bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract W P286: Assessing Wisconsin Hospitals’ Capacity to Treat Acute Stroke
Authors: Baumann Julie E
Published: July 2021

Introduction:
Establishing regional stroke systems of care can improve timely treatment and survival, and reduce disability and related healthcare costs for persons experiencing acute stroke. A well-functioning stroke system requires seamless coordination between EMS, hospitals and certified stroke centers. Of 127 non-specialty hospitals in Wisconsin, 2% are comprehensive stroke centers and 24% have achieved primary stroke center certification. However, little is known about other hospitals’ capacity to treat acute stroke. The Wisconsin Stroke Coalition (WSC) wanted to better understand the need to improve stroke care capacity among hospitals not certified to treat stroke. The hypothesis was that few non-stroke certified hospitals in Wisconsin have all the criteria in place to treat acute stroke.

Methods:
WSC developed a short survey based on the Brain Attack Coalition’s recommendations for an acute stroke-ready hospital (ASRH). The tool included a user-friendly checklist that captured the status of each recommendation; in place currently or within six months; could be developed with assistance; or no plan to develop. WSC distributed the survey to 88 non-specialty, non-stroke certified hospitals and requested that each self-report their level of stroke care.

Results:
Fifty-nine percent of hospitals responded to the survey. Among respondents, 5% reported having all recommendations in place within six months, 53% reported having some of the recommendations in place and 1% reported no plan to develop any of the recommendations. While only a few had implemented every recommendation, the majority either had in place or were receptive to adopting individual suggestions. Nearly half of respondents reported having telestroke in place (either by phone, with video, or both).

Conclusions:
According to self-reported data, non-specialty, non-stroke certified hospitals in Wisconsin appear well-positioned or receptive to developing basic recommendations for acute stroke-ready hospitals. WSC plans to disseminate findings to Wisconsin hospitals and gather further information about technical assistance that would improve their level of stroke care and coordination with EMS.
Abstract W P287: Collaborative Cryptogenic Stroke Clinic Improves Secondary Stroke Prevention While Helping Achieve Stroke Metrics
Authors: Richards Mark , joseph Kelley , Auberle James , Zaidi Syed , Jumaa Mohommad
Published: July 2021

Introduction:
Stroke centers are faced with the challenges of achieving stroke metrics to meet certification requirements. Recent trials have demonstrated the efficacy of the implantable cardiac monitor (ICM) in detecting atrial fibrillation (AF) in cryptogenic stroke patients. We have created a Comprehensive Cryptogenic Stroke Clinic (CCSC), a collaborative effort between electrophysiology (EP) and stroke neurology, which improves patient care and provides a venue for successfully addressing stroke metrics.

Methods:
All acute ischemic stroke patients (n= 2100) in the ProMedica Stroke Network were screened and evaluated by an EP and vascular stroke neurologist. Appropriate cryptogenic patients are offered an ICM for AF detection, ideally during their stroke admission. Patients are evaluated periodically, both for their rhythm status and their stroke recovery, and important stroke metric follow-up data such as medication compliance, obtaining Modified Rankin scores at 90 days and prevention of stroke readmission through availability of resources.

Results:
We have enrolled 135 patients in our CCS clinic and implanted 92 loop monitors for AF detection. Through follow-up in CCSC, we have: detected AF in 11 patients; identified 27 patients with additional therapy needs; and modified medical management for 38 patients to decrease their secondary stroke risk. 90-day Modified Rankin score compliance improved from 27% to 67%. The collaboration and efficiency has improved stroke outcomes and helped reduce readmission rates by 22% since the CCSC’s inception.

Conclusions:
Our CCSC has improved compliance with multiple stroke metrics, while ensuring patients are cognizant of their real risk for another stroke. Our collaborative team approach has been instrumental in reducing stroke readmission rates, changing medical therapies, and offering additional resources are streamlined through medical collaboration. The CCSC has proven to be a critical venue for accomplishing successful stroke outcomes.
Abstract W P296: Care Trajectories and Costs after Ischemic Stroke for Patients in the Veterans Health Administration
Authors: Arling Greg , Ofner Susan , Meyers Laura , Daggy Joanne , Reeves Mat , Williams Linda , Bravata Dawn
Published: July 2021

Background:
Patients vary greatly in their use of care after hospitalization for stroke. We classified stroke patients according to their care trajectories and associated costs in the 12-month period after hospital discharge.

Methods:
We followed a cohort of 3,811 veterans for one year after hospitalization with ischemic stroke in Veterans Health Administration facilities in 2007. Three discharge outcomes -- nursing home care, home care, and mortality -- were modeled jointly with Latent Class Growth Analysis. VA and Medicare costs were obtained for use of institutional care (inpatient acute, rehabilitation facility, and nursing home) and home care (home health, other home care, and outpatient rehabilitation). Covariates included patient age, NIHSS stroke severity and FIM scores measured at hospital discharge.

Results:
Members of the cohort had one of five care trajectories: 49% had a Rapid Recovery with little or no use of care in the 12 months after discharge, 15% had a Gradual Recovery with initially high nursing or home care use that tapered off over time, 9% had consistent use of Long-Term Home Care (HC), 13% had consistent use of Long-Term Nursing Home Care (NH), and 14% had an Unstable trajectory with multiple transitions between long-term and acute care. Patients with Long-Term NH and Unstable trajectories had the highest average total costs (greater than $60,000 per person) and patients with the Rapid Recovery trajectory had the lowest cost (less than $11,000 per person). Medicare accounted for 23% of total costs. In a multinomial regression model, the likelihood of a Long-Term NH, Long-Term HC or an Unstable Trajectory was greatest for persons with more severe strokes (higher NIHSS score), more disability (lower FIM score), and age 65 or older. About half of the veterans received rehabilitation services. Most rehabilitation was delivered in the NH. There was no clear association between use of rehabilitation and subsequent care trajectory.

Conclusions:
Care trajectories were explained partly by veteran health and functional status. However, we need a better understanding of system factors shaping care trajectories, particularly access to and use of rehabilitation services.
Abstract W P302: Assessment of a New Method of Warfarin Management vs the New Oral Anticoagulants and Conventional Warfarin Management in Atrial Fibrillation
Authors: Bussey Henry I , Nutescu Edith
Published: July 2021

PURPOSE:
To assess the impact of International Normalized Ratio (INR) self testing and online remote monitoring and management (STORM2) on clinical events and costs vs. traditional warfarin management and the new oral anticoagulants (NOACs) in atrial fibrillation (AF).

METHODS:
Seven STORM2 trials had a weighted mean INR time in the target range (TTR) of 77.2%. Thromboembolism (TE) and major bleeding (MB) rates at 30%, 45%, 55%, 65%, and 75% TTR were calculated using linear regression equations from a systematic review of 38 AF studies. MB = 10.104 - 0.120x[TTR], (p = 0.004) and TE = 8.313 - 0.098x[TTR], (p = 0.03). MB and TE rates were sub-divided based on the distribution in the NOAC trials. TTR-based mortality was calculated based on a 6%/yr rate multiplied by the adjusted relative risks from a data base analysis of approximately 38,000 AF patients. Projected event rates at 75% TTR, expressed as number per 1,000 patient-years, were compared to event rates at lower TTR ranges and to rates reported in the NOAC trials. Differences in major event rates were used to calculate cost avoidance.

RESULTS:
Projected event rates with STORM2 (TTR of 75%) when compared to “conventional ” TTR of 55% to 65% were 64% to 71% lower for MB, 47% to 64% lower for TE, and 47% to 57% lower for mortality. Compared to the NOAC study results, the projected rates were 48% to 70% lower for MB, 41% to 66% lower for TE, and 40% to 53% lower for mortality. Projected cost avoidance was $10.4 million vs. a TTR of < 30%, $2.2 million vs. a TTR of 65%; and from $1.4 to $3.1 million vs the NOACs. Costs of “other” MB and TE , drug costs, and monitoring costs were not included in the estimates.

CONCLUSIONS:
STORM2 management of warfarin is projected to produce a 50% or greater reduction in major event rates with a cost avoidance of $1.4 to $10.4 million per 1,000 patients per year.

CLINICAL IMPLICATIONS:
STORM2 management may transform the safety and efficacy of anticoagulation for the millions of people with AF while substantially reducing costs. These findings warrant randomized, prospective trials in AF and other indications for anticoagulation.
Abstract W P307:
Novel Application of Reversible Parental Anti-platelets in Patients with Aneurysmal Subarachnoid Hemorrhage
Authors: Mehta Siddhart , Hussain Mohammed , Brar Jaskiran , Korya Daniel , Chahal Harina , Ahmad Javaad , Karim Erfan , Moussavi Mohammad , Kirmani Jawad
Published: July 2021

Background and Objective:
The International Subarachnoid Aneurysm Trial (ISAT) showed a greater likelihood of survival free 1 year disability in patients undergoing endovascular coiling who were started on antiplatelet agents after SAH compared to ones undergoing neurosurgical clipping. However, data on safety of acute parental antiplatelet agents after aneurysmal coiling is lacking. We report on the safety of IV Eptifibatide (rapidly reversible Glyprotein IIbIIIa inhibitor) on patients presenting with acute subarachnoid hemorrhage undergoing endovascular coiling for aneurysmal embolization.

Methods:
All the patients from 2009-13 who presented to our university affiliated comprehensive stroke center with aneurysmal subarachnoid hemorrhage and underwent endovascular coiling were included for the study. Patients that received IV Eptifibatide for various reasons including acute need for stent assist coiling after securing the ruptured aneurysm with endovascular coiling were reviewed. Eptifibatide was administered intra-arterially as a 135-μg/kg single-dose bolus, and then continued on intravenous infusion of 0.5-μg/kg/min post-procedurally. Charts were reviewed for all patients to assess for medical/procedural complications including symptomatic and asymptomatic intra- and extra-cranial hemorrhages, groin hematomas, epistaxis and gross hematuria.

Results:
Of the total of 93 patients treated with coil embolization during this period, 5 patients (mean age 56 years, 20% male [n=1]) received acute intra-procedural Eptifibatide followed by IV infusion for a mean duration of 77 hours (range 20-130 hours). Various reasons for use of Eptifibatide included: stent assist coiling [n=2], multiple stents for flow diversion [n=1], partial coil prolapse [n=1] and vascular lumen flow compromise [n=1]. None of the patients demonstrated symptomatic/asymptomatic hemorrhage, groin hematoma, epistaxis or hematuria.

Conclusion:
Our results may highlight safety of administering IV Eptifibatide to prevent thrombotic complications after endovascular coil embolization in select patients with aneurysmal subarachnoid hemorrhage. Multicenter prospective trials are warranted to corroborate our findings.
Abstract W P317: Early CSF Volume Changes Predict Malignant Edema in Large Hemispheric Infarction
Authors: Dhar Rajat , Yuan Kristy , Kulik Tobias , Chen Yasheng , Heitsch Laura E , Khoury Naim , Guilliams Kristin , Vo Katie , An Hongyu , Ford Andria , Lee Jin-Moo
Published: July 2021

Background:
Early clinical and radiographic measures (such as NIHSS or early CT hypodensity) incompletely predict which patients with hemispheric stroke will develop malignant cerebral edema. We evaluated whether quantitative changes in volume of CSF compartments on early follow-up (FU) CT predict peak radiographic edema and clinical worsening.

Methods:
We retrospectively identified patients with hemispheric infarcts, NIHSS≥8, baseline CT within 6 hours of stroke onset and FU CT within 48 hours (i.e. prior to development of maximal edema). Volumes of CSF in ipsilateral (IL) and contralateral (CL) sulci and lateral ventricles were manually outlined on both scans, as was infarct volume on FU CT. Midline shift (MLS) was measured on later CT at time of peak edema (if available). Reduction in CSF compartments from baseline and symmetry (IL:CL ratios) were correlated to peak MLS and edema-related clinical deterioration (need for hemicraniectomy, osmotic therapy, or GCS decline, with MLS>5mm).

Results:
Ten patients were analyzed (median NIHSS 13, FU CT at median of 30 hours, IQR 15-37). Sulcal asymmetry (ratio of IL:CL volume) on FU CT was greater in the 4 subjects who deteriorated from malignant edema (median 0.26 vs. 0.79, see Figure), as was % reduction in IL sulcal volume from baseline (76% vs. 35%, p=0.06), while volume of early infarct was not. Hemispheric CSF asymmetry and % reduction in IL ventricular volume at early FU CT were strongly correlated with peak MLS (r=-0.95 and -0.96, both p=0.01). Linear regression found that both early infarct volume and % reduction in IL ventricle volume were strongly associated with MLS, adjusting for baseline CSF volume (Betas 0.55 and -0.48, both p=0.001).

Conclusions:
In this preliminary study, early CSF asymmetry and reduction in IL CSF volumes appear to predict development of MLS and malignant edema. Further validation is needed to test whether CSF volumetrics have utility in selection of patients for early aggressive interventions.
Abstract W P346: Sustainable Reduction in IV TPA Door to Needle Time Using Key Elements from Target Stroke Tool Kit
Authors: Selleck Lorie F , Feeser Venkata R , Stalnaker Gilbert R , Stevens Stacie , Wacksman Leah , Felton Warren L
Published: July 2021

Current literature clearly demonstrates decreased in-hospital mortality and increased functional outcomes with every 15 minute reduction in door-to-needle (DTN) time for IV-TPA treatment. At VCU Health System, 70% of eligible acute ischemic stroke (AIS) patients received IV-TPA treatment within 60 minutes of hospital arrival, with a median DTN time of 56 minutes for the time period between May 2012 to April 2013. The goal was to further increase percentage of eligible AIS patients receiving IV-TPA within 60 minutes of hospital arrival and decrease DTN time for IV-TPA treatment. A systematic approach was used to retrospectively analyze IV-TPA charts, identify rate limiting factors in administration of IV-TPA and implement clinical process changes. As a result of implementing an organized team approach, pre-hospital stroke alerts, immediate aggressive BP management, pre-mixing IV-TPA and prompt feedback, the number of eligible AIS patients that received IV-TPA within 60 minutes increased 43% from 70% to 100%. The median DTN time decreased 36% from 56 minutes to 36 minutes for the time period between May 2013 to May 2014.
Abstract W P353: Stroke Beat the Clock: A Lesson in Staff Engagement for Quality Stroke Care
Authors: McDowell Judian L
Published: July 2021

Background and Purpose:
The introduction and continued growth in electronic medical record use introduced overall challenges in filtering critical information on stroke and TIA patients, and an opportunity for improvement in chart navigation in the care of stroke patients. The purpose for the game was to improve the ease of navigating the patient’s course of treatment from arrival through discharge in a timely and efficient manner.

Methods:
The game was developed to familiarize the stroke unit staff nurses with pertinent information in the electronic medical record. The navigational guide was distributed to the staff for study or review prior to the onset of the game. Each day tracers were completed using designated charts for speed, accuracy and care plan development. Prizes were given for participation, champions posted daily and the overall winners were recognized by the department as well as a hospital board member, a local stroke champion.

Results:
Every participating nurse improved in both time and accuracy during the eight week period. There was an increased participation of this new process as it afforded the staff the ability to independently summarize a patient’s course of treatment in a shortened period of time. Subsequently, there were requests for similar tools for additional disease processes. Concurrent chart reviews showed better documentation in plan of care development, increased productivity, and improved connection with patient and family members.

Conclusions:
Stroke Beat the Clock proved to be an effective tool in teaching the nurses how to navigate the electronic medical record for pertinent information from patient arrival to discharge accurately. Improvements in speed with consistency provided the nurses a better understanding of patient care as they coordinate with the multidisciplinary team involved in stroke care and recovery.
Abstract W P356: Neuroscience ICU Advanced Practice Provider Competency Model
Authors: Hawkins Angela , Martin Coleman , Olds Karin , Kelsey Jessica , Summers Debbie
Published: July 2021

Background:
A large community based stroke program began utilizing advanced practice providers (APPs) 24/7 in the 18-bed Neuroscience ICU. The nurses needed 24/7 in-house support in managing these complex patients. Literature shows that APPs impact the length of stay and health care cost. This practice change led to an evaluation of the process of educating and ensuring competency to the APPs.

Purpose:
The goal was to ensure competency of APPs demonstrated by complete understanding of complex disease management and ongoing skills to manage critical neuro patients.

Methods:
Core Competency models were designed and used as a framework to aid in critical care specialization. Advanced classes, applicable clinical rotations, and procedure based skills lab were utilized to train the APPs. Initial measures to evaluate efficacy of the model included 14-item knowledge tests administered before and after a critical care symposium. Two versions of the test were administered using a crossover design, and changes in test scores were examined using analysis of variance. Additional competency measures included procedure and skill check-off competencies, neuro-monitoring utilization, provider sign-offs and one-on-one education by system educators.

Results:
APPs scored significantly higher on the post-test than the pre-test (mean difference = 19.71%, CI:14.3%-25.2%; p-value <0.0001), suggesting the symposium advanced their neuroscience knowledge. There was no difference in scores between the two versions of the test (p=0.98). Strict adherence to integration of current evidence based practices combined with an in-depth orientation is critical to ensuring clinical competence. Program focus includes facilitating ongoing education in a variety of neuroscience topics via lecture and clinical experiences to advance knowledge to the highest level within their Scope of Practice.

Conclusions:
Utilizing a combination of specially trained critical care physicians, 24/7 accessible neurologists, neurosurgeons and neuro interventionalists on the training of the APPs for this complex patient population is the key to the success of the neurocritical care APP competency model.
Abstract W P369: International Variability in Stroke Preventive Care
Authors: Sico Jason , Viscoli Catherine , Tayal Ashis , Spence David , Ford Gary , Kernan Walter
Published: July 2021

Introduction:
Research protocols for stroke prevention trials commonly specify goals for preventive care. We report variability in goal achievement between 3 countries participating in an on-going stroke secondary prevention trial.

Methods:
The Insulin Resistance Intervention after Stroke (IRIS) trial is testing pioglitazone, compared with placebo, for prevention of stroke and myocardial infarction among non-diabetic patients with a recent ischemic stroke/TIA. Preventive care is provided by personal physicians, although achievement of prevention goals is monitored and reported to participants and their physicians annually. Goals are from the American Heart Association guidelines: blood pressure (BP) <140/90 mmHg, statin therapy, and anti-platelet or anticoagulation depending on clinical indications. At baseline and year 1, we compared the proportions of participants meeting these goals in the largest enrolling countries: Canada (CA), United Kingdom (UK) and United States (US).

Results:
Participant characteristics were similar across countries, except the proportions of women and blacks were lower in the UK and CA than the US, and self-reported hypertension was more common in US than CA or UK. At baseline, achievement of BP goal was lower in the UK (53%) compared with the US (66%) and CA (75%) (Chi
2
p<0.0001). Statin therapy was used more commonly in the UK (91%) and CA (88%) compared with the US (80%) (Chi
2
p<0.0001). Differences persisted at year 1. At baseline, use of antithrombotic therapy was high (99%) in all countries. However, at year 1, use fell in US (96%) compared to CA and UK (p=0.02).

Conclusions:
Secondary preventive care for stroke varied among 3 countries for BP, statin therapy and antithrombotic therapies despite the IRIS protocol specifying uniform goals. These findings may be the result of disagreement among practitioners in the 3 countries for secondary prevention goals, variability in care delivery, or variability in research implementation. Understanding and resolving variability may lead to more efficient research and improved care for patients.
Abstract W P374: Population-Based Eligibility for a Stroke Prevention Trial Evaluating Novel Anticoagulants and Embolic Strokes of Uncertain Etiology: Similar Eligibility as for IV Rt-PA
Authors: Kleindorfer Dawn , Kasner Scott , Moomaw Charles J , Alwell Kathleen , Adeoye Opeolu , Woo Daniel , Flaherty Matthew L , Ferioli Simona , De Los Rios la Rosa Felipe , Eckerle Bryan , Mackey Jason , Martini Sharyl , Kissela Brett M
Published: July 2021

Introduction:
The RESPECT-ESUS trial is proposed to evaluate the best stroke prevention strategy for patients with strokes of uncertain etiology. This trial will compare a novel anticoagulant with antiplatelet agents to prevent recurrent stroke among cryptogenic stroke patients. We sought to evaluate the eligibility for this trial within a large, biracial population representative of the US.

Methods:
All adult ischemic stroke patients in 2010 among residents of the 5-county Greater Cincinnati/Northern Kentucky region (population 1.3 million) were ascertained from all local hospitals via ICD-9 codes 430-436. Inclusion and exclusion criteria supplied by the corporate sponsor as of 6/30/14 were applied to the ischemic stroke population. Per trial protocol, a complete workup was defined as brain and both intra- and extracranial vascular imaging, ECHO, telemetry, and EKG.

Results:
Of 1894 ischemic stroke patients without hemorrhagic transformation who survived the hospital stay (and not sent to hospice), 138 (7.4%) would have been eligible for RESPECT-ESUS. Inclusion and exclusion criteria are listed in the Table. If we were to assume that every stroke patient received a complete workup and no further etiologies were identified, the “hypothetical” eligibility could be as high as 18.7%.

Discussion:
We found that the potential eligibility for the RESPECT-ESUS trial to be low, and in fact is similar to population-based estimates of rt-PA eligibility (6%-8%). Extrapolation of eligibility across the US would be further limited by presentation to an enrolling center and consent refusal rates. Our estimates are based on information obtained during hospitalization, which may over- or underestimate eligibility within the 3-6 month post-event enrollment window. It is likely that centers that participate in the trial will have more complete diagnostic workups, which was a major exclusion in our population, especially the requirement for intracranial vascular imaging.
Abstract W P380: Asymptomatic Carotid Stenosis is Not a Walking Time Bomb
Authors: Yang Catherine , Bogiatzi Chrysi , Spence J David
Published: July 2021

Background & Objective:
Patients with asymptomatic carotid stenosis are often persuaded to have carotid stenting or endarterectomy on the grounds that they are “walking time bombs”, headed for disaster if the artery occludes. However, this approach ignores the protection afforded by the Circle of Willis. We therefore sought to determine the risk of stroke at the time of carotid occlusion, among patients being followed in a vascular prevention clinic.

Methods:
Complete data were available in 386 asymptomatic patients who had a new carotid occlusion while being followed with annual carotid ultrasound examinations in our clinic. Mean followup after the occlusion was 3.42 ± 4.07 years. Percent stenosis was ≥ 80% in 60% and ≥ 90% in 53% of cases. Prior asymptomatic occlusion on the contralateral side was present in 11 cases. Mean age was 66.5 ± 10.7 years; 71.8% were male, 21% diabetic, and 24.4% still smoking prior to the occlusion.

Results:
Only 1 patient (0.3%) had an ipsilateral stroke at the time of the new carotid occlusion. Percent stenosis did not predict a higher risk of any stroke/TIA/death during followup in Kaplan-Meier survival analysis ( Log rank p=0.60), nor did prior contralateral occlusion at the time of the index occlusion (p=1.0).

Conclusions:
The risk of ipsilateral stroke at the time of carotid occlusion is well below the risk of either carotid stenting or carotid endarterectomy. Preventing carotid occlusion is not a valid indication for intervention, and percent stenosis or contralateral occlusion do not identify patients who would benefit from intervention. Patients with ACS should be treated with intensive medical therapy unless they have characteristics such as microemboli on transcranial Doppler, or other features of vulnerable plaque that identify them as high-risk.
Abstract W P381: Type and Duration of Exercise in the SAMMPRIS Trial
Authors: Hannah Jessica , Turan Tanya N , Nizam Azhar , Lynn Michael J , Derdeyn Colin P , Fiorella David , Janis L S , Lane Bethany F , Montgomery Jean , Chimowitz Marc I ,   for the SAMMPRIS Investigators
Published: July 2021

Background:
Previous analyses of SAMMPRIS trial data showed that good risk factor control resulted in a significant reduction in the risk of vascular events (stroke, MI, and vascular death), with exercise as the most important predictor of good outcome. We sought to determine the type and duration of exercise that SAMMPRIS patients reported during the trial.

Methods:
In SAMMPRIS, 451 patients with recent TIA or stroke attributed to 70-99% intracranial stenosis were randomized to aggressive medical management (AMM) alone or percutaneous transluminal angioplasty and stenting plus AMM at 50 USA sites. AMM included a telephonic lifestyle modification program, INTERVENT, that was provided free of charge to all subjects during their participation in the study. We analyzed self-reported data collected by INTERVENT on the patients’ type and duration of exercise from baseline (n= 394) to 4 years (n=34). We calculated the mean duration for each exercise type at each time period and then compared the change in exercise duration from baseline using paired t-tests and Wilcoxon signed rank tests.

Results:
Data from subjects who completed the INTERVENT questionnaires were included in these analyses. As shown in the Figure, walking was the most common form of exercise at all time points, as measured by both the duration of exercise and the number of patients performing the exercise. The mean duration of walking and other aerobic activities increased significantly from baseline to all other time points.

Conclusions:
The type of self-reported exercise performed by SAMMPRIS patients included mostly walking or other aerobic activity and increased significantly during follow-up. Given that exercise was protective against recurrent vascular events, future secondary prevention stroke trials should encourage and monitor exercise participation and neurologists should encourage physical activity in clinical practice.
Abstract W P411: Effect of Normobaric Oxygen Therapy (NBO) on Oxidative Stress in Acute Ischemic Stroke
Authors: Singhal Aneesh B , SPOTRIAS Investigators Partners
Published: July 2021

BACKGROUND:
There is little human data concerning the effect of hyperoxia on markers of oxidative stress after acute ischemic stroke (AIS); rodent studies show conflicting results.

METHODS:
In this NIH-SPOTRIAS Trial of normobaric oxygen therapy (NBO) in AIS, tPA-ineligible subjects with imaging-confirmed AIS < 9 hours and NIHSS score 4 or higher were randomized to NBO or Medical Air, delivered for 8 hrs. Of n=85 enrolled, we analyzed n=53 (24 NBO, 29 Air) who had NIHSS, oxidative stress biomarkers, and serial CT/MRI obtained at 0 hrs (admission/pre-therapy), 4 hrs (during therapy) and 48 hrs (post-therapy).

RESULTS:
At baseline, the NBO arm showed a trend for higher DWI lesion volumes (39.8±42 vs 20.3±20 cc, p=0.06), but there was no significant difference between NBO and Air for mean age (73±15y vs 74±14y, p=0.9), median NIHSS (11.5 vs. 9.0, p=0.5), or perfusion-MRI "mean transit time" lesion volumes (100.9 vs 74.3 cc, p=0.6). Pre-therapy antioxidant capacity, assessed with the oxygen radical absorbance capacity assay, was significantly lower in the NBO arm (p=0.02), suggestive of greater baseline oxidative stress associated with larger infarct volumes. Pre-therapy levels of the matrix metalloproteinases MMP-2 and MMP-9, and F2isoProstane (F2isoP, a direct marker of non-enzymatic oxidation of membrane phospholipids) were similar between groups. There was no significant change from 0-4 hours or from 0-48 hours in NIHSS scores, DWI volumes, and levels of MMP-2, MMP-9, and F2isoP (Table). The NBO and Air groups showed no significant differences in rates of tissue reperfusion, or indirect MRI markers of free radical injury such as stroke-related mass effect, brain hemorrhage, or the hyperacute reperfusion injury marker (HARM) sign.

CONCLUSION:
In patients with acute ischemic stroke, there is no significant change in direct and indirect markers of oxidative stress with hyperoxia therapy.
Abstract W P87: Characteristics of T-cells Infiltrating Ruptured Intracranial Aneurysm
Authors: Krzyzewski Roger M , Stachura Magdalena K , Krupa Mariusz , Morga Rafal , Sagan Agnieszka , Mikolajczyk Tomasz , Moskala Marek , Guzik Tomasz J
Published: July 2021

Introduction:
Recently the role of adaptive immunity has been implied by microarray studies. But the results are contradictory. T-cell infiltration is a frequent histological finding in ruptured IA, T-cell phenotype, characteristic and true quantitation remains unknown. We preformed a prospective study to determine the subpopulation and expression of activation markers of T-cells infiltrating ruptured IA in relation to peripheral blood.

Hypothesis:
IA have different subsets and activation levels of T-cells than peripheral blood.

Methods:
We collected the tissue of ruptured IA of 8 patients operated on within 24 hours after subarachnoid hemorrhage symptoms onset. IA tissue was digested, stained with fluorescently labeled monoclonal antibodies and submitted to flow cytometry. In addition we collected and analyzed venous blood from 6 age, sex and risk factor-matched controls.

Results:
CD4+ cells are less prevalent in IA tissue than in peripheral blood (42.14±17.28 vs. 65.88±5.32%; p=0.011), while there was no difference in CD8+ T-cells infiltrating IA (30.28±9.07 vs. 27.78±5.45%; p=0.585), and double negative (CD4-CD8-CD3+) T-cells were more prevalent in wall of IA than in circulation, (15.68±11.94 vs. 2.81±1.32%; p=0.026). Importantly, CD4+ infiltrating IA wall showed higher expression of HLA-DR (25.9±6.42 vs. 9.19± 3.58%; p<0.001) higher expression of CD 69 (26.8±19.66 vs. 2.73±0.93%; p=0.014). Similarly, there significantly more CD8+ cells showed HLA-DR+ in the IA than in blood. (45.96±15.57 vs. 22.47±11.46%; p=0.018) and CD69 (30.32±22.73 vs. 5.03±1.55%; p=0.022). Double negative cells in IA also had higher expression of HLA-DR (46.56±21.40 vs. 22.58±5.1%; p=0.025), CD69 (31.05±16.79 vs. 7.83±2.05%; p=0.016).

Conclusion:
The tissue of ruptured IA is highly infiltrated by T-cells which show high expression of activation markers such as CD69 or HLA-DR. The importance of these cells to immunopathogenesis of intracranial aneurysm rupture should be further characterized.
Abstract W P98: Monocyte Chemotactic Protein-3 Elevated in Stoke and Aging
Authors: Townshend Courtney A , Koellhoffer Edward C , Grenier Jeremy , Chauhan Anjali , DiMauro Sharon , Venna Venugopal , McCullough Louise D
Published: July 2021

Background:
It is now recognized that stroke is a systemic stressor that triggers profound changes throughout the body, leading to alterations in the immune system and response. In the CNS, cell death from ischemic stroke activates glial cells, leading to trafficking of leukocytes into the brain and subsequent inflammation. Chemokines play an active role in modulating this recruitment process. Monocyte chemotactic protein-3 (MCP-3), also known as CCL7, is a chemokine that attracts a broad spectrum of immune cells. Although secreted at lower levels than the better-understood monocyte chemotactic protein-1, MCP-3 is released after injury and regulates migration of leukocytes, thus facilitating inflammation. As neuroinflammation is a well-documented complication after ischemic stroke, we hypothesized that MCP-3 levels would be elevated after stroke. In light of the fact that age is the principle risk factor for stroke, and that a chronic pro-inflammatory milieu is associated with aging, we also hypothesized that MCP-3 would increase with age.

Methods:
Young (10 weeks) and aged (18 months) male C57B16 mice were subjected to transient (60 minute) middle cerebral artery occlusion (MCAO) or a sham surgery. MCP-3 protein levels in brain tissue and serum samples from these stroked mice, as well as from cohorts of young and aged naïve mice, were analyzed with an ELISA.

Results:
The comparisons of naïve aged (n=4, mean=0.042±0.005 pg/μg) to naïve young (n=4, mean=0.017±0.009 pg/μg) mice showed a significant increase (p<.01) in MCP-3 in aged brain tissue. Additionally, when comparing aged MCAO to young MCAO (n=3, mean=0.01±0.007 pg/μg), MCP-3 was significantly elevated (p<.01) in the aged group. In comparing aged MCAO (n=6, mean=0.31±0.11 pg/ug ) to aged sham (n=6, mean=0.03±0.006 pg/μg), MCP-3 was significantly elevated (p<.05). No significant differences in MCP-3 levels in serum or between young stroke and young sham brain were seen.

Conclusions:
We demonstrated that levels of MCP-3 are increased post-stroke in aged mice, but not in young mice. Given what is known about the role of MCP-3 in immune cell trafficking, our data imply that MCP-3 plays a role in inflammation post-stroke, and that it also primes the aged brain for a greater inflammatory response post-stroke.
Abstract 10: Smooth Muscle Peroxisome Proliferator-Activated Receptor γ Plays a Critical Role in Formation and Rupture of Cerebral Aneurysms in Mice in vivo
Authors: Starke Robert M , Gu He , Wilson Katina , Chu Yi , Chalouhi Nohra , Heistad, Donald , Faraci Frank , Sigmund Curt , Hasan David
Published: July 2021

Background and Purpose:
Vascular inflammation plays a critical role in the pathogenesis of cerebral aneurysms. Peroxisome proliferator-activated receptor γ (PPARγ) protects against vascular inflammation and atherosclerosis, whereas dominant-negative mutations in PPARγ promote atherosclerosis and vascular dysfunction. In this study, the role of PPARγ in aneurysm formation and rupture was tested.

Methods:
Aneurysms were induced with a combination of systemic infusion of angiotensin-II and local injection of elastase in (1) mice that received the PPARγ antagonist GW9662 or the PPARγ agonist pioglitazone, (2) mice carrying dominant-negative PPARγ mutations in endothelial or smooth muscle cells, and (3) mice that received the Cullin inhibitor MLN4924. Incidence of aneurysm formation, rupture, and mortality was quantified. Cerebral arteries were analyzed for expression of Cullin3, Kelch-like ECH-associated protein 1, nuclear factor (erythroid-derived 2)-like 2, NAD(P)H dehydrogenase (quinone)1 (NQO1), and inflammatory marker mRNAs.

Results:
Neither pioglitazone nor GW9662 altered the incidence of aneurysm formation. GW9662 significantly increased the incidence of aneurysm rupture, whereas pioglitazone tended to decrease the incidence of rupture. Dominant-negative endothelial-specific PPARγ did not alter the incidence of aneurysm formation or rupture. In contrast, dominant-negative smooth muscle-specific PPARγ resulted in an increase in aneurysm formation (P<0.05) and rupture (P=0.05). Dominant-negative smooth muscle-specific PPARγ, but not dominant-negative endothelial-specific PPARγ, resulted in significant decreases in expression of genes encoding Cullin3, Kelch-like ECH-associated protein 1, and nuclear factor (erythroid-derived 2)-like 2, along with significant increases in tumor necrosis factor-α, monocyte chemoattractant protein-1, chemokine (C-X-C motif) ligand 1, CD68, matrix metalloproteinase-3, -9, and -13. MLN4924 did not alter incidence of aneurysm formation, but increased the incidence of rupture (P<0.05).

Conclusions:
Endogenous PPARγ, specifically smooth muscle PPARγ, plays an important role in protecting from formation and rupture of experimental cerebral aneurysms in mice.
Abstract 102: Carotid Endarterectomy versus Stenting in Patients on Chronic Hemodialysis
Authors: Arhuidese Isibor , Obeid Tammam , Nejim Besma , Yin Kanhua , Wang Sophie , Malas Mahmoud B
Published: July 2021

Introduction:
There has been an increase in the number of hemodialysis (HD) patients seeking treatment for carotid artery stenosis in recent times. These patients suffer from a unique course of cardiac and vascular disease and are often considered high risk for surgery. In this study, we compare long-term outcomes after carotid endarterectomy (CEA) versus angioplasty and stenting (CAS) in a large contemporary cohort of HD patients.

Methods:
We studied all HD patients who underwent CEA and CAS in the United States Renal Disease System (USRDS) database between January 2006 and December 2011. Patient data were linked to the Medicare database to capture long-term outcomes. Univariable, multivariable cox regression, and propensity score matched analyses were employed to compare perioperative (stroke, death, MI) and long-term (stroke and death) outcomes following CAS vs. CEA.

Results:
There were 6183 (CEA: 5121; CAS: 1062) carotid revascularizations performed in this cohort with a mean age of 67 (S.D 10.1) years. The majority of patients were male (60%), white (76%) and asymptomatic (CEA: 83%; CAS: 83%). Mean follow-up was of 1.6±1.3 years. Thirty day stroke (3.2 vs 5.5%) and death (4.6 vs 5.5%) were significantly lower after CEA. However, 30-day MI was similar between groups (3.2 vs 3.5%). Propensity score matched analysis showed a significantly higher risk of perioperative stroke after CAS compared to CEA (Table 1). Symptomatic status was a significant predictor of perioperative stroke (OR: 1.92; 95%CI: 1.33-2.77; P<0.001). Stroke-free survival for CEA vs CAS was 92% vs 90% at 1 year, 87% vs 85% at 2 years, and 81% vs 76% at 4 years.

Conclusions:
This is the first study to compare long-term outcomes after CEA and CAS in a large cohort of HD patients. CAS is associated with a significantly higher risk of perioperative stroke compared to CEA. Long term stroke free survival is similar between groups, and differences appear to be largely driven by perioperative stroke rates.
Abstract 115: Improving Door-to-Needle Times in Acute Ischemic Stroke: Interim Findings From Target: Stroke Phase II
Authors: Fonarow Gregg C , Cox Margueritte , Smith Eric E , Saver Jeffrey L , Reeves Mathew J , Bhatt Deepak L , Suter Robert , Schulte Philip J , Xian Ying , Hernandez Adrian F , Peterson Eric D , Schwamm Lee H
Published: July 2021

Background:
The benefits of intravenous tPA in acute ischemic stroke are time-dependent with guidelines recommending a door-to-needle (DTN) time of ≤60 minutes. The implementation of Target: Stroke Phase I in 2010 was associated with an increase in the proportion of patients with DTN times ≤60 minutes in the US from 28.9% in 2009 to 51.0% in 2013. This study aims to assess whether these improvements in DTN times could be maintained or further improved since the launch of Target: Stroke Phase II in Q2 2014.

Methods:
Target: Stroke Phase II identified and disseminated additional best practice strategies, provided updated clinical decision support tools, and set new hospital recognition goals. Rates of DTN times ≤60 minutes were compared during final 4 quarters of Phase I (Q4 2012-Q3 2013) vs. Phase II (Q2 2014-Q1 2015) and overall by linear weighted regression.

Results:
There were 99,176 intravenous tPA treated patients from 1228 GWTG-Stroke hospitals. Patient characteristics were similar during Phase I and II. Median DTN time significantly declined from the last 4 quarters of Phase I to the first 4 quarters of Phase II: 61 minutes (IQR 47-81) to 57 minutes (IQR 43-74) (P<0.0001). The % of patients with DTN times ≤60 minutes increased from last 4 quarters of Phase I to Phase II: 49.7% to 58.5%, absolute difference +8.8%, (P<0.0001). The % of patients with DTN times ≤45 minutes also increased from Phase I to Phase II: 22.0% to 29.2%, absolute difference +7.2%, (P<0.0001). The estimated annual rate of increase in patients with DTN times ≤60 minutes was 0.6% per year pre-Target Stroke, 5.6% per year during Phase I, and 8.6% in the first year of Phase II (P<0.0001) (Figure).

Conclusions:
The timeliness of tPA administration is continuing to improve in GWTG-Stroke hospitals participating in Target: Stroke Phase II. Nevertheless, ongoing quality improvement efforts will be required to meet the goals of ≥75% of patients with DTN times ≤60 minutes and ≥50% of patients with DTN times ≤ 45 minutes.
Abstract 117: A Province-wide Triaging System Improves Mortality After Transient Ischemic Attacks: The Alberta Stroke Prevention in TIAs and Mild Strokes (ASPIRE) Interventions
Authors: Yu Amy Ying Xin , Jeerakathil Thomas , Choi Philip M , Fang Shoufan , Shuaib Ashfaq , Majumdar Sumit R , Demchuk Andrew M , Butcher Kenneth S , Watson Tim J , Dean Naeem , Gordon Deb , Edmond Cathy , Coutts Shelagh B ,   ASPIRE investigators
Published: July 2021

Introduction:
Previous work suggests that early evaluation and treatment may reduce the stroke risk after TIA by up to 80%. These models of care are resource intensive involving same day access to stroke prevention services, often in urban areas. This is not feasible in many settings, especially where large distances and rural populations are concerned.

Hypothesis:
We hypothesize that implementation of a province-wide, systematic, multifaceted intervention would lower the recurrent stroke rate in Alberta.

Methods:
This was a prospective quasi-experimental health services research in the province of Alberta involving a population of 4 million living in an area larger than France (660,000 km2). The ASPIRE interventions, implemented over 15 months, involved education to the public and healthcare providers, creation of a triaging algorithm based on clinical symptoms and onset time, and a 24-7 available TIA Hotline for rapid access to stroke expertise. The primary outcome was the 90-day stroke rate tested with an interrupted time-series regression analysis. Stroke outcomes were adjudicated by two stroke neurologists independently with discrepancies resolved by panel. Secondary outcomes were the composite of stroke, myocardial infarction, death, and the individual components from administrative data tested with age-sex adjusted logistic regression analysis.

Results:
We included 15709 TIA events in 13671 patients. Age-sex adjusted rate (and %) of stroke recurrence was 1.81 per 100,000 (1.85%) pre-implementation and 1.79 (1.65%) post. The primary outcome was neutral (autoregression coefficient 0.13, p-value 0.70). The 90-day mortality was significantly lower post-implementation (OR 0.75, 95%CI 0.60-0.94). There was a trend in decreased composite endpoint of stroke, myocardial infarction, and death (OR 0.88, 95%CI 0.77-1.01).

Conclusions:
In a population with low stroke recurrence rates, the successful province-wide implementation of the ASPIRE interventions was associated with decreased mortality, but did not significantly change stroke recurrence. Further studies on improving the identification of high-risk patients is necessary.
Abstract 12: Buenos Aires Experience With Flow Diverter in our First 1000 Patients Safety, Efficacy and Long Term Follow-up
Authors: Lundquist Javier , Ferrario Angel , Ceratto Rosana , Scrivano Esteban , Chudyk Jorge , Lylyk Pedro
Published: July 2021

Background:
Hemodynamic flow is one of the major factors in the progression and rupture of intracranial aneurysms (IA). Flow diverter devices (FD) reduce blood flow in the aneurysm sac, allow gradual stagnation, thrombosis and neointimal remodeling while maintain outflow in the side branches and perforators.

Objectives:
We present our experience and long-term follow-up on endovascular reconstruction of complexes IA using flow diverter device. Particularly we analyze our experience with (Pipeline endovascular device) PED.

Methods:
Since March 2006 to July 2015, 1000 patients (pt) with IA were treated with FD or FD/coils. Of this group 633 pt were with PED, 113 Surpass (SNEG), 111 P64, 78 Cardiatis, 40 WEB and others 25. Angiographic follow-up was performed at 3, 6, 12 months and yearly until 8 y Fup. An inclusion criteria was unfavorable anatomy for coil, dome to neck ratio ≥ 2, Neck ≥ 4 mm and recurrence following previous treatment.

Results:
We treated 633 Pt with 704 IA with 932 PED. (77 % female); mean age 55 y (range 7-88). History of SAH was present in 18,5%; 81,5% were unruptured IA; mass effect in 125 pt; incidental IA 96 pts; headache 77 pts, others 23 pts. Large/giant IA were present in 51,2%, and wide neck (>4mm) 65%. The technical success was 98,4%. Occlusion rate at 1yr was 90 % and 8 yr 100 %, without recurrences. Peri-procedural (30 days) morbi-mortality rate was 5.9%: 2.7% had definitive neurologic defects; death rate was 3.2%.

Conclusion:
Endovascular treatment of complex IA with FD is a safe, effective and stable procedure, with an acceptable morbi-mortality rate.

Abbreviations:
AICA, anterior inferior cerebellar artery • BA, basilar artery • DSA, digital subtraction angiography • IA, intracranial aneurysm • ICA, internal carotid artery • MRA, MR angiography • PcomA, posterior communicating artery • PED, Pipeline • SNEG, Surpass •Embolization Device • SAH, subarachnoid hemorrhage • SCA, superior cerebellar artery