bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract T P216: A Program for Sustaining Improvements in Acute Stroke Treatment
Authors: Bentaleb Abdeljalil , Golding Larisa , Jackson Robin , Desmond Natasha , Eberly Lewis B
Published: July 2021

Introduction:
Efficacy of thrombolytic therapy in acute stroke patients improves when time to treatment is reduced. Previously we demonstrated improved treatment outcomes after utilizing value stream mapping to improve the efficacy of processing acute stroke patients in the emergency department (ED). We then developed programs to provide sustainability of this process.

Hypothesis:
Attention to process in ED management of acute stroke patients through communication, feedback and multidisciplinary stroke meetings should promote sustainability of the process and improve outcome measures.

Methods:
After formally implementing value stream mapping technology we took steps to maintain improved processing of acute stroke patients and improved outcomes. We developed mechanisms to communicate stroke treatment outcomes to medical staff at all levels. Our stroke coordinator meets regularly with all medical staff involved after a treated case to provide feedback. We have regularly scheduled multidisciplinary stroke meetings where successes are shared and opportunities are discussed. We have scheduled stroke quality meetings to discuss opportunities and communicate with staff involved.

Results:
As a result of constant surveillance, our door to needle (DTN) times have continued to go down, most recently to 42.9 minutes (graph). The number of patients treated with IV-tPA increased from 5% to 14% following implementation of value stream technology, and is currently at 15%. The percent of patients treated within the golden hour has continued to rise, and has now reached 78%.

Conclusions:
Improved outcome measures in acute stroke can be maintained and further improved by regular communication and feedback provided to all members of the stroke team. This fosters a competitive spirit and a sense of ownership that helps to sustain the process. Through this effort we continue to see increases in the number of patients treated and a reduction in treatment times.
Abstract T P234: Multiparametric Assessment of Longitudinal Changes in Tissue Microstructure in Normal and Abnormal Brain Tissue in Patients with Small Vessel Disease
Authors: Valdes-Hernandez Maria D , Armitage Paul A , Sakka Eleni , Munoz Maniega Susana , Royle Natalie A , Makin Stephen , Wardlaw Joanna M
Published: July 2021

Background:
Volume measures of normal brain tissue and white matter hyperintensities (WMH) between two time points gives limited information about the complex dynamics of tissue change. We evaluated two quantitative parameters that characterise the microstructure of normal-appearing white matter (NAWM), deep grey matter (DGM) and WMH on brain images obtained at presentation with minor stroke and at 1 year to investigate the microstructural changes.

Methods:
From 182 brain MRI datasets of patients with minor stroke obtained at baseline and 1 year, we extracted the WMH, DGM and NAWM, and separated WMH into less-intense and intense WMH, using validated semi-automatic methods and validated criteria. We registered the binary structural masks to diffusion space and performed a voxel-wise subtraction of the combined masks at both time points. Then we measured fractional anisotropy (FA) and mean diffusivity (MD)(valuex10
-9
m
2
/s) in each tissue mask at baseline and 1 year.

Results:
WMH volume median increase was 1.4ml (IQR 6.98) mainly due to changes in less-intense WMH: 0.94ml (7.13). WMH that were visible at both time points, ie damage that remained after a year, had the lowest FA=

0.21(0.06) and highest MD=1.05(0.12) at baseline, and were mainly intense WMH at baseline (FA=0.12(0.03), MD=1.55(0.27)). WMH seen only at follow-up, ie that were NAWM at baseline, had the highest FA=0.30(0.06) and lowest MD=0.85 (0.06) at baseline. WMH that were observed only at baseline had intermediate

FA=0.26(0.08) and MD=0.90(0.10). NAWM FA=0.26(0.03), MD=0.78(0.04) and DGM

FA=0.23(0.03), MD=0.79(0.06) did not change between time points.

Conclusions:
WMH at baseline can partially evolve to normal-appearing tissues, remain or precede tissue loss. Differentiation between severe and subtle damage and spatial analysis are necessary to characterise the dynamic of

WMH evolution.
Abstract T P237: Effect of Danger Associated Molecular Pattern Receptor Complex Proteins CD24 and Siglec-G on Stroke Outcome and Microglial Responses
Authors: Weinstein Jonathan R , Hanson Josiah , Hood Lauren , Chao Diana , Murphy Sean P , Moeller Thomas
Published: July 2021

Background:
Both microglia and Toll-like receptors (TLRs) are critical in stroke pathophysiology. In ischemic brain, microglia sense endogenous TLR agonists (danger associated molecular patterns or DAMPs) and respond with varied immune reactions. CD24 and Siglec-G form a receptor complex that modulates TLR4 function and controls responses to DAMPs. The role of CD24 and Siglec-G in stroke is unknown.

Methods:
We performed 45 min middle cerebral artery occlusion (MCAO) on 12 - 14 week old wild-type, TLR4-/-, CD24-/- and Siglec-G-/- male mice and assessed total and regional adjusted infarct volumes at 48 hours with 2,3,5-triphenyltetrazolium staining. Number of mice per group was determined by power analysis. Cerebral blood flow was assessed with laser doppler flowmetry. In vitro, we examined the effects of endogenous TLR4 agonists heat shock protein-70 and high mobility group box 1 on cytokine (TNFα, IL-6) and chemokine (CXCL10, CCL5) release from microglia derived from wild-type, TLR4-/-, CD24-/- and Siglec-G-/- mice.

Results:
Following exclusions for weight, temperature and sub-optimal vessel occlusion/reperfusion, total infarct volumes (mean±SEM) were 51±8 mm3 (n = 21), 51±10 mm3 (n = 8), 28±8 mm3 (n = 13) and 54±8 mm3 (n = 19) in wild-type, TLR4-/-, CD24-/- and Siglec-G-/- mice, respectively (p>0.05, one-way ANOVA). Release of cytokines and chemokines was absent (as expected) in microglia from TLR4-/- mice and differentially regulated in microglia from CD24-/- and Siglec-G-/- mice.

Conclusions:
Genetic deficiency in TLR4, CD24 or Siglec-G modulated microglial response to endogenous TLR4 agonists but did not significantly alter post-stroke infarct volume.
Abstract T P247: Neuronal Sirt1 Activation Negatively Regulates Rho Kinase in Photothrombotic Stroke
Authors: Ahn Yong-Joo , Kim Maya Hwewon , Lee Eun-Hye , Kwon Ye-Rim , Zhong Wenliang , Yi Zheng , Qiu Jianhua , Lee Angela Mingie , Koh Seong-Ho , Kim Hyung-Hwan
Published: July 2021

Background and Purpose:
Sirt1 is a NAD+ dependent deacetylase that is known as one of important regulators for ischemic stroke. Because the role and mechanism of genetic sirt1 over-expression in ischemic brain injury has not yet been studied, we examined that brain-specific sirt1-overexpressing transgenic (BRASTO) mice might have significant beneficial effect in ischemic stroke through regulation of sirt1-Rho kinase (ROCK) signaling pathway.

Methods:
We induced a middle cerebral artery occlusion model in mice and tested the effect of resveratrol (100 mg/kg, i.p.) in ischemia/reperfusion (2h/22h) injury and tested the role and mechanism with BRASTO mice in photothrombotic stroke. Protein levels in mice brain tissue lysates were determined using western blotting.

Results:
Sirt1 activation by resveratrol treatment reduced infarction volume and improved neurological deficit score in transient focal cerebral ischemia. BRASTO mice did not show any obvious phenotypic abnormalities and BRASTO mice improved relative cerebral blood flow and reduced infarction volume by 68.4% compare to that of WT in photothrombotic stroke. Sirt1 over-expression in BRASTO mice was significantly increased by 4.2 fold higher than that of WT mice and Rho-kinase activity was significantly decreased by 54.6% in BRASTO mice.

Conclusions:
These findings indicate that neuronal specific sirt1 activation in BRASTO mice reduced infarction volume in photothrombotic stroke via down-regulation of ROCK signaling pathway. These results suggest that effect of neuronal sirt1 activation may have therapeutic benefits in ischemic stroke via ROCK signaling pathway.
Abstract T P25: Angiographic Predictors Of Hemorrhagic Transformation In Acute Endovascular Treatment Of Ischemic Stroke: A Retrospective Review
Authors: Sandhu Divyajot , Kim Jae H , Vasquez Ciro , Sandhu Gauravjot , Jagadeesan Bharathi , Tummala Ramachandra
Published: July 2021

Background:
Hemorrhagic transformation can follow endovascular recanalization in the setting of acute ischemic stroke (AIS). There are several case series and reports that have looked at CT based predictors of hemorrhage, none exist for conventional angiography. Herein, we present preliminary data on conventional digital subtraction angiography (DSA) predictors of hemorrhagic transformation.

Objectives:
To identify DSA predictors of hemorrhagic transformation in AIS patients undergoing endovascular treatment.

Methods:
We retrospectively identified 27 consecutive AIS patients who underwent endovascular treatment at two large tertiary urban hospitals. DSA images from endovascular intervention and post-procedure CTs were reviewed in these patients. DSA images were screened for time to recanalization, as well as presence of early venous shunting (VS) and early and persistent parenchymal contrast staining (CS).

Results:
There were 14 males and 13 females with a mean age of 59.5 ± 17.1 years and an average NIH stroke scale of 16 ± 6.1. Fourteen patients also received IV tPA prior to DSA. Average time from symptom onset to recanalization was 346 ± 250 minutes, 6/27 patients did not have known time of onset. New hemorrhage on post-procedure CT was seen in 13/27 (48%) patients. In these 13 patients DSA showed early VS in 11 (84%) and CS in 9 (69%) , both VS and CS were present in 8 (61.5%). Neither VS nor CS was noted in the 14 patients who did not have hemorrhagic transformation following endovascular intervention.

Conclusion:
Our findings suggest that the presence of early VS and/or CS in DSA images of AIS patients may predict subsequent hemorrhagic transformation. The presence of such findings should alert the interventionalist to cease further attempts at endovascular revascularization.
Abstract T P273: Internet-Based Information Seeking Behavior for Transient Ischemic Attack
Authors: Abedi Vida , Mbaye Marieme , Tsivgoulis Georgios , Male Shailesh , Goyal Nitin , Alexandrov Andrei , Zand Ramin
Published: July 2021

Background &Purpose:
In recent years, Internet became an increasingly important tool for accessing health information and is being used more frequently to promote public health. In this study, we used Google search data to explore information seeking behavior for transient ischemic attack (TIA).

Methods:
We selected two groups of keywords related to TIA -“Transient Ischemic Attack” and “Mini Stroke” - after examining several related search keywords. We obtained all available online search data performed in the United States from the Google search engine for a ten year span - January 2004 to December 2013. The monthly and daily search data for the selected keywords were analyzed - using a moving window strategy - to explore the trends, peaks and declining effects.

Results:
There were three significant concurrent peaks in the Google search data for the selected keywords. Each peak was directly associated with media coverage and news headlines related to the incident of TIA in a public figure. (Figure 1) Following each event, it took an average of two weeks for the search trend to return to its respective average value. The trend was steady for “Transient Ischemic Attack”; however, the search interest for the keyword “mini stroke” shows a steady increase. The overall search interest for the selected keywords was significantly higher in the southeastern United States.

Conclusions:
Our study shows that changes in online search behavior can be associated with media coverage of key events (in our case TIA) in public figures. These findings suggest that online health promotion campaigns might be more effective if increased promptly after similar media coverage.
Abstract T P289: Long-term Outcome Analysis in Patients With Malignant Middle Cerebral Artery Stroke Who Underwent Decompressive Hemicraniectomy
Authors: Xu Jindong , Warren Sonisha A , Khanna Anna Y
Published: July 2021

Background and Purpose:
Decompressive hemicraniectomy (DHC) reduces mortality and improves physical outcome in selected patients with malignant middle cerebral artery (mMCA) stroke. In this study, we performed comprehensive functional evaluation in mMCA stroke patients who underwent DHC, and attempted to identify the pre-surgical factors that correlated with long-term physical outcome.

Methods:
We identified mMCA stroke patients treated with DHC in our institution between January 2007 and April 2013. Functional outcome was assessed in survivors through clinic visit or telephone interview using modified Rankin Scale (mRS), Barthel Index, Geriatric Depression Scale, Stroke Impact Scale, Satisfaction of Life Scale, and retrospective consent. In addition, all patients including survivors and deceased were classified into acceptable outcome (mRS<=4) and bad outcome (mRS>4) groups. Pre-surgical factors including age, gender, stroke risk factors, time to surgery, cerebral vessel involvement, cause of stroke, use of intravenous tPA or endovascular intervention were compared between two groups.

Results:
37 patients were identified meeting our study criteria. 11 out of 16 survivors were enrolled for functional assessment (mean age 54.7 years, 73% male, 27% left hemisphere stroke, and mean time after stroke 3.4 years). Psychosocial aspect scored much higher than physical outcome in comprehensive functional evaluation. The majority of participants were satisfied with life and agreed for the retrospective consent. Comparing two groups with acceptable (n=9) and bad (n=23) outcomes, pre-surgical characteristics including age>60, anterior cerebral artery involvement, hemorrhagic transformation, history of diabetes and coronary artery diseases were potentially associated with worse long-term outcome.

Conclusions:
A better psychological recovery suggests that appropriate mMCA stroke patients should not be deprived a DHC only based on a presumed unfavorable physical outcome. Some pre-surgical factors may be predictive for a worse outcome, which will assist physicians and families making critical decisions.
Abstract T P29: The Impact of Contrast Based CTA/CTP Brain Attack Protocol on Kidney Function
Authors: Folsom Jamie , Ezerioha Nnadozie , Chhatbar Pratik , Pawar Swaroop , Holmstedt Christina , Jauch Edward , Ovbiagele Bruce , Adams Robert J , Feng Wuwei(Wayne)
Published: July 2021

Background:
We aimed to evaluate the occurrence of acute kidney injury (AKI) associated with contrast based CTA/CTP Brain Attack (BAT) Protocol in a cohort of patients who presented to an academic stroke center with acute stroke symptoms.

Methods:
Consecutive patients who presented to the Emergency Department with acute stroke symptoms from 01/12 to 12/12 and received CTA/CTP contrast-based BAT protocol were identified and their medical records reviewed. Clinicodemographic information was retrieved. Serum creatinine values at baseline, at discharge, and at a follow-up visit, as well as the highest in-hospital value were recorded. AKI was defined as a 0.3 absolute increase in creatinine level from baseline. A logistic regression was fit to identify the potential predictors for AKI.

Results:
Of 348 patients had complete information. 37(11%) patients experienced AKI during hospitalization. Of 38 patients, 16 (43%) patients had persistent elevated creatinine at hospital discharge (5 patients also received endovascular therapy); 11(38%) patients returned to baseline, and the rest 10(26%) patients’ creatinine improved but did not return to baseline. No patient develops end stage renal disease requiring hemodialysis. Baseline creatinine level (p<0.002), comorbidity index (p=0.05) and endovascular therapy (p=0.01) were the three main predictors of AKI. Race, gender and age were not predictors of AKI.

Conclusion:
Contrast based CTA/CTP BAT protocol may incur a small risk of AKI in patients but clinical consequences are minimal. Risks seem greater in patients with higher presenting creatinine level, more comorbidities and those receiving additional contrast from endovascular therapy. More data are required to understand the clinical impact of contrast-based CT stroke imaging protocols.
Abstract T P299: Ambulatory Status: A Protective Mechanism against Venous Thromboembolism in Acute Stroke Patients
Authors: Sisante Jason-Flor , Abraham Michael , Billinger Sandra , Mittal Manoj
Published: July 2021

Introduction:
Deep vein thrombosis (DVT) is reported in 23% to 50% of hemiplegic stroke survivors and the highest rate of incidence occurs within one week of stroke onset. Pulmonary embolism (PE) is reported in up to 5% of stroke patients. There is limited data about the relationship of ambulatory status and the rate of venous thromboembolism (VTE) following a stroke.

Hypothesis:
The goal of our retrospective cohort study was to understand the relationship between VTE and a patient’s ambulatory status, adjusting for age, gender, and stroke type (ischemic, intracerebral hemorrhage, or subarachnoid hemorrhage). We assessed the hypothesis that the stroke patients who are able to ambulate during hospitalization would have lower rates of DVT and PE.

Methods:
We retrospectively analyzed 1670 acute stroke patients who were admitted to an academic comprehensive stroke center between Feb 2006 and May 2014. “Get with the guideline data” was used to identify stroke patients and their ambulatory status (yes/no). VTE was identified using discharge diagnosis. Chi square test and logistic regression methods were used for statistical analysis.

Results:
Mean age was 64.9 ± 14.6 years with 51% men. 1138 (68%) patients were classified as having ischemic stroke; 291 (17.5%) patients had intracerebral hemorrhage; and 241 (14.5%) patients had subarachnoid hemorrhage. During hospitalization, 444 (27%) were ambulatory. Patients able to ambulate during hospitalization had less rate of DVT (6.3% vs 15.3%; p<0.0001) and PE (2.9% vs 5.3%; p=0.04), when compared to non-ambulating patients. After adjusting for age, gender, and stroke type; patients who were able to ambulate still had lower rates of DVT (OR: 0.42, 95% CI 0.27-0.63) and PE (OR: 0.49, 95% CI 0.25-0.88).

Conclusion:
In conclusion, our findings suggest that the patient’s ambulatory status during hospitalization is an independent predictor of VTE. Further research is needed to understand if early mobilization in non-ambulatory stroke patients would have similar protective effect against VTE or not.
Abstract T P314: Higher Modified Graeb Scores May Predict Early Fever In Patients With Spontaneous Intracranial Hemorrhage
Authors: Takahashi Courtney E , Hinson Holly E
Published: July 2021

Introduction:
Both Intraventricular hemorrhage (IVH) and fever after spontaneous intracranial hemorrhage (ICH) have been consistently associated with poor outcomes. Additionally, IVH is an independent risk factor for fever after hemorrhagic stroke (ICH), but it is not known if the degree of intraventricular hemorrhage is predictive of fever. We hypothesized that the extent of intraventricular hemorrhage, defined by modified Graeb score, is associated with intensity of fever.

Methods:
We performed a single center, retrospective review of consecutively admitted adult patients with spontaneous ICH from April 2008 through June 2009. Patients were divided into two groups; those who registered a temperature of 38.5°C at least once during the first 48 hours of their hospitalization (“Early fever”) and those who did not (“No fever”). The degree of IVH was quantified by the Graeb score. Group comparisons were made using a student’s t-test for parametric data and a rank sum test for non-parametric data. Simple linear regression was performed to investigate the relationship between maximum temperature within the first 48 hours (Tmax) and Graeb score.

Results:
Of the 90 patients identified, 20% exhibited early fever. Age and intraparenchymal bleed volume were similar between groups. There was a trend toward more IVH in the febrile group (50% v. 30%, P=0.13), but this did not meet significance. Patients with early fever, however, had higher admission ICH scores (2 [0-2] vs. 1 [1-3], P = 0.01) and modified Graeb scores (1 [0-2] vs. 0 [0-13], P = 0.05). Patients with early fever had a worse GOSE at discharge than those without early fever (3[2-3] v. 3 [3-3], P=0.02). Amongst patients with IVH (n=28), the Graeb score was predictive of the Tmax (t=2.55. CI 0.01-0.08, P=0.02)

Conclusion:
Early fever in ICH is associated with worse outcomes at discharge. Increasing IVH, as reflected by increasing Graeb scores, is associated with higher temperatures in the first 48 hours of admission after ICH, suggesting early fever may be dose-dependent on the degree of IVH.
Abstract T P321: Thrombelastography Can Detect Differences In Patients With Intracerebral Hemorrhage With And Without Intraventricular Hemorrhage
Authors: Bowry Ritvij , McDonald Mark , Cai Chunyan , Rahbar Mohammad , Choi Huimahn A , Edwards Nancy , Lee Kiwon , Grotta James , Chang Tiffany
Published: July 2021

Background:
Intraventricular hemorrhage (IVH) is an important variable for predicting outcomes in patients with intracerebral hemorrhage (ICH). Thrombelastography (TEG) analyzes the dynamics of coagulation (Figure 1) and has previously demonstrated a hypercoagulable state in patients with acute ischemic stroke. Less is known about TEG and patients with ICH, especially those associated with IVH. We sought to determine whether TEG can detect differences between patients with ICH with and without IVH.

Methods:
Venous blood of patients with spontaneous ICH was analyzed with TEG. Demographics and baseline TEG values were compared between patients with and without IVH on initial CT scan. Multivariable linear regression models were conducted to compare the differences in TEG components between the two groups after adjusting for potential confounders.

Results:
Sixty-nine patients with ICH (32 with IVH, 37 without IVH) were analyzed. Baseline antiplatelet use, platelet count, coagulation studies (PT/PTT), and hematoma volume were similar between the two groups. Increased R time (table 1) was seen in patients with IVH (R=4.9) compared to those without IVH (R=4.0, p=0.04), indicating increased time to clot formation. No differences were observed in other baseline TEG values.

Conclusion:
TEG can detect differences in the coagulation profile of ICH patients with and without IVH. ICH patients with IVH have a coagulopathy detectable by TEG independent of antiplatelet or anticoagulant use. TEG may be valuable in the control of hemostasis in patients with ICH.
Abstract T P346: ‘Expedite For Thrombolytic’ Patient Designation and Early Ordering for Improved Door-to-Needle Times in Acute Ischemic Stroke
Authors: Bajkiewicz Christopher T , Kalafut Mary , Olson Lindsay , Afshar Katherine
Published: July 2021

Purpose:
The American Heart Association’s ‘Target: Stroke Phase 2’ (TS2) ‘door-to-needle’ time sets a goal for IV tPA administration of <45 minutes in >50% of eligible patients. In order to meet this goal we delineated a set of patient characteristics which would trigger an expedited pathway for IV tPA administration. These characteristics included a well documented time of onset, obvious and significant stroke and no history of anticoagulant use. We then used this patient group to implement processes to decrease door to needle time. Methods: A retrospective cohort of 35 IV tPA, ED-administered cases from 5/2013-2/2014 were reviewed. DTN <60 minutes was achieved in 22 cases (62.9%, mean 62.0 min, median 45.0 min). EMS, field-initiated stroke codes expedited evaluation in 65.7% of patients. Turn-around-times (TAT) in Stroke Code processes (non-contrast head CT and laboratory results) demonstrated 95.7% compliance with benchmark times. The time of presentation to orders received for IV tPA revealed a mean of 48.8 min and median of 45.0 min. Cases with DTNs >60 minutes (n=13), documented reasons include family indecision (38.5%), blood pressure management (15.4%) and other (46.1%). Results: Neurologists, ER physicians, nursing, pharmacy, and radiology used the data to construct a new, consistent processes to safely deliver IV tPA in <45 minutes.

In the first 90 days, ED IV tPA times (N=16) dropped to 48.5 min, median 49.5 min.

The expedite-for-thrombolytic principle ‘to treat unless excluded’ aligns and assists in meeting the benchmarks identified in TS:2 (goal IV tPA <45 minute DTN). Additional research is needed to identify time-reducing means while improving patient stroke outcomes.
Abstract T P349: Pre-Hospital Notification by Emergency Medical Services and Improved Stroke Care
Authors: Love Tracy , Schneiderman Jessica
Published: July 2021

Background:
In rural settings, distance is a factor when medical assistance is critical. Every minute can make a difference in treatment and recovery of a stroke patient. Early recognition and notification of a possible stroke are key elements in the chain of survival for stroke victims. Emergency Medical Services (EMS) involvement in pre-hospital notification of a stroke patient can improve assessment and diagnostic times and use of alteplase.

Purpose:
The purpose of this study was to compare times of specific assessments, diagnostics, and treatments with EMS stroke alert activation prior to arrival compared to stroke alert activation by hospital personnel after patient arrival.

Methods:
In the setting of a rural, community hospital, the local fire department/paramedics were trained to use a screening tool and to provide pre-hospital activation of a stroke alert. The trial demonstrated positive results. Subsequently, education was disseminated to EMS providers throughout the five county service area. Data was collected from January to December 2013, with 30 alerts activated by Emergency Department (ED) personnel and 22 activated by EMS pre-hospital (n=52). Data consisted of times from door to: physician, Computer Tomography (CT) scan, CT read, laboratory, stroke team, decision for alteplase, and needle time.

Results:
The average time from door to physician yielded a decrease by 13 minutes for an EMS alert compared to ED alert. Average door to CT scan time were decreased by 6 minutes using the EMS alert. Average times from door to laboratory completion decreased by 5 minutes using the EMS alert. Average time for door to stroke team was decreased by 9 minutes using the EMS alert. Door to needle times did not differ between groups, but the percentage of patients receiving alteplase increased in the EMS alert group (18.2% with EMS alert compared to 3.3% with an ED alert).

Conclusion:
In conclusion, the findings of this study suggest times for assessment are improved through EMS pre-notification and early initiation of the hospital stroke-alert system. It also shows an increase in the use of alteplase when there is pre-hospital notification of a potential stroke patient.
Abstract T P351: Stroke Care Team Associations with Acute Stroke Quality Improvement in Veterans Healthcare Administration
Authors: Damush Teresa M , Yu Zhangsheng , Slaven James , Daggett Virginia , Sager Danielle , Plue Laurie , Mathias Marianne , Miech Edward , Williams Linda S
Published: July 2021

Background and Objective:
We conducted standardized semi-structured baseline interviews to understand organizational constructs of stroke teams on a composite, acute stroke quality indicator across 11 VA Medical Centers (VAMCs).

Methods:
We conducted 104 semi-structured, in person, baseline interviews with clinical providers of acute stroke care services. Respondents were from nursing, emergency medicine, neurology, rehabilitation, inpatient care, medicine and quality management. We audiotaped the interviews, transcribed verbatim, and de-identified the data. Data were qualitatively coded using Nvivo software to tag segments of text into meaningful units based upon our Facilitating Best Practices Framework. Coders met regularly to review and consolidate emergent themes. Additionally a standardized team of chart abstractors collected 10 acute stroke quality indicators from a central location which comprised the composite. The follow up period included 6 (early response) and 12 (late response) months after a stroke collaborative.

Results:
At baseline, the VAMCs with a higher proportion of its respondents reporting regular monthly communication about stroke were associated with a late response in stroke quality improvement while sites with a lower proportion reporting regular monthly communication were associated with an early response in quality. VAMCs reporting the use of a designated nurse to promote guideline adherence and disease management were associated with an early response in quality. VAMCs reporting tracking their quality data and providing feedback to clinicians were associated with an early and late response in stroke quality improvement compared to those who did not. Finally, sites reporting the timely detection of acute stroke in the Emergency Department as a barrier at baseline were associated with no improvement in stroke quality.

Conclusion:
Our data suggests that clinical teams that wish to improve their quality may redesign their organization of care as structured to communicate regularly among their team, utilize nurses as designated for guideline adherence, track their quality data and provide feedback to clinicians, and triage presenting strokes in a timely manner.

Funded by VA HSRD QUERI SDP #09-105
Abstract T P364: Carotid Narrowing and Stroke in Childhood Cavernous Sinus Thrombosis
Authors: Press Craig A , Lindsay Aaron J , Fenton Laura Z , Stence Nicholas V , Bernard Timothy J , Mirsky David M
Published: July 2021

Introduction:
Cavernous sinus thrombosis (CST) is a rare and potentially life-threatening disease in children. While the incidence of neurological complication is unknown, CST can cause carotid artery narrowing, carotid vasospasm, and/or ischemia. Given the lack of data regarding childhood CST, decisions about antithrombotic and antispasmodic management remain uncertain.

Hypothesis:
We describe the clinical presentation, imaging findings, treatment and outcome of childhood CST at a tertiary care center, hypothesizing that carotid narrowing and stroke are common in this condition.

Methods:
We performed a single-center retrospective review of children with imaging confirmed CST from 2003-2013. Clinical data were extracted from the electronic medical record and all available imaging reviewed by two neuroradiologists. Data was analyzed with descriptive statistics.

Results:
Eight patients with childhood CST (Table 1) were identified. All had carotid artery narrowing and 63% (5/8) developed ischemia. The most common complication was visual impairment secondary to infectious neuritis. Of the seven patients treated with anticoagulation, three developed new ischemia on therapy. Similar results were seen with nimodipine therapy. Despite the high incidence of stroke, outcomes were generally good, with all but one patient attaining a mRS of ≤ 1at discharge.

Conclusion:
In childhood CST, carotid narrowing and arterial ischemic stroke appear to be common. While therapeutic interventions to prevent clot propagation and/or vasospasm did not prevent all new ischemia, they may have contributed to the prevention of medium/large ischemic events, which were uncommon in this series. Despite the high incidence of carotid vasospasm and stroke, outcomes were generally favorable. Large multicenter cohorts are needed to understand the preferred therapeutic strategies for childhood CST.
Abstract T P385: Cortical Deficits and Prior Stroke Predict Stroke Recurrence in Patients with Mild Deficits
Authors: Yaghi Shadi , Willey Joshua Z , Andrews Howard , Boehme Amelia K , Quarles Leigh , Marshall Randolph S , Boden-Albala Bernadette
Published: July 2021

Background:
Predictors of stroke recurrence after a transient ischemic attack have been studied and validated, however those in patients with mild deficits have not been established. Identifying predictors of stroke recurrence may help risk stratify patients based on their stroke risk. We hypothesize that patients with cortical deficits on the National Institute of Health Stroke Scale (NIHSS) (language, neglect, and visual) are at higher risk of stroke recurrence than those without these deficits independent of other known predictors of recurrence.

Methods:
Data was retrieved from the Stroke Warning Information and Faster Treatment (SWIFT) study dataset. All patients with NIHSS between 0 and 5 and not treated with intravenous thrombolysis were included. Patients were prospectively followed from December 2006 to June 2011. Adjusted logistic regression models assessed the relationship between stroke recurrence and cortical deficits, baseline demographics, risk factors, and NIHSS score.

Results:
The sample included 894 patients; 108 (12%) had recurrent stroke over the study period. Cortical deficits (OR=1.84, p=0.05) were a predictor of recurrent stroke independently of other well characterized predictors including age, gender, ethnicity, hypertension, diabetes, and atrial fibrillation; history of prior stroke (OR=2.35, p=0.001) was an additional predictor of recurrent stroke. The other variables (age, gender, ethnicity, hypertension, diabetes, and atrial fibrillation) were not associated with risk of recurrent stroke.

Conclusion:
Cortical deficits and a prior stroke are predictors of stroke recurrence in this sample of patients with minor stroke enrolled in a randomized clinical trial. This group may be a target for more aggressive stroke prevention measures.
Abstract T P401: Human Albumin Confers Neurovascular Protection And Long-term Neurobehavioral Improvement After Subarachnoid Hemorrhage
Authors: Xie Yi , Ye Ruidong , Liu Xinfeng
Published: July 2021

Introduction:
Subarachnoid hemorrhage (SAH) patients suffer from high mortality and worsening of their daily functioning. Currently no clinically effective agents have been recognized yet.

Hypothesis:
This study aimed to investigate whether albumin (Alb) confers a sustained improvement in SAH, and whether the salutary effects are associated with neurovascular preservation.

Methods:
Endovascular perforation method was used to induce SAH. Alb (0.63 g/kg or 1.25 g/kg) was immediately intravenously administered after surgery. Cerebral blood flow and early vasospasm-induced arterial morphology changes were measured to evaluate vascular dysfunction. Fluoro-Jade C staining and TUNEL staining were used to evaluate neuronal injury. To determine the blood-brain barrier (BBB) integrity, EB extravasation, IgG leakage, and tight junction protein levels were assessed. Gelatin zymography was also used to gelatinolytic activity of MMP-2 and MMP-9. Neurological deficits were assessed up to post-operative day 42.

Results:
SAH grade and mortality were not significantly different among groups. Alb prevented early cerebral blood flow reduction and vasospasm with decreased arterial luminal perimeter, wall thickness and increased arterial diameter as compared with vehicle group. Upon SAH, neuronal degeneration and cell apoptosis were noticed in the hippocampal and cortical areas, which was significantly attenuated by Alb. This neurovascular protection was accompanied with lowered IgG leakage and EB extravasation. Mechanically, the expression levels of tight junction proteins (ZO-1, occludin, claudin-5) and adherent junction protein (VE-cadherin), which maintain the BBB structure and function, were remarkably preserved after treatment of Alb. The expression and activity of gelatinase were also conserved. As for neurological deficits, SAH led to a sensorimotor dysfunction up to 28 days after the insult, which could be improved by Alb. Alb also improved the long-term cognitive outcomes, as assessed by novel object recognition and Morris water maze.

Conclusions:
In conclusion, Alb preserves neurovascular functions and long-term neurobehavioral outcomes in experimental SAH.
Abstract T P403: Permanent Ventricular Shunting In Subarachnoid Hemorrhage And Intracerebral Hemorrhage Patients Requiring Temporary Ventriculostomy
Authors: Moradiya Yogesh , Murthy Santosh , San Luis Christa , Hanley Daniel , Ziai Wendy
Published: July 2021

Background and Purpose:
Aneurysmal subarachnoid hemorrhage (SAH) and spontaneous intracerebral hemorrhage (ICH) frequently lead to obstructive and/or communicating hydrocephalus. A permanent ventricular shunt is required in cases with failure to wean ventriculostomy. Large-scale studies comparing rates of ventricular shunting after SAH and ICH are lacking. Therefore, we studied the rates of shunting among SAH and ICH requiring ventriculostomy.

Methods:
We analyzed the Nationwide Inpatient Sample, a 20% sample of non-federal hospitalizations in US from 2002 to 2011 to select adults with ICH (ICD-9 code 431) and SAH (430) undergoing ventriculostomy (02.2, 02.21). We excluded patients surviving <7 days after ventriculostomy. We compared rates of ventricular shunting (02.32-02.34) between SAH and ICH after adjusting for baseline characteristics using logistic regression. Population estimates were obtained using sample weighting.

Results:
23,541 cases with ICH (median age 59 y) and 31,883 cases with SAH (median age 56 y) were included. Unadjusted shunting rate was higher in SAH compared to ICH (19.9% vs 11.4%, P<0.001), and it remained higher in SAH in multivariate analysis (adjusted OR: 1.69; 95% CI: 1.45-1.98, P<0.001). There was no difference in the interval between ventriculostomy and shunting between SAH and ICH (mean: 18.9 +/- 11.8 [SD] vs 18.1 +/- 10.9 days, P=0.196). Among SAH cases, shunting rate was higher with coiling compared to clipping (23.8% vs 18.1%, P<0.001). There was a significant trend toward higher shunt utilization over time among SAH patients (16.3% in 2002-03 to 21.4% in 2010-11, trend P<0.001). The shunting rate remained unchanged among ICH patients (11.3% in 2002-03 to 11.5% in 2010-11, trend P=0.363). Patients requiring ventriculostomy within 24 hours of admission comprised 61.8% of all cases, and had higher shunting rate (adjusted OR: 1.17; 95% CI: 1.07-1.28, P=0.001).

Conclusions:
SAH compared to ICH has higher rates of failure to wean ventriculostomy requiring permanent ventricular shunting. Increasing trend in shunt utilization after SAH is co-incident with increase in aneurysm coiling during recent years.
Abstract T P408: Suboptimal Quality of Reporting of Neuroimaging Methods for Studies of Cerebral Small Vessel Disease
Authors: Peters Steven , Switzer Aaron , Patil Shivanand , McCreary Cheryl R , Dichgans Martin , Wardlaw Joanna M , Smith Eric E
Published: July 2021

Introduction:
The quality of reporting of neuroimaging methods for studies of cerebral small vessel disease is unknown. We systematically reviewed studies of MRI white matter hyperintensities (WMH) of vascular origin to determine the frequency of reporting of key aspects of neuroimaging methods, and whether reporting varied by sample size, study design or journal impact factor.

Methods:
Three raters independently reviewed 100 consecutive papers reporting WMH severity, either as a primary outcome or covariate, to abstract 50 study characteristics based on the published STRIVE standards (Wardlaw et al Lancet Neurol 2013). Final determinations were made by consensus. An aggregate quality score (range 0-11) was created by adding one point for reporting of each of 11 key characteristics (Table). Spearman correlation or chi-square test, as appropriate, were used to test associations with quality score.

Results:
Papers were published between 2009 and 2013 with journal impact factors ranging from 0.56 to 15.3, with cohort (79%) and case control (21%) studies represented. Quantitative computational methods were used in 28 studies. MR field strength, MRI sequence types, type of WMH measurement method, blinding and number of raters were reported frequently, but reporting of other characteristics was inconsistent (Table). Study quality score was not correlated with journal impact factor, sample size or cohort study design.

Conclusions:
There is inconsistent reporting of neuroimaging methods in the small vessel disease imaging literature. Increased adherence to published reporting standards, such as the STRIVE criteria, may facilitate more objective peer review of submitted manuscripts and increase the reproducibility of published results. More work is needed to facilitate adoption of standards and checklists by authors, reviewers and editors.
Abstract T P412: Cerebral Microbleeds and Cognition: The Framingham Heart Study
Authors: Romero Jose R , Preis Sarah R , Beiser Alexa , Shoamanesh Ashkan , Au Rhoda , DeCarli Chalres , Wolf Philip A , Seshadri Sudha
Published: July 2021

Objective:
To study the association of cerebral microbleeds (CMB) on MRI and performance on a comprehensive neuropsychological test battery in a community based cohort free of stroke and dementia.

Background:
CMB represent hemorrhage-prone cerebral small vessel disease (SVD) and have been related to increased risk of dementia. In non-demented individuals, CMB may negatively affect cognition and the pattern of impaired cognitive performance may differ according to lesion topography.

Methods:
We evaluated 1744 Framingham Offspring Study participants (mean age 64.6 years, 54% women) attending a baseline examination (1998-2008), who had brain MRI allowing for CMB detection and underwent concurrent NP testing. Using multivariable linear regression we related CMB presence overall and stratified by brain location (lobar, deep or mixed) to performance on NP tests representing cognitive domains including memory, executive function, abstraction, language and visuospatial function.

Results:
CMB were observed in 7.7% of subjects (66% lobar, 20% deep, 14% mixed). After adjustment for sex, age, level of education and MRI markers of ischemic small vessel disease, presence of any CMB was associated with impaired performance on tests of abstraction (β -0.71, p=0.02) and language (β -0.13, p=0.04). The associations were attenuated after adjustment for vascular risk factors (hypertension, diabetes, smoking, prevalent cardiovascular disease). Lobar CMB showed similar marginal associations (p=0.05), also attenuated after adjustment for vascular risk factors. Mixed location CMB were associated with tests of executive function, an association that remained significant after adjustment for MRI markers of ischemic SVD and vascular risk factors (β-0.12, p= 0.02). CMB in only deep location did not show any significant association with NP test performance.

Conclusions:
CMB were associated with lower cognitive performance in a community-based sample of middle-aged adults. Our findings are limited given the cross sectional study design and small sample in subgroups of deep and mixed CMB, but concur with studies suggesting a negative impact of CMB on cognition, and expand prior studies by showing that the relations are independent of ischemic cerebral SVD.
Abstract T P415: Assessment Of Cognitive Symptoms In Sub-acute Stroke With An iPad Test-battery
Authors: Willer Lasse , Pedersen Palle M , Gullach Anders , Forchhammer Hysse B , Christensen Hanne K
Published: July 2021

Introduction and hypothesis:
Research into the time-course of cognitive symptoms in stroke as well as planning of rehabilitation is dependent on reliable and sensitive cognitive testing. Usually, it is not possible to have all patients seen by a neuropsychologist. Moreover, a battery for stroke patients poses special challenges as symptoms like aphasia, hemineglect and hemiplegia may exclude many patients from performing a number of traditionally employed test methods. Finally, the battery has to be performed in a short timespan because many patients are easily fatigued.

Method:
We developed a battery comprising tests for anosognosia, aphasia, neglect, depression, episodic memory, attention span, working memory, mental speed, manual motor speed, and executive function (response inhibition). We present data from sub-acute stroke patients and age-matched controls. Both groups were tested twice with a 3 month interval in order to: 1) assess the proportion of patients able to perform the different tests; 2) determine the typical time needed to do the testing; 3) demonstrate the sensitivity to cognitive symptoms in sub-acute stroke

Results:
51 stroke patients 43 healthy controls were included. 49 patients (96%) were able to do at least one test and 41 (80%) were able to do all tests. Mean duration for the testing of sub-acute stroke patients was 39 minutes (range 30-60 minutes). Mean Age 67 years (patients 65 and controls 69, range 33-90). Mean verbal fluency correct in 1st session: patients 29.2 and Controls 45.3; Mean difference 16.03, 95%CI (10.1-22.0) p 〈0.001. Mean change in patients from 1st to 2nd Session: 6.2, 95%CI(1.2-11.2) p=0.017. Mental speed by coding: patients 29.3 and controls 45.7; mean difference 16.4, 95% CI(10.3-22.4) p〈0.001. Similar analysis of memory, attention span, and executive function showed significant differences between control and patient groups as well as in patients from 1st to 2nd session.

Conclusion:
Our cognitive test-battery for iPad can be used with most stroke patients in the sub-acute phase. It can be performed in a relatively short time span. It is sensitive to cognitive reduction after stroke and remission of symptoms.
Abstract T P46: Final Infarct Volume Discriminates Outcome In Mild Strokes
Authors: Vagal Achala , Sucharew Heidi , Prabhakaran Shyam , Khatri Pooja , Michel Patrik , Jovin Tudor , Wintermark Max
Published: July 2021

Introduction:
Final infarct volume (FIV) is a well-established predictor of outcomes in moderate and severe stroke. However, our knowledge of how FIV predicts disability in the mild stroke population is very limited. Our objective was to determine if FIV could differentiate good versus poor outcome after mild stroke. We hypothesized that smaller FIV will be associated with favorable clinical outcome.

Methods:
We used a retrospective, multicenter registry for consecutive patients who presented with mild stroke (NIHSS ≤ 5) within 24 hours of stroke onset. The imaging data included baseline head CT, noninvasive vascular imaging and follow up imaging (24-72 hour MR/3-5 day CT). Baseline ASPECTS, proximal arterial occlusion (PAO), collateral scores and FIV (using MIPAV) were assessed by core lab. Clinical data included age, sex, baseline NIHSS and 90 day modified Rankin Scale (mRS). Logistic regression was used to evaluate associations between favorable outcome (mRS 0-1) and imaging and clinical data, and to determine a data-driven cut-point for FIV based on the maximal sensitivity and specificity of the receiver operating characteristic curve.

Results:
Among 90 patients with mild stroke, 3 who received intravenous thrombolysis and 22 who did not have follow-up imaging were excluded, leaving 65 patients (mean age 86 years, 38% female, median NIHSS score 4) in whom FIV calculations were performed. An optimal FIV cut-point at 20 cc was identified, for differentiating between favorable and poor outcomes (area under curve 0.73, 95% CI: 0.58-0.88). Of the 45 patients with FIV <20 cc, 37 (82%) had a favorable outcome compared to 5 out of 14 (36%) with FIV ≥ 20 cc (P<.01). In the multivariable model, FIV ≥ 20cc remained strongly associated with poor outcome (adjusted OR, 0.11; 95% CI, 0.02- 0.50, P<.01), irrespective of age, gender, stroke severity, ASPECTS and PAO. A higher collateral score was also found to be associated with favorable outcome (adjusted OR, 2.43; 95% CI, 1.12- 5.27, P=0.02).

Conclusions:
A final infarct volume cut point of 20 cc was found to best differentiate between the likelihood of good versus poor outcome in patients with mild stroke. Further validation of FIV as a surrogate marker is essential to improve risk prediction in mild stroke patients.