bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP303: Integrating Stroke Center Quality Metrics Into Pre-hospital Triage in Acute Ischemic Stroke
Authors: Ehrlich Matthew , Graffagnino Carmelo , Kolls Bradley J , Yang Julian P
Published: June 2021

Background:
Rapid treatment of acute ischemic stroke (AIS) is key to improving outcomes, yet pre-hospital transportation decisions are rarely considered. Decisions on acute care destinations for AIS patients are often poorly guided and based on patient preference. In a complex urban environments with multiple stroke centers, proper guidance these decisions may reduce delays in treatment. We hypothesize that the integration of stroke center quality metrics and traffic patterns into pre-hospital transportation of AIS patients would reduce treatment times.

Methods:
Travel times to Duke University Hospital (DUH) and Duke Raleigh Hospital (DRAH) from three locations (RDU airport, Falls Lake, Apex town center) were examined at 5 times of day (2AM, 8AM, 12PM, 5:30PM, 8PM) taking traffic delays into account using Google Maps estimates from historical data. Average door-to-needle times (DTN) for each hospital were obtained for the prior 6 months. The 6 month average DTN as well as individual monthly averages were added to travel times to simulate stroke-onset-to-needle times (ONT) for hypothetical patients transported from each location to each hospital.

Results:
The six-month average DTN were 59.8 mins (DUH) and 64.8 mins (DRAH). Based on these times, patients originating from RDU or Falls Lake have shorter estimated ONT at DUH, regardless of time of day and despite greater geographical distances. Patients transported from Apex had shorter ONT at DRAH except at 5:30PM, when ONT at DUH was estimated 5.5 mins faster. In June alone, average DTN were 44 mins (DUH) and 55 mins (DRAH). Simulated patients transported during this month had faster ONT at DUH when traveling from any of the three locations and at any time of day examined, again despite greater geographic distances or longer transport times.

Conclusion:
In this proof of concept model, integrating DTN averages and traffic patterns into transportation of AIS patients demonstrated instances when traveling further geographical distances reduced ONT. This emphasizes the need to develop regional and statewide integrated systems of care, which may reduce reperfusion times, and improve quality of care.
Abstract WP306: Admission Stroke Severity is a Major Driver of Variation in Acute Stroke Care
Authors: Sila Cathy , Louttit Megan , Ash Chris
Published: June 2021

Introduction:
High reliability and bundling initiatives focus on reducing unnecessary practice variation to improve the value of care. It is uncertain whether models that address provider variability for elective procedures can be translated to analyze team-based care of patients with acute stroke.

Methods:
All stroke discharges from 2015 at University Hospitals- Case Medical Center were analyzed for clinical and quality data from the
GWTG
PMT, including admission stroke severity scores, and reconciled with
EPSi
™
financial data. Tableau was used for statistical analysis.

Results:
Variation by provider for the 6 Stroke faculty for DRGs 61-69 ranged from average LOS 2.3-5.6 days and total margin $257,301 to ($51,846). However, the provider-defined as Attending at Discharge- represented the key decision-maker in < 50% of cases (mean 103, range 16-176) due to service rotations of 2-18 wks/year. Variation in total cost/case was driven by Room & Board and LOS- especially ICU LOS- more than pharmacy, radiology or lab costs. Variation by admission stroke severity score tracked with patient outcome at discharge. The lowest variation in LOS and total cost was observed for patient groups: NIHSS 0-3, 4-6, ICH Score 4, 5, and Hunt & Hess Score 5 and was significantly related to either rapid recovery or early mortality. The greatest variation in direct cost per case, LOS and ICU LOS was seen for NIHSS 21+, 16-20, ICH Score 2, 3, and Hunt & Hess Score 1, 2. Patients with severe ischemic stroke NIHSS 21+ had the highest utilization of pharmacy and radiology resources.

Conclusions:
Admission stroke severity is a major driver of clinical variation in the cost of care, resource utilization and length of stay for patients with acute stroke. Using stroke severity scores to guide data analysis showcases opportunities for new clinical practice guidelines and care paths. Provider variability data is only reliable when is the attributed provider was the key decision maker in the patient’s care.
Abstract WP32: Good Reperfusion Can Rescue Acute Ischemic Stroke Patients Treated With Endovascular Therapy Beyond 6 Hours After Onset.
Authors: SUZUKI KENTARO , Aoki Junya , Takayama Yohei , Abe Arata , Suda Satoshi , Kimura Kazumi
Published: June 2021

Objective:
Endovascular therapy (EVT) within 6 hours from ischemic stroke onset were recommended by 2015 AHA/ASA guideline. Effectiveness and factors for favorable outcome for EVT beyond 6 hours are unclear. We investigated whether onset to puncture time (O2P) beyond 6 hours is associated with outcome at 3 months and what is the favorable factors in patients treated with EVT beyond 6 hours.

Methods:
We performed a retrospective, single center analysis of patients with acute ischemic stroke who underwent EVT. The O2P, risk factors, reperfusion success rate and outcome at 3 month were assessed. First, all patients were classified into the two groups with EVT beyond 6 hours or not. Second, we compared any characteristics and favorable outcome between two groups. Finally, we investigated independent factors for favorable outcome in patients treated with EVT beyond 6 hours. Favorable outcome and good reperfusion were defined by modified Rankin scale ≤ 2 and thrombolysis in cerebral infarction (TICI) score ≥ 2B, respectively.

Results:
Of the 130 EVT cases, 124 cases with known onset time were enrolled (age; 75 [66-83] and 74 (60.5%) men). 98 (79%) were treated with EVT within 6 hours and 26 (21%) patients were beyond 6 hours. Absence of atrial fibrillation (11[42%] vs. 70[71%], p=0.01), high DWI-ASPECTS (9 [7-10] vs. 7 [6-9], p=0.01), no use of intravenous tissue plasminogen (1[4%] vs. 50[51%], p<0.01) and low achievement of good reperfusion (14[54%] vs. 77[79%], p=0.01) were more frequently observed in beyond 6 hours group than within 6 hours group. However, favorable outcome was not different between two groups (beyond 6 hours group ;10(38%) vs. within 6 hours group; 43(44%), p = 0.66). In beyond 6 hours group, good reperfusion (9[90%] vs. 5[31%], p=0.01) and presence of hyperlipidemia (7[70%] vs. 3[19], p=0.02) were associated with favorable outcome. On multivariate analysis, only good reperfusion (OR 45.6, 95%CI 3.7-2271.4, p<0.01) was the independent factor associated with favorable outcome.

Conclusions:
The frequency of favorable outcome in beyond 6 hours group was not lower than within 6 hours group. Good reperfusion can improve patient outcome in O2P within 6 hours as well as beyond 6 hours.
Abstract WP332: Early Stroke Detection in Postoperative Patients: A Simple Educational Intervention and Feasibility Study
Authors: Chaicharoentanaporn Charoenratt , Slisatkorn Worawong , Hunnangkul Saowalak , Pipatsatukit Usa , Saposnik Gustavo , Nilanont Yongchai
Published: June 2021

Background:
Stroke is one of the most feared postoperative complications. However, the diagnosis is usually delayed leading to a reduced therapeutic window.

Objective:
To develop a protocol aimed to shorten the time of detecting a neurological deficit in postoperative patients.

Methods:
We used a pre-post intervention design to evaluate time of stroke recognition in post-opened heart surgery patients. The intervention consisted of: 1) A new postoperative protocol to evaluate any new neurological deficit
<
14 days after surgery. Nurses were trained to perform a simple sequential neurological assessment including observing eye deviation and testing for asymmetrical limb movement. The protocol was applied during the vital sign measurement schedule. Stroke code was activated if the deficit was confirmed by MD. 2) Educational program for nurses concerning postoperative stroke complications and the importance of time.

Results:
During Jan, 2014 - Oct, 2015, we consecutively reviewed 27 patients with acute neurological deficit
<
14 days after surgery. Twenty-five consecutive patients with postoperative neurological deficit were enrolled during post-intervention period (Nov, 2015 - Jul, 2016). Male consisted of 19/27 (70.4%)
and
179/297 (60.3%) (
P
=0.303), the mean ± SD age of 64.56 ± 13.13 and 62.43 ± 13.45 years (
P
=0.432) and the mean initial NIHSS of 16.25 ± 8.45 and 12.92 ± 10.78 (
P
=0.402) in pre and post intervention respectively. When comparing between pre and post intervention, we found that stroke fast track activation was significantly increased from 4/27(14.8%) to 13/25(52%) (
P
=0.004), the median (min-max) duration from time last seen normal to first neurological deficit detection reduced from 690 (20-9190) to 120 (5-5935) minutes (
P
=0.004), the median duration from onset to CT decreased from 150 (33-11009) to 65 (31-3779) minutes (
P
=0.163). Number needed to treat for early detection when the protocol being used was 2.4. There was an increasing trend in endovascular treatment from 0 to 2/25 (8%) after the intervention.

Conclusions:
A simple protocol for a postoperative neurological assessment after cardiac surgery showed a significant reduction in the time to diagnosis thus, increasing the patients’ therapeutic opportunity.
Abstract WP343: A Causative Analysis of the Role of Hyperglycemia in the Outcome of Spontaneous Intracerebral Haemorrhage
Authors: Lioutas Vasileios-Arsenios , Salem Mohamed M , Locascio Joseph J , Selim Magdy
Published: June 2021

Background:
The role of hyperglycemia in acute intracerebral hemorrhage (ICH) is controversial: Some studies find an association with poor outcomes; others report neutral relationship. All interventions aiming at glucose lowering in acute ICH have yielded neutral or negative results. We attempt an explanation of the causal role of hyperglycemia in ιCH outcome using path analysis.

Methods:
235 consecutive primary ICH patients (69.2±13.2 years, 44% female) admitted to an academic hospital in Boston. We recorded hematoma volume (HV) on presentation, mean 72-hour glucose and age for each patient as continuous variables. Intraventricular extension (IVE), infratentorial location, coagulopathy (INR≥1.4 or platelets <100,000), hematoma expansion (HE, defined as >33% relative increase in HV) and presence of diabetes were recorded as dichotomous variables. 90-day functional outcome was dichotomized as favorable vs unfavorable (modified Rankin Scale of ≤ 2 vs >2). We used generalized structural equation modelling for model estimation.

Results:
Mean 72-hour glucose was 143± 35 mg/dl, median HV was 23.3 cm
3
. 66 (28%) were diabetic, 103 (44%) had IVE, 56 (26%) had HE, 29 hemorrhages (12%) were infratentorial. 60 (26%) patients had favorable functional outcome. HV (p=0.001), diabetes (p<0.0001), IVE (p=0.02) but not HE were significant predictors of hyperglycemia. HV and IVE were associated with unfavorable outcome but the effect was not mediated by elevated glucose levels. On bivariate analysis, higher glucose levels were negatively correlated with favorable outcome (p=0.002, 95% CI 0.97-.099) but this effect lost its significance when introducing the rest of the variables in our model (figure).

Conclusion:
Elevated glucose in ICH appears to be strongly influenced by markers of ICH severity; this is a possible explanation for the lack of response to intensive glucose lowering interventions. Its direct effect on functional outcome in ICH merits further investigation.
Abstract WP345: Pretreatment with Sulfonylurea Drugs is Associated with Smaller Baseline Hematoma Volumes and Better Functional Outcomes in Diabetic Patients with Acute Intracerebral Hemorrhage
Authors: Chang Jason J , Khorchid Yasser , Kerro Ali , Burgess Lucia G , Goyal Nitin , Alexandrov Anne W , Alexandrov Andrei V , Tsivgoulis Georgios
Published: June 2021

Introduction:
Intracerebral hemorrhage (ICH) is associated with worse clinical outcome and high mortality. Secondary mechanisms of injury promoting cerebral edema play a major role. One proposed mechanism for cerebral edema lies with sulfonylurea receptor 1 (SUR1), which is upregulated in focal cerebral ischemia and leads to passive vasogenic edema. Sulfonylureas (SFU) inhibit SUR1, and recent results of GAMES-Pilot trial indicate that they may also provide neuroprotection against malignant cerebral edema and improve clinical outcome in ischemic stroke. We sought to evaluate the association of prehospital SFU use with outcomes in diabetic (DM) patients with acute ICH.

Methods:
We retrospectively analyzed a prospective cohort of patients presenting with acute (<24 hrs) ICH at a tertiary care center. Study inclusion criteria included history of DM, spontaneous ICH etiology, and age > 18 yo. Baseline ICH severity was documented using ICH-score. Hematoma volumes (HV) on admission were calculated using ABC/2 formula. Unfavorable functional outcome was documented as a mRS score of 2-6 at discharge.

Results:
230 patients with ICH and DM fulfilled inclusion criteria; 37 patients were pretreated with SFU (mean age 67 ±10 years, male 41%). Patients with SFU pretreatment had significantly (
p
<0.05) lower median ICH-score (1 point, IQR: 0-2) and median admission HV (4cm
3
, IQR:1-12) compared to controls [ICH-score: 1 point (IQR:0-3); HV: 9 cm
3
(IQR:3-20)]. Unfavorable functional outcome was less common in SFU pretreated patients (49% vs 81 %;
p
=0.004). SFU pretreatment was independently (
p
=0.043) and negatively associated with the natural logarithm of admission HV (linear regression coefficient: -0.62; 95%CI: -0.02, -1.23) in multiple linear regression models adjusting for potential confounders. Pretreatment with SFU was also independently (
p
=0.013) associated with lower likelihood of unfavorable functional (OR: 0.12; 95%CI: 0.02, 0.64) outcome in multivariable logistic regression models adjusting for potential confounders.

Conclusions:
Pretreatment with SFU may be an independent predictor for smaller hematoma volume and improved functional outcome in diabetic patients with acute ICH. This association requires independent confirmation.
Abstract WP35: Penumbra Saved in Acute Stroke Patients Treated with IV Thrombolysis Predicts Minimal Infarct Growth Independent of Onset to Treatment
Authors: Luby Marie , Nadareishvili Zurab , Cullison Kaylie , Benson Richard T , Hsia Amie W , Leigh Richard , Lynch John K , Latour Lawrence L
Published: June 2021

Purpose and Hypothesis:
The ability to measure the immediate tissue effects in patients treated with thrombolysis ultra-early relative to their known onset has increased. We hypothesized that shorter onset to treatment times (OTT) would lead to more penumbra saved, calculated using multimodal MRI.

Methods:
Patients were included in this study if they met the following criteria: (1) were admitted between January 2010 and June 1, 2014 at one of two regional stroke centers, (2) had known last seen normal, acute MRI and IV tPA start times, (3) received an admit diagnosis of ischemic stroke, and (4) were treated with standard IV tPA. Penumbral volumes were calculated using the baseline MRI-defined mismatch regions minus the infarcted regions defined by the co-registered DWI at 24 hours. Patients were categorized to the “early” IV tPA cohort if their OTT was ≤ 120 minutes. Infarct growth was quantitatively defined as lesion volume increase > 5 mL from baseline DWI to 5-day FLAIR. Favorable clinical outcome was defined as discharge or later mRS < 2.

Results:
Sixty-three patients, 23 early- and 40 late-treated, were included in the study with mean age 75 (±15) years, 48% female, median [IQR]: admit NIHSS 10 [5-19], OTT 139 [109-185] minutes, baseline DWI volume 11.2mL [3.5-39.6], baseline MTT volume 120.9mL [37.8-220.7], and baseline mismatch volume 119.3mL [34.6-200.7]. Aside from time-based variables, only the amount of penumbra infarcted at 24 hours (p=0.015) was significantly different between the early- (9mL [1.7-19.7] and late-treated (2.4mL [0.7-7]) cohorts. The patients with favorable outcome were younger (p=0.012) with less severe admit NIHSS (p=0.026), smaller baseline DWI volume (p=0.017), smaller 24 hour DWI volume (p=0.041), and greater percentage of penumbra saved at 24 hours (p=0.010) but no difference in OTT (p=0.267). Using binomial logistic regression, percentage of penumbra saved at 24 hours (95%CI:0.000-0.011, p=0.010) was the only independent predictor of no infarct growth.

Conclusions:
This study establishes that significantly larger penumbral tissue saved at 24 hours, not early OTT, is predictive of both favorable clinical outcome and no infarct growth.
Abstract WP355: Predictors and Outcome of Intubation for Patients with Primary Intracerebral Hemorrhage
Authors: Khawaja Ayaz , Venkatraman Anand , Mirza Maira
Published: June 2021

Background:
Patients with primary intracerebral hemorrhage (pICH) are at risk of airway compromise and commonly undergo intubation. Poor outcomes have been reported for these patients. Factors predicting intubation prior to admission (PTA), and after admission are unknown. These factors may be helpful in predicting which pICH patients require intubation, and its optimal timing.

Methods:
Patients with pICH directly admitted or transferred from another facility to our center were included. Patients with SAH, SDH, epidural hemorrhage, underlying lesions, or infarct with hemorrhagic transformation were excluded. Intubation note from medical chart was used to determine the timing of intubation. Demographic and clinical data were recorded. The primary outcome was a discharge mRS (dmRS) of 4-6.

Results:
A total of 370 patients were included. Patients intubated PTA had a lower average GCS (6 vs. 9; p=0.0003) and a higher average NIHSS (26 vs. 18; p=0.0007) than those intubated after admission. Higher incidences of hematoma expansion (30.9% vs. 16.3%; p=0.0253), tracheostomies performed (17.5% vs. 4.8%; p=0.0004), ICH volumes > 30cc (40% vs. 25.5%; p=0.0352), and pneumonia (35.1% vs. 5.4%; p<0.0001) were seen in patients intubation after admission, when compared to other patients. Patients requiring intubation at any time had statistically non-significant higher incidences of cortical and brainstem hemorrhage (see Table 1), compared to patients not intubated. After adjusting for pneumonia and ICH score, intubation is significantly associated with a dmRS of 4-6 (OR 4.87, 95%CI 1.27-18.7, p=0.0208).

Conclusions:
Lower GCS and higher NIHSS significantly predict intubation in pICH patients PTA. ICH volumes > 30cc, hematoma expansion and pneumonia significantly predict intubation after admission. Intubation is significantly associated with poor functional outcomes independent of ICH score and pneumonia. Location of ICH does not predict intubation.
Abstract WP372: The Acute ICH Growth Score: Simple and Accurate Predictor of Hematoma Expansion in Patients with Acute Intracerebral Hemorrhage
Authors: Al-Ajlan F S , Demchuk A M , Aviv R I , Rodriguez-Luna D , Molina C , Silva Y , Dzialowski I , Czlonkowska A A , Boulanger J M , Lum C , Gubitz G , Padma V , Roy J , Kase C S , Hill M D , Dowlatshahi D
Published: June 2021

Background and Purpose:
Acute intracerebral hemorrhage (ICH) hematoma expansion predicts high mortality and morbidity, occurring in a third of patients presenting with this condition. Recent studies correlated ultra-early hematoma growth and hematoma morphologic appearance with ICH expansion. Our purpose was to develop simple and clinically useful score that would predict ICH hematoma expansion accurately.

Methods:
This cohort included patients with primary or anticoagulation-associated ICH patients presenting <6 hours post ictus prospectively enrolled in the PREDICT study. Patients underwent baseline CT, CT angiography and 24-hour CT for hematoma expansion analysis. A risk score model was developed for predicting hematoma expansion (> 6 ml or > 33%). A 7-point acute ICH growth score was based on ultra-early hematoma growth > 5 mL/hour (yes=1), irregular morphology (yes=1), density heterogeneity (yes=1), presence of fluid-blood levels (yes=1), spot sign (yes=1), and use of anticoagulation (yes=2). Discrimination of the expansion score was assessed.

Results:
We retrospectively studied 301 primary or anticoagulation-associated intracerebral hemorrhage patients. The 7-point acute ICH growth score demonstrated good discrimination for hematoma expansion>6 mL or 33% (area under the curve of 0.76). Median and significant HE are shown in the table below (p<0.001).

Conclusions:
In a multicenter prospective study, the ICH expansion score demonstrate good correlation with hematoma expansion, and included recently reported variables such as morphology and ultraearly growth.
Abstract WP373: Emergency Medical Service Stroke Education in a Rural Community: Need for Improvement
Authors: Rankin Pauline M , Marsh Dianne , McLaughlin James
Published: June 2021

According to The Journal of Emergency Medical Services (EMS) the goal of stroke care is to minimize brain injury and maximize recovery. The stroke chain of survival links actions taken by patients, family, EMS and healthcare providers. Recent innovations in stroke treatment require accurate identification and appropriate triage to the appropriate treatment facility. Evidence in the literature demonstrates variability with EMS correct identification of stroke patients between 30% and 80%. Our 164 bed primary stroke center in rural Pennsylvania has been active in providing stroke education on an annual basis to emergency medical services within a two county radius. As part of our ongoing process improvement we wanted to evaluate the emergency medical technicians and paramedics knowledge of stroke signs and symptoms, their understanding of the evaluation, treatment and triage of stroke patients. A standard questionnaire with 14 variables was developed using the American Heart and Stroke Association prehospital guidelines. The questionnaire included 16 stroke and non stroke symptoms, identifying transport to primary verses comprehensive stroke centers and initial evaluation. A sample population of 90 emergency medical service staff were asked to complete the questionnaire with 28 (31%) responses received. All participants indicated they were confident to recognize stroke signs and symptoms but 6 of the non stroke items were chosen as stroke symptoms. All participants indicated they were confident in the initial evaluation of a stroke patient but 14 (50%) appropriately identified airway, breathing, circulation as the first evaluation. Evaluating triage knowledge, 26 (93%) stated confidence in decision to transport to a primary stroke center and 22 (79%) to a comprehensive stroke center, however, appropriate decision to transport to a primary stroke center was identified correctly by 46% a comprehensive stroke center 66%. In conclusion, results from this study suggest that in this rural setting, barriers exist in prehospital recognition and evaluation of the stroke patient for which proper education may be remediable. Our goal is to use this information to revise our current EMS stroke education program and enhance prehospital assessment and triage.
Abstract WP387: Predictors of Loneliness in African American Women with Cardiovascular Disease
Authors: Saban Karen L , Bryant Fred B , DeVon Holli , Janusek Linda
Published: June 2021

Background:
Social connections are a basic need of all humans. Loneliness is a perceived lack of both quantity and quality of social relationships. Prior research demonstrates that loneliness increases the risk of cardiovascular disease (CVD) and poor health outcomes. Although African American (AA) women are at greater risk than non-Hispanic White (NHW) women for CVD, the influence of social disadvantages on loneliness in AA women at risk for CVD have not been examined.

Purpose:
The purpose of this study was to compare protective and risk factors posited to predict loneliness in AA women and NHW women at risk for CVD.

Methods:
A cross sectional sample of post-menopausal women (50 AA and 49 NHW) with at least two risk factors for CVD completed standardized measures of loneliness, depressive symptoms, financial stress, subjective social status, social support provisions, and resilience.

Results:
Compared to NHW, AA women reported greater loneliness (t=-2.09, p=.039), financial stress (t=-2.92, p=.004), and lower subjective social status (t=2.68, p=.009). In addition, AA women described less attachment (t=2.34, p=.028) and reliable alliance social support provisions (t=3.27, p=.002) than NHW women. Predictors of loneliness differed between AA and NHW women in that higher levels of depressive symptoms and financial stress and lower levels of resilience, subjective social status, and the social provision of guidance predicted loneliness in AA women in the overall model (r
2
=.91, p=.000). In NHW women, only depressive symptoms and social integration uniquely predicted loneliness (r
2
=.79, p=.000).

Conclusions:
AA women experienced higher levels of loneliness than NHW women. Although depressive symptoms were a strong predictor of loneliness in both groups, high levels of financial stress and low levels of social status, resilience, and social guidance were unique contributors of loneliness in AA women. Findings from this study may assist researchers in developing and testing tailored interventions to address the effects of social disadvantages on loneliness in vulnerable populations.
Abstract WP40: Quick CT Perfusion Evaluation of Leptomeningeal Collateral Circulation: Single Cortical CBV-ROI
Authors: Rubiera Marta , Garcia-Tornell Alvaro , Boned Sandra , Romero Nicolas , Coscojuela Pilar , Muchada Marian , Juega Jesus , Rodriguez-Villatoro Noelia , Rodriguez-Luna David , Pagola Jorge , Molina Carlos A , Ribo Marc , Tomasello Alejandro
Published: June 2021

Good collateral circulation (CC) is a strong outcome predictor in acute stroke patients. CT angiography (CTA) is wide-world available but does not provide accurate information about parenchymal status. CT perfusion (CTP) is frequently used to determine ischemic core and tissue at risk. Our aim was to identify an easy and quick method to evaluate CC status by CTP.

Methods:
Consecutive ischemic stroke patients <8h from symptoms onset evaluated for reperfusion therapies were studied. Non-contrast CT, CTP and multiphase CTA were performed. Patients with confirmed M1-MCA or TICA occlusion on CTA were included. CC evaluation was determined by multiphase CTA (mCTA) according to the Calgary CC Scale and classified as poor (grades 0-2) or good (grades 3-5). In CTP maps, one single ipsi- and contralateral regions of interest (ROI) were defined in the MCA cortical territory (M4, M5, M6). We studied the association of absolute and relative to contralateral ROI-CTP values with CC degree determined by mCTA.

Results:
33 patients were included, median NIHSS 17.5 (2-22). Twenty-five patients (75.8%) presented a M1 and 8 (24.2%) a TICA occlusion. On mCTA, 27 (81.8%) patients presented with a favourable CC status and 6 (18.2%) with poor CC. Mean ROI values in the ischemic MCA territory were: CBV 3.5±1.5 ml/100mg, CBF 46.9±29.3 ml/100mg/min, MTT 8.1±3.1 s, Tmax 23.2±4.4 s. In the contralateral non-ischemic MCA, the mean ROI values were: CBV 3.48±1.4, CBF 66.5±32.7, MTT 5.6±2.3, Tmax 20.4±4.8. Absolute and relative CBV-ROI data (relCBV= ischemic CBV value / contralateral CBV value) were the only values significantly associated with CC status on mCTA (good CC mean CBV: 3.8 ml/100g VS poor CC mean CBV: 1.9, p=0.006; good CC mean relCBV 1.1 vs poor CC mean relCBV 0.6, p=0.019). A ROC curve defined 2.5 ml/100mg as the better cut-off point of ROI-CBV that identified patients with good CC status (sensitivity 96%, specificity 84%, VPP 0.96, VPN 0.83). Patients with a ROI-CBV >2.5 presented lower median NIHSS after 24 hours (4 vs 18, p= 0.012) and smaller mean infarct volume on control CT (27.9 vs 88.3, p=0.021).

Conclusion:
A single cortical ROI-CBV allows an easy and quick accurate evaluation of collateral circulation in CTP. ROI-CBV>2.5 ml/100mg is related to good clinical and radiological outcomes.
Abstract WP404: Stroke Cognitive Recovery Model
Authors: Alderman Susan
Published: June 2021

Background:
After an acute stroke, 90% of patients have cognitive deficits; 50% remain impaired and 30% develop dementia within one year. Cognitive recovery may not occur without early and coordinated care. Many cognitive deficits, i.e. memory and neglect, are not addressed early, care is not coordinated, and depends on each institution’s guidelines. Nurses must consider all patient needs yet no holistic cognitive recovery model exists to guide them.

Purpose:
To create a holistic, post-stroke, patient-centered cognitive recovery model capable of guiding care.

Methods:
Concept synthesis is a new way of grouping or ordering information when relevant data is unclear or unknown. A concept synthesis was performed due to limitations in prior biomedical models, specifically in psychology and rehabilitation, which resulted in ill-defined terms and bias.

Results:
Cognitive recovery is defined as a transitional state in which a person’s cognitive abilities can be modified to approach pre-injury levels, by the interactions of personal capabilities and four encompassing Environments. Personal capabilities (acceptance, agency and congruence) are internally oriented forces which control self-care behavior. The Environments (resources or forces interacting to help/hinder recovery) are depicted as the
Physical
(the body),
External
(social support, therapists, etc.),
Internal
(psychiatric or emotional forces), and
Created
(belief systems, attitudes, etc.).

Conclusions:
When interactions between personal capabilities and Environments are adequate cognitive recovery will progress. Recovery should be comprehensive and nurses are uniquely qualified to ensure all aspects of the person are addressed. This model promotes collaboration among healthcare providers and guidance in identifying and addressing patient needs.
Abstract WP409: Impact of Nursing Expertise and Staffing Ratio on Compliance with Post-tPA/Endovascular Patient Monitoring
Authors: Montgomery Kelly , Sindelar Danielle , Fussner Julie , Supan Erin , Sila Cathy
Published: June 2021

Introduction:
In 2014, the Post-tPA/Endovascular nursing monitoring flow sheet was revised to harmonize with the NIHSS exam. The challenges to performance and documentation compliance posed by the intensity and frequency of assessments have been the focus of an ongoing quality improvement initiative.

Methods:
All Post-tPA/Endovascular monitoring flow sheets from June 2014- June 2016 at University Hospitals Case Medical Center were reviewed for presence of neurologic assessments, vital signs, and management of hypertension per protocol. Stroke staff conducted in-services on the enhanced assessments and modified NIHSS training and house staff mentored bedside RNs in performing the NIHSS. A tip sheet was developed for staff on the modified NIHSS and real time feedback was given on all outliers.

Results:
Of 459 patients, compliance with all of the 684 monitoring data points ranged from 67-100% in the Neuroscience ICU (Patient: RN ratio 2:1), 75-100% in the Neuro-Intermediate Unit (Patient: RN ratio 3:1) and 40-100% in the Emergency Department (Patient: RN ratio 4:1). Overall compliance to > 95% of data points was seen in all but 5 patients with missing flow sheets. Symptomatic hemorrhagic complications after IVtPA decreased from 6.5% to 2.7%. Root-cause analysis of missing data points revealed seven areas of opportunity: Interference by diagnostic testing (29%), during patient transportation (22%), and following endovascular treatment (15%) or due to travelling RNs (8%). Missing documentation was most frequent during the q15 minute phase due to the intensity of monitoring (11%)- with the Emergency Department the most vulnerable location- and less during the q30 minute (4%) or q1 hour (3%) assessments. Units with dedicated neuroscience nursing adjusted more rapidly to the revision compared to units that do not routinely perform such assessments.

Conclusions:
Optimum compliance with nursing assessments and monitoring occur when there is no interference with diagnostic testing or procedures, the patient needs were a high priority and the patient acuity was well matched to the RN staffing ratio. This data supports a care model where a neuroscience trained RN nurse transitions with the patient during the first 24 hours after tPA/Endovascular therapy.
Abstract WP414: Dabigatran Has the Lowest Risk of Hemorrhage and Death Among Patients Taking SSRI/SNRIs That Require Anticoagulation
Authors: Al Jerdi Salman , Sarrazin Mary , Leira Enrique
Published: June 2021

Introduction:
Antidepressants have a vital role in treating post-stroke depression and improving motor recovery. SSRI/SNRI’s have antiplatelet effects, possibly increasing the risk of hemorrhage when taken with anticoagulants. The impact of concomitant SSRI/SNRI use on patients taking different anticoagulants for atrial fibrillation is not known.

Methods:
Data included Medicare Part A, B, and D claims for 2010-2013. Patients 66 years or older, with a new diagnosis of AF who initiated warfarin, dabigatran (150 mg bid) or rivaroxaban (20 mg od) within 90 days of diagnosis were included. SSRI/SNRI use was identified using prescription claims within +/- 90 days of anticoagulation initiation. Patients taking warfarin, dabigatran, and rivaroxaban with concurrent SSRI/SNRI were matched using a 3-way propensity algorithm. The relative hazards of death, stroke, GI hemorrhage, and other major hemorrhage were compared between anticoagulants.

Results:
We identified10,773 patients with SSRI/SNRI use, and 37,278 without SSRI/SNRI use. At baseline, patients who received SSRI/SNRIs were more likely than other patients to have several comorbid conditions, including coronary artery disease, liver disease, kidney disease, previous hemorrhage, and previous stroke. In matched samples of patients taking SSRI/SNRI, dabigatran users had the lowest incidence of any hemorrhage, with Hazard Ratio [HR]=0.78 (p=0.07) relative to warfarin; 0.68 (p=0.01) relative to rivaroxaban. Non-GI-hemorrhage was less likely with both dabigatran and rivaroxaban, compared to warfarin, while GI hemorrhage was most likely with rivaroxaban. The risk of death was significantly lower with dabigatran (HR 0.60; p<0.001) and rivaroxaban (HR 0.67; p=0.007), compared to warfarin. There was no difference in stroke incidence by anticoagulant type.

Conclusion:
In patients with AF and concomitant SSRI/SNRI use, dabigatran has the lowest risk of hemorrhage and mortality.
Abstract WP416: Tai Chi Exercise Reduces Stroke Risk Factors: A Randomized Controlled Trial
Authors: Chan Aileen W , Leung Doris Y , Sit Janet W , Chair S.Y.
Published: June 2021

Background and Purpose:
Risk factors for stroke include hypertension, diabetes, low blood high-density lipoprotein (HDL), physical inactivity and obesity. Among these, hypertension is the most important controllable risk factor for stroke. A total of at least 30 minutes exercise every day is recommended for prevention of stroke. This study aims to evaluate the effectiveness of Tai Chi exercise versus brisk walking exercise in reducing stroke risk factors.

Methods:
This was a randomized controlled trial. A total of 246 subjects with stroke risk factors were recruited from two outpatient clinics. They were randomly assigned into one of the three groups, namely, Tai Chi group (n=82), walking group (n=82), and control group (n=82). The Tai Chi group received Tai Chi training, which consisted of two 60-minute sessions each week for three months, and self-practice for 30 minutes every day. The walking group performed brisk walking for 30 minutes every day. The control group was advised to maintain their routine activities. The primary outcome was blood pressure. Secondary outcomes included fasting blood for lipid profile and sugar; body mass index, waist circumference and body fat percentage. Data were collected at baseline and 3-month post-intervention. Generalized estimating equations (GEE) model was used to compare the changes in outcomes across time between groups.

Results:
The mean age of the 246 subjects was 64.4 (SD=9.8), with 45.5% (n=112) were male. The GEE analysis showed that, as compared to the control group, the Tai Chi group demonstrated statistically significant greater reduction in systolic blood pressure (B=-10.25, P=0.001) and diastolic blood pressure (B=-6.50, P=0.002), and significant increase in HDL (B=0.16, P=0.012), while no significant differences were noted in the walking group. No significant changes were noted in the other outcome variables at 3-month.

Conclusion:
Regular Tai Chi exercise was effective in reducing the stroke risk factors by reducing high blood pressure and increasing HDL. Longer follow-up period was suggested for monitoring the sustainability of both Tai Chi and brisk walking to reveal the empirical effects of both exercises on stroke prevention.
Abstract WP42: Prediction of Blood-brain Barrier Disruption and Intracerebral Hemorrhagic Infarction Using Arterial Spin-labeling MRI
Authors: Niibo Takeya , Ohta Hajime , Miyata Shirou , Ikushima Ichirou , Yonenaga Kazuchika , Takeshima Hideo
Published: June 2021

Background and Purpose:
Arterial spin-labeling (ASL) MRI is sensitive for detecting hyperemic lesions (HLs) in patients with acute ischemic stroke (AIS). We evaluated whether HLs could predict blood-brain barrier (BBB) disruption and hemorrhagic transformation (HT) in AIS patients.

Methods:
In a retrospective study, ASL was performed within 6 hours of symptom onset before revascularization treatment in 25 patients with anterior circulation large vessel occlusion on baseline MR angiography. All patients underwent angiographic procedures intended for endovascular therapy and a noncontrast CT scan immediately after treatment. BBB disruption was defined as a hyperdense lesion present on the posttreatment CT scan. A subacute MRI or CT scan was performed during the subacute phase to assess HTs. The relationship between HLs and BBB disruption and HT was examined using the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) locations in the symptomatic hemispheres.

Results:
A HL was defined as a region where CBF
relative
≥1.4 (CBF
relative
=CBF
HL
/CBF
contralateral
). HLs, BBB disruption and HT were found in 9, 15, and 15 patients, respectively. Compared with the patients without HLs, the patients with HLs had a higher incidence of both BBB disruption (100% versus 37.5%, P=0.003) and HT (100% versus 37.5%, P=0.003). Based on the ASPECTS locations, 21 regions of interests (ROIs) displayed HLs. Compared with the ROIs without HLs, the ROIs with HLs had a higher incidence of both BBB disruption (42.8% versus 3.9%, P<0.001) and HT (85.7% versus 7.8%, P<0.001).

Conclusion:
HLs detected on pretreatment ASL maps may enable the prediction and localization of subsequent BBB disruption and HT.
Abstract WP43: Diffusion and T2 Star Weighted MR Angiography Mismatch Predicts Ischemic Penumbra in the Acute Stage
Authors: Yamaguchi Susumu , Horie Nobutaka , Tateishi Yohei , Morikawa MInoru , Suyama Kazuhiko , Matsuo Takayuki
Published: June 2021

Background and purpose:
T2 star weighted MR angiography (SWAN) can detect hemodynamic insufficiency as hypointensity areas in the medullary or cortical veins. In this study, we investigate whether SWAN in 1.5T MRI can help to detect ischemic penumbra-like lesions in acute ischemic stroke (AIS) patients.

Materials and methods:
Patients showing acute major vessel occlusion (ICA and MCA) within 4.5 hours from onset were consecutively analyzed with MRI including SWAN, DWI, and MRA. To evaluate ischemic area in SWAN and DWI, modified ASPECT (mASPECTS) were used. SWAN- and DWI- based mASPECTS was calculated, and correlation between DWI-SWAN mismatch and final infarct lesion or outcome was evaluated.

Results:
Thirty-five patients were included in this study. Of the 35 patients (mean age: 73.5
±
13.5 years), cardioembolic stroke was confirmed in 26 patients, atherothrombotic stroke was in 4 patients, and the others had unknown etiology. Overall, recanalization was achieved in 23 patients (65%), showing higher mASPECTS in follow up DWI and lower mRS at 90 days than patients with no recanalization (
P
=0.037 and
P
<0.001). Initial SWAN-based mASPECTS and follow-up DWI-based mASPECTS were both significantly higher in atherothrombotic stroke than in cardiogenic stroke (
P
=0.016 and
P
=0.042). Of 12 patients showing no recanalization, DWI-SWAN mismatch was significantly correlated with infarct growth (R
2
=0.6160,
P
=0.0025). On the other hand, there was no such correlation for patients showing recanalization. Interestingly, initial SWAN-based mASPECTS was significantly correlated with mRS at 90 days (R=-0.38,
P
=0.037) regardless of recanalization.

Conclusions:
DWI-SWAN mismatch in 1.5T MRI could show penumbra-like lesions in AIS patients with major vessel occlusion. Low mASPECTS in initial SWAN might predict unfavorable outcome. Assessment of ischemic penumbra from venous side using SWAN can visualize a lesion’s viable tissue and is quite useful without contrast media.
Abstract WP433: Targeting Organic Anion Transporting Polypeptide 1a4 (Oatp1a4) Expression at the Blood-brain Barrier: Implications for Treatment of Ischemic Stroke
Authors: Abdullahi Wazir , Brzica Hrvoje , Ronaldson Patrick
Published: June 2021

Introduction:
Stroke is a leading cause of mortality and morbidity. Several drugs with neuroprotective properties have been proposed for stroke treatment but many have failed in clinical trials. These failures may be due to limited drug permeability across the blood-brain barrier (BBB). Targeting endogenous BBB uptake transporters (i.e., organic anion transporting polypeptides (Oatps)) is a novel approach that can improve CNS delivery of drugs relevant to stroke therapy (i.e., statins). Optimal CNS drug delivery via Oatp in the setting of stroke requires characterization of regulatory pathways such as transforming growth factor (TGF)-β signaling. The goal of the present study was to investigate,
in vivo
, involvement of TGF-β signaling via the activin-like kinase (ALK)-1 receptor on Oatp1a4 expression at the BBB.

Methods:
Female Sprague-Dawley rats (200-250 g) were administered bone morphogenic protein-9 (BMP-9; 0-5 μg/kg, i.p.), an ALK1 agonist, or vehicle (i.e., 0.9% saline). Inhibition experiments were performed using LDN193189 (0-5 mg/kg, i.p.), an ALK1 antagonist. Western blot analysis and fluorescence microscopy of isolated brain microvessels were used to determine protein expression and localization in rat brain microvessels respectively.

Results:
Fluorescence staining demonstrated localization of Oatp1a4 and ALK1 in rat brain microvessels. Western blot analysis showed a dose dependent increase in Oatp1a4 protein expression in brain microvessels isolated from BMP-9 treated rats as compared to controls. Treatment with 0.5 μg/kg and 5 μg/kg BMP-9 resulted in a 55% and 116% increase in Oatp1a4 protein expression, implying that activation of ALK1 signaling can up-regulate Oatp1a4 at the brain microvasculature. In contrast, 6 h treatment with LDN193189 did not alter Oatp1a4 expression across a dose range of 0-5 mg/kg, suggesting that ALK1 inhibition does not modulate basal Oatp1a4 expression at the BBB.

Conclusions:
Taken together, our data implies that TGF-β/ALK1 signaling may play a role in altering Oatp1a4 protein expression at the BBB. Studies are currently being undertaken in our laboratory to fully characterize the role of TGF-β/ALK1 signaling in determining CNS delivery of drugs relevant to stroke treatment (i.e., statins).
Abstract WP447: Increased Platelet- and PMN-derived Extracellular Vesicles in Mice With Type 2 Diabetes
Authors: Nishijima Yasuo , Kanoke Atsushi , Yang Shih Y , Norris Philip , Liu Jialing
Published: June 2021

Introduction:
Extracellular vesicles (EV) including microvesicles, microparticles and exosomes are now being recognized as key players in cardiovascular/metabolic diseases, hemostasis and thrombosis. Platelet-derived EVs are particularly important in mediating thrombotic events, whereas monocytes-associated EVs are known to increase inflammation, which can potentiate and exacerbate platelet activation and platelet-leukocyte aggregation. However, the signature of EVs in the db/db mice with metabolic syndrome (MetS) is yet to be established.

Hypothesis:
EV numbers or phenotype differ between the control db/+ mice and db/db mice that are procoagulant.

Methods:
Platelet poor plasma (PPP) was collected from adult db/+ and db/db mice subjected to experimental stroke via distal middle cerebral artery occlusion or sham surgery. PPP was tested by flow cytometry using panels of antibodies to detect EVs derived from leukocytes (CD11b), neutrophils (Ly6G), platelets (CD41), and RBCs (Ter119), as well as those expressing the oxidized LDL receptor CD36. The rate of clot formation and maximum clot firmness of whole blood was determined using thromboelastography for the intrinsic and extrinsic pathways.

Results:
No significant differences were seen in total EV counts or those bearing CD36, CD11b, or Ter119 between genotypes. However, PMN and platelet-derived EV counts were higher in db/db mice compared to db/+ mice. RBC-derived EVs were higher in mice post-stroke, likely reflecting fragmentation of RBCs during the clotting process. PPP from db/db mice accelerated the coagulation of blood from db/+ mice and increase their clot strength.

Conclusions:
The plasma of db/db mice is procoagulant and with higher levels of platelet-derived and proinflammatory EVs, which may underlie the impaired retrograde collateral flow and poor outcome after ischemic stroke. Ongoing studies will investigate the causal relationship between EVs and the thrombophilia tendency observed in those with type 2 diabetes.
Abstract WP50: Computed Tomography Angiography is Better at Predicting Lesion Core Volume in Acute Ischemic Stroke Patients with Proximal Occlusion
Authors: O’Donnell Steve , Linn Alex , Majersik Jennifer , Wang Haimei , Chung Lee , de Havenon Adam
Published: June 2021

Introduction:
The Alberta Stroke Program Early CT Score (ASPECTS) is a validated tool measuring early ischemic changes on noncontrast CT (NCCT). We hypothesized an ASPECTS using CT angiography-source images (CTA-SI) would be superior to NCCT for predicting lesion core in patients with acute ischemic stroke (AIS).

Methods:
We included AIS patients from 2010-2014 with M1 middle cerebral artery (MCA) occlusion, NCCT, CTA-SI, and CT perfusion (CTP). Two raters through consensus assigned an ASPECTS to both NCCT and CTA-SI. CTP lesion core was independently determined with the Olea Sphere, OsiriX, and Siemens
syngo.via
software. MRI lesion core (diffusion weighted imaging (DWI) MRI lesion within 3 days of stroke onset) was measured with the Olea Sphere software. Statistical comparisons between continuous and ordinal variables were performed with Spearman’s rank correlation coefficient and between continuous variable with linear regression.

Results:
We included 61 patients in the final analysis, of which 24 also had MRI. The mean±SD age was 61±18 years and 61% were male. Mean NIH Stroke Scale at admission was 14.1±8.0 and median (IQR) follow-up modified Rankin Scale was 3 (1,6). The CTA-SI ASPECTS had superior correlation with lesion volume on all 3 software platforms compared to the NCCT ASPECTS; CTA-SI ASPECTS showed a significant correlation with MRI lesion core volume while NCCT ASPECTS did not (see Table 1).

Discussion:
CTA-SI likely shows regions with less cerebral blood flow that might not yet be hypodense on NCCT. Our results suggest that in patients with AIS and proximal MCA occlusion CTA-SI ASPECTS better predicts lesion core volume, itself an independent predictor of clinical outcome, defined on both CTP and MRI DWI compared with NCCT ASPECTS.