bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP373: Saving Time for Initial Management of Stroke by Reorganization of In-Hospital Stroke Code Protocol
Authors: Kawano Hiroyuki , Ebisawa Shiori , Ayano Mizuki , Nakanishi Kaoru , Yamashita Hitomi , Honda Yuko , Amano Tatsuo , Unno Yoshiko , Komatsu Yuka , Ogawa Yuriko , Shiokawa Yoshiaki , Hirano Teruyuki
Published: June 2021

Introduction:
Stroke is a relatively common in hospitalized patients. However, previous studies have shown delays in recognition and initial assessment of in-hospital stroke. We aimed to elucidate that reorganization of in-hospital stroke code protocol can improve process of acute stroke care and save the treatment time.

Methods:
Our reorganization of in-hospital stroke code comprises the development of in-hospital stroke code protocol and workshop for hospital medical staff. Before the intervention, if the medical staff identified patients with suspected stroke, they first contacted the attending physician, then the physician consulted the stroke neurologists immediately or after imaging. After the intervention, to quickly identify stroke patients, the medical staff can directly consult stroke neurologists when they identified patients with at least one of acute-onset symptoms, including face droop, arm drift, speech disturbance, eye deviation, aphasia, or neglect, within 6-hour from last seen well or stroke recognition. As an educational intervention, we held workshop for nurses and residents with an understanding of how to evaluate stroke symptoms, use the protocol, and manage stroke. Data were compared between 24-month period before and 12-month period after the intervention. Outcome measure included the time from stroke recognition to initial imaging, and evaluation by stroke neurologist, and from initial imaging to groin puncture.

Results:
One hundred four patients were included (before, 42; after, 62). Significant time savings were seen in the median time from stroke recognition to evaluation by stroke neurologist (91 vs. 56 minutes, p=0.015), and time from initial imaging to groin puncture (113 vs. 68, p=0.040). The rate of consultation to stroke neurologists before initial imaging was significantly increased (21% vs. 47%, p=0.012). The time from stroke recognition (234 vs. 103, p=0.126), and evaluation by stroke neurologist (135 vs. 81, p=0.056) to groin puncture tended to decrease.

Conclusion:
Reorganization of in-hospital stroke code protocol can improve the time for initial management of in-hospital stroke.
Abstract WP382: Cardiac Troponin Assessment in Acute Ischemic Stroke Patients Presenting Within 4.5 Hours From Last Known Well
Authors: Sun Yuyao , Miller Malgorzata M , Henninger Nils
Published: June 2021

Introduction:
American Heart Association guidelines recommend obtaining baseline troponin in all acute ischemic stroke (AIS) patients to detect an acute coronary syndrome (ACS). Yet, data regarding the prevalence and diagnostic yield of troponin elevation in patients presenting within the time window for thrombolysis is limited. We sought to determine the diagnostic yield of cTnI in detecting ACS when assessed before or after 4.5h from last known well (LKW).

Methods:
We retrospectively analyzed 526 consecutive patients admitted for AIS or transient ischemic attack, who presented within 4.5h and had cardiac troponin I (cTnI) obtained within 48h from LKW.

Results:
The median time from LKW to cTnI measurement was 3.8h (IQR 1.5h-7.9h). 58% patients (n=306) had cTnI obtained ≤ 4.5h from LKW. After adjustment, factors independently relating to an elevated cTnI were the time to cTnI assessment (p<0.001), patient age (p=0.012), history of congestive heart failure (p<0.001), and a history of stroke/TIA (p=0.049). Patients who had a cTnI obtained within 4.5 hours from LKW, had significantly more often a normal (≤0.04 ng/mL) than elevated (>0.04 ng/mL) cTnI levels (61.9% vs. 44.7%; p=0.001). The sensitivity, specificity, and overall accuracy of an elevated cTnI assessed within 48h from LKW for ACS was 63.6%, 80.2%, and 79.5%, respectively. After stratification by the time to cTnI assessment within 4.5 h versus beyond 4.5h, the sensitivity of an elevated cTnI for ACS was markedly reduced to 42.9% whereas the specificity remained high at 84%. The optimal threshold to assess cTnI for detecting an ACS was 320 min in all included patients (sensitivity = 0.54, specificity = 0.67, Youden’s J = 0.203) and 340 minutes in patients with ACS (sensitivity 0.79, specificity 0.88, Youden’s J 0.661).

Conclusions:
Among patients presenting within the time window for rtPA treatment, the sensitivity of cTnI obtained within 4.5 hours from LKW to detect ACS is low. Our data suggests that cTnI routine assessment of cTnI in AIS subjects without cardiac symptoms should not be done within the first 6 hours from LKW.
Abstract WP384: Improving the Alert/Care Process for Inpatients Who Suddenly Develop Stroke Symptoms
Authors: Fuhrman Susan , Lazzaro Marc , Cotton Jolene
Published: June 2021

Introduction:
The Inpatient (IP) FAST Stroke process was confusing to many and key people were missing in the current flow process. Pre-project, different processes were used to activate the emergency response for various conditions. Work done on improving stroke patient arrival in the Emergency Department to assessment/intervention (Door-to-needle (DTN) has successfully improved outcomes and efficiency to allow for Alteplase intervention to occur an average of 30 minutes or less on eligible patients for the past 2 years. Confusion and inefficiencies in the current Inpatient FAST Stroke Process has led to patient safety concerns.

Objective of Project:
To revise the inpatient Stroke FAST process by utilizing key aspects of the DTN flow to assure key personnel are present and expectations are clear.

Methods:
Interprofessional team with key area represented was chartered. Component of the Six Sigma Quality strategies were utilized for this project. Baseline information and feedback was gathered so consensus on current process could be reached. A root cause analysis with a fishbone diagram technique was used to identify gaps in the current process and revision priorities. The priorities identified included: Clarification of the IP Stroke activation process; revision to the IP FAST Stroke Team composition to expedite care delivery; and clarification of process mechanics, roles, and scopes.

Results/Conclusions:
Clarified IP activation process so our Rapid Response Team (RRT) will be initial response for ANY sudden change in condition. (Like EMS in field); then after their assessment, RRT will activate the Stroke FAST team as needed. The composition of the Stroke FAST team revised to expedite care delivery. (i.e. includes Neuro resident, NICU charge/designee, FAST Stroke Pharmacist, Transporter, etc.). To further improve efficiency mechanics (i.e. order process, CT location to use, etc.), roles, and care expectations were delineated as is found in this flow process.
Abstract WP386: Predictors of Length of Hospitalization in Patients Admitted With Intracerebral Hemorrhage in the United States
Authors: Chaudhry Saqib A , Chaudhry Mohammad Rauf A , Akhtar Iqra N , Qureshi Adnan I , Zafar Werdah
Published: June 2021

Background:
We performed this study to determine the predictors of length of hospitalization in patients admitted with intracerebral hemorrhage using nationally representative data.

Methods:
We used the National Inpatient Sample (NIS) from 2010 to 2015 to assess the factors associated with length of stay in patients admitted with intracerebral hemorrhage using (ICD-9 CM diagnosis-related code 431). Patients who were transferred from another acute hospital or died within 2 days of admission were excluded. All variables pertaining to hospitalization were compared in 4 quartile groups on basis of length of hospital stay distribution (≤3, 4-6, 7-10 and ≥11 days) and median length of stay was calculated. The predictors of hospital stay exceeding the median length of stay were identified using multivariate logistic regression.

Results:
A total of 296,792patients were admitted with the diagnosis of intracerebral hemorrhage during the study period. The length of hospitalization was (≤3, 4-6, 7-10 and ≥11 days in 79,008 (26.5%), 89,019 (30.0%), 55,555 (18.7%) and 73,211 (24.6%) patients, respectively; median length of stay for the cohort was 6 days. In the multivariate logistic regression analysis, the following clinical factors were associated with length of hospitalization of ≥6 days (median): male (odds ratio [OR] 1.10), hypertension (OR 1.41 ), APRDRG severity (OR 2.87), history of alcohol use (OR 1.27 ), and in-hospital complications such as sepsis (OR 2.73), pneumonia (OR 2.30), urine tract infection (OR 2.34), pulmonary embolism (OR 1.42), and deep vein thrombosis (OR 5.06). Similarly in-hospital procedures such as craniotomy (OR 3.40), and transfusion (OR 2.09), were associated with length of hospitalization of ≥6 days. The excess hospitalization charges associated with length of hospitalization of ≥6 days was $107,915.

Conclusion:
Prolonged hospitalization is associated with significantly higher cost of hospitalization. The most important determinants being pre-existing medical comorbidities and potentially preventable in-hospital complications.
Abstract WP390: Regional Differences in Blood Pressure Management After Acute Stroke in International Randomized Controlled Trials
Authors: Song Lili , Sun Lingli , Wang Xia , Moullaali Tom J , Robinson Thompson G , Chalmers John , Anderson Craig S
Published: June 2021

Background and Aims:
Epidemiological studies show significant variations in hypertension management within and between countries. The level of regional variation in early blood pressure (BP) management after acute stroke is uncertain.

Methods:
Data are from the Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED), a partial-factorial, international randomized controlled trial (RCT) of thrombolysis-eligible acute ischemic stroke (AIS) patients with systolic BP (SBP >150 mmHg) assigned to intensive (target SBP 130-140 mmHg) vs. guideline-recommended (SBP <180 mmHg) treatment; and INTERACT2, an international RCT of patients with spontaneous intracerebral hemorrhage (ICH) (<6 hours) with elevated SBP randomized to intensive (target SBP <140 mmHg) or guideline-recommended (SBP <180 mmHg) treatment. BP management was compared between five participating regions of these RCTs: west (Europe/Australia/US), China, other Asia (South Korea, Singapore, Thailand, Vietnam), India (India and Pakistan), and South America (Argentina, Chile, Brazil, Colombia).

Results:
There were 2196 AIS (38% women, mean age 67[12] years) and 2829 acute ICH (37% women, mean age 63[13] years) patients in these analyzes. Commonly used intravenous BP lowering agents are labetalol, nitroglycerin, and topical Nitrates in western countries; mannitol, urapidil, and sodium nitroprusside in China; nicardipine in other Asian countries; and sodium nitroprusside and labetalol in South America. Western patients were more likely to receive BP lowering treatment in the first 24 hours and treated with multiple agents, and had larger magnitude of SBP reduction and greater SBP variability. BP control parameters over 2-7 days were comparable between regions.

Conclusion:
Regional variations in early BP management in acute stroke translated into differences in magnitude of SBP reduction and SBP variability in patients.
Abstract WP391: Management of Ischemic Stroke Following Left Ventricular Assist Device: A Retrospective Case Series
Authors: Rettenmaier Leigh , Limaye Kaustubh , Leira Enrique , Adams Harold , Shaban Amir
Published: June 2021

Introduction:
Acute ischemic stroke (AIS) is a common complication and an important source of morbidity and mortality in patients with left ventricular assist devices (LVAD). There are currently no universal protocols to guide management of AIS among patients with LVAD. Management of anticoagulation is challenging, requiring clinicians to balance risk of hemorrhagic transformation vs development of LVAD thrombosis. We sought to evaluate treatment strategies among patients who had an AIS following use of a LVAD.

Methods:
We retrospectively reviewed all patients who underwent LVAD placement at our institution from 2010-2019. We identified patients who had AIS and extracted clinical data.

Results:
Of 238 patients having LVAD placement, we identified 19 (7.9%) with AIS (median age 59 years; median NIHSS score 9). Mean interval to AIS following LVAD placement was 405 days (8 days-5.7 years). At initial presentation, 16/19 (84.2%) patients were taking both antiplatelet and anticoagulation therapy, 1/19 (5.3%) was receiving only anticoagulants, 1/19 (5.3%) was taking aspirin and dipyridamole, and 1/19 (5.3%) was not taking antithrombic agents. Mean INR was 2.1 (1.0-3.2). INR was subtherapeutic (INR<2.0) in 8/19 (42.1%). No patient was eligible to receive thrombolytic therapy (therapeutic anticoagulation in 12 patients, delayed presentation in 4, major surgery in 2, and intracerebral hemorrhage in 1), while 5/19 (26.3%) underwent mechanical thrombectomy. Anticoagulation was continued in the acute stroke phase in 11/19 (57.9%); however, anticoagulation was temporarily held in 8/19 (42.1%). Hemorrhagic transformation occurred in 6/19 (32.6%) with median time of 6 days (0-18 days) from onset of AIS. Mean INR at the time of hemorrhagic transformation was 2.6 (1.0-6.0). There was no interruption in anticoagulation in 4/6 (66.7%) patients with hemorrhagic transformation. Median discharge NIHSS was 2 (0-42) and median modified Rankin Scale was 3 (0-6).

Conclusions:
Thrombolytic therapy is not used in management of AIS in patients with LVAD. Endovascular interventions remain a valid option. Anticoagulation is frequently continued through the acute phase of AIS secondary to concerns for LVAD thrombosis. Hemorrhagic transformation is a common complication.
Abstract WP394: Compliance With Statin Therapy and Risk of Recurrent Adverse Events in Intracerebral Hemorrhage: Analysis of the ATACH II Trial
Authors: Krishnaiah Balaji , Saeed Omar , Alexandrov Andrei , Malkoff Marc , Singh Savdeep , Ishfaq Muhammad F , Shahripour Reza B , Qureshi Adnan I
Published: June 2021

Background:
Hypercholesterolemia is associated with increased risk of ischemic strokes. Statin therapy has been shown to reduce risk of cardiovascular mortality including ischemic strokes. Despite these benefits there still exists a debatable effect of statin use in outcome of patients with intracerebral hemorrhage.

Methods:
Retrospective analysis was performed using data from the Antihypertensive treatment of acute cerebral hemorrhage II (ATACH-2) trial to determine effect of baseline compliant statin use on occurrence of adverse events, mortality and death and disability at 90 days. We compared demographic, clinical characteristics and outcomes of subjects dichotomized into those on statin therapy at baseline versus those who were not. We performed a multivariate analysis using binary logistic regression model after adjusting for all potential confounders for binary variables as well as linear regression model for continuous variables.

Results:
Of the total 1000 participants in the ATACH-2 trial total of 931 responded and were included. Of the 931 there were 271 (29.1%) who were complaint with baseline statin use, with mean age 61.6 SD± 13.0 and 60.9% were males. Those were complaint with statin use had significantly higher rates of previous stroke (13.9% vs 19.7%), coronary artery disease (2.3% vs 7.7%), hyperlipidemia (15.7% vs 42.0%), and type 2 diabetes mellitus (14.2% vs 25.2%). In the multivariate analysis after adjusting for age, race, hypertension, and smoking those who were compliant with baseline statin use had significant lower odds of recurrent hemorrhagic adverse events (OR 0.4, 95% CI 0.21- 0.89; p-value .023) and lower odds of requiring surgical evacuation (OR 0.3, 95% CI 0.12 - 0.91; p-value .032). In a linear regression model those who were compliant with statin use had lower 24hr NIHSS score (
β
-1.2, S.E 0.5; p-value .031) and higher baseline GCS score (
β
0.3, S.E 0.1; p-value .02). There was no difference in favorable outcome mRS 0-2 or death in the multivariate analysis.

Conclusion:
Patient who are compliant with statin use seem to have higher GCS score at baseline and improved NIHSS scores at 24hrs. They were at lower odds of having recurrent hemorrhagic bleeds after discharge and required less surgical evacuations.
Abstract WP399: Delayed Response to Intensive Blood Pressure Lowering and Poor Clinical Outcomes in Acute Intracerebral Hemorrhage
Authors: Tanaka Kanta , Koga Masatoshi , Qureshi Adnan I , Yamamoto Haruko , Toyoda Kazunori
Published: June 2021

Background and purpose:
We aimed to highlight temporal trajectories of systolic blood pressure (SBP) in patients with acute intracerebral hemorrhage (ICH) to investigate the clinical relevance of heterogeneity in responses to blood pressure lowering therapy.

Methods:
A post-hoc analysis of ATACH-2 trial, in which ICH patients were randomly assigned to intensive or standard SBP lowering with intravenous administration of nicardipine. Using data for all 1000 patients enrolled from 110 clinical sites, temporal changes of hourly maximum SBP up to 24 hours after randomization were analyzed with the group-based trajectory modeling (GBTM). Model selection was mainly based on the Bayesian Information Criteria. The primary outcome was death or disability (modified Rankin Scale score 4-6) at 3 months. Secondary outcomes included hematoma expansion within 24 hours and acute kidney injury (AKI). AKI was defined as an increase in serum creatinine by ≥0.3 mg/dl or to ≥1.5 times baseline within 48 hours. The outcomes were compared between the trajectory groups using multivariable logistic models with random-effects by clinical sites.

Results:
Of the analyzed 1000 patients, death or disability, hematoma expansion, and AKI were encountered in 367, 161, and 101 patients, respectively. GBTM revealed 4 SBP trajectory groups: early response-low SBP (38.2%), moderate SBP (16.8%), delayed response-low SBP (14.2%), and high SBP (30.8%). Nicardipine dosage was highest in the delayed response-low SBP group, 81.7% of which were from the intensive SBP lowering group. The risk of death or disability was higher only in the delayed response-low SBP group (adjusted odds ratio [aOR] 2.86; 95% confidence interval [CI] 1.66-4.93) than in the early response-low SBP group. The risk of hematoma expansion was not significantly different among the groups. The delayed response-low SBP group had higher risk of AKI (aOR 2.78; 95% CI 1.46-5.31; reference, the early response-low SBP group).

Conclusions:
An SBP trajectory group with delayed SBP lowering despite intensive treatment was associated with increased risk of death or disability at 3 months. Resistance to intensive SBP lowering may predict poor clinical outcomes, and intensive SBP control in these cases will increase the risk of AKI.
Abstract WP401: Burden of Intracranial Hemorrhage in Patients With Reversible Cerebral Vasoconstriction Syndrome
Authors: Patel Smit D , Saini Vasu , Patel Neel , Oliver Otite Fadar , Malik Amer , Khandelwal Priyank , Yavagal Dileep , Pervez Mubashir
Published: June 2021

Introduction:
Reversible Cerebral Vasoconstriction Syndrome (RCVS) is described as reversible constriction of cerebral arteries, presenting with severe headaches and associated with hemorrhagic or ischemic strokes. There is a dearth of the literature on demographics and risk factors associated with intracranial hemorrhage (ICH) in patients with RCVS in the US.

Methods:
All patients with a primary or secondary diagnosis of RCVS in 2016 Nationwide Readmission Database (NRD) using ICD-10 code I67.841 after excluding cerebral angiitis (N=57). Unique patients were included using a unique patient identifier. Weighted discharges were used to generate national estimates. ICH was defined as both intraparenchymal and subarachnoid hemorrhage. A multivariable logistic model was used to identify ICH predictors.

Results:
Among total 1,152 RCVS patients, 25.7% (296) patients developed ICH. Patients with ICH mean age was (years) (Mean±SE) 47.8 ±1.2 vs. 47.0±1.1 (P=0.62), female 85.4% vs. 78.0% (P=0.06), longer inpatient LOS 12.1±0.9 vs. 6.4±0.5 days (P<0.0001) and higher inpatient cost 42,638±4,451 vs. 18,199±1,117 (P=0.018). After multivariable analysis, two independent predictors of ICH were identified: increasing age (OR 1.02, 95% CI: 1.01-1.04, P=0.042) and female gender (OR 2.37, 95%CI: 1.25-4.50, P=0.009). Patients with ICH were at a greater risk of cerebral edema (OR 13.25, 95% CI: 5.10-34.43, P<0.0001) (Figure). Among disposition, 63.2% of patients with ICH were discharged home requiring no assistance and no mortality was observed.

Conclusion:
This nationally representative sample suggests that increasing age and female gender were independent predictors of ICH. There is no difference in comorbidities including migraine contrary to prior literature, modifiable lifestyle risk factors and pregnancy in this cohort. Excellent outcome was observed as the majority of patients were discharged home. Higher LOS and cost were reported in ICH cohort.
Abstract WP408: Risk of Lobar Intracerebral Hemorrhage From Hypertension is Greatest at an Early Age
Authors: Stanton Robert , Gusler Matthew , Moomaw Charles , Gilkerson Lee , Behymer Tyler P , Coleman Elisheva , Woo Daniel
Published: June 2021

Background:
The risk of intracerebral hemorrhage (ICH) with hypertension (HTN) is well documented, with prior studies showing that HTN is the most important risk factor associated with ICH. Prior studies have shown that while the prevalence of HTN increases with age, the odds ratio (OR) of HTN for non-lobar ICH is greater earlier in life. We have previously found a lack of Apolipoprotein E allele association with lobar ICH in minority populations. Here we seek to determine if, similar to non-lobar ICH, the odds ratio of HTN for lobar ICH is greater at an earlier age.

Methods:
The Ethnic/Racial Variations of ICH (ERICH) study is a prospective multicenter case-control study of ICH among whites, blacks, and Hispanics. Cases were enrolled from 42 sites. Controls matched to cases 1:1 by age (±5 years), sex, ethnicity/race, and metropolitan area were identified by random-digit dialing. Participants were interviewed to determine history of HTN. Participants were divided into age groups based on ethnicity-specific quartiles. Cases in each ethnic/age group were compared to controls using logistic regression (i.e., cases and controls unmatched). ORs were calculated to show the risk of lobar ICH associated with HTN by quartile.

Results:
Overall, 917 lobar ICH cases and 932 controls were included. The Table shows the multivariable OR. ORs were highest in the youngest age quartile across all races (6.47 for blacks, 5.72 for Hispanics and 2.74 for whites). HTN produced a significant increase in risk for the youngest two quartiles in blacks and Hispanics, but only the youngest quartile in whites. However, the age of the lowest quartile in whites was equivalent to the bottom two quartiles in minorities.

Discussion:
Similar to non-lobar ICH, HTN earlier in life bears a greater risk of lobar ICH than later in life and this risk is across a greater range in disproportionately affected minorities. Research into how new onset or early life HTN leads to disproportionate risk compared to late life is needed.
Abstract WP414: Transcranial Photobiomodulation of Clearance of Blood Products From the Neonatal Brain via the Meningeal Lymphatics
Authors: Semyachkina-Glushkovskaya Oxana , Klimova Maria , Nikita Navolokin , Shirokov Alexander , Juergen Kurths
Published: June 2021

In human data we observed the presence of products of degraded blood (the iron/hemosiderin) in the meningeal lymphatic vessels (MLVs) and in the deep cervical lymph node (dcLN) in newborns who died after intracranial hemorrhages. Here we demonstrate novel data related to transcranial photobiomodulation (tPBM) of clearance of blood products (the iron/hemosiderin) from the brain via MLVs in newborn rats after stress-induced intracranial hemorrhages (SIH). Experiments were carried out in 73 newborn rats (5 g) with SIH. All procedures were performed in accordance with the “Position of the American Heart Association on Research Animal Use” (Circulation 1985; 71:849A). The new generation laser 1268 nm (30 nm, 7 min) was used for tPBM of lymphatic clearance of blood products that was analyzed in vivo (two-photon, fluorescent, optical coherent tomography imaging) and ex vivo (immunohistochemical, confocal data) using markers of cerebral and lymphatic endothelium (CD31, LYVE-1/LYVE-1 conjugated with Alexa 488 and Prox-1). The results clearly demonstrated that 30 min after SIH the iron/hemosiderin (detected by atomic absorption spectroscopy and histological method) accumulated in the dcLN and observed in the MLVs. The tPBM caused stimulation of lymphatic drainage function that was accompanied by decrease in the iron/hemosiderin level in the brain tissues with an appropriate increase of their level in the dcLN. The tPBM (one time a day) during one week contributed a better recovery after SIH vs. the control group (without tPBM) that was confirmed by analysis of inflammatory factors (C-reactive protein, IL-6 and lipoprotein-associated phospholipase A2, immunoassay analysis), macrophages infiltration (confocal imaging), edema, necrotic and ischemic events (histological data). In sum, our results suggest that tPBM by stimulation of endogenous processes of cerebral lymphatic drainage and clearing function might be a novel non-invasive approach for brain recovery after neonatal intracranial hemorrhages. The research was supported by grant of Russian Science Foundation No 18-75-10033.
Abstract WP422: The BPV Score to Predict Blood Pressure Variability After Acute Intracranial Hemorrhage: A Secondary Analysis of ATACH-2
Authors: de Havenon Adam H , Wong Ka-Ho , McNally J Scott , Grandhi Ramesh , Alexander Matthew
Published: June 2021

Introduction:
Increased blood pressure variability (BPV) is associated with worse neurologic outcome in patients with acute intracerebral hemorrhage. However, it is difficult to identify which patients will have elevated BPV and would be best for clinical trials aimed at reducing BPV.

Methods:
This is a secondary analysis of the Antihypertensive Treatment of Acute Cerebral Hemorrhage II (ATACH-2) trial. Our primary outcome is the top quintile of the systolic blood pressure standard deviation (SBP SD), which was calculated using all available blood pressures after the first 2 hours. With stepwise backwards selection and an interactive process, we created the BPV Score to predict the top quintile of SBP SD.

Results:
We included 997 patients. The BPV Score is calculated by adding one point each for: female sex, Caucasian race, baseline NIHSS>10, intubation, and external ventricular drain. After collapsing the scores of 4 and 5, the breakdown of scores was 0=19.1%, 1=34.2%, 2=29.3%, 3=10.5%, 4=6.9%. The AUC for the BPV Score is 0.722 (Figure 1) and probability of accurately predicting the top quintile of SBP SD is seen in Figure 2.

Conclusion:
The BPV Score is a promising tool for predicting higher levels of BPV in the days following acute intracerebral hemorrhage. A clinical trial to reduce BPV may chose to target patients with scores of 3 or 4 and confirm elevated BPV during a run-in period.
Abstract WP423: Advanced Machine Learning in Action: Radiomic Based Outcome Prediction of Acute Intracranial Hemorrhage on Computed Tomography
Authors: Nawabi Jawed , Kniep Helge , Schön Gerhard , Fiehler Jens , Hanning Uta
Published: June 2021

Background:
Intracranial hemorrhage (ICH) requires prompt diagnosis to optimize patient outcomes
1
. We hypothesized that machine learning algorithms could automatically analyze non-contrast computed tomography (NECT) of the head and predict clinical outcome of ICH patients
2
.

Methods:
300 NECTs with acute spontaneous ICH between 2014-2019 were retrospectively included from the database at a tertiary university hospital. A binary outcome was defined as Modified Ranking Scale (mRS) 0-3 (good outcome) and mRS 4-6 (bad outcome) at discharge. Radiomic features including shape, histogram and texture markers were extracted from non- , wavelet- and log-sigma-filtered images using regions of interest of ICH. The quantitative predictors were evaluated utilizing random forest algorithms with 5-fold model-external cross-validation.

Results:
The model achieved an area under the ROC curve of 0.81 (95% CI [0.077; 0.86]; P<0.01), specificities and sensitivities reached 78% at Youden’s Index optimal cut-off point for the prediction of functional clinical outcome at discharge (mRS).

Discussion:
In conclusion, quantitative features of acute NECT images in a machine learning algorithm provided high discriminatory power in predicting functional outcome. In clinical routine, this proposed approach could allow early triage of high-risk patients for poor outcome. Indication of source:1 Qureshi, A. I. et al. Intracerebral haemorrhage. Lancet. 2009.
2
Mohammad R. Arbabshirani et al. Advanced machine learning in action: identification of intracranial hemorrhage on computed tomography scans of the head with clinical workflow integration. npj Digital Medicine. 2018.
Abstract WP429: A Nurse Driven Acute Stroke Alert Process Improves Treatment Times and Treatment Rates
Authors: D'Amour Daniel , Strauss Jayme , Starosciak Amy K
Published: June 2021

Introduction:
Treatment time has gained sufficient popularity because it is now well-known that “Time is Brain”. Treatment rates, however, lag behind in importance even though more lives can be saved by treating more often. Our TJC Comprehensive Stroke Center has a nurse-led stroke alert process that focuses on multiple, rapid, parallel steps to reduce DTN for IV alteplase. The Baptist Emergency Stroke Team (BEST) responders are highly-trained and skilled nurses that assess, coordinate, and initiate processes to ensure the best times. We identified that our treatment rate was lower than the national rate for certified CSCs, so the BEST responders used a stepwise process to develop their own interventions to improve rates.

Methods:
First, the BEST responders started tracking our monthly rate. Next, they set a rate goal, and then brainstormed how to influence treatment decision-making. The BEST team initiated a monthly PI meeting that focused on the importance of treating disability rather than an NIHSS score. Then the team scripted and rehearsed critical conversations to have providers that advocated specifically for treating disability. The team adopted the motto, “Treat Disability, Not Numbers”.

Results Conclusions:
Our CSC observed a small decrease in median DTN but double the treatment rate after the BEST responder intervention. In comparison, these statistics did not change at the national CSC level. The sICH rate was reduced from Period A to C, meaning that increased treatment rate did not lead to increased hemorrhagic rate. Nursing initiatives can have a substantial positive effect on increasing the number of patients treated with IV alteplase for acute ischemic stroke.
Abstract WP440: Stay at Home With Home Care: The Evidence for Readmission Reduction With Home Visits After Ischemic Stroke
Authors: Leonhardt-Caprio Ann M , Sellers Craig R , Caprio Thomas V
Published: June 2021

Background:
Following hospitalization due to ischemic stroke (IS), 14.4% of Medicare recipients are readmitted within 30 days. Readmission after IS is associated with increased mortality, disability, and elevated costs.

Purpose:
To identify evidence-based practices to guide reduction of all-cause, 30-day hospital readmissions following IS in a comprehensive stroke center (CSC).

Methods:
A literature review focusing on readmissions in IS patients was performed using the PubMed, CINAHL, Embase, and Web of Science databases. Search terms: hospital readmission, IS, transition of care, and care transition. Limitations included English publications in the last 5 years. The 39 articles and abstracts reviewed included 2 meta-analyses, 4 literature reviews, 2 randomized controlled trials, 2 qualitative studies, 2 program evaluations, 2 design descriptions without results, and the remainder observational and cohort studies. Most studies were single site or limited geographic areas. Differing patient populations, definitions, and study methods limited the ability to combine results. Literature review results were then compared with baseline practices at our CSC.

Results:
While multiple best-practices were in place at our CSC, only 44% of IS patients were being referred to home care. Six of the publications reviewed identified home care as a successful component in reducing readmissions within 30 days, reporting statistically significant reduction in readmission rates ranging from 30% to 93% with 3 of 6 reporting
p<
.05, treatment effect of 1.7 reported by 1, and 2 study groups did not report significance of findings.

Conclusions:
Reducing readmissions for IS improves outcomes and is a focus of quality efforts across the nation. Using literature, we identified a gap in current best practices (the under-utilization of home care referrals) in our CSC. Despite limitations in the literature, there is clear evidence that the use of home care has reduced readmissions in multiple settings. This has been a successful first step in guiding development of an evidence-based readmission reduction program. An initiative to increase home care utilization at our CSC is currently under evaluation. More study is needed on home care use in the stroke-specific population.
Abstract WP454: Benefits of a Multidisciplinary Stroke Wellness, Exercise and Education Program (SWEEP) for Chronic Stroke Survivors
Authors: Kernich Catherine , Lloyd Ashley , Henniger Dennyse(Bri) , Ogbogu King , Heinz Sara , Habenicht Stephnie , Tran Daniel , Hicks Aaron , Pundik Svetlana
Published: June 2021

Background and Purpose::
Stroke patients typically receive rehabilitation for only a limited time period after stroke. However, therapies in the chronic phase after stroke are often needed to both maintain and improve function. In addition, many patient lack knowledge about stroke and as a result are frequently non-compliant with secondary stroke prevention measures despite stroke education during hospitalization. The SWEEP program was developed to address these issues. The purpose of this study was to evaluate health outcomes before and after participation in the program.

Methods:
The SWEEP consisted of twice weekly group sessions for 10 weeks. The sessions included 45 minutes of focused exercise led by therapists and 15 minutes of multidisciplinary education on secondary stroke prevention and adjustment to life after stroke. Criteria for admission into the program included: greater than one year since stroke, intact cognition, and ability to transfer with no more that moderate assist. Outcome measures were collected at baseline, at the end of 10 weeks of participation, and at 3- and 6-months post participation. The measures assessed functional status (grip strength, Sit-to-Stand time, Timed-Up-And-Go (TUG),) and indicators of secondary stroke prevention (systolic and diastolic blood pressure (SBP, DBP), LDL, HgbA1c and weight). We used paired (sign rank test) and repeated measure analyses (ANOVA).

Results:
There were 23 participants between Fall 2016 to Spring 2019, 21 were males. They were 4.74±6.75 years after stroke. There was improvement in grip strength (p=0.006), Sit-to-Stand (p=0.004) and TUG (p=0.003) between baseline and at the end of the program. SBP was reduced to <130 at 3 months and was maintained at 6 months (ANOVA, p=0.003). Four out of 5 people reduced their abnormal HgbA1C (>7), 2 out of 2 reduced their elevated LDL (>100) and 12 people lost weight.

Conclusions:
The SWEEP program was largely effective in improving functional status and secondary stroke prevention measures. Continued emphasis on secondary stroke prevention is needed for our patient population. A larger study is needed to confirm the results.
Abstract WP460: Stroke Awareness is a 911: Stroke Team and EMS Collaboration for Stroke Education
Authors: Steiner Nili E , Levesque Denise , Paletz Laurie , Robertson Betty , Rosenfield Paula , Stokes Sean , Wolber Nicole , Lyden Patrick
Published: June 2021

Background:
Accurate pre-hospital recognition of acute stroke is essential, but current training of EMS providers varies across agencies. We created targeted classes specifically for prehospital providers to increase their knowledge of stroke symptoms, emphasizing posterior circulating artery stroke (PCA) symptoms, with the goal to increase awareness of neurological emergencies and enhance patient destination decisions.

Purpose:
To enhance prehospital providers’ stroke knowledge, improve provider confidence levels of symptom identification and to help guide the prehospital providers with their stroke patient destination decision-making.

Implementation process:
Our stroke team collaborated with Beverly Hills Fire Department (BHFD). We created three educational modules using recorded stroke-specific paramedic calls that involved BHFD paramedics and Cedars-Sinai Mobile Intensive Care nurses. 77 EMS providers total attended the three classes. Each educational module outlined pathophysiology of stroke and reviewed treatment provided and final disposition of each case. Pre- and post-class knowledge assessment and evaluation Likert-scale surveys were distributed to each class participant. These surveys were collected and tallied.

Results:
Of 63 pre-class survey respondents, 25% felt

definitely

adequately trained and 54% felt

somewhat

adequately trained to recognize an acute ischemic neurologic event and felt somewhat likely to designate a patient as a Stroke Center candidate if their chief complaints coincided with PCA symptoms. Of 40 post-class survey respondents, 75% indicated that the class

definitely

augmented their previous training in recognizing an acute ischemic neurologic event, and 83% would

very likely

designate a patient as a Stroke Center candidate if their chief complaints coincided with PCA symptoms. Using Chi-square analysis, the improvement is stroke symptom confidence was statistically significant (p<0.01).

Conclusions:
The post-class surveys showed a substantial and statistically significant increase in the confidence levels of recognizing PCA symptoms in the field. Further studies will measure persistence of knowledge gained over time and extension of the educational modules to other agencies.
Abstract WP462: Improving Nurses’ Comfort and Practice Towards Neuroscience Patients Utilizing High-fidelity Simulation
Authors: Supan Erin , Patton Lauren , Fussner Julie M , Beilman Colin , Sajatovic Martha
Published: June 2021

Introduction:
University Hospitals Health System (UHHS) has seen an interest by nursing in using simulation and case studies as an adjunct to classroom education to instruct in emergency situations and mock codes. UHHS is currently expanding neuroscience services at 2 community hospitals while maintaining services at the quaternary care hospital. There is a need for further neuroscience education of both experienced nurses who have limited neuroscience exposure and novice nurses employed in neuroscience specialty areas. Patient simulators have been used in a variety of education settings, yet their effectiveness in training nurses to manage neurologic patients and neurologic emergencies has not been widely examined. The purpose of this project is to evaluate the use of high-fidelity simulation on nurses’ assessment skills, critical thinking and comfort in caring for neuroscience patients.

Methods:
A pre and post survey design was used for this project with nurses completing a survey immediately prior to and after participating in 3 simulation scenarios: intracerebral hemorrhage with intracranial pressure, subdural hematoma with seizures, and brain tumor complicated by pulmonary embolism. After completion of each scenario a debriefing occurred. Surveys allowed nurses to assess their confidence levels in responding to neurologic emergencies using a 5-point Likert-type scale (1= strongly disagree to 5 = strongly agree).

Results:
Comfort level was assessed in five different categories. Comfort in performing a neurologic assessment improved from a pre-survey average of 4.02 to a post-survey average of 4.59, a variance of 11.4%. Comfort in managing a stroke patient improved from 3.98 to 4.45, a variance of 9.5%. Comfort in administering emergency medications improved from 3.02 to 3.98, a variance of 19.1%. Comfort in identifying neurologic changes improved from 3.82 to 4.43, a variance of 12.3%. Comfort in communicating neurologic changes to the provider improved from 4.00 to 4.66, a variance of 13.2%. There was an overall improvement in the variance in all 5 categories of 13.1%.

Conclusion:
The use of high-fidelity simulation allowed nurses to gain comfort in assessment, management, and provider communication specific to neuroscience patients.
Abstract WP463: Moderator Role of Preparedness on the Association Between Depression and Quality of Life in Stroke Survivor-Caregiver Dyads
Authors: Pucciarelli Gianluca , Lyons Karen S , Simeone Silvio , Alvaro Rosaria , Lee Christopher S , Vellone Ercole
Published: June 2021

Background:
Although several studies have clearly shown that depressive symptoms in stroke survivors and caregivers decreases their quality of life (QOL), previous research has not yet analyzed the role of potential moderators in the relationship between the above two variables.

Aims:
To examine the moderating effect of caregiver preparedness between depressive symptoms and QOL in stroke survivor and caregiver dyads.

Methods:
Longitudinal design with 222 stroke survivor-caregiver dyads enrolled at survivor discharge from rehabilitation hospitals. Data collection was performed over 12 months. We measured survivor and caregiver QOL dimensions (physical, psychological, social and environmental), depression and preparedness. Hierarchical Linear Modeling was used to test four longitudinal dyadic moderation models (one for each QOL domain).

Results:
Survivors (50% males) and caregivers (65% females) were 70.8 (SD=11.9) and 52.5 (SD=13.1) years old, respectively. Controlling for baseline covariates, caregiver preparedness significantly moderated the association between survivor depressive symptoms and survivor psychological (B = 0.56, p < .01) and environmental (B = 0.58, p < .01) QOL at baseline and social QOL over time (B = 0.24, p < .05). In each case, higher levels of caregiver preparedness were protective and buffered the influence of survivor depressive symptoms on survivor QOL. Similarly, caregiver preparedness significantly moderated the association between caregiver depressive symptoms and caregiver physical (B = 0.25, p < .01) and environmental (B = 0.18, p < .05) QOL over time.

Conclusions:
Caregiver preparedness is a positive variable for both members of the dyad and the paper highlights the importance of implementing tailored intervention which could improve caregivers’ preparedness already during the rehabilitation period.
Abstract WP469: The Art of Health: A Pilot Program for Stroke Survivors
Authors: Henderson Melanie
Published: June 2021

Background and Purpose:
Along with physical and cognitive effects, psychosocial well-being may be affected post-stroke, including depression, anxiety, and feelings of isolation. Incorporating holistic activities into stroke survivors’ recovery may be beneficial. An innovative pilot program was developed by a community hospital and a local university art therapy department to provide art classes to stroke survivors. The aim of this pilot program,
The Art of Health
, was to determine if stroke survivors and caregivers would participate in an art program for addressing overall well-being.

Methods:
Five art classes of 1.5 hours in length were scheduled for the program and advertised to hospital leaders and the rehab unit. Art therapy students volunteered to teach the art classes. Patients and caregivers were invited from the stroke support group and from the inpatient rehab unit to attend. The Stroke Coordinator prepared a small health topic to introduce to the art class attendees prior to the art activity. Art therapy students attempted to match their art class activity to the health topic, but were given freedom of choice for overall art project. Classes were held in the evening to accommodate caregivers’ potential schedules. Attendees were surveyed regarding the art classes to gain feedback on improving the program.

Results:
A total of 47 participants attended the five art classes (class median = 9). Of those surveyed, 100% (n = 47) stated that they would attend another type of art program at the hospital. Two students inquired if there was opportunity to complete their university clinical internship at the hospital. Due to
The Art of Health
pilot program success, the stroke coordinator collaborated with the art therapy department instructor to create a clinical rotation. With the support of the hospital CEO and CNO, an interprofessional team was formed to develop and support an Art Therapy Internship program at the hospital.

Conclusions:
In conclusion, innovative programs which include creative-arts based therapies and activities may be beneficial to both stroke survivors and caregivers. Future research on creative-arts and their impact on psychosocial well-being post-stroke would be of benefit.
Abstract WP473: Diabetic Male and Female Rats Are More Susceptible to Infarction and Cognitive Decline in a Microemboli Based Model of Vascular Cognitive Impairment
Authors: Li Weiguo , He Lianying , Abdul Yasir , Jamil Sarah , Falangola Maria Fatima , Ergul Adviye
Published: June 2021

Diabetes increases the risk of VCID but underlying reasons remain unclear. We reported that diabetes-mediated early cerebrovascular dysfunction facilitates the entrapment of microemboli (ME) and results in demyelination/neurodegeneration 6 weeks after ME injection in male diabetic but not control rats. Cognitive decline became apparent by week 8 and further amplified by week 12 in diabetes. The goals of the current study were to determine whether ME injection 1) mediates demyelination and cognitive decline in females, 2) activates microglia and promotes inflammation, 3) causes gait abnormalities and 4) mediates changes in cerebral blood flow (CBF) and brain structure as determined by diffusion MRI. Diabetes was induced by a high fat diet and low dose streptozotocin (35 mg/kg) injection in male and female Wistar rats. After 8 weeks onset of diabetes, control and diabetic rats received cholesterol crystal ME (40-70 μm) injection. In study 1, histology was done at week 6 after injection (3000 crystals) to determine early structural changes and cognition was assessed by novel object recognition (NOR) test. In Study 2, MRI, gait (stand on catwalk) and NOR tests were done at baseline and week 8 after injection (6000 crystals) in male rats and will be further monitored at weeks 12 and 16. Diabetic animals developed inflammation, demyelination, and neurodegeneration associated with cognitive decline that was greater than that observed in males (TABLE). In Study 2, initial analyses show higher infarct score and lower CBF after ME injection with no gait pattern change in diabetic male rats. Longitudinal measurements at weeks 12 & 16 will demonstrate the disease progression. These data suggest that 1) endothelial dysfunction renders diabetic animals more susceptible to infarction and subsequent cognitive decline caused by ME, and 2) intervention strategies can be tried in this clinically relevant model of VCID.