bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP364: Concordance Between Self-Reported and Physician Diagnosis of Stroke Type in Hypertensive Minority Stroke Survivors: Implications for Population Health Research
Authors: Ogunlade Adebayo O , Joseph Jennifer , Payano Leydi , Montesdeoca Jacqueline , Spruill Tanya , Williams Stephen K , Teresi Jeanne , Williams Olajide , Ogedegbe Gbenga
Published: January 2019

Background:
Population-based studies often rely on self-reported medical history. Studies have shown that self-reported histories are often inconsistent with medical records. We sought to evaluate the concordance between self-reported and physician-diagnosed stroke type.

Methods:
Analysis was performed using data from an ongoing clinical trial comprising community-dwelling Blacks and Hispanics (N=450), with recently diagnosed stroke and elevated blood pressure (BP) recruited from New York City stroke centers. Two blinded neurologists used medical records to independently adjudicate whether the index event qualified as an ischemic or hemorrhagic stroke. Participants self-reported their stroke type during baseline interviews. The Cohen’s κ (kappa) statistic was used to measure the agreement between self-reported and adjudicated stroke type. Logistic regression was performed to identify predictors of accurate self-report of stroke type, adjusting for race/ethnicity, age, gender, marital status, education, vascular risk factors and stroke severity.

Results:
Participants had a mean age of 61.7±11.1 years and were 61.9% English-speaking, 51.0% Black and 56.1% male. Almost half had less than high school education (49.0%) and 70.4% had an income ≤$25,000. Majority of participants (75.6%) were adjudicated as having an ischemic stroke. Ischemic stroke was endorsed by 19.3% of participants, while 18.7% endorsed hemorrhagic stroke. The remainder were unaware of their stroke type. Only 30.7% of the self-reported stroke type matched the adjudicated diagnosis. The Kappa coefficient indicated moderate agreement (0.472) for hemorrhagic strokes and slight agreement (0.119) for ischemic strokes. The degree of agreement was not associated with race/ethnicity or education. Income ≥$25,000 was the strongest predictor of accurate self-report of stroke type, but it did not reach statistical significance.

Conclusions:
Self-report accuracy of stroke type was found to be better in hemorrhagic versus ischemic stroke survivors but low overall. The vast majority of participants acknowledged not knowing their diagnosis. Use of self-reported stroke type would not provide accurate disease prevalence estimates in a population-based study.
Abstract TP366: Using Machine Learning to Predict Tracheostomy After Intracerebral Hemorrhage
Authors: Garg Ravi , Prabhakaran Shyam , Holl Jane , Faigle Roland , Naidech Andrew
Published: January 2019

Objective:
Tracheostomy employment after intracerebral hemorrhage indicates the need for continued medical care and predicts patient dependence. Our objective was to determine if advanced machine learning methods could help predict tracheostomy using patient data collected from two institutions.

Methods:
We used prospectively collected dataset of large number of patients, who had been confirmed for the diagnosis of intracerebral hemorrhage, from Northwestern Medicine and John Hopkins Medicine. Next, we trained several machine learning models in conjunction with predictors such as Age, Glasgow comma scale (GCS), ICH score, and Race. The machine learning methods we used and compared were K-nearest neighbors, Logistic regression, Support vector machines, Random forests, Gradient boosting machines, XGBoost and Stacking. We compared Receiver operating curves (Area under the Curve, AUC) between logistic regression and other machine learning techniques. In order to test the generalizability of our results we tested out methods on external test data set provided by John Hopkins medicine.

Results:
531 patients - 434 negatives (who did not receive tracheostomy) and 77 positives (who did receive tracheostomy) were included in the cohort from Northwestern medicine. We randomly divided the dataset into 80% for training and 20% for testing. 107 patients - 92 negatives and 15 positives were included in the external test dataset from John Hopkins. In Northwestern test patients, logistic regression predicted tracheostomy with lower AUC (0.68) as compared to Random forests (AUC 0.74), Gradient boosting machines (AUC 0.75), XGBoost (AUC 0.74), and Stacking (AUC 0.76). Results for external test data were similar.

Conclusions:
Modern machine learning techniques as compared to logistic regression were significantly more accurate in predicting tracheostomy. Modern machine learning techniques are likely to enable future research and help predict other outcomes and complications with greater accuracy.
Abstract TP375: Using Simulation to Improve Medical Student Knowledge and Comfort in Early Management of Acute Stroke
Authors: Kornspun Alana , Kaur Gurmeen , Motiwala Rajeev , Fabian Michelle , Stein Laura K
Published: January 2019

Introduction:
Given the narrow time window, high acuity, and growing complexity, medical student experience with early management of acute stroke (EMAS) is often limited. However, all medical students need experience recognizing and treating acute stroke regardless of their eventual specialty. Simulation-based education has been demonstrated to improve knowledge acquisition without compromising patient safety. We utilized simulation as part of an educational quality improvement initiative to address a gap in medical student experience and comfort in EMAS.

Methods:
In the 2017-2018 academic year, 104 third year medical students participated in stroke code simulation during the neurology clerkship. Stroke fellows led groups of ten students through two cases: right M1 occlusion requiring intravenous alteplase (IV tPA) and mechanical thrombectomy (MT) and left thalamic intracerebral hemorrhage complicated by status epilepticus. In each case, students identified and triaged stroke syndromes, performed the NIH Stroke Scale, interpreted CT and CTA images, and formulated treatment plans utilizing IV tPA and MT as well as blood pressure and antiepileptic medications. All participants completed pre- and post-simulation tests targeting clinical knowledge of EMAS (score range 0-7). Additionally, 45 students completed an anonymous post-simulation survey on subjective feelings of confidence managing acute stroke and seizure (Likert scale of 1-5).

Results:
Mean EMAS test score improved from 4.85 (SEM 0.089) pre-simulation to 5.25 (SEM 0.101) post-simulation (p<0.01). Students demonstrated significant improvement on questions assessing the role of supplemental oxygen in EMAS (p<0.01) and lacunar stroke syndromes (p<0.05). Subjectively, 77.8% of participants reported that simulation was the best form of acute stroke instruction they received, and 73.4% agreed or strongly agreed that the simulation improved their level of comfort with EMAS.

Conclusion:
Simulation improved medical student knowledge and level of comfort with EMAS. All medical school graduates should be trained to recognize signs and initiate management of acute stroke.
Abstract TP379: Antithrombotic Bridging in Patients With Acute Ischemic Stroke and Atrial Fibrillation
Authors: Swafford Kara , Lee Jessica D
Published: January 2019

Introduction:
Atrial fibrillation (AF) is the most common cardiac arrhythmia, with a prevalence of 5.9% in those over age 65. AF increases stroke risk 5-fold, causing 1 in 6 acute ischemic strokes (AIS). Stroke from AF carries a higher early mortality and poorer functional outcome, and a risk of recurrent AIS, when compared to ischemic stroke patients in sinus rhythm, of approximately 5% in the first 2-4 weeks. The CHADS2 score is used to estimate stroke risk of non-valvular AF. Anticoagulation is recommended for a score of
>
2 unless contraindicated. Controversy exists regarding whether AF patients with AIS should receive parenteral anticoagulation or antiplatelet therapy as a bridging method to oral anticoagulation.

Methods:
We conducted a single center retrospective chart review of patients admitted between 6/2011 and 3/2014, with diagnosis of AIS and AF (n=354), as part of quality improvement. Bleeding complications related to bridging therapy and incidence of recurrent stroke were reviewed.

Results:
Complications were seen in 24 (13.3%) patients receiving parenteral bridging anticoagulation (n=180, 50.8%), including 14 intracranial and 14 extracranial bleeding events (7.7% each). Multiple bleeding complications were seen in 2.2% (n=4). Bleeding complications were seen in 5.5% (n=9) of patients receiving antiplatelet bridging (n=161, 45.4%), with 4.3% intracranial (n=7) and 1.2% extracranial (n=2) bleeding events. None had more than one bleeding complication. Relative risk for bleeding complications with parenteral anticoagulation versus antiplatelet bridging was 2.38 (CI 1.1426 to 4.9793, p=0.02). Thirteen patients (3.6%) received no bridging and had no bleeding complications. Two patients of 354 (0.5%) had recurrent ischemic events, one each in the parenteral anticoagulation and antiplatelet groups.

Conclusions:
Preliminary data does not support bridging with parenteral anticoagulation in AIS and AF due to higher incidence of bleeding complications and low incidence of recurrent AIS. These findings may be related to the limited number of patients included in this study. A future goal is to increase the number of patients reviewed to strengthen the validity of these results.
Abstract TP382: Novel and Modifiable Factors Associated With Adherence to Cpap Therapy During Acute Stroke Rehabilitation: A Qualitative Analysis
Authors: Khot Sandeep P , Barnett Heather , Davis Arielle , Byun Eeeseung , Bunnell Aaron , Kunze Allison , McCann Barbara , Bombardier Charles , Longstreth W.t. , Billings Martha , Garrison Michelle
Published: January 2019

Background:
Continuous positive airway pressure (CPAP) for the treatment of obstructive sleep apnea (OSA) may improve stroke recovery but prior studies have been limited by poor adherence. In a single-arm study of stroke rehabilitation patients treated with CPAP, we evaluated environmental, behavioral and social factors associated with CPAP adherence.

Methods:
As part of an intensive CPAP adherence protocol, stroke rehabilitation patients were assessed for OSA based on CPAP device download. Qualifying patients underwent motivational interviewing (MI) sessions to set goals and address barriers for CPAP use. Patients who planned to continue CPAP after rehabilitation unit discharge were asked after 3-months to detail facilitators or barriers to continued CPAP use. We conducted a thematic analysis of the MI and 3-month interview notes, with four authors each coding modifiable and less modifiable barriers and facilitators.

Results:
Among 52 subjects who planned to continue CPAP over 3-months, 32 (62%) were adherent, defined as ≥ 4 hours on ≥ 70% of days. Adherent patients were less likely to complain of claustrophobia than non-adherent patients (13% vs. 42%,
p
=0.02). Facilitators for adherence were improved sleep quality and daytime function, self-efficacy with CPAP, social support, and positive expectations of treatment benefit. Common modifiable barriers included discomfort using a new health technology, common CPAP side effects and anxiety. Several patients described more complex and less modifiable barriers such as social stressors, sleep disturbance, lack of social support and competing health issues.

Conclusions:
An intensive CPAP adherence protocol with MI sessions during rehabilitation yielded a high rate of adherence even outside of the supportive inpatient environment. Adherence programs for CPAP after stroke should focus on interventions to address modifiable barriers, including early desensitization to improve anxiety or claustrophobia and continued education or training to address perceived self-efficacy and importance of CPAP therapy. Future studies should assess the effectiveness of MI to identify factors associated with CPAP adherence and to design interventions to improve long-term adherence by modifying these factors.
Abstract TP387: Development and Implementation of a Comprehensive Stroke Center Clinical Peer Review Process
Authors: Sinogui Cynthia , Zrelak Patricia , Hartman Jonathan , Axelrod Yekaterina , Zarate Wally , Pham Quynh , Tang Xiannan , Jennings Amber
Published: January 2019

Background:
Comprehensive Stroke Centers (CSC) are required by The Joint Commission to have an interdisciplinary peer review process. Most hospitals structure their peer review programs, also known as morbidity and mortality meetings, by specialty and not by Centers of Excellence. Often these meetings are closed, with minimal information sharing for making program-wide improvements.

Purpose:
To develop and implement a process for conducting morbidity and mortality reviews for a CSC based on best practices to foster improved clinical outcomes.

Methods:
A literature review was performed to establish best practices for such reviews. An interdisciplinary team including key stakeholders was developed for a non-biased comprehensive chart review. All deaths within 30-days, sentinel events, serious incidents, adverse events, close calls, stroke mimics treated with alteplase, delays in care, complications, and major complaints were reviewed. Cases were captured by formal and informal processes (see diagram). Outcomes and trends are monitored. Recommendations are made for changes in clinical processes.

Results:
Between January 2016 - June 2018, 853 charts were reviewed for the criteria discussed above. A total of 89 charts were referred to the committee for further chart review, of which, 3 were identified for department peer review. Of those 3 cases, all were determined to be outliers, and no trends have been identified . While there were no blatant opportunities identified for improvement, the review process provides helpful information regarding the quality of the program. Members of the interdisciplinary team feel that the process is robust and valuable.

Conclusion:
Establishing a succinct process for chart evaluation and interdisciplinary team review has proven effective in identifying cases for referral to peer review. These data have been helpful in improving performance and monitoring patient-centered outcomes.
Abstract TP392: Evaluating Rehabilitation Discharge Decision Indicators Among Hospitals Participating in Michigan’s Ongoing Stroke Registry to Accelerate Improvement of Care
Authors: Wall Samantha R , Nickles Adrienne V , Ibrahim Ghada , Allen Justin , Wahl Robert , Quartermus Krystal , Scorcia-Wilson Teri , O'Brien Suzanne L , Reeves Mathew J
Published: January 2019

Background:
There is considerable patient and hospital level variation in the selection of rehabilitation settings at the time of hospital discharge and contributing factors in decision making for post-acute care are poorly defined.

Objective:
Describe variability in frequency of discharge destination (acute, sub-acute, other facility type) of stroke patients to rehabilitation facilities across hospitals participating in Michigan’s Ongoing Stroke Registry to Accelerate Improvement of Care (MOSAIC), a statewide Coverdell stroke registry. Sample: Patients discharged from hospitals participating in MOSAIC’s hospital inventory between January 1- December 31, 2017 with clinical diagnosis of Ischemic or Hemorrhagic Stroke (N=3,129).

Methods:
Multinomial logistic regression analysis conducted to quantify associations between patient and hospital level factors related to discharge destination. Discharge destination was utilized as the outcome variable with all other factors (age, gender, race, insurance, functional status- admission/discharge, stroke type, hospital size, and stroke volume) as indicator variables.

Results:
From the model, 4 variables indicated significance with discharge destination. Patients suffering a hemorrhagic stroke were less likely to be discharge to acute or sub-acute facilities. Patients who were female, unable to ambulate at discharge, or of increased age (60+ years) were more likely to be discharged to a sub-acute facility. As such, hospitals with small bed sizes were more likely to discharge patients to sub-acute facilities than any other destination.

Conclusions:
Patient and hospital-based factors may predict discharge destination, with hospital bed size, stroke type, and discharge ambulatory status showing the strongest associations. Knowing major indicators related to decision-making processes, hospitals can reduce variability in decision making and improve quality of life outcomes for stroke patients.
Abstract TP393: Sex Differences in Neurologist Diagnosis of Transient Ischemic Attack in Association With Presenting Symptoms
Authors: Gocan Sophia , Fitzpatrick Tess , Wang Chu Qi , Taljaard Monica , Cheng Wei , Bourgoin Aline , Dowlatshahi Dar , Stotts Grant , Shamy Michel
Published: January 2019

Effective management of Transient Ischemic Attack (TIA) and stroke hinges on accurate diagnosis. Research suggests that women and men present with different TIA/stroke symptoms, and those more commonly reported by women are often considered atypical, or benign. For this reason, TIA or stroke in women may be underdiagnosed and undertreated. Growing evidence that women are disproportionately affected by stroke underpins this study focused on neurologist diagnosis of stroke/TIA in association with presenting symptoms. A retrospective chart review was performed using data from the charts of all patients referred to The Ottawa Hospital Stroke Prevention Clinic in 2015 with a provisional diagnosis of TIA/stroke. Demographics, event characteristics, and final diagnosis were extracted from each chart. Multinomial logistic regression analysis with backwards elimination and a significance level staying in the model of α=0.15 was used to identify variables associated with a final diagnosis of definite TIA/stroke. A sub-analysis was completed for the final model by sex. Of the 1864 included patients, 932 (50%) were women. There were no significant differences in age or final diagnosis of definite TIA/stroke based on sex. Among patients reporting classic stroke symptoms such as unilateral weakness, aphasia, and amaurosis fugax both sexes demonstrated significantly higher odds of a final diagnosis of TIA/stroke; however the odds were higher for men than women. For example, men with unilateral weakness, aphasia or amaurosis fugax had an odds ratio (OR) of 32.7, 7.7, and 27.8 respectively of having a final diagnosis of TIA/stroke, whereas the OR for women was 10.9, 5.4, and 22.2 respectively, although the 95% confidence intervals overlapped. In contrast, women reporting homonymous hemianopsia or any combination of ataxia, diplopia, or vertigo had a higher odds than men of being diagnosed with TIA/stroke (OR 21 and 8.5 respectively for women and OR 11.4 and 5.1 respectively for men). The trend in differences noted for the odds of definite TIA/stroke diagnosis among men and women may imply that women are less likely to be diagnosed with TIA even when reporting classical symptoms. More research is needed to understand sex-based differences in the diagnosis of TIA/stroke.
Abstract TP398: Improving Tpa Utilization and Door to Tpa Times in a Community Hospital: Lessons Learned
Authors: Caller Tracie , Rieser Carol , Barnes Sheree , Savelle Jonathan , Kisicki Jessica
Published: January 2019

Objective:
To improve door to thrombolysis time to less than 60 minutes for acute stroke patients in a community hospital with telestroke access.

Background:
Earlier initiation of thrombolysis (tPA) therapy in acute stroke patients is associated with improved patient outcomes. Delays in the identification and workup of stroke patients can impact thrombolysis treatment time.

Methods:
A multidisciplinary workgroup was created in 2015. The care of stroke alert patients was observed over several weeks, identifying barriers and delays in treatment. Multiple interventions were implemented utilizing plan-do-study-act (PDSA) cycles. Door-to-tPA (DTT) times were retrospectively collected for patients with final diagnosis of ischemic stroke and monitored monthly using statistical process control charts.

Results:
Baseline average DTT was 77 minutes. Initiation of a stroke launch pad and revision of the process to obtain CT scans resulted in a significant decrease in average time to CT to 9 minutes, which was sustained, but without subsequent improvement in DTT times. Further interventions to the stroke alert process improved DTT times transiently but performance was not sustainable. Multiple PDSA cycles were carried out targeting various inefficiencies in the process, knowledge gaps amongst staff, and cultural barriers within the ER physicians. DTT times have gradually improved over time, with average DTT of 48 minutes achieved for Jan-June 2018 (Figure 1). The average number of tPA cases per month increased from 1.3 in 2015 to 2.5 in 2017-2018, likely attributable to revisions in the stroke alert process and stroke alert criteria, and staff education.

Conclusion:
Continuous quality improvement methodology can be utilized to improve door to tPA times in acute stroke patients. This may require multiple PDSA cycles, addressing cultural and educational barriers, as well as continually revisiting the process to ensure sustained performance.
Abstract TP40: Outcomes of Thrombectomy in Basilar Artery Occlusions: A Single Center Study
Authors: Hawkins Angela M , Morris Harold , Olds Karin , Martin Coleman , Akhtar Naveed , Holloway William
Published: January 2019

Background:
Basilar artery occlusion (BAO) remains a devastating ischemic stroke subtype leading to high mortality rates and poor outcomes. Recently, mechanical retrieval therapy (MER) became a standard of care and a influential predictor of favorable outcomes in anterior circulation stroke patients. However, the use of MER in AIS patients with BAO is not established.

Purpose:
Our hospital sees over 1600 stroke patients a year with over 18% of stroke patients receiving MER therapy compared to the national average of 4.3%. We sought to evaluate our BAO patients who received MER therapy for efficacy and outcomes.

Methods:
Patients presenting to our facility between January 1, 2015 and June 30, 2018 were studied in a retrospective chart review. AIS patients who had BAO were evaluated for types of treatment, age, outcomes, recanalization rate TICI score of >2b, and disability or mortality after stroke. Of the 4,212 stroke patients presenting at our facility in the timeframe, 441 underwent MER therapy with 20 patients having a primary occlusion of basilar artery. Data was analyzed and compared to meta-analysis data.

Results:
Our patients with BAO had a (mRS) modified Rankin Score (0-2) of 81.8% (95% CI 7.8%, 96.8%) compared to the national average of 42.0% (95% CI 36%, 48%). Reperfusion scores (TICI >2b) in our patients was 90.9 % (95% CI 57.1%, 99.5%), while the reperfusion scores (TICI >2b) in the comparison group as 81% (95% CI 73%, 87%). Our sICH rate was 0.0% (95% CI 0.0%, 31.1%) while the comparison group was 4% (95% CI 2.0%, 8.0%). Our overall mortality rate of our BAO patients was 5.1%, with the comparison group’s mortality rate at 30.1%. There was no significance noted in patients’ ages or in the use of thrombolytics between the two groups.

Conclusion:
Patients presenting with stroke caused by BAO who receive MER at our facility have more favorable outcomes than those in the systematic review. Potential reasons include shorter time to recanalization, improved catheters and technology, experienced staff and strict attention to seamless transitions of care. MER therapy can be a safe treatment modality for patients with BAO. Further clinical trials are needed to show MER efficacy in patients experiencing a BAO.
Abstract TP401: Red Cell Distribution Width Predicts Prognosis of Stroke-Associated Infection in Patients With Acute Ischemic Stroke
Authors: Kang MinKyung , Kim Tae Jung , Ko Sang-Bae
Published: January 2019

Purpose:
The red cell distribution width (RDW) is a rapid, inexpensive laboratory test. Elevated RDW values are associated with poor outcomes in adult critical illness, especially in cardiovascular disease and infection. We examined the association between RDW and stroke-associated infection, need for critical care and infection-related in-hospital mortality in ischemic stroke.

Methods:
A consecutive 1,973 patients who were admitted within 7 days after ischemic stroke onset between March 2010 and September 2016 were included for analysis. The patients were categorized into two groups on the basis of RDW(>14.0%). We evaluated the stroke-associated infection, initiation of critical care and infection-related in-hospital
mortality
using a combination of clinical assessment, radiological imaging and appropriate microbiological tests. Logistic regression was used to identify risk factors for stroke-associated infection, need for critical care and infection-related in-hospital mortality.

Results:
The patients were divided into two groups according to RDW scores identified as RDW above group (n=342, 17.3%) with mean age 71±11.2 years; 58.8% males and RDW below group (n=1631, 81.7%) with mean age 67±12.5 years; 61.2% males. As expected, the patients with stroke-associated infection were older and more likely to have atrial fibrillation, history of diabetes mellitus, higher NIHSS on admission and higher RDW (19.0% vs 8.2%,
p
<0.001). The stroke-associated infection rate was higher in the RDW above groups as compared to RDW below group with odds ratio 2.279; confidence interval 1.637 to 3.173;
p
<0.001, even
after adjustment
for traditional cardiovascular risk
factors
. Similar significant robust associations post multivariable adjustments are seen with critical care initiation as well as infection-related in-hospital
mortality
:
odds ratio 1.166; confidence interval 1.054 to 1.290;
p
=0.003, odds ratio 1.194; confidence interval 1.010 to 1.412;
p
=0.038, respectively.

Conclusion:
This study demonstrated that higher RDW predicted stroke-associated infection and its prognosis in patients with acute ischemic stroke. This study has shown that RDW provides additive prognostic data for infection of patients with acute ischemic stroke.
Abstract TP406: Treatment Outcome in Older Patients With Pfo Attributable Cryptogenic Embolism
Authors: Liu Kai , Song Bo , Deng Wen J , McMullin David , Fisher Lindsay , Chou I-ying , Bunda Bridget , Wang Andrew , Coates Gillian , Wang Xiao Y , Inglessis-Azuaje Ignacio , Palacios Igor , Lo Eng H , Xu Yu M , Buonanno Ferdinando , Ning Ming M
Published: January 2019

Background:
Recent successful randomized clinical trials showed that patent foramen ovale (PFO) closure lower risk of recurrent stroke or transient ischemic attack (TIA), compared to medical therapy. However, older patients (age≥60 years old) were excluded in these trials. In this study, we investigate the effect of PFO treatment in older adults with PFO related cryptogenic embolism.

Methods:
We prospectively enrolled 209 patients older than 60 years of age, with cryptogenic stroke or TIA attributed to PFO from MGH Cardio-Neurology Clinic. Extensive cryptogenic stroke workup included MRI/A, echo, and MCOT. Primary end point was a composite of recurrent ischemic stroke, TIA.

Results:
Of the 209 PFO stroke patients, 66 patients underwent PFO closure and 143 patients received medical therapy (
Table 1
). The mean duration of follow-up was 49 months in the closure group and 45 months in the medical-therapy group. The primary end point occurred in 4 patients (6.1%) in the closure group and in 27(18.9%) in the medical therapy group (HR for medical therapy vs. closure, 3.763; 95% CI, 1.306 to 10.840; P = 0.014) (
Figure 1
). The respective rates were 1.5% vs 4.9% for TIA (P = 0.426) and 4.5% vs 14.0% for stroke (P = 0.043).

Conclusions:
Older patients with PFO related cryptogenic embolism may also derive more benefits from PFO closure compared to medical treatment.
Abstract TP410: Early Diagnosis of Stroke-associated Pneumonia by Blood Biomarkers. Correlation With Thoracic High-resolution Computer Tomography
Authors: Bustamante Alejandro , Zapata-Arriaza Elena , Moniche Francisco , Pardo-Galiana Blanca , Serrano-Gotarredona Pilar , Navarro-Herrero Silvia , Pallisa Esther , Faura Júlia , Sánchez-Martínez Ana Lucía , Vega-Salvatierra Ángela , Penalba Anna , Mancha-Molina Fernando , Escudero-Martínez Irene , Sanchez Jean Charles , Montaner Joan
Published: January 2019

Introduction:
One of the main limitations in biomarker research for stroke-associated pneumonia (SAP) is the lack of a gold-standard for clinical diagnosis. We aimed to evaluate the diagnostic accuracy of candidate biomarkers related to the features on thoracic high-resolution computed tomography (HRCT).

Methods:
Patients with ischemic stroke with baseline NIHSS>10 were enrolled between March-2016 and August-2017. Blood samples were collected at baseline, 24 and 48 hours after stroke onset, to determine C-reactive protein (CRP), serum amyloid protein A (SAA), mid-regional proadrenomedullin (MR-proADM), and soluble receptor of urokinase-type plasminogen activator (suPAR). Biomarkers were measured by immunoassays. Pneumonia was diagnosed as the presence of a new consolidation, infectious nodules or ground-glass pattern, in a thoracic HRCT performed 5-7 days after stroke.

Results:
From 46 included patients, thoracic HRCT was performed in 41 patients. Five (12.5%) were diagnosed as pneumonia and 3 (7.3%) with acute bronchitis. No blood marker was associated with pneumonia on thoracic HRCT at baseline. At 24 hours, a cut-off of MR-proADM>1.023 nmol/L had 80% sensitivity and 72.2% specificity for pneumonia. At 48 hours, both SAA>25.15 mg/dL (60% sensitivity, 85.7% specificity) and suPAR>3.14 ng/mL (80% sensitivity, 57.1% specificity) were associated with infections. The combination of SAA>25.15 mg/dL and suPAR>3.14 ng/mL at 48 hours had 80% sensitivity and 95.8% specificity when both biomarkers were above the cut-off, and 60% sensitivity and 94.1% specificity when one of them was above the cut-off.

Conclusions:
An objective diagnostic test such as thoracic HRCT could be of interest for future research in SAP. The evaluated biomarkers will require further validation in larger samples. However, these biomarkers represent promising tools to be evaluated in future projects on SAP early diagnosis and guidance on antibiotic therapy.
Abstract TP419: PFO Stroke With Thrombophilia Has Higher Risk of Recurrent Stroke and Responds to PFO Closure
Authors: Liu Kai , Deng Wen J , Song Bo , Fisher Lindsay , Chou I-ying , Bunda Bridget , Wang Andrew , Coates Gillian , McMullin David , Wang Xiao Y , Inglessis-Azuaje Ignacio , Palacios Igor , Lo Eng H , Xu Yu M , Buonanno Ferdinando , Ning Ming M
Published: January 2019

Background:
Hypercoagulability due to thrombophilia may increase the risk of paradoxic embolism. However, previous randomized controlled trials that evaluated the efficacy of PFO closure or medical therapy on the risk of recurrent stroke and/or transient ischemic attack (TIA) events, have excluded these potentially high-risk thrombophilia patients. In this study, we want to investigate the effect of PFO management on the risks of recurrent stroke and/or TIA among patients with thrombophilia.

Methods:
Patients with a PFO attributable ischemic stroke or TIA are prospectively recruited. Hypercoagulable tests for protein C, protein S, antithrombin III, homocysteine levels, IgG and IgM anticardiolipin antibodies, factor V Leiden and prothrombin gene variant were obtained. The primary outcome was occurrence of stroke and/or TIA after index event.

Results:
Thrombophilia is diagnosed in 120 PFO stroke patients who subsequently underwent PFO closure (n= 76) vs medical therapy (n= 44) (
Table 1
). The mean duration of follow-up was 45 months in the closure group and 40 months in the medical-therapy group. The primary end point occurred in 5 patients (6.6%) in the closure group and in 14 (31.8%) in the medical therapy group (hazard ratio for medical therapy vs. closure, 5.797; 95% confidence interval [CI], 2.094 to 16.051; P = 0.001) (
Figure 1
) with recurrent rate of 18.2% vs. 5.3% for TIA (P = 0.023) and 13.6% vs. 1.3% for stroke (P = 0.018) respectively.

Conclusions:
PFO stroke patients with hypercoagulable state had higher rate of recurrent stroke than those patients in clinical trials. Among patients who had cryptogenic embolism with thrombophilia, closure of a PFO was associated with a lower rate of recurrent stroke and/or TIA than medical therapy.
Abstract TP42: First Pass Rates Differ Between Anterior and Posterior Circulation During Mechanical Thrombectomy for Emergent Large Vessel Occlusions
Authors: Memon Muhammad Z , Grewal Manjot K , Daniel David , Olan Wayne , Sigounas Dimitri , Putman Christopher , Greenberg Edward
Published: January 2019

Background:
Patients with vertebrobasilar occlusion were excluded from all major mechanical thrombectomy trials, therefore the evidence regarding the effectiveness of mechanical thrombectomy devices in these patients is limited. First pass effect (FPE) is defined as achieving a TICI 3 recanalization with a single device pass with no use of rescue therapy. We aimed to compare the FPE rates of existing mechanical devices between anterior circulation and vertebrobasilar occlusion and their clinical outcomes from a pooled data of two institutions outside of clinical trial or registry.

Methods:
Patients were identified from 2 prospectively collected stroke databases from Jan 2015 to March 2018. We compared the FPE rates between anterior circulation and vertebrobasilar occlusions. Other clinical outcomes were favorable functional outcome at hospital discharge (modified Rankin Scale (mRS) score of 0-3), and the rate of intracranial hemorrhage (ICH).

Results:
A total of 245 patients who underwent thrombectomy were identified. FPE was achieved in total of 97(39.5 %)patients [mean age 68.8 ± 14.1 years, 51 (52.6%) were women]. Overall, 79 (37.2%) of anterior circulation patients had FPE versus 18 (54.5% )with vertebrobasilar occlusions ( p-value<0.001) Since the general protocol was to use ADAPT technique for the first thrombectomy attempt, FPE was achieved in 57(72.2 %) of the cases in the anterior circulation occlusions versus 12 (66.6%) in posterior circulation with aspiration alone (p-value=0.09]. Mean time from symptoms onset to revascularization was significantly longer in posterior circulation compared to anterior circulation [510 ±581.1 vs 302±175.7 ( P <0.001)]. There was no statically significant difference between the 2 groups in good clinical outcome,mRs 0-3 [55.6% versus 55.7% p-value 0.6]. Similarly rate of ICH 2(11.1%) in vertebrobasilar versus 21(26.6%) in anterior circulation were not statistically different (p-value 0.13)

Conclusion:
In this analysis, vertebrobasilar occlusions had significantly higher percentage of FPE with current thrombectomy devices compared to anterior circulation large vessel occlusions.However, both groups with FPE have similar good functional outcomes and ICH rates.
Abstract TP423: Risk Factors for Intracranial Hemorrhage in Cerebral Venous Thrombosis
Authors: Afifi Khaled , Bellanger Guillaume , Zuurbier Yvonne , Garcia Esperon Carlos , Barboza Miguel , Buyck Pieter-Jan , Costa Paolo , Escudero Irene , Renard Dimitri , Lemmens Robin , Hinteregger Nicole , Fazekas Franz , Jimenez Conde Jordi , Giralt-Steinhauer Eva , Hiltunen Sini , Pezzini Alessandro , Montaner Joan , Weimar Christian , Churilov Leonid , Gattringer Thomas , Asadi Hamed , Tatlisumak Turgut , Coutinho Jonathan , Demaerel Philippe , Thijs Vincent
Published: January 2019

Cerebral venous thrombosis is associated with intracranial hemorrhage. The occurrence of brain bleeding complicates management and is associated with worse outcomes. We aimed to identify clinical and imaging risk factors for intracerebral hemorrhage. We hypothesized that higher clot burden would be associated with a higher risk of intracerebral hemorrhage.

Methods:
We performed a retrospective analysis of an international, multicenter cohort of patients with cerebral venous thrombosis who underwent CT within 2 weeks of symptom onset and who had a subsequent confirmed diagnosis of CVT on MRV, CTV or DSA. Clinical and imaging features were compared between patients with and without intracranial hemorrhage. Clot burden was assessed by counting the number of thrombosed venous sinuses and veins on confirmatory imaging.

Results:
We recruited 260 patients with cerebral venous thrombosis from 10 institutions in Europe and Mexico. The mean age was 42 and 74% were female. Intracranial hemorrhage was found in 102 (39%). Intracerebral hemorrhage occurred in 64 (63%), small juxtacortical hemorrhage in 30 (29%), subarachnoid hemorrhage in 24 (24%) and subdural hemorrhage in 11 (11%). Combinations of these types of hemorrhage occurred in 23 (23%). Intraparenchymal hemorrhages in multiple locations occurred in 6 (6%). Older age, presence of hematological disease and superior sagittal thrombosis involvement were significantly associated with presence of hemorrhage. The number of thrombosed venous sinuses was not associated with intracerebral hemorrhage (average number of sinuses/veins involved with hemorrhage 2.1 versus 1.9 without hemorrhage, p=0.4).

Conclusion:
The high rate of intracranial hemorrhage in cerebral venous thrombosis is not explained by widespread involvement of the venous sinuses. Superior sagittal sinus involvement is associated with the presence of intracranial hemorrhage.
Abstract TP430: Early Neurological Improvement and Deterioration in Patients With Primary Intracerebral Hemorrhage Predicts 90-Day Functional Outcome: Analysis From ATACH-2 Trial
Authors: Majidi Shahram , Martin Renee H , Kellner Christopher P , Suarez Jose I , Palesch Yuko Y , Qureshi Adnan I
Published: January 2019

Background:
The significance of early neurological improvement (ENI) and deterioration (END) in patients with primary intracerebral hemorrhage (ICH) is unclear. We sought to determine the prevalence and predictors of ENI and END and their impact on long term clinical outcome in patients with primary ICH recruited within 4.5 hours after symptom onset.

Methods:
We analyzed data from Antihypertensive Treatment at Acute Cerebral Hemorrhage (ATACH)-2 trial. ENI and END were defined by ≥ 4 points decrease or increase in NIHSS score within 24 hours post randomization, respectively. Baseline characteristics of patients that predicted ENI and END were identified. The association between ENI and END with favorable 90-day outcome (defined as modified Rankin Scale (mRS) <2) was analyzed after adjustment for potential confounders.

Results:
Ninety five of 1000 patients with ICH had END (9.5%). END was more common among non-Asians compared to Asians (55% vs 42%), patients with hematoma volume >=30 cc (26% vs 8%, p=<.0001) and intraventricular hemorrhage (IVH) (41% vs 25%, p=0.0015). Similarly, patients with END had higher baseline NIHSS score (median value 14 vs 10, p=<.0001). Patients with END had significantly lower rate of favorable 90-day outcome (6% vs 28%, p=<.0001). ENI was seen in 165 (19%) of patients. ENI was associated with lower initial Glasgow Coma Scale (GCS) score, lack of IVH, basal ganglia hematoma, and prior antihypertensive treatment. Patients with ENI had significantly higher chance of favorable 90-day outcome (29% vs 20%, p=0.019). In multivariate models that adjusted for initial GCS score, age and presence of IVH, both ENI and END were independent predictors of 90-day favorable outcome with (RR=1.40; 95% CI: 1.00, 1.97) and (RR=0.26; 95% CI: 0.11, 0.63), respectively. IVH and GCS score were independent predictors of early neurological changes.

Conclusions:
We found a relatively high prevalence of early neurological improvement or deterioration in ICH patients. Both ENI and END are independent predictors of 90-day functional outcome.
Abstract TP436: Minimally Invasive Endoscopic Hematoma Evacuation vs. Best Medical Management for Spontaneous Basal Ganglia Intracerebral Hemorrhage
Authors: Goyal Nitin , Tsivgoulis Georgios , Malhotra Konark , Katsanos Aristeidis , Pandhi Abhi , Alsherbini Khalid , Chang Jason , Hoit Daniel , Alexandrov Andrei , Elijovich Lucas , Fiorella David , Nickele Christopher , Arthur Adam S
Published: January 2019

Background:
We conducted a case-control study to assess the relative safety and efficacy of Apollo assisted minimally invasive endoscopic surgery (MIS) for clot evacuation in patients with basal-ganglia intracerebral hemorrhage (ICH).

Methods:
We evaluated consecutive patients with acute basal ganglia ICH at a single center over a 42-month period. Patients received either best medical management according to established guidelines (controls) or Apollo assisted MIS (cases) with best medical management. The following outcomes were compared before and after propensity-score matching (PSM): in-hospital mortality, discharge National Institutes of Health Stroke Scale (NIHSS) score, discharge disposition, modified Rankin Scale scores at discharge and at 3 months.

Results:
Among 224 ICH patients, 19 (8.5%) underwent MIS [mean age 50.9±10.9; 26.3% female, median ICH volume 40 (IQR; 25-51)]. The interventional cohort was younger with higher ICH volume and stroke severity as compared to the medically managed cohort. After PSM, 18 patients in the MIS cohort were matched to 54 medically managed individuals. The two cohorts did not differ in any of the baseline characteristics. The median ICH volume at 24 hours was lower in the intervention group [40cm
3
(IQR:25-50) vs. 15cm
3
(IQR:5-20), p<0.001). The two cohorts did not differ in any of the pre-specified outcomes measures with the exception of in-hospital mortality which was lower in intervention cohort (28% vs. 56%, p=0.041). The three-month mortality rates tended to be lower in the intervention cohort (38% vs. 60%, p=0.107). The intensive care unit length of stay was similar in the two groups [median LOS in days (IQR): intervention: 9 (7-12) vs. control: 9 (6-12), p=0.497]. The distribution of mRS-scores at discharge and at three months did not differ between the intervention and the control cohort (p by Cochran-Mantel-Haenszel test>0.4).

Conclusions:
Minimally invasive Apollo assisted endoscopic hematoma evacuation was associated with lower rates of in-hospital mortality in patients with spontaneous basal ganglia ICH. These findings support a randomized controlled trial of MIS versus medical-management for ICH.
Abstract TP437: Machine Learning Based Approach for Predicting High In-Hospital Systolic Blood Pressure Variability Among Intracerebral Hemorrhage Patients During Early Hospitalization
Authors: Fraher Christopher J , Bambhroliya Arvind B , Meeks Jennifer R , Savitz Sean I , Vahidy Farhaan S
Published: January 2019

Introduction:
Recent data suggest that early high systolic blood pressure variability (HSPBV) is associated with poor long term outcomes in intracerebral hemorrhage (ICH) patients. We employed a Machine Learning (ML) based approach to predict HSBPV during hospitalization.

Methods:
Adult radiologically confirmed ICH patients were enrolled in a multisite cohort. A semi-automated algorithm extracted systolic blood pressure (SBP) data from electronic medical records (EMR) and linkage to database with demographic, clinical, and outcomes information was created. Pre-hospital and early admission variables were used to develop predictive algorithms. Patients who expired during hospitalization were excluded. Generalized estimating equations quantified inter and intra-patient SBPV. An 80/20 data split was used to train and test predictive models for HSBPV. Two supervised ML models were trained using a repeated cross-validation bagged classification and regression tree, the first with a complete set of records and the second utilizing imputation (Figure).

Results:
A total of 455 patients were included with mean(SD) age 63.6 (14.98), females 36.7%, African American 34.5%, and median ICH score 2.0. The average per-patient observation time was 9.7 days resulting in 152,691 SBP readings. A 25 variable imputed model was parameterized (accuracy: 72.2%, sensitivity: 76.5%, specificity: 66.7%, and kappa: 0.43) (Figure). The top influential variables were age, hemorrhage volume, glucose, LDL, and platelets. Methodological and output contrasts with traditional likelihood-based modeling approaches will be presented.

Conclusions:
We demonstrate that ML-based pipelines can be developed for predicting HSBPV by utilizing SBP values generated from routine monitoring of ICH patients. Future development will incorporate streaming EMR SBP data points during patient stay, and evaluating high-dimensionality reduction methods such as principal component analysis.
Abstract TP461: Predictors of Groin Punction Complication After Edovascular Therapies
Authors: Sanjuan Estela , Rodriguez Maria Teresa , Ramos Montserrat , Dalmases Gloria , Giron Pilar , Rubiera Marta , Santana Katherine E , Sala Victoria , Pancorbo Olalla , Ribo Marc , Boned Sandra , Rodriguez Noelia , Juega Jesus M , García-Tornel Alvaro , Muchada Marian , Rodriguez Luna David , Pagola Jorge , Montiel Estefania , Requena Manuel , Molina Carlos A
Published: January 2019

Background:
Endovascular therapies(EVT) have exponentially increased in the last few years. To maximize the benefits of EVT, complications related to the treatment need to be prevented or minimized with early detection and appropriate management. We implemented a specific registry to collect femoral post-puncture complications detected at different timepoints. Our aim was to identify factors associated with severe groin punction complications.

Methods:
Prospective study of consecutive patients treated with acute EVT or scheduled (angioplasty), admitted to our Stroke Unit from February2017-June2018. Post-catheterization femoral complications included: groin bleeding(GB), groin hematoma(GH), retroperitoneal hematoma(RH), femoral artery pseudoaneurysm(FAP), and artery dissection(AD). A specific registry was created for data collection at different timepoints: During or immediate post-EVT, at 24h post-compression and at discharge.

Results:
384patients were treated with EVT(73%acute), mean age 71+/-13y.o, 69% men. Mynxgrip closure system was used in 346(91,8%). Compressive measures needed to be reinforced in 55 cases(14,5%)/changed in 15(4%). Early mobilization protocol(24-48h) was initiated in 335patients(92,3%). 9patients (2,8%) did not maintain the first 24h absolute rest. 57patients(15,1%) presented mild immediate complications(49GH,6GB). At 24h, 181(47,1%)patients presented GH(28,6%superficial, 18,2%internal) and 5GB(1,3%). At discharge, 29(8,1%)patients had presented clinically significant femoral complications: 16GH(13deep), 5FAP, 1AD, 4RH. 2 of those complications were fatal. Variables associated with severe complications at discharge were: age(p=0.037), non-use of mynxgrip(p=0.001), compressive replacement(p<0.001), non-compliance of early mobilization protocol(p=0.014).

Conclusion:
In our series, we found a yield of 8,1% of clinically significant groin complications associated with the EVT (0,5% fatal). We indentified age, closure device, requirement to replace compressive and lack of accomplishment of the early mobilization protocol as predictors of these complications.