bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP270: Outcomes of Telestroke tPA Patients Who Stay at Community Hospitals vs Transfer to a Comprehensive Stroke Center
Authors: Wysocki Nicole A , Bambhroliya Arvind , Bozorgui Shima , Ankrom Christy , Trevino Alyssa , Malazarte Rene , Cossey Tiffany , Jagolino-Cole Amanda , Jagolino-Cole Amanda , Savitz Sean , Wu Tsu-Ching , Sharrief Anjail
Published: October 2018

Introduction:
Telemedicine (TM) is increasingly utilized for tPA delivery. The destination of the patient after tPA, whether to stay at the presenting hospital or transfer to a hub stroke center, is unclear. A prior US study showed that TM tPA treated patients who stayed at their presenting hospital had longer length of stay (LOS), worse discharge dispositions (DD), and an increased in-hospital mortality (IHM). We did a similar analysis to assess reproducibility in our TM network.

Objective:
We hypothesized that there would be no difference in LOS, IHM, and discharge disposition (DD) between drip and stay (DST) and drip and hub transfer (DSH) in our network.

Methods:
We identified patients treated with tPA at of one our 19 spoke hospitals between 9/2015 and 12/2016. Demographic, clinical, and outcome data were obtained from our TM registry. We compared characteristics of DST and DSH patients using univariate analyses including student t-test, Wilcoxon sum rank, or chi square analyses where appropriate. We used negative binomial regression, logistic regression, and multinomial regression to evaluate LOS, IHM, and DD.

Results:
Among 430 TM patients, 232 (53.9%) were transferred to the hub following tPA treatment. The median presenting NIHSS was significantly higher for DSH (10; IQR 5,6) compared to DST (6; IQR 4-10; p < 0.001), but other characteristics were similar. Though median LOS was significantly higher for DSH in the univariate analysis (p < 0.01), there was no significant difference in the adjusted analysis. There were no significant differences in IHM or DD.

Conclusion:
There are no differences in LOS, IHM, or DD comparing DSH and DST patients. The DSH patients had higher NIHSS but were otherwise similar. Our findings did not corroborate a prior study and instead suggest that it is safe for TM tPA patients to remain at spoke hospitals. Further studies across multiple TM networks are needed to confirm the quality of the drip and stay model of care.
Abstract WP273: Infections Increase The Risk Of 30-day Readmissions Among Stroke Survivors: An Analysis Of The National Readmission Database
Authors: Khaksari Bijan , Kulick Erin , Omran Setareh , Willey Joshua Z , Elkind Mitchell S , Boehme Amelia K
Published: October 2018

Background and Purpose:
Hospitals are increasingly utilizing 30-day readmission as a quality of care metric. We hypothesize that common infections common during the stroke stay are associated with 30-day readmission (30dRA).

Methods:
We conducted a weighted analysis of the federally managed 2013 National Readmission Database to assess the relationship between infection during a stroke hospitalization and 30dRA among ischemic stroke survivors. Ischemic stroke, common infections (defined as sepsis, pneumonia (PNA), and urinary tract infection (UTI)), and comorbidities were identified using ICD-9 diagnosis codes, and IV-tPA or intra-arterial therapy were identified using ICD-9 procedure codes. Survey design logistic regression models were fit to estimate crude and adjusted odds ratios (OR) and 95% confidence intervals (CI) for the association between infections and 30d-RA.

Results:
Of the 402042 ischemic stroke patients, 11.2% (n=45247) were readmitted within 30 days, and ~16% (n=7240) had an infection during their index hospitalization. Patients who had a common stroke infection during their stroke admission had a 36% higher odds of being readmitted than patients without any type of infection (OR 1.36, 95%CI 1.30-1.42; Figure 1). The increased odds of readmission remained after adjusting for confounders (OR 1.16, 95%CI 1.11-1.22; Figure 1). Stratifying by age, patients under 65 who had an infection during their stroke admission had an increased adjusted odds of 30d-RA (OR 1.38, 95%CI 1.28-1.49), than those over 65 (OR 1.11, 95%CI 1.06-1.17). The increased odds of readmission remained for those who had sepsis, PNA and a UTI (Figure 1), even after adjusting for covariates of interest.

Conclusions:
Using a nationally representative cohort we show that patients who have a common infection during their stroke stay are at increased odds of being readmitted. This presents a unique patients population who may benefit from an earlier post-stroke follow-up.
Abstract WP283: Infections Present on Admission, Hospital Acquired Infections and Short Term Outcomes in Ischemic Stroke Patients in a Large Administrative Dataset
Authors: Rastogi Sonal , Canning Michelle , Kulick Erin , Omran Setareh , Willey Joshua Z , Elkind Mitchell S , Boehme Amelia K
Published: October 2018

Background and Purpose:
We hypothesized that acute ischemic stroke (AIS) patients with hospital acquired infection (HAI) would have worse outcomes than patients with an infection present on admission (IPOA) or no infection.

Methods:
We used the 2007-2009 California State Inpatient Database from the Health Care Utilization Project (HCUP). Patients who were over the age of 18 and hospitalized with AIS, defined by previously validated ICD-9 codes, were included. Validated ICD-9 codes for sepsis, pneumonia and urinary tract infections were used to categorize patients as having IPOA (infection diagnosed within 24 hours of admission), HAI (infection during admission), or no infection using federal guidelines. The outcomes of interest were length of hospital stay (LOS), and poor discharge outcome (discharge someplace other than home).

Results:
A total of 133,678 patients with diagnosis of AIS were identified; 2.6% (N=3436) had HAI, 15.1% (N=20126) had IPOA, and 82.3% (N=110026) had no infection. Mean LOS was longer for patients with HAI compared to IPOA and no infection (18.5 vs. 8.5 vs. 5.1 days: p<0.0001). In adjusted models (Figure), LOS has longer for those with HAI compared to those with IPOA or no infection (8.2 vs. 6.4 vs. 5.5 days; p<0.0001). Adjusting for the same covariates plus LOS, HAI and IPOA remained associated with death (Figure). In adjusted models, patients with HAI or IPOA had higher odds of poor discharge outcome (HAI OR 1.82, 95% CI 1.51-2.21 and POA OR 1.49, 95% CI 1.38-1.61). In an adjusted model, patients with HAI are at increased odds for a poor discharge outcome when compared to those with an IPOA (OR 1.28, 95%CI 1.04-1.58). Using a mediation analysis, LOS explains 46% of the relationship between HAI and poor discharge outcomes, and 87% of the relationship between IPOA and poor discharge outcome.

Conclusion:
IPOA and HAI were each associated with increased LOS. Even after accounting for LOS, patients with HAI had poor discharge outcomes and a higher risk of death.
Abstract WP286: Code Status Prior to Admission Dose Not Influence Timing of Transition to Inpatient Hospice in Devastating Stroke
Authors: Nouh Amre M , Ferrante Francesca , Staff Ilene , McCormick Lauren , Albert Ross H , Hosley Catherine
Published: October 2018

Background:
The transition of care from an aggressive disease-directed plan to comfort focused hospice care is a difficult choice for patients with devastating stroke and their family members particularly in the absence of advance directives. However, it is not clear if preexisting Do Not Resuscitate (DNR) status influences the timing of this decision.

Objectives:
To evaluate factors associated with transfer time to hospice for patients with devastating stroke and, particularly, the influence of defined code status prior to admission.

Methods:
A retrospective analysis of patients with stroke admitted to inpatient hospice from January 2013-December 2014 at our institution was conducted yielding 71 patients. The group was dichotomized to those with a preexisting DNR (n=19) or not (n=52). Clinical variables and sociodemographic factors were collected and compared using chi-square tests of proportion and t-tests for independent groups. Specifically, median time from admission to inpatient hospice for both groups was compared using a Wilcoxon Ranked Sum test set at 0.05 to test statistical significance.

Results:
For all patients, the mean age was 82.01 +/- 9.64 years, 60.6% female and 84.5% Caucasian. Approximately 66% of strokes were ischemic and 34% hemorrhagic with a mean NIH score of 21.45 +/- 6.03. Age (83.7 +/- 9.8 vs. 81.4 +/- 9.6;
p=0.377
), ethnicity (% Caucasian: 84.2 vs. 84.6;
p= 0.967
), stroke subtype (% ischemic: 73.7 vs. 61.5;
p= 0.343
), severity (NIH: 21.2 +/- 8.8 vs. 20.9 +/- 4.6;
p=0.852
), insurance status (% Medicare Plus: 73.7 vs. 57.7;
p=0.219
), history of prior stroke (26.3% vs. 23.1%;
p=0.777
), dementia (21.1% vs. 28.9%;
p=0.511
), malignancy (10.53% vs. 13.46%;
p=0.742
), and living arrangement (% living with family: 73.7 vs. 51.9;
p=0.132
) were not statistically different in the DNR and no DNR cohorts respectively. The median time from admission to inpatient hospice for preexisting DNR vs. no DNR did not differ (3.0 vs. 4.5 days
; p=0.176
).

Conclusion:
In our study, there were no significant factors, including preexisting DNR status, that influenced transition time to inpatient hospice. Code status on admission is not an indicator of goals of care. Future studies are needed to validate these findings
Abstract WP291: Stroke Code Simulation Improves Resident Preparedness for Call
Authors: Legault Catherine , Tai Waimei , Vora Nirali
Published: October 2018

Introduction:
Didactic lectures on acute stroke do not teach neurology residents nuances of the stroke code process. Successful execution of this process requires functioning in a high stress environment, interaction with a multidisciplinary team, and ability to enter the correct orders. Simulation technology is increasingly available for resident education, but underutilized in neurology.

Hypothesis:
Medical education innovation with stroke code simulation can improve resident understanding of the stroke code process and achievement of learning goals in preparation for call.

Methods:
Learning goals derived from the stroke code process were written into 4 clinical scenarios enacted by a standardized patient, nurse, CT technician, and stroke fellow at the institution’s simulation center (see Table 1). Junior neurology residents alternated leading or observing simulated stroke codes, followed by debriefing sessions to review learning goals. Achievement of learning goals was measured with a pre- and post- multiple-choice quiz. Residents submitted anonymous written feedback that the authors analyzed with thematic coding.

Results:
Between July 2016 and July 2017, 22 junior adult and pediatric neurology residents completed stroke code simulation. Quiz grades improved from 67.5% to 78.3% after the simulation. Common feedback themes reference comfort with code logistics, imaging order entry, team member roles, benefit of realistic scenarios, and desire for more scenarios. The residents perceived simulation would relieve the stress of stroke call. The use of simulation was overall highly valued.

Conclusions:
Medical education innovation with stroke code simulation targeting specific learning goals improves residents comprehension of the acute stroke code process and can prepare junior neurology residents for call.
Abstract WP296: Prospective e-Diary Captures Elusive Oost Stroke-Symptoms as Patterned and Cyclical
Authors: Calvanio Ronald J , Levine Minna , Deng Wenjun , Song Bo , Bunda Bridget , Fisher Lindsay , Lee Rebekah , Goldstein Richard , Buonanno Ferdinando S , Ning MingMing
Published: October 2018

Introduction:
In the post-acute phase of a stroke, some of the most difficult symptoms (fatigue, headache, cognitive lapses, emotional outbursts, somato-sensory changes and dizziness) are often elusive and difficult to capture and quantify. Retrospective reports/scales lack sensitivity and specificity for neuro-psychological behavior intervention (BI) as a supplement to medication management. We hypothesized that symptoms occur in cycles, provoked by an activity pattern or circadian rhythm, which could be a focus for a BI.

Method:
Post-stroke patients were prospectively recruited to use electronic diary (e-diary) to quantify a primary symptom 3 times per day (TD), for each day of the week (DW), up to 12 weeks (n=30).

Results:
Cluster analysis shows a majority of patients (89%) to have a statistically significant cyclical pattern, specifically: 63% DW; 48% TD, 17% both; 89% either DW or TD, as shown in Fig 1. DW cyclical patterns can be simple (one high phase/week), or complex (2/week) with a relative risk of high to low phases of 2 to 1 or greater. A few patients (7%) demonstrated a “random” fixed pattern (i.e., non-cyclical 2 to 1 or greater high-low DW variations).

Conclusion:
Common cyclical patterns of elusive symptom expression post stroke can be reliably quantified and analyzed by prospective e-diary, like a “fitbit” for the brain. Recognition of these patterns for elusive symptoms can serve as the basis for formulating more effective BI as a supplement, or alternative, to medication management post stroke.
Abstract WP297: Increasing Interfacility Transfers Among Northeastern Hospitals in the Care of Stroke Patients
Authors: Zachrison Kori S , Onnela Jukka-Pekka , Hernandez Adrian , Reeves Mathew J , Camargo Carlos A , Cox Margueritte , Matsouaka Roland A , Metlay Joshua P , Goldstein Joshua N , Schwamm Lee H
Published: October 2018

Introduction:
Little is known about how hospitals are connected in the care of patients with acute ischemic stroke (IS). We aimed to describe changes over time in the IS interfacility transfer network in the Northeastern U.S.

Methods:
We used data from inpatient and outpatient Medicare claims in the Northeast region to identify IS patients transferred between hospitals from 2007 to 2011. Receiving hospitals (RHs) were defined as hospitals with annual IS volume of at least 120 admissions and ≥15% of these admissions received as transfers. Transferring hospitals (THs) were defined as non-RHs that transferred ≥15% of total (ED plus inpatient) IS discharges. A connection between hospitals was defined as ≥5 patients/year transferred between any given TH and RH in the region. We generated a map of hospital connections for each year during the study period using ArcGIS 10.3.1.

Results:
Among 130,338 IS admissions, we identified 6,898 (5%) patient transfers in the Northeast region from 2007-2011. The number of patients transferred increased from 960 (4%) in 2007 to 1772 (7%) in 2011 (p for trend <0.0001). Of the 402 hospitals in the region, the number of THs increased from 17 (8%) to 49 (12%); the number of RHs increased from 6 (2%) to 16 (4%) from 2007 to 2011 (p<0.0001) (Figure). 88% of RHs performed mechanical thrombectomy. Most THs were exclusively connected to a single RH (88%, n=15 in 2007, 94%, n=46 in 2011).

Conclusion:
From 2007 to 2011, hospitals in the U.S. Northeast became more connected in the care of IS patients, with a growing number of connections between hospitals. Yet, by our definition, the majority of hospitals remained unconnected, potentially representing a missed opportunity. Further characterization of this transfer network will be important for understanding and improving regional stroke systems of care.
Abstract WP300: Complications After Intracerebral Hemorrhage and Intracranial Procedures: A Nationally Representative Estimate
Authors: Kaur Gurmeen , Stein Laura , Liang John , Tuhrim Stanley , Dhamoon Mandip S
Published: October 2018

Background:
Intracranial procedures (including craniotomy/ craniectomy, external ventricular drain [EVD], ventriculoperitoneal shunt [VPS], stereotactic craniotomy, and administration of intraventricular alteplase [tPA]) are performed in severe cases of intracerebral hemorrhage (ICH). However, severity-adjusted national estimates of complications after such procedures are not known.

Methods:
The Nationwide Readmissions Database contains >14 million discharges for all payers and uninsured in 2013. International Classification of Disease, Ninth Revision, Clinical Modification codes were used to identify index cases of ICH, intracranial procedures, and comorbidities. We summarized demographics, comorbidities, and Charlson Comorbidity Index (CCI) during the index admission. Preventable causes of admission were determined by Prevention Quality Indicators. Multivariable Poisson regression models estimated associations between intracranial procedures and readmission rates up to 1 year. Model 1 adjusted for age, discharge status, and CCI; Model 2 adjusted for All Patients Refined Diagnosis Related Groups severity measures.

Results:
Among 26,160 index admissions for ICH with intracranial procedures, mean age (SD) was 68.6 (14.9) years; 48% were female; 28% diabetic; 70% hypertensive; 23% smokers, mean CCI (SD) was 3.5 (2.2). 25% were discharged home; 24% died during index admission; 30.7% had readmission during follow-up, 13.2% of which were preventable. Top reasons for 30-day readmission were acute cerebrovascular disease (21%), septicemia (8%), and renal failure (4%). In unadjusted models, craniotomy, EVD, and VPS were associated with higher readmission rates. In adjusted models, higher readmission rates were seen only after craniotomy (Model 1 rate ratio [RR] 1.13, 95% CI 1.08-1.19; Model 2 RR 1.10, 1.04-1.15). tPA and stereotactic craniotomy showed no significant associations.

Conclusions:
This analysis of nationally representative US data of ICH admissions showed a 10-13% increased rate of readmissions after craniotomy, most of which were non-preventable. Further research would clarify causal relationships and suggest ways to reduce readmission risk after this potentially life-saving procedure for ICH.
Abstract WP302: Ethnic Differences in Midlife Stroke Outcomes
Authors: Lisabeth Lynda D , Aparicio Hugo , Li Chengwei , Case Erin , Morgenstern Lewis
Published: October 2018

Objective:
Stroke rates are stable or increasing in midlife. The implication is many years of stroke-related disability, the impact of which may be greater in Mexican Americans (MAs), a sub-group with high stroke rates, earlier onset strokes, and worse outcomes. Our objective was to compare stroke outcomes by ethnicity (MAs vs non-Hispanic whites (NHWs)) in those age <65 years.

Methods:
Incident ischemic strokes (IS) among those <65 years of age were identified from the population-based Brain Attack Surveillance in Corpus Christi (BASIC) Project (2008-2015) conducted in south Texas. In-person baseline and 90-day patient interviews were conducted. Outcomes included functional, neurologic, and cognitive outcomes, quality of life (QOL), and depression, which were compared by ethnicity in regression models adjusted for sociodemographics, stroke severity, stroke treatment, risk factors, and pre-stroke factors.

Results:
Of 609 IS cases with baseline interview, 508 had outcome data (341 MA, 167 NHW). At baseline, MAs had lower levels of education, higher average BMI, and were more likely to have hypertension and diabetes, but were less likely to smoke, than NHWs. At 90 days post-stroke, MAs reported low physical QOL scores, some difficulty with activities of daily living, and a high prevalence of depression (41%). MAs had significantly worse ninety-day outcomes than NHWs in every domain except depression after adjustment for confounders (Table).

Conclusion:
MAs with midlife stroke had significantly worse outcomes than NHWs. The growing number of midlife stroke survivors will have unique rehabilitation and healthcare resource needs. Particular attention to MA midlife stroke survivors is warranted.
Abstract WP303: Defining the Limits of Technology-based Tools for Stroke Patients and Caregivers
Authors: Freddolino Paul , Swierenga Sarah , Woodward Amanda , Lounds Nathan , Fitzgerald Joseph , Coursaris Constantinos , Hughes Anne , Fritz Michele , Reeves Mat
Published: October 2018

For many stroke patients and caregivers, the transition back to home is often complex resulting in hospital readmissions, poor quality of life, and high caregiver burden. Providing access to high quality information on stroke is a potential cost effective intervention to improve stroke transitions. We report on the development and utilization of a patient-centered web-based tool that complemented a case management intervention which were both tested in the Michigan Stroke Transitions Trial (MISTT), an RCT designed to improve the transition experience for stroke patients and caregivers.

Methods/Methodology:
A social work case management (SWCM) program was designed to address patient and caregiver needs, improve quality of life, and decrease caregiver burden. In addition, we addressed informational needs by developing a curated, patient-centered website with access to communication, information, and support resources. Website content and structure were developed through focus groups with key patient, caregiver, and provider stakeholders. Refinements were made after structured usability and accessibility testing. Acute stroke patients (N=263) discharged home from three acute-care hospitals were randomly assigned to one of three groups: usual care, SWCM, or SWCM plus website access. For the 87 subjects randomized to the website group, utilization was monitored over the 90-days intervention period by Google Analytics ® which generated data on log-in sessions and page views.

Results:
Utilization data demonstrated that approximately one third (n= 28) of eligible patient/caregiver dyads randomized to the website did not access the website at all. Among website users, 25% (n=14) only accessed the site when assisted during SWCM home visit; another 25% (n=14) logged in 1-5 times in addition to the first home visit; and the remaining 50% (n=28) logged in on their own 1 to 9 times. The most popular pages were stroke information, medication information, stroke recovery, and prevention.

Conclusion:
Despite the fact that stakeholders report the need to access reliable stroke information during the transition home, we found that utilization of a website designed for this purpose was low. These analyses identify areas for further research and program development.
Abstract WP309: Utilization of a Patient Selection Protocol for Mechanical Thrombectomy in Acute Ischemic Stroke Improves Outcomes
Authors: Dornbos David L , Priddy Blake H , Wang Joshua L , Ikeda Daniel S , Marlin Evan S , Youssef Patrick P , Nimjee Shahid M , Powers Ciaran J
Published: October 2018

Introduction:
The emergence of mechanical thrombectomy has extended the time window for treatment of acute ischemic stroke and improved patient outcomes. Our institution developed a patient selection protocol aimed to improve patient outcomes following the procedure.

Hypothesis:
Implementation of a patient selection protocol based on evidence-based best practices improves patient outcomes following endovascular intervention in acute ischemic stroke.

Methods:
In January 2015, our institution developed a patient selection protocol for anterior circulation stroke, including patients with a documented large vessel occlusion, an NIH stroke scale ≥6, a pre-morbid modified Rankin Scale (mRS) ≤2, and with the initial groin puncture within 6 hours of stroke onset. Patients were excluded if pre-morbid life expectancy was ≤90 days, CT perfusion demonstrated <30% cerebral blood flow of 70 mL, ASPECTS score ≤6, presence of intracranial hemorrhage (ICH), INR ≥3 or platelet count ≤40. Age, sex, co-morbidities, treatment times and outcomes were retrospectively collected. Statistical analysis was performed using χ
2
test, unpaired t test, and multivariable logistic regression analysis where appropriate.

Results:
Forty patients underwent endovascular treatment prior to protocol implementation with 65 patients treated under the protocol. Protocol implementation resulted in improved rates of TICI 2B/3 revascularization (87.7% protocol, 57.5% pre-protocol; p<0.001) and increased 90-day functional independence (41.5% protocol, 15.4% pre-protocol; p<0.01), defined as mRS≤2 (Figure 1). There was no difference in symptomatic ICH or 90-day mortality. Use of a uniform patient selection protocol was an independent predictor of functional independence at 90 days (p<0.01).

Conclusions:
The development and implementation of a patient selection protocol for endovascular treatment of large vessel occlusion improves revascularization rates and functional outcomes.
Abstract WP313: Predictors of Early Depression in Stroke Patients Enrolled in the Michigan Stroke Transitions Trial (mistt)
Authors: Fritz Michele C , Woodward Amanda T , Hughes Anne K , Freddolino Paul P , Nasiriahmadabadi Mojdeh , Reeves Mathew J
Published: October 2018

Background:
The period immediately after returning home from the acute care setting is a particularly stressful time for stroke patients. We report on depressive symptoms collected shortly after returning home in stroke patients enrolled in the Michigan Stroke Transitions Trial (MISTT) - a randomized trial designed to improve transition experience.

Methods:
Acute stroke patients were recruited from 3 Michigan hospitals. Eligible subjects were those discharged home or expected to return home within 4 weeks of discharge to a rehab facility. Baseline data, which included demographics, socio-economic factors, stroke type, medical history, type and duration of rehab care, and recent hospital or ED visits, were abstracted from hospital charts or collected by phone interview conducted 7 days after returning home. Data on depressive symptoms at 7 days was collected using the PHQ-9 instrument (score range 0-27). A depressive disorder was defined as PHQ-9 score >=10 (equivalent to at least moderate depression). Risk factors for depression were identified using multivariable logistic regression. Race, sex and discharge destination were forced into the model regardless of significance.

Results:
Of 199 subjects randomized in the first 12 months of the study, 156 (78%) had PHQ-9 data collected at 7 days, and 29 (18.6%) had a PHQ9 score of >= 10. Final multivariable model results (Table) indicate that only age and recent ED or hospital use were significantly associated with depression. Depression was much lower in older age groups, and a hospital or ED visit since returning home was associated with a 4-fold increase in the odds of depression. When history of past depression was added to the model the impact of recent hospital or ER visits attenuated.

Conclusion:
Depressive symptoms are relatively common among stroke survivors within the first week of returning home. Young age, recent hospital visits, and a past diagnosis of depression were significant risk factors for early depression.
Abstract WP320: Blood Pressure Reduction During Endovascular Stroke Therapy is Associated With Poor Functional Outcome
Authors: Wang Anson , Mampre David M , Sheth Kevin N , Tan Can O , Matouk Charles C , Hebert Ryan M , Petersen Nils H
Published: October 2018

Background:
Endovascular therapy (EVT) has been demonstrated to be beneficial regardless of baseline blood pressure (BP). However, questions concerning optimal BP management during EVT remain unanswered. Lowering BP may reduce penumbral perfusion resulting in increased infarct volume and poor outcomes. In this study, we examined the relationship between reductions in intra-procedural BP during EVT and functional outcome.

Methods:
We prospectively enrolled patients with acute large-vessel occlusion ischemic stroke undergoing EVT at Yale-New Haven Hospital. Baseline BP was measured at the start of EVT and monitored throughout the procedure. Reductions in BP were calculated as the difference between baseline systolic BP (SBP) and lowest SBP during the intervention. In addition, to distinguish between one time SBP reductions and sustained hypotension, we measured the area between baseline SBP and continuous measurements of intra-procedural SBP. Functional outcome was assessed using the modified Rankin scale (mRS) at discharge and 90 days. Associations between BP reduction and outcome were assessed using ordinal logistic regression.

Results:
68 patients (mean age 73+/-16.7, 36F, mean NIHSS 17) were included in the study. Mean baseline BP was 152/82 mmHg. The median SBP reduction among patients with favorable outcome (mRS ≤2) was 23 mmHg (IQR 11-52) compared to 54 mmHg (IQR 28-86) in the group with poor outcome (p=0.03). A decrease in SBP from initial levels during EVT was independently associated with an increased likelihood for higher (worse) scores on the mRS at discharge (p=0.02) and 3 months (p=0.03) after adjusting for age and admission NIHSS. Every 10 mmHg reduction in SBP from baseline was associated with a 1.4 fold increase in the odds of an unfavorable outcome at 90 days.

Conclusions:
BP reduction during EVT may be harmful and lead to worse functional outcomes for patients affected by large-vessel stroke. Even modest, one time reductions in SBP, as frequently occurs during induction of anesthesia, appear to be associated with increased risk for worsened functional status. These results underline the importance of BP management during EVT, and highlight the need for further investigation of active BP management strategies to optimize clinical outcomes.
Abstract WP324: Improving Stroke Care Delivery for In-Hospital Stroke Alerts by Addition of Overhead "Code Stroke" Announcements: Single Comprehensive Stroke Center’s Experience
Authors: Girotra Tarun , Schultz Lonni , Katramados Angelos , Brady Megan , Cohen Lisa , Raper Lee Anne , Miller Daniel J
Published: October 2018

Introduction:
In-hospital strokes account for 2-17% of all stroke patients. Mobilization of resources for in-hospital strokes is challenging and it takes longer to complete the necessary evaluations as compared to those presenting to the emergency room. Dedicated “stroke code teams” for in-hospital stroke patients have been shown to improve the adherence to the AHA’s get with the guidelines (GWTG) initiative but there is a paucity of research analyzing this process.

Aim:
To assess whether the addition of an overhead “code stroke” announcement to an existing group paging system for in-hospital strokes decreases the time required for obtaining the necessary evaluations.

Methods:
An overhead “code stroke” announcement and process education was introduced at our hospital in addition to the existing stroke group paging system. We analyzed prospectively collected time based measures for in-hospital stroke code activations 4 months before and after implementation. Wilcoxon two-sample test was used to analyze the relevant time variables between the two groups.

Results:
The post-stroke group had significantly shorter times from stroke alert to CT and CTA interpretation, time from symptom onset to CT and CTA interpretation, and time for CT and CTA interpretation when compared to the pre-stroke alert group (see table). The post-stroke alert period captured significantly more acute strokes than the pre-stroke alert period (6.25 vs 1.75 per month, p=0.001 from binomial test).

Conclusion:
The addition of an overhead “code stroke” along with process education can drastically reduce important GWTG’s acute stroke evaluation times at a comprehensive stroke center. We suggest that improved coordination between the services, along with the urgency associated with an overhead “code stroke”, led to improvement in the evaluation times. We also noted an increase in the number of stroke-code activations, probably due to increased perception and awareness of stroke as a true emergency.
Abstract WP326: Fever Promotes Worse Outcomes in Reperfused Patients Irrespective of Febrile Duration
Authors: Bowen Meredith T , Haussen Diogo C , Bouslama Mehdi , Frankel Michael , Nogueira Raul G , Dehkharghani Seena
Published: October 2018

Introduction:
Fever following acute ischemic stroke (AIS) promotes greater consumption of ischemic penumbra despite reperfusion; however, the influence of timing of onset and duration of fever remains unexplored. We assessed the impact of such temporal features on infarct growth and clinical outcome in AIS, hypothesizing a dose-dependent negative response to sustained fever.

Methods:
Retrospective study of AIS patients presenting with proximal large vessel occlusion within 12h of onset, and achieving reperfusion (mTICI 2b/3). Pretreatment CTP was obtained in all subjects in a fully automated environment (RAPID) for segmentation of ischemic core and penumbral mismatch volumes. Final infarct volumes (FIV) were measured by DWI, and relative infarct growth (RIG) computed as (FIV-CTPcore/CTPmismatch). Systemic temperatures were obtained up to q15 minutes from presentation to DWI. Fever (>37.5) onset and duration were documented. Pearson’s correlation and linear and logistic regressions tested the association of fever onset and duration vs. RIG and favorable clinical outcome (90d mRS≤2).

Results:
119 subjects (59 men, age 63±14 yrs) met inclusion. Median[IQR] NIHSS=18[8]; last known well to groin puncture=355min[310]; median[IQR] core, mismatch, and FIV=9.6[23.8], 109[104], and 19.6[37]ml, respectively. Median fever duration=9h. Fever duration and time to onset were not independently associated with RIG (p=0.4, 0.6). The best fit model for prediction of RIG included fever, procedure duration and initial core. The OR for 90d mRS≤2 in febrile patients controlling for fever onset, age, NIHSS, core and procedure parameters was 0.6 (0.14-2.85). The adjusted OR for 90d mRS≤2 given one additional hour of febrile time was non-significant (0.99, 0.9-1.0). Earlier timing of fever onset was independently correlated to clinical outcome (p=0.04).

Conclusions:
While fever promotes infarct growth despite reperfusion, these findings suggest duration of fever is less influential upon imaging and clinical outcomes than hypothesized, with the negative impact of fever in the early aftermath of AIS driving worse outcomes irrespective of duration. The findings underscore the importance of temperature control during early temperature dysregulation after AIS.
Abstract WP327: CHADSVASC and HASBED Scores in Patients With Intracerebral Hemorrhage and Atrial Fibrillation
Authors: Stanton Robert , Woo Daniel , Moomaw Charles , Haverbusch Mary , Flaherty Matthew , Kleindorfer Dawn
Published: October 2018

Background:
Patients with intracerebral hemorrhage (ICH) and atrial fibrillation (a-fib) are at risk for having future ischemic events after stopping anticoagulation. Risk calculators (CHA
2
DS
2
-VASc and HAS-BLED) have been validated to assess risk for ischemic stroke and for major bleeding in a-fib patients. We sought to compare the distribution of these scores among ICH patients with a-fib within a large biracial population.

Methods:
The Genetic and Environmental Risk Factors for Hemorrhagic Stroke (GERFHS III) Study included a population-based retrospective chart review of spontaneous ICH among residents of the five-county Greater Cincinnati/Northern Kentucky region between 7/2008 and 12/2012. CHA
2
DS
2
-VASc (risk of ischemic stroke) and HAS-BED (risk of bleeding with anticoagulation; minus “L” because “labile INR” was unavailable) scores were calculated for all ICH patients with a-fib who survived the hospital stay. Published risk coefficients for each score were used to calculate predicted ischemic and bleeding events within one year of onset.

Results:
Among 1186 cases of spontaneous ICH, 232 had a-fib, of which 123 patients were excluded due to inpatient death or discharge to hospice. Among the remaining 109 cases, 7-8 would be expected to have a major bleeding event (on anticoagulation), and about 6 patients would be expected to have an ischemic stroke within one year (off anticoagulation), with 73 of the 109 patients having higher risk for major bleeding than for ischemic stroke. The correlation between the two scores was weak (Spearman r=.220, p=.021).

Discussion:
Comparison of CHA
2
DS
2
-VASc and HAS-BED scores suggest a higher CHA
2
DS
2
-VASc threshold for considering anticoagulation is needed for ICH a-fib patients to balance their higher risk of major bleeding. Further evaluation of the consequences of ischemic stroke and major bleeding would be needed to better understand the best treatment strategies for our patients.
Abstract WP337: Frequency, Determinants, and Outcomes of Intracerebral Hemorrhage Expansion in Hyperacute EMS-Transported Patients
Authors: Vilaisaktipakorn Pitchamol , Shkirkova Kristina , Brown Christa D , Avila-Rinek Gilda , Sanossian Nerses , Liebeskind David , Villablanca Pablo , Starkman Sidney , Eckstein Marc , Stratton Samuel , Pratt Frank , Conwit Robin , Hamilton Scott , Saver Jeffrey L ,   the FAST-MAG Investigators and Coordinators
Published: October 2018

Background:
As clinical and research interventions for intracerebral hemorrhage (ICH) migrate to the prehospital setting, patients are being treated earlier than ever before. The frequency, determinants, and outcomes of hematoma expansion among hyperacute, EMS-transported patients have not been previously characterized.

Methods:
We analyzed all ICH patients enrolled in the NIH Phase 3 Field Administration of Stroke Therapy - Magnesium (FAST-MAG) prehospital trial who had both ED-arrival and 6 to 48-hour follow-up brain CT or GRE-MRI. Hematoma expansion (HE) was defined as hematoma volume growth by ≥ 6 ml.

Results:
Among 262 ICH patients meeting entry criteria, age was 64.8±12.9, 32.4% were female, and last known well to ED arrival was 52 mins (IQR 44-70). Hematoma expansion occurred in 80 (30.5%). Clinical predictors of HE included: anticoagulant use at onset, 11.3% vs 3.8%, p=0.03; lower level of consciousness at ED arrival, median GCS 14 vs 15, p<0.001; greater neurologic deficit at ED arrival, NIHSS 21 vs 13, p<0.001, basal ganglia ICH location, 63.7% vs 46.2%, p =0.009; and shorter interval from onset to first imaging, 80.2 vs 84.5 mins, p=0.04. Features not predictive of HE in this hyperacute cohort included: age, blood pressure, and intraventricular hemorrhage extension on initial imaging. In multivariable analysis, independent predictors of HE were: anticoagulants at onset (aOR 4.2, 95%CI 1.5-12.9), GCS at arrival (aOR 1.2, 95%CI 1.0 – 1.4), and NIHSS at arrival (aOR 1.1, 95%CI 1.1 – 1.2), with c statistic 0.73. HE was associated with increased early (48h) neurologic deterioration (45.6% vs 15.5%, aOR 5.3, 95%CI 2.8-10.1), reduced 90d functional independence (mRS 0-2, 15.0% vs 36.5%, aOR 0.27, 95%CI 0.13-0.56), and increased 90d mortality (46.3% vs 11.0%, aOR 8.1, 95%CI 4.0-16.6).

Conclusions:
Hematoma expansion is frequent among hyperacute, EMS-transported ICH patients, occurring in more than 3 in 10 patients. Anticoagulant use, reduced level of consciousness, and greater neurologic deficit are independent determinants of HE, and collectively predict HE moderately well. Hematoma expansion is clinically consequential, associated with a 5-fold increase in odds of early neurology deterioration and 8-fold increase in odds of death by 90 days.
Abstract WP34: Endovascular Treatment in Large Core Strokes
Authors: Nogueira Raul G , Veznedaroglu Erol , Budzik Ronald , Gupta Rishi , Krajina Antonin , Haussen Diogo C , Grossberg Jonathan , Barreira Clara M , English Joey , Baxter Blaise , Bartolini Bruno , Frankel Michael , Liebeskind David ,   Trevo Retriever Registry Investigators
Published: October 2018

Introduction:
The recent thrombectomy trials were largely limited to patients with small strokes on presentation.

Methods:
Patients derived from a large prospective multinational stent-retriever registry (Trevo Registry, n=2,010). Baseline NCCT SPECTS and CTP Core Volumes (rCBF<30%) were adjudicated by a Core Lab. Baseline and outcome variables were compared for ASPECTS 0-5 vs. 6-10 on NCCT and large age-adjusted cores (>70mL if age <=70 years; >50mL if age >70-80 years; >30mL if age >80 years) vs. not on CTP. The primary and secondary efficacy endpoint were the rates of 90-day mRS 0-2 and mTICI 2b-3, respectively. Safety endpoints included sICH and 90-day mortality.

Results:
As compared with patients with higher baseline ASPECTS (n=1037), low baseline ASPECTS (0-4, n=78; 5, n=78) patients were younger, had higher stroke severity, and tend to have less comorbidities and undergo thrombectomy at later times (Table 1a). TICI-3 reperfusion was higher in the higher-ASPECTS group but other reperfusion outcomes were nearly the same. Safety outcomes were comparable. Rates of 90-day mRS 0-2 were significantly higher in the high-ASPECTS group (p<0.001); however, 41.8% of ASPECTS 0-5 patients were independent at 90 days and safety outcomes were similar (Table 1b). Analysis according to large age-adjusted core (n=86) vs not (n=431) yielded similarly encouraging results (Table 2a-b).

Conclusion:
Patients with large baseline cores as measured by either NCCT or CTP may still achieve favorable outcomes with endovascular treatment. A randomized clinical trial in this patient population is warranted.
Abstract WP340: Primary Intracerebral Hemorrhage and Perihematomal Edema Volumes in Diabetics on Sulfonylureas: A Case-Control Study
Authors: Irvine Hannah J , Male Shailesh , Robertson Jetter , Bell Caitlin , Streib Christopher
Published: October 2018

Introduction:
Sulfonylureas (SU) drugs have been linked to reduced cerebral edema, lower rate of hemorrhagic transformation, and improved functional outcome following ischemic stroke, but their effects in primary intracerebral hemorrhage (pICH) have not yet been explored. We investigated whether pre-existing SU use influenced intracerebral hemorrhage (ICH) volume, perihematomal edema (PHE) volume and hospital discharge disposition in type II diabetics (DMII) presenting with pICH.

Methods:
We performed a retrospective chart review of all diabetic patients presenting with ICH to 2 tertiary academic centers between 2006 and 2016. All patients with DMII, pICH, admission computed tomography (CT) scan, and current SU use at the time of admission were included in our study. For each case, 2 matched controls (by admission date ± 5 years, age ± 5 years, hematoma location [deep vs. lobar], use of antiplatelet agent or anticoagulant) with DMII and pICH were consecutively selected for study inclusion. Intracerebral hemorrhage volumes and PHE volumes were measured via region-of-interest analysis on admission CT for each patient. To mitigate the influence of ICH volume on PHE, the PHE/ICH surface area ratio was calculated. Lastly, hospital discharge disposition was determined for each patient. We utilized the Wilcoxon rank sum test and Fischer’s exact test to assess differences between the 2 groups.

Findings:
Of 317 patients screened, 21 SU cases and 42 non-SU matched controls met criteria for study inclusion. Patients on SUs had significantly lower admission ICH volumes (median 4mL, IQR 2-30 vs. median 25mL, IQR 6-60;
p
=0.011), PHE volumes (median 4mL, IQR 0.9-24 vs. median 17, IQR 6-37;
p
=0.0095), and PHE/ICH surface area ratios (median 0.28, IQR 0.1-0.4 vs. median 0.43, IQR 0.3-0.6;
p
=0.013) as compared to matched controls. Sulfonylurea use was also associated with improved discharge disposition (
p
=0.0062).

Conclusions:
In patients with type II diabetes and pICH, SU use predicted lower ICH and PHE volumes, lower PHE/ICH surface area ratios, and favorable discharge disposition. Further studies are warranted to better elucidate the potential benefits of SUs in pICH.
Abstract WP341: Imaging Predictors of Intracerebral Hematoma Expansion in Hyperacutely-Presenting Patients
Authors: Vilaisaktipakorn Pitchamol , Shkirkova Kristina , Sanossian Nerses , Liebeskind David , Villablanca Pablo , Starkman Sidney , Eckstein Marc , Stratton Samuel , Pratt Frank , Conwit Robin , Hamilton Scott , Saver Jeffrey L ,   the FAST-MAG Investigators and Coordinators
Published: October 2018

Background:
Several noncontrast CT findings may increase risk of intracerebral hemorrhage (ICH) expansion, including ICH volume, location, margin irregularity, heterogeneity, the blend sign, and leukoaraioisis. Hyperacute EMS-transported patients have more frequent hematoma progression and may have distinctive predisposing imaging features.

Methods:
We analyzed consecutive patients enrolled in the NIH Phase 3 Field Administration of Stroke Therapy - Magnesium (FAST-MAG) prehospital trial and who had both ED-arrival and 6 to 48h follow-up brain CT or GRE-MRI. Hematoma expansion (HE) was defined as hematoma volume growth by ≥ 6ml.

Results:
Among 262 ICH patients meeting entry criteria, age was 64.8 (±12.9), 32.4% were female, arrival GCS was median 15 (IQR 11-15), and arrival NIHSS median 15 (IQR 9-24). Initial imaging was with CT in 95.8% and GRE-MRI in 4.2%. Median time from last known well to first imaging was 80 min (IQR 66-98) and from first to follow-up imaging 16.7 hr (IQR 11.3-22.3). Overall, 30.5% of patients experienced hematoma expansion. Univariate imaging predictors of HE were: hematoma volume, 25.1 vs 18.6 ml, p<0.001; perihematomal edema volume, 16.0 vs 11.7 ml, p<0.001; basal ganglia location, 63.7% vs 46.2%, p=0.009; moderate-severe midline shift, 31.3% vs 12.6%, p<0.001; greater hematoma shape irregularity, 2.8 vs 2.3, p=0.01; and high hematoma density heterogeneity, 62.5% vs 40.4%, p=0.001. Intraventricular hemorrhage, leukoaraiosis, and blend sign were not associated with HE. In multivariable analysis, independent imaging predictors of HE were: moderate-severe midline shift (aOR 3.7, 95%CI 1.4-9.5) and hematoma density heterogeneity (aOR 2.2, 95%CI 1.1-4.4). HE was associated with substantially reduced 90d functional independence (mRS 0-2, 15.0% vs 36.5%, p=0.001) and increased 90d mortality (46.3% vs 11.0%, p<0.001).

Conclusions:
Among hyperacute, EMS-transported intracerebral hemorrhage patients, several conventional and novel imaging findings on noncontrast CT are associated with hematoma expansion. Key independent predictors of hematoma growth are early evidence of moderate-severe midline shift and hematoma density heterogeneity.
Abstract WP343: EEG Seizures in Patients With Intraparenchymal Hemorrhage Reveals a Significant Role for Subcortical Hemorrhages in Epileptogenicity
Authors: Parikh Prachi , George Pravin , Newey Christopher R , Hantus Stephen
Published: October 2018

Introduction:
Patients with intra-parenchymal (IPH) have seizures detected on continuous EEG (cEEG) monitoring, but data that define seizure risk in IPH patients is limited.

Methods:
A retrospective chart review of 110 consecutive patients that had ICH on CT or MRI imaging and cEEG monitoring from January 2013 to December 2014 was completed. Patients with isolated cerebellar or brainstem hemorrhages were excluded. Primary aim was to examine the incidence of seizures and abnormal EEG patterns in patients with IPH, particularly those patients with deep IPH. Secondary aim was to examine time from EEG placement to first seizure

Results:
Median age was 73 [IQR 83-60]. 25 (22.73%) of the 110 patients had an abnormal EEG, defined as the presence of periodic lateralized epileptiform discharges (PLEDS) and/or seizures. 40 (36.36%) had subcortical white matter or thalamic or basal ganglia IPH +/- IVH. 5 (12.5%) of these 40 patients had EEG seizures. 66 (60%) patients had cortical IPH +/- IVH. 11 (16.67%) of these 66 patients had seizures. [OR=0.71, CI=0.23 to 2.23, p=0.56]. 4 patients had both deep and cortical IPH and were excluded. A total of 18 (16.36% of the 110) patients had EEG seizures. Of these 18 patients, 5 (27.78%) patients had deep IPH +/- IVH, defined as subcortical white matter, thalamic or basal ganglia IPH. 11 (61.11%) of the 18 had cortical hemorrhage +/- IVH. 2 (10.5 %) additional patients had both cortical and deep IPH. Additionally, of the 25 patients with abnormal EEG, 7(28%) patients had deep IPH +/- IVH 15(60%) of the 25 patients had cortical hemorrhage +/- IVH. Thus 17.5% of patients with deep IPH and 22.7% of patients with cortical IPH had abnormal cEEG.[OR=0.55, CI=0.20 to 1.48, p=0.23]. Average time for EEG placement from admission was 6 hours and 9 minutes. Average time from EEG placement to first seizure was 7 hours and 4 minutes.

Discussion:
Subcortical IPH is common and can lead to seizure risk. Our results show that a significant portion of the patients with IPH and seizures on cEEG monitoring had subcortical hemorrhages. They accounted for 28% of cases with seizures and abnormal EEG as well as for 13% of all the patients with subcortical ICHs. This data suggests that patients with supratentorial IPH should be evaluated for subclinical seizures.