bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 3141: Elderly Ischemic Stroke Patients are Less Likely to be Treated with Rt-PA
Authors: Kleindorfer Dawn , Meganathan Karthikeyan , Adeoye Opeolu , Khatri Pooja , Hornung Richard
Published: July 2021

Intro:
Numerous reports have found that overall, rates of rt-PA treatment are low. Previously we have reported the rate of eligibility for rt-PA treatment to be approximately 8% of ischemic stroke patients,, but that eligibility actually significantly increases with age. However, we hypothesize that treatment with rt-PA in practice is actually utilized less among the elderly. We sought to describe treatment rates by decade within the Premier database.

Methods:
This analysis utizlied the Premier database, a representative sampling of US hospitals that includes approx. 15% of hospital discharges, with access to pharmacy records Study period was FY 2009-2010. Cases potentially eligible for rt-PA treatment based on diagnosis were defined as those patient visits within DRGs 61-66 who did not have a transient ischemic attack (TIA) or hemorrhagic stroke discharge ICD-9 code (430, 431, 432, and 435). Cases receiving thrombolysis were identified by having an ICD-9 code of 99.10, which denotes thrombolytic use, OR who had pharmacy billing codes for thrombolytic therapy, limited to alteplase (activase), 50 mg and 100 mg vials. Rates of thrombolytic use were stratified by fiscal year.

Results:
There were 101567 ischemic stroke cases included in this analysis, which were 16.2% black, 63.7% white, and 20.1% other, with a mean age of 71.2 (SD=15). During each study year, the overall rates of tpa treatment were 4.2% and 4.7% for 2009 and 2010. Rates of thrombolysis use stratified by age of the patient are presented in the
Table
. Overall there was a statistically significant decrease in treatment rates with increasing age (p<0.001) after adjustment for race and gender.

Discussion:
Despite previously shown higher rates of eligibility, elderly patients are significantly less likely to be treated with rt-PA than younger aged patients. Whether this represents ageism by the healthcare system, or unmeasured/undocumented co-morbidities or exclusions requires further study.
Abstract 3160: Tolerance to a Tilt Table Standing Protocol In an Acute Stroke-Unit Setting: A Pilot Study
Authors: Sausser Ida M , Lietz Hendrika , Kalpakjian Claire , Brown Devin , Baltz Mathew
Published: July 2021

Background:
objective was set to describe and examine physiological and self-reported indices of tolerance of a standing tilt table protocol (STTP) among patients following an acute stroke.

Design:
Prospective, observational pilot study of patients admitted to a stroke unit of a single academic medical center.

Methods:
A clinical protocol for the use of the tilt table was developed and applied to subjects in the acute phase following a stroke. The protocol involved a step-wise process to gradually raise the subject into a standing position with lower extremities in a weight bearing position on the tilt table platform, at 10 degree intervals from 60 to 90 degrees. The STTP clinical indices of tolerance were operationally defined as: Systolic blood pressure

(SBP) maintained within 20 mmHg of baseline, diastolic blood pressure (DBP) maintained within 10 mmHg of baseline, heart rate (HR) maintained within 10 beats per minute of baseline, oxygen saturation (SpO
2
) maintained at 90% or above while on supplemental O
2
or room air, absence of pallor. Subjective indices of tolerance were operationally defined as: rating of perceived exertion (RPE) < 15 per Borg Rating of Perceived Exertion Scale, pain < 5 using a numerical pain rating scale ranging from 0 to 10, and absence of angina, dizziness, nausea, dyspnea, or request to discontinue the STTP. No single measure was considered to be of primary importance, and any value falling outside the predetermined parameter was considered indicative of intolerance. Overall, tolerance of the STTP was defined as the ability to sustain 60 degrees or greater of tilt table inclination (minimum of 87% total weight bearing) for a minimum 5 minutes, without signs or symptoms of intolerance. Specifically, frequencies of the highest angle achieved, the duration of standing time tolerated, and physiologic response were recorded.

Results:
Thirty-six patients with ischemic or hemorrhagic stroke (22 females, 14 males) aged 24 to 87 years (62 + 16 years) enrolled. Fifty three percent of subjects (N = 19) attained 60 degrees or higher on the standing tilt table. Ten subjects were unable to achieve 45 degrees. Subjects tolerated a mean total standing time at or above 60 degrees of 8.9 + 7.2 minutes. All subjects met tolerance criteria for dyspnea, pain, pallor, perceived effort, and nausea at 60 degrees or higher. All subjects were tolerant by heart rate criteria at 70, 80 and 90 degrees; 96% were tolerant at 60 degrees. For diastolic blood pressure, tolerance ranged from 72% (80 degrees) to 90% (70 degrees). For systolic blood pressure, tolerance ranged from 84% (70 degrees) to 100% (90 degrees). Oxygen saturation tolerance was achieved in 100% of subjects at each angle.

Conclusion:
This pilot study suggests that use of a tilt table is well tolerated among patients in the acute stroke phase, and may be an effective tool for introducing early mobilization to a medically fragile patient population.
Abstract 3198: Procedural Outcomes in Mechanical Thrombectomy for Acute Stroke: Atrial Fibrillation Predicts Single Device Therapy
Authors: Raychev Radoslav , Liebeskind David , Saver Jeffrey , Vinuela Fernando , Hao Qing , Tateshima Satoshi , Jahan Reza , Gonzalez Nestor , Yallapragada Anil , Rao Neal , Abcede Linda , Adamczyk Peter , Cramer Ryan , Viktor Szeder , Amit Balgude , Ali Latisha , Sarah Song , Salamon Noriko , Duckwiler Gary ,   UCLA Stroke Investigators
Published: July 2021

Background
Timely and efficient reperfusion is associated with better outcome from acute cerebral ischemia. The predictors of procedural success in patients treated with multimodal mechanical device strategies (Merci ± Penumbra ± angioplasty and stenting) have not been well delineated.

Methods
In a prospectively maintained database, we analyzed consecutive patients with acute ICA and M1 occlusions treated with endovascular recanalization following multimodal MRI. We investigated the pretreatment clinical and imaging factors affecting three procedural outcomes: number of passes, single device-type therapy, and presence of SAH after the procedure. We also sought to determine the relationship between these procedural variables with substantial recanalization (TICI≥2b) and clinical outcome.

Results
Among 105 patients meeting study entry criteria, mean age was 66.6 (±17.8), 65% were female and 34% had history of atrial fibrillation. The median pretreatment NIHSS was 18 (range 2-31), mean baseline DWI volume was 30.6cc (SD±35.1), and mean time to groin puncture was 412min (SD±207.6). The median number of mechanical device passes was 2 (range 0-8). 73 (70%) patients were treated with a single device. IV tPA was used in 43 patients (41%). Substantial recanalization occurred in 43 patients (41%). In the final binary logistic regression multivariate analysis, among all baseline clinical and imaging variables, history of atrial fibrillation was the most significant factor associated with a single device therapy (OR 0.249; p=0.024). Age, gender, baseline DWI volumes, arterial occlusion site and time to recanalization did not correlate with the number of attempts, single or multiple device usage, or presence of SAH after the procedure. None of the procedural or baseline variables correlated with recanalization rates. The strongest predictors of poor outcome (mRS≥3 at discharge) were high baseline NIHSS (OR 0.87; p<0.001) and presence of SAH after the procedure (OR 0.05; p=0.001). However, the presence of SAH did not correlate with the number of attempts or devices used.

Conclusions:
A history of atrial fibrillation predicts single device usage in mechanical thrombectomy for acute ischemic stroke treatment. This is likely due to the fibrin-rich histological composition of the clot. In contrast to prior studies involving a single type of device, increased number of passes with multiple different mechanical devices was not associated with lower recanalization rates and did not worsen clinical outcome.
Abstract 3214: Acute Stroke Treatment In Patients Older Than 80 Across The Spotrias Consortium
Authors: Willey Joshua Z , Petersen Nils , Merino Jose , Ford Andria L , Ali Latisha K , Rost Natalia S , Khatri Pooja , Gonzales Nicole , Meyer Brett C , Marshall Randolph S
Published: July 2021

Introduction:
Prior studies caution against use of intravenous thrombolysis (IVrtPA) for acute ischemic stroke in patients ≥80 years old, but few have described outcomes in this population treated with intra-arterial therapy (IAT). In this study we describe patterns of treatment with IVrtPA and IAT based on age across a network of academic stroke centers, and in-hospital outcomes in patients ≥80 years treated with IAT.

Methods:
Stroke centers within the Specialized Program of Translational Research in Acute Stroke (SPOTRIAS) prospectively collected data on all patients treated with IVrtPA or IAT including demographics, pre-treatment National Institutes of Health Stroke Scale (NIHSS), discharge destination, and in-hospital mortality. Symptomatic hemorrhage data was not systematically collected. Pre-stroke modified Rankin scale (mRS) was collected at only 6 sites (n = 2074). Proportions of total treated patients based on two age categories (<80 and ≥80), stroke severity (NIHSS), treatment modality (IVrtPA alone vs. IAT combined with IVrtPA), and center were compared using a chi-square statistic. In-hospital mortality in patients ≥80 with an NIHSS≥12 was analyzed using logistic regression, with IAT as the principal explanatory variable.

Results:
Over 6 years a total of 2879 were treated with IVrtPA alone, and 425 with combined IVrtPA and IAT between 1/1/05 and 12/31/10. The proportion of patients ≥80 years treated with IVrtPA varied significantly between the centers (19.4%-50.4, p<0.0001). Those ≥80 years were more likely to have severe strokes (NIHSS≥12) than younger patients (64.9% vs. 48.4%, p<0.0001) and were less likely to receive combined therapy (9.5% vs 14.5%, p<0.0001). When limited to those patients with an NIHSS≥12, the patients ≥80 years were less likely to receive IAT (12.8% vs 24.6%, p < 0.0001). The number of patients with age≥80 and an NIHSS≥12 discharged home were 68 (9.1%). When limiting analyses to those age ≥80 and an NIHSS≥12 (n = 751), and adjusting for race, glucose, center, and gender, IAT was not associated with mortality (adjusted OR 1.27, 95% CI 0.70-2.27). Inclusion of pre-stroke mRS did not appreciably change the results. The number of patients discharged home with age≥80 and an NIHSS≥12 were too low to run multi-variable models.

Conclusions:
Older patients are less likely to be treated with IAT, though there is significant variability in patterns of IVrtPA and IAT treatment across a consortium of academic stroke centers. IAT appeared safe in this population.
Abstract 3235: Low LDL is Associated with Hematoma Expansion in Chronic Daily Alcohol Users with Intracranial Hemorrhage
Authors: Pletsch Gayle R , Burns Christopher , Albright Karen C , Boehme Amelia K , Beasley T. M , Martin-Schild Sheryl
Published: July 2021

Background:
Prior studies have reported elevated blood pressure, platelet inhibition, and low LDL cholesterol in chronic daily alcohol users (CDA). Each of these has been shown to be associated with intracerebral hemorrhage (ICH) growth. We hypothesized that CDA patients with ICH and low LDL were at higher risk for ICH growth than CDA users with high LDL.

Methods:
Retrospective chart review was performed on patients who presented to Tulane University from 7/1/08-12/31/10 with a spontaneous ICH. Patients who underwent hematoma evacuation were excluded. Clinical and demographic variables were abstracted. Hemorrhages volumes were calculated based on ABC/2 method. LDL was dichotomized into low (<100mg/dl) and high (≥100mg/dl) values. Comparisons were made using t-tests, Chi-square and non-parametric equivalents where appropriate. ICH growth in 24 hours and CDA use were evaluated using linear regression.

Results:
Of the 99 patients with spontaneous ICH, 25.3% were CDA users. No significant differences were observed when comparing baseline demographics of CDA users with LDL<100 and CDA users with LDL>=100 (
Table
1). Patients with low LDL had larger baseline ICH volumes (21.4 vs. 7.5, p=.03) and were more likely to experience ICH growth (87.5% vs. 57.1%, p=0.0002). Initial LDL was an independent predictor for 24 hour ICH growth. Every 10 points the initial LDL was below 100 predicted 1 cc of growth. LDL did not predict ICH growth in non-CDA users (p=0.9430).

Discussion:
Our data suggest that initial LDL level in chronic daily alcohol users can be used to predict ICH growth. The role of LDL in the importance of vessel fragility and clot stabilization needs to be further explored as this appears be important in patients who are chronic daily alcohol users.
Abstract 3251: Relationship Between tPA and Factor VIII Levels in Patients with Acute Ischemic Stroke
Authors: Chang Tiffany R , Albright Karen C , Kruse-Jarres Rebecca , Lessinger Cindy , Boehme Amelia K , Beasley T. M , Martin-Schild Sheryl
Published: July 2021

Background:
Factor VIII levels may be screened as part of a hypercoagulable work-up in patients with ischemic stroke. However, it is unknown how treatment with IV tPA may affect these levels during the acute phase of ischemic stroke.

Methods:
From our prospective registry, we identified patients who presented with acute ischemic stroke to our stroke center between July 2008 and April 2011 and determined if factor VIII levels had been measured during the acute hospitalization. We compared mean factor VIII levels using independent sample t test in patients not treated with IV tPA to post-tPA treatment levels using independent samples t tests.

Results:
Of the 72 patients who had factor VIII levels checked during admission, 25 (34.7%) received IV tPA. The mean factor VIII level was observed to be lower in patients who were treated with tPA (140.8 vs 180.5, p=0.048). Patients who experienced averted stroke (36%, 9/25) had significantly lower mean factor VIII level than patients who completed infarction on diffusion-weighted MRI (64%, 16/25) (132.7 vs 175.2, p=0.002). Of patients with post-tPA factor VIII levels, the mean factor VIII level of those whose samples were drawn within 24 hours of tPA were not different than the mean factor VIII level of those whose samples were drawn more than 24 hours after tPA (p=0.784).

Conclusion:
Our observations found that factor VIII levels were lower in both patients treated with IV tPA and in patients with averted stroke. As factor VIII levels were drawn after thrombolytic therapy was administered, this raises the question of whether tPA lowers factor VIII levels or if factor VIII can serve as a potential surrogate marker for recanalization. Prospective studies examining factor VIII levels (1) before and after treatment with IV tPA and (2) in comparison to recanalization are needed to clarify this interesting observation.
Abstract 3259: Leukocyte Subset Specific Gene Expression In Acute Stroke Patients
Authors: Adamski Mateusz G , Li Yan , Yu Hua , Wagner Erin , Amarjeet Sareen , Soper Steve A , Baird Alison E
Published: July 2021

Background:
Alterations in gene expression in the peripheral blood of patients with acute stroke have been demonstrated using microarray technology. Whole blood and peripheral blood mononuclear cells (PBMCs) were used in prior studies in which panels of genes diagnostic for stroke were developed. We aimed to determine the cellular sources of alterations in gene expression by studying individual leukocyte subsets.

Methods:
The expression of four genes previously found to be upregulated in ischemic and hemorrhagic stroke (IL1R2, S100A9, ETS2 and F5) was measured in four leukocyte subsets: CD14+ monocytes, CD4+ T cell lymphocytes, CD20+ B cell lymphocytes and PBMCs. These four genes had been reported in at least two of the previously published stroke-related gene panels. Peripheral blood was obtained from six acute stroke patients (all <48 hours from symptom onset) and 6 age, race and sex matched control subjects. Leukocytes were separated from whole blood using density gradient centrifugation and column magnetic bead cell sorting. The purity of separated leukocyte subsets exceeded 90% and was verified with flow cytometry. Messenger RNA was isolated from each leukocyte subset and analyzed by two step RT PCR and qPCR. The expression of the four stroke-related genes was compared to the expression of a housekeeping gene (GAPDH). The relative expression of individual genes and of the 4 gene panel within cellular subsets was compared between stroke patients and control subjects.

Results:
Individually, IL1R2 and S100A9 were significantly over-expressed in stroke patients with a 10 fold increase for IL1R2 in PBMCs (p<0.05) and a 3 fold increase for S100A9 in the CD4+ T and CD20+ B lymphocyte subsets (p<0.05). When analyzed as a panel of four genes the expression of IL1R2, S100A9, ETS2 and F5 was significantly higher in both the CD4+ T lymphocytes (p<0.05) and CD20+ B lymphocytes (p<0.05) of stroke patients but not in the monocytes or the PBMCs.

Conclusion:
These results show the potential diagnostic value of selected genes from panels previously found in microarray studies in stroke patients. They also emphasize the value of panel analysis over that of single gene expression and the potential cellular specificity of alterations in gene expression. Analysis of whole blood and PBMCs alone may not reflect important dynamic changes in stroke-related gene expression.
Abstract 3306: Effect Of General Obesity On Neurological Deterioration After Acute Stroke
Authors: Kubo Satoshi , Ohtsuki Toshiho , Hara Naoyuki , Takamatsu Kazuhiro , Fukushima Tomoko , Ota Taisei , Kuriyama Masaru , Matsumoto Masayasu
Published: July 2021

Objective:
The increasing prevalence of obesity in Asia has led to concern that obesity negatively affects outcomes after acute cardiovascular events and stroke. Here, we examined the relationship between body mass index (BMI), as a general indicator of obesity, and neurological deterioration after acute stroke.

Patients and Methods:
Consecutive acute stroke patients (n=2310: 489 hemorrhagic stroke, 1702 ischemic stroke, 119 TIA; median age 73.0; 1392 male) participated in this study. All patients were admitted within 7 days of stroke onset to a regional brain attack center in Japan between January 2005 and December 2010, and provided written informed consent. Patient attributes (age; sex; current smoking and/or drinking status; past history of stroke, hypertension, diabetes mellitus, and hypercholesterolemia; and body weight and height) were recorded upon admission; BMI was calculated using the height and weight measurements. Patients whose NIHSS score increased by 4 or more from admission to discharge or who died during hospitalization were classified into the neurological deterioration group; all other patients were classified into the non-deterioration group. Logistic regression analysis was performed using the deterioration and non-deterioration groups as dependent variables, and factors related to deterioration were examined using SPSS version 15.0.

Results:
The deterioration group comprised 221 patients, and had a higher proportion of patients with hypertension and/or diabetes mellitus and age over 75 years, but these patients had significantly lower BMI values than the 2089 patients in the non-deterioration group (22.4 ± 4.2 kg/m
2
vs. 23.2 ± 3.5, p=0.002). No intergroup differences were observed for history of stroke, smoking and/or drinking status, or hypercholesterolemia. Logistic regression analysis of the patient attributes listed above indicated that age and history of hypertension (odds ratio=1.77 and 1.75, 95% CI: 1.24-2.52 and 1.07-2.85, respectively) were positively correlated with neurological deterioration; in contrast, a larger BMI was negatively correlated with neurological deterioration (odds ratio by 1 kg/m
2
increase in BMI=0.948, 95% CI: 0.899-0.999, p=0.04).

Conclusion:
Lower BMI at admission was positively correlated with neurological deterioration after acute stroke after adjusting for other cerebrovascular risk factors.
Abstract 3392: Silent Cerebral Infarctions in Healthy Subjects with Right-Left Shunt on Transcranial Doppler
Authors: Shin Hee Young , Kim Jae Ha , Kim Suk Jae , Ha Yeon Soo , Kim Ji Won , Kang Kun Woo , Na Duk L. , Bang Oh Young
Published: July 2021

Background:
In healthy elderly people, silent cerebral infarction (SCI) and white matter lesions are common, but little is known about their relevance. In the present study, we evaluated the association between SCI located outside the perforating artery territory and paradoxical embolism detected by agitated saline transcranial Doppler (TCD) monitoring in healthy subjects. We also compared the frequency and amount of paradoxical embolism between healthy subjects with SCI and acute stroke patients with presumed cryptogenic embolism.

Methods:
This study is a prospective observational study undertaken from January 2009 to January 2011 by a university health promotion center and from January 2008 to January 2010 by a university stroke center. We defined SCI as evidence on MRI of one or more infarcts, without a history of a (corresponding) stroke or TIA; brain infarction was defined as a focal hyperintensity lesion 3 mm or large in diameter in the fluid-attenuation inversion recovery (FLAIR) images. We also evaluated neuroimaing indicators of microangiopathy, SCI within perforator territory and leukoaraiosis (LA), in all subjects.

Results:
Among 1103 consecutive healthy adults who underwent MRI, 347 (31%) had one or more SCI. After excluding subjects with poor temporal window, refusal or having SCI within only striatocapsular area, 253 subjects underwent agitated saline TCD monitoring and 128 (51%) had right-to-left shunts (RLS). Similarly, 145 out of 234 patients (62%) with presumed cryptogenic embolic stroke showed RLS. However, RLS was less frequently observed in stroke patients with determined mechanisms (34 out of 94 patients (38%)) than healthy subjects with SCI (p=0.017). Moreover, the number of SCI within perforator territory and the degree of LA were inversely correlated with the amount of RLS in healthy subjects.

Conclusion:
Our results suggest that paradoxical embolism plays an important role in the development of SCI outside the perforating artery territory in apparently healthy adult.
Abstract 3422: Prevalence Of Vertebral Artery Origin Stenosis In Outpatients Referred For Extracranial Duplex
Authors: Koch Sebastian , Campo Nelly , Bustillo Antonio , Campo Bertha , Campo-Bustillo Iszet , McClendon Steven , Ortiz Gustavo , Katsnelson Michael , Romano Jose G
Published: July 2021

Introduction:
Extracranial atherosclerotic stenosis of the vertebral artery occurs characteristically at the vertebral artery origin (VAo) and is an important cause of posterior circulation stroke. The proximal segment of the vertebral artery is technically difficult to insonate. Only a few studies have reported on the prevalence of VAo disease in patients with stroke and little is known about its prevalence in non-hospitalized populations. Our objective was to determine the prevalence of VAo stenosis in subjects referred for outpatient extracranial ultrasonography.

Methods:
All studies performed in an outpatient neurosonology laboratory, affiliated with an academic medical center were retrospectively reviewed for VAo stenosis. The proximal vertebral segments were insonated following a standard protocol. VAo stenosis was diagnosed if the peak systolic velocity (PSV) > 114cm/sec, according to previously validated criteria. We also considered the VAo to be occluded if no flow signal could be found in any of its pre-and intraforaminal segments. Studies were also analyzed for internal carotid artery origin (ICAo) stenosis >50% to allow comparison between prevalence of carotid and VAo stenosis.

Results:
A total of 2490 subjects were available for analysis. The right and left VAo could not be insonated in18% and 25% of patients. Right-sided VAo stenosis or occlusion was present in 52/1955 (2.7%) and 74/1955 (3.9%) respectively; left-sided VAo stenosis or occlusion was present in 45/1793 (2.5%) and 64/1973 (3.6%) respectively. Overall, in those with at least one VAo insonated, 204/ 2119 (8.2%) patients had VAo stenosis or occlusion. In 29/ 2119 (1.4%), bilateral VAo stenosis or occlusion was found. Mean flow velocities were significantly lower in patients without stenosis (right 54.2±18.9 vs.149.0±57.8cm/s; left 53.5±17.5 vs.143.9±31.4cm/s). The prevalence of having either right or left ICAo stenosis or occlusion was 453/ 2401 (18.9%) and bilateral ICAo stenosis or occlusion was 112/ 2401 (4.7%). In univariate analysis, but not multivariate analysis, hypertension and diabetes were risk factors for VAo stenosis.

Conclusion:
The prevalence of VAo stenosis and occlusion was 8.2% in a diverse population of patients presenting to an ambulatory ultrasound laboratory. We found the prevalence of ICAo stenosis to be higher than VAo stenosis in the same population. Our findings contribute to the understanding of the prevalence of proximal vertebral artery disease in non-hospitalized patients.
Abstract 3429: Implementation of Electronic Medical Record Stroke Templates Increases Compliance with Stroke Performance Measures
Authors: Perdomo Crismely A , Kauari Vepuka E , Suarez Elizabeth , Williams Olajide , Stillman Joshua , Marshall Randolph S , Willey Joshua Z
Published: July 2021

Background and Purpose
The literature demonstrates how utilizing evidence-based, standardized stroke care can improve patient outcomes; however, the contribution of electronic medical record (EMR) systems may also impact outcomes by ensuring utilization and compliance with established stroke performance measures, facilitating and improving documentation requirements, and standardizing approach to care. In 2008, documentation in patients’ medical records was done in combination of paper and a template free EMR. Originally, the EMR was used for order entry, then transitioned to full electronic documentation in 2009. At that time we implemented our stroke templates and performance measures based on regulatory standards. We hypothesized that the stroke template implementation would help us achieve performance measure criteria above state benchmarks as set out by the New York State Department of Health (NYS DOH).

Methods
Implementation was phased in [over 18 months], initially using a template that only included neurological assessment and free text fields for stroke measures. By July 2010, existing templates were modified and additional stroke templates were implemented to meet new regulatory requirements and meaningful use criteria. Retrospective data review was conducted for performance comparison between 2008 -- one year prior to EMR/template implementation -- and 2010. In Quarter 1 of 2011 EMR was also implemented in the Emergency Department (ED). Data was reviewed for compliance with stroke measures.

Results
Documentation compliance substantially improved between 2008 and Quarter 1 2011: Compliance for these measures has been maintained ≥ 85% since November 2010, ≥ 90% Q1 2011

Conclusions
The EMR implementation of stroke templates and performance measures can produce substantial improvement in performance measure compliance. Future steps will include automated documentation alerts to retrieve information and real time discovery of missing documentation for concurrent quality review and improvement
Abstract 3442: A Regional Assessment of Mismatch between Joint Commission Certified Stroke Centers and Population Requirements
Authors: Connelly Bo , Meland Will , Chaudry Saqib A , Reshetar Jacob , Qureshi Adnan I
Published: July 2021

Background:
The Joint Commission identifies high performing stroke centers through their certification program. Since the certification program does not incorporate a population based needs assessment, we hypothesized that some population centers may not contain certified centers. Furthermore, we hypothesized that inter-competitive behaviors of centers may be lead to clustering of certified centers.

Methods:
We identified all the primary stroke centers (PSCs) that were certified by Joint Commission through a directory maintained by the organization. We identified the addresses of all the certified stroke centers in the upper Midwest (ND, SD, MN, IA, WI) and determined the latitude and longitude coordinates for these locations. We then obtained a list of all the census blocks in the upper Midwest that included the populations and latitude and longitude coordinates for each census block. We used the Haversine formula to calculate the great circle distance between each stroke center and each census block and then identified the five stroke centers closest to each census block. From this we were able to identify the census blocks within 15 miles of multiple stroke centers in the upper Midwest. We also identified every census block within 15 miles of each stroke center. From this we calculated the total population within 15 miles of each stroke center.

Results:
We identified a total of 56 PSC hospitals that are serving a population of 15.4 million in 2010 in upper Midwest. Of the population served, 53% of the population lives within 15 miles of a PSC. Of these, 3%, 6%, and 1% live within 15 miles of 2,3, and 4 PSCs; 21% live within 15 miles of 5 or more PSCs. Seven PSCs have a population of ≤100,000 per PSC within 15 miles, and 49 PSCs have a population of >100,000 per PSC within 15 miles; 18 PSCs have a population of 1 million or greater within 15 miles.

Conclusions:
We found that almost half of the population in the Midwest does not reside within 15 miles of a PSC while one-fifth of the population resides within 15 miles of 5 or more PSCs. Such mismatches highlight the need for PSC designation to consider population needs to ensure homogeneity of care.
Abstract 3503: Ovarian Cancer Increases the Risk of Stroke, but Not in Patients with Hypertension, Diabetes or Both
Authors: Chen Tsang-Shan
Published: July 2021

Background and Purpose:
Cancer and stroke are the first and third leading cause of death in Taiwan respectively. Cancer has been considered to be a stroke risk factor. Ovarian cancer as a cause of stroke has appeared in the literature as case reports featuring increase in systemic thromboembolic tendency, frequently associated with non-bacterial endocarditis. To the best of our knowledge, no systemic assessment of ovarian cancer as a stroke risk factor has been made. Based on the Taiwan National Health Insurance claim files covering 1997 - 2008, we explored ovarian cancer as a stroke risk factor.

Methods:
There were a total of 8,728 patients with diagnosis of ovarian cancer from 1997 to 2007. A cohort of 34,912 age- and gender-matched patients without cancer served as the control group. Both groups were followed until the end of 2008. The ovarian cancer and control cohorts were further divided into 2 subgroups with and without key stroke risk factors (hypertension, diabetes, or both). Cox proportional hazard regression analysis was used to estimate the stroke risk in patients with ovarian cancer to derive hazard ratios (HRs) and 95% confidence intervals (CIs)

Results:
In the ovarian cancer cohort without hypertension or diabetes, the incidence rate was 4.89 per 1000 person-years in comparison with 4.70 in the control group without comorbidity. The hazard ratio (HR) is 1.44 (95% CI 1.22-1.77). For the ovarian cancer cohort with hypertension, diabetes or both, the incidence rate of stroke was 12.05 per 1000 person-years as compared to 30.67 in the control cohort with hypertension, diabetes or both. The HR is 0.44 (95% CI 0.29-0.68).

Conclusion:
Ovarian cancer increased the risk of stroke by 44% in patients without hypertension, diabetes or both in comparison with the age- and gender-matched control without the same comorbidity. However, patients with ovarian cancer who had hypertension, diabetes or both had signnificantly lower stroke risk than the control group with the same comorbidity. The mechanism for the apparent paradox associated with comorbidity (hypertension, diabetes or both) known to increase the stroke risk in patients with ovarian cancer remains to be determined.
Abstract 3633: A National Assessment of Factors Influencing Emergency Medical Services Times Among Acute Stroke patients.
Authors: Jadhav Vikram , Chaudhry Saqib A , Rodriguez Gustavo J , Suri M. Fareed K , Qureshi Adnan I
Published: July 2021

Background:
The time spent in Emergency Medical Services [EMS] assessment and transport is a critical determinant of time interval between symptom onset and treatment for acute stroke.

Objective:
To study the determinants that influence EMS times which is a composite of response, assessment, and transport times for acute stroke patients.

Methods:
The 2009 national Emergency Services Information System [NEMSIS] Research dataset representing 26 states in US was accessed to identify the patients diagnosed by EMS personnel to be having stroke / cerebrovascular accident [CVA] on arrival at the scene of incident. Total EMS times defined as time interval between dispatch call and completion of transport to emergency department [reported in mins (confidence intervals)] were calculated and compared in various patient strata defined by factors such as dispatch center identification of stroke / CVA, barriers (language and physical) at the scene, location and demographical factors.

Results:
A total of 52282 patients were identified to have stroke / CVA by EMS personnel on arrival at scene. Significant differences were seen in EMS times with accurate identification compared to non-identification of stroke / CVA by dispatch center [41.8 (41.5-42.2) vs 49.8 (49.3-50.2),
P
<0.001]. Language and physical barriers at scene were associated with EMS time delays [48.4 (47.3-49.6) vs 45.2 (44.8-45.6),
P
<0.001]. EMS times increased from urban to suburban, rural, and wilderness settings [42.6 (42.3-42.9) vs 48.6 (47.6-49.5) vs 50.5 (49.6-51.4) vs 62.4 (59.8-64.9),
P
<0.001]. Similarly, Pacific and Mid-Atlantic regions had faster EMS times compared to Mountain regions [35.2 (34.6-35.8) vs 36.5 (35.6-37.4) vs 46.6 (45.4-47.8),
P
<0.001]. Patients ≥65 years had less EMS times compared to those aged <65 years [44.9 (44.5-45.2) vs 46.9 (46.4-47.4),
P
<0.001].

Conclusion:
EMS times in patients with acute stroke are influenced by multiple factors. A better understanding of modifiable and region specific factors can expedite time interval between symptom onset and treatment for acute stroke patients.
Abstract 3640: From Data to Action: Improving Knowledge Translation through Ontario's Stroke Report Cards
Authors: Linkewich Beth , Khan Ferhana , Hodwitz Kathryn , Hall Ruth , O'Callaghan Christina , Lumsden Jim , Kapral Moira , Bayley Mark , Fang Jiming
Published: July 2021

Background:
The Ontario Stroke Evaluation Program has been reporting on the quality of stroke care since 2005. This information has been used inconsistently by stakeholders outside the stroke system. Consultation with stakeholders revealed that a concise reporting tool was needed. In 2009, the Stroke Evaluation Quality Committee (SEQC) developed a one-page report card to communicate the performance of stroke care in Ontario regionally and provincially.

Method:
Through a series of internal reviews, and utilizing the Canadian Stroke Strategy 2008 Performance Measurement Manual, the SEQC selected 20 key performance indicators to be presented in the report card. The primary data sources for indicator calculation were the FY 2008/09 Ontario Stroke Audit and FY 2008/09 and 2009/10 Canadian Institute for Health Information acute and inpatient rehabilitation databases. Indicator benchmarks were calculated using the Achievable Benchmarks of Care methodology. Red, green and yellow colour bands were used to rate regional performance relative to the benchmark, red representing poor performance (below the fiftieth percentile), green indicating exemplary performance (within 5% of the benchmark), and yellow representing acceptable performance (at or above the fiftieth percentile but outside of 5% of the benchmark). Stroke directors distributed the report cards to their regional management teams. Feedback about the report card was collected through a focus group with the stroke directors, who provided their own opinions and shared feedback they had received from management teams. Thematic analysis was conducted on qualitative data.

Results: Among the fourteen regions, eleven had 1 - 4 indicators exhibiting exemplary performance with minimal indicator overlap (4/11 shared the same indicator).
Thematic analysis of focus group data revealed four main themes: 1) Process (strategy of dissemination), 2) Content (information and layout), 3) Utility (function) and 4) Results (management’s responses). Feedback indicated that the report cards were a valuable tool for planning and were helpful in facilitating communication between stroke directors and regional management teams. Stakeholders were satisfied with the content and process of the report cards as well as the potential they have for driving system change. Recommendations for future iterations of the report card, such as the timing of distribution, were also identified for process improvement purposes.

Conclusions:
The report card is a concise document that serves as a valuable stakeholder communication tool, allowing for consistent planning across the Ontario Stroke System (OSS). The report card and dissemination process has effectively engaged the Ontario stroke regions in dialogue relating to stroke system improvement.
Abstract 3648: Detection Of Paroxysmal Atrial Fibrillation In Patient With Acute Brain Ischemia Combining Cardiac And Holter Monitoring: Prevalence And Predictors
Authors: Martinez-Sanchez Patricia , Correas Callero Elisa , Cruz Herranz Andres , Fuentes Gimeno Blanca , Martin Montes Angel , Mangas Guijarro Maria de los Angeles , Ruiz Ares Gerardo , Martinez Martinez Marta , Diez-Tejedor Exuperio
Published: July 2021

INTRODUCTION:
The yield of serial electrocardiograms (ECG) plus 72-hour cardiac monitoring and Holter monitoring in detection of paroxysmal atrial fibrillation (PAF) is not well known.

METHODS:
consecutive patients with stroke or transient ischemic attack (TIA) admitted to a Stroke Unit (SU) during January 2009-June 2010 were studied. Patients underwent serial ECG and cardiac monitoring in the first 72 hours. Furthermore, 24-hours Holter monitoring were performed in patient with brain ischemia of unknown origin or if cardiac embolism was suspected. The presence of atrial fibrillation (AF) and PAF was recorded.

RESULTS:
537 patients were included, 59.6% males. Mean age 69.1 (SD 13.5) years. Previous AF was present in 15.8% patients. ECG on admission showed not previously known AF in 22 (4%) patients. Cardiac monitoring and serial ECG in the SU detected PAF in 12 (2.2%) cases more. 24-hours Holter monitoring was completed in 156 patients, in 42 cases PFA was detected, of them 6 had been previously detected by serial ECG/cardiac monitoring. One case of PAF detected by serial ECG was not confirmed by Holter monitoring. In total, 10.8% of patients were diagnosed with new PAF. In multivariate analyses, NIHSS on admission (OR 1.1 for each 1 point increase; 95% CI, 1-1.2), enlarged left atrial (OR 5.8; 95% CI, 2.8-12), absence of carotid plaques by duplex ultrasound (OR 2.1; 95% CI 1-4.4) and hyperlipidemia (OR 2.4; 95% CI 1.119-5) were predictors of PAF.

CONCLUSIONS:
24-hours Holter monitoring increased by 6 fold the detection of PAF as compared to ECG plus cardiac monitoring in acute stroke patients. Stroke severity, enlarged left atrial, absence of carotid plaques and hyperlipidemia are associated with PAF.
Abstract 3651: Reducing Incidence of Hospital Acquired Pneumonia After Acute Stroke Through Implementation Of Simple Bedside Swallow Assessment
Authors: Videtto Catherine J , Finnegan Mary Jane
Published: July 2021

The incidence of hospital-acquired pneumonia (HAP) has been estimated to occur in acute stroke patients with rates reported as high as approximately 10 - 25%. Mechanical ventilation, multiple infarct locations, dysphagia and abnormal chest x-ray findings all contribute to increased risk for dysphagia and ultimately development of pneumonia. Because fatality rates of 20 - 45% have been reported in HAP, stroke care nurses are urged to comply with guidelines recommending implementation of simple bedside swallow assessments to identify high risk patients and institute appropriate nursing interventions to avoid development of the potentially fatal complication of stroke related pneumonia. A retrospective review of 493 patients admitted to the stroke service of a community hospital was performed to determine incidence of hospital acquired pneumonia in acute stroke patients. The sample of patients were admitted through the emergency department and depending on the severity of stroke, were admitted to either an ICU or step-down unit bed. The simple bedside swallow screen was completed by an emergency department nurse. The patient was not allowed anything by mouth until the assessment was completed. If the assessment revealed the patient had a competent level of cognition, ability to adequately handle secretion in a sitting position, and maintain a venous pulse oxygenation of greater than 94%, the patient was asked to swallow three sequential one ounce medicine cups of water. If coughing, choking, drooling, or oxygen desaturation was assessed, the patient was maintained nothing by mouth until a formal swallow evaluation was completed by a speech therapist. During the period of 1/1/09 - 7/30/11, this hospital’s annual incidence of HAP in the post stroke patient was found to be significantly less than nationally published incidence. The diagnosis of HAP was based upon Center for Disease Control Guidelines for Hospital-Acquired Pneumonia. The patients reported as developing HAP met the criteria of having a primary discharge of stroke and a secondary discharge diagnosis of hospital acquired pneumonia. This community hospital’s mean incidence of hospital acquired pneumonia over the total 31 month study period was 3.6%. A simple bedside swallow screen performed by competent emergency department nurses to detect swallowing difficulty quickly and accurately in stroke patients prior to administering anything by mouth, has achieved the goal of identifying patients at high risk for dysphagia and avoiding the potential complication of hospital acquired pneumonia.
Abstract 3652: Sex Differences in CD200 and CD200R1 Expression in the Brain Following Experimental Stroke
Authors: Ritzel Rodney , Moore Craig S , McCullough Louise D
Published: July 2021

Background and Purpose
Emerging data suggests that stroke-induced inflammation significantly contributes to neuronal injury and clinical outcome. Local inflammatory responses following cerebral ischemia have highlighted a pivotal role for the innate immune system in the brain’s response to injury, including activation of microglia and macrophages. Cell-surface receptors (e.g. CD200R1) on microglia and other myeloid-derived cells directly interact with specific endogenous ligands (e.g. CD200) expressed on neurons and act to suppress pro-inflammatory signaling by maintaining microglia in an “inactive state”. Recent studies investigating the imbalance of CD200-CD200R1 signaling in models of neurodegenerative disease support the hypothesis that this interaction may also be disrupted following stroke. We investigated the role of the immune inhibitory receptor CD200R1, and its ligand, CD200, after experimental stroke in both male and female mice.

Methods
Gonadally intact male and female C57BL/6 mice were subjected to middle cerebral artery occlusion by reversible right MCA occlusion for 90min followed by 6h of reperfusion. Brains were harvested and processed for RNA and protein. mRNA and protein were analyzed for CD200 and CD200R1 expression using qPCR and Western blotting respectively in both stroke and sham mice. Immunohistochemistry was performed to identify the cellular source of CD200 and CD200R1 expression.

Results
At 6h post-reperfusion, decreased CD200 gene expression was seen in both sexes compared to sham. Western blot analysis demonstrated that CD200 was significantly decreased in males compared to females after stroke. CD200R1 gene levels were also downregulated in males compared to sham, however expression levels in females were increased after stroke. A relative 4-fold increase in CD200R1 protein levels was seen in stroke males compared to sham, in contrast CD200R1 expression in females decreased following stroke.

Conclusions
Early in the post-ischemic period, a marked difference between males and females in both CD200 and CD200R1 expression was seen, suggesting sex-dependent modulation of the stroke-induced inflammatory response. The decrease in CD200 ligand expression in males following stroke would be expected to lead to decreased CD200R1 activation, freeing microglial inhibition, thereby promoting a pro-inflammatory response. The increase in CD200R1 expression following stroke in males may act as a compensatory mechanism, potentially serving to enhance CD200-CD200R1 interactions between neurons and myeloid cells and thus suppress inflammation. These results provide a novel explanation for the larger cerebral infarcts seen in males, by a mechanism whereby stroke-induced disruption of the immunosuppressant interaction between CD200 and CD200R1 leads to worse outcome.
Abstract 3740: Using Standardized Web-based Tests in Clinical Trials to Improve Investigator and Coordinator Protocol Familiarity: Experience from Antihypertensive Treatment of Acute Cerebral Hemorrhage II trial
Authors: Dillon Catherine , Connelly Bo , Kim Jaemyung , Patterson Lynn , Palesch Yuko Y , Qureshi Adnan I
Published: July 2021

Background:
Prior to site initiations, the Antihypertensive Treatment of Acute Cerebral Hemorrhage II (ATACH-II) trial steering committee require that all investigators and coordinators participating in the trial pass a multiple choice web based test that assesses the individual’s knowledge of the trial protocol and manual of procedures. Requiring a test of this nature was expected to increase the probability that key individuals participating in the trial at various clinical sites had acquired protocol familiarity that would enable them to conduct the trial properly. This benefit was weighed against the additional burden imposed on the site initiation process.

Methods:
The steering committee developed a bank of 38 multiple choice questions based on the ATACH-II protocol and manual of procedures (MoP). These questions were identified as appropriate for an investigator, a coordinator, or both. The test was programmed by the ATACH-II Data Coordination Unit and hosted on a web page linked to the ATACH-II Clinical Trial Management System (CTMS). Each time a user registers to take the test a random selection of 14 questions appropriate for that user type (investigator or coordinator) is generated. When a user passes the test, the test certification document is automatically created and uploaded into the ATACH-II CTMS.

Results:
In the first year of the trial the test has been taken 418 times. Users are required to answer 12 questions correctly in order to pass. Users registered as investigators have taken the test 263 times with a 55.9% pass rate. Users registered as coordinators or other study team members have taken the test 155 times with a 56.1% pass rate. The pass ratio has increased from 49.5% at the end of the first quarter to 56.0% at the end of the last quarter of the first year. The mean score is 10/14 and the median score is 12/14 among all participants taking the test.

Conclusion:
Requiring each investigator and coordinator to become certified by passing this test adds substantial burden to the site initiation process. However, the 56% pass rate observed provides evidence that such efforts may be required to promote the necessary familiarity with the protocol and MoP for this trial.