bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP250: Migraine and Deep White Matter Hyperintensities are Independently Associated With Post-Stroke Recrudescence
Authors: Conforto Adriana , Rocha Eva A , Giese Anne-Katrin , Rost Natalia , Sampaio Gisele S , Singhal Aneesh B
Published: January 2019

Introduction:
Transient reemergence of previous stroke-related deficits (or post-stroke recrudescence, PSR) may be triggered by infections, hypotension and hyponatremia. Patients with PSR (PSR+) are more often women, non-White, have more diabetes, dyslipidemia, history of smoking, infarcts from small-vessel disease and more severe deficits at stroke onset than patients without PSR (PSR-). Whether increased white matter hyperintensities (WMH) burden is also more frequent in PSR+ than in PSR- remained to be determined. We compared WMH burden in patients with stroke who experienced PSR and in controls.

Methods:
We assessed WMH burden in MRIs of 75 patients with stroke and PSR (PSR+) and 150 age- and gender-matched controls with DWI-confirmed ischemic stroke (PSR-). We evaluated the extension of periventricular WMH (PWMH) and deep WMH burden (DWMH). A conditional logistic regression model was used to identify independent predictors of PSR.

Results:
Multivariate analysis showed that patients with diabetes (Odds ratio, OR, 5.02), hyperlipidemia (OR 2.97), higher NIHSS (OR 1.2), DWMH (OR 3.94) and migraine (OR 8.06) were significantly more likely, and that White patients were less likely (OR 0.22) to have PSR.

Conclusions:
DWMH and migraine were more frequent in PSR+ than in PSR-. PSR is not a migraine attack because transient worsening of residual focal deficits, or transient recurrence of previous stroke-related deficits are required for diagnosis. It has been hypothesized that recurring migraine attacks are associated to ischemia, and that DWMH may be caused by ischemia. Migraine, diabetes and hyperlipidemia may increase the risk of DWMH. DWMH may disrupt brain connectivity and increase susceptibility to PSR. Alternatively, spreading depression or other abnormal neuronal activity may lead to migraine attacks and to PSR. DWMH, migraine and PSR may share a common, yet unveiled underlying mechanism.
Abstract TP262: Factor VIII Elevation Associated With Worse Functional Outcomes Among Patients With Suspected Large Vessel Occlusion
Authors: Samai Alyana A , Boehme Amelia , Navalkele Digvijaya , Alemayehu Carmel , Martin-Schild Sheryl
Published: January 2019

Background:
Evidence suggests that elevation of clotting factor VIII (FVIII) increases incidence of acute ischemic stroke (AIS) and may be associated with worse outcomes following an AIS event. The extent of this relationship has not been studied among patients with suspected large vessel occlusion (LVO).

Methods:
This study is a retrospective case-control study using prospectively collected data from a single high-volume stroke center. Patients over 18 years old diagnosed with AIS between 2008-2015 were included if they had FVIII levels drawn during the acute hospitalization. A positive or negative VAN (vision, aphasia, neglect) score, highly sensitive for LVO, was determined for all patients via abstraction from the NIHSS score. After adjusting for key covariates, we analyzed whether VAN+ patients with elevated FVIII (VAN+/eFVIII), defined as FVIII over 150%, experienced worse outcomes compared to VAN+ patients with normal FVIII and VAN- patients. The primary outcome of interest was poor functional outcome, defined as a modified Rankin Scale score (mRS) of 3 or greater at discharge.

Results:
Of the 430 patients included, 155 patients (36.04%) were VAN+. Among those, 124 patients (80.0%) were in the VAN+/eFVIII group. The median FVIII level was higher in VAN+ patients than VAN- patients (207% vs. 192%, p=0.019). After adjustment for age, baseline NIHSS, and tPA exposure, the odds of poor functional outcome was 1.91 times greater in the VAN+/eFVIII group compared to all others (OR 1.91, 95% CI 1.03-3.57).

Discussion:
Among patients with suspected LVO, FVIII levels are higher and elevation is associated with increased odds of poor functional outcome. These findings support the utility of FVIII as a biomarker in the development of stroke patient risk profiles.
Abstract TP264: Telestroke Diagnosis of Conversion Disorder
Authors: Wen Yuang , Mohammed Alaa E , Ulep Robin D , Chokhawala Himanshu , Vidal Gabriel , Iwuchukwu Ifeanyi , McGrade Harold C , Chehebar Daniel , Zweifler Richard M
Published: January 2019

Conversion Disorder (CD) is a common stroke mimic of ischemic stroke (IS) or TIA. Although studies comparing stroke mimics with IS or TIA exist, there is a paucity of data comparing demographic and clinical features of CD and IS/TIA and evaluating diagnostic accuracy of CD via telemedicine.

Methods:
We retrospectively reviewed telestroke consultations at our center between April 2015 and July 2016. All patients were assessed remotely using telestroke service by physicians at the Ochsner Neuroscience Institute. Consultations were classified into one of 2 diagnostic categories: IS/TIA and CD; other stroke mimics were excluded. Initial diagnosis was compared with final diagnosis, determined after review of additional emergency department testing or hospital admission. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for diagnosis of CD were calculated. Bivariate analysis based on the diagnostic categories was used to examine association with sex, age, NIH Stroke Scale (NIHSS), stroke risk factors (CAD, DM, HLD, HTN, history of stroke/TIA, smoking, atrial fibrillation (AFIB)), TPA given, bleeding after TPA, and consult duration. Area under receiver-operating curve (AUC) for telestroke diagnostic accuracy of CD was calculated.

Results:
616 telestroke evaluations were included in our analysis. Sensitivity, specificity, NPV, PPV of CD diagnosis were 0.82, 0.998, 0.985 and 0.976, respectively. Variables that reached statistical significance between CD and IS/TIA were female gender (0.0006), age (<0.0001), DM (0.0252), HTN (0.0004), AFIB (<0.0001), TPA given (<0.0001), and median consult duration (0.0175). Median consult duration (min) of misdiagnosed cases was 27.5 (18.5, 32) and that of correctly diagnosed cases was 10.5 (7, 16). Adjusted AUC (95% CI) was 0.92 (0.87, 0.97).

Conclusions:
Our unadjusted telemedicine CD diagnostic accuracy is 0.98. In the bivariate analysis CD patients are more likely to be female, younger, and have no history of DM, HTN or AFIB compared with IS/TIA patients. CD patients received shorter consult time compared with IS/TIA patients, and received less TPA. CD misdiagnosed cases had a longer median consultation time than correctly diagnosed cases.
Abstract TP278: Paramedic Ischemic Stroke Recognition Predicts Favorable Outcomes
Authors: Oostema John A , Chassee Todd , Baer William , Edberg Allison , Reeves Mathew
Published: January 2019

Background:
Emergency Medical Services (EMS) transport facilitates rapid ischemic stroke treatment. We hypothesized that EMS stroke recognition is critical to delivery of optimal stroke care and favorably impacts downstream outcomes.

Methods:
We identified consecutive EMS-transported ischemic stroke (IS) and transient ischemic attack (TIA) patients at 4 primary stroke center hospitals over a 2-year period. Cases were categorized as EMS recognized or unrecognized based on documented EMS impression. Compliance with EMS performance measures (stroke screen use, onset time documentation, prenotification), hospital-based measures (door-to-CT [DTCT] times, t-PA delivery), and hospital discharge disposition were compared among EMS recognized and unrecognized cases. Logistic regression was used to adjust for confounders such as age, gender, stroke severity, and clustering by agency or hospital.

Results:
EMS transported 1,056 IS/TIA patients during the study period; 719 (68%) were recognized and 337 (32%) unrecognized. EMS recognized cases were more likely to receive recommended prehospital care, early CT, and t-PA (Table). EMS recognized cases also had higher odds of being discharged home and lower odds of death in adjusted analysis.

Conclusion:
EMS recognition of IS/TIA was associated with prehospital quality measure compliance, faster ED evaluations, t-PA delivery, and superior outcomes. Quality improvement efforts should focus on improving EMS stroke recognition.
Abstract TP286: Improvement in tPA Treatment Across a Large Community-Based Stroke Receiving System
Authors: Kenner Brininger Amelia , Olson-Mack Lindsay , Koenig Kristi L , Hemmen Thomas
Published: January 2019

Background:
Despite proven outcome improvements after acute ischemic stroke (AIS), adoption of intravenous tPA has been slow, particularly in non-academic medical centers. In 2010, San Diego County established a comprehensive stroke registry to benchmark stroke care across our region. We analyzed the change in tPA use frequency, treatment rate over time, and treatment variance between receiving facilities.

Methods:
The San Diego County EMS Stroke Registry includes all 16 stroke receiving centers in San Diego County, from which we analyzed mode of arrival (EMS, walk-in), door-to-needle (tPA) times (DTN), and treatment rate (ischemic stroke cases receiving tPA divided by total ischemic stroke cases) over time (January 2010- June 2017).

Results:
We captured a total of 23,913 discharges with AIS (
Table
). Of these, 58.5% arrived via EMS (41.5% walk-ins). The use of tPA increased from 7.5% in 2010 to 15.2% in 2017. The stroke incidence varied little; DTN reduced over time (2010: 128.8(±426.2) minutes; 2017: 58.4(±31.2) minutes); the variance of DTN between hospitals decreased (DTN SD: 2010: 426.2 minutes; 2017: 31.2 minutes).

Conclusion:
We show, across a large regional stroke registry, that tPA use increased and time to treatment decreased. This effect was similar across variant sized hospitals and seen in academic and non-teaching facilities. Through collaborative data-sharing, analysis and internal benchmarking, overall tPA treatment rates and times improved.
Abstract TP287: Efficient Multimodal-MRI versus CT Selection for Anterior Circulation Large Vessel
Authors: Atchaneeyasakul Kunakorn , Liebeskind David S , Jahan Reza , Starkman Sidney , Sharma Latisha , Yoo Bryan , Avelar Johanna , Rao Neal , Hinman Jason , Duckwiler Gary , Nour May , Szeder Viktor , Tateshima Satoshi , Colby Geoffrey , Hosseini Mersedeh B , Raychev Radoslav , Kim Doojin , Saver Jeffrey ,   UCLA Reperfusion Therapy Investigators
Published: January 2019

Background:
Prompt diagnosis and revascularization of large vessel occlusion ischemic stroke is associated with better functional outcome. While both MRI and CT modalities are current standard of care options for initial imaging, and MR imaging provides greater lesion conspicuity and spatial resolution to inform management, few series have yet demonstrated that multimodal MR may be performed speedily and efficiently in AIS-LVO patients.

Methods:
In a prospectively maintained Comprehensive Stroke Center Registry, we analyzed all anterior circulation LVO thrombectomy patients: 1) arriving directly by EMS transport from the field, 2) with initial NIHSS ≥6, between 2012-2017. Throughout this period, imaging policy was multimodal MRI (including DWI/GRE/MRA w/wo PWI) as the initial evaluation in all patients without contraindications, and multimodal CT (including CT with CTA, w/wo CTP) in the remainder. Achieved process times were compared with national recommendations for door-to-needle (45m, AHA/ASA Target Stroke) and door-to-puncture (90m, SVIN).

Results:
Among 106 LVO thrombectomy patients, MRI was used in 62.3% and CT in 37.7%. MRI and CT patients were similar in age, 72.5 v 71.3y; severity (NIHSS) 16.4 v 18.2); and IV tPA door-to-needle times, median 45 vs 46 mins. However, MRI patients had longer onset-to-door times, median 100 vs 50 mins. From Jan 2012-Dec2014, in MRI vs CT groups, median door-to-imaging times were 20 min vs 18 min, p=0.88 and door-to-puncture times 102 vs 93 min, p=0.39. From Jan 2015-Dec2017, after the publication of the positive thrombectomy trials and endorsement of endovascular stroke treatment in US guidelines, in MRI vs CT groups, median door-to-imaging times were 17 min vs 17 min (p=0.93) and door-to-groin puncture 86 vs 71 min (p=0.02). There was no difference in functional outcome (mRS 0-2) between groups.

Conclusions:
Optimized imaging processes enable acute AIS-LVO patients to be evaluated by multimodal MR with care speeds faster than national recommendations for door-to-needle and door-to-puncture times. While some patients have absolute contraindications to high magnetic fields, MRI, with its greater pathophysiologic insight, remains a highly viable primary imaging strategy in acute ischemic stroke patients.
Abstract TP289: Legal Authorized Representative Feedback on the use of Smartphone Platform for Electronic Informed Consent in an Acute Stroke Trial
Authors: Haussen Diogo C , Craft Leah , Doppelheuer Shannon , Schindler Kiva , Rodrigues Gabriel M , Grossberg Jonathan A , Al-Bayati AlHamza , Shaad Erin , Sutherly Loretta , Schultz Meagan , Frankel Michael , Nogueira Raul G
Published: January 2019

Introduction:
We have recently reported the pilot use of a smartphone platform for electronic informed consenting (e-Consent) in acute stroke trials. We here report the feedback provided by legal authorized representatives (LAR) after consenting for a large vessel occlusion acute ischemic stroke (LVOS) randomized clinical trial.

Methods:
This is a single-center prospective study investigating the criticism of LAR after the use of e-Consent for a clinical trial of neuroprotectant in LVOS within 12 hours of last normal. REDCap (Research Electronic Data Capture) is a secure, Health Insurance Portability and Accountability Act compliant, web-based platform designed for research data capture that was used to create a survey project located on a static URL that can be remotely accessed (via smartphone browser). Regardless of the geographical position of the LAR, a standard link to the URL was sent via text message to the LAR and signed. A structured survey was applied to each LAR at least 12 hours after enrollment.

Results:
From February-August 2018, 33 patients were enrolled in the trial. Four LARs were unavailable, 3 expired before the questionnaire could be applied, and 1 refused to participate, leaving 25 patients for the primary analysis. Mean LAR age was 49±13 years, 68% were female, 44% black/48% white, 44% had high-school education or less. All LARs reported e-Consent to be “clear”. Eighty percent felt “ very confortable” in signing an e-Consent, 16% “somewhat” and 4% “not comfortable at all”. Four (16%) LARs would prefer paper consent. The overall experience was “excellent” in 64%, “good” in 28%, and “poor” in 8%. Seventy-two percent of surveys were done via phone and 28% in person. The patient’s median baseline and discharge NIHSS was 17[IQR 12-22] and 2[1-7], and 60% had discharge modified Rankin Scale 0-2. Male gender (75% vs 6%;p=0.04) and education level less than college (100% vs 0%);p=0.03 were associated with preference of paper over e-consent, while baseline and discharge NIHSS were not.

Conclusion:
e-Consent was overall very well perceived by LAR in a randomized clinical trial of LVOS. A small percentage of LAR, who were more commonly male and formally less educated, preferred paper consent.
Abstract TP290: Site-Specific Education Significantly Improves Door-In-Door-Out Times Within a Large Telestroke Network
Authors: Ekstrom Erin , Pochert Angeliqua , Smith Jaleen , Chung Lee S , Hannon Peter M , Majersik Jennifer J
Published: January 2019

Introduction:
Door-in-door-out (DIDO) is the time between patient arrival at a Stroke Receiving Facility (SRF) and departure for definitive care, with long DIDO times associated with worse outcomes. Our goal was to, in a subset of telestroke (TS) sites, identify barriers to shorter DIDO times and then improve DIDO times.

Methods:
Our TS network consists of a comprehensive stroke center (hub) and 27 spokes (2 primary stroke centers, 25 SRFs, none thrombectomy-capable). The average spoke-to-hub distance is 190 miles, with only 25% of sites within a 50-mile radius. Based on close proximity to the hub, high consult volumes, and either on-site air or close availability of ACLS ground transport, we chose 5 TS sites as intervention sites to interview and receive targeted education. Baseline data was collected from Jan-Mar 2018 and post-intervention data from Apr-Jun 2018. We conducted site interviews in Mar 2018 to understand current DIDO processes and perceived barriers to shortening times. Customized education was provided based on site demographics, interview data, and State Stroke Task force recommendations. Content focused on the EMS activation process, LVO recognition, and improving ED provider comfort with earlier TS activation. All sites including the 22 control sites received DIDO education through a network newsletter and site coordinator phone calls. We used a t-test to determine if DIDO times differed between the interventional and control sites in the 3 mo pre- vs post-intervention.

Results:
Pre-intervention mean DIDO time was 185 min for the whole network, 192 (SD 106) for the intervention sites (n=13 transfers), 164 (SD 63) for the control (n=8) (p=NS). Post-intervention, DIDO times were mean 125 min for the network, 90 (SD 28) for intervention sites (n=9 transfers), 148 (SD 75) for controls (n=13) (p<0.02); p<0.005 for intervention site DIDO change between quarters. Intervention sites reported their biggest success was in empowering nursing to active TS sooner and improved communication with EMS activation.

Conclusion:
Targeted, customized education can significantly reduce DIDO times in a subset of sites of a large TS network. We hope to use this information to facilitate sustainable, reproducible improvement in DIDO times across all our TS sites.
Abstract TP294: Women Admitted for Suspected TIA are Less Likely to Have Imaging Evidence of Infarction than Men: Results from the Rhode Island Hospital Prospective TIA unit cohort
Authors: Madsen Tracy E , Baird Janette , Kwon Michelle H , Godbout Edmond E , Burton Tina , Cutting Shawna , Furie Karen L , Saad Ali , Yaghi Shadi , Siket Matthew S
Published: January 2019

Introduction:
Previous studies have shown sex differences in the presentation and management of patients with transient ischemic attack (TIA), but little is known about how outcomes differ by sex among those admitted to emergency department observation units (ED OU), an increasingly common ED disposition for patients with suspected TIA.

Objective:
To determine if there are sex differences in the rate of positive diffusion weighted MRIs (DWI) among patients with suspected TIA admitted to an ED OU.

Methods:
Patients in a large, urban, academic ED admitted to the ED OU for suspected TIA from 4/2013 - 7/2018 were included. Patients with persistent deficits, fever, heart rate <60 / >100, SBP >180 / < 100 mm Hg, pulse ox <93%, or other competing diagnoses were excluded. Standard blood tests, EKG, echocardiogram, MRI, and neurology consultation were performed. Rates of acute infarct on DWI were compared between women and men in unadjusted analyses, followed by multivariable logistic regression. The final model included covariates that were significantly associated with infarct on DWI in unadjusted analyses (p<0.05).

Results:
1208 patients were included; (52.9% women, 24.3% non-white). Women and men were of similar age (63.4 vs. 64.8) and had similar median duration of symptoms (45: IQR (15-90) vs 30 (10-90) min, p=0.51). Less women than men had hypertension (59.0% vs. 66.6%, p=0.02) or diabetes (17.5% vs. 22.5%, p=0.01), while more women had histories of migraines (12.8% vs. 3.5%, p<0.001). More women than men had pain on presentation (30.5% vs. 21.4%, p=0.001) and had a discharge diagnosis of something other than TIA/stroke (45.3% vs. 35.5%, p=0.002). Unadjusted, 19.1% vs. 13.0% had acute infarcts on DWI (p=0.08). After adjusting for age, race, history of hypertension, prior stroke/ TIA, and presenting symptoms (TABLE), women were less likely than men to have infarcts on DWI (aOR 0.55, 95% CI 0.38-0.79, p=0.001).

Conclusions:
Among patients with suspected TIA admitted to an ED OU, women were less likely to have acute infarcts on DWI. Our findings of sex differences in DWI infarct rate as well as co-morbidities and presenting symptoms may suggest a sex difference in diagnostic uncertainty and/or stroke mimics among those with suspected TIA/mild stroke.
Abstract TP295: Neighborhood Factors are Associated With Strokes but Not EMS Utilization in Chicago
Authors: Gordon Christopher D , Richards Christopher T , Prabhakaran Shyam
Published: January 2019

Introduction:
Neighborhood factors, such as income level and crime, may be risk factors for stroke and barriers to emergency medical services (EMS) utilization. We sought to identify neighborhoods with high rates of stroke and low EMS utilization and investigate neighborhood factors that influence these patterns.

Methods:
We conducted an analysis of confirmed stroke patients in Get with the Guidelines-Stroke database from 15 Chicago hospitals between Jan 2, 2013 and Jun 23, 2017. We included records with documented primary diagnosis of stroke, patient ZIP code, and mode of arrival. ArcGIS Pro 2.1.2 (Esri Inc., Redlands, CA) was used for analysis. We acquired ZIP code-level median age, median household income, insurance status, percentage white, percentage black, percentage Hispanic, and crime using U.S. Census Bureau American FactFinder database and City of Chicago Data Portal database. Using geographically-weighted regression, we estimated variance in stroke rates and EMS utilization for stroke associated with these neighborhood factors.

Results:
From 2013-2017, there were 10,040 stroke hospitalizations (Figure A) among which 47.7% arrived by EMS (Figure B). Approximately 79% of the variance in stroke hospitalizations in Chicago was explained by median household income and percentage of black residents. EMS use was modestly explained by percentage of white residents and median household income (maximum R-squared: 0.27). Crime and insurance rates were not associated with stroke or EMS use.

Conclusions:
Neighborhood factors are strong determinants of stroke hospitalization but not EMS utilization for stroke in Chicago. While socioeconomic status is relevant for stroke incidence, it has a small effect on EMS use. Patient-level factors that influence EMS use for stroke should be further explored.
Abstract TP3: Mechanical Thrombectomy for Cerebral Venous Thrombosis is Associated With Increased Inpatient Mortality: Outcomes From the Nationwide Inpatient Sample
Authors: Nguyen Peggy , Zheng Ling , Cen Steven , Sanossian Nerses , Kim-Tenser May
Published: January 2019

Introduction:
Cerebral venous thrombosis (CVT) is a rare form of stroke which can lead to both ischemic or hemorrhagic infarcts. The mainstay of treatment is therapeutic anticoagulation. Endovascular treatments, specifically, mechanical thrombectomy (MT) has been increasingly utilized, likely owing to the increasing concomitant use of MT in acute ischemic stroke patients. However, despite some small series and case reports demonstrating success, endovascular treatment, consisting of thrombolysis with or without MT, has not been shown to be superior to anticoagulation. Likely owing to its rarity, however, the use of MT alone has not been widely evaluated in large studies. Here, we utilize the Nationwide Inpatient Sample (NIS) to determine national rates of MT among patients with CVT over a 5-year epoch and characterize their outcomes.

Methods:
Cases with CVT were retrospectively obtained from the NIS for the period from January 1, 2006 through December 31, 2011. The primary outcome is inpatient mortality. Demographic and sample characteristics were compared using a chi-squared test between MT group and no MT group for categorical variables and using two-sample t-test for continuous variables. Poisson regression was performed to examine the mortality rate difference between MT vs. no MT groups, stratified by patients’ likelihood of dying at admission (major/extreme vs. minor/moderate).

Results:
3605 cases of CVT were identified, with 64 patients (1.8%) undergoing MT. Patients who underwent MT were on average younger, more likely to be admitted to a large teaching hospital, had extreme likelihood of dying at admission, and had longer length of stay (LOS). The MT group had higher inpatient mortality (22% vs 4%) and was more likely to be discharged to institutional care (38% vs 16%) than no MT group (p < 0.01). Among high risk patients with either major or extreme likelihood of dying at admission, the MT group showed statistically significantly higher inpatient mortality than the no MT group (31.2%±3.2% vs. 15.9%±0.7%, p<0.01).

Conclusions:
Patients with CVT undergoing MT were rare, with an extremely high acuity at presentation. Overall, these patients did poorly, with high inpatient mortality, longer LOS and high rates of discharge to institutional care.
Abstract TP30: Mechanical Thrombectomy in Acute Ischemic Stroke: Etiology and Trends of Readmissions in a National Population-based Cohort Study (2010-2014)
Authors: Savani Chirag , Kumar Varun , Yi Xiyan , Singh Tejinder , Pathak Ambarish , Chib Anjula , Renati Swetha
Published: January 2019

Background:
Our primary aim was to estimate national rates of preventable readmissions after Mechanical thrombectomy in Acute ischemic stroke (AIS) using National readmission database. Understanding the causes associated with 30-day readmissions following mechanical thrombectomy (MT) is critical to reduce the cost and improving the quality of life in AIS patients.

Methods:
Nationwide Readmissions Database (NRD) from 2010-14 was utilized to identify AIS using appropriate ICD-9CM codes in primary diagnosis fields. MT was identified by ICD9 procedure code 39.74 and IVT by 99.10 in any procedural field. Admissions within 30 day of index admission were considered as early readmission. Readmission causes were identified by ICD 9 CM code in primary diagnosis field of readmissions. P values for trends were generated by Cochrane-Armitage test for categorical variables and simple linear regression for continuous variables.

Results:
We identified 20,772 AIS patients who underwent MT, Mean age was 68 years and procedures were distributed equally in both genders. MT hospitalization progressively increased from 2,533 in 2010 to 5,598 in 2014, with similar rising trends in 30-day readmission from 272 in 2010 to 597 in 2014. Most patients received MT at large (85.9%) and teaching (83%) hospitals. 2237 (10.8%) patients were readmitted within 30 days. 50% of all readmissions were within 11 days of discharge from index admission. Common causes of readmission were neurological (22.8%), cardiac (21.5%), infections (13.3%), kidney or urinary causes (9%), pulmonary causes (8.5%), bleeding (4.8%). Major neurological causes were ischemic stroke (11.8%), intracerebral hemorrhage (3.7%) and transient ischemic attack (1.2%). Heart failure (4.8%), atrial were the most common cardiac causes of readmission.

Conclusion:
1 in 10 patients who underwent MT for AIS were readmitted; 50% of them in first 11 days; due to neurological and cardiac causes. Our study could help early identification of high risk patients and aid in allocation of resources to reduce readmissions.
Abstract TP306: Streamlining the Enrollment Process in Acute Stroke Trials: Perspective From a Comprehensive Stroke Center
Authors: Aitken Kinga , Wong Ka-Ho , Neate Crystal , Dela Cruz Michael , Chung Lee S , de Havenon Adam H , DeWitt Dana L , Hannon Peter M , Meyer Chelsea , Ruff Jerdan , Wold Jana J , Majersik Jennifer J
Published: January 2019

Introduction:
Acute stroke is a stressful time for patients, families, and medical staff. Adding potential clinical trial enrollment to this mix further complicates the situation, and can result in chaos, delaying randomization or losing potential patients due to time constraints. Streamlining processes can decrease enrollment times and improve flow, compliance, and data quality.

Methods:
Our stroke research team developed multiple processes to improve acute trial enrollments. We developed an enrollment grid that details which trial to offer to patients who qualify for multiple acute trials, allowing us to equitably enroll in all trials without bias. We house enrollment binders in the emergency room with documents to be completed during enrollment, tabbed by research member (MD vs coordinator). These include the current consent form version with a cover sheet requiring the consenter to verify the latest version of the consent is being used and is accompanied by a study-specific script that includes all consent elements. This helps team members to uniformly present information, and not miss important elements due to stress and time constraints. This binder also includes protocol reminders, drug orders, and references to a secure share drive with additional helpful documents. We hold yearly consenting practice sessions for new fellows and research team members. We created electronic health record “smart phrases” including a consent process note and subsequent trial-specific documentation needs.

Results:
We analyzed 11 enrollments from 2 acute stroke trials that were enrolling between 1/1/16-1/1/18, split into two cohorts of pre- vs post-process implementation on 1/1/17. We found major improvement in our internal workflow and consistency while staying compliant with regulatory requirements. Times from patient arrival to signed consent decreased from 3.2±1.5 to 0.99±0.1 hrs (p<0.005). Additionally, our overall data quality remained excellent with an error rate well below <1%.

Conclusion:
Our new processes support our vision of efficient trial conduction in the acute setting with reduction of enrollment times and maintained excellent data quality. We are now implementing and disseminating these processes to our spokes and telestroke sites.
Abstract TP322: Viral Mediated Gene Delivery of TMBIM6 Protects the Neonatal Brain
Authors: Doycheva Desislava , Xu Ningbo , Tang Jiping , Zhang John H
Published: January 2019

Introduction:
A wide variety of conditions may contribute to oxidative protein folding processes in the endoplasmic reticulum (ER) which cause ER stress and play a major role in the pathogenesis of neonatal hypoxic ischemic (HI) injury. ER stress triggers the unfolded protein response (UPR) resulting in the activation of pro-apoptotic signaling causing cells to undergo apoptosis. Here were explored the role of Bax Inhibitor-1 (BI-1) protein, an evolutionary protein encoded by the Transmembrane Bax inhibitor Motif Containing 6 (TMBIM6) gene, as a novel modulator of ER stress induced apoptosis after HI brain injury in a neonatal rat pup. BI-1 may modulate the UPR response via a direct physical interaction with the stress sensor receptor, IRE1α, and thus inhibiting it’s pro-apoptotic signaling.

Hypothesis:
Overexpression of BI-1, using viral-mediated gene delivery of human adenoviral-TMBIM6 (Ad-TMBIM6) vector, will protect the neonatal brain from HI by inhibiting ER stress induced apoptosis.

Methods:
Ten-day old (P10) unsexed Sprague-Dawley rat pups underwent right common carotid artery ligation, followed by 1.5h of hypoxia. To overexpress BI-1, rat pups were intracerebroventricularly (icv) injected at 48h pre-HI with the human adenoviral vector-TMBIM6 (Ad-TMBIM6). To determine BI-1 confers protection via inhibition of IRE1α, we administered BI-1 siRNA, to silence BI-1, and an IRE1α CRISPR activation plasmid (AP), to counteract BI-1’s effects, at 48h pre-HI. Percent infarct area, immunofluorescent staining and western blot were performed at 72h post HI.

Results:
Overexpression of BI-1 showed to significantly reduce percent infarcted area, attenuated neuronal degeneration, reduced ER stress induced neuronal apoptosis and improved long-term neurological outcomes. Either silencing BI-1 or over activating IRE1α with a CRISPR AP significantly reversed BI-1’s protective effects.

Conclusions:
Overexpression of BI-1 attenuated the morphological and neurological consequences post neonatal HI via inhibition of the ER stress sensor, IRE1α.

This study showed a novel role for BI-1 and ER stress in the pathophysiology of HI and provided a basis for BI-1 as a potential therapeutic target.
Abstract TP325: Neuronal Gluconeogenesis: A Novel Neuroprotective Target in Ischemic Stroke
Authors: Geng Xiaokun , Stone Christopher , Shen Jiamei , Guan Longfei , DeGracia Donald , Ding Yuchuan
Published: January 2019

Introduction:
Although it is known that ischemic hyperglycolysis causes lactic acidosis and oxidative stress-induced ischemia/reperfusion injury, attempts to diminish these effects by targeting established mechanisms have not yet yielded improvement in clinical trials. Emerging evidence that gluconeogenesis (GNG) occurs in the brain suggests a novel manner in which ischemia, by shunting GNG intermediates, generates reactive oxygen species (ROS) and lactate, and thus also suggests a novel therapeutic target. We hypothesized that ischemia induces overactivation of the GNG enzymes phosphoenolpyruvake carboxykinase (PCK) 1&2, contributing to ROS and lactate-related damage. By inducing pharmacologic hypothermia (PH) with chlorpromazine and promethazine (C+P, FDA-approved), we tested the neuroprotective potential of suppressing these enzymes.

Methods:
Male Sprague-Dawley rats were subjected to 2 h intraluminal middle cerebral artery occlusion followed by 6 or 24 h reperfusion, upon which C+P (8mg/kg) and Troglitazone (TZD, a PCK inhibitor; 2.5mg/kg) were given intraperitoneally. Infarct volume and neurological deficit were determined. Additionally, primary rat and human neural cell lines were subjected to 2 h oxygen-glucose deprivation (OGD) and 6 or 24 h re-oxygenation, with or without C+P, TZD, or shRNA knockdown of PCK 1&2. Cell damage was assessed by colorimetric viability assay. In animal and cell culture models, ROS and lactate were measured. PCK 1&2 mRNA and protein levels were measured by real-time PCR and Western blotting. Levels of glucose and oxaloacetate (OAA), the GNG substrate of PCK, were obtained by biochemical assay. Cellular expressions of PCKs were determined by immunocytochemistry.

Results:
GNG occurred in the brain, and was dysregulated by ischemia: ROS and lactate levels correlated with increased neuronal PCK1&2 activity and with decreased OAA and glucose. C+P decreased oxidative/acidotic stress and overall brain injury by inhibiting PCK1&2 in neuronal and whole brain lysates. PCK1&2 were expressed primarily in neurons, but the effects of stroke on PCKs were largest in astrocytes.

Conclusion:
Our findings implicate GNG in ischemia/reperfusion pathogenesis and establish a new target of C+P neuroprotection.
Abstract TP326: Nitro-Oleic Acid Ameliorates Blood-Brain Barrier Disruption and Promotes Neurovascular Protection After Ischemic Stroke
Authors: Su Moxi , Tang Xuelian , Zhang Xuejing , Hamblin Milton H , Yin Ke-Jie
Published: January 2019

Introduction:
Nitro-oleic acid (OA-NO
2
), a nitroalkene formed in nitric oxide-dependent oxidative reactions, has been found in human plasma and is thought to regulate pathophysiological functions. Recently, accumulating evidence suggests that OA-NO
2
may function as an anti-inflammatory mediator, and ameliorate the progression of diabetes and cardiovascular diseases. However, the role of OA-NO
2
in ischemic brain injury remains unexplored.

Hypothesis:
OA-NO
2
stabilizes the blood-brain barrier (BBB), and is a neurovascular-protective regulator in ischemic brain injury.

Methods:
C57BL/6 mice were subjected to 1h transient middle cerebral artery occlusion (MCAO) followed by 24-72h reperfusion. These mice were intravenously treated with vehicle, OA or OA-NO
2
at 2h after the onset of MCAO. BBB integrity was assessed by using fluorescent-dextrans. Brain water content was measured by using a dry-wet method. Brain infarct was analyzed by 2%TTC staining or anti-map2 immunostaining. Infiltration of peripheral immune cells into brain parenchyma were examined by immunofluorescent methods. Total RNA was extracted from brain tissues and the expression of BBB tight junctions (TJs) and pro-inflammatory cytokines was detected by qPCR, Western blotting, and ELISA.

Results:
Compared to OA and vehicle controls, intravenous administration of OA-NO
2
led to reduced BBB leakage in ischemic brains, evidenced by significantly reduced extravasation of BBB tracers and less brain water content. OA-NO
2
treated mice also exhibited a smaller brain infarct and improved neurological functions in response to ischemic insults. Also, OA-NO
2
significantly reduced BBB leakage-triggered infiltration of neutrophils and macrophages in the ischemic brains. Mechanistically, OA-NO
2
increased major endothelial TJs including Claudin 5 and ZO-1 levels in stroke mice. Treatment of OA-NO
2
also significantly inhibited stroke-induced pro-inflammatory cytokines, IL-6 and MCP-1, in mouse brains.

Conclusions:
OA-NO
2
preserves BBB integrity and confers neurovascular protection in ischemic brain damage. OA-NO
2
-mediated brain protection may help us to develop a novel therapeutic strategy for the treatment of ischemic stroke.
Abstract TP329: Continuous Intracerebroventicular Injection of Brain-derived Neurotrophic Factor Increases Stroke Onset via Elevation of Blood Pressure in Hypertensive Rats
Authors: Hasegawa Yu , Takemoto Yushin , Hayashi Kenyu , Kim-Mitsuyama Shokei
Published: January 2019

Introduction:
Increasing evidences describe that Brain-derived neurotrophic factor (BDNF) is neuroprotective against cerebrovascular injuries and we previously revealed BDNF preservation on cerebral vessels was associated with inhibition of stroke onset in hypertensive rats. As BDNF was reported to increase blood pressure (BP) in hypertension, however, the upregulation might show conflicting results regarding stroke onset. In this study, we pursued the role of BDNF on stroke onset induced by high-salt diet (HSD) in hypertensive rats.

Methods:
In experiment 1, spontaneously hypertensive stroke-prone rats (SHRSP) were fed an 8% (n=22) or 0.3% (n=8) sodium diet from 11 weeks of age through 28 days. In experiment 2, SHRSP were treated with continuous intracerebroventricular injection of 2.1μg/day BDNF (n=10) or the vehicle (PBS; n=10) and fed an 8% sodium diet from 11 weeks of age through 24 days.

Results and Conclusions:
In experiment 1, stroke onset (95%) and mortality (55%) were frequently seen in the rats with HSD, whereas the rats with normal-salt diet were healthy. The expression level of BNDF was upregulated in the cerebral hemisphere and the increase were seen in reactive astrocytes at somatosensory cortex, whereas it was downregulated in endothelial cells. In experiment 2, in comparison with vehicle group, SHRSP with BDNF showed significant increase of incidence of stroke signs (60% vs. 89%), mortality (20% vs. 67%), BP at 2 weeks (214±6 vs. 244±12 mmHg), heart rate (366±20 vs. 457±17 beat/min) and decrease of body weight at 2 week (253±6 vs. 212±11 g), symptom score (5.6±0.3 vs. 2.8±0.8), and gastrocnemius muscle/BW (57±1 vs. 53±1 mg/g). Conclusion Despite the consistent observations of protective roles of BDNF in endothelial cells against the stroke, the present study demonstrated that endogenous BDNF was produced in reactive astrocytes in relation to stroke onset and additive application of exogenous BDNF by continuous intracerebroventricular injection enhanced the onset via elevation of BP in hypertensive rats. As BDNF is a potential candidate treatment not only for post-stroke but also stroke inhibition, we suggest that hypertensive patients need care for the elevation of BP in the clinical trials with BDNF.
Abstract TP352: Work Flow Optimization in Acute Stroke Therapy in a Community Based Comprehensive Stroke Center
Authors: Aghaebrahim Amin N , Granja Manuel F , Agnoletto Guilherme , Santos Roberta , Camp Wendy , Day Jason , Dellorso Scott , Naval Neeraj , Chmayssani Mohamad , Savageau Eric , Hanel Ricardo
Published: January 2019

Background and Purpose:
In acute stroke therapy, faster reperfusion leads to better outcome. We analyzed optimization steps to reduce treatment delays at a comprehensive stroke center in a non-academic tertiary hospital.

Methods:
Consecutive patients with ischemic stroke treated with either IV tPA, endovascular therapy or both were analyzed. Patient metrics were divided into two periods: pre-optimization period and post-optimization period. Key interventions of this workflow included: (1) addition of pre notification by EMS to ER and stroke team; (2) dividing stroke alert to level 1 (potential IV/IA candidate) vs. level 2; (3) direct transportation of level 1 stroke patients to brain CT imaging; (4) limitation of non-essential interventions; (5) 24/7 code stroke response by an in house trained vascular midlevel (NP/PA) and vascular neurologist (either in house or through telestroke network);(6) earlier notification of IR team; (7) CT to angiosuite direct transportation for LVO; (8) multidisciplinary monthly meetings to discuss delayed cases. Door to needle time and door to puncture time were used as target metrics in order to measure improvement.

Results:
A total of 279 patients were identified (101 in the pre-optimization and 178 in the post- optimization periods). No significant differences in any of the patient’s baseline characteristics were documented in the two observation periods. Almost all metrics favored the post-optimization period with a remarkable improvement in door to puncture time (64 (IQR 36-86) vs. 47 (IQR 20-62) min, p=0.002). Although non-statistically significant, we observed an increased percentage of good clinical outcomes in the post-optimization group (60.1% vs 54.8%, p=0.500).

Conclusions:
For patients undergoing acute reperfusion therapies, significant reductions in workflow time-frames can be achieved after simple optimization steps in a non-academic community based hospital.
Abstract TP358: Delirium is Associated With Increased Readmissions and Mortality in Patients With Acute Ischemic Stroke
Authors: Savani Chirag , Kumar Varun , Singh Tejinder , Yi Xiyan , Pathak Ambarish , Chib Anjula , Renati Swetha
Published: January 2019

Background:
Delirium is characterized by a fluctuating level of awareness and cognition. It is frequently seen in patients hospitalized with strokes. Despite delirium being a temporary condition it can lead to worsened outcomes. We sought to examine the effect of delirium during hospitalizations for acute ischemic strokes (AIS) using the Nationwide Readmission Database.

Methods:
We utilized Nationwide Readmissions Database (NRD) to identify AIS using appropriate ICD-9CM codes in primary diagnosis field and delirium was identified by appropriate ICD-9CM in secondary diagnosis field. Predictors to assess the association between baseline characteristics and 30-day readmission were analyzed using multivariable logistic regression model.

Results:
We identified 1958231 patients with hospitalizations for AIS between 2010-2014. Patients had an average age of 70.9 years, 48.3% were male and 51.7% female. 58738 (3%)of patients had a concurrent diagnosis of delirium. Patients with delirium were older (75.4 vs. 70.7 years; p<0.0001), and had a higher comorbidity index (p<0.0001). They were less likely to have received thrombolysis or mechanical thrombectomy (p<0.0001). Patients with delirium and AIS were less likely to be discharged home (42% vs. 63.4%; p<0.0001). The presence of delirium was also associated with a longer median length of stay (6 vs. 4 days; p<0.0001), and increased 30-day readmission (15.4% vs 11.8%; p<0.0001). Delirium in AIS patients increases 30-day readmission by 28% (OR 1.28, 95% CI, (1.24-1.33); p <0.0001). Etiologies of readmission were most commonly neurological (25.3%), with 12.8% being ischemic stroke. This was followed by readmission for infection (14.7%), kidney or urinary complications (12.6%), pulmonary (10.3%), and cardiac causes (10.2%). Presence of delirium was associated with a significantly higher mortality compared to AIS alone (10.3 % vs 5%; p<0.0001).

Conclusion:
In conclusion, the concurrent diagnosis of delirium during acute stroke hospitalization leads to markedly worse outcomes with increased rate of readmission and mortality. Protocols to prevent delirium should be implemented during hospitalizations for AIS.
Abstract TP362: Comparison of the Simplified Modified Rankin Scale Questionnaire With Conventional Neurological Scales in the Dose Arm of the Enchanted Study
Authors: Chen Xiaoying , Anderson Craig S , Wang Xia , Robinson Thompson , Lavados Pablo M , Lindley Richard I , Chalmers John , Delcourt Candice
Published: January 2019

Background:
The simplified modified Rankin scale questionnaire (smRSq) was developed to facilitate scoring and precision in assessment of disability outcome on the mRS. We aim to determine the strength of associations between smRSq and mRS among participants of alteplase-dose arm of the ENCHANTED, and also in relation to other stroke outcomes (EQ-5D, NIHSS).

Methods:
In the ENCHANTED trial, assessments of mRS were made at Days 3, 28 and 90, and smRSq at Days 28 and 90; EQ-5D at Days 28 and 90; NIHSS at 24 and 72 hours. Kappa statistic assessed relationships between smRSq and mRS; and Spearman correlation coefficients of relationship between smRSq and NIHSS and EQ-5D.

Results:
Of 3010 included patients, good agreement existed between smRSq and mRS (Kw=0.79, 95% CI 0.78-0.81). Moderate correlations between NIHSS and smRSq (r = 0.44, P<0.0001) and of NIHSS and mRS (r = 0.455, P<).0001). Strong relationships were between EQ-5D utility score and smRSq (r = -0.836, P<0.0001) and mRS (r = -0.874, P<0.0001).

Conclusions:
In a large dataset of a broad range of thrombolysis-eligible patients with acute ischemic stroke, there was a good agreement between smRSq and mRS, and consistence in correlating with other measure of neurological impairment and health-related quality of life. The data confirm the utility of smRSq as a reliable, valid, and simple structured assessment of stroke outcome.