bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP258: Unique Properties Associated With the Iron Chelator HBED Reveal Remarkable Beneficial Effect After Brain Trauma
Authors: Khalaf Saher , Chamara K.V.D. Ranga , Ahmad Abdullah S. , Golovachev Nikita V , Dadamyan Artem F , Sahagian Todd J , Doré Sylvain
Published: October 2018

Introduction:
Iron is postulated to contribute to secondary injury after brain trauma through many pathways. Iron participates in the oxidative stress and inflammation processes. The N,N’-Bis(2-hydroxybenzyl)ethylenediamine-N,N’-diacetic acid (HBED) is a unique iron chelator as it has ability to cross the blood brain barrier, higher affinity to iron, and longer half-life than most commonly used chelators.

Hypothesis:
Our study is investigating the efficacy of HBED in protecting brain tissue and improving behavioral outcomes after brain trauma. We are also exploring the histological and biochemical mechanisms behind its beneficial effect.

Methods:
WT C57BL/6 mice were injected with HBED SQ after TBI and then twice a day till an end point of 3 days. Controlled-cortical impact trauma model was used to inflict injury. Neurobehavioral tests were performed to assess the degree of neurological deficit and short-term recovery over 3 days. We determined cortical Injury volume, hemispheric volume, hippocampal swelling, and corpus callusom volume/thickness. Perls’ and immunohistochemical staining analysis is being performed to assess iron deposits and to inspect microgliosis, oxidative stress injury, and determine the astrocyte roles in regulating brain edema.

Results:
Thus far, data revealed that HBED treatment significantly decreases motor deficits and improves short term recovery. It also reduces each of cortical injury volume by 36.5±23.5% (p<0.001), hippocampal swelling by 23.3±13.2% (p<0.05), and total hemispheric volume by 13.2±9.5% (p<0.05). Recent data on upcoming results will also be reported.

Conclusion:
This iron chelator HBED protects against acute traumatic motor deficits and promotes short-term recovery. It reduces cortical injury, hippocampal swelling, and total hemispheric volume after traumatic brain injury. These findings indicate that using HBED in humans may have similar robust effect and ultimately facilitates functional recovery.

[This work was supported in part by grants from the McKnight Brain Research Foundation, Brain and Spinal Cord Injury Research Trust Fund, and AHA 33450010, and NIH R21NS095166.]
Abstract WP259: AT2 Receptor-interacting Protein Enhances Protective Effect of AT2 Receptor Stimulation in Ischemic Brain Damage
Authors: Iwanami Jun , Mogi Masaki , Wang Xiao-Li , Tsukuda Kana , Higaki Akinori , Kawakami Moe , Kukida Masanori , Nakaoka Hirotomo , Yamauchi Toshifumi , Bai Hui-Yu , Shan Bao-Shuai , Min Li-Juan , Horiuchi Masatsugu
Published: October 2018

Objective:
Accumulating evidences and previous our research suggest that angiotensin II type 2 (AT
2
) receptor stimulation could contribute to protection against ischemic brain damage. We have cloned ATIP (AT
2
receptor interacting protein) as a protein interacting specifically with the C-terminal tail of the AT
2
receptor, and reported that ATIP might play key roles in diverse mechanisms of AT
2
receptor signaling. However, the effect of ATIP on ischemic brain damage is still unclear. Therefore, we investigated the effects of the ATIP and compound 21 (C21), a selective non-peptidic AT2 receptor agonist, on focal cerebral ischemia.

Method:
Ten-week-old male ATIP-transgenic (ATIP-Tg) and littermate (WT) mice were subjected to middle cerebral artery occlusion (MCAO) with silicon-coated micro-filament. C21 (10 μg/kg/day) was administered 2 weeks before MCAO. Twenty-four hours after MCAO, ischemic area was determined. Cerebral blood flow (CBF) before and after MCAO was measured by laser speckle flowmetry. Collateral circulation was evaluated by the perfusion of India ink. Expression of mRNA was determined by real-time RT-PCR.

Results:
There was no significant difference in ischemic size without C21 treatment between two strains. Treatment with C21 decreased ischemic size in both strains. Interestingly, this protective effect of C21 was more marked in ATIP-Tg compared with WT mice. In CBF of core region of ischemic area, there were no significant differences among all groups. However, the reduction of CBF in penumbra region just after MCA occlusion was attenuated in ATIP-Tg mice with C21 administration. Treatment with C21 tended to increase the cerebral collateral number before MCA occlusion in ATIP-Tg mice. Expression of vascular endothelial growth factor (VEGF) mRNA in the cortex before MCA occlusion did not differ among all groups. Expression of methyl methanesulfonate sensitive 2 (MMS2) as a neuroprotective factor increased in ipsilateral hemisphere of ATIP-Tg mice compared with contralateral hemisphere.

Conclusions:
These results suggested that ATIP could enhance the cerebral protective effects of AT
2
receptor stimulation at least in part due to the attenuation of CBF reduction and increase of MMS2 expression after ischemia.
Abstract WP262: Neuroglobin Mediates Neuroprotection of Hypoxic Postconditioning Against Transient Global Cerebral Ischemia in Rats via Preserving the Activity of Na
+
/K
+
ATPases
Authors: Xu En , Wen Haixia , Liu Liu , Zhan Lixuan , Liang Donghai , Li Luxi , Liu Dandan , Sun Weiwen
Published: October 2018

Introduction:
Hypoxic postconditioning (HPC) is an innovative neuroprotective strategy with pro-survival effects on hippocampal neurons against transient global cerebral ischemia (tGCI), but the mechanisms have not yet been completely elucidated. Neuroglobin (Ngb) is an endogenous neuroprotectant with hypoxia-inducible property whose role in experimental stroke has increasingly been attractive. In this study, we explored the role and underlying mechanism of Ngb in HPC-mediated neuroprotection after tGCI.

Methods:
HPC was carried out with air containing 8% O
2
and 92% N
2
24 h after 10 min tGCI induced by a four-vessel occlusion method in adult male Wistar rats. The level of Ngb and Na
+
/K
+
ATPases β1 subunit (Atp1b1) were measured by immunohistochemistry, western blot and immunofluorescence after tGCI and HPC with or without the administration of Ngb antisense oligodeoxynucleotide (AS-ODNs) and lentivirus. Then reactive oxygen species (ROS) was detected via DCFH-DA and immunoprecipitation was performed to measure the glutathionylation of Atp1b1. Finally, the activity of Na
+
/K
+
ATPases (NKA) was detected by a Na
+
K
+
-ATPase assay kit.

Results:
HPC increased Ngb expression in CA1 subregion after tGCI. Inhibition of Ngb expression with Ngb AS-ODNs abolished HPC-mediated neuroprotection, whereas overexpression of Ngb ameliorated neuronal damage in hippocampal CA1 subregion after tGCI, confirming that Ngb upregulation is involved in the neuroprotection of HPC against tGCI. Similar to the tendency of Ngb expression, the membranous level of Atp1b1, a Ngb-interacting protein, reduced after tGCI while increased after HPC. Notably, knockdown of Ngb reversed the increase of membranous Atp1b1 mediated by HPC, whereas Ngb overexpression induced an opposite result. Furthermore, we found that Ngb upregulation after HPC maintained membranous Atp1b1 through the direct Ngb-Atp1b1 interaction and reduced the glutathionylation of membranous Atp1b1 via suppression of ROS, finally enhancing the activity of NKA.

Conclusions:
Our results suggested that Ngb preserved the activity of NKA after tGCI via its regulation on both the level and the glutathionylation of membranous Atp1b1, which contributed to HPC-mediated neuroprotection against tGCI.
Abstract WP264: Early Rehospitalization for Stroke Higher With Aspirin or No Antithrombotic Therapy Than With Oral Anticoagulation in an Unselected Population of Patients With Atrial Fibrillation
Authors: Alberts Mark , James Roberta A , Marcsisin Victoria S , Shah Bimal R , Berger Peter B , Pokorney Sean , Naccarelli Gerald V , Hylek Elaine M , Granger Christopher B
Published: October 2018

Introduction:
Rehospitalization after discharge for a wide variety of medical conditions is common and is associated with increased morbidity and cost. We investigated the rates of rehospitalization for stroke in a population of patients hospitalized with atrial fibrillation (AF) who were at risk of stroke.

Methods:
Using the Premier Healthcare Database (representing 1 in 5 US hospital discharges), we identified 1,147,866 patients hospitalized from January 1, 2011 through June 30, 2015 with AF and a guideline indication for an oral anticoagulant based on a CHA
2
DS
2
-VaSC score ≥ 2. The primary outcome was readmission within 90 days due to acute ischemic stroke (AIS) or intracranial hemorrhage (ICH). Multivariable logistic regression was used to compare rehospitalization rates for patients receiving various oral antithrombotic therapies, while controlling for numerous patient risk factors, reasons for current hospitalization, and hospital characteristics. Confidence intervals and p-values were adjusted for multiple comparisons using Holm-Bonferroni.

Results:
Patients were 53% female with a mean age of 77 (±11) years. The distribution of patients on various antithrombotic agents at discharge was 23% with no therapy, 20% ASA only, 1% dual-antiplatelet therapy (DAPT), 17% non-vitamin K oral anticoagulants (NOAC), and 39% warfarin. Table 1 displays rehospitalization rates, unadjusted (therapy only), and adjusted for all covariates using logistic regression analysis.

Conclusions:
AF patients discharged on ASA alone or no antithrombotic therapy, compared to warfarin, were more likely to have early rehospitalization for acute ischemic stroke. Patients treated with NOACs had early ischemic stroke rehospitalization rates similar to warfarin, but were less likely to be have early rehospitalization for ICH when compared to warfarin.

Table 1: 90-Day Rehospitalization Rates by Antithrombotic Agents
Abstract WP266: Associations Between Temporal Improvement of Stroke Care Capabilities and Functional Outcome in Acute Ischemic Stroke: J-aspect Study
Authors: Kamitani Satoru , Nishimura Kunihiro , Kada Akiko , Kurogi Ai , Kurogi Ryota , Nakamura Fumiaki , Onozuka Daisuke , Hagihara Akihito , Ono Junichi , Nakagawara Jyoji , Okuchi Kazuo , Nagata Izumi , Matsuda Shinya , Suzuki Akifumi , Toyoda Kazunori , Yoshimura Shinichi , Miyachi Shigeru , Shiokawa Yoshiaki , Ogasawara Kuniaki , Aruga Toru , Miyamoto Yoshihiro , Ido Keisuke , Nishimura Ataru , Arimura Kouichi , Sayama Tetsuro , Iihara Koji
Published: October 2018

Introduction:
Certification system of the primary and comprehensive stroke center (PSC and CSC) is still under discussion in Japan. This study attempts to examine associations between the variation of stroke center capabilities and the improvement of outcomes for acute ischemic stroke on a national scale.

Hypothesis:
Improvements in hospital stroke center capabilities leads to better outcome of acute ischemic stroke patients.

Methods:
Using a validated score for evaluating CSC capabilities, which consists of 5 categories (personnel, diagnostic techniques, specific expertise, infrastructure, and education) on a 25 point scale, we assessed CSC capabilities for 137 certified training hospitals in 2011 and 2015 (Kada et al. BMC Neurol 2017). A consecutive health insurance claims data known as the Japanese Diagnosis Procedure Combination/Per Diem Payment Systems of 2011 and 2015 was obtained from the hospitals. The proportion of favorable outcome—score 0 to 1 on the modified Rankin Scale (mRS)—at discharge was quantified as the primary outcome. The change in CSC score with more than two points over time was quantified as an independent variable. We regressed the change of CSC score on morbidity with adjustment of average age and sex in the hospitals.

Results:
In total, 18,658 in 2011 and 29,999 in 2015 ischemic stroke patients were admitted to 137 hospitals. Median annual number of ischemic stroke patients per hospital increased from 115 to 183 over time. Mean age (74.5 year vs 74.2 years) and proportions of men (56.8% vs 58.2%) were almost the same. The mean CSC scores increased from 15.9±4.0/25 to 17.2±4.2/25 point. The mean hospital mortality decreased from 6.1% to 4.3%. The mean proportion of patients with the favorable outcome at discharge increased from 39.2% to 45.5%. We selected random-effect model based on Housman test. In regression analyses, the increase of CSC score over time was significantly associated with the increasing proportion of the favorable outcome at discharge (coefficient, 2.76; 95% CI, 0.04-5.47; p-value, 0.047).

Conclusions:
Improvements in CSC capabilities overtime was significantly related to the improvement of functional outcome at discharge in ischemic stroke patients.
Abstract WP269: Induced Harking: Selective Reporting Bias After Changes in Instructions for Preparing Abstracts for the International Stroke Conference
Authors: Hou Jesse W , Rao Neal M , Saver Jeffrey L
Published: October 2018

Background:
Irreproducibility is a systemic problem in medical research, affecting 75-89% of major reported findings. An important cause of irreproducibility is hypothesizing after the results are known (HARKing): presenting a
post hoc
hypothesis according with findings as if it were a confirmed
a priori
hypothesis. Meeting abstract instructions may deter or encourage HARKing.

Hypothesis:
Compared with abstract instructions NOT indicating a "hypothesis" should be stated, instructions indicating THAT a "hypothesis" should be stated will increase the proportion of abstracts judged by field content experts to exhibit HARKing.

Methods:
We analyzed purposefully random-sampled abstracts from 3 ISC meeting years with highly forceful (2015), moderately forceful (2017), and no (2013) requirements for statement of a “Hypothesis” in abstract preparation instructions, regardless of whether a hypothesis statement was appropriate (confirmatory science) or inappropriate (exploratory science).

Results:
The 153 abstracts, 51 in each meeting year, equally sampled 17 ISC topic categories. Explicit “hypothesis” statements were most common in the highly forceful instruction year (35%), intermediate in the moderately forceful year (26%), and least frequent in the no requirement year (11%) (p < 0.02). Among hypothesis statements, 84% were deemed falsifiable, and 16% non-falsifiable. Of falsifiable hypotheses, 74% were adjudicated by two independent content experts as likely to be hypotheses generated after the results were known (HARKing). 0% of hypotheses were stated as pre-registered prior to study conduct. HARKing was most common in the highly and moderately forceful instruction years (24% each) and less frequent in the no requirement year (10%) (p < 0.01).

Conclusions:
Abstract preparation instructions suggesting use of a hypothesis statement likely promote hypotheses after the results are known. To improve reproducibility of stroke science, ISC abstract preparation instruction revisions may be desirable, recommending hypothesis statements only for the small proportion of stroke studies that are of confirmatory, rather than exploratory, design.
Abstract WP277: Stroke Triage and Diagnosis Processes Associated With Improved Door-to-Needle Time and tPA Rates
Authors: Nadasdy Zoltan , Shpak Maxim , Cowperthwaite Matthew C , Ramakrishnan Anurekha , Jennings Jon , Moody Ashley , Orndorff Kevin , Fanale Christopher V
Published: October 2018

Introduction:
The rapid diagnosis of an acute (AIS) ischemic stroke and determination of tPA eligibility requires efficient clinical processes and care coordination. Several quality initiatives have focused on door to needle time (DNT) and tPA rates, but few studies have investigated the impact of specific clinical-process elements on improving these quality metrics.

Hypothesis:
There are specific elements of triage and diagnosis processes that are associated with reduced DNT and higher tPA rates.

Methods:
A 42-item survey assessing the implementation times of 21 interventions was distributed to facilities in a large hospital system; median quarterly DNT and tPA rates were extracted for 2015-2017 for all hospitals surveyed. We compared the average DNT and tPA rates before and after implementation of the intervention using t-tests and ANOVA. When before-after comparisons were not possible, we compared the average DNT and tPA between facilities that implemented and did not implement the intervention.

Results:
83 (47%) hospitals completed the survey. We found that strong predictors of post-intervention reduction of DNT (p < 0.01) included (i) implementation of pre-hospital communications with EMS, (ii) employment of a full-time stroke coordinator, (iii) bypassing the ED to go directly to a CT scan and (iv) pre-mixing tPA prior to CT. Including a pharmacist and registrar when responding to stroke alerts had the strongest effect on tPA rate (p < 0.01). Weaker effects on tPA rates were seen for implementations of point of care testing for different laboratory values and prioritizing the processing of labs orders for strokes.

Conclusions:
This study identified several interventions with the strong effect on DNT and tPA rates, suggesting these interventions could be prioritized at stroke centers. Our results also suggest some commonly cited clinical processes are not associated with shorted DNT and increased tPA rates.
Abstract WP278: Underutilization of Outpatient Cardiac Monitoring in Patients With Embolic Stroke of Unknown Source
Authors: Ricci Brittany A , Chang Andrew D , Hemendinger Morgan , Narwal Priya , Dakay Katarina , Cutting Shawna M , MacGrory Brian , Burton Tina , Song Christopher , McTaggart Ryan , Jayaraman Mahesh , Panda Nikhil , Chu Antony , Merkler Alexander , Gupta Ajay , Kamel Hooman , Fuire Karen , Yaghi Shadi
Published: October 2018

Background:
Recent studies have shown that outpatient cardiac monitoring for 30 days or longer increases detection rate of paroxysmal atrial fibrillation (AF) after Embolic Stroke of Unknown Source (ESUS). For patients with AF detected on monitoring, anticoagulation can be initiated to reduce risk of recurrent stroke. In this study, we aim to compare characteristics between patients who received cardiac monitoring and those who did not to further elucidate trends in the use of prolonged outpatient cardiac monitoring following ESUS.

Methods:
We analyzed a retrospective cohort of patients discharged with a diagnosis of ESUS over a period of 18 months in whom outpatient cardiac monitoring was ordered. Patients who were deceased or without follow-up at 90 days were excluded. Patients were divided into two groups based on whether or not they received outpatient cardiac monitoring. We compared demographic data, clinical risk factors, and NIHSS between the two groups.

Results:
Out of 282 patients with ESUS, 189 (67.0%) patients had 90 day follow-up data available; 118 (62.4%) underwent cardiac monitoring and 71 (37.6%) did not undergo cardiac monitoring. Of the patients who were monitored, 81.4% (96/118) received a 30 day non-invasive monitor and 43.2% (51/118) patients had an ICM implanted. There were no significant differences in baseline characteristics among patients who underwent cardiac monitoring versus those who did not.

Conclusion:
More than one-third of patients with ESUS for whom outpatient cardiac monitoring was recommended and ordered did not actually receive it. This finding supports the need for more convenient, effective processes by which patients can follow through with outpatient cardiac monitoring which could perhaps be initiated at discharge.
Abstract WP279: Modelling the Impact of Multiple Mobile Stroke Units Surrounding a Metropolitan Area
Authors: Holodinsky Jessalyn K , Kamal Noreen , Zerna Charlotte , Zhu Luke , Hill Michael D , Goyal Mayank
Published: October 2018

Introduction:
The Mobile Stroke Unit (MSU) has brought stroke imaging and alteplase administration to the field, shortening onset to needle time in some situations. In areas with widespread urban sprawl, having MSUs stationed in the community may improve patient outcomes. For patients with suspected large vessel occlusion (LVO) using the Los Angeles Motor Scale (LAMS) we compare the probability of good outcome for patients taken direct to Comprehensive Stroke Centre (CSC) (mothership) vs. utilizing multiple MSUs.

Methods:
Using conditional probability models for patients with suspected stroke with LVO (LAMS ≥4) the probability of good outcome for the mothership and MSU scenarios were generated. A sliding dichotomy was used to define good outcome, mRS 0-2 at 90 days was used for LVO patients and mRS 0-1 was used for non-LVO patients. Data from the HERMES collaboration was used for EVT patients, data from the Emberson meta-analysis (extrapolated to the HERMES population for LVO) was used for alteplase treated patients. Probability of good outcome for intracranial hemorrhage and stroke mimics was considered time invariant.

Results:
The results are visualized using temporal-spatial diagrams with one CSC and four MSUs stationed at various distances from the CSC with each MSU covering one quarter of the city. The addition of four MSUs in a small geographic area (60 min radius from CSC) does not predict improved patient outcomes. However, as the size of the geographic area increases the relevance of the MSU becomes apparent in the areas closest to the MSU.

Conclusions:
From a patient outcomes perspective multiple MSUs may be necessary to have the possibility of superior patient outcomes than the mothership transport method if they are situated far away from the CSC. This in addition to the individual environment and cost-effectiveness should be taken into context when deciding the best place to house future MSUs.
Abstract WP28: Safety and Feasibility of Angioplasty and Stenting in Symptomatic Internal Carotid Artery Occlusive Disease
Authors: Panczykowski David M , Jadhav Ashutosh P , Jumaa Mouhammad A , Aghaebrahim Amin , Ranginani Manasa , Nguyen Felix , Grandhi Ramesh , Ducruet Andrew F , Gross Bradley A , Jankowitz Brian T , Jovin Tudor G
Published: October 2018

Introduction:
Symptomatic internal carotid artery occlusion (ICAO) can lead to subsequent neurologic decline, recurrent stroke, and mortality. We sought to evaluate safety and feasibility of endovascular revascularization for ICAO without tandem intracranial large vessel occlusion (LVO).

Methods:
This is a retrospective cohort analysis of all patients presenting to a single academic center with ischemic stroke and ipsilateral, cervical ICAO from November 2003 through April 2016. Patients were excluded if pre-procedural angiography demonstrated tandem LVO or if patients were known to have chronic ICAO. Study endpoints included discharge neurologic exam, post-procedural infarct burden, 3-month functional outcomes, and treatment durability.

Results:
A total of 107 patients with symptomatic, angiographically confirmed cervical ICAO without tandem LVO were identified. Median admission NIHSS was 8 (IQR 11). Baseline radiographic stroke severity was assessed by ASPECT score (median 9; IQR 2), perfusion mismatch (present in 93%), and clinical-diffusion mismatch (42%). Median time from symptom onset to treatment was 25 hours (IQR 61). Successful revascularization was achieved in 92% of patients. At discharge, 83% had stable or improved NIHSS, while at 3-months 65% achieved functional independence (mRS ≤2). The most common complication was distal embolization (22%) of which 16% required intra-arterial treatment. Rate of significant restenosis (≥70%) was 15% at 1-year.

Conclusions:
Stenting in selected patients at risk of neurological deterioration due to symptomatic ICAO can be performed with high rates of technical success and good clinical outcomes. Because of significant peri-procedural risks and high rates of restenosis, randomized studies are necessary to understand the benefit of this approach.
Abstract WP280: Sleep Apnea Screening is Uncommon After Stroke
Authors: Brown Devin L , Jiang Xiaqing , Li Chengwei , Case Erin , Garcia Nelda , Sozener Cemal , Lisabeth Lynda
Published: October 2018

Introduction:
Sleep apnea (SA) predicts poor functional outcome and mortality after stroke. Minority populations, including Mexican Americans (MAs), have worse outcomes after stroke than non-Hispanic whites (NHWs) and tend to have poorer access to care. We therefore sought to (1) assess access to SA-related care among post-stroke patients within a population-based study without an academic medical center, and (2) to compare ethnic differences in access to SA-related care in the post-stroke period in MAs and NHWs.

Methods:
MA and NHWs with ischemic stroke or intracerebral hemorrhage in the Brain Attack Surveillance in Corpus Christi project between 2011-2015 were interviewed at approximately 90 days after stroke in reference to the post-stroke period. Questions included whether their clinical provider directly asked about (1) snoring or (2) daytime sleepiness, or (3) had offered polysomnography. Logistic regression was used to test the association between ethnicity and the three outcomes unadjusted and adjusted for potential confounders: age, sex, insurance status, primary care provider status (PCP), BMI, stroke type, NIHSS at stroke presentation, hypertension, diabetes, atrial fibrillation, hyperlipidemia, and current smoking.

Results:
Of the almost 1,000 respondents, 49% were male, 63% MA, 81% had hypertension, 48% had diabetes, and 10% did not have a PCP. Mean age was 69 (SD=12) and mean BMI was 30 (SD=6.8). MAs were younger, had a higher BMI, greater prevalence of hypertension, diabetes, never smoking, and lower prevalence of atrial fibrillation than NHWs. Of the 985 respondents to the symptom questions, 50 (5%) reported being directly queried about snoring and 86 (9%) reported being directly queried about sleepiness. Fifty-five of 981 (6%) reported having been offered polysomnography by their providers. No ethnic differences were found among the three outcomes in unadjusted or adjusted analyses.

Conclusion:
Screening for classic symptoms of SA and offers for formal testing of SA by clinical providers are rare by 90 days post-stroke, without ethnic differences. Provider education is needed to raise awareness about the very high prevalence of SA among stroke patients and its association with poor outcomes after stroke.
Abstract WP285: Advanced Directives and Care Planning in the Stroke Clinic: Results of a Quality Improvement Survey
Authors: Johnson Paul , Siv Jenny , Creutzfeldt Claire
Published: October 2018

Introduction:
Stroke is the 2
nd
most common cause of death and the leading cause of disability worldwide. Stroke survivors have high rates of comorbid medical conditions; one in 5 stroke survivors will suffer a recurrent stroke within 5 years, and a TIA doubles the risk for heart attack. In the acute stroke setting, patients are frequently unable to participate in their own medical decision making. Therefore, advanced care planning (ACP) should be a fundamental part of post-stroke care.

Methods:
We surveyed stroke survivors and stroke physicians in our tertiary care stroke clinic as part of a quality improvement program. All new and follow-up patients were invited to complete a 12 question survey on ACP, including history of relevant discussions and perceived risk of recurrent stroke or disability. Stroke physicians documented demographic data, NIHSS, any acute treatment received, mRS and provided a risk estimate for recurrent stroke or death.

Results:
Between March and July 2017, 198 surveys were completed. Median age was 61 years (IQR 50-70), 94 (47.5%) were female, and 61% presented to the stroke clinic for the first time after their stroke. The majority (55%) had an initial NIHSS of 5 or less, and 10% had received IV tPA or thrombectomy during their acute stroke care. At the time of follow-up, median mRS was 1 (IQR 0-2). Almost ¾ (n=145) had had a conversation with a physician about ACP, and 110 (56%) wanted to discuss ACP with their stroke physician. Less than one half (n=88) had advance directives (AD) in place. Patients were significantly more likely to have AD if they were white (53% compared to 24% in all other races, p<0.001) and less disabled (55% for those with mRS 0-1 compared to 31% in those with mRS ≥ 2 (p=0.002). Having discussed their risk of recurrent stroke with a physician was also associated with higher rates of AD (58% vs 37%, p=0.004).

Conclusions:
Most patients presenting to stroke clinic do not have advance directives, but a willingness to discuss ACP is common. We identified certain groups who were less likely to have advance care plans. Our findings suggest that the stroke clinic may be an optimal setting for a targeted intervention to increase access to ACP.
Abstract WP288: Patient, Caregiver, and Layperson Preferences of Informed Consent for tPA
Authors: Mendelson Scott J , Gordon Elisa , Capo-Lugo Carmen E , Thomas Leena , Holl Jane , Prabhakaran Shyam
Published: October 2018

Objective:
Based on patient, caregiver, and layperson input, we aimed to identify themes, preferences, content, framing, and sequencing of the informed consent process for tPA in acute ischemic stroke (AIS) patients.

Background:
Informed consent potentially delays or results in refusal of tPA in up to 10% of eligible AIS patients. There remain critical gaps in the appropriate content, delivery mode, and optimal timing of the informed consent process for tPA.

Methods:
Using a mixed-methods qualitative approach through separate focus groups of stroke patients and caregivers, and laypeople with limited experience with stroke and from diverse race and ethnic backgrounds, we identified preferences in describing risks and benefits of tPA during AIS patient evaluation. All focus groups followed a structured guide designed to elicit participant feedback regarding (1) decision-making preferences, (2) existing and hypothetical decision aid content, and (3) timing of information delivery for an informed consent process for tPA.

Results:
Stroke patients (n=15) and their caregivers (n=7) preferred a shared decision-making model that included minimal information and emphasized rapid decision making. Laypeople (n=31) also preferred a shared decision-making model for providing informed consent, but had higher information needs than stroke patients and caregivers. The majority of all focus group participants expressed a preference for a verbal description of risk and benefits. A minority of laypeople desired detailed visual aids to facilitate information exchanged during the informed consent process. The majority of focus group participants preferred stacked bar graphs or pie charts over pictograms to convey information regarding outcomes following tPA.

Conclusions:
Qualitative analyses of informed consent for tPA suggest that laypeople have higher information needs than stroke patients and caregiver. Given that the majority of patients who receive tPA do not have a history of prior stroke, shared decision-making aids should consider laypeople preferences while remaining brief given the time-sensitivity of tPA therapy. Optimizing the shared decision-making process for tPA could reduce consent-related delays and refusals of tPA.
Abstract WP289: Comparison of Ischemic Stroke in China versus India: Patient Characteristics, Performance Measures and Outcomes
Authors: Li Zixiao , Pandian Jeyaraj , Sylaja PN , Wang Yilong , Wang Xingquan , Liu Liping , Wang Chunjuan , Padma MV , Khurana Dheeraj , Kaul Subhash , Schwamm Lee H , Wang Yongjun , Singhal Aneesh B ,   the Indo-US Stroke Project and the China NationalStroke Registry-II
Published: October 2018

Background:
Although major stroke burden occurs in developing countries, there is lack of comparable assessment of patient characteristics, adherence to guideline-recommended performance measures, and outcomes in acute ischemic stroke (AIS). We compared data from Indo-US Stroke Registry (ISR) and China National Stroke Registry-II (CNSR-II).

Methods:
The ISR prospectively enrolled N=2066 over 2 years across five large academic hospitals in different geographic regions in India. From CNSR-II we selected 31 large academic hospitals mainland provinces in China, where N=1973 were prospectively enrolled over an overlapping 9-month period. In-hospital patient characteristics, adherence to guideline-recommended performance measures, in-hospital mortality, and 3-month outcomes were compared.

Results:
As compared to ISR, patients in the CNSR-II were significantly older (mean age 63.9 vs. 58.3 years, p=0.001), had less diabetes mellitus and dyslipidemia but more hypertension and atrial fibrillation (AF), and lesser stroke severity (NIHSS median 4 vs. 10, p<0.001). Patients in China were more likely to receive early antithrombotic, dysphagia screening, antiplatelet at discharge, and stroke education, but less likely to receive IV rt-PA, anticoagulation for AF, statin treatment, and antihypertensive medication. Patients in China had lower in-hospital mortality (1.2% versus 7.9%) and better 3-month outcomes (modified Rankin Scale score <2, 78.1% vs. 49.3%, p<0.001).

Conclusions:
Chinese and Indian populations have a significantly different vascular risk profile. Differences in the care delivery, stroke resources and infrastructure (e.g. Indian hospitals preferably admit more severe strokes and thrombolysed patients), may explain the differences in outcomes. Our results are relevant to tailoring National approaches to acute and in-hospital stroke management in China and India, and may have implications for other developing countries.
Abstract WP29: The Causes of 30-Day Unplanned Readmission in Acute Ischemic Stroke Patients Treated With MT, IV-tPA and Combined Group: A National Analysis
Authors: Patel Smit , Desai Rupak , Patel Upenkumar , Patel Neel , Kiran NFN , Mehta Tapan
Published: October 2018

Background:
Acute ischemic stroke (AIS) patients undergoing complex treatments are highly vulnerable to readmission. Limited studies have been performed to compare the 30-day readmission rates and causes in AIS patients treated with Intravenous tissue plasminogen activator (IV-tPA), mechanical thrombectomy (MT), and both.

Methods:
We obtained national readmission dataset (NRD 2014), a subset of Healthcare Cost and Utilization Project (HCUP) to analyze the 30-day readmission estimates from January to November 2014 after excluding elective readmission. The AIS patients undergoing IV-tPA and MT were identified by using ICD-9 diagnosis codes 99.10, V45.88 and 39.74 respectively. We used SAS 9.4 version for data analysis and SURVEYMEANS procedure was used to measure readmission rate. Discharge weights were provided by HCUP applied to produce national estimates.

Results:
The NRD contained 341621 admissions (weighted N =741129) of AIS patients in 2014. After excluding elective readmissions, all cause 30-day readmission rate was 10.64%, 13.07%, and 10.66% for IV-tPA, MT and combined treatment group. The top causes of unplanned readmission in all 3 groups were infections and acute cerebrovascular disease. The next common causes for readmission were congestive heart failure, acute renal failure in MT group, transient cerebral ischemia and congestive heart failure in IV- tPA group whereas, cardiac dysrhythmia and complications of medical and surgical care in combined group. Other causes are shown in
Table 1
.

Conclusions:
Infections and acute CVD were the most common culprits of readmissions in all 3 groups. Amidst the ongoing debate over advantage of adding IV-tPA in stroke patients undergoing MT, the insights into 30-day readmission rates and causes comparison will help to strategize post-AIS preventive care to lower down the readmission rates and health care burden.
Abstract WP293: Long-Term Healthcare Costs of Stroke and Major Bleeding in Patients With Atrial Fibrillation Treated With Non-Vitamin K Antagonist Oral Anticoagulants
Authors: Rozjabek Heather M , Coleman Craig I , Ashton Veronica , Laliberté François , Oyefesobi Paul , Lejeune Dominique , Germain Guillaume , Schein Jeff R , Yuan Zhong , Lefebvre Patrick , Peterson Eric D
Published: October 2018

Background:
Patients with non-valvular atrial fibrillation (NVAF) use oral anticoagulants (OACs) to decrease their risk of stroke; however, taking OACs may also increase their risk of bleeding.

Objective:
To assess long-term healthcare costs related to ischemic stroke/systemic embolism (SE) and major bleeding events in patients with NVAF treated with non-vitamin K antagonist oral anticoagulants (NOACs).

Methods:
Clinformatics™ Data Mart database from 1/2009-12/2016 was analyzed. Patients aged ≥18 with ≥1 ischemic stroke or SE hospitalization claim (index date) were matched 1:1 to patients without a stroke based on propensity scores. Patients with a major bleeding event identified using a validated algorithm (Cunningham et al., 2011) were similarly matched to patients without major bleeding. A randomly selected index date was imputed for patients without an event. All patients had a dispensing of a NOAC agent overlapping with the index date, had ≥12 months of eligibility pre-index date and ≥1 NVAF diagnosis. Healthcare costs were calculated from index date until the earliest date of death, switch to warfarin, end of insurance coverage or end of data availability. Mean costs were evaluated at 1, 2, 3 and 4 years using Lin’s method (Kaplan-Meier product-limit estimator, accounting for death) and compared using non-parametric bootstrap procedures.

Results:
The additional cost of care for patients with vs. without ischemic stroke/SE were $48,822, $50,418, $56,721 and $59,354 at 1, 2, 3 and 4 years, respectively (
Table
; p<.0001 for all comparisons). The additional cost of care for patients with vs. without major bleeding at 1, 2, 3 and 4 years were $30,990, $35,443, $43,685 and $46,662, respectively (p<.0001 for all comparisons).

Conclusions:
Patients experiencing an ischemic stroke/SE or major bleeding event incur higher healthcare costs than those patients that do not, and the all-cause costs associated with ischemic stroke/SE appeared higher than major bleeding.
Abstract WP294: Randomized Trial of an Attending Nurse Model of Care for Acute Stroke
Authors: Stein Laura , Liberman Ava L , Zamzam Ahmad , Smolka Janice , Dubendorf Phyllis , Luciano Jean M , Cosan Alexandra , Roberts Zachary , Carmen Jacob , Cucchiara Brett , Mullen Michael , Messe Steven R , Cunningham Regina , Kasner Scott
Published: October 2018

Introduction:
Poor medication adherence and insufficient stroke related knowledge may contribute to worse outcomes.

Hypothesis:
A relationship-based attending nurse (AN) model of inpatient care for stroke patients will enhance medication adherence, stroke-related knowledge, and QOL after hospital discharge.

Methods:
We performed a pseudo-randomized trial of AN + standard care vs. standard care at a single comprehensive stroke center (CSC). We enrolled patients with ischemic stroke, TIA, or ICH. The AN intervention consisted of a dedicated nurse focused on individual patient goals, expectations, and disease related knowledge deficits. After discharge, subjects were consented and assessed via structured telephone interviews using the Morisky Medication Adherence Scale (MMAS-4), Stroke Patient Education Retention tool (SPER), and Stroke Impact Scale (SIS).

Results:
We randomly allocated 278 subjects to AN and 392 to standard models of care; 47% and 43% consented to participate, respectively. Patients in the AN group tended to have more severe strokes and lower baseline health literacy on a single Health Read question (Table). Overall, no significant differences were observed in the MMAS-4, SPER, or SIS. However, among those with low baseline health literacy, medication adherence was nearly doubled in the AN group, but no significant effect was observed on other outcomes.

Conclusion:
Compared to standard nursing care alone, an attending nurse model did not improve medication adherence, stroke knowledge, or QOL in patients treated at a CSC. However, this intervention may hold promise and warrant further study in those with low baseline health literacy.
Abstract WP298: Clinical Outcomes and Prognostic Factors in Patients With Spinal Dural Arteriovenous Fistulas:a Prospective Cohort Study
Authors: Yongjie Ma , Sichang Chen , Chao Peng , Chunxiu Wang , Guilin Li , Chuan He , Ming Ye , Tao Hong , Lisong Bian , Jiang Liu , Zhichao Wang , Qureshi Adnan I , Feng Ling , Hongqi Zhang
Published: October 2018

Background:
The short-term outcomes and prognostic factors of patients with spinal dural arteriovenous fistulas (SDAVFs) have not been defined in large cohorts.

Objective:
To define the short-term clinical outcomes and prognostic factors in patients with SDAVFs.

Methods:
A prospective cohort of 112 patients with SDAVFs were included consecutively in this study. The patients were serially evaluated with the modified Aminoff and Logue’s Scale (mALS) on 1 day before operation and at 3 months, 6 months, 12 months after treatment. Univariate and multivariate analyses were performed to identify demographic, clinical, and procedural factors related to favorable outcome.

Results:
A total of 94 patients (mean age of 53.5 years, 78 were men) met criteria and included in final analyses. Duration of symptom ranged from 0.5-66 months (average time period of 12.7 months). The location of SDAVFs was as follows: 31.6% above T7 level, 48.4% between T7 to T12 level (including T7 and T12), and 20.0% below T12 level. A total of 81 patients (86.2%) underwent neurosurgical treatment, 10 patients (10.6%) underwent endovascular treatment, and 3 patients (3.2%) underwent neurosurgical treatment after unsuccessful embolization. A total of 78 patients demonstrated an improvement in mALS score of 1 points or greater at 12 months. Pre-operative mALS score was associated with clinical improvement after adjusting for age, gender, duration of symptom, location of fistula and treatment modality used unconditional logistic regression analysis (P<.05).

Conclusion:
Approximately four fifths of the patients experienced clinical improvement at 12 months and pre-operative mALS was the strongest predictor of clinical improvement in cohort.
Abstract WP3: Cerebral Venous Sinus Thrombosis: Clinical Outcomes in Medical Management and Mechanical Thrombectomy
Authors: Vu Quang D , Neth Bryan J , Guzik Amy K
Published: October 2018

Introduction:
Anticoagulation (AC) is the mainstay treatment for cerebral venous sinus thrombosis (CVST). However, not all patients respond to AC alone. Patients may benefit from mechanical thrombectomy (MT), however, there is limited data. We assessed the clinical outcomes of CVST patients who underwent MT compared to those treated with AC alone.

Methods:
Retrospective analysis of the electronic medical record was performed from January 2012 to July 2017. Those with CVST secondary to infection, trauma, and those without follow-up were excluded. Primary analysis was modified Rankin Score (mRS) within one year. Recanalization was assessed as a secondary outcome.

Results:
Chart review identified 169 acute CVST patients; 81 were included in the analysis. All were treated with AC. Of these, six underwent MT. Adjusting for age, initial NIH stroke score (NIHSS) was higher in the MT group (11 vs 2.5, p = 0.0006). Intracranial hemorrhage (ICH) was seen at presentation in 67% of the MT patients, and 28% of the AC group. The majority of patients with CVST achieved functional independence (85.2% mRS ≤ 2) at follow-up. Patients who presented with an infarction or intracranial hemorrhage (ICH) had a higher mean mRS at follow-up (infarct 1.9 vs. 0.66, p = 0.034. ICH 2.0 vs. 0.51, p = 0.004). The MT group had a higher mean mRS at follow-up (2.7 ± 2.1 vs 0.80 ± 1.5, p = 0.0057). There was no significant difference in recanalization between the two groups.

Discussion:
While patients who received MT had a higher mean mRS at follow-up, the initial clinical presentation was worse than those treated with AC alone. The majority of patients achieved functional independence, even with ICH or infarction at presentation.

Conclusion:
MT may be an efficacious therapy in CVST. However, with good clinical outcomes in most patients, it is unclear which patients benefit from MT. Further investigation is ongoing to determine predictors of poor outcomes in CVST.
Abstract WP305: Predictors of Early Improvement of Swallow Function in Acute Ischemic Stroke Patients With Severe Dysphagia
Authors: Brown Kristin , Cai Chunyan , Barreto Andrew , Woellner Jade , Savitz Sean , Sharrief Anjail
Published: October 2018

Introduction:
Dysphagia is a common complication of stroke that often improves with time. Percutaneous endoscopic gastrostomy (PEG) tubes are used to bridge patients with dysphagia until oral feeding is safe. We sought to evaluate factors associated with early improvement in swallow for patients in whom PEG tube was deferred after an initial failed instrumental assessment of swallow (IAS) study.

Methods:
Consecutive cases of AIS were identified from our inpatient registry (6/14- 4/15). We included patients who failed an initial IAS with Fiberoptic Endoscopic Evaluation of Swallowing or Modified Barium Swallow Study. Speech language pathologists (SLP) calculated Penetration-Aspiration (PEN-ASP) scores (1-2 normal; 3-5 penetration; 6-8 aspiration) based on performance on IAS. Recovery of swallow was defined as improvement in the PEN-ASP category with thin or nectar-thickened liquids. Univariate analyses and multiple logistic regression were used to assess predictors of improvement in swallow with demographic data, medical history, stroke etiology, and NIHSS as independent variables.

Results:
Among 104 patients who failed an IAS an average of 5.5 days after hospital admission, PEG was deferred in 60 pending repeat IAS. Younger patients (62.9±13.1 vs 69.3±14.2) and those with lower NIHSS (median 10.5; IQR 5,15 vs median 13.5; IQR 8.0, 20) were more often referred for second IAS (p < 0.05). Improvement in swallow function was seen in 45% of patients on a 2
nd
IAS performed an average of 3.9 days after the initial study. Race, but not stroke etiology, stroke severity, stroke location or other clinical factors, was associated with recovery of swallow. The odds (adjusted) of improving on a subsequent evaluation in African Americans (AA) were 5.91 (95% CI: 1.56, 22.40 ) times higher than the odds for Whites.

Conclusion:
Our study shows that AA race is associated with early improvement in swallow function for reasons that are unclear. There was no association with age, stroke severity, or stroke etiology. Further analysis of factors associated with recovery of swallow is necessary in order to avoid PEG placement in patients with rapid recovery. A follow-up IAS 3-4 days after an initial study should be considered in select patients before PEG placement.