bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP244: Review Criteria For Transfer Elderly Patient From Community Hospital To Comprehensive Stroke Center
Authors: Cardona Pedro , Quesada Helena , Lara Blanca , Cayuela Nuria , Mora Paloma , Garces Moises , Ustrell Xavier , Catena Ester , Puiggros Elsa , Bernal Teresa , Aja Lucia , Rubio Francisco
Published: June 2021

Background:
Recent guidelines recommend thrombectomy to treat stroke due to large vessel occlusions within first six hours after onset stroke time. There is no age limit, however elderly patients (>=80 years old) transferred from community hospital (CH) to comprehensive stroke center (CSC) possibly present different radiological findings in comparison with younger patients, that finally exclude them of endovascular treatment and could avoid unnecessary transfers to CSC.

Method:
We reviewed consecutive patients transferred from five CH to our CSC from January 2012 to July 2016. We analyzed radiological findings in ASPECTS (Alberta Stroke Program Early CT Scale) and segment of occluded artery in NonContrastCT (NCCT) and CT-angiography, both realized in CH (pre-transfer) and CSC. We evaluated the changes in NCCT between both centers related to onset stroke time, time of transfer, vascular occlusion segment and other epidemiological variables.

Results:
A total of 3825 patients were evaluated in our CSC as stroke code (24% elderly and increasing annually); 21% were transferred from CH to CSC with large vessel occlusion diagnosis and NIHSS>8. Subgroup of elderly patients presented worse score in ASPECTS-NCCT evaluated at CSC previous to endovascular treatment than younger patients (mean 6.8 vs 8.4;p: 0.001). An ASPECT score <8 in NCCT performed at CH pre-transfer was significant associated to important ASPECT score decay of respective NCCT performed at CSC for endovascular treatment assessment. This age-association was not demonstrated in younger patients. The occluded segments TICA and M1 were associated to lower ASPECTS. As a result less than 30% elderly patients transferred to CSC for thrombectomy were treated due to low ASPECT score in NCCT performed in CSC; confirmed by CT-perfusion. In ROC analysis we found a cut-off of 83 years for patients with good ASPECTS (dichotomized as ASPECTS>6) in NCCT at CSC (AUC: 0.69; S: 61%, E: 85%).

Conclusions:
Patients over 83 years old and low score in ASPECT (score<8) evaluated in CH presents low benefit when they are transferred to CSC in our area. Criteria to transfer elderly patient from CH to CSC for possible endovascular treatment must be reviewed according new guidelines to get efficient our Emergency Departments.
Abstract WP27: Endovascular Treatment in Elderly Patient. Should We Continue Treating Them?
Authors: Cardona Pedro , Lara Blanca , Quesada Helena , Cayuela Nuria , Aja Lucia , Barranco Roger , Aixut Sonia , Luttich Alex , De Miquel Maria Angeles , Gomis Meritxell , Ribó Marc , Rubio Francisco
Published: June 2021

Background:
Endovascular treatment has been approved and has demonstrated effective in treating strokes with large vessel occlusion in trials published. A short number of elderly patients were included in these trials of thrombectomy. Current criteria admit patients without limit age but demand good baseline Rankin. However, despite those efforts in subgroup of older patients, we could achieve outcomes and long-term results different after endovascular treatment.

Methods:
We performed an analysis of consecutives patients treated with stent-retriever from March 2010 to May 2016. We dichotomize between younger (<80 years old) and elderly (>=80y) patients. We assessed good functional outcome in Rankin scale (0-2) at 3 month and long-term follow-up, percentage of successful recanalization (TICI 2b-3), symptomatic intracranial hemorrhage (SICH) and mortality. Moreover we determine percentage of futile recanalization in elderly patients and variables associated to failed thrombectomy.

Results:
A total of 622 patients were analyzed, mean age 67+/-12, baseline NIH:17, OSTP (onset stroke time to groin puncture): 279 min, baseline Rankin 0-1: 92%. Subgroup of elderly patients represented 21% of patients (131pt): mean age 83 (80-92), NIH:18, OSTP: 272 min, baseline Rankin 0-1:96%. We compare percentage of successful recanalization (TICI 2b-3) between younger and older patient (75% vs 60%; p:0.001). In multivariate analysis functional independence at 3 month (mRs 0-2) was significantly worse in elderly subgroup compared with younger patients (23% vs 51% ) and mortality (25% vs 17%). In a subgroup of long-term follow-up we found in elderly patient an increase of mortality (49%) after 2.5 years and lower percentage mRS 0-2 (18%), due to morbidity and fragility after stroke. Futile recanalization was higher in elderly patients compared with younger (31% vs 17%). Variables associated to futile recanalization in this subgroup of patients were ASPECTS<8 and hostile vascular access to occluded artery.

Conclusions:
We recommend more restrictive criteria to endovascular treatments in elderly patients. A low percentage of good outcome and high percentage of mortality at long-term follow-up don’t contribute to recent health target of successful aging.
Abstract WP271: Door to Page Time to Initiate a Telemedicine Consult Varies Among Spoke Hospitals for Acute Stroke
Authors: Jagolino Amanda L , Ankrom Christy M , Bozorgui Shima , Bambhroliya Arvind B , Vahidy Farhaan , Cossey TC D , Trevino Alyssa D , Savitz Sean I , Wu Tzu Ching
Published: June 2021

Introduction:
Although telemedicine (TM) has increased tPA use for acute ischemic stroke (AIS), there are delays between when an AIS patient enters the ED and when the TM consultant is paged. We identified predictors of delayed door-to-page time (DTP) for AIS patients evaluated on TM.

Hypothesis:
We investigated spoke characteristics associated with the time between patient arrival and the TM code stroke page.

Methods:
We identified suspected AIS patients in our telestroke registry who were evaluated by video consultation at one of 15 spoke hospitals within six hours of symptom onset (9/2015-3/2016). We compared DTP among spokes and identified factors associated with prolonged DTP.

Results:
Median DTP was 22 minutes (12-38, Q1-Q3). Of 382 cases 44.0% had DTP ≤20 minutes and 13.5% >60 minutes (Figure). There was no significant difference in DTP among patients of different age, gender, race/ethnicity, and stroke severity (Table). Hospitals with fewer beds, no pre-notification protocols, location in a medically underserved area (MUA), and less in-house neurology availability had delayed DTP.

Conclusions:
Bed capacity, pre-notification, location in a MUA, and in-house neurology availability are associated with prolonged DTP. While retrospective in nature, our study confirms the utility of pre-notification for spoke hospitals. Further investigation is needed to understand why smaller hospitals and spokes in a MUA have longer DTP, and how in-house neurology coverage affects DTP. In addition, standardized acute stroke metrics over TM are needed.
Abstract WP281: Incorporating Biological Variability in Experimental Stroke to Better Mimic Human Stroke
Authors: Kent Thomas A , Rea Harriett C , Dalmeida William , Fabian Roderic H , Ayata Cenk , Mandava Pitchaiah
Published: June 2021

Introduction:
Failures to translate pre-clinical results have been discouraging. We have contended that stroke is too heterogeneous with respect to factors influencing outcome to expect small studies to be balanced. It is not only difficult to control for biological and methodological variability but efforts to improve homogeneity, such as minimizing physiological variability, may render results less applicable to humans. Here, we report a predictive outcome model in experimental stroke which incorporates baseline variability and provides statistical thresholds a treatment must exceed to be efficacious in a broad population.

Methods:
We generated a mathematical model to predict outcome using transient MCA occlusion in 23 unfasted rats. To create baseline variability, we varied occlusion times from 90-120 min, altered baseline glucose with streptozotocin, and assessed neurological outcome 3 days later with a modified Bederson Score (BS; 0-6 functional measure, 7 death). Statistical surfaces in 3 dimensions were generated using Jacobian matrices flanking the model to provide a screening threshold (1 SD) for comparing new therapies against this model.

Results:
We successfully generated an outcome model from occlusion time, glucose and BS (Fig; R
2
=.49, p=.0003; middle surface is the model surrounded by ±SD surfaces). Outcome was sensitive to change in glucose and time, suggesting small imbalances in these factors between groups may influence outcome, and hence the perceived efficacy of a new therapeutic intervention. At normoglycemia and 90 mins, the lower surface overlapped with no deficit, indicating it would be difficult to reliably demonstrate benefit under those conditions.

Conclusions:
These results indicate it is feasible to incorporate biological variability to generate more clinically relevant conditions. The method will be tested with other stroke models and modifiers towards a generalized model to screen for therapies worthy of further study.
Abstract WP282: Gender-Dependent Differences in the Cerebrovascular System in Wildtype Mice and Cerebrovascular Lesions in a Mouse Model of Moyamoya Disease
Authors: Starosolski Zbigniew , Wright Jamie , Milewicz Dianna , Annapragada Ananth
Published: June 2021

Mutations in
ACTA2
predispose to a spectrum of vascular diseases, including Moyamoya-like cerebrovascular disease (MMD).

Acta2
-/-

mice show straightening of cerebral arteries, narrowing and occlusions characteristic of MMD. They do not show typical MMD collaterals, but exhibit thick bypasses, perfusing ischemic zones. We found a set of altered morphological parameters with females exhibiting the most advanced vascular alterations.

Methods:
Animals (n=12) at 7 wk age were injected with liposomal blood pool CT contrast agent, average particle size 130 nm, iodine concentration 2.2 mg/g and imaged immediately with μ-CT. Individual scan time was ~50 min. Detailed morphometric analysis of Circle of Willis (CoW) territory was performed.

Results:

Acta2
+/+

males and females do not show significant differences for morphometric features associated with MMD. Knockout animals

Acta2
-/-

exhibit several morphometric changes compared to wild type.

Acta2
-/-

females revealed the greatest severity of cerebral malformation in the narrowing of L-SCA, curvature and mean circularity of L-ITCD and the smallest CoW area.

Conclusion:

Acta2
-/-

animals show straightening of large cerebral arteries and narrowing, characteristic features of MMD,

Acta2
-/-

females have more prominent malformations compared to males, as in the human patients. Results of this study may help in better understanding the complexity of MMD and shed light on possibilities for new therapy development.
Abstract WP296: Short Term Acute Preconditioning Exercise Improves Stroke Outcomes and Reduces Neurovascular Injury via Increased Endothelial Nitric Oxide Synthase Activity
Authors: Hafez Sherif , Khan Mohammad B , Wagner Jesse D , Hess David C
Published: June 2021

Physical exercise is becoming a prominent therapeutic strategy to improve stroke outcomes. It was previously shown that long term exercise reduces infarct volume, but this was never tested in acute short term preconditioning exercise in a thromboembolic model of stroke. Exercise induced shear stress improves vascular function through increased activity of endothelial nitric oxide synthase (eNOS) and its upstream principal activator, AMP-activated protein kinase (AMPK). However, this was not previously tested in a stroke setting. Accordingly, we tested the hypothesis that acute short term preconditioning exercise improves stroke outcomes through increased AMPK and eNOS activity.

Methods:
Male Wistar rats (300g) were subjected to treadmill exercise for four days (25 minutes/day), break for 2 days and then one acute bout for 30 minutes. Exercised animals were subjected to thromboembolic stroke at 1h, 6h or 24h after the last exercise session. At 24h, control (sedentary) and exercised rats were tested for neurological outcomes, infarct size and edema. Western Blotting was used to measure the expression of active eNOS (p-S1177-eNOS) and active AMPK (p-T172-AMPK).

Results:
Acute exercise significantly reduced infarct size and edema and improved functional outcomes compared to control. It also significantly increased the expression of peNOS and pAMPK in the brain, cerebral vessels and aorta (Table).

Conclusion:
Acute exercise preconditioning significantly reduced neurovascular injury and improved functional outcome after stroke through increased eNOS activity. Our findings are novel to point out the role of preconditioning exercise induced AMPK and eNOS activation in improving stroke outcomes.
Abstract WP307: Lone Star Stroke Consortium TeleStroke Registry (LESTER)
Authors: Bambhroliya Arvind B , Bozorgui Shima , Ankrom Christy M , Trevino Alyssa D , Jagolino Amanda L , Cossey Tiffany D , Tippinayani Bhargav , Vahidy Farhaan , Misra Vivek , Morton Johanna L , Savitz Sean I , Wu Tzu-Ching
Published: June 2021

Background:
The Lone Star Stroke Consortium TeleStroke Registry (LESTER) currently consisting of 3 academic hub centers and 25 partner spokes is a statewide initiative organized by UTHealth to understand practice patterns of acute stroke management via telemedicine (TM) in Texas, a state with one of the largest rural populations in the US.

Methods:
All presumed stroke patients for whom a TM consultation has been obtained in the network are entered into a web-based, HIPAA-compliant database from 9/2013 to 3/2016. 90-day mRS and disposition are obtained by a standard phone interview.

Results:
A total of 3390 TM consults were performed: 57.3% acute ischemic stroke (AIS); 8.6% TIA; 1.4% ICH; 32.3% non-stroke related diagnoses (Table). Half of the cases were < 65 years of age. Overall 38.3% of AIS cases received tPA and 12.5% of all cases were transferred to a hub. tPA rates varied from 19% to 50% and transfer rates varied from 0% to 37.5% among spokes with at least 10 AIS consults.

Conclusions:
In this statewide registry of telestroke organized by academic health centers, TM leads to substantially high rates of tPA administration for AIS cases compared with national treatment rates in the US. TM provided by academic centers also leads to low rates of transfer from spoke hospitals, suggesting improvement in allocation of healthcare resources.
Abstract WP309: Effects of Comprehensive Stroke Care Capabilities on Outcome of Carotid Endarterectomy and Carotid Artery Stenting (from the J-ASPECT Study [2013 to 2015])
Authors: Nishimura Ataru , Nishimura Kunihiro , Kada Akiko , Kamitani Satoru , Ogasawara Kuniaki , Ono Junichi , Shiokawa Yoshiaki , Aruga Toru , Toyoda Kazunori , Nakagawara Jyoji , Miyachi Shigeru , Yoshimura Shinichi , Okuchi Kazuo , Nagata Izumi , Matsuda Shinya , Nakamura Fumiaki , Onozuka Daisuke , Hagihara Akihito , Suzuki Akifumi , Sayama Tetsuro , Arimura Koichi , Kurogi Ai , Ido Keisuke , Iihara Koji
Published: June 2021

Background:
The effectiveness of comprehensive stroke center (CSC) capabilities on outcome of carotid endarterectomy (CEA) and carotid artery stenting (CAS) remains uncertain. We performed a nationwide study to examine whether CSC capabilities influenced in-hospital outcome of CEA and CAS.

Methods:
We analyzed 12,943 carotid artery stenosis patients treated with CEA or CAS in 350 certified training hospitals in Japan. Data between April 1, 2013 and May 31, 2015 was obtained from Japanese Diagnosis Procedure Combination Database. Among the institutions that responded, outcome was assessed by in-hospital mortality, ischemic stroke and myocardial infarction. CSC capabilities were evaluated from the 749 certified training institutions in Japan, which responded to a questionnaire survey regarding CSC capabilities that queried the availability of personnel, diagnostic techniques, specific expertise, infrastructure, and educational components recommended for CSCs. Total CSC scores of the participating hospitals were classified into quartiles (Q1: 0-15, Q2: 16-17, Q3: 18-19, Q4: 20-24).

Results:
The proportion of CEA and CAS were 5068 and 7875 (2013: 1685 and 2590, 2014: 1668 and 2564, 2015: 1715 and 2721). Between CEA and CAS, mortality rates were 0.24% and 0.75%, ischemic stroke were 8.41% and 7.56% and myocardial infarction were 0.76% and 0.17%. These outcomes had no differences among the years. There was tendency that mortality rates were lower with high total CSC scores in patients with CEA (Q1: 0.42%, Q2: 0.26%, Q3: 0.12%, Q4: 0%, P=0.16), but there were no differences with CAS (Q1: 1.0%, Q2: 0.74%, Q3: 0.63%, Q4: 0.83%, P=0.73). Ischemic stroke were significantly lower with high CSC scores in CEA (Q1: 9.76%, Q2: 10.77%, Q3: 9.14%, Q4: 6.59%, P<0.05) and CAS (Q1: 9.86%, Q2: 8.76%, Q3: 7.14%, Q4: 6.98%, P<0.05). Myocardial infarction had no correlation with CSC scores in CEA (Q1: 0.21%, Q2: 0.35%, Q3: 0%, Q4: 0.36%, P=0.37) and CAS (Q1: 0.3%, Q2: 0%, Q3: 0.31%, Q4: 0.16%, P=0.19).

Conclusion:
It is reported using the data of Nationwide Inpatient Sample that operator volume was an important predictor of postprocedural outcomes in CAS. We demonstrated that CSC capabilities were associated with reduced in-hospital ischemic stroke in patients with CEA and CAS.
Abstract WP321: Endovascular Stroke Alert Improves Door to Groin Stick Times
Authors: Neff Julie , Prado Sharie , Terry John B
Published: June 2021

Background and Issues:
Endovascular thrombectomy in large vessel occlusive stroke (LVO) improves patient outcomes. This therapy is highly time dependent. Inefficiencies in coordination of care may delay treatment. A standardized response protocol for thrombectomy may help avoid delays and improve response times.

Purpose:
We sought to determine the effect of an Endovascular Stroke Alert (ESA) protocol on door to Interventional (IR) Suite arrival and door to groin stick times for patients undergoing thrombectomy for LVO stroke.

Methods:
An ESA (distinct from the already existing stroke alert) was created. During initial stroke evaluation, discussion between the stroke neurologist and neuro-interventionalist resulted in an ESA activation in appropriate candidates. The ESA group page resulted in a conference call including: stroke neurologist, neuro ICU nurse team leader, neuro ICU advanced practice provider, and ED physician. This team was notified that a potential endovascular patient was to undergo vascular imaging. The Neuro ICU nurse team leader was mobilized to the patient’s bedside to direct and transport. This person also notified the neuro-interventionalist as soon as vascular imaging was complete. The average door to arrival in IR and door to groin stick times for patients presenting through our ED for 4 months preceding ESA implementation were compared to these times in the 7 months following implementation.

Results:
Pre-implementation average door to IR time was 157+/-63 (SD) minutes (N=8), and the post-implementation time was 85 +/-25 (SD) minutes, a 46% decrease in time (N=17; P<0.001). Pre-implementation average door to groin stick was 184+/-47 (SD) minutes (N=8), and the post-implementation time was 114+/-25 (SD) minutes, a 38% decrease in time (N=17; P<0.001). The Mann-Whitney test was used for comparative statistics.

Conclusions:
The implementation of an ESA significantly reduced the door to IR arrival and door to groin stick times. Given the known time dependency on treatment effectiveness, these changes likely were beneficial. Response treatment protocols appear to be advantageous in the endovascular treatment of stroke.
Abstract WP325: Designing Patient-centered Solutions for Enhanced Home-based Recovery After Mild-moderate Stroke
Authors: Lin Chen , Khorzad Rebeca , Capo-Lugo Carmen , Rahman Ayesha , Hoffman Jonathan F , Hong Annette , He Chulun , Stuzynski Kristen A , Lee Estelle , Venetianer Sarah M , McCardel Nathan A , Roth Elliott , Prabhakaran Shyam
Published: June 2021

Introduction:
After discharge from a structured rehabilitation setting, mild-moderate stroke patients report feeling unprepared to manage their home recovery plan. Through Design for America, we worked with undergraduate students to develop prototypes to empower patients in their post-stroke home-based recovery.

Methods:
“User centered design”, a six step process, was applied over a 6-week summer program, with design and process experts’ mentorship. We obtained qualitative data from patients, caregivers and healthcare professionals through focus groups, interviews and web-based surveys (N=60). The insights gained from users were utilized to design solutions.

Results:
Insights gained include: 1) 96% of patients reported they were unable to follow home rehabilitation schedules; 2) 66.7% reported being “comfortable” with technology and 10% having previously used Apps for exercise; 3) often insurance does not cover rehabilitation in mild strokes cases; and 4) patients like to hear from others and often develop their own exercises. Solutions designed included:1) a wearable device (Figure 1A) for stroke survivors to alert them of exercise schedule, track activity, appointments, and medication reminders, 2) a website (Figure 1B) that provides patients an online community to find user-submitted therapeutic exercises, share stories, and motivate others.

Conclusion:
In partnership with Design for America, we created unique solutions that fill a gap in the continuity of stroke recovery: community-based, patient-centered, and self-empowering tools. In the coming months, we plan to build and pilot test these products in a clinical setting.
Abstract WP329: 30-day Readmission After Stroke and Transient Ischemic Attack by Age and Sex
Authors: Lichtman Judith H , Leifheit-Limson Erica C , Wang Yun , Goldstein Larry B
Published: June 2021

Background:
30-day readmission after hospital discharge is considered an indicator of the quality and efficiency of hospital-level care. Readmission rates are commonly reported for elderly Medicare stroke patients, but there is limited information about rates for younger stroke patients. We used a nationally representative readmission database that includes both insured and uninsured patients to compare 30-day readmission by age and sex subgroups for patients hospitalized with stroke and transient ischemic attack (TIA).

Methods:
Hospitalizations for subarachnoid hemorrhage (SAH; ICD-9 430; N=7061), intracerebral hemorrhage (ICH; ICD-9 431; N=17325), ischemic stroke (IS; ICD-9 433, 434, 436; N=212306), and TIA (ICD-9 435; N=67606) were identified for patients aged ≥18y in the 2013 Nationwide Readmissions Database. We fit hierarchical logistic models with hospital random intercepts and adjustment for demographic characteristics, medical history, and clinical factors to assess differences in 30-day readmission by age (18-44, 45-64, 65-84, 85+y) and sex for each condition.

Results:
Readmission rates were lowest for SAH (11.1%), followed by TIA (12.2%), IS (12.3%), and ICH (13.8%). Despite modest increases in readmission with age for IS and TIA, rates remained relatively stable across subgroups (table). Readmissions increased from 18-44y to 65-84y for both SAH and ICH but decreased at age 85+y. In adjusted analyses, each 5-year increase in age was associated with a 3% increase in the odds of readmission after ICH (OR 1.03, 95% CI 1.005-1.05) and 2% increase after IS (OR 1.02, 95% CI 1.01-1.03). Women aged ≥65y with IS and aged 45-64y with TIA had lower odds of readmission in risk-adjusted analyses versus men (figure).

Conclusions:
Readmission rates varied by age and sex subgroups, but the differences were small. Using 30-day readmissions as an indicator of care, our results suggest stroke and TIA patients receive comparable quality of care regardless of age or sex.
Abstract WP339: Herniation Despite Decompressive Hemicraniectomy in Large Hemispherical Ischemic Stroke Patients
Authors: Hinduja Archana , Hannawi Yousef , Feng Dongxia , Samant Rohan
Published: June 2021

Background:
Despite timely decompressive hemicraniectomy (DHC), clinical failure or progressive herniation requiring a second decompression procedure and mortality has been reported in acute middle cerebral artery (MCA) strokes.

Hypothesis:
Our objective was to determine the stroke and surgical parameters measured on head CT scan that are associated with progressive herniation despite DHC in patients with large hemispheric MCA strokes.

Methods:
Retrospective chart review of all medical records and imaging features of patients with malignant hemispheric infarction who underwent DHC for cerebral edema from July 2010 to June 2015, was performed. Patients who died from postoperative hemorrhagic complications were excluded. Infarct volume was calculated using ABC/2 method on CT scans within 48 hours of symptom onset (Kostov et al, 2012, World Neurosurg). Radiologic parameters of the craniectomy bone flap (length, width, area) and brain volume protruding out of the skull (height and volume) were measured (Chung et al, 2011, Neurologist). Images were reviewed by a board certified neuroradiologist to determine whether the craniectomy bed was sufficiently centered on the stroke bed (Zweckberger et al, 2014, Cerebrovasc Dis) and the brain volume not included in the craniectomy bed. Groups were compared using Fisher exact test for categorical variables and T-test or Mann-Whitney U test for continuous variables, as appropriate.

Results:
Out of 41 patients who underwent DHC for cerebral edema (mean age 53.1 ±12, 48.7% females, 36.5% African Americans) 7 had progressive herniation leading to mortality. Radiographic parameters that were significantly different between both groups were presence of malignant edema (p=0.047), insufficient centering of the craniectomy bed on the stroke bed (p=0.03), large infarct volume not centered on the craniectomy bed (p=0.011), presence of anterior cerebral artery infarction (p=0.047), and smaller craniectomy length (p=0.05). There was a trend in protruding brain volume (p=0.056).

Conclusion:
Besides the craniectomy length, sufficient centering of the craniectomy over the stroke bed may be required to prevent progressive herniation.
Abstract WP346: Persistent Hyperglycemia is Independently Associated With Increased Mortality After Intracerebral Hemorrhage
Authors: Wu Teddy , Putaala Jukka , Sharma Gagan , Strbian Daniel , Tatlisumak Turgut , Davis Stephen , Meretoja Atte
Published: June 2021

Background and purpose:
Hyperglycemia may be associated with worse outcome after intracerebral hemorrhage (ICH). We assessed the association of early glycemic trajectory on ICH mortality.

Methods:
We included patients from the Helsinki ICH study with glucose measurements at least once between both 0-24 hours and 24-72 hours from ICH onset. Hyperglycemia was defined as blood glucose ≥8 mMol/L (144 mg/dL) based on the local threshold for treatment. Glucose trajectory was defined on maximum values 0-24 hours and 24-72 hours after ICH; 1) persistent normoglycemia in both epochs, 2) late hyperglycemia (only between 24-72 hours), 3) early hyperglycemia (only prior to 24 hours), 4) persistent hyperglycemia in both epochs. Logistic regression adjusted for factors associated with 6-month mortality estimated the association of glycemic trajectory with mortality.

Results:
There were 576 patients meeting eligibility criteria, of whom 214 (37.2%) had persistent normoglycemia, 44 (7.6%) late hyperglycemia, 151 (26.2%) early hyperglycemia, and 167 (29%) persistent hyperglycemia. Six-month mortality was higher in the persistent (51.1%) and early (26.3%) hyperglycemia groups than the normoglycemia (19.0%) and late hyperglycemia (3.6%) groups. Persistent hyperglycemia was independently associated with 6-month mortality (OR 3.453; 95% CI 1.863-6.400;p<0.001) adjusted for baseline ICH and oedema volume, age, warfarin use, anti-hypertensive use, baseline Glasgow Coma Scale, National Institutes of Health Stroke Scale and ventricular extension.

Conclusion:
Early persistent hyperglycemia is associated with markedly higher risk of mortality after ICH. Strategies to achieve glycemic control after ICH may improve patient outcome and need to be assessed in clinical trials.
Abstract WP348: Blood Pressure Lowering in Patients With Intracerebral Haemorrhage: Data from the Ongoing Tranexamic Acid for Hyperacute Primary Intracerebral Haemorrhage (TICH-2) Trial
Authors: Sprigg Nikola , Robson Katie , Law Zhe K , Appleton Jason , Bath Philip
Published: June 2021

Background:
Intensive lowering of blood pressure in the hyperacute phase after intracerebral haemorrhage may improve outcome (as observed in the INTERACT-2 trial) or have no effect (ATACH-2). Clinical guidelines recommend BP lowering.

Methods:
We investigated the relationship between BP, and BP lowering treatment on functional outcome, death and serious adverse events at day 90. Statistical models were adjusted for baseline characteristics.

Results:
As at 18
th
July 2016, 1161 (71.4%) of patients were on BP lowering treatment by day 2; these patients were younger (mean (SD): 67.7 (13.9) vs 71.9 (12.9) years, p-value<0.0001), more likely to be male (660/1161 (56.9%) vs 241/466 (51.7%), p-value=0.0598) and had lower NIHSS at baseline (12.5 (7.2) vs 14.2 (8.0), p-value<0.0001). Patients on BP lowering were found to have significantly better mRS and Barthel Index by day 90 (p-values: 0.0171, 0.0482, respectively) as compared to those not on treatment, and fewer of these patients died or suffered an SAE (p-values: 0.0074, 0.0002, respectively). However, there was no relationship between systolic BP levels (<140 vs >= 140 mmHg) on day 2, and outcome at day 90.

Conclusion:
Early BP lowering is associated with improved functional outcome, and fewer deaths and SAEs, at day 90. Those achieving a BP target of <140mmHg by day 2 did not have a better outcome, suggesting that the optimal BP target may need more investigation.
Abstract WP349: Updated Meta-Analysis of Randomized Controlled Trials Investigating Blood-Pressure Lowering for Acute Intracerebral Hemorrhage
Authors: Boulouis Gregoire , Morotti Andrea , Goldstein Joshua N , Charidimou Andreas
Published: June 2021

Objective:
We performed a meta-analysis of randomized controlled trials (RCTs) to assess whether intensive blood pressure (BP) lowering in acute intracerebral haemorrhage (ICH) patients is safe and effective in improving clinical outcomes.

Methods:
We searched PubMed, EMBASE and the Cochrane databases for relevant RCTs and calculated pooled odds ratios (OR) for 3-month mortality (safety outcome) and 3-month death or dependency (efficacy outcome), in acute ICH patients randomized to either intensive BP-lowering vs. standard BP lowering treatment protocols. We also investigated the association between treatment arm and significant ICH expansion at 24h. Random effects models with DerSimonian-Laird weights were used.

Results:
Five eligible studies including 4360 acute ICH patients were pooled in meta-analysis. The risk of 3-month mortality was similar between patients randomized to intensive BP-lowering treatment vs. standard BP-lowering treatment (OR: 0.99; 95%CI: 0.82-1.20, p=0.909). Intensive BP-lowering treatment showed a (non-significant) trend for an association with lower 3-month death or dependency risk compared to standard treatment (OR: 0.91; 95%CI: 0.80-1.02), p=0.106). Intensive BP-reduction was associated with a trend for lower risk of significant ICH expansion compared to standard treatment (OR: 0.82; 95%CI: 0.68-1.00, p=0.056), especially in larger RCTs.

Conclusion:
For acute ICH patients similar to those included in RCTs and without contraindication to acute BP treatment, intensive acute BP-lowering is safe (Class I; Level of Evidence A), but does not seem to provide an incremental clinical benefit in terms of functional outcomes (Class I; Level of Evidence B). The effect of intensive BP-lowering on significant hematoma expansion at 24 hours warrants further investigation.
Abstract WP358: A Population-Based Study of Intracerebral Hemorrhage Outcomes: The BASIC Project
Authors: Griauzde Julius , Lisabeth Lynda D , Li Chengwei , Sanchez Brisa N , Case Erin , Garcia Nelda , Morgenstern Lewis B , Zahuranec Darin B
Published: June 2021

Background:
We evaluated 3-month neurologic, functional, cognitive, and quality of life (QOL) outcomes in intracerebral hemorrhage (ICH) overall, and by sex and ethnicity in a population-based community study.

Methods:
Spontaneous ICH patients were identified from the Brain Attack Surveillance in Corpus Christi (BASIC) project from November 2008 to December 2013. Demographics and Glasgow Coma Scale were abstracted from medical records. Outcomes assessed included neurologic (National Institute of Health Stroke Scale (NIHSS): range, 0-42), functional (activities of daily living/instrumental activities of daily living: range 1-4, higher worse), cognitive (Modified Mini-Mental State Examination (mMMSE): range, 0-100), and QOL (Short-form Stroke Specific QOL scale: range, 0-5, higher better). Ethnic and sex differences were assessed with Tobit regression adjusted for age, sex or ethnicity, and presenting Glasgow Coma Scale.

Results:
A total of 245 patients completed baseline interviews, with 103 (42%) dying prior to follow-up, leaving 142 eligible for outcome assessment. 3-month follow up was completed on 100 (neurologic), 107 (functional), 79 (cognitive), and 83 (QOL) participants. Median age was 66 (interquartile range (IQR), 58.0-77.0). The overall median 3-month NIHSS was 2.0 (IQR, 1.0-6.0), with other baseline characteristics and outcomes shown in Table 1. Cognitive outcomes were worse in Mexican Americans (MA) compared to non-Hispanic Whites (NHW) after multivariable adjustment (MA scoring 13.3 mMMSE points lower than NHW (95% CI: 5.8, 20.7; p=.0005)). There was no difference by sex or ethnicity in neurological, functional, or QOL outcomes either before or after adjustment.

Conclusions:
In this population-based study, ICH survivors have remarkably favorable neurologic, functional, cognitive and QOL outcomes. There is an important disparity for worse cognitive outcome in MAs compared with NHWs.
Abstract WP359: Higher Risk of Intracerebral Hemorrhage Recurrence Among African American and Latino/Hispanic Individuals
Authors: Rodriguez-Torres Axana , Kourkoulis Christina , Schwab Kristin , Ayres Alison M , Gurol M. Edip , Greenberg Steven M , Viswanathan Anand , Anderson Christopher D , Rosand Jonathan , Biffi Alessandro
Published: June 2021

Introduction:
Intracerebral hemorrhage (ICH) is more prevalent among African American (AA) and Latino/Hispanic (LH) individuals. While ICH survivors are at high risk for rebleeding, it is unclear whether recurrence risk differs based on race / ethnicity.

Hypothesis:
We sought to clarify: 1) whether ICH recurrence risk is higher for AA and LH patients; 2) whether this disparity is explained by the most potent ICH risk factors, i.e. hypertension severity and the APOE gene variant ε4.

Methods:
We conducted a single-center longitudinal study enrolling 738 ICH survivors presenting to a single center from January 2006 to December 2014. Participants had APOE genotype determined at enrollment, and were followed via phone calls and review of medical records. We captured hypertension severity as absolute blood pressure (BP) measures, as well as BP variability (average percent variation during follow-up). We created univariable and multivariable (Cox regression) models to identify risk factors for ICH recurrence.

Results:
Systolic BP (SBP) was associated with increased ICH recurrence risk
(
Hazard Ratio [HR]=1.30, 95% Confidence Interval [CI] 1.02 -1.66, p=0.036), as was SBP variation (HR=1.75 per variation quartile, 95% CI 1.09-2.81, p=0.021). APOE ε4 was also associated with ICH recurrence (HR=1.66, 95% CI 1.10-2.50, p=0.016). After adjusting for BP and APOE ε4, both LH
(
HR=1.68, 95% CI 1.01-2.78, p
=
0.045
)
and AA
(
HR= 2.12, 95% CI 1.14-3.95, p
=
0.019
)
patients when at higher risk for ICH recurrence. Both AA and LH patients had a significantly higher systolic BP (SBP) during follow-up (Figure, A); AA individuals also had greater SBP variation during follow up (Figure, B
).

Conclusions:
AA and LH patients are at higher risk for ICH recurrence, and hypertension severity / APOE ε4 did not fully account for this disparity. Additional studies will be required to further elucidate biological determinants for this health
Abstract WP363: Outcomes for Intracerebral Hemorrhage Patients with Renal Failure as Comorbidity in the United States
Authors: Afzal Mohammad R , Qureshi Mohtashim A , Qureshi Ihtesham A , Piriyawat Paisith , Maud Alberto , Cruz-Flores Salvador , Rodriguez Gustavo J
Published: June 2021

Background:
Clinical characteristics and outcomes for patients with intracerebral hemorrhage and underlying chronic kidney disease (CKD) are not well determined. We hypothesized rate adverse events and in-hospital mortality is higher in patients with intracerebral hemorrhage and underlying renal disease.

Objective:
To determine the Outcomes for intracerebral hemorrhage stroke patients with renal failure as comorbidity in the United States

Methods:
We analyzed the data from Nationwide Inpatient Sample
(2009-2011)
for all intracerebral hemorrhage stroke patients with or without renal failure as comorbidity. Patients were identified using the International Classification of Disease, Ninth Revision. Baseline characteristics, in-hospital complications including myocardial infarction), sepsis, pneumonia, deep venous thrombosis, urinary tract infections, and discharge outcomes (mortality, minimal disability, and moderate-to-severe disability) were compared between the two groups. All in-hospital outcomes were analyzed after adjusting for potential confounders using multivariate analysis.

Results:
Of the
33521
patients with intracerebral hemorrhage stroke,
3899 (11.6%)
had renal failure as comorbidity. Patients with underlying renal disease were higher rates for in hospital complications like myocardial infarction
(3.64% versus 2.03%, P≤.0001)
, sepsis
(5.82% versus 3.14%, P≤.0001)
, pneumonia
(6.92% versus 5.18%, P≤.0001)
, deep venous thrombosis
(1.67 % versus 1.17%, P≤ .0.0078)
, urinary tract infections
(16.41% versus 15.08%, P≤ 0.0293)
and hypernatremia
(8.62% versus 4.98%, P≤ <.0001).
In multivariate analysis adjusted for baseline cormorbitdities and in hospital complications, intracerebral hemorrhage patients with underlying renal disease had higher in hospital mortality
(OR 1.146 (95% confidence interval (CI)
1.058- 1.240p-value=0.0008)
, while there is no statistically significant difference for minimal/moderate disability between two groups (
OR = 0.980 (95% CI
0.896- 1.072 p-value=0.6571).

Conclusions:
Intracerebral hemorrhage patients with underlying renal disease have higher rate of in hospital complications and mortality. Future prospective studies are indicated to study this finding.
Abstract WP365: Radiographic Predictors of Prognosis in Intracerebral Hemorrhage: "If It Ain’t Broke, Don’t Fix It"
Authors: Pennington Amanda R , Boehme Amelia K , Albright Karen C , Singh Mini , Lyerly Michael J , Gropen Toby I , Hays Shapshak Angela
Published: June 2021

Background/Purpose:
The ICH score (ICHS) is commonly used to predict 30-day mortality in spontaneous ICH. Several investigators have evaluated additional factors in an attempt to refine this score, though none of these modifications have been incorporated into routine practice. We sought to determine whether incorporating additional radiographic features, specifically herniation and/or the degree of midline shift (MLS), improved the performance of the ICH score.

Methods:
We retrospectively reviewed 180 consecutive ICH patients admitted to a single comprehensive stroke center between September 2014 and November 2015. The outcome of interest was poor prognosis, defined as mRS of 4-6, at time of discharge. Admission head CTs were evaluated by a vascular neurologist to determine whether uncal, tonsillar or subfalcine herniation were present, and to quantify the degree of midline shift. Midline shift was treated as a categorical variable determined by measuring the shift of the septum pellucidum from midline at the level of the basal ganglia.

Results:
Patients with radiographic herniation present on admission had a much higher odds of poor outcome; however, this measure was specific (98%) but not sensitive (23%). Degree of midline shift performed similarly, with a specificity of 86% and a sensitivity of 36%. In our population, the ICH score was a better predictor of poor outcome than any of the combinations shown in the Table. For each unit increase in ICH score, the odds of a poor outcome increased by a factor of 2.6.

Conclusion:
Although clinicians often view radiographic evidence of herniation and midline shift as indicators of dire prognosis, incorporation of these features into a modification of the ICH score failed to improve upon the original scale.
Abstract WP383: The Effect of Stretching on Pulse Wave Velocity
Authors: Logan Jeongok G , Kim Suk-Sun , Lee Mijung , Yeo SeonAe
Published: June 2021

Introduction:
Large-artery stiffness is an independent predictor of hypertension which is a leading cause of excess cardiovascular morbidity and mortality. Carotid-femoral pulse wave velocity (cf-PWV) is considered the ‘gold-standard’ measure of arterial stiffness because it measures along the aorto-iliac pathway, which makes the largest contribution to the arterial buffering function. While there is well-documented evidence on the health benefits of aerobic and resistance exercise, the information for the effect of stretching on arterial stiffness is limited. Previous studies have shown that arterial stiffness is associated with trunk flexibility. Stretching exercise targeted to improve flexibility may exert a beneficial effect on reducing arterial stiffness.

Purpose:
This study aimed (1) to determine the association between trunk flexibility and arterial stiffness and (2) to examine whether one bout of stretching exercise will increase trunk flexibility and decrease arterial stiffness.

Methods:
Thirty healthy women (mean age = 44.37 years) were instructed to follow a 20-minute DVD demonstration of whole-body stretching. Before and after stretching, cf-PWV and trunk flexibility were measured by using the SphygmoCor system and by sit-and-reach test, respectively, as well as systolic and diastolic blood pressure (SBP and DBP) and heart rate (HR) by using a Welch Allyn Monitor. All data were measured after taking a 10-minute rest in a supine position.

Results:
cf-PWV was not related to trunk flexibility, however, cf-PWV was significantly decreased after stretching compared with before stretching (mean difference [MD]=.63, , p=.01). Trunk flexibility was also significantly increased after stretching (MD=-3.08, p=.00). Furthermore, while SBP and DBP did not change significantly, HR was significantly reduced after stretching compared with before stretching (MD=3.12, p=.00).

Conclusions:
Our results showed that one bout of stretching exercise had significant effects on reducing arterial stiffness and heart rate. Further testing of long-term effects of stretching exercise is warranted for development of preventative interventions to reduce arterial stiffness, an important subclinical biomarker of cardiovascular disease.
Abstract WP390: Closing the Gap: Integrating Community Paramedics in Stroke Patients Transition to Home
Authors: Ashcraft Susan J , Post Laura , Young Camron
Published: June 2021

Background and Issues:
The transition of stroke patients home is complex. Assessment of functional status and coordination of healthcare and support services while engaging patient and family to be active participants in secondary prevention is essential in preventing stroke recurrence. Readmission rates for stroke patients are also high. Reductions in stroke readmissions must target unresolved problems at discharge and the quality of immediate post-hospital care.

Purpose:
The purpose of the Community Paramedic program is to reduce stroke readmissions. An additional goal is to identify key areas which may contribute to poor patient outcomes or readmission and develop and implement action plans for their prevention.

Methods:
Use of a community paramedic transitional care model is an innovative approach to reduce readmissions in the stroke population. Using the Model for Improvement, an interprofessional team developed a transitional care program focusing on patient-centered care delivery, and on reducing readmissions and adverse outcomes. Use of The National Transitions of Care Coalition’s essential interventions categories, the program addressed: medication management, transitional planning, shared accountability, provider engagement, patient and family engagement and education, follow-up care, and information transfer.

Results:
Despite a 13% increase in stroke patient volume from 2014 to 2015, the program realized a statistically significant reduction in readmission rate (10.7% to 8.51%;
p
= .045, α =.05) in 2015 and has sustained the reduction through 2016. This reduction represents 21 avoided readmissions in the stroke population with cost avoidance of at least $210,000.00. The decrease in readmission rate is well below both the goal and stretch goals of 5% and 10% reduction in stroke readmissions.

Conclusion:
The impact of integrating Community Paramedics into a transitional care program coordinated through Stroke Navigators shows a significant impact on reducing 30-day readmissions. Replication in other patient populations and other counties may have a significant impact for both patients and hospitals focused on improving similar outcomes.
Abstract WP391: You Can Make Them an Appointment, But You Can’t Make Them Show: A 3-year Review of a Stroke Clinic Process Evolution
Authors: Morrison Kathy , Richardson Alicia , Hesser Page , Swords Donna , Reichwein Raymond , Ermak David
Published: June 2021

Background:
Stroke patients are at a significant risk of inconsistent care and adverse events after discharge from the hospital. Follow-up contact has been thought to facilitate continuity and compliance with the discharge plan of care, but evidence is lacking as to optimal timing and intensity of follow-up. Our organization established a stroke clinic in 2009 with a schedule for follow up at 30 days, 90 days, and 1 year. In 2014, in effort to increase follow-up volume, the process was amended to ensure that appointments were made prior to discharge.

Method:
Analysis of 2014 follow-up appointments was conducted by the Stroke Clinic Process Improvement Group. The appointment order was added to the stroke admission order sets so that appointments would display on discharge paperwork.

Discussion:
There was a 55% increase in patients who followed-up from 2013 to 2014. This improvement continued through 2015. However, despite the successful increase in appointments, the clinic reported an atypical no-show rate of 29% for 2014 and 40% for 2015, a loss of $51,165, in addition to the cost of provider down-time. A deeper analysis of appointment type revealed a significant drop in 1-year visits. Since the data also revealed that most patient visits are at either 30-days, or 30 and 90-days, our process was amended once again to exclude 1-year visits. In addition, the follow-up appointments are now ordered 48 hours prior to discharge, ensuring appointments continue to display on discharge paperwork.

Conclusion:
Process improvements sometimes result in unexpected downstream effects. We determined that the increase in follow-up appointments did not justify the financial and productivity loss to the clinic. Monitoring of no-show data and stroke clinic volume will be essential as this stroke clinic process evolves. Until we find a way to make patients come for stroke clinic follow-up visits, we will continue to be challenged to find a way to support them through their post-stroke recovery.