seizures, hemorrhagic stroke, and other neurological sequelae. Previous studies revealed robust inflammatory cell infiltration and selective synthesis of IgG within the lesions. Recently, in situ antigen-driven B- cell clonal expansion and immune complex deposits were demonstrated in CCM lesions. However, we do not know whether B cells indeed could play a role in CCM genesis and maturation. Therefore we hypothesize B-cell depletion could inhibit CCM development in a murine model of CCMs.

Methods:
Based on the two-hit hypothesis, we crossed Ccm3 heterozygotes into a Trp53 background, a mouse model that demonstrated 100% penetrance with severe lesion burden. Three weeks after birth, 5 CCM3+/-Trp53-/- mice were assigned into treatment group, receiving anti-mouse BR3 (Genentech) to deplete B cells with IP injection once a week (5mg/kg/week) for a total of 12-15 weeks. At 4 months of age, the mouse brains were harvested and fixed. B cell depletion was demonstrated by FACS analysis of peripheral blood and spleen cell suspensions, further confirmed in the spleens via immunohistochemistry. CCM lesion burden was assessed using either poisson regression (number) or student t test (area).

Results:
CD19+, CD22+, and CD45R/B220+ B cells of peripheral blood and spleen cell suspensions was significantly decreased in all 5 CCM3+/-Trp53-/- mice treated with anti-mouse BR3, as compared with those in the control group. B cell depletion was further confirmed in spleen. Anti-mouse BR3-treated mice exhibited a significantly lower CCM burden, including the number of ballooned capillaries (stage 1) and multicavernous lesions (stage 2), and the areas of stage 2 lesions per animal, as compared to 15 placebo mice. Infiltrated B cells in CCM3+/-Trp53-/- CCM lesions were also depleted.

Conclusions:
This represented the first report of therapeutic benefit of B- cell depletion therapy in the development and progression of CCMs and provide proof of principle that B cells is a critical step in CCM lesion genesis and maturation.
Abstract T P232: Combination Therapy With Taurine Plus Tissue Plasminogen Activator in a Rat Model of Embolic Stroke
Authors: Jin Rong , Zhu Xiaolei , Wang Cuiping , Zhang Shihao , Minagar Alireza , Nanda Anil , Granger D Neil , Li Guohong
Published: March 2022

Background:
Tissue plasminogen activator (tPA) is the only FDA-approved therapy for acute ischemic stroke, but it has narrow therapeutic window (within 4.5h) and increased risks of intracerebral hemorrhage. Taurine, an endogenous 2-aminoethansulfolic amino acid, exhibits a plethora of physiological functions. It has been found to protect against ischemic brain injury in animal models of stroke by diverse mechanisms. Strikingly, published data show that the therapeutic window of taurine was at least 8h after the onset of ischemic stroke, thus potentially allowing for delayed or more effective thrombolysis. In this study we investigated whether combination therapy with taurine plus tPA can block hemorrhagic transformation and thus extend the time window of tPA after delayed tPA treatment for ischemic stroke.
Methods and Results:
Male adult rats (330-380g) were subjected to embolic middle cerebral artery occlusion and then randomized into different treatment groups: saline injected at 4h; taurine (50 mg/kg) at 4h, tPA (10 mg/kg) at 6h, and combination therapy with taurine at 4h plus tPA at 6h after the onset of ischemia. Delayed 6-hour tPA did not decrease infarction but instead worsened brain hemorrhage. Combining taurine with delayed 6-hour tPA reduced tissue infarction, attenuated blood-brain barrier disruption by reduced degradation of tight junction proteins (claudin-5 and collagen IV), and ameliorated brain hemorrhage. These protective effects are correlated with decreased brain matrix metallopeptidase-9 activity possibly through inactivation of NF-kB and CD147 (a potent inducer of MMPs) in the postischemic brain, particularly in the cerebral microvessels (using structurally intact microvessels isolated from the brain).
Conclusion:
The present study demonstrates for the first time that combination therapy with taurine may attenuate delayed tPA-associated hemorrhagic transformation and extend tPA treatment time windows in a clinically relevant thromboembolic stroke model. Inhibition of MMP-9 in brain microvessels via inactivation of NF-κB and CD147 signaling may underlie the protective mechanisms of taurine.
Abstract T P238: Evaluating the Stent-Wall Interaction in a Hemodynamically Induced Swine Model of Carotid Atherosclerosis: Correlation of Pre-Treatment Black-Blood 3T MRI with Post-Stenting Histopathology
Authors: Raychev Radoslav , Fujimoto Motoaki , Tateshima Satoshi
Published: March 2022

Introduction:
We evaluated the histopathologic characteristics of the stented arterial segments in a swine model of carotid atherosclerosis.

Methods:
Atherosclerotic plaque was created by inducing 80% stenosis via partial surgical ligation (without endothelial balloon injury) in combination with dietary hypercholesterolemia in a single Yucatan minipig (Fig A). High-resolution black-blood 3T MRI of both carotid arteries was obtained at 6 months. Stenting was performed immediately after imaging. The animal was sacrificed 4 weeks after stenting. Histopathologic and morphometric analysis was performed.

Results:
MRI: Figure A. Contrast-enhanced MRA. B. Cross-sectional 2mm views of proton density (PD), T2, T1, T1 post contrast, and time-of-flight (TOF) sequences of the stenotic segments of the R (top) and L (bottom) carotid arteries.

The image characteristics of the R carotid stenosis are consistent with an American Heart Association Lesion Type IV/V. No athermoatous features are seen in the L carotid.

Histopathology:
Moderate lymphocyte proliferation was noted in the narrowest mid-section (N-Mid) from the right carotid, corresponding to the depicted lesion on MRI. This segment had the smallest neointimal/thrombus thickness (Table). Only mild residual atherosclerosis was appreciated within the stent.

EEL - external elastic lamina

IEL - internal elastic lamina

Conclusions:
Our findings indicate histologic reversibility of the MRI-defined carotid atherosclerotic lesion four weeks after stenting, possibly due to improved flow within the hemodynamically-induced plaque. Unlike prior studies, neointimal proliferation was least prominent at the pre-existing atheroma.
Abstract T P243: Death Receptors and Mitochondria as Crucial Targets for Drug Discovery in Cerebral Amyloid Angiopathy
Authors: Fossati Silvia , Giannoni Patrizia , Solesio Maria , Hernandez Maria del Mar , Ghiso Jorge , Rostagno Agueda
Published: March 2022

The vascular deposition of amyloid, known as Cerebral Amyloid Angiopathy (CAA) is an age-associated condition featured in about 90% of Alzheimer’s disease cases and in the aging brain. Amyloid beta (Abeta) deposition in CAA compromises cerebral blood flow and can cause cerebral hemorrhage and cognitive impairment, by mechanisms that are still poorly understood. Our goal was to identify the molecular events underlying the apoptotic cascade generated by Abeta in cerebrovascular cells and to pinpoint new targets for drug discovery. Human brain microvascular endothelial cells were challenged with vasculotropic Abeta variants associated with cerebrovascular deposition and hemorrhagic outcome, and the resulting signaling pathways were analysed. The
in vitro
findings were validated
in vivo
in mice subjected to intrahippocampal Abeta injections and confirmed in human CAA cases. Our findings highlighted an activation of caspase-8 and -9, together with mitochondrial dysfunction and release of cytochrome C, suggesting death receptor mediated apoptosis, which was confirmed by an overexpression of the TRAIL (TNF-related apoptosis inducing ligand) death receptors DR4 and DR5. Signaling cascades typical of TRAIL death receptor-mediated pathways were activated. The same receptors colocalized with Abeta on the cell membrane after amyloid challenge, and immunoprecipitated
in vitro
with Abeta oligomers. SiRNAs against DR4 and DR5 and the prevention of mitochondrial dysfunction through Carbonic Anhydrase Inhibitors, significantly diminished Abeta mediated apoptosis in endothelial cells.
In vivo
experiments in mice injected with vasculotropic Abeta peptide and in human CAA cases confirmed the upregulation of the receptors, their colocalization with Abeta on the cerebral vasculature, and the activation of caspases, which could be prevented by carbonic anhydrase inhibitors. Our data strongly suggests that TRAIL death-receptors and mitochondrial functioning are key cellular targets for therapeutic intervention against Abeta-induced vascular cell death in CAA.
Abstract T P244: Correlation between Vasospasm and Microcirculatory Disturbance in Early and delayed Phase following Experimental Subarachnoid Hemorrhage
Authors: Kikkawa Yuichiro , Kurogi Ryota , Matsuo Satoshi , Mizoguchi Masahiro , Kayahara Tomomichi , Yokosako Suguru , Ueno Ryu , Yamaguchi Yohei , Fushihara Goji , Ikeda Toshiki , Takeda Ririko , Ogura Takeshi , Ooigawa Hidetoshi , Kurita Hiroki
Published: March 2022

Background & Objectives:
Role of cerebral vasospasm in cerebral microcirculatory disturbance after subarachnoid hemorrhage (SAH) remains to be elucidated. This study investigated the correlation between changes of cerebral microcirculation and time course of arterial narrowing after SAH using rabbit cisterna magna double-blood injection model.

Methods:
Using 256-multidetector-row computed tomography (CT), CT angiography and CT perfusion were repetitively performed at 0, 1, 6, 24, 48 hours after initial hemorrhage for early changes observation group (ECOG; n=8), and on days 0, 3, 5, 7 for delayed changes observation group (DCOG; n=8). Regional cerebral blood flow (rCBF), cerebral blood volume (CBV), mean transit time (MTT) and mean cross-sectional area of basilar artery (BA) were evaluated at each time point.

Results:
In ECOG, BA transiently narrowed immediately after SAH and progressively narrowed again after 6 hours. CBV and rCBF were transiently decreased immediately after SAH and restored, and then progressively increased after 6 hours. MTT was transiently prolonged immediately after SAH and gradually restored over 24 hours. In DCOG, basilar arterial narrowing reached a peak on day 5 and improved after day 7. CBV and rCBF were persistently decreased after day 3, while MTT was prolonged after day 5. In both observation groups, there were no significant differences in CTP parameters between in perfusion territory of BA and that of non-BA.

Conclusions:
Presumably, in this model, delayed cerebral ischemia is caused by the cerebral microcirculatory disturbance which is regulated by independent mechanisms from vasospasm of major arteries both in the early phase and delayed phase following SAH.
Abstract T P251: Overseeing a Multicenter Clinical Trial: Our Experience in Creating a New Model
Authors: Burks Bree , Oravec Chesney , Smith Stephanie , Gilchrist Emily , Mocco J , Froehler Michael
Published: March 2022

The model for overseeing multicenter clinical research trials continues to evolve. In the late 1990’s electronic medical records became more common across institutions. Subsequently, the integration of the World Wide Web into clinical care enhanced the ability to connect clinical and research data across multiple sites. For years, research data has been handled in a hybrid fashion with the use of hard-copy and electronic sources for data entry and verification. Recently, leaders behind multicenter clinical trials have incorporated electronic data capture (EDC) systems in an effort to store multicenter clinical trial data in a secure and structured environment. The implementation of EDC’s has led to better control and accuracy of data; however, many aspects of multicenter clinical trial workflow are still captured in a hard-copy format. Therefore, the oversight of these additional components is still subject to an in-person, on-site review.

While the paper-based model focuses on reviewing hard-copies of patient records long after the data originates at the point of care, new models must allow for real-time oversight of clinical trial data. In conjunction, the source documentation needed to recreate the clinical trial data, as well as the ongoing regulatory and compliance documentation associated with a clinical trial, should be readily available for remote review. In order to promote best practice and effectively utilize current technology, the Food and Drug Administration released guidance in August of 2013 encouraging sponsors to focus on risk-based and centralized monitoring techniques.

The Cerebrovascular Clinical Research Office (CCRO) at Vanderbilt University has recently implemented a risked-based monitoring model that incorporates a comprehensive electronic trial infrastructure. The CCRO has identified many advantages with the incorporation of this new method. These advantages have led to a significant cost-savings, increased protocol and regulatory compliance, a heightened level of accountability for all involved parties, and a more streamlined approach to ensuring data accuracy. In conclusion, the CCRO’s experience incorporating a new monitoring model has been one full of exciting challenges and opportunities for originality.
Abstract T P257: Analysis for Usefulness of Worsen Score; the Predicting Score for the Deterioration of Acute Ischemic Stroke
Authors: Miyamoto Nobukazu , Tanaka Ryota , Ueno Yuji , Watanabe Masao , Tanaka Yasutaka , Shimada Yoshiaki , Kuroki Takuma , Yamashiro Kazuo , Hattori Nobutaka , Urabe Takao
Published: March 2022

Introduction:
One third of patients with acute ischemic stroke develop early neurological worsening, a situation associated with increased mortality and long-term functional disability. It is important to prevent patients with acute ischemic stroke from deteriorating. We made WORSEN score for predicting factors in deteriorating stroke within 1 week from onset, and investigated its usefulness.

Methods:
At first, we retrospectively investigated 537 patients who were admitted to Juntendo University Hospital within 2 days of the occurrence of an acute ischemic stroke, between April 2007 and March 2009. Deterioration of neurological findings was defined as the worsening of 4 points or more on the National Institute of Health Stroke Scale (NIHSS) score during admission to the hospital within 1 week. After logistic regression analysis, we made WORSEN score, and scoring those patients. Second, we investigated this score for another 453 patients who admitted Juntendo University Hospital and Juntendo Urayasu hospital between April 2010 and June 2014.

Result:
Out of 537 patients, deterioration was noted in 64 patients (11.9%; deterioration group). After multivariate analysis, we set WORSEN score as follows; W; wrong blood sugar control (HbA1c (NGSP) >7.4%), O; old myocardial infarction, R; radiological findings; ICA-MCA M1 proximal occlusion, striate-capsular infarction, pontine infarction S; size of infarct (15-30mm), E; elevated LDL-cholesterol (>140mg/dl), N; neurological findings; NIHSS>8 at onset, and each factor set scored as 1 point. Next, we checked WORSEN score in those group, deterioration was noted in 35% at score 3, 57% at score 4 and 100% at score 5. Finally, in another 453 patients group, deterioration was detected in 74% over 3 points.

Conclusion:
It is important to predict deterioration in patients with minor ischemic stroke and those with many risk factors for deterioration should be given the best possible treatment. To careful attention should be paid to acute stroke patients with high WORSEN score, this scale might become one of an important tool for detect neurological deterioration of ischemic stroke.
Abstract T P261: Stroke Care Improvement Trends in Puerto Rico Hospitals Participating in the Florida-Puerto Rico Collaboration to Reduce Stroke Disparities (FL-PR CReSD) Study - the NINDS Stroke Prevention Intervention Research Program
Authors: Zevallos Juan C , Ciliberti-Vargas Maria A , Wang Kefeng , Dong Chuanhui , Carrasquillo Olveen , Garcia-Rivera Enid J , Nobo Ulises , Santiago Fernando L , Perez Enmanuel J , Rundek Tatjana , Romano Jose G , Burgin W S , Koch Sebastian , Meschia James F , Nelson Joe A , Robichaux Mary , Rose David Z , Waters Michael F , Sacco Ralph L ,   for the FL-PR CReSD Investigators and Collaborators
Published: March 2022

Background:
Racial and ethnic disparities in stroke care are known to contribute to inequality in stroke outcomes. The goal of the FL-PR CReSD Study is to assess and evaluate Get With The Guidelines-Stroke (GWTG-S) quality improvement data collected among Florida and Puerto Rico hospitals to evaluate for race-ethnic, sex, and regional disparities in stroke performance metrics. We sought to analyze the temporal trends in stroke performance metrics among the 9 hospitals located in Puerto Rico from 2010 to 2013.

Methods:
Age-adjusted temporal trends were evaluated in the following GWTG-S pre-defined performance measures (IV tPA treatment within 3 hours among eligible patients arriving in 2 hours, in-hospital antithrombotic therapy, DVT prophylaxis, antithrombotic therapy at discharge, anticoagulation therapy, statin medication at discharge, and smoking cessation counseling) and defect-free care (compliance with all 7 performance measures).

Results:
The mean age of 3,094 registered stroke cases was 69.5 ± 14.0 years, 50% were men, and 2,184 (71%) were diagnosed as ischemic strokes. Defect-free care occurred in 60% of ischemic stroke patients. Lower performance metrics were found for IV tPA treatment (78%), DVT prophylaxis (64%), and statin medication at discharge (83%). An additional IV tPA measure of treatment by 4.5 hours when arriving by 3.5 hours was observed in 65% of patients. The performance metrics that significantly improved over time from 2010 to 2013 included: IV tPA treatment within 3 hours (64% to 87%, p=0.04), DVT prophylaxis (33% to 87%, p<0.0001), statin medication at discharge (78% to 87%, p=0.01), and defect-free care (37% to 79%, p<0.0001).

Conclusions:
In only four years, Puerto Rico hospitals participating in GWTG-S showed significant improvement across all pre-defined acute stroke performance measures. Wider implementation of quality improvement programs like GWTG-S among the 3.7 million inhabitants of Puerto Rico could further improve acute stroke care.
Abstract T P275: Quantification of Potential Bias in Databases That Require Consent in Acute Stroke
Authors: Ramani Hami , Raman Rema , Ernstrom Karin , Ali Maysun N , Meyer Dawn M , Modir Royya , Rapp Karen S , Meyer Brett C , Hemmen Thomas M
Published: March 2022

Background:
The stroke database at our institution includes patients who gave consent and are followed up at 90 days after acute stroke and a group entered into our registry in whom only limited data is available under a consent waiver. We explore the potential bias that is introduced by the requirement to obtain consent.

Methods:
We included patients with an admission diagnosis of acute ischemic stroke. For each of the groups (database versus registry), we analyzed age, sex, race/ethnicity, hypertension, diabetes, history of atrial fibrillation, smoking status, pre-stroke mRS, baseline NIHSS, presence of aphasia, and use of IV rt-PA. We used Wilcoxon Rank-sum test for continuous and Fisher's Exact for categorical variables.

Results:
A total of 1800 patients were included (database 849, registry 951). In the database versus registry 84.6% were white versus 79.9% (p=0.006); baseline NIHSS was 8.6±8.1 versus 10.6±9.2; aphasia 38.6% versus 44% (p=0.03); pre-stroke disability (mRS >1) 21.5% versus 30% (p<0.0001) and IV rt-PA use 47.7% versus 26.5% (p<0.0001). There was no difference in age, sex, smoking status, the frequency of diabetes, atrial fibrillation, hypertension and ethnicity (Hispanic) between the groups.

Conclusion:
In our comparison between a database requiring consent and a registry utilizing consent waiver, we found that the database included more whites, patients with lower NIHSS, fewer patients with aphasia and pre-stroke disability. Requiring consent in acute stroke may introduce bias against minorities and patients with more severe stroke and/or aphasia. Future projects should take this into consideration and focus on reducing bias.
Abstract T P277: “The July Effect” in Ischemic Stroke Patients Receiving tPA
Authors: Nalleballe Krishna C , Galla Krishna M , Bollu Pradeep C , Onteddu Sanjeeva Reddy
Published: March 2022

Objective:
Each July thousands begin residencies and acquire increased responsibility for patient care. There is disagreement in the medical literature about whether a so-called July Effect, actually exists. There is paucity of data specifically looking at ischemic stroke patients receiving tPA. Approximately 1.9 million neurons die each minute from the onset of ischemia so we tried to evaluate if there is improvement in door to needle times for tPA administration from July to June.

Methods:
A Retrospective Review of patients admitted with symptoms of stroke to the Neurology department at our hospital from July 2013 to June 2014. Inclusion Criteria were all patients who met the criteria and received IV tPA.

Results:
During the study period, 60 patients met the criteria. The average tPA door to needle time in the month of July 2013 was 74.5 minutes and it increased to 93.5 minutes in the month of August 2013. The average door to needle time in the month of June 2014 was 45 minutes. There was significant decrease in the door to needle times form the month of July 2013 to June 2014 (p= 0.015). Please see figure 1 below for the average door to needle time over the year starting from July 2013 to June 2014.

Discussion:
The average door to need time is significantly lower in June 2014 when compared to July 2013 (P=0.015). It could be due to multiple factors including the new residents in the Emergency Department(ED) and Neurology residents taking call, as door to needle time includes the time when stroke alert was called after patient arrives in the ED, time taken by the neurology resident to examine the patient, time taken for the imaging, time taken for the decision to be made to give tPA, time taken by the pharmacy to get tPA ready and time to start tPA. Close supervision of the new residents with senior housestaff and adequate training including mock stroke activations may be helpful in overcoming this variation.
Abstract T P280: Do-not-resuscitate Orders Are Not Increasing Observed or Risk Adjusted In-hospital Mortality in Patients With Intracranial Hemorrhage
Authors: Hemmen Thomas , Hemmen Eema
Published: March 2022

Background:
Patients with Intracranial Hemorrhage (ICH) have a significant in-hospital mortality. Health systems are compared using risk adjusted mortality indices, which factor in Do Not Resuscitate (DNR) status. It is possible that hospitals overuse DNR and affect mortality and/or influence adjusted outcome measures. We explored a large inpatient database, the University HealthSystem Consortium® (UHC) to assess the frequency of DNR orders and effect on outcomes in patients with ICH
.

Methods:
We included all hospitals within the UCH UHC database that had more than 50 ICH discharges (ICD-9 code 431) between 01/2012 and 12/2013. Hospitals were grouped by frequency of DNR order status: Group 1: 0-22.9% of all ICH discharges, Group 2: 23.0-40%. The groups were compared by frequency of DNR order (ICD-9 v49.86), Mortality and Case Mix Index (CMI), and in-hospital mortality. We used unpaired t-test for comparing means (continuous variables).

Results:
We analyzed 25,273 discharges from 120 hospitals (63 in Group 1, 57 Group 2). There was no significant difference in volume (209.2±137.0 versus 212±115.8) or in-hospital observed mortality (22.2%±5.2% versus 24.1%±6.2%). The Mortality Index (1.07±0.62 versus 0.92±0.24) and CMI (3.39±0.78 versus 3.02±0.66) were higher in Group 1.

Conclusion:
There is no evidence that frequent use of DNR orders affects in-hospital mortality in patients with ICH, or the DNR orders are used to influence risk adjustment models in the UHC database. Further nationwide analyses using diverse health systems are required to confirm these findings to assure generalizability.
Abstract T P294: An Electronic Medical Record Order Set Change To Increase In-Hospital Statin Use In Ischemic Stroke Is Associated With Improved Post-Stroke Outcomes
Authors: Flint Alexander , Conell Carol , Klingman Jeff , Chan Sheila , Rao Vivek , Cullen Sean , Sidney Steve , Johnston S. Claiborne
Published: March 2022

Introduction:
In-hospital statin use is associated with improved ischemic stroke outcomes. Here we examine the impact of an electronic order set change to increase statin use during stroke hospitalization.

Methods:
An electronic order set for ischemic stroke admission across 20 hospitals was changed from an ‘opt-in’ mode of statin ordering to an ‘opt-out’ mode of statin ordering. We performed interrupted time series analysis (2 years before and after), examining the impact on in-hospital statin use and on patient outcomes. We examined features of inpatient statin use as well as death by 90 days and discharge to home or inpatient rehabilitation. We examined two subpopulations: severe stroke (mNIHSS 21-42) and less severe stroke (mNIHSS 1-20). We ruled out seasonality, autoregressive effects, and moving average effects for in each of the time series.

Findings:
We analyzed electronic records for 8993 patients. Measures of inpatient statin use increased when the order set change went live: high dose statin use increased by a factor of 2.5 (2.0-3.1) and statins within 8 hours by a factor of 1.8 (1.5-2.0) (P <0.001). For patients with less severe strokes, the increase in overall statin use in-hospital was not significant (86.2% before vs. 88.4% after). However, among patients with higher stroke severity, there was a significant increase in statin prescription (57.6% before vs. 62.8% after), and this increase was associated with a decline in the odds of death within 90 days by a factor of 0.53 (0.36-0.79) and a 1.8 (1.1-3.0) increase in the odds of being home or in inpatient rehabilitation within 2 weeks.

Discussion:
A simple change in an electronic medical record system led to a significant increase in statin prescription during ischemic stroke hospitalization, particularly among patients with more severe stroke. This increase in statin prescription was associated with improved post-stroke outcomes.
Abstract T P309: Early Initiation of Blood Pressure Lowering Medication and the Outcomes of Hypertensive Acute Ischemic Stroke Patients
Authors: Kim Beom Joon , Han Moon-Ku , Cho Yong-Jin , Hong Keun-Sik , Park Sang-Soon , Park Tai Hwan , Lee Jun , Kim Joon-Tae , Yeom Jiyoon , Lee Ji Sung , Lee Juneyoung , Bae Hee-Joon
Published: March 2022

Background:
Elevated blood pressure (BP) in acute stage of ischemic stroke is common but the management of hyperacute hypertension in stroke patients was only vaguely described in the current clinical guidelines. The aim of our study was to determine the effect of expedited initiation of BP-lowering medication on the functional recovery and vascular events after acute ischemic stroke.

Methods:
The authors constructed a prospective multicenter registry containing in-hospital BP profiles and BP-lowering medications from 3997 acute ischemic stroke cases. From the data, we selected 841 acute stroke patients who arrived less than 24 hours from onset and who had ≥140 mm Hg of mean systolic BP from ≥3 BP measurement within 24 hours from onset. Initiation of any BP-lowering medications at the day or the next day of stroke onset was defined as “early initiation.” Clinical outcomes of stroke patients have been collected prospectively as quality improvement activity of stroke care and included early neurological deterioration until 3 weeks, mRS score and vascular events at 3 months and 1 year. Adjustment for relevant confounders was performed using ordinal logistic models for mRS scores and using binary logistic models for clinical event outcomes.

Results:
Of the 841 stroke cases with mean systolic BP ≥140 during the first 24 hours, early initiation of any BP-lowering medication was documented in 36%. Early initiation group, compared with delayed or none, had more frequent atrial fibrillation (34% vs. 17%) and thrombolytic treatment (23% vs. 17%); other baseline characteristics were well balanced. Multivariable regression analyses showed that early initiation was significantly associated with increasing scores of mRS at 3 months (adjusted OR [95% CI]; 1.33; 1.02 _ 1.73) and at 1 year (1.34; 1.01 _ 1.78). However, early initiation was not linked to any vascular events or mortality after stroke.

Conclusions:
Our study documented that early initiation of BP-lowering medication hindered functional recovery after stroke without increasing adverse clinical events.
Abstract T P310: PHQ-2 Screens for Early Depression in Acute Stroke
Authors: Jackson Nancy , Alshekhlee Amer
Published: March 2022

Background:
New quality care requirements include screening for depression in patients with acute stroke. The Patient Health Questionnaire-2 and -9 (PHQ-2, PHQ-9) are validated tools utilized for depression screening. Early screening during the hospital stay may have a higher yield for earlier initiation of treatment and potentially better recovery outcomes. In addition, patients with higher stroke severity may exhibit a higher PHQ-2 and -9 scores.

Purpose:
Average length of stay of all patients with acute stroke at our institution is 3.87 days; this requires depression screening within 2-4 days of admission. The purpose of this study is to identify the utility of post-stroke depression screening tool in acute care in correlation with the day the tool was utilized. Further correlation with the stroke severity will be determined. .

Methods:
All staff on every stroke unit were educated on the depression screening tool which was used in compliance with our protocols. We performed a retrospective chart review, in which we collected information on the type of stroke, treatment, history of depression, NIHSS score on admission and discharge, PHQ-2 and PHQ-9, and hospital day of screening. Pearson correlation coefficient was measured for the scores on screening tools with days it was performed.

Results:
Among all patients, screening for depression was performed on 206 patients,. The mean age of the cohort 68.6 ± 14.1; 53% females with initial mean NIHSS 7.6 ± 8.3 and discharge NIHSS 3.8 ± 7.9. The average hospital day when the tool was utilized was 3.73 ± 2.7. There was a positive correlation found with the PHQ-2 and the days when the tool was utilized (Pearson coefficient 0.16, P = 0.01). This correlation was not found between PHQ-9 (Pearson coefficient 0.053, P > 0.05). PHQ-2 also correlated with the initial and discharge NIHSS scale (Pearson coefficient 0.31 and 0.30, P <0.05); this correlation was not found with PHQ-9.

Conclusion:
PHQ-2 is a helpful tool in detecting depression when used early in the course of acute stroke. In addition, there is a positive correlation between PHQ-2 and stroke severity.
Abstract T P311: Lipid Profile and Clinical Outcomes in Acute Intracerebral Hemorrhage: The SAMURAI-ICH Study
Authors: Koga Masatoshi , Todo Kenichi , Kamiyama Kenji , Kario Kazuomi , Hasegawa Yasuhiro , Furui Eisuke , Shiokawa Yoshiaki , Kimura Kazumi , Okada Yasushi , Okuda Satoshi , Arihiro Shoji , Takasugi Junji , Higashida Kyoko , Tokunaga Keisuke , Yamagami Hiroshi , Nagatsuka Kazuyuki , Minematsu Kazuo , Toyoda Kazunori
Published: March 2022

Background and purpose:
Although low serum total cholesterol (TC) levels are associated with an increased risk of intracerebral hemorrhage (ICH), the prognostic value of lipid parameters is not fully known. We aimed to determine the association between lipid parameters on admission and clinical outcomes in acute ICH patients.

Methods:
This study is a post-hoc analysis of the SAMURAI-ICH study, which was a prospective, multicenter, observational study. Hyperacute (hospitalized <3 hours from onset) ICH patients were included. Serum TC, triglyceride (TG), high-density lipoprotein cholesterol (HDLC) and low-density lipoprotein cholesterol (LDLC) were measured on admission. Clinical outcomes were hematoma expansion (>33% increase), neurological deterioration (a decrease of ≥2 in GCS or an increase of ≥4 in NIHSS from baseline to 72 hours), favorable outcome (3-month mRS 0-2) and unfavorable outcome (3-month mRS 4-6).

Results:
Of the 204 patients (78 women; 66±12 years; median baseline NIHSS, 13 [8-17]), a statin was prescribed in 16 (8%). Of all, 35 (17%) showed hematoma expansion, 16 (8%) experienced neurological deterioration, and 80 (of 199 with premorbid mRS 0-2, 40%) and 84 (41%) had favorable and unfavorable outcomes, respectively. Levels of TC, TG, HDLC and LDLC were 196±40, 125±69, 59±17and 112±34mg/dl, respectively. On multivariate regression analyses adjusted for established prognostic predictors, TG (odds ratio per 10mg/dl [OR], 1.06; 95% confidence interval [CI], 1.002-1.13; p=0.042) was associated with hematoma expansion, and HDLC (OR, 1.30; 95% CI, 1.04-1.65; p=0.024) was positively, and LDLC (OR, 0.89; 95% CI, 0.80-0.999; p=0.048) was inversely associated with favorable outcome. Although prior statin use was not associated with any clinical outcomes, HDLC (OR, 1.20; 95% CI, 0.95-1.53; p=0.123) and LDLC (OR, 0.90; 95% CI, 0.79-1.01; p=0.071) were no more significantly associated with favorable outcome after excluding patients with prior statin. No parameters were significantly associated with neurological deterioration and unfavorable outcome.

Conclusions:
High TG level was associated with hematoma expansion. High HDLC and low LDLC levels were associated with independence at 3 months after onset in patients with acute ICH.
Abstract T P316: Occurrence of Intracranial Hypertension in the First 400 Patients Enrolled in the Clot Lysis: Evaluation of Accelerated Resolution of Intraventricular Hemorrhage Trial (CLEAR III)
Authors: Ziai Wendy , Mayo Steven , McBee Nichol , Freeman William D , Dlugash Rachel , Ram Malathi , Awad Issam , Hanley Daniel F ,   CLEAR III Investigators
Published: March 2022

Background:
Elevated intracranial pressure (ICP) is one proposed mechanism leading to poor outcomes in patients with spontaneous intraventricular hemorrhage (IVH). We characterized occurrence and significance of intracranial hypertension in severe IVH requiring extraventricular drainage (EVD).

Methods:
Prospective analysis of ICP in the first 400 patients enrolled in the CLEAR III trial, a multicenter, double-blind, randomized study comparing EVD plus intraventricular recombinant tissue plasminogen activator (rtPA) vs. EVD plus placebo for treatment of IVH in patients with obstructive IVH and intracerebral hemorrhage (ICH) volume <30cc. Maximum and minimum ICP was recorded every 4 hours in all patients until 7 days post randomization. ICP readings were analyzed at pre-defined thresholds and proportion of high ICP events compared by clinical/radiological variables. Impact on 30 day mortality was assessed.

Results:
of 17,593 ICP readings, maximum ICP ranged from -4 to 115 mm Hg (median, interquartile range; 11,8); 90.2% (15,861) were ≤ 20 mm Hg, 2.0% were >30, 0.5% were >40, and 0.2% were > 50 mm Hg. Proportion of threshold events > 20 and > 30 mm Hg were more frequent in patients with persistent closure of the lower ventricular system after day 3 (p=0.047 and p=0.04, respectively), but were not correlated with initial or end of treatment (72 hours after last dose of study agent) ICH or IVH volumes. ICP elevation > 20 mm Hg occurred during a required 1 hr EVD closure time after study agent injection in 507/3364 (15.1%) injections although early re-opening of EVDs occurred in only 3.9%. Shunting for hydrocephalus was required in 18% of patients over 1 yr follow-up and was not associated with high ICP events. Percentage of ICP readings per patient > 30 mmHg and ICH/IVH volumes were independent predictors of 30 day mortality after adjustment for other outcome predictors (p=0.01; p=0.04; p<0.001, respectively).

Conclusions:
ICP is not frequently elevated during monitoring and drainage with an EVD in patients with severe IVH. ICP > 30 mm Hg predicts higher short-term mortality. Early opening of the lower ventricular system may reduce frequency of high ICP events. Injection of thrombolytics can be performed without additional ICP management in the majority of patients.