bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract T P172: Temporal Correlation Perfusion Mapping Introduces a Robust and Rapid Method of Identifying Penumbra in Acute Ischemic Stroke
Authors: Song Sunbin , Luby Marie , Shah Shreyansh , Edwardson Matthew , Brown Tyler , Latour Lawrence L
Published: March 2022

Background and Purpose:
We implemented new temporal correlation perfusion (TCP) analyses that were rapid, model-free and automated. We assessed the reliability and robustness of TCP mapping compared to the standard method of time-to-peak (TTP) mapping used in the identification of perfusion deficit in acute ischemic stroke.

Methods:
A model-free and automated method of detecting aberrant perfusion was developed to create TCP maps based on the maximum temporal correlations of the signal time-intensity waveforms following contrast injection. For validation purposes, the TCP and TTP maps from IV tPA treated ischemic stroke (n=20) and untreated imaging negative TIA (n=20) patients were visually read for presence of perfusion deficit by two expert readers blinded to the clinical diagnosis. Next, the perfusion lesion volumes on the TCP and TTP maps were segmented by two other experts and were compared for inter-rater reliability, volumetric and spatial concordance, and contrast to noise ratio. Pearson’s r correlation and t-test for TCP and TTP maps were used with degrees of freedom indicated by parentheses. Additionally, inter-rater reliability and contrast to noise ratios were compared.

Results:
Both readers identified all of the subjects (40/40) correctly as either having perfusion deficits or not based on the TCP maps alone. Improved rater inter-reliability in lesion volume segmentation was found in TCP compared to TTP maps, with high correlation in lesion volume (r
(18)
= 0.85) and spatial overlap (91.1+/-9.5%) between TCP and TTP maps. Better contrast to noise ratio in lesions segmented with TCP compared to TTP maps (t
(19)
= 14.9, p<0.0001) was demonstrated which led to increased lesion conspicuity.

Conclusions:
We conclude that temporal correlation mapping holds promise as a reliable and more robust method for perfusion deficit identification as demonstrated by correct identification and improved lesion segmentation compared to current standard methods.
Abstract T P175: Arterial and Venous Uptake of F-18 Fdg Could Predict Ischemic Stroke in Patients With Cancer
Authors: Choi Kang-Ho , Kim Ja-Hae , Park Man-Seok
Published: March 2022

Backgrounds:
Arterial and venous thromboses readily occurs under hypercoagulable conditions and often occur together in patients with cancer. These thromboses is the main cause of ischemic stroke with cancer. F-18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) is a reliable and well-established method for imaging of inflammation in thrombus and plaque. However, it is not known whether both arterial and venous FDG uptake detected on PET/CT imaging are associated with an enhanced risk of ischemic stroke in malignancy. We evaluated the association of vascular F-18 FDG uptake with the subsequent ischemic stroke in patients with cancer.

Methods:
Patients referred to FDG PET/CT for oncologic indications were compared between 27 patients occurred symptomatic ischemic stroke within a month after taking PET imaging and 81 controls, matched to age, gender, cancer type and staging. The maximal standardized uptake value (maxSUV) was divided by the blood-pool maxSUV, yielding a target-to-background ratio (TBR) for each vascular segment. The mean TBR was calculated in the common carotid artery (CCA), aorta, internal jugular vein (IJV), superior and inferior vena cavae (IVC).

Results:
The maxSUVs and TBRs of the CCA, abdominal aorta (AA), IJV and IVC were significantly higher in symptomatic ischemic stroke patients than in controls. In multiple logistic regression analysis, the maxSUVs and the TBRs of the CCA, AA, IJV and IVC were independent predictors for subsequent ischemic stroke after adjustment for covariates. The TBR of the CCA among the arterial PET parameters and the TBR of the IVC among the venous PET parameters had the highest odds ratio, and were the best for discriminating symptomatic ischemic stroke patients from controls and for predicting subsequent ischemic stroke. The optimal cut-off value of the TBRs of the CCA and IVC for predicting ischemic stroke were 1.08 and 1.04, respectively.

Conclusion:
This study suggests that increased arterial and venous uptake of F-18 FDG could be predict subsequent ischemic stroke in patients with cancer. Additional prospective studies with larger numbers of patients are needed to confirm the association of vascular FDG uptake with ischemic stroke.
Abstract T P190: A Model for Predicting Persistent Elevation of Factor VIII Among Patients with Acute Ischemic Stroke (AIS)
Authors: Samai Alyana A , Boehme Amelia K , Shaban Amir , George Alexander , Monlezun Dominique J , Dowell Lauren , Leissinger Cindy , Schluter Laurie , El Khoury Ramy , Martin-Schild Sheryl
Published: March 2022

Background and Purpose:
Recent studies have demonstrated that elevated levels of coagulation factor VIII (FVIII), a risk factor for stroke, may persist independent of the acute-phase response; however, this relationship has not yet been investigated in the context of acute ischemic stroke (AIS). We sought to determine 1) the proportion of AIS patients with acutely elevated serum FVIII levels who had persistently elevated FVIII levels in the outpatient setting and 2) the characteristics at baseline predictive of persistently elevated FVIII levels.

Methods:
From our stroke registry, patients diagnosed with AIS between 07/2008-05/2014 were included if the initial FVIII level was elevated and a repeat FVIII level was obtained. A score was developed to predict which patients are at the greatest odds of remaining persistently elevated at both the 150% and 200% thresholds.

Results:
Among 1,616 AIS cases, 106 patients had initially elevated FVIII levels and repeat FVIII levels obtained. A total of 82.7% of patients had persistent elevation at the 150% threshold and 75.7% had persistent elevation at the 200% threshold. Time from initial FVIII measurement to second FVIII measurement was not different between the two groups (p=0.054). According to the models developed, for every one-point increase in the score, an individual is at ten-fold increased odds to have persistently elevated FVIII at both the 150% threshold (OR=10.43, 95% CI 1.63-66.9, p=0.0134) and 200% threshold (OR=10.2, 95% CI 1.82-57.5, p=0.0083).

Conclusions:
Persistent elevation in FVIII is common and in most AIS patients likely represents a constitutional risk factor. Persistent elevation in FVIII can be predicted by baseline characteristics in the setting of AIS, potentially proving useful in identifying patients at high risk for developing subsequent stroke.
Abstract T P193: Neurological Deterioration Within the First 24-hours After Fibrinolysis is Not as Frequent as Previously Reported in Stroke Patients
Authors: Hansen Christine K , Christensen Anders , Ovesen Christian , Havsteen Inger , Christensen Hanne
Published: March 2022

Background:
Studies have reported neurological detoriation at 24 hours in 20- 40% of patients with symptoms of ischemic stroke.

Aim:
To asses the frequency of neurological deterioration in patients after fibrinolysis.

Methods:
A prospective single hospital registry was based on 481 unselected consecutive patients admitted from July 2009- December 2011 with symptoms of acute ischemic stroke within 4.5 hours from symptom onset. Patients fulfilling international guidelines were treated with i.v tPA. Clinical status was assessed by National Institute of Health Stroke Scale (NIHSS) and Computerized Tomography was conducted at admission in all 481 patients and at 24 hours in patients treated with i.v tPA to assess neurological as well as radiological status. Patients were stratified as having neurological deterioration of 1, 2, 3 or > 3 NIHSS points.

Results:
Three-hundred and twenty three (67.2%) of the admitted stroke patients were treated with i.v tPA (median NIHSS 7, 1-42). At 24 hours, neurological detoriation was observed in 24 of the treated patients (7.4 %) (ΔNIHSS median +2; 1-9). Eleven patients had ΔNIHSS=+1, 3 patients had ΔNIHSS=+2, 4 patients had ΔNIHSS=+3 and 6 patients had ΔNIHSS>+3.Any degree of haemorrhagic transformation was detected in 28 (8.7 %) of the patients treated with i.v tPA (median ΔNIHSS -1.5; -10 - +4), of which 3 were symptomatic (0.9%) (median ΔNIHSS +2, 1-4). Neurological deterioration occurred significantly more often in patients admitted with moderat-severe stroke (p=0.003) and in patients with large vessel occlusions (p=0.041).

Conclusion:
The neurological deterioration observed in patients treated with i.v tPA was modest and less frequent than previous reported in patients with symptoms of acute stroke prior to general implementation of thrombolysis. Deteriation due to haemorrhagic transformation was rare and of limited scale in this population. If this phenomena is due to better care, selection of patients for treatment in accordance with international guidelines or due to an unknown effect caused by tPA is uncertain.
Abstract T P204: t-PA Utilization is Improving within Kaiser Permanente Southern California
Authors: Sauser Kori , Sangha Navdeep , Neil William P , Ajani Zahra , Sharp Adam L
Published: March 2022

Background and Objectives:
Despite the efficacy of t-PA for acute ischemic stroke (IS), most patients do not receive the treatment. Due to aligned incentives, integrated health systems have shown to deliver higher-value care than their counterparts, therefore we sought to describe patterns of t-PA use within a large integrated health system (Kaiser Permanente Southern California). Our objectives were to describe the proportion of IS patients treated with t-PA, and to identify predictors associated with t-PA receipt.

Methods:
This was a retrospective cohort analysis using existing structured data from an electronic health record encompassing 14 emergency departments between 2009-2013. We included patients 18 years or older with a primary or secondary ICD-9 diagnosis of acute IS. To focus on patients with acute presentations, we limited our sample to those who were imaged within 180 minutes of arrival. We built a multivariable regression model using random intercept for medical center to identify predictors of t-PA receipt.

Results:
Of the 11,630 patients in our analysis, half were female (49.5%) and median age was 72 years (IQR 61-81). Four percent received t-PA during the study period (n=453), and treatment rate increased from 2.6% in 2009 to 6.4% in 2013 (p-value for trend <0.0001). Of the treated patients, median door-to-needle time was 73 minutes (IQR 55-103). Predictors of t-PA receipt are outlined in the table.

Conclusion:
Between 2009-2013, 4% of all acute IS patients presenting to an integrated health system were treated with t-PA. Utilization of t-PA is improving over time, with age, gender, prior stroke, and ambulance arrival associated with t-PA treatment.
Abstract T P209: Post -Thrombolysis Blood Pressure Guideline Violation in “Drip And Ship” Acute Ischemic Stroke Patients is Associated With Higher Mortality
Authors: Arora Rohan , Shaji Jane , Burshtein Reuben , Kodankandath Thomas , Pishanidar Sammy , Burshtein Joshua , Burshtein Aaron , Kohn Nina , Salamon Elliot , Libman Richard , Gribko Michele , Katz Jeffrey
Published: March 2022

Background:
The “drip and ship” protocol is an important treatment for acute ischemic stroke patients who do not have immediate access to comprehensive stroke centers (CSC). Intravenous thrombolysis is initiated at a primary stroke center followed by expeditious transfer to a CSC typically during the tPA infusion. National guidelines recommend attention to blood pressure control (<180/105 mmHg) during and after tPA administration for the first 24 hours. We sought to determine the frequency of BP protocol violations during transfer and the impact on patient outcomes.

Methods:
This is a retrospective analysis of 130 consecutive “drip and ship” patients transferred to North Shore University Hospital between July 2012 to June 2014. BP upon arrival to CSC was used to determine adherence to BP guidelines. Poor patient outcome was defined as discharge to hospice or expired, discharge modified Rankin score (mRS) >2, and symptomatic intracerebral hemorrhage (sICH).

Results:
A total of 123 patients were confirmed to have an ischemic stroke (7 stroke mimics were excluded). Blood pressure was available for 120 patients. Mean age of the cohort was 62.7 years (range 24 to 100 years). Mean CSC admission NIHSS was 11.0 (range 0 to 28). Mean BP upon CSC arrival was 143.3/77.8 (systolic range 90 to 200 mmHg/diastolic range 44 to 112 mmHg). Mean mRS at discharge was 2.76. Blood pressure parameter violations were documented in 15 (12.5%) patients. Of these, 7 (46.7%) were discharged to hospice or expired, whereas 9/105 (8.6%) without blood pressure parameter violation were discharged to hospice or expired. This difference was statistically significant (p<0.0006, Fisher’s exact test). Symptomatic ICH was observed in 1/15 (6.7%) patients with BP parameter violations and 10/105 (9.5%) patients without BP parameter violations (not significant). Eleven (73.3%) of 15 patients with BP violations had a discharge mRS >2, compared to 54/103 (52.4%) patients without BP parameter violation (not significant).

Conclusions:
Post thrombolysis blood pressure guideline violations during drip and ship transfer were significantly associated with in hospital mortality or discharge to hospice, but not with high discharge mRS or symptomatic ICH. Larger studies are needed to confirm these results.
Abstract T P221: Anti-amyloid Immunotherapy Results in Exacerbation of Cerebrovascular Disease Through Activation of Matrix Metalloproteinases
Authors: Weekman Erica M , Sudduth Tiffany L , Wilcock Donna M
Published: March 2022

Cerebrovascular disease is frequently co-morbid with Alzheimer’s disease (AD) and we hypothesize this co-morbidity could complicate the development of disease-modifying therapies. The amyloid-beta (Aβ) peptide has been the intense focus of therapeutic development for the treatment of AD. One therapeutic approach uses passive immunization against Aβ using anti-Aβ antibodies. We further hypothesize that inflammation mediated activation of MMP9 and MMP2 lead to the exacerbation of cerebrovascular pathologies following immunotherapy. To test our hypothesis we took aged 21 month old APP transgenic mice (PDAPP mice) that have cerebral amyloid angiopathy (CAA) and disruptions of the blood-brain barrier and administered anti-Aβ antibody or control IgG2a for 8 weeks at a dose of 12.5mg/kg. Expression of the MMP2 and MMP9 families were measured by qPCR and Western blot, total Aβ, CAA and albumin for vasogenic edema were measured using immunohistochemistry, and finally, microhemorrhages were assessed with Prussian blue staining.

Treatment with the anti-Aβ antibody resulted in significantly decreased Aβ in the frontal cortex and hippocampus. Further, we found increased microhemorrhage associated with increased gene expression of MMP9, MMP2 and MMP14 (the activator of MMP2). Assessment of vasogenic edema, as well as CAA and inflammatory states is currently ongoing.

Overall, while anti-Aβ treatment leads to decreased Aβ, cerebrovascular pathologies, most notably microhemorrhages, are increased by immunotherapy. This increased microhemorrhage is associated with increased MMP2 and MMP9 expression. These data suggest that co-morbidity of cerebrovascular pathologies with AD will significantly impair efficacy of therapeutics for AD and could potentially lead to adverse events.
Abstract T P230: Multiple Applications of Dodecafluropentane emulsion (DDFPe) Prevents Death in a Rabbit Stroke Model of Permanent Ischemia
Authors: Brown Aliza , Arthur Melinda C , Skinner Robert D , Lowery John D , Hendrickson Howard P , Culp William C
Published: March 2022

Background:
Stroke remains the 4
th
leading cause of death in the US with stroke related deaths occurring every 4 minutes. Perfluorocarbons (PFC) have been used to circulate oxygen and rescue ischemic tissue. Intravenous Dodecafluoropentane emulsion (DDFPe), a PFC, has shown great promise as a neuroprotective agent in embolic ischemic stroke models. Our recent experience in rabbit stroke models normally compares stroke size and neurological effect outcomes, but here we review the overall death rates in the permanent ischemic model in control and DDFPe treated groups. These deaths are sometimes associated with occlusions of posterior branches of the Circle of Willis or angiographic difficulties in the embolization procedure.

Methods:
Previous data collected on 195 New Zealand White male or female rabbits (3.8 to 6.6 kg bw) with permanent occlusion of the cerebral arteries with two to three 700-900 micron diameter spheres was further reviewed to determine incidence of mortality in all controls and DDFPe treatment groups. In multiple applications, the DDFPe was administered at 90 min intervals. We studied total number of applications regardless of spasm or specific arterial occlusions, including occlusions in the posterior circulation.

Results:
See Table.

Conclusion:
Increasing the number of DDFPe applications was significant in reducing the incidence of premature death in a model of permanent ischemic stroke and extending survival to scheduled sacrifice. This new PFC has previously demonstrated decreased stroke volume in the rabbit stroke model and now further indicates its ability to significantly reduce the incidence of death. This warrants further studies with DDFPe use in situations of critical major vessel occlusions, vascular spasm and abnormal vasculature in animal stroke models.
Abstract T P233: Diabetes Potentiates Ischemia-reperfusion (I/R) Brain Injury: Role for Methylglyoxal, Glutathione, and Cerebral Microvascular Thrombosis
Authors: Wang Bin , Li Wei , Stokes Karen Y , Aw Tak Y
Published: March 2022

Introduction:
Diabetes is a risk factor for stroke. We previously showed that hyperglycemic and low glutathione (GSH) conditions (as is found in diabetes), enhanced methylglyoxal (MG)-induced occludin-MG glycation and disrupted barrier integrity in brain microvascular endothelial cells.
In vitro
, MG activated platelets and promoted platelet-leukocyte aggregation. These results suggest that MG-mediated carbonyl stress could promote thrombotic events and brain microvascular dysfunction.

Hypothesis:
GSH, MG and/or a pro-thrombotic phenotype play important roles in brain I/R injury.

Methods:
The streptozotocin mouse model of type 1 diabetes was used as an
in vivo
model of carbonyl stress. Untreated mice (NT) and citrate buffer vehicle (Veh) served as controls. Brain infarct area, edema, and tissue or plasma GSH and MG were examined after ischemia (45min) and reperfusion (24h) at 4-wks diabetes, and MG-adduct formation in brain microvessels at 8-wks. Blood platelet-leukocyte aggregation and thrombus formation in venules and arterioles were examined at 4-wks diabetes, and intravital videomicroscopy at 20-wks diabetes, respectively.

Results:
As compared to NT and Veh, cerebral infarct area and edema were significantly increased in diabetic mice that paralleled elevated plasma glucose levels. Diabetic brain injury was associated with high brain MG and low GSH contents. Infarct areas were positively correlated with MG, and MG-to-GSH ratio. Immunohistochemistry revealed increases in MG-positive microvessels in diabetic brain, suggesting a susceptibility of the cerebral microvasculature to MG-protein glycation. Dramatic hepatic GSH depletion occurred at 4-wk diabetes that correlated with elevated plasma MG at 8-wks. At diabetes onset (4-wk), aggregation of platelets with neutrophils and lymphocytes was enhanced. Onset of thrombus formation in brain venules and arterioles was accelerated, and time to complete occlusion of arterioles was shortened in 20-wk diabetic mice.

Conclusion:
These results show that the diabetic brain is susceptible to I/R injury in association with elevated MG, decreased GSH, and heightened pro-thrombotic events, factors that could contribute to enhanced stroke risk and worse outcome in diabetes.
Abstract T P235: Assessing the Impact of Rotorcrafts in a Model of Induced Cerebral Embolism (AIR-MICE)
Authors: Leira Enrique C , Khan Mohd. Moushahid , Zaheer Asgar , Schnell Thomas , Torner James C , Olalde Heena M , Nagaraja Nandakumar , Ortega-Gutierrez Santiago , Pieper Connie , Adams Harold P
Published: March 2022

Objective:
Stroke is a time-dependent emergency that often requires emergent helicopter evacuation, a critical early setting for which little is known about the positive or deleterious effect of altitude change, noise, acceleration and vibration. While many of these factors could worsen ischemic injury, the low frequency vibrations might augment clot lysis and enhance rtPA treatment. The objective of this study is to measure the feasibility, safety and potential effect of helicopter transport during thrombolysis in an animal model.

Methodology:
Prospective, randomized, open intervention and blinded end-point pilot study that combines a controlled experimental model with a real life helicopter flight exposure. Subjects were adult C57BL/6 male mice that simultaneously underwent an embolic middle cerebral artery occlusion (eMCAO) in pairs. Each pair of mice were randomized to receive 10 mg/kg of rtPA at two hours after eMCAO either during a one hour local flight in a MI2 turbine helicopter, or to simultaneously receive the same rtPA infusion while waiting in an airport hangar. Mice were sacrificed at 24 h. Primary outcome measure was infarct volume. Secondary outcome was neurological scores.

Results:
Eighteen mice (9 pairs) were analyzed. Lower infarction volumes were seen in the helicopter assigned group in 6/9 pairs. The mean infarction volumes were 246.6 mm
3
(SD 154) for ground group and 213.6 mm
3
(SD 170) for the helicopter group. A paired t-test analysis showed lesser infarction volumes in the helicopter group (mean difference 33 mm
3
, p=0.33), a difference that was not influenced when adjusting for ambient temperature and atmospheric pressure. The neurological scores were similar in the ground and helicopter groups (1.28 vs. 1.22, p=0.88).

Conclusion:
Randomized trials of the effect of helicopter transport in a mouse model of eMCAO are feasible, and desirable to test the effect of neuroprotective therapies in this unique setting. These results endorse the safety of aerial transport, which might be associated with lower infarction volumes. The potential synergist effect of vibration in the rotorcraft with reperfusion needs to be explored further.
Abstract T P246: Phenotypic Characterization of Cerebral Microvasculature in Transgenic Mice With Endothelium Targeted Over-expression of GTP Cyclohydrolase I
Authors: Santhanam Anantha Vijay R , d'Uscio Livius V , Katusic Zvonimir S
Published: March 2022

Background:
Optimal availability of tetrahydrobiopterin (BH4) is a critical determinant of nitric oxide (NO) production by endothelial nitric oxide synthase (eNOS) in the vascular endothelium. Biosynthesis of BH4 is regulated by the enzymatic activation of GTP cyclohydrolase I (GTPCH-I). While the physiological role of GTPCH-I and BH4 have been extensively characterized in peripheral vasculature, their role in regulation of cerebral vascular function has not been investigated.

Methods:
The role of GTPCH-I in regulation of cerebral vascular function was studied in cerebral microvessels isolated from wild-type (WT) mice and from mice with endothelium-targeted overexpression of GTPCH-I (eGTPCH-I Tg) mice. Vascular protein expression, intracellular levels of biopterin and cGMP (second messenger of NO) as well as production of NO and superoxide anions were determined.

Results:
Endothelium targeted over-expression of GTPCH-I resulted in significant increase in levels of BH4, as well as its oxidized product, 7,8-dihydrobiopterin (7,8-BH2). Importantly, ratio of BH4 to 7,8-BH2, indicative of BH4 available for eNOS activation, was significantly increased in cerebral microvessels of eGTPCH-I Tg mice. However, protein expression of eNOS, levels of nitrate/nitrite - indicative of NO production remained unchanged between cerebral microvessels of WT mice and eGTPCH-I Tg mice. Furthermore, increased BH4 biosynthesis did not affect production of superoxide anions or expression of antioxidant enzymes. Moreover, intracellular levels of cGMP, reflective of NO signaling and activation of soluble guanylate cyclase, were not affected in eGTPCH-I Tg mice.

Conclusion:
Our results suggest that, despite a significant increase in BH4 bioavailability, generation of endothelial NO in cerebral microvessels remained unchanged in eGTPCH-I Tg mice. We conclude that under physiological conditions the levels of BH4 are optimal for activation of eNOS and NO/cGMP signaling in wild-type mice.
Abstract T P267: Admission Hemoglobin and Sodium Values are Important Factors Associated with Good Outcome After Acute Ischemic Stroke
Authors: Cohen Abigail S , Siddiqui Khawja A , Ali Syed F , Anderson Christopher D , Silverman Scott B , Schwamm Lee H
Published: March 2022

Introduction:
Prognostic factors in patients with acute ischemic stroke (AIS) are useful in assessing therapeutic interventions. Our aim was to investigate if commonly measured admission lab values (BUN, creatinine, hemoglobin, INR, platelets, and sodium) added value to models built using only clinical variables in predicting outcome after AIS.

Methods:
We included 5,886 consecutive patients from 12/2002 to 5/2014 in our local Get with the Guidelines-Stroke registry in whom labs collected within two days of admission could be extracted from an administrative research data registry (RPDR). Univariate and multivariable analyses were performed to identify predictors of good outcome, defined as discharge to home.

Result:
Among 5,886 patients, 2340 (39.7%) had a good outcome. In unadjusted analyses, patients with good outcomes were more often younger and male, had a lower median NIHSS and fewer vascular risk factors, except they were more often smokers. They underwent IV and IA thrombolysis less often. After adjustment for clinical and hyperacute variables present on admission, increasing age, male gender and NIHSS, diabetes, prior stroke/TIA, atrial fibrillation and heart failure independently reduced the odds of a good outcome; but IV tPA use nearly doubled it. Additional adjustment for lab values further attenuated some variables (e.g., heart failure), and increasing hemoglobin and sodium independently increased the odds of a good outcome (Table 2).

Conclusion:
Many factors impact the likelihood of good outcome following acute ischemic stroke. Our study shows that hemoglobin and sodium on admission may add important prognostic information.
Abstract T P272: Improvement in Door to Thrombolytic Time in a Rural Community Hospital
Authors: Siwiec Elaine , Gerard Daniel , Moriarty-Smith Toni , Levy Robert
Published: March 2022

Background:
Receiving thrombolytic therapy as soon as possible from stroke onset improves chance of complete or near complete neurologic recovery and reduces risk of bleeding. McLaren Northern Michigan (MNM) is a 213 bed nonacademic, regional referral hospital servicing 22 counties. The decision to give thrombolytic therapy at MNM has been the responsibility of the on-site neurologist. Neurological assessment, completion of inclusion/exclusion checklist and verification of stroke onset time were the responsibilities of the Code Stroke neurologist after arrival from home or office.

Hypothesis:
In a rural community hospital door to thrombolytic time can be reduced by using telephone neurology consultation and a revised multidisciplinary approach to treatment.

Methods:
Reviewed select Code Stroke data from 2012 to 2013 by a multidisciplinary team:

Notification to neurologist arrival in ED

Neurologist arrival to decision to treat

Decision to treat to start of thrombolytic bolus

Door to start of thrombolytic bolus

Results:
Identified delays:

Neurology travel from home or office to ED

Completed inclusion exclusion checklist, verification of onset time and neuro assessment by on-site neurologist

Mixing of thrombolytic agent by nursing

Revised the Code Stroke protocol to shift responsibilities from on-site neurologist to onsite ED nurses and ED physician. Provided with phone consultation with neurology:

Documentation and verification ”Last Known Well” time

Initial NIH Stroke Scale score and major deficits

Results of Inclusion / Exclusion checklist

Revised Code Stroke protocol to include a pharmacist at bedside to mix thrombolytic.

Conclusion:
Door to thrombolytic time was significantly decreased by shifting Code Stroke responsibilities and incorporating a pharmacist at the bedside. There were no major bleeds or adverse events
Abstract T P278: The Addition of the Post-Stroke Checklist to Standard Outcome Measures During a 90 Day Post-Stroke Follow-up Evaluation Identifies Unique Unmet Needs Relevant to Stroke Recovery
Authors: Reichwein Raymond K , Good David , Iskandarani Khaled , Chinchilli Vernon , Morrison Kathy , Graybeal John
Published: March 2022

Background:
The Post Stroke Checklist (PSC) is an easily administered tool to identify unmet needs in stroke patients. The relative value of the PSC compared to other outcome measures has yet to be determined. We have evaluated the utility of the PSC at 30 days post-stroke, and now report the use of the PSC at 90 days post-stroke.

Methods:
We evaluated 213 ischemic stroke patients 90 days post discharge in our Stroke Clinic. The PSC was administered as well as the Barthel Index (BI) and modified Rankin Scale (mRS) - scored by a nurse and reviewed by a stroke physician. We stratified each scale according to severity and identified actionable PSC items. Using Fisher’s Exact Test we tested for differences in each of the 11 individual items across the two mRS and BI stratified severity groups. Wilcoxon Rank Sum test measured differences in total PSC score (range 0-9) across mRS and BI severity groups.

Results:
103 patients responded positively to one or more PSC items. The cognition item had the highest frequency, 51 (23.9%) of positive responses followed by the mood item, 33 (15.49). The median (range) BI was 100 (10-100) and mRS was 1 (0-5). Patients were distributed across the two BI and mRS severity groups: BI-S (more severe) 0-89 (n=26) and BI-L (less severe) 90-100 (n=187); mRS-S (more severe) 3-5 (n=31) and mRS-L (less severe) 0-2 (n=159). There were significant differences in total PSC scores across both mRS (p=<0.0001) and BI (p=.002) severity groups. There were significant differences in the mood (p=<0.0001), cognition (p=0.004), and life after stroke (p=0.014) items across the mRS severity groups. Patients in the more severe mRS group had higher proportion of positive responses on the mood, cognition and life after stroke items.

Conclusion:
The PSC identified a substantial proportion of unmet needs in both low severity and high severity stroke patients. The highest frequency related to cognitive function and mood/mental health - often overlooked if not probed for. Our results suggest the importance of cognitive and mental health assessment/referral, especially for high severity stroke patients.
Abstract T P281: Low Household Income and Medication Co-pays are Associated with Higher Risk of Anticipated Medication Non-adherence in a Cross-section of Admitted Stroke Patients
Authors: Arnan Martinson K , Bushnell Cheryl
Published: March 2022

Objectives:
Successful secondary stroke prevention is dependent on medication adherence. However, medication non-adherence can be highly variable and results in suboptimal management of risk factors. Our aim was to determine patient-specific barriers to anticipated medication adherence.

Methods:
We surveyed patients admitted to a large tertiary hospital with a diagnosis of stroke or TIA from September 2012 to June 2014. Participants were asked: “Are you likely to skip medication doses if you do not believe that the medication will improve your health in the long run?” “Yes” or “maybe” responses were coded as anticipated non-adherence; and “no” was coded as anticipated adherence. Univariate and multivariable logistic regression analyses were performed on demographic characteristics including socioeconomic status (SES) to determine risk factors associated with anticipated non-adherence.

Results:
A total of 123 patients were surveyed; mean age 63 (+/-16), 51.2% women, and 71.5% white. Participants with anticipated non-adherence had a mean age 58y vs. 65y for participants with anticipated adherence (p = 0.014). Only 27.7% of white participants admitted anticipated non-adherence compared to 54.3% blacks (p =0.006). Participants who were “home by choice” were more likely to report anticipated adherence (76.6%) vs those who were “home not by choice” (41.2%) or “working” (54%); p= 0.007. Having insurance with no copay or having no insurance was associated with high anticipated adherence (85.7%) compared to having insurance with copay (52.6%; p =0.029). Annual household income < $20,000 was associated with high anticipated non-adherence (54.8%) compared to household income > $35,000 (32.6%; p =0.029). In multivariable logistic regression (adjusted for age, sex and race), anticipated non-adherence was associated with having insurance with copay (OR 21.6, 95% CI 3.6-133.0), household income < $20,000 (OR 5.2, 1.3-21.1) and being home by choice (OR 0.18, 0.04-0.77).

Conclusion:
There is a high risk of anticipated non-adherence when patients do not believe that medications will improve their health in the long run. We have identified factors that increase this risk. Awareness of these factors may inform patient-specific strategies to improve adherence.
Abstract T P282: Withdrawal of Life Sustaining Therapy and In Hospital Death after Intracranial Hemorrhage
Authors: Weimer Jonathan M , Gordon Errol , Frontera Jennifer A
Published: March 2022

Introduction:
Despite relatively high in hospital mortality, studies on withdrawal of life sustaining therapy (WOLST) and physician ability to predict in hospital death after intracranial hemorrhage remain sparse.

Methods:
Prospectively collected data from 2008-2011 was reviewed in patients with intraparencymal (IPH), subdural (SDH), and subarachnoid (SAH) hemorrhage. Baseline demographic data, medical comorbidities, and admission clinical status were assessed to determine predictors of WOLST. Statistically significant variables were included in a forward stepwise multivariable logistic regression model to identify independent predictors of WOLST. The model was then tested as a predictor of in hospital death amongst patients who received maximal medical and surgical therapy.

Results:
379 patients were enrolled: 127 (33.5%) SDH, 133 (35.1%) SAH, and 119 (31.4%) IPH. 31 (8.2%) patients underwent WOLST and died, 36 (9.5%) continued maximal therapy and died in hospital, and 312 (82.3%) continued maximal therapy and survived to discharge. Patients who underwent WOLST had more medical comorbidities, worse baseline functional status, worse clinical admission status, and were more likely to have IPH. There were no ethnic or level of education predictors of WOLST. Additionally, there were no differences in hospital complications, cost, or length of stay amongst patients who underwent WOLST versus those who died despite maximal therapy. On multivariable analysis, admission GCS, herniation, and history of cardiovascular disease predicted WOLST (Area under the curve [AUC]=0.83, all p<0.01). This model predicted in hospital death amongst patients who received maximal therapy with a sensitivity of 76.5% and specificity of 83.5% (AUC=0.89, all p<0.001).

Conclusions:
Physicians identified intracranial hemorrhage patients who would die irrespective of maximal medical and surgical therapy with a high sensitivity and specificity. Physicians may be able to transition to WOLST more quickly to attenuate hospital complications, cost, and length of stay.
Abstract T P283: A Survey of Certified Stroke Center Medical Directors in the United States
Authors: Krug Aaron , Ramirez Lucas , Nhoung Heng , Perese Joshua , Gasparian Gregory , Kazaryan Suzie , Kelly Cade , Breen Justina , Majersik Jennifer J , Sanossian Nerses
Published: March 2022

Background:
Certification of hospitals as advanced primary stroke centers (PSC) and comprehensive stroke centers (CSC) leads to improvements in stroke care. We aimed to characterize the specialization and demographics of programmatic leadership at stroke centers nationwide, and to determine the proportion of programs lead by Vascular Neurologists.

Methods:
We identified hospitals holding advanced primary stroke center and comprehensive stroke center designation using the Joint Commission, DNV, and HFAP websites as of September 2013. The identity of the stroke center director was obtained by contacting each individual hospital via their website or telephone. Specialization of each director was confirmed using data available from relevant medical subspecialty board. Gender and date of graduation from medical school was obtained from an online physician database (Healthgrades).

Results:
There were 1167 PSC and 50 CSC hospitals in the United States certified by the JC (N=1121), DNV (67) and HFAP (35). The director, confirmed at 940 of 1217 (77%) centers, was most often a neurologist (N=747, 81%) followed by Emergency Medicine (58), internal medicine (17), radiology (15), neurosurgery (13) and psychiatry (11). Neurologists with added certification in vascular neurology (n=319) made up just over one third of identified certified stroke center directors. Certified stroke center directors were most often male (N=764, 81%) and experienced, with a median year of graduation from medical school of 1990 (IQR 1981-1997). Among vascular neurologists 84% were male and the median year of medical school graduation was 1991 compared to 1988 for non-vascular neurologists (p=0.023 by Mann-Whitney). A higher proportion of Medical Directors in CSCs were board certified in Vascular Neurology (74%).

Conclusions:
Most certified stroke centers were lead by a neurologist, and a third by Vascular Neurologists. Certified stroke center directors are predominantly male, with over 20 years of post-medical school experience.
Abstract T P285: Heart Disease Affect the Prognosis of Acute Non-Cardiogenic Stroke
Authors: Okubo Seiji , Abe Arata , Suzuki Kentarou , Kimura Kazumi
Published: March 2022

Background and purpuse:
Prognosis of cardioembolic stroke is poor In comparison with non-cardiogenic cerebral infarction. Impact of heart disease for non-cardiogenic cerebral infarction is not well known. We investigated the effects of heart disease for the prognosis of acute non-cardiogenic cerebral infarction.

Methods:
We retrospectively examined medical records of patients with acute ischemic stroke until April 2009 from March 2013, who was admitted in stroke care unit of our hospital. Stroke subtype were divided using the TOAST classification, cardioembolic stroke were excluded. Patients suffering from heart disease, such as ischemic heart disease, valvular disease, and congestive heart failure were classified in heart disease group. Other patients were in non-heart disease group. The two groups were compared in age, sex, clinical types of stroke based on TOAST, NIH stroke scale (NIHSS) at admission, modified Rankin scale (mRS) at discharge, risk factors for arteriosclerosis; hypertension, dyslipidemia, diabetes mellitus, smoking and obesity.Multivariate analysis for poor prognosis; mRS>5 at discharge, were underwent.

Results:
Of the 1106 acute ischemic stroke patients, 799 patients were non-cardiogenic stroke. Significant difference were showed between heart disease group (n=182) and non-heart disease group (n=617) in age (74.5 v.s. 68.7, p<0.0001), history of stroke (33.5% v.s. 24.2%, p=0.01), hypertension (87.9% v.s. 74.6%, p<0.0001), smoking (19.2% v.s. 31.3%, p=0.001), NIHSS at admission (6.4 v.s. 5.2, p=0.001), and mRS at discharge (2.5 v.s. 1.8, p<0.0001). Factors independently associated with poor outcome were NIHSS at admission (p<0.0001, 95% CI 1.03-1.10) and heart disease (p=0.04, 95% CI 1.01-2.07).

Conclusions:
Heart disease had a negative impact on prognosis of non-cardiogenic stroke. Further study is required strict control of heart disease may improve the prognosis.
Abstract T P290: Improvement in ICH Outcomes Not Detected During Emergence of a Comprehensive Stroke Center
Authors: Waring Elizabeth D , Monlezun Dominique J , Cho Min C , Ryan Matthew T , George Alexander J , Freeman Melissa , Schluter Laurie , El Khoury Ramy , Martin-Schild Sheryl
Published: March 2022

Background:
Our previous research has demonstrated improved acute ischemic stroke (AIS) care and outcomes as the program evolved to primary stroke center (PSC) and then comprehensive stroke center (CSC) certification from The Joint Commission. We explored the impact of program accreditation on patients with intra-cerebral hemorrhage (ICH) who presented directly to our center.

Methods:
Patients admitted to Tulane University Medical Center (TUMC) from 07/2008-10/2013 for ICH were retrospectively assessed. Transfers were excluded. Patient outcomes were compared according to patient admission date: admitted while our center was an emerging PSC (ePSC, 07/08-03/10) or an emerging CSC (eCSC, 04/10-10/13).

Results:
Out of the 273 patients with ICH during the study period, 12 (16.22%) and 29 (14.57%) transferred patients were excluded from ePSC and eCSC groups, respectively. ePSC and eCSC patients did not differ significantly in age, race, gender, baseline NIHSS, baseline ICH severity, or time to hospitalization. Short-term outcomes including poor functional outcome (modified Rankin scale 3-6), favorable discharge disposition (home or rehab facility), and in-hospital mortality did not differ. eCSC patients had a reduced incidence of nosocomial pneumonia (10.71% vs. 20.97%, p=0.043). eCSC patients received more CT angiograms (72.19% vs. 51.61%, p=0.003) with a notable decrease in spot signs (10.26% vs. 25.00%, p=0.030). Rates of any neurosurgical intervention did not significantly change.

Conclusion:
Short-term outcomes for ICH patients did not significantly change as our center evolved into a certified CSC. While we were more aggressive with acute neuroimaging, we detected fewer patients with active bleeding, and the rate of neurosurgical intervention did not change. Overall, progression from PSC to CSC certification was associated with potential over-utilization of resources and no detected improvement in early outcomes for ICH, despite lower incidence of pneumonia. Additional research is needed to assess whether this pattern holds true at other centers.
Abstract T P292: Utility of Depression and Cognitive Impairment Screening during Hospitalization for Acute Stroke
Authors: Owada Kumiko , Brasher Cynthia , Dunn Joshua , Bryant Katja , Hockenberry Jason , Kasshout Omar , Belagaje Samir , Dharia Robin , Anderson Aaron , Smith Heather , Hoffman Theresa , Caldwell Kizzy , Hamby Hannah , Jenkins Jeanelle , Carkhum Rasheedah , Pucciano Carol , Ayala Lauren , Nahab Fadi
Published: March 2022

Background:
Comprehensive stroke center standards currently require that stroke patients are assessed for cognitive impairment and depression prior to discharge. There is limited data on the utility of cognitive and depression screening within the first week after a stroke.

Methods:
We retrospectively identified patients discharged with a primary diagnosis of stroke [ischemic stroke (IS), intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH)] from January 1 to August 31, 2013 at Emory University Hospital. The Patient Health Questionnaire 2 (PHQ-2) was administered to screen for depression with a score of ≥ 3 considered a positive depression screen. The 6-item screener was administered to screen for cognitive impairment with a score of ≤ 4 considered a positive cognitive impairment screen. Reliability of the screens was determined by comparing results of inpatient and follow-up screens performed 7-14 days after discharge in a subgroup of patients.

Results:
Of 315 patients (mean age 61 years, 57% female), 43% had IS (mean NIHSS 8), 31% had SAH (mean Hunt/Hess score 2), and 26% had ICH (mean ICH score 2). Screens were completed (mean 4 days) in 183 (58%) patients, including 64% of IS, 55% of SAH and 46% of ICH patients (IS vs ICH, p=0.01); intubation (32%), delirium (23%), and aphasia (17%) were the most common reasons for inability to complete a screen. A positive depression screen was seen in 22% and a positive cognitive screen in 26% of patients. In age and risk adjusted analysis, history of prior stroke was associated with a positive depression screen (OR 3.39, p=0.01). Having a SAH was a significant predictor of a positive cognitive impairment screen (OR 2.74, p=0.04) while being female was associated with a lower odds of a positive cognitive impairment screen (OR 0.36, p=0.01). Among a random subgroup of 36 patients, reliability of the inpatient screening results was low when compared to screening results after discharge.

Conclusions:
More than 40% of stroke patients were unable to complete their inpatient depression and cognitive screens due to acute medical illness. Further study is needed to evaluate the reliability of these screening test results when administered before discharge.
Abstract T P304: A Retrospective Cohort Study: Effect of Ambulation on Urinary Tract Infections in Acute Stroke Patients
Authors: Sisante Jason-Flor , Abraham Michael , Billinger Sandra , Mittal Manoj
Published: March 2022

Introduction:
Urinary tract infection (UTI) is reported in 4-20% ischemic stroke patients. Age, sex, indwelling urinary catheter, and atrial fibrillation have been reported as independent predictors of UTI in stroke patients. There is limited data about the relationship of ambulatory status and the rate of urinary tract infection (UTI) following a stroke admission.

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

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” dataset was used to identify acute stroke patients and their ambulatory status (yes/no). UTI 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 UTI (1.4% vs 9.8%; p<0.0001) when compared to non-ambulating patients. After adjusting for age, gender, stroke type, atrial fibrillation, and indwelling urinary catheter use; patients who were able to ambulate still had lower rates of UTI (OR: 0.41, 95% CI 0.25-0.63).

Conclusion:
In conclusion, our findings suggest that the stroke patients who are able to ambulate during their index hospitalization have lower rate of UTI. Early ambulation may result in earlier removal of indwelling urinary catheter which may explain the protective effect of ambulation against UTI.