bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP212: Have Clinicians Adopted the Use of Brain MRI for Patients With TIA and Minor Stroke?
Authors: Chaturvedi Seemant , Ofner Susan , Baye Fitsum , Phipps Mike , Sico Jason , Damush Teresa , Miech Edward , Reeves Mat , Johanning Jason , Williams Linda S , Bravata Dawn
Published: July 2021

Background:
Use of MRI with diffusion weighted imaging (DWI) can identify infarcts in 30-50% of patients with transient neurovascular symptoms. Previous guidelines have indicated that MRI-DWI is the preferred imaging modality for patients with TIA symptoms. We assessed the frequency of MRI utilization and predictors of MRI performance in a national integrated health system.

Methods:
A review of TIA and minor stroke patients evaluated at Veterans Affairs Hospitals (fiscal year 2011) was conducted. Administrative data was reviewed with regard to demographic factors, past medical history, use of diagnostic imaging within two days of presentation, and in hospital care variables. Detailed chart abstraction was performed in a patient subset of large volume hospitals to assess clinical variables.

Results:
8427 patients with TIA or minor stroke were included in the administrative data cohort. Overall, 6817 patients (80.9%) had cranial imaging (either CT or MRI) within two days of presentation, with 3420 (50.2%) having CT without MRI and 3397 (49.8%) having MRI. 3.6% of patients with CT only had a pacemaker. Specific variables that were associated with CT performance (rather than MRI) in the administrative data cohort included the following: age>80 years, prior stroke, atrial fibrillation, dementia, and congestive heart failure (p<0.0001 for each). On chart review, diplopia as a complaint (87% with diplopia had MRI vs. 13% had CT only, p=0.03), neurological consultation in the Emergency Department (73% had MRI vs. 27% had CT only, p< 0.0001), and symptom duration of >6 hours (74% had MRI vs. 26% had CT only, p=0.0009) were associated with MRI performance.

Conclusions:
Within a large national health system, about 40% of patients with TIA or minor stroke had MRI performed within two days. Performance of MRI appears to be influenced by several variables, including age, nature of the symptoms, prior stroke, and neurological consultation in the ED. These data suggest that there has been partial acceptance of the previous guideline which endorsed MRI for patients with TIA.
Abstract TP218: Transoesophageal Echocardiography in the Diagnostic Work-up of Patients With Embolic Stroke of Undetermined Source: A Necessary Investigation That Should Not Be Overlooked
Authors: Tsivgoulis Georgios , Katsanos Aristeidis H , Bhole Rohini , Frogoudaki Alexandra , Giannopoulos Sotirios , Goyal Nitin , Vrettou Agathi-Rosa , Ikonomidis Ignatios , Paraskevaidis Ioannis , Pappas Konstantinos , Parissis John , Kyritsis Athanassios P , Alexandrov Anne W , Malkoff Marc D , Voumvourakis Konstantinos , Alexandrov Andrei V
Published: July 2021

Background&Purpose:
The currently proposed criteria for the definition of embolic strokes of undetermined source (ESUS) do not include investigation with transesophageal echocardiography (TEE) among the mandatory diagnostic work-up. We sought to evaluate the diagnostic yield of TEE in consecutive patients fulfilling ESUS criteria.

Methods:
We prospectively evaluated ischemic stroke (IS) patients fulfilling ESUS criteria from three tertiary care stroke centers during a twelve month period. All patients underwent additional diagnostic work-up with TEE to estimate both the diagnostic yield and the impact of TEE findings in the therapeutic management of patients with ESUS.

Results:
We identified 61 patients with ESUS who underwent investigation with TEE [mean age 44.3±11.5 years; 49.2% males; median NIHSS=5 (IQR, 3-8)]. TEE revealed additional findings in 52.4% (95%CI by the adjusted Wald method: 40.2%-64.5%) of the patients. Patent foramen ovale (PFO) and atrial septal aneurysm (ASA) were reported in 27.8% (95%CI: 18.1%-40.2%) and 13.1% (95%CI: 6.5%-24.1%) of the study population respectively. The concurrence of PFO and ASA was reported in 4 patients (6.5%, 95%CI: 2.1%-16.1%). The presence of valvular vegetations was documented in 2 patients (3.2%; 95%CI: 0%-11.8%), while thrombus was found in the left atrium of one patient (1.6%, 95%CI: 0%-9.5%). Complex aortic arch atheromatosis was reported in 6.5% (95%CI: 2.1%-16.1%) of the patients. Neither myxomas, nor ventricular septal defects were found in TEE examinations. TEE findings changed the management in 16.4% (95%CI: 8.9%-27.8%) of the patients. Anticoagulants were initiated in 5 patients, while the other 2 patients with endocarditis received treatment with intravenous antibiotics. Finally, 3 of the 61 patients underwent a PFO-closure procedure due to the large size of the shunt and the previous history of recurrent cryptogenic IS.

Conclusions:
Our findings suggest that ESUS patients should undergo investigation with TEE in search of potential cardioembolic or aortogenic sources. TEE findings may have a decisive impact on the selection of the appropriate therapeutic approach for these patients.
Abstract TP223: Mechanisms of Lateral Medullary Infarction Based on Combined MR Diffusion/Perfusion Imaging Patterns
Authors: Lee Younggun , Kim Ji Hwa , Lee Kyung-Yul
Published: July 2021

Introduction:
Steno-occlusive lesion in vertebral artery and posterior inferior cerebellar artery (PICA) or perforator occlusion could result in lateral medullary infarction. However, exact mechanism of lateral medullary infarction is not straightforward due to limited information from MR angiography (MRA) and variations of posterior circulation.

Hypothesis:
The mechanism of lateral medullary infarction could be evaluated based on DWI/PWI pattern.

Methods:
We selected the acute ischemic stroke patients in whom acute ischemic changes were in the lateral medulla with or without PICA territory on DWI and available PWI. We categorized cases in 4 groups based on DWI/PWI patterns. Cases with isolated lateral medullary infarction were divided into those with normal perfusion (LM) and with perfusion delay (LM-P) on PICA territory. Cases having both lateral medullary and PICA territory cerebellar infarction were further divided into those with mismatched perfusion delay (LC-UP) and with matched perfusion delay (LC-MP).

Results:
A total number of 43 patients were included and DWI revealed infarction solely on lateral medulla (n=36) or both lateral medulla and cerebellum (n=7). The number of cases was 24, 12, 4 and 3 in LM, LM-P, LC-UP and LC-MP respectively. One third of isolated lateral medullary infarction shows perfusion delay in PICA territory (LM-P) suggesting proximal large artery pathology. In contrast, two thirds of isolated lateral medullary infarction may be due to perforator occlusion either by perforator pathology or less likely embolic occlusion.

Conclusion:
DWI/PWI pattern classification of PICA territory is useful to understand the underlying mechanism of lateral medullary infarction.
Abstract TP236: Early Dispensing of Tpa After Patient Arrival is Associated With Faster Door to Needle Time for Tpa Administration
Authors: Siddiqui Khawja A , Anderson Christopher D , Rost Natalia , Schwamm Lee H
Published: July 2021

Intro:
Many strategies have been suggested to increase the propotion of patients with an IV tPA door to needle time (DTN) within 60 minutes of ED arrival (DTN≤60), which ahs been shown to improve outcomes. We sought to investigate the effect of early tPA dispensing on DTN≤60.

Methods:
Using our local GWTG database and pharmacy dispensing logs from the automated pharmacy cabinet (Omnicell), we identified all patients administered IV tPA from 4/07-6/14. We defined an early tPA treatment decision as the dispensing of tPA from the Omnicell before the CT scan was performed.

Results:
Patients achieving a DTN≤60 were less likely to be white and more likely to present with weakness compared to those with DTN>60. They had shorter door-to-tPA dispensed (DTD) and door-to-CT (DTCT) times (Table). On multivariable analysis, white race (aOR=0.19, p=0.05), DTD (aOR=0.97 per min, p=0.001) and DTCT (aOR=0.93 per min, p<0.001) remained significantly associated with DTN<60. DTD time was highly correlated with the DTN time (R2=0.44, p60 (16.6+9.5 vs. 37.3+24.5 min, p<0.001). An early treatment decision was associated with a shorter absolute DTN time (36 min (27,52) vs. 50 min (37.5,66), p-value<0.001) and remained significant in multivariable testing (aOR 7.43(0.80,14.06); p=0.03) with DTD time (a0.80 per min (0.65,0.93); p<0.001).

Conclusion:
Our study supports the Target Stroke best practice of premixing tPA in high likelihood tPA candidates, and confirms that early determination of tPA eligibiltiy can be a successful strategy in reducing DTN times.
Abstract TP241: High-yield Interventions Reduce Time to tPA in Ischemic Stroke
Authors: Kozak Benjamin , Singh Vineeta , Cole Sara , Martin Christine , Mutch Christopher , Rehani Bhavya
Published: July 2021

Introduction:
Tissue plasminogen activator (tPA) reduces disability from ischemic stroke, but this benefit is time dependent. Guidelines recommend a door-to-tPA time of < 60 mins. We retrospectively evaluated the effect of eight interventions on door-to-tPA time at a large safety net public hospital.

Hypothesis:
High-yield interventions would significantly reduce door-to-tPA times, especially a stroke code activation system.

Methods:
From Jan 2008 to Dec 2014, all patients (n=537) presenting to our emergency department (ED) with possible stroke and for whom tPA was considered were entered into a database. Critical ischemic stroke times were recorded and compared annually (physician at bedside, labs resulted, CT scan read, tPA given). Interventions to reduce time to tPA were introduced intermittently (Figure). Mean time to tPA was compared for the six-month period before and after each intervention was implemented. Student’s t-test was used with significance at p<0.05.

Results:
The mean time to tPA improved from 2008 (98.9 min) to 2014 (60.0 min; p<0.001). This was largely driven by reductions in mean times from ED physician evaluation to head CT read (-35.3 min; p<0.0001) and from ED physician to neurologist evaluation (-23.3 min; p<0.0001). The interventions associated with the greatest reductions in mean time to tPA were an ED stroke pharmacist/giving tPA in the CT scanner (-17.5 min) and conducting monthly multidisciplinary stroke peer reviews (-15.9 min).

Conclusions:
A safety net public hospital significantly reduced its time to tPA for stroke through a combination of interventions, including multidisciplinary stroke peer reviews and infusing tPA in the CT scanner.
Abstract TP255: The Emergency Department Dysphagia Screen is Associated With Lower Rates of Pneumonia in Acute Ischemic Stroke Patients
Authors: Schrock Jon W , Lou Linda
Published: July 2021

Introduction:
Dysphagia is a common problem in acute ischemic stroke (AIS) patients predisposing them to pneumonia and leading to worse outcomes. The Joint Commission mandated that dysphagia screening be performed at hospital presentation which for most patients with AIS, is the Emergency Department (ED). No evidence exists to demonstrate if the use of an ED dysphagia screen is associated with lower rates of pneumonia.

Hypothesis:
We assessed the hypothesis that the use of our ED dysphagia screen would not be associated with lower rates of pneumonia in AIS patients.

Methods:
We performed a pre-post cohort study evaluating the rates of pneumonia in AIS patients presenting to our ED. Our pre group were AIS patients presenting from 2005-2009 and our post group from 2011-2015. The presence of pneumonia was pre-defined as new pulmonary infiltrate treated with antibiotics. We collected demographic and clinical data including rates of dysphagia and stroke severity. Data are presented as frequencies and medians with interquartile ranges (IQR) where appropriate. Rates of pneumonia were compared using the t-test.

Results:
We evaluated 419 pre screen and 1022 post screen AIS patients. Both groups were 50% female. The use of thombolytics in the pre group was 10% and post group was 11%. The median ages and ED NIHSS scores for the pre and post population were 63 years (IQR 53-73), 6 (IQR 3-10) and 64 years (IQR 56-76), 4 (IQR 2-8). Rates of dysphagia during hospitalization were 20% and 31% for the pre-post groups respectively. Rates of pneumonia for the pre-post groups were 13.8% and 8.0% respectively which was significantly different P=0.0007.

Conclusion:
The use of an ED dysphagia screen is associated with a lower rate of pneumonia in AIS patients. This study was not designed to prove causation so other factors also may have influenced the lower rate of pneumonia including possibly slightly less severe strokes. The rates of diagnosed dysphagia were higher in the post group suggesting ED screening may heighten awareness resulting in increased diagnoses of dysphagia. Given the rates of dysphagia and pneumonia early screening of AIS patients in the ED seems prudent.
Abstract TP256: Mouse Model of Uremic Cerebral Microbleeds
Authors: Lau Wei Ling , Tarbiat-Boldaji Mary , Smalls Hayley , Nunes Ane , Savoj Javad , Vaziri Nosratola D , Fisher Mark
Published: July 2021

Introduction:
Cerebral microbleeds are more common in chronic kidney disease (CKD) and dialysis patients compared to the general population. Diminished kidney function alone appears to be a risk factor for microbleeds, independent of age and hypertension. Microbleed burden in CKD patients is associated with increased risk of future hemorrhagic stroke and with cognitive dysfunction. The mechanisms that drive uremic microbleed formation are unclear.

Hypothesis:
We hypothesized that CKD mice are predisposed to develop cerebral microhemorrhages (the pathologic substrate of microbleeds), and that a standardized inflammatory stimulus (lipopolysaccharide, LPS) will amplify microhemorrhage burden in CKD mice compared to non-CKD controls (CTL). We also hypothesized that uremia induces depletion of tight junction proteins, altering blood-brain barrier integrity and representing a potential mechanism of microbleed formation.

Methods:
Animal groups included CTL (n=3), CKD (n=3), CTL+LPS (n=5) and CKD+LPS (n=5). CKD induction in male C57BL/6 mice was achieved via nephrotoxic adenine diet x18 days. Two weeks following CKD induction, CKD and control mice were treated with LPS 1 mg/kg i.p. dosed at 0, 6 and 24 hours. Brains were harvested one week after LPS injections and 40-micron sections were stained using Prussian blue to identify microhemorrhages. Immunohistochemistry was performed for the blood-brain barrier tight junction protein claudin-5.

Results:
CKD mice had significantly elevated blood urea nitrogen, and tubulointerstitial fibrosis was present on kidney histology. Total number of microhemorrhages per brain was 2.3±1.5 (mean ± standard error of the mean) for CTL mice, 8.3±1.5 for CKD mice, 23.2±4.2 for CTL+LPS mice, and 27.6±6.2 for CKD+LPS mice (p<0.05 for CKD+LPS vs. CTL). Immunostaining showed decreased claudin-5 expression in CKD mice compared to CTL.

Conclusions:
We have generated a mouse model that will facilitate future mechanistic studies in the field of uremic microbleeds. Our initial findings suggest that CKD alters blood-brain barrier integrity and that inflammation amplifies development of microbleeds in CKD.
Abstract TP262: Computational Fluid Dynamics Characterization of Hemorheology in the Lenticulostriate Arteries
Authors: Li Xiaofei , Wang Bochu , Ren Peng
Published: July 2021

Background and Purpose:
Intracerebral hemorrhage (ICH)’s ictus frequently locates in the lenticulostriate arteries (LSAs) which are perforator arteries from the horizontal segment (M1) of middle cerebral artery (MCA). LSAs supply the basal ganglia and the internal capsule. And the arteriopathy of LSAs may increase the occurrence of ICH. The goal of this study is to clarify the pathogenesis of ICH in the LSAs and provide a basic theory on the prevention of ICH. At the previous stage, computational Fluid dynamics (CFD) technology has been used to qualitatively analysis blood pressure and flow velocity in LSAs to investigate the initial state of ICH.

Methods:
Firstly, 2D model of LSAs is generated by GAMBIT2.4.6, including M1 segment of MCA (the diameter of 3 mm, the length of 1 mm), three levels of LSA branches (the diameter of 0.1 mm, 0.1mm, 0.2mm, respectively). Secondly, the circulating Fluid dynamics is simulated under pulsatile Flow conditions using FLUENT6.3.26.Navier-Stokes equation (N-S equation) has been used to perform numerical calculation of Newton fluid (circulating blood: density ρ=1055 kg/m3, dynamics viscosity υ=3.3*10-4 Pa·s), and the vessel walls are assumed to be rigid. The inlet pressure of M1 has the simplified waveform of an aortic with period T=0.8s. The outlet pressure at M1 and LSAs are imposed to be 10667 Pa.

Results:
It shows from contours of velocity magnitude that the velocity is intimately associated with the diameter of LSAs. The bigger the diameter is, the faster the velocity is. Relative to the same diameter of LSAs, the different location of LSAs show great difference on the velocity as well. With the computed streamlines, there are vortical structures in the origin of LSAs. From contours of total pressure, blood pressure in LSAs and M1 reduces gradually. With LSAs closer to the inlet of M1, the pressure gradient along LSAs is increased significantly. Besides, the pressure change demonstrates that the total pressure in M1 and LSAs changes periodically in a waveform.

Conclusion:
The pressure and velocity distributions in LSAs tend to be relevant to the diameter and original position of LSAs. However, to improve CFD model in this study, additional investigations should be performed to evaluate the relevance of the vasoactivity.
Abstract TP277: Diabetes Amplifies Vascular Injury and Worsens Ischemic Stroke Outcome in Young Female Rats: Loss of Protection
Authors: Valenzuela John P , Li Weiguo , Abdul Yasir , Ward Rebecca , El-Shafey Sally , Guo Xinyue , Fagan Susan C , Ergul Adviye
Published: July 2021

Women are protected from stroke until they reach menopause in part due to neuroprotection conferred by sex hormones. We and others have shown that that diabetes increases neurovascular injury and worsens stroke outcomes in males. Given the clinical evidence that diabetes increases stroke risk especially in younger individuals and females, we hypothesized that diabetes worsens stroke outcome even in young females. We further postulated that moderate hyperglycemia worsens hemorrhagic transformation (HT) and outcomes independent of changes in infarct size. High fat diet plus low dose streptozotocin model of diabetes was used. Control and diabetic weight-matched male and female rats (10-12 weeks old, n=5-7) were subjected to embolic stroke with a fibrin-rich humanized clot. Neurological deficits (Bederson score, adhesive removal test -ART and grip strength), infarct size, HT index, and edema ratio were assessed 3 days after surgery (Table). As expected in the control group, females rats had smaller infarct size, less edema, and better functional outcomes as compared to male rats. In the diabetic group, however, HT score was greater and this was more profound in females. Diabetes worsened the functional outcome to a much greater extent in females. While there was partial improvement of neurological deficits by Day 3 in control animals, diabetic animals did not improve but worsened. Additional studies will explore the long-term effects and the underlying mechanisms contributing to worse outcome in young and old diabetic females.
Abstract TP285: Levers for Facilitating the Establishment of Stroke Systems of Care
Authors: Amoozegar Jacqueline , Teixeira-Poit Stephanie M , Elmi Joanna , McGowan Devon , Tardif-Douglin Miriam , Mirambeau Alberta , Foltz Jennifer , King Sallyann
Published: July 2021

Introduction:
During 2012-2015 the Centers for Disease Control and Prevention’s (CDC) Paul Coverdell National Acute Stroke Program (PCNASP) funded 11 state health departments to improve quality of stroke care by developing systems of care that span the continuum of pre-hospital, hospital, and post-hospital care.

Hypothesis:
We assessed the hypothesis that state- and health system-level factors facilitate establishing stroke systems of care.

Methods:
We conducted 72 semi-structured telephone interviews with stakeholders of the 11 PCNASP grantees, such as program and quality improvement (QI) personnel, and emergency medical services (EMS) and hospital staff. Using grounded theory (Glaser and Strauss), we developed and applied a coding scheme to interview transcripts to identify emerging themes related to factors affecting establishing stroke systems of care.

Results:
Findings indicate that state- and health system-level characteristics affect experiences establishing stroke systems of care. State-level characteristics include demographics and geography, incidence of stroke, existence of legislation, and leadership. Large states, low population density, and low incidence of stroke posed a challenge to establishing systems of care. The existence of state stroke care hospital designation and the centralization of authority to establish and implement statewide standard of care and destination protocols played a key role in incentivizing participation in QI efforts across the continuum of care. Infrastructure, capacity, and relationships at the health system-level were associated with establishing systems of care. Respondents shared examples of barriers, such as the high number of volunteer versus paid EMS providers, the feasibility and resources to convene EMS and hospital staff for trainings and building support; facilitators included the existence of well-established, collaborative relationships between EMS, hospitals, and rehabilitation agencies.

Conclusion:
Contextual factors unique to each state affected the achievement that PCNASP grantees experienced in establishing systems of care. Individualizing implementation given contextual factors may facilitate success of stroke systems of care throughout the nation.
Abstract TP306: Characteristics and Outcomes Among Patients Transferred to Regional Stroke Centers Across the United States for Specialized Stroke Care
Authors: Ali Syed F , Fonarow Gregg , Smith Eric , Liang Li , Sutter Robert , Xian Ying , Peterson Eric , Bhatt Deepak , Schwamm Lee
Published: July 2021

Intro:
Many patients are transferred to stroke centers for advanced stroke care, especially after IV tPA. We sought to determine differences in the baseline characteristics and outcomes between AIS cases presenting directly to stroke centers’ front doors vs. transfers-in from another regional acute care hospital.

Methods:
Using data from the national GWTG-Stroke registry, we analyzed 970,390 AIS cases (01/2010 - 03/14). Patients at hospitals with high transfer-in rates (>15%) were selected (284 hospitals, 303,739 patients). Due to large sample size, instead of p-values, standardized differences were reported. Multivariable model (MV) examined the association of transfer-in vs. front door with the primary and secondary outcomes, adjusting for patient and hospital characteristics including NIHSS.

Results:
High volume transfer-in hospitals admitted 31% of their patients via transfer. Transfer-in patients were younger, more often white and non-Hispanic. They had similar stroke risk factors except for hypertension and previous stroke/TIA which were less common. Transfer-in had worse initial NIHSS, more often had altered consciousness and language disturbance. Transfer-in patients had longer length of hospital stay, higher mRS at discharge, and were less often discharged home. In-hospital mortality was ∼ 3% higher in transfer-in as compared with front-door. Among tPA treated patients, sICH < 36hr was more common in transfer-in patients. On MV, transfer-in patients had overall worse outcomes as shown by the higher odds of in-hospital mortality, longer length of stay, and not able to ambulate independently at discharge (Table).

Conclusion:
Many hospitals receive high volumes of stroke patients via transfer. Because transfer-in patients have worse outcomes, these patients have the potential to negatively influence institutional outcomes rates. Transfer-in patients should be carefully accounted for in risk adjusted models of hospital outcomes.
Abstract TP318: Rates of In-hospital Procedures and Outcomes Among Subarachnoid Hemorrhage Patients Admitted to Joint Commission Primary Stroke Centers in United States
Authors: Chaudhry Saqib A , Afzal Mohammad R , Chaudhry Burhan , Riaz Ahmed , Saeed Ali , Sachdeva Gautam , Safdar Adnan , Kassab Mounzer , zafar aimen , Qureshi Adnan I
Published: July 2021

Background:
Although targeted towards ischemic stroke patients, the benefit of primary stroke centers (PSCs) certification by Joint Commission (JC) may extends to patients with subarachnoid hemorrhage. We compared the rates of in-hospital procedures, adverse events and discharge outcomes among subarachnoid hemorrhage patients between PSCs and non PSCs hospitals in United States.

Methods:
We analyzed the data from Nationwide Inpatient Sample from 2010 and 2011. The analysis was limited to States that publicly reported hospital identity and included patients (age ≥18 years) discharged with a principal diagnosis of subarachnoid hemorrhage (ICD9 codes 430). PSCs were identified by matching the NIS hospital files with the list provided by JC.

Results:
A total of 4,350 subarachnoid hemorrhage patients were analyzed of which 3,098 (71.1%) patients were admitted at PSCs. After adjusting for DRG-based disease severity, and hospital characteristics, patients admitted at PSCs had higher rate of in-hospital procedures; endovascular treatment (odds ratio [OR], 2.9; 95% confidence interval [CI], 2.1 to 3.9), intracranial angioplasty (OR, 1.6; 95% CI, 1.4 - 1.8), and ventriculostomy (OR, 1.5; 95% CI, 1.3 to 1.9). There was no difference for procedures such as surgical treatment (OR, 1.2; 95% CI, 0.9 - 1.5), mechanical ventilation (OR, 1.1; 95% CI, 0.9 - 1.3) or ventriculo-peritoneal shunt (OR, 0.8; 95% CI, 0.6 to 1.4). In-hospital adverse events were similar between two groups. After adjusting for age, co-morbidities, DRG-based disease severity, and hospital characteristics, patients admitted at PSCs were more likely to more likely to be discharged to home (OR, 1.4; 95% CI, 1.2- 1.7) .

Conclusions:
Compared with non PSCs admissions, patients with subarachnoid hemorrhage admitted to PSCs are more likely to receive endovascular treatment and had higher odds of being discharged to home. Such observations support the notion that PSC certification may favorably impact outcomes in all stroke subtypes.
Abstract TP335: Lower NIHSS Score on Presentation to the Emergency Center Delays Head CT Turnaround Times
Authors: Grysiewicz Rebbeca , Glaser Anna , Kotzen Lisa , Weissman Holly
Published: July 2021

Background:
Rapid assessment of patients that present to the emergency center with acute stroke symptoms is crucial to the timely administration of intravenous thrombolysis. The “golden hour” is recognized by the American Heart Association as the standard of care for treatment of acute ischemic stroke [1]. Door to treatment in ≤ 60 minutes can be difficult to achieve, and in 2010 < 30% of hospitals participating in GWTG attained this goal [2]. One step that can be particularly challenging during the expedited stroke assessment is door to head CT interpretation time in ≤ 45 minutes. We sought to determine factors that delay head CT turnaround times > 45 minutes.

Methods:
A retrospective stroke database review was completed on 165 patients presenting to the emergency center with acute stroke symptoms in the 0-4.5 hour time window from January 2014 to May 2015. Inclusion criteria was age 18-95 years with an initial NIHSS of 1-42, and a head CT completed at our hospital. Inpatients that developed acute stroke symptoms were excluded from the study. Patients were further stratified by NIHSS and age.

Results:
The mean age was 75 years and 50% were female. The average head CT turnaround time was 38.1 minutes and the average NIHSS was 8.11. Fifty three patients (32.1%) received acute reperfusion therapy. The average head CT turnaround time for a NIHSS of 1-3 was 47.4 minutes; NIHSS of 4-9 was 38.4 minutes; NIHSS of 10-24 was 25.2 minutes; NIHSS ≥ 25 was 34.5 minutes. There was no significant difference in the head CT turnaround time based on age.

Conclusion:
Patients presenting to the emergency center with a NIHSS of 1-3 had delayed head CT turnaround times compared to patients presenting with more severe stroke symptoms, and furthermore, did not meet the goal head CT interpretation time of ≤ 45 minutes. One possible reason for this finding is that patients with minor stroke symptoms are less likely to receive intravenous thrombolysis. However, expanding literature suggests that nearly 30% of patients with lower NIHSS scores at discharge have significant disability at 90 days [3]. Multiple educational interventions will be implemented in the emergency center to improve head CT turnaround times in patients with low NIHSS scores on presentation.
Abstract TP337: Variation in Total and Daily Relative Costs of Stroke Hospitalization by Departments
Authors: Mahmood Sadiqa , Siddiqui Khawja A , Liu Xiu , Lynch Karen E , Zheng Hui , Shahian David M , Schwamm Lee H
Published: July 2021

Intro:
Stroke is a major public health burden, but few data are available on the distribution of relative inpatient stroke costs. We determined key drivers of cost in patients hospitalized with ischemic stroke (IS) to inform decisions regarding optimal resource use.

Methods:
We linked 1,578 IS patients in our local Get with the Guidelines Stroke database (2010- 2013) to administrative, cost accounting data (EPSI, inc). Relative hospital costs by department within 30 days post admission were stratified by quartiles into very high (n=394), high (n=395), low (n=394) and very low (n=395). We analyzed mean daily relative cost per patient, stratified by mortality. All financial data are relative costs, reported as medians [IQR] multiplied by a constant.

Results:
The median overall relative cost was $274 (IQR $183-$525) per admission. In the very high cost group, ICU nursing, nursing and operating room were the top three cost areas and accounted for 64% of all IS costs (Figure 1). The highest relative mean daily costs occurred during the first two inpatient days, and were 40.4% and 27.1% higher respectively for patients dying during the index admission than survivors (p<0.0001) (Figure 2).

Conclusions:
Inpatient IS costs vary widely, and patients in the highest cost quartile account for a majority of overall costs. The greatest per day costs occur in the first few days of care, regardless of survival. Improvements in major cost drivers, including use of bed days (and associated nursing costs), radiology and pharmacy may be possible. These findings should be validated at other medical centers in different cost accounting software systems.
Abstract TP359: Admission Systemic Inflammatory Response Syndrome and Outcome Following Intracerebral Hemorrhage in a Multicenter Study
Authors: Boehme Amelia K , Comeau Mary , Langefeld Carl , Lord Aaron , Moomaw Charles , Osborne Jennifer , Martini Sharyl , Testai Fernando , Elkind Mitchell , Woo Daniel
Published: July 2021

Background and Purpose:
Systemic Inflammatory Response Syndrome (SIRS) has been shown to predict outcomes after intracerebral hemorrhage (ICH) in a single-center cohort. We hypothesized that SIRS would predict outcomes in a multicenter multi-ethnic cohort of ICH patients.

Methods:
The Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study is a multi-center observational study of ICH among whites, blacks, and Hispanics. SIRS on admission was defined according to standard criteria as 2 or more of the following: (1) body temperature 38°C, (2) heart rate > 90 beats per minute, (3) respiratory rate > 20/minute, or (4) white blood cell count 12,000/mm3. Patients were excluded if they died within 72 hours of admission, or if missing vital signs or laboratory tests did not allow for assessment of SIRS on admission. Associations of SIRS with baseline characteristics, infection, and poor outcomes (modified Rankin Scale 3-6) at discharge and 3 months were assessed using t-tests, chi-square, and logistic regression.

Results:
Of 2411 patients included, 340 (14%) met SIRS criteria at admission. Patients with SIRS were younger (58.0 vs. 62.3 years; p<.0001) and more likely to have intraventricular hemorrhage (IVH) (52.9% vs. 36.5%; p<.0001), higher baseline ICH volume (25.2 vs. 17.4; p<.0001), and lower baseline Glasgow Coma Score (GCS; 10.7 vs. 13.1; p<.0001). SIRS was not associated with subsequent infection (OR 1.40, 95%CI 0.84-2.34). In unadjusted analyses, SIRS was associated with poor outcome at discharge (OR 2.0, 95%CI 1.5-2.7) and 3-months (OR 1.8, 95%CI 1.4-2.3). In patients with milder ICH (ICH score 0-2), SIRS was associated with poor mRS at discharge and 3 months, but SIRS was not related to outcomes for patients with baseline ICH score 3-5. After adjusting for age, IVH, ICH volume, GCS, ICH location, and pre-onset mRS, SIRS was no longer associated with poor outcomes.

Conclusions:
SIRS at admission is an indicator of stroke severity and thus a predictor of poor functional outcome, but not infection, after ICH. Further study is needed to better understand systemic inflammation after ICH.
Abstract TP36: Predictors and Associated Outcomes of Subarachnoid Hemorrhage Following Endovascular Treatment for Acute Ischemic Stroke
Authors: Geordiadis Alexandros L , Saleem Muhammad A , Qureshi Adnan I
Published: July 2021

Introduction:
The rates of occurrence, predictors, and associated outcomes of subarachnoid hemorrhage (SAH) following endovascular treatment are not well studied.

Methods:
We retrospectively analyzed data from the Interventional Management of Stroke Trial (IMS III). This prospective trial randomized patients to intravenous (IV) rt-PA alone versus IV rt-PA followed by endovascular intervention. All patients underwent computed tomography (CT) at 24 hours post randomization. The scans were assessed by independent reviewers at a core laboratory for the presence, location, and type of intracranial hemorrhage.The primary outcome assessment was by modified Rankin Scale (mRS) score at 3 months.

Results:
Thirty four out of 434 (7.8%) patients who received endovascular treatment suffered SAH at 24 hours. There were 19 men (55.9%), and 19 patients were older than 70 years.In univariate analysis only pre-existing ischemic heart disease was identified as a predictor of SAH (p=0.03) while patient age was borderline significant (p=0.055). Three-monthmRS score was available for 24/34 patients with SAH and for 318/400 among the other patients. There was no difference in mortality (12.5% vs. 4.1%, p=0.167) or favorable outcome defined as mRS =<2 (41.7% vs. 53.5%, p=0.366).

Conclusions:
SAH following endovascular intervention for acute stroke is more common among patients with history of ischemic heart disease. It does not impact on functional outcome or mortality at 3 months.
Abstract TP376: Infections in Patients With Spontaneous Intraventricular Hemorrhage- Results From the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage (CLEAR) III Trial
Authors: Shah Jharna N , Murthy Santosh B , McBee Nichol , Dlugash Rachel , Ram Malathi , Lane Karen , Awad Issam , Hanley Daniel F , Ziai Wendy C
Published: July 2021

Introduction:
Intraventricular hemorrhage (IVH) occurs in about 40% of patients with intracerebral hemorrhage (ICH) and is associated with higher mortality and worse outcomes than ICH patients without IVH. Infections are common in ICH patients but data in IVH patients are limited.

Methods:
Prospective analysis of adjudicated adverse event infection reporting during first 180 days in 500 patients enrolled in the CLEAR III trial, a multicenter, double-blind, randomized study comparing external ventricular drain (EVD) + intraventricular recombinant tissue plasminogen activator (rtPA) vs. EVD + placebo for treatment of obstructive IVH and intracerebral hemorrhage (ICH) volume <30cc. Primary outcome measures were 90-day and 180-day mortality. Secondary outcome measures were hospital length of stay (LOS). We constructed binary logistic and linear regression models for multivariable analysis.

Results:
Infection was reported in 269 patients (53.8%). Pneumonia was the most common infection (33%), followed by UTI (16%), and bacterial ventriculitis (4.4%). Overall 180-day mortality was 20%. Patients with infection were more likely to have older age (p=0.012), lower admission GCS (p=0.007), higher ICH volume (8.8 vs 6.7ml, p=0.001), and higher ICH+IVH volume (37.7 vs 31.7 ml, p=0.002). In the regression model, IVH volume was associated with higher odds of 90-day or 180-day mortality, but presence of any infection was not a significant predictor of mortality. Infection was however associated with longer length of stay (26 vs 22 days, p<0.001). Subgroup analysis of individual infections, showed only bacterial ventriculitis to be associated with 90-day (OR: 3.84, CI: 1.36-10.82), and 180-day mortality (OR: 2.9, CI: 1.05-8.06), while pneumonia and UTI were not.

Conclusion:
Patients with IVH have a high incidence of infections, which is associated with longer hospitalization but does not appear to influence mortality. Of the infections, bacterial ventriculitis is a significant predictor of mortality in our 7-factor model. IVH volume did not predict infections but predicted mortality.These results form a basis for future correlation of infectious complications with treatment rendered (thrombolysis versus placebo), with upcoming unblinding of the trial.
Abstract TP378: Intracerebral Hemorrhagic Expansion Occurs in Patients Using Novel Anticoagulants
Authors: Melmed Kara R , Lyden Patrick , Moheet Asma
Published: July 2021

Background:
Novel oral anticoagulant (NOAC) use has significantly reduced Intracerebral Hemorrhagic (ICH) risk compared to standard anticoagulant treatment. Increased ICH hematoma expansion (HE) is a known predictor of mortality in warfarin associated ICH. Little is known about ICH expansion in patients using NOACs.

Methods:
We conducted a retrospective chart review of patients with ICH admitted to CSMC from Oct 2010 through March 2015. We identified patients with concomitant administration of either a NOAC or warfarin and collected data including the following: reason for agent prescription, time to brain imaging, evidence of HE on imaging, and discharge status and mRS at discharge. We defined HE as either relative expansion (≥ 33% increase) or absolute expansion (≥ 12 mL). We compared outcomes of patients with and without HE.

Results:
Out of 642 patients admitted with ICH within this time period, we identified 7 patients with concomitant NOAC use and a sample of 14 matched patients on warfarin. Patients on NOACs vs warfarin patients had no significant differences in NIHSS or ICH score on presentation (median [IQR] 21 [11,22] vs 16 [5,26] and 2 [1,4] vs 2 [1,2]). 4 out of 7 coagulopathic NOAC patents demonstrated HE, compared to 5 out of the 14 warfarin patients that demonstrated HE, with no significant difference. Of the NOAC subset, the median NIHSS on presentation was 21 [13,23.5] and the median ICH score on presentation was 2 [2,4]. There were no significant differences in mRS on discharge in NOAC patient with HE vs without or warfarin patients with HE vs without (5 [4,6] vs. 5.5 [4.5,6] and 4 [3.5,6] vs 3 [3,5.5]).

Conclusions:
In our coagulopathic NOAC patient population, HE continues beyond 6 hours in 57% of patients. To our knowledge, this is the largest case series reporting on HE with concomitant NOAC use. This case series was not statistically powered to show significant differences between groups, although outcomes in patients suffering from HE appear to be poor in general. Expansion of the initial hematoma is a possible target for medical intervention. The better outcomes in warfarin patients in our cohort are likely related to the targeted reversal of coagulopathy.
Abstract TP405: Raising the Bar, Lowering the Target
Authors: Price Theresa M
Published: July 2021

Background:
In 2013 our growing regional stroke referral center was not meeting Target Stroke® best practice recommendations for door to needle times within 60 minutes. A Rapid Improvement Event (RIE) was held to decrease process waste and therefore improve treatment times. Process changes were implemented in January 2014. Twelve months of monitoring identified sustained improvement and evidence that the process could continue to improve therefore a second rapid improvement event was held in January 2015 targeting door to needle times within 45 minutes.

Purpose:
The purpose of the process improvement event was to decrease treatment times below 60 minutes targeting 45 minutes.

Methods:
The RIE was utilized as the platform to incorporate process improvement principles and evidence based practice in order to elevate the standard of care for patients experiencing ischemic stroke. A multidisciplinary team including pre-hospital and hospital staff met to develop a care model that would impact patients presenting with stroke like symptoms. Lean tools were used to capture waste and bring transparency to the process. A standardized pathway and standard work for each role were developed. Huddles to debrief on successes and barriers from each case were implemented as a way to increase staff engagement and familiarize them with the new process.

Results:
Significant improvement was achieved. Median door to needle treatment times decrease from 86 minutes to 49 minutes, a 43% improvement. Treatment within 60 minutes improved from 23% of eligible patient to 67% of eligible patients, this was an improvement of 66%. Treatment within 45 minutes improved from 6% of eligible patients to 45% of eligible patients, this was an improvement of 87%.

Conclusion:
Lean principles proved to be an effective tool for improving the thrombolytic delivery process for acute ischemic stroke patients.
Abstract TP422: High Pulse Pressure and Risk of Stroke Recurrence in Patients With Tia
Authors: Zurru Maria C , Alonzo Claudia , Brescacin Laura , Pigretti Santiago , Colla Machado Pedro , Camera Luis , Fucile Giselle , Waisman Gabriel , Cristiano Edgardo
Published: July 2021

Introduction:
stroke recurrence in patients with TIA is one of the most frustrating medical situations and it is very important to identify strong predictors of stroke recurrence to enable practitioners to take clinical decisions

Hypothesis:
to evaluate the relationship between pulse pressure (PP), a marker of vascular disease, and the risk of stroke recurrence in patients with TIA.

Methods:
TIA patients were prospectively included in a multidisciplinary secondary stroke prevention program. Pre-stroke vascular risk factor profile and control were obtained from electronic medical records. Stroke recurrence was analyzed after five years of follow up. For the purpose of the analysis, three groups were defined according to pre-stroke PP: < 60, 60-69 and > 70 mmHg.

Results:
357 patients (mean age 75±10 years, 55% females) were included. Vascular risk factors profile: hypertension 83%, dislipidemia 74%, obesity 54%, smoking 41%, diabetes 12%, AF 12%, CKD 28%, CHD 18%. Mean SBP was 130 mmHg and DBP 80 mmHg; 78% was receiving antihypertensives, 47% statins, 43% antiplatelets and 9% anticoagulants before the event. There was a direct relationship between pre-stroke PP and stroke recurrence during follow-up (figure).

Conclusion:
PP is related to higher burden of vascular disease, mainly an increase in arterial stiffness, which might be a key element in clinical decision making in the setting of stroke recurrence prevention.
Abstract TP426: PFO Closure Reduces Plasma Levels of Serotonin in Long Term Follow up of Stroke Patients
Authors: Deng Wenjun , McMullin David , Wickham Thomas , Feeney Kathleen , Inglessis Ignacio , Palacios Igor , Buonanno Ferdinando , Lo Eng H , Ning MingMing
Published: July 2021

Background:
PFO allows venous clots and vasoactive circulatory factors to bypass pulmonary filtration and remain in circulation. Serotonin (5-HT) has procoagulant and oxidative roles in both cardiovascular and neurovascular injury. We previously identified an immediate reduction of 5-HT in left atrial blood post PFO closure. To understand the long-term effect of PFO closure, we report the changes of 5-HT in peripheral venous blood in 1-year follow-up.

Method:
97 PFO-related stroke patients were recruited in accordance with IRB. Venous blood was collected at baseline (BL) and 1 year follow-up (FU) post treatment (PFO closure or medical therapy). Plasma 5-HT was quantified by mass spectrometry. Patients with serotonin modifying medications (e.g. SSRIs) or conditions (e.g. anxiety/depression) were excluded.

Result:
5-HT concentration in peripheral venous blood was significantly reduced by 27.27% (BL: 7.57 ± 8.04 μmol/l; FU: 5.51 ± 5.72 μmol/l; p = 0.0034) in 61 patients receiving PFO closure (Fig 1A). In the 37 PFO patients treated with medical therapy alone, no changes were observed (5-HT: BL: 5.79 ± 7.15 μmol/l; FU: 6.25 ± 6.68 μmol/l; p = 0.4050) (Fig 1B). This decrease in serotonin was independently associated with PFO closure after adjusting for age, gender, medical history and medication status in a multivariate regression (Fig 1C).

Conclusion:
We found that PFO closure independently reduced 5-HT level in peripheral venous blood. These results support the hypothesis that PFO associated right-to-left interatrial shunting may foster higher levels of procoagulant and vasoactive substances in circulation. We have previously found PFO closure to decrease prothrombotic markers immediately post closure; this effect is now shown also to be sustained in long term follow-up up to 1 year. Further studies are ongoing on the clinical outcome of these PFO related stroke patients with respect to their prothrombotic circulatory profiles.
Abstract TP429: Early Oral Anticoagulation After Acute Ischemic Stroke in Patients With Atrial Fibrillation
Authors: Buletko Andrew B , Cherian Rejo P , Ahrens Christine , Uchino Ken , Russman Andrew
Published: July 2021

Introduction:
Uncertainty exists as to the optimum interval for initiation of oral anticoagulation (OAC) after an acute ischemic stroke (AIS) in patients with atrial fibrillation (AF). Randomized clinical trials of novel oral anticoagulants excluded patients with AIS within 7-14 days. We sought to identify patients at low risk for early initiation of OAC after AIS.

Hypothesis:
The benefit of starting OAC within 2 days to prevent recurrent AIS outweighs the risk of hemorrhagic transformation (HT) in select patients.

Methods:
Following IRB approval, we completed a retrospective review of patients from the Cleveland Clinic from 2012-2014 with AIS, AF, and at least 1 follow up visit. In addition to demographic and medical history, acute infarct volume on imaging, presence of HT on imaging prior to OAC, timing and type of oral anticoagulation, and ischemic and hemorrhagic complications were noted. Early OAC was defined as starting within 48 hours after stroke onset, and late OAC was thereafter. The two groups were compared using Fisher’s exact test for categorical and Wilcoxon Rank Sum for numeric variables.

Results:
One hundred patients (median age 76, interquartile range 66-84) met our study criteria. Thirty-one patients were started on OAC within 2 days vs 53 patients after 2 days (median 1 days vs median 11 days). Compared to patients started on OAC after 2 days, those who initiated OAC within 2 days had significantly lower infarct volume (median 3.35 ml vs median 9.8 ml; p<0.0001), initial NIHSS (median 3 vs median 7; p <0.0001), and fewer people with blood on brain imaging (3% vs 26%; p= 0.0074). Age, prior stroke, and choice of OAC were not significantly associated with timing of OAC. No patients had recurrent AIS or symptomatic HT at median follow-up observation of 37 days. One patient had a non-CNS major hemorrhage after starting OAC. Sixteen patients were not started on OAC for a variety of reasons.

Conclusions:
Our results suggest the safety of early initiation of OAC with 2 days in an appropriately selected population of patients with AIS, who have small infarct volumes, mild stroke severity, and lack of HT.