bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP132: Relationship Of Neck Circumference And Insulin Resistance On The Cerebrovascular Reactivity In Subjects With Obesity.
Authors: Rodríez-Flores Marcela , GarcíGarcía Eduardo , Cano-Nigenda Claudia Vanessa , Cantúto Carlos
Published: March 2022

Background:
Transcranial doppler (TCD) can be used to detect incipient vascular disease. The breath-holding index (BHI) is a measure of vasomotor reactivity of the brain which can be measured with the TCD. We aim to evaluate the effect of insulin resistance and neck circumference on the cerebrovascular reactivity in subjects with obesity.

Methods:
BHI was induced by a 30-second apneic stimulus to produce vasodilation in non-diabetic, non-hypertensive individuals with and without obesity (body mass index >35). Neck and abdominal circumference, insulin resistance determined by the HOMA-IR and Matsuda index, scores to detect risk for obstructive sleep apnea (OSA), and cerebrovascular reactivity (BHI) were calculated between the comparison groups. A multivariable linear regression was calculated between the cerebrovascular reactivity with obesity adjusting for insulin resistance indexes, and neck circumference. Neck circumference was considered high when >37 cm in women and >42 cm in men.

Results:
BHI was measured in 164 right middle cerebral arteries (RMCA) and 152 left MCA (LMCA) of 85 obese patients and 85 non obese individuals. The BHI was significantly lower in the obese individuals: median of 0.83, IQR 0.56-1.21 and 0.89, IQR 0.69-1.11 in the RMCA and LMCA, respectively, vs. median of 1.27, IQR 0.94-1.58 and 1.14, IQR 0.92-1.48 in the RMCA and LMCA (p<0.001) of the non-obese individuals. There was a significant linear association between the HOMA-IR (r
2
0.03, βstd 0.005, p=0.05), the Matsuda index (r
2
0.03, βstd 0.003, p=0.04), and the neck circumference (r
2
0.05, βstd 0.03, p=0.005), and the cerebrovascular reactivity. In the multivariate linear regression model, there was a negative association between the cerebrovascular reactivity and obesity after adjusting for insulin resistance and elevated neck circumference (r
2
0.11, βstd 0.052, p=0.02).

Conclusions:
We found a diminished vasomotor reactivity in individuals with obesity, which is not explained by insulin resistance or increased neck circumference. Neck circumference showed a more important role in the decrease of cerebrovascular reactivity than the indexes of insulin resistance.
Abstract WP139: Ulceration and Symptomatic Plaque Predict Post Procedural Plaque Protrusion Following Carotid Artery Stenting
Authors: Hashimura Naoki , Mutoh Tatsushi , Matsuda Kazuya , Matsumoto Keigo
Published: March 2022

Purpose:
Plaque protrusion may cause thrombo-embolic events following carotid artery stenting (CAS). We evaluated the temporal profile and the treatment options of plaque protrusion (PLP) in our series.

Methods:
In 32 consecutive cases since April 2009 to December 2011, we checked intravascular status using ultrasound (US) and CT angiography (CTA) within 1 week after CAS. For these cases, medical risk factors, procedural factors, and pre-operative CTA and plaque MRI were also evaluated.

Results:
As for medical factors including hypertension, diabetes mellitus and hyperlipidemia, there were no significant effects on PLP. Effects of neurological and radiological factors on post procedural PLP are shown in table1. Symptomatic and ulcerative plaque were the risk factor of the post procedural PLP (symptomatic plaque, RR 2.33; 95% CI, 1.31-4.16; p=0.01; ulceration, RR 2.33; 95% CI, 1.31-4.16; p=0.01). High intensity of T1-black blood (BB) MRI tended to induce PLP (RR 1.62; 95% CI, 1.03-2.54; p=0.09). Pre-dilatation may reduce PLP (RR, 0.53; 95% CI, 0.21-1.34; p=0.09). All cases of PLP were treated by reinforcement of anticoagulation and/or antiplatelet therapy, and one case needed stenting following balloon angioplasty for progression of plaque protrusion in spite of medical treatments. In 8 cases of PLP, 7 cases were uneventful and 1 case had a minor stroke in the post-operative course.

Conclusions:
1. In terms of plaque characteristics, ulceration and symptomatic plaque relevant to post procedural PLP. 2. Post procedural neuroimaging studies such as CTA and US are crucial to detect plaque protrusion. 3. In case of plaque protrusion, careful managements including reinforcement of thrombotic therapy and endovascular procedures are required.
Abstract WP144: Long Term Safety And Efficacy Of Dual Versus Mono Antiplatelet Therapy In Patients With Previous Stroke Or TIA
Authors: Krishnan Kailash , Bath Philip M
Published: March 2022

Background:
In comparison with mono antiplatelet therapy, dual therapy is effective and safe in patients with recent ischaemic heart disease, ischaemic stroke, and TIA. However, the balance between safety (increased bleeding) and efficacy (reduced recurrence) remains unclear when given chronically to patients with prior ischaemic stroke or TIA.

Methods:
Completed randomised controlled trials comparing dual versus mono antiplatelet therapy in patients with prior ischaemic stroke or TIA were searched for electronically (Cochrane Library, PubMed) and in the reference lists of identified publications. Outcomes included stroke (all, ischaemic, haemorrhagic), composite vascular, bleeding and death. Data were analysed using random effects models with Review Manager software.

Results:
Eight completed trials were identified, these including 48,650 patients. In comparison with monotherapy (aspirin, clopidogrel or dipyridamole), chronic dual antiplatelets (aspirin/clopidogrel, aspirin/dipyridamole, aspirin/vorapaxar) significantly reduced ischaemic stroke (odds ratio OR 0.87, 95% confidence intervals CI 0.77-0.97) and composite vascular events (OR 0.87, 95% CI 0.79-0.96 *), but increased intracranial haemorrhage (OR 1.38, 95% CI 1.00-1.90 *) and life threatening bleeding (trend: OR 1.39, 95% CI 0.99-1.97 *). Death did not differ (OR 1.00, 0.91- 1.10) between the antiplatelet regimens. * Heterogeneity was present in most analyses; the combination of aspirin and dipyridamole was not associated with increased bleeding.

Conclusions:
Long-term use of dual antiplatelet therapy post stroke/TIA reduces further vascular events but increases intracranial haemorrhage. In view of the balance between benefit and hazard, the use of such treatment needs to be tailored to individual patients.
Abstract WP146: Degree of Carotid Stenosis is Associated with Coated-platelet Levels
Authors: Kirkpatrick Angelia , Vincent Andrea , Dale George , Prodan Calin
Published: March 2022

Background:
Coated-platelets, a subset of procoagulant platelets observed upon dual agonist stimulation with collagen and thrombin, support a robust prothrombinase activity and provide a unique measure of platelet thrombotic potential. Coated-platelet levels are elevated in patients with non-lacunar ischemic stroke and decreased in patients with spontaneous intracerebral hemorrhage compared to controls. Because these findings suggest that extremes in coated-platelet levels may be associated with either thrombotic or hemorrhagic events, we investigated coated-platelet synthesis in symptomatic and asymptomatic patients with carotid artery stenosis.

Methods:
Coated-platelet levels were determined in 3 consecutively recruited groups: 1) patients with acute transient ischemic attack or stroke and ≥50% ipsilateral internal carotid artery stenosis (n=45); 2) asymptomatic patients with ≥50% carotid stenosis (n=68), and 3) asymptomatic patients with <50% carotid stenosis (n=92). Results are reported as percent of cells converted to coated-platelets. Differences between groups were assessed using independent t-tests and Fisher’s exact tests. The relationship between group and coated-platelet levels was assessed with a three-way ANOVA and Tukey’s HSD test.

Results:
Coated-platelet levels (mean±SD) differed among the groups (F = 5.12, p = 0.007) with significant elevations among symptomatic carotid stenosis patients (39.5±16.3, p = 0.003) and asymptomatic ≥50% carotid stenosis patients (37.1±12.6, p = 0.028) compared to <50% carotid stenosis patients (32.5 ± 11.5).These differences remained significant after adjusting for age and medication use (F=5.07, p<0.0001). No significant difference was noted between symptomatic and asymptomatic carotid stenosis patients with ≥50% stenosis (p = 0.33).

Conclusions:
These results suggest that the presence of ≥50% carotid stenosis is associated with an increase in platelet prothrombotic potential. Further study of coated-platelet levels in patients with asymptomatic carotid stenosis is warranted to assess for an association with stroke incidence.
Abstract WP16: Stentrievers Increase Recanalization Rate But Not Good Outcome After Large Vessel Stroke.
Authors: Simonsen Claus Z , Søen Leif H , Karabegovic Sanja , Juul Niels , Andersen Grethe
Published: March 2022

Ischemic stroke is a common cause of death and disability in the western world. Intraveneous (iv) recombinant tissue plasminogen activator (t-PA) has proven efficacious as acute treatment. Intraarterial treatment with t-PA and/or instrumentation of the vessel with the attempt to manipulate the clot and remove it (called Intra Arterial Therapy (IAT)) is emerging as a tool for treating patients with contraindications to iv t-PA or for patients with large clot burden, where iv t-PA is often unsuccessful. IAT is also potentially hazardous and in large series, 10% of patients suffer symptomatic Intracerebral Hemorrhage (ICH).

Stentreivers (a new form of removable stent) have shown promise in improving recanalization and outcome in IAT.

At our institution 153 patients underwent IAT from 2004-2011. Stentreivers (ST) were used as part of the recanalization procedure in 42 patients. In the ST group, mean age was 63.7 years and mean presenting NIHSS was 16.6. In the non-ST group the same numbers were 63.3 years old and an NIHSS of 15.9. Using an unpaired t-test, there were no statistical differences in neither age nor NIHSS at presentation. Time to groin puncture was 257 minutes in the ST group and 275 minutes in the non-ST group, again no statistical difference.

Recanalization (defined as TICI 2b or 3) was achieved among 35 of the 42 = 83.3% in the ST group and in 47/111 = 42.3% of the patients in the non-ST group, giving an odds ratio (OR) for recanalization using ST on 6.81 (p<0.001, Fischers exact test.) Good outcome defined as a modified Rankin Score of 0-2 90 days after the stroke was achieved among 16/42 = 38.1% in the ST group and among 47/111 = 42.3 % in the non-ST group. There was no statistical difference in these numbers.

Recanalization was important for good outcome in both groups. OR for good outcome given recanalization was 5.89 in the ST group (p=0.03) and 6.97 in the non-ST group (p<0.001).

Recanalization is important for good outcome, but even though recanalization was achieved much more often in the ST group, this did not translate into better outcomes. One explanation could be, that recanalization seems more obvious when using stentrivers.
Abstract WP165: Prevention of JNK Phosphorylation and Activation of Dual Specificity Phosphatase as a Mechanism for Rosiglitazone in Neuroprotection after Transient Cerebral Ischemia.
Authors: Okami Nobuya , Narasimhan Purnima , Maier Carolina M , Chan Pak H
Published: March 2022

Rosiglitazone, a synthetic peroxisome proliferator-activated receptor-γ (PPAR γ) agonist, prevents cell death after cerebral ischemia in animal models, but the underlying mechanism has not been clarified. We examined how rosiglitazone protects neurons against ischemia. Mice treated with rosiglitazone were subjected to 60 minutes of focal ischemia followed by reperfusion. Rosiglitazone reduced infarct volume after ischemia and reperfusion. We found that this neuroprotective effect was reversed with a PPAR γ antagonist. Western blot analysis showed a significant increase in expression of phosphorylated stress-activated protein kinases (c-Jun N-terminal kinase [JNK] and p38) in ischemic brain tissue, especially in the cortex area after early reperfusion (3 hr). Rosiglitazone blocked this increase of phosphorylation which caused cell death signaling activation. Furthermore, we observed that rosiglitazone increased expression of the dual-specificity phosphatase 8 (DUSP8) protein and mRNA in ischemic brain tissue. DUSP8 is a mitogen-activated protein kinase phosphatase that can dephosphorylate JNK and p38. Another key finding of the present study was that knockdown of DUSP8 in primary cultured cortical neurons that were subjected to oxygen-glucose deprivation diminished rosiglitazone’s effect on downregulation of JNK phosphorylation. Thus, rosiglitazone’s neuroprotective effect after ischemia is mediated by blocking JNK phosphorylation induced by ischemia via DUSP8 upregulation.
Abstract WP176: Racial Differences in Perceived Risk, Self-efficacy, and Fear of Stroke
Authors: Anderson Aaron M , Khoury Jane , Frankel Michael , Kissela Brett M , Rademacher Eric , Flaherty Matthew L , Woo Daniel , Khatri Pooja , Alwell Kathleen , Ferioli Simona , Lapinski Maria , Martini Sharyl , Mackey Jason S , Felipe De los rios la rosa , Kleindorfer Dawn
Published: March 2022

Introduction:
Stroke is the fourth leading cause of death in the United States, yet awareness of stroke risk factors, warning signs and symptoms remain low. Perceptions of risk affect health behavior: higher perceived risk leads to increased behavioral change to lower risk. Within a population representative of ischemic stroke patients, we sought to evaluate racial differences in perceived risk and fear of stroke, as well asself-efficacy to modify risk.

Methods:
Telephone survey respondents were drawn from our biracial population of 1.3 million using random-digit dialing to reflect the age, race, and gender distribution of stroke patients, based an ongoing stroke incidence study in the same region. Selected questions from the validated Risk Behavior Diagnosis Scale assessed respondents’ perception of personal risk, self-efficacy, and fear of stroke, using a modified Likert scale assigning 1 point for strongly agree and 5 points for strongly disagree.

Results:
Analysis was restricted to1959 of 2036 respondents contacted in 2010 who were of black or white race. Respondents were matched to previous descriptions of ischemic stroke populations: 28% black, 61% female, with a mean age of 66.3(± 14.7). Overall, respondents thought controlling blood pressure reduces stroke risk and they had the skills to reduce their blood pressure. However, fear and perceived risk of stroke was significantly lower among blacks than whites, after adjusting for age, education, hypertension, diabetes, smoking, coronary artery disease and prior stroke.

Discussion:
The general public believes stroke is a severe condition, and they have the skills to control blood pressure and lower their risk for stroke. Blacks were less likely to believe stroke is extremely harmful and had lower personal risk of stroke compared to whites after adjusting for confounders. Future public awareness campaigns should focus on communicating personal risk and severity of stroke, especially to black communities.
Abstract WP177: Factors Associated with Delays in Patient Presentation to REACH TeleStroke Hospitals in South Carolina
Authors: de Leonni Stanonik Mateja , Voeks Jennifer H , Adams Robert J , Jauch Edward J ,   on behalf of the MUSC Comprehensive Stroke and Cerebrovascular Program
Published: March 2022

Introduction:
Excessive prehospital delay between acute stroke onset and hospital arrival remains an ongoing problem contributing to low thrombolysis rates. The REACH Telemedicine Network of South Carolina (SC) provides neurologic expertise for acute stroke interventions to 15 hospital Emergency Departments (ED) across rural SC. Our aim was to investigate the demographic factors associated with delays in hospital presentation.

Methods:
For a 51-month period, 2412 REACH consults were analyzed. Analysis was limited to those with information about the time of symptom onset and time of ED arrival. The prehospital delay time was calculated and patients were dichotomized within 180-min from symptom onset or greater. Univariate logistic regression assessed the relationship between prehospital delay and patient characteristics including age, race, sex, type of insurance (self pay, private insurance, Medicaid, Medicare, or unknown), NIHSS at admission (<10 vs >10) and the type of hospital (urban vs rural) as a surrogate for residential area. Backwards multivariate logistic regression was performed to determine the most parsimonious model of predicting factors associated with delay from symptom onset to ED arrival.

Results:
Univariate analyses indicated that patients who presented greater than 180-min from symptom onset were more likely to be African American (AA) and to be self-pay rather than have insurance for services. Results of multivariate modeling further revealed that having NIHSS < 10 and being AA or self-paying for services were all associated with longer delay from symptom onset to ED arrival.

Conclusions:
Data from REACH Telemedicine of SC suggest that being AA, being self-insured, and having more minor stroke symptoms are associated with delaying ED arrival to more than 3 hours. Analysis of these data has focused on patient demographic characteristics. Further studies are needed to examine other contributing factors, such as patients’ educational level, social/societal factors and hospital characteristics in order to be able to design effective population-based interventions to decrease prehospital delay in rural settings where the REACH Telemedicine network provides access to cutting-edge acute stroke care across the state of SC.
Abstract WP193: Secular Trends in Ischemic Stroke Subtypes
Authors: Bogiatzi Chrysi , Hackam Daniel G , Spence J David
Published: March 2022

Background:
In the past it was thought that ~ 20-25% of ischemic strokes were cardioembolic, ~ 20% from large artery disease and ~ 20% from small vessel disease. With the aging of the population, and with increasing prevalence of therapy for hypertension and hyperlipidemia, it might be expected that stroke subtypes would be changing over time.

Purpose and Methods:
We studied the change over time of ischemic stroke subtypes from 2000-2012, among 2300 patients referred to the Urgent TIA Clinic at University Hospital, London, Canada. We divided the patients into 3 eras that were approximately equal in numbers: Era 1 (2000-2004), Era

2 (2005-2007) and Era 3 (since 2008). Ischemic stroke subtypes were defined by clinical and imaging criteria into evident, probable and possible causes.

Results:
Mean age + SD was 63.39 + 17.47 years; 50% were women, 17.7% were diabetic, 19.6% current smokers. The proportion of patients with known atrial fibrillation increased from 4.2% in Era 1 to

6.6% in Era 2, to 9.6% in Era 3 (p-0.001). Among patients thought to have cardioembolic stroke, atrial fibrillation accounted for 95.8% in Era 1,

93.4% in Era 2 and 90.4% in Era 3 (p=0.001). Among patients whose stroke subtype was regarded as evident or probable (n=1699), stroke subtypes changed over time, as shown in Table 1:

Similar trends were observed If all patients (evident, probable, possible) were included. Stroke subtypes have changed significantly since 2000 (Chi-Square 2p=0.0001), with a marked increase in cardioembolic stroke, and a decline in large artery stroke.

Conclusion:
In recent years, the proportion of patients with cardioembolic stroke has increased significantly. This has important implications for treatment to reduce the risk of recurrent stroke
Abstract WP209: Serum Anti-Periodontal Pathogen Antibody associated with Atrial Fibrillation and Carotid Plaque
Authors: Hosomi Naohisa , Aoki Shiro , Nezu Tomohisa , Ohtsuki Toshiho , Yamawaki Takemori , Matsumoto Masayasu
Published: March 2022

Background:
We evaluated whether serum antibody levels against individual periodontal pathogens are significantly associated with ischemic stroke subtypes and their risk factors.

Methods:
Patients with acute ischemic stroke (n=132; 74 male and 58 female, 71.3±10.7 years) and patients with no previous stroke (n=77; 38 male and 39 female, 70.7±9.5 years) were consecutively enrolled in this study. Stroke subtype was evaluated based on the TOAST classification. Serum was obtained from each patient after obtaining the patient’s consent to participate in this study. The levels of serum antibodies against Aggregatibacter actinomycetemcomitans (Aa), Porphyromonas gingivalis (Pg), and Prevotella intermedia (Pi) were evaluated by ELISA.

Results:
The serum-antibody level of Pi was significantly higher in atherothrombotic-stroke patients than in patients with no previous stroke (p<0.005). Serum anti-Pg antibody was significantly associated with atrial fibrillation (overall X2=35.5, R2=0.18, n=209, p<0.001; anti-Pg antibody: odds ratio 4.36 [95%CI 1.71-12.10], p<0.005), and serum anti-Pi antibody was significantly associated with bulb/internal carotid artery atherosclerosis after controlling for the statistically selected associated factors (overall X2=46.1, R2=0.18, n=209, p<0.001; anti-Pg antibody: odds ratio 16.58 [95%CI 3.96-78.93], p<0.001). The levels of serum anti-Pi antibody were significantly associated with atherothrombotic stroke with the statistically selected associated factors excluding bulb/ICA atherosclerosis (overall X2=77.0, R2=0.44, n=129, p<0.001; anti-Pi antibody: odds ratio 23.6 [95%CI 2.65-298.2], p=0.008). However, when we included bulb/ICA atherosclerosis into this model, the levels of serum anti-Pi antibody were no longer significantly associated with atherothrombotic stroke (overall X2=98.0, R2=0.56, n=129, p<0.0001; anti-Pi antibody: p=0.107).

Conclusions:
Our results suggest that anti-Pg antibody is associated with atrial fibrillation and anti-Pi antibody is associated with carotid artery atherosclerosis. Additionally, anti-Pi antibody may be associated with atherothrombotic stroke through its association with carotid artery atherosclerosis.
Abstract WP215: Stroke Without Ischemic Lesions On The Initial Diffusion Weighted Image ~Fukuoka Stroke Registry~
Authors: Fujimoto Shigeru , Mezuki Satomi , Matsuki Takayuki , Jinnouchi Juro , Ishitsuka Takao , Ishitsuka Takao , Kitazono Takanari
Published: March 2022

Background & Purpose:
Diffusion weighted image (DWI) is indispensable in the early diagnosis of acute ischemic stroke. However, DWI cannot always detect an acute ischemic lesion. We investigated the clinical features and outcome of stroke patients without an ischemic lesion on the initial DWI.

Subjects & Methods:
Among the consecutive 3062 patients with sudden neurological deficits who were admitted to the 7 stroke centers in Fukuoka prefecture Japan within 24 hours after the symptom onset, 1731 patients with neurological deficits duration of 24 hours or more and pre-stroke modified Rankin scale (mRS) of 0 or 1 were included in the present study. All patients underwent MRI studies including DWI. We investigated clinical features, a neurological deterioration (a NIHSS score worsening of ≥1-point), and stroke recurrence.

Results:
Among 1731 patients, 102 (5.9%) had no ischemic lesions on DWI (DWI-negative Group), and other 1629 had ischemic lesions on DWI (DWI-positive Group). Atrial fibrillation (16.7% vs 29.2%, p=0.0064) and intracranial or extracranial cerebral artery stenosis of ≥50% in diameter (16.7% vs 36.3%, p<0.0001) were less frequent, and the initial NIH stroke scale score was lower (3.2±2.8 vs 5.8±5.9, p<0.0001) in the DWI-negative than the DWI-positive Group. Analysis on 285 patients who underwent transesophageal echocardiography (TEE), there was no significant differences in the frequency of complicated aortic arch lesions or patent foramen ovale between both groups. Stroke recurrence during the hospital days was relatively less frequent in the DWI-negative than the DWI-positive Group (2.9% vs 4.2%), however, stroke recurrence during 3 months after the onset was relatively more frequent in the DWI-negative than the DWI-positive Group (7.8% vs 6.2%). A good outcome (modified Rankin scale of 0 or 1) on 3 months after the onset was more frequent in the DWI-negative than the DWI-positive Group (73.1% vs 57.7%, p=0.0035).

Conclusions:
Although a good outcome was more frequent in the DWI-negative than the DWI-positive Group, a stroke recurrence was not rare in the DWI-negative Group. Evaluations for the etiology of stroke, such as TEE, were required even in the stroke patients without ischemic lesions on the initial DWI.
Abstract WP219: Whole Brain Perfusion In Tia
Authors: Bivard Andrew , Parsons Mark
Published: March 2022

Transient ischemic attack (TIA) is the major predictor of future ischemic stroke risk. However clinical diagnosis of TIA is extremely inaccurate. We aimed to investigate whole brain perfusion CT as a screening tool for TIA.

Methods:
Patients presenting to the John Hunter Hospital with a clinical diagnosis of TIA were scanned within 6 hours of symptom onset with 320 slice CT, which allows whole brain perfusion (CTP). Patients then underwent diffusion weighted MRI within 24 hours of symptom onset. A pixel based analysis was undertaken to determine perfusion based anomalies, and correlate findings to the 24 hour DWI lesion.

Results:
156 patients with a clinical diagnosis of TIA were enrolled in the study. Whole brain perfusion imaging in 79 patients was normal, 35 patients had a delay time hypoperfusion lesion (>2 seconds compared to normal tissue) > 10mL, and 44 showed hyperperfusion at a threshold of Cerebral blood flow >120% . The volume of the delay 2 seconds lesion was strongly correlated to the acute NIHSS r=0.769 p=0.05. 44 patients had a DWI lesion of >5mL. Most patients with an acute delay 2 seconds lesion would develop a DWI infarct at 24 hours (41 patients, p=0.01).

Discussion:
Clinical assessments of resolving or mild neurological symptoms are poorly sensitive, and as a result imaging is required. We have shown that acute perfusion imaging findings are a sensitive and specific marker for recent (<24 hours) TIA.
Abstract WP228: Measurement Of Oxygen Extraction Fraction (OEF) By A Novel MRI Technique
Authors: Menon Rajiv G , Walsh Edward G , Sutton Bradley P , Twieg Donald B , Cantrell Charles G , Vakil Parmede , Jonathan Sumeeth V , Prabhakaran Shyam , Carroll Timothy J
Published: March 2022

We report a novel application of an MRI technique called Parameter Assessment by Retrieval from Signal Encoding (PARSE) to measure OEF. OEF is of crucial importance, providing information about the stage of neurovascular impairment in a patient and the risk of stroke in such a patient. In this study, we test the hypothesis that PARSE can be used to measure oxygen extraction in the brain. This method uses a more accurate MR signal model, employs a non-Cartesian Rosette trajectory to encode multiple parameters and can simultaneously estimate M
0
, R
2
*, and local frequency in a single, non-invasive 5 second acquisition. Of particular interest here, is the feasibility to directly measure susceptibility related frequency changes from local frequency estimates. Since OEF abnormalities are focal, contralateral measurements were used to estimate the relative frequency change. We acquired data on 5 human subjects. In the series of 5 normal volunteers (M/F 3/2,  = 26 +/-10 years) we acquired a single slice, 5.0 mm thick, 220 mm x 220 mm FOV, 64 x 64 matrix, image resolution = 3 x 3 x 5.0 mm
3
) 2D PARSE images. The total sequence time was 5 seconds. One arterio-venous malformation (AVM) patient was also tested with the PARSE-OEF sequence. The parameters were identical to the volunteer scans. For the 5 volunteers, the average frequency change (δω) across the brain image slice was 15.49 Hz ±2.77 Hz. This corresponded to an average whole brain-slice OEF of 37.23 ± 6.60%. This is in agreement with gold-standard Positron Emission Tomography (PET) OEF studies of normative values from Carpenter (35±7%), Yamauchi (42±5%), Diringer (41±6%) and Raichle (40±9%). Our current values are in excellent agreement with PET literature values. Upon further validation, this technique may be a viable clinical alternative to PET-OEF.
Abstract WP249: Telestroke Is not Associated with a Longer Door-to-needle Time
Authors: Khaja Aslam M , Hoelzel Sandra L , Shafi Neelofer , Grysiewicz Rebbeca , Testai Fernando D , Gordon Jeffrey B , Ruland Sean
Published: March 2022

Background:
Telestroke is a promising avenue for treatment of acute stroke patients when a vascular neurologist is not available for bedside assessment. We provide stroke hospitalist services at a local community hospital Monday-Friday, supplemented by telestroke coverage by the same vascular neurologists on night and weekends. We compared door-to-needle (DTN) times via telestroke vs. at the bedside.

Methods:
We reviewed cases of acute ischemic stroke patients who received IV r-tPA treatment and determined whether they were assessed at the bedside vs. telestroke. We collected age, risk factors, symptom onset time, admission NIH stroke scale, DTN time, and discharge disposition. A favorable discharge disposition was considered home or acute rehab. Mann-Whitney U and Fisher’s Exact tests were used when appropriate.

Results:
Between April 2011 and May 2012, 39 patients were treated with IV r-tPA, 49% (19/39) at the bedside, and the remainder (20/39, 51%) via telestroke. Table 1 is a comparison of the baseline characteristics. The bedside group was slightly older with a higher incidence of atrial fibrillation, but this difference was not significant. Mean DTN times were not significantly different in the bedside group (mean 76.1±34.9 min) compared with the telestroke group (83.5±29.5 min) (p=0.15). Goal DTN times of <60min were met in 9 (47%) of the bedside group versus 4 (20%) in the telestroke group (p=0.06) Mean symptom onset to treatment time was 150.6±61.2 min in the bedside group, versus 145.9±41.0 min in the telestroke group (p=0.46). 9 patients (47%) in the bedside group had a favorable discharge, compared with 15 (75%) in the telestroke group (p=0.21).

Conclusion:
In a community hospital, there was no significant difference between door-to-needle times in patients treated with IV r-tPA at the bedside versus via telestroke. This supports the use of telestroke to provide extended coverage to hospitals.
Abstract WP254: The Contribution of Serpinf2 to Tissue Plasminogen Activator Therapy for Stroke: Effects on Neuronal Cell Death, Brain Swelling, Breakdown of the Blood Brain Barrier and Mortality
Authors: Wang Dong , Houng Aiilyan , Reed Guy
Published: March 2022

For poorly understood reasons, tissue plasminogen activator (TPA) therapy for ischemic stroke is limited by a narrow therapeutic window and by toxicities including hemorrhage. In this study we investigated the contribution of serpinf2 (Sf2, a2-plasmin inhibitor, a2-antiplasmin) to the success and complications of TPA therapy.

Methods:
Ischemic stroke was induced by MCA thromboembolism in anesthetized mice. Infarct size, hemorrhage and swelling were examined by a blinded observer. Breakdown of the blood brain barrier, MMP-9 expression and apoptosis were determined by quantitative immunohistochemistry.

Results:
TPA treatment within 15 min. of ischemia significantly reduced infarction (p<0.001). However, after 1 hr TPA had no effect and after 2.5 h TPA significantly increased infarction (p<0.01). As ischemic time prolonged, TPA treatment increased brain hemorrhage (p<0.001). Increasing levels of Sf2 doubled infarct size after TPA treatment (p<0.001) and quadrupled brain swelling (p<0.001). In contrast, when mice were given a specific Sf2 inactivator (Sf2-i) in combination with TPA, there was a significant increase in the dissolution of the thromboembolus by comparison to the same dose of TPA alone (p<0.001). The combination of an Sf2-I and TPA significantly decreased stroke size (p<0.001) and markedly reduced hemorrhage by comparison to TPA alone (p<0.001). In addition, the combination of TPA and an Sf2-i significantly improved survival (p<0.05). Consistent with its effects on reducing brain swelling, the addition of sf2-i to TPA therapy markedly reduced expression of matrix metalloproteinase 9 (p<0.01) and breakdown of the blood brain barrier (p<0.01). Addition of the Sf2-i also significantly reduced apoptosis (p<0.01) assessed by TUNEL and activated caspase 3 staining.

Conclusion:
Sf2 reduces TPA’s efficacy and enhances toxicity by increasing stroke infarct size and brain swelling. In contrast, inactivation of Sf2 increased the therapeutic window for TPA, which in turn reduced infarction, brain swelling and hemorrhage. Sf2-i also significantly reduced break down of the blood brain barrier and apoptosis. Thus inactivation of Sf2 may increase the therapeutic value of TPA.
Abstract WP264: The Growth Factor Progranulin Suppresses Inflammatory Reactions and Attenuates Neuronal Injury Induced by Cerebral Ischemia-Reperfusion in Mice.
Authors: Egashira Yusuke , Sugitani Sou , Suzuki Yukiya , Mishiro Keisuke , Tsuruma Kazuhiro , Shimazawa Masamitsu , Yoshimura Shinichi , Iwama Toru , Hara Hideaki
Published: March 2022

Objective
—The growth factor progranulin (PGRN) is a widely expressed protein with various biological functions, and it is known to have an anti-inflammatory effect. The aim of this study was to investigate the possible ameliorative effects of PGRN against cerebral ischemia-reperfusion (I/R) injury.

Methods
—In vivo ischemic stroke was induced in 4-week-old male ddY mice by 2 h of middle cerebral artery occlusion (MCAO) followed by 22 h of reperfusion. The following 4 experimental protocols were devised: (1) to determine the expression level of PGRN in the I/R brain (n = 4 per group); (2) to establish the dose-response effects of intracerebroventricularly administered recombinant PGRN (r-PGRN; 0.1 to 1.0 ng) on cerebral I/R injury (n = 6 to 8 per group); (3) to establish the therapeutic time window of r-PGRN treatment (n = 8 to 9 per group); and (4) to investigate the effects of r-PGRN treatment on the expression of inflammatory cytokines in the I/R brain (n = 5 per group).

Results
—We found that the expression level of PGRN was significantly reduced in the I/R brain (P < 0.01, vs. Sham; t test). The administration of 1.0 ng of r-PGRN at 2 h after MCAO resulted in a reduction in the infarct volume and brain swelling at 24 h after MCAO (P < 0.01, vs. Vehicle, in each; Dunnett test), and this led to an improvement in neurological scores (P < 0.05; Wilcoxon signed-rank test). Delayed administration of r-PGRN at 6 h after MCAO did not reduce the infarct volume, but significantly reduced brain swelling (P < 0.05; t test). We also confirmed that r-PGRN administration significantly reduced the phosphorylation of NF-κB and expression of MMP-9 in the I/R brain (P < 0.05, vs. Vehicle, in each; t test).

Conclusion
—r-PGRN treatment exerts ameliorative effects on experimental ischemic stroke, and these effects are due to the prevention of harmful inflammatory reactions following cerebral I/R. This study suggests the feasibility of r-PGRN administration as a novel therapeutic strategy for treatment in the acute phase of ischemic stroke.
Abstract WP325: The Appropriate Body Position During Nasal-gastric Tube Feeding To Prevent The Aspiration Pneumonia In Acute Stroke Patients
Authors: SUZUKI HARUKA , TAKEDA SAYAKA , NAKAZAKI MASAHITO , SONE SACHIKO , MORI TAKAHISA
Published: March 2022

Purpose:
In acute stroke patients when initiating Nasal-gastric tube feeding (NGF) have a high risk for aspiration pneumonia, which may be related to the body position. We investigated the relationship between body position during NGF and aspiration pneumonia.

Method:
We enrolled consecutive acute stroke patients, 1) who were admitted from June 2011 to May 2012, 2) with a diagnosis of acute stroke within five days, and 3) who initiated NGF within two days from admission due to altered mental state or severe dysphagia. We allocated these enrolled patients into two Group alternately according to the body position during NGF; patients in the complete lateral position (Group L [n=27]) with keeping nonparalyzed side below and head up at 30-60 degrees during NGF, and patients in the spine position (Group S [n=26]) with head up at 30-60 degrees. We evaluated patients’ baseline characteristics including neurological status and vital signs, inflammatory response parameters, and the number of patients with aspiration pneumonia. Aspiration pneumonia fit three criteria: 1) at least one event of aspiration during NGF, 2) infiltrative shadows on the plain chest radiograph, and 3) no evidence of community acquired pneumonia.

Results:
We finally evaluated 47 patients (median age was 85 years old, 43% female). There were 32 patients with cerebral infarction and 15 with intracranial hemorrhage, median NIHSS score on admission was 17.5, and on the seventh day was 18 respectively. We analyzed 24 patients in Group L, and 23 in Group S. There was no difference in patients’ baseline characteristics, and inflammatory reaction parameters between the groups statistically significantly. However, the number of patients with aspiration pneumonia after admission was lower in Group L compared to Group S statistically significantly ( nine cases in Group L, 9 cases in Group S, P=0.034).

Conclusion:
The complete lateral position during the NGF has the potential to prevent aspiration pneumonia for acute stroke patients
Abstract WP341: Improving Nursing Documentation Compliance for Patients Treated with Alteplase Diagnosed with Ischemic Strokes
Authors: Cruz Kevin , Liable Deborah
Published: March 2022

Purpose:
This project developed an audit tool for improving documentation post Alteplase infusion.

Background:
The American Heart Association and Brain Attack Coalition have set forth guidelines for the monitoring of ischemic stroke patients receiving Alteplase. These guidelines are standards of practice required for Primary Stroke Center certification.

Methods:
This real-time audit tool allows for entry of the precise start time of the Alteplase infusion and auto populates the subsequent time frames for care within the first 24 hours. The tool facilitates documentation of necessary components related to vital signs and neurological checks and triggers follow-up warnings when a “NO” is entered. The tool creates a very visual snapshot to facilitate concurrent auditing and promote accuracy in documentation. The audit tool can be used as either a hard copy or electronic version. The electronic version automatically calculates compliance percentages. The tool is handed off from shift to shift to maintain consistent follow through across direct care nurses. Key measures within the tool include venous thromboembolism prophylaxis, dysphagia screening, and lipid management.

Results:
Eighteen inpatients received stroke care from January 2012 to May 2012 with a documentation compliance rate of 86.7% Documentation compliance for the 9 stroke patients cared for following tool implementation increased to 94.4%. Stroke Core Team members conduct ongoing evaluations of the tool to ensure quality control.

Conclusion:
Initiation of a real time audit tool used during the first 24 hours of ischemic stroke care for patient receiving Alteplase has shown improvement in documentation compliance rates. Of note, this tool was recognized by a Joint Commission site surveyor as highly innovative and a potential best practice in the care of stroke patients.
Abstract WP355: Impact of Target Stroke on Reducing Door-to-Needle Times
Authors: Moore Kari , Liu Ruolan , Bays Cathy , Bystrek Laura , Cochrane Betty , Wise Elizabeth , Remmel Kerri
Published: March 2022

Background:
Intravenous tissue plasminogen activator (IV-tPA) is the only FDA approved drug treatment for Acute Ischemic Stroke (AIS) within 3 hours or less from onset of stroke symptoms. The guidelines also recommend that stroke centers be able to administer IV-tPA in less than 60 minutes from the time the patients arrive, door-to-needle (DTN) time. Since less than one third of hospitals achieve this DTN goal, the American Stroke Association developed a national initiative to reduce the door to needle time called “Target Stroke” (TS).

Methods:
A retrospective analysis was conducted of DTN times on 59 consecutive patients receiving IV-tPA at the University of Louisville Hospital from January 2009 to July, 2012. TS was instituted the fourth quarter of 2011. The percentage of patients meeting the target DTN time of less than 60 minutes was compared before and after TS was instituted (Quarter 1 and 2, 2011 vs Q1-2, 2012). Q1-2, 2010 and Q1-2, 2009 were also compared to Q1-2, 2012. Data were analyzed using 2X2 Fisher’s exact test. A two-tailed probability value of
p
<0.05 was considered significant.

Results:
The data show a statistically significant association between DTN time in less than 60 minutes and target stroke implementation (
p
<0.001, Q1-2, 2011 vs Q1-2, 2012;
p
<0.001, Q1-2, 2010 vs Q1-2, 2012 and
p
<0.020 Q1-2, 2009 vs Q1-2, 2012).

Conclusions/Discussion:
More patients received IV-tPA in less than 60 minutes after implementation of TS than before. Utilization of TS significantly improved DTN times at University of Louisville Hospital. Our next step will be to compare outcomes for the same data set using discharge modified Rankin Scale and discharge disposition.
Abstract WP357: Transforming A Neuro Naï Facility Into A Comprehensive Stroke Center
Authors: Gallagher Eileen , Donley Kathy
Published: March 2022

Background:
There are few Comprehensive Stroke centers in the Southern New Jersey region. Over four hundred patients in need of Comprehensive Stroke care were transferred out of this hospital throughout 2010 to other hospitals in the Philadelphia and Central New Jersey regions, requiring lengthy commutes and the loss of valuable time and progression of the patient’s stroke. The senior leadership recognized the need to provide the community with this much needed resource. A gap analysis resulted in development of a comprehensive program to advance stroke and neurosurgical care and meet the needs of the community.

Purpose:
The purpose of this abstract is to summarize the process involved in the development, implementation, and outcomes of a state designated comprehensive stroke center in a previously neurologically naïve acute care facility.

Methods:
Care of the neurologically impaired patient is a new demographic for the multidisciplinary team at this facility. Development of a comprehensive educational and implementation plan for the multidisciplinary team was constructed. Although recently designated a primary stroke center, staff needed to participate in didactic, experiential and simulation driven educational sessions. Vital to the success of the program was the recruitment of experienced neurological nurses and ancillary staff. Staff participated in observational experiences at comprehensive stroke centers. Implementation of shadowing experienced neurological nurses with inexperienced nurses was initiated. A stroke algorithm was developed and implemented to streamline the triage process.

Results:
Between December 1, 2011 and July 31, 2012 three hundred fifty patients were admitted to the Comprehensive stroke program. Of these three hundred fifty stroke patients, sixty three received interventional treatment for stroke. Patients remained in their community receiving comprehensive, state of the art individualized stroke treatment. A review of patient outcomes will be summarized including length of stay, disposition, morbidity and mortality data.

Conclusions:
Refinement of current processes is ongoing. Planning is underway to develop a Neuroscience Clinic providing educational opportunities to the community served.
Abstract WP361: The Golden Hour: A Team-Based Approach to Targeting Door to Needle Time
Authors: Brackman Jennifer M , McGee Angela , Wright Katie
Published: March 2022

Background and Issues:
Restoring perfusion to the brain is key to the patient’s recovery and has been at the forefront of stroke treatment and research for the past decade. In 2010, AHA/ASA challenged acute stroke programs to reduce their IV t-PA door-to-needle times. Developing an interdisciplinary, team-based approach has helped our stroke program meet, and at times, exceed the door-to-needle time goal for IV t-PA.

Purpose:
In 2010, in response to the AHA goal, the team re-designed the processes for ordering and administering IV t-PA. Critical improvements of the current process were identified such as order entry, order confirmation, patient eligibility and staff education.

Methods:
When a patient is deemed a potential candidate for t-PA, the order is placed for the medication. A “stat” sticker was added to the t-PA order sheet, to place the medication in a priority queue within the pharmacy. A phone call is placed to the pharmacist to confirm receipt of the order. Diagnostic testing and further medical evaluation takes place and informed consent is obtained while the medication is being prepared by the pharmacist. The ED staff was educated regarding the AHA/ASA goal and the importance of rapid patient triage, prompt initiation of the stroke alert process including initiating the t-PA order sets, coordination of diagnostic evaluation and the administration of t-PA.

Results:
In 2008, our door to needle time was 92 minutes. From 2009 to 2010 our time decreased by almost 10 minutes. In 2011, despite a record high of t-PA cases, our time decreased by almost 30 minutes. Aultman was a recipient of the Target: Stroke award in 2011 and we have maintained our Gold Plus status for Get With The Guidelines performance for three years running.

Conclusions:
Developing a team approach and identifying opportunities for improvement for care are essential in the success of a stroke program. In 2012, Aultman has seen a slight increase in the door to tPA time due to the implementation of electronic physician order entry. Effective and efficient stroke care remains our program’s goal and we strive for excellence in stroke care.
Abstract WP369: Doctorate of Nursing Practice-led Transitions of Care Model for Stroke and Transient Ischemic Attack
Authors: Haynes Helena N , Smith Carol J , Haenchen Steven D , Drake Kendra , Reel Sally J , Ritter Leslie S
Published: March 2022

Background and Purpose:
The chances of experiencing a second event are significantly increased in those with recent stroke or transient ischemic attack (TIA). Gaps in care due to the movement of patients between health settings and/or practitioners, also known as transitions of care (TOC), may contribute to secondary events. The impact of TOC on stroke/TIA outcomes has not been thoroughly examined. The Doctorate of Nursing Practice (DNP) is a relatively new role within the nursing profession that provides advanced practice nursing care, leadership and research expertise. As the first phase of a long term goal to evaluate a DNP-led TOC model specific to the stroke/TIA population in Southeastern Arizona, the purpose of this study was to identify the essential elements of a model specific for stroke/TIA using data from one urban primary stroke center.

Methods:
1) Existing TOC models such as PRISMA, Hospital to Home, and STEPS were identified with applicability to the stroke/TIA patient.

2) Get With The Guidelines [GWTG®]-stroke database from a primary stroke center located in an urban setting in Southern Arizona was used to identify patient demographics and the essential elements that best reflect TOC.

Results:
We found 1) the Care Transitions Intervention model best suits a DNP-led TOC model for stroke-TIA. Key elements of this model include an interdisciplinary team approach utilizing case-management strategies, discharge planning, and patient self-management education. In addition, the advanced practice nurse has been found to be most successful in leading TOC models aimed at reducing readmissions.

2) Key outcome variables in a stroke specific TOC model include frequency of admission/readmission, patient demographics, prior hospitalizations, length of stay, discharge disposition, presence of stroke risk factors and urban vs. rural settings.

3) Post-discharge phone interviews may be needed to explore gaps in care not captured in GWTG.

Conclusions:
While TOC models have been described for other diagnoses, models for stroke/TIA are lacking. The use of the Care Transitions Intervention model for stroke/TIA could yield important reductions in the burden, morbidity, and mortality of stroke/TIA in Southeastern Arizona and thus, deserves further study.