bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP441: Diagnostic Accuracy of
Glial Fibrillary Acidic Protein
and
Ubiquitin Carboxy-Terminal Hydrolase-L1
for Differentiating Acute Intracerebral Hemorrhage From Ischemic Stroke
Authors: Luger Sebastian , Jæger Henriette S , Dixon Joanna , Schaefer Jan H , Bohmann Ferdinand O , Ranhoff Hov Maren , Bache Kristi , Foerch Christian
Published: January 2019

Background:
Biomarkers indicative of intracerebral hemorrhage (ICH) may help triage acute stroke patients in the pre-hospital phase. The objective of this study was to investigate whether serum levels of glial fibrillary acidic protein (GFAP) in combination with ubiquitin carboxy-terminal hydrolase-L1 (UCH-L1) can reliably distinguish ICH from ischemic stroke.

Methods:
This prospective two-center study recruited patients with a clinical diagnosis of acute stroke both in the pre-hospital phase and at hospital admission (within 4 and 6 hours after symptom onset, respectively). Blood samples were analyzed for concentrations of GFAP and UCHL1 using ELISA techniques. Reference standard was the diagnosis of ICH, ischemic stroke, or stroke mimicking condition achieved after clinical work-up including brain imaging.

Results:
A total of 251 patients were included (mean age [±SD] 72±15 years; 5 ICH, 23 ischemic strokes and 14 stroke mimics in the pre-hospital part; and 59 ICH, 148 ischemic strokes and 2 stroke mimics in the in-hospital part). Both GFAP and UCH-L1 serum concentrations were higher in patients having ICH as compared to other diagnoses (GFAP: median 330 ng/L [interquartile range 64-7060] vs. 27.5 ng/L [14-57.25], p<0.001; UCHL1: 401 ng/L [265-764] vs. 338 ng/L [213-549.5], p=0.025). Area-under-the-curve values were 0.866 (95% CI 0.809-0.924, p<0.001) for GFAP, and 0.590 (0.511-0.670, p=0.033) for UCH-L1. Regarding overall diagnostic accuracy, UCH-L1 did not add significantly to the performance of GFAP.

Conclusion:
GFAP differentiates ICH from ischemic stroke and stroke mimics. A point-of-care test may improve the pre-hospital triage and treatment of acute ICH patients.
Abstract WP443: The Impact of Delirium and Impaired Consciousness on Withdrawal of Life-Sustaining Treatment After Spontaneous Intracerebral Hemorrhage
Authors: Reznik Michael E , Mac Grory Brian C , Moody Scott , Murray Kayleigh , Costa Samantha , Yaghi Shadi , Burton Tina M , Cutting Shawna , Mahta Ali , Wendell Linda C , Thompson Bradford B , Rao Shyam S , Asaad Wael F , Jones Richard N , Furie Karen L
Published: January 2019

Introduction:
Established predictors for outcome after intracerebral hemorrhage (ICH) may be subject to self-fulfilling prophecy, as studies examining their effects on mortality have generally not considered changes in code status leading to withdrawal of life-sustaining treatment (WLST). We aimed to identify factors specifically associated with WLST, and hypothesized that impaired consciousness and delirium would be especially implicated.

Methods:
We analyzed data from consecutive patients admitted with ICH from February-June 2018. ICH score and other clinical predictors were prospectively adjudicated, and most patients had delirium assessments performed by an expert clinician; for those who did not, we established the presence of probable delirium via chart review. Using logistic regression models that adjusted for ICH severity, we determined the association of impaired consciousness on admission (Glasgow Coma Scale [GCS] <13) with early WLST (defined as <24 hours from admission), and the presence of delirium on subsequent assessments with WLST after 24 hours.

Results:
Of 106 patients in our cohort (mean age 68.7 [SD 17.8], median ICH score 1.5 [IQR 1-2]), WLST occurred in 29% (22/40 with admission GCS <13, 9/66 with GCS 13-15). After adjusting for ICH severity, admission GCS <13 was more strongly associated with early WLST (OR 26.8, 95% CI 2.8-255.8) than other components of the ICH score (OR 9.9, 95% CI 1.5-67.0 for age >80; OR 8.4, 95% CI 1.7-40.7 for size >30cc; intraventricular hemorrhage and infratentorial location were not significant). Of 92 patients who survived >24 hours without early WLST, 52% had delirium. We found that delirious patients were significantly more likely than patients without delirium to have subsequent WLST (33% vs. 2%, p<0.001; OR 18.8, 95% CI 2.1-165.5 after adjusting for ICH severity). Finally, we found that a composite predictor—initial GCS <13 or subsequent delirium—was strongly associated with WLST at any time during hospitalization (OR 19.0, 95% CI 2.3-158.0 after adjusting for ICH severity).

Conclusion:
Impaired consciousness and delirium likely play a significant role in WLST after ICH. However, whether this phenomenon is due to effects on clinician or surrogate decision-making remains unclear.
Abstract WP444: Identification of Intraoperative Bleeding at the Location of a Spot Sign During Intracerebral Hemorrhage (ICH) Endoscopic Evacuation
Authors: Pan Jonathan S , Song Rui , Lieber Adam C , Chartrain Alexander G , Scaggiante Jacopo , Mocco J , Kellner Christopher P
Published: January 2019

Background:
Intracerebral hemorrhage (ICH) is a devastating disease with the worst morbidity and mortality of all the stroke subtypes. A predictor of hematoma expansion and poor functional outcome is the spot sign, a small enhancing focus within the hematoma that can be visualized on computed tomography angiography (CTA). A number of minimally invasive surgical (MIS) techniques have emerged to treat ICH, including MIS endoscopic ICH evacuation. However, there is limited literature correlating intraoperative bleeding with the location of the spot sign. The goal of this study is to determine if intraoperative bleeding at the location of a spot sign could be regularly detected and treated.

Methods:
A retrospective analysis on prospectively collected data was performed on ICH patients who received MIS endoscopic evacuation from December 2015 to June 2018. Patients qualified for MIS evacuation with hematoma volume ≥15cc, National Institute of Health Stroke Scale ≥6, Glasgow Coma Scale (GCS) ≥4, and baseline modified Rankin Score ≤ 2.

Results:
Of the 100 ICH patients who received endoscopic evacuation, 15 had a spot sign. The average age of these patients was 62.5 (SD: 16.7) and 14 (93%) were male. The average pre-operative, post-operative volume, and evacuation rate was 62.5 mL (SD: 31.0), 10.4 mL (SD: 15.6), and 81% (SD 33.7%) respectively. Intraoperative bleeding was reported in 9 (60%) cases, treated with irrigation in 2 (22%) cases and irrigation with cautery in 7 (78%) cases. Postoperative rebleeding within 24 hours occurred in 2 (13%) patients. 7 out of the 15 (47%) patients who had a spot sign also had a bleeding vessel identified at the same location as the spot sign. The average 30-day mRS was 3.6 (SD: 1.3).

Conclusion:
MIS endoscopic ICH evacuation reveals a bleeding vessel in spot sign patients in approximately 50% of cases. Evacuation of these hematomas carries a higher risk of encountering a bleeding vessel during the procedure but in all cases bleeding was effectively managed. Although evacuation of spot sign patients may mitigate the risk of hematoma expansion, it also carries a higher risk of post-operative rebleeding in this small patient cohort. Future studies will be necessary to determine the impact of this procedure on long-term functional outcomes.
Abstract WP445: Characteristics of Methamphetamine-Related Intracerebral Hemorrhage and Factors Associated With Outcomes
Authors: Zhu Zhu , Osman Sahar , Farag Mark , Stradling Dana , Shafie Mohammad , Abcede Hermelinda , Yu Wengui
Published: January 2019

Background and Purposes:
Methamphetamine use is on the rise worldwide. There are limited data and cognizance on methamphetamine-related intracerebral hemorrhage (ICH). This study aimed to investigate the characteristics of methamphetamine-related ICH and to explore the factors associated with outcomes.

Methods:
This retrospective cohort study enrolled consecutive ICH patients at a comprehensive stroke center between January 2011 and December 2017. Patients with methamphetamine related ICH were included for analysis of demographics, clinical features, and outcomes at hospital discharge. Factors associated with discharge outcomes were explored using multivariate logistic regression models.

Results:
Among the 686 consecutive patients admitted for spontaneous ICH during the study period, 412 (60.1%) had urine toxicology tests and 60 (8.7%) were identified to have methamphetamine use per history and positive urine test. Of note, 30 patients who denied substance use had positive urine test. The mean age was 51.8 years old and 78.3% patients were male. There was significant racial disparity in methamphetamine use, with highest ratio in Hispanics (14.9%), followed by White (9.2%), African Americans (5.7%), and Asians (1.2%). The mortality rate of methamphetamine-related ICH was 18.3% and only 25.0% patients achieved functional independence at hospital discharge. NIHSS (OR=0.15; 95% CI 0.04-0.62; P=0.005), GCS (OR=0.05; 95% CI 0.01-0.43; P=0.001), ICH score (OR=0.08; 95% CI 0.01-0.67; P=0.005), smoking history (OR=6.76; 95% CI 1.82-25.00; P=0.002), surgical intervention (OR=0.13; 95% CI 0.03-0.66; P=0.007) and ventilator support (OR=0.11; 95% CI 0.02-0.56; P=0.003) were independently associated with functional status. Risk factors of mortality include NIHSS (OR=2.45; 95% CI 1.75-3.44; P<0.001), GCS (OR=3.06; 95% CI 2.05-4.59; P<0.001), ICH score (OR=4.46; 95% CI 2.65-7.52; P<0.001), creatinine level (OR=8.97; 95% CI 2.12-37.98; P=0.001) and ventilator support (OR=2.89; 95% CI 1.96-4.24; P<0.001).

Conclusion:
Methamphetamine use is a major cause of ICH, especially in Hispanic population. Clinical severity scores, elevated creatinine levels, and ventilator support are associated with poor outcomes at hospital discharge.
Abstract WP446: Predictors of 30-Day Readmissions and in Hospital Mortality Following Intracerebral Hemorrhage (ich)-A 5-Year National Estimate
Authors: Kumar Varun , Savani Chirag , yi Xiyan , Singh Tejinder , Pathak Ambarish , Chib Anjula , Renati Swetha
Published: January 2019

Background:
Intracerebral hemorrhage (ICH) is one of the more devastating types of stroke with worse short-term outcomes. There is a paucity of data regarding preventable causes of readmission and predictors of short-term outcomes post-ICH.

Method:
Nationwide Readmissions Database (NRD) from 2010-14 was utilized to identify ICH using appropriate ICD-9CM codes in the primary diagnostic field. Admissions within 30 days of discharge were considered as early readmission and predictors to assess an association between baseline characteristics and 30-day readmission and mortality were analyzed using multivariable logistic regression model.

Result:
We identified 276,401 patients with ICH in our study, of which 37,689 (10%) were readmitted within 30 days (Mean age 68.3 years; 52.8% male). Hypertension was the major comorbidity in the readmitted population (77.7%) followed by diabetes (33.5%), anemia (21.9%), and atrial fibrillation (20.7%). Comorbid conditions like diabetes, heart failure, atrial fibrillation (AF), anemia, coagulopathy, chronic renal failure (CRF), valvular heart disease (VHD), liver disease, in-hospital septicemia, urinary tract infection, Pneumonia, deep venous thrombosis and discharge to another facility were significant predictors of 30-day readmission. Advancing age, heart failure, AF, CRF, liver disease, coagulopathy, hospitalization on weekends, in-hospital complications such as acute renal failure, sepsis, pneumonia was predictive of increased 30-day mortality. Non-emergent index admissions in large bed size, teaching hospital and private insurance were associated with decreased mortality.

Conclusion:
In conclusion, ICH was associated with a 10% readmission rate during our study period. Identification of high-risk population based on certain preexisting comorbidities and in-hospital complications, better follow up and transition of care can have improved outcomes in these patients and reduce healthcare burden.
Abstract WP449: Distribution of Cerebellar Microbleeds and Their Correlation with Underlying Microangiopathy in Patients with Spontaneous Supratentorial Intracerebral Hemorrhage
Authors: Singh Ravinder-Jeet , Teleg Ericka S , Kashani Nima , Smith Eric E
Published: January 2019

Background:
Cerebral amyloid angiopathy (CAA) and hypertensive cerebral small vessel disease (HTN-cSVD) exhibit distinct distributions of intracerebral hemorrhages (ICHs) and microbleeds (MBs), but little is known about cerebellar hemorrhage patterns and how they relate to the underlying microangiopathy. The Boston criteria for CAA do not discriminate between lobar and deep cerebellar hemorrhages. We investigated if distinct topographical patterns of MBs exists in the cerebellum.

Methods:
Patients with spontaneous symptomatic supratentorial ICH were included if they had brain MRI with gradient echo T2*-weighted sequence. Cerebellar MBs were classified into lobar or superficial (cortical/corticosubcortical), deep (dentate/peridentate) and mixed patterns. We compared the frequency and distribution of cerebellar MBs between lobar and deep/mixed ICH and correlated with supratentorial MBs (dichotomized into lobar and deep/mixed MBs).

Results:
130 patients were included (median age 68.6-years [IQR 57.9-79.0]; 50% male); 87 patients (67%) had lobar ICH (possible CAA, n=26; probable CAA, n=37; nonCAA, n=24) and 43 (33%) had deep/mixed ICH. Cerebellar MBs were seen in 26 patients (20.0%); lobar pattern among 16 patients (61.5%), deep in 4 (15.4%), and mixed pattern in 6 patients (23.1%). Lobar ICH patients often had superficial cerebellar MBs (81.3% vs deep/mixed in 18.8%) while deep/mixed ICH patients more often demonstrated deep/mixed cerebellar MBs (66.7% vs superficial in 23.5%) [
P
=0.046]. The distribution of supratentorial MBs correlated with the distribution of cerebellar MBs (
P=
0.047). Two patients with possible CAA had MBs confined to superficial cerebellum and incorporation of cerebellar MBs into the Boston criteria would have resulted in their reclassification into probable CAA, while another two probable CAA had deep/mixed cerebellar MBs reclassifying them into nonCAA ICH.

Conclusion:
Distinct superficial and deep cerebellar MB patterns can be distinguished which segregate with lobar and deep/mixed ICH locations, suggesting differential cerebellar involvement by CAA and HTN-cSVD. If validated, lobar (superficial) cerebellar MBs might be used to further improve the accuracy of the Boston criteria for CAA.
Abstract WP451: Frequency and Characteristics of Intracerebral Hemorrhage in a Population-based Study
Authors: Arnold Fiebelkorn Catherine , Aakre Jeremiah , Rabinstein Alejandro , Flemming Kelly , Brown Robert D. , Mielke Michelle , Knopman David , Petersen Ronald , Vemuri Prashanthi , Jack Clifford , Lower Val , Kantarci Kejal , Graff-Radford Jonathan
Published: January 2019

Objective:
To determine the frequency and characteristics of symptomatic intracerebral hemorrhage in a population-based study

Patients and Methods:
The population-based Mayo Clinic Study of Aging included 4,994 participants age ≥50 years entered from 11/29/2004 to 3/11/2017. Participants with intracranial hemorrhage were identified using the Rochester Epidemiology Project medical records linkage system. Medical records of these individuals were reviewed. Each hemorrhage was classified as deep, lobar, or cerebellar intracerebral hemorrhage (ICH) or convexity subarachnoid hemorrhage (cSAH). Traumatic, subdural, non-convexal SAH, and epidural hemorrhages were excluded. Patient demographics, presence of hypertension, antithrombotic regimen, APOE genotype, and amyloid PET scan results were collected when available. Individuals with hemorrhages were matched 3:1 on age and gender to controls without symptomatic hemorrhage. Analyses within the cases and between the groups were performed.

Results:
Symptomatic hemorrhages were identified in 57 individuals for a frequency of 1.14%. Twenty-one were classified as deep, 26 lobar, 5 cerebellar, and 5 cSAH. Mean age at the time of hemorrhage was 80.9 years (SD ±7.9). 54.4% of hemorrhages occurred in men. Hypertension was present in 45.6%. Of those with lobar ICH or cSAH, 87.1% were on an antithrombotic compared to 65.6% of controls (p=0.02) and 32.3% of these were on warfarin compared to 12.9% of controls (p=0.01). APOE genotype was available in 54 of the 57. APOE e2 and/or e4 was found in 46.7% of those with lobar ICH/cSAH compared to 39.1% of controls (p=0.47) and 35.0% of those with deep ICH versus 39.3% of controls (p=0.73). Of the 31 with either lobar ICH or cSAH, 7 underwent amyloid PET scans; of these, 71.4% were abnormal compared to 42.9% of controls with mean SUVR of 1.911 and 1.565, respectively (p=0.08).

Conclusions:
Symptomatic ICH occurred in approximately 1 in 100 individuals age 50-94 years in this population-based study. In a matched case-control study, antithrombotic use (particularly warfarin) was statistically associated with the development of an ICH. While only a subset underwent amyloid PET, there was a trend towards greater amyloid load in those who developed a lobar or cSAH compared to controls.
Abstract WP454: Multi-modal Neuroimaging Biomarkers of Aneurysmal Subarachnoid Hemorrhage
Authors: Churchill Nathan , Maher Monica , Graham Simon , MacDonald Loch , Schweizer Tom
Published: January 2019

Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high mortality rates and survivors of aSAH often experience persistent deficits across multiple domains, including language, memory, perception and frontal lobe executive function. At present, little is known about the alterations in brain structure and function associated with aSAH, and specific brain biomarkers of post-stroke impairment. In this study, N=28 individuals were scanned using a comprehensive multi-modal neuroimaging battery, including 14 with chronic aSAH and 14 matched controls. Using a 3T Magnetic Resonance Imaging (MRI) scanner, we acquired resting state functional MRI (rs-fMRI), diffusion tensor imaging (DTI) and T1-weighted voxel-based morphometry (VBM). Comparing aSAH patients to controls, we observed elevated rs-fMRI measures of global connectivity and decreased VBM measures of grey matter, primarily within the midcingulate cortex, but no consistent alterations were seen in DTI measures of white matter. Within-group analysis of aSAH patients subsequently showed that greater impairments in executive function were associated with altered DTI measures, including elevated diffusivity and reduced fractional anisotropy, mainly within posterior corona radiata. These findings indicate that brain function and cortical volume are reliably altered post-stroke, whereas the effects on white matter microstructure depend on the severity of post-stroke impairment. These results provide novel information about potential neuroimaging biomarkers of recovery following aSAH.
Abstract WP456: Validation of the NIH Stroke Scale Score for Clinical Assessment of Intracerebral Hemorrhage
Authors: Dusenbury Wendy , Tsivgoulis Georgis , Brewer Barbara B , Chang Jason , Goyal Nitin , Swatzell Victoria , Rhudy James P , Alexandrov Andrei V , Alexandrov Anne W
Published: January 2019

Background:
Both Glasgow Coma Scale (GCS) and NIH Stroke Scale (NIHSS) are commonly used as serial assessment tools in ICH, however, the NIHSS lacks formal validation in this population.

Methods:
We prospectively collected ICH assessments, imaging, and outcome data. Direct comparisons of discrimination were made using GCS and NIHSS on prediction of 24-hour poor functional outcome (mRS-3-6) and hematoma volume >30cm
3
using ROC analysis;
c
statistics were calculated and compared with DeLong test.

Results:
672 ICH patients (mean age 62±14 years; 56% men; median ICH score = 1, IQR 0-2; median ICH volume 7cm
3
, IQR 2-19) were included in the analysis. Median NIHSS and GCS were 8 (IQR 3-18) and 15 (IQR 7-15) respectively. NIHSS correlated strongly to GCS (r -0.773; p<0.001). NIHSS (c statistic: 0.91; 95%CI: 0.89-0.93) discriminated better than GCS (c statistic: 0.78; 95%CI: 0.75-0.81) for 24-hour poor functional outcome (DeLong p<0.001; Figure 1A). NIHSS (c statistic: 0.82; 95%CI: 0.78-0.86) also discriminated better than GCS (c statistic: 0.78; 95%CI: 0.73-0.83) for large hematoma volume (DeLong p=0.029; Figure 1B).

Conclusions:
The NIHSS has greater discriminative power than GCS to identify patients with poor functional outcomes and large hematoma volumes.
Abstract WP458: Blood Pressure at Hospital Arrival Does Not Reliably Distinguish Hypertensive Intracerebral Hemorrhage
Authors: Fakhri Nasir H , Moody Scott , Murray Kayleigh , Costa Samantha , Yaghi Shadi , Burton Tina M , Cutting Shawna , Mahta Ali , Wendell Linda C , Thompson Bradford B , Rao Shyam S , Potter N. Stevenson , Furie Karen L , Mac Grory Brian C , Reznik Michael E
Published: January 2019

Introduction:
Hypertension is a known risk factor for intracerebral hemorrhage (ICH), but it is unclear whether blood pressure (BP) elevation at hospital arrival can reliably distinguish ICH caused by hypertensive angiopathy from other potential etiologies.

Methods:
We performed a retrospective single-center cohort study using data from consecutive patients admitted with ICH from February-June 2018. Presumed ICH etiology, location, and other clinical predictors were prospectively adjudicated by two attending neurologists. We compared patients’ first recorded systolic BP (SBP) and mean arterial pressure (MAP) at hospital arrival stratified by hypertensive vs. non-hypertensive primary ICH etiology, with further adjustment for demographics and initial arrival location (direct arrival vs. transfer) using linear regression models. In a sensitivity analysis, we used ICH location (deep, lobar, or infratentorial) rather than etiology in our models to account for potential subjectivity in adjudication.

Results:
There were 110 ICH patients in our cohort (mean age 69.1 [SD 17.7], 55% male, median ICH score 1.5 [IQR 1-2]). The most frequent ICH etiologies were hypertension (58%), cerebral amyloid angiopathy (19%), vascular lesions (6%), and malignancy (5%); 43% of hemorrhages occurred in deep subcortical locations, 37% were lobar, and 14% were infratentorial. Mean SBP and MAP for patients with hypertensive ICH was 158.8 (SD 29.7) and 109.0 (SD 18.3), respectively, compared to 157.1 (SD 33.4) and 108.2 (SD 21.2) in patients with ICH caused by other etiologies (p=0.78; p=0.82). Fully-adjusted regression models showed that, relative to hypertensive ICH, those caused by non-hypertensive etiologies had similar arrival BP (mean SBP and MAP difference [95% CI], -0.2 [-12.3-11.8] and -0.8 [-8.4-6.8], respectively). In a sensitivity analysis, we found that lobar and infratentorial ICH had similar arrival BP relative to deep ICH (mean SBP and MAP difference [95% CI] 2.1 [-11.1-15.3] and 0.2 [-8.3-8.6] for lobar ICH; 6.5 [-12.0-25.0] and 3.8 [-8.0-15.6] for infratentorial ICH).

Conclusion:
BP at hospital arrival should not be used as a primary determinant of likely ICH etiology, as hypertension may be implicated in various subtypes of ICH.
Abstract WP46: Association of Onset-to-Reperfusion Time With 90-Day Outcome in Octogenarian: RESCUE-Japan Registry 2
Authors: Todo Kenichi , Uchida Kazutaka , Yamagami Hiroshi , Kono Tomoyuki , Imamura Hirotoshi , Adachi Hidemitsu , Nakamura Hajime , Sakaguchi Manabu , Morimoto Takeshi , Sakai Nobuyuki , Yoshimura Shinichi
Published: January 2019

Background and Purpose:
Clinical outcomes after successful endovascular therapy in patients with acute ischemic stroke are associated with several factors including onset-to-reperfusion time (ORT). The objective of the current study was to assess whether ORT is associated with outcomes in elderly.

Methods:
Among 2420 patients enrolled in the RESCUE 2 study, a prospective stroke registry with acute cerebral large-vessel occlusion at 46 centers between October 2014 and January 2017, we enrolled 397 elderly patients more than 80 with successful reperfusion after thrombectomy (thrombolysis in cerebral infarction [TICI] score of 2b or 3) in the current analysis. The rates of good outcome (modified Rankin Scale [mRS] scores of 0-2 at 3 months) were compared among the three categories of ORT (<180 minutes, 180-239 minutes, and ≥240 minutes). We developed multivariate logistic regression model to assess the independent association of the ORT with good outcome by adjusting for clinically relevant factors.

Results:
The rates of good outcome were 41% (30/73), 34% (26/77), and 25% (62/247) in each category of ORT. Odds ratio and 95% confidence interval for good outcome were 0.68 and 0.49-0.94 per 1 category delay.

Conclusion:
ORT was associated with good outcome even in elderly patients.
Abstract WP463: Baseline Leukoaraiosis Does Not Modify Clinical Outcomes in Patients With Spontaneous Intracerebral Hemorrhage
Authors: Turabova Charoskhon , Olowu Adeola , Cai Chunyan , Jagolino Amanda L , Gonzales Nicole R
Published: January 2019

Background:
Prior studies have suggested that baseline leukoaraiosis before ICH may be associated with high mortality, initial large hematoma volume, and may be an independent risk factor for worse outcomes after ICH, yet leukoaraiosis is not included in prognostic criteria for ICH. We hypothesized that increased leukoaraiosis burden at baseline would be associated with worse outcomes in patients enrolled in the Safety of Pioglitazone for Hematoma Resolution in ICH (SHRINC) trial.

Methods:
Patients enrolled in SHRINC had a baseline brain MRI per protocol. We performed a retrospective analysis of leukoaraiosis measured on baseline MRI. Baseline leukoaraiosis scoring was measured using the Fazekas score (FS). Patients were stratified into two groups based on FS, none-mild (FS 0-1) and moderate-severe (FS 2-3). FS was evaluated as a treatment modifier for mRS, NIHSS and Barthel Index. Comparisons were performed by Chi-square, Fisher’s Exact or Wilcoxon rank sum, linear or logistic regression models were developed to test FS as a treatment effect modifier on outcomes.

Results:
A total of 78 subjects had baseline MRIs (37 PIO, 41 Placebo) suitable to determine FS. There was no difference in important prognostic variables between the two groups (Table). There was no significant interaction between FS and treatment group at 90 or 180 days regarding good outcome, NIHSS, Barthel index (p= 0.18, 0.31, 0.40, respectively).

Conclusions:
Our analysis revealed that the presence of baseline moderate to severe leukoaraiosis was not associated with baseline presentation nor treatment effect on outcomes. Our findings raise the question whether our traditional outcome measures are able to detect deficit due to leukoaraisosis and future studies should consider outcomes measures which can better quantify deficits attributable to leukoaraiosis.
Abstract WP464: Stress-Induced Hyperglycemia After Intracerebral Hemorrhage Predicts In-Hospital Mortality and Temporary CSF Diversion
Authors: Delpirou Noah Clair , Sidorov Evgeny , Koriesh Ahmed , Hollabaugh Kimberly , Santucci Joshua , Ray Bappaditya
Published: January 2019

Introduction:
Stress-induced hyperglycemia (SIH) in critical illnesses, including intracerebral hemorrhage (ICH) is often associated with increased morbidity and mortality. Objective parameters to determine SIH and associated clinical outcome are not systematically evaluated due to lack of standard definition for SIH.

Hypothesis:
We investigated if recently standardized definition for SIH, glycemic gap (GG) correlates with disease severity at presentation and in-hospital morbidity and mortality after ICH.

Methods:
Five-year retrospective chart review of patients with spontaneous ICH. GG defined as the difference between admission glucose (AG) and an A1C derived average glucose (GG= AG-28.7*HbA1c+46.7). Receiver operating curve (ROC) analysis was used to determine a GG threshold to predict a adverse outcome defined as death or discharge to hospice. We used multivariate analyses to determine role of GG in patients with different ICH scores.

Results:
A GG threshold of 30 mg/dL determined worse clinical outcome in a cohort of 334 patients with ICH. Patients with higher ICH score of 3-5 were more likely to present with SIH as compared to those with ICH score of 0-2, 51/95 (53.7%) vs. 56/239 (23.4%), p<0.001. SIH also showed a dose-dependent correlation to ICH score. Patient with ICH score 0-2 had lower incidence of external ventricular drain (EVD) placement as compared to those with scores 3-5, 31/233 (13.3%) vs. 35/93 (37.6%), p<0.001. In multivariate model ICH score at presentation, history of hypertension, diabetes mellitus, in-hospital EVD placement and mortality were independently associated with SIH. Patients with ICH score 0-2 had 5.7 times more odds in having an EVD placed (p<0.0001).

Conclusion:
Using objective definition for SIH, i.e. GG our study shows definitive association of SIH with in-hospital morbidity and mortality. Such association alludes to adverse outcome related to neurohumoral response after ICH.
Abstract WP466: Improving Stroke Dysphagia Screening Core Measure Compliance and Patient Outcomes
Authors: Fuhrman Susan , Lazarro Marc , Herman Ashley
Published: January 2019

Background and Issues:
Prior to this project, an internally created dysphagia screen had been used. A validated stroke dysphagia screen was needed. Knowledge deficits existed on who, when, and how to perform the screen. With record patient census, stroke patients got admitted wherever there was an open bed, so all units needed this education. Evidence also showed that swallowing issues were related to aspiration.

Purpose:
Evaluate the impact of expanded education and use of a validated stroke dysphagia screen on core measure compliance and hospital acquired pneumonia incidence on stoke/TIA patients.

Methods:
An interprofessional team selected the validated, stroke dysphagia screen. Education was provided via an online module, tipsheets, and live demonstrations. More resources and demonstration videos were made available on the internal stroke program website. All inpatient stroke/TIA patients were monitored for core measure compliance at least 4 days/week, with real time follow-up to involved nurses as needed. The stroke core measure of dysphagia screening compliance and documentation of hospital-acquired aspiration pneumonia was entered into a database for 100% of the coded stroke/TIA patients during the study periods (i.e. July-December over 2 years: Baseline= 2016 and Intervention=2017).

Results:
More than 2000 nurses attended the live presentations and/or completed the online module. Compliance and outcome findings were as follows:

Conclusions:
Though no direct cause and effect with the pneumonia results can be proven with this quality improvement effort, favorable findings occurred. The percentage of stroke/TIA patients being screened went up and the percentage of those patients developing hospital acquired pneumonia went down after the screening tool change, education, and monitoring process were put into place.
Abstract WP467: Utilizing a Communication Platform to Improve Stroke Care
Authors: Hamm Theresa L
Published: January 2019

Background and Purpose:
Stroke care continues to evolve requiring an ever growing number of participating team members. Communication between team members can often be fragmented leading to gaps or delays in provision of acute care, leading us to seek solutions facilitating the clear transfer of information to all team members.

Methods:
Primary to this process was identification of stakeholders. This included Emergency Medical Services (EMS), both Primary Stroke Centers, and the local community hospitals. Stakeholders validated the importance of full community participation and a platform was agreed upon. Training was initiated, followed by a slow roll-out with dual process communications until all appropriate EMS services and hospitals were on-boarded.

Results:
A single step process for providing real time information to the entire stroke team from field through completion of acute stroke treatment has improved communication and facilitated rapid administration of Activase in appropriate patients and has reduced our door to needle times from an average of 46.2 minutes to 38.3 minutes. This platform also allows our interventional team additional preparation time for probable thrombectomy cases, leading to fewer delays. This platform also allows each member of the care team to access a case summary which provides immediate feedback to EMS providers.

Conclusion:
A communication platform shared by all members of the care team leads to improved flow of information and reduction in treatment times.
Abstract WP469: The Effect of Different Doses of Remote Ischemic Conditioning on Patients’ Comfort
Authors: Zhao Jie , Chang Hong , Wang XiaoJuan , Cao WenYa , Yang Xin , Yao Hui , Qiao Yuchen , Zheng Ruan , Fan KaiTing
Published: January 2019

Objective:
This study aimed to provide a basis for the clinical application of the remotic ischemic conditioning (RIC) by comparing two commonly used doses with the Visual Analogue Scale.

Methods:
From June to August 2017, 80 healthy adults who were working at the hospital were enrolled in the study. According to the order of enrollment, they were randomly divided into 2 groups by random number method, with 40 subjects in Group1 and Group 2 respectively. The procedure for Group 1 consisted of 3 cycles of simultaneous bilateral upper arm ischemia for 3 minutes followed by reperfusion for another 3 minutes. The procedure was performed by using an electric auto control device with cuffs that inflated to a pressure of 200 mm Hg during the ischemic period. The procedure for Group 2 consisted of 5 cycles of simultaneous bilateral upper arm ischemia for 5 minutes followed by reperfusion for another 5 minutes with same pressure. At the same time, the differences of comfort visual analogue scales in the whole process of remote ischemia were observed.

Results:
The two groups were similar in the age, sex, BMI, and pre-test blood pressure (P0. 05). The comfort of group 2 was significantly lower than that of group 1 during the whole observation period(P0. 05.

Conclusions:
Subjective comfort was different for subjects with different RIC treatment doses. Subjects with shorter training durations had higher comfort, while higher comfort levels might improve the patient's compliance with RIC treatment.
Abstract WP47: Efficacy and Safety of Nimodipin During Mechanical Thrombectomy
Authors: Chalumeau Vanessa , Nguyen Thi Ngoc Phuong , Cortese Jonathan , Chassin Olivier , Mihalea Cristian , Caroff Jildaz , Ikka Léon , Ozanne Augustin , Gallas Sophie , Iacobucci Marta , Rouchaud Aymeric , Yasuda Thomas , Marenco Joaquin , Pagiola Igor , Bani Hashemi Gelareh , Naderi Soheil , Ahmed Awais , Ebrahimi Reza , Denier Christian , Moret Jacques , Spelle Laurent
Published: January 2019

Background:
Randomized controlled trials for calcium antagonists therapy in patients with acute ischemic stroke have failed to show a benefit as a stand-alone therapy, due largely to the reduction of blood pressure, especially in the absence of early recanalization. Since mechanical thrombectomy (MT) has led to high successful recanalization rates, the effect of nimodipin as an adjuvant therapy during MT has not been evaluated.

Materials and Methods:
We retrospectively reviewed all consecutive cases of MT for which Nimodipin was used as an adjuvant therapy after at least one pass of any device. Clinical and angiographic characteristics, as well as immediate vessel caliber modifications, reperfusion status and early neurological improvement were collected between January 2016 and December 2017.

Results:
Procedural intra-arterial nimodipin infusion was administered in 10.3 % (58/559; 95%CI 7.8-12.8 %) of patients, after at least one pass of MT device. In 52/58 patients, < 3 manoeuvers of MT were performed. Angiographic vasospasm was identified on the carotid artery in 17/58 (29.3%) cases, on the middle cerebral artery in 35/58 (60.4%) cases and in vertebro-basilar artery in 6/58 (10.3%) cases. The vasospasm was responsible for an immediate reocclusion in 12% of the patients. Angiographic effect of nimodipin with the restauration of a normal vessel caliber and the improvement of the reperfusion without supplementary maneuver was observed in 77.5% % of the cases. Successful recanalization TICI 2b/3 was reached in 81% patients. Significant drop of blood pressure (BP) with need for additional vasopressive drugs was observed in 6 cases. Symptomatic hemorrhage occurred in 3 patients (5%). Concomitant fibrinolytic therapy did not influence the rate of intracranial hemorrhage rate after procedural nimodipin infusion (p=0.912). Early neurological improvement was reached in 46% and was not associated with a high initial systolic and diastolic BP at the admission (p=0.89) or with the modality of anesthesia (p =0.76).

Conclusion:
Nimodipin can be an efficient and safe adjuvant therapy in the setting of vasospasm due to MT, by normalizing the caliber of the recanalized artery and then, improving the reperfusion status without supplementary maneuver of MT.
Abstract WP474: Stroke Severity upon Discharge Does Not Predict Post-Discharge Nurse Navigator Needs
Authors: Sher Karen , Hoffman Emily , Mack Kelsey , Nouh Amre
Published: January 2019

Background:
Post stroke care after hospital discharge is complex and influenced by many factors. Stroke severity is commonly thought to correlate with a need for navigator services.

Objective:
To identify factors predicting patient complexity of post-discharge navigator needs.

Methods:
We conducted a retrospective quality improvement analysis of patients seen in the hospital and called within 30 days by our nurse navigator between January 2017 and July 2018 yielding 373 patients. All patients had been assigned a level of complexity pre-discharge that was finalized after the first call. Complexity was dichotomized to low and medium/high. Possible predictors of complexity included patient demographics, diagnosis, disposition, NIHSS, mRS, outpatient cardiac monitoring, smoking habits, number of medications, and referrals placed. Chi squared test of proportions and Paired T-test analysis were used to determine complexity predictors.

Results:
Of the 373 patients, 50.9% (n = 190) were female. Discharge diagnoses included ischemic stroke 72.92% (n=272), ICH 17.69% (n=66), TIA 6.43% (n=24) and other 2.95% (n=11). Discharge dispositions included acute rehab 26% (n=97), home 26% (n=98) home with services, 23% (n=84), and short-term rehab 25% (n=94). The majority of patients were designated as low complexity 62% (n=231). The mean NIHSS for low vs. med/high complexity (3.42 +/-4.59 vs. 3.48 +/- 4.27;
p=0.90
) and mRS (2.06 +/-1.43 vs. 1.9 +/-1.5
p=0.60
) did not differ. Factors associated with higher level of complexity included referrals either upon discharge or within 30 days (p<0.0001), younger age, (p< 0. 00001), and active smoking (p=0.003). Gender (p = 0.776) and outpatient cardiac monitoring (p = 0.919) did not impact complexity. Surprisingly, a lower number of discharge medications was associated with higher complexity (p = 0.004).

Conclusion:
Determining post-stroke acuity is complex and not influenced by stroke severity in our analysis. Younger patients, need of referrals and active smokers were higher complexity post discharge and should be identified early after stroke.
Abstract WP478: Characterization of False Negative Vision, Aphasia, Neglect Screening Scores in Patients With Confirmed Large Vessel Occlusion
Authors: Stevens Stacie C , Selleck Lorie , Green Jessica
Published: January 2019

Endovascular thrombectomy (EVT) is the standard of care for acute ischemic stroke patients with a large vessel occlusion (LVO). The Vision, Aphasia, Neglect (VAN) assessment is one method by which patients are screened for LVO. The purpose of this study was to assess the sensitivity and specificity of VAN for patients with ischemic stroke arriving within 24 hours of last known well (LKW) or LKW not known. VAN scores were retrospectively extracted from NIHSS performed on arrival by neurologists for patients discharged CY 2017 with a final diagnosis of ischemic stroke. Head and neck CTA were performed for all of these patients. VAN scores were correlated with CTA findings. Of 518 patients with final diagnosis of ischemic stroke, 143 patients had LVO. The VAN scale was consistent with LVO in 97 (68%) patients confirmed by CTA. The VAN scale demonstrated a false negative rate in 32% (46 patients). Within the VAN false negative subgroup, the following LVO were identified: M2 15 (33%), proximal M1 10 (22%), ICA 6 (13%), VA 5 (11%), distal MCA 4 (9%), BA 3 (7%), PCA 1 (2%) and other 2 (4%). Of the 46 VAN negative patients with LVO, 37 patients (80%) did not have arm drift and 24 patients (52%) underwent EVT. In conclusion, of the patients with negative VAN scores, 32% were found to have LVO by CTA and of these 52% underwent EVT.
Abstract WP48: Real-world Outcomes Following Mechanical Thrombectomy and tPA Treatment of Acute Ischemic Strokes
Authors: Nadasdy Zoltan , Shpak Maxim , Cowperthwaite Matthew
Published: January 2019

Introduction:
Tissue plasminogen activator (tPA) and mechanic thrombectomy (MT) are the gold-standard treatment options for acute ischemic stroke (AIS). While the short-term benefits and outcomes of these treatments are well studies, the long-term “real world” outcomes are less well understood.

Hypothesis:
We hypothesize that readmission reasons and rates will differ between strokes treated with MT or tPA.

Methods:
We obtained de-identified clinical data on 37,381 AIS cases admitted to 177 US hospitals. AIS were grouped by treatment type MT and tPA. 30-day all-cause readmission data was captured for all AIS cases studied. The readmission reasons were classified according to the primary (first) ICD-10 code. Odds ratios (OR’s) were computed for the MT and tPA groups using Fischer’s exact tests with Bonferroni correction for multiple comparisons.

Results:
Overall, 10 times more patients received tPA treatment (n=33,992) than MT (n=3,389) with a slightly higher rate of male patients receiving tPA (52 %) than female patients, while the opposite was true for MT (48 %). The leading reason for readmission was the group of symptoms related to the circulatory system (14-23 % of patients, p<0.001), more specifically to nontraumatic intracerebral hemorrhage. The intracerebral hemorrhage was also responsible for explaining the largest difference between post-MT and post-tPA re-admittance as it showed a much higher prevalence (p<<0.001) within the post-MT population than in the post-tPA group.

Conclusions:
The statistical analysis confirmed the hypothesis that MT, tPA, and the combined treatment differently affect the recurrence of cerebrovascular symptoms. Among those, the leading reason was nontraumatic intracerebral hemorrhage, which occurs much more likely following MT, than following tPA treatment or following the co-application of MT and tPA.
Abstract WP480: Stroke Risk Among Post-menopausal Breast-cancer Survivors
Authors: An Kyungeh , Shin Chanam , Sim Jeongha
Published: January 2019

Background and Purpose:
Cancer is a well-known risk factor for stroke, yet whether the stroke comorbid with a cancer or the risk further increases along with a long-term survivorship is unclear. Also, whether the stage of cancer and receiving hormonal therapy affect stroke risk particularly in post-menopausal breast cancer survivors (BCS) is yet to be determined. This study aimed to (1) identify comorbid stroke risks at the time of the cancer diagnosis; (2) examine the changes of stroke risk at one, five and ten years after survival; and (3) explore relationships between demographic and cancer-related factors and stroke risks among BCS.

Methods:
We retrieved 4,152 deidentified BCS data from a Massey Cancer Registry. After excluding 39 pre-existing stroke and selecting who met the Framingham Stroke Risk Score (FSRS) criteria, we included 2141 (mean age of 64.22; SD=7.30 years). Among them, 616 who had all components for the FSRS equation (age, sex, systolic blood pressure, presence of cardiovascular disease, left ventricular hypertrophy, smoking, atrial fibrillation, and presence of diabetes) were included in this analysis.

Results:
We found that (1) comorbid stroke risk at the time of the diagnosis was 10.6 in terms of the FSRS; among individual risk factors, elevated systolic blood pressure (SBP>140mmHg, 43.3 %) was prominent followed by the presence of cardiovascular disease markers (39.56%) and diabetes (23.11%). (2) The FSRS consistently increased overtime with the largest increase during the first year of survival (10.60 at baseline vs. 16.07, 17.27. and 17.76 at year 1, 5, and 10, respectively). (3) The FSRS was significantly higher in Non-Hispanic Black than Non-Hispanic White (12.55 vs. 9.25,
p=0.016
) across time. Those who received hormonal therapy showed higher FSRS than those who did not (15.88 vs. 8.17,
p=0.000
); tumor stage was not associated with the FSRS.

Conclusion:
Stroke risk consistently increase along with the survivorship of a breast cancer, particularly among women after their menopause. Prevention and control of high blood pressure and diabetes should be a target of intervention to reduce the stroke risk among post-menopausal breast cancer survivors.
Abstract WP483: Clinical Social Work Perspective Positively Impacts Comprehensive Stroke Center
Authors: Rossi Carly , Casper Christy , Graves Alexandra , Kiernan Terri
Published: January 2019

Background:
The Licensed Clinical Social Worker (LCSW) scope of practice is similar to other healthcare providers in conducting assessments, providing diagnoses and recommending treatment plans. The LCSW is unique in that they are also equipped to assess a patient’s environment and other significant factors which impact individual needs and outcomes. The LCSW is skilled at providing individual, interpersonal and societal assessments helping to optimize biopsychosocial needs within the continuum of care. Integrating a social work perspective offers a unique vantage point within the CSC.

Purpose:
The purpose of this initiative was to align the LCSW scope of practice with the CSC scope of service and assess the CSC program from the LCSW perspective. The goal was to identify gaps in the care continuum to improve transitions of care, increase patient satisfaction, and reduce readmission rates.

Methods:
After implementing the LCSW role to assess transitional care needs identified by a gap analysis, the CSC utilized qualitative research and PDSA methodology to provide ongoing oversight and assessment and achieve the identified goals. The outcomes were determined by FY2017 to FY2018 data.

Results:
Based on identified gaps, the CSC established a stroke clinic for follow-up, and 7-day patient satisfaction phone calls were completed by the LCSW. In follow-up, 82% of scheduled patients were seen in the stroke clinic. Post-discharge LCSW intervention was provided to 74% of the 134 patients reached during the 7-day satisfaction phone call. Of the patients reached by phone, 82% reported satisfaction scores above average as compared to other healthcare experiences. The CSC Stroke Support Group attendance increased by 50%, from 12 to 24 survivors. CMS criteria for AIS readmission rates decreased from 7.20% out of 477 patients in FY2017, to 4.78% out of 474 patients in FY2018.

Conclusion:
In conclusion, implementation of the LCSW role had a positive impact on the CSC program, improving transitions of care, increasing patient satisfaction, and reducing readmission rates, thereby validating the efficacy of the role. It is recommended that other CSC programs consider integrating the LCSW role and perspective into their continuum of care.