bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP389: Utilizing A Stroke Protocol to Improve Stroke Prevention Education
Authors: Wells Allison ,   Norton healthcare/UK HealthCare-Stroke Care Network, Bellamy Lisa
Published: June 2021

Background:
Although stroke is a preventable disease, it remains a leading cause of death and disability in the United States. Public knowledge of stroke prevention is relatively low. Stroke education is necessary to improve this knowledge deficit. Primary care providers play an important role in stroke education due to their ability to reach more patients and their ability to help manage the patient’s modifiable risk factors. The purpose of this project is twofold: to increase stroke knowledge in patients and to increase the amount of stroke education provided by the primary care provider.

Methods:
A stroke prevention protocol was created for primary care providers to utilize. The protocol helps the provider decide which patients benefit the most from stroke prevention education. If the patient has more than four stroke risk factors, the provider should initiate the stroke prevention protocol. The protocol assists the provider in delivering the stroke prevention education. Brochures were created for the provider to give to the patient. The goal of the project is to include five providers in Kentucky primary care offices. Each provider will complete an evaluation of the protocol after using it for a month.

Results:
Although the implementation is currently in progress, it is anticipated that the stroke protocol will improve stroke prevention education in the primary care office. Ultimately, practice will be changed by increasing the number of people who receive stroke prevention information by their primary care provider.

Conclusion:
Stroke education can be incorporated into primary care office visits to improve community awareness regarding stroke prevention. It is anticipated that the implementation of the stroke protocol will increase the amount of stroke education delivered to patients in the primary care setting. The evaluations completed by each healthcare provider are predicted to reflect an increase in the number of patients who receive stroke education. These evaluations will include the healthcare provider’s insight of the protocol which will assist in improving it for future use in primary care office visits.
Abstract TP393: Information Technology to Measure and Drive Outcomes for Acute Ischemic Stroke Patients
Authors: Brendle Kellie , Zhang Hao , Turner Michelle , Holder Derek , Ng Kwan
Published: June 2021

Background:
The stroke program did not have a formal system to gather data elements needed for driving processes and measuring outcomes. Abstracting data was done by manually auditing every stroke electronic medical record.

Purpose:
The purpose was to use technology:

To collect data for baseline and benchmarking patient demographics and outcomes.

To communicate and educate healthcare professionals and improve processes.

Methods:
Based on the AHA/ASA Get with the Guidelines (GWTG). We identified and abstracted data from discrete fields in the electronic medical record (EMR). Using Clarity the Information Technology (IT) department built discrete fields in EMR to capture 23 missing fields for GWTG. Manual concurrent review and monthly clarity reports were completed. This data was used retrospectively for benchmarking and prospectively for telemedicine and transition of care follow-up.

Results:
To keep in alignment with AHA/ASA guidelines for GWTG data collection on the 48 GWTG discrete fields 43 are now automated. Random chart review is completed to validate data abstraction. We now have completed demographic and outcomes data on over 600 patients.

Conclusions:
In conclusion, the use of IT is a reliable and valid way of abstracting GWTG AIS data to provide benchmarking and process improvement. This IT process facilitates clinical data collection, transmission and communication between providers, enabling modification of treatment regimens and transitions of care.
Abstract TP395: Completing Stroke Education Requirements for Comprehensive Stroke Center Certification
Authors: Adams Georgann R , Wallbank Belinda
Published: June 2021

Background:
The Joint Commission outlines requirements for Comprehensive Stroke Centers (CSC) which includes 8 hours of stroke education for staff providing care to the complex stroke patient. This requirement was initially a hurdle due to unit budgets and staff time constraints. Innovation in providing types, methods and variety of stroke education helped bridge the gap and enabled a wide range of learning types to complete the education requirements and improve the care of the complex stroke patient.

Methods:
Stroke education was provided and tracked using an electronic learning management system (eLMS). Evidenced based stroke articles and guidelines were selected by stroke team leadership based upon a needs assessment completed by unit staff. Stroke lectures were recorded and added on targeted topics for new research evidence including the 2015 AHA/ASA Focused Update of the 2013 Guidelines for the Early Management of Patients with Acute Ischemic Stroke Regarding Endovascular Treatment. Questions were developed to validate learning from the modules. Webinars and live sessions were offered in 1-4 hour time blocks as requested by staff and administrators limiting overtime for unit staff working 36 hours per pay period. A variety of staff were educated included nursing, social workers, care managers, radiology technicians, nursing assistants, and administrators.

Results:
Stroke education was provided to over 300 staff members in a flexible manner that included multiple learning styles, shifts and types of professionals to fulfill the requirements of providing 8 hours of stroke education annually at a Certified Comprehensive Stroke Center with minimal stress on unit budgets.

Conclusion:
Pertinent stroke education was provided to professional staff using multiple approaches, tracked by the hospital’s eLMS program thus improving stroke quality metric, staff understanding of those metrics and contributed to a successful CSC certification and recertification.
Abstract TP400: Evoked Functional Cerebral Hemodynamic and Metabolic Responses in Premature Infants with and without Germinal Matrix Hemorrhage
Authors: Lin Pei-Yi , Cheng Fang-Yu , Hagan Katherine , Sheldon Yvonne , Grant Ellen P. , Franceschini Maria Angela
Published: June 2021

We have created an innovative new method which uses frequency domain near-infrared spectroscopy (FDNIRS) in

combination with diffuse correlation spectroscopy (DCS) to quantitatively measure cerebral blood flow (CBF) and oxygen

metabolism (CMRO
2
) right at the infant’s bedside. We have previously found CBF and CMRO
2
are more sensitive indicators

of cerebral pathophysiology than hemoglobin saturation (SO
2
). Using FDNIRS-DCS, we had found extremely premature

infants with germinal matrix hemorrhage (GMH) have lower cerebral blood flow (CBF) and oxygen metabolism

(CMRO
2
)

than gestational age-matched controls. For this study, we investigate whether GMH, along with age and

hematocrit levels, affect evoked hemodynamic responses. The study protocol was reviewed and approved by the

Institutional Review Board for Partners Healthcare. We enrolled eleven premature infants in the neonatal intensive care

unit at Brigham and Women’s Hospital. Three of them had Grade I GMH diagnosed by head ultrasound on the first three

days of life. We integrated continuous wave NIRS (CWNIRS) with DCS to measure dynamic changes of cerebral hemoglobin

concentrations (HbO) and CBF in response to somatosensory stimuli. For each measurement, we measured differential

path length factors and baseline cerebral hemoglobin concentrations with FDNIRS to quantify relative hemodynamic and

metabolic changes (rHbO, rCBF and rCMRO
2
) in response to tactile stimulation. We observed a faster response time to

reach peak value in preterm infants with increasing postmenstrual age (PMA), demonstrating the response matures with

age to become more adult-like (r=-0.513, p=0.007). In addition, infants measured at older PMA tend to have responses

with a larger undershoot in HbO. However, the HbO undershoot did not translate into an undershoot in CMRO
2
. The HbO

undershoot may therefore be a consequence of low hematocrit during the first two months of life which results in

insufficient oxygen supply and leads to abnormally large oxygen extraction from the blood. We found the activation

pattern of Grade I GMH infants did not differ from premature infants without hemorrhage. The study is ongoing and shows

our method is suitable to measure cerebral maturation in neonates with hemorrhage.
Abstract TP409: Reporting of Key Demographic Characteristics in Neurological Trials Registered on ClinicalTrials.gov
Authors: Fansiwala Kush , Southwick Lauren , Goldmann Emily , Parikh Nina S , Madubuonwu Joy , Boden-Albala Bernadette
Published: June 2021

Introduction:
To increase the transparency of clinical trial information, U.S. Congress passed the Food and Drug Administration (FDA) Amendments Act of 2007, which expanded prior legislation to mandate inclusion of specific trial characteristics, such as funding source and gender demographics, in a new basic results section on ClinicalTrials.gov. Few studies have examined the extent to which key demographic characteristics such as sex and race/ethnicity are reported for neurological trials on ClinicalTrials.gov.

Methods:
As part of the National Initiative for Minority Involvement in Neurological Clinical Trials (NIMICT), we systematically identified neurological clinical trials on ClinicalTrials.gov (for stroke, epilepsy, Alzheimer’s Disease [AD]) and examined the proportion that reported sex, race, and ethnicity (Hispanic/Latino or not) of study participants. We used the website’s advanced search feature to evaluate demographic information reported from trials conducted between 1999 and 2015. We first calculated frequencies of trials reporting these characteristics, then assessed differences in reporting of each characteristic (yes/no) by condition (stroke, epilepsy, AD) and between trials conducted before and after the basic results section update (pre- and post-2008) using chi-square tests.

Results:
Our sample comprised 251,847 subjects across 393 trials (147 stroke, 127 epilepsy, 115 AD). Overall, sex was reported for nearly all trials (99.0%), while reporting of race and ethnicity was low (ethnicity: 14.0%, race: 19.8%). Reporting of these characteristics did not differ significantly across the three conditions or between periods preceding and following the FDA act.

Conclusion:
While ClinicalTrials.gov mandates reporting of sex, it does not require reporting of race/ethnicity, and few trials report these characteristics. This lack of information prevents understanding of neurological trial participation and how interventions might impact patients differently by race/ethnicity. Mandatory reporting of race/ethnicity would enhance transparency and increase awareness of the limited participation of racial/ethnic minorities-who suffer disproportionately from neurological diseases-in neurological trials.
Abstract TP425: How do Different Outcome Measures Reflect Outcome After Aneurysmal Subarachnoid Hemorrhage
Authors: Haenggi Daniel , Etminan Nima , Steiger Hans Jakob , Macdonald R. Loch , Mayer Stephan A , Aldrich Francois , Diringer Michael , Hoh Brian , Mocco J. , Strange Poul , Miller Michael , Faleck Herbert ,   NEWTON Investigators
Published: June 2021

Few treatments for aneurysmal subarachnoid hemorrhage (aSAH) have been effective in randomized clinical studies. One reason may be that the outcome measures used are not sensitive enough to detect efficacy of treatments in this disease. This hypothesis was examined by comparing 6 outcome measures for 72 patients with aSAH. Patients with aSAH who were World Federation of Neurological Surgeons grades 2 to 4 with an external ventricular drain inserted as part of standard of care were entered in a Phase 1/2a multicenter, controlled, randomized, open-label, dose escalation study to determine the maximum tolerated dose and safety and tolerability of a sustained release formulation of nimodipine (EG-1962, NEWTON study) in patients with aSAH. Clinical outcome was assessed at 90 days after aSAH using the extended Glasgow outcome scale (eGOS), modified Rankin scale (mRS), Montreal cognitive assessment (MoCA), telephone interview of cognitive status (TICS), NIHSS and Barthel index. The relationship between each outcome measure and the eGOS was plotted on arithmetic graphs (Figure). The eGOS and mRS gave very similar results. More detailed cognitive assessments (MoCA, TICS) were more exponential in shape with more variability. The NIHSS and Barthel had outcomes clustered towards the highest ends of the scales with distributions that did not discriminate as much as the eGOS or mRS. The MoCA and TICS gave similar results. It was concluded that the eGOS or mRS produce a similar and varying range of outcomes after aSAH, whereas cognitive assessments like the MoCA and TICS and scales designed for ischemic stroke like the NIHSS and BI are less discriminatory of outcomes after aSAH.
Abstract WMP111: Socioeconomic Determinants of Outcome After Childhood Arterial Ischemic Stroke
Authors: Jordan Lori C , Hills Nancy K , Lo Warren , Ichord Rebecca N , Fox Christine K , Pergami Paola , Elbers Jorina , deVeber Gabrielle A , Fullerton Heather J ,   The VIPS Investigators
Published: June 2021

Introduction:
Lower socioeconomic status (SES) is associated with poorer outcome after adult stroke. In a large cohort of children with arterial ischemic stroke (AIS), we determined 12-month neurological outcome and tested the hypothesis that SES is a determinant of outcome in children.

Methods:
From 2009-2014, the Vascular Effects of Infection in Pediatric Stroke (VIPS) study enrolled 355 children with AIS (29 days-18 years) at 37 international centers, including 3 in lower and middle income (LAMI) countries. Outcome was assessed at 12 months via the recurrence and recovery questionnaire (RRQ) parental report of the pediatric stroke outcome measure (PSOM). Poor outcome was defined as a PSOM of ≥1.

Results:
Of 355 children, outcome was available for 310 (87%) at a median of 12 months (IQR 11-13). Ten children died prior to hospital discharge and 4 by 12 months. Outcomes improved from discharge to 12 months (Figure). Of 23 cases in LAMI countries, 88% had an income <USD$10,000, compared to 11% of 287 cases in non-LAMI countries. Overall, only 39% LAMI cases had a good outcome, versus 61% of non-LAMI cases (p=0.052). There were too few cases to analyze outcome predictors in LAMI countries. However, in non-LAMI countries, income did not independently predict poor outcome (OR 1.7, 95% CI 0.57, 4.8, for income <$10,000 vs. >$100,000). Other markers of SES (maternal education level and rural/suburban/urban residence) also did not predict outcome. Independent predictors of poor outcome included moderate (OR 4.6, 95% CI 2.0, 11) or severe (OR 21, 95% CI 7.1, 60) neurological deficits at discharge (compared to no deficits) and recurrent stroke (OR 3.5, 95% CI 1.5, 8.3).

Conclusion:
Outcomes after childhood stroke may be worse in LAMI countries, although we were underpowered to study this subgroup. Within non-LAMI countries, SES does not appear to impact outcome in children, unlike reports in adults, perhaps reflecting better access to rehabilitation services in the pediatric population.
Abstract WP133: A Novel Collateral Metric of MCA Hemodynamics in SAMMPRIS
Authors: Liebeskind David S , Li Yongkun , Woolf Graham W , Scalzo Fabien , Cotsonis George A , Zaidat Osama O , Fiorella David J , Derdeyn Colin P , Feldmann Edward , Chimowitz Marc I ,   for the SAMMPRIS Investigators
Published: June 2021

Background:
Collateral status has been shown to be a potent determinant of long-term clinical outcomes in subjects with intracranial atherosclerosis, yet the grading of collaterals can be challenging. We developed a simple collateral metric of spatial and temporal hemodynamic changes at the anterior borderzone in MCA stenoses.

Methods:
Conventional angiography acquired at baseline in SAMMPRIS was analyzed in the subset of MCA stenoses. Two readers independently measured the anterior watershed angle (AWSA) or borderzone shift on AP views. The angle and the relative timing of arterial flow of the MCA and ACA were compared with the previously recorded collateral composite of TICI antegrade flow combined with compensatory ASITN grade.

Results:
176/195 (90%) subjects with MCA stenoses in SAMMPRIS had baseline angiography with AP projections adequate for both the spatial and temporal characterization of the anterior borderzone, with previously defined collateral status in 165/195 (85%). AWSA ranged from 16-65° (mean RR°, SD TT). Arterial opacification at this borderzone revealed synchronous ACA and MCA filling in 116 or 59% of cases, delayed ACA collaterals in 54/176 (31%) and early collaterals in 6/176 (3%). Inter-rater reliability was excellent (IRR=0.87). AWSA > 30° was associated with impaired MCA TICI flow, yet the relative arrival of arterial collaterals varies extensively. AWSA was closely related (r=-.72, p<0.001) to the previously established TICI score of antegrade flow reduction in the MCA. The combined spatial and temporal data of AWSA and associated arterial filling exhibited strong association (AUC of 96% for nonlinear regression) with SAMMPRIS collateral status (impaired, normal, robust collaterals).

Conclusions:
A novel metric incorporating both the degree of borderzone shift and arterial collateral filling may be easily and reliably quantified to determine collateral status, a strong predictor of outcome in intracranial atherosclerosis. Validation of this simple marker and correlation with noninvasive imaging features are proceeding.
Abstract WP211: Prognostic Significance of White Blood Cell Count in Acute Ischemic Stroke With Nonvalvular Atrial Fibrillation: The SAMURAI-NVAF Study
Authors: Fujita Kyohei , Sato Shoichiro , Yoshimura Sohei , Ide Toshihiro , Yoshimoto Takeshi , Shiozawa Masayuki , Matsubara Soichiro , Arihiro Shoji , Yamagami Hiroshi , Koga Masatoshi , Toyoda Kazunori ,   the SAMURAI Study Investigators
Published: June 2021

Background and Purpose:
White blood cell count (WBC), a marker of the atherosclerotic burden, has reportedly been a predictor of poor outcome in the general stroke population. The purpose of this study was to clarify associations between WBC on admission and outcomes among patients having acute ischemic stroke with nonvalvular atrial fibrillation (NVAF), that was principally cardioembolic.

Methods:
Of those enrolled in the multicenter observational Stroke Acute Management with Urgent Risk-factor Assessment and Improvement (SAMURAI)-NVAF study, acute ischemic stroke/TIA patients (within 7 days of onset) with NVAF with premorbid modified Rankin Scale (mRS) score of 0-2 were included in the analysis. WBC on admission was categorized into quartiles. Associations between WBC count and major disability or death (mRS score of 3-6) at 90 days and 2 years were analyzed using logistic and proportional odds regression models.

Results:
A total of 789 patients were studied (306 women, 76.2±9.5 years old, the median NIHSS score was 6 [IQR, 2-16], the median WBC count was 6700 [IQR, 5475-8300], the median mRS score at 90 days was 2 [IQR, 1-4], the median mRS score at 2 years was 2 [IQR, 0-5]). WBC had a significant linear association with major disability or death at 90 days (adjusted odds ratio [OR] for highest versus lowest quartile 3.53; 95% confidence interval [CI] 2.07-6.13; P for trend<0.001). Associations were similar for the outcome at 2 years (adjusted OR for highest versus lowest quartile 2.16; 95% CI 1.31-3.56; P for trend<0.001).

Conclusions:
Higher WBC count on admission seems to predict a short- and long-term poor outcome in acute ischemic stroke patients with NVAF.

Clinical Trial Registration:
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT01581502.
Abstract WP256: High Rate of Subject Retention into Prehospital Stroke Research with Telephone-based Physician-investigator Driven Enrollment
Authors: Rosell Bryant J , Saver Jeffrey L , Liebeskind David S , Starkman Sidney , Kim-Tenser May , Sharma Latisha K , Conwit Robin , Hamilton Scott , Sanossian Nerses ,   FAST-MAG Trial Investigators
Published: June 2021

Background:
Explicit informed consent for prehospital research can be achieved by physician-investigators using cellular phones to communicate with potential subjects or legally authorized representatives (LAR). Subject retention into clinical trials is vital, and prehospital enrollment may be associated with higher rates of subject withdrawal than more traditional methods of enrollment.

Objective:
To describe rates of subject retention in a prehospital trial of acute stroke therapy and to determine if method of consent was associated with subject withdrawal.

Methods:
All subjects were enrolled in the NIH Field Administration of Stroke Therapy-Magnesium (FAST-MAG) clinical trial. Paramedics screen eligible subjects, contact the physician-investigator using dedicated in-ambulance cellular phone. Physician-investigators obtain explicit informed consent from the subject or on-scene LAR. In the later years of study, enrolment under exception from informed consent (EFIC) was permitted. The consent provider was given a consent form, which they reviewed with the physician investigator on the phone and signed prior to study initiation. Retention, defined as study subject completion without withdrawal.

Results:
There were 1700 subjects enrolled; 1,017 provided consent (60%), 662 enrolled via LAR (39%) and 21 via EFIC (1%). Of 1,700 patients, 1413 (83%) completed the 90-day cvisit, 265 (16%) died prior to the 90-day visit and 22 (1.3%) withdrew from the study before completion. Of the 22 cases what withdrew, 11 were lost to follow-up, 11 had the patient or LAR withdraw consent. There were no differences in rates of withdrawal by method of study enrolment: Self consent (n=14) 1.4%, LAR (n=8) 1.2%, EFIC (n=0) 0%. Potential factors related to higher rates of withdrawal were evaluated including language of consent (Spanish 4/165, 2.1%, English 18/1248, 1.2%), but none were significant. The most common reason for withdrawal of consent was family objection to continued participation in research.

Conclusion:
There was a high rate of retention when subjects were enrolled into prehospital stroke research using a phone-based method to obtain explicit consent. We were not able to identify factors associated with study withdrawal, likely due to high retention.
Abstract WP304: Leveraging the Power of a System: A Team-based Approach to Improving Door-to-alteplase Administration
Authors: Behrens Dolores , Klassman Lynn , Peppa Royce , Jennrich Mary Kay , Dabbous Firas ,   Advocate Stroke Collaborative
Published: June 2021

Background/Purpose:
As stroke remains the leading cause of disability, hospitals are challenged to streamline processes that deliver alteplase promptly. A large Midwestern healthcare system (2 comprehensive and 8 primary stroke centers) committed to expand the stroke team approach beyond the walls of individual hospitals to a system stroke team to improve alteplase administration rates and times. A team-based approach is 1 of 11 Target Stroke best practice strategies used to enhance treatment rates and reduce administration times. The team-based approach included review/standardization of processes, clinical outcomes review, and proposals for improvement. Examples of initiatives included EMS partnership, development of standardized stroke orders, direct-to-CT protocol, timers to signal time critical events, and debriefing/feedback tools.

Method:
A retrospective system data analysis was performed on all patients presenting to an emergency room with acute stroke symptoms who received alteplase between 2012 and 2015. The specific data elements scrutinized were alteplase treatment rates and administration times. Additionally, with the introduction of Target Stroke Phase II in 2014 progression towards those goals between January, 2014 and June, 2016 was examined.

Results:
Statistical analysis of treatment rates for acute ischemic stroke confirmed an increasing trend in the probability of receiving alteplase over time (6.3% in 2012 vs 11.2% in 2015, p<0.0001). Alteplase administration times revealed an average of 5.3 minute reductions per year over time (p<0.0007). Progress toward Target Stroke phase II goals demonstrated an increasing trend in alteplase administration rates for less than 60 minutes (38.5% in 2014 vs 67% in 2016, p<.001) and for less than 45 minutes (11% in 2014 vs 30% in 2016, p<.001).

Conclusion:
This study substantiated that utilizing a team-based approach at the system level yielded positive results. It has inspired and challenged each hospital’s stroke team to embrace the team approach and implement best practices and improve the administration rates and times for alteplase.
Abstract WP411: Evaluation of Strategies to Reduce Time to Revascularization in Acute Ischemic Stroke
Authors: Doerr Abbigayle M , Davis Janet , Jenkins Sheryl
Published: June 2021

Background:
There is growing support for the need for process improvement surrounding treatment of acute ischemic stroke, specifically, reducing time to reperfusion in endovascular therapy (EVT). Streamlining protocols from patient presentation to revascularization can lead to improved timelines to treatment and functional outcomes.

Purpose:
The purpose of this study was to identify the impact on specific hospital based process improvement strategies in the acute ischemic stroke patient population undergoing endovascular therapy with specific intent to decrease median arrival to revascularization time, thus increasing the potential for good functional outcome.

Methods:
The study includes a pre- and post-intervention retrospective review of patients 18 years or older, hospital admission between January 1, 2014 and December 31, 2015, who underwent EVT for treatment acute ischemic stroke. The primary outcome variable was time from arrival to revascularization during the acute ischemic stroke admission. The secondary outcome variables were specific to functional outcome analysis in the acute ischemic stroke patient. The data points were collected from the local America Heart Association’s Get with the Guidelines-Stroke (GWTG) dataset.

Results:
Twenty eight consecutive endovascular ischemic stroke patients were reviewed, pre process improvement (PI) (Group 1, n=10) and post PI (Group 2, n=18). There were no significant differences between baseline characteristics between the groups. The primary outcome analysis revealed significant improvement in door to revascularization between the pre and post PI groups, 2:56 and 2:11 (p=.002) respectively, a 45 minute decrease in time to treatment. Rates of good clinical outcomes (modified Rankin Scale 0-2 at 3 months) were similar in both groups, 33.3% pre PI and 46.2% post PI (p=0.59).

Conclusions:
Hospital based PI initiatives including: early notification, streamlined transport process, and utilization of feedback tool significantly improve door to revascularization times and can potentially lead to improved functional outcomes in the acute ischemic stroke patient undergoing EVT.
Abstract 31: The Frequency of Thrombectomy in Early and Late Post-Onset Time Windows Among EMS Transported Patients With Acute Ischemic Stroke
Authors: Bosson Nichole E , Saver Jeffrey L , Lyden Patrick D , Gausche-Hill Marianne ,   The Los Angeles County Stroke Data Collaborative
Published: June 2021

Introduction:
With recent trials demonstrating benefit to thrombectomy up to 16 or 24 hours (h) from last known well time (LKWT), EMS systems must consider stroke center routing for patients with LKWT ≤24h. Increased transport times can strain resources and may be unnecessary if few patients receive the intended therapy. We sought to determine the frequency of thrombectomy by prehospital-determined LKWT (p-LKWT) in a large regional acute stroke care system.

Methods:
In January 2018 Los Angeles (LA) County EMS initiated two-tiered routing within its regional system of 50 approved stroke center (ASC) serving 10 million persons. Patients with suspected stroke with p-LKWT ≤24h are routed to ASCs. Patients with potential LVOs (LA Motor Scale (LAMS) of 4 or 5) are routed directly to a designated thrombectomy-capable center (TSC or comprehensive stroke center (CSC)) if within 30 minutes; others are routed to the closest ASC. We abstracted adult EMS transports to a TSC or CSC from January 2018 to March 2019 with final diagnosis of AIS. We excluded transfers and patients without documented LKWT. We determined the frequency of thrombectomy by time intervals from p-LKWT to first medical contact (FMC).

Results:
During the study period, 1317 AIS patients with p-LKWT ≤24h were transported to a TSC or CSC; 360 (27.1%) received endovascular thrombectomy. Patients were 47% male, median age 77 years (IQR 66-86), median NIHSS 11 (IQR 4-19), and median p-LKWT-to-FMC time interval 69 minutes (IQR 22-360). The table shows the frequency of thrombectomy by p-LKWT-FMC time intervals. Respectively, the ≤6h, >6 to ≤16h, and >16 to ≤24h windows accounted for 76.8%, 18.3%, and 4.9% of transports to thrombectomy-capable centers.

Conclusion:
With two-tier routing in this regional stroke system, patients in the >6h post-onset window accounted for nearly one quarter of transports to TSCs and CSCs and 22% received thrombectomy. These findings support EMS stroke routing policies up to 24h post-onset.
Abstract 45: Intracerebral Transplantation of Autologous Bone Marrow Stem Cell (BMSC) Against Acute Ischemic Stroke, Preliminary Data of Phase 1 Clinical Trial (RAINBOW Project)
Authors: Kawabori Masahito , Shichinohe Hideo , Kuroda Satoshi , Houkin Kiyohiro
Published: June 2021

Background:
Recent breakthrough in cell therapy is expected to reverse the neurological sequelae of stroke. Prior studies have demonstrated that bone marrow stromal cells (BMSC) have therapeutic potential against stroke. In this study, we investigated the use of autologous BMSC transplantation for acute ischemic stroke through direct transplantation route with several new aspects including cell labeling and tracking, socioecomonic analysis using QALY, and the use of human platelet lysate (PL) instead of fetal bovine serum. This study is called the Research on Advanced Intervention using Novel Bone marrOW stem cell (RAINBOW, UNIN ID: UMIN000026130).

Methods/Design:
RAINBOW is a phase 1, open-label, uncontrolled, dose-response study, with the primary aim to determine the safety of the autologous BMSC administered to the patients with acute ischemic stroke. Estimated enrollment is 7 patients suffering severe neurological deficits. Approximately 50 mL of the bone marrow is extracted from the iliac bone of each patient 15 days or later from the onset, and BMSCs are cultured with allogeneic PL and are labeled with superparamagnetic iron oxide for cell tracking using magnetic resonance imaging (MRI). BMSCs are stereotactically administered around the area of infarction in the subacute phase. Each patient will be administered a dose of 20 or 50 million cells. Neurological scoring, MRI for cell tracking,
18
F-fuorodeoxyglucose positron emission tomography, and
123
I-Iomazenil single photon emission computed tomography will be performed throughout 1 year after the administration.

Results:
6 patients have successfully finished cell transplantation, and there was no severe adverse event in any of the patient during surgical and follow-up period. Favorable motor recoveries are seen in 5 of 6 patients, and cell engraftment and migration to ischemic site was also observed by magnetic resonance imaging.

Discussion:
This is a first-in-human trial to use labelled BMSC to the patients with acute

ischemic stroke. Intracerebral transplantation of autologous BMSC is safe and well tolerated. Moreover, it is expected that the bio-imaging techniques can clarify the therapeutic mechanisms.
Abstract 50: RNA Expression for Diagnosis of Stroke Etiology Differentiating Large Artery and Cardioembolic Stroke: Analytical Validation of Testing From the BASE Clinical Trial
Authors: Jauch Edward C ,   BASE Investigators
Published: June 2021

Background:
An accurate test to differentiate large artery stroke (LAS) patients from those with cardioembolic stroke (CES) would be of significant clinical utility. Using the Biomarkers of Acute Stroke Etiology (BASE) trial (NCT02014896) dataset, our purpose was to utilize blood gene expression signatures for accurately differentiating LAS from CES acute stroke etiologies.

Methods:
The BASE trial enrolled suspected stroke patients presenting to 20 hospitals within 24 hrs of symptom onset. Final gold standard diagnosis and stroke etiology were determined by an adjudication committee using all hospital data but blinded to RNA test results. Whole blood, obtained in PAX tubes, was frozen at -20C within 72 hrs and analyzed at a core lab (Ischemia Care, Dayton, OH) using Affymetrix HTA microarrays. Genes on the HTA microarray were filtered to eliminate genes with low expression or high CV (> 10%) when run on replicate samples leaving 9,513 potential signature genes. A two-way random forest classifier was built through cross validation of the training data resulting in a 45 gene diagnostic signature.

Results:
This is a planned interim cohort study of the 1700 patients enrolled in the BASE trial that does not include lacunar strokes, TIA, or stroke mimics. Overall, 222 patients were enrolled with NIHSS>5, 70 (32%) with LAS and 152 (68%) with CES; 59% were male, and median (IQR) age was 70.7 yrs (62.0, 80.2). Median (IQR) time from symptom onset to blood collection was 1200 (448, 1568) minutes. Coexistent pathology at presentation included atrial fibrillation 90 (48%), hypertension 153 (82%), hyperlipidemia 87 (47%), diabetes 60 (32%), and coronary artery disease 70 (37%). Patients were randomly divided into training (148), early symptom onset (<18hrs) validation (39) and a late symptom onset (>18 hrs) validation (35). The diagnostic gene signature results in the early validation cohort distinguished LAS from CES; C-statistic 0.78 (0.50-1.0, 95% CI), sensitivity 0.90 (0.55-1.0, 95% CI) and specificity of 0.70 (0.43-1.0, 95%

CI).

Conclusion:
Early RNA expression differentiates large artery stroke patients from those with cardioembolic stroke, and may have therapeutic and secondary prevention implications.
Abstract 62: A Statewide Cooperative Motivational Strategy Significantly Improves IV Alteplase Rates in Maryland: Golden Brain Award
Authors: Yarbrough Karen L , Aycock Anna ,   Maryland Stroke Cntr Consortium, Schrier Chad , Wozniak Marcella
Published: June 2021

Introduction:
The Maryland Stroke Coordinators Consortium and the Maryland Institute for Emergency Medical Services Systems, Health Care Facilities formed the Maryland Stroke Coalition (MSC) to improve stroke practices in Maryland. The aim of this performance improvement project was to determine if a motivational strategy improves thrombolytic metrics.

Methods:
In 2018 a stroke summit for Maryland stroke centers with expert faculty discussed thrombolytic best practices. Then MSC members met bimonthly to discuss how to implement AHA’s Target: Stroke Phase III. In October 2018 a motivational strategy was implemented to improve thrombolytic benchmarks. Quarterly, the stroke center with the fastest median door to needle time was awarded a Golden Brain trophy and a monetary award. After four quarters the stroke center with the fastest door to needle time will be recognized at a regional conference. Stroke coordinators voluntarily submitted quarterly data to the Chief of Special Programs, MIEMSS. Data submitted: quarterly rates IV Alteplase, median door to needle time, and % of IV Alteplase
<
45 minutes.

Results:
Seventeen out of 39 possible stroke centers participated during the study period. Baseline data for the quarter prior to implementation revealed 84 pts received IV Alteplase. For the next three quarters IV Alteplase rates increased from baseline, respectively by 52% (n=128), 54% (n=129) and 65% ( n=139); and the median door to needle time was 48 minutes. The winning centers for each quarter reported median door to needle times
<
30 minutes. From baseline (36%, 42/114) to quarter 3 there was a 15.5% (51.5%, =49/95) increase in patients being treated with IV Alteplase in
<
45 minutes.

Conclusion:
Implementation of a motivational strategy and sharing best practices appears to be associated with increasing IV Alteplase administration volumes. The results of this PI project will be used to engage stakeholders to develop strategies to assist stroke centers remove barriers to improve door to needle times. The limitations of this project may be the small number of stroke centers participating and the effect of highly functioning centers participating.
Abstract 89: Incidence and Characteristics of Hemorrhagic Stroke Among Post-STOP Participants
Authors: Leykina Liza A , Fox Christine K , Hills Nancy K , Kanter Julie , Kwiatkowski Janet L , Tinker Ariana , Voeks Jenifer H , Fullerton Heather J , Adams Robert J ,   Post-STOP Study Investigators
Published: June 2021

Introduction:
The Stroke Prevention Trial in Sickle Cell Anemia (STOP) changed standards of care for stroke screening and treatment of high-risk children with sickle cell anemia (SCA), reducing the risk of ischemic stroke. However, the incidence of hemorrhagic stroke in young patients with SCA in the post-STOP era remains poorly characterized.

Methods:
The Post-STOP multicenter cohort study collected follow-up data from prior participants (all with SCA) of the STOP or STOP II clinical trials. From 01/2012 – 05/2014, medical records analysts abstracted clinical, imaging and laboratory data collected after the STOP studies ended at 19 of the 26 original sites. Two stroke neurologists reviewed data to confirm hemorrhagic stroke, defined as primary spontaneous intracerebral, subarachnoid or intraventricular hemorrhage; we excluded traumatic hemorrhage or hemorrhagic conversion of ischemic infarcts. Incidence rates among those with no prior hemorrhagic stroke at the start of Post-STOP were calculated using survival analysis techniques.

Results:
Follow-up data were collected from 2,851 of 3,835 participants participated in the STOP trials. Patients (51% male) were a median age of 10.4 years (interquartile range [IQR] 6.8-14.1) at the start of Post-STOP. Over a median of 10.3 (IQR 7.3-11.4) years of follow-up, 35 patients with hemorrhagic stroke were identified (Table 1). The incidence rate was 63 per 100,000 person-years overall (95% CI 45-87). Stratified by age, the incidence rate per 100,00 person-years was 50 (95% CI 34-75) for children less than 18 years old and 134 (95% CI 74-243) for adults over the age of 50.

Conclusion:
In our cohort, we observed that the risk of hemorrhagic stroke in patients with SCA rises as patients age, most sharply after the first decade of life. Structural vascular abnormalities such as moyamoya syndrome and aneurysms are common etiologies for hemorrhage and screening may be warranted.
Abstract 95: The Mobile Interventional Stroke Team (MIST) Model Improves Early Outcomes in Elvo Stroke: The NYC Mist Trial
Authors: Morey Jacob R , Oxley Thomas J , Wei Daniel , Shoirah Hazem , Zhang Xiangnan , Wheelwright Danielle , Rubinstein Liorah , Mocco J , Bederson Joshua , Fifi Johanna T ,   Mount Sinai Stroke Investigators
Published: June 2021

Introduction:
Endovascular therapy (EVT) has become the standard of care for treatment of emergent large vessel occlusion (ELVO) in ischemic stroke. It is a time sensitive procedure that has previously only been performed at comprehensive stroke centers (CSC). Transfer was required for patients presenting at a primary stroke center (PSC). PSCs with interventional capacity (PSCI) have emerged to increase access to EVT. We have developed a Mobile Interventional Stroke Team (MIST) model, in which a MIST transfers from a CSC to PSCI to perform EVT.

Hypothesis:
The delivery of care by the MIST at PSCIs is more time efficient and leads to improved clinical outcomes in comparison to transferring patients from a PSC to PSCI or CSC and comparable to direct presentation to a CSC.

Methods:
Analysis of prospectively collected data from 228 patients who received EVT for ELVO at a CSC or 4 PSCIs between June 2016 - December 2018 was performed. The cohorts include: Mothership with patient presentation to CSC (n=20), Drip-and-Ship with patient transfer from PSC or PSCI to CSC (DS) (n=114), MIST and patient presentation to PSCI (n=64), and DS with patient transfer from PSC to PSCI and MIST (DS/MIST) (n=30). The primary outcome was initial door-to-recanalization. Secondary outcomes measured other time intervals and clinical outcomes at discharge and 3 months.

Results:
MIST had a faster mean initial door-to-recanalization time than DS by 83 minutes (p < 0.05). MIST and Mothership had similar median times of 192 minutes and 181 minutes, respectively (p = 0.84). A greater proportion of patients reached a discharge NIHSS of 0 or 1 in MIST compared to DS (34% vs. 17%; p < 0.01). MIST led to 53% with a mRS of ≤ 2 at 3 months compared to 39% in DS, although not statistically significant (p = 0.10).

Conclusions:
MIST has led to significantly faster initial door-to-recanalization times compared to DS. This decrease in time has translated into improved short-term outcomes and a trend towards improved long-term outcomes.
Abstract TMP2: Reduction of Time to Endovascular Treatment and Improved Outcomes After Ischemic Stroke in Routine Clinical Practice: Comparison of the MR CLEAN Registry First and Second Cohorts
Authors: Compagne Kars C , Kappelhof Manon , Goldhoorn Robert-Jan B , Majoie Charles B , Roos Yvo B , van Zwam Wim H , van Oostenbrugge Robert J , Boiten Jelis , Lycklama à Nijeholt Geert J , den Hertog Heleen , Gerrits Dick , Sturm Emiel J , Brouwers Paul J , van Walderveen Marianne A , Wermer Marieke J , Boogaarts Hieronymus D , van Dijk Ewoud J , van Hasselt Boudewijn A , Fransen Puck , de Kort Paul L , van Tuijl Julia , Peluso Jo P , de Bruijn Sebastiaan F , van Dijk Lukas C , Schonewille Wouter J , Vos Jan Albert , Uyttenboogaart Maarten , Bokkers Reinoud P , Martens Jasper M , Hofmeijer Jeannette , van der Worp Bart , Lo Rob , Dippel Diederik W , van der Lugt Aad ,   on behalf of the MR CLEAN Registry Investigators
Published: June 2021

Introduction:
Outcomes after endovascular treatment (EVT) for acute ischemic stroke are highly time dependent, but whether active reduction of time to treatment leads to better outcome has not been demonstrated. We compared data of the two subsequent MR CLEAN Registry cohorts, comprising all patients in the Netherlands who had EVT for acute ischemic stroke from 2014-2017, for a trend in time to treatment and its association with outcome.

Methods:
We compared workflow, successful reperfusion (eTICI 2B-3), NIHSS at 24h, functional outcome (mRS) at 90 days, occurrence of symptomatic intracranial hemorrhage (sICH) and mortality in patients with ischemic stroke and a proximal intracranial occlusion in the anterior circulation included in the second cohort of the Registry (June 2016-November 2017; n = 1779) to those in patients included in the first cohort (March 2014-June 2016; n = 1526) using logistic regression.

Results:
Baseline NIHSS was 16 in both cohorts. Times from onset-to-groin and onset-to-reperfusion were shorter in the second cohort than in the first (185 versus 210 minutes; p<0.01 and 238 versus 270 minutes; p<0.01, respectively) (Figure 1). Successful reperfusion was achieved more often in the second than in the first cohort (72% versus 58%; p<0.01). Rates of sICH and mortality did not differ (5.9% versus 5.7%; p=0.94 and 29% versus 29%; p=0.60). However, follow-up NIHSS was lower (median 10 versus 11; p<0.001) and more patients achieved functional independence at 90 days (42.6% versus 38.9%; p = 0.012) in the second cohort (Figure 1). In a logistic regression model, the difference in good outcome between the two cohorts (aOR 1.27; 95%CI 1.08-1.50) was reduced after additional adjustment for time to reperfusion (aOR 1.15; 95%CI 0.96-1.36) as well as successful reperfusion (aOR 1.16; 95%CI 0.95-1.41).

Discussion:
Our data show that outcomes after EVT in routine clinical practice are improving, likely attributable to improved workflow and experience.
Abstract TMP25: Long Non-Coding RNA Mediates Stroke-Induced Neurogenesis
Authors: Fan Baoyan , Pan Wanlong , Wang Xinli , Chopp Michael , Zhang Zheng Gang , Liu Xian Shuang
Published: June 2021

Background and Purpose:
Adult neurogenesis contributes to functional recovery after stroke. Long non-coding RNAs (lncRNAs) regulate stem cell self-renewal and differentiation. However, the role of lncRNAs in stroke-induced neurogenesis remains unknown.

Methods and Results:
Using lncRNA array and
in situ
hybridization, we analyzed lncRNA profiles of adult neural stem cells (NSCs) isolated from the subventricular zone neurogenic region in rats subjected to middle cerebral artery occlusion. We found that H19 was the most highly upregulated lncRNA (19 fold) in ischemic NSCs compared with non-ischemic NSCs. Reduction of endogenous H19 in NSCs by CRISPR-Cas9 genome editing significantly decreased the proliferation and increased the apoptosis of ischemic NSCs, as assayed by the number of BrdU
+
cells (56±5% vs 22±3%, p<0.01, n=3) and Caspase-3/7 activity compared to NSCs transfected with scrambled small guide RNA (sgRNA). Knockdown of H19 significantly decreased the number of Tuj1
+
neuroblasts (8±2% vs 5±0.4%, p<0.01, n=3) and NG
2
+
oliogodendrocyte progenitor cells (10±1% vs 5±0.3%, p<0.01, n=3), suggesting that deletion of H19 suppresses the proliferation and survival and blocks the differentiation of NSCs into neurons and oligodendrocytes. Additional RNA-sequencing and bioinformatics analyses revealed that genes deregulated by H19 knockdown were involved in transcription, apoptosis, proliferation, cell cycle and response to hypoxia. Western blot analysis validated that loss-of-function and gain-of-function of H19 significantly increased and reduced, respectively, the transcription of cell cycle-related genes including p27. Using ChIRP assay, we found that upregulated H19 in NSCs was physically associated with EZH2 which catalyzes the repressive H3K27me3 histone marker. Knockdown of H19 significantly reduced the enrichment of H3K27me3 at the promoter of p27, leading to the upregulation of p27 expression and consequently inhibition of NSC proliferation.

Conclusions:
H19 mediates stroke-induced neurogenesis by regulating genes involved in cell cycle and survival through the interaction with chromatin remodeling proteins. Our data provide novel insights into epigenetic regulation of gene expression by lncRNA in neurogenesis.