bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WMP114: Improving Initiation Time and Frequency of Patient and Family Stroke Education
Authors: Turner Heather L , May-Cowgill Melinda , Mahanes Dea , Hundt Beth
Published: October 2018

Background:
While our stroke education (stroke education= patient, family and caregiver stroke education) documentation demonstrated that we met Joint Commission education requirements 94% of the time, we found that this teaching was usually being documented all at one time, typically on the day of discharge. Given that most adult learners can only retain 1 to 2 teaching points at a time and that repetition increases learning, we identified the need to revise our teaching process.

Purpose:
To improve the quality and frequency of stroke education.

Methods:
RNs from the neuro ICU, neuro intermediate care unit (NIMU) and the acute care stroke unit reviewed, revised and supplemented the institution’s written stroke education materials, and created standard work for providing initial and ongoing stroke education. The standard work focuses on providing a personalized stroke education packet within 24 hours of admission, breaking down key concepts into individual teaching points, and daily documentation of education. This standard work was then shared with the RNs from all three units via e-mail, flyers, and review at change of shift huddles and staff meetings. Daily audits were performed with email reminders going out to RNs who cared for patients who had no stroke education documented for >24 hours. Public recognition was given to RNs who consistently documented stroke education including a drawing for a $50 gift card on each unit.

Results:
To evaluate the effectiveness of the new standard work we compared the number of days with documented stroke education for 6-week periods before and after implementation of the standard work. In the neuro ICU and NIMU, the number of patient days with documented stroke education increased from 10% (8/79) prior to implementation to 65% (126/194) after implementation. In the stroke unit, days with documented stroke education increased from 31% (40/129) to 72% (156/216).

Conclusion:
Developing and implementing standard work for the process of stroke education and following up with documentation audits, one-on-one feedback, public recognition and prize drawings led to earlier stroke education and significantly increased the frequency of stroke education.
Abstract WMP13: The Prediction of the Hemorrhagic Transformation Locations After Reperfusion Therapy in Acute Stroke Patients: A Magnetic Resonance Perfusion Study Using Deep Learning
Authors: Yu Yannan , Guo Danfeng , Zhang MinMing , Lou Min , Liebeskind David S , Scalzo Fabien
Published: October 2018

Objective:
Hemorrhagic transformation (HT) is a major complication of reperfusion therapy in acute stroke. We aim to explore the feasibility of HT location prediction from baseline magnetic resonance perfusion (MRP) source images.

Methods:
Consecutive acute ischemic stroke patients who had HT after reperfusion therapy (IV tPA and/or endovascular thrombectomy) were reviewed from two stroke centers. Patients with MRP and diffusion-weighted imaging (DWI) before and 24h after treatment and follow-up susceptibility weighted imaging (SWI) were included. The HT was depicted on follow-up SWI semi-automatically. The DWI lesions and HT were classified into 12 cerebral vascular territories (Fig 1A). Then a total of 80,000 tissue-voxels were extracted from both HT region and non-HT region randomly with the ratio of 1:1. Each voxel included a set of values of MRP source image and baseline DWI. Convolutional neural networks (CNN) were trained with 3-fold cross-validation. Prediction maps were generated from the CNN for each patient. The prevalence of HT after infarction and the sensitivity and specificity of HT prediction in each vascular territory were calculated.

Results:
Seventy-seven HT patients were analyzed (40 male, age 73 ±14 years, median baseline NIHSS score 14 [IQR 8-19], median onset-to-treatment time 242 min [IQR 152-355], median modified Rankin score 3 [IQR 1-4], 28 with Parenchymal hematoma). HT occurred most frequently in the territory of middle cerebral artery superficial branches (67.5%) and basal ganglia (37.6%), and least frequently in brain stem or thalamus (3.9%). HT was not evenly distributed throughout the vascular territories (Fig 1A). The best model was a locally-connected CNN (area under curve of 0.88). The average sensitivity and specificity for HT location prediction in anterior circulation were 89% and 60% (Fig 1BC).

Conclusion:
The CNN trained from DWI and MRP source images could predict the HT locations in acute ischemic stroke patients.
Abstract WMP15: Serial Aspects in the Dawn Trial: Infarct Evolution and Clinical Impact
Authors: Liebeskind David S , Bhuva Parita , Xiang Bin , Yoo Albert J , Jadhav Ashutosh J , Nogueira Raul G , Haussen Diogo C , Budzik Ronald F , Bonafe Alain , Yavagal Dileep R , Hanel Ricardo A , Ribo Marc , Cognard Christophe , Sila Cathy , Hassan Ameer E , Smith Wade S , Saver Jeffrey L , Jovin Tudor G ,   for the DAWN Investigators
Published: October 2018

Background:
The impact of baseline ischemia on Aspects and evolution over 24 hours may be distinct in the late thrombectomy time window recently established by dawn. Aspects may enable practical triage of thrombectomy candidates more than 6 hours after onset.

Methods:
The dawn Imaging Core Lab independently scored Aspects at baseline and 24 hours. Descriptive statistics characterized Aspects on CT or MRI at baseline and 24 hours, delineating serial ASPECTS change or infarct evolution over 24 hours and analyzing associations with clinical variables, treatment arm and clinical outcomes.

Results:
193 DAWN subjects (mean age 70.2 ± 13.7 yrs; 56% female; baseline NIHSS median 17 (14, 21) had core lab adjudicated Aspects at both baseline and 24 hours. Baseline Aspects was median 8.0 (3-10), with 89/193 (46.1%) between 0-7 and 104/193 (53.9%) between 8-10. 24-hour ASPECTS was median 6.0 (0-9), with serial ASPECTS change or infarct evolution of median -1, ranging from -8 to 0. Multivariate logistic regression showed age (OR 1.03 (yr) 95%CI (1.01-1.05), p=0.011) and male sex (OR 0.51 95%CI (0.30-0.86), p=0.012) predicted higher baseline ASPECTS. Higher 24-hour ASPECTS was predicted by endovascular treatment (OR 2.42 95%CI (1.42-4.12), p=0.001), baseline glucose < 150 mg/dL (OR 2.23 95%CI (1.19-4.18), p=0.012), lower baseline NIHSS (OR 0.92 95%CI (0.88-0.97), p=0.003) and age (OR 1.03 (yr) 95%CI (1.01-1.05), p=0.002). Good clinical outcome (day 90 mRS 0-2) was predicted by 24-hour ASPECTS (OR 1.50 95%CI (1.22-1.85), p<0.001). Dramatic infarct evolution (ASPECTS decrease ≥ 6) occurred in 15/193 (7.8%). Elevated baseline serum glucose (mg/dL) was a potent predictor of serial ASPECTS change of 4, 5, or 6 points (OR 1.01, all p<0.010). Serial ASPECTS change was dramatically influenced by treatment arm (p=0.004), including 0 ASPECTS change in 40/99 (40.4%) of the endovascular arm and only 18/94 (19.1%) of the medical arm.

Conclusions:
DAWN subjects enrolled with small infarct cores in the late time window had a broad range of baseline ASPECTS. 24-hour ASPECTS, strikingly influenced by endovascular therapy, predicted good clinical outcomes. Infarct evolution on serial ASPECTS provides robust biomarker data for endovascular therapy up to 24 hours from onset.
Abstract WMP16: Elevated Cerebral Neurite Orientation Dispersion and Density Imaging and Diffusion Kurtosis Values Are Associated With Poor Neurologic Outcome in Comatose Cardiac Arrest Patients
Authors: Wu Ona , Rosenthal Eric S , Mills Brittany B , Cudemus-Deseda Gaston , Edlow Brian L , Kimberly William T , Ning Mingming M , Copen William A , Schaefer Pamela W , Giacino Joseph T , Greer David M
Published: October 2018

Background:
For cardiac arrest survivors initially comatose after restoration of spontaneous circulation (ROSC), the extent of brain injury and expected neurologic outcome are crucial for patient management decisions. Advanced diffusion imaging approaches such as neurite orientation dispersion and density imaging (NODDI) or diffusion kurtosis imaging may provide additional insight into tissue integrity and potential for recovery of consciousness complementary to standard diffusion tensor imaging (DTI).

Methods:
Multi-shell diffusion imaging was acquired in a prospective study of comatose cardiac arrest patients and in 5 controls. Neurite orientation dispersion (OD), intracellular volume fraction (ICVF), mean kurtosis (MK), axial kurtosis (AK), radial kurtosis (RK), mean diffusivity (MD), axial diffusivity (AD), radial diffusivity (RD) and fractional anisotropy (FA) were calculated. Median whole-brain values in patients with poor outcomes (no arousal recovery [AR] by discharge) were compared with those with AR and to controls (1-way ANOVA, post-hoc 1-sided Wilcoxon exact test).

Results:
18 patients (mean ±SD 48±23 y, 39% men) and 5 controls (37±19 y, 40% men) were analyzed. Median (range) Glasgow Coma Scale was 3 [3-5]. 10 patients exhibited AR, 8 did not. Median [IQR] time-to-MRI was 5 [4-8] days. FA (P=0.009), MK (P=0.017), AK (P=0.026), RK (P=0.014), OD (P=0.018) and ICVF (P=0.0038) were significantly different (see Figure). FA control values were greater than AR and no AR (P<0.05). MK, AK, RK, OD and ICVF values in the no AR group were greater than in the AR and control groups (P<0.05).

Discussion:
This is the first report investigating early NODDI and diffusional heterogeneity changes in post-cardiac arrest comatose patients. Patients who failed to recover arousal demonstrated greater values for all kurtosis and NODDI metrics compared to controls. Potential bias from early withdrawal of life sustaining treatment and small cohorts are limitations.
Abstract WMP2: Outcomes of Endovascular Therapy Following Interhospital Transfer
Authors: Shah Shreyansh , Sheng Shubin , Xian Ying , Zachrison Kori S , Sheth Kevin N , Saver Jeffrey L , Smith Eric E , Fonarow Gregg C , Schwamm Lee H
Published: October 2018

Purpose:
Interhospital transfer for endovascular therapy (EVT) is increasingly frequent. We sought to compare the patient characteristics and in-hospital outcomes of EVT by arrival groups (transfer-in vs. front-door).

Methods:
We analyzed data from 22,881 acute ischemic stroke (AIS) patients treated with EVT in Get With The Guideline (GWTG)-Stroke from January 2012 through September 2016 at 553 hospitals. Patient level characteristics were compared by arrival groups. Multivariable logistic regression models were generated to examine the association between arrival mode and in-hospital outcomes.

Results:
Of 22,881 patients receiving EVT 41.5% (9,510) arrived to the EVT providing hospital after interhospital transfer. Transfer-in patients were more likely to be younger and of white race, with arrival during off-hours and lower initial recorded blood pressure. Transfer-in patients had significantly longer last known well to EVT initiation time (296 min vs 224 min, absolute standardized difference 67.09) but were more likely to have door to EVT initiation time of ≤ 90 minutes (Table 1). In-hospital outcomes were worse for transfer-in EVT patients in unadjusted analyses but in the risk adjusted models, there was no difference in the rates of in-hospital mortality and symptomatic intracranial hemorrhage. After risk adjustment, transfer-in patients were still less likely to have independent ambulation at discharge and discharged to home (Table 1).

Conclusions:
Interhospital transfer of AIS patients for endovascular therapy is associated with significant delay to treatment. In spite of similar risk adjusted in-hospital mortality and symptomatic intracerebral hemorrhage rates, transfer-in patients are less likely to have favorable discharge functional status.
Abstract WMP28: Hemorrhage Associated With External Ventricle Drain Placement in Aneurysmal Sub Arachnoid Hemorrhage Patients on Dual Anti Platelet Therapy: A Retrospective Analysis
Authors: Hudson Joseph , Prout Benjamin , Nakagawa Daichi , Nagahama Yasunori , Hasan David
Published: October 2018

Object:
Stenting and flow diversion of ruptured intracranial aneurysms requires the use of dual antiplatelet therapy (DAPT). These patients may be at increased risk for post surgical hemorrhagic complication. In this study, we sought to investigate whether DAPT is a risk factor for hemorrhagic complication associated with placement of external ventricular drains (EVD) in patients with aneurysmal sub-arachnoid hemorrhage (aSAH).

Methods:
Patients at our institution with aSAH requiring placement of an EVD for obstructive hydrocephalus between July of 2009 and November of 2016 were included. Rates of radiographically identified hemorrhage associated with EVD placement were compared between patients who were on DAPT for use of a stent or flow diverter, and patients who underwent microsurgical clipping or coiling and were not on DAPT by way of a backward stepwise multivariate analysis. Hemorrhages were judged to be clinically significant if they were temporally associated with neurologic declines, required surgical intervention, or caused seizures.

Results:
443 patients were admitted for management of aSAH. 298 Required placement of an EVD. 120 (40%) were treated with stent assisted coiling or flow diverters and required DAPT, while 178 (60%) were treated with coiling without stents or microsurgical clipping and were not on DAPT. 42 (14%) cases of new hemorrhage along the EVD catheter were identified radiographically. 32 of these hemorrhages occurred in patients on DAPT, while while 10 occurred in patients not on DAPT. After multivariate analysis, DAPT was significantly associated with radiographic hemorrhage [OR: 4.92, 95% CI: 2.45-9.91, p=.0001]. 5 hemorrhages (5 of 10 [50%]) were classified as symptomatic in those patients not receiving DAPT, while 10 hemorrhages (10 of 32 [31%]) were classified as symptomatic in those patients on DAPT (p=.4508).

Conclusions:
Our series confirms that patients with aSAH who receive stent assisted coiling or flow diversion are at higher risk for radiographic hemorrhage associated with EVD placement. This increased hemorrhage risk does not appear to be clinically significant. These data suggest that stent assisted coiling and flow diversion for aSAH are viable options in an era of evolving endovascular therapeutics.
Abstract WMP35: Endothelialized 3D Cerebrovascular Modeling: A Novel in vitro Approach to Study Gene Expression in Realistic Vascular Geometry
Authors: Kaneko Naoki , Tateshima Satoshi , Chen David , Duckwiler Gary , Hinman Jason D
Published: October 2018

Aberrant flow conditions are implicated in aneurysmal growth or rupture. Current approaches that analyze the effects of flow stress on vascular cells are limited by their simplistic design, lacking patient-specific vascular anatomic features that contribute to disease. Computational fluid dynamics (CFD) is commonly used to characterize the biophysical properties of patient-specific anatomy but neglects the biologic interface between the blood stream and the endothelial surface. The purpose of this study is to develop a new research model for analyzing gene expression influenced by complex-flow stress on endothelial cells using a precision medicine approach that incorporates three-dimensional (3D) patient-specific vascular geometry. Hollow vessel models were created with silicone using 3D printing technology from image data obtained by routine MRA, CTA or rotational angiography obtained in normal clinical practice. The vessel models coated with fibronectin were rotated in 3D with endothelium in culture incubator for cell lining. CFD study was performed to characterize the flow dynamics with specific regions of the vessel models. Viscosity-adjusted culture media was perfused using perfusion conditions calculated by CFD in the circulation with the endothelialized vascular model. After perfusion, RNA was extracted from endothelial cells in the parent artery and the aneurysm and gene expression was examined using quantitative PCR (qPCR). In addition, the morphology of endothelial cells in specific regions of the model were observed with confocal microscopy. Endothelial cells in regions of low wall shear and oscillatory flow within the aneurysm were irregular in shape and size and associated with up-regulation of inflammatory genes compared with cells in the parent artery that exhibited typical spindle shape and aligned with the directionality of flow. This novel in vitro model enables a new research approach to bridge the gap of biophysical flow phenomonology and the biological impact of complex flow patterns on endothelial cells using patient-derived imaging data. Such models are likely to be useful to determine flow-driven biologic changes in vascular endothelium that contribute to aneurysmal growth and rupture.
Abstract WMP36: Reduced Accumulation of Specific Serum MicroRNAs Associated With Formation of Intracranial Aneurysms
Authors: Lina Zheng , Liping Liu
Published: October 2018

Introductions:
There is increasing interest in identifying novel methods for intracranial aneurysm(IA) diagnosis. Non-coding RNA molecules such as microRNAs (miRNAs) are stable within the circulation and may serve as biomarkers for IA.

Hypothesis:
This study aims to identify miRNAs associated with a diagnosis of human IA and to gain comprehensive insight into the molecular mechanism of formation and development of intracranial aneurysms (IAs) .

Methods:
We included 45 patients with IAs and 35 normal controls. A microarray study was carried out using serum miRNAs. Differentially expressed miRNAs were identified. Then the differential expressed miRNAs screened out was validated in an independent cohort of 40 IAs patients and 30 controls using real-time quantitative reverse-transcription PCR (RT-PCR). And cluster analysis was performed in order to make the results looks more intuitive and potential gene targets were retrieved from miRNA target prediction databases.

Results:
Microarray study identified 14 miRNAs which were significantly changed in the IAs patients at an adjusted significance level of P ≤ 0.05 and fold change ≥ 2. Among them 6 were up-regulated and 8 were down-regulated. Among the miRNAs identified, hsa-miR-23b-3p, miR-590-5p, miR-20b-5p and miR-142-3p were found to be significantly down-regulated between the IAs patients and control groups of the independent 70 individuals. A total of 3815 predicted target genes are related to the 14 differentially expressed miRNAs. Bioinformatic analysis revealed that several target genes were closely related to aneurysm formation, growth and rupture, such as TGM2, EDN1, AGT and EGER. Among them TGM2 played great roles in positive regulation of inflammatory response, smooth muscle cell proliferation and cell adhesion, at the same time participated in blood vessel remodeling.

Conclusions:
Several serum miRNAs have been found to be associated with intracranial aneurysms, suggesting that miRNAs may participate in the regulation of the occurrence and development of intracranial aneurysms. All the 4 differently expressed miRNAs in aneurysm patients are down-regulated, which suggests reduced accumulation of special serum miRNAs may be a risk factor of the forming of intracranial aneurysms.
Abstract WMP41: Risk of 1 Month Stroke, Adverse Events and Mortality following Carotid Endarterectomy (CEA) According to Body Mass Index, Analysis of National Surgical Quality Improvement Program (NSQIP) Registry
Authors: Yousaf Muhammad Hammad , Zafar Aiman , Qureshi Adnan I
Published: October 2018

Background:
Carotid revascularization procedures are increasingly performed in overweight and obese patients. However, whether such procedures are associated with a higher risk of peri-procedural complications is not known.

Methods:
We studied all patients who underwent CEA in the CEA targeted American College of Surgeons (ACS) NSQIP Registry between years 2011 and 2013. The ACS-NSQIP prospectively collects data on over 300 variables pertaining to patient characteristics, comorbidities, operative details and 30 day post-operative outcomes. Patients were divided into four groups according to body mass index (BMI in kg/m
2
): underweight (<18.5), normal weight (18.5-24.9), overweight (25-29.9), obese (30-39.9) and morbidly obese (≥40). The odds ratios for selected outcomes were calculated after adjusting for age, gender and symptomatic status using logistic regression.

Results:
Among the 8576 patients who underwent CEA, 117, 2251, 3339, 2569 and 300 patients were underweight, normal weight, overweight, obese and morbidly obese. Compared with normal weight patients, the risk of stroke within 30 days was not different in overweight (1.6% vs. 2.2%; p=0.17), obese (1.6% vs. 2.4%; p=0.07) and morbidly obese patients (1.6% vs. 1.7%; p>0.999). Compared with normal weight patients, the risk of mortality within 30 days was not different in overweight (0.8% vs. 1.0%; p=0.43) and morbidly obese patients (0.7% vs. 1.0%; p>0.999) but was significantly lower in obese patients (0.5% vs. 1.0%; p=0.04). The one month stroke and/or mortality was not higher in overweight (OR: 1.16; 95% CI: 0.83-1.64; p=0.38), obese (OR: 1.06; 95% CI: 0.88-1.28; p=0.53) and morbidly obese patients (OR: 1.06; 95% CI: 0.81-1.40; p=0.65) after adjusting for potential confounders. There were no differences in the rates of adverse events such as myocardial infarction/arrhythmia, acute renal failure and unplanned intubations according to BMI strata while need for blood transfusions was significantly lower in overweight (2.1% vs. 3.7%; p<0.001) and obese (1.6% vs. 3.7%; p<0.001) patients as compared to normal weight.

Conclusions:
CEA can be performed with similar rates of stroke, adverse events and mortality in obese and morbidly obese patients as those observed in normal weight patients.
Abstract WMP48: Prediction of Irregular Plaque Protrusion After Stenting by Magnetic Resonance Imaging Plaque Characterization
Authors: Yamada Kiyofumi , Kawasaki Masanori , Miura Masatomo , Kanamaru Takuya , Shirakawa Manabu , Uchida Kazutaka , Yuan Chun , Hatsukami Thomas , Yoshimura Shinichi
Published: October 2018

Background:
One disadvantage of carotid artery stenting (CAS) is a high incidence of distal embolism (DE) during or after the procedure. Also, irregular plaque protrusion (PP) after stent placement has been suggested as one of the major causes of post procedural ischemic complications. The aim of this study was to evaluate the relationship between unstable plaque identified on black-blood magnetic resonance imaging (BB-MRI) and the occurrence of irregular PP after CAS using optical frequency domain imaging (OFDI).

Materials and Methods:
We enrolled 41 patients who underwent CAS with OFDI image acquisition. We measured signal intensity ratios (SIR) from T1 weighted images of all carotid plaques. The plaque with high SIR is considered as unstable plaque with intraplaque hemorrhage (IPH) according to previously published criteria. Cross-sectional OFDI images were evaluated at every 0.125-mm intervals within the stented segments, and assessed the relationships among the occurrence of irregular PP (I-PP), smooth PP (S-PP) or non-PP, and SIR measured by MRI.

Results:
PP and I-PP were detected in 34 cases (83%) and in 20 cases (49%), respectively. There were two minor strokes in the I-PP group. There was a positive correlation between PP volume and SIR (r=0.47, p<0.01). The SIR was significantly higher in the I-PP group than the S-PP or non-PP groups [I-PP vs. S-PP or non-PP: 1.67 (IQR: 1.39-1.9) vs. 1.36 (IQR: 1.25-1.62), p<0.01]. From analysis of receiver operating characteristic curves, a SIR of 1.57 on BB-MRI was the most reliable cutoff values for predicting I-PP. In multivariate logistic regression analysis, the independent predictor of I-PP was SIR (p=0.012) even after adjusted by plaque volume.

Conclusions:
Quantitative tissue characterization of carotid plaques using BB-MRI was useful to predict I-PP. These data suggest that identification of carotid plaque components such as IPH by BB-MRI before CAS may improve the clinical outcome of this procedure.
Abstract WMP49: Epidemiology of Transient Ischemic Attacks and Risk of Stroke in the Community-The Framingham Study
Authors: Lioutas Vasileios-Arsenios , Ivan Cristina S , Romero Jose Rafael , Aparicio Hugo , Beiser Alexa , Himali Jayandra , Seshadri Sudha
Published: October 2018

Background:
Most prior estimates of transient ischemic attack (TIA) incidence and post-TIA stroke risk are derived from case-based cohorts recruited in hospitals or TIA clinics, but are less well described in population-based cohorts. We report the incidence, clinical features of first-ever TIA, risk and timing for subsequent stroke in the community-based Framingham Study (FHS) cohort.

Methods:
Longitudinal follow-up (1948-2015) of all FHS participants free of stroke or TIA at age 35-94. Medical records, evaluation by a study neurologist and review of brain imaging were used to establish diagnosis of TIA and stroke. We examined the annual age- and sex-specific incidence rates of TIA. Each case was randomly assigned 5 age- and gender- matched controls, stroke- and TIA-free prior to the date of TIA. Cox models were used to examine the risk of subsequent stroke.

Results:
435 participants (229 women, 71.9±11.2 years) suffered a first-ever TIA over 366,209 person-years of follow-up. The overall crude incidence was 1.19/1,000 person-years. Incidence increased with age, peaking in the 85-94 years group (4.88/1,000 person-years). Age-adjusted annual incidence was 1.04/1,000 person-years for women and 1.41 for men. The most common symptom was unilateral weakness (47.4%) followed by sensory (36.5%) disturbances. Most TIAs were referable to the anterior circulation (~69%), 13% to retinal ischemia, 18% to the vertebrobasilar distribution. Symptoms lasted < 1hour in 66% of subjects. Over 4.27±6.18 years of follow-up 149 patients (34.3%) had a stroke, occurring within the first week in 18.8%, 1 week-3 months in 16%, 3-12 months in 10%, and ~50% beyond 12 months. Compared to controls, persons with TIA had a 4-fold higher 5-year risk of stroke, adjusting for age, sex, hypertension, diabetes, atrial fibrillation, coronary artery disease and current smoking (Odds Ratio 4.45, 95% CI 3.28-6.03, p<0.001).

Conclusion:
TIA incidence increases with age, is higher in men, and is a strong independent predictor of subsequent stroke which occurs in >30% of TIA patients. Although the risk is high early on, ~50% of strokes occur beyond 12 months. Our findings highlight the need for both early intervention but also continued surveillance in this high-risk patient population.
Abstract WMP52: Prevalence of Undiagnosed Risk Factors in Patients With First-Ever Ischemic Stroke
Authors: Jasne Adam , Khoury Jane , Madsen Tracy , Alwell Kathleen , Moomaw Charles , Flaherty Matthew , Adeoye Opeolu , Woo Daniel , Mackey Jason , Ferioli Simona , Martini Sharyl , De Los Rios La Rosa Felipe , Kissela Brett , Kleindorfer Dawn
Published: October 2018

Introduction:
Undiagnosed RF (URF) are a missed opportunity for primary stroke prevention. We sought to determine the prevalence of URF (RF newly diagnosed during inpatient evaluation) among first-ever ischemic stroke (IS) cases within a large, bi-racial population.

Methods:
Within the population-based Greater Cincinnati/Northern Kentucky (GCNK) stroke study catchment area of 1.3 million, we ascertained all hospitalized first-ever acute IS in 2010 among individuals ≥20 years old through screening of ICD-9 codes 430-436, with all cases verified by study physicians. We evaluated the prevalence of undiagnosed diabetes mellitus (DM), hypertension (HTN), hyperlipidemia (HLD), and atrial fibrillation (AF) among all IS patients and those with each risk factor. We also evaluated the association between URF and insurance status (private, Medicaid/Medicare, or uninsured) for each RF using chi-square tests.

Results:
There were 1737 first-ever IS cases in the GCNK region in 2010 (55.8% female, 19.5% black, median age 71). Of these, 21% had at least one URF (Table), most commonly HLD (13%) or HTN (6%). Among patients with a given risk factor, 21% of those with HLD, 13% with AF, 9% with DM, and 7% with HTN were undiagnosed prior to inpatient evaluation for first-ever IS. Uninsured individuals (48%) were significantly more likely than those with private (22%) or government (20%) insurance to have at least one URF.

Conclusions:
One in five IS patients had at least one URF upon presentation with their first-ever stroke, and URF were more prevalent among uninsured individuals. Our data reinforce the importance of screening for URF during IS evaluation and highlight the importance of earlier detection of treatable RF.

Future research should evaluate factors that may predict URF, such as insurance status, race, or sex.
Abstract WMP55: Temporal Trends of Sex Differences in Transient Ischemic Attack Incidence Within a Population
Authors: Madsen Tracy E , Khoury Jane C , Munir Armin , Alwell Kathleen , Moomaw Charles J , Flaherty Matthew , Woo Daniel , Mackey Jason , De Los Rios La Rosa Felipe , Martini Sharyl , Ferioli Simona , Adeoye Opeolu , Khatri Pooja , Broderick Joesph P , Kissela Brett M , Kleindorfer Dawn O
Published: October 2018

Introduction:
Previously we reported that ischemic stroke incidence is declining over time for men but not women. We sought to describe temporal trends of sex differences in TIA incidence within a large, biracial population.

Methods:
Among the biracial population of 1.3 million in the Greater Cincinnati Northern Kentucky Stroke Study (GCNKSS) region, all first-ever transient ischemic attacks (TIAs) among area residents (≥20 years old) were identified at all local hospitals. Out of hospital cases were ascertained using a sampling scheme. All cases were reviewed by study physicians. Sex-specific TIA incidence rates over time (during 7/93-6/94 and calendar years 1999, 2005, and 2010) were determined. Incidence rates were calculated using the age-, race-, and sex-specific number of TIAs divided by the population in that group; rates were standardized to the 2010 U.S. population. Statistical testing for differences over time was done using linear regression models adjusted for age and race. The delta method was used to estimate the ratio of female to male TIA incidence and the associated standard error (SE).

Results:
There were a total of 3203 patients with incident TIA; 54% were female, and 12% were black. Overall, mean age for men was 66 (SE 0.36) compared to 71 (SE 0.33) for women, p=0.01. Compared with men, women had lower rates of TIA in all 4 study periods, and TIA incidence rates were stable over time for women (p=0.19) and men (p=0.12). (See table). TIA patients were younger in 2010 than in 1993/4 and 1999 (P<0.05) with means of 68 (SE 0.53), 70 (SE 0.50) and 71 (SE 0.47) respectively.

Conclusions:
Within the GCNKSS population, women had lower TIA incidence rates than men. In contrast to what we have previously described in ischemic stroke incidence, neither the sex difference in incidence nor the sex-specific incidence rates are changing over time. Further research is needed to understand the drivers of higher TIA incidence in men and the lack of change in TIA incidence over time.
Abstract WMP77: Anti-Inflammatory Signaling by Leukemia Inhibitory Factor is Suppressed in Aged Animals After Stroke
Authors: Davis Stephanie M , Collier Lisa A , Martha Sarah R , Powell David K , Pennypacker Keith R
Published: October 2018

Objective:
To determine whether the anti-inflammatory effects of leukemia inhibitory factor (LIF) are altered in aged male and female rats.

Methods:
Focal ischemia was induced in 3 month old male and 18 month old male/female Sprague-Dawley using the middle cerebral artery occlusion (MCAO) procedure. Animals were treated with PBS or LIF at 6, 24, and 48 h after MCAO (125 μg/kg). Infarct volume in aged animals was quantified with T2-weighted MRI. Functional motor skills were assessed immediately prior to euthanization at 72 h post-MCAO. Protein levels of CD11b and IL-12 p40 in brain and spleen tissue were measured using immunoblotting.

Results:
At 72 h, there was a trend towards decreased infarct volume in aged male (189 ± 45OD; n=4) and female LIF-treated rats (104 ± 71 OD; n=4) compared to PBS-treated aged male (188 ± 45; n=4) and female rats (179 ± 72; n=5). LIF-treated aged female rats showed significant decreases in circling (p=0.0209) and body swing bias (p=0.05) compared to the PBS-treated aged females. Normalized CD11b levels were significantly in LIF-treated young males (1.1 ± 0.3 OD; n=5) compared to PBS-treated young males (2.5 ± 0.5 OD; n=6; p<0.05). Although aged male (1.2 ± 0.4 OD) and females (1.2 ± 0.3 OD) had lower levels of CD11b in the brain 72 h post-MCAO compared to young males, LIF had no effect on brain CD11b levels in aged rats. LIF increased spleen size (1.6 ± 0.1 g) and splenic CD11b levels (0.11 ± 0.01 OD) compared to PBS-treated females (0.6 ± 0.1 g; 0.08 ± 0.01 OD; p<0.05), and there was a significant positive correlation between these two factors in the aged female rats (r = 0.6775; p<0.05). Furthermore, IL-12 p40 levels in splenic tissue were significantly higher in young male PBS-treated rats (0.38 ± 0.06 OD) compared to aged male (0.12 ± 0.01 OD; p<0.01) and female rats (0.16 ± 0.04 OD; p<0.01). LIF treatment reduced IL-12 p40 levels in the spleen in young rats (0.24 ± 0.04; p<0.05) but not in either of the aged rat groups.

Conclusions:
LIF is more effective at decreasing splenic IL-12 expression and immune cell infiltration in young rats compared to aged rats. However, LIF counteracts the post-stroke splenic response in aged females but not aged male rats.
Abstract WMP82: The Role of Nicotine in the Development of Intracranial Aneurysmal Rupture
Authors: Kamio Yoshinobu , Miyamoto Takeshi , Kudo Daisuke , Kimura Tetsuro , Hashimoto Tomoki
Published: October 2018

Introduction:
Tobacco smoking is an independent risk factor for intracranial aneurysmal rupture. Nicotine is one of main chemicals of tobacco smoke that promotes atherosclerosis and stroke. Nicotine induces vascular remodeling through activation of α7nicotinic acetylcholine receptor (α7nAChR) that is expressed in the vascular wall. Using a mouse model of intracranial aneurysm, we examined whether the activation of α7nAChR by nicotine promotes intracranial aneurysmal rupture.

Methods and Materials:
To induce aneurysm, we combined induced systemic hypertension (deoxycorticosterone acetate-salt hypertension) and a single injection of elastase (17.5mU) into the cerebrospinal fluid at the right basal cistern. We used α7nAChR knockout (α7KO) mice and the wild-type (WT) mice. Mice were treated with (1) nicotine (5 mg/kg/day); (2) vehicle (saline) subcutaneously from one week before aneurysm induction, and the treatments were continued until 21 days after aneurysm induction.

Results:
Nicotine treatment significantly increased aneurysmal rupture compared to the vehicle treatment in the WT mice (WT + vehicle vs. WT + nicotine: 46% vs. 84%,
P
< 0.01). Furthermore, the harmful effect of nicotine was abolished in the α7KO mice compared (WT + nicotine vs. α7KO + nicotine: 84% vs. 27%;
P
< 0.05). There was no difference in the incidence aneurysmal rupture between the α7KO mice treated with nicotine and the α7KO mice treated with the vehicle (α7KO + nicotine vs. α7KO + vehicle: 27% vs. 44%; P = 1.00).

Conclusion:
Our data indicate that α7nAChR mediates nicotine’s promotion of intracranial aneurysmal rupture.
Abstract WMP83: Bidirectional Brain-Microbiome Interaction in a Murine Thrombotic Stroke Model
Authors: Ramadan Ahmad Riad , Lin Yun , Wu Xinqun , White James R , Sears Cynthia L , Koehler Raymond C , Stevens Robert D
Published: October 2018

Introduction:
Recent evidence suggests a role of the gut microbiome in modulating the secondary injury seen after an ischemic stroke. In a novel model of thrombotic stroke in mice, the collagen model, we hypothesized that (a) stroke induces changes in the composition of the microbiome, and (b) depletion of the gut flora with cefoxitin is associated with a reduced infarct size.

Methods:
C57BL/6 male mice were assigned to one of 4 groups (n=8/group): Control, Stroke (anesthesia, ICA cannulation, collagen injection into the MCA), Sham (same as Stroke without collagen injection), and Stroke+Antibiotic. Cefoxitin was administered in drinking water for 7 days, before stroke induction. Stool pellets were collected before surgery and on the day of euthanasia for taxonomic analysis via 16S rRNA sequencing. Brains were retrieved for infarct volume measurement 2 days after surgery.

Results:
We observed a significant decrease in Lactobacillus and relative increases in Bacteroides, Streptococcus and Clostridium taxa after surgery in both Sham and Stroke groups (Fig 1). Antibiotic treatment was associated with a significant reduction in infarct volume in cortex and striatum (respectively 36.9% and 17.8% reductions, p<0.05) (Fig 2).

Conclusions:
Thrombotic stroke in mice is associated with significant changes in the relative preponderance of several bacterial taxa in the gut. Intriguingly, a similar pattern was observed in sham animals, indicating effects on the microbiome not mediated by stroke, possibly by exposure to anesthetic drugs or surgery itself. Cefoxitin administered prior to stroke dramatically altered the gut microbiome and led to a significant reduction in infarct size.
Abstract WMP85: Frequency of Neurological Consultation in Medicare Patients With Ischemic Stroke
Authors: Sacchetti Daniel C , Chung Caroline D , Navi Babak B , Segal Alan Z , Kamel Hooman
Published: October 2018

Introduction:
Given recent advances in diagnostic and therapeutic tools, delivery of stroke care has become more complex. We sought to investigate what proportion of patients with stroke are evaluated by neurologists, and specifically by vascular neurologists.

Methods:
Using 2008-2015 claims data from a 5% nationally representative sample of Medicare beneficiaries, we identified all patients >65 years of age who were hospitalized for ischemic stroke, as defined by previously validated
ICD-9-CM
codes. Our primary outcome was the proportion of patients evaluated during the stroke hospitalization or within 90 days of discharge by a neurologist, as determined from evaluation and management
CPT
codes and Medicare provider specialty codes. To ascertain which of these neurologists were vascular neurologists, we used a Python script and National Provider Identifier numbers to merge in publicly available data from the American Board of Psychiatry and Neurology on all board-certified vascular neurologists in the U.S. As a comparison, we used previously validated diagnosis codes to identify patients hospitalized with acute myocardial infarction (MI) and determined the proportion seen by a cardiologist during the hospitalization or within 90 days of discharge. Statistical analysis involved descriptive statistics with exact confidence intervals (CI)s and the chi-square test.

Results:
Among 66,989 patients with ischemic stroke, 49,335 (73.7%; 95% CI, 73.1-74.0%) were evaluated by a neurologist. A board-certified vascular neurologist evaluated 11,001 patients, equating to 16.4% (95% CI, 16.1-16.7%) of all stroke patients and 22.3% (95% CI, 21.9-22.7%) of stroke patients seen by a neurologist. In comparison, a cardiologist evaluated 53,481 of 61,232 patients with acute MI (87.3%; 95% CI, 87.1-87.6%), a proportion significantly higher than the proportion of stroke patients seen by a neurologist (
P
<0.001).

Conclusions:
In a nationally representative cohort of Medicare beneficiaries, we found that approximately 75% of patients with ischemic stroke were evaluated by a neurologist, a proportion significantly lower than the comparable metric for acute MI. Furthermore, about one of every six stroke patients was evaluated by a vascular neurologist.
Abstract WMP90: Comparison of Acute Ischemic Stroke Care Between Comprehensive Stroke Centers and Primary Stroke Centers Participating in Get With the Guidelines-Stroke
Authors: Man Shumei , Zhao Xin , Uchino Ken , Smith Eric E , Bhatt Deepak L , Xian Ying , Schwamm Lee H , Shah Shreyansh , Khan Yosef , Fonarow Gregg C
Published: October 2018

Background:
To improve stroke care, the Brain Attack Coalition recommended establishing primary stroke center (PSC) and comprehensive stroke center (CSC) certification. Achieving CSC designation requires the ability to provide more complex services. However, it remains unknown whether CSCs have better performance than PSCs for ischemic stroke care. This study compared ischemic stroke care between CSCs and PSCs.

Methods:
The study included consecutive patients who were admitted to the 134 CSCs and 1047 PSCs participating in Get With The Guidelines (GWTG)-Stroke between January 1, 2013 and December 31, 2015 with a final diagnosis of acute ischemic stroke. Multivariable logistic regression models were generated to examine the association between stroke center certification (CSC vs PSC) and performance measures and outcomes, after adjusting for potential confounders including patient and hospital characteristics.

Results:
Of the 605,136 patients who were admitted directly from the emergency department, 110,624 were admitted to CSCs and 494,512 to PSCs. CSCs were larger than PSCs (median number of beds 481 vs 263). Performance differences between CSCs vs. PSCs are shown in the table. CSCs and PSCs had comparable overall conformity to the seven performance measures represented by the summary defect-free care measure. CSCs outperformed PSCs in several key measures, especially the use of intravenous tissue plasminogen activator (IV tPA) and intra-arterial thrombectomy (IA-therapy). Compared with patients at PSCs, patients at CSCs were more likely to receive IV tPA in both unadjusted and adjusted models. The door to IV tPA time was shorter at CSCs. Patients at CSCs were more likely to receive IA therapy, with shorter door to IA therapy times. Mortality was higher at CSCs.

Conclusions:
Stroke care at CSCs exceeded PSCs for many but not all quality measures, particularly timely acute reperfusion therapy. Risk adjusted in-hospital mortality was modestly higher at CSCs.
Abstract WP10: Risk of Hemorrhagic Transformation in Large Vessel Anterior Circulation Stroke Patients Receiving Emergent Carotid Stenting With Mechanical Thrombectomy
Authors: Mehta Tapan , Rath Subhendu , Mirtchev Dimitre , Hussain Mohammed , Spiegel Gary , McCullough Louise , Ollenschleger Martin
Published: October 2018

Introduction:
Mechanical thrombectomy (MT) for the treatment of acute ischemic stroke (AIS) in patients with large vessel anterior circulation occlusion has become a standard of care. Our study examines the risk of hemorrhagic transformation (HT) in patients that also underwent emergent carotid stenting (approximately 10%) during MT which potentially requires immediate antiplatelet use to prevent stent thrombosis.

Methods:
A hospital based stroke registry was used for retrospective analysis of 225 consecutive cases of large vessel anterior circulation strokes. Parenchymal hematoma (PH - PH1 and PH2) type of HT on 24 hour CT or MRI was defined as primary outcome. The study cohort was divided into carotid stenting and non stenting group. Baseline clinical and demographic characteristics were compared with uni-variate analysis. Multivariate logistic regression model was used to identify demographic and clinical predictors of PH.

Results:
Seventeen patients (7.55%) required immediate carotid stenting. 2 patients (11.8%) in the stenting group had PH compared to 24 (11.9%) in the non-stenting group (p=0.98). Intravenous thrombolytic was given to 59.2% patients in non-stenting group compared to 64.7% in stenting group (p=0.82). 52.9% were immediately started on antiplatelet or anticoagulation (29.4% - eptifibatide, 5.9% aspirin + clopidogrel, 17.6% heparin) in stenting group. In non stenting group 5% patient were immediately started on antiplatelet or anticoagulation (1.5% - eptifibatide, 1% aspirin + clopidogrel, 2% heparin, 0.5% aspirin alone). None of the patients in either group who had been started on antiplatelet or anticoagulation had PH. Multivariate analysis remained insignificant with small sample size.

Conclusion:
In this small, single center study, emergent carotid stenting during mechanical thrombectomy for large vessel anterior circulation stroke did not increase the risk of hemorrhagic transformation despite the early use of antiplatelet or anticoagulant medication or prior administration of intravenous thrombolytics.
Abstract WP104: Dicer, a miRNA Biogenesis Protein, in Adult Neural Stem Cells Regulates Hypothalamic Neurogenesis After Stroke
Authors: Zhang Ruilan , Liu Xianshuang , Landschoot-Ward Julie , Teng Hua , Wang Xinli , Wei Min , Chopp Michael , Zhang ZhengGang
Published: October 2018

Introduction:
The hypothalamus regulates the neuroendocrine system. Hypothalamic neurogenesis is localized to the arcuate nucleus (AR) close to the third ventricle (3V) and to the bottom of the 3V in the median eminence (ME). Molecular mechanisms, in particular miRNAs, in regulating hypothalamic neurogenesis remain unknown. Dicer processes precursor miRNAs into mature miRNAs. Using a transgenic mouse line with an inducible and conditional ablation of Dicer in adult neural stem cells (NST), we tested the hypothesis that Dicer regulates stroke-increased hypothalamic neurogenesis.

Methods and Results:
Using a NST reporter mouse line (Ascl1-CreERT2:Tomatoflox/flox ), we found that NST were present in the AR and the ME. Tamoxifen was administered to mice (n=32) with conditional ablation of Dicer (Dicer/Cko) in NTSs (Ascl1-CreERT2:Dicerflox/flox) to knockout Dicer. Mice were then subjected to focal cerebral ischemia and wild-type mice (n=26) were used as control. Double and triple immunofluorescent staining with 3D confocal microscopic analysis was performed to quantify proliferation and phenotypes of NST. In wild-type mice, stroke significantly (P<0.05) increased BrdU+ NST in the AR (52 ± 3 cells/mm2 vs 40 ± 4 no-stroke) and the ME (45 cells/mm2 ± 4 vs 29 ± 4 no-stroke) 14 days after stroke. The increased proliferating NST were associated with substantial augmentation of newly generated neurons (BrdU+/NeuN+ cells) in the AR (6 ± 1% vs 3 ± 0.4%, no-stroke) and in the ME (5 ± 1% vs 2 ± 0.3%, no-stroke) 30 days after stroke. These data indicate that stroke increases hypothalamic neurogenesis. However, compared to wild-type ischemic mice, ischemic Dicer/Cko mice exhibited significant (p<0.01) reduction of BrdU+ NTS in the AR (41 ± 4) and in the ME (33 ± 4) 14 days after stroke, and significant (p<0.01) decreases of newly generated neurons in the AR (4 ± 0.6%) and in the ME (3 ± 0.5%) 30 days after stroke. Ablation of Dicer in NTS of mice without stroke also resulted in significant reduction of proliferating NST (23 ± 2 cells/mm2 AR, 17 ± 3 ME) and newly generated neurons (2 ± 0.4% AR, 1 ± 0.2 ME) compared to non-ischemic wild-type mice.

Conclusion:
Our data provide first evidence that Dicer regulates adult hypothalamic neurogenesis under physiological and ischemic conditions.