bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP335: Cohorting Patients From Door to Discharge Impact on Improved Patient Outcomes
Authors: Muller Kathleen , D’Ambrosio Robin , Gray Marcia
Published: July 2021

Background:
Evidence-based studies illustrate the effectiveness of specialized stroke services in improving stroke patient outcomes. The American Stroke Association (ASA) has recommended the development of primary (PSC) and comprehensive (CSC) stroke centers to ensure that organizations have the expertise and resources to provide stroke care.

Purpose:
Cohorting (grouping) stroke and transient ischemic attack (TIA) patients on a dedicated neurological intensive care unit (ICU) and providing continuum of neurological patient care through the stroke unit has shown to improve patient outcomes through 90-100% compliance with stroke core measures and
Get With The Guidelines
(
GWTG
) quality measures.

Methods:
The ICU redesigned and selected eight neurological beds; while simultaneously, the medical/surgical stroke unit transitioned to include neuroscience/telemetry. The transition utilized the theoretical framework of Appreciative Inquiry (AI) to promote positive culture change. Through the dedication of nursing leadership, stroke coordinator and neuro educators, a comprehensive education plan was executed for all registered nurses of these units. Through utilization of coordinated NIHSS during change of shift and inter-department report, subjective differences were eliminated and baseline assessment created consistently. A neuroscience task force established and incorporated nurses from emergency room, intensive care unit and neuroscience/telemetry unit to facilitate collegiality and stroke patient care continuum.

Results:
Examination of the Stroke Core Measures and
GWTG
quality measures pre and post the transitions confirmed improved compliance with ASA’s stroke core measures and quality indicators. In addition, the patient length of stay decreased well below the national average and 30 day readmission rate decreased as well.

Conclusions:
The benefit from treatment in a dedicated stroke unit remains a key component of improved outcomes. Therefore, creating a coordinated stroke/TIA continuum of care from door to discharge has exhibited improvement of the core measures and quality indicator compliance thus improving patient outcomes.
Abstract TP345: Improving Door to Drug Times for Ischemic Stroke Patients Using a Team Approach
Authors: Sorenson Denise , Flood Alyson
Published: July 2021

Background and Purpose:
Decreasing door to drug times for ischemic stroke patients has been proven to optimize preservation of brain tissue, resulting in better functional outcomes. In prior years, the stroke team focus was to meet or exceed the 50% goal for the Joint Commission measure; patients arriving within 2 hours of last known well receive alteplase within 180 minutes. In the fall of 2011, the Neuroscience Medical Director challenged the team to meet target stroke goals and achieve the gold standard of excellence.

Methods:
Guided by the Plan Do Study Act model and principles of shared governance, the team refocused efforts to enhance stakeholder collaboration, educate, and provide monthly evaluation of door to door times. Code Stroke pathways were revised to improve efficiency, and inclusion / exclusion criteria were revised. The team is presented with state and national benchmark best practice data on an ongoing basis. Individual alteplase case feedback sheets are sent to all involved providers and departments, who are encouraged to provide input into the process. All alteplase cases are reviewed during team meetings, and outcomes are shared. Role modeling, physician engagement, positive feedback to team members and celebration of successes instill team motivation and confidence. In June, the program hosted an inaugural Stroke Symposium, where national speakers shared the ‘state of the science’, validating the rationale for improving processes for acute stroke care.

Results:
In the first 6 months of 2012, the median door to drug time was reduced by 48% to 55 minutes from 104 minutes in 2011. In the same time period, 10 of 15 patients had alteplase administered in < 60 minutes, versus 2 of 25 in 2011.

Conclusions:
Significant improvements in stroke care can be gained by establishing a cohesive team with a shared goal of excellence. Strong leadership, the ability of staff on all levels to be partners in decision making, information sharing, education and recognition are keys to success. Future challenges include ensuring the processes are sustainable, and maintaining team motivation to continue to find opportunities to reduce door to drug times.
Abstract TP349: Advanced Practice Registered Nurses Provide Cost-effective, Quality Stroke Care
Authors: Jones Brenda , Taylor Katherine , Dorssom Joyce
Published: July 2021

Background:
Our institution is a nationally known stroke center. The number of stroke patients treated yearly grew from 235 in 2000 to 917 in 2011. We are challenged to provide clinically excellent, ground breaking care in a fiscally responsible manner to this growing population.

Purpose:
To meet this challenge our institution utilizes Advanced Practice Registered Nurses (APRNs) to improve and streamline stroke care.

Methods:
An APRN was part of the stroke team at the inception and continues as Coordinator. In 2008 the team implemented an additional APRN role to provide acute inpatient care to stroke and general Neurology patients. There are now 3 Board Certified APRNs who meet Certified Stroke Center requirements and fill this role. Their backgrounds are Emergency Medicine, Intensive Care, and Internal Medicine, and they are Certified Neurology Registered Nurses. They work collaboratively with the Neurologists in 12 hour shifts, 7 days a week. The APRNs complete History and Physicals, participate in research, provide education, assist with acute strokes and perform patient rounds.They address patient and staff concerns, and maintain collaborative care with other disciplines.

Results:
APRN collaboration assures continuous patient monitoring and allows physicians to address more acute issues. The Interval Summary dictation improves accurate coding of patient visits, assists in documenting core stroke measures, and provides current follow up to referring facilities. The APRNs designed and utilize a Neuroscience History and Physical form, which provides uniform and streamlined documentation. Their productivity logs show during June of 2012, a completion of 139 new consults, 169 routine follow ups, and monitoring of 97 ICU patients. This is in addition to dictation and multiple workplace demands. The Neurologists requested additional APRN coverage and are favorable of collaborative practice.

Conclusion:
In conclusion, the organized, streamlined, evidenced- based APRN care results in cost effectiveness meeting the challenges of the growing stroke population. Future plans for the APRN role include continued efficient care, educational efforts, preceptors for APRN students and residents, and participation in the hospital APRN Council.
Abstract TP352: U.S. National Survey on Stroke Center Coordination: Time for Role Standardization?
Authors: Cudlip Fern , Swatzell Victoria , Alexandrov Andrei V , Alexandrov Anne W
Published: July 2021

Background:
The stroke coordinator is largely responsible for Stroke Center quality. With more than 800 certified Stroke Centers now available, we sought to understand how coordinators manage their mission.

Methods:
U.S. Stroke Center coordinators were invited to participate in two surveys via mail, fax, or SurveyMonkey.
TM
Data were entered and analyzed in SPSS using descriptive methods.

Results:
Responses (n=301) were received from coordinators in 48 states and the District of Columbia. Highest degree earned was RN Diploma (4%), ADN (6%), BSN (36%), MSN (44%), PhD (3%), and post-APN neurovascular fellowship training (7%); approximately 15% of hospitals did not utilize the stroke coordinator role. Stroke coordinators were self-taught 59% of the time and all worked at certified Stroke Centers; 58% of centers were considered Comprehensive Stroke Centers, however 100% of Primary Stroke Centers identified goals for comprehensive status. The most common educational needs identified were neuroimaging interpretation (68%), research design (60%), how to conduct/interpret statistical analyses (58%), and developing a research program (56%). There was considerable diversity in the definition of sICH, with 11% of coordinators confusing the term sICH with primary ICH despite the term being defined on the survey. The most significant barrier to role conduct was competing job functions, followed closely by data collection/entry that removes coordinators from clinical; 49% of Master’s prepared nurses were expected to collect/enter data, spending on average 11.6 hours/week + 6.3 (median 10 hours/week) in this function; of these, 52% would prefer to this work give away. Most valued role functions included overseeing clinical practice and quality management (> Master’s), and data collection/entry and patient education (< BSN).

Conclusions:
The stroke coordinator role has largely evolved without educational support and standardization to oversee the quality needs of Stroke Centers. Formal education, credentialing and role standardization based on education level may empower stroke coordinators to improve role effectiveness.
Abstract TP353: Use of Telestroke in a Metropolitan Stroke Code Process
Authors: Castle Amy , Stein Lana , Hanson Sandra , Ormiston Charles , Porth Karen
Published: July 2021

BACKGROUND:
Reperfusion therapy is the most important recent advance in early treatment for acute ischemic stroke, but remains underused and the timing of administration of treatment continues to be unacceptably delayed. The complexity of the decision tree and risk of treatment may be limiting use in the emergency department (ED) when those directing the therapy have limited knowledge and less comfort with administration of the drug. This review supports the hypothesis that utilizing telestroke to increase the Stroke Neurology expertise early in the stroke code in an organized stroke code process in a metropolitan hospital ED will improve the rate of use of reperfusion therapy and decrease the door-to-drug (DTD) times.

METHODS and RESULTS:
Telestroke was used to allow for Stroke Neurology presence and leadership in a redesigned stroke code process at 2 busy metropolitan hospitals beginning in 2009 at St. Joseph’s Hospital and 2010 at St. John’s Hospital.

CONCLUSION:
Telemedicine run stroke codes in a busy metropolitan ED resulted in increased use of reperfusion therapy and dramatic decreases in DTD times.
Abstract TP363: Action Plan Improves Order Set Use Compliance
Authors: Motz Deb , Moore Tracy , Huey Dicky , Ireland Catrina , Austin Tommye
Published: July 2021

Background:
It is known that order sets improve clinical performance and regulatory compliance by establishing standards of care and advancing the practice of evidence-based medicine, however, compliance in order set use can be a challenge. We are a five-hospital system operating as one with 1,500 stroke patient admissions per year. During our initial Primary Stroke Center certification review in May 2009, we received a Requirement for Improvement (RFI) citation because the order sets were not used consistently. The purpose is to describe actions taken to improve and maintain compliance of admission order set use.

Methods:
Stroke program leaders met to develop an action plan to address the order set RFI. A baseline audit of order set use revealed a 14.9% compliance rate. This information was reported to the system President and Chief Nursing Officer (CNO) at each location. The President met with the Medical Executive Committee who made the decision to make order sets mandatory, effective immediately. A follow-up article summarizing the survey results, metrics and action plan was published in the electronic physician newsletter. The Stroke Medical Director drafted a letter to the medical staff. Educational meetings with the Hospitalists were held and the CNOs implemented a stop-the-line plan. Compliance was monitored monthly. Physicians who did not comply received a letter. After three letters, the physician is required to report to the Quality Peer Review Committee.

Results:

Conclusion:
This action plan was an effective means to improve and maintain order set use compliance resulting in increased compliance with performance measures. We are in the process of phasing in computerized physician order entry. Interactive forms (I-forms) have been developed with functionality to aide in meeting compliance, quality and safety measures. It is imperative that we continue to monitor and address I-form order set compliance monthly.
Abstract TP374: Data Linkage is Effective for Improving the Available Data for Stroke: An Example from the Australian Stroke Clinical Registry.
Authors: Kilkenny Monique F , Dewey Helen M , Lannin Natasha A , Sundararajan Vijaya , Lim Joyce , Anderson Craig , Donnan Geoffrey A ,   AuSCR Management Committee, Cadilhac Dominique A
Published: July 2021

Introduction:
Multiple data collections can be a burden for clinicians. In 2009, the Australian Stroke Clinical Registry (AuSCR) was established by non-government and research organizations to provide quality of care data unavailable for acute stroke admissions. We show here the reliability of linking complimentary registry data with routinely collected hospital discharge data submitted to governmental bodies.

Hypothesis:
A high quality linkage with a > 90% rate is possible, but requires multiple personal identifiers common to each dataset.

Methods:
AuSCR identifying variables included date of birth (DoB), Medicare number, first name, surname, postcode, gender, hospital record number, hospital name and admission date. The Victorian Department of Health emergency department (ED) and hospital discharge linked dataset has most of these, with first name truncated to the first 3 digits, but no surname. Common data elements of AuSCR patients registered at a large hospital in Melbourne, Victoria (Australia) between 15 June 2009 and 31 December 2010 were submitted to undergo stepwise deterministic linkage.

Results:
The Victorian AuSCR sample had 818 records from 788 individuals. Three steps with 1) Medicare number, postcode, gender and DoB (80% matched); 2) hospital number/admit date; and 3) ED number/visit date were required to link AuSCR data with the ED and hospital discharge data. These led to an overall high quality linkage of >99% (782/788) of AuSCR patients, including 731/788 for ED records and 736/788 for hospital records.

Conclusion:
Multiple personal identifiers from registries are required to achieve reliable linkage to routinely collected hospital data. Benefits of these linked data include the ability to investigate a broader range of research questions than with a single dataset. Characters with spaces= 1941 (limit is 1950)
Abstract TP381: Stroke Morbidity And Mortality In Patients With A History Of Psychosis-an Observational Study Of 158478 Stroke Cases In The National Swedish Riks-Stroke Cohort
Authors: Henriksson Karin M , Malfert Mauricio , Bergman Eva Mathilda , Terént Andreas , åsberg Signild
Published: July 2021

Background and purpose:
Patients with a psychosis (P) have a much higher risk of cardiovascular ischemic morbidity and mortality as compared to the general population without psychosis (NP). The aim of this prospective observational study was to investigate associations between hemorrhagic and/or ischemic stroke and 90 days mortality in patients with different types of psychoses.

Methods:
Data on stroke, psychoses and diagnoses of co-morbidity (atrial fibrillation, hypertension, diabetes, ischemic heart disease) were collected from the national in patient registry. All adult stroke patients registered in 2001-10 in the Swedish Stroke Register were identified. Incidence of stroke, and all-cause mortality for PP and NP as well as subgroups with schizophrenia, bipolar disease and other psychoses were calculated. Crude and adjusted (sex, age, consciousness, co-morbidities) OR and 95% confidence intervals (CIs) were estimated in a logistic regression model.

Results:
PP had a 1.19 (CI: 1.153-1.2176) higher risk of having a stroke as compared to NP. Out of 158478 cases of stroke, 6796 (total 4.3%), PP 759 (0.5%) had schizophrenia, 566 (0.4%) bipolar, and 5503 (3.5%) other psychoses. No statistical difference in type of stroke was seen between PP (12.7%) and NP (12.6%). Among NP 24617 (16.2%) died within 90 days as compared to 18.9% in PP and in the adjusted model the OR of death was 1.11 (CI 1.027-1.194) for PP vs NP. Corresponding ORs for schizophrenia was 1.76 (CI 1.402-2.214), bipolar disease 1.32 (CI 1.011-1.717) and 1.04 (CI 0.952-1.124) for other psychoses.

Conclusions:
Patients with a history of psychoses have a higher risk of death within 90 days of a stroke and patients with schizophrenia were found to have the highest risk of all.
Abstract TP386: Prompt Preventive Treatment of TIA Could Reduce the Need for Weekend Service
Authors: Anjum Qazi T , Dacey Lynne , Wani Mushtaq
Published: July 2021

Background:
There is 10% risk of stroke in the week after transient ischaemic attack (TIA). Urgent evaluation and early preventive treatment can reduce recurrence after a TIA by 80% at 90 days. Specialist assessment of high risk TIA patients within 24 hours and low risk within a week is recommended. Many centers struggle to provide a 7 day service. In our center, specialist assessment is available on weekdays only but the referrer is asked to initiate preventive treatment (anti-platelets, statins) followed by rapid referral for vascular imaging and TIA clinic.

Hypothesis:
Prompt treatment started by the referring physician is effective and safe in reducing recurrent cerebrovascular events.

Methods:
Planned service evaluation of patients referred to TIA service between December 2009 - September 2011 (21 months). Data was collected at 1st presentation to TIA clinic and at 90 day follow up.

Results:
The TIA service received 537 patients (median age 67 years [range 19 - 96years], 42% over 70 years, 48% females). 60% referrals were from emergency department (rest from primary care). 47 patients did not attend, hence 490 included in final analyses. Referrers started preventive treatment in 436(89%) patients. 12% (54/436) of these patients had side effects [SE] (headaches, GI upset) from early treatment (none required hospitalisation). 62% (303/490) referrals were truly TIA’s on specialist assessment. Recurrent events occurred in 8/303(2.6%) TIA patients. 6 of 8 of these patients did not receive treatment; mean delay of 4.8 days before specialist review. Recurrences were lower in treated patients (2/279 [0.7%] vs.6/24 [25%] in the non-treated group; p<0.0001). Weekend referrals constituted 33% (161/490) vs. 67% (329/490) weekday patients; 110 weekend vs. 193 weekday confirmed TIA’s. 90% weekend referrals had early treatment (16% had SE) vs. 88% weekday referrals (10% had SE). Weekend recurrence rate was 1.8% (2/110) vs. 3% weekday recurrences (6/193) (p=0.7). Median TIA clinic review delay was 1 day in both groups (IQR 0-2days).

Conclusion:
Weekend TIA service would be desirable. However, prompt treatment before specialist assessment appears to be equally effective and safe in reducing recurrent cerebrovascular events.
Abstract TP390: Ethnic and Regional Disparities in Access to Endovascular Embolectomy for Acute Ischemic Stroke
Authors: Attenello Frank , Adamczyk Peter , Wen Ge , He Shuhan , Russin Jonathan , Sanossian Nerses , Amar Arun P , Mack William J
Published: July 2021

Background:
Endovascular stroke treatment volume has significantly increased in recent years. Data from the Nationwide Inpatient Sample (NIS) database in 2008 demonstrates an association between improved outcomes and centers that perform substantial procedural volume (>10/year). Few reports have described demographics of patient populations or centers performing mechanical thrombectomy.

Methods:
We collected data from the 2008 NIS database for patients hospitalized for ischemic stroke, and those undergoing mechanical clot retrieval. Patients were characterized by ethnicity, payment source, and regional hospital variables of population density and median zipcode wealth. Patients were evaluated for admission and treatment at substantial thrombectomy volume centers.

Results:
Approximately 1.1 million patients were hospitalized for acute stroke, with 2749 patients receiving mechanical thrombectomy in 2008. Asian patients received the highest frequency of intervention (0.39%) with Blacks and Native Americans receiving the lowest (0.18%, 0.17%). Patients from zipcodes with highest median wealth most frequently received intervention (0.29%, p<0.001). Among all stroke patients, Whites, Hispanics, individuals in highest salaried zip codes and patients residing in counties with population > 1 million were most often admitted to centers with substantial endovascular procedural volume (all, p<0.001 in multivariate analysis). Among those undergoing thrombectomy, Hispanics (p=0.03, OR 0.654 [0.442,0.967]), Asians (p=<0.001, 0.205 [0.120,0.350]) and Blacks (p=0.09, OR 0.717[0.489,1.050]), were treated less frequently than Whites at substantial volume centers.

Conclusion:
Native Americans and Blacks received the lowest frequency of thrombectomy for acute ischemic stroke. Whites, individuals residing in wealthy and high population density regions were more often admitted to centers performing substantial procedural volume. Among patients undergoing mechanical thrombectomy, Whites were more often treated at substantial volume centers than Hispanics, Blacks or Asians. Though noted correlations may be multi-factorial, socioeconomic factors may predict admission and treatment in high volume procedural centers.
Abstract TP395: Transition Coaching for Stroke (TRACS): Assessing Health Literacy and Readmissions
Authors: Bushnell Cheryl , Myers Charlotte , Fidali Brian , Sides Elizabeth , Suwatcharangkoon Sureerat , Duncan Pamela
Published: July 2021

Objective:
There is a critical need for tailoring transition care for stroke survivors, especially those that address health literacy. The objective of this pilot program is to provide individualized coaching for stroke risk factors at discharge, and to assess the role of health literacy on readmissions.

Methods:
We enrolled patients discharged home with ischemic or hemorrhagic stroke, or TIA from 9/2011 to 7/2012. Transition coaching was performed one-on-one in the hospital using a take-home packet that included review of a check list of their risk factors, medication information, instructions for stroke awareness, action with new symptoms, and post-hospital follow-up care. Materials were in large font for a 7th to 8th grade reading level, with a one-page summary for ease of reading. Data collection forms were programmed for online data entry of baseline variables (education, prior hospitalizations, health literacy) using REDcap. All cause readmissions within 30 days or longer were obtained from medical records and hospital reports.

Results:
90 patients with NIHSS information were enrolled. Mean age was 63.3 yrs (std 14.3), 53% female, 69% white, 30% Black, 68% ischemic stroke, 10% hemorrhagic stroke, 20% TIA, and median NIHSS 2.0 (range 0-27). 16% were not confident filling out medical forms by themselves, 15% needed help with doctor/pharmacy materials, and 5% were not happy with the way they read. 37% preferred to learn new things by reading brochures, 14% preferred someone going over materials with them, 13% watching videos, and 12% by having someone tell them. 41% preferred alternative learning methods outside the choices provided. 22 patients were readmitted, 9 of which were within 30 days of discharge. 33% of those readmitted were not very confident or not confident at all with filling out medical forms vs 11% of those not readmitted (p= 0.026). Although attenuated after adjustment for education, low confidence with medical forms was independently associated with readmission (OR 3.235; 95% CI: 0.819-12.785; p=0.094).

Conclusions:
Accounting for health literacy and patient preferences for learning should be a key component in transition programs to provide appropriately tailored coaching to reduce adverse outcomes, such as readmissions.
Abstract TP398: Stroke prevention opportunities being missed: the Australian Stroke Clinical Registry experience.
Authors: Kilkenny Monique , Dewey Helen , Lannin Natasha , Lim Joyce , Anderson Craig , Donnan Geoffrey A ,   AuSCR Management Committee, Cadilhac Dominique
Published: July 2021

Introduction:
Stroke utilizes a large portion of hospital resources. Little is known about the frequency of contacts with hospitals prior to first-ever stroke and potentially missed opportunities for stroke prevention. In addition, re-admissions may indicate failed secondary prevention.

Hypothesis:
Many patients have had a presentation or admission to hospital in the year prior to a first-ever stroke event.

Methods:
Data from the prospective, national Australian Stroke Clinical Registry (AuSCR) obtained between 15 June 2009 and 31 December 2010 from a large hospital in Melbourne, Victoria (Australia) were linked to the Victorian government emergency department (ED) and hospital discharge datasets for a 3 year ‘look-back’ period and any re-presentation up until February 2011 using stepwise deterministic linkage methods. Descriptive statistics are presented.

Results:
Matched linkage to ED (731/788) and hospital discharge (736/788) datasets was achieved in 93% of AuSCR registrants, of whom 513 were first-ever strokes (51% male, average age 74 [±16] years, 82% ischemic). Prior to the first-ever stroke, 221 (47%) registrants had ED presentations and 283 had a hospital admission on average 2.9 months before stroke. The mean number of ED presentations within 3 years of AuSCR registration for a first-ever event was 2.1 (SD 1.6); and 48/466 (10%) occurred in the month prior to stroke. Among first-ever stroke registrants, 200 were re-admitted on average within 5 months following discharge; 3.5% for recurrent stroke/TIA.

Conclusion:
Contact with hospitals was common (~50%) before first stroke, raising opportunities to screen and intervene in people at risk of stroke. As one in 5 hospital re-admissions is for recurrent stroke, a closer monitoring of secondary prevention measures in the early post-discharge period may be warranted.
Abstract TP406: Impact Of Warfarin Pharmacogenomics In The Time In Therapeutic Range In Korean Patients With Atrial Fibrillation.
Authors: Kim Jae Ha , Park Yun Kyung , Kim Suk Jae , Ryoo Sookyung , Ha Yeon Soo , Lee Jin Soo , Park Rae Woong , Park Ho Young , Lee Ji Hyun , Lee Soo-Youn , Bang Oh Young
Published: July 2021

Background:
Warfain is highly effective for stroke prevention in patients with atrial fibrillation (AF), but also has narrow therapeutic window (usually INR 2-3). Even in clinical trials with selected, closely monitored patients, the times in therapeutic range (TTR) of those taking warfarin is less than two thirds. Single nucleotide polymorphisms in genes affecting warfarin metabolism (cytochrome-P450 2C9, CYP2C9) and response (vitamin-K epoxide reductase complex 1, VKORC1) have an important influence on warfarin therapy. Initial INR response to warfain was reportedly associated with genetic variability in VKORC1 than with CYP2C9. However, warfarin pharmacogenics associated with long-term intraindividual variation (TTR during the warfarin maintenance) is unsettled.

Methods:
Clinical and genetic data form 330 Korean patients with AF (200 had AF-related stroke) were collected and followed for average 36 months. Patients were included who had AF, who were eligible to take warfarin , in whom genetic testing was available, and who were followed for more than 6 months. Thromboembolism and hemorrhagic complication was monitored with clinical and laboratory findings, including thromboemoblic [CHADS2 and CHA2DS2-Vasc] and hemorrhagic [ATRIA] risk schemes, as confounders.

Results:
Genotypic frequencies of CYP2C9 *1/*1, *1/*3, and *3/*3 were 90%, 6.7%, 0.3%, respectively, whereas VKORC1 +1173 TT, CT, and CC were 84%, 15.2%, 0.6%, respectively. TTR varies greatly depending on the CYP2C9 polymorphism: TTR of INR 2-3 was 65±20% in *1/*1 carriers, 42±22% in *1/*3 carriers, and 1.4±2.2% in *3/*3 carriers. TTR of INR was not different depending on the VKORC1 polymorphism.

Conclusions:
Novel oral anticoagulants have recently been introduced. However, there is a lack of consensus regarding the indication of these novel agents in patients with AF. Our results indicated that TTR during warfarin maintenance was associated with genetic variability in CYP2C9 than with VKORC1. Warfarin alternatives could be particularly helpful in patients who have specific CYP2C9 polymorphism other than *1/*1. Further studies are needed testing the impact of warfarin genetic polymorphism in other ethnic group (i.e. white) where these CYP2C9 polymorphisms were prevalent.
Abstract TP412: Neurologic Severity and Functional Outcome Are Not Affected By Prestroke Antiplatelets Use in Patients with First-ever Ischemic Stroke
Authors: Kim Tae-Won , Lee Si Baek , Koo Jaseong , Mun Hyojin , Park Jong-Moo , Kang Kyusik , Kim Jiyeon
Published: July 2021

Objectives:
We aimed to investigate whether taking antiplatelets before the occurrence of ischemic stroke is associated with lessened initial neurologic severity or better outcome at 3 months compared to taking no antiplatelets.

Methods:
We consecutively included first-ever ischemic stroke patients within 72 hours of onset from Feb 2008 to Sept 2010. Demographics, stroke subtype and risk factors were obtained. Initial NIHSS scores and mRS at 3 months were used to compare initial severity and functional outcome (good outcome, mRS 0 or 1) between prestroke antiplatelets users and non-users. We performed multivariate analysis using linear regression for initial NIHSS score and logistic regression for good functional outcome. Antiplatelet users were defined as those taking antiplatelets at least for 7 days before stroke onset.

Results:
Total 353 patients were included for this study. Compared to non-users, age (years) was older (67 vs. 71, p=0.02) and more patients (%) had hypertension (63 vs. 92, p<0.01), diabetes (42 vs. 64, p<0.01), atrial fibrillation (4 vs. 12, p<0.01), and history of coronary heart disease (3 vs. 16, p<0.01) in prestroke antiplatelets users. Mean initial NIHSS scores were not different between the two groups (4 vs. 5, p=0.1) and less prestroke antiplatelets users had good functional outcome than non-users (116 (45%) vs. 30 (32%), p=0.03). In multivariate analysis, old age, diabetes, atrial fibrillation and absence of hypertension were significantly associated with high initial NIHSS score. Old age (RR, 95% CI; 0.99, 0.96~1.0, p=0.03) and initial NIHSS score (0.67, 0.60~0.75, p<0.01) were related to good functional outcome. Prestroke antiplatelets was associated with neither initial NIHSS score nor good functional outcome.

Conclusion:
In patients with first-ever ischemic stroke, prestroke antiplatelets was not associated with initial stroke severity and functional outcome at 3 months.
Abstract TP429: The Protective and Withdrawal Effects of Atorvastatin on Endothelial Barrier in Cerebral Ischemia and Reperfusion Injury
Authors: Hong Hua , He Juan j , Shang Jin w , Liao Quan h , Zhou Ming x , Wang Xuan h , Li Jing j
Published: July 2021

Background and purpose—
Statins can effectively attenuate focal cerebral ischemic injury. However, the role of statins in modulating permeability of endothelial barrier in ischemia-reperfusion (IR) and the impact of statins withdrawal on endothelial barrier during the acute phase of IR are unclear.

Methods—
Focal cerebral ischemia (2 hours) was created in adult male Sprague-Dawley rats (240 to 270 g) by middle cerebral artery occlusion (MCAO) using a suture. Rats were randomly treated with vehicle, atorvastatin daily for 7 days before MCAO (pretreatment), 3 days after MCAO (post operative treatment), or both 7 days before and 3 days after MCAO (continuous treatment). Brains were harvested at 24 and 72 hours after reperfusion for assays of brain edema (n=5), BBB leakage (n=5), calculations of occludin and claudin-5 positive vessels (n=5) and expression of occludin, claudin-5 and Phosphoinositide 3-kinase (PI3K)-γ (n=5), respectively.

Results—
24 hours after reperfusion, pretreatment with atorvastatin significantly reduced BBB leakage (7.55±0.63ng/g versus 9.38±0.77ng/g; P<0.05) and brain edema (83.96%±1.11% versus 86.77%±1.26%; P<0.05), as evidenced by Evans blue extravasation and brain water content measurement. Immunofluorescence assay and western blot revealed atorvastatin significantly increased the expression of occludin and claudin-5 and attenuated IR-induced increased expression of PI3Kγ compared with vehicle treatment. 72 hours after reperfusion, post operative treatment with atorvastatin for 3 days and continuous treatment both attenuated the above IR injuries to endothelial barrier (P<0.05), particularly the latter. However, atorvastatin pretreatment no longer had protective effects on BBB leakage, brain edema and the expression of PI3Kγ (P<0.05), although pretreatment with atorvastain for 7 days increased the expression of occludin and claudin-5 up to 72 hours after reperfusion (P<0.05).

Conclusions—
These results demonstrate that protective effects of atorvastatin against endothelial barrier breakdown may be related to the up-regulation of occludin and claudin-5 and down-regulation of PI3Kγ. However, there are no withdrawal effects of atorvastain on endothelial barrier during the acute phase of IR (72 hours).
Abstract TP442: Baseline Cognitive Impairment and Associated Risk Factors in Patients with Intracranial Stenosis in the SAMMPRIS Trial
Authors: Ilkanich Erin V , Smock Alison P , Cotsonis George A , Helwig Stephanie , Lynn Michael J , Lane Bethany F , Montgomery Jean , Derdeyn Colin P , Fiorella David , Janis L. S , Chimowitz Marc I , Turan Tanya N
Published: July 2021

Background and Purpose:
Cognitive impairment is an important outcome in stroke prevention trials. The Montreal Cognitive Assessment (MoCA) score is a cognitive measure used in the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial due to its sensitivity in detecting cognitive impairment in stroke patients. We sought to determine the prevalence of low baseline MoCA scores and the baseline risk factors associated with lower MoCA scores in SAMMPRIS patients.

Methods:
The main entrance criteria in SAMMPRIS were a TIA or non-disabling stroke within 30 days prior to enrollment attributed to 70-99% intracranial atherosclerosis. Patients with stroke as the qualifying event who had an NIH Stroke Score indicating aphasia or neglect were excluded from these analyses. Low MoCA score was defined as <26, the standard value that has 90% sensitivity for detecting mild cognitive impairment. Baseline demographic, medical history, laboratory, and neuroimaging characteristics were compared between patients with low vs. normal MoCA scores in univariate and multivariate analyses.

Results:
The prevalence of low baseline MoCA scores was 207/377 (55%). Baseline features associated with low MoCA scores in the univariate analyses are shown in Table 1. In the multivariate analyses, older age (p<0.0001) and physical inactivity (p=0.0166) were associated with low MoCA scores. MoCA score was not related to other vascular risk factors, severity of stenosis, prior stroke, or white matter lesions on CT or MRI.

Conclusions:
SAMMPRIS patients had a high prevalence of cognitive impairment at baseline, which was not explained by the presence of vascular risk factors, such as hypertension and hypercholesterolemia. This finding suggests that cognitive impairment may be an important source of potential disability in patients with intracranial stenosis.
Abstract TP46: ASPECTS Performance in a Series of Patients Undergoing CT and MRI: Reader Agreement, Modality Agreement, and Outcome Prediction
Authors: McTaggart Ryan A , Jovin Tudor G , Lansberg Maarten G , Mlynash Michael , Inoue Manabu , Marks Michael P , Albers Greg
Published: July 2021

Objective:
To compare the performance of pre-treatment Alberta Stroke Program Early CT scoring (ASPECTS) using NCCT and MRI in a large endovascular therapy cohort.

Methods:
This is a DEFUSE 2 substudy. Prospectively enrolled patients underwent baseline CT, MRI and started endovascular therapy within 12 hours of stroke onset. Inclusion criteria for this analysis were evaluable pre-treatment NCCT, diffusion-weighted MRI (DWI) and 90-day modified Rankin Scale (mRS) score. Two expert readers graded ischemic change on NCCT and DWI using the ASPECTS and were blinded to all clinical information except stroke side. ASPECTS scores were analyzed either full scale, trichotomized (0-4 vs. 5-7 vs. 8-10), or dichotomized (0-7 vs. 8-10). Good functional outcome was defined as a 90 day mRS of 0-2. Infarct volumes were calculated using rapid processing of perfusion and diffusion (RAPID) software.

Results:
71 patients fulfilled our study criteria. Their mean age was 68±15 years, median NIHSS score was 17 (IQR 12-20), and 49% were female. There were 31 (44%) right-sided strokes. Reader and modality agreement are presented in the Table. Median (IQR) time between NCCT and MRI was 1.62 (1.14-2.38) hours. There was greater correlation of DWI ASPECTS with DWI volume (p<0.001) and functional outcome (p=0.001) than NCCT ASPECTS. DWI ASPECTS correlated with 90 day mRS with OR (95%) of: 12.3 (1.4-105) 8-10 vs.0-4; 4.0 (1.2-13.2) 8-10 vs. 5-7; 3.1 (0.3-30) 5-7 vs. 0-4; and 5.4 (1.8-16.2) 8-10 vs.0-7. NCCT ASPECTS did not correlate with mRS with OR (95%) of: 1.4(0.2-8.3) 8-10 vs. 0-4, 1.02(0.4-2.8) 8-10 vs. 5-7, 1.4(0.2-8.5) 5-7 vs. 0-4, and 1.1(0.4-2.9) 8-10 vs. 0-7.

Conclusion:
Inter-rater agreement on NCCT ASPECTS, as well agreement between NCCT and DWI ASPECTS, ranged from slight to moderate. DWI ASPECTS outperformed NCCT ASPECTS in correlation with DWI volume and predicting functional outcome at 90 days. These results may be influenced by differences in acquisition times for NCCT and MRI.
Abstract TP51: Decreased Internal Cerebral Vein Filling - A New Radiographic Sign of Acute Ischemic Stroke
Authors: Klourfeld Evgenia , Patel Apurva , Mohamed Karim , Jin Albert Y
Published: July 2021

INTRODUCTION:
CT signs of acute ischemic stroke focus on parenchymal and arterial lesions. Little is known about venous changes. The aim of this study was to determine the value of decreased deep venous outflow as a predictor of acute ischemic stroke.

METHODS:
Multimodal CT findings of 182 patients presenting for acute stroke evaluation within 4.5 hours of symptom onset were retrospectively reviewed for evidence of deep venous outflow changes. Interhemispheric symmetry of internal cerebral vein (ICV) opacification on CT angiogram was assessed by 3 raters. Discharge diagnosis, neurological assessment details, and radiographic data were extracted from electronic hospital records, and radiology reports.

RESULTS:
Of 182 patients included in the study, 46 showed diminished ICV opacification (dICV) on the side of the expected ischemic lesion. Anterior circulation stroke was diagnosed in 87% of dICV cases, but in only 31% of subjects with ICV symmetry (sICV), suggesting a strong correlation of dICV with ipsilateral anterior circulation infarction (P<0.0001). Patients with dICV presented with greater neurologic impairment (NIHSS 14±1.0 vs. 6±0.8, P<0.0001), proximal arterial lesions, and lower ASPECTS (8±0.3 vs. 9±0.2, P=0.0022). In 48 patients who had a CT perfusion scan at the time of initial evaluation (dICV N=20 vs. sICV N=28), dICV was associated with larger perfusion defects: mean transit time ASPECTS 3±0.7 vs. 8±0.3 (P<0.0001), cerebral blood flow ASPECTS 3±0.8 vs. 8±0.5 (P<0.0001), and cerebral blood volume ASPECTS 7±0.7 vs. 9±0.2 (P=0.006). The sensitivity, specificity, and positive predictive value of dICV for anterior circulation stroke were 48%, 94%, and 87% respectively. Inter-rater agreement was very good with a free marginal kappa of 0.75.

CONCLUSION:
Decreased ICV may be a useful radiographic sign of ipsilateral acute ischemic stroke and a marker of a large cerebral territory at risk of infarction. Prospective studies are needed to help validate this finding, and its role in predicting stroke outcomes.
Abstract TP56: Insight Into Human Ischemia Reperfusion Injury in Acute Stroke: A Voxel-Based MRI Analysis of Tissue Fate
Authors: Nour May , Scalzo Fabien , Alger Jeffery R , Starkman Sidney , Ali Latisha K , Kim Doojin , Vespa Paul M , Rao Neal M , Yallapragada Anil , Saver Jeffery L , Salamon Noriko , Liebeskind, for the UCLA Stroke Investigators David S
Published: July 2021

Background:
Reperfusion is characterized by initial restriction of blood supply followed by subsequent vascular restoration and concomitant reoxygenation of downstream tissue. In spite of mitigating initial tissue hypoxia, exacerbation of tissue injury may occur. Animal models have delineated reperfusion injury on the cellular and molecular levels, yet, no study has quantified voxel-based analyses of tissue fate due to reperfusion injury in human stroke.

Methods:
Evaluation included 58 stroke patients with an age range of 65±18 years, 65% of whom were woman and 35% men. All patients presented with M1 MCA occlusion and a subset received mechanical thrombectomy (38) while another received intravenous tPA followed by mechanical thrombectomy (20). Serial perfusion MRI images were obtained on presentation as well as 3-6 hours following reperfusion and processed to extract Tmax parameters. These images were co-registered serially at the voxel level with tissue fate outcomes on FLAIR and GRE 4-5 days following presentation. Reperfusion was defined by serial changes observed in Tmax voxels. The volume of reperfusion, injury, as well as tissue fate relative to initial perfusion were calculated.

Results:
Hemorrhage was noted on GRE in 28.9% of the patients who received thrombectomy alone and in 20% of those who received IV tPA followed by thrombectomy. In pure thrombectomy cases without later hemorrhage, average voxel-based reperfusion was 72.3% with 18% demonstrating reperfusion injury and tissue death as assessed by FLAIR imaging 4-5 days following presentation, averaging 86.2%. In patients who received IV tPA followed by mechanical thrombectomy without any subsequent hemorrhage, average voxel-based reperfusion was 66.0% with 6.2% demonstrating reperfusion injury in reperfused voxels and tissue death as assessed by FLAIR imaging 4-5 following presentation, averaging 90.3%.

Conclusions:
Non-hemorrhagic forms of reperfusion injury are common in acute stroke patients treated with standard therapies. Despite reperfusion and irrespective of treatment modality, substantial amounts of tissue are destined to infarct. Voxel-based analyses of serial imaging studies may provide a framework to develop therapies for reperfusion injury.
Abstract TP59: Clinical Course and Radiological Outcome of Mild Stroke Patients Treated and not Treated with Thrombolysis
Authors: Urra Xabier , Ariño Helena , Amaro Sergi , Obach Víctor , Cervera Alvaro , Chamorro ángel
Published: July 2021

Background:
Around 30% of patients with acute stroke are excluded from thrombolysis because of mild or improving symptoms, but some of these patients don’t achieve a good recovery. We compared the clinical and radiological course in a cohort of 239 patients with mild stroke treated and not treated with thrombolysis in the same institution.

Methods:
We studied all patients with ischemic stroke admitted within 6 hours of symptom-onset with previous mRS≤1 and mild symptoms (NIHSS≤5) at arrival or during initial evaluation. We compared the baseline characteristics, clinical course (NIHSS), radiological outcome (final DWI lesion volume), incidence of symptomatic intracranial hemorrhage (sICH) and favourable 3-month outcome (mRS≤1) of patients treated with thrombolysis (123 tPA only and 9 endovascular interventions) or not treated (n=107).

Results:
Treated patients had greater clinical severity at presentation and after imaging and arrived to the hospital faster than not treated patients. In a general linear model of repeated measures, their course was significantly different (p=0.03) and thrombolised patients improved more during hospitalization. Patients with significant neurological improvement (NIHSS score>1) had more severe strokes at presentation but similar outcome, and were more often treated with tPA (p<0.001). Infarct volume was significantly correlated with NIHSS score especially at day 1. Despite the differences in the initial clinical severity, final infarct volume was similar in treated and not treated patients. The rate of sICH was similar in both groups. Outcome at 3-months was associated to past history of stroke, glucose levels and deterioration during hospital stay. On multivariate analysis, thrombolysis remained associated to neurological improvement (OR 4.34;p<0.001) and was non-significantly associated to greater chances of good functional outcome at 3-months (OR 2.38;p=0.099).

Conclusions:
In patients with mild stroke thrombolysis was safe and was associated to better neurological course. Overall, these results suggest that patients presenting with mild symptoms do benefit from thrombolysis.
Abstract TP61: Elevated CRP Between Day 1 And 7 and not Admission CRP Is An Independent Predictor For Outcome at 3 Months In Thrombolized Acute Stroke Patients
Authors: Rocco Andrea , Geraldine Fam , Ringleb Peter , Nagel Simon
Published: July 2021

Background:
The value of CRP in stroke patients undergoing thrombolysis, in the acute and subacute phase of ischemic stroke as a prognostic tool for outcome is unclear, since conflicting reports exist. Aim of our study was to explore the role of admission CRP and follow-up CRP between day 1 and 7, for outcome and mortality in stroke patients treated with rtPa.

Methods:
From March 1998 to 2011 all patients admitted to our hospital and undergoing thrombolysis for acute ischemic stroke were included into an open, prospective database. Stroke severity was assessed using the NIHSS. In all patients CRP levels was measured upon admission in the emergency room, after 24 hours from the acute event and in the following days. CT scan before treatment and routine brain CT scan 24-36 h after thrombolysis were performed. Symptomatic haemorrhage (sICH) was defined according to ECASS II criteria. Functional outcome was assed by mRS at three months and divided into independent (mRS0-2) and dependent (mRS 3-5).

Results:
In total, 1292 patients were registered in our database. About 70% of patients had an increase of CRP values in the first 7 days after admission. Infection occurred in 22% of patients and about 25% had a large brain infarction (>1/3 of vessel territory). sICH occurred in 6.7% of patients. Follow-up CRP levels between day 1 and 7 were significantly associated with cardio embolic stroke (p=0.033), infarct size (p<0.001), infection (p<0.001), symptomatic haemorrhage (p<0.001), independent (p<0.001), dependent outcome (p<0.001) and mortality (p<0.001). CRP values between day 1 and 7 (OR 2.824 CI95%; 1.534 - 5.201, p=0.001), infarct size (OR 2.254; CI95% 1.480 - 3.432, p<0.001), infection (OR1.752; CI95% 1.100 - 2.789, p=0.018) and NIHSS (OR 1.043; CI95% 1.016 - 1.069, p=0.001) were independent predictors for dependent outcome. Admission CRP values were not independently associated with outcome and mortality after multivariate logistic regression analysis.

Conclusion:
Together with know predictors like infarct size, NIHSS and infections, maximally elevated CRP levels within day 1 and 7 were strongly and independently associated with long-term outcome in thrombolyzed stroke patients after correction for baseline variables.