bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract T P197: Variation in Last Known Normal Times of Stroke Code Patients
Authors: Spokoyny Ilana , Kim Alex J , Choe Jessica S , Raman Rema , Ernstrom Karin , Meyer Brett C , Karanjia Navaz P
Published: March 2022

Introduction:
Given the time-sensitivity of thrombolytic therapy, the accurate documentation of the patient’s last known normal (LKN) time is crucial to ensure safe and effective management of stroke patients. There exist no studies comparing first recorded LKN times to final verified LKN times. This study investigates whether a difference exists, and the potential impact on treatment and emergent management of acute stroke.

Methods:
All stroke code patients evaluated at UCSD hospitals (4/2008-7/2013) with 90 day mRS scores available were included. Electronic chart review was performed to obtain first recorded LKN time. Onset to arrival (OTA) intervals were calculated using both the first recorded LKN and official LKN times. Patients were split into three groups based on the disparity between the OTA intervals. Group A: longer OTA interval using first LKN, Group B: two intervals equal, and Group C: shorter OTA interval using first LKN. These groups were compared by baseline characteristics, rates of tPA administration, 90 day mRS score, and rates of symptomatic ICH.

Results:
Of 226 patients included, 74.3% had disparity between first and official LKN time; 16.8% in Group A and 57.5% in Group C. The median discrepancy between the times was 30 minutes for Group A and 45 minutes for Group C. Baseline characteristics were not significantly different between groups. In stroke/TIA patients, rates of tPA administration were significantly different (A: 65.4%, B: 39.5%, C: 34.8, p=0.022). In Group A, 62.5% had 90 day mRS of 0-1, versus 50% of Group B and 34.4% of Group C, without significant difference. There were no symptomatic ICHs in Group A, compared to 1 (5.6%) in Group B and 3 (9.1%) in Group C.

Conclusions:
There was a significant proportion of patients with disparity between the first and official recorded LKN times, with the majority falling into Group C (shorter OTA interval using first LKN). If this first recorded time were used to make treatment decisions, as may be the case at community hospitals without stroke neurologists, patients may be frequently treated outside of the recommended window, with a higher risk of adverse safety outcomes. This study highlights the need for accurate determination of last known normal time in order to make the proper treatment decisions.
Abstract T P204: Thioredoxin Interacting Protein: A Novel Target for Neuroprotection in Experimental Thromboembolic Stroke in Mice
Authors: Ishrat Tauheed , El-Remessy Azza B , Pillai Bindu , Soliman Sahar , Ergul, Adviye , Fagan Susan C
Published: March 2022

Background & Objective:
Redox imbalance in the brain significantly contributes to ischemic stroke pathogenesis but antioxidant therapies have failed in clinical trials. Activation of endogenous antioxidant defense mechanisms may provide better protection against stroke-induced oxidative injury. TXNIP (thioredoxin-interacting protein) is an endogenous inhibitor of thioredoxin (TRX), a key antioxidant system. We tested the hypothesis that inhibition of TXNIP is neuroprotective in a clinically relevant model of embolic stroke.

Methods:
We determined the contribution of TXNIP inhibition to neuronal injury and functional outcome after embolic middle cerebral artery occlusion (eMCAO) using male TXNIP-knockout (TKO), wild-type (WT) and WT mice treated with a pharmacological inhibitor of TXNIP, resveratrol (RES; 5mg/kg body weight).

Results:
TKO and RES-treated mice exhibited 45.2% and 52.4% decrease in infarct size and improved neurological score and grip strength compared to WT mice after eMCAO. Moreover, the levels of nitrotyrosine, a marker of oxidative damage increased significantly after eMCAO, indicating oxidative brain injury. TXNIP inhibition reduced oxidative marker generation. Furthermore, TXNIP was involved in ischemic brain damage, as less TXNIP expression was found in the RES-treated mice following eMCAO.

Conclusions:
The present study suggests that unregulated TXNIP is contributes to acute ischemic stroke, and that inhibition of TXNIP may provide a new target for therapeutic interventions. This study also affirms the importance of the antioxidant effect of RES on the TRX/TXNIP system.

Table 1
. Summary of experimental stroke data presented as mean ±SE.
#
p<0.05
*
p<0.05 vs. respective control.
Abstract T P209: SIRT3 is Upregulated During Stroke and Contributes to Ischemic Damage by Depressing the Transcription of Nuclear Genes
Authors: Crapser Joshua , Verma Rajkumar , McCullough Louise
Published: March 2022

Introduction:
The impairment of energy metabolism during stroke is a major contributor to ensuing tissue damage and death. The NAD+-dependent histone deacetylase SIRT3 has been identified as a key regulator of mitochondrial energy metabolism. It has also been found to repress the transcription of nuclear genes via histone deacetylation. This study aimed to elucidate the function of nuclear SIRT3 in ischemic stroke.

Methods:
Focal cerebral ischemia was induced by transient right middle cerebral artery occlusion (MCAO) for 90min followed by 72hrs of reperfusion. Infarct area was quantified with Sigma ScanPro5 on 30μm coronal sections stained with Cresyl Violet. Expression of SIRT3 and acetylated lysine proteins was examined by immunohistochemistry (IHC) and western blotting with anti-SIRT3 and anti-acetylated lysine antibodies. NAD+ levels were measured with a colorimetric kit.

Results:
SIRT3 expression was increased in the ischemic hemisphere of wild-type (WT) mice at 72hrs. Higher magnification of the IHC image demonstrated localization of SIRT3 to both the nucleus and mitochondria of labeled cells. Subcellular fractionations confirmed this localization, and revealed a dramatic increase in nuclear translocation of SIRT3 with ischemia. With the same duration of MCAO and reperfusion, SIRT3 knockout (KO) mice displayed a reduction in striatal infarct from 60.6±7.2% to 24.9±9.7% (P<0.05), as well as reduced cortical and hemispheric infarct compared to WT mice. Western blotting of whole cell lysate from WT and KO mice following stroke revealed increased cellular protein acetylation in KO mice. KO mice displayed higher intra-ischemic NAD+ levels than WT mice.

Conclusions:
Our findings suggest that SIRT3 contributes to brain injury during stroke via ischemia-induced upregulation and translocation to the nucleus, where it deacetylates both histone and non-histone proteins and represses nuclear gene transcription. Consistent with the neuroprotection afforded by the protein’s absence in KO mice, the inhibition of SIRT3 may serve as a potential therapeutic strategy for minimizing stroke damage.
Abstract T P214: A Multifunctional Nitroxylated Albumin for Early Treatment of Stroke
Authors: Hsia Carleton J , Ma Li
Published: March 2022

Objective:
To determine if early treatment with a multifunctional nitroxylated albumin (MNA) in a rat embolic model of ischemic stroke can overcome the time limitation of tPA with better efficacy than human serum albumin (HSA).

Background:
A recently published clinical trial in JAMA concluded that the treatment time has a profound influence on outcome to stroke victims. We have published a series of animal studies to show the antioxidant activities including superoxide dismutase and catalase mimic properties of MNA support its development as an early stroke treatment

Methods:
Early treatment of MNA was tested for the reduction of infarction and hemorrhage with delayed tPA treatment in a rat embolic model of ischemic stroke. Thirty animals were used. In anesthetized rat, a catheter was inserted into the middle cerebral artery (MCA) at its origin followed by injection into MCA of a 25 mm clot to cause occlusion. Two hours following occlusion, 10 ml/kg of MNA (n=10) was given and 4 hours following occlusion 10 mg/kg of tPA was given. As controls, HSA (n=10) plus tPA or saline (n=10) plus tPA was administered using the identical protocol. After 14 days animals were anesthetized and euthanized. Their brains slices were examined for the volume of cerebral tissue infarction and evidence of hemorrhagic transformation.

Results:
The results show that the level of infarction with tPA treatment at 4 hours was about 38%. Co-treatment with HSA at 2 hours and tPA at 4 hours did not cause a significant decrease in infarct volume compared to saline plus tPA. However, treatment at 2 hours with MNA and 4 hours with tPA resulted in a significant reduction in infarct volume (p<0.01). About 22 % of the brain slices exhibited microscopic hemorrhage with saline plus tPA group. There was no significant difference comparing HSA and saline groups. However, microscopic hemorrhage was significantly reduced in rats that were treated with MNA at 2 hours (p<0.01 and p<0.05, MNA vs. saline and HSA, respectively). In addition, the conjunctive treatment with MNA completely prevented gross hemorrhage.

Conclusions:
MNA treatment data in rat embolic stroke model supports its development as an early stroke treatment drug, which may fill the void of recently failed HSA stroke trials.
Abstract T P216: Regulation of Neuronal Survival by NMDA Receptor Subunit GluN2C Following Ischemia
Authors: Chung Connie , Chen Bo-Shiun
Published: March 2022

BACKGROUND:
Glutamate-mediated excitotoxicity is a key mechanism underlying neuronal death following ischemia. Postischemic activation of NMDA receptors has been linked to subunit-specific effects that can be attributed to factors such as unique channel kinetics and protein-protein interactions. GluN2C-containing NMDARs have lower calcium permeability and open probability compared to GluN2A/2B and behave as a functional NMDAR under physiological conditions.

Hypothesis:
We hypothesize that GluN2C plays a neuroprotective role following ischemia in the hippocampus.

METHODS:
To determine the level of endogenous GluN2C mRNA following oxygen-glucose deprivation (OGD), qPCR was performed on acute hippocampal slices dissected from P30-45 Sprague Dawley rats. Slices were treated with 4-30 min of OGD, followed by 90 min of recovery. To test the survival outcome of GluN2C expression, hippocampal neurons were transfected with SEP-GluN2C and 30 min time-lapse imaging was performed following 200uM NMDA application. Neuronal injury was assessed by determination of cellular morphology (cell body swelling and dendritic varicosities) and DAPI staining. Yeast two-hybrid assay was used to determine 14-3-3 isoform interactions with GluN2C.

RESULTS:
We found an initial 20% increase in GluN2C mRNA following 4 min exposure to OGD (normalized expression=1.193**; n=4). At 10, 15 and 30 min OGD, GluN2C progressively decreased (0.709, 0.739*, 0.301** respectively; n=9). GluN2A expression remained stable and GluN2B significantly increased at 10 min* and 30 min**. GluN2C expressed neurons showed marked resistance to NMDA toxicity (n=6). To characterize pro-survival binding partners of GluN2C, yeast two-hybrid assay revealed distinct 14-3-3 isoforms bind specifically to GluN2C. (**p<0.001, *p< 0.05)

CONCLUSION:
These results support our hypothesis that GluN2C plays a neuroprotective role in ischemia. Following ischemia, a reduction in GluN2C leads to increased calcium permeability through GluN2A/2B and greater cell death. Its association with 14-3-3 provides additional evidence of its neuroprotective role. This study can lead to the development of subunit-specific therapeutic strategies to minimize ischemic cell death.
Abstract T P218: Peripheral Organ Proteomics, a Novel Approach to Biomarker Discovery for Brain Disorders
Authors: Cao Li , Bian Fang , Umejiego Ezigbobiara , Yang Tao , Simon Simon P , Zhou An
Published: March 2022

Introduction:
Brain disorders may produce changes in function of peripheral organs. The lack of omics characterization of peripheral organs hinders development of novel approaches for diagnosing/managing brain disorders. We have characterized proteomes of ischemic brain injury (Stapels et al., 2010, Science Signaling 3 (111):ra15).

Here, we demonstrate: 1) Acute brain disorders induce systemic responses in peripheral proteomes; 2) Brain disorder-induced peripheral proteomic changes are specific to injury conditions. Renal proteomic responses to focal brain ischemia are examples.

Methods Ischemia:
suture occlusion (30 or 60 minutes: n=5, sham: n=4) of middle cerebral artery (MCAO) in mice. After 4 hours reperfusion, brain cortices and one kidney were removed at sacrifice. Proteins were extracted from individual tissues. Tryptic digests from animals of the same experimental group were pooled, and analyzed by quantitative mass spectrometry with triplicate replications. Proteins showing differences in abundance between sham and 30 minutes or 60 minutes brain ischemia were further analyzed by bioinformatics.

Results and Conclusion:
At 4 hours after 30 or 60 minutes MCAO, kidney proteome showed significant changes compared to that of sham controls: 72 and 56 proteins with increased abundance in the former and latter brain conditions, respectively. Interestingly, among up-regulated proteins, only 24 showed an overlap between the 30 and 60 minute brain ischemic conditions. Results of bioinformatic analyses of regulated kidney proteins indicated an association with cellular pathways or processes of cell adhesion, small molecule metabolism, protein folding, as well as immune response, for both brain ischemic conditions. Differential changes were also observed: an increase of amino acid metabolism and nucleoside catabolic processes were detected only in 60 but not 30 minutes brain ischemic conditions. Our previous work has shown that 30 minutes MCAO results in very limited cortical injury whereas 60 minutes MCAO leads to broad tissue infarction. Hence, our results present distinguishable kidney proteomic characteristics associated with different brain ischemic conditions.
Abstract T P22: Intra-procedural Heparin Increases Mortality and Reduces Rates of Favorable Outcome in Acute Ischemic Stroke Patients Undergoing Endovascular Treatment.
Authors: Jani Vishal B , Saed Aveen , Mohindroo Tanya , Qureshi Mushtaq , Hussain Sayed , Suri Fareed , Qureshi Adnan I
Published: March 2022

Background:
Heparin is thought to provide an anticoagulant effect preventing catheter related thrombosis duting acute intra-arterial thrombolytics in acute ischemic stroke patients undergoing endovascular procedures.

Objective:
To perform a systematic review to determine the effect of intra-procedural heparin (and intensity) on rates of symptomatic intracerebral hemorrhage (ICH), mortality, and favorable outcome (mRS of 0-2) at 1-3 months.

Methods:
All published trials until 2012 evaluating endovascular treatment were identified from Pubmed using searches with keywords “Catheter based therapy AND Stroke,” “Intra-arterial acute stroke,” “Intra-arterial thrombolysis,”. Studies that reported their treatment time window, baseline median NIH Stroke Scale (NIHSS) score, mean age, and 3-month outcomes were selected. The studies were divided into two groups; endovascular treatment performed with or without intra-procedural heparin. Among those who received heparin, patients were divided into high and low dose heparin. Low dose of heparin was defined as less than 2500 U/hr, and high dose heparin was defined as more than 2500 U/hr.

Results:
A total of 957 (patients in both arms were analyzed) from 33 trials. Intra-procedural heparin was used in 485 of 957 patients (51%); 228 and 257 patients were treated with low dose and high dose heparin, respectively. The rate of symptomatic ICH was not different in patients who received or did not receive intra-procedural heparin (80 of 485 versus 60 of 472, p=0.09). However, trial defined mortality was significantly lower in those who did not receive heparin (107 of 472 versus 141 of 485, p=0.02). There was a significantly higher rate of favorable outcomes at 1 to 3 months in patients who did not receive heparin compared with those who received heparin (305 of 472 versus 264 of 485, p=0.001). . Among patients who received intra-procedural heparin, the rate of symptomatic ICH was significantly higher in those who received high dose heparin as compared to low (dose (55 of 257 versus 25 of 228, p=0.001).

Conclusion:
Intra-procedural use of heparin during endovascular treatment among acute ischemic stroke patients was associated with higher rates of mortality and lower rates of favorable outcomes at 1-3 months.
Abstract T P227: The Safety of Pioglitazone for Hematoma Resolution in IntraCerebral Hemorrhage (SHRINC) Trial: Safety Results
Authors: Gonzales Nicole R , Sangha Navdeep , Kauffman Teslyn , Cai Chuyan , Sline M. Rick , Pandurengan Renga , Peng Hui , Sosa Lenis , Bowry Ritvij , Prieto Maria P , Hossain M. Monir , Kawano-Castillo Jorge , Choi Ellie E , Villamar Gustavo D , Ofori Kwami , Aramburo-Maldonado Linda A , Shen Loren , Acosta Indrani , Kasam Mallikarjunarao , Harun Nusrat , Barreto Andrew D , Wu Tzu-Ching , Sarraj Amrou , Savitz Sean I , Lopez George , Ifejika Nneka L , Rahbar Mohammad H , Zhao Xiurong , Aronowski Jaroslaw , Grotta James C
Published: March 2022

Background and Objectives:
Peroxisome proliferator activated receptor-gamma agonists, such as pioglitazone (PIO) enhanced hematoma resolution and improved functional recovery in our animal model of intracerebral hemorrhage (ICH). We conducted a translational Phase II randomized, controlled clinical trial to determine the maximum tolerated dose (MTD) of PIO in patients with spontaneous ICH and to explore the rate of hematoma resolution and clinical outcome.

Methods:
Patients with spontaneous ICH within 24 hours of symptom onset were randomly allocated 1:1 to placebo or PIO. Patients received escalating doses of PIO daily for three days, followed by a 30mg maintenance dose for the duration of treatment. Duration of treatment was when 75% of the ICH had resolved as determined by serial MRI or 10 weeks of treatment, whichever occurred first. The primary safety outcome was mortality at Day 14. Secondary measures of safety include any mortality, symptomatic cerebral edema, congestive heart failure, edema, hypoglycemia, anemia, and hepatotoxicity. Secondary measures of efficacy include hematoma resolution and clinical outcome. The MTD was determined using the Continual Reassessment Method.

Results:
From March 2009 to April 2013, 84 patients (42 PIO, 42 control) were enrolled into 11 dose tiers, with a planned range from 0.1-2.0 mg/kg/d. Table 1 demonstrates preliminary baseline and clinical characteristics of patients by treatment group. Overall, 2/84 patients died within 2 weeks after ICH; however mortality rate never exceeded prespecified criteria. The study will be complete in October 2013 and the treatment team remains blinded to treatment allocation. Secondary outcomes by treatment group and the MTD of PIO will be reported.

Conclusions:
We have completed the treatment phase of the SHRINC Trial. Long term follow-up is on-going. These results will provide the foundation for an efficacy trial evaluating PIO as a potential treatment for patients with spontaneous ICH.
Abstract T P233: Intravenous Nicardipine Dosage for Blood Pressure Lowering in Acute Intracerebral Hemorrhage: The SAMURAI-ICH Study
Authors: Koga Masatoshi , Arihiro Shoji , Hasegawa Yasuhiro , Shiokawa Yoshiaki , Okada Yasushi , Kimura Kazumi , Furui Eisuke , Nakagawara Jyoji , Yamagami Hiroshi , Kario Kazuomi , Okuda Satoshi , Tokunaga Keisuke , Takizawa Hotake , Takasugi Junji , Nagatsuka Kazuyuki , Minematsu Kazuo , Toyoda Kazunori
Published: March 2022

Purpose:
Intravenous nicardipine is commonly used to reduce elevated blood pressure (BP) in acute intracerebral hemorrhage (ICH). We determined factors associated with nicardipine dose and the association of the dose with clinical outcomes in hyperacute ICH.

Methods:
Hyperacute (<3 h from onset) ICH patients with initial systolic BP (SBP) >180 mmHg were registered in a multicenter observational study (the SAMURAI-ICH study). All patients initially received 5mg/h of intravenous nicardipine to lower BP. The dose was adjusted to maintain SBP between 120 and 160 mmHg based on BPs measured every 15 min during the initial 2 h and every 60 min in the following 22 h. Maximum hourly and total doses during the initial 24 h were calculated. Associations of the doses with neurological deterioration (a decrease of ≥2 in GCS or an increase of ≥4 in NIHSS score at 72 h after treatment initiation), hematoma expansion (>33% from baseline to 24 h), and unfavorable outcome (modified Rankin Scale score 4-6 at 3 months) were assessed.

Results:
Of 211 patients in the registry, 206 patients (81 women, 65.8±11.8 years old) whose nicardipine data were available throughout 24-h observation were studied. Initial BP was 201.9±15.9/107.9±15.1 mmHg. Median time to reach target SBP range was 30 min (IQR 15-45). Maximum and total doses were 9.1±4.2mg/h and 123.7±100.2mg/day, respectively. Multivariate analyses revealed that male sex [standardized regression coefficient (β)=0.20, p=0.0030 for maximum dose; β=0.25, p=0.0002 for total dose], age (β= -0.28, p=0.0002; β= -0.25, p=0.0005) and initial SBP (β=0.19, p=0.0018; β=0.18, p=0.0021) were independently associated with both maximum and total doses. Body weight (β=0.20, p=0.0084) was independently associated with total dose. After multivariate adjustment, maximum dose (per 1mg/h; OR 1.25, 95% CI 1.09-1.45; p=0.0022) was independently and total dose (per 10mg/day; OR 1.06, 95% CI 0.998-1.132; p=0.0555) tended to be associated with neurological deterioration. Nicardipine dose was not associated with hematoma expansion and unfavorable outcome.

Conclusions:
Nicardipine dosage is roughly predictable with sex, age, body weight and initial SBP in acute ICH. Maximum hourly nicardipine dose was associated with neurological deterioration.
Abstract T P236: Safety of Venous Thromboembolism Prophylaxis in Intracranial Hemorrhage Patients with External Ventricular Drains
Authors: Frontera Jennifer A , Jovine Maximo , Zach Victor , Gordon Errol
Published: March 2022

Introduction:
Despite high rates of venous thromboembolism (VTE) among critically ill patients with intracranial hemorrhage, there is a reluctance to use pharmacologic VTE prophylaxis in patients with external ventricular drains (EVD) due to concerns of procedure site hemorrhage.

METHODS:
In a prospective study of intracranial hemorrhage patients with an EVD (subarachnoid hemorrhage N=64; intracerebral hemorrhage N=41 and subdural hemorrhage N=5) conducted between 7/2008-11/2011, we compared bleeding complications, VTE rates and 3-month functional outcomes between patients who received pharmacologic VTE prophylaxis (either heparin or enoxaparin) plus compression boots versus mechanical prophylaxis (compression boots) alone.

RESULTS:
Of 110 patients with an EVD, 98 (89%) received pharmacologic prophylaxis (heparin BID N=3 [3%]; heparin TID N= 34 [31%]; enoxaparin N=61 [56%]) in addition to compression boots, while 11 (11%) received compression boots alone. The median time to initiation of pharmacological prophylaxis was 4 days post hemorrhage. Compared to mechanical prophylaxis alone, pharmacologic prophylaxis patients were more likely to have SAH (60% versus 22%, P=0.028), less likely to have SDH (2% versus 33%, P<0.0001) and less likely to be DNR/comfort care (19% versus 44%, P=0.035). Admission GCS and APACHE 2 scores did not differ between groups. There were no significant differences in bleeding events (EVD associated hemorrhage, ICH expansion, new ICH, new SDH, SDH reaccumulation, bleeding at the craniotomy site, GI bleeding or anemia requiring transfusion) or thombotic events (DVT or PE) between groups. At 3-months, fewer patients receiving pharmacologic prophylaxis were dead (25% versus 67%, P=0.012) or severely disabled (51% versus 89%, P=0.049). After adjusting for admission GCS, age, DNR status, and bleed type this trend for reduced 3-month mortality remained (adjust OR 0.1, 95%CI 0.004-1.2,P=0.065).

CONCLUSIONS:
In intracranial hemorrhage patients with EVDs, pharmacological VTE prophylaxis is not associated with higher bleeding risks and is associated with improved 3-month mortality rates compared to mechanical VTE prophylaxis alone.
Abstract T P239: Utilization and Outcomes of Ventriculostomy in Non-Traumatic Intracerebral Hemorrhage During Last Decade in United States
Authors: Moradiya Yogesh , Modi Sumul
Published: March 2022

Background:
Large studies describing recent trends in ventriculostomy utilization in non-traumatic ICH are lacking.

Purpose:
To describe trends, outcomes and predictors of ventriculostomy utilization in ICH.

Study-design and Setting: Population based serial cross-sectional study of non-federal US hospitals from 2001-2010.

Methods:
Nationwide Inpatient Sample was searched for patients with primary diagnosis of ICH (ICD-9 code 431) undergoing ventriculostomy (ICD-9 code 02.2). Primary outcome measures were inpatient mortality and good functional outcomes as indicated by discharge to home. Resource utilization was measured by length of stay and inflation adjusted cost of care (2013 US dollar value). Logistic regression was used to identify independent predictors of ventriculostomy utilization. Population estimates were obtained by complex sample analysis taking into account the discharge weights, clustering and stratification used for sampling design.

Results:
A total of 652,738 ICH cases were included, of which 41,235 (6.3%) underwent ventriculostomy. The rate of ventriculostomy increased from 5.4% in 2001 to 7.5% in 2010 (trend p <0.001). Predictors of higher ventriculostomy utilization were younger age, male gender, African-American ethnicity, lower Charlson comorbidity index, larger bed-size, urban location, teaching status, western US and more recent calendar year. Patient requiring ventriculostomy had higher inpatient mortality (40.2% vs. 28.1%, p<0.001) and lower rate of good outcome (7.2% vs. 20.0%, p<0.001). They also had longer length of stay (mean +/- SE: 19.2 +/- 0.3 vs. 7.2 +/- 0.1 days; p<0.001) and incurred higher cost of care (USD 57,420 +/- 1,073 vs. 16,438 +/- 221; p<0.001). Patient requiring early ventriculostomy (within 24 hours of admission) had increased mortality compared to those with late ventriculostomy (44.9% vs 32.8%, p<0.001). Inpatient mortality in patients undergoing ventriculostomy decreased from 45.5% in 2001 to 37.7% in 2010 (trend p <0.001).

Conclusions:
Patients requiring ventriculostomy in non-traumatic ICH have worse outcomes and higher resource utilization. Utilization of ventriculostomy for ICH increased and the mortality decreased in US hospitals during the last decade.
Abstract T P242: High Mortality Rates Among Acute Intracerebral Hemorrhage Patients with PT-INR Vales of More than 2.0 Taking Warfarin
Authors: Yamashita Shinji , Matsumoto Noriko , Saji Naoki , Uemura Jun-ichi , Shibazaki Kensaku , Kimura Kazumi
Published: March 2022

Background and objectives:
The relationship between the prothrombin time (PT)-international normalized ratio (INR) at intracerebral hemorrhage onset and patient outcome is unknown. Therefore, we investigated this relationship in the present study.

Methods:
Clinical backgrounds, physical and imaging findings, and outcomes were compared among 76 consecutive patients who were administered warfarin within 24 hours of acute intracerebral hemorrhage onset and had PT-INR values of <2.0, 2.0-2.6, and ≥2.6 at admission.

Results:
The PT-INR <2.0, and 2.0-2.6 and ≥2.6 groups comprised 23, 23, and 30 patients, respectively (female, 35%, 26%, and 53%, respectively; median age, 75, 73, and 75 years, respectively). The Glasgow Coma Scale (GCS) medians of the PT-INR <2.0, 2.0-2.6, and ≥2.6 groups were 14 (25th-75th percentile: 13-15), 12 (4-14), and 10 (4-14) (p = 0.01), respectively, and hematoma volumes were 6.8 (2.0-26.8), 28.8 (7.0-111.9), and 25.3 (6.0-100.0) mL, respectively (p = 0.03). No other significant differences were observed in regards to the patients’ clinical backgrounds. The in-hospital mortality rates were 17% (n = 4), 57% (n = 13), and 53% (n =16), respectively (p = 0.01) (Fig.).

Conclusion:
The in-hospital mortality rate was significantly higher for acute intracerebral hemorrhage patients taking warfarin with PT-INR ≥2.0 than for the other patients. To avoid significantly higher mortality rates, alternatives to warfarin should be considered.
Abstract T P244: Risk Factors of Delirium During Acute Phase After a Stroke Screened by the Intensive Care Delirium Screening Checklist
Authors: Ishida Emika , Kamata Tomoyuki , Shibamoto Haruna , Shinchi Miyuki , Kusunoki Sakura , Yokote Hiroaki , Sato Yohei , Tone Osamu
Published: March 2022

Background:
Delirium, a well-known psychiatric syndrome occurring after a stroke, is an obstacle to rehabilitation, resulting in prolonged hospital stay. The Intensive Care Delirium Screening Checklist (ICDSC) is a simple method to help nursing staff detecting delirium. Risk factors for post-stroke delirium have been reported, but use of the ICDSC as a screening tool has rarely been reported.

Purpose:
This study investigated risk factors of delirium during acute phase after a stroke by using the ICDSC.

Methods:
We retrospectively examined 418 acute stroke patients treated in our Stroke Care Unit (SCU) between September 2011 and September 2012. Patients who died within 24 h after hospitalization and those with transient ischemic attacks, subarachnoid hemorrhage, and severe consciousness impairment were excluded. Patients were assessed usingthe ICDSC every 8 h while in the SCU. Delirium was defined as an ICDSC score > 4. Patients were divided into the delirium (those assessed as having delirium at least once) and non-delirium (those assessed as not having delirium) groups. Using univariate and multivariate logistic regression analyses, risk factors of age, sex, past medical history, consciousness level at admission, stroke onset (ischemia or hemorrhage), lesion, symptoms (hemiparesis, hemispatial neglect, or aphasia), and period of hospitalization were compared between the groups.

Results:
Of 310 patients ultimately included, 104 (33.5%) were included in the delirium group. Age (p=0.0456), consciousness level at admission (p<0.0001), history of stroke (p=0.0013), hemorrhagic onset (p=0.0017), suffering from aphasia (p=0.013) and period of hospitalization (p=0.0018) were independent risk factors for post-stroke delirium.

Conclusions:
The incidence and risk factors of delirium were similar to those previously reported. The ICDSC may be a useful and simple method for detecting delirium in the acute phase after a stroke.
Abstract T P266: Training and Certification of Research Teams Across Countries: The INDO-US Project Experience
Authors: Thankachan Tijy K , Arora Deepti , Pandian Jeyaraj D , Sylaja PN , Kaul Subash , Padma Vasantha , Khurana Dheeraj , Singhal Aneesh B
Published: March 2022

Background:
The Indo-US Stroke Registry and Infrastructure Development Project, jointly funded by NINDS and the Indian Dept. of Biotechnology, currently includes 5 academic tertiary hospitals in India and 1 in USA. The aim is to develop high-quality stroke centers in India, modeled after the US center.

Methods:
From Jun’12-Jun’13, 5 Indian PIs (one per center) hired 19 research coordinators or fellows and one project manager across all sites. The US collaborators developed a web-based registry with data variables/definitions consistent with the NINDS Stroke Common Data Elements and the AHA GWTG-Stroke Projects. Before launch of prospective data collection, the US PI and project manager trained the Indian collaborators as follows: (a) coordinator training via 2 video-conferences/web discussions and 1 interactive telephone training session for data entry, NIHSS and mRS certification, stroke classification, and imaging data (b) 2 teleconferences for MD training on data definitions, stroke subtypes using an automated web-based system, and image analysis (c) Data entry, logic check and query resolution for all co-investigators via 6 sessions using teleconference and remote computer access (d) Recently, we developed video training modules. Enrollment progress reports were sent out monthly. Post-launch, we conducted 5 teleconferences (one every 2 months) to resolve queries. In April ’13, site monitoring and audit visits were conducted by the Project managers. We compared our experience before and after the in-person site monitoring visit.

Results:
After the in-person site monitoring visit in April ’13, enrollment improved by 150% (27 patients per month in May-June 2013, vs. an average of 17 per month from Nov-2012 to May-2013). The in-person site visit resulted in significantly better data quality, with a 60% decrease in data entry errors. Research coordinators unanimously expressed a better understanding of consent procedures, regulatory aspects, and accurate data collection.

Conclusion:
Cross-country research collaboration requires extensive resources for training and certification purposes. In-person site visits appear essential for improving data quality and should be conducted in addition to video, telephone and web-based training.
Abstract T P268: Restarting Antihypertensive Medications in Acute Ischemic Stroke (AIS) with Pre-Existing Diagnosis of Hypertension: What is the Current Practice and Trends?
Authors: Berger Lynn D , Olson-Mack Lindsay , Bajkiewicz Christopher , Clarkson Katherine , Richetts Renee
Published: March 2022

Background/Issue:
Practitioners do not have clear guidelines on when to restart antihypertensive medications in an AIS patient with pre-existing diagnosis hypertension. The current guidelines by the American Heart Association states to restart antihypertensive medications within 24 hours of AIS is relatively safe especially in patients with pre-existing hypertension and who are neurologically stable(Class IIa; Level B). Currently there are no set guidelines for providers to follow for blood pressure control or what point during the admission the blood pressure should be treated.

Purpose:
The purpose of study was to review the current practice for providers caring for AIS patients and when antihypertensive medications were restarted.

Methods:
A retrospective cohort study of 240 charts was reviewed from a five hospital campuses during the months of May and June 2013. Inclusion criteria included for the study consisted of discharge diagnosis of ischemic stroke, pre-existing diagnosis of hypertension, and the patients was prescribed antihypertensive medications prior to admission. Charts were reviewed for: when home antihypertensive medication regimen was restarted, if the antihypertensive medication was held, and if so, was there a documented reason. Exclusion criteria consisted of: diagnosis of hypertension prior to admission, but the patient was not on any medication; or newly diagnosis of hypertension.

Results:
Of the 240 charts reviewed, 49 patients were identified with the pre-existing hypertension, currently taking antihypertensive medication, and discharged diagnosis with AIS. Of the 49 patients, 67% had antihypertensive medication restarted, while 33% of patient’s antihypertensive were held or restarted at time of discharge. On the day of hospital admission, 66% were restarted on home medications, while 34% of the patients had home medications held. Of those who held the home medications, approximately 8% of providers documented a reason.

Conclusions:
While more than half of the patients with AIS with hypertension had home medications restarted, providers inconstantly documented reasons why antihypertensive medications were held. There needs to be clarification in documentation in order to determine the variation in practice.
Abstract T P27: Arterial Spin-Labeled Perfusion Imaging to Predict Mismatch in Acute Ischemic Stroke
Authors: Niibo Takeya , Ohta Hajime , Yonenaga Kazuma , Ikushima Ichirou , Miyata Shirou , Takeshima Hideo
Published: March 2022

Background and Purpose:
We assigned a threshold to arterial spin-labeling (ASL) perfusion-weighted images (PWI) from patients with acute ischemic stroke (AIS) and compared them with dynamic susceptibility contrast (DSC) perfusion images to examine whether mismatch can be determined.

Methods:
Pseudo-continuous ASL was combined with DSC-PWI in 23 AIS patients. Scans were obtained within 24 hours of symptom onset. PWI volumes were defined by ASL cerebral blood flow- (<15, <20, and <25 mL/100 g/min) and DSC-mean transit time (MTT) thresholds (>10 seconds) that show a strong association with CBF <20 mL/100 g/min in Xenon CT studies. Agreement between the ASL-DWI and MTT-DWI mismatch and the correlation between penumbra salvage and infarct growth, defined as the difference between the baseline PWI- and the baseline DWI lesion, respectively, and the final infarct volume were assessed.

Results:
The lesion volumes defined by MTT >10 seconds and ASL <20 mL/100 g/min showed an excellent correlation. There were 100% agreement on the mismatch status between MTT >10 seconds and ASL <20 mL/100 g/min. The correlation between infarct growth and penumbra salvage volume was significantly better for PWI lesions defined by ASL <20 mL/100 g/min and MTT >10 seconds.

Conclusion:
In AIS, PWI lesions based on ASL threshold of <20 mL/100 g/min can provide a reliable estimate of mismatch in correspondence at MTT threshold of >10 seconds.
Abstract T P272: Improving Staff Nurse Confidence in Responding to Inpatient Stroke
Authors: Beidatsch Jodie L , Vilar Paul S , Anagnostopoulos Kristin M
Published: March 2022

Background and Issues:
Studies reveal greater in-hospital delays on evaluation for stroke when they occur in the hospitalized patient. Only 15 percent of in-hospital strokes are evaluated by a physician within 3 hours of onset. This significantly surpasses the Golden Hour target of 60 minutes to treat eligible patients. The more time that passes in eligible patients, the greater the extent of brain ischemia to be expected. Well-planned and executed stroke response processes must be developed within hospitals so that teams treating hospitalized stroke patients can achieve the time sensitive goal of door to needle within 60 minutes.

Purpose:
The purpose of this study was to optimize the response of inpatient staff nurses and promote their confidence with executing a newly developed inpatient stroke response process.

Sample:
Fifty-seven staff RNs in two medical-surgical units of a community hospital

Method:
The method included educational inservices with pre and post survey data collection. Each survey assessed RN knowledge of responding to inpatients having acute stroke symptoms and their confidence level in implementing the appropriate response. Simulation drills were conducted a month later. The drills assessed the RNs’ response to a stroke scenario and provided opportunities to role play each step of the interdisciplinary process. A post-drill survey assessed the RNs’ confidence with implementing the inpatient stroke response process.

Results:
Measureable increase in self-reported RN confidence with both recognizing and responding to acute stroke in hospitalized patients. On a 4 point likert-type scale, mean overall confidence in recognizing stroke symptoms went from 2.91 to 3.3 among all experience levels. Mean overall confidence in responding to stroke increased from 2.77 to 3.26. Data was stratified to reflect years of RN experience.

Conclusions:
RNs who participated in focused education and stroke process drills reported increased confidence in their role in stroke recognition and response. Additional data is needed to determine if increased RN confidence will lead to earlier detection of stroke, earlier interventions, and better outcomes.
Abstract T P275: Hospital’S Role In Community Stroke Risk Screening
Authors: Catinella Rachel , Biller Heath , Heinbeck Beth , Pugh Kristin , Bratt Sarah , Bilek Kristen , Price Theresa M
Published: March 2022

Background:
Hospitals can contribute to the success of the American Heart Association’s 2020 Impact Goals through community stroke risk screenings and educational awareness events.

Purpose:
The purpose of this quality project was to evaluate the effectiveness of strategies used to conduct community stroke risk and education events.

Method:
Marketing strategies were utilized to promote free community stroke risk screenings and awareness events at nine sites. Stroke nurses used standardized risk screening and FAST teaching tools. Participant data was aggregated into a dashboard and analyzed. A survey was developed and distributed to participants in order to evaluate satisfaction and responses to recommendations from the screening events.

Results:
423 participants attended the stroke events. The average age of participants was 51 years and the majority of participants were Caucasian (82%) and female (73%). Two or more risk factors were identified in 67% of participants. Nearly half (48%) of participants were classified as pre-hypertensive, with 12% of participants presenting with stage I hypertension, and 3% with stage II hypertension. Over half (53%) of participants made appointments with a PCP after the screening, and 5% of participants without a PCP at the time of the event found a provider. After the stroke events, 47% of participants began an exercise program, 47% implemented a change in diet, and 23% implemented strategies to decrease stress. Overall, 75% of participants agreed that their stroke risk factors were fully explained, 75% agreed recommendations were informative, and 80% would recommend the screening events to family and friends.

Conclusions:
Hospital-based stroke programs with a commitment to the communities they serve should provide free risk screening and educational stroke awareness events. Events should be evaluated for effectiveness. Goals should focus on the quality of the screenings rather than quantity of participants. Effective strategies for community outreach include the utilization of marketing departments, offering year round events, and engaging with local employers to expand screening locations.
Abstract T P283: Developing a Stroke Survivor Peer Visitor Program in a Community Hospital
Authors: Andrade Christina , Goulson Janet
Published: March 2022

Background and significance:
Strokes are the 4
th
leading cause of death in the United States and a leading cause of disability. About 795,000 people experience strokes each year in the US. It is a devastating event that leaves survivors feeling alone and bewildered as they struggle to adjust to new limitations and rebuild their lives. It also affects their families and caregivers who often feel helpless and overwhelmed. The emotional impact of stroke is too often overlooked.

As a primary stroke center, committed to patient and family centered care, we recognized the need to provide support to patients/families affected by stroke in the acute phase. Prior to this program, our hospital did not provide stroke survivor peer visits to any patients diagnosed with stroke.

Purpose:
In 2012, the purpose of our program was to provide one or more stroke survivor peer visits to >/=50% of stroke inpatients.

Methods:
In February 2012 our first group of stroke survivor peer visitors was trained. The peer visitors then progressed through our hospital’s volunteer program and were ready to begin visiting patients in May 2012. Our primary outcome measure was number of stroke survivor peer visits to patients admitted to our hospital with a diagnosis of stroke.

Results:
The data was collected monthly and peer visits were provided to 57 out of 96 (59%) patients with a primary diagnosis of stroke between May 1, 2012 and December 31, 2012. The primary challenge was coordinating the scheduling of the peer visits with patient admissions.

Conclusion:
A successful stroke survivor peer visitor program in a community primary stroke center requires creative scheduling of visits to consider the needs of the patients, their families, and the peer visitors. We addressed this need by creating a dedicated visiting schedule. The peer visitors committed to visiting on specific days and times. In conclusion, by providing stroke survivor peer visits to patients who have experienced strokes, we have begun to address the emotional impact of stroke and provide hope to these patients and their families that they can successfully rebuild their lives.
Abstract T P284: Use of Lean Six Sigma in a Primary Stroke Center: Improving the Time to Care
Authors: Giannelli Patricia D
Published: March 2022

Background:
Stroke is the fourth leading cause of death and the leading cause of severe long term disability for adults in the US. Each minute of brain ischemia can lead to varying degrees of neurological compromise. The purpose of this study was to identify time wasting work flow processes during the evaluation phase for the suspected stroke patient (SSP) and to minimize or eliminate them. The National Institute of Neurological Disorders and Stroke (NINDS) time targets were used as the benchmark for this research.

Methods:
An audit of 98 emergency department patient records revealed variation and inconsistency in meeting expected time targets that included door to: physician evaluation, stroke alert call, CT completion, CT interpretation, all lab and diagnostic completion. Lean Six Sigma methodologies were used and a two day Kaizen Event was held with an interprofessional process improvement team empowered to identify and reduce wastes, synchronize work flow processes, manage variability, devise communication and sustainability plans. A quasi-experimental pretest posttest design was used with a non-probability, structured method of sampling to select all pre- and post-intervention SSPs presenting to the emergency department for symptom evaluation (
N
= 222).

Results:
Results indicated that time was saved and variation decreased in all areas during the last 3 weeks of the study. The post-intervention work flow redesign group was faster than the baseline group at evaluating the SSP across all time targets,
F
(5, 642) = 2.98,
p
= .01 and two were significantly faster: lab completion (
M
pre
= 48.10,
SD
= 20.70;
M
post
= 35.54,
SD
= 14.80) and all diagnostics completion (
M
pre
= 49.74,
SD
= 20.26;
M
post
= 37.77,
SD
= 13.76);
SE
decreased (3.38 to 2.84) indicating decreased work flow variability.

Conclusion:
Work flow process redesign conceived and implemented by front line care providers resulted in substantial time savings for both patients and staff. Whether patients chose to receive a thrombolytic agent as a treatment modality, each must be assured that time delays do not deny them this therapy option. Time efficient, value added activities for this patient translates into a greater chance to preserve brain tissue, function and quality of life.