bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 162: Clinical and Neuroradiological Characteristics of Moyamoya Syndrome: UT Houston Experience
Authors: sahota Preeti , Sedrak Peter , Lee Paul S , Lal Aditya P , Hicks William J , Sangha Navdeep , Wu Tzu-Ching , Vahidy Farhaan , Grotta James C , Savitz Sean I
Published: July 2021

Background:
Moyamoya (MM) is a rare progressive arteriopathy characterized by progressive stenosis and occlusion of the internal carotid arteries (ICA) and ultimately the arteries of the circle of Willis. It is called moyamoya disease (MMD) when idiopathic and involving bilateral ICA, and moyamoya syndrome (MMS) when associated with well-recognized risk factors, or when idiopathic but unilateral. Given the paucity of literature on MMS, we analyzed the clinical and radiological characteristics of MM patients presenting to our institute.

Methods:
We retrospectively identified patients admitted with acute neurological deficits and had ‘moyamoya-like’ physiology from our stroke registry (07/04 to 03/11). We collected demographics, clinical and laboratory data, and prior and subsequent hospital admissions. Two clinically blinded neuroradiologists collected radiological data including vessels involved, type of collateralization, and disease stage and progression. Patients were categorized into MMD or MMS based on risk factors and the side of disease.

Results:
We identified 36 MM patients (mean age 41.3 years), 13 (36.1%) with MMD and 23 (63.9%) with MMS. Both groups had female preponderance and multiracial involvement; hemiparesis was the leading clinical sign, and most patients had low HDL levels (83%). In MMS group, 4 (17.4%) patients had idiopathic unilateral disease, 4 (17.4%) had atherosclerotic disease, 3 (13%) each had vasculitis and intracranial dissection, 2 (8.7%) each had sickle cell disease and APLA syndrome, and 1 (4.3%) each had Down’s syndrome, Lupus, thyrotoxicosis, hypercoagulable disorder and chronic cocaine use. The MMS patients tended to be older, and higher proportion had ischemic stroke (87%) and neurological worsening after acute event (35%). On the other hand, higher proportion of MMD patients had hemorrhagic stroke (38.5%), multiple (>5) hospital admissions (23%) and EEG abnormality (80%) and were discharged home (62%). In MMS group, 2 (8.7%) patients underwent hemicraniectomy. In MMD group, 12.5% had disease progression radiographically. The clinical and radiological characteristics of these patients are summarized in tables 1 and 2 respectively.

Conclusion:
We present the single-center experience of clinical and neuroradiological characteristics of patients with MMS.
Abstract 174: Economic Benefit of an Educational Intervention to Improve tPA Use in Community Hospitals: Secondary Analysis of the INSTINCT Trial
Authors: Sozener Cemal B , Hutton David W , Meurer William J , Frederiksen Shirley M , Kade Allison M , Scott Phillip A
Published: July 2021

Introduction:
Prior work demonstrates substantial economic benefit from tPA use. We hypothesized a T2 knowledge translation (KT) program to increase community tPA treatment would provide a cost-effective method to increase tPA use in AIS.

Methods:
Data were utilized from the INcreasing Stroke Treatment through INterventional behavior Change Tactics (INSTINCT) trial, a prospective, cluster randomized, controlled trial involving 24 randomly selected acute care community hospitals in matched pairs. Within pairs, hospitals were randomly assigned to receive a barrier assessment-interactive educational intervention (BA-IEI) or no intervention (control). Cost analyses were conducted from a societal perspective for 2 cases: 1) using the total trial research costs and 2) using the intervention costs alone (without research overhead) as an estimate of the costs of generalization of the results. Total trial costs were calculated by combining direct and indirect INSTINCT funding with the opportunity costs of local health professionals attending study events. Savings attributable to increased tPA use were determined by applying published stroke economic data, adjusted for inflation, to the study cohorts. These data were integrated in a Markov model to determine the long-term economic impact of the INSTINCT BA-IEI program versus no intervention.

Results:
The total INSTINCT trial cost (US)$3.3 million. In the intervention and post-intervention phases, the intervention sites treated 2.30% (244/10,627) of stroke patients with tPA compared to 1.59% (160/10,071) at control sites (per protocol analysis). This increase in tPA use resulted in a direct medical cost savings of approximately $540,000 due to reduced LOS and use of rehab and nursing facilities in the model. In addition, the increased usage resulted in an estimated additional 81 quality adjusted life years (QALY), with an incremental cost-effectiveness ratio of $34,000/QALY. Using $50,000 as a conservative estimate of societal value per QALY, this provided an additional societal benefit of $4,100,000, or a net economic societal benefit of $1.3 million for the trial. Generalizing the intervention in a similar population (excluding the cost of research overhead) would cost an estimated $680,000 and provide a net economic benefit of $3.9 million, assuming similar intervention effectiveness and treatment outcomes.

Conclusions:
Due to the underlying cost-effectiveness of tPA, community knowledge translation efforts which show modest absolute gains in tPA usage demonstrate substantial societal economic returns and are considered good value when compared to spending on other health interventions.
Abstract 181: Common Angiogenic Signalling Pathways Induced by Monomeric c-Reactive Protein and FGF-2 Through Phosphatidylinositol 3-kinase
Authors: Boras Emhamed A , Matou-Nasri Sabine , Kuprinski Jerzy , Badimon Lina , Potempa Lawrence A , Slevin Mark
Published: July 2021

Angiogenesis is the process of new blood vessel growth from pre-existing vascular structures. The new vessels from atherosclerotic lesions may be a focus of instability, since they facilitate the infiltration of inflammatory cells and due to their tendency to leak, they may produce haemorrhagic complications. Pentameric C-reactive protein (CRP), a strong marker of inflammation, is a risk factor for cardiovascular diseases with a direct role in the development of atherosclerotic lesions. In hypoxic tissue damage, CRP dissociates irreversibly into monomeric CRP (mCRP), which was previously demonstrated to be pro-angiogenic on bovine aortic endothelial cells (BAEC). Our main study was to examine the vessel forming capability of CRP in the presence of other angiogenic factors known to be present in the micro-environment of unstable plaques with immature vasculature. Here we studied the effects of mCRP in presence or absence of FGF-2 on BAEC proliferation, migration, tube formation in Matrigel and on the vascular remodelling using spheroids, a tri-dimensional system of endothelial cell culture embedded in collagen gel. A significant synergic effect of mCRP combined with FGF-2 was observed in all angiogenesis assays used, compared to the effect of mCRP or FGF-2 alone. Using the spheroids, both mCRP and FGF-2 stimulated the length of sprouts with endothelial cells more dispersed giving an aspect of thin structures. For a better understanding of the molecular mechanisms involved, the signalling pathways were investigated by Western blotting and all the assays were performed in the presence or absence of pharmacological inhibitors of MAPK (PD98059), γ-secretase (DAPT inhibitor) and phosphatidylinositol 3-kinase (PI3K) pathways (LY294002). We showed mCRP-induced endothelial cell proliferation, migration and tube formation required activation of the PI3K pathway. MAPK activation was essential in mCRP-induced cell proliferation and differentiation (tube formation and sprouting from the core of spheroids) and γ-secretase activity was required for mCRP-induced tube formation only. For its pro-angiogenic activity, FGF-2 required all of these key pathways with the exception that γ-secretase activity was not associated with FGF-2-induced cell migration. In all assays including the over-expression of phospho-ERK, the synergistic pro-angiogenic effect of mCRP added to FGF-2 was completely inhibited by LY294002. Thus, mCRP and FGF-2 have a common signalling pathway through PI3K and an eventual deregulation of their pro-angiogenic effects due to an excessive inflammation inducing a hyper-vascularisation which could contribute to formation of unstable plaque with haemorrhagic risk, and therefore, might be prevented by targeting the key proteins of the PI3K pathway.
Abstract 196: Thrombolytic Treatment using Drip and Ship Treatment Paradigm among Acute Ischemic Stroke Patients in the United States: Outcomes and impact on regional thrombolytic utilization and referral patterns
Authors: Tekle Wondwossen G , Chaudhry Saqib A , Qaiser Habib , Hassan Ameer E , Rodriguez Gustavo J , Suri M. Fareed K , Qureshi Adnan I
Published: July 2021

Background:
While single center and regional estimates of thrombolytic administration using drip and ship treatment paradigm are available, patient outcomes, thrombolytic utilization, cost, and referral patterns has not been assessed in United States.

Objective:
To provide national estimates of patients treated with thrombolytics using drip and ship paradigm and determine the impact of drip and ship treatment on regional thrombolytic utilization, treatment cost, and referral patterns of acute stroke patients in a large cohort.

Methods:
We determined the proportion of patients treated with drip and ship paradigm among all acute ischemic stroke patients treated with thrombolytic treatment and obtained comparative in-hospital outcomes from the Nationwide Inpatient Survey (NIS) data files from October 2008 to December 2009. All the in-hospital outcomes were analyzed after adjusting for potential confounders using multivariate analysis. Thrombolytic utilization, hospitalization cost, and patterns of referral related to drip and ship treatment of acute stroke were estimated.

Results:
Of the 26,814 ischemic stroke patients who received thrombolytic treatment, 5144 (19%) were treated using drip and ship paradigm. Seventy nine percent of all the drip and ship treated patients were referred to urban teaching hospitals for further care, and 7% of them received follow up endovascular treatment at the referral facility. States with higher proportion of patients treated using the drip and ship paradigm had higher rates of thrombolytic utilization (3.1% vs. 2.4%, p<0.001). After adjusting for age, gender, presence of hypertension, diabetes mellitus, renal failure, and hospital teaching status, outcomes of patients treated with drip and ship paradigm was similar to those who received thrombolytic and stayed in the same facility: self care (odds ratio [OR], 1.055, 95% confidence interval [CI], 0.910-1.224, p=0.4779); death(OR , 0.821 95% CI, 0.619- 1.088, p=0.1688); and nursing home discharge (OR, 1.023, 95% CI, 0.880- 1.189, p=0.7659) at discharge. Drip and ship paradigm was associated with shorter hospital stay (mean [days, SE] 5.9± 0.18 vs. 7.4 ± 0.15, p<0.001), and lower cost of hospitalization (mean total charges [$, SE) 57,000 ± 3,324 vs. 83,000 ± 3,367, p<0.001).

Conclusions:
One out of every five patients who received thromboytic treatment in United States is currently treated using drip and ship paradigm with comparable adjusted rates of favorable outcomes.
There was a
higher rates of thrombolytic utilization in States where drip and ship was more commonly implemented.
Abstract 199: Pre-treatment Of Human Embryonic-derived Neural Progenitor Cells With Bdnf Increases Migration Of Cells To The Brain And Elicits Functional Recovery In A Mouse Model Of Hypoxic-ischemia
Authors: Rosenblum Sahar , Wang Nancy , Chua Joshua , Westbroek Eric , Smith Tenille , Lawrence Samuel , Guzman Raphael
Published: July 2021

Intro:
Increasing cell migration through upregulation of chemokine and adhesion molecule receptors could improve intravascular cell treatment for stroke and BDNF has been shown to induce these pathways. Therefore we tested whether BDNF cell-pretreatment would improve cell migration and functional recovery in an experimental stroke model.

Methods:
hES-derived NPCs (5x10
5
in 5µl saline) pre-treated with BDNF for 5 hours and harboring a reporter gene construct containing renilla luciferase and eGFP in serum free media, non-treated hES-derived NPCs (5×10
5
in 5[l saline) in media, and media control with BDNF were delivered to the brain via the ipsilateral carotid artery at 3 days after hypoxic-ischemic stroke in NODSCID mice (n=11/group). Cell engraftment was monitored by
in-vivo
bioluminescence imaging (BLI). The ladder test was used to assess behavioral recovery throughout a 4 week time course. Brain homogenates from animals at 28 days were analyzed using RT-qPCR for common chemokines, adhesion molecules, and neurotrophins. Mechanisms of cell migration were evaluated by assessing cell receptor expression of chemokines and adhesion molecules on hES-derived NPC and by analyzing the change in expression profile in the mouse brain at 3 days after stroke. Boyden-chamber migration assays were used to evaluate cell migratory potential
in vitro
.

RESULTS:
One day after cell transplantation the subset of animals transplanted with BDNF-pretreated cells showed significantly higher BLI signal at 1 (p=0.021) and 7 days after transplantation (p=0.002). Histological analysis also revealed engraftment of hES-derived NPC at 1 week after transplantation. Behavioral assessment revealed significant functional recovery in the BDNF pre-treated group throughout the 28 day time course (ANOVA, p<0.05). BDNF-pretreatment of hES-derived NPCs upregulated CXCR4 expression 12.5 times and
in vitro
led to significantly greater migration in response to CXCL12 (CXCR4 ligand) compared to untreated cells. At 28 days after transplantation, neurotrophic factors IL6, IL10, Ntrk1 were upregulated 3.3, 3.4, and 3.3 times. Common T-cell and neutrophil cytokine receptors IL8rb, IL8ra and IL1a were all downregulated, while several chemokines that increase migration of inflammatory cells were downregulated including CCL2, CCL5, CCL8, and CCL12. Anti-Angiogenic factor Adamts8 was also downrgulated in the brains of animals transplanted with BDNF pre-treated cells. Lastly, MMP3, MMP8, and MMP9 were downregulated at 28 days after stroke indicating increased blood brain barrier integrity.

Conclusion:
Intravascular transplantation of BDNF pre-treated hES-derived NPCs elicits functional gains via increased migration of cells, immunomodulation, increased BBB integrity, and by influencing the upregulation of neur0protective factors.
Abstract 20: Vitamin D Deficiency Exacerbates Ischemic Cell Loss and Sensory Motor Dysfunction in an Experimental Stroke Model.
Authors: Balden Robyn L , Sohrabji Farida
Published: July 2021

Vitamin D deficiency is widespread and considered a risk factor for cardiovascular disease and events such as stroke, and low Vitamin D (VD) levels are predictive for stroke and more fatal strokes in humans. VD’s ability to act as a selective endocrine and immunomodulator suggests a role for this hormone in reducing stroke-induced inflammation in the brain. However, the specific contribution of Vitamin D deficiency to stroke is not clear since it occurs with other co-morbid conditions, such as type 2 diabetes and obesity, which are also risk factors for cerebrovascular disease. To directly assess the impact of VD deficiency on stroke severity, adult female rats were fed control or VD deficient (VDD) diet for 6 weeks. The VDD diet reduced circulating VD levels to 25% of controls (p<0.05). Control and VDD groups were then subject to ischemic stroke by vasoconstriction of the Middle Cerebral Artery (MCA) by endothelin-1. Both groups displayed cortical and striatal infarction, however, infarct volumes were significantly larger in the VDD group in both the cortex (20%) and striatum (50%), when measured 5d post stroke. Furthermore, sensory motor function was more severely impaired in the VDD group, as measured by the tape test and the vibrissae evoked forelimb placement task (p<0.05). In the ischemic brain, IGF-1, which is a neuroprotective peptide hormone, is routinely elevated and the elevation was attenuated in the VDD groups (p<0.05). Additionally, VDD significantly reduced IL-1α, IL-1β, IL-2, IL-4, IFN-γ, and IL-10 expression in ischemic brain tissue, but elevated ischemia-induced IL-6. IL-6 was positively correlated with infarct volume (r2=.83 cortex, r2=.90 striatum) (p<.05). IL-6 promotes development and expansion of the Th17 cohort, whose cytokines secretions are a key factor in blood brain barrier disruption after stroke. These data support the hypothesis that VD deficiency independently modulates stroke severity by disrupting the expression of normally neuroprotective compounds (IGF-1) and elevating cytotoxic proteins (IL-6) in the ischemic brain. Supported by NIH AG027684 and AG028303 to FS.
Abstract 203: Chronic and Acute Estrogen Replacement Therapy Has Different Effects in Aged Animals After Experimental Stroke
Authors: Liu Fudong , Benashski Sharon E. , Xu Yan , McCullough Louise D.
Published: July 2021

Introduction:
The effect of estrogen replacement therapy (ERT) on stroke incidence and severity has been extensively debated. Clinical trials of ERT demonstrated an increased risk of stroke in treated women, but study participants were well past menopause when therapy was initiated. It has been suggested that detrimental effects of ERT may be unmasked after prolonged periods of hypoestrogenicity. To date, very few studies have examined the effect of ERT in aged animals although the timing of replacement may be critical to the neuroprotective effects of ERT.

Hypothesis:
We hypothesized that chronic estrogen replacement (CER) initiated in late middle age, would decrease infarct size after an induced stroke whereas acute estrogen replacement (AER) would have no beneficial effects in the aged female brain.

Methods:
CER was administered to aged C57BL6 mice from 17 to 20 months of age, and AER was initiated at 20 months of age. Both CER and AER treated mice were subjected to 90-minute middle cerebral artery occlusion (MCAO) at 20.5 months of age. Stroke outcomes at 24 hours of MCAO were measured. Protein levels of nuclear factor κB (NFκB), estrogen receptor α (ERα) and serum levels of pro-inflammatory cytokines were also examined.

Results:
Female mice that received CER showed improved stroke outcomes after MCAO (total infarct: CER vs. vehicle 34.7±2.4% vs. 58.2±2.6%; n=9/gp,
p
<0.05); whereas females that had AER did not. CER females exhibited diminished levels of NFκB translocation compared to AER females after stroke. AER females demonstrated both an increase in nuclear NFκB and enhanced expression of pro-inflammatory cytokines. The differential NFκB translocation was related to corresponding changes in ERα expression. Aged males benefited from ERT regardless of the timing of initiation of ERT, and had significantly reduced expression of pro-inflammatory markers after stroke compared to age-matched females.

Conclusions:
AER worsened stroke outcomes whereas CER was protective in aged females. A pro-inflammatory milieu emerges with age in females which was attenuated by CER treatment. Interestingly both AER and CER reduced stroke injury in aged males, suggesting sexually dimorphic effects on inflammation.
Abstract 21: Patient and Hospital Characteristics Associated with Assessment for Rehabilitation During Hospitalization for Acute Ischemic Stroke
Authors: Prvu Bettger Janet , Kaltenbach Lisa , Reeves Mathew , Smith Eric E , Fonarow Gregg C , Schwamm Lee H , Peterson Eric D
Published: July 2021

Introduction:
Delays in post-stroke rehabilitation can negatively affect functional recovery and health-care costs. While clinical guidelines recommend that all stroke patients receive a standardized assessment during the acute hospitalization, the degree and determinants of acute assessment for rehabilitation (AAR) following ischemic stroke are unknown.

Methods:
We analyzed data from 1540 Get With The Guidelines-Stroke hospitals from 01/08/2008 to 03/31/2011. Patients who died in hospital, left AMA, or were transferred in from or out to another acute hospital were excluded. Univariate (chi-square or Wilcoxon as appropriate) and multivariable logistic regression analyses with GEE were used to identify factors independently associated with an AAR while accounting for within hospital clustering.

Results:
Among 616,982 ischemic stroke patients, 89.5% had an AAR documented. Those without AAR were more likely white, older, female, unable to ambulate prior to admission, from a chronic care facility, have Medicare health insurance and comorbid conditions. Also without an AAR were those with moderate-severe stroke (NIHSS≥6), unable to ambulate on day 2, and were not cared for in a stroke unit. Nine percent of patients discharged home without services were not assessed for rehabilitation. In multivariable analysis, many factors were independently associated with receiving an AAR; however, patients with the greatest odds (OR>1.2) were of Black race, without a history of carotid stenosis, ambulating independently prior to admission, had stroke symptoms outside of a healthcare facility, were treated at a Northeast hospital, in a stroke unit, had complications from thrombolytic therapy, and were ambulating on hospital day 2 (
Table
).

Conclusion:
Although 90% of ischemic stroke patients received an AAR, the results suggest important subpopulations were overlooked. Quality improvement efforts are needed to ensure that all stroke patients are assessed and referred for the appropriate level of rehabilitation care for their needs. Further research of the unexplained variation in AAR is warranted.
Abstract 2131: Prediction of Discharge Walking Ability from Initial Assessment in a Stroke IRF Population
Authors: Bland Margurhetta D , Sturmoski Audra , Whitson Michelle , Connor Lisa T , Fucetola Robert , Huskey Thy , Corbetta Maurizio , Lang Catherine E
Published: July 2021

The purpose of this study was to investigate which physical therapy assessments administered at admission to an inpatient rehabilitation facility (IRF) could predict discharge walking ability in a local population of people with stroke. The sample consisted of 111 IRF participants with stroke who consented to have records stored in the Brain Recovery Core database between January 2010 and January 2011. Independent variables from the admission assessment included: lower extremity Motricity Index, somatosensation, Modified Ashworth Scale, Functional Independence Measure (FIM) locomotor item, Berg Balance Scale, walking speed, age, history of previous stroke, and time from stroke onset to IRF assessment. The dependent variable was discharge walking ability, defined as walking speed on the 10 m Walk Test. Correlational analyses examined relationships with and between the admission variables and discharge walking ability. Step-wise multiple regression was used to determine the most parsimonious combination of variables that could explain variance in discharge walking ability. Logistic regression was used to determine the likelihood of achieving household (< 0.4 m/s) versus community (≥ 0.4 - 0.8, > 0.8 m/s) ambulation categories. Results from the stepwise model indicated that 2 admission variables, Berg Balance score and FIM locomotor score, explained 80% of the variance in discharge walking ability. For the logistic model, the odds ratio of achieving only household ambulation at discharge was 20 (95%CI: 6-63) when the combination of having a Berg Balance < 20 and a FIM locomotor score of 1 or 2 was present. The logistic model correctly classified 92% of subjects achieving only household ambulation and 64% of subjects achieving better than household ambulation. These findings suggest that performance on the Berg Balance Scale and the FIM locomotor item at admission to an IRF can explain most of the variance in discharge walking ability. Having the combination of a Berg Balance score < 20 and a FIM locomotor score of 1 or 2 at admission indicates that a person is highly likely to be only a household ambulator at discharge from the IRF. Knowing at the time of IRF admission that a person with stroke is
not
likely to achieve limited community or community ambulation status will allow for earlier discharge planning with respect to needed assistance at home, durable-medical equipment, and home modifications.
Abstract 2187: Are Procedural Characteristics Associated with Early Outcomes in Either Women or Men Revascularized in the Merci Registry?
Authors: Lutsep Helmi , Jovin Tudor , Devlin Thomas , Budzik Ronald , Smith Wade , Walker Gary , Rymer Marilyn
Published: July 2021

Introduction:
Data suggest a higher periprocedural risk for endovascular treatment than surgery for carotid artery stenosis in women but not in men. The objective of this analysis was to determine if a similar risk profile applies to acute ischemic stroke (AIS).

Hypothesis:
Sex differences in procedural characteristics could be associated with early outcomes after successful endovascular treatment for AIS.

Methods:
The study investigated whether procedural characteristics in recanalized patients (TICA 2a, 2b or 3) in the Merci Registry, a prospective database of AIS patients treated with the Merci Retriever, were associated with favorable discharge outcome (mRS 0-2) in either women or in men. Procedural characteristics included the length of the procedure; use of intra-arterial lytics and other devices; intubation; or systolic blood pressure. Clinical variables included age, baseline National Institutes of Health Stroke Scale (NIHSS), time from symptom onset and emergency department (ED) arrival to arterial puncture, intravenous tPA use, co-morbidities and risk factors. The procedural and clinical variables were assessed with univariate and then multivariate analysis for associations with the early outcomes separately in women and in men.

Results:
Of 872 Merci Registry patients with complete follow-up data, similar numbers of women (327/418 (78%)) and men (369/454 (81%)) had successful revascularization. Revascularized women compared to revascularized men were older, had more hypertension and atrial fibrillation and revascularized men had more history of coronary artery disease than women. Clot location was more often vertebrobasilar in men. While the procedure duration and number of attempts to remove the clot was equivalent in the two groups, angioplasty and stenting proximal to the occlusion occurred more often in men. The number of women and men that had a discharge mRS 0-2 was similar (20.3% and 21.5% respectively). In multivariate analysis, baseline NIHSS (p<0.0001) was negatively associated with discharge outcome in both women and in men. Additionally, while procedure length (p=0.0050) and diabetes (p=0.0228) were negatively associated with outcome in men, in women intubation (p<0.0001), age (p=0.0016) and congestive heart failure (p=0.0124) were negatively associated with discharge outcome.

Conclusions:
Procedure length and diabetes in successfully revascularized patients in the Merci Registry were negatively associated with discharge outcome in men but not in women in multivariate analysis, while intubation was the only procedural characteristic associated (negatively) with early outcome in women and baseline NIHSS was negatively associated in both groups.
Abstract 2208: Sex Differences in Ischemic Stroke Mortality
Authors: McKinney James S , Deng Yingzi , Paolucci Ugo , Kostis John B
Published: July 2021

Introduction---
Stroke is becoming increasingly more prevalent in women. Prior studies of sex differences in stroke mortality have reported variable findings. Although crude stroke fatality is higher in women, this appears to be mediated by age and other baseline differences. We hypothesized that no differences existed between genders in in-hospital and longer term mortality, as well as in cause of death, after stroke admission.

Methods---
We used the Myocardial Infarction Data Acquisition System (MIDAS) database, which includes demographic and clinical data on patients discharged with a primary diagnosis of cerebral infarction from all non-federal acute care hospitals in New Jersey between 1996 and 2007. Out-of-hospital deaths were assessed by matching MIDAS records with New Jersey death registration files. In-hospital, 1-year, and interval (discharge to 1-year) mortality were calculated. Total, cardiovascular disease (CVD), and non-CVD mortality were calculated. Multivariate logistic and Cox regression models were used to measure the effect of sex on in-hospital, 1-year, and interval mortality after adjusting for demographics, comorbidities, hospital type, year of admission, and treatment. Statistical significance was defined as a
P
-value ≤ 0.01.

Results---
134,441 patients (54.8% female) were admitted with a primary diagnosis of cerebral infarction during the study period. Women were on average 5.1 years older than men. Although the average Charlson Index was lower for women, hypertension, atrial fibrillation, congestive heart failure, dementia, and connective tissue disorders were all more common (p<0.0001). Women were significantly less likely to be treated with intravenous tPA than men (OR = 0.81; 95% CI = 0.73 to 0.89). In-hospital and 1-year mortality rates were 9.3% and 27.2% for women and 8.0% and 22.6% for men. After adjusting for available covariates, women had significantly higher in-hospital (OR = 1.04; 95% CI = 1.01 to 1.09) and 1-year (HR = 1.03; 95% CI = 1.01 to 1.05) mortality than men. Comparisons of in-hospital and interval CVD and non-CVD death rates are presented in the
Figure
.

Conclusion---
Adjusted in-hospital and 1-year mortality was significantly higher for women than men hospitalized for a first ischemic stroke in New Jersey. This excess in morality appears to be driven by significant differences in non-CVD related in-hospital deaths in women. Women were also less likely to receive IV tPA then men after adjusting for available covariates.
Abstract 2223: Diagnoses and Outcomes of t-PA Treated Patients with No Imaging Evidence of Acute Ischemic Stroke
Authors: Spokoyny Ilana , Raman Rema , Ernstrom Karin , Meyer Brett C , Hemmen Thomas M
Published: July 2021

Background/Purpose:
Intravenous Alteplase (t-PA) improves outcome in patients with acute ischemic stroke. Of those who recover fully, some may not have had ischemia. We analyzed the frequency and post-treatment outcomes of patients with no imaging evidence of stroke and aimed to delineate the frequency of strokes with full recovery from that of stroke mimics treated with t-PA.

Methods:
We included all adult stroke patients treated with IV t-PA within 3 hours of stroke onset from the UCSD SPOTRIAS database. Group 1: Patients with neuroimaging evidence of acute stroke (IPS); Group 2: no neuroimaging evidence of acute stroke (INS). All diagnoses were established by an independent adjudicating body. We reviewed medical records, neuroimaging, and compared discharge diagnosis, 90-day mRS, and incidence of intracranial hemorrhage. We adjusted for age, admission NIHSS, and pre-stroke mRS in multivariable models.

Results:
We identified 61patients with IPS and 25 with INS, with similar baseline characteristics, except for baseline NIHSS (IPS 13.4±8.2, INS 8.4±5.9, p=0.007) and incidence of cardiac arrhythmias (IPS 36.1%, INS 4.0%, p=0.002). Adjusted for age and baseline NIHSS, we found no difference in outcome. ICH was found in 23% of the IPS patients and was symptomatic in 4.9%. None of the INS patients had ICH.

Conclusions:
Radiologic evidence of acute ischemic stroke was absent in 10.5% of the 86 patients in the UCSD SPOTRIAS database who were treated with t-PA and given a clinical diagnosis of acute ischemic stroke on adjudicating body review at discharge. The majority (64%) of imaging negative stroke patients in our study ultimately received the clinical diagnosis of acute stroke. No significant difference in outcomes (mRS) was found between imaging negative and imaging positive stroke code patients, aside from the increased ICH frequency in imaging positive patients. This lack of outcome difference emphasizes that while imaging plays an important role as a surrogate marker in determining the diagnosis, a detailed clinical evaluation is essential in the correct treatment of acute ischemic stroke. Imaging negative stroke patients are common and future larger scale prospective data is required to analyze the true frequency of stroke mimics versus imaging negative stroke.
Abstract 2237: Gender and Quality of Life after Ischemic Stroke: The Adherence eValuation After Ischemic stroke_Longitudinal (AVAIL) Registry
Authors: Bushnell Cheryl , Reeves Mathew , Zhao Xin , Pan Wenqin , Prvu-Bettger Janet , Zimmer Louise , Olson DaiWai , Peterson Eric
Published: July 2021

Background:
Multiple studies have shown that women have poorer quality of life (QOL) than men after stroke. We hypothesized that women would have lower QOL scores measured with the EuroQOL-5D (EQ5D) up to 1 year after ischemic stroke than men in the AVAIL cohort, a large, nationally representative, observational registry.

Methods:
After excluding proxy responses (n= 190), lost-to-follow-up (n= 62), and missing EQ5D scores (n=77), this analysis included 2,450 patients with ischemic stroke or TIA enrolled at 99 sites participating in the GWTG program. Baseline and 3 month sociodemographic and clinical data were compared by gender. EQ5D, a 5-item measure that assesses self-reported mobility, self care, usual activities, pain/discomfort, and anxiety/depression, was obtained at 3 and 12 months via telephone by centrally located and trained interviewers. A mixed effect multivariable model of EQ5D (primary outcome at record level) at 3 and 12 months was performed with gender and other relevant covariates as fixed effects and patient ID as the random effect.

Results:
Women were older than men (mean 65.8 versus 64.2 years). At three months, women were less likely to have household income meet needs (68.4% vs. 72.5%), to be married (47.7% vs. 69.3%), working (31.8% vs. 47.8%), or ambulating at discharge (66.9% vs. 71.7%) than men. Women were more likely to be living alone (30.1% vs 18.3%), and were discharged on more medications (mean 7.2 vs. 6.6; p=0.0006), but men were more likely to have > 4 risk factors (15.4% vs. 11.1%; p<.0001). The EQ5D score was lower in women (median 0.80, IQR 0.71-0.85) than men (median 0.83, IQR 0.71-1.00; p<.0001), indicating poorer QOL. However, in the multivariable model, gender was not independently associated with EQ5D, whereas decreased number of risk factors, discharge home, ambulating at discharge, being married, living alone, working vs. home not by choice, having an adequate income, lower number of medications at discharge, not having rehab, and having insurance were all significant (Table). There was no evidence of a significant interaction between gender and living status in the multivariable model (p=0.128).

Conclusions:
In this cohort, QOL was independently associated with socioeconomic status, disability, marital status, number of medications, and comorbidities, but not gender.
Abstract 2249: Stroke Intervention Website: Design and Usage Evaluation
Authors: Pierce Linda L , Steiner Victoria
Published: July 2021

Background and Purpose:
Web-based interventions have the potential to increase accessibility and efficiency of healthcare services, such as education and support for family caregivers. The major aim of this project was to evaluate the design and usage, of a stroke intervention website, which was guided by Friedemann’s framework of systemic organization, for new caregiving families residing in home settings.

Methods:
Thirty-six caregivers had access to this intervention of education and support used in a one-year randomized controlled trial (RCT) in Ohio and Michigan. The average participant was 54 years of age, white, female, and the spouse of the care recipient. Four questions related to the website were asked of the participants as part of a bi-monthly telephone interview. Additionally a 33-item telephone Survey at the conclusion of the RCT evaluated the website design and usage of its components. Number of visits to the website was also counted. Descriptive statistics and content analysis were used with these data. At the end of the RCT, the intervention was opened to everyone on the Internet, and website visits were counted for a 15-month period.

Results:
On average, the RCT participants accessed the website one to two hours per week, although participants’ usage declined after several months. There were a total of 7,121 visits over the one-year period. The participants found the training to be adequate and positively rated the website’s appearance and usability. They also agreed or strongly agreed that they learned a lot from the intervention’s components. In the 15-month period following the RCT, there were 19,431 total visits to the website.

Conclusions:
The family caregivers in the RCT, as well as subsequent website visitors, used the intervention for education information and social support in dealing with stroke and its outcomes. Healthcare providers can suggest this website to stroke caregiving families and website developers can replicate the design of this intervention website for other health conditions.
Abstract 2286: Ultrasonographic And Pathological Measurement Of Fibrous Cap In Rupture-prone Carotid Plaques Using Advanced Ultrasound Technology
Authors: Watanabe Akihiro , Saito Kozue , Iihara Koji , Ueda Hatsue , Nagatsuka Kazuyuki
Published: July 2021

[Background and Purpose]
In carotid stenosis, thin fibrous cap, as one of the characteristics of unstable plaques, have been thought to be an important risk factor for plaque rupture and acute cerebral ischemic events. A study reported there was good agreement between ultrasonographic and pathological fibrous cap thickness(FCT). The fibrous cap of ultrasound image in this study, however, was not measured at the same location in pathology. So, we precisely aligned ultrasonographic images with pathology in carotid plaques by advanced ultrasound with global position system (GPS)-like positon-sensing technology, and examined the characteristics of fibrous cap in rupture-prone plaques.

[Methods and Results]
24 patients(symptomatic=18, asymptomatic=6) undergoing carotid endarterectomy for carotid stenosis between June 2010 and January 2011 were subjected in this study. We performed carotid ultrasound using a LOGIQ E9(GE Healthcare) within three days before carotid endarterectomy. Three-dimensinal images with the positonal information were obtained using an electromagnetic transmitter and sensors mounted on a linear probe. Endarterectomy specimens were cut every 3mm from carotid bifurcation in the short axis view. The three-dimensinal images alined with the specimens were extracted every 3mm of the same location in the short axis view. We measured maximal and minimal FCT in these ultrasonographic and pathological images. There was a positive relation(r=0.74) between fibrous cap thickness in pathology(maximal FCT =571μm[93 to 1062]) and ultrasound(maximal FCT =439μm[242 to 809]). Maximal FCT in pathology was significantly less in the pathologically ruptured plaques(n=16) than in the nonrupured plaques(n=8) (456μm VS 803μm, P<0.05). In contrast, maximal FCT in ultrasound had no difference in the two groups(389μm VS 497μm, P=0.09). In pathology fibrous cap was ruptured in 16 patients(67%, minimal FCT=0μm), and thin, restored and sparse though nonruptured in other 5 patients(21%, minimal FCT=177μm[50 to 339]). At the same location, the fibrous cap of ultrasound image disappeared in all these 21 patients. The other 3 patients(13%) without plaque rupture showed thick fibrous cap in pathology(minimal FCT =301μm[279 to 325]) and ultrasound(minimal FCT =283μm[250 to 300]).

[Conclusions]
Using advanced ultrasound with GPS-like technology, we were able to examine the pathological characteristics of fibrous cap in ultrasound in detail. It is difficult to sort out preoperatively more pathologically unstable plaques only by measuring FCT in ultrasound. Ultrasonographic disappearance of fibrous cap is more significant sign of pathologically unstable plaques.
Abstract 2317: A Multidisciplinary Team Approach to Improving Laboratory Results and Thrombolytic Treatment in Acute Code Stroke Patients.
Authors: Tay Debbie , Boyd Connie , Imbus Andrew , Ohanian Arbi , Graves Jessica , Au Anne
Published: July 2021

Despite improvement in acute stroke care, stroke remains the third major cause of death and leading cause of disability nationwide. An increase in the number of certified Primary Stroke Centers (PSC) over the past years has been credited for the improvement. Los Angeles County proactively implemented the Approved Stroke Center Network in which Emergency Medical Systems may passes non-certified PCS for acute stroke treatments. Our hospital’s journey towards building a stroke program began in early 2008, and in 2009 a CODE STROKE algorithm was implemented. Over the past two years, the team has strived to continuously improve ‘door to needle’ times. Opportunity to improve door-to-lab results was recognized so we sought to investigate and identify barrier(s)/reason(s) for delays.

Methods
The LEAN Six Sigma team guided our multidisciplinary committee for identifying contributing delays. A review of the clinical pathway from the patient’s arrival time (door) and activation of Code Stroke are time-stamped at every step. Phase I identified delays with phlebotomist transit times. The laboratory management addressed this issue by reinforcing the need to expedite the specimen collection, transit time and processing. Some improvement was noted in the door-to-lab results time but significant delays remained a problem. Phase II incorporated lab draws being performed prior to the patient going for their CT scan. Phase III involves utilization of an iStat unit within the emergency department for analysis of a CHEM 8 panel.

Results
Analysis of data initially showed door-to-lab results had a median time of 52 minutes, with 38% having results within 45 minutes. Ten patients received tPA within median times of 66 minutes, with 53% receiving tPA within 60 minutes. In 2010 action plans initiated yielded significant improvements with door-to-lab results median times of 44 minutes, 64% having lab results within 45 minutes. Twenty one patients received tPA within a median time of 55 minutes, and 70% having received tPA within 60 minutes.

Conclusion
The multidisciplinary stroke team identified barriers and implemented process changes yielding improvements in door-to-lab results that in turn resulted in overall improvements in tPA treatment times. Data collection and process evaluation continue.
Abstract 2319: Improving Inter-facility Transfer Times for Acute Ischemic Stroke Patients: The Stroke Rescue Program
Authors: Katz Jeffrey M , Libman Richard , Power Paul M , Tsu Adelyn , Thomas Nimmy , De Geronimo Marcella , Kwiatkowski Thomas
Published: July 2021

Background and Purpose:
The inter-facility transfer of acute ischemic stroke (AIS) patients to a comprehensive stroke center (CSC) must be rapid. Transfer delays increase the likelihood of exclusion from endovascular stroke therapy and therefore are an obstacle to time sensitive stroke treatments. Reducing transport times and improving transfer efficiency is integral to the success of a comprehensive stroke network.

Methods:
The Stroke Rescue Program was created within a large metropolitan health system to facilitate the rapid transfer of AIS patients from regional (both health system (n=8) and non-system (n=4)) primary stroke centers (PSC) to the network's CSC. Program interventions included creation of a transfer center and stroke rescue hotline with a new priority dispatching protocol; standing order medical treatment guidelines with paramedic, referring physician and staff education; and the development of transport time elements and targets. Selected time elements included Transport 1 (Tr-1, initial phone call to EMS arrival at PSC), ED Time (PSC arrival to PSC departure), and Transport 2 (Tr-2, PSC departure to CSC arrival). Total transport time target was set at <60 min and to achieve this we aimed at decreasing ED Time.

Results:
Between January 1, 2010 and June 30, 2011, 128 patients underwent Stroke Rescue. The median PSC to CSC distance was 14.4 miles (range 3.0 to 32.1 miles). Ischemic stroke was confirmed in 116 (91%) patients and 65 (51%) patients were “drip and ship” transports (intravenous tPA infusion during Tr-2). Overall, median total transport time was 48 min (ED Time 18 min). Comparing first quarter 2010 (baseline quarter, n=21) to second quarter 2011 (most recent quarter, n=31), the percent transported within 60 min increased from 57% to 81%. Statistically significant improvement was seen for both median ED Time (23 min versus 14 min; U = 171, p <.01, r = .40) and median total transport time (56 min versus 44 min; U = 199, p <.05, r = .33).

Conclusion:
Process organization with inter-facility stroke transfer protocols that minimize the time paramedics spend in a PSC emergency department can significantly reduce transport duration making transfer for time limited stroke therapies practical. Further study is needed to determine whether improved stroke network efficiency translates into better clinical outcomes, but the concept of “time is brain” supports this approach.