bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP4: Accuracy Of Patient-Reported Body Weight On A Mobile Stroke Unit Compared To Measured Body Weight And Alteplase Dosing Implications
Authors: Zhang Andrew J , Buletko A. Blake , Huang Merry , Hayes Alexa , Russman Andrew N
Published: February 2022

Background:
Administration of intravenous tissue plasminogen activator is standard of care for patients presenting with acute ischemic stroke. The optimal dose, per American Heart Association guidelines, is 0.9 mg/kg of IV alteplase to maximize clinical effectiveness while minimizing complications. With the integration of mobile stroke units (MSUs), IV alteplase is more frequently administered in the prehospital setting. Patient-reported body weights, instead of measured body weights, remain commonplace in MSUs due to logistical challenges of accurate weighing systems on MSUs. It is unknown whether patient-reported weights can be safely used, as previous cohort studies have reported that 16% to 33% of patient-reported weights are inaccurate.

Methods:
We retrospectively analyzed all MSU patients from January 2018 to July 2021 who were given IV alteplase and subsequently transported to one of our network hospitals. Patient or family-reported weights used in the MSU for IV alteplase administration and subsequent measured patient weights were retrospectively collected. Reported weights were deemed accurate if within 10% of the measured patient weights.

Results:
A total of 66 patients received IV alteplase on the MSU. The median age of these patients was 64 years (interquartile range (IQR) 53-78). Forty eight percent of IV alteplase treated patients were women. Median last known well to IV alteplase bolus time was 58.5 minutes (IQR 47- 92). Twenty of the 66 patients had a reported body weight greater than 100 kg, all of whom were confirmed to weigh more than 100 kg at hospital arrival. Of the remaining 46 patients, the median administered dose of IV alteplase was 0.90 mg/kg (IQR 0.88-0.95). Seventeen percent of patients were inaccurately dosed; 4% of patients were underdosed and 13% of patients were overdosed. One patient who was overdosed (1.01 mg/kg) had symptomatic intracranial hemorrhage.

Conclusion:
Within our single-center cohort, patient-reported weights were an accurate surrogate for measured patient weights for administration of IV tPA in the prehospital MSU setting. However, patient-reported weights may increase dosing errors which could have both efficacy and safety implications.
Abstract TP41: Clinical Challenges Of The Complex Icu Stroke Patient
Authors: Amatangelo Mary P
Published: February 2022

Ten percent to twenty percent of Stroke patients will require an ICU admission. This population of stroke patients are managed aggressively in the acute phase and often present with many complex clinical challenges for the Emergency Department (ED) and Intensive Care Unit ICU) Nurse.

The clinical challenges of the complex stroke patient include complications such as; blood pressure, glucose and airway management, hemorrhagic transformation, extension of the stroke infarct, malignant hemispheric strokes complicated by cerebral edema, and the need for hyperosmolar therapy, and potential progression to hemicraniectomy. Common ICU challenges also apply to this patient population; hospital acquired infections, aspiration pneumonia, and skin breakdown.

This presentation will provide an overview of the ICU clinical challenges caring for the acute stroke patient. The importance of expert nursing care is essential to the management of this patient population. Pharmacologic interventions that are common in caring for the ICU stroke patient will be discussed. This lecture is aimed at the experienced stroke nurse as well as the ED and ICU Nurse and the Nurse new to stroke and critical care.
Abstract TP43: Incidence And Characteristics Of Transient Ischemic Attack Mimics In Emergency Department Observation Unit
Authors: Dai Xing , Kala Narendra , Madsen Tracy , Rana Maheen , Yaghi Shadi , Godbout Edmond , SIKET Matthew S , Sacchetti Daniel C
Published: February 2022

Objective:
Transient Ischemic Attack (TIA) observation units in the emergency department (ED) were developed to expedite medical evaluation and to reduce recurrent strokes. However, TIA remains a clinically challenging diagnosis due to its reliance on patient history and has multiple mimics including complex migraine, seizure, and peripheral vertigo. This study attempts to review the proportion of common mimics in the TIA observation unit at a comprehensive stroke center.

Methods:
We included 1525 patients enrolled in a TIA registry over 7 years (2013-2020) in a single comprehensive stroke center. Inclusion criteria of TIA unit admissions are age >18 years with focal neurological symptoms for < 24 hours. This population excludes patients with refractory hypertension, baseline immobility, or recurrent deficits. While in the ED, patients were evaluated by neurologists and assigned a final diagnosis of TIA or mimics. Data on demographics, past medical history, home medications, magnetic resonance imaging (MRI) results, and 30-day follow-up were collected.

Results:
The mean age was 64.2 (SD 15.2), 52.3% were women, and 76.7% were White, 6.0% were Black, 13.6% were Hispanic, and 3.7% other ethnicities. We found 44.7% of patients had neurologist-adjudicated TIA and 15.2% had diffusion-weighted imaging (DWI) positive lesions on MRI. TIA mimics comprised 42% of the cohort, of which 28.9% had migraine, 14.1% had peripheral vertigo, 4.7% had seizure and 52.1% were classified in other miscellaneous diagnoses including medication effect, recrudescence of prior stroke deficits, anxiety, and radiculopathies. Among the 394 patients with the diagnosis of TIA the 30-day recurrent stroke or death rate was 1.3%.

Conclusion:
In our investigation of TIA unit admissions, we found a relatively high proportion of TIA mimics. In patients with a diagnosis of TIA, however, the rate of subsequent stroke or death is lower than that in prior observational studies. The potential benefit of a TIA unit in stroke prevention needs to be tested against the cost of stroke mimic TIA unit admission.
Abstract TP48: IV-tPA In Elderly With Occult Trauma Is Associated With High Risk For Hemorrhagic Complication
Authors: Sultan-qurraie Ali , Previti Michael C , Eddington Alden Erin , Han Jennifer , Sheibani Nazanin , de Havenon Adam H
Published: February 2022

Intro:
IV-tPA was approved for the treatment of acute ischemic stroke in 1996. IV-tPA administration in the setting of trauma can propagate hemorrhagic complications, such as Disseminated Intravascular Coagulation, which can be difficult to reverse especially in the elderly. Robust data on outcomes in patients with undiagnosed traumatic fracture receiving IV-tPA for acute ischemic stroke is lacking. Our study investigates the safety of IV-tPA in patients with occult trauma.

Methods:
We reviewed our database over a three-year period, August 2018 to August 2021, for complications of reperfusion therapy as defined and reported to GWTG registry. These charts were retrospectively reviewed for patients who were determined to have presented with acute traumatic fracture.

Results:
IV-tPA was administered 329 times. 18 total hemorrhagic complications were discovered. Four of these patients presented with occult acute traumatic fracture - three had rib fractures; one had pelvic fracture. Hypovolemic shock was attributed to the respective traumatic fracture in all cases. All required blood products and intravenous fluid resuscitation. Three patients underwent invasive treatment in an attempt to abort or alleviate hemorrhagic complication including intercostal artery embolization, video-assisted thoracoscopic surgery, thoracentesis, and internal iliac artery branch embolization. Two patients developed a severe consumptive coagulopathy and suffered in-hospital death. All four patients were elderly, age range 83-90, median 87.5. All had presented with Emergent Large Vessel Occlusion (ELVO) and underwent Mechanical Thrombectomy (MT).

Conclusion:
Elderly patients with occult trauma may be at high-risk for serious hemorrhagic complication after receiving IV-tPA. Our findings suggest increased caution in administering IV-tPA to elderly with stigmata of trauma who may have underlying traumatic fracture. Our findings are relevant as alternatives to IV-tPA become available and as rapid advanced imaging enables individualized precision medicine - in elderly patients presenting with concomitant trauma and ELVO who are candidates for MT, the risk versus benefit of IV-tPA may be questioned. Larger studies are needed to validate our findings.
Abstract TP50: Rescue Thrombolysis Or Hemorrhage Reversal In The Emergency Room After Transport By Mobile Stroke Treatment Unit
Authors: Gopal Mangala , Powers Ciaran , Nimjee Shahid M , Heaton Sharon , Forrest Cassandra , Lee Vivien
Published: February 2022

Introduction:
Mobile Stroke Treatment Units (MSTU) can reduce time to pre-arrival intravenous thrombolysis (IVtPA) and reversal for intracerebral hemorrhage (ICH). We are reporting our experience as a comprehensive stroke center (CSC) receiving MSTU patients.

Methods:
We retrospectively reviewed consecutive patients transported by MSTU to our academic CSC from May 2019-May 2021 for suspected stroke. The Columbus MSTU is owned by a separate health system, but is a collaborative venture with 3 CSCs and Columbus Division of Fire, operating daily from 7am-7pm. Data was abstracted on demographics, clinical presentation, last known normal (LKN) time, initial National Institutes of Health Stroke Scale (NIHSS), neuroimaging, and IVtPA administration.

Results:
Among 144 patients transported to our CSC by MSTU, mean age was 66 years (range, 21-99) and 84 (88%) were female. Mean initial NIHSS was 8.6 (range, 0 to 32) and 84 (58.2%) had a final diagnosis of stroke. IVtPA was administered in 26 (18.1%) with a mean LKN to IVtPA time of 109 minutes (range, 41 to 243). Among 26 patients treated with IVtPA, 18 (69.2%) received IVtPA in MSTU and 8 (30.8%) received rescue IVtPA in CSC Emergency Room (ER). 14 patients underwent thrombectomy with median door-to-groin time of 63.5 minutes (range, 28 to 129). We identified 10 (6.9%) cases that received rescue thrombolysis or reversal for ICH after arrival to the CSC ER. Dispatch data was available in 7 of these patients. The median dispatch to on-scene time was 7 minutes (range, 5 to 17). Median dispatch to CSC ER arrival was 53 minutes (range, 40 to 88). Among patients who received rescue therapy in CSC ER, 8 received IVtPA and 2 received reversal for ICH (prothrombin complex concentrate for warfarin and cryoprecipitate/transhexamic acid for IVtPA). Among the 8 MSTU patients who received IVtPA in the CSC ER, reasons included clinical worsening en route (1), new collateral information obtained at the CSC ER (4), and other (3).

Conclusion:
In our series of suspected stroke patients evaluated by MSTU, 6.9% of the overall cases received rescue stroke treatment after arrival to the CSC ER. Among MSTU patients who received IVtPA, 30% had thrombolytic treatment after arrival to the CSC ER. Further studies are warranted to assess limitations of MSTU care.
Abstract TP56: Low Cost, Portable Electroencephalograph May Improve The Accuracy Of Prehospital Stroke Diagnosis And Detection Of Large Vessel Occlusion
Authors: Wilkinson Cassandra M , Burrell Jennifer I , Thangeswaran Jeyaram , Ishaque Noman , Fairall Paige , Kate Mahesh P , Mathewson Kyle E , Buck Brian H
Published: February 2022

Accurate and timely prehospital stroke diagnosis and detection of large vessel occlusion (LVO) are essential to ensure stroke patients are transported to hospitals that offer emergent reperfusion therapies. However, symptom based prehospital stroke scales often fail to identify LVO. Thus, a need exists for cost-effective and portable diagnostic tools, such as portable electroencephalography (EEG) to improve the accuracy of prehospital stroke diagnosis.

Hypotheses: 1) Quantitative EEG measures will differ between LVO and non-LVO stroke patients, particularly in regards to brain slowing (ratio of low to high frequency oscillatory brain power) and brain asymmetry (ratio between oscillations in the affected and unaffected hemisphere) 2) Combining EEG with prehospital stroke scales will improve the accuracy of LVO detection.

We enrolled patients with acute suspected stroke on presentation to an emergency department at a comprehensive stroke centre. Patients were rapidly evaluated with the Los Angeles Motor Scale followed by a 3-minute resting-state EEG recording using a modified Muse EEG headband (InteraXon). The LVO diagnosis and the extent of cerebral blood flow abnormalities were determined from CT angiography and CT perfusion imaging performed in close temporal proximity to the EEG recording.

The study enrolled 74 patients (n= 8 LVO, n=66 non-LVO, including stroke mimics). Initial analysis suggests that LVO patients have trends towards brain slowing, as measured by the delta alpha ratio (LVO: mean = 1.21, SEM = 0.03; non-LVO: mean = 1.19, SEM = 0.01; p-value = 0.34). Additionally, LVO patients showed a trend towards increased brain asymmetry from 6-8 Hz, suggesting physiological differences between hemispheres specific to the theta frequency (LVO: mean = 0.02, SEM = 0.006; non-LVO: mean = 0.01, SEM = 0.002; p-value = 0.13). Quantitative measures will be assessed using classification trees to determine which combination of EEG and clinical features is most predictive of LVO.

In conclusion, acute differences in brain activity between LVO and non-LVO patients can be detected with portable EEG, which when combined with clinical stroke scales, have the potential to improve the diagnosis and triage of suspected stroke patients in a prehospital setting.
Abstract TP60: Stroke Recovery Using Brain Computer Interface
Authors: Hosseini Thomas K , Remsik Alexander B , Nair Veena A , Bui Anthony H , PRABHAKARAN Vivek
Published: February 2022

Introduction:
Non-invasive electroencephalographic (EEG) based brain-computer interface (BCI) therapy has been shown to increase upper extremity mobility in stroke survivors with persistent upper extremity motor impairment. Previous studies have shown that in order to evoke movement from a particular motor system, sensory cues are combined in an essentially linear model. That is, the feedback from each sensory system is summed and torque is generated as a function of the summed signal. This subanalysis aims to evaluate the efficacy of EEG-based BCI-functional electrical stimulation (FES). The goal was to determine whether greater sensory feedback improves BCI task performance in stroke survivors with upper extremity motor impairment.

Methods:
Data were acquired from 31 ischemic stroke patients, with persistent upper extremity motor impairment (mean age = 66 years old, F = 14, M = 17, mean time since stroke onset = 100 months). Participants were kept in one group and all patients received two types of therapies: BCI-only therapy followed by BCI-FES therapy. Participants were instructed to move either their left or right hand to control a virtual cursor in a cursor and target task. A successful trial was recorded if the participant successfully moved the cursor into the target area. The task was first performed with only visual stimulation, then participants received cutaneous stimulation via the paired FES in addition to the visual display of the cursor and target. EEG data was acquired using BCI2000 software and a 16 channel EEG cap.

Results:
Although improvement was seen for participants when they received BCI therapy as well as when they received BCI-FES therapy, BCI performance scores over time were not significantly different from one another (p = 0.13). The BCI-only and BCI-FES pre-study averages were 5.58 (SD = 1.64) and 5.86 (SD = 1.66) respectively and the post-study averages were 5.99 (SD = 1.41) and 6.33 (SD = 1.75) respectively.

Conclusions:
For chronic stroke survivors, both BCI visual only and BCI-FES intervention may help promote restoration of upper extremity motor function at similar rates.
Abstract TP62: Predictive Factors For Depressive Symptoms In The Stroke Recovery Follow-up Period
Authors: Yi Julie , Lu Justin , Yang Annie , Marsh Elisabeth B
Published: February 2022

Introduction:
Although SSRIs are no longer widely prescribed for post-stroke motor recovery, fluoxetine demonstrated beneficial effects on post-stroke depression (PSD). Given potential side effects of SSRIs, targeted initiation among individuals at highest risk for PSD warrants consideration. While previous studies have identified stroke severity and psychiatric history as factors associated with PSD, the predictability of PSD remains unknown. The purpose of this study is to investigate inpatient predictive factors to better identify individuals who might derive the most benefit from targeted initiation of SSRIs.

Methods:
All adult patients presenting to our tertiary academic stroke center with acute ischemic stroke between 2016-2020 were enrolled in a prospectively-collected stroke registry. Patients were seen 4-6 weeks post-discharge and a subset were administered the PHQ-9 (Patient Health Questionnaire-9) to screen for PSD (PHQ-9 ≥5). Demographics, history of depression, stroke severity, and inpatient PHQ-9 scores were abstracted. Logistic regression was used to determine factors associated with PSD and an ROC analysis determined the predictability of PSD in the inpatient setting.

Results:
307 individuals were administered the PHQ-9 at follow-up. This group was younger with less severe strokes, but had no difference in history of depression or inpatient PHQ-9 scores than those without follow-up screening. The mean age of the cohort was 65.5 years; 52% were female. Individuals with history of depression (OR=4.22, 95% CI: 2.40-7.42), inpatient depression (OR=2.82, 95% CI: 1.80-4.43), higher stroke severity (OR=1.05, 95% CI: 1.01-1.10), and those living alone (OR=1.86, 95% CI: 1.01-3.40) had increased odds of PSD at follow-up. Marital status, employment, and outpatient therapy were not associated PSD. The ROC curve using a positive inpatient PHQ-9 achieved an area under the curve (AUC) of 0.62 (95% CI:0.57-0.67), while the AUC was 0.69 (0.64-0.74) after adding history of depression.

Conclusion:
History of depression and a positive inpatient PHQ-9 appear to be most strongly associated with long-term PSD. Initiating SSRIs only in those individuals at higest risk for PSD may help reduce the burden of stroke recovery in this targeted population.
Abstract TP64: Determining The Role Of Single Support Center Of Pressure Distance For Characterizing Post-stroke Walking Impairment And Response To Rehabilitation Training
Authors: Chan Dorothy , Drury Colin , Boyne Pierce E , Dunning Kari , Bhattacharya Amit , Woo Daniel , Kissela Brett , Awosika Oluwole
Published: February 2022

Introduction:
Stroke is a major cause of balance and walking impairment and is on the rise. The most widely used walking impairment measure is the 10-meter walk test (10-mWT), which provides information about walking speed but does not inform about walking kinematics or neuromuscular control.

Objective:
Herein, we evaluate single support center of pressure distance (SS CoP Dist), a kinematic measure of dynamic postural control and walking stability, as a complementary measure of walking impairment. We hypothesize that SS CoP Dist will be closely associated with baseline walking speed, and will improve with Backward Locomotor Treadmill Training (BLTT).

Methods:
Thirty-six chronic stroke survivors with residual walking impairment, based on 10-mWT speed [ mild >0.8 m/s (n =7); moderate 0.4-0.8m/s (n =18); and severe <0.4 m/s (n = 11)] , underwent six 30-minute BLTT sessions over two consecutive weeks. During testing (10-mWT), participants were instructed to walk as fast as possible over the gait analysis mat to capture SS CoP Dist and walking speed.

Results:
At baseline, there was a weak to moderate positive relationship between walking speed and SS CoP Dist (R
2
paretic
= 0.22,
p
= 0.0036; R
2
Nonparetic
= 0.44,
p
< 0.0001). Following BLTT, SS COP Dist increased (more stable) in the mild and moderate groups [mild
paretic
(
p
= 0.0039)/mild
Nonparetic
(
p
= 0.0034)
,
moderate
paretic
(
p
= 0.0360)/ moderate
Nonparetic
(
p
= 0.0087)], with improved interlimb symmetry in the mild group. In contrast, no significant improvement in SS CoP Dist was seen in participants with severe walking impairment (
p
= 0.3830). Training-related changes in walking speed were strongly correlated with change in SS CoP Dist (R
2
Nonparetic
= 0.54,
p
= 0.0007).

Conclusion:
Our preliminary findings suggest that SS CoP Dist compliments walking speed for characterizing walking severity and response to training in chronic stroke survivors. In addition, BLTT significantly improved SS CoP Dist in mild-moderately impaired stroke survivors but not in survivors with severe walking impairment. Future well-powered, prospective studies with BLTT and other training paradigms are needed to validate these findings.
Abstract TP7: Phase 2a Study Of Elezanumab In Patients With Acute Ischemic Stroke
Authors: Smith Elaine , Ford Andria L , Perez-Sanchez Soledad , Shuaib Ashfaq , Schwefel Brittany , Ziemann Adam
Published: February 2022

Introduction:
Treatment of acute ischemic stroke focuses on reperfusion but is limited by timing and other exclusions, and despite intervention, patients may sustain residual neurologic impairment. In addition to initial excitotoxic reactions following occlusion, upregulation of factors such as repulsive guidance molecule A (RGMa) inhibits cell survival and neuronal repair in infarcted regions. In vivo neutralization of RGMa is associated with decreased lesion size, reduced glial scarring, and enhanced functional recovery in animal models of cerebral artery occlusion; thus, RGMa suppression represents a novel therapeutic target due to its potential protective and restorative mechanisms. Elezanumab is an investigational monoclonal antibody that binds specifically to RGMa and is being evaluated for its function after ischemic stroke.

Methods:
Elezanumab in Acute Ischemic Stroke (EAISE) is a 52-week, phase 2a, randomized, double-blind, placebo-controlled study evaluating safety, efficacy, and pharmacokinetics of elezanumab in patients with acute ischemic stroke (NCT04309474). Patients will be randomized 1:1 within 23 hours since “last known normal” to receive elezanumab or placebo and every 4 weeks thereafter through week 48. Patients must be aged 30-90 years with a clinical diagnosis of acute ischemic stroke in anterior circulation and have a National Institutes of Health Stroke Scale (NIHSS) total score of 7 to 21. Patients who receive tissue plasminogen activator or endovascular therapy will be eligible if they continue to exhibit an NIHSS of 7 to 21 after treatment. Patients with evidence of seizure on stroke onset and history of repeated episodes of complex migraines will be excluded.

Results:
Projected enrollment is 120 patients across 45 sites in multiple countries. Primary endpoint is the NIHSS total score throughout the treatment period. Secondary endpoint is a favorable outcome based on the modified Rankin Scale, defined as a score of 0-2 at week 52. Exploratory outcomes include activities of daily living, cognition, mood, and fluid and imaging biomarkers.

Conclusion:
This phase 2 study will evaluate safety and efficacy of elezanumab, a novel therapeutic intervention to improve neurological recovery after acute ischemic stroke.
Abstract TP74: Risk Assessment Of The Acute Stroke Diagnostic Process
Authors: Holl Jane , Maas Matthew , Song Sarah , Vargas Alejandro , Romo Elida , Prabhakaran Shyam
Published: February 2022

Introduction:
Acute stroke (AS) is a high-harm, high-cost condition that affects nearly 800,000 people/year in the US. Proven, time-sensitive treatments can reduce disability. However, to deliver an AS treatment, a timely and accurate diagnosis is first needed. Yet, diagnostic error is the most common type of error in AS, occurring in ~10% of AS patients, and higher in patients with mild or atypical presentations.

Hypothesis:
The identification, characterization, and ranking of failures of the AS diagnostic process, by clinicians who provide AS care in the ED, is an essential step prior to designing feasible, robust, and effective solutions to reduce AS diagnostic error.

Methods:
A Learning Collaborative (LC) of clinicians involved in the AS diagnostic process at 3 health systems in Chicago, IL participated in a Failure Modes, Effects, and Criticality Analysis (FMECA) to identify the steps in the AS diagnostic process, failures of each step and their underlying causes, and to characterize each failure’s frequency (F), impact (I) on making a timely and accurate AS diagnosis, and any existing safeguards (S), using standardized scores. A risk priority index (RPN=FxIxS) and a criticality number (CN=FxI) was calculated for each failure and rank ordered.

Results:
In a series (N=7) of 60-90 minute virtual sessions, the LC, comprised of Emergency Medicine (N=9), Neurology (N=10), and Radiology (N=1) clinicians of all professions (MD, RN, Technician) and levels (resident, attending, coordinator), created an AS diagnostic process map and risk table. The process map included 27 specific steps. The highest risk steps were failure to use a severe stroke/large vessel occlusion scale (RPN=432; CN=72); inability to establish patients’ last known well (RPN=384; CN=48); failure to use an AS screening scale (RPN=384; CN=54); lack of a “witness” of the event to confirm information (RPN=378; CN=42); and failure to recognize potential stroke and activate a stroke code at triage (RPN=288; CN=48).

Conclusion:
This study, for the 1
st
time, reveals specific targets, particularly in the early phase of the AS diagnostic process, for which solutions should be designed (e.g., standardized process to use a severe stroke/LVO tool) to reduce AS diagnostic error.
Abstract TP83: Benefit Of Multimodal Intraoperative Neuromonitoring Techniques During Carotid Procedures
Authors: Nguyen Brandon , Aulivola Bernadette , Joyce Cara , Schneck Michael J
Published: February 2022

Background:
Carotid intervention is done for reduction of stroke risk. Intraoperative neuromonitoring (IOM), including electroencephalography (EEG), somatosensory evoked potential (SSEP), and cerebral oximetry/near-infrared spectroscopy (NIRS) may be used to guide operative decision-making and minimize the risk of perioperative complications. The utility of combining IOM methods is unclear. Therefore, we sought to investigate the value of multimodal IOM for carotid interventions.

Methods:
A retrospective review of all patients undergoing carotid intervention from January 1, 2012 to December 31, 2019 at a single academic medical center was done. Patients with acute stroke undergoing catheter directed thrombectomy were excluded. Data collected included: patient demographics, IOM parameters, surgical intervention with endpoints of 30-day post-operative complications. Surrogate end-points of IOM change and intraoperative hemodynamic interventions were also assessed. Efficacy and diagnostic value of each IOM modality alone, and in combination, were assessed using multivariable logistic regression.

Results:
409 carotid interventions in 311 patients meeting inclusion criteria were identified. Patients were 63.3% male, 36.7% female, 83.4% white, 7.1% Hispanic, and 5.9% other. 162(39.6%) interventions were performed for ipsilateral symptoms including 111(27.1%) ipsilateral stroke, 91(22.3%) TIA. Use of a single versus multiple IOM modalities was not associated with a reduction in post-operative neurologic events. Changes in SSEP demonstrated a 2.97 odds ratio for predicting neurologic adverse events (AE), though this was not statistically significant.

Conclusion:
IOM changes were associated with an increase in AEs but IOM impact on intraoperative changes in surgical plans were infrequent. It is unclear whether IOM had a significant impact on procedural modifications though this may reflect an underpowered sample size. The low impact of IOM on outcome raises the question of cost-effectiveness of these techniques in reducing intraoperative complications from carotid procedures.
Abstract TP9: Depression And Not Cognitive Ability Is Most Strongly Associated With Long-term Functional Outcomes Following Stroke
Authors: Drag Lauren L , Musabbir Muhith , Mlynash Michael , Mendez Maria P , Kim Da Eun K , Aghaeepour Nima , Lansberg Maarten G , Buckwalter Marion S
Published: February 2022

Introduction:
Cognitive impairment is common following stroke and is associated with poor functional outcomes. We examined how cognitive domain and depression scores predict long-term functional disability following stroke.

Methods:
Data were analyzed from 70 participants with chronic ischemic stroke as part of the StrokeCog study. The battery yielded a global composite score and composite scores of memory, processing speed, working memory, language, and spatial ability. The Stroke Impact Scale was used to assess depression (SIS-Depression) and 3 functional disability measures: subjective memory and thinking (SIS-Cognition), activities of daily living (SIS-ADL), and participation in work, social, and leisure activities (SIS-Participation). A correlation network was constructed using a t-SNE algorithm to examine relationships amongst variables. Partial least squares analyses (PLS) were used to determine whether cognitive domains and depression predicted functional disability, with depression, cognitive composites, age, stroke severity (NIHSS), and fatigue (FACIT) as predictor variables.

Results:
Both the t-SNE plot and PLS indicated that functional disability is more closely related to depression than to cognitive composite scores. PLS analyses demonstrated that depression was the most significant predictor of SIS-Cognition, SIS-Participation, and SIS-ADL, accounting for 37%, 60%, and 47% of the variances, respectively. Processing speed accounted for an additional 11% of variance in SIS-Cognition. Spatial ability accounted for an additional 12% of variance in SIS-Participation and an additional 12% of variance in SIS-ADL. There were no other significant predictors.

Conclusions:
Depression was significantly associated with all 3 of the long-term functional outcomes we examined. Neuropsychological performance (namely processing speed and spatial ability) was also associated with functional disability, but to a lesser degree than depression, even for self-reported cognition. These findings are of interest given that depression is a common but treatable sequela of stroke.
Abstract TP92: Inappropriately Prolonged Dual Antiplatelet Therapy In The Treatment Of Stroke And Transient Ischemic Attack At An Urban Safety Net Hospital
Authors: Ford Thomas , Sahoo Anurag , Spears William E , Elhassan Noon , Weinberg Janice , Romero Jose R
Published: February 2022

Introduction:
Time-limited dual antiplatelet therapy (DAPT) with aspirin and clopidogrel has emerged as an important treatment modality for secondary stroke prevention in patients with symptomatic intracranial atherosclerotic disease, minor stroke, or high-risk transient ischemic attack. However, continuation beyond the indicated treatment period may expose patients to bleeding risk without additional benefit.

Methods:
We conducted a retrospective study of a prospectively maintained registry (the Get-With-The-Guidelines database at our hospital) evaluating patients discharged on time-limited DAPT for secondary stroke prevention between January 1st, 2019 and July 31st, 2020. Intended and actual duration of therapy were extracted from clinical notes and prescription records. We assessed the frequency of inappropriate continuation within the entire cohort and performed univariate analyses to assess for differences in outcome with respect to clinical and demographic characteristics, including social determinants of health (such as race and primary spoken language).

Results:
Of the 127 patients included, 17 (13%) had inappropriately prolonged treatment with DAPT. Black patients had a significantly higher incidence of inappropriate continuation than non-Black patients and individuals speaking languages other than English or Spanish exhibited a trend toward more frequent occurrence. Patients intended to transition to monotherapy with clopidogrel and those initially presenting with stroke (rather than transient ischemic attack) had similar trends toward more frequent occurrence.

Conclusions:
Our study represents the first attempt to approximate the incidence of inappropriate prolongation of time-limited DAPT for secondary stroke prevention at a hospital caring for a large underserved population. Our results suggest that social determinants of health may contribute to this phenomenon, but further studies are required to replicate our observations in larger multicenter cohorts. Systems-based interventions should be aimed at ensuring proper duration of therapy to minimize bleeding risk and other side effects.
Abstract TP94: Stroke Severity Scales Do Not Predict Adverse Hospital Outcome Variables In Young Stroke Patients: Results From A Regional Stroke Center Of Excellence
Authors: Armaignac Donna L , Ramamoorthy Venkataraghavan , Rubens Muni , Belnap Starlie , Starosciak Amy K , Ramirez Maygret , De Los Rios La Rosa Felipe
Published: February 2022

Introduction:
Acute ischemic stroke (AIS) among young patients is increasing in the US. This study sought to describe the risk factors, clinical characteristics, and hospital outcomes of young AIS patients who were treated in intensive care units (ICU).

Methods:
The current study was retrospective analysis of electronic healthcare data from a Regional Comprehensive Stroke Center of Excellence. The data was collected from admitted patients between Oct 2016 and Feb 2021 and included AIS patients between 18 and 45 years of age. Correlation and regression analysis were performed in order to understand the relation between risk predictors such as Acute Physiology and Chronic Health Evaluation (APACHE) IV score, Acute Physiology Score (APS), National Institute of Health Stroke Score (NIHSS), and Intensive Care after Thrombolytic (ICAT) and hospital outcomes.

Results:
There were 217 young AIS patients and 50.2% were males. More than half of the patients were white Hispanic (54%), followed by African American (24%), and whites (13%). Nearly 8% patients received intravenous thrombolysis, 2% endovascular reperfusion therapy, and 6% both treatments. Nearly 16% were smokers, 46% were hypertensive, 31% were dyslipidemic, 18% had previous stoke, 49% were obese or overweight, 18% were diabetic, 2% had carotid stenosis, 6% had CAD, and 1% had dysrhythmia. The mean (standard deviation) of APACHE, APS, NIHSS and ICAT scores were 5.0 (3.8), 33.8 (17.5), 5.5 (8.5), and 1.5 (1.5) respectively. Severity adjusted mean (SD) length of stay in hospital and ICU were 1.2 (0.9) and 1.2 (1.2) days, respectively. Severity adjusted ventilator days were 1.7 (2.1) days. Mean severity (SD) adjusted ICU and in-hospital mortality rates were 0.05 (0.54) and 0.60 (2.8) respectively. Analysis showed no association between risk predictors and adverse hospital outcome variables.

Conclusion:
Risk predictor scores did not predict adverse hospital outcomes in our AIS patients. Significant number of young AIS patients had chronic conditions which could have increased their stroke risk. Considering that majority of stroke risk factors are modifiable, strategies to decrease these risk factors to lower stroke rates should be prioritized among all these patients, independent of their risk scores.
Abstract TP97: White Matter And Deep Grey Matter Structural Variations In Childhood Moyamoya Disease
Authors: Walker Kirstin , Domi Trish , Burton Isaiah , Choi Eun Jung , Robertson Amanda , Mangone Lorenzo , Kassner Andrea , Krishnan Pradeep , Muthusami Prakash , Deveber Gabrielle A , Logan William , Dlamini Nomazulu
Published: February 2022

Background:
Moyamoya disease is a progressive steno-occlusive arteriopathy that increases stroke risk. Clinically, cognitive decline is known to occur over time, even in the absence of stroke. MRI measures of cerebrovascular reactivity (CVR) provide an in vivo assessment of cerebrovascular reserve and stroke risk. Typically, in normal-appearing white matter (WM) lower (quantified as negative) CVR is associated with increased apparent diffusion coefficient (ADC). However, the association between negative CVR and ADC in children is not well understood.

Objectives:
To determine (i) whether negative CVR is associated with changes in ADC in normal-appearing WM of children with Moyamoya, ii) whether there is an association between CVR and ADC with structural damage to the brain (by measuring the volume of subcortical structures).

Methods:
Retrospective analysis of a consecutive cohort of nine children with Moyamoya (male = 4, median age = 12.1) with no history of stroke, and seven age and sex-matched controls. ADC values and fractional negativity (fneg), calculated from CVR parametric maps as the fraction of negative CVR voxels within a region of interest (ROI), were extracted from WM and subcortical GM ROIs. Volumes from the subcortical GM regions were extracted and normalized for head size. Analyses of differences was calculated per hemisphere (n=18, bilateral disease n = 4, unilateral n=5) and categorized as affected and unaffected and compared to controls.

Results:
Mean (m) ADC in WM of affected hemispheres (m=807.05, p<0.01) and unaffected (m=814.68, p<0.05) hemispheres were significantly larger compared to controls (m=761.04). A positive relationship was found between fneg and ADC in affected (r=0.37, p=0.24) and unaffected (r=0.26, p=0.62) hemispheres, but with no statistical significance. Increased ADC in the caudate was associated with smaller volume in the affected hemisphere of patients (r =-0.83, p=0.02).

Conclusions:
ADC in normal appearing WM in children with Moyamoya is elevated, and is associated with volume of the caudate in this cohort demonstrating the association between abnormal CVR, perfusion and structural damage in children with Moyamoya and no stroke.
Abstract WMP106: Acute Ischemic Stroke Treatments And Outcomes In Patients With Hematological Malignancies
Authors: Garg Aayushi , Chopra Saurav , Leira Enrique C. C , Shaban Amir
Published: February 2022

Background:
There is limited evidence to guide treatment decisions in patients with acute ischemic stroke (AIS) who have concurrent hematological malignancies. In this study, we aimed to evaluate the impact of acute stroke interventions and clinical outcomes in this patient population.

Methods:
Hospitalizations with primary diagnosis of AIS were identified from the Nationwide Readmissions Database 2016-2018. Hospital records with age<18 or with concomitant diagnosis of solid organ malignancy were excluded. Logistic regression was used to compare the differences in acute stroke interventions and clinical outcomes in patients with and without hematological malignancies. Survival analysis was used to evaluate recurrent AIS after discharge.

Results:
There were 1347150 hospitalizations due to AIS (mean±SD age 70.3±14.1 years, female 50.2%). Of these, 11863 (0.9%) had a concurrent diagnosis of hematological malignancy. Patients with malignancy were older and were less likely to have comorbid cerebrovascular risk factors, except atrial fibrillation. Patients with malignancy were less likely to receive intravenous thrombolysis (tPA) but the rates of endovascular thrombectomy (ET) did not differ between the two groups. After adjustment for baseline differences, patients with malignancy had higher in-hospital mortality [odds ratio (OR): 1.2, 95% confidence interval (CI): 1.0-1.3] but other outcomes like intracranial hemorrhage and discharge disposition were comparable between the two groups. Sub-group analysis according to the type of malignancy (leukemia, lymphoma, plasma cell neoplasms, histiocytic/other) showed that only patients with leukemias had higher mortality and adverse discharge disposition. Among the subgroups of patients treated with tPA or ET, the clinical outcomes were comparable between patients with and without malignancy. Further, the overall risk of readmission due to recurrent ischemic stroke was also similar between patients with and without malignancy (hazards ratio: 1.0, 95% CI: 0.9-1.1).

Conclusion:
Acute reperfusion in ischemic stroke is safe in patients with hematological malignancies. While patients with malignancy have higher in-hospital mortality, they are not at an increased risk of stroke recurrence.
Abstract WMP110: Cerebral Ischemia-Reperfusion Alters Postsynaptic Kinase Activities Through Ubiquitination
Authors: Palfini Victoria , Poon Carrie , Resch Ulrike , Kahl Anja , Hambright Emma , Blanco Ismary , Benakis Corinne , Balachandran Vaishali , Zhang Sheng , Iadecola Costantino , Hochrainer Karin
Published: February 2022

Background:
Aberrant activity of the postsynaptic density (PSD)-associated kinases CaMKII, PKC, Pyk2 and Cdk5 contributes to post-ischemic neuronal death. However, the mechanism(s) leading to altered activity after ischemia have not been discovered. We investigated the role of ubiquitination in post-ischemic PSD kinase activity regulation.

Methods:
Cerebral ischemia was induced in male C57BL6 mice by middle cerebral artery occlusion (MCAO), followed by 1-hour reperfusion. Ubiquitinated and phosphorylated proteins in the ischemic neocortex were identified by nanoLC-MS/MS and analyzed for GO enrichment. PSD isolation was carried out by detergent extraction. Kinase ubiquitination was confirmed by co-immunoprecipitation with ubiquitin. Protein phosphorylation was assessed with phospho-specific antibodies and kinase activities were measured by transfer of γ
32
P to peptide substrates. Removal of ubiquitin from PSD lysates was achieved by addition of USP2 deubiquitinase.

Results:
MS analysis revealed that MCAO increases ubiquitination of proteins associated with the PSD (p=5.14x10
-33
, n=60/group). This is also evidenced by biochemical detection of ubiquitin at the synapse and PSD but not cytosol of cortical MCAO extracts (p<0.001, n=6/group). Interestingly, a significant number of ubiquitinated PSD proteins exhibit kinase activity (p=1.02x10
-23
, n=60/group) and include the kinases CaMKII, PKC, Pyk2 and Cdk5, which were biochemically verified (n=3/group). Concurrent with ubiquitination, MCAO also changes the phosphorylation state of PSD-associated proteins (p=3.66x10
-13
, n=60/group). Pyk2 and Cdk5 target sites are hyper-phosphorylated in post-ischemic PSD extracts, while CaMKII and PKC targets show decreased phosphorylation (p<0.05, n=5/group). In line with this, post-ischemic CaMKII (-69±6% of sham, p<0.001, n=9/group) and PKC (-63±8% of sham, p<0.001, n=6/group) activities are severely suppressed at the PSD, which is restored by de-ubiquitination (CaMKII: 105.8±23% of sham, n=6/group; PKC: 101.4±11% of sham, n=4/group).

Conclusions:
Ubiquitination is a potent and reversible modulator of kinase activity at the PSD that could impact tissue outcome and, as such, may open new avenues for the treatment of ischemic stroke.
Abstract WMP14: White Matter Free Water Drives Diffusion Abnormalities And Correlates With Conventional MRI Markers Of Small Vessel Disease In Cerebral Amyloid Angiopathy
Authors: Zanon Zotin Maria Clara , Chokesuwattanaskul Anthipa , Schoemaker Dorothee , Sveikata Lukas , Greenberg Steven , Viswanathan Anand
Published: February 2022

Introduction:
Increased extracellular fluid, measured by the free water (FW) diffusion model, was found to be the main contributor to diffusion tensor imaging (DTI) alterations in monogenic and sporadic non-amyloid cerebral small vessel diseases (SVD). We investigated whether the FW component also drives DTI changes in cerebral amyloid angiopathy (CAA) and to what extent it correlates with conventional MRI markers of SVD.

Methods:
Non-demented probable CAA patients, without symptomatic intracerebral haemorrhage, were recruited from a memory-clinic cohort and underwent structural MRI, including diffusion-weighted imaging. Primary DTI metrics (mean diffusivity [MD] and fractional anisotropy [FA]), FW maps and tissue compartment tensors (tMD, tFA) were computed using a freely available script (https://markvcid.partners.org/). To reduce contamination by cerebrospinal fluid, diffusion metrics were analyzed within the white matter skeleton, using tract-based spatial statics. White matter hyperintensities (WMH) and total brain volume (TBV) were normalized by total intracranial volume. Images were rated for lobar microbleeds count (CMB), perivascular spaces scored in the centrum semiovale (CSO-PVS), and presence of cortical superficial siderosis.

Results:
Thirty-eight subjects (mean age 72.5 ± 7.4 years; 47.4% female) were included in the analysis. In simple linear regression models, conventional mean MD and FA were more strongly associated with the FW component (β=0.999, p<.001; β=-0.907, p<.001, respectively) than with their respective tissue compartment tensors (β=0.263, p=.111; β=0.659, p<.001, respectively). In multivariable regression analyses, adjusted for age, WMH (β=0.395, p=.002), CMB (β=0.346, p=.003) and CSO-PVS (β=0.496, p<.001) were independently associated with mean FW, whereas TBV was the only independent predictor for tissue compartment metrics (tMD and tFA) (β=0.506, p=.033; β=0.505, p=.040, respectively).

Conclusion:
FW imaging findings suggest that DTI changes in CAA are mainly driven by increased extracellular fluid rather than disruption of fiber structure. FW content was strongly associated with core SVD MRI markers, which could imply similar underlying pathogenesis.
Abstract WMP16: Race, Gender, And Cognition In Heart Failure
Authors: Ibeh Chinwe , Pavol Marykay , Willey Joshua Z
Published: February 2022

Background:
Cognitive impairment is prevalent in the heart failure (HF) population, eventually complicating the disease course in over 50%. Disease management and risk factor control are thought to play a role. Disparities in healthcare utilization and access may also contribute. We hypothesize gender, ethnic and racial disparities in HF contribute to accelerated cognitive decline.

Methods:
We performed a cross-sectional analysis of study participants age ≥ 60 years in the biannual NHANES survey. Medical history, clinical variables, and Digit Symbol Substitution Test (DSST) scores from cycles 1999, 2001, 2011, and 2013 were extracted. The DSST assesses visuomotor, attention, and processing speed, and in prior studies was found to be strongly associated with vascular-related cognitive impairment. Survey-weighted regression models adjusting for age, race, gender, education, vascular risk factors and history of stroke were used to generate nationally representative estimates.

Results:
6,651 study participants representing 51,841,223 adults ≥ 60 years were included, 7% with prevalent HF. Participants with HF were older (73.8 vs 70.0, P <0.001) but there were no significant differences in the proportion of women or in the racial/ethnic makeup of participants with and without HF. Stroke was 3 times more prevalent in the HF population (20.1% vs 6.5%, P <0.001). Individuals with HF had significantly lower DSST scores (mean 39.6 [0.97] vs 50.2 [0.45], P<0.001). We found a significant interaction between HF and sex (P <0.10). Among men, prevalent HF was associated with a 2.95 (95% CI: -4.75, -1.16) decrease in DSST. In women, larger decreases in cognition were observed (-5.18, 95% CI: -7.34, -3.02). There was no interaction between heart failure and race.

Conclusions:
Women with HF experience greater levels of HF-related cognitive impairment. These differences may be a consequence of known differential rates of early HF detection and disease maintenance across genders.