bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP264: ST2 Signaling is Essential in Restricting Acute Ischemic Brain Injury
Authors: Yang Yuanyuan , Zhang Haiyue , Wang Guohua , Hu Xiaoming , Chen Jun
Published: March 2022

Background and Purpose:
ST2, a member of the interleukin 1 receptor family, and its ligand interleukin 33 (IL-33) play critical roles in immune regulation and inflammatory responses. The engagement of ST2 has been shown to reduce myocardial infarction and preserve heart function. Recent study documented an increase in blood ST2 expression after stroke. The exact roles of ST2 in the ischemic brain injury, however, are not explored.

Methods:
C57/BL6 wild type and ST2 knockout mice were subjected to 60-minute transient cerebral ischemia (tMCAO). The expression of ST2 and IL-33 in the ischemic brain was measured at different time points after tMCAO using RT-PCR. Brain infarct was quantified using TTC staining and MAP2 immunostaing. Neurobehavioral tests were performed up to 14 days after tMCAO. Differences of immune cell components in blood, spleen, bone marrow and brain between wild type and ST2 knockout mice were assessed by flow cytometry analysis. For experiments with ST2 activation, IL-33 was injected intraperitoneally(i.p.) or intracerebroventricularly (i.c.v.) into wide type mice right after the induction of tMCAO.

Results:
In wild type mice, the mRNA expression of ST2 in the ischemic brainexhibited a delayed elevation 7d after tMCAO, while the mRNA expression of IL-33 was transiently increased 1d after tMCAO. The deficiency of ST2 resulted in enlarged infarct volume 3d after tMCAO and aggravated neurological deficits lasted out to 14d. The worsened stroke outcome was accompanied by dramatic changes in the number of Th1, Th2 and regulatory T cells in the spleen, bone marrow and brain. Further study showed that either i.p. or i.c.v. injection of IL-33 at the time of reperfusion attenuated the severity of brain infarct in wide type mice, suggesting that both systemic and central activation of ST2 could protect against acute ischemic brain injury.

Conclusions:
ST2/IL-33 signaling plays an essential role in restricting acute ischemic brain injury. Such protective effect of ST2/IL-33 involves both immune regulation in the peripheral immune system and a direct protection within the central nervous system. Our study may provide a new therapeutic target for stroke treatment.
Abstract TP269: Therapeutic Application of an Angiotensin II Peptide Vaccine in a Middle Cerebral Artery Occlusion Model in Rats
Authors: Wakayama Kouji , Shimamura Munehisa , Suzuki Jun-ichi , Isobe Mitsuaki , Nakagami Hironori , Morishita Ryuichi
Published: March 2022

Background & purposes:
Although there were a number of studies that apply angiotensin II (Ang II) peptide vaccine to treat hypertension, no therapeutic attempt has been made to show efficacy of Ang II peptide vaccine for ischemia stroke. The purpose of this study is to investigate whether pre-exposure Ang II vaccination exhibits the cerebroprotective effects after permanent middle cerebral artery occlusion (p-MCAo) in rats.

Methods:
After subcutaneous injection of Ang II peptide vaccine (10μg/200μl) or saline (200μl) to Wistar rats (male, 4week-old) at the time point of 4, 6 and 7 week-old, MCAo or sham surgery was performed at 8 week-old. Neurological function was evaluated at 24 hours of MCAo using Neurological Severity Score (NSS). The plasma Ang II antibody titer or brain parenchymal Ang II antibody level was quantified using ELISA. Serial sections were stained with cresyl violet to measure infarction volume. Neuronal degeneration and oxidative stress were evaluated using Fluoro Jade B (FJB) and 4-Hydroxynonenal (4-HNE) staining. The expression of brain renin-angiotensin-system (RAS) components or NOX2 was quantified using real-time PCR.

Results:
Systemic blood pressure was not affected by vaccination. Infarction volume 24 hours after MCAo was reduced not in plasma low-titer (Lo) group (OD50%<6000) but in plasma high-titer (Hi) group (OD50%≧6000) compared with saline (S) group, thus Hi group was defined as vaccine treated (V) group. Parenchymal anti-Ang II antibody level in the ischemic hemisphere was significantly higher in Hi group compared with Lo group. Both FJB positive neurons and 4-HNE positive cells were significantly decreased in V group. The expression of brain AngII type 1 receptor mRNA and brain NOX2 mRNA were less in V group compared with S group. Amelioration on neurological function was observed because of low score of neurological severity score in V group.

Conclusions:
Prior vaccination ameliorates ischemic injury and neurological function in p-MCAo rats. The inhibitory effects against brain RAS and /or its anti-oxidative effects in the ischemic lesion were the suggested mechanisms of Ang II peptide vaccine in cerebral ischemia. Therapeutic vaccination targeting Ang II may provide a new approach to treat cerebral ischemia.
Abstract TP28: Impact of Variations in Thrombolysis in Cerebral Infarction Grading Scheme Between Clinical Trials on Rates of Post Thrombectomy Partial Recanalization
Authors: Khan Asif A , Afzal Mohammad Rauf , Jahangir Nauman , Qureshi Mushtaq H , Herial Nabeel , Suri M. Fareed K , Qureshi Adnan I
Published: March 2022

Background:
There have been different methods in clinical trials to quantify partial angiographic recanalization after mechanical thrombectomy for large vessel acute ischemic stroke.

Objective:
To determine the variation in quantification between different methods for grading angiographic recanalization.

Methods:
We reviewed clinical and angiographic data for consecutive patients who underwent mechanical thrombectomy at a single center. The post procedural angiographic recanalization was graded using three different methods which were used by the Interventional Management of Stroke III (IMSIII) trial investigators (filling>50% of territory affected), Endovascular treatment for Small Core and Anterior circulation Proximal occlusion with Emphasis on minimizing CT to recanalization times (ESCAPE) trial investigators (filling all branches but with delay) and definition used by Multicenter Randomized Clinical trial of Endovascular treatment for Acute ischemic stroke in the Netherlands (MRCLEAN) investigators (filling of more than 66% of territory affected).

Results:
Post procedural angiograms were reviewed for 61 consecutive patients (mean age ± SD, 73.52 ± 14.4, 26 were men) who underwent mechanical thrombectomy. The initial median NIHSS score was 14.The occlusion site was in middle cerebral artery (n= 39), internal carotid artery (n= 15), anterior cerebral artery (n = 3), posterior cerebral artery (n = 1), orbital artery (n = 2), basilar artery (n = 1) TICI 2b was categorized in 19 patients by IMS III definition and in 12 patients by MRCLEAN criteria that was categorized 2a by ESCAPE method. TICI 2b was categorized in 19 patients by IMS III method was categorized as 2a by the MRCLEAN definition. The rate of favorable outcome (mRS 0-2) in patients classified as TICI 2b in IMS III was 10 of 19 (52.6%) but not in other trials was 24 of 42(57%).

Conclusions:
The differences in definitions used between trials and impact upon rates of partial recanalization (TICI 2b) reported should be recognized
Abstract TP283: Hemorrhagic Risk Assessment of DS-1040 in a Cerebral Ischemia/reperfusion Model of Rats With Hypertension and Hyperglycemia
Authors: Edo Naoko , Noguchi Kengo , Ito Yusuke , Morishima Yoshiyuki , Yamaguchi Kyoji
Published: March 2022

Introduction:
DS-1040 is a novel inhibitor of the activated thrombin-activatable fibrinolysis inhibitor (TAFIa) and is in clinical development for the treatment of acute ischemic stroke. The objectives of this study were to establish a tissue plasminogen activator (tPA)-sensitive cerebral hemorrhage model and to assess the hemorrhagic risk of DS-1040.

Methods:
After glucose administration (i.p.), male SHR/Izm rats were subjected to middle cerebral artery occlusion (MCAO) using an intraluminal monofilament.

Establishment of tPA-sensitive model: Rats were subjected to MCAO for 1, 2, or 3 h followed by recanalization. tPA (10 mg/kg) or saline (control) was intravenously administered by 10% bolus and 90% infusion just before recanalization. At 2.5 h after recanalization, cerebral hemorrhage was quantified by measuring the excess hemoglobin in the ischemic hemisphere compared to the contralateral side.

Hemorrhagic risk assessment: Rats were subjected to MCAO for 3 h followed by recanalization. At 135 min after MCAO, saline (control) and DS-1040 (30 mg/kg) were intravenously injected as bolus. The dosage of DS-1040 was set to achieve full inhibition of TAFIa. As a positive control, tPA (7 mg/kg) was intravenously administered by 10% bolus and 90% infusion at 5 min before recanalization. The excess hemoglobin was determined at 1 h after recanalization.

Results:
Establishment of tPA-sensitive model: Excess hemoglobin in the tPA group significantly increased in animals subjected to 2 and 3-h MCA occlusion compared to each corresponding control group.

Hemorrhagic risk assessment: In the rt-PA group, excess hemoglobin was significantly increased (63.03 ± 8.38 mg/dL, mean ± SE) compared to the control group (38.74 ± 2.10 mg/dL). In contrast, excess hemoglobin in the DS-1040 group was 33.21 ± 3.28 mg/dL.

Conclusions:
Using hypertensive rats with transient hyperglycemia, we have established a tPA-sensitive cerebral hemorrhage model. DS-1040 did not significantly increase the cerebral hemorrhage compared to the control. These data suggest DS-1040 has the potential to be a thrombolytic enhancer with low risk of cerebral hemorrhage.
Abstract TP289: Time to Neurologic Evaluation Predicts the 90-Day Outcome After Ischemic Stroke
Authors: Mayasi Yunis M , Helenius Johana , Richard Goddeau , Moonis Majaz , Henninger Nils
Published: March 2022

Introduction and Hypothesis:
Since the introduction of thrombolysis with recombinant rtPA for the treatment of acute ischemic stroke it has been well-established that there exists a relatively narrow window for therapeutic intervention. Therefore, a substantial number of investigations sought to identify factors that delay patient presentation. However, little is known regarding the impact of time to presentation (TTP) on final outcome particularly when considering patient presenting outside the established time window for acute stroke therapy. We sought to determine whether the TTP is independently associated with the 90-day outcome.

Methods:
Retrospective analysis of 270 consecutive acute ischemic stroke patients prospectively evaluated between January 2013 and February 2014. Multivariable logistic regression with backward elimination was used to determine whether greater TTP independently predicted a poor 90-day outcome as defined as a modified Rankin scale (mRS) score of 3-6 after adjustment for known predictors of stroke outcome.

Results:
TTP (per hour; P=0.014; OR 1.013; 95%-CI 1.003-1.023), age (per year; P=0.005; OR 1.044; 95%-CI 1.013-1.076), NIHSS (per point; P<0.001; OR 1.247; 95%-CI 1.168-1.331), and preadmission mRS (per step; P=0.001; OR 1.969; 95%-CI 1.316-2.948) independently predicted a poor 90-day outcome These results did not meaningfully change when patients eligible for rtPA or neurointervention were excluded.

Conclusion:
Each hour delay of presentation to neurological evaluation decreased the chance for a good outcome by 1.3% independent of other established outcome predictors. Continued efforts to counsel the public to seek immediate medical attention as well as to expedite patient evaluation by neurologists after ischemic stroke, even when ineligible for acute intervention, are critical to reduce the risk for a poor outcome.
Abstract TP291: Outcomes of Intravenous Thrombolysis in Mild and Rapidly Resolving Ischemic Stroke
Authors: Frischmann Lindsey , Birnbaum Lee
Published: March 2022

Introduction:
Mild and rapidly resolving ischemic strokes (RRIS) are controversial, relative contraindications for IV thrombolysis.

Methods:
A retrospective review of GWTG database was performed for a 5-hospital stroke network between 2010 and 2014. Acute ischemic stroke (AIS) patients that arrived within 4.5 hours from symptom onset and had a baseline NIHSS <=5 were included. The short-term outcome measures were ambulation status at discharge, discharge disposition, mortality, and length of stay. 29% of admission and 26% of discharge ambulatory statuses were unknown and included in the independent ambulatory groups. Discharge disposition was dichotomized as good (home or rehab) or bad (SNF, hospice, or death).

Results:
Of 5133 AIS patients, 480 (44% women, 49% White, 41% Hispanic, and 5.7% Black) met inclusion criteria, of which 122 (27%) were treated with IV TPA. The average age of treated patients was 73 (range of 29-92) and not treated was 67 (range 18-100). Outcome measures were not significantly different between groups (Table 1).

Discussion:
This study did not find a significant difference in discharge outcomes for mild and RRIS patients who did or did not receive IV TPA. Our sample size may be too small to demonstrate a treatment effect. Both groups, however, had significant disability at discharge with ∼25% unable to ambulate independently and ∼15% bad discharge disposition. These findings provide further evidence that strokes with low NIHSS can be disabling.
Abstract TP296: Analytic Study of Neurology Residents’ Clinical Assessment of Potential Stroke Patients Prior to MRI Results
Authors: Abdelhamid Nour , Mehla Sandhya , Farooq Salman , Kavak Katelyn , Crumlish Annemarie , Ching Marilou
Published: March 2022

Introduction:
MRI has emerged as the gold standard for confirming the diagnosis of acute ischemic stroke (AIS). This resulted in an increase in the number of MRIs ordered which in turn may influence neurology residents to rely on imaging for the diagnosis of AIS at the expense of their clinical skills.

Objectives:
1) To assess the clinical accuracy of residents in the initial evaluation of the potential stroke patient. 2) To investigate different variables in the patient’s clinical picture that influences the clinical diagnosis of residents, and determine if these variables are predictive of the ultimate diagnosis of AIS.

Methods:
The study period was from July 2014 to May 2015. Neurology residents at SUNY Buffalo were requested to complete online questionnaires for potential stroke patients wherein a brain MRI was ordered. Questionnaire included preliminary clinical diagnosis made by the resident (stroke yes or no) and on what clinical basis was the diagnosis made. MRI reports were later reviewed and compared to residents’ clinical diagnosis. Chi-square test was used in data analysis.

Results:
A total of 231 brain MRIs were ordered. Resident’s clinical diagnosis was correct in 191 Patients (accuracy = 83%, p <0.001). Accuracy per PGY level was calculated to be 80%, 79% and 93% for PGY2, 3 and 4 respectively (p< 0.001). Embolic risk factors and cortical stroke signs were the variables used by residents which correctly had the highest association with positive MRI finding, 85%. Functional patients and history of seizure disorder were variables used by residents which correctly had the highest association with negative MRI results, 100 and 89% respectively. Residents’ clinical evaluation was incorrect in 26% of patients with history of previous stroke.

Conclusion:
Neurology residents at our institution are accurate in their initial clinical assessment of potential stroke patients prior to MRI results greater than 80% of the time. PGY4s performed better, while PGY2 and 3 performed at the same level which needs further studies. Variables in clinical presentation such as functional symptoms and history of seizure were most helpful to our residents. Patients with history of previous stroke were the most challenging for our residents to evaluate.
Abstract TP300: tPA Administration Affects Stroke Patient Disposition and Mortality
Authors: Sauser-Zachrison Kori , Land Thomas , Soare Thomas W , Christie Anita , Nasuti Laura , Schwamm Lee H
Published: March 2022

Introduction:
Shorter onset-to-arrival (OTA) time is critical for acute ischemic stroke (AIS) patients potentially eligible for disability-reducing treatment including intravenous tPA and endovascular thrombectomy.

Hypothesis:
Patients with earlier arrival would be more likely to be discharged home and have lower 30-day and 1-year mortality.

Methods:
Prospective study of all AIS patients presenting to the 60 of 70 Massachusetts hospitals participating in the Coverdell Registry from 2005-13, excluding patients without documented onset or arrival times. Logistic regression analyses identified predictors of discharge disposition, in-hospital, 30-day, and 1-year mortality, accounting for clustering by hospital.

Results:
Among the 41,856 patients in the sample, 30-day mortality was 6.7% and 1-year mortality was 12.6%. Of the 17,664 patients from 2011-13 with confirmed discharge disposition, 43.1% were discharged home, 8.4% died in-hospital or were discharged to hospice. Predictors of discharge disposition and mortality are outlined in the Table. OTA within 3.5 hours was associated with discharge to home, but had no affect on in-hospital, 30-day, or 1-year mortality. This pattern persisted both with and without tPA administration included in the model. Patients treated with tPA were more likely to be discharged to home. tPA administration was associated with in-hospital mortality, but reduced 1-year mortality. 30-day and 1-year mortality improved over the 8 years in the study period.

Conclusions:
Patients arriving within 3.5 hours are more likely to be discharged to home, and patients treated with tPA are more likely to be discharged to home and have lower 1-year mortality.
Abstract TP305: International Comparison of Patient Characteristics and Performance Measures in Acute Ischemic Stroke: Analysis of the American Heart Association Get With the Guidelines-Stroke Registry and China National Stroke Registry
Authors: Xian Ying , Li Zixiao , Wang Yilong , Liang Li , Schulte Phillip J , Zhang Qihui , Zhao Xingquan , Liu Liping , Wang Chunxue , Wang Chunjuan , Li Hao , Saver Jeffrey L , Fonarow Gregg C , Bhatt Deepak L , Smith Eric E , Schwamm Lee H , Bettger Janet Prvu Bettger P , Hernandez Adrian F , Peterson Eric P , Wang Yongjun
Published: March 2022

Background:
Stroke is a key contributor to the global burden of disease and the second leading cause of death worldwide. Efforts to measure and improve care are rapidly extending to low and middle income countries. Yet there is lack of comparative assessment of characteristics and adherence to evidence-based performance measures in acute ischemic stroke for most world regions.

Methods:
We analyzed data of consecutive acute ischemic stroke patients in the Get With The Guidelines Stroke (n=194,876 from 1548 sites) and the China National Stroke Registry (n=19,604 from 217 sites) between 2012 and 2013. Patient characteristics and adherence to guideline-based performance measure in both countries were compared.

Results:
Compared with their US counterparts, Chinese patients were much younger (mean 64.8 vs. 70.5 years), had lower prevalence of comorbidities except for prior stroke/TIA and smoking, had less severe stroke (NIHSS, mean 5.4 vs. 6.8) and more delay from symptom onset to arrival (median 22 vs. 11 hours) (all p<.001). Overall, use of intravenous thrombolytic therapy was 2.4% in China (tPA 1.4% and urokinase 1.0%) and 8.1% in US (tPA). Chinese compared with US patients experienced more treatment delay (door-to-needle time, median 95 vs. 62 minutes, p<.001). Adherence to early and discharge antithrombotics, smoking cessation counseling, and dysphagia screening were fairly high in China (>80%), although numerically lower than in the US. The largest differences between performance measure adherence in Chinese and US care were seen in timeliness of tPA treatment, venous thromboembolism prophylaxis, lipid lowering therapy, anticoagulation for atrial fibrillation, and rehabilitation assessment (Figure).

Conclusion:
We found important differences in clinical characteristics and gaps in adherence to certain performance measures between China and the US. National efforts are needed for continued improvements in acute ischemic stroke care in both countries.
Abstract TP309: The Role of Teleconsultation in Acute Stroke Trial Enrollment
Authors: Shoirah Hazem , Kenmuir Cynthia L , Al-Bayati Alhamza R , Aghaebrahim Amin , Hammer Maxim D , Reddy Vivek K , Starr Matthew T , Wechsler Lawrence R , Jovin Tudor G , Jadhav Ashutosh P
Published: March 2022

Background:
A major barrier to enrollment into acute stroke clinical trials is timely access to a tertiary care center conducting the study. Tertiary centers often receive the majority of their patients through broad referral networks. Remote consent via telephone, telemedicine or web-based technology are strategies that have been suggested to broaden enrollment. There is limited data on the feasibility and efficacy of those methods.

Methods:
There are 19 telemedicine sites and 23 non-telemedicine sites in our network. We describe our experience with screening and enrolling patients into acute stroke clinical trials via our referring network. Based on mode of presentation, we divided all patients enrolled in trials into 3 cohorts; direct presentation with no prior consultation, transfer after consultation by telephone only and transfer after full telemedicine consultation. We classified trials based on required timeframe of enrollment into urgent and non-urgent. We used two-way ANOVA to compare the differences between the three cohorts across both types of trials.

Results:
Between January 2013 and July 2015, 175 patients were enrolled into 13 clinical trials, 8 of which were urgent. Telephone consults resulted in the highest volume of enrollment (46.3%). Telemedicine consults resulted in higher enrollment into urgent vs non-urgent trials (18.6% vs 11%). Combined; telephone and telemedicine consults comprised the majority of enrollment volume (61.7%). The results were statistically significant (Urgency of Enrollment, p = 0.02. Type of Consult, p = 0.002).

Conclusion:
Tele-consultation is a feasible and efficacious resource for recruitment into acute stroke trials. Wide implementation of this method can achieve broader recruitment and more rapid completion of trials. Although no major protocol violations or delays were reported in our study, future trials can assess the reliability of the different methods.
Abstract TP314: Current Use of Strategies to Improve Door-to-Needle Times With Tissue Plasminogen Activator in Acute Ischemic Stroke: Findings From the Target: Stroke Phase II Survey
Authors: Xian Ying , Lytle Barbara , Blevins Jason , Hernandez Adrian F , Peterson Eric D , Smith Eric E , Saver Jeffrey L , Messe Steven R , Paulsen Mary , Suter Robert , Reeves Mathew J , Jauch Edward C , Schwamm Lee H , Fonarow Gregg C
Published: March 2022

Background:
The benefits of intravenous tissue plasminogen activator (IV tPA) in acute ischemic stroke are time-dependent. The implementation of Target: Stroke Phase I, the first stage of the American Heart Association’s national quality improvement initiative to accelerate door-to-need (DTN) times, was associated with an average 15 minutes reduction in DTN times. To further reduce DTN delays, Target: Stroke Phase II was launched in 2014 and disseminated additional new best practice strategies.

Methods:
All active Get With The Guidelines-Stroke hospitals (n=1701) were invited to participate in Target: Stroke Phase II and completed an online survey regarding their use of DTN strategies. Hospital respondents reported the use of specific strategies in the 6 months preceding the survey as a binary yes/no or a continuous 0 to 100% of the time scale.

Results:
A total of 1034 hospitals (61% response rate) completed the survey between Dec 2014 and Apr 2015. The majority of participating hospitals reported routine use of Target: Stroke key practice strategies, although direct transfer to CT scanner, point of care testing, pre-mix of tPA ahead of time, tPA stored in Emergency Department (ED), or initiation of tPA bolus in the imaging suite were used less frequently (Table). Brain imaging located within the ED was reported by 44% of hospitals and 78% had access to an in-house stroke expert 24/7. Among those who did not have stroke expertise at all times, a majority of hospitals used telestroke systems for imaging interpretation (78%) or clinical evaluation (58%).

Conclusions:
GWTG-Stroke hospitals reported moderate to extensive use of most Target: Stroke key practice strategies to evaluate acute stroke cases for tPA eligibility and reduce DTN times. Nevertheless, use of point of care testing, pre-mixing of tPA, ED storage of tPA, initiation of tPA in the imaging suite, and direct transfer to CT scanner remained low, representing potential targets for additional improvements.
Abstract TP319: Racial and Gender Differences in Tissue Plasminogen Activase Metrics Over Telemedicine
Authors: Jagolino Amanda L , Bozorgui Shima , Patel Jignesh , Irani Malcolm K , Ankrom Christy , Cossey T C , Sharrief Anjail Z , Vahidy Farhaan S , Savitz Sean , Wu Tzu Ching
Published: March 2022

Introduction:
Several studies have demonstrated racial/ethnic and gender disparities in acute ischemic stroke (AIS) management which persist after adjustment for measures of socioeconomic status. As AIS management and intravenous tissue plasminogen activase (tPA) treatment via telemedicine (TM) increases, it is important to assess for differences in treatment metrics by race/ethnicity and gender.

Hypothesis:
We hypothesized that there are no racial/ethnic or gender differences in tPA metrics over TM.

Methods:
We identified 349 patients in our TM stroke registry who received tPA at one of our 14 spoke hospitals from 2/2014 to 5/2015. We abstracted baseline characteristics, and compared tPA metrics among different groups, including race/ethnicity (White, Black, Hispanic, Asian) and gender.

Results:
Baseline characteristics and clinical variables are found in both tables. The median time between TM code stroke alert and tPA administration was longer for women compared to men (44.5 vs 40, p=0.00), which is reflected in a significantly longer median DTN time for women (73 vs 64, p=0.01) (Table 1). This difference persisted when adjusted for age, race, and baseline NIHSS (p=0.01). However, there was no significant difference in tPA metrics between race in our dataset (Table 2).

Conclusion:
Further investigation is needed to define factors contributing to gender difference in tPA treatment metrics over TM.
Abstract TP32: Endovascular Treatment of Posterior Circulation Strokes Improves Outcome
Authors: Moussavi Mohammad , Mehta Siddhart , Korya Daniel , Brar Jaskiran , Shaikh Azka , Kalola Rushil , Nizam Shayan , Panezai Spozhmy , Kirmani Jawad
Published: March 2022

Introduction:
Patients presenting with acute ischemic stroke due to a large vessel occlusion of the anterior circulation (usually M1), are now offered thrombectomy after 6 major trials demonstrated superior results over IV tPA alone. However, there are few trials evaluating the benefit of clot retrieval in posterior circulation strokes. Our goal was to evaluate the benefit of thrombectomy for posterior circulation strokes.

Methods:
We conducted a comprehensive record review of patients who underwent acute endovascular intervention for posterior circulation ischemia at a community based, university affiliated comprehensive stroke center during a 5-year period (2010-2015). The initial NIHSS, discharge NIHSS and discharge mRS were abstracted. We compared discharge mRS to composite 90 DAYS mRS of six recent multi-centered prospective randomized control trials (MPRCT) for acute endovascular treatment of acute ischemic stroke involving large vessel occlusions (SWIFT PRIME, ESCAPE, MR CLEAN, EXTEND-IA, REVASCAT, THERAPY).

Results:
There were 2,980 patients who presented with acute ischemic stroke during the pre-specified time period. Of those 310 were posterior circulation strokes; of which, 34 underwent endovascular treatment. These were compared with 1,386 patients with proximal anterior circulation strokes included in the recent MPRCTs. The mean age was 62 (SD=12). Mean initial NIHSS was 12 (SD=11). Mean change in NIHSS was 4 (SD =6). Mean discharge NIHSS was 9 (SD=11). Mean discharge mRS was 2.6 (SD=2.1).

Conclusion:
The benefits of thrombectomy for posterior circulation strokes compare well with those recently achieved by the trials evaluating the treatment for anterior circulation strokes. A prospective randomized trial comparing this option with the standard of care should be attempted to better elucidate the results.
Abstract TP320: Fluoroscopy Time: an Early Predictor of Outcome After Thrombectomy for Acute Ischemic Stroke
Authors: Sharrock Matthew F , Abraham Michael , Albadareen Rawan , Keshary Sanjeev , Mittal Manoj
Published: March 2022

Introduction:
Endovascular thrombectomy for acute ischemic stroke (AIS) is time sensitive and faster intervention can lead to better patient outcomes. Quality improvement (QI) measures typically focus on door to needle and groin puncture times. Increased fluoroscopy time (FT) has been associated with increased cerebral angiography complication rates. We aimed to understand the predictors of lower FT and its effect on 3-month clinical outcomes.

Methods:
We performed a retrospective study of AIS patients with large vessel occlusion who underwent mechanical thrombectomy at our center from 2008 to 2014. We performed univariate analysis between FT (dichotomized in ≤ 50 minutes (lower) and >50 minutes (higher) based on the 75th percentile) and patients demographics, stroke severity, procedural data and outcomes measured including TICI recanalization scores and 90-day modified Rankin Scale (mRS). Significant predictors (p<0.05) from univariate analysis were entered into a multivariate logistic regression model to identify independent predictors.

Results:
Out of 98 patients, 77 (79%) patients had FT ≤50 minutes. Significant predictors of lower FT were men (56% vs 44%, p=0.01), no congestive heart failure (87%% vs 13%. P=0.0005), no atrial fibrillation (74% vs 26%, p=0.01), no ICA occlusion (83% vs 17%, p=0.01), and non-aspiration device (81% vs 20%,p=0.01). In a multivariate logistic regression model, only non-aspiration device was an independent predictor of lower FT (OR 3.19, 95% CI 1.001-10.43). Lower FT was associated with lower total procedure time (80 vs 149 minutes, p<0.0001), favorable revascularization scores (TICI 2b and 3, 70% vs 38%, p=0.01), and 90 days MRS (41% vs 10%, p=0.01). Lower FT was associated with improved 3-month outcome after adjusting for age and admission NIHSS (OR 5.8 95% CI 1.3-44.5).

Conclusions:
FT is an early predictor of 3 month clinical outcomes. The use of non-aspiration devices predicted lower FT and may reflect the complexity of using different devices. Occlusion at the ICA and cardiovascular comorbidities were also associated with prolonged FT. These results suggest that FT should be considered in the evaluation of device performance and followed as a measure of QI as this field rapidly evolves.
Abstract TP328: Kentucky SEQIP Statewide Approach to Improving Bedside Dysphagia Screening
Authors: Moore Kari D , Bobo Bonita , Herbert Melisa , Hunt Polly , Rock Peter , Singletary Bill , Tate Debbie , Turner Stephanie , Block Starr
Published: March 2022

Background and Issues:
Research has shown that dysphagia occurs within 3 days of a stroke in 42-67% of patients. Of those, 50% aspirate, leading to higher morbidity and mortality due to complications such as pneumonia, dehydration and malnutrition. After reviewing aggregate Get With The Guidelines data, a voluntary group of Kentucky hospitals named SEQIP (Stroke Encounter Quality Improvement Project) was convened and agreed to share data. SEQIP, which included certified stroke centers and those pursuing certification working in collaboration with the AHA/ASA and the KY Department of Public Health, implemented a statewide QI Plan in an effort to improve the care of stroke patients with regard to bedside dysphagia screening prior to oral intake.

Purpose:
The purpose of this hospital collaboration was to increase overall compliance of bedside dysphagia screening for acute stroke patients by implementing a unified statewide effort.

Methods:
Baseline bedside dysphagia screening results were reviewed from 16 SEQIP hospitals. Using an interdisciplinary continuous quality improvement process, SEQIP hospitals shared best practices and dysphagia screening tools, such as Just Add Water, NPO Until You Know, Toronto Bedside Swallowing Screening Test, and other validated screening tools. SEQIP then developed a statewide QI Plan that supported integration of evidence-based bedside dysphagia screening, monitoring, evaluation, reporting and accountability at each member hospital.

Results:
SEQIP’s participating hospitals achieved improvement in screening rates compared to 2008 baseline data as a direct result of quality improvement techniques. Between 2008 and 2014, SEQIP achieved a 28.9% increase in proportion of eligible patients (n=27616) receiving screening (from 62.87% to 91.81%). SEQIP hospitals demonstrated year-by-year improvement in performance. In the analysis, statistically significant (p<0.001) improvements occurred in every subsequent year compared to baseline.

Conclusions:
Collaboration between hospitals, sharing of best practices, identification of evidence-based dysphagia screening tools, and the development of a unified QI Plan resulted in improved statewide compliance with bedside dysphagia screening before oral intake.
Abstract TP333: Independent Variables Contributing to Stroke Mortality in a Tertiary Medical Center With a Large Rural Referral Base
Authors: Tadevosyan Aleksey , Chen Patrick , Anandaram Sanjay , Rojas-Soto Diana , Lukovits Timothy
Published: March 2022

Background:
Inpatient mortality rates have been used as a quality measure in stroke. Some factors are within the control of healthcare providers and others, such as age or severity of illness are by nature non-modifiable. Various risk adjustment models (UHC, GWTG) attempt to account for severity of illness based on patient characteristics with the presumption that remaining differences in mortality are accounted by differences in health care quality. In this study we examine how patient mortality can be effected by a number of independent variables, including care provided prior to admission, involvement of palliative care team, and patient and family preference

Methods:
We initially reviewed our mortality reports from GWTG-Stroke and UHC for 2014 at Dartmouth-Hitchcock Medical Center (DHMC), and identified a cohort of 49 patients deceased from stroke using the appropriate ICD-9 codes and the discharge status of “expired”. We compared cases reviewed by The Division of Quality, Safety, and Value (DQSV) at DHMC with independent chart review performed by neurologists from our stroke program, who focused on factors such as route of hospitalization, management prior to admission and end of life care. Deaths were categorized into three categories: 1. Non-preventable. 2. Possible iatrogenic mortality 3. Non-iatrogenic, but possibly preventable based on specific circumstances of the case.

Results:
A significant number of preventable cases were found on clinician’s review compared to the case reviews based on the DQSV. Notably at least 7 cases were found to have complications prior to transfer to our facility. None of these preventable deaths were due to premature withdrawal of care.

Conclusions:
These results suggest that institutions similar to ours would benefit from improving quality of care of stroke patients at the referral hospitals prior to transfer. This work also implies that as health care moves towards an incentivized and outcome-based system, using mortality scores alone to label hospitals as excellent or poor may have the unintended consequences of compromising patient care in order to reach benchmarks that do not take into account the unique variables of different hospital settings.
Abstract TP338: Outcomes After Carotid Endarterectomy Among Dual-eligible Medicare-Medicaid Beneficiaries, 2003-2010
Authors: Lichtman Judith H , Leifheit-Limson Erica , Wang Yun , Meschia James F , Howard George , Howard Virginia , Brott Thomas
Published: March 2022

Background:
Over 9 million dual-eligible beneficiaries rely on both Medicare and Medicaid to obtain critical medical services. Medicaid serves as a safety net for low-income Medicare beneficiaries with limited assets; however, it is unknown whether dual-eligible patients have comparable outcomes for procedures to non-dual-eligible Medicare beneficiaries. We compared outcomes by dual-eligible status for patients undergoing carotid endarterectomy (CEA).

Methods:
We identified Medicare fee-for-service beneficiaries aged ≥65y who underwent CEA (ICD-9 38.12) from 2003-2010. Beneficiaries with ≥1m of Medicaid coverage were considered dual eligible. We fit mixed models with a random intercept for state and adjustment for demographics, comorbidities, and symptomatic status to assess the relationship between dual-eligible status and outcomes.

Results:
A total of 35,832 dual-eligible and 470,134 non-dual-eligible beneficiaries were hospitalized for CEA during the study period. The percentage of dual-eligible CEA patients decreased from 7.9% in 2003 to 6.7% in 2010. Dual eligibles were more likely to be younger, female, of nonwhite race, and living with comorbid conditions (e.g., heart failure, renal failure, diabetes) and symptomatic carotid disease. Dual eligibles had higher 30d composite outcomes including stroke (Table), but the associations with 1y stroke became nonsignificant from 2003-2010. Dual-eligible status was associated with higher 30d and 1y mortality after CEA throughout the study period.

Conclusions:
Dual-eligible Medicare-Medicaid beneficiaries had worse short-term stroke and mortality outcomes than other beneficiaries, even after adjustment for comorbidities. Our results indicate a need to understand factors contributing to poorer outcomes. Challenges include the split accountability between the two programs and the diverse sociodemographics, clinical characteristics, and generally poorer health of the patients.
Abstract TP340: Imaging Related Radiation Dose and Cancer Risk Assessment of Brain in Acute Ischemic Stroke Patients
Authors: Sharma Vijay K , Seow Philip A , Ting Eric Y , Kapur Subhash
Published: March 2022

Background and aims:
Recently, safety concerns were raised about the radiation dose for acute ischemic stroke (AIS) patients undergoing computed tomography (CT), CT angiography (CTA) and CT perfusion (CTP). We evaluated precise radiation dose to the brain during various imaging studies in our AIS patients.

Methods:
Brain imaging was performed with 64-detector row CT scanner (Phillips-iCT256) using standard protocols recommended by American Association of Physicist in Medicine. For each procedure, volume weighted CT dose index (CTDIvol, mGy) and dose-length product DLP (mGy.cm) were obtained from dose reports generated at the time of acquisition. Organ specific dose to brain, eye, bone marrow and thyroid were also obtained. The estimates of cancer risk were interpolated.

Results:
In this prospective study, a total of 18 patients who underwent CT, CTA as well as CTP were included. Mean DLP for non-enhanced CT, CTA and CTP were 1068.25, 1150 and 1197 mGy.cm, respectively. Corresponding whole body effective dose for the CT, CTA and CTP were calculated as 2.57, 2.6, 2.4 mSv, respectively. Cumulative doses to the brain, eyes, bone marrow and thyroid gland were 33.81, 32.8, 1.21 and 1.31 mGy for the non-contrast brain CT. CTDIvol measurements for different protocols tested by the phantom were in agreement with values given in dose reports.

Conclusions:
The effective radiation doses are less than previously reported and much below the radiation threshold level for deterministic effects for brain and optic lens (500-2000mGy). Estimated life-time attributable cancer risks are very low with the current radiation doses.
Abstract TP343: Differential TNFα Expression in Patients of Acute Ischemic Stroke
Authors: Modak Janhavi M , Roy-O'reilly Meaghan , DiMauro Sharon , Fortunato Gil , Staff Ilene , McCullough Louise
Published: March 2022

Introduction:
Inflammation plays a critical role in the pathophysiology of ischemia and atherosclerosis. TNFα plays a multifaceted role in stroke progression, having both protective and deleterious effects. Animal studies have shown that TNFα levels increase in cerebral tissue within the first 24 hours after experimental stroke.

Hypothesis:
Expression of TNFα is related to outcomes after acute ischemic stroke. Differences in expression will be seen with respect to patient gender and other stroke characteristics.

Methods:
Patients admitted to Hartford Hospital between January 2011 and March 2014 were considered for this study. Blood samples were collected within 24 hours of stroke presentation. Patients with a history of active cancer, primary or secondary neoplastic brain lesions, traumatic brain injury or intracranial hemorrhage were excluded from the study. Serum was analyzed using a multiplex human cytokine panel/Bio plex (Bio-Rad laboratories Inc.). Statistical analysis was performed using SPSS.

Results:
A total of 163 ischemic stroke patients were included in the study. Outcome variables including NIH stroke scale, modified Rankin scale (mRS) at discharge, 3 months, 12 months and modified Barthel’s index (BI) were collected. Composite outcome scores were determined using the mRS and BI. A negative outcome was defined as death or BI ≤ 14 or mRS >2.There was a statistically significant difference (p=0.003) in the expression of TNFα between male - 21.74 pg/ml (15.11-30.21) and female 27.9 pg/ml (19.07-35.497) stroke patients. A significant difference (p=0.009) was observed in TNFα expression in patients with a good outcome - 22.96 pg/ml (15.69-30.85) as compared to those with a poor outcome (discharge to worse/hospice or death) - 30.78 pg/ml (22.03-35.38) post stroke.

Conclusions:
Male- female sex differences are associated with changes in the post ischemic inflammatory cascade. Higher TNFα levels predict poorer outcomes post stroke. Cytokines like TNFα may serve as a potential therapeutic targets in patients with acute ischemic stroke.
Abstract TP351: Early Comfort Care Measures in Acute Stroke Patients: Analysis From the Get With the Guidelines Stroke Registry
Authors: Prabhakaran Shyam , Cox Margueritte , Schulte Phillip J , Xian Ying , Zahuranec Darin , Smith Eric E , Reeves Mathew , Fonarow Gregg C , Schwamm Lee H
Published: March 2022

Introduction:
Mortality after stroke is often hastened by forgoing life-sustaining measures. We sought to determine the patient and hospital characteristics associated with early comfort measures only (CMO) after ischemic stroke (IS), intracranial hemorrhage (ICH), and subarachnoid hemorrhage (SAH) in the Get With the Guidelines-Stroke registry.

Methods:
We identified patients with IS, ICH, or SAH between November 5, 2009 and September 30, 2013 who: 1) had known early CMO status; 2) were not transferred in from or out to another acute care facility; and 3) from sites with > 10 patients during the study period. Using multivariable logistic regression, we assessed patient and hospital factors associated with early CMO use by stroke type. Early CMO was defined as occurring on hospitals day 1 or 2.

Results:
Among 963,525 patients from 1,675 hospitals, 54,794 (5.6%) received early CMO (IS: 3.0%; ICH: 19.4%; SAH: 13.1%). There was a decrease in early CMO use (p<0.001) over the study period. In multivariable analysis, several patient (advancing age, female gender, non-white race-ethnicity), hospital (bed size and stroke case volume), and geographic factors (Midwest and West) were independently associated with early versus no early CMO use overall and by stroke type (Table).

Conclusions:
Nationwide, early CMO is utilized in over 5% of stroke patients being more common in ICH and SAH than IS. Different patient and hospital characteristics influence CMO use among stroke types.
Abstract TP352: Intracranial Pressure Measured Immediately After Hemicraniectomy in Malignant Middle Cerebral Artery Infarction
Authors: Jeon Sang-Beom , Kwon Sun U. , Park Jung Cheol , Ahn Jae-Sung , Kwun Byung-Duk , Kang Dong-Wha , Kim Jong S.
Published: March 2022

Introduction:
Decompressive hemicraniectomy is a life-saving procedure for patients with malignant middle cerebral artery (MCA) infarction. However, substantial numbers of patients still die despites hemicraniectomy due to refractory intracranial hypertension. The role of monitoring of intracranial pressure (ICP) in patients who underwent hemicraniectomy is largely unknown.

Hypothesis:
We hypothesized that ICP during the immediate post-hemicraniectomy period may be an early indicator of effectiveness of decompressive hemicraniectomy.

Methods:
We included 25 patients 1) who underwent hemicraniectomy for malignant MCA infarction, 2) whose ICP probes were inserted during the hemicraniectomy, and 3) whose ICP was measured hourly during the first postoperative day. Non-contrast brain CT was obtained within the first hour after hemicraniectomy. Midline shift at levels of septum pellucidum and pineal gland was measured on CT. Level of consciousness was evaluated with Glasgow coma scale 24 hours after hemicraniectomy. Survival status was assessed at six months. We analyzed the relationship between ICP, midline shift, Glasgow coma scale, and survival.

Results:
Initial ICP was correlated with mean ICP (p<0.001) and maximal ICP (p<0.001) during the first post-operative day. Initial ICP was associated with midline shift at the septum pellucidum (p=0.009), midline shift at the pineal gland (p=0.012), and Glasgow coma scale (p=0.025). Sixteen (64.0%) patients survived at six months. In Cox proportional hazard model, elevated initial ICP was associated with survival for six months (hazard ratio, 1.130; 95% CI, 1.032 - 1.237; p=0.008).

Conclusion:
ICP measured during the immediate post-hemicraniectomy period was associated with midline shift, level of consciousness, and survival at six-months in patients with malignant MCA infarction. Our findings suggest that early ICP may be an indicator of effectiveness of decompressive hemicraniectomy and a predictor of long-term survival after hemicraniectomy for malignant MCA infarction. Further studies are necessary to explore clinical implications of our findings with regard to triggering additional and timely interventions after a hemicraniectomy.