bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P377: Real-Word Performance of Two Automated Software Platforms for Large-Vessel Occlusion Identification in Acute Ischemic Stroke Patients: A Single Center Experience
Authors: Katramados Angelos M , Kole Maximilian , Marin Horia , Alsrouji Owais , Varun Pala , Miller Daniel , Hefzy Hebah , Malik Shaneela , Ramadan Ahmad Riad , Mitsias Panayiotis D , Rehman Mohammed , Brady Megan , Scozzari Dawn , Lewandowski Christopher A , Danoun Omar A , Grover Kavita , Newman Daniel , Barkley Gregory L , Chebl Alex B
Published: March 2021

Background and purpose:
Modern stroke treatment has been revolutionized by image-guided selection of patients for endovascular thrombectomy. Current automated platforms allow for real-time identification of large vessel occlusion and salvageable brain tissue. We had previously demonstrated that a “CTA for all” policy for stroke patients immediately upon arrival assists in the earlier identification of treatment candidates. We now sought to evaluate the performance of these platforms under this policy.

Methods:
All patients that presented to Henry Ford Health System hospitals over a period of 6 weeks received CTA of the head and neck upon initial presentation. The images were processed with two automated software platforms. We prospectively collected processing times, large-vessel-occlusion alerts, performance warnings, and LVO density ratios. We compared these with the interpretations of board-certified radiologists, and analyzed the performance of each platform.

Results:
276 patients presented with stroke symptoms and received CT angiography upon presentation. Both platforms were able to image all stroke patients within their FDA-approved indications. Both platforms were noted to have comparable sensitivity, specificity, PPV and NPV, and excellent accuracy. The overall prevalence of LVO was extremely low (8/276). As a result, for both, NPV was much better than PPV because of the percentage of false positive results. Further ROC analysis, demonstrated an area under the ROC curve of 0.982, and overall model quality of 0.97. Optimal LVO density cutoff was <0.093 in order to maximize overall accuracy, or
<
0.271, in order to maintain a sensitivity of 100% as an absolute priority (both significantly lower than the current threshold of <0.45).

Conclusions:
Automated software platforms are an invaluable aid in the selection of patients for endovascular thrombectomy. Different LVO detection algorithmic thresholds may be necessary (and should be part of individual stroke center validation pathways) to avoid fatigue alert, and optimize test accuracy, when LVO prevalence is low. Stroke teams should be aware of the limitations of automated analysis and need for expert review.
Abstract P379: Automatic Segmentation of Atherosclerotic Plaques in Transverse Carotid Ultrasound Images Using Deep Learning
Authors: Yeo Leonard L , Engin Melih , Lange Robin , Tang David , Nemes Andras , Monajemi Sadaf , Mohammadzadeh Milad , Ebrahimpour Laleh , Sharma Vijay
Published: March 2021

Purpose:
Ultrasound imaging is commonly used for patients with atheroscelerotic plaques in the carotid artery. While B-mode ultrasound can be used for detection and measurement of these plaques, interpreting these images can be a subjective and time-consuming task. Deep learning algorithms have been proven to be an effective tool for interpreting medical images, especially for classification and segmentation tasks. Here, we propose a deep learning model to automatically detect and measure plaques in transverse B-mode images of the carotid artery.

Methods:
The proposed automated method takes a transverse B-mode image of the carotid artery as an input and segments the vessel wall in the transverse cross section image using convolutional neural networks. To ensure that the method can perform well in clinical settings, the method has been evaluated on not only healthy subjects (max IMT below 1.2 mm) but also on patients with atheroscelerotic plaques and other vessel wall pathology. Given the B-mode transverse image as an input, the neural network first finds a region of interest (ROI) surrounding the artery and then segments both the inner and outer wall of the carotid artery. We determined the accuracy of the system by F1 Score, a common metric to evaluate the performance of machine learning algorithms.

Results:
The network was trained and tested on a transverse ultrasound carotid artery dataset that has 506 images, gathered from 4 hospitals. Annotations of an expert reader were used as the ground truth and the performance of the method was evaluated using 5-fold cross validation. The proposed method reaches an F1 score of 0.91 for correctly detecting the ROI and an F1 score of 0.78 for detecting and segmenting the vessel walls in transverse B-mode images.

Conclusions:
The results show that the proposed deep learning method can be used for accurate analysis and interpretation of carotid ultrasound scans in a clinical setting and potentially reduce the reporting time while increasing objectivity of the analysis.
Abstract P381: Pre-Treatment Perfusion Mismatch Volumes in Ischemic Stroke Patients Treated With Tenecteplase or Alteplase
Authors: Dula Adrienne N , Alrahwan Ian M , Warach Steven J
Published: March 2021

Introduction:
The overall goal of this study is to evaluate the relationship of pretreatment perfusion mismatch volumes to outcomes in patients receiving alteplase (ALT) to those receiving tenecteplase (TNK).

Methods:
This study included patients receiving treatment with ALT (0.9 mg/kg; max, 90 mg) or TNK (0.25 mg/kg; max, 25 mg) between 09/01/2017 - 06/30/2020 identified through our local stroke registry stroke registry. Of the 505 patients meeting these criteria, 280 have been screened, including patients receiving EVT (n=94) and a sampling of n=111 from the ALT group and 75 from the TNK group. Final eligibility will be patients with a pretreatment perfusion deficit, mismatch > 15 mL, and mismatch (MM) ratio ≥ 1.2. Volumes are based on RAPID software (iSchemiaView). Using univariate (chi-squared with continuity correction or Mann-Whitney U) and adjusted logistic models, the effect of lysis type and pre-treatment imaging were assessed on the primary outcome of discharge disposition.

Results:
A total of 93 patients were included in our analysis, 40 receiving ALT and 53 patients receiving TNK, demographics found in Table 1. Discharge to home occurred in 48.8% (20/40) of patients treated with ALT and 30.7% (16/53) treated with TNK, odds ratio (OR), 0.47; 95% CI [0.20, 1.09], (P-value for OR=0.0766). Upon adjustment for EVT, age, sex, NIHSS on admission, imaging modality, cohort imbalances (marked by *), and MM, the relation of lysis type to discharge to home gave an OR of 0.25; 95% CI [0.06, 0.90], P= 0.0383) with age (P<0.0001) and imaging modality (P=0.0020) significantly contributing to the model. Lysis type did not significantly influence discharge to hospice or death (OR, 0.62; 95% CI [0.05, 6.86], P=0.6945) upon adjustment for baseline factors.

Conclusion:
In this preliminary analysis, MM volumes did not contribute to the outcome of discharged to home. Analysis of the full cohort is ongoing and final analyses will relate lytic type to infarct volume growth and clinical outcomes.
Abstract P387: Stroke Despite Anticoagulation Therapy Predicts Early Recurrence After Cardioembolic Stroke: The IAC-Study
Authors: Yaghi Shadi , Henninger Nils , Leon Guerrero Christopher , Mistry Eva , Liberman Ava L , Asad Syed Daniyal , Liu Angela , Nagy Muhammad , Kaushal Ashu , Azher Aidan , Mac Grory Brian C , Fakhri Hiba , Espaillat Kiersten , Pasupuleti Hemanth , Martin Heather , Tan Jose T , Veerasamy Manivannan , esenwa charles , Cheng Natalie , Moncrieffe Khadean , Moeini-Naghani Iman , Siddu Mithilesh , Trivedi Tushar , Lord Aaron , Furie Karen L , Keyrouz Salah G , Nouh Amre , De Havenon Adam H , Khan Muhib , Giles James A
Published: March 2021

Background and purpose:
A proportion of patients with ischemic stroke and atrial fibrillation (AF) have an ischemic stroke despite being prescribed anticoagulation therapy. In this study of patients with ischemic stroke in the setting of AF, we aim to determine the association between prior anticoagulant therapy and 90-day recurrent ischemic events and delayed symptomatic intracranial hemorrhage (sICH).

Methods:
We included consecutive patients with acute ischemic stroke and AF from the Initiation of Anticoagulation after Cardioembolic stroke (IAC) study from 8 comprehensive stroke centers in the United States. We compared recurrent ischemic events and delayed sICH risk using unadjusted and adjusted cox-regression analyses between patients who were prescribed anticoagulation (AC
p
) vs. were naïve to anticoagulation therapy prior to the ischemic stroke (AC
n
). For ischemic events, we adjusted for CHA
2
DS
2
-Vasc, anticoagulation initiation, and switching anticoagulant (DOAC to Warfarin or Warfarin to DOAC). For delayed sICH, we adjusted for age, sex, NIHSS score, and early hemorrhagic transformation.

Results:
2070 patients had home anticoagulation treatment status recorded. When compared to the AC
n
group, the AC
p
group were more likely to have higher median (IQR) CHA
2
DS
2
-Vasc score [5 (4-6) vs. 5 (3-6), p = 0.001], lower NIHSS score [8 (3 - 18) vs. 10 (4 - 18), p = 0.015], severe left atrial enlargement (43.5% vs. 34.5%, p < 0.001), and less likely to receive alteplase (14.4% vs. 36.2%, p < 0.001). In the adjusted cox hazard model, AC
p
was associated with increased risk of 90-day recurrent ischemic events (adjusted HR 1.52 95% CI 1.01 - 2.29, p = 0.047) but not increased risk of 90-day sICH (adjusted HR 1.10 95% CI 0.46 - 2.61, p = 0.838). In a sensitivity analysis, with severe left atrial enlargement added to the model, the association between AC
p
and recurrent ischemic event risk did not meaningfully change (adjusted HR 1.41 95% CI 0.87 - 2.28, p = 0.162).

Conclusion:
Patients with AF and ischemic stroke despite being prescribed anticoagulation therapy are at higher risk of recurrent events. Studies are needed to understand mechanisms of ischemic stroke in these patients to improve stroke prevention strategies.
Abstract P388: Trends in Cardiac Monitoring After Ischemic Stroke and Transient Ischemic Attack: The Florida Puerto Rico Atrial Fibrillation Stroke Study
Authors: Sur Nicole B , Wang Kefeng , Koch Sebastian , Di Tullio Marco , Gutierrez Carolina M , Dong Chuanhui , Gardener Hannah , Garcia-Rivera Enid J , Zevallos Juan C , Burgin William S , Rose David , Goldberger Jeffrey J , Romano Jose G , Sacco Ralph L , Rundek Tatjana
Published: March 2021

Introduction:
Prolonged cardiac monitoring after cryptogenic stroke reveals a cardiac cause in up to 30% of patients; however, practice patterns for monitoring vary widely. We sought to evaluate overall and race/ethnic trends in the rate of ECG monitoring and types of cardiac monitoring performed after ischemic stroke and transient ischemic attack (TIA) across a network of hospitals in Florida and Puerto Rico(PR).

Methods:
We identified 46,878 ischemic stroke and TIA cases with data on ECG monitoring in the Florida Stroke Registry from 2016-18. Univariate analysis was performed to determine the overall rate of ECG monitoring and the characteristics of patients who received cardiac surface monitoring ≤7days and >7days, and implantable cardiac monitoring. Multivariate logistic regression was performed to identify factors associated with the types of monitoring.

Results:
Overall, 39,333 (84%) patients admitted for stroke/TIA received ECG monitoring during hospital admission (mean age 71±14 years; 49% female; 63% white, 18% black, 15% FL-Hispanic, 4% PR-Hispanic). Compared to patients who received ECG monitoring, patients who did not were more likely to be younger (mean age 70±15 years), PR-Hispanic (24% vs 4.3%), and have TIA (13% vs 8%), Medicare (42% vs 35%), large vessel disease (14% vs 9%) and greater admission NIHSS (median score 5 vs 4). After adjustment, smokers and patients >80years were less likely to receive ECG monitoring overall (OR 0.95, 95% CI 0.9-0.99 for both). Black race was associated with receiving extended surface monitoring >7 days (OR 1.15, 95%CI 1.04-1.26), but negatively associated with implantable cardiac monitoring (OR 0.81, 95%CI 0.68-0.96). Patients with moderate/severe stroke had higher odds of extended surface monitoring >7days (OR 2.29, 95%CI 1.89-2.77), yet lower odds of implantable cardiac monitoring (OR 0.80, 95%CI 0.71-0.89).

Conclusion:
The majority of patients received ECG monitoring during hospital admission for stroke/TIA; however, significant differences were found with respect to age, race/ethnicity and stroke severity across the various types and duration of cardiac monitoring. Further research is needed to understand and address the underlying drivers of these differences.
Abstract P390: Prediction Enhancement of the Post-Stroke Delirium by Adding of the Brain Lesional Characteristics to the Clinical Features in Acute Ischemic Stroke Patients
Authors: Jeong Hye Seon , Yang Hee Won , Lee Seo Hyun , Hyon Yun Kyong , Jeon Kiwan , Lee Miji , Ha Taeyoung , Kim Jeong Lan , Lee Sukhoon , Kim Jei
Published: March 2021

Background:
We evaluated whether the brain regional features could enhance the prediction of the occurrence of the post-stroke delirium along with consideration of clinical features in acute ischemic stroke patients.

Method:
We analyzed magnetic resonance imaging and clinical datasets prospectively collected from 1,024 acute ischemic stroke patients (620 men; mean age±SD, 70.2±11.8 years), who were admitted in stroke unit. Delirium occurrence in the patients was initially screened with Confusion Assessment Method and finally diagnosed using the criteria of the Diagnostic and Statistical Manual of Mental Disorders (fifth edition). The prediction performance of the clinical features was evaluated using the logistic regression analysis, and then, compared with the performance obtained after adding of the brain lesional features.

Results:
Post-stroke delirium occurred in 100 (9.8%) of the total patients. Independent features of the clinical features were old age (odds ratio [OR] for the delirium prediction: 1.07, 95% confidence interval [CI] 1.038-1.103), preexisting dementia (OR 0.423, CI 0.209-0.853) and atrial fibrillation OR 1.599, CI 0.938-2.726), neglect (OR 2.395, CI 1.152-4.976), visual defect (OR 2.209, CI 0.994-4.907), diplopia (OR 2.42, CI 1.021-5.738), dysuria (OR 2.404, 95% CI 1.155-5.000), Foley catheter insertion (OR 0.46, CI 0.24-0.881) and pneumonia (OR 1.954, CI 1.004-3.803). Right-sided hemispheric and mixed acute lesions (p=0.003), lesion locations in occipital lobe (OR 1.814, CI 0.923-3.564), cerebellum (OR 2.875, CI 1.32-6.258) and brainstem (OR 4.057, CI 1.714-9.601), and the presence of the periventricular white matter change (OR 1.321, CI 0.964-1.811) increased the risk for delirium. Sensitivity to predict the delirium of the regression model was enhanced from 10% obtained with the clinical features to 18% by adding the brain lesional features. Area under the curve of the receiver operating characteristics analysis was also enhanced from 0.827 with the clinical features to 0.847 after adding the brain lesions to the clinical features.

Conclusion:
The present study shows brain lesional characteristics that could enhance the prediction of the post-stroke delirium in acute ischemic stroke patients.
Abstract P392: Early Brain Injury and Soluble ST2 After Non-Traumatic Subarachnoid Hemorrhage
Authors: Schleicher Riana , Bevers Matthew , Rubin Daniel , Koch Matthew , Bache Soeren , Patel Aman B , Rosenthal Eric , Moller Kirsten , Kimberly William T
Published: March 2021

Intro:
Early Brain Injury (EBI) after non-traumatic subarachnoid hemorrhage (SAH) is a significant mediator of neurological injury, but the injury pathways and markers are not well understood. We hypothesized that the inflammatory mediator soluble ST2 (sST2) is associated with markers of EBI.

Methods:
We studied two independent cohorts, including 190 SAH patients in a discovery cohort and 50 patients in a replication cohort. Clinical markers of EBI included early loss of consciousness, Glasgow Coma Scale (GCS) score at 24 hours, and neurological deterioration within the first 72 hours (defined as a decrease in GCS ≥ 2 points). Radiographic markers included bicaudate index, clinically significant hydrocephalus requiring external ventricular drainage (EVD), and global cerebral edema. Serial plasma sST2 level was measured at early (3.5 ± 1.2 days post-hemorrhage), intermediate (7.8 ± 1.3 days post-hemorrhage), and late (13 ± 2.3 days post-hemorrhage) time points in the discovery cohort and daily during post-hemorrhage days 1-9 in the replication cohort. In the discovery cohort, the relationship between EBI markers and poor functional outcome (90-day modified Rankin Scale; mRS ≥ 3) was assessed using multivariable logistic regression. The association between sST2 level and EBI markers was evaluated using repeated measures analysis. In the replication cohort, associations were examined using an analysis of response profiles.

Results:
Clinical and radiographic markers of EBI, except for global edema, were each associated with functional outcome in univariate analysis. Of these EBI markers, independent predictors of poor outcome included 24-hour GCS (OR=5.76, 95% CI 2.31-14.4, p<0.001) and clinically significant hydrocephalus (OR=8.74, 95% CI 2.44-31.3, p=0.001). Elevated sST2 was associated with all markers of EBI except for global edema, and independently predicted poor outcome in a multivariate model that included EBI markers. These findings were further replicated in an independent cohort.

Conc:
Of the potential clinical and radiographic contributors to EBI, poor 24-hour GCS and clinically significant hydrocephalus remain independent predictors of poor outcome. Furthermore, soluble sST2 level is associated with EBI and poor outcome.
Abstract P394: Association Between Admission Dehydration and In-Hospital Mortality in Patients With Intracerebral Hemorrhage
Authors: Gao Bin , Gu Hongqiu , Liu Shimeng , Zhou Qi , Kaijiang Kang , Zhang Jia , Li Zixiao , Wang Yongjun , Zhao Xingquan
Published: March 2021

Background and purpose:
Our aim was to investigate the associations between dehydration status at admission and in-hospital mortality in patients with intracerebral hemorrhage.

Methods:
Data of consecutive patients with intracerebral hemorrhage between August 2015 and July 2019 based on China Stroke Center Alliance (CSCA) were analyzed. The patients were stratified based on the blood urea nitrogen (BUN) to creatinine (CR) ratio (BUN/CR) on admission, into dehydrated (BUN/CR ≥ 15) and non-dehydrated (BUN/CR < 15) groups. Data were analyzed with multi-variate logistic regression models to analyze the risks of death at hospital and baseline dehydration status.

Results:
A total number of 84043 patients with intracerebral hemorrhage were included in the study. The median age of patients on admission was 63.0 years, and 37.5% of them were women. Based on the baseline BUN/CR, 59153 (70.4%) patients were classified into dehydration group. Patients with admission dehydration (BUN/CR ≥ 15) had 13% lower risks of in-hospital mortality than those without dehydration (BUN/CR < 15, adjusted OR=0.87, 95%CI: [0.78-0.96]). In patients aged <65 years, patients with baseline dehydration (BUN/CR ≥ 15) showed 19% lower risks of in-hospital mortality (adjusted OR=0.81, 95%CI: [0.70-0.94].adjusted p=0.0049) than non-dehydrated patients (BUN/CR<15).

Conclusion:
Admission dehydration is associated with lower in-hospital mortality in intracerebral hemorrhage,which provides an imaging clue that fluid management could be important for acute intracerebral hemorrhage.
Abstract P396: Hospital Management of Major Stroke Types in Urban and Rural China: Findings From a 11-Year Community-Based Studies Involving >20,000 Hospitalized Stroke Cases
Authors: Qin Haiqiang , Chen Yiping , Wright Neil , Pei Pei , Guo Yu , Clarke Robert , Li Liming , Wang Yongjun , Chen Zhengming ,   China Kadoorie Biobank Collaborative Group
Published: March 2021

Background:
Little is known about the contemporary use of hospital treatments for major stroke pathological types in urban and rural areas of China.

Methods:
The China Kadoorie Biobank recruited >0.5 million adults (mean age 51 years, 59% women) during 2004-08 from ten (five urban, five rural) diverse areas in China. In-hospital medical records were retrieved from 20,229 participants (n=261 hospitals) hospitalised with a first-ever incident stroke over an 11-year follow-up period. Details of hospital management of stroke cases were analysed by sex, age of stroke onset, calendar year, hospital tier, region and other factors.

Results:
Among the 20,299 first-ever stroke cases, 17,306 (85%) had ischaemic stroke (IS; 7,123 non-lacunar, 6,690 lacunar and 3,493 silent lacunar), 2,623 (13%) had intracerebral haemorrhage (ICH), and 370 (2%) had subarachnoid haemorrhage (SAH). Among IS cases, anti-platelet treatment was used by 64% (65% non-lacunar, 66% lacunar, 56% silent lacunar), lipid-lowering by 50% (52% non-lacunar, 53% lacunar, 43% silent lacunar), blood pressure-lowering by about 42% of all IS subtypes, along with traditional Chinese medicines (TCM) by 59% (50% non-lacunar, 62% lacunar, 74% silent lacunar), with positive trends in use of these treatments by calendar year (Figure 1A), but inverse trends by hospital tier except TCM (Figure 1B). Approximately half of ICH (52.6%) or SAH (50.5%) cases received blood pressure-lowering medication, which did not vary significantly by area. A small proportion of cases with SAH had surgery to insert a coil (7.0%) or clip on aneurysm (5.7%).

Interpretation:
Among IS cases, use of antiplatelet, lipid-lowering and TCM increased in recent years and exceeded use of blood pressure-lowering treatment. In contrast, about half of all ICH and SAH cases used blood pressure-lowering treatments and there is significant under-use of surgery for SAH cases.
Abstract P401: Subocclusive and Occlusive Intracranial Thrombi in Acute Ischemic Stroke
Authors: Handshoe Lacy S , Santucci Joshua , Shimoyama Takashi , Uchino Ken
Published: March 2021

Background:
Non-occlusive thrombus in an intracranial artery in acute ischemic stroke is an uncommon occurrence. We compared the clinical course and outcome of intracranial subocclusive to occlusive thrombi.

Methods:
We conducted a review of patients who presented with acute ischemic stroke and received CT angiogram at a single comprehensive stroke center from January 2018 to December 2019. Patients with intracranial subocclusive thrombus were compared to a control group with complete occlusion matched for occlusion location. Subocclusive thrombus was reviewed by two raters on CT angiography, disagreement resolved by consensus. Patient and stroke characteristics and the clinical course were analyzed. Neurological deterioration was defined as an increase in NIH Stroke Scale (NIHSS) score
>
4 compared from baseline to 48 hours. Good outcome at discharge was defined as modified Rankin Score of ≤2.

Results:
Among 1151 acute ischemic strokes, there were 896 patients with CT angiograms. Sixteen out of 896 (1.8%) patients had intracranial subocclusive thrombus. Thirty-two with comparable intracranial occlusions were identified. In the subocclusive group, 3 of 16 (19%) of received acute endovascular intervention, compared to 13 of 32 (41%) in the occluded group. Sex, median age or time from last known well to hospital arrival did not differ between the two groups. The subocclusive thrombus group had less severe strokes, with median NIHSS score at arrival 3 compared to 8.5 in the occlusion group (p<0.01) and median NIHSS at discharge 1 compared to 5.5 in the occlusive group (p<0.01). Frequency of neurological deterioration in hospital did not differ between the subocclusive and occluded groups at 48 hours (15% vs 15% p=1.00). The subocclusive group was associated with a good outcome at discharge, OR 0.5.71, 95% confidence interval 1.41-23.1.

Conclusion:
Intracranial subocclusive thrombus in acute ischemic stroke has a more mild presentation compared to complete intracranial occlusion without a high rate of neurological deterioration.
Abstract P402: Blood Pressure Control Poses Significant Delays to Discharge After an Acute Ischemic Stroke
Authors: Chan Hannah Y , Gulbis Brian , Savitz Sean I , Allison Teresa A
Published: March 2021

Acute ischemic stroke (AIS) patients often experience an extended length of stay (LOS) due to multiple factors, including blood pressure management (BPM). The aim of this quality improvement project was to assess the impact of BPM on LOS in AIS patients. This was a retrospective review of 99 AIS patients randomly selected at a comprehensive stroke center from January to June 2020. The primary outcome was the percentage of patients with LOS observed/expected (O/E) ratio ≥ 0.8. Factors associated with delayed hospital discharge (DHD) were evaluated. Chi-square, student t-test, and Mann-Whitney U test were used as appropriate for analysis. Patients had a mean (SD) age of 65 (14) years, median (IQR) NIHSS 7 (4, 15), HTN history (67%), and were African American (40%), Caucasian (32%), or Other (28%). Table 1 shows types of strokes. Twenty-three (23%) patients received tPA. Forty-five (45%) patients had a LOS O/E ratio of ≥ 0.8. Reasons for DHD included BPM (38%), medical management (33%), stroke management (25%), and disposition (4%). Patients with DHD had an initial mean (SD) SBP of 164 (32) mmHg compared to 161 (33) mmHg in patients with no DHD, p=0.603. Figure 1 shows mean SBP trends. Patients with DHD had a median (IQR) of 2 (0, 3) home BP medications compared to 1 (0, 2) in patients with no DHD, p=0.040. Nine patients (20%) with DHD compared to 7 patients (13%) with no DHD were initiated on a nicardipine drip upon admission, p = 0.416. Oral therapy was initiated on median (IQR) hospital day 2.5 (2, 3) in DHD patients vs. 3 (2, 3) in patients with no DHD, p = 0.951. Median (IQR) number of BP medications on discharge was 2 (1, 2) in DHD patients vs. 1 (0, 2) in patients with no DHD, p=0.170. Reasons for elevated BP included delayed therapy initiation (12%), medication titration (59%), and titration intolerability (29%). Blood pressure management in this cohort was one of the most significant factors in delaying discharge. Protocols should focus on better and faster BPM as a means of reducing length of stay.
Abstract P403: Healthcare Resource Utilization and Costs Associated With Oral Anticoagulant Reversal With Idarucizumab or Andexanet Alfa for Patients Hospitalized With Life-Threatening Bleeding Events
Authors: Spyropoulos Alex , Hartaigh Briain O , Cao Zhun , Caberwal Harjeet S , Lipkin Craig , Petrini Michaela M , Wang Cheng
Published: March 2021

Introduction:
This study compared healthcare resource utilization and costs associated with the use of idarucizumab for the reversal of dabigatran, and andexanet alfa for the reversal of rivaroxaban/apixaban, in nonvalvular atrial fibrillation (NVAF) and venous thromboembolism (VTE) patients hospitalized with life-threatening bleeds.

Methods:
This retrospective observational study utilizing the Premier Hospital Database included NVAF and VTE patients aged ≥18 years with a major life-threatening bleed discharged between May 1, 2018 and June 30, 2019 who received idarucizumab or andexanet alfa. Key study outcomes included total hospital and Intensive Care Unit (ICU) length of stay (LOS) and costs, and percentage of patients with an ICU admission. The inverse probability of treatment weighting (IPTW) method was employed to adjust for potential differences in demographic, hospital, visit, and clinical characteristics between treatment cohorts.

Results:
Idarucizumab patients were older compared with andexanet alfa patients (median age 81 vs. 77 years; p<0.001). Idarucizumab patients were less likely to experience an intracranial hemorrhage (ICH) (73.8% vs. 37.1%; p=0.001), but more likely to have a gastrointestinal bleed (56.3% vs. 24.6%, p<0.001). Idarucizumab patients incurred lower IPTW-adjusted mean total hospital costs compared with andexanet alfa patients ($30,413 ± $33,028 vs. $44,477 ± $30,036; p<0.001). The adjusted mean ICU cost among those with ICU admission was also significantly lower in idarucizumab patients ($25,114 ± $30,433 vs. $43,484 ± $29,335; p<0.001). Notably, the adjusted percentage of ICU admissions, mean hospital and also ICU LOS did not differ appreciably between both cohorts (Table).

Conclusions and Discussion:
While LOS measures did not differ significantly between patient cohorts, reversal therapy with idarucizumab was associated with lower total hospital and ICU costs as compared with those treated with andexanet alfa.
Abstract P405: A Time-Series Forecast Model to Assess Vital Sign Waveform Variability Prior to Vasospasm
Authors: Chaudhry Farhan , Mohamed Ghada , Aboul Nour Hassan O , Johnson Kipp W , Hunt Rachel J , Rathnam Anirudha , Ramadan Ahmad Riad
Published: March 2021

Introduction:
Symptomatic vasospasm (SV) is a complication of aneurysmal subarachnoid hemorrhage (aSAH) and can lead to cerebral infarction. Changes in vital trends, such as heart rate (HR) and mean arterial blood pressure (MAP), have been associated with SV in aSAH. Real-time assessment of instantaneous vital sign waveform data could improve detection of vital sign variability associated with vasospasm. However, no model using instantaneous waveform data exists to predict SV. We hypothesize that autoregressive integrated moving average (ARIMA) analysis, a time-series forecast model, is a useful approach to assess the variability of vital sign waveforms associated with SV.

Methods:
In this small case-control study, vital signs of patients admitted to the neuroICU with aSAH were obtained using a software-based analytics platform, Sickbay. HR and MAP from 15 aSAH patients were continuously obtained from ECG and arterial line waveforms. Ten patients developed neurologic deficits attributed to angiographically-confirmed SV (Det). Five controls (Con) without SV were matched based on age. 3 Det and 3 Con were randomly selected for further analysis. For Det, waveforms were analyzed at 5-second intervals for 48 hours prior to clinical deterioration. For Con, waveforms were analyzed at a random 48-hour interval.

Results:
Visually, MAP and not HR was more variable in Det than in Con patients (Figure). The ARIMA model plotted the forecasted-fit for each delta-variable waveform. The MAP confidence interval margins were significantly larger for Det patients compared to the Con patient. This trend was consistent across all other patients.

Conclusion:
ARIMA is a useful tool to assess HR and MAP waveform variations prior to SV in aSAH. Larger studies are required to solidify this concept and further explore the combination of data analytics platform and ARIMA to predict neurological deterioration in SV.
Abstract P406: Revised Intracerebral Hemorrhage Expansion Definitions and Relationship With Care Limitations
Authors: Lun Ronda , Yogendrakumar Vignan , Walker Greg B , Shamy Michel , FAHED Robert , Qureshi Adnan I , Dowlatshahi Dar
Published: March 2021

Background:
Hematoma expansion (HE) is an important therapeutic target in intracerebral hemorrhage. Recently proposed HE definitions have not been validated, and no previous definition has accounted for withdrawal of care (WOC).

Objective:
To compare conventional and revised definitions of hematoma expansion (HE), while accounting for WOC.

Methods:
We analyzed data from the ATACH-2 trial, comparing revised definitions of HE incorporating intraventricular hemorrhage (IVH) expansion to the conventional definition of “≥6 mL or ≥33%”. The primary outcome was modified Rankin Scale of 4-6 at 90-days. We calculated the incidence, sensitivity, specificity, positive and negative predictive values, and
c-
statistic for all definitions of HE. Definitions were compared using non-parametric methods. Secondary analyses were performed after removing patients who experienced WOC.

Results:
Primary analysis included 948 patients. Using the conventional definition, the sensitivity was 37.1% and specificity was 83.2% for the primary outcome. Sensitivity improved with all three revised definitions (53.3%, 48.7%, and 45.3%, respectively), with minimal change to specificity (78.4%, 80.5%, and 81.0%, respectively). The greatest improvement was seen with the definition “≥6 mL or ≥33% or any IVH”, with increased
c
-statistic from 60.2% to 65.9% (p < 0.001). Secondary analysis excluded 46 participants who experienced WOC. The revised definitions outperformed the conventional definition in this population as well, with the greatest improvement in
c
-statistic using “≥6 mL or ≥33% or any IVH” (58.1% vs 64.1%, p < 0.001).

Conclusions:
HE definitions incorporating intraventricular expansion outperformed conventional definitions for predicting poor outcome, even after accounting for care limitations.
Abstract P41: Integrating Demographics, TCD and EEG Diagnostic Modalities Improves Delayed Cerebral Ischemia Prediction After Subarachnoid Hemorrhage
Authors: Chen Hsin Yi , Elmer Jonathan , Ghanta Manohar , Valdery-Moura Junior , Zahar Sahar F , Rosenthal Eric , Gilmore Emily J , Hirsch Lawrence , Zaveri Hitten , Sheth Kevin N , Petersen Nils H , Westover M B , Kim Jennifer A
Published: March 2021

Introduction:
Delayed cerebral ischemia (DCI) is the leading complication of subarachnoid hemorrhage (SAH). Because DCI was traditionally thought to be caused by large vessel vasospasm, transcranial Doppler ultrasounds (TCDs) have been the standard of care. Continuous EEG has emerged as a promising complementary monitoring modality and predicts increased DCI risk. Clinical variables have also been used in DCI prediction. We hypothesize integrating these diagnostic modalities improves DCI prediction.

Methods:
We assessed 107 patients with moderate-severe SAH (2011-2015) who had both TCD and EEG monitoring during hospitalization. Clinical demographics, including Hunt-Hess and aneurysm treatment (clipping/coiling), were collected via retrospective chart review. Middle cerebral artery (MCA) peak systolic velocities (PSV) and the presence or absence of epileptiform abnormalities (EA), defined as seizures, epileptiform discharges, and rhythmic/periodic activity, were recorded daily. Logistic regressions were used to identify EEG, TCD, and clinical variables associated with DCI. Group-Based Trajectory Modeling (GBTM) was used to account for changes over time by identifying distinct group trajectories of MCA and EA associated with DCI risk.

Results:
Independent predictors of DCI in logistic regressions are: presence of high MCA velocity (PSV≥200cm/s) and presence of EA on or before day 3. There are 2 univariate GBTM trajectories of EA (%DCI in group 1=32.1, group 2=70.4) significantly associated with DCI, but MCA velocity trajectories are not significant. Logistic regression and GBTM models using both TCD and EEG monitoring improve upon models using either modality alone. Hunt-Hess score at admission and aneurysm treatment as covariates further improved model performance. The best models used both TCD and EEG monitoring modalities and clinical variables as predictors (logistic regression: Se=90%, Sp=70%; GBTM: Se=89%, Sp=67%).

Conclusions:
EEG and TCD biomarkers combined provide the best prediction of DCI, compared to either alone. Models that considered the timing of EA and high MCA velocities plus clinical variables improved model performance.
Abstract P411: Prevalence, Characteristics and Outcomes of Undetermined Intracerebral Hemorrhage: A Systematic Review and Meta-Analysis
Authors: MALHOTRA Konark , Zompola Christina , Theodorou Aikaterini , Katsanos Aristeidis , Shoamanesh Ashkan , Gupta Himanshu , Beshara Simon , Goyal Nitin , Chang Jason , Tayal Ashis H , Boviatsis Efstathios , Voumvourakis Konstantinos , Cordonnier Charlotte , Werring David J , Alexandrov Andrei V , Tsivgoulis Georgios K
Published: March 2021

Objective:
We sought to determine the prevalence, radiological characteristics, and clinical outcomes of intracerebral hemorrhage (ICH) of undetermined etiology.

Methods:
Systematic review and meta-analysis of studies involving patients with spontaneous ICH was conducted to assess the prevalence and clinical-radiological characteristics of undetermined ICH. Additionally, we assessed the rates for ICH secondary to hypertensive arteriopathy (HTN-A) and cerebral amyloid angiopathy (CAA). Subgroup analyses were performed based on the use of a) etiology-oriented ICH classification, b) detailed neuroimaging, and c) Boston criteria among CAA-ICH.

Results:
24 studies were included (n=15,828; mean age: 64.8 years, males: 60.8%). The pooled prevalence of HTN-A ICH, undetermined ICH and CAA-ICH were 50% (95%CI: 43-58%), 18% (95%CI: 13-23%), and 12% (95%CI: 7-17%; p<0.001 between subgroups). The volume of ICH was largest in CAA-ICH 24.7mL (95%CI: 19.7-29.8mL), followed by HTN-A ICH 16.2mL (95%CI: 10.9-21.5mL) and undetermined ICH 15.4mL (95%CI: 6.2-24.5mL). Among patients with undetermined ICH, the rates of short-term mortality and intraventricular hemorrhage were 33% (95%CI: 25-42%) and 38% (95%CI: 28-48%), respectively. Subgroup analysis demonstrated a higher rate of undetermined ICH among studies that did not use an etiology-oriented classification (22%; 95%CI: 15-29%). No difference was observed between studies based on the completion of detailed neuroimaging to assess the rates of undetermined ICH (p=0.62).

Conclusions:
The etiology of spontaneous ICH remains undetermined among one in five patients in studies using etiology-oriented classification and among one in four patients in studies that avoid using etiology-oriented classification. The short-term mortality in undetermined ICH is high despite the relatively small ICH volume. Our findings suggest the use of etiology-oriented classification to approach ICH patients (Figure).
Abstract P412:
Klotho
-vS Heterozygosity is Associated With Lower Risk of Non-Traumatic Subarachnoid Hemorrhage
Authors: Acosta Julian N , Szejko Natalia , Torres Lopez Victor , Both Cameron , Sansing Lauren H , Sheth Kevin N , Matouk Charles , Gunel Murat , Falcone Guido J
Published: March 2021

Introduction:
Klotho is a transmembrane protein that modulates insulin sensitivity and suppresses oxidative stress and inflammation. Two missense variants in the
Klotho
gene (
KL
) form the functional haplotype
KL-VS
. Heterozygosity for
KL-VS
(
KL-VS-Het+
) increases serum levels of Klotho and is associated with healthy aging and decreased risk of stroke. We tested the hypothesis that
KL-VS-Het+
lowers the risk of Non-traumatic Subarachnoid Hemorrhage (SAH).

Methods:
We conducted a genetic association study that used publicly available individual-level data from the UK Biobank, a large cohort study that enrolled ~500,000 participants across the UK. We included participants from European ancestry. We ascertained the two missense genetic variants that define
KL-VS
(rs9536314 and rs9527025) using the UK Biobank Axiom Array. We tested for association between
KL-VS-Het+
and SAH risk using univariable and multivariable logistic regression models. We conducted stratified analyses using the known effect modifiers of SAH risk sex, hypertension, and smoking.

Results:
A total of 385,709 participants were included (1,083 SAH cases and 384,626 controls). The mean age at recruitment was 56.8 (SD 8) and 208,042 (54%) were female. KL-VS-Het+ was present in 27% of the population.
KL-VS-Het+
was associated with a lower risk of SAH in univariable (OR 0.85, 95%CI 0.74-0.98; p=0.02) and multivariable (OR 0.85, 95%CI 0.74-0.98; p=0.02) models adjusting by age, sex, hypertension, smoking and genetic principal components, This effect was stronger in men (0.80, 95%CI 0.63-1.00; p=0.05) versus women (OR 0.88, 95%CI 0.74-1.05; p=0.15), hypertensives (OR 0.77, 95%CI 0.61-0.97; p=0.03) versus non-hypertensives (OR 0.90, 95%CI 0.75-1.07; p=0.23) and ever-smokers (OR 0.82, 95%CI 0.68-0.99; p=0.04) versus never-smokers (OR 0.89, 95%CI 0.71-1.10; p=0.27).

Conclusion:
KL-VS
-Het+ is associated with a lower risk of SAH. This protective association was stronger in men, hypertensives, and ever-smokers. Further research should validate these associations in non-Caucasian populations and identify possible biological underpinnings behind these relationships.
Abstract P414: Outcomes of Incident Hemorrhage From Cranial Dural Arteriovenous Fistulae: Analysis of the Multi-Center International Condor Registry
Authors: Koch Matthew , Stapleton Christopher , Guniganti Ridhima , Zipfel Gregory J , Amin-hanjani Sepideh
Published: March 2021

Introduction:
Dural artertiovenous fistulae (dAVF) are rare causes of secondary intracranial hemorrhage (ICH) and there remains a paucity of knowledge regarding their natural history. To date our knowledge comes from small case series. CONDOR, (Consortium for Dural Arteriovenous Fistula Outcomes Research), a large multi-institutional retrospective registry, provides a unique opportunity to evaluate the outcomes of patients presenting with dAVF related hemorrhages.

Methods:
We performed a retrospective review of 1077 dAVF patients from the CONDOR registry and selected those patients who presented with hemorrhage secondary to the dAVF. Patient characteristics, clinical presentation/follow-up, and radiographic details were analyzed for associations with patient outcomes. An outcome of mRS 0-2 was categorized as a “good” outcome and 3-6 as “poor”. Statistics were performed in SAS 9.4 with chi square, fisher’s exact test, and stepwise select variable multivariate analysis; P<.05 was marked as the level for statistical significance.

Results:
Evaluation of the CONDOR dataset yielded 267 patients who presented with hemorrhage. The mean age of the population was 59 ±13y.o, 30% were female, 40% had a history of smoking and 93% were not on anticoagulants. The median follow-up was 1.4 years. The mortality was 4.0 % at follow-up, and 83% of patients had a good outcome (mRS 0-2). Univariate analysis found age (p=0.001), anticoagulant use (p=0.006), and presentation mRS (p=0.03) were associated with poor outcome at follow-up. Subtype of hemorrhage (parenchymal hemorrhage or subarachnoid hemorrhage), smoking, and cortical venous shunting of the lesion, (i.e. Cognard grade IIb and greater) did not reach statistical significance. On multivariate analysis age (p=0.023) and mRS (p=0.035) at presentation but not anti-coagulant use (p=0.11) was associated with follow-up mRS.

Conclusion:
Within the largest individual patient series to date, we found that dAVF presenting with hemorrhage was associated with a relatively low risk of mortality. Age and mRS at presentation were most strongly predictive of outcome. Our results suggest that dAVF hemorrhage may be associated with a less morbid outcome than other forms of secondary hemorrhage.
Abstract P416: Remote Ischemic Conditioning Reduces Perihematomal Edema After Intracerebral Hemorrhage: First Proof-Of-Concept Randomized Controlled Trial
Authors: Wenbo Zhao , Jiang Fang , Li Sijie , Ding Yuchuan , Ji Xunming
Published: March 2021

Introduction:
The prognosis of intracerebral hemorrhage (ICH) is poor because of the mass effect arising from the hematoma and the associated perihematomal edema (PHE). Remote ischemic conditioning (RIC) has been shown to promote hematoma clearance and reduce PHE in animal models, however it remains unknown whether RIC is safe and effective in reducing PHE in ICH patients.

Objective:
To evaluate the safety and efficacy of RIC in reducing PHE after ICH.

Methods:
In this open-label, rater-blind, randomized control trial, 40 subjects with supratentorial ICH (hematoma volume:10-30 ml) diagnosed between 24 to 48 hours of onset were assigned to the RIC group or control group. All subjects received standard background medical therapy. Subjects in the RIC group underwent repeated daily RIC (4 cycles of 5 minutes inflation [200 mmHg] /deflation [0 mmHg] of cuff on one arm) for 7 consecutive days. The primary efficacy outcome was PHE volume at 7 days, and both absolute PHE volume and relative PHE volume (defined as absolute PHE volume divided by hematoma volume) were measured. Safety outcome included death, neurological deterioration, hematoma expansion, and any other severe adverse events.

Results:
All 40 subjects completed this study. Mean age was 59.3±11.7 years, and 57.5% were male. At baseline, the median National Institutes of Health Stroke Scale score was 9.5 (range 1-28), median Glasgow Come Score was 15 (range 10-15), and mean ICH volume was 13.9±4.5 ml. The mean relative PHE volume was 1.11±0.26 in the control group and 1.05±0.23 in the RIC group at baseline; and 1.49±0.30 vs. 1.33 ±0.32 at Day 3 (p>0.05 each) respectively. After 7 days of treatment, RIC significantly reduced the relative PHE volume as compared to the control (1.77±0.39 vs. 2.02±0.27, p=0.02). The absolute PHE volume and hematoma volume at Day 3 and Day 7 had no significant difference between groups (p>0.05 each). No subject died or suffered from neurological deterioration or hematoma expansion and no adverse event was associated with RIC.

Conclusion:
RIC seemed to be safe in patients with ICH and induced a significant reduction in the relative PHE volume after 7 day of treatment. These results warrant a further study with large sample to examine the effect of RIC on functional outcome after ICH.
Abstract P421: Google Auto ML Based Prediction of Outcomes in Intracerebral Hemorrhage - Bringing Machine Learning to Clinicians
Authors: Mandava Pitchaiah , Hegde Ajay , Sandesh Onkarappa , Menon Girish
Published: March 2021

Background:
Application of Machine Learning (ML) techniques in the prediction of Neurological Disorders has been growing rapidly. ML techniques require novel computer programming skills along with domain knowledge to produce a useful tool. We used Google Auto ML and Google ML Tables, a Cloud based front-end tools to develop, validate and deploy a prognostic model for Intracerebral Hemorrhage (ICH) without a single line of programming code.

Methods:
Data from Kasturba Medical College (KMC) Hospital ICH Stroke Registry between January 2015 and May 2019 was accessed. Google Auto ML Tables splits the dataset into training, validation and testing sets. 80% of the dataset was used for training, 10% for validation, and 10% for testing.
Cramers V
correlation statistic (
ϕ

c

) between 30 variables and outcome was used to select 20 variables to predict the dichotomous outcome of good (mRS 0-3) vs bad outcome (mRS 4-6). The ML model generated was evaluated using Area Under the Curve (AUC) and Receiver Operating Characteristic (ROC) measures and by confusion/error matrix. Logistic Regression model was developed in parallel using Wizard Pro with the same set of 20 variables.

Results:
1000 patients from KMC Registry were analysed.
Cramers V
correlation was highest for Glasgow Coma Scale (GCS) on admission (
ϕ

c

=0.6), followed by hematoma volume (
ϕ

c

=0.57). The AUC ROC of the model for good and bad outcome was 0.89 with an accuracy of 85.6%. Confusion matrix predicted 84% patients with good outcome and 87% with poor outcome. Feature importance chart showed that GCS had the highest relative importance at 25.7, followed by hematoma volume and age. A similar model created with simple logistic regression yielded a ROC of 0.87 with comparable results to the machine learning platform.

Conclusion:
Useful ML models can be easily developed and implemented by clinicians possessing domain expertise using Google Auto ML without computer programming experience.