bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP230: The Severity of Cerebral Small Vessel Disease is Associated With Tooth Loss but Not With Serum Titer to Periodontal Pathogens in Acute Stroke Patients
Authors: Shiga Yuji , Hosomi Naohisa , Nezu Tomohisa , Nishi Hiromi , Aoki Shiro , Nakamori Masahiro , Kinoshita Naoto , Maruyama Hirofumi
Published: January 2019

Introduction:
Oral health conditions, including periodontal disease has been considered as a risk factor for cerebral or cardiovascular disease. Cerebral small vessel disease (SVD) such as white matter lesions (WMLs) or cerebral microbleeds (CMBs) are also associated with the incidence of stroke. However, it is unclear how oral health conditions are associated with the severity of SVD.

Hypothesis:
The purpose of this study is to examine the associations of oral health conditions (serum titer of periodontal pathogens or tooth loss) with the severity of SVD (WMLs or CMBs) in acute stroke patients.

Methods:
Acute stroke patients were enrolled in two stroke centers. Serum antibody titers of periodontal pathogens (16 pathogens) were evaluated within 3 days after stroke onset. The severity of WMLs was assessed by Fazekas classification; grade 0 and 1 were defined as mild and grade 2 and 3 as severe WMLs. The presence or numbers of CMBs was assessed by T2*-weighted MRI. The patients were evaluated for the numbers of tooth loss by a dentist in single center (Hiroshima university hospital). The severity of tooth loss was classified by the number 0 to 5 as mild and 6 or more as severe.

Results:
In total, 664 acute stroke patients were enrolled (ischemic, n=558 and hemorrhagic, n=106). No significant associations were detected between the grades of any serum antibody titers of periodontal pathogens and the severity of WMLs or CMBs. Of these, 124 patients were evaluated for the numbers of lost teeth. The patients with severe WMLs had severe tooth lost frequently compared to those with mild WMLs (70.7% vs. 39.4%, P=0.020). The patients with multiple CMBs (more than 2) had severe tooth lost frequently compared to those without (67.6% vs. 48.8%, P=0.048). After adjusting for age, sex, hypertension, diabetes, dyslipidemia and atrial fibrillation, severe tooth loss (odds ratio [OR] 2.82, 95% CI 1.23-6.47, P=0.014) were associated with the severity of WMLs. Similarly, severe tooth loss was also associated with the multiple CMBs after adjusting for those factors (OR 2.73, 95% CI 1.05-7.11, P=0.040).

Conclusion:
No association is detected between any serum antibody titer to periodontal pathogens and the severity of SVD. On the other hand, the severe tooth loss is associated with the severity of SVD.
Abstract TP233: Sex Differences in30-DayReadmission Rates After Ischemic Stroke - A Nationwide Study
Authors: Wabnitz Ashley , Lekoubou Looti Alain , Bishu Kinfe , Ovbiagele Bruce
Published: January 2019

Introduction:
As far as we are aware, there are no published studies that have examined the influence of sex on U.S. national short-term readmission rates after hospitalization for an index ischemic stroke. Baseline differences between men and women (eg, age, comorbidities, risk factor profiles, stroke severity, and pre-stroke disability) can have an impact on early readmissions, the latter of which, are associated with worse clinical outcomes and excess medical costs.

Methods:
Patients with ischemic stroke were extracted from the 2014 National Readmission Database. Multivariable logistic regression analysis was used to identify independent predictors of 30-day readmission after ischemic stroke.

Results:
A sample of 230,869 ischemic stroke patients (weighted N= 502,604) were included in this study, 48.86% were women. Female had statistically and significantly lower odds of 30-days readmission (OR=0.865; 95% CI: 0.816-0.917) than male.

Conclusion:
In this national representative sample analysis, we found that females were 14% less likely compared to males to be readmitted. Other predictors of 30 day readmission included age, length of stay, and comorbidity severity. Understanding the interaction of sex on these factors may help to reduce health care costs and improve quality of life in stroke survivors.
Abstract TP242: Internal Carotid Artery Angle and the Risk of Floating Mural Thrombosis in Acute Cerebral Infarction Patients
Authors: Abe Yuko , Mima Yohei , Esa Yoshiki , Tanaka Aimi , Ueda Naoko , Otsubo Ryoichi
Published: January 2019

Background and Purpose:
Floating mural thrombosis in an internal carotid artery (ICA) is a rare and uncommon pathology with a high risk of embolism. Carotid anatomy and geometry may play a role in the pathogenesis of internal carotid artery stenosis. However, their effects to the formation of thrombus are unknown. Therefore, we sought to find whether the ICA angle affected the formation of thrombus or not.

Method:
We retrospectively analyzed 603 consecutive patients with a diagnosis of acute cerebral stroke from April 2015 to June 2017. We conducted brain MRI/MRA scans and carotid ultrasonography to assess the atherosclerotic change and the prevalence of mural thrombosis. We found four patients (0.6%) with a mobile mural thrombus in the ICA without a significant stenosis. As a control group, we also chose 24 patients who had atherothrombotic infarctions with 50% or less ICA stenosis. We measured the ICA angle which is the angle of deviation of the ICA from a vertical line drawn through the center of the common carotid artery. We investigated the degree of ICA angle as well as traditional vascular risk factors and coagulation factors.

Results:
The mural thrombosis group was younger than the control group (60.5±14.7 vs. 76.5±8.7 years, p<0.01). The ICA angle was significantly wider in patients with floating mural thrombosis (56.0°:IQR 33.3 to 69.6° vs. 24.5°:IQR 19.9 to 34.6°, p=0.009). There were no significant differences in coagulation factors, vascular risk factors, and comorbidities between the mural thrombosis group and the control group.

Conclusion:
Our study implies that wide ICA angle is an important factor for the formation of the floating mural thrombosis as well as developing carotid artery atherosclerosis.
Abstract TP251: Metabolomic Biomarker Predictors of Infarct Size in Acute Ischemic Stroke
Authors: Beaver Bahar M , Indukuri Vijay V , Bejar Cynthia , Sanghera Dharambir , Reddivari Lavanya , Apple Blair , Xu Chao , Ray Bappaditya , Vanamala Jairam K , Sidorov Evgeny
Published: January 2019

Background:
Acute ischemic stroke (AIS) is the fifth leading cause of death in the United States. Although early diagnosis is difficult, no reliable biomarker that categorizes ischemic stroke is currently available. Metabolome profiling is a useful method to identify such biomarkers. Correlation of these biomarkers to objective imaging data such as infarct volume can better delineate stroke pathophysiology and prognosis.

Hypothesis:
Disturbances of serum metabolites in AIS correlate with infarct volume.

Methods:
We conducted a prospective pilot study of 20 AIS patients with serum collection in the acute (72 hours) and chronic (2 to 9 months) phases. Global metabolite profiling of each serum sample was performed using Thermo Scientific Q Exactive Plus, and targeted analysis was performed using the in-house metabolomic database. We calculated the volume of ischemic lesions on diffusion-weighted imaging using the ABC/2 formula and correlated it to metabolite levels in the acute phase. The chronic phase served as a reference. We employed the LASSO (least absolute shrinkage and selection operator) regression with hypothesis testing to examine the association of the relative change of metabolite levels in acute and chronic phases with the volume of stroke in the acute phase.

Results:
The following four metabolites related to oxidative stress showed a significant correlation with infarct volume: 4-pyridoxic acid (B6 metabolism), asparagine (amino acid), serine (sphingolipid metabolism), and citraconic acid (fatty acid) [p-values for all <0.0001]. The infarct volume positively correlated with relative changes of 4-pyridoxic acid and serine (effect size 3.04 (95% CI [2.73, 3.35]) and 1.14 (95% CI [0.56, 1.73]), respectively), while asparagine and citraconic acid negatively correlated with infarct volume (effect size -2.20 (95% CI [-3.47, -0.93]) and -6.75 (95% CI [-10.34, -6.75]), respectively).

Conclusion:
Although all discovered metabolites were previously associated with ischemia, this is the first study that demonstrates that objective infarct volume correlates with these metabolite levels, which may have prognostic implications. Larger studies in the future are needed to validate our findings.
Abstract TP258: Clinical and Radiographic Features of Stroke in Cryptococcal Meningoencephalitis in a US Cohort Study
Authors: Vela-Duarte Daniel , Sillau Stefan H , Nyberg Eric , Castellanos Paula , Chastain Daniel , Franco-Paredes Carlos , Henao-Martínez Andrés F
Published: January 2019

Background:
Cryptococcal meningitis can present with small vessel vasculitis and ischemic stroke. Acute and chronic infection carry a high mortality in both immunocompetent and immunocompromised patients. Among the survivors, multiple neurological deficit cause marked disability. Predictors of poor outcome and stroke recurrence remain unrecognized.

Methods:
We aim to describe clinical and radiographic features of stroke in a prospectively collected cohort of patients with Cryptococcal meningitis. A retrospective analysis of neuroimaging studies, cerebrospinal fluid(CSF) and clinical presentation was performed at the University of Colorado Hospital between 2000-2018. A multivariable logistic regression model was constructed to explore associations between dichotomous variables and informed as risk ratios. A T-Test and Wilcoxon test were applied to means of continuous variables. Fisher's exact test and contingency tables were used.

Results:
A total of 42 patients had cryptococcal meningitis, of which 31 had available imaging. Ischemic stroke was present in 8 patients (26%). Most strokes were acute (75%), lacunar (100%), multiple (88%), bilateral (63%) and localized in the basal ganglia (75%). Hyponatremia carried a RR: 5.7 (95% CI, 1.7-34.1) p=0.005. Other variables such malignancy, basal exudates, cryptococcoma, meningeal enhancement, hydrocephalus and CSF WBC did not seem to increase or reduce the risk of stroke. Anemia and hyponatremia were associated with presence of stroke, p=0.02 and p=0.03, respectively. Every unit decrease in hemoglobin is associated with 0.26 times the risk of ischemic stroke, (95% CI, 1.7-34.1) p=0.0312. Cryptococcal meningitis lead to death in 13 patients (30%) and 3 (14%) in patients with pulmonary manifestations only.

Conclusion:
Cryptococcal meningitis carries a high risk of neurologic complications, including lacunar stroke, particularly in the basal ganglia. Predisposing risk factors include anemia and hyponatremia regardless of the immune status of the patients. We report a mortality comparable to developing countries in the setting of a center of reference. The most common radiographic features of cryptococcal vasculitic infection may play a role in the high mortality of the population.
Abstract TP261: Red Blood Cell Distribution Width is Associated With Collateral Flow and Infarct Volume Growth in Acute Stroke With Large Artery Atherosclerosis
Authors: Hong Lan , Fang Kun , Ling Yifeng , Yang Lumeng , Cao Wenjie , Parsons Mark , Cheng Xin , Dong Qiang
Published: January 2019

Background and Purpose:
Red cell distribution width (RDW) has been recognized as a prognostic marker in cardiovascular diseases and stroke. Increased RDW is predictive of poor outcome and mortality in acute ischemic stroke patients. However, the underlying mechanisms are not fully understood. We aimed to explore the association between RDW, collateral flow, infarct volume growth, final infarct volume (FIV), and clinical outcomes in acute stroke patients with large artery atherosclerosis.

Methods:
This is a single-center retrospective cohort study based on a prospective registry of consecutive acute ischemic stroke patients within 6 hours of onset. Acute ischemic stroke identified with anterior circulation large artery atherosclerosis (LAA) with complete baseline and follow-up imaging (Non-contrast CT, CT Angiography, Perfusion CT) as well as clinical profiles were enrolled. Collaterals was assessed using the volume ratio between delay time (DT) >3s and DT>6s lesions. Baseline infarct core volume was defined by relative cerebral blood flow<30%. FIV was calculated by manually drawing regions of interest on the follow-up images. Infarct volume growth was determined from FIV minus baseline infarct core volume. A good functional outcome was defined as a 3-month modified Rankin Score of 0-2. The relationship between RDW, collaterals, infarct volume growth, FIV and clinical outcomes were evaluated using multivariate models.

Results:
A total number of 100 patients were included in this study. Multivariate adjusted general linear models revealed that increased RDW was associated with poorer collaterals (multivariate adjusted coefficient -0.11, 95% CI -0.20 — -0.02, p=0.02) and increased infarct volume growth (multivariate adjusted coefficient 0.06, 95% CI 0.03 — 0.08, p<0.001). No significant relationship was found between RDW and FIV (multivariate adjusted coefficient 0.08, 95% CI -0.01 — 0.13, p=0.08), RDW and clinical outcomes (multivariate adjusted OR 1.66, 95% CI 0.44 — 6.28, p=0.46) probably due to the small sample size.

Conclusion:
For patients with LAA stroke, high RDW was associated with poorer collateral flow and increased infarct volume growth, which may explain the predictive value of RDW and poor functional outcomes in acute stroke.
Abstract TP263: Is Altitude Associated With Ischemic Stroke in the Young?
Authors: Salottolo Kristin , McCarthy Kathryn , van Vliet Rebecca , Bartt Russell , Bar-Or David
Published: January 2019

Background:
Stroke in the young (< 45 years old) is rare, yet may be increasing in prevalence due to the rise in traditional risk factors such as hypertension and smoking status. Whether altitude is a risk factor for stroke in the young has not been examined. At our high elevation state (Colorado), we report a high prevalence of stroke in the young. We hypothesized that the rate of stroke in the young was positively associated with state elevation.

Methods:
We conducted an ecologic study utilizing the most recent data from the Healthcare Cost and Utilization Project (HCUPnet- 2015), provided by the Agency for Healthcare Research and Quality, and U.S. Census data (2010). The proportion (%) of stroke admissions in the young within each state was identified from HCUPNet data using ICD9 diagnosis codes of 433-434. Prevalence rates (per 100,000 persons) of stroke in the young population within each state were calculated from US census data. Proportions and prevalence rates of stroke in the young were plotted against the average state elevation (feet above sea level) and examined with a generalized linear regression model.

Results:
HCUPNet data were available for 35 of 50 U.S. states. As shown in figure 1, high altitude states had the highest proportion of stroke admissions in young persons < 45 years, which was highest in Colorado (5.6%, altitude 6,800 feet) and lowest in Rhode Island (2.3%, altitude 200 feet). However, contrary to our hypothesis, high altitude states reported the lowest prevalence rate of stroke in the young (Figure 1, p=0.002). The rate of stroke was highest in South Carolina (16.5/100,000 young persons, altitude 43 feet) and lowest in Wyoming (4.6/100,000, altitude 6,700 feet).

Conclusions:
This hypothesis generating data does not appear to support an association between higher stroke prevalence rates in the young in high altitude states. Still, clinicians at higher altitude states should remain vigilant and suspect ischemic stroke in younger persons.
Abstract TP273: DISTINCTION: Automated Detection, Identification, Selection, and Triage using Artificial Intelligence in Large Vessel Occlusions Requiring Critical and Timely InterventION
Authors: Devlin Thomas , Shah Ruchir , Patterson Jennifer , Fleming James , Nichols Jennifer , Knowles Brenda , McClellan Benjamin , Calvert Justin , Hawk Harris , Quarfordt Steven
Published: January 2019

Background:
Accurate and rapid identification of large vessel occlusions (LVOs) in acute ischemic stroke patients is critical for early notification of specialists and access to reperfusion therapy. Recent advances in artificial intelligence have enabled the development of a fully automated convolutional neural network (Viz LVO) to detect LVOs on CT angiography (CTA) imaging and notify specialists. Early specialist notification of LVOs may benefit patients who initially present at non-interventional centers and must be transferred, as well as patients who present directly to interventional centers.

Methods:
A multicenter observational trial compared a prospective cohort of CTA-proven LVO patients (exposed to Viz LVO) to a retrospective cohort of patients (controls). Patients were segmented based on initial presentation at (1) a non-interventional center or (2) an interventional center. Clinical performance was measured through time-based workflow metrics, rates of treatment, and patient outcome endpoints. Further, an economic analysis was performed based on internal financial data.

Results:
Preliminary results of 231 retrospective control patients not exposed to Viz LVO and who initially presented directly to interventional centers between 2016 - 2018 had a mean door-in to groin puncture (DTG) time of 95 minutes. In comparison, 21 prospective patients exposed to Viz LVO and presenting directly to interventional centers showed a mean picture to specialist notification time of 6 minutes, and all had DTG times of less than 95 minutes. Further, the mean contribution margin and net revenue for MS-DRG Codes 023-024 were higher than DRG 061-063 or 064-066 in the prospective patients.

Conclusions:
This initial cohort of patients demonstrated improved DTG times for LVO patients initially arriving at interventional centers. Although these improvements were not statistically significant, we are continuing additional data collection to provide sufficient power for this study. Preliminary economic analysis demonstrates that Viz LVO can improve net revenue for hospitals through increased volume of a positive contribution margin procedure.
Abstract TP274: Comparison of Human and Machine Learning Based Facial Weakness Detection
Authors: McDonald Mark , Uribe Omar A , Zhuang Yan , Lin Iris L , Pitchford Haydon , Darlymple William A , Rohde Gustavo K , Southerland Andrew M
Published: January 2019

Background:
Prehospital stroke screening tools are essential to rapid diagnosis and treatment, but variable recognition of common stroke deficits by EMS providers limits the accuracy and reliability of these tools. An automated screening tool could yield more consistent assessments and reduce operator variability. We hypothesized that a video-based, machine learning algorithm can detect facial weakness with comparable accuracy to EMS providers.

Methods:
Videos with normal smile and facial weakness were collected from open access, online repositories. Two senior neurology residents independently rated videos using a 5-point scale to denote the likely presence or absence of pathological facial weakness. Only videos rated concurrently by both raters were included for training and testing of the algorithm. Facial landmarks were extracted per frame using an open-source face-detector and landmark detector followed by normalization of landmarks and intensity values. Optical-flow based features and facial landmark based configural features were calculated for each video and classified with a logistic regression model. Accuracy was calculated using a 5-fold cross validation scheme. To interpret algorithm performance, we analyzed ratings of three EMS providers against the resident ratings.

Results:
Of 160 videos with concordant ratings, 24 were excluded due to issues with muscle activation or head orientation, resulting in 31, 36, and 69 videos with left, right, and no facial weakness, respectively. Mean accuracy for the algorithm was 84.6% (95% Cl [74.3-94.9]) compared with 89.0% (95% Cl [86.0-92.0]) for EMS providers. More severe facial weakness compromised the performance of the landmark detector, limiting detection to optical flow analysis alone.

Conclusion:
Our study demonstrates that a learning algorithm can detect facial weakness in videos, however, the algorithm was not as accurate as EMS. Videos with more pronounced weakness presented a challenge for the algorithm whereas human examiners can more easily identify weakness in these cases. Future research will include refining the algorithm for severe facial weakness and expanding to detect other stroke deficits such as limb weakness and ataxia.
Abstract TP279: The Multiple-Encounter Telestroke Patient - A Unique Patient Population
Authors: Morton Johanna L , Northington Diamond K , Jolly B. T
Published: January 2019

Background:
Thrombolysis with alteplase is the standard of care for treatment of eligible patients presenting with acute ischemic stroke (AIS). Telestroke physicians must use available information to make timely treatment decisions remotely. Through this practice, an unusual subset of patients presenting multiple times with symptoms of AIS has emerged. This study describes the largest known sample of this multiple-encounter population within a single teleneurology practice spanning 34 states.

Methods:
A retrospective observational study of the experience of a single teleneurology practice serving over 400 hospitals from July 1, 2015 to August 1, 2018 was performed. The alteplase patient database was queried to identify patients with multiple telestroke encounters (n=56). Demographic and clinical data were abstracted.

Results:
Within the queried period, 56 patients were identified to have had multiple encounters with the teleneurology practice, 37 males and 19 females. Of these, 29 were seen twice, 10 were seen three times, 8 were seen four times, and 9 had five or more encounters. Four patients received care in multiple states. Alteplase was administered on more than one encounter in 45 patients, with a maximum alteplase administration of 4 times in a single patient. The overall alteplase rate was 54.6% (106 of 194 encounters). The median NIHSS score for patients seen in multiple encounters was 5. Of the 56 patients, 98.2% had stroke risk factors, 42.9% had noncerebrovascular neurological comorbidities, and 42.9% had psychiatric disease history. All patients presented with at least one motor symptom, while 64.3% presented with a sensory symptom, 26.8% presented with aphasia, and 55.4% presented with other neurological symptoms.

Conclusions:
The observance of multiple teleneurology encounters for patients presenting with AIS symptoms and receiving alteplase at high rates is anecdotal and not yet largely described. History of cerebrovascular disease is a risk factor for recurrent stroke, but the true composition of this patient population is undefined. Given the associated risks and resource utilization involved with alteplase, future study of the characteristics and disease mechanism of this population is warranted.
Abstract TP29: Complete Occlusion is Associated With Lower Recanalization Rate in Patients With Acute Stroke With Tandem Lesion Treated With Thrombectomy
Authors: Anadani Mohammad , Spiotta Alejandro , Piotin Michel , Turjman Francis , Steglich-Arnholm Henrik , Holtmannspötter Markus , Holtmannspötter Markus , Taschner Christian , Eiden Sebastian , Haussen Diogo C , Nogueira Raul G , Papanagiotou Panagiotis , Boutchakova Maria , Siddiqui Adnan , Lapergue Bertrand , Dorn Franziska , Cognard Christophe , Killer Monika , Mangiafico Salvatore , Ribo Marc , Psychogios Marios N , Labeyrie Marc A , Mazighi Mikael , Biondi Alessandra , Richard Sébastien , Anxionnat René , Bracard Serge , Gory Benjamin ,   on behalf of TITAN (Thrombectomy In TANdem Lesions) investigators
Published: January 2019

Introduction:
Previous studies showed that mechanical thrombectomy (MT) is safe and effective in tandem steno-occlusive lesion. The effect on initial tandem extracranial internal carotid artery (ICA) lesion severity on outcome is unknown. In this study, we aimed to compare angiographic, functional and hemorrhagic outcomes according to initial lesion severity

Methods:
A multicenter international retrospective study that included 18 stroke centers. Patients were included if they presented with ischemic stroke due to tandem lesion and were treated with MT with or without carotid stenting. Tandem lesion was defined as proximal intracranial occlusion (distal ICA, M1/M2) and extracranial internal carotid artery (ICA) occlusion or ≥90% stenosis NASCET. We divided patients into two groups based on extracranial ICA lesion severity (severe stenosis vs. complete occlusion) at the first angiographic run. Outcome measures included 90 day mRS, final mTICI score, procedural complications and symptomatic hemorrhage. Symptomatic hemorrhage (Sich) was defined based on ECASS criteria.

Results:
A total of 305 patients were included in the present analysis. 134 patients had complete ICA occlusion (group 1) ,and 170 had ≥90% ICA stenosis (group 2). Hyperlipidemia was more frequent in group 1 ((46.5% vs. 33.6%, p=0.032), and diabetes was less frequent (12.4 vs. 23.8%;p=0.011). Otherwise there was no significant difference in baseline characteristics, pretreatment tPA , and ASPECTS between two groups. With respect to outcome, successful recanalization (TICI 2b-3) was lower in group 1 than group 2 (70% vs. 80%; p=0.038). Similarly TICI 3 was achieved in less patients in group 1 (24% vs. 40%;p=0.022). Favorable outcome (mRS 0-2), sICH and procedural complications were similar in both groups.

Conclusion:
Initial angiographic severity of extracranial ICA lesion in tandem occlusions was associated with lower recanalization rates after MT, without impact on clinical outcomes.
Abstract TP292: Impact of Structured Feedback on Emergency Department Physician Culture to Reduce Door-to-Telestroke Activation Times
Authors: Anderson Anne M , Martinez Julie , Malmberg Elisabeth , Hoesch Robert
Published: January 2019

Introduction:
Emergency Department (ED) Physicians typically consult with a specialist
after
pertinent results are gathered. In the case of acute stroke, delays in neurologist consultation equate to valuable time lost for treatment. When Telestroke went live in June 2015 at our 148-bed regional medical center, the physician norm was challenged because Telestroke protocol stipulates activation of the system
before
the CT scan. Despite education about the importance of calling early, ED physicians continued to activate Telestroke
after
gathering results.

Hypothesis:
Implementation of timely, structured feedback to ED physicians will change ED physician culture to reduce Door-to-Telestroke Activation (DTA) times.

Methods:
In February 2017, monthly feedback was initiated with ED physicians. Graphs showing current performance related to activation times were discussed, goals were reviewed, small improvements were acknowledged, and physicians were encouraged to share their successes. Using a prospective observational study design and a REDCap database, data from June 2015 to February 2017 were compared to data from March 2017 to July 2018.

Results:
From June 10, 2015 to July 18, 2018 Telestroke was activated 246 times in the ED. After the feedback initiation, the median DTA of 20 m (n=145) was significantly lower than the baseline median of 32 m (n=101, p<0.0001) and the percentage of activations prior to the CT scan rose significantly from 20% to 46% (p=0.0003). Also, Door-to-Needle (DTN) time decreased to a median of 48 m (n=27), compared to the baseline of 56 m (n=19, p=0.15) and the percentage of ischemic stroke patients treated with IV Alteplase increased to 17.7% from 13.4%. Median Door-to-CT (DTCT) remained unchanged at 17 m both pre and post intervention, demonstrating consistent ED processes.

Conclusions:
Timely ED physician feedback led to faster Door-to-Telestroke Activation times. While statistically insignificant, post intervention DTN times rose from a baseline of 63% (n=19) to 81% (n=27, p=0.29) which met the primary Target: Stroke Phase II goal to treat 75% of patients within 60 minutes. Faster activation resulted in faster treatment and ultimately improved chances of a better outcome.
Abstract TP299: Longing for Monday Morning? -Time Period From Admission Until Working Hours and Stroke Prognosis in K-PLUS Registry
Authors: Nakajima Makoto , Ito Yasuyuki , Kouzaki Yanosuke , Wada Kuniyasu , Inatomi Yuichiro , Yonehara Toshiro , Terasaki Tadashi , Hashimoto Yoichiro , Ando Yukio
Published: January 2019

Background:
When considering weekend effect or off-hour effect, time period from admission to regular hospital working hours might affect stroke prognosis more strongly than the timing of admission. We investigated whether admission time until working hours affects clinical prognosis using a regional multicenter stroke registry.

Methods:
We recruited data from the stroke registry ‘K-PLUS,’ between 2013 and 2017. Acute stroke patients admitted within 24 hours from the last time to be well were included. Patients with premorbid modified Rankin Scale (mRS) score of 3 or more were excluded. Working hours were defined as 9:00-17:00 on weekdays. Patients were divided into those admitted during working hours (WH group) and two other groups according to the time from admission to working hours: within 24 hours (short-wait group), over 24 hours (long-wait group). In-hospital complications and the mRS score at discharge were compared among the groups.

Results:
Out of 4,729 participants, 2,912 (62%) were admitted outside working hours. Although in-hospital pneumonia after stroke occurred more frequently in the long-wait group (10%) than in the other groups (7%), mortality was not different among the 3 groups. The proportion of patients with mRS score 0-1 at discharge showed a decreasing trend with the time period before working hours: 37% in the WH group, 34% in the short-wait group, and 31% in the long-wait group (p< 0.001). When the WH group was used as a reference, the odds ratio for mRS score 0-1 was 0.86 (95% confidence interval, 0.73-0.93) in the short-wait group and 0.78 (0.65-0.93) in the long-wait group, respectively, after adjusting for other factors including age, stroke severity, and thrombolytic therapy.

Conclusion:
Our regional multicenter stroke registry demonstrated the evidence that acute stroke patients admitted before 24 hours or more until the regular hospital working hours have poor prognosis.
Abstract TP307: Clinical and Neuroimaging Criteria to Improve Transfers to Comprehensive Stroke Centers for Endovascular Reperfusion Treatment Evaluation
Authors: Rubiera Marta , Requena Manuel , Boned Sandra , Perez de la Ossa Natalia , Quesada Helena , Urra Xabier , Cardona Pere , Chamorro Angel , Davalos Antoni , Molina Carlos A , Abilleira Sonia , Ribo Marc ,   Catalan Stroke Code and Reperfusion Consortium
Published: January 2019

Transfer protocols from primary (PSC) to comprehensive stroke centers (CSC) are crucial for the success of endovascular treatment (EVT). We aimed to identify clinical and neuroimaging predictors of EVT outcome in patients first assessed at non-capable EVT centers.

Methods:
Retrospective analysis of consecutive patients included in a prospective, population-based, mandatory registry of acute ischemic strokes (AIS). Inclusion criteria: AIS firstly evaluated at a PSC with suspected large vessel occlusion (LVO) transferred to a CSC for EVT assessment. PSC and CSC-ASPECTS, time-metrics and clinical data were analyzed.

Results:
Between February 2016 and May 2018, 1185 EVT candidates were transferred from PSC to CSC in our stroke code network (see Graph). Median baseline NIHSS was 13(7-19). 53.4% received iv tPA in the PSC. Upon CSC arrival, LVO was confirmed in 63.1% patients, and 42.8% received EVT. After a median of 130(107-169)min between both CT-acquisitions, the median inter-facilities ASPECTS decay was 1(0-2) and only 11.9% showed a CSC-ASPECTS<6. A ROC curve identified baseline NIHSS>16 as the best cut-off point that predicted CSC-ASPECTS<6(Sensitivity 67%, specificity 75%, AUC 0.7). A logistic regression analysis adjusted by age, time from symptoms to PSC-CT and time from PSC-CT to CSC-CT showed that only a baseline NIHSS>16 independently predicted a CSC-ASPECTS<6(OR 3.8, CI 2.1-6.9, p<0.001). The rate of CSC-ASPECTS<6 increased to 21% among AIS with NIHSS>16, and to 38.1% in patients with NIHSS>16 and PSC-ASPECS≤7.

Conclusion:
ASPECTS<6 scores are uncommon in CSC even after long transfer times. Except for selected cases (NIHSS>16 or PSC-ASPECTS≤7), confirming ASPECTS upon CSC arrival may not be necessary among AIS transferred from PSC.
Abstract TP309: Increase in Video Evaluations but Not Complications Over Time in a Large Stroke Network
Authors: Bhatt Archit , Baraban Elizabeth , Corless Leslie , Lucas Lindsay
Published: January 2019

Introduction:
Telestroke technology allows evaluation of stroke patients remotely. We sought to determine if there was any change in the standard of care and evaluation of stroke patients over time and whether there were differences in complication rates between those who were evaluated using telestroke technology and those who were not.

Methods:
Data from April 2010 to May 2018 from a large stroke network were used. Acute ischemic stroke patients who presented to the emergency departments (ED) with last-known-well-to-door less than 4.5 hours and were treated with IV-alteplase were included. The number of facilities ranged from 7 in 2010 to 18 in 2017. Primary outcomes included the number and percentage of cases that were treated using telepresence (Beam-In) versus conventional care (no Beam-In) over time, as well as their discharge status and complications. Chi-squared or Linear By Linear Association were used to compare categorical variables and Mann-Whitney U Tests were used to compare continuous variables.

Results:
A total of 1,150 patients were treated from 2010 to 2018, 75.8 % (n=872) via Beam-In. The number of Beam-Ins increased overtime and there was a significant increased trend in the percentage of treated Beam-Ins (p<.001) (graph). There were fewer patients discharged home (38.0% vs 50.4%, p<.001), more transferred to acute care facilities (37.6% vs 13.8%, p<.001) and fewer hospice or deaths (5.9% vs 12.9%, p<.001) for those treated via Beam-In. There was no significant difference in number of symptomatic intracranial hemorrhage, life threatening systemic hemorrhage or other serious complications.

Conclusion:
Stroke care has evolved from traditional bedside care to more video evaluations in patients who received alteplase without increase in complications.
Abstract TP310: Barriers Experienced by Emergency Medical Service Providers When Responding, Assessing, and Transporting Stroke Patients in a Rural State: Findings from Mission: Lifeline North Dakota
Authors: Barnes Olivia N , Pietrzak Janna , Cook Mindy , Thorson Shila , Hyder S S , Shay Christina M
Published: January 2019

Introduction:
In predominantly rural states, effective and efficient response of Emergency Medical Services (EMS) to stroke cases is often delayed by geographically large, sparsely populated service areas and limited access to healthcare professionals and services. North Dakota is a rural state with 36 of 53 counties designated as Frontier (less than six persons per square mile) and a total population estimated at 755,393.

Purpose:
To identify barriers experienced by EMS professionals in North Dakota when responding to, assessing, providing care, and transporting potential stroke patients.

Methods:
EMS providers were recruited to participate in in-person focus groups. Four focus groups were performed (n=24) using a semi-structured interview guide. Sessions were digitally recorded and field notes with abridged transcripts were analyzed for recurrent themes using content analysis.

Results:
Participants were 37.5% male, 91.7% non-Hispanic White and included unpaid EMS volunteers (29.0%). Several common themes were identified, including: 1) importance of public awareness for timely recognition of stroke symptoms and the importance of calling 9-1-1 at early onset of symptoms; 2) frequent receipt of inaccurate/insufficient information from Dispatch; 3) difficulties notifying accepting hospitals due to loss of cell service in rural areas; 4) perceptions that accepting hospital staff due not trust EMS clinical assessments; 5) technical barriers and time restraints experienced when providing written and verbal patient reports to hospitals; and 6) lack of formal feedback from hospitals to EMS agencies regarding stroke patients transported by EMS agencies.

Conclusions:
EMS providers in North Dakota experience several challenges inhibiting their ability to provide timely pre-hospital care to stroke patients. Although several barriers were identified, most are modifiable and can be remedied with enhanced education and training focused on improving effectiveness and efficiency of EMS communications with dispatch and hospitals.
Abstract TP316: Histone Deacetylase 3 as a Novel Therapeutic Target for Ischemic Stroke
Authors: Shehadah Amjad , Matheson Rudy , Chida Kohei , Selim Magdy , Lo Eng
Published: January 2019

Introduction:
Histone deacetylase 3 (HDAC3) has been implicated as neurotoxic in several neurodegenerative conditions. However, the role of HDAC3 in ischemic stroke has not been thoroughly explored. We tested the hypothesis that selective inhibition of HDAC3 after stroke affords neuroprotection.

Methods:
To investigate the effects of ischemia on HDAC3 expression, adult male Wistar rats (n=6/group) were subjected to middle cerebral artery occlusion (MCAO) and sacrificed 24 h later. Double immunohistochemistry was performed with antibodies against HDAC3 and NeuN (a neuronal marker). To investigate whether selective HDAC3 inhibition affords neuroprotection after stroke, another set of rats (n=7/group) was subjected to 2-h MCAO, and randomly selected animals were treated with either vehicle (1% Tween 80) or a selective HDAC3 inhibitor (RGFP966, 10 mg/kg) at 2 and 24 h after MCAO. Behavioral tests were performed at 3 h, 1 d, and 3 d after MCAO. Rats were sacrificed 3 d after MCAO. Infarct volumes were measured with H&E. Immunostaining for Akt, TNF-alpha, toll-like receptor 4 (TLR4), cleaved poly (ADP-ribose) polymerase (PARP), and TUNEL assays were performed by blinded investigators.

Results:
The numbers of HDAC3+ cells and HDAC3+/NeuN+ neurons were increased in the peri-infarct cortex compared to the contralateral cortex (p<0.05). Total and neuronal HDAC3 expressions were positively and significantly correlated with infarct volumes (r=0.8, p<0.001; r=0.6, p=0.03; respectively). Selective HDAC3 inhibition improved functional outcome (p=0.01) and reduced infarct volume (p<0.001). RGFP966 treatment reduced apoptosis—as measured by the numbers of TUNEL+ and cleaved PARP+ cells—in the ischemic brain (p<0.05). Selective HDAC3 inhibition reduced total and neuronal TNF-alpha and TLR4 in the ischemic border compared to vehicle control (p<0.05). RGFP966 treatment also increased Akt expression in the ipsilateral cortex (p=0.007).

Conclusions:
HDAC3 is upregulated after stroke and correlates with infarct volumes. Selective HDAC3 inhibition after stroke improves functional outcome and decreases infarct volume. The neuroprotective effects of HDAC3 inhibition are associated with a reduction in apoptosis and attenuation of inflammation.
Abstract TP324: Carbon Monoxide Improves Behavioral and Anatomical Outcomes After Brain Trauma in Middle-Aged Female Mice
Authors: Khalaf Saher , Golovachev Nikita , Dadamyan Artem , Dore Sylvain
Published: January 2019

Introduction:
Traumatic brain injury (TBI) is a major cause of mortality and long-lasting disabilities. After TBI, secondary brain injury processes trigger.

Hypothesis:
Carbon monoxide (CO), when given in low concentrations, is postulated to alleviate secondary injury and promote cell survival. This effect is expected to be mediated through the Nrf2 pathway.

Methods:
In this study, four groups of female mice at the age of 12±2 months old were subjected to controlled-cortical injury (CCI) trauma model (n=13/group). CO or air control were delivered through inhalation to wildtype (WT) and Nrf2
-/-
cohorts, for a duration of one hour, and at a rate of 250 ppm. Behavioral assessments through the open field, rotarod, and neurological deficit score tests were performed every day until a 7d endpoint.

Results:
WT/CO-treated mice show the best behavioral outcomes compared with WT/Air and both Nrf2
-/-
mice groups (p<0.05). However, Nrf2
-/-
/CO-treated mice have better behavioral outcomes compared with Nrf2
-/-
/Air mice group (p<0.05). Nrf2
-/-
/Air mice group shows not only the most significantly detrimental behavioral outcome (p<0.05) but also, significantly, the largest cortical injury volume compared with Nrf2
-/-
/CO-treated mice and both WT mice groups (p<0.05). The cortical injury volume was not significantly different between both WT groups and Nrf2
-/-
/CO-treated mice. Additional investigations of gliosis, edema and oxidative stress after CO administration are in process.

Conclusion:
Brain tissue that lacks Nrf2 protein and CO gas showed the worst behavioral and cortical injury outcomes. When CO is provided to Nrf2
-/-
or WT mice, better outcomes appeared. Even more, WT mice which treated with CO have the most improved outcomes. This influence could partially be mediated through the Nrf2 pathway. Taken together, these findings suggest that CO treatment may be considered as part of therapy for TBI and will open the door for further investigation. [This work was supported in part by grants from the McKnight Brain Research Foundation, Brain and Spinal Cord Injury Research Trust Fund, and AHA33450010, and NIH R21NS095166 (SD).]
Abstract TP33: Diminished Likelihood of Favorable Stroke Outcomes Following Endovascular Therapy in Octogenarians
Authors: Prakapenia Alexandra , Barlinn Jessica , Siepmann Timo , Moustafa Haidar , Pallesen Lars-Peder , Haedrich Kevin , Abramyuk Andrij , Gerber Johannes , Puetz Volker , Linn Jennifer , Barlinn Kristian
Published: January 2019

Introduction:
While data from randomized controlled trials suggest an overall benefit of endovascular therapy (EVT) in older patients suffering from anterior circulation large vessel occlusion (acLVO), real world evidence is lacking. We aimed to explore the likelihood of achieving favorable stroke outcomes in octogenarians undergoing EVT for acLVO.

Methods:
We prospectively studied consecutive ischemic stroke patients aged 80 years or older who were considered for EVT due to acLVO at our tertiary stroke center (01/2016-06/2018). We compared clinical characteristics and efficacy outcomes including 90-days functional independence (i.e., mRS scores 0-2) and 90-days survival among patients who underwent EVT and those who did not undergo EVT. A multivariable regression model was built to identify predictors of favorable outcomes.

Results:
In total, 185 patients aged 80 years or older were prospectively screened for EVT eligibility during the 30-months study period: median age was 84 years (interquartile range, 82-88); 30% were men; median NIHSS score was 18 (interquartile range, 14-21) points. Of these patients, 97 (52.4%) were eventually treated for proximal acLVO. The main reasons to withhold EVT were large infarct size (54.6%) and recanalization (30.7%), followed by unknown time window (5.7%), lack of perfusion mismatch or collaterals (4.5%) and early clinical improvement (2.3%). No differences according to vascular risk factors, baseline imaging and clinical variables were evident among both groups. There was a non-significant trend toward survival (50.6% versus 37.3%, p=0.09) but not functional independence (9.9% versus 5.3%, p=0.39) at 90 days in patients who underwent EVT compared with the non-EVT group. In the multivariable model, favorable outcomes were not predicted by pre-stroke disability, stroke severity, infarct size or treatment with intravenous tPA.

Conclusions:
While age alone should not exclude patients from endovascular therapy, diminished likelihood of favorable outcomes may challenge postacute stroke care in octogenarians.
Abstract TP343: Achieving Stroke Honor Role Elite Plus by Implementing a 24/7 Neuro-Hospitalist Program
Authors: Vivar Carolina , Hudson Satabdi , Cummings Christopher , Noto Anthony , Beckett Lisa , Baldwin Kelly
Published: January 2019

Patients with acute ischemic stroke benefit most from intravenous tissue plasminogen activator (tPA) when given as fast as possible. The American Heart Association/American Stroke Association’s (AHA/ASA) highest target is the Stroke Honor Role Elite Plus. This is designed for programs that give IV tPA within 60 minutes in 75% of patients and within 45 minutes in 50% of patients. The current literature however is not clear on the benefit of a comprehensive 24/7 neurohospitalist model on the treatment times of acute ischemic stroke patients with IV tPA. The purpose of our study was to determine the impact of a 24/7 in-house neurohospitalist model on door-to-needle times (DTN) for patients with acute ischemic stroke presenting to the emergency department within 4.5 hours. There were 76 patients treated from 2016-2017 and 83 patients treated from 2017-2018, DTN times were compared before and after implementation of the neurohospitalist program in July 2017. The DTN in 2016-2017 (mean = 53.32 minutes, SD = 29, n =76) was greater than the DTN in 2017-2018 (mean = 44 minutes, SD = 20, n = 83). This difference was statistically significant with p = 0.010 (1 tail). In addition, the improvement in DTN allowed recognition of Stroke Honor Role Elite Plus by the AHA/ASA.

Conclusion:
Implementation of a 24/7 in-house neurohospitalist program is associated with faster DNT for IV tPA and ability to achieve target AHA/ASA’s Stroke Honor Role Elite Plus.
Abstract TP344: Adding Depression Screening at 90-Days Post-Stroke Increases the Number of Positive Screens
Authors: Sinogui Cynthia , Jennings Amber , Zrelak Patricia , Gregory Jeanette , Marion Tara , Melville Judy , Mitchell Hillary , Keear Leslie , Moiseyenko Anna , DelaCruz Lloyd , Baumert Dalene , Girado Carolyn , Hartman Jonathan
Published: January 2019

Background:
Comprehensive Stroke Centers are required by The Joint Commission to screen stroke patients with stroke for depression prior to discharge. Stroke related depression, however, may occur weeks or months after the acute event. Adding a 90-day screen may help identify additional patients with depression after discharge from the acute hospital setting.

Purpose:
To evaluate the impact of having a registered nurse (RN) perform 90-day post-discharge depression screening by telephone for patients with recent stroke.

Methods:
A team of RNs were trained on the Patient Health Questionnaires (PHQ2 and PHQ9). Both tools have been validated for telephone use. All ischemic and hemorrhagic stroke patients discharged home were included. Patients were called 90 days +/- 15 days post-discharge. Patients scoring positive on the PHQ2 (a score of > or equal to 3) were further evaluated by the RN using the PHQ9. Nurses referred patients scoring > or equal to 9 on the PHQ9 to the Stroke Medical Director for further evaluation. See graphic below.

Results:
Between August 2017 and July 2018, 297 patients were screened (56% of total stroke discharges, 297/527), of whom 8.8% (26/297) scored > or equal to 3 on the PHQ2. Of these, 73% had a PHQ9 score > or equal to 9 (19/26). All patients with a positive PHQ9 screen (19/19) were referred to the Stroke Medical Director and received appropriate triage and referral for ongoing care. This yielded a 6.4% rate (19/297) of stroke patients with symptoms of depression 90-days post-discharge. While some patients had a history of depression, most had no history or risk factors for depression.

Conclusion:
Conducting RN-facilitated 90-day post-hospital discharge telephone depression screening in patients with recent stroke appears to be an effective method to identify additional patients with stroke related depression who would not have been identified otherwise.