bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP288: Inter-Alpha Inhibitor Proteins Reduce the Presence of Neutrophils and Matrix Metalloproteinase-9 Positive Neutrophils in Damaged Brain Regions of Neonates with Hypoxic-Ischemic (HI) Brain Injury
Authors: Barrios-Anderson Adriel , Chen Xiaodi , Lim Yow-Pin , Stonestreet Barbara S
Published: June 2021

Introduction:
Inter-alpha inhibitor proteins (IAIPs) are immunomodulatory proteins that play a significant anti-inflammatory role in hypoxic ischemic (HI) brain injury. We have shown that administering IAIPs after HI improves histopathological brain injury, brain weight, and behavioral outcomes in neonatal rats. Neutrophils are specialized leukocytes known to infiltrate the brain parenchyma and exacerbate neuronal injury after HI. One molecular mechanism by which neutrophils exert damage on the blood-brain barrier (BBB) and brain tissue after ischemia is by the release of matrix metalloproteinase-9 (MMP9), an enzyme that breaks down the extracellular matrices of surrounding cells.

Objective:
To determine the effect of IAIPs on neutrophil infiltration and release of MMP9 in neonatal rats after HI.

Methods:
The Vannucci model was used to induce neonatal HI in postnatal day 7 rats that were assigned to a Non-ischemic sham-control group (Sham, n=12), right-sided carotid ligation with exposure to hypoxia (8% oxygen for 90 min) treated with placebo group (PL-HI, n=17), or an IAIP treated group (IAIP-HI, n=17). Rat sex was recorded. IAIP (30 mg/kg) or PL was given intraperitoneally at 0, 24 and 48 h after HI. We removed the rat brain after 72h and performed immunohistochemistry using MPO (neutrophil selective) and MMP9 fluorescent markers. We performed stereological analyses with the StereoInvestigator 10.0 Fractionator probe without knowledge of group assignment to quantify neutrophils and MMP9 positive cells present within the right hemisphere, cortex, corpus callosum, and hippocampus.

Results:
MPO positive cells were significantly reduced in male IAIP treated rats compared with PL-HI in the overall damaged hemisphere (p<0.01) and the corpus callosum (p<0.05). Further, we observed MPO and MMP9 co-localization, and IAIP treatment reduced the presence of MMP9 positive neutrophils in the cortex of male rats compared to placebo (P<0.05).
Abstract WP295: Remote Limb Ischemic Conditioning in Murine Focal Cerebral Ischemia
Authors: Kitagawa Kazuo , Saitoh Moeko , Ishizuka Kentaro
Published: June 2021

Background & Aims:
Remote ischemic conditioning (RIC) could induce brain protection in cerebral ischemia. The conditioning can be divided into pre-, per- and post-conditioning. The aim of this study is to clarify which RIC is the most effective in murine focal ischemia.

Methods:
Adult male C57BL/6 mice were used in this study. Transient focal cerebral ischemia was produced with nylon-suture model by occluding middle cerebral artery (MCAO) for 45 minutes. Cortical cerebral blood flow (rCBF) was continuously measured during ischemia with laser Doppler flowmeter. Twenty-four hours after MCAO, the animals were sacrificed and their brains were removed. After cutting coronal 1-mm brain sections, infarct volume was measured after TTC staining. Fifty mice were divided into five groups (each n=10); sham RIC group, delayed preRIC group (RIC 24 hours before MCAO), early preRIC group (RIC 5 minutes before MCAO), perRIC group (RIC during MCAO), and postRIC group (RIC 5 minutes after MCAO). Hind limb ischemia was induced by making the snare as tight as possible using a hemostatic forceps for 5 minutes followed by loosening it for 5 minutes. Four cycles were performed as RIC.

Results:
Infarct volume were 58.8±10.1 mm
3
in sham RIC, 54.8±19.4 mm
3
in delayed preRIC, 69.3±10.8 mm
3
in early preRIC, 38.0±22.1 mm
3
in perRIC, and 64.5±13.5 mm
3
in postRIC groups. Infarct volume in perRIC was significantly smaller than that in sham RIC and other groups (P<0.01). However, infarct volume of other RIC groups was not different with sham RIC group. After MCAO, rCBF reduced to 15.6% of baseline level in sham RIC, 11.2% in delayed preRIC, 11.9% in early preRIC, 13.4% in perRIC, and 10.8% in postRIC group. No difference was found in residual rCBF among all groups. At the end of MCAO, rCBF compared to rCBF immediate after occlusion was 102±21% in sham RIC, 112±25% in delayed preRIC, 98±22% in early preRIC, 131±33% in perRIC and 105±19% postRIC groups. Relative rCBF change at the end of MCAO in perRIC was significantly more than that in sham RIC group (P<0.05).

Conclusions:
Among four RIC procedures, only perRIC showed clear brain protection against transient MCAO. Change during rCBF may suggest that enhancement of collateral circulation play a role in part on brain protective effect of perRIC.
Abstract WP297: Moderate Alcohol Preconditioning Activates BKCa Channels to Protect Brain Damage-Induced by Cerebral Ischemic/Reperfusion
Authors: Zhao Yi L , Guo An C , Wang Yong J , Wang Qun
Published: June 2021

Objective:
We hypothesis that moderate EtOH-PC activates BKCa channel to protect brain damage induced by focal cerebral I/R. This project will utilize focal cerebral ischemic/reperfusion (I/R) animal model to explore the function of BKCa channel in EtOH-PC protection in vivo levels by means of pharmacological intervention such as BKCa channel opener(NS11021)and blocker(Paxilline).

Methods:
The SD rat were randomly divided into the following six groups (n=10) : sham, I/R ,EtOH-PC+I/R, NS11021-PC+I/R, Paxilline+EtOH-PC+I/R, Paxilline+NS11021-PC+I/R. Both EtOH-PC and NS11021-PC (0.1mg/kg; ip) were induced 24h before I/R. The volume of 95% ethanol to be instilled (in μL) was calculated as follows: [body weight (g)х0.6] + 0.3. This volume of ethanol was mixed in 0.3mL of sterile distilled water just before administration to the animals by gavage. The Paxilline(2.5mg/kg; ip) was administered 10min before EtOH-PC and NS11021-PC.The right middle cerebral artery occlusion (MCAO) was produced by inversion of a 4-0-nylon filament. The filament was withdrawn 2h after onset of MCAO and then reperfused. Neurological deficits and infarct volume were measured 24 hours after I/R. Another 36 rats were randomly divided into 6 groups as above, 6 in each group. DWI were performed 2h after ischemic and T2WI MRI were performed 24h after ischemic/reperfusion to observe the infarct volume of brain and the penumbra volume of brain in each group. Then rats were killed and detected the apoptotic cell death and degeneration of neurons.

Results:
Compared to ischemic-reperfusion group, the neurological score (P < 0.01), the infarct volume of brain (P < 0.01), the infarct volume of ischemic penumbra(P < 0.01),the percentage of apoptotic cell death (P < 0.01) and the percentage of degenerative neurons (P < 0.01) were significantly decreased after ethanol and NS11021 preconditioning,while these changes were reversed by Paxilline(P < 0.05).

Conclusion:
Our results show that moderate alcohol preconditioning activates BKCa channels to protect brain damage induced by focal cerebral ischemic/reperfusion.
Abstract WP299: Patients Transferred to Tertiary Care Centers with Fatal Ischemic Strokes Increase Center Specific Mortality Rates
Authors: Johnson Paul , Freeburg Nickolas , Tirschwell David
Published: June 2021

Background:
The Center for Medicare and Medicaid Services (CMS) tracks annualized 30 day mortality data for patients with ischemic stroke across hospitals. Due to the increased complexity and severity of stroke patients transferred to tertiary centers, mortality rates would be expected to be higher than at institutions which transfer these patients. Publicly available mortality data may not adequately account for this referral pattern, making tertiary care centers appear to provide inferior care.

Methods:
We retrospectively analyzed all recorded deaths within 30 days of ischemic stroke from 2009-2011 at our Comprehensive Stroke Center. Data was abstracted from patient charts, including the NIHSS as recorded or calculated retrospectively based on documented exam, admission time, time of first palliative care consult, time of comfort care orders and time of death. Descriptive and nonparametric statistics were used.

Results:
There were 42 CMS patient deaths reviewed, median age (interquartile range, IQR) was 82 (75-87), median NIHSS = 22.5 (IQR 19-27), 55% were transferred in, 24% received IV tPA, 36% died within 72 hours of admission, 36% had Palliative Care consults and 90% were placed on comfort care. Transfer patients that died did not differ from direct admit deaths by age, NIHSS or death within 72 hours; NIHSS scores averaged 21 in the transferred group vs. 23 in the direct admits, death within 72 hours was 39% for transfers vs 31% for direct admits. There was a trend toward increased use of tPA (35% transfers vs. 11% direct admits, P = 0.07). Patients that died within 72 hours of admission had significantly higher NIHSS scores (26 (IQR 24-31) vs. 20 (IQR 13-25), P = 0.0025) and were less likely to have received a Palliative Care consult (13% vs. 48%, P = 0.024); there were no differences in age or other factors.

Conclusions:
Over half of the deaths counted in our institutions 30 day ischemic stroke mortality rate were from transfers. Almost all of these patients were placed on comfort care. Many passed away within 72 hours of admission. Early withdrawal of care for severe ischemic strokes in elderly patients may reflect higher, rather than lower, quality of care. Including early deaths with comfort care may bias the CMS mortality measure against tertiary referral centers.
Abstract WP301: Onset to Arrival Time in Acute Ischemic Stroke Patients : Neuroscience Institute in Western India Experience
Authors: Vaishnav Anand , Vaishnav Radhika , Shah Rakesh
Published: June 2021

Objective:
To evaluate factors that influence onset to arrival time of Acute Ischemic Stroke (AIS) patients at a Western Indian Neuroscience Institute.

Introduction:
Thrombolytic therapy for AIS is in the developing stages in India. In order to increase availability of intravenous tissue plasminogen activator (IV rtPA) to AIS patients, it is essential to understand the current scenario and factors affecting onset to arrival time of AIS at Indian hospitals. Limited data is available regarding onset to arrival time and associated demographic, epidemiological and clinical characteristics of hospitalized AIS Indian patients.

Methods:
Vadodara Institute of Neurological Sciences (VINS) is a standalone Neurological Hospital situated in Vadodara, India. Prospective data (onset to arrival time, demographics and clinical features) was collected on AIS patients admitted to VINS from June 2014 to July 2016. Onset to arrival time was stratified into 5 groups: < 3 hours, 3-4.5 hours, 4.5-6 hours, 6-24 hours and beyond 24 hours. Univariate and multivariate analysis was performed on collected data based on whether they arrived early (< 6 hours) or late (> 6 hours).

Results:
Data was collected on 519 AIS patients of whom 55, 18, 32, 120 and 294 presented < 3 hours, 3-4.5 hours, 4.5-6 hours, 6-24 hours and beyond 24 hours respectively. Thus, 105 and 414 patients belonged to early and late arrival groups respectively. Univariate and multivariate analysis showed that higher educational status (p=.002), history of prior stroke (p=.0009), coronary artery disease (p=.0001) and atrial fibrillation (p=.0009) was associated with early arrival to the hospital. No difference was noted between the two groups with reference to age, sex, hypertension, diabetes, hyperlipidemia, smoking, mean NIHSS, hemiparesis or any cortical signs.

Conclusion:
Patients presenting within the time window for IV rtPA (<4.5 hours) and intraarterial thrombectomy (< 6 hours) were 14% and 20% respectively in our cohort. Prior vascular events and higher educational status were associated with early arrival within the thrombolysis/thrombectomy treatment window for AIS. Grass-root level stroke education to communities with poor educational status can significantly enhance AIS thrombolysis treatment.
Abstract WP305: Uniting Hospital Leaders in a Competitive Region to Improve Intravenous Thrombolysis Rates: Analysis of the SETRAC Stroke Registry
Authors: Jaeger Andrea , Suarez Jose I , Savitz Sean I , Ramos Kate , Pile Darrell , Farquhar Grace , Bissell Catherine
Published: June 2021

Uniting Hospital Leaders in a Competitive Region To Improve Intravenous Thrombolysis Treatment Rates: Analysis of the SETRAC Stroke Registry

Background:
The Southeast Texas Regional Advisory Council (SETRAC) convenes representatives from area hospitals belonging to different health systems to discuss how to improve the delivery of stroke care in a nine county area that includes Houston, Texas. In 2014, area hospitals agreed to focus upon improving tissue plasminogen activator (tPA) administration rates in the area.

Hypothesis:
By sharing stroke metrics in a blinded fashion on a consistent basis, tPA administration rates will improve. The theory was tested by tracking the following metrics:

a. percent of ischemic stroke patients receiving tPA.

b. percent of treated patients receiving tPA within 60 minutes of arrival at the hospital.

Methods:
SETRAC aligned regional metrics with stroke treatment and timing metrics in Get With The Guidelines®-Stroke beginning in Q3 2014. SETRAC compiled and shared this data with stroke coordinators and hospital administrators on a quarterly basis. Bar graphs were utilized for benchmarking hospitals in a blinded fashion. Linear tests were performed to validate increases in the percent of patients treated with tPA and the percent of patients treated within 60 minutes of arrival at the hospital. Results from hospitals that consistently reported data for each of the six quarters were included in the analysis.

Results:
Twenty-six area hospitals reported 10,396 ischemic stroke patients between Q3 2014 through Q4 2015. In that time, tPA administration increased from 10.3% in Q3 2014 to 12.0% in Q4 2015 (p<0.001). Further, tPA administration within 60 minutes of arrival in emergency room increased from 55.3% in Q3 2014 to 66.7% in Q4 2015 (p<0.001).

In conclusion, following the uniting of hospital leaders and utilizing nationally aligned stroke metrics, a higher percentage of ischemic stroke patients received tPA. Of those that received tPA, an improvement in the timeliness of administration was also realized.
Abstract WP31: Fibrin Rich Thrombus versus Erythrocyte Rich Thrombus in Acute Large Vessel Occlusion
Authors: Maekawa Kota , Shibata Masunari , Seguchi Masaru , Kobayashi Kazuto , Nakajima Hidetaka , Mizutani Akane , Kitano Yotaro , Yamasaki Masayoshi , Sano Takanori , Mori Motonobu , Shimizu Shigetoshi , Yabana Tadashi , Naito Yutaka , Miya Fumitaka
Published: June 2021

Objective:
The aim of this study was to evaluate thrombus composition and its association with clinical, laboratory, and neurointerventional findings in patients treated by mechanical thrombectomy due to acute large vessel occlusion.

Methods:
From August 2015 to June 2016, 72 patients were treated in our hospital by mechanical thrombectomy using stent retriever and/or aspiration catheter. Retrieved thrombi underwent semiquantitative analysis to quantify red blood cells, white blood cells, and fibrin by area. We divided patients into two groups as fibrin rich group or erythrocyte rich group according to predominant composition in thrombus. Two groups were compared with respect to imaging, clinical, and neurointerventional data.

Results:
Histopathologic analysis of retrieved thrombus from 37 patients with acute stroke due to internal carotid artery, middle cerebral artery, or basilar artery occlusion was performed. Erythrocyte rich thrombi were present in 13 (35%) of cases, and fibrin rich thrombi in 24 (65%). Cardioembolic etiology was significantly more in patients with fibrin rich thrombi than those with erythrocyte rich thrombi (79% vs. 38%; p=0.01). All other clinical and laboratory characteristics did not differ. Patients with fibrin rich thrombi had greater number of recanalization maneuvers (2.8 ± 1.2 vs. 1.8 ± 1.6, p=0.04) and longer interval time between puncture and recanalization (62 ± 33.6 minutes vs. 42 ± 21.3 minutes; p=0.04). There is no significant difference in occluded vessels and mechanical thrombectomy devices between two groups. Patients with fibrin rich thrombi were lower rate of functional independence (mRS score, 0-2) at 90 days (33% vs. 75%; p=0.04).

Conclusion:
This study showed that fibirin rich thrombus was associated with extended procedure time, unfavorable clinical outcome and cardioembolic etiology.
Abstract WP311: Early Lessons Learned in the Stroke Bundled Payment Experience
Authors: Ermak David , Reichwein Raymond , Morrison Kathy , Richardson Alicia , Lehman Travis M
Published: June 2021

Introduction:
The Bundled Payments for Care improvement (BPCI) initiative was launched by the Centers for Medicare and Medicaid Services (CMS) in 2014. Our organization contracted for Model 2, making us responsible for all costs associated with index hospital stay plus 90 days post discharge for straight Medicare patients. It was anticipated that we would find opportunity for reduction in readmission rates, which would lead to reduced cost of care. Analysis of Q1 & Q2 2014 data revealed other opportunities. First, cases coded as non-traumatic Subdural Hematoma (SDH) - regardless of readmission - accounted for significant financial deficit. Second, 67% of patients utilized Post-Acute Care (PAC - SNF, acute rehab, home health) at least once and 54% utilized a second PAC. All patients discharged to acute rehab who then transitioned to SNF exceeded the target price for the bundle.

Methods:
A case review of SDH episodes revealed that many were traumatic but not documented as such. A summary of these cases was presented to providers with recommendations for appropriate wording to ensure appropriate coding. Education was also provided to coders related to BPCI regarding the impact of clarifying traumatic cause of SDH. Protocols for post-acute management were developed with partners in acute rehab & SNF’s in the region and gain-sharing agreements were developed. Partner facilities reviewed each bundled stroke patient for opportunities to reduce post-acute care LOS.

Results:
Analysis of Q3 2015 demonstrated that the number of SDH cases in the bundle dropped significantly, improving the financial picture six-fold. A reduction in SNF LOS of 25% was appreciated.

Conclusion:
Stroke is a leading cause of disability in the United States and post-acute care for a 90 day episode carries a prohibitive cost. Accurate documentation and partnering with post-acute facilities does improve the financial position. Ultimately though, post-acute care - not readmissions - is the major driving force for dollars spent in Stroke BPCI.
Abstract WP316: Stroke Simulation Improves Resident Confidence in Acute Stroke/TIA Management
Authors: Wadhwa Anant , Katyal Nakul , Singh Niranjan N
Published: June 2021

Objective/Background:
The goal of this study was to determine if clinical simulation improved resident confidence in delivering acute stroke care including patient interaction in acute setting, rapid neurological assessment including NIHSS and ABCD2 and medical decision making.

Design/methods:
Between 2010-2016, a total of 31 neurology residents participated in acute stroke simulation by the end of PGY-1 year before starting stroke calls.Five different case scenarios using standardized patients were used - TIA, Intraparenchymal hemorrhage, acute ischemic stroke within 3 hours, within eight hours and acute ischemic stroke with wake up symptoms.The simulation was video & audio taped. Historic controls consisting of PGY2 residents without simulation were used. Pre & post simulation survey, SP comments and debriefing was done for each scenario.

Results:
Residents reported 100 % satisfaction with quality of demonstrations and hands-on learning experience.The accuracy and timing of decision making - IV thrombolytic, No Thrombolytic and catheter based reperfusion was significantly better to historic control and pre and post simulation competency. The decision making also improved from 1
st
to the 5
th
case scenario. Significant improvement was also seen in patient interaction, utilization of NIHSS and ABCD2 score in decision making, indications and contraindications to thrombolytic, utilization of resources including CT & CTA, CT perfusion and MRI of brain, door to needle time and consulting Neurointerventionist.

Conclusion:
Simulation training using SPs is a superior teaching method in the management of acute stroke/TIA and helps to manage real life patients. Residents felt that this way of learning was superior to classroom didactics. It may be a useful teaching tool for smaller hospitals where patient volume is low, in addition to being utilized as an annual competency test.
Abstract WP317: The Impact of Post-acute Discharge Disposition on Outcomes in the SWIFT PRIME Trial
Authors: Belagaje Samir R , Haussen Diogo C , Saver Jeffrey L , Goyal Mayank , Liebeskind David S , Yavagal Dileep R , Jovin Tudor G , Nogueira Raul G
Published: June 2021

Intro:
Post-acute stroke care in an inpatient rehabilitation facility (IRF) demonstrates better outcomes compared to a skilled nursing facility (SNF). With advancements in endovascular acute stroke, the impact that post-acute care plays is unclear. Here, we analyze a successful endovascular acute stroke trial to demonstrate that more improvement is seen in patients discharged to an IRF compared to a SNF.

Methods:
From SWIFT PRIME, a prospective, multi-center randomized acute endovascular trial, subject characteristics, and modified Rankin scores (mRS) were obtained. Post-acute hospital discharge was classified as home, IRF, and SNF. A favorable outcome was defined as 90 day mRS ≤ 2 and improvement was defined as ≥ 1 point decrease in mRS score. The effect of each disposition on a favorable outcome was calculated overall and stratified by stroke severity class (defined as discharge mRS 0-3, 4, 5)

Results:
A total of 165 subjects (mean age 64.8 years, mean initial NIHSS= 16.5, and 50 % male) were analyzed. Discharge disposition included: 51 (31%) going home, 92 (56%) IRF, 22 (13%) SNF. The baseline characteristics were similar between patients that went to IRF and SNF: age (p =0.76), gender (p= 0.81), baseline NIHSS (p=0.055), final infarct volumes (p=0.20), and recanalization rates (p=0.19). However, IRF subjects had lower NIHSS (p<0.001) and mRS (p=0.017) at day 7. Time to treatment defined as symptom onset to groin puncture was not significantly associated with discharge disposition (p=0.119). Only 1/22 (4.5%) subjects who were discharged to SNF achieved a 90 day mRS ≤2, compared to 41/92 (44.6%) in the IRF group or 48/51 (94.1%) in the home group (p < 0.001). When stratified by stroke severity: for mRS=0-3, there were no differences in favorable outcomes; mRS=4, 1/7 (14.3%) showed improvement at SNF compared to 21/27 (77.8%) at IRF (p=0.008); mRS =5, 5/14 (35.7%) showed improvement at SNF compared to 28/37 (75.7%) at IRF (p=0.013).

Conclusions:
Despite having similar characteristics following acute stroke treatment, not only did subjects who went to SNF compared to IRF have more unfavorable outcomes, they were less likely to make improvement. These findings show the continued importance of post-stroke rehabilitation, even in the endovascular era.
Abstract WP319: Prevalence and Trends of Insomnia Among Stroke Survivors in United States: National Health and Nutrition Examination Surveys 2005 to 2015
Authors: Qureshi Adnan I , Afgan Sher , Saleem Muhammad A
Published: June 2021

Background:
Insomnia is reported among stroke survivors but the prevalence in United States population has not been determined.

Methods:
Using a standard questionnaire, we examined trends and prevalence of insomnia in regards to moderate (5 to 15 times a month) to severe (16 to 30 times a month) difficulty in going to sleep and moderate (5 to 15 times a month) to severe (16 to 30 times a month) difficulty in maintaining sleep in a nationally representative sample of the United States population. Insomnia was classified via a combination of self-reported positive physician diagnosis and high-frequency of ’trouble falling asleep’, ’waking during the night’, ’waking too early’, and ’feeling un-rested during the day’. We analyzed 10887 subjects from 2005 to 2008 National Health and Nutrition Examination Survey (NHANES).

Results:
Moderate to severe difficulty in going to sleep (42[9.3%] versus 1097[10.5%], p-value = 0.31) and moderate to severe difficulty in maintaining sleep (52 [11.5%] versus 1258 [12.0%], p-value = 0.58) were observed among stroke survivors and those without stroke subjects, respectively. After adjustment for differences in age and gender, stroke subjects did not have any increase in risk of moderate to severe difficulty in going to sleep (odds ratio [OR] 1.2; 95% confidence interval [CI] 0.8 to 1.6) and moderate to severe difficulty in maintaining sleep (OR 1.1; 95% CI 0.8 to 1.5). Insomnia was observed in 117 (25.9%) stroke and 2651 (25.4%) non stroke survivors (OR 1.1; 95% CI 0.8-1.3).

Conclusions:
There is no significant increase in sleep initiation and sleep maintenance or insomnia among stroke survivors in the United States.
Abstract WP320: Uncertainty: A Key Influence in the Decision to Admit Patients With Transient Ischemic Attack
Authors: Homoya Barbara J , Damush Teresa M , Sico Jason J , Miech Edward J , Arling Gregory W , Ferguson Jared B , Phipps Michael S , Cheng Eric M , Bravata Dawn M
Published: June 2021

Introduction:
Hospitalization of TIA patients has been shown to improve the timeliness and quality of TIA care yet admission rates for patients presenting with TIA vary considerably across centers.

Methods:
We sought to identify patient and system level factors linked to the decision to admit a patient with TIA. Trained interviewers conducted face-to-face semi-structured interviews with staff involved in TIA care at diverse Veterans Administration (VA) sites. All transcripts were de-identified and imported into a single NVivo10 project file for data coding and analysis.

Results:
70 audiotaped interviews of multidisciplinary clinical staff took place at 14 Veterans Administration Medical Centers (VAMCs). We identified emergent themes and patterns in providers’ decision making. Uncertainty was a key theme in factors that staff reported as an influence in providers’ decisions to admit including: lack of guidance at sites without a facility TIA-specific policy, diagnostic uncertainty related to the TIA event (versus stroke or stroke mimic), general lack of confidence in the ability to complete a timely workup, and specific concerns about patients living a long distance from a VAMC or lacking a support system. Overall, the ABCD
2
score was reported by participants not as a rationale for decisions to admit, but rather for decisions not to admit. Other reported factors related to the decision not to admit included: longer period of time since symptom onset, lack of symptoms, confidence in the ability to get a timely workup as an outpatient, recent evaluation for a prior TIA or stroke event, close proximity of the patient’s residence to a VA facility, strong patient support at home, currently maximized medical management, and availability of observation beds.

Conclusions:
Issues related to uncertainty were reported as key factors in clinical decisions concerning admittance of patients presenting with TIA. Quality improvement interventions for TIA care may need to take into consideration how factors like uncertainty relate to the TIA admission decision-making process.
Abstract WP33: Reperfusion Therapy in Carotid Artery Occlusion with Collaterals Through the Circle of Willis
Authors: Ahn Seong Hwan , Choo In Sung , Kang Hyun Gu , Jung Ji Yeon , Ha Sang Woo
Published: June 2021

Introduction:
In large artery occlusion, endovascular treatment shows better recanalization rate than intravenous tPA alone. In reperfusion therapy, excellent collaterals through the circle of Willis has better prognosis. We hypothesized that intravenous tPA only is comparable to endovascular therapy in carotid occlusion with patent ‘T’.

Methods:
Between January 2010 and December 2015, in acute stroke patients who had received a reperfusion therapy, carotid artery occlusion with good collateral via the circle of Willis were selected. In all patients, non-contrast CT and CT angiography were conducted before reperfusion therapy and at 24 (+/-6) hours and/or clinical worsening. Stroke severity was assessed with NIHSS at baseline and discharge. The prognosis of reperfusion therapy was assessed by modified Rankin Scales at 3 months.

Results:
In 529 patients treated by reperfusion therapy, 29 patients (5.5%, male 21, median age 76) had internal carotid artery occlusion with patent ‘T’. In tPA alone (24 patients, 82.8%), baseline NIHSS were non-significantly lower than in endovascular treatment (10 vs 15, p=0.224). Recurrent stroke, which was confirmed with follow up angiography, was developed in 8 of tPA alone. In endovascular treatment, one had a distal embolization. In 22 patients who could be assessed by MRS, 10 patients (45.5%, tPA in 9, IA in 1) had good mRS and 6 patients (27.3%) were expired.

Conclusions:
Carotid occlusion with good collaterals via the circle of Willis was uncommon. tPA alone resulted in recurrent stroke with clinical worsening. Endovascular treatment may be better option in carotid occlusion with patent ‘T’.
Abstract WP331: Identifying Stroke Subtypes with High Accuracy Using Machine Learning and Icd-9 Claims Data
Authors: Esenwa Charles , Luna Jorge , Kummer Benjamin , Salmasian Hojjat , Kamel Hooman , Vawdrey David , Elkind Mitchell
Published: June 2021

Introduction:
Stroke research using widely available institutional, state-wide and national retrospective data is dependent on accurate identification of stroke subtypes using claims data. Despite the abundance of such data and the advances in clinical informatics, there is limited published data on the application of machine learning models to improve previously reported administrative stroke identification algorithms.

Hypothesis:
We hypothesized that machine learning models can be applied to claims data coded using the International Classification of Disease, version 9 (ICD-9), to accuracy identify patients with ischemic stroke (IS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH), and these models would outperform previously published algorithms in our patient cohort.

Methods:
We developed a gold standard list of 427 stroke patients continuously admitted to our institution from 1/1/2015 to 9/30/2015 using an internal stroke database and applied 75% of it to train and 25% to test two machine learning models: one using classification and regression tree (CART) and another using regularized logistic regression. There were 2,241 negative controls. We further applied a previously reported stroke detection algorithm, by Tirschwell and Longstreth, to our cohort for comparison.

Results:
The CART model had a κ of 0.72, 0.82, 0.59; sensitivity of 95%, 99%, 99%; and a specificity of 88%, 78%, 75%; for IS, ICH and SAH respectively. The regularized logistic regression model had a κ of 0.73, 0.80, 0.59; sensitivity of 95%, 99%, 99%, and a specificity of 89%, 78%, 75%; for IS, ICH and SAH respectively. The previously reported algorithm by Tirschwell et al, had a κ of 0.71,0.56, 0.64; sensitivity of 98%, 99%, 99%; and a specificity of 64%, 52%, 50%; for IS, ICH and SAH.

Conclusion:
Compared with the previously reported ICD 9 based detection algorithm, the machine learning models had a higher κ for diagnosis of IS and ICH, similar sensitivity for all subtypes, and higher specificity for all stroke subtypes in our cohort. Applying machine learning models to identify stroke subtypes from administrative data sets, can lead to highly accurate models of stroke subtype identification for health services researchers.
Abstract WP335: Intracranial Mycotic Aneurysms in Infective Endocarditis: Incidence, Predictors and Outcome
Authors: Topcuoglu Mehmet A , Kursun Oguzhan , Buonanno Ferdinando S , Singhal Aneesh B
Published: June 2021

Introduction:
Intracranial mycotic aneurysms (IMA) are rare but serious complications of infective endocarditis (IE).

Methods and Results:
In this retrospective study (1980-2011) we used original Duke criteria to diagnose IE in 1149 episodes (1081 patients; 81% definite, 80% native valve). Neuro complications occurred in 28%, stroke in 22% (202 infarcts, 53 hemorrhages) and 1% had TIA/TMB. N=33 IMA were detected in 23 (2%) patients. IMA were detected in 8% with focal neuro deficits, 13% with seizures, and 3% with encephalopathy. IMA-related symptoms were present in 22 of 23 cases: headache 48%, seizure 13%, altered sensorium 35% and focal deficits 61%. IMA were detected in 0/885 without stroke, 5.4% with infarcts and 22.6% with hemorrhages (p<0.001); the latter included 9/36 (25%) with ICH, 3/13 (23%) with SAH, and 0/4 with SDH. Of the 23 IMA patients 61% had hemorrhage, 30% had SAH and 57% had infarcts. IMAs were detected by DSA in 21/166 (12.7%). The mean size was 3.6±2.4 mm; 30% multiple; 61% located in distal segments; and 67% in MCA branches. On MRI, 31 had any SAH and 45 had any ICH; IMA detected in 6/9 with diffuse SAH, 2/22 with convexal SAH, 11/45 with ICH, and 11/202 with infarcts. Patients with IMA had higher rates of women, hypertension, known cardiac valve disease, mitral regurgitation, mitral vegetation and
S.viridians
infection (all p<0.05). On multivariable analysis, mitral regurgitation with vegetation (OR 5.9, 95% CI 2.5-14.0, p<0.001) was the only independent predictor of IMA. Clipping was performed in 8 (all pre-2000); endovascular treatment in 7 (all post-1997); 2 died pre- treatment; 1 detected on autopsy; 1 no follow-up available, and 4 regressed/disappeared with antibiotics. Patients with and without IMA showed no difference in rates of in-hospital mortality (22% v. 19%, p=0.93), and length of stay (32d v. 24d, p=0.28). IMA rates did not decrease during the study period (2.2% in 784 episodes 1980-2000 vs. 1.6% of 365 episodes 2001-2011, p=0.653).

Conclusion:
IMA are invariably heralded by neurological symptoms and stroke (especially hemorrhages) on brain imaging. Mitral IE has the highest risk for IMA. IMAs can resolve with antibiotics however studies are needed to determine the efficacy of different treatment approaches.
Abstract WP338: A Prospective Study of Post-thrombolysis related coagulopathy in Acute Ischemic Stroke Patients
Authors: Osteraas Nicholas , Cutting Shawna , Cherian Laurel , Conners James , Song Sarah , Ouyang Bichun , Garg Rajeev , John Sayona , Bleck Thomas , Lee Vivien
Published: June 2021

Introduction:
Although alterations in fibrinogen and fibrinogen degradation products are well-established after intravenous tissue plasminogen activator (IVtPA) in acute stroke, IVtPA is not recognized to cause markedly abnormal international normalized ratio (INR).

Methods:
With IRB approval, we prospectively screened 99 consecutive acute stroke patients who received IVtPA admitted from November 1, 2015 to July 1, 2016. Laboratory tests including INR, activated partial thromboplastin time (aPTT), fibrinogen, and d-Dimer were drawn at intervals of 6, 12, 24, and 48 hours. Data was collected on patient demographics, last known normal (LKN), IVtpA dose and timing, and National Institutes of Health Stroke Scale (NIHSS). Post-IVtPA coagulopathy was defined as INR ≥ 1.5. Reference range for fibrinogen was 190 - 395 mg/dL.

Results:
Among 44 patients prospectively enrolled, the mean age was 66.5 years (range, 32 to 91). Mean time from LKN to IVtPA administration was 2.6 hours (range 0.07 to 10.8). Initial pre-IVTPA mean NIHSS was 14 (range, 3 to 26) and 24 hour mean NIHSS was 7.4, (range 0 to 30). Mean pre-IVtPA INR was 1.05 (range, 0.9 to 1.4). Mean peak post-IVtPA INR was 1.28 (range 1.01 to 3.08). Mean deviation of actual to ideal IVtPA dose was 1.02 mg (range, 22.9 to 14.4). Post IVtPA coagulopathy occurred in 6 patients (14%), with peak INR noted at a mean of 13 hours after IVtPA administration (range, 5.6 to 18.6). Five patients of the six (83%) with post IVtPA coagulopathy had low fibrinogen, and mean fibrinogen nadir was 97 mg/dL (range, 37 to 242). Post-IVtPA coagulopathy was not significantly associated with initial NIHSS, 24 hour NIHSS, LKN to IVtPA time, or deviation of actual IVtPA dose from ideal dose.

Conclusion:
Post-IVtpA coagulopathy occurs in 14% of patients when studied prospectively and is associated with hypofibrinogenemia, but does not appear to correlate with severity of stroke or IVtPA dosing/timing.
Abstract WP34: Prevalence and Predictors of Endovascular Treatment-related Nephropathy in Acute Ischemic Stroke Patients: an Analysis of the Acute Stroke Due to Intracranial Atherosclerotic Occlusion and Neurointervention Korean Retrospective (ASIAN KR) Registry
Authors: Sohn Sung-Il , Hong Jeong-Ho , Chang Hyuk-Won , Kim Chang-Hyun , Hong Ji M , Choi Jin W , Yi Sung E , Kim Yong-Won , Kang Dong-Hun , Kim Yong-Sun , Ovbiagele Bruce , Hwang Yang-Ha , Lee Jin S
Published: June 2021

Background and Purpose:
As endovascular therapy (EVT) occupies a growing role in the management of acute ischemic stroke (AIS), contrast-induced nephropathy (CIN) associated with consecutive contrast media administration for vascular imaging and distal subtraction angiography is an emerging concern. We investigated the incidence, risk factors and clinical outcome of CIN in AIS patients who underwent EVT.

Methods:
Multicenter data from the ASIAN KR registry collected between January 2011 and Mar 2016, on consecutive patients who received EVT for AIS, were analyzed. Diagnostic criteria for CIN were: an absolute increase in serum creatinine (SCr) by ≥0.3 mg/dL from baseline within 48 hours after EVT; or a relative increase in SCr levels by ≥50% from baseline.

Results:
Of 721 patients, 616 patients (85%) were eligible for this study. CIN was diagnosed in 47 (7.6%), and was more associated with history of hypertension (p=0.011), history of diabetes mellitus (DM) (p=0.002), and higher initial NIHSS score (16.6 vs. 18.7 p=0.006). In multivariable analysis, independent risk factors of CIN were hypertension history (OR 2.465, 95% CI 1.027-5.919, p=0.043), DM history (1.978, 1.023-3.822, p=0.042), initial NIHSS score (1.071, 1.014-1.132, p=0.014), initial SCr level (1.603, 1.159-2.217, p=0.004) and duration from puncture to final angiography (1.006 per minute, 1.000-1.012, p=0.045). In multiple logistic regression, CIN was an independent risk factor of poor clinical outcome (modified Rankin Scale at 3 months 4-6; 3.782, 1.770-8.083, p=0.001) after adjusting age, sex, initial NIHSS, hypertension history, DM history, onset to puncture time and successful reperfusion.

Conclusions:
CIN is not uncommon and associated with poor clinical outcome after EVT in AIS. Clinicians should be aware that key factors associated with an increased likelihood of CIN are hypertension history, DM history, abnormal SCr level, higher NIHSS score and longer procedure duration.
Abstract WP341: Outcomes After Percutaneous Endoscopic Gastrostomy in Stroke Patients With Dysphagia
Authors: Xavier Andreea , Vu Kim Yen thi , Alexander Woellner Lauren Jade , Elkins Courtney , De Jesus Aubrey , Clark Rya , Nodecker Anna , Moser Hope , Ragland Jeremy , Choi Alex HuiMahn , Harrison Nicole , Brown Robert
Published: June 2021

Learning objectives: Inability to swallow without aspiration is a common complication of acute stroke. In patients with prolonged swallowing dysfunction, a percutaneous endoscopic gastrostomy (PEG) tube is placed. Although PEG placement is an increasingly common practice, there is a paucity of and sometimes conflicting information about utility and clinical outcomes after PEGs. PEG complications can range from minor to major and complication rates range from 16-75%. For a better understanding of PEG complications versus recovery of swallowing a retrospective study was performed on acute stroke patients who had a failed swallow evaluation and had a PEG placed.

Methods:
A retrospective review was performed of all patients with acute ischemic and hemorrhagic stroke admitted to a large academic medical center who had a PEG placed after failing a swallowing study between January 2016 and March 2016. Complications reviewed included acute bleeding within 24 hours, chronic GI bleeding related to PEG, inadvertent dislodging of PEG, PEG infections and unexpected return to the operating room. Additionally, information about recovery of swallowing function was collected.

Results:
64 patients were included. Average age was 70 years (SD 13.5). A PEG was placed on average 9.1 (SD 5.3) days into hospitalization and LOS averaged 7.6 days (SD 7.7) after PEG placement. The total number of patients who experienced a complication after PEG placement was 14 (21.9%). The most common complications were PEG infections, 6 patients (9.4%) and GI bleeding within 30 days of PEG placement, 6 patients (9.4%). There were 2 inadvertently pulled PEGs (3.1%) and 2 unexpected returns to the OR (3.1%). Out of the complications 2 (3.1%) resulted in death, 2 (3.1%) required surgical intervention. At least 20 patients recovered swallowing within a median of 26 days. At least 5 (7.8%) patients achieved recovery of swallow function within 14 days of PEG placement. Five patients had PEGs placed for inability to swallow liquids.

Conclusions:
In the acute stroke population, placement of PEG tubes was associated with a 21.9% complication rate and a 3.1% risk of mortality.
Abstract WP350: Targeting Lower Blood Pressure in Acute ICH Increases Silent and Symptomatic Infarcts
Authors: Buletko Andrew Blake , Thacker Tapan , Organek Natalie , Mathew Jason , Hussain Muhammad , Frontera Jennifer , Uchino Ken
Published: June 2021

Intro:
Recent clinical trials suggest that intensive blood pressure lowering in acute intracerebral hemorrhage (ICH) does not result in a lower rate of death or disability. We aimed to compare the incidence of restricted diffusion and acute neurological deterioration in patients after an institutional protocol change in systolic blood pressure (SBP) target from <160 to <140 in all acute ICH regardless of time since onset.

Hypothesis:
Intensive blood pressure lowering in acute ICH increases chance of silent and symptomatic acute cerebral ischemia.

Methods:
We retrospectively compared persons with acute, primary ICH from 2013 to 2014 before and after a protocol change in SBP target from <160 to <140. Criteria included admission for acute ICH, MRI within 2 weeks from ICH, no emergent surgical evacuations, and death or withdrawal of care within the first 72 hours of admission. Patient characteristics, BP values, imaging, discharge data, neurological deterioration (not explained by hematoma expansion, seizures, or general medical condition) were collected. Groups were compared using chi-square test for categorical and Wilcoxon Rank Sum for numeric variables.

Results:
Of 286 primary ICH patients in the study period, 119 underwent MRI and met the study criteria (median age 72, interquartile range (IQR) 59-83, median ICH volume 5.7 cc, IQR 1.3-17.6), 62 patients with target SBP <160 (Group 1) and 57 patients in target SBP <140 (Group 2). There was no difference in frequency of MRI imaging between study periods. There were no significant differences between the 2 groups in age, initial NIH Stroke Scale, history of hypertension, hematoma volume, lobar ICH, time to MRI, or initial SBP (median 190 v 188; p=0.831). Mean SBP over the first 24 hours was lower in Group 2 (Group 1: 143 v Group 2: 134; p<0.001). In Group 1, 10 (16%) were found to have DWI changes compared with 18 (32%) of patients in Group 2 (p=0.047). Neurological deterioration increased from Group 1 to Group 2 (3% v 21%; p=0.003).

Conclusions:
Intensive lowering of SBP in acute ICH patients can result in increased cerebral ischemia on MRI and higher rates of neurological deterioration.
Abstract WP352: Clinical Outcomes of Patients Undergoing BrainPath-assisted Evacuation of Intracerebral Hematomas
Authors: Lang Min , Witek Alex M , Moore Nina Z , Bain Mark D
Published: June 2021

Introduction:
Multiple clinical trials have failed to show that surgical intervention leads to better outcomes than medical management for patients with intracerebral hemorrhage (ICH). Newer and less invasive surgical techniques have been reported to be safe and technically effective for evacuation of ICH. The purpose of this study is to evaluate clinical outcomes following ICH evacuation using the BrainPath system (NICO, Indianapolis, IN), a tool that allows minimally invasive access to the subcortical space.

Methods:
IRB-approved prospective data were collected on patients who underwent ICH evacuation using BrainPath at the Cleveland Clinic from August 2013 to April 2016. Glasgow Coma Score (GCS) was collected upon admission and discharge. NIH stroke score (NIHSS) and modified Rankin score (mRS) were collected upon admission and discharge, and at the 3- and 6-month months follow-up visits.

Results:
Thirty-five patients underwent BrainPath-assisted ICH evacuation, with a mean age of 57 ± 16 years and average ICH volume of 50.4 ± 23.5mL. Complications included two patients requiring re-operation due to hematoma re-accumulation (6%), both of whom had serum creatinine greater than 1.5, and one case of wound infection (3%). Eight (23%) patients died during the follow-up period, of which four (11%) died within 30 days of hemorrhage. GCS was 10.1 ± 3.7 on admission and improved to 11.9 ± 2.9 at discharge. NIHSS of surviving patients at pre-operation, discharge, 3-month follow-up, and 6-month follow-up were 18.6 ± 7.7 (n=35), 19.0 ± 8.7 (n=26), 7.8 ± 5.9 (n=19), and 3.7 ± 3.8 (n=12), respectively. mRS at pre-hemorrhage baseline, 3-month follow-up, and 6-month follow-up was 0.7 ± 1.2 (n=35), 4.3 ± 1.5 (n=30), and 3.9 ± 1.9 (n=26), respectively.

Conclusions:
Evacuation of ICH using BrainPath is associated with acceptable rates of surgical morbidity. The 30-day mortality rate was better than expected based on admission ICH scores. Patients showed improvement in GCS between admission and discharge, and they showed improvement in NIHSS and mRS at three and six months postoperatively. A comparative study is needed to investigate whether surgical evacuation using this technique results in improved clinical outcomes compared to medical management.
Abstract WP357: Prevalence of Pre- and Post-intracerebral Hemorrhage Sleep-disordered Breathing
Authors: Scheer Richard V , Lisabeth Lynda D , Li Chengwei , Case Erin , Chervin Ronald D , Morgenstern Lewis B , Garcia Nelda M , Tower Susan , Brown Devin L
Published: June 2021

Background:
Sleep-disordered breathing (SDB) is an independent risk factor for stroke. The reported prevalence of SDB after stroke ranges from 60 to >70%, while the pre-stroke prevalence of SDB is less well described. Moreover, much of these data are derived from ischemic stroke or mixed ischemic stroke and intracerebral hemorrhage (ICH) cohorts. Studies that assess the prevalence of SDB before and after ICH are lacking, with only one prior study (n=32) that reported a post-ICH SDB prevalence of 78%. We report herein the results of a second, larger, prospective study that assessed the prevalence of pre- and post-ICH.

Methods:
Participants enrolled in the population-based stroke surveillance study, the Brain Attack Surveillance in Corpus Christi (BASIC) project, with ICH from 2010-2015 were screened for SDB with the well validated ApneaLink Plus portable monitor (SDB defined as apnea-hypopnea index (AHI) ≥10). The Berlin questionnaire was administered, with reference to the pre-ICH state, to assess for possible pre-stroke SDB.

Results:
Of the 60 ICH participants screened, the median age was 63 years (interquartile range (IQR): 55.5, 74.5). Twenty-one (35%) were female, 54 (90%) were Mexican American, and 53 (88%) had a history of hypertension. The median Glasgow Coma Scale score was 15.0 (IQR: 15.0, 15.0) and the median NIHSS was 5.5 (IQR: 1.5, 8.0). Post-ICH, the median AHI was 9.5 (IQR: 5.5, 19.0); almost half (46.7%) met criteria for SDB. Thirty-four participants (56.7%) screened as high risk for SDB pre-ICH.

Conclusion:
Sleep-disordered breathing was highly prevalent after ICH, and also likely common before ICH, in this mostly Mexican American, community-based sample. If SDB increases risk for ICH, the findings suggest a potential new treatment target to prevent ICH and recurrent ICH.