bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP253: Is Target Stroke Initiative Effective in Reducing Door-To-Needle Times in All Size Hospitals?
Authors: Jones Peggy , O'Neill Kathleen , Scharnott MIchelle , Prabhakaran Shyam
Published: March 2022

Background & Purpose:
National guidelines recommend door-to-needle (DTN) times <60 minutes for stroke thrombolysis. Several best practices have been reported to be associated with decreased DTN times. The extent to which hospitals of varying sizes are implementing these strategies has not been well studied. Target Stroke is a national initiative sponsored by AHA/ASA to assist hospitals in increasing the proportion of IV-tPA treated patients who achieve guideline recommended DTN within 60 minutes. Illinois Get With The Guidelines hospitals have been participating in the Target Stroke initiative since 2011.

Methods:
We reviewed aggregate data from the Illinois Get With The Guidelines stroke registry benchmark, including data from 24 critical access hospitals participating in Target Stroke as part of the Illinois Critical Access Hospital Network stroke systems of care initiative.

Results:
Aggregate data from 78 hospitals, representing 2394 patient records, demonstrates the overall decrease in median DTN times in ALL IL hospitals, including 24 ICAHN critical access hospitals. Primary Stroke Centers, community hospitals and 25 bed or less critical access hospitals implemented Target Stroke strategies during the 4 year period of Target Stroke implementation.

Conclusion:
Target Stroke strategies can improve timely intervention in hospitals regardless of hospital size. Critical access hospitals also demonstrated steady decrease in DTN times over four years. Further research is needed to identify which strategies are most effective in decreasing DTN times in the various size hospitals.
Abstract WP254: Emergency Medicine Pharmacist Impact on Door-to-Needle Time in Patients with Acute Ischemic Stroke
Authors: Jacoby Joshua S , Dumkow Lisa E , Farooq Muhammad U , Draper Heather M , DeYoung G. R , Bucher Kasey L
Published: March 2022

Introduction:
Current AHA/ASA guidelines recommend a door-to-needle time (DTN) of 60 minutes or less when administering tPA for acute ischemic stroke (AIS). Several studies have correlated early administration of tPA for AIS to improved outcomes. At the study setting, emergency medicine pharmacists (EMPs) are part of the acute stroke care team and are heavily involved in initial stroke care including patient evaluation, acute hypertension management, and preparation and administration of tPA. The purpose of this study was to determine the impact of EMPs on the outcomes of patients with AIS treated with tPA in the emergency department.

Methods:
This was a retrospective, single-center, cohort study of patients who received tPA between August 1, 2012 and August 30, 2014. Patients were included if they had a preliminary diagnosis of AIS. Patients were excluded if they received tPA at an outside medical facility or received tPA for an indication other than AIS. The primary objective of this study was to compare DTN times with or without EMP involvement in AIS care. Secondary objectives included evaluating changes in neurological status via measurement of the National Institutes of Health stroke scale (NIHSS), rate of symptomatic intracranial hemorrhage, rate of in-hospital mortality, and discharge disposition.

Results:
A total of 100 patients were included. EMPs were involved in the care of 49 patients. EMP care was associated with a significant improvement in DTN time (median 46 [IQR 34.5 - 67] minutes vs. 58 [IQR 45 - 79] minutes), p=0.019. There was also a significant improvement in NIHSS scores at 24 hours post-tPA in favor of the EMP group (median NIHSS 1 [IQR 0 - 4] vs. 2 [IQR 1 - 9.25]), p=0.047. There were no other significant differences between groups with regard to secondary outcomes.

Conclusions:
The involvement of an EMP in the initial care of AIS patients was associated with a significant improvement in DTN times and NIHSS scores at 24 hours post-tPA.
Abstract WP255: Cftr Deficiency Increases Systolic Blood Pressure and Exacerbates Cerebrovascular Remodeling in Angiotensin-induced Hypertension
Authors: Yuan Feng , Zhao Li-Yan , Zhang Bin , Chen Wen-Liang , Pan Ni , Chai Wei-Lu , Hu Jim , Sun Hong-Shuo , Liu Jie , Guan Yong-Yuan , Wang Guan-Lei
Published: March 2022

Introduction:
Cystic fibrosis transmembrane conductance regulator (CFTR) functions as a cAMP-dependent chloride channel, has primarily been studied in the secretary epithelia, where the mutation in the CFTR leads to classic CF phenotype. CFTR has been linked to vascular tone regulation and clinical hypotension. The study aims to examine whether CFTR plays a role in cerebrovascular pathological changes during hypertension.

Methods:
The wild type (WT) and CFTR null mice were implanted with mini-osmotic pumps loaded with Ang II (1000ng/kg/min) to establish Ang-II induced hypertension model. The 2-kidney-2-clip (2k2c), stroke prone hypertensive rats was also applied.

Results:
There is no significant difference in systolic blood pressure (SBP) and basilar arterial morphological features between WT and CFTR-/- mice. However, after Ang-II infusion, SBP and medial cross-sectional area, media thickness, and media-lumen ratio of the basilar artery was significantly increased in CFTR-/- mice, indicating that CFTR deficiency exacerbates hypertension and cerebrovascular remodeling. The exacerbating cerebrovascular remodeling was confirmed by the disarray of VSMCs and extracellular matrix accumulation using electron microcopy; by enhanced VSMC proliferation using BrdU assay and VSMC differentiation marker gene analysis. Moreover, CFTR protein/mRNA expression in hypertensive basilar arteries was markedly reduced and negatively correlated with the level of SBP. In vitro, Ang-II (100nM) induced BASMCs proliferation and the phenotype switch from a contractile to a proliferative type, accompanied by a decrease in CFTR protein expression. Adenovirus-mediated hCFTR overexpression inhibited, whereas CFTR siRNA enhanced Ang II-induced proliferation and cell cycle transition from G0/G1 to S phase via modulating cyclin D1, cyclin E and p21. Moreover, CFTR was required for AT1R-RhoA-p38 MAPK pathway activated by Ang II, which reduced CFTR channel activation and thus activated AT1R-mediated signaling.

Conclusion:
Our findings indicated that CFTR deficiency promotes the development of hypertension, which may be ascribed to CFTR negatively modulating hypertension-related VSMC proliferative phenotype switch and cerebrovascular remodeling.
Abstract WP260: The Dramatic Alteration of Microvascular Complexity and Endothelial Cell Gene Expression in Mice With Metabolic Syndrome
Authors: Xiao Guanxi , Nunez Stefanie , Hinman Jason D
Published: March 2022

Introduction:
Obesity is a leading public health problem in the US. More than one-third of adult are obese. It is closely related to development of the metabolic syndrome, which produces various vascular risk factors, including hyperglycemia, hyperlipidemia, hypertension and low high-density lipoprotein. All these factors increase the risk of developing chronic vascular diseases, particularly cerebral vascular disease. Studies show that patients with metabolic syndrome have a six-fold increase in the risk of developing microvascular infarcts in the brain, which predominantly injure white matter leading to dementia, disability and even death.

Hypothesis:
The purpose of this study is to assess the effects of metabolic syndrome on cerebral microvasculature and unveil the molecular mechanisms that regulate these changes.

Methods:
Transgenic mice (Tie2-Cre:flox-stop tdtomato plus flox-RiboTAG) were fed with 60%kCal from fat diet to induce metabolic syndrome for 12 weeks at 2 months age and 10%kCal from fat diet was used as control. The volume of cerebral vasculature in white matter was evaluated by reporter gene expression in endothelial cells of Tie2-Cre:flox-stop tdtomato mice. Transcriptomes from cerebral endothelial cells were isolated using Ribotag ribosomal immunoprecipitation technology (Tie2-Cre:flox-RiboTAG). Following ribosomal associated transcriptome isolation, RNA-seq was performed.

Results:
Metabolic syndrome results in a significant decrease in white matter vascular volume in both large (30±2.2%, P< 0.04) and micro vessel (23±3.7%, P<0.01). Transcriptional profiling of white matter endothelial cells reveal a difference of expression profile between normal mice and mice with metabolic syndrome. The significant changes in endothelial cell gene expression are associated with the decreased volume of vessels in white matter with metabolic syndrome through changes in angiogenic receptor ligands.

Conclusion:
Metabolic syndrome decreases the volumes of large and micro vessels in white matter and significantly changes endothelial cell gene expression. These findings help to develop molecular therapeutic approaches for patients with metabolic syndrome to prevent cerebral microvascular complications including stroke.
Abstract WP267: 9-Tert-Butyl Doxycycline Inhibits Neuronal Injury and Neutrophil Trafficking After Global Cerebral Ischemia
Authors: Mai Nguyen , Prifti Landa , Halterman Marc W
Published: March 2022

Introduction:
Cardiac arrest induces a robust systemic inflammatory response that exacerbates CNS injury and is characterized in part by neutrophil (PMN) migration to the brain. Tetracyclines have been shown to reduce inflammation after stroke, and here we test the effects of the tetracycline derivative 9-tert-butyl doxycycline (9TB) on PMN activation, trafficking, and ischemic neuroprotection in a mouse model of global ischemia-reperfusion.

Hypothesis:
Inhibition of PMN activation by 9TB will decrease PMN extravasation in the CNS and mitigate ischemia-reperfusion injury.

Methods:
Transient global cerebral ischemia was induced in LysM-EGFP mice by 3-vessel occlusion (3VO). Mice were given 50 μg/kg lipopolysaccharide (LPS) to simulate endotoxemia observed after cardiac arrest and daily injections of 25 mg/kg 9TB or vehicle control. Blood was collected 4 hours after 3VO/LPS for fluorescence-activated cell sorting (FACS) analysis of PMN activation. Brain and spleen immunohistochemistry were performed after 3 days to assess injury and PMN burden.

Results:
Expression of the PMN activation marker CD11b was increased 4 hours after 3VO/LPS compared to sham (mean fluorescence intensity = 55,516 vs. 6,537) and lower in 3VO/LPS animals treated with 9TB (MFI = 36,445). While sham-treated groups showed little PMN infiltration into the brain (7.5 PMN/mm2 ± 2.2 vs. 1.9 PMN/mm2 ± 1.3; NS), 9TB treatment of shams increased splenic PMN sequestration (81.4 ± 8.3 vs. 38.0 ± 7.5; p<0.001). This effect was enhanced with 3VO/LPS (112.2 ± 8.9 vs. 37.3 ± 0.1; p<0.0001). 3VO/LPS animals receiving 9TB exhibited lower cortical PMN counts (19.3 PMN/mm2 ± 13.6) compared to those receiving vehicle (46.5 PMN/mm2 ± 5.5; p<0.05). Daily 9TB after 3VO/LPS also decreased cortical injury compared to vehicle-treated controls (9.7% ± 6.8 vs. 32.2% ± 6.4; p<0.05) with no difference between sham groups (5.5% ± 0.9 vs. 6.8% ± 5.8; NS). PMN burden was positively correlated with neuronal injury (Pearson’s r=0.8621, p<0.01).

Conclusions:
9TB treatment rapidly inhibits PMN activation and reduces PMN migration and CNS injury when delivered acutely following cerebral ischemia-reperfusion. Future studies are required to link ischemic neuroprotection with the observed effects on PMN activity.
Abstract WP269: New Insights Into Worsened Cerebral Ischemia in Hypertensive Rats: Roles of WNK-SPAK/OSR1-NKCC1 Signaling
Authors: Bhuiyan Mohammad Iqbal H , Yuan Hui , Kahle Kristopher T , Yang Sung-Sen , Lin Shih-Hua , Alper Seth L , Subramanya Arohan R , Sun Dandan
Published: March 2022

Background and Purpose:
WNK kinases [with-no-lysine (K)], Ste20-related proline alanine-rich kinase (SPAK) and oxidative stress-responsive kinase-1 (OSR1) are a family of evolutionarily conserved regulators of ion transporter proteins. The kinases alter the phosphorylation state of ion transporter proteins and so play an important role in renal salt handling and in the pathogenesis of hypertension. We previously reported that pharmacological inhibition or genetic knockout of Na+-K+-2Cl- cotransporter 1 (NKCC1) is neuroprotective against ischemic injury. Our current study investigated whether WNK-SPAK/OSR1-NKCC1 signaling is augmented in cerebral ischemia in hypertension.

Methods:
Cerebral ischemia was induced in adult male Wistar Kyoto (WKY) or spontaneously hypertensive rats (SHR) by 2-hour occlusion of the left middle cerebral artery (MCAO) followed by reperfusion. Brain tissues were harvested for immunoblot assessment of expression levels of NKCC1, SPAK/OSR1 or WNK1-4. Another two cohorts of WKY and SHR were treated with saline or NKCC1 inhibitor bumetanide (BMT, 10 mg/kg/day, i.p.) after MCAO. In these animals, ischemic infarct volume was determined by TTC staining and behavioral deficits were analyzed by neurological scoring and turning-alley test.

Results:
Basal levels of total NKCC1 protein were significantly higher in the contralateral (CL) cortical tissues in SHR brains than WKY brains. Ischemia was associated with increased phosphorylation of NKCC1 in the ipsilateral (IL) cortex of SHR, but not WKY at 6 hours post-ischemia. WNK1 increased 6.1±1.5 fold and WNK4 increased 8.7±1.7 fold in IL cortex of SHR, but not in that of WKY, and phosphorylated SPAK/OSR1 was unchanged. Lastly, sensitivity to pharmacological NKCC1 inhibition was higher in SHR than WKY rats. BMT blunted the MCAO-induced infarction and improved neurobehavioral score and sensory motor function in SHR rats.

Conclusion:
These findings suggest that augmented WNK1/4-NKCC1 signaling is responsible, at least in part, for the increased susceptibility to ischemic brain damage associated with hypertension. They highlight the potential for inhibition of WNK1/4-NKCC1 signaling as part of anti-ischemic stroke therapy.

Supported by NIH Grant R01 NS38118 (D Sun).
Abstract WP27: Endovascular Treatment Improves Executive Functioning in Acute Ischemic Stroke
Authors: López-Cancio Elena , Millán Monica , Muñoz Lucia , Ribó Marc , Serena Joaquín , de Miquel Maria Angels , Rovira Alex , San Roman Luis , Cobo Erik , Molina Carlos , Jovin Tudor , Dávalos Antoni ,   REVASCAT Trial Investigators
Published: March 2022

Background:
Endovascular treatment has demonstrated benefit in functional outcomes after acute stroke but the effect on cognitive outcomes has not been explored yet.

Hypothesis:
Our hypothesis is that endovascular treatment is associated with better cognitive outcome after ischemic stroke.

Methods:
REVASCAT (Randomized Trial of Revascularization with Solitaire FR Device versus Best Medical Therapy in the Treatment of Acute Stroke Due to Anterior Circulation Large Vessel Occlusion Presenting within Eight Hours of Symptom Onset) enrolled 206 patients with stroke of anterior circulation<8h and without cognitive impairment at onset that were randomized to receive thrombectomy or best medical treatment. Executive function was measured by means of Trail Making tests (TM-A and B) at 90 day. Time of completion of each test and number of errors were recorded.

Results:
Excluding deaths, 120 patients were able to complete TM-A in due time (less than 5 min), 61 in thrombectomy and 59 controls (p=NS), and 65 patients could complete TM-B, 39 in thrombectomy and 26 controls (p=0.026). Time required to complete TM-A was not different between groups but controls needed more time (unadjusted Beta,1.0; 95%CI, 0.15-1.84) than thrombectomy patients to complete TM-B.

Conclusion:
Patients treated with thrombectomy showed more frequently preserved and faster executive functioning compared to controls 3 months after stroke.
Abstract WP270: Myeloid P2X4 Receptor Deletion Confers Neuroprotection in Females but not in Males After Experimental Stroke
Authors: Venna Venugopal Reddy , Benashski Sharon E , Verma Rajkumar , McCullough Louise D , Liang Bruce T
Published: March 2022

Objective:
Stroke is a sexually dimorphic disease. A growing body of literature from both clinical and experimental studies suggests that the outcomes after stroke differ in males versus females. Peripheral immune cells play a key role in stroke outcomes and also show sexual dimorphism. However, general immunosuppression has not shown an overall benefit in stroke patients. Therefore, identifying novel targets to improve stroke outcomes are urgently needed. P2X4 receptors (P2X4R) and P2X7 receptors (P2X7R) are the predominant subtypes expressed on immune and neural cells. The P2X7R and P2X4R interact and may physically associate with each other. Recent evidence demonstrates that P2X4R is necessary for the pro-inflammatory function of P2X7R. The goal of this study is to test the hypothesis that genetic deletion of P2X4R in myeloid immune cells impacts on stroke outcome and that such outcome differs in males vs. female mice.

Methods:
P2X4R myeloid knockout mice and wild type littermates of both sexes (∼20-25g; C57BL/6), were randomized and subjected to right middle cerebral artery occlusion (MCAO-90min) followed by 3 days of reperfusion. At 72h after stroke mice were perfused and infarcts were quantified from 30μicron cut cresyl violet stained sections. The effect of myeloid P2X4R deletion on chronic functional recovery was assessed with neurological scores, corner test, Open field and the novel object recognition test. Data are expressed as mean±sem. ANOVA was performed and a P < .05 was set for statistical significance.

Results:
A significant neuroprotective effect is seen in P2X4R KO compared to WT females (Cortex 36.1±1.5 vs 27.5±4.7; Striatum 67.4±1.5 vs 56.3±7.0; Total 34.8±1.6 vs 26.9±2.8. P<.05; n=7KO, 9WT). Ongoing studies in P2X4R KO ovariectomized females will determine if these sex specific effects are dependent on hormones (estrogen).

Conclusions:
There is a sex-specific effect of immune cell P2X4R deletion. Myeloid specific deletion of P2X4R protects females from ischemia/reperfusion injury but has no salutary effect in males. This is the first study to demonstrate a deleterious effect of myeloid P2X4R on stroke outcomes. These initial findings implicate myeloid P2X4 as a novel therapeutic approach to improve ischemic outcomes in females.
Abstract WP272: Exogenous Hydrogen Sulfide With Normoxic Resuscitation Protects Hippocampal Neurons in a Mouse Model of Cardiac Arrest
Authors: Nakayama Shin , Taguchi Noriko , Tanaka Makoto
Published: March 2022

Hyperoxia following cardiac arrest (CA) and cardiopulmonary resuscitation (CPR) is associated with worse neurological outcome. This effect is partly mediated through reactive oxygen species (ROS) generation by hyperoxic ventilation during reperfusion. Hydrogen sulfide donor, sodium hydrogen sulfide (NaHS), reduces ROS levels in hyperoxia, which protects cells from oxidative stress. Therefore, this study was designed to test whether NaHS treatment, with and without hyperoxia during CPR, improves neurological outcomes in a mouse model of CA/CPR.

Methods:
Adult male mice (20–26 g) were subjected to 8 min of CA induced by IV potassium chloride followed by CPR with IV epinephrine, mechanical ventilation, and chest compressions (rate 300/min). Mice were randomly assigned to 4 groups: ventilated with 30% O
2
for 1 h and treated with either normal saline (Normo+NS) or NaHS (3mg/kg i.p. followed by 3mg/kg for 3 days: Normo+NaHS); ventilated with 100% O
2
and either treated with vehicle (Hyper+NS) or NaHS (3mg/kg i.p. followed by 3mg/kg for 3 days: Hyper+NaHS). Four days after CA/CPR, brains were removed for histological evaluation of neurons in the hippocampal CA1 region and the striatum.

Results:
No difference was found between treatment groups in overall survival, duration of CPR and dose of epinephrine. Histological damages in the hippocampal CA1 region and striatum were reduced in the normoxia groups compared with the hyperoxia groups. Between the hyperoxia groups, NaHS did not alter the outcome in the hippocampal CA1 region or striatum. In contrast, between the normoxia groups, NaHS reduced neuronal damage in the hippocampal CA1 region (Normo+NaHS: 5.9±3.1% vs Normo+NS 20.7±6.3%, P<0.05). Data are expressed as mean±SEM.

Conclusions:
Combined treatment with NaHS and normoxic ventilation following CA/CPR exerts neuroprotection.
Abstract WP299: An Expanded Definition of Caregiving Among Elderly US Stroke Survivors: Have We Understated the Problem?
Authors: Skolarus Lesli , Fredman Vicki A , Feng Chunyang , Wing Jeffrey J , Burke James F
Published: March 2022

Introduction:
Previous studies exploring stroke caregiving have estimated that the average stroke survivor receives as many as 16 hours per week hours of informal caregiving at a societal cost of as much as $26.8 billion per year. However, these studies have focused on basic and instrumental activities of daily living, and have not included healthcare and transportation activities. We sought to determine whether, and at what cost, caregiving differs between stroke survivors and matched controls using an expanded definition of caregiving.

Methods:
A total of 892 stroke survivors were drawn from the 2011 wave of the National Health and Aging Trends Study (NHATS), a nationally representative survey of Medicare beneficiaries. One-to-one propensity matching was performed on demographics and comorbidities to create a sample of matched non-stroke controls. Caregivers were identified by detecting all helpers for NHATS respondents who had help with self-care or mobility activities or with household activities due to health or functioning. Stroke survivors and controls were compared using survey-weighted chi-square tests and Wald tests. The annual cost of caregiving was estimated using reported paid caregiving data and estimates of informal caregiving costs.

Results:
On average, stroke survivors received about 10 hours of additional caregiving per week compared to controls (22 hours vs. 12 hours, p<0.01). We estimate that the average annual cost for caregiving for an elderly stroke survivor is approximately $11,300. This extrapolates to a total cost of about $40 billion annually among all Medicare beneficiaries.

Conclusion:
Our expanded definition of caregiving suggests that prior studies may underestimate both the time and costs invested in caregiving to older stroke survivors.
Abstract WP303: Stability of High-Quality Warfarin Anticoagulation in a Community-Based Atrial Fibrillation Cohort: The ATRIA Study
Authors: Dallalzadeh Liane O , Go Alan S , Chang Yuchiao , Borowsky Leila H , Fang Margaret C , Singer Daniel E
Published: March 2022

Introduction:
Warfarin reduces stroke risk in atrial fibrillation (AF), but increases bleed risk. Frequent testing with dose adjustment is needed to maintain INR levels in the therapeutic range of 2.0-3.0. Novel anticoagulants (NOACs) now challenge warfarin as stroke-preventive therapy for AF. They are available at fixed doses but costlier. Warfarin anticoagulation at a time in therapeutic range (TTR) ≥70% is similarly effective and safe as NOACs. It is unclear whether AF patients with TTR ≥70% will remain stably anticoagulated and avoid the need to switch to a NOAC. We assessed stability of warfarin anticoagulation in AF patients with an initial TTR ≥70% primarily managed by anticoagulation clinics.

Hypothesis:
AF patients who achieve TTR ≥70% in the first 6 months of warfarin therapy will maintain high TTR subsequently.

Methods:
Within the community-based ATRIA cohort of AF patients, we identified 2521 new warfarin users who continued warfarin therapy over 15 months. We excluded months 1-3 to achieve stable dose. For patients with TTR1 (months 4-9) ≥70% (TTR by Rosendaal method), we describe the distribution of TTR2 (months 10-15) and assess multivariable (logistic regression) correlates of persistent TTR ≥70%.

Results:
Of 1074 patients with TTR1 ≥70%, 57% (95%CI: 53-61%) persisted with TTR2 ≥70% (Figure). Of multiple patient features, only initial TTR1 ≥90%, aOR [95% CI]: 1.43 [1.05,1.93]); and heart failure aOR: 0.78 [0.57, 1.06]) independently predicted TTR2 ≥70%.

Conclusions:
Nearly 60% of AF patients with high quality initial 6-month TTR on warfarin will maintain TTR ≥70% over the next 6 months. A minority deteriorate to very poor TTR. Patient features do not strongly predict deterioration. Our analyses support watchful waiting for AF patients with initial high quality warfarin anticoagulation before switching to a NOAC.
Abstract WP306: Low Rates of Screening and Treatment for Osteoporosis Following Stroke
Authors: Prager Marla , Fang Jiming , Austin Peter , Cheung Angela , Casaubon Leanne , Cram Peter , Alibhai Shabbir , Stamplecoski Melissa , Rashkovan Brennan , Kapral Moira
Published: March 2022

Introduction:
Following stroke, bone mineral density (BMD) has been found to decline, particularly in the paretic extremity. Decreased BMD in combination with an increased risk of falls predisposes individuals to post-stroke fractures, which can result in serious disability. Despite this, current post-stroke best practice guidelines do not include recommendations on screening and treatment for osteoporosis or bone loss. The purpose of this study was to determine the frequency of BMD testing and prescribing of medications for treatment and prevention of osteoporosis following stroke.

Hypothesis:
We hypothesized that rates of screening and treatment for osteoporosis would be low following stroke.

Methods:
We performed a retrospective cohort study of patients aged over 20 years who were seen in the emergency department or hospitalized with stroke at any Ontario acute care institution between 2003 and 2012 and discharged alive. We identified BMD testing through the physician claims database and medication prescriptions in patients aged over 65 years using the Ontario Drug Benefits database.

Results:
Among 23,751 patients with stroke, only 4.8% of patients underwent BMD testing within 1 year and 15.5% of those aged over 65 were prescribed therapy for osteoporosis. In the 1,912 patients who sustained a low-trauma fracture within 2 years after stroke, BMD testing was conducted in only 9% and osteoporosis therapy was prescribed to 31.3% of those over 65 years.

Conclusions:
Following stroke, rates of testing and treatment for osteoporosis are very low, even in those with fractures. Due to the bone loss that may occur following stroke, it is recommended that high-risk individuals be targeted for BMD screening after stroke and treated accordingly.
Abstract WP308: Changes in Depressive Symptoms From the Hospital Setting to Outpatient Clinic Among Ischemic Stroke Patients
Authors: Okpala Munachi N , Wadhwania Rozina , Denny Mary C , Vahidy Farhaan , Savitz Sean I , Sharrief Anjail
Published: March 2022

Introduction:
Depression is prevalent after ischemic stroke and is associated with increased morbidity. No studies have described subsequent changes in depressive symptoms detected during the acute stage of stroke.

Hypothesis:
We sought to assess changes in depressive symptoms from hospitalization to clinic follow-up and to explore variables associated with worsening depressive symptoms at clinic follow-up.

Methods:
Ischemic strokes (7/14- 7 /15) were identified from the stroke prevention clinic registry. Prior to hospital discharge, patients are screened for depressive symptoms using Patient Health Questionnaire 9 (PHQ-9; range 0 - 27) and then re-assessed in clinic. Higher scores reflect more severe symptoms. Univariate and multivariable linear regression analyses were used to evaluate associations between change in PHQ-9 and age, sex, race, baseline NIHSS, mRS, and antidepressant use.

Results:
Among 160 ischemic stroke patients, 82 had both baseline and follow-up PHQ-9 scores. Median time to follow-up was 41.5 days (IQR 35-50). Mean age was 60.7 (SD 14.5) and 40.2% were female. Median PHQ-9 scores were 2 (IQR 0, 5) and 5.5 (IQR 1, 10) for inpatient and clinic, respectively. During inpatient stay, 67% of patients had 0 to minimal depressive symptoms; 31.7% mild to moderate; and 1.3% moderately severe to severe. At follow-up 43.9% had 0 to minimal symptoms; 46.3% mild to moderate; and 9.7% moderately severe to severe symptoms. There was a statistically significant increase in PHQ-9 at follow-up [mean change 2.79 (SD 5.7); paired t-test p < 0.001] and a significant difference in depression category (Wilcoxon rank-sum test, p < 0.0001). Neither age, sex, race, marital status, admission NIHSS, baseline or clinic mRS, nor antidepressant treatment were associated with change in depressive symptoms.

Conclusions:
Depressive symptoms were more severe at clinic follow-up for ischemic stroke patients who were initially screened during hospitalization. Depression screening should be repeated at clinic follow-up.
Abstract WP32: When and Where ADAPT in Anterior Circulation Ischemic Strokes Really Works?
Authors: Blanc Raphaël , Redjem Hocine , Smajda Stanislas , Ciccio Gabriele , Abrivard Marie , Piotin Michel
Published: March 2022

Introduction:
The ADAPT (a direct aspiration first pass technique for acute stroke thrombectomy), using large bore aspiration catheters, has been reported to be a fast, safe, simple and effective method of mechanical thrombectomy (MT) that has facilitated the treatment of acute ischemic strokes.

Hypothesis:
An attempt to determinate the favorable factors leading to a satisfactory reperfusion (TICI 2b/3) with ADAPT in anterior circulation ischemic stroke patients with confirmed large vessel occlusions.

Methods:
Based on our prospectively gathered database we extracted patients who were admitted for MT in anterior circulation ischemic strokes since August 2013 and for whom ADAPT was used as the first MT option. Patient demographics, initial NIHSS, localization and lateralization of the occlusion, DWI-ASPECTS, IV thrombolysis prior to MT, time from stroke onset to femoral puncture, final TICI score and 3-month mRS were analyzed.

Results:
ADAPT was effective in achieving a TICI2b/3 in 54.7% of 309 patients. Two factors influenced positively the success of reperfusion with ADAPT as a stand alone procedure: an isolated MCA occlusion (p<0.0001) and a shorter time from stroke onset to femoral puncture (p=0.0156). Age, Gender, initial NIHSS, DWI-ASPECTS and IV thrombolysis prior to MT did not influence the success of the ADAPT procedure. The additional use of stent retrievers improved the TICI 2b/3 revascularization rate to 84.1% (p<0.0001). When ADAPT was the sole technique used to achieve satisfactory reperfusion, 3-month mRS≤2 was achieved in 70.4% of the patients, while only 41.7% of mRS≤2 at 3-month was achieved in patients for whom ADAPT then stent retrievers were used (p=0.0001).

Conclusions:
ADAPT is very effective in case of isolated MCA occlusion ischemic strokes. The relevance of ADAPT over stent retrievers in other anterior circulation localizations (carotid siphon and tandem occlusions) has to be evaluated with a randomized study.
Abstract WP321: Smartphone Application Iodine: A Novel Method for Screening and Identification of Specific Stroke Study Population
Authors: Dennis Lauren C , Thakker Parth , Cartrett Karen , Patel Neil , Toub Josh , Sen Souvik
Published: March 2022

Background and Purpose:
Stroke studies and trials frequently require identification and screening of specific stroke patients based on set selection criteria, missed by traditional methods that rely on physician reporting and discharge diagnosis codes. Our aim was to determine the utility of a smartphone application, Iodine, in screening and identifying cervical artery dissection (CAD) patients.

Methods:
Iodine is used to notify healthcare providers regarding specific patient populations for the purpose of process and quality improvement. Real-time patient data is sent to Iodine via feeds secured by encrypted virtual private network tunnels, and continuously evaluated against Iodine’s library of Alert rules. All communication between Iodine and users are encrypted, all data accesses are audited, and data is not stored on mobile devices, thereby ensuring Health Insurance Portability and Accountability Act compliance. CAD is an uncommon cause for stroke or TIA that can affect young patients without traditional risk factors. Recent advances in imaging, including MRI and CT angiogram, have led to more frequent identification of CAD. Based on the identification of the keyword “dissection” in all radiological reporting, we setup a notification to alert study investigators. These notifications were reviewed daily for enrollment in an ongoing prospective study COMPASS. These patients were compared with those identified by ICD-9 discharge diagnosis codes.

Results:
In a six month period between January 01, 2015 and June 30, 2015, 18 patients with CAD were identified through the Iodine out of 289 total dissection alerts. (Mean age ± SD = 57 ± 17, 50% male, 61% Caucasian, and 39% African American). Of these 18 patients, 3 died in-hospital and thus could not be identified using traditional methods. Of these, only 13 patients were identified through ICD-9 discharge diagnosis codes, out of 4683 total discharges. Iodine was found to have a significantly higher proportion of detecting CAD (χ2=146.1; p<0.0001).

Conclusions:
We report real time screening and identification of CAD using Iodine, which appears to be superior to traditional methods. This method may be successfully applied for other disease conditions for consecutive study patient identification.
Abstract WP325: Transitional Care Interventions Result in Statistically Significant Reduction in Stroke Readmission Rate
Authors: Gray Kimberly , Hickenbottom Susan
Published: March 2022

Background:
Readmissions can negatively impact patients, families and health care organizations. Readmission penalties have resulted in focused efforts around discharge planning, patient engagement and transitional care.

Purpose:
We hypothesized that development of a transitional care intervention 'bundle' could decrease our stroke readmission rate.

Methods:
A literature search related to readmission reduction strategies for stroke patients and a transitional care gap-analysis were completed. The literature review defined at-risk patients as over 80 years old with cardiovascular comorbidities, dysphagia, diabetes and high stroke severity. Additional variables included a lack of stroke-validated readmission predictive models, variable causes for readmissions and different insurance and databases used. A retrospective review of our 30-day readmitted stroke patient records from November 2012- October 2013, showed our patients were most often low stroke severity, low risk of mortality and readmission based on an internal risk assessment tool called PRISM, most often discharged home, younger than reported in the literature, and most often returned within a week from discharge. We noted there was vast variation between the literature findings and our stroke readmissions. The literature review included best practices for non-stroke related readmissions. The gap-analysis showed we were not doing many best practices at our organization related to transitional care. We created a set of stroke-specific interventions including: scheduled follow-up appointments based on PRISM score, new patient education and teach-back tools, then targeted patients discharged home. Implementation was complete in July 2014.

Results:
January 2014-June 2014 readmissions were 12%. July 2014- December 2014 readmissions decreased to 8%. Using a 2 sample t-test, a comparison of these time periods showed a significant improvement: P = 0.046.

Conclusion:
Standardizing transitional care by implementing strategies focusing on stroke patients discharged home has resulted in a statistically significant reduction in readmissions. The reason for the differences between the organization's readmission profile and that discussed in the literature remains unclear.
Abstract WP33: Anticoagulation, Mechanical Thrombectomy and rTPA: an Outcome Analysis
Authors: Mehta Tapan V , Hussain Mohammed , Nouh Amre , Ollenschleger Martin , Spiegel Gary , McCullough Louise
Published: March 2022

Background:
There is paucity of data on safety outcomes in the subgroup of patients who are on anticoagulation (AC) that undergo mechanical thrombectomy (MT) for anterior circulation large vessel stroke (AS).

Methods:
The Healthcare Cost and Utilization Project's (HCUP) Nationwide Inpatient Sample (NIS) data was queried between 2006 and 2010 using validated ICD 9 diagnostic codes for acute ischemic stroke. ICD-9 99.1 for IV tPA and ICD-9 procedure code 39.71 (mechanical thrombectomy) were used. Patients with AS treated with MT were divided into three groups: 1. On AC not receiving iv tPA, 2. On AC receiving iv tPA, 3. Not on AC. Group 3 was subdivided into 3a. Received iv tPA and 3b. Did not receive iv tPA. Mortality, hemorrhagic transformation (HT) and disability at discharge were used to compare outcomes. In addition to demographics, comorbid vascular risk factors, concurrent use of antiplatelet agents, in-hospital complications (DVT, PE, sepsis, hospital acquired infections) were controlled. Patients on novel oral anticoagulants were excluded.

Results:
A total of 10,475 AS patients received MT: Group 1- 398 (3.8%), Group 2 - 439 (4.1%), and Group 3 - 9638 (92.1%). Group 3A - 3918 (37.4%) and 3B - 5719 (54.6%). After controlling for confounders, there was no statistically significant increase in the risk of mortality, hemorrhagic transformation and disability at the time of discharge (Table) in Cohort 1 vs. to other cohorts.

Conclusion:
The subgroup of patients who are on AC receiving MT for AS with or without tPA did not have an increased risk of HT, mortality or disability.
Abstract WP34: Associations Between CTP Ischemic Core Volume, ASPECTS Scores and Clinical Outcomes After Endovascular Reperfusion
Authors: Marks Michael P , Christensen Soren , Tsai Jenny P , Mlynash Michael , Kemp Stephanie , Mishra Nishant , Federau Christian , Kim Sun , Haussen Diogo C , Dehkharghani Seena , Devlin Thomas G , Yavagal Dileep R , Akhtar Naveed , Jovin Tudor , Nogueira Raul G , Bammer Roland , Straka Matus , Zaharchuk Gregory , Albers Gregory W , Lansberg Maarten G
Published: March 2022

Introduction:
ASPECTS and CT perfusion (CTP) lesion volumes have been used to triage patients with large artery occlusions to endovascular therapy. Specifically, ASPECTS ≤5 and CTP infarct core >50 mL excluded patients from some recent endovascular trials. It is unclear how well these criteria select patients who will have poor functional outcomes despite reperfusion and if the criteria are interchangeable.

Hypothesis:
ASPECTS and CTP infarct volumes are correlated and both predict clinical outcome.

Methods:
Patients with anterior circulation strokes were enrolled in a prospective multi-center study (CRISP) if CTP could be obtained <90 minutes before endovascular treatment, and intervention performed <18h from onset. Reperfusion was defined as >50% reduction from baseline Tmax>6s volume on early follow-up MRI (<36h from baseline CT) or final TICI 2b/3 if follow-up MRI unavailable. A single blinded reader at the core imaging facility determined ASPECTS on baseline CT. Baseline ischemic core volumes were assessed using automated software (RAPID). Good outcome was defined as mRS 0-2 and poor outcome as mRS 5-6.

Results:
This analysis includes 165 patients with reperfusion after endovascular therapy. Baseline ASPECTS and infarct core volume are inversely associated (p=0.009). Lower ASPECTS and larger infarct core were associated with a lower chance of good outcome in univariate analysis: OR for good outcome was 0.8 (95% CI 0.7-1.0) per point decrease in ASPECTS and 0.8 (95% CI 0.6-0.9) per 10mL increase in infarct core. Adjusted for baseline NIHSS and age, core remained a predictor of good outcomes (p=0.025) while ASPECTS showed a strong trend (p=0.072). The PPV for poor outcome despite reperfusion was 38% (5/13) for infarct core >50 mL and 0% (0/7) for ASPECTS ≤5 (p=0.1 for difference in PPV). No patient met both criteria.

Conclusions:
The ASPECTS and ischemic core volume criteria used to exclude patients from some endovascular therapy trials, did not agree in identifying patients with presumed poor outcomes. Neither criterion had a high specificity for identifying patients destined to have a poor outcome despite reperfusion. Randomized trials are warranted to assess the efficacy of endovascular therapy in patients with ischemic core lesions >50 ml and ASPECTS ≤5.
Abstract WP348: Palliative Care is Underutilized in Ischemic Stroke Patients With Poor Functional Outcome
Authors: Sisson April , Albright Karen C , Lakkur Sindhu , Bakitas Marie , Sands Kara , Kaur Manmeet , Lyerly Michael , Gropen Toby , Burgio Kathryn
Published: March 2022

Background and Purpose:
Palliative care (PC) should be an essential component of stroke care, particularly in patients with severe strokes given their poor prognosis and symptom burden. Despite the potential benefits of PC, a recent AHA scientific statement found that PC use in stroke was understudied and poorly understood.

Methods:
We performed a retrospective review of consecutive ischemic stroke patients presenting to our comprehensive stroke center (CSC) from 3/14-4/15. Demographic and clinical data were collected. We compared the proportion of patients that received an inpatient PC consult to the proportion of patients with a discharge modified Rankin scale (mRS) score of 4-6 (unable to walk without assistance and unable to attend to own bodily needs without assistance) by NIHSS score on admission.

Results:
Of the 776 ischemic stroke patients admitted to our CSC, only 6% received a palliative care consult. Even among the 254 patients discharged with a mRS of 4-6, only 16% received an PC consult. Figure 1 displays discharge mRS 4-6 and PC consult proportions by NIHSS severity. Patients that received a PC consult were older (median age 75 vs. 65, p<0.001), had more severe strokes (median NIHSS score 17 vs. 5, p<0.001), and more inpatient complications (56.5% vs. 21.8%, p<0.001). On average, PC consults occurred 3.5 days after admission (IQR 2,9). Of the 43 patients who received a PC consult, 78.3% had “do not resuscitate/do not intubate” (DNR/DNI) orders prior to the PC consult as compared to 95.7% after. Before the PC consult, 30.4% had “comfort care” (CC) orders. After the consult, the proportion with CC orders nearly doubled (58.7%).

Conclusions:
Our observations suggest that PC may be underutilized in ischemic stroke patients, particularly in those who may benefit from it the most. PC has great potential to diminish suffering through physical and psychological symptom management. Providers should at least consider PC consults for hospitalized stroke patients.
Abstract WP353: What Makes New Ischemic Lesions Symptomatic After Aortic Valve Replacement?
Authors: Leker Ronen , Messe Steven , Erus Guray , Bilello Michel , Fanning Molly , Acker Michael , Giovannetti Tania , Kasner Scott E , Floyd Thomas ,   Determining Neurologic Outcomes from Valve Operations (DeNOVO) Investigators
Published: March 2022

Introduction:
New diffusion weighted imaging (DWI) lesions are very common after cardiothoracic surgery. However, most of these lesions are asymptomatic and what determines whether a lesion would be symptomatic or not remains unclear.

Hypothesis:
New ischemic lesions are more likely to be symptomatic if large and if affecting primary motor areas.

Methods:
Patients over 65 years undergoing surgical aortic valve replacement (AVR) for calcific stenosis were prospectively recruited (n=196). All patients underwent neurological evaluation on post-op days 1, 3, and 7, and MRI scans on planned post-op day 5. Among those with new post-op DWI lesions, we compared baseline characteristics, surgery, and imaging data between subjects who were symptomatic and asymptomatic.

Results:
Of the 129 patients who completed a post-surgical MRI, 79 (61%) had new DWI lesions and 17 of those (22%) had new neurological symptoms. New symptoms were associated with longer times on bypass (132±43 vs. 103±36 min, p=0.006), smaller intra-operative drops in arterial pressures (28±2 vs. 40±15 mm Hg, p=0.001), and more concomitant procedures (59% vs. 29%, p=0.047). Symptomatic patients had a greater number of new DWI lesions (5±8 vs. 3±3, p=0.012), higher DWI total lesion volumes (7±15 vs. 1±14 mL, p=0.002), and higher old lesion burden on FLAIR (11±11 vs. 5±7 mL, p=0.028). Symptomatic lesions more frequently involved the frontal (92% vs 62%, p=0.043) and parietal white matter (67% vs 29%, p=0.020) and were more common in right hemispheric lesions (100% vs.58%, p=0.005).

Conclusions:
New DWI lesions are common after AVR, but most are asymptomatic. Patients are more likely to have symptoms with right frontal and parietal involvement, with larger absolute DWI lesion count and volumes, and with longer bypass durations, complicated surgeries, and higher pre-existing lesion burdens.
Abstract WP354: Prophylactic Anti-epileptic Drugs and Spontaneous Intracerebral Hemorrhage
Authors: Zandieh Ali , Messé Steven R , Cucchiara Brett , Mullen Michael T , Kasner Scott E ,   VISTA-ICH Collaborators
Published: March 2022

Introduction:
Seizure is a common complication after intracerebral hemorrhage (ICH) but there are conflicting data about the impact of seizure on ICH outcome and the clinical utility of prophylactic antiepileptic drugs (AEDs) in ICH treatment.

Hypothesis:
We hypothesized that prophylactic AEDs would be associated with worse outcomes after ICH.

Methods:
We queried the Virtual International Stroke Trials Archive (VISTA), and identified 802 ICH patients who were followed for 90 days in prior clinical trials. Uni- and multivariate logistic and Cox regression models were designed to evaluate the effect of prophylactic AEDs on ICH outcome reflected by mortality and modified Rankin Scale (mRS)>3 at 90 days.

Results:
Eighty two (10.2%) subjects received prophylactic AEDs after ICH. Patients who received AED prophylaxis had higher ICH volume (median [IQR] 23.2 [10.5, 38.0] vs. 14.3 [7.1, 27.0] cm3, P=0.001), and ICH score (1 [0, 2] vs. 1 [0, 1], P=0.028). In univariate analysis (Table), patients who received prophylactic AEDs had higher mRS at 90 days (4 [2, 6] and 3 [2, 5], P=0.03), and numerically greater mortality (27% vs. 18%, P=0.06). Phenytoin was the most commonly used AED and appeared to have a larger effect size than other AEDs. The ICH score and its components were strongly associated with outcomes (Table). Multivariable models adjusting for ICH score components attenuated the effect of prophylactic AEDs overall (mRS OR 1.33, 95% CI: 0.78-2.26, P=0.29; mortality HR 1.14, 95% CI: 0.72-1.80, P=0.58). Similar results were obtained for mRS and mortality outcomes when adjusted for overall ICH score, and for all AEDs as well as specifically for phenytoin.

Conclusion:
Patients with higher ICH scores and larger hemorrhages are more likely to receive prophylactic AEDs and more likely to have poor outcomes. In this large multitrial cohort from VISTA, prophylactic AEDs were not independently associated with outcome after adjustment for these confounders.