bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 7: Quality Of Life Trajectories In The Year After Large Vessel Occlusion Stroke And Their Association With 90-day Functional Outcome
Authors: de Havenon Adam H , Braun Robynne , Worrall Bradford B , Sunmonu N. Abimbola , Lindgren Arne , Cole John W , Lohse Keith , Broderick Joe , Cramer Steven C
Published: February 2022

Background:
While research has focused on the trajectory of functional recovery after ischemic stroke, the trajectory of quality of life (QoL) has not been fully explored, nor has its relation to functional recovery.

Methods:
In a post hoc analysis of the IMS-III trial, we included patients with an imaging-confirmed large vessel occlusion and QoL assessed as EQ-5D at 5 study visits up to 1 year after ischemic stroke onset. We used group-based trajectory modelling (GBTM) to identify trajectories of EQ-5D index values with US-based weights and report patient demographics in each trajectory and the modified Rankin Scale (mRS) score at 90 days.

Results:
We included 266 patients, who had QoL measured at a mean of 4.6, 93.0, 184.3, 274.3, and 367.6 days after stroke onset. GBTM identified four trajectories with excellent fit (Figure). These QoL trajectories can be described as [1] persistent low, [2] low to medium, [3] persistent medium, and [4] medium to high. The corresponding mRS at 90 days are shown in the Figure, demonstrating a clustering of trajectories by mRS but also a diversity of trajectories. In particular, low to medium and persistent medium trajectories are represented across all mRS scores. Patient demographics are shown by trajectory in the Table, with significant differences in sex, baseline NIHSS, infarct volume, WMH burden, and diabetes.

Conclusion:
We demonstrate four distinct trajectories of QoL in the year after large vessel occlusion stroke, with a diversity of functional recovery and unique demographic compositions. Early recognition of a likely future QoL trajectory could suggest patient-specific rehabilitation therapies and inform prognostication and goals of care.
Abstract 9: Pervasive White Matter Microstructure Dysintegrity Related To High Blood Pressure Among Asymptomatic Population
Authors: Acosta Julian , Haider Stefan P , Rivier Cyprien , Leasure Audrey C , Sheth Kevin N , Falcone Guido J , Payabvash Sam
Published: February 2022

Background:
Blood pressure is the strongest contributor to clinically evident cerebrovascular disease. We investigated the role of blood pressure on white matter (WM) microstructure among asymptomatic individuals without clinically evident cerebrovascular disease.

Methods:
We conducted a nested study within the UK Biobank, restricting our analysis to participants without cerebrovascular disease or dementia and with available brain diffusion tensor imaging (DTI). We tested for association between systolic blood pressure (SBP) and six different DTI metrics: fractional anisotropy (FA), mean diffusivity (MD), tensor mode (MO), intra-cellular volume fraction (ICVF), isotropic or free water volume fraction (ISOVF), and orientation dispersion index (OD) across 48 WM tracts using multivariable linear regression adjusted for potential confounders. We used Bonferroni-corrected p-values (0.05/48) for statistical significance.

Results:
We analyzed 33,440 participants. Mean age was 63.0 (SD 7.7), and 17,688 (53%) were female. Higher SBP is independently associated with pervasive decrease in FA and ICVF and increase in MD (Figure), after adjustment for vascular risk-factors. SBP was also associated with lower neurite OD (a more specific metric of axonal damage) in bilateral posterior corona radiata, external capsule, medial lemniscus, and corticospinal tracs. FA and OD of external capsule and posterior corona radiata had the largest drop per 10 mmHg increase of SBP (steepest slope).

Conclusions:
Higher SBP is associated with pervasive WM microstructure dysintegrity in asymptomatic individuals without evident cerebrovascular disease. DTI metrics of the posterior corona radiata and external capsule are most reflective of variations in SBP and may provide a potential biomarker to assess subtle WM microstructural damage in hypertensive patients or monitor treatment response in clinical trials.
Abstract 91: Large Vessel Occlusion Stroke Patients With Rapid Early Infarct Progression And Poor Collaterals Are Vulnerable To Blood Pressure Reductions
Authors: Begunova Yelyzaveta , Bartolome David , Kobsa Jessica , Prasad Ayush , Soto Alexandria , Quispe-Orozco Darko , Farooqui Mudassir , Zevallos Cynthia , Sansing Lauren H , Schindler Joseph L , De Havenon Adam H , Matouk Charles , Sheth Kevin N , Ortega-Gutierrez Santiago , Petersen Nils H
Published: February 2022

Introduction:
The precise interactions between collateral perfusion, hemodynamics, and infarct growth after large vessel occlusion (LVO) require further definition. This study examined whether patients with poor collateral circulation and rapid early infarct progression are more vulnerable to reductions in blood pressure (BP).

Methods:
We prospectively enrolled patients with LVO stroke who underwent thrombectomy. Volumes of arterial tissue delay and relative cerebral blood flow (CBF) were estimated with RAPID software; a poor collateral profile was defined by a hypoperfusion intensity ratio >0.4. Early infarct growth rate (EIGR) was defined as ischemic core volume (CBF<30%) divided by the time from symptom onset to imaging. A fast progressor profile was assigned to patients whose EIGR was >10 mL/h. The final infarct growth rate (FIGR) was the quotient of final infarct volume (FIV) and time from symptom onset to reperfusion. BP reduction was measured as the difference between admission mean arterial pressure (MAP) and lowest MAP before reperfusion.

Results:
Fifty-five patients (mean age 69
+
15, mean NIHSS 13) with successful reperfusion (TICI 2B/3) were included in the analysis. The median MAP reduction was 17 (IQR 9, 32). Poor collateral perfusion and EIGR were independent predictors of FIV after adjusting for age and admission NIHSS (mean FIV 70 vs. 31 mL, p=0.012 and 60 vs. 29 mL, p=0.01, respectively). A significant interaction was found between MAP reduction and both collateral status (p=0.04) and progressor profile (p=0.01). For every 10 mmHg MAP reduction, patients with poor collaterals experienced an average increase in FIGR of 3.6 mL/h (Fig. 1A). Above a critical MAP reduction threshold of 30 mmHg, mean FIV was significantly larger in patients with rapidly progressing infarcts (p<0.01, Fig. 1B).

Conclusions:
Patients with poor collaterals and rapid early infarct growth are at higher risk of accelerated infarct growth and larger FIV related to BP reductions.
Abstract 97: Development And Validation Of A Deep Machine Learning Tool For Automated Intraventricular Hemorrhage Segmentation And Volume Measurement Using 3d Convolutional Neural Networks
Authors: Wong Alexander , Baig Saif , Chen Zejia , Volders David , Huynh Thien
Published: February 2022

Introduction:
Development of new intraventricular hemorrhage (IVH) within 24 hours of presentation or expansion of 1mL or more independently predicts poor outcome. Current methods for IVH volume estimation lack sufficient precision to detect this level of change. The best method of quantification with manual/semi-automated segmentation remain clinically impractical. We aimed to train and validate a convolutional neural network (CNN) to autonomously segment and quantify IVH volume in acute intracerebral hemorrhage (ICH) patients.

Methods:
Imaging data for training and validation was obtained from 3 international multicenter studies. IVH volumes were assessed using CNN, IVH Score (IVHS), Original Graeb Score (oGS), Modified Graeb Score (mGS), and manual segmentation using ITK-SNAP. Agreement between CNN volume and IVHS estimated volume compared to manual segmentation was assessed using intraclass correlation coefficient (ICC) and Bland-Altman charts. Accuracy of CNN segmentation was compared to manual segmentation with Dice similarity coefficient (DSC). Accuracy of hematoma expansion detection was assessed using receiver operating characteristic curves.

Results:
A total of 172 patients and 311 CT scans were included. Intra-rater reliability was significantly greater for CNN versus IVHS method (ICC 0.99 [95%CI 0.99 - 1.00] vs 0.76 [95%CI 0.66 - 0.83]). Accuracy of CNN segmentation was satisfactory (DSC 0.76 [95%CI 0.75 - 0.78]). Accuracy of hematoma expansion detection was substantially greater in CNN (AUC 0.91 [95%CI 0.85 - 0.97]) versus IVHS, oGS and mGS.

Conclusion:
Our results demonstrate that a fully automated CNN algorithm is capable of segmenting IVH volumes on multi-center data with higher intra-rater reliability and satisfactory accuracy over the current methods of IVH volume measurement tools. The algorithm has proven to be capable of detecting hematoma expansion with substantially greater accuracy over existing methods of IVH measurement.
Abstract NS6: ED Pause: A Nursing Driven Approach To Improving Thrombectomy Times
Authors: Thorsen Tawnae , karstens raquel c , Bernardino Tina , Gupta Atul , Punsalang Lorina , Gaffney Denise , Mkrtumyan Alvina , Ajani Zahra , Le Duy , Cheng Pamela , Sangha Navdeep S
Published: February 2022

Introduction:
The current Joint Commission recommendation for door to skin puncture is less than 60 minutes for transfer cases. It is imperative that no time is lost in moving these patients safely through the Emergency Department (ED) to the Interventional Radiology (IR) Suite. The goal of this study was to assess if a rapid, 11-step nursing driven checklist could decrease time spent in the ED and subsequently improve our thrombectomy times in transfer patients.

Methods:
We developed the following 11 steps: (1) ED staff is notified of incoming ED Pause transfer. (2) ED receives report from sending facility RN. (3) Register the patient upon arrival.(4) Activate EMS Stroke alert. (5) Verify patient’s identity using two patient identifiers, apply wristband. (6) Vital signs (to ensure no decompensation en route), connect patient to the transport monitor. (7) Chart weight in the system. (8) Confirm two working IVs. (9) Confirm negative Covid test or send a rapid if a negative Covid test cannot be confirmed. (10) Ensure the patient is undressed and ready to go to IR. (11) Confirm the “admit to inpatient” order is placed. ED staff were educated and checklists were posted in the ambulance bay and nurses’ station. Data were reviewed pre- (April 2019 to March 2020) and post- (April 2020 to March2021) implementation to assess the percentage of patients captured by the tool and its impaction thrombectomy times. Data were analyzed using a t-test.

Results:
There were 25 patients transferred in the post vs 16 in the pre-implementation group. The median door to skin puncture (DTS) (post: 37 mins {IQR 31-43} vs. pre: 50 mins {IQR 47-71}p=0.045), door to device deployed (post: 52 mins {IQR 45-65} vs. pre: 70 mins {IQR 65-94}p=0.037), and door to recanalization (post: 71 mins {IQR 54-102} vs. pre: 99 mins {IQR 70-118}p=0.043) times decreased in the post implementation group.

Conclusion:
A nursing driven ED checklist is a successful tool in decreasing thrombectomy times in transfer patients.
Abstract NS9: Two Level Stroke Activation: Fine Tuning Stroke Criteria
Authors: Sinkey Shanda D , Roper Deborah , Wylie Mary , Hasan Rashedul , Marcucci John , Fagan Elizabeth , Fournier Lauren E , Coffey Amanda , Martin Kimberlee , Uy Juliet , Moats Susan , Rasmussen-Winkler Jennifer
Published: February 2022

Background:
The burden of acute stroke alerts on hospital resources and staff have grown with expanding treatment timelines. The purpose of this project is to develop a nurse activated acute stroke process to accurately capture ischemic and hemorrhage stroke amendable for acute treatment with a two level activation model for 0-4 hours (level 1) and 4-24 hours (level 2) from last known well.

Methods:
Prospective quality improvement data abstracted on patients in a five-hospital regional telestroke network from October 2020 thru June 2021 with the current single level 24-hour stroke symptom protocol. We retrospectively applied our proposed two level activation model to our data to look for accuracy in stroke diagnosis, proportion of stroke mimics, missed stroke interventions, including intracerebral hemorrhage (ICH), and telestroke provider time spent. We used standard error of mean (SEM) to measure discrepancy of process.

Results:
A total of 340 stroke activation were captured. Of those, 54% (183/340) were discharged without a stroke diagnosis, 27% (93/340) ischemic, 14% (48/340) transient ischemic attack, 4% (13/340) ICH, 1% (3/340) subarachnoid hemorrhage, and 34% (117/340) arrived in the level 2 window. We excluded 5 ICH patients due to arriving comatose necessitating emergent imaging outside of stroke alert process. Comparing single activation versus two level activation resulted in a reduction of stroke alerts (117 versus 21), telestroke provider time (2501 minutes versus 713 minutes), increase in accurate stroke diagnosis (46% versus 76%), decrease in stroke mimics (54% versus 29%), with 1 missed ICH and 1 missed thrombectomy (5%). The single activation showed a mean 11.11% and SEM of 0.023 compared to the two level activation mean 1.99% and SEM of 0.006.

Conclusion:
Two level stroke activation process was validated to reduce stroke mimics, improve accurate stroke diagnoses, maximize resources utilization, and capture 95% of all ischemic strokes with large vessel occlusions, therefore the new process will be implemented within our large telestroke system following staff education.
Abstract TMP113: Conditional Expression Of Mir-20a-3p In Neurons Versus Astrocytes And Its Impact On Acute Stroke Outcomes
Authors: Branyan Taylor , Sohrabji Farida
Published: February 2022

Introduction:
MiR-20a-3p was found to be upregulated in the brains of adult female rats, who typically sustain smaller infarcts, compared to that of middle-aged rats, who typically sustain larger infarcts. In fact, qRT-PCR analysis shows that miR-20a-3p is profoundly upregulated (>240,000-fold elevation) in adult
astrocytes
post-stroke, while ischemic neurons do not exhibit this upregulation. Intravenous injections of miR-20a-3p mimic, given 4h after stroke, reduced infarct size and improved sensory motor function in middle-aged rats, and surprisingly exogenous miR-20a-3p was preferentially taken up by
neurons
. To better understand the cellular target of this miRNA, we compared the efficacy of conditional expression of miR-20a-3p in neurons versus astrocytes in improving acute stroke outcomes.

Methods:
Two viral vectors to conditionally express miR-20a-3p in neurons (rAAV5-TetOn-NSE-miR-20a-3p-mCherry) and astrocytes (rAAV5-TetOn-GFAP-miR-20a-3p-mCherry) were injected into the striatum of middle-aged female rats.Control subjects were given an identical vector minus miR-20a-3p. After 6 weeks, the rats were subjected to middle cerebral artery occlusion, and the virus was activated by i.p. doxycycline 4h post-stroke. Behavioral assessments were performed at 2d and 5d. Animals were terminated at 5d, and infarct size was assessed.

Results:
Astrocytic miR-20a-3p improved survival compared to control (p=0.0372), and neuronal miR-20a-3p showed a trend for improved survival (p=0.0805). Neuronal miR-20a-3p reduced latency on the adhesive removal task at 2d and 5d, while astrocytic miR-20a-3p demonstrated modest improvement only at 5d. Moreover, neuronal miR-20a-3p significantly reduced infarct size relative to control (p=0.0087), while astrocytic miR-20a-3p did not improve infarct size(p=0.1117).

Conclusions:
Both rAAVs resulted in improvement in stroke outcomes; however, the results from the neuronal vector were much more robust. The fact that astrocytes upregulate miR-20a-3p after stroke yet neurons more efficiently use the miRNA to improve stroke outcome suggest that this miRNA may be transferred from astrocytes to neurons to confer neuroprotection. Supported by RFAG042189 to FS and 1F31NS118970-01A to TEB.
Abstract TMP14: Value Of Chest Computed Tomographic Scan Added To Acute Stroke Neuroimaging Protocol For Identifying Sars-cov-2 Infection In Acute Stroke Patients
Authors: ISHFAQ Muhammad F , Yelam Anudeep , Bhagavan Sachin , Huang Wei , Jaura Attiya , French Brandi , Siddiq Farhan , Gomez Camilo , Qureshi Adnan I
Published: February 2022

Background:
Undiagnosed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may be seen in acute stroke patients. Rapid screening is important to reduce exposure to medical professionals and other patients during acute assessment and treatment. Chest computed tomographic (CT) scan may be another time-sensitive option for identification of SARS-CoV-2 infection in acute stroke patients.

Objective:
We report our experience of incorporating chest CT scan in the initial neuroimaging protocol for evaluation of acute stroke patients.

Methods:
All acute stroke patients underwent chest CT scan concurrent to CT head, CT angiogram of head and neck and CT perfusion for 10 months. We identified patients who had chest CT scan findings that were suggestive of SARS-CoV-2 infection including bilateral, multilobar ground glass opacification with a peripheral or posterior distribution, and/or consolidation. All patients subsequently underwent polymerase chain reaction (PCR) testing using nasopharyngeal specimen for identification of SARS-CoV-2 with contact isolation. Sensitivity, specificity, and likelihood ratios were calculated.

Results:
A total of 530 consecutive acute stroke patients (mean age in years 65.6± SD; 15.4; 280 were men) underwent neuroimaging with concurrent chest CT scan. The chest CT scan identified findings suggestive of SARS-CoV-2 infection in 34 (6.4%) patients. Subsequent PCR testing confirmed the diagnosis of SARS-CoV-2 infection in 21 of 34 patients. Among 491 patients in whom chest CT scan did not identify any findings suggestive of SARS-CoV-2 infection, 387 underwent PCR tests; PCR testing confirmed the diagnosis of SARS-CoV-2 infection in 13 of 34 patients. Sensitivity and specificity of chest CT scan for detecting SARS-CoV-2 infection was 61.9% and 96.2%, respectively. Positive and negative likelihood ratio of chest CT scan for detecting SARS-CoV-2 infection is 16.26 and 0.39, respectively.

Conclusions:
Although specificity was high, the relatively low sensitivity of chest CT scan in identifying SARS-CoV-2 infection limits the value of adding this imaging to standard neuroimaging in acute stroke patients. At our institution, we have subsequently discontinued the protocol.
Abstract TMP17: Demographics, Characteristics, And Outcomes Of Stroke Patients With Concurrent Sars-cov-2 Infection From March 1, 2020 To February 28, 2020: An Analysis From The N3c Database
Authors: Narrett Jackson A , Assefa Ethan D , Patel Arti , Mallawaarachchi Indika , Loomba Johanna J , Ratcliffe Sarah , Sadan Ofer , Monteith Teshamae , Worrall Bradford B , Brown Donald E , Johnston Karen C , Southerland Andrew M
Published: February 2022

Background:
Studies have shown that patients with ischemic stroke (IS) and concurrent COVID-19 have increased stroke severity. These analyses were limited by use of prepandemic era controls or by utilization of a sample from the early pandemic period when stroke care delivery was affected by lockdown. Studies on the severity of hemorrhagic stroke (HS) in patients with concurrent COVID-19 are few and limited by small sample sizes.

Methods:
Using the National Institute of Health (NIH) National COVID Cohort Collaborative (N3C) database, we identified patients diagnosed with stroke between Mar 1, 2020 - Feb 28, 2021. Hospitalized stroke patients with concurrent COVID-19 (stroke within 3 months after or one week prior to positive SARS-COV-2 PCR or AG lab test) were matched to all other hospitalized stroke patients in a 1:3 ratio. Nearest neighbor matching with a caliper of 0.25 was used for most clinical and demographic factors; exact matching for race/ethnicity and site. Within our matched sample, we used Poisson regression to calculate stroke severity incident rate ratio (IRR).

Results:
Our query identified 10,394 patients hospitalized with IS with available NIHSS scores upon admission (802 with concurrent COVID-19 and 9,592 without) and 2138 patients hospitalized with HS (181 with concurrent COVID-19 and 1957 without). Average NIHSS was greater in concurrent groups with both IS and HS (11.1 vs 7.68, p < 0.001 and 15.7 vs 11.7, p < 0.001 respectively). Propensity matched analysis also demonstrated that stroke patients with concurrent COVID-19 had increased initial NIHSS (IS: IRR = 1.4, 95% CI:1.3-1.5, p-value < 0.001; HS: IRR = 1.3, 95% CI:1.2-1.5, p < 0.001). Average NIHSS in both IS and HS patients was greater in the Mar-Apr 2020 epoch than in all other 2 month epochs studied in these respective groups.

Conclusions:
This analysis suggests that the association between increased stroke severity and concurrent COVID-19 that was observed during the early pandemic was present throughout the pandemic as stroke care utilization normalized. Further work will center on the interaction between COVID-19 illness severity and stroke severity.
Abstract TMP27: Direct To Angio-suite Large Vessel Occlusion Stroke Transfers Achieve Faster Arrival-to-puncture Times And Improved Outcomes
Authors: Regenhardt Robert W , Rosenthal Joseph A , Dmytriw Adam A , Vranic Justin E , Bonkhoff Anna K , Bretzner Martin , Hirsch Joshua A , Rabinov James D , Stapleton Christopher J , Patel Aman B , Singhal Aneesh B , Leslie-mazwi Thabele M , Rost Natalia S , Etherton Mark R
Published: February 2022

Introduction:
For patients with large vessel occlusion (LVO) stroke, time to treatment with endovascular thrombectomy (EVT) is crucial to prevent irreversible infarction and improve outcomes. We sought to evaluate the arrival-to-puncture times and outcomes for LVO patients transferred directly to the angio-suite (LVO2OR) versus those accepted through the emergency department (ED).

Methods:
Consecutive patients transferred for EVT within a hub-and-spoke model with spoke CTA-confirmed LVO, spoke ASPECTS >6, and last known well-to-hub arrival <6 hours were identified from a prospectively maintained database. The LVO2OR protocol began implementation in January 2017. The LVO2OR cohort includes patients who underwent EVT from July 2017 to October 2020, and the ED cohort includes those from January 2011 to December 2016. Arrival-to-puncture time and 90-day modified Rankin Scale (mRS) were prospectively recorded.

Results:
The LVO2OR cohort was comprised of 91 patients and the ED cohort 90 patients. LVO2OR patients had more atrial fibrillation (AF, 51% vs 32%, p=0.02) and more M2 occlusions (27% vs 10%, p=0.01), but otherwise similar demographics, medical history, and presentations. They had dramatically faster median hub arrival-to-puncture times (11 vs 92 min, p<0.001), more TICI 2b-3 (92% vs 69%, p<0.001), and more 90-day mRS 0-1 (35% vs 21%, p=0.04). In a multivariable model, LVO2OR significantly increased the odds of 90-day mRS 0-1 (aOR 2.77, 95%CI 1.07,7.20; p=0.04) even when controlling for age, baseline mRS, AF, NIHSS, M2 location, and TICI 2b-3.

Conclusion:
Within a hub-and-spoke Telestroke network, transferring eligible LVO patients directly to the angio-suite was associated with dramatically reduced arrival-to-puncture times and improved 90-day outcomes. Direct to angio-suite systems of care should be considered in Telestroke networks to expedite high-quality stroke care.
Abstract TMP50: Increased Systolic Blood Pressure In The Subacute, But Not Acute, Period After Ischemic Stroke Is Associated With Good Functional Outcome At 90 Days
Authors: de Havenon Adam H , Yaghi Shadi , Anadani Mohammad , Petersen Nils H
Published: February 2022

Background:
Prior research has shown that increased blood pressure variability (BPV) after ischemic stroke is associated with lower odds of good functional outcome, but the number, intervals between, and epochs of blood pressure measurements have not been standardized.

Methods:
We include patients enrolled in the FAST-MAG trial with a final diagnosis of ischemic stroke, premorbid modified Rankin Scale (mRS) of 0, 4 “early” blood pressure measurements (prehospital and 3 in the hour after arrival), and 9 “later” measurements (q4 hours from hours 4-24 and q8 hours from hours 24-48). The primary outcome was 90-day mRS of 0-1 (good outcome). The BPV exposure was the top tertile (highest level) of systolic standard deviation (SD). We fit logistic regression models adjusted for patient age, race, sex, baseline NIH Stroke Scale, tPA, endovascular therapy, mean systolic blood pressure, smoking, atrial fibrillation, hypertension, and diabetes.

Results:
We included 455 patients, with a mean age of 70.8 years, 46.8% female, 50.8% had tPA, 6.4% had endovascular therapy, the median baseline NIH Stroke Scale was 12 (5-19) and good outcome occurred in 152/455 (33.4%). The mean early SD was not significantly lower in patients with good outcome (p=0.12), but later SD was lower in patients with good outcome (13.5±5.6 vs. 15.1±5.6, p<0.01). The adjusted odds ratio for good outcome in the top tertile of early BPV was 1.09 (95% CI 0.63-1.89), while for the top tertile of later BPV it was 0.54 (95% CI 0.30-0.95). The predicted probability of good outcome for a range of later BPV values is seen in Figure 1.

Conclusion:
Increased BPV in the hours after ischemic stroke onset was not associated with 90-day good outcome, but increased BPV during hours 4-48 after hospital arrival had a significant association with lower odds of good outcome. While these results are hypothesis-generating, the rigor of outcome adjudication and standardization of blood pressure measurements strengthens the findings.
Abstract TMP55: Post-stroke Blood Pressure Variability In The Acute Phase Is Associated With Pre-stroke Blood Pressure Variability In Patients Undergoing Mechanical Thrombectomy
Authors: Soto Alexandria L , Prasad Ayush , Kobsa Jessica , Bartolome David , Begunova Yelyzaveta , Kodali Sreeja , Quispe-Orozco Darko , Farooqui Mudassir , Zevallos Cynthia , Sansing Lauren H , Schindler Joseph L , Matouk Charles , Sheth Kevin N , de Havenon Adam H , Ortega-Gutierrez Santiago , Petersen Nils H
Published: February 2022

Introduction:
High blood pressure variability (BPV) after endovascular thrombectomy is associated with post-stroke complications and poor neurological outcomes. However, whether BPV is an epiphenomenon of the stroke itself or causally related to the outcome remains unknown.

Objective:
In this study we aimed to evaluate if a relationship exists between pre-and post-stroke BPV in patients with large vessel occlusions (LVO).

Methods:
From our prospective stroke registry, we identified patients who had an anterior circulation LVO, underwent EVT, and had at least three blood pressure measurements recorded in the electronic medical record in the six months prior to their stroke admission. All patients had repeated time-stamped blood pressure data recorded for the first 72 hours after thrombectomy. Using the standard deviation of systolic BP, we calculated BPV for each patient and separated patients into tertiles based on their post-EVT BPV. The relationship between pre-stroke BPV and post-EVT BPV was analyzed using an ordinal logistic regression and Spearman’s rank correlation analysis.

Results:
Two hundred fifty-two patients were included in our analysis (mean age 70±16.2 years, mean admission NIHSS 15±7, median pre-stroke BP measurements 14.5 (IQR 5.0-55.8)). Pre-stroke BPV gradually increased for patients with higher post-EVT BPV tertiles (tertile 1 = 13.2(±5.2) mmHg, tertile 2 = 15.0(±5.5) mmHg, tertile 3 = 16.7(±7.0) mmHg, p=0.001). A positive correlation was observed between pre-stroke BPV and post-EVT BPV (p<0.001, R=0.21). After adjusting for age and admission NIHSS, pre-stroke BPV was significantly associated with post-EVT BPV tertile membership (OR 1.37, 95% CI 1.02-1.86, p=0.039).

Conclusion:
High pre-stroke BPV is correlated with high post-EVT BPV. Although larger, prospective studies are needed to provide definitive evidence of this relationship, our work suggests that high post-EVT BPV may be related to an underlying biological phenomenon and not merely a consequence of the stroke itself. Individuals with high BPV may benefit from more intensive blood pressure management in the acute phase after EVT.
Abstract TMP57: Acute Ischemic Stroke Patients Receiving Reperfusion Therapy Do Not Have Worse 90-day Outcomes After Delirium.
Authors: Ahmad Mohammad Jamil , Anjum Sahar , Kumar Aditya , Sebaugh Jacob , Joseph Michele , Williams Bethany , Zha Alicia
Published: February 2022

Background:
Post-stroke delirium (PSD) is associated with increased mortality and worse long-term functional outcomes. Patients who receive reperfusion therapies in the hospital are frequently kept from regular sleep-wake cycles the first 24 hrs after treatment, and this disruption could lead to an increase in PSD. In this study, we evaluate the effect of PSD on immediate and long-term outcomes in AIS patients receiving reperfusion therapies.

Methods:
Between September 2019 and June 2021, pts diagnosed with AIS within 48 hrs of stroke onset were prospectively evaluated for PSD using the Confusion Assessment Method (CAM)-ICU daily for the first eight days of their hospital stay. Patients with severe stroke and expected mortality within the first month at the time of admission or with severe aphasia unable to follow commands were excluded. Reperfusion therapies were defined as any IV thrombolytic, IA thrombolytic, or mechanical thrombectomy (MT). The primary outcome was considered a 90-day mRS score of 0-2.

Results:
Of 179 patients assessed with the CAM-ICU, 89 (49.7%) had PSD. We identified 94 patients that had undergone one or both reperfusion therapies; 52 (55.3%) had delirium. Patients who received tPa had a higher risk for delirium (42 vs 29, p = 0.04), but no difference was observed with MT (Table 1). Patients with PSD had a longer hospital length of stay and a higher median admission NIHSS. Patients with delirium who received tPA were more likely to be discharged to inpatient rehabilitation facilities than home (p-value 0.004, OR 10.1 95%CI 2.1,48). No significant difference was found in 90-day modified ranking scale (mRS) scores of 0-2 in those with or without PSD.

Conclusion:
AIS patients with PSD after reperfusion therapy had no significant difference in 90-day good outcomes despite having longer hospital admissions and being less likely to be discharged home. Further evaluation into how reperfusion therapies convey protection to patients is necessary.
Abstract TMP59: Low Value Of Inherited Thrombophilia Testing Among Patients With Stroke Or Transient Ischemic Attack: A Single-institution Study
Authors: Majmundar Shyam , Rhoades Ruben , Miller Elan
Published: February 2022

Background/Purpose:
Inherited thrombophilia testing in the acute inpatient setting is controversial and expensive, and in many cases does not change clinical management. We sought to determine the value of inpatient inherited thrombophilia testing for patients who presented with an isolated acute ischemic stroke or transient ischemic attack (TIA) without concurrent venous thromboembolism.

Methods:
We retrospectively analyzed a database comprising patients who were admitted for acute ischemic stroke or TIA in 2019 at Thomas Jefferson University Hospitals in Philadelphia, PA and had inherited thrombophilia testing performed during the hospital admission. Charts were reviewed to determine stroke risk factors, test results, and clinical management.

Results:
The study included 102 patients (median age 49.0 years, 53.9% female) who presented with acute ischemic stroke or TIA (including branch and central retinal artery occlusions) and underwent inpatient testing for factor V Leiden, prothrombin G20210A variant, hyperhomocysteinemia, PAI-1 elevation, and deficiencies of protein C and S and antithrombin. 406 tests were ordered, among which 14.0% resulted abnormal, and 41.2% of patients had at least one abnormal test. Patients without stroke risk factors were more likely to have an abnormal result (60.0% vs 35.1%, P = .028). However, 40% of abnormal tests were borderline positive antigen or activity assays that likely represented false positives. Considering only definitively positive results, there was no significant difference in the likelihood of a positive test in patients with vs without stroke risk factors (32.0% vs 26.0%, P = .557) or those under vs over age 50 years (30.2% vs 24.5%, P = .519). No patients with an abnormal result had their clinical management changed as a result. Charges for the tests totaled $182,994 USD.

Conclusions:
Inpatient inherited thrombophilia testing immediately following isolated acute arterial ischemic stroke or TIA was associated with high rates of false positive results and was expensive. Positive results did not change clinical management in a single case.
Abstract TMP82: Comparison Of Direct Oral Anticoagulants To Vitamin K Antagonists For Treatment Of Cerebral Venous Sinus Thrombosis
Authors: Humayun Mariyam , Schmitt Barrie , Somani Sana , Lin Chen , Lyerly Michael J , Sandefer Kristen , Bakradze Ekaterina
Published: February 2022

Introduction:
Direct oral anticoagulants (DOACs) have gained popularity in treating cerebral venous thrombosis (CVT). However, studies comparing the use of DOACs to Vitamin K antagonists (VKA) among patients with CVT are limited.

Methods:
We conducted a single-center retrospective cohort study comparing VKA to DOAC-treated CVT patients. Clinical, radiographic findings and outcomes were compared. Continuous and categorical variables were compared using t-test or Wilcoxon test and Chi-square or Fisher's exact test, as appropriate.

Results:
82 CVT patients were included in final analysis (mean age 41.3±16.3, 76.8% women). Thirty (37%) were treated with DOACs. There was no difference in clinical or radiographic characteristics between the two groups. There was no death and majority of patents were discharged home (p=0.11). Sixty-one patients (74.4%) had follow-up imaging within a year. Fifteen, thirty-seven and nine patients had complete, partial, and no vessel recanalization, respectively. There was no difference in recanalization status between the DOAC and VKA groups (p=0.53). 68 patients (82.3%) had follow-up data on headache status: 21(31%) reported resolution and 45(66%) partial improvement with no difference between DOAC and VKA groups (p=0.81). One patient in the DOAC group had a recurrent CVT. One patient in the VKA group had a major hemorrhage within 3 months.

Conclusion:
We found no significant difference in venous recanalization or outcomes in patients with CVT treated with DOAC vs VKA. DOAC appears to be a safe alternative to VKA. Large multicenter studies are needed to better evaluate the efficacy and safety of DOAC in CVT.
Abstract TMP84: Baseline Cerebral Blood Flow Association With Cognitive Functions: Prospective Cohort Study.
Authors: Ashouri Yazan , Chou Ying-hui , Murphy Devin , Hsu Chiu-hsieh , Trouard Theodore , Zhou Wei
Published: February 2022

Introduction:
Carotid occlusive disease is reported to impact cognitive function. Reduced cerebral blood flow is considered a culprit in carotid disease-related cognitive impairment. However, the association is not consistent.

Aim:
To investigate the relationship between baseline cerebral blood flow (BCBF) and cognitive functions in a well-defined cohort of patients with severe occlusive extracranial carotid disease.

Methods:
Patients undergoing carotid intervention for occlusive diseases were prospectively recruited from two academic institutions. All patients received neurocognitive testing and MRI scanning pre-intervention. For neurocognitive testing, raw scores were normalized against age, education, and standard scores as appropriate. The cognitive domain-specific normalized scores were derived using principal component analysis. Univariate and multiple linear regression models were fitted to evaluate predictors of various cognitive domains including memory, executive function and language. Variables with P<0.1 in the univariate analysis were included in the multiple models.

Results:
A total of 140 patients were included in our analysis. Most patients were males (96%) with a mean age of 69.9 years. Almost half of the cohort (50.8%) were symptomatic. Most patients were smokers (78.1%) and hypertensive (86.4%). Diabetes was prevalent (39.4%). In the multiple regression model, BCBF was independently associated with Trail Making Test (TMT) [regression coefficient(B)=-0.015, Standard Error (SE):0.008, p=0.04]. Other significant predictors of TMT were prior stroke and diabetes. BCBF was also associated with scores on the Stroop test (B=0.023, SE=0.009), albeit nonsignificant, in the multiple regression model (P=0.06). Age, renal insufficiency, and prior stroke were independently associated with Stroop test, p<0.5.

Conclusion:
Our study showed an association between BCBF and baseline executive function measured by TMT in patients with severe carotid occlusive disease. BCBF was also associated with Stroop test in a trend that did not reach statistical significance. Inconsistency in the association between CBF and cognitive function may be due to diverse cognitive measures and patient-related comorbidities.
Abstract TMP86: Hippocampal Neuron Loss, Synaptic Plasticity Deficits, And Impaired Learning And Memory In A Mouse Model Of Neonatal Middle Cerebral Artery Stroke
Authors: Mitchell Danae , Frazier Alexandra P , Orfilla James E , Quillinan Nidia , Herson Paco S , Dingman Andra L
Published: February 2022

Background:
Cognitive deficits are common long-term sequelae after neonatal stroke, occurring in to 70% of school aged children. Despite this, chronic cognitive deficits have not been evaluated in animal models of neonatal stroke.

Objective:
To determine whether neonatal mice have behavioral memory and hippocampal cellular and plasticity changes after transient middle cerebral artery occlusion (tMCAO).

Methods:
C57/BL6 mice underwent 60 minutes of right tMCAO using the intraluminal filament model, or sham surgery, followed by reperfusion on postnatal day 10 (p10). Mice underwent contextual fear conditioning (CFC) testing to evaluate spatial memory 14 days after tMCAO (p24, juvenile equivalent). A separate set of animals were sacrificed at the same timepoint for Crestly Violet staining and stereology of CA1 neurons, or for LTP recordings. Increase in field excitatory post-synaptic potential (fEPSP) slope 60 min after theta-burst stimulation (TBS) was analyzed as a measurement of synaptic plasticity (LTP).

Results:
Animals had a significant decrease in % time freezing in the CFC paradigm 14 days after p10 tMCAO compared to sham surgery animals, indicating behavioral spatial memory impairment (Figure 1A). Animals who underwent p10 tMCAO also had a deficit in LTP after TBS in ipsilateral compared to contralateral CA1 (figure 1B). Animals had a decrease density of CA1 hippocampal neurons in the ipsilateral hippocampus compared to contralateral hippocampus 14 days after p10 tMCAO (Figure 1C).

Conclusion:
Our results show that neonatal stroke causes CA1 hippocampal pyramidal cell death and synaptic plasticity deficits which contribute to chronic memory impairment.
Abstract TMP88: Development Of An Interprofessional Pediatric Stroke Program Across A Fourteen Hospital Healthcare System In Southern California
Authors: Urbayan Carmen , Akamine Aaron , Han Paul , Lewis Keith , mahmoudian camelia , BUGNON Valerie , Briano Natalia , Hanke Sandra , Punsalang Lorina , Rho Howard , Sangha Navdeep S
Published: February 2022

Background:
An annual estimate of 1.0 to 2.0 in every 100,000 children are affected by stroke. The American Stroke Association (ASA) recommends the development of education programs to expand provider knowledge and establish systems to facilitate efficient pediatric stroke care. We embarked on establishing a regionwide, multidisciplinary pediatric stroke program consistent with the ASA goals of prompt recognition and management of stroke in pediatric patients across the organization’s 14 hospitals.

Methods:
In February 2020, we established a workgroup consisting of a stroke neurologist, pediatric physicians, stroke coordinators, clinical nurse specialists, nurse educators, clinical informaticists, and clinical nurses. The objectives were to standardize the pediatric stroke algorithms for the inpatient, emergency, and ambulatory settings; identify documentation tools specific for pediatric stroke; and develop education modules. The primary goal was immediate specialty consultation and transfer of pediatric stroke patients to the appropriate level of care. Nursing flowsheets were enhanced to include the Pediatric NIH Stroke Scale. The pediatric stroke education was designed as a multimodal program tailored for each professional role and work area. Education was implemented utilizing strategic methods to
initiate
(interactive online modules),
reinforce
(huddles, skills day), and
sustain
(annual updates) knowledge on pediatric stroke recognition, escalation, and management.

Results:
The organization’s pediatric stroke algorithms, documentation tools, and online modules raised awareness on this low-volume, high-risk pediatric condition. It is anticipated that referrals to the regional telestroke and the comprehensive stroke center will increase, resulting in timely treatment and better outcomes.

Conclusion:
Development of a regionwide pediatric stroke program requires the support and commitment from leadership and clinical stakeholders. Next steps for the organization’s pediatric stroke workgroup will include establishment of quality metrics relevant to pediatric stroke, including timeliness of subspeciality assessment and transfers, and initiation of emergent interventions.
Abstract TMP92: Clinical Outcomes Of Surgical Clipping Versus Endovascular Coiling For Aneurysmal Subarachnoid Hemorrhage In Pediatric Patients
Authors: Garg Aayushi , Bohnstedt Bradley , Jadhav Ashutosh , Limaye Kaustubh
Published: February 2022

Background:
Surgical clipping (SC) and endovascular coiling (EC) are both being utilized in the management of ruptured intracranial aneurysms in pediatric patients. However, the data regarding the comparative safety of these techniques is limited. In this study, we aimed to evaluate the clinical outcomes of SC versus EC in pediatric patients presenting with aneurysmal subarachnoid hemorrhage (SAH).

Methods:
Pediatric hospitalizations undergoing surgical intervention for non-traumatic SAH were identified from the Nationwide Readmissions Database, 2016-2018. Hospitalizations with the diagnoses of arteriovenous malformation, cerebral arteritis, or traumatic SAH were excluded. Logistic regression analysis was used to compare outcomes between SC and EC. Survival analysis was used to evaluate 30-day non-elective readmissions.

Results:
During the study period, 238 patients met the inclusion criteria (mean±SD age: 10.8±6.4 years; female: 46.8%). Of these, 81 (34.0%) patients underwent SC and 157 (66.0%) underwent EC. There were no statistically significant differences in the baseline demographics, clinical presentation, and hospital-level characteristics between the two groups. Clinical outcomes including post-operative stroke, seizures, prolonged mechanical ventilation, acute cardiac complications, venous thromboembolism, infections, length of hospital stay, in-hospital mortality, and discharge disposition were similar between the two groups, however, patients with EC were less likely to develop acute renal failure (OR: 0.2, 95% CI: 0.1-0.9). Further, 14 patients were readmitted within 30 days of discharge due to a non-elective reason (mean±SD time to readmission: 17.2±8.0 days). Patients with EC were less likely to get readmitted, however, the difference was not statistically significant (HR: 0.5, 95% CI: 0.1-2.3). While most of the readmissions were due to non-neurologic etiology, 29% were due to hydrocephalus or post-surgical complications. There was no in-hospital mortality among readmissions.

Conclusions:
The safety profiles of SC and EC for the treatment of aneurysmal SAH in pediatric patients were comparable. However, we identified a trend towards better clinical outcomes in patients treated with EC as compared to SC.
Abstract TP113: Association Of External Ventricular Drain Duration And Outcomes In Aneurysmal Subarachnoid Hemorrhage
Authors: Gonzalez Wendy , Forman Elyse , Stretz Christoph , Potter Nicholas S , Wendell Linda C , Reznik Michael , Furie Karen L , Thompson Bradford , Mahta Ali
Published: February 2022

Introduction:
Hydrocephalus is a common complication following aneurysmal subarachnoid hemorrhage (aSAH) and is usually treated with external ventricular drain (EVD). However, there is no consensus on EVD weaning process and duration of cerebrospinal fluid (CSF) drainage. We aimed to determine association of EVD duration and outcomes.

Methods:
We performed a retrospective cohort study of consecutive patients with aSAH who were admitted to an academic referral center between 2016 and 2021. Binary logistic regression was used to test the association of EVD duration (continuous variable) and outcomes including functional outcome defined as modified Rankin scale of 4-6 at 3 months after discharge and requirement for ventriculoperitoneal shunt (VPS) placement. Multiple linear regression analysis was used to test the association of EVD duration and hospital length of stay (both continuous variables)

Results:
Of 316 patients with aSAH, 253 patients received external ventricular drain (EVD) on admission for symptomatic hydrocephalus and we included survivors (n=204) in final analysis. (mean age 57.9 years (SD 13.8), 62% female, 71% white). VPS was placed in 15% (30/204) prior to hospital discharge. Duration of EVD was longer in patients with worse functional outcome (median 18 days [IQR 13.5-23] vs 12 days [IQR 8-19); p=0.006). EVD wean was interrupted in 39% of survivors (80/204) due to persistent hydrocephalus (61%) and asymptomatic vasospasm (19%) based on transcranial Doppler criteria. Longer EVD duration was associated with higher VPS requirement (odds ratio 1.17 per day, 95% CI 1.09-1.26; p<0.001) after adjustment for age, aneurysm related factors, Hunt and Hess grades, modified Fisher scales and delayed cerebral ischemia. EVD related complications such as infections (2%) and tract hemorrhage (9%) were non-significantly higher in patients with longer EVD duration. (p=0.070) Longer EVD duration was associated with longer hospital length of stay (0.88 more days, 95% CI 0.73-1.04; p<0.001) independent of aSAH complications.

Conclusions:
Longer EVD duration can be associated with worse outcomes and higher need for VPS placement and longer hospital length of stay. Further studies are needed to justify early VPS placement in selected patients.