bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 2893: Robot-based Assessments Of Upper Extremity Function Are Valid And May Be Useful For Tele-outcomes After Stroke
Authors: McKenzie Alison , Der-Yeghiaian Lucy , See Jill , Le Vu , Cramer Steven C
Published: July 2021

INTRODUCTION:
The increasing number of restorative stroke trials has generated increased discussion about optimal endpoints to detect changes in behavior over time. Robotic devices are under study as a therapeutic intervention, and in some cases the design of these devices might also make them useful for assessing behavioral status. If true, similar devices might be useful for remote assessment of behavioral status after stroke, i.e., tele-outcome. As an initial step, the current study examined the validity of 3 robot-based behavioral assessments.

METHODS:
Data were collected at baseline for patients enrolled in a study of robotic therapy for arm weakness after stroke (clinicaltrials.gov #
NCT01244243
). Entry criteria include age >18 yr, arm motor deficits, and stroke 3-6 months prior. Pre-treatment assessments included the Fugl-Meyer Arm Motor Scale (FM-total), which has often been used as a behavioral endpoint in clinical trials, as well as 6 secondary, related tests: the Box/Blocks (B/B) Test, Action Research Arm Test, the hand/wrist subsection of the FM-total, hand motor subscale of Stroke Impact Scale-2, affected hand grasping force, and affected hand pinching force. These 7 tests were compared with score on robotic games that require targeting movements by wrist or by finger and that therefore emphasize movement speed and accuracy (using Bonferroni-adjusted p<0.007). In addition, score from the live version of the B/B test was compared with score from a robot-based version of the B/B test.

RESULTS:
The 28 subjects were age 59 +/- 14 yr (mean +/- SD), stroke affecting R side in 14 and L in 14, and had moderate-severe impairment (FM-total scores = 34 +/- 15, range 14-60). Robot-based assessments were rapidly and successfully obtained in all subjects. Performance on the robot-based test of wrist targeting correlated significantly with baseline FM-total score (r = 0.73, p<0.0001) as well as all 6 secondary tests (r = 0.54 - 0.83, B/B score being highest). Performance on the robot-based test of finger targeting also correlated significantly with baseline FM-total score (r = 0.69, p<0.0001) as well as all 6 secondary tests (r = 0.52 - 0.70). Values of the live version (real blocks) and the robot-based version (virtual blocks) of the B/B test were correlated (r=0.48, p<.02). While 10 subjects demonstrated a floor effect on the live B/B test, only 2 subjects had a floor effect with the robot-based B/B test.

CONCLUSION:
The current findings support the validity of robot-based methods for assessing upper extremity motor function in subjects with chronic stroke. Potential advantages of this approach as compared to traditional scales include simplicity, speed, and fewer subjects with a floor effect. In addition, the overall approach described here suggests the utility of tele-outcome assessments after stroke.
Abstract 29: Initial NIHSS Predicts Poor Short-term Outcome After Minor Stroke Even at Very Low Scores
Authors: Raser Jonathan M , Washington Arthur Z , Ishida Koto , Wilson Christina A , Pawar Swaroop A , Mullen Michael T , Cucchiara Brett L , Messe Steven R , Kasner Scott E
Published: July 2021

Background:
Minor ischemic stroke patients often do not receive IV tPA due to mild or rapidly resolving symptoms as it is assumed that they will have excellent outcomes without treatment. Nevertheless, a substantial proportion of these patients have a poor outcome. It is unclear if this is due to factors such as preexisting disability, medical comorbidities, or recurrent stroke, or due to the deficits associated with the minor stroke, We hypothesized that initial stroke severity would predict poor short-term outcome even when the deficits are mild.

Methods:
We conducted a retrospective cohort study based on chart review of all patients with minor ischemic stroke, as defined by NIHSS≤6 at presentation, who were admitted to our hospital over a 30-month time period. Poor short-term outcome was defined by in-hospital death or discharge to any destination other than home.

Results:
Data were complete for 461 of 471 patients with minor stroke. A substantial proportion, 38% (95%CI 34-43%), had a poor short-term outcome, including 31% discharged to rehabilitation, 5% discharged to a nursing facility, and 2% dead or discharged to hospice. Impaired ambulation prior to admission was associated with a poor outcome (OR 3.4; 95%CI 1.1-10, p<0.03), but only present in 3% of patients. In multivariable analysis, poor outcome was strongly associated with initial NIHSS (
figure
; OR 1.5; 95%CI 1.3-1.7, p<0.001) and age (OR 1.04; 95%CI 1.03-1.06, p<0.001). Similarly, NIHSS predicted poor outcome when analysis was limited to initial NIHSS≤3 (OR 1.8; 95%CI 1.3-2.4, p<0.001). Of the 112 patients presenting within 4.5 hours of time last seen well, 15% received IV tPA and 45% were excluded solely due to mild or rapidly improving symptoms. NIHSS was lower in those patients excluded than in those who received tPA (median 2 vs. 5, p<0.001). After adjustment for age, NIHSS, and prior ambulatory status, there was no significant difference in poor outcome, which occurred in 42% of patients treated with tPA and 24% of those excluded due to mild or rapidly improving symptoms (OR 1.9 for poor outcome after tPA; 95%CI 0.4-9.5, p=0.43).

Conclusions:
More than one-third of patients with minor stroke had a poor short-term outcome, including nearly one-fourth of those who were excluded from IV tPA due to mild or rapidly improving symptoms. NIHSS was predictive of poor outcome at very low scores, consistent with the hypothesis that the deficits due to the initial stroke were responsible for poor outcome. However, the impact of tPA treatment in this population is uncertain.
Abstract 2919: Do Premature Ventricular Contractions Play a Role in the Etiologic Subtypes of Ischemic Stroke?
Authors: LEE JUN , Kim Na-Young
Published: July 2021

Background
The relationship between stroke and non-atrial fibrillation cardiac arrhythmias remains unclear. Frequent premature ventricular contractions (PVCs) are associated with impaired ventricular relaxation and may increase the risk of clot formation and subsequent embolization. This study investigated the relationship between frequency of PVCs and etiologic subtypes of ischemic stroke.

Methods
Consecutive ischemic stroke patients admitted within 7 days of onset who underwent 24-hour Holter monitoring were enrolled (n=451). Subtypes of ischemic stroke were defined according to the SSS-TOAST classification as Large artery atherosclerosis (LAD), cardioembolic stroke (CE), small vessel occlusion (SVO), other causes (OC), and cryptogenic stroke (CS). Risk factors, demographic information, and 24-hour Holter recordings were compared between the subtypes of ischemic stroke.

Results
There were 182 women and 269 men (191 LAD, 90 CE, 93 SVO, 13 OC, 64 CS), with a mean age of 66 years (median 68). PVCs were seen in 305 patients (67.5%) on 24-hour Holter monitoring (median 3, IQR 0-48). CE had a higher median number of PVCs (median 24, IQR 0-258) than LAD (median 2, p=0.01), SVO (median 1, p<0.001), OC (median 0, p=0.013), and CS (median 4, p=0.2). The proportions of frequent PVCs (>50 in a 24-hour Holter monitoring) were higher in CE (43.3%) compared with the other groups (20.9% in LAD, 15.1% in SVO, 15.4% in OC, and 23.4% in CS; p<0.001). Compared with the SVO, the upper 3 quartiles of PVCs were associated with CE (OR 2.93; 95% CI, 1.69 to 5.06) and CS (OR 1.86; 95% CI, 1.07 to 3.2) in ordinal logistic regression analysis after adjustment for traditional risk factors.

Conclusions
The number of PVCs detected by 24-hour Holter monitoring is associated with CE and CS. The presence of high frequency of PVC may help in stratifying patients with different stroke subtypes, particularly embolic stroke. The role of these arrhythmias as a risk marker for ischemic stroke deserves further investigation.
Abstract 2922: Patent Foramen Ovale Is A Cause Of Ischemic Stroke In Patients With Antiphospholipid Syndrome
Authors: Shimada Yoshiaki
Published: July 2021

Background:
The antiphospholipid syndrome (APS) is a systemic autoimmune disorder characterized by a combination of arterial and/or venous thrombosis and recurrent fetal loss, and can be an independent risk factor for a first-ever ischemic stroke especially in young female patients. Patent foramen ovale (PFO) has been established as a cause of cryptogenic stroke. Atrial septal aneurysm (ASA) is associated with PFO. Until recently, the precise pathophysiology of APS as causing ischemic stroke has been essentially unknown. In the present study, we investigated the relationship between APS and potential embolic sources including PFO and ASA using transesophageal echocardiography (TEE).

Methods:
This study was a retrospective case series design. From July 2006 to June 2008, 120 patients with ischemic stroke who admitted to Juntendo University Hospital underwent TEE. In this study period, consecutive ischemic stoke patients diagnosed as APS based on the modified Sapporo criteria were enrolled and classified into APS group. Controls were selected among age- and gender-matched stroke patients without APS who also underwent TEE. We assessed clinical characteristics and presence of embolic sources including PFO and atrial septal aneurysm (ASA) between APS and Control groups.

Results:
Nine of ischemic stroke patients with APS and 41 controls were included. Primary APS was present in one patient (11.1%) of the APS group, and APS with SLE were found in eight patients (88.9%). There is no significant difference in age, risk factors for ischemic stroke, and MRI findings between two groups. The prevalence of PFO and ASA were significantly higher in APS group compared to Control group (89% vs 41%, P=0.027; 67% vs 20%, P=0.015, respectively). C reactive protein was relatively higher in APS group. Multiple logistic regression analysis showed that PFO (OR: 13.71; 95% CI: 1.01 to 185.62; P=0.049) and ASA (OR: 8.06; 95% CI: 1.17 to 55.59; P=0.034) were independently associated with the APS group.

Conclusion:
Atrial septal abnormalities including PFO and ASA are strongly associated with APS group, and could be potential embolic sources in ischemic stroke patients with APS.
Abstract 2925: DWI-ASPECTS As A Predictor Of Neurological Recovery In Acute Stroke Patients With The Middle Cerebral Artery Occlusion Treated With IV t-PA.
Authors: Aoki Junya , Kimura Kazumi , Iguchi Yasuyuki , Shibazaki Kensaku , Matsumoto Noriko , Inoue Takeshi , Watanabe Masao
Published: July 2021

Background and Purpose:
Diffusion-weighted imaging-Alberta Stroke Programme Early CT Score (DWI-ASPECTS) has been associated with short-term and long-term neurological recovery and outcome in acute stroke patients treated with intravenous tissue plasminogen activator (IV-tPA). However, previous reports did not analyze the DW-ASPECTS based on the presence of major arterial occlusion. We investigated whether initial DWI-ASPECTS can predict the short-term neurological recovery in acute stroke patients with the middle cerebral artery occlusion (MCAO) treated with IV t-PA.

Methods:
Consecutive acute stroke patients with MCAO treated with IV t-PA within 3 hours of onset were enrolled from 2005 October to 2011 May. All patients were examined using DWI and magnetic resonance angiography on admission. Only patients with horizontal MCAO were included. Neurological deficits were assessed using National Institutes of Health Stroke Scale (NIHSS) score on admission and day 7. On day 7, dramatic recovery (DR) was defined as a ≥10 point reduction or a total NIHSS score of 0 or 1. Good recovery (GR) was a ≥4 point reduction, excluding DR. Worsening was a ≥4 point increase.

Results:
Seventy-one patients (median age [quartiles]; 77 [70-83], male; 44 [62%]) were enrolled into the study. The median NIHSS score was 18 (12-22). The median DWI-ASPECTS was 4 (6-9). Median DWI-ASPECTS was 7 (6-9) in 27 patients with DR group, 5 (4-9) in 13 with GR group, and 3 (2-6) in 17 with worsening (p<0.001). Median DWI-ASPECTS was 4 (3-6) in 4 (6%) patients with type2-parencymal hematoma within 7 days. Using ROC curve, the optimal cut-off DWI-ASPECTS to differentiate DR group from others was >5 (sensitivity of 85% and specificity of 57%, area under curve [AUC] 0.692, p=0.007), and that for worsening group was <4 (sensitivity of 96% and specificity of 59%, AUC 0.785, p<0.001). Multivariate regression analysis demonstrated that initial DWI-ASPECTS of >5 was significantly associated with DR (OR 9.75, 95%CI 1.41-67.67, p=0.021), and <4 with worsening (OR 15.94, 95%CI 4.01-63.25, p<0.001).

Conclusion:
DWI-ASPECTS can predict the short-term outcome in acute stroke patients with MCAO treated with IV-tPA.
Abstract 2991: Utilization Of A Statewide Telestroke Network And Sustainability Over Time - The Michigan Stroke Network Experience
Authors: Narayanan Sandra , Madhavan Ramesh , Parliament Connie F , Bhattacharya Pratik D , Xavier Andrew R , Chaturvedi Seemant
Published: July 2021

Introduction:
Telemedicine for patients with acute stroke represents a method to extend neurologic expertise to hospitals without established Stroke Teams. The Michigan Stroke Network (MSN) is a comprehensive telestroke service providing emergency stroke consultations at 34 spoke hospitals throughout Michigan since 2007. Several non-member health systems also contribute patients to the hub, St. Joseph Mercy Oakland Hospital (SJMO) in Pontiac, MI. Maintaining a large telestroke network is a demanding practice due to the geographic coverage, multidisciplinary communication, need for precision in remote neurological examination and PACS viewing, and rapid and complex decision making.

Objective:
To evaluate the sustainability of a statewide telemedicine stroke network.

Results:
Telestroke utilization data from 2008-2011 were prospectively collected from MSN member hospitals and are provided in the attached table. Patients were more likely to be transferred if endovascular intervention was planned. Although the percentage of transferred patients for intervention decreased somewhat over time, this likely reflects improved efficiency of triaging appropriate revascularization candidates.

Conclusions:
Our results demonstrate the feasibility of maintaining a large statewide telemedicine network. The steady call volumes demonstrate the value of facilitated acute stroke decision making at hospitals without established Acute Stroke Teams. The turnaround time for the consultant and time for robot activation remained stable. Consult duration was slightly increased in 2011 as compared to prior years. A substantial number of patients were candidates for acute stroke intervention each year. On average, patients receiving IV-tPA through MSN experienced a >7-point reduction in NIHSS by the end of their hospital stay. 30-day follow-up NIHSS/mRS were not available at the time of this analysis.
Abstract 2993: Effects of Education and Immediate Feedback on Improved rt-PA Door-to-Needle Time
Authors: Taulli-Lasseigne Janice , Ryno Kellen , Mathisen Kimberly , Subervielle Mary
Published: July 2021

Background & Issues:
The American Stroke Association reports earlier administration of intravenous rt-PA following symptom onset is associated with greater functional recovery. The Target: Stroke Campaign has identified a door-to-needle goal of 60 minutes or less. Our adoption of the Target: Stroke guidelines led to the improvement of emergency staff awareness and interventions for immediate feedback and correction of misperceptions of goal time for rt-PA administration and improved results.

Purpose:
To improve door-to-needle time to 60 minutes or less.

Methods:
In April 2010, we initiated a process to improve door-to-needle time for rt-PA administration within 60 minutes of arrival to Emergency Department (ED) for anyone presenting with indication of stroke. Target: Stroke guidelines are implemented for initial patient evaluation within 10 minutes of arrival to ED, stroke team activation within 15 minutes of arrival, CT scan within 25 minutes of arrival, and interpretation of CT scan within 45 minutes. First responders notify the Emergency Department of a possible stroke patient enroute. The triage nurse activates the Stroke Team through mass paging the team members. The Stroke Team Nurse assesses the patient, determines the onset of symptom time and possible rt-PA exclusions, follows the patient to CT Scan notifying the neurologist of CT scan results, and initiates the immediate discussion between the Emergency Physician and neurologist to determine if rt-PA is appropriate. If rt-PA is administered, immediate feedback is given to all stroke team members using a door-to-needle tracking form. All time delays are reviewed by the Stroke Team Medical Director to determine causes for delay. The Stroke Team meets to determine where improvements can be made.

Results:
From April 2010 through June 2011, door-to-needle time was decreased from 107.75 minutes to 52 minutes per quarter average.

Conclusions:
Improvements were realized following the extensive education of the Emergency Department with clarification of door-to-needle goal. This resulted in the ED staff’s design and implementation of a standardized process for following each stroke emergency, including early stroke team activation for patients presenting with any sign of acute stroke and the early initiation of a second intravenous line.
Abstract 3005: Stroke Support: Survivors Become Givers of Support
Authors: Morrison Kathy , Watson Gayle , Dillon Judith
Published: July 2021

Background:
Stroke recovery is a different experience for every survivor. The recovery process can continue for many years after the initial event. Reintegration into the community can be difficult, as stroke patients have both short and long-term needs. A stroke support group must be flexible enough to assist patients over the time spectrum of their recovery. Our stroke support group was established 21 years ago and has many of its original members still active as leaders. Because younger people are having strokes and have different recovery demands, we were concerned that our program had not evolved to meet the full spectrum of our patients’ needs.

Purpose:
To evaluate our current program with the goal to update and expand its programming.

Methods:
Stroke group members were asked for their suggestions to improve the program. A multidisciplinary team then met to review ideas and design action plans.

Results:
As a result of the suggestions, the following program changes have been made: 1) a new program brochure was created with snapshots of members to reinforce that strokes do not always make people invalids; 2) support group meetings are now scheduled at two times on the same day of the month: during the afternoon for members who want to be home before dark, and in the evening for members (younger stroke survivors/caregivers) who want to attend after work; 3) the older group has changed their name to “Stroke Survivors & Thrivers”, and its members have volunteered to visit patients in the hospital and to make phone calls to stroke patients and their caregivers; 4) creation of a steering committee to facilitate meeting organization; 5) meeting content selection is done by group members; 6) quarterly sessions devoted to open discussions for idea sharing and questions; 7) information is provided via social media sites, email, and the stroke center web site in addition to traditional mailings; and 8) both groups join together to participate in the annual American Heart Association Heart & Stroke Walk.

Conclusions:
Involving members of the Stroke Support Group to participate in the structure and function of the program has increased member satisfaction, improved attendance at meetings, and allowed the program to reach a broader range of survivors. As a result, the Support Group has become empowered to meet the needs of more stroke survivors and their caregivers in our community - helping them to become Thrivers as well.
Abstract 3023: The Association of Insurance Status, Quality of Care, and In-Hospital Outcomes among Patients Hospitalized with Intracerebral Hemorrhage: Findings from GWTG-Stroke
Authors: James Michael L , Yand Julian P , Grau-Sepulveda Maria , Olson DaiWai M , Bhatt Deepak L , Peterson Eric D , Hernandez Adrian F , Schwamm Lee H , Smith Eric E , Fonarow Greg C
Published: July 2021

Introduction
Intracerebral hemorrhage (ICH) can be a devastating condition, requiring intensive intervention. Yet, few studies have examined whether patient insurance status is associated with ICH care or acute outcomes.

Methods
Using data from 1,711 sites participating in GWTG-Stroke database from April 2003 to April 2011, we identified 156,848 non-transferred subjects with ICH who had known discharge status. Insurance status was categorized as private, Medicaid, Medicare or none. We explored associations between lack of insurance (using private insurance status as the reference group) and in-hospital outcomes (mortality, ambulatory status, & length of stay) and quality of care measures (DVT prophylaxis, smoking cessation, dysphagia screening, stroke education, imaging times, & rehabilitation). We utilized multiple individual (including demographics and medical history) and hospital (including size, geographic region and academic teaching status)lcharacteristics as covariates.

Results
Subjects without insurance (n=10647) were younger (54.4 v. 71 years), more likely men (60.6 v. 50.8%), more likely black (33.2 v. 17.4%) or Hispanic (15.8 v. 7.9%), from the South (50.6 v. 38.9%), and had fewer vascular risk factors with the exception of smoking when compared with the overall subject population. Further, subjects without insurance were more likely to experience in-hospital mortality (25.9 v. 23.9%; adjusted OR 1.29) and longer length of stay (11.4 v. 7.8 days), but were more likely to receive all quality measures of care, be discharged home (52.1 v. 36.1%), and ambulate independently (47.5 v. 38.5%) at discharge compared with subjects with private insurance (n=40033).

Conclusions
Among GWTG-Stroke participating hospitals, ICH patients without insurance were more likely to die while in the hospital but experienced higher quality measures of care and were more likely to ambulate independently at discharge should they survive.
Abstract 3028: Muscle Microdialysis to Confirm Subischemic Injury in a Clinical Trial of Remote Ischemic Preconditioning
Authors: Bilgin-Freiert Arzu , Dusick Joshua R , Etchepare Maria , Stein Nathan , Vespa Paul , Gonzalez Nestor
Published: July 2021

Introduction:
Transient exposure to sublethal ischemia-reperfusion injury of one tissue confers a protective effect to remote organs, referred to as remote ischemic preconditioning (RIPC). Confirmation that the desired effect of sublethal ischemia is occurring in the tissues used to induce RIPC requires an objective measure before this technique can be used consistently in the clinical practice.

Methods:
Three to four RIPC sessions were conducted during non-consecutive days in patients with aneurysmal SAH aged 18-80, within days 4-12 of aneurysm rupture. Sessions consisted of 4 cycles of 5-minutes of lower extremity blood pressure cuff inflation to 30 mmHg above the systolic blood pressure, followed by 5 minutes of reperfusion. The absence of dorsalis pedis pulse was confirmed by Doppler evaluation and, if pulse signals were detected, the cuff was inflated until they disappeared. During periods of reperfusion, distal pulse recovery was confirmed. To evaluate limb sublethal ischemic injury, patients were monitored with a microdialysis probe inserted into the mass of the gastrocnemius muscle on the preconditioning limb. Glucose, lactate, pyruvate, lactate/pyruvate ratio, and glycerol levels were compared before and immediately after the RIPC sessions.

Results:
Twenty-one RIPC sessions were performed in 6 patients (50% male, mean age 48.5, Fisher 4, H&H 2-4). The procedure was well tolerated and there were no systemic changes in HR, BP or CVP. An average follow up of 25 days of daily examination after the last RIPC session demonstrated no complications associated with the RIPC procedure or the microdialysis probe implantation. Muscle microdialysis during the RIPC sessions showed a significant increase in L/P ratio (21.2 to 26.8, p=0.001) and lactate (3.0 to 3.9mmol/L, p=0.002), indicating muscle ischemia. There was no significant variation in glycerol (234 to 204μ g/L, p=0.43), indicating no permanent cell damage.

Conclusion:
The RIPC protocol used in this study is safe, well tolerated, and induces transient metabolic changes in skeletal muscles comparable with sublethal ischemia. Muscle microdialysis can be used safely as a confirmatory tool in the induction of RIPC.
Abstract 3030: Meta-analysis of Cost Effectiveness of Different Stroke Unit Subtypes
Authors: Jain Minal , Jain Anunaya , Kanthala Abhijit R , Jahromi Babak S
Published: July 2021

Aim:
To perform a systematic review and metanalysis, comparing outcome and cost of stroke care in a stroke unit (SU) versus conventional care (CC). Secondary aim was to compare cost effectiveness of different SU subtypes. Methods: Pubmed search was performed for “Stroke Unit” among all English language articles from 01/01/1996 to 01/01/2011. Only articles from developed countries, reporting the length of stay (LOS) and/or cost and outcomes for ischemic stroke were included. Studies wherein data was collected before 01/01/1996, articles only on rehabilitation units, and all systematic reviews were excluded. LOS was taken as a surrogate marker of stroke care cost in studies wherein direct care costs were not reported. Non-QALY outcomes were converted to QALYs using reported logistic regressions. Ratios less than $50,000/QALY were considered cost effective while greater than $100,000 /QALY were considered non-cost effective. All cost were reported in 2010 US$.

Result:
A total of 5,537 articles in Pubmed were studied, of which 19 studies met the inclusion criteria. LOS for patients managed at SU ranged from 9.2-32.3 days versus 8-35.3 days for CC units and average incremental QALYs between them were 0.09. The average incremental cost/QALY was $41,204.37. The average cost/QALY for different types of SU were $19,428.64 for Acute only SU (A SU), $44,228.81 for Acute+Rehabilitation SU (A+R SU), $29,145.93 for Acute+Rehabilitation+Early Supported Discharge (A+R+ESD) SU and $20,460.56 for SU with Continuous monitoring (SU CM). In comparison to an A SU, SU CM and A+R+ESD SU were cost effective alternatives (ICER SU CM estimated at $25,120.89, ICER A+R+ESD SU estimated at $24,574.59).

Conclusion:
Stroke Units are cost effective when compared to the conventional systems of care. Acute + rehab SU with early supported discharge appears to be the most cost effective model amongst different subtypes of SU.
Abstract 3072: Prolonged Cardiac Monitoring for Detecting Paroxysmal AF or Flutter after Acute Ischemic Stroke: A Meta-Analysis
Authors: Bhatt Archit , Hammoud Ramadan , Majid Arshad
Published: July 2021

Background and Purpose-
Detecting AF/flutter is a critical aspect of workup of ischemic stroke patients. Recent studies have shown variable detection rates of AF with variable duration of monitoring. We performed a systematic review to determine the frequency of AF or flutter on prolonged cardiac monitoring (> or =3 days), in ischemic stroke patients.

Methods-
Studies published in English language were identified from standard databases which included Medline, EMBASE, Science Citation Index and bibliographies of pertinent manuscripts. All studies who enrolled ischemic stroke patients to cardiac monitoring>3 days were eligible.

Results-
Five studies met eligibility criteria. There were total 399 participants in the study which were included in the analysis. All studies evaluated cardiac monitors > or = 3 days. Duration of monitoring ranged from 3 days to more than 30 days. New AF was detected in 16% (95% CI: 8% to 28%) of patients with ischemic stroke. In a subgroup analysis of 3 studies which monitored patients for more than 20 days, AF detection rate was even higher 27% (95% CI: 22% to 33%)

Conclusions-
Prolonged cardiac monitors detects new atrial/fibrillation or flutter in approximately 16 % cases. There was a trend of higher detection rates with longer duration of monitoring. Prospective studies
Abstract 3074: Acute Stroke Nurse Response Pilot Program
Authors: Wilson Susan E , Huang David Y , Aucutt-Walter Natalie , Jordan Joseph D , Marino Sierra R , Knafl George , Benjamin Barbara
Published: July 2021

Background:
Less than 10% of ischemic stroke patients receive tissue plasminogen activator. Low treatment rates have been associated with delay in hospital presentation and reluctance to treat. Studies have found that a combination of community and professional education increase thrombolytic therapy from 2.2% to 11.3% with the data suggesting that professional education made the most impact. An Acute Stroke Nurse Response educational program was piloted as a means of providing specialized treatment education for nurses in North Carolina.

Project goals:
A. Increase the number of nurses across the state experienced to provide acute stroke assessment and treatment. B. Determine the best educational approach: on-line vs. class room vs. both. C. Develop a mock code stroke training module. D. Provide guidance in developing individualized models of stroke care protocols.

Measurable objectives:
A. Gauge interest in the program. B. Assess pre and post-test knowledge measuring effectiveness of modules. C. Assess nurse preference for teaching method. D. Evaluate the methodology of the mock code stroke module.

Methods:
The educational program covered stroke topics through on-line modules and a one day lecture series to meet the needs of the working nurse. The program consisted of 10 specialized stroke training modules: Module 1: Introduction to Stroke Module 2: Emergency Management Module 3: Acute Stroke Treatment Module 4: Management of ICH Module 5: Stroke Prevention Module 6: Nursing Care of the Stroke Patient Lecture 7: Neurological Assessment Lecture 8: Stroke Imaging Lecture 9: Quality Improvement/Joint Commission Primary Certification Lecture 10: Mock Stroke Code 6 weeks were allowed to complete the on-line modules prior to the day lecture series. Pre and post-test exams were administered to assess baseline knowledge and knowledge gained.

Results:
42 nurses showed interest in the program. 12 nurses completed the pilot program. 10 were from NC, originating throughout the state and 2 from SC. Two participants were NP’s, 2 ED nurses, 3 staff nurses and 5 stroke coordinators. Participants had a mean pre-test score of 53.2, which increased significantly (p<0.001) to a mean post-test score of 77.8 (absolute mean improvement of 24.6%). The improvement in the scores ranged from 11.1 to 44.5% with one participant experiencing a decrease in test scores by 5.6%. Program feedback was positive, with strengths identified as “convenient and informative”. All participants requested the program continue as originally developed with on-line modules and the one day lecture series.

Conclusions:
There was a significant educational benefit from this program, as demonstrated by participant responses to the pilot program.
Abstract 3077: Meta-analysis & Simulation Models For Cost Effectiveness and Sustainability of Telestroke
Authors: Jain Anunaya , Jain Minal , Kanthala Abhijit R , Jahromi Babak S
Published: July 2021

Introduction:
Telestroke networks can readily address the challenges of stroke care in rural/isolated health care settings.

Method:
A PubMed search for all studies on “Telestroke” networks was conducted. Only English language studies from the developed world were included. A meta-analysis comparing the cost savings offered by a Telestroke networks to traditional care models for treating acute ischemic stroke patients was performed. Revenue generation from Telestroke consultations was simulated and compared to reported costs of initiation of Telestroke networks to conduct a break-even probability analysis. A sensitivity analysis was done to investigate the robustness of this model to changing variable costs of Telestroke mediated care. All costs were in 2010 US$.

Results:
A total of 15 Telestroke networks and 23,952 consultations were analyzed. Nearly 10.8% received IV-tPA therapy. From prior studies it was estimated that total cost savings per patient treated with IV rt-tPA was $6000 (1996 US$) after taking into account the increased hospitalization cost ($1,700 per patient), decreased average in-patient length of stay (1.5 days), decreased rehabilitation cost ($1400) and decreased nursing cost per patient ($4,800). Application of this cost saving to the Telestroke studies resulted into a total cost savings of $90,000 per 100 consultations. The average duration of consultation reported by these networks was 28.25 minutes (SD 18.86 minutes) generating average potential revenue of $48.7 per consultation as per Medicare reimbursement guidelines. The total approximate fixed costs of setup was $33,400/year/spoke site. Simulation analysis revealed that 283 patients per "spoke site" were needed to break-even upon investment costs of Telestroke, with just reimbursement of consultation costs accounting for revenue. After introducing uncertainties, the model generated a probability of 80.1% that the network would break-even on its costs within the first year of operation. Taking into account the increasing variable costs of operations and network maintenance, if the spoke-unit saw at least 283 patients annually, and if variable costs were kept below $35/patients, the Telestroke model would prove to be sustainable and cost effective.

Conclusion:
Telestroke appears to be a cost effective strategy with a potentially sustainable business model in delivery of health care to ischemic stroke patients.
Abstract 3097: Acute In-hospital Stroke: How Do We Do Compared To Strokes In The Emergency Department?
Authors: Wisco Dolora , Newey Christopher , George Pravin , Gebel James
Published: July 2021

Introduction:
Intravenous tissue plasminogen activator (IV tPA) has been approved for treating strokes up to 3 hours after onset of symptoms and may be beneficial up to 4.5 hours in patients who qualify. Additionally, neuro-intervention, i.e., intra-arterial thrombolysis or thrombectomy, is also an approved treatment option. Population studies show that 6% receive IV tPA within 3 hours of stroke onset. However, in-hospital strokes present challenges to treating within an adequate time. We present here our experience with in-hospital strokes, treatments, and identifiable delays in treatments.

Methods:
Single, tertiary center retrospective study of 55 in-hospital strokes over a one-year period from January 2009 to January 2010, and strokes in the Emergency Department over 6 month period from January 2010 to June 2010.

Results:
Twenty-nine in-hospital strokes were evaluated within 3 hours of symptoms onset. Two (6.9%) received IV tPA, and four (13.8%) received neuro-intervention (either intra-arterial thrombolysis or thrombectomy). None of the patients who presented greater than 3 hours after symptom onset was treated with any treatment (n=28). When compared to patients who present to the ED within 3 hours, in-hospital strokes were less likely to get IV tPA (6.9% vs. 20.8%), and they were more likely to receive neuro-intervention (13.8% vs. 10.3%). Neuro-intervention was performed on 9.09% of all in-hospital strokes (1 of 5 presented beyond the 3 hour time window). For in-hospital strokes that receive any treatment within 3 hours, the average time to neurology evaluation, to CT, and to treatment are 35 min, 68 min, and 237 min, respectively. For strokes in the Ed, the average time to evaluation, to CT, and to treatment are 90 min, 28 min, and 66 min respectively. The delay for in-hospital strokes is in obtaining the CT and initiating the treatment.

Discussion:
In-hospital stroke patients wait longer than their ED counterparts to be taken to CT and to receive stroke treatment. They are also less likely to receive IV tPA, and more likely to receive neuro-intervention. The longer time to neuro-imaging and thrombolytic treatment may reflect the fact that patients suffering in-hospital strokes have more complex medical co-morbidities that must be taken account during the evaluation and administration of thrombolytic therapy.
Abstract 3098: Docosahexaenoic Acid Protects The Brain After Experimental Stroke By Modulating Protein Phosphorylation In The Penumbra
Authors: Eady Tiffany N , Belayev Ludmila , Khoutorova Larissa , Atkins Kristal D , Bazan Nicolas G
Published: July 2021

Background and purpose:
Docosahexaenoic acid (DHA), a member of the omega-3 essential fatty acid family, improves behavioral deficit and reduces infarct volume and brain edema after focal cerebral ischemia in rats. We hypothesize that DHA elicits neuroprotection by inducing protective cellular cascades, which in turn lead to cell survival. We used behavioral tests in conjunction with immunohistopathology and western blots to expand our understanding of the early mechanisms responsible for DHA-induced neuroprotection.

Methods:
Physiologically-controlled male Sprague-Dawley rats (304-370g) received 2h middle cerebral artery occlusion (MCAo) by intraluminal suture. Animals were treated with DHA (5mg/kg, iv) or saline (5ml/kg) at 3h after the onset of stroke. Behavioral function was evaluated at 1h after occlusion onset and at 24h on a grading scale of 0-12 (0=normal and 12=maximal deficit). GFAP (reactive astrocytes), ED-1 (activated microglia/microphages), and NeuN (neurons) were analyzed in the ischemic core and the penumbra regions (A, B and C) at 4 and 24h. Western blot/immunohistochemical analysis of pAKT, pGSK, and pS6 (proteins of the AKT signaling pathway) was conducted in the core and penumbra at 4 and 24h.

Results:
Physiological variables were stable and showed no significant differences between groups. Behavioral deficit was significantly improved by treatment with DHA compared to vehicle at 24h (7.3±0.5 vs. 10±0; p<0.001, respectively). DHA treatment significantly reduced the number of microglia cells in penumbra regions A and C (by 86% and 76%) and increased GFAP-positive cells in penumbra regions B and C (by 53% and 51%) at 24h after stroke. There were no significant differences in expression of cell markers between groups at 4h and in the ischemic core. DHA upregulated activation of AKT compared to vehicle at 4h (36% increase in p473 AKT and 79% increase in p308 AKT) and at 24h (114% increase in p473 AKT; 98% increase in p308 AKT). DHA also increased pS6 at 4h by 160% and pGSK at 24h by 61% as compared to vehicle-treated animals. DHA-treated animals had significantly higher p308 AKT cell counts in the penumbra at 4h (region A by182%, region B by 160% and region C by 103% increase).

Conclusions:
DHA treatment confers behavioral improvement, reduces microglial infiltration, increases astrocytosis at 24h, activates pro-survival AKT cascades as early as 4h, and has potential for the treatment of ischemic stroke.
Abstract 3103: Symptomatic Intracranial Hemorrhage Following Intravenous Thrombolysis For Acute Ischemic Stroke: A Critical Review Of Case Definitions
Authors: Seet Raymond C , Rabinstein Alejandro A
Published: July 2021

Background:
Symptomatic intracranial hemorrhage (SICH) is the most feared complication of intravenous recombinant tissue plasminogen activator (rtPA). Differences exist in the criteria used to define neurologic decline, cerebral hemorrhage and interval between rtPA treatment and onset of cerebral hemorrhage.

Methods:
We performed a systematic review to investigate SICH rates following rtPA treatment and assess their consistency with respect to mortality rates reported in the literature. Studies were identified from the PubMed and EMBASE databases from January 1994 to June 2011 by cross-referencing the following MeSH terms: “thrombolysis”, “recombinant tissue plasminogen activator”, “rtPA”, “TPA”, “Alteplase”, “thrombolytics”, “cerebral ischemia” and “stroke”. We restricted our selection to stroke registries and larger cohort studies that comprised consecutively recruited stroke patients with an operational cutoff of >200 subjects. Studies that (1) involve endovascular-treated patients, (2) applied pre-selection criteria (e.g. the presence of demonstrable arterial occlusion and pretreatment MRI), and (3) did not report both SICH and mortality rates, were excluded. We calculated the age, baseline NIHSS scores, time from stroke onset to rtPA treatment, SICH and mortality rates using published data from these studies.

Results:
The initial search identified 3538 studies which were reduced to 211 potentially eligible studies that were relevant to our investigation. After application of exclusion criteria, 7 clinical trials, 7 stroke registries and 10 cohort studies (4 multi-center and 6 single-center) were included in this analysis. The mean (SD) age of these patients is 68.8 years (2.9), of whom 56.3% (4.5%) were men. These patients presented with mean baseline NIHSS 12.5 (1.4) and received intravenous rtPA 175 (62) minutes from stroke onset. The mean SICH and mortality rates were 5.6% (2.3%) and 14.7% (4.8%) respectively. Higher SICH rates were reported in randomized controlled trials (mean, 7.45%) compared with those in stroke registries (mean, 3.50%). Studies that defined SICH as parenchymal hemorrhage with neurologic decline NIHSS≥4 occurring within 36 hours of rtPA treatment have a higher consistency between SICH and mortality rates (correlation coefficient, 0.631).

Conclusion:
We highlight several inconsistencies in the criteria used to define the neurologic decline, neuroimaging classification and interval between rtPA treatment and cerebral hemorrhage. These discrepancies may, in part, explain the rather striking disparities between SICH and mortality rates reported in randomized controlled trials, stroke registries and cohort studies.
Abstract 3111: Translating Evidence into Clinical Practice: Can it Always Be Done? The Example of Intensive Stroke Rehabilitation
Authors: Foley Norine C , Pereira Shelialah , Salter Katherine , Meyer Matthew , McClure Andrew , Teasell Robert
Published: July 2021

Background and Purpose:
While it remains unclear how much therapy patients should receive to maximize motor recovery, specifically during inpatient rehabilitation, recommendations regarding the daily minimum dose of therapy are included in many clinical practice guidelines. Since these documents are evidence-based, we examined the related literature to determine if a specific recommendation could be supported.

Methods:
Six clinical practice guidelines were retrieved and examined to determine what recommendation, if any, had been made regarding the daily provision of therapy during inpatient rehabilitation. We then identified all studies cited by the guideline authors to support their recommendations. Studies in which treatment was focused on motor recovery, were initiated during inpatient rehabilitation and provided within 3 months of stroke onset were reviewed in greater detail. Study design, details of the therapy contrasts, the duration of scheduled daily therapy (min/day), actual therapy received (min/day), the primary outcome and the results, were noted for each trial.

Results:
Three of the 6 identified guidelines recommended daily minimum amounts of therapy, ranging from 45 to 60 minutes each day of occupational (OT) and physiotherapy (PT), one made no recommendation, and two made general statements indicating that increased intensity of therapy was either recommended or was not recommended. Among the 6 guidelines, a total of 73 studies had been cited to support the recommendations. Sixteen randomized controlled trials and 2 controlled trials were reviewed in detail. The majority of trials not reviewed further examined treatments provided in the chronic stage of stroke and/or were non-hospital based. Treatment contrasts included comparisons of intensive inpatient rehabilitation vs. standard inpatient therapy or standard inpatient therapy plus additional therapy provided by OT and/or PT vs. standard therapy only. Details of daily therapy either prescribed or received was included in 9 studies. Patients in the control condition received an average of 48 minutes of therapy per day while those in the experimental group received an average of 61% more, or 77 minutes per day. In only 6 (33%) studies did patients in the experimental group perform significantly better on the primary outcome compared with those in the control group.

Conclusions:
Although included in several best practice guidelines, we believe the evidence base cannot support a specific recommendations related to therapy intensity during inpatient rehabilitation following stroke.
Abstract 3116: The Effect of Stroke on Bone Marrow: Studies from a Cell-Therapy Clinical Trial
Authors: Tanksley Jessica , Vahidy Farhaan , Durett April , Grotta James C , Savitz Sean I
Published: July 2021

Objective:
The application of autologous bone marrow cells has emerged as an investigational cell-based therapy for ischemic stroke. Previous animal studies have reported that stroke affects leukocytes in the bone marrow. In addition, older age and presence of comorbidities raise concerns about the variability in yield of bone marrow stem cells. These issues may potentially impact autologous applications of bone marrow cell therapies in stroke patients. We examined whether acute ischemic stroke (AIS) affects the bone marrow in patients by assessing various cell subpopulations within the mononuclear fraction of bone marrow harvested from healthy donors and study patients in our clinical trial testing mononuclear cells (MNCs) in patients with AIS.

Methods:
This study examined the bone marrow composition of 22 consecutive patients with AIS enrolled into our clinical trial testing the safety of autologous bone marrow MNCs administered intravenously within 24 to 72 hours after symptom onset. After bone marrow harvest, MNCs are isolated, separated, and characterized at a GMP facility. The bone marrow from 15 healthy donors was also processed at the same GMP facility. Descriptive analysis comprised calculation of means for absolute cell counts and determination of proportions for subtypes of different cell subpopulations. Samples of healthy bone marrow donors were compared with that of AIS patients.

Results:
AIS patients had a median age of 61 (IQR 50-73), had CAD (5%), Afib (14%), diabetes (32%), hypertension (50%), hyperlipidemia (32%), or were actively smoking (27%). Onset time to harvest was 48 ±11 hours after stroke onset.
Figure 1
shows no significant differences among the proportions of cell populations including lineage negative, CD34+ cells (a marker of hematopoietic stem cells - HSCs). There was no significant difference in the variance of the cell subpopulations between healthy donors and stroke patients, except for NK cells which were significantly higher among the stroke patients (p = 0.0074). Age, history of DM, or the location of the infarct depending on vascular territory did not affect the proportion of the different cell populations.

Conclusions:
AIS does not cause significant changes in the proportions of different cell types in the MNCs of bone marrow including the HSCs. We found no evidence that autologous MNCs are different, in terms of cell composition, from study patients who are older and have vascular comorbidities compared with healthy donors.