bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP313: Dual Antiplatelet Therapy Reduced Early Stroke Risk After Transient Ischemic Attack Patients with Acute Diffusion-weighted Imaging Hyperintensities: A Real-world Experience in Clinical Practice
Authors: Song Bo , Chen Pei , Pei Lulu , Cao Yuan , Fang Hui , Gao Yuan , Zhao Lu , Wu Ju , Li Yusheng , Sun Shilei , Xu Yuming
Published: June 2021

Background:
Transient Ischemic Attack (TIA) patients with acute Diffusion-Weighted Image (DWI) hyperintensities bear a high risk of a subsequent ischemic stroke. Few studies focused on the efficacy of dual antiplatelet therapy (DAPT), clopidogrel plus aspirin, in TIA patients with acute DWI hyperintensities. The study aimed to identify whether dual antiplatelet therapy could decrease early stroke risk after TIA with acute DWI lesion.

Methods:
Patients with a transient ischemic attack within 72 hours and acute DWI lesions, within the prospective TIA database from the First Affiliated Hospital of Zhengzhou University, were screened in the present study. Baseline characteristics including antiplatelet therapy during hospitalization were recorded. The relationship between DAPT and the 90-day stroke risk after the index TIA were analyzed in a Cox proportional hazards model to adjust confounding factors.

Results:
Overall, 270 TIA patients with acute DWI lesions were recruited in the present study.The 90-day stroke risk was 13.4% in patients with dual antiplatelet therapy compared with 23.6% in those with monotherapy (p=0.0491). Dual antiplatelet therapy was associated with reduced early stroke risk in TIA patients with DWI hyperintensities (HR, 0.53; 95% CI, 0.29-0.96) , after adjusting for confounding factors.

Conclusions:
Dual antiplatelet therapy reduced early stroke risk in TIA patients with acute DWI hyperintensities. Randomized controlled trials are needed to validate our results.
Abstract TP32: Endovascular Therapy for Acute Ischemic Stroke Beyond the 6 Hour Window
Authors: Mao Yi , Sharma Sameer , Masoud Hesham , Latorre Julius G
Published: June 2021

Background:
Recent randomized trials demonstrated the efficacy of endovascular therapy (EVT) in managing acute ischemic stroke (AIS), though EVT was initiated <6 hours from time last seen well in nearly all patients, and posterior circulation strokes were excluded. Current data is limited for patients receiving EVT >6 hours, and more so for those with posterior circulation strokes. We aim to assess safety and clinical outcome of EVT in patients presenting >6 hours, with anterior or posterior circulation strokes.

Methods:
We conducted a retrospective review of patients with AIS receiving EVT >6 hours between 2012-2015, including those with unknown time of onset and wake-up strokes. Outcomes observed include mRS at ≥90 days, rates of recanalization (TICI 2b-3), sICH and mortality.

Results:
A total of 34 patients were identified presenting with AIS and receiving EVT >6 hours, including 25 anterior and 9 posterior circulation strokes. See Table 1 for comparison with published data from recent EVT trials.

Conclusion:
Our results are not significantly different from some of the recent trials. MR CLEAN, the only trial that did not employ advanced imaging in patient selection, had similar outcomes. The IV-tPA only groups of recent trials (where data is available) also produced comparable results. It should be noted that the patients in our study all have large vessel occlusions and high NIHSS, are mostly ineligible for tPA, and thus would be expected to have very poor outcomes without treatment. Our data supports the possibility of expanding the EVT window to >6 hours, and with advanced imaging screening, better rates of functional outcome/mortality may still be achieved. DAWN and DEFUSE3 trials currently underway should provide further insight into this subject.
Abstract TP330: Insular Cortex Lesions are Associated With Early Mortality in Patients With Intracerebral Hemorrhage
Authors: Prats-Sánchez Luis , Fayos Fernando , Pascual-Goñi Elba , Painous Celia , Camps-Renom Pol , Martínez-Domeño Alejandro , Delgado-Mederos Raquel , Martí-Fàbregas Joan
Published: June 2021

Introduction:
Insular lesions have been described as an independent predictor of death in acute ischemic stroke. This study was undertaken to determine the influence of insular damage on the mortality of patients with intracerebral hemorrhage (ICH).

Hypothesis:
Insular cortex lesions are an independent predictor of death in acute ICH.

Methods:
This is an observational study of consecutive patients with spontaneous acute ICH who were admitted to a tertiary care hospital. The following data were collected prospectively: age, sex, traditional vascular risk factors, vital signs, CT findings (secondary intraventricular hemorrhage, hematoma volume), Glasgow Coma Scale score, time and cause of death within hospitalization. The insular cortex damage (right, left or any) was assessed by a blind evaluator using an interactive brain atlas. The association between insular lesions and mortality was investigated by use of logistic regression and Cox proportional hazards models.

Results:
We included 276 patients whose mean age was 77±14.3 years; 52.7% of them were men. During a median of 7 days (interquartile range 2-15) of hospitalization, 91 (32.9%) deaths were recorded. We observed 72 (26%) patients with insular cortex lesions (right insula=34, left insula=38). Cox regression analysis showed that age (adjusted hazard ratio [aHR] 1.02, 95% CI 1.00-1.04; p<0.001), Glasgow Coma Scale (aHR 0.84, 95% CI 0.80-0.89; p<0.001), lesion volume (aHR 1.10, 95% CI 1.06-1.15; p<0.001) and any insular damage (aHR 2.19, 95% CI 1.40-3.42, p=0.002) were significant predictors of death within hospitalization.

Conclusions:
In conclusion, insular cortex lesions adversely influence survival after spontaneous ICH. This finding was observed even after adjustment for other well-known predictors of ICH mortality.
Abstract TP337: Multiphase CTA Improves ICH Expansion Prediction and Might Provide Additional Information on the Pathophysiology of the Spot Sign
Authors: Rodriguez-Luna David , Coscojuela Pilar , Rodriguez-Villatoro Noelia , Juega Jesus M , Boned Sandra , Muchada Marian , Pagola Jorge , Rubiera Marta , Ribo Marc , Tomasello Alejandro , Demchuk Andrew M , Goyal Mayank , Molina Carlos A
Published: June 2021

Background:
Although the spot sign is a strong predictor of hematoma expansion, there is no accepted consensus on the timing of CTA acquisition, mainly because its pathophysiologic significance is uncertain. We investigated the yield of the spot sign in the prediction of hematoma expansion and its pathophysiological underpinnings using multiphase CTA.

Methods:
Single-center prospective observational cohort study of 123 consecutive patients with acute (<6 hours) ICH. Patients underwent multiphase CTA performed in 3 automated phases after contrast dye injection (delay of 8, 4, and 15 seconds, respectively). According to spot sign positivity in the 3 phases, patients were categorized into 1 of 4 patterns: A (+/+/-), B (+/+/+), C (-/+/+), and D (-/-/+). Outcomes included frequency of the spot sign, significant hematoma expansion at 24 hours (>33% or >6 mL, primary outcome), and absolute hematoma growth.

Results:
The frequency of the spot sign was higher the later the phase of CTA was: 29.3% in phase 1, 43.1% in 2, and 46.3% in 3 (
P
<0.001). The presence of the spot sign in phase 1, 2, 3, or any phase was related to significant hematoma expansion (
P
<0.001 for all comparisons). Predictive values varied depending on the CTA phase, with highest PPV observed in phase 1 (63%) and highest NPV in phase 2 (88.9%). Onset to imaging time was not significantly lower the more arterial the pattern of spot sign presentation was (Figure). The frequency of significant hematoma expansion was higher the earlier the pattern of spot sign presentation: A 100%, B 59.1%, C 40%, and D 0% (
P
=0.013). Absolute hematoma growth analysis showed a hierarchical distribution of patterns of spot sign presentation: A > B > C > D > no spot sign (
P
=0.003, Figure).

Conclusions:
Multiphase CTA improves hematoma expansion prediction and might provide additional information on the pathophysiology of the spot sign. Arterial spot signs may represent the point of active hemorrhage, and venous spot signs the site of resolved bleeding.
Abstract TP360: Nursing Unit Stroke Patient Education Initiative Improves Documentation
Authors: Weilbacher Georgia , Paessun Emily
Published: June 2021

Background:
Patient education in our organization historically had been delivered in a single session. This was observed to overwhelm the stroke patient and lead to missed documentation by the nursing staff.

Purpose:
The purpose of this study was to evaluate the impact of a robust daily patient education plan that included: delivery of patient education in smaller increments with a visual management system and incremental documentation by nursing staff to increase documentation accuracy, as well as a mechanism to indicate when family presence is required for education.

Methods:
Our hospital, a high volume academic medical center, implemented a unit led education initiative beginning in January 2016. A core team of nurses worked to define the education pathway for the acute stroke patient covering three days, the average length of stay. The team included a color coded visual management system, placed outside of patient rooms, to facilitate nursing communication of patient progression and status along this education pathway. Nursing staff were educated on the newly created pathway, visual management systems, and the documentation process. The new education process was initiated in May 2016. Patient charts were audited for nursing accuracy in education documentation for the three months preceding implementation and compared to the three months post-implementation.

Compared with the pre-implementation period, when documentation on the core unit was 99% (n= 91), the post-implementation period showed an improvement to100% (n=80).

Conclusion:
In conclusion, a robust education plan developed by nursing improves documentation. Further research is warranted to determine the effectiveness of extending model to other units providing care to stroke patients across the organization.
Abstract TP361: Stroke Alert Outcomes Impacted by Nurse Activated Stroke Alert
Authors: Allen Leigh , Rasmussen Jennifer
Published: June 2021

Purpose:
Decrease time from emergency department (ED) arrival to stroke activation and time from ED arrival to ED physician.

Background:
Delay to stroke alert may lead to a delay in administration of IV thrombolysis. In reviewing our facility’s ED stroke alert data a difference was noted in ED MD arrival time and stroke alert time between patients arriving by emergency medical service (EMS) versus private operated vehicle (POV).In 2015 stroke alert patients that arrived by EMS - median arrival to ED physician time was 5 minutes with median arrival to stroke alert time was 11 minutes; for patients that arrived by POV - median arrival to ED MD time was 16 minutes with median arrival to stroke activation time was 22 minutes. At our rural facility it had historically been an ED physician driven stroke alert process, after reviewing this data we sought to go to an ED nurse led stroke alert process.

Methods:
Nurse led stroke alert criteria were developed. Activation criteria included specific signs and symptoms of stroke and last known well/seen normal within 4 hours. ED nurses were educated on the new activation process during shift huddles prior to implementation Feb 2016.

Results:
For Feb-July 2016 stroke activation patients that arrived by EMS - median arrival to ED MD time decreased to 5 minutes with median arrival to stroke alert time decreased to 3 minutes; for patients that arrived by POV - median arrival to ED MD time decreased to 8 minutes with median arrival to stroke alert time decreased to 11 minutes. Additional impact was indentified in the number of average monthly stroke activations - in 2015 there were 20 stroke activations per month compared to 38 for months from Feb -July 2016. Discharge disposition of ischemic stroke activation patients demonstrated changed. In 2015 45 % home, 40% IRF/SNF, and 15% expired/comfort care; compared to Feb - July 2016 63% home, 29% IRF/SNF, and 8% expired/comfort care. Relative reduction of 46% in expired/comfort care.

Conclusions:
Nurse led stroke activation had a positive impact not only in decreasing the time to stroke activation and time of ED MD to the bedside for both EMS and POV patients but also decreased mortality and increased patients discharged home for patients with ischemic stroke.
Abstract TP370: Comparing Time to IV Alteplase Administration by Arrival Mode in Midwest Hospitals
Authors: Vilar Paul , Serdynski Lynn , Scharnott Michelle , Bluma Dot , Cook Mindy , Fladten David
Published: June 2021

Background & Objectives:
Stroke is the fifth leading cause of death and the leading cause of disability in the U.S. Timely administration of IV alteplase, can lead to reduction in the severity of disability and improve patient outcomes. The American Heart Association and the American Stroke Association have focused community awareness efforts on the importance of calling 9-1-1 when stroke symptoms are present. Our objective is to determine if arrival mode, specifically arriving by Emergency Medical Services (EMS) vs. privately owned vehicle (POV), impacts timely administration of IV alteplase.

Methods:
Get With the Guidelines (GWTG) -Stroke is a quality improvement initiative to improve care by promoting adherence to scientific guidelines. A retrospective review was conducted of 10,948 stroke patients from 261 hospitals using GWTG-Stroke in the Midwest from 2013 through 2015. Arrival mode, as well as IV alteplase administration times were analyzed.

Results:
In 2013, the median arrival to IV alteplase administration (admin) time was 58 minutes (min) when arriving by EMS vs. 64 min when arriving by POV. In 2014, patients arriving by EMS had a median arrival to admin time of 54 min in comparison to 59 min when arriving by POV. In 2015, patients arriving by EMS had a median door to admin of IV alteplase time of 51 min, whereas patients arriving by POV arrival to IV alteplase median time was 58 min.

Conclusions:
Midwest Stroke patients arriving by EMS received treatment of IV alteplase more timely than those that arrived by POV. Throughout the three years of this study, an average of 64.6% of patients arriving by EMS received IV alteplase within 60 min of hospital arrival in comparison to 52% of patients when arriving by POV. This demonstrates the collaboration, communication, and systems of care work being done by hospitals and EMS. With less than 40% of patients arriving by EMS, this data also identifies the continued need for community education regarding the importance of calling 9-1-1.
Abstract TP371: Monitoring a Large-scale International Cluster Stroke Trial: Lessons From Head Position in Stroke Trial
Authors: Lim Joyce Y , Hackett Maree , Munoz-Venturelli Paula , Arima Hisatomi , Middleton Sandy , Olavarria Veronica V , Lavados Pablo M , Brunser Alejandro M , Peng Bin , Cui Liying , Lee Tsong-Hai , Lin Ruey-Tay , Pontes-Neto Octavio M , Watkins Caroline L , Robinson Thompson , Mead Gillian , Pandian Jeyaraj D , de Silva H A , Anderson Craig S
Published: June 2021

Background and Purpose:
There is limited evidence on head positioning in acute ischemic stroke (AIS) or intracerebral hemorrhage (ICH). Potential benefits for lying flat (0°) include improved collateral blood flow in AIS and for head up (30°) reduced cerebral oedema in ICH. The Head Positioning in Stroke Trial (HeadPoST) aims to provide reliable evidence on the optimum head position in acute stroke.

Methods:
HeadPoST is a prospective, cluster randomised, crossover, blinded outcome assessed, clinical trial with consecutive patient recruitment who were positioned within 24 hours of admission. Hospitals were randomised to service organisation to compare lying flat vs. sitting up (≥30°) head positioning of stroke patients. An innovative centralized remote monitoring system was used to assess data quality across participating countries.

Results:
Over a 30 month study period, 10,000+ patients were recruited across 114 hospitals in 9 countries. A web-based monitoring system provided alerts for cross-over time points and achievement of cluster balance. Centralised reports included serious adverse events, protocol deviations, forms completion, data queries, entry delays and data validation, which were distributed to regional co-ordinating centres for action. Details of these procedures are outlined.

Conclusions:
Reliable, complete, and high quality data were required for this pragmatic international nursing care clinical trial, which used a novel cluster cross-over design.
Abstract TP373: Advancing Stroke Recovery Through Social and Emotional Support
Authors: Amatangelo Mary , Prvu Bettger Janet , Collins Karen J , Jackson Barry , Miller Elaine , Nguyen Meredith , Sadwin Larry , Wait Kristina , Lombardi Hill Debbie
Published: June 2021

Background:
Post-stroke disability often disrupts family roles and responsibilities. Role reversal, in combination with the disabilities, is emotionally taxing and physically fatiguing for both the stroke survivor and the family caregiver. Depression can result and when left undermanaged can lead to poor health outcomes. Research has shown social support is an important factor in recovery, post-stroke and caregiver depression. Studies have indicated high levels of social support are associated with faster functional recovery and more extensive recovery in stroke survivors. Also, that social support is independently associated with the presence and severity of post stroke depression and that positive social interaction is a significant contributor to variance in initial post stroke depression.

Purpose:
The purpose of this critical review was to examine the research literature on the relationships of social support and coping strategies with health-related outcomes among stroke survivors and their family caregivers.

Methods:
Twenty-five articles published between 2000 and 2016, identified by key terms related to stroke survivor and caregiver emotional and adjustment support needs, social support, depression and effective interventions, were reviewed.

Results:
We found overwhelming evidence that attention to stroke survivor and caregiver social network can advance recovery and improve the health and well being of both stroke survivors and caregivers. Knowledge gaps and focus on emotional and adjustment support needs are not being adequately met by community-based health services. This points to an important need for changes in practice to acclimate stroke survivors and their family caregivers to their new life roles, but also the need for more rigorous studies.

Conclusions:
In addition to more research, there is a critical need for changes in facilitating transitions of care to meet the emotional and adjustment needs in the stroke population. Encouraging health professionals to screen for social network presence and size and promoting support-seeking behavior may help advance recovery and improve the health and well being of stroke survivors and family caregivers.
Abstract TP374: Stroke versus Stroke Mimic for Inpatient Code Brain
Authors: Steiner Nili E , Paletz Laurie , Robertson Betty , Wolber Nicole , Guerra Sonia
Published: June 2021

Introduction/Background:
Functional outcome from stroke is better if the stroke is identified and treated immediately. The acute stroke pathway at Cedars Sinai is known as Code Brain. This pathway is often activated for inpatients and is a large part of the total number of Code Brain activations. The inpatient Code Brain pathway is inherently a nursing-driven process, most often initially activated by an inpatient nurse. The purpose of this project is to look at the number of Code Brain activations that are truly acute stroke versus stroke “mimics” - common conditions that appear to be consistent with acute stroke, but turn out to be diagnoses that are not stroke related.

Methods:
Plan: Retrospective patient case review of all in-house Code Brain activations, excluding prehospital/ED activations from January 2015 through December 2015.

Do:
We meet weekly to asses every Code Brain and evaluate and adjudicate patients

Study:
Examined results of adjudicated diagnoses to determine how many in-house Code Brain patients had a stroke/TIA diagnosis versus other diagnoses

Act:
Hospital-wide staff education regarding Code Brain activation criteria, including symptoms of acute stroke/sudden neurologic change in patient status

Results:
Out of 242 Code Brain in-house activations, 128 were adjudicated to stroke/TIA diagnoses and 114 were adjudicated to “other diagnoses”. Some of the most common non-stroke/non-TIA diagnoses were encephalopathy, migraine and seizure.

Conclusions:
The national average of over-triage of inpatient stroke activations is a little over 20%. Our study shows that in this time period, 47% of the inpatient Code Brain activations turn out to be non-stroke related diagnoses. There are many factors that can be taken into account for this. However, these outcomes also prove that with the education provided, the nursing staff is empowered to call a Code brain independent of physician advice, which is an excellent example of nursing autonomy. We will continue to monitor this data and educate the staff as needed.
Abstract TP385: Evolution of an Organized System of Care Positively Impacts Regional Stroke Treatment
Authors: Motz Deb , Patterson Michele , Moore Tracy , Barrett Diana , Buford Martha , Baker Cheryl , Blanchette Adam , Hunt Kassandra , Widemon Sonja , Epley Eric , Love Preston , Birnbaum Lee , Miramontes David , Wampler David , Mcalpine Candace , Prentiss Cheryl , Huey Dicky
Published: June 2021

Background:
The Southwest Texas Regional Advisory Council (STRAC) Stroke Systems of Care Committee is comprised of hospital, physician and EMS leaders who meet monthly to discuss process improvement and system development with a commitment to improve stroke recognition, response and treatment. Over a seven- year period, this community with a population of 1.5 million people progressed from no organized approach for stroke care to an organized system which includes 12 Primary centers, 2 Comprehensive centers, and over 40 EMS agencies.

Purpose:
To evaluate how an organized system has impacted stroke care in Southwest Texas over the past 5 years.

Methods:
A retrospective review of Get With The Guidelines®-Stroke data from the STRAC service area was conducted. Specific data points reviewed include diagnosis, mode of arrival, STK 4- IV tPA measure compliance, IV tPA door to needle (D2N) times and discharge disposition.

Results:
A total of 20,175 patients were entered between 2010 and 2015 of which 95% (n=19,080) were discharged with stroke diagnosis. Seventy-six percent (n=14,540) of the stroke patients arrived via EMS or walk in. EMS arrivals ranged from 61% (n=1,110) in 2010 to 54% (n=2,015) in 2015. STK 4 measure compliance ranged from 62.8% (n=140) in 2011 to 88.9% (n=158) in 2013. The 2015 STK 4 measure compliance was 84.3% (n=209). IV tPA treatment rates ranged from a low of 9.6% in 2012 to >12% in 2014, 2015 and 2016. D2N
<
60 minutes and the percentage of patients discharged home trended upward by over 20% during this period.

Conclusions:
Development of an organized system of care has impacted regional stroke treatment as demonstrated by the upward trend and stabilization of compliance of the STK 4 measure, IV tPA treatment rates, and percentage of patients discharged home. Despite improvement there is opportunity to provide community education emphasizing the importance of calling 911 when stroke is suspected. Current performance improvement initiatives include the formation of a regional public education committee and the provision of an annual regional stroke conference. The next focus is to engage area hospitals and EMS in the commitment to advance and improve stroke care.
Abstract TP396: Strategies for Successful Stroke Survey
Authors: Mathiesen Claranne , Conahan Erin M
Published: June 2021

Background:
Comprehensive Stroke Center (CSC) certification has been available since 2012. Over 100 hospitals have completed this rigorous advanced disease specific certification. Stroke certification occurs every two years and can be resource intensive for hospitals. No matter how experienced a center is, preparation of the extended team takes considerable time and energy. Issue: Stroke Centers operate in a dynamic healthcare environment, continuously undergoing series of changes that impact care delivery across the continuum. In theory, survey preparation is an on-going process. In reality people get comfortable once certified and return to previous workflows with less attention to detail. Current literature focuses on improved quality and outcomes that result from disease specific certification. There is a limited amount of published literature regarding stroke survey preparation activities, and available publications are over ten years old.

Purpose:
The purpose of this presentation is to formally contribute successful survey strategies to the experience of the stroke community.

Method:
Various aspects of preparation, including team development, standards and clinical practice guidelines review, the role of data, and methods to prepare staff will be discussed. In addition the use of resources, the value of pre-survey consultation to provide external gap analysis, and equitable distribution of preparation activities will be explored.

Result:
Thorough survey preparation has led to an initial survey and two recertifications with a total of 11 RFIs. Multidisciplinary teamwork requires ongoing commitment to assure adoption of standards and continued engagement to ensure all involved areas are ready to actively participate in the on-site review process.

Conclusion:
More research and publication is needed to assist stroke centers to prepare for a successful stroke survey. As CSC’s mature expectations are increased to grow the way programs meet the needs of presenting stroke patients and develop the professional team. By comparing and sharing strategies, comprehensive stroke programs can share experiences that lead to decreased stress and improved confidence at the time of on-site certification visit
Abstract TP412: Predicting Pharmacokinetic versus Pharmacodynamic Aspirin Resistance in Patients
Authors: Westphal Erica S , Rainka Michelle M , Amsler Michelle , Aladeen Traci , Snyder Caitlin , Bates Vernice , Gengo Fran M
Published: June 2021

20%-40% of patients being treated with aspirin for secondary prophylaxis of stroke or myocardial infarction may derive no antiplatelet effects. Early identification of patients as pharmacokinetically or pharmacodynamically resistant to aspirin has the potential to become an invaluable clinical tool, reducing delays to optimal treatment, cardiovascular events, and healthcare costs. This study tested the capability of an assay that was previously developed in healthy volunteers, to differentiate between these two types of resistance in patients.

Patients who needed aspirin treatment in the course of normal medical care were included. Dose escalation of chewable aspirin from 81 mg, to 162 mg, to a maximum 325 mg daily occurred every 10-14 days based on the results of whole blood impedance aggregation testing to the agonists, collagen (1 ug/mL, 5 ug/mL) and arachidonate (0.5 mM). The in vitro test was conducted in triplicate by performing the same aggregometry test on blood samples spiked to a concentration of 10 uM of aspirin in 0.05% dimethyl sulfoxide. Resistance was defined as a response to collagen 1 ug/mL >10 ohms, and/or response to arachidonate >6 ohms, and/or the ratio of collagen 1 to 5 ug/mL >0.5. Patients were excluded if they had any disorders affecting platelet function, an abnormal CBC, alcohol use within 24 hours of a test, NSAID use, or had any conditions that would affect absorption.

Of the 36 patients included who were compliant with their 81 mg aspirin regimen based on pill count, 16 were found to be resistant to 81 mg of aspirin. Nine of these patients were predicted to stay resistant despite dose increase. Once tested at higher doses, ten actually remained resistant. Seven of the 16 patients were predicted to become sensitive to a higher dose of aspirin while six actually did. No statistical difference was found between predicted aspirin response and actual aspirin response (p=0.61). Sensitivity was 83% and specificity was 80%.

In conclusion, results are promising and indicate that it is possible to predict, with reasonable accuracy, if a patient will have an adequate platelet response to aspirin or if the patient will never respond to aspirin therapy necessitating an alternative antiplatelet regimen. Larger, multi-site studies are inevitably needed.
Abstract TP413: Baseline Characteristics and Clinical Outcomes of a Non-valvular Atrial Fibrillation Patient Population Treated with Dabigatran or Warfarin - A Retrospective Database Analysis
Authors: Reynolds Shannon L , Annavarapu Srinivas , Moretz Chad , Stemkowski Stephen , Sheer Richard , Clore Gosia , Petrini Michaela , Andrews George
Published: June 2021

Objective:
This study evaluated safety and effectiveness outcomes among non-valvular atrial fibrillation (NVAF) patients treated with dabigatran or warfarin using an administrative claims database.

Methods:
NVAF patients with no oral anticoagulant (OAC) use prior to their first prescription claim for FDA-approved dosages of either dabigatran or warfarin between 01-Oct-2010 and 30-Apr-2014 were identified. Patients aged 18-89 years with medical and pharmacy benefits were selected. Patients with valvular heart disease, transient causes of AF, or hyperthyroidism at baseline were excluded. Patients were followed until discontinuation of index medication, OAC switch, disenrollment, death, or end of observation period. Dabigatran and warfarin patients were propensity score matched (PSM, 1:2) using baseline demographics and clinical characteristics. Outcomes were measured either using diagnosis codes from all service lines in medical claims (Method A) or using an algorithm to derive principal diagnosis (Method B). Outcome measurements using Method B are comparable to prior database studies that used principal diagnosis. Safety and effectiveness outcomes of the matched cohorts were assessed using Cox-proportional hazards models.

Results:
A total of 7,245 dabigatran (1,016 receiving 75 mg and 6,229 receiving 150 mg) and 14,490 warfarin patients were analyzed (Table 1). The patients were 56% male, with a mean age of 74 years, mean CHADS
2
stroke risk score of 2.2, and mean HAS-BLED bleeding risk score of 3.4. Based on the hazard ratios, lower risks for primary (major bleeding) and secondary (hemorrhagic stroke, major intracranial bleeding, major extracranial bleeding [major urogenital and other bleeding], and death) outcomes were observed in the PSM dabigatran cohort compared to warfarin cohort (Method B).

Conclusions:
These results are largely consistent with findings from previous studies that support the benefits of dabigatran therapy in NVAF patients.
Abstract TP42: Risk of Acute Ischemic Stroke in Monocular Vision Loss of Vascular Etiology
Authors: Zhang Jason , Zhang Lucy Y , Matthews Jared , Rudich Danielle , Greer David , Lesser Robert , Amin Hardik
Published: June 2021

Purpose:
To evaluate the risk of concurrent acute cortical ischemic stroke in the setting of monocular vision loss of vascular etiology.

Design:
Retrospective and prospective, cross-sectional study.

Subjects:
Patients age 18 or older diagnosed with monocular vision loss of suspected or confirmed vascular etiology who had no other neurologic deficits and who received brain magnetic resonance imaging (MRI) within 7 days of onset of visual symptoms.

Methods:
Medical record review was performed from 2013-2016 at Yale-New Haven Hospital. Subjects were included if vision loss was unilateral, permanent or transient, and thought to be due to a vascular etiology such as central retinal artery occlusion (CRAO) or branch retinal artery occlusion (BRAO). Any subjects with neurologic deficits other than vision loss were excluded. Other exclusion criteria were positive visual phenomena, non-vascular intraocular pathology, and intracranial pathology other than ischemic stroke. Institutional Review Board/Ethics Committee approval was obtained.

Main Outcome Measures:
Presence or absence of acute cortical stroke on diffusion weighted imaging (DWI) sequence on brain MRI.

Results:
A total of 641 records were reviewed, with 293 subjects found to have monocular vision loss. After excluding subjects with focal neurologic deficits, there were 41 subjects who met inclusion criteria and received a brain MRI. 8 of the 41 subjects (19.5%) were found to have brain MRI positive for acute cortical strokes. The proportion of lesion positive MRI was 1/23 (4.3%) in transient monocular vision loss subjects, 4/12 (33.3%) in patients with CRAO, and 2/5 (40%) in BRAO.

Conclusions:
Patients with transient or permanent monocular vision loss of vascular etiology such as CRAO or BRAO may have up to 19.5% risk of concurrent cortical ischemic stroke, even when there are no other neurologic deficits. This highlights the importance of urgent stroke evaluation in this patient population.
Abstract TP420: Fluctuations in Glasgow Coma Scale Score Correlate with Non-invasive Continous Cerebral Autoregulation Monitoring in Comatose Patients
Authors: Healy Ryan , Zorrilla-Vaca Andres , Ziai Wendy , Geocadin Romer , Mirski Marek A , Hogue Charles , Rivera Lara Lucia A
Published: June 2021

Introduction:
The Glasgow Coma Scale (GCS) score is the most commonly used scale for assessment of patients with acute neurological injury in critical care settings. The post-resuscitation admission GCS score is also a predictor for long term outcome in patients with acute traumatic brain injury. Similarly, cerebral autoregulation (CA) monitoring at the bedside has shown to be an accurate technique for predicting clinical outcomes. This study aimed to investigate the correlation between GCS score and continuous CA measured by near-infrared spectroscopy (NIRS).

Methods:
Twenty-six comatose patients with acute neurological injury admitted to a neurocritical care unit were monitored continuously with NIRS using ICM plus software from one hour up to three days after the coma onset. The cerebral oximetry index (COx) was calculated as the correlation between the slow waves from regional cerebral oxygen saturation (rSO
2
) and mean arterial blood pressure (MAP). COx, rSO
2
, MAP and GCS data were prospectively extracted each hour. Pearson correlation was used for determining the relation between the NIRS-based measurements (rSO
2
and COx) and GCS every hour of monitoring.

Results:
A total of 655 observations (hours) were analyzed from 26 patients (65.4% female) with a mean age of 58 years. Eleven patients had ICH, 8 had SAH, 4 had TBI, one had an ischemic stroke, one had a cardiac arrest, and one had status epilepticus. GCS was significantly correlated with COx (r = 0.21, P < 0.001) and MAP (r = 0.15, P < 0.001). Conversely, rSO
2
showed non-significant correlation with GCS (r = 0.06, P = 0.12).

Conclusions:
This study shows that GCS correlates well with COx, but not with rSO
2
. Our findings support the utility of NIRS-based COx to follow fluctuations in neurological status of critically ill patients that may be particularly useful in sedated and paralyzed patients.
Abstract TP448: Genome-wide CNV Array Analysis Following Post-hoc Targeted Amplicon Sequencing Revealed Genetic Anticipation in Parent-offspring Pairs with Moyamoya Disease
Authors: Ito Masaki , Uchino Haruto , Kazumata Ken , Hama Yuuka , Hamauchi Shuji , Nishihara Hiroshi , Sasaki Hidenao , Houkin Kiyohiro
Published: June 2021

Introduction:
Molecular mechanisms underlying clinical observation of progressively earlier age of onset of Moyamoya disease (MMD) as it is passed on to the next generation, as known as clinical anticipation, is still obscure. This study investigates copy number variation (CNV) in parent-offspring pairs with MMD with and without clinical anticipation using genome-wide CNV array following high-throughput DNA sequencing.

Methods:
Fifteen out of 25 consecutive Japanese parent-offspring pairs with MMD treated at our institute since 1980 were enrolled. Demographics, inheritance pattern, angiographical stage, disease type at onset were reviewed. Using genomic DNA from whole blood, rs112735431 in RNF213 gene was genotyped, then genome-wide CNV analysis was conducted using a 2.6 M oligonucleotide array to compare CNV profile in parent-offspring pairs with and without clinical anticipation. Amplicon Sequencing was further conducted using Miseq.

Results:
Clinical anticipation was observed in 10 pairs (67%) and was not in 5 pairs (33%). In clinical anticipation group, mean age at onset was significantly lower in the offsprings than in the parents (p<0.001). There were no significant differences in other clinical and genetic backgrounds, including the genotype in RNF213 between the generations and between the groups with and without clinical anticipation. Genome-wide CNV profiling revealed that 10 CNV in chr7q, 8p, 9q, 14q, 16p, 19p, 20q, and 22q were overlapped for more than 3 individuals in the whole studied population. Of these CNV, copy number was different only in chr16p13.3 between the generations in clinical anticipation group (P=0.06). Fourteen genes were observed in this locus, including GNPTG gene, whose mutation is known to be associated with mucolipidosis. Amplicon sequence targeting these 14 genes revealed significant copy number loss at GNPTG gene locus, in the offsprings compared to their parent (P = 0.02, copy number = 1.8 and 2.0, respectively).

Conclusion:
These data suggest clinical anticipation of MMD in Japanese population can be observed regardless of the RNF213 genotype. This is the first genome-wide CNV profiling, suggesting the CNV in chr16p13.3 might be underlying mechanism for anticipation in familial MMD by reducing gene dosage.
Abstract TP48: Automated Deep Learning-based Measurement of DWI Lesion Volume in Acute Stroke Using Convolutional Neural Networks
Authors: Winzeck Stefan , Bouts Mark J , McIntosh Elissa , Bezerra Raquel , Diwan Izzuddin , Mocking Steven J , Garg Priya , Kimberly W T , Arsava E M , Copen William A , Schaefer Pamela W , Ay Hakan , Singhal Aneesh B , Wu Ona
Published: June 2021

Background:
In acute ischemic stroke (AIS), therapeutic decisions are increasingly being based upon the volume of likely-unsalvageable brain tissue, which is often estimated using DWI. Deep learning algorithms, e.g. convolutional neural networks (CNN), have been employed for chronic stroke lesion segmentation. Here we investigate the applicability of CNN for DWI lesion measurement in acute stroke.

Methods:
50 AIS patients underwent DWI < 12h from last known well. Apparent diffusion coefficient maps, T2WI, and DWI were used as covariates in a 2D CNN (5-fold cross validation). Including convolutional, inception and fully connected dense layers, a CNN of 15 layers was trained using manually outlined DWI lesions. To avoid overfitting, statistical dropout, L1- and L2-regularization and batch-normalization were used. Automatically segmented lesion volumes (ALV) using a 50% risk threshold were compared to the manual lesion volumes (MLV) using Dice similarity index (DSI, a measure of overlap) and Spearman’s correlation coefficient. Subset analysis was performed evaluating results between small (<10 ml) and large lesions (Wilcoxon rank sums).

Results:
The figure shows examples of CNN segmentation. The median [IQR] measured lesion volume and DSI were 25 [13-46] mL and 66% [35-75%], respectively. The correlation of MLV with ALV was 86% (P<0.001). 21 subjects (42%) had lesion volumes less than 10 ml. DSI for small lesions (28% [14-46%]) was significantly lower (P<0.001) than large lesions (73% [67-79]%). Correlation of ALV with MLV for small lesions compared to large lesions were 31 and 84 respectively and differed significantly (P=0.001).

Discussion:
Automatic DWI lesion segmentation for large lesions is feasible using CNN. CNN tended to overestimate the volumes of small lesions. Prior methods have used a priori heuristics or morphometric operations to remove artifacts. CNN methods show promise for “learning” to discriminate artifacts from real lesions.
Abstract TP53: NIHSS and Variation of Infarct Volume by Hemisphere
Authors: Behymer Tyler P , Vagal Achala , Sucharew Heidi , Yeluru Vineeth , Minhas Arjun , Hazenfield J. M , Reddy Mahati , Frey Courtney , Alwell Kathleen , Moomaw Charles J , Flaherty Matthew , Ferioli Simona , Mackey Jason , De Los Rios La Rosa Felipe , Martini Sharyl , Adeoye Opeolu , Kleindorfer Dawn O , Kissela Brett M , Khatri Pooja , Woo Daniel
Published: June 2021

Introduction:
The National Institute of Health Stroke Scale (NIHSS) is the most widely used measure of neurological deficits in clinical trials. Using the placebo arm of the NINDS t-PA Stroke Trial, it has been demonstrated that the total volume of cerebral infarction in patients with similar NIHSS scores is greater for right compared to left hemisphere strokes. Our objective was to verify this finding in a non-clinical trial, independent data set of acute ischemic strokes.

Methods:
The Greater Cincinnati/Northern Kentucky Stroke Study (GCNKSS) is a population-based study that tracks the incidence of stroke. A convenient subsample from the 2010 GCNKSS ischemic stroke cohort (N= 368) underwent detailed imaging analysis. Research nurses abstracted patient reords to include baseline retrospective NIHSS score. The 24 hour infarct volume was segmented using manual tracing. NIHSS was compared between left and right brain using Wilcoxon rank sum test. Spearman rank correlation determined the association between the NIHSS score and infarct volume by hemisphere. Patients were stratified by NIHSS (0 to 5, 6 to 20, and greater than 20).

Results:
Among 368 ischemic stroke subjects with imaging data, excluded were 77 brainstem or cerebellar infarcts, 37 undetermined volume, 1 missing NIHSS, and 3 undetermined laterality. For the remaining 250 patients, 132 were left and 118 were right hemisphere strokes, and 210 had an MRI and 40 had CT. Median time from onset to imaging was 24 hours. Baseline NIHSS was similar by hemisphere and correlated with stroke volume (r=0.38, p<0.01). The infarct volumes of right hemisphere strokes were greater than left hemisphere (p-value=0.02) (Table).

Conclusion:
The NIHSS score correlates with volume by hemisphere, but has a larger infarct volume for right hemisphere than left hemisphere for similar NIHSS. This likely reflects the different weighting of the NIHSS with regard to language. This finding confirms prior results in an independent dataset.
Abstract TP57: Altered Functional Connectivity in Transient Ischemic Attack Patients
Authors: Stringer Michael S , Varsou Ourania , Fernandes Catarina , Schwarzbauer Christian , MacLeod Mary J
Published: June 2021

Introduction:
The pathophysiology and sequelae of transient ischaemic attacks (TIA) merit further study,. Particular challenges arise from the on-going debate on diagnostic criteria and the fact that few studies use the modern tissue-based definition. Differences in functional connectivity have previously been identified in a number of conditions, including stroke, have been implicated in the symptom profile and are known to vary during recovery. In this pilot study we investigate whether there were functional connectivity differences between TIA patients and healthy controls.

Methods:
Patients were referred for a standard clinical magnetic resonance imaging (MRI) neurovascular protocol, with the addition of a resting state functional MRI (fMRI) sequence. Eight patients diagnosed with a TIA (4 women, 57±9) were recruited, along with eight healthy controls (4 women, 30±5). Independent component analysis was used to isolate the networks before performing non-parametric two-sample t-test using both threshold-free cluster enhancement (TFCE) and voxel-wise statistics.

Results:
Significant differences (p<0.05, FWE-corrected) emerged using TFCE, in particular increased connectivity was noted in the mid-cingulate area with contrasting decreases in the cerebellum within the sensorimotor network. Additionally clusters of decreased connectivity were noted in the right insula in an attentional component, the pre-cuneus within the default mode network and the supplementary motor area in a visual component. No significant differences between the TIA and control group were above the threshold using voxel-wise statistics.

Conclusion:
In line with previous research in groups of stroke patients, this study has identified evidence of differences in neural connectivity associated with TIA, which cannot be explained by age. Differences in the sensorimotor network may be linked to the symptoms experienced by patients, with the mid-cingluate area being implicated in memory and learning. Alterations in functional connectivity may be relevant for recovery, including the on-going cognitive deficits reported in TIA patients. These findings suggest an important area for further research with a larger cohort.
Abstract TP64: Intravenous Thrombolysis in Chinese Patients with Mild Stroke
Authors: Chen Weiqi , Pan Yuesong , Zhao Xingquan , Liu Liping , Li Hao , Liao Xiaoling , Wang Chunjuan , Wang Yilong , Wang Yongjun
Published: June 2021

Objectives:
Thrombolysis treatment for patients with mild stroke is controversial. The aim of this study is to investigate whether patients with mild stroke or its specific etiologic subtype could benefit from recombinant tissue plasminogen activator (rt-PA) therapy.

Methods:
Data were derived from two cohorts of patients with and without rt-PA treatment: (1) the Thrombolysis Implementation and Monitor of Acute Ischemic Stroke in China database and (2) the China National Stroke Registry database. Patients with mild stroke (defined as National Institutes of Health Stroke Scale≤5) receiving the rt-PA therapy and without rt-PA therapy were matched in 1:2 for age, sex, stroke severity and etiologic subtype. Good functional outcome was defined as modified Rankin Scale 0-1 at 3 months. Odds ratios (ORs) with 95 % confidence intervals (CIs) were estimated using conditional logistic regression in total patients and by etiologic subtype, respectively.

Results:
A total of 134 rt-PA treated patients were matched to 249 non-rt-PA treated patients in the study. Among them, 104 (76%) rt-PA-treated patients with mild stroke had good outcome after 3 months compared with 173 (69.5%) non-rt-PA-treated matching cases (odds ratio [OR], 1.48; 95% confidence interval [CI], 0.91-2.43; P=0.12). Compared with non-rt-PA treatment group, rt-PA-treated patients had good outcome after 3 months in those with stroke subtype of large-artery atherosclerosis (LAA) (80.5% vs 65.1%; OR, 2.19; 95%CI, 1.14-4.21; P=0.02).

Conclusions:
For patients with mild stroke, intravenous rt-PA treatment may be effective. Patients with stroke subtype of LAA could benefit more from intravenous rt-PA treatment.