bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP307: Patients’ and Surrogates’ Experiences and Views of Consent in Acute Stroke Trials
Authors: Dickert Neal W , Frankel Michael , Goldkind Sara F , Mitchell Andrea R , Nogueira Raul G , Pentz Rebecca D , Silbergleit Robert , Speight Candace D , Weinfurt Kevin P
Published: October 2018

Introduction:
Informed consent for clinical trials in acute stroke is challenging. Enrollment decisions must be made quickly, in stressful situations, and typically by a surrogate. Moreover, trials are complex and unfamiliar. Understanding patients’ and surrogates’ experiences may help maximize respect for them while facilitating important studies.

Methods:
Telephone interviews were conducted with consented patients or surrogates for patients enrolled in acute stroke trials at 3 US sites between 2011 and 2016. Interviews assessed trial recall, experiences with consent, and preferences regarding consent. Questions were primarily closed-ended. Descriptive statistics were calculated, and bivariate analyses (Fisher’s exact) were conducted to examine predictors of consent preference.

Results:
Eighty-four respondents (69 surrogates, 15 patients) across 3 sites and 10 trials were interviewed and included in final analysis. Nine did not recall enrollment, and only about half (53%) recalled that the trial involved an intervention. Of 75 respondents who remembered enrolling, 65 (87%) remembered signing a consent form, 52 (80%) of whom said they read at least some of it. Most respondents reported being treated respectfully during consent. Only 12 respondents (16%) wished they had been enrolled in the trial without prospective consent. Individuals with low health literacy were less likely to prefer enrollment without consent (p<0.0007) but more likely to wish they had not had to sign a consent form (p<0.0001). Forty-six (61%) recalled someone talking with them about the study after enrollment.

Conclusions:
Patients and surrogates in stroke trials reported mostly positive consent experiences and generally appreciated having been asked for consent prior to enrollment. Recall of trial details, however, was low, and post-enrollment contact was recalled to be somewhat infrequent. Further work may help to identify the most context-appropriate strategies.
Abstract WP311: A Widely Accepted Metric (Telephone Assessment of the Modified Rankin Scale Score at 90 Days) May Not Accurately Reflect the Real-Life Outcome of Endovascular Stroke Treatment
Authors: Katramados Angelos M , Mitsias Panayiotis D , Hefzy Hebah , Malik Shaneela , Miller Daniel J , Marin Horia , Kole Maximilian , Romanchuk Kyle , Marmagkiolis Konstantinos , Tsitlakidou Despina , Scozzari Dawn , Cohen Lisa , Brady Megan , Varelas Panayiotis N , Mayer Stephan A
Published: October 2018

Introduction:
The modified Rankin Score (mRS) collected at approximately 90 days after stroke onset is a reliable and reproducible measure of stroke outcome. It was utilized in the randomized controlled trials that established the safety and efficacy of endovascular stroke treatment. It has been incorporated as a core metric for measuring quality of care in comprehensive stroke centers. We aimed to evaluate the value of the 90-day mRS considering that a certain percentage of patients may fail to respond to coordinator phone calls.

Methods:
We retrospectively analyzed patients who received endovascular stroke treatment in a comprehensive stroke center from January 2015 to March 2017, and who were prospectively enrolled in the Get With The Guidelines-Stroke Registry. We calculated the response rates to coordinator phone calls at approximately 90 days from stroke onset. Several calls were placed according to the established institutional policy. We compared the response rates of patients who had successful or unsuccessful recanalization, as reported by the endovascular specialist at the time of the procedure.

Results:
We identified 79 patients who received endovascular treatment, and who were contacted by the coordinators at approximately 90 days after stroke onset. 58 patients had successful recanalization (as defined by reported TICI grades IIb and III), whereas 21 patients had unsuccessful recanalization (as defined by reported TICI grades O, I, and IIa). 44/58 patients with successful recanalization responded to coordinator calls, compared to 11/21 patients with unsuccessful recanalization. The difference in proportions was statistically significant (p=0.045).

Conclusions:
Patients who have unsuccessful recanalization after endovascular stroke treatment are significantly less likely to respond to coordinator calls. Therefore, their mRS cannot be estimated, and the long-term outcome of the endovascular procedure cannot be assessed. Since these patients are more likely to have died, or be in a supervised facility (and therefore not accessible at their previous phone number), the telephone assessment of the mRS is likely not an accurate measure for the long-term therapeutic effect of endovascular stroke treatment.
Abstract WP315: Neutrophil-to-lymphocyte Ratio is a Useful Predictor of Aspiration Pneumonia in Patients With Acute Ischemic Stroke
Authors: Kim Tae Jung , Lee Chan-Hyuk , Mo Heejung , Jeong Han-Yeong , Ko Sang-Bae , Yoon Byung-Woo
Published: October 2018

Introduction:
Aspiration pneumonia is a common complication in the acute phase after ischemic stroke. Inflammation is associated with the initiation and progression of pneumonia after stroke. The neutrophil-to-lymphocyte ratio (NLR) has recently been described as a predictor of clinical outcomes in stroke. However, impact of NLR on the aspiration pneumonia in patients with ischemic stroke remains unclear.

Hypothesis:
Therefore, we investigated that NLR on admission was related to the risk of aspiration pneumonia after ischemic stroke.

Methods:
A consecutive 1,200 patients who were admitted within 7 days after ischemic stroke onset between March 2010 and March 2015 were included for analysis. The NLR was calculated as the ratio of neutrophils to lymphocytes. The patients were categorized into tertile groups based on the NLR. We evaluated aspiration pneumonia complication during hospitalization. We compared the clinical characteristics and NLR according to the presence of aspiration pneumonia.

Results:
Among the included patients (mean age, 67.7 years; men, 59.7%), 97 (8.1%) patients experienced aspiration pneumonia during hospitalization following ischemic stroke. The patients with aspiration pneumonia were older and more likely to have atrial fibrillation, and diabetes mellitus. In addition, patients with aspiration pneumonia tended to have lower body mass index and higher initial NIHSS. The proportion of the NLR tertile 3 were significantly higher in the aspiration pneumonia group (30.7% vs. 64.9%,
P
< 0.001). Moreover, higher NLR patients were more likely to be admitted to the intensive care unit (1.0% vs. 1.3% vs. 5.0%,
P
< 0.001), and were more likely to have sepsis (defined by quick Sepsis-related Organ Failure Assessment score of ≥ 2; 0.5% vs. 1.8% vs. 4.2%,
P
= 0.001) After adjustment for covariates, the highest NLR tertile groups had an exaggerated risk for aspiration pneumonia [Odds ratio (95% confidence interval); tertile 3, 2.39 (1.20 – 4.77),
P
= 0.014].

Conclusions:
This study demonstrated that higher NLR predicted aspiration pneumonia and severe infection following acute ischemic stroke. This suggests that NLR could be a useful and reliable prognostic biomarker for severe aspiration pneumonia after ischemic stroke.
Abstract WP317: Early and Late Vascular Events and Fatality amongst Transient Ischemic Attack Hospitalization
Authors: Patel Urvish K , Bhesania Siddharth , Lunagariya Abhishek , Lotlikar Priti P , Dhrangdhariya Virali S , Patel Kulin , Lavado Liseth , Mehta Parag , Jani Vishal , Qureshi Adnan I
Published: October 2018

Background:
Risk of acute ischemic stroke (AIS) or an acute coronary syndrome was 12 to 20% during the first 3 months after a transient ischemic attack (TIA) or minor stroke. We aimed to find out early vascular events (EVEs) and late vascular events (LVEs) [AIS, hemorrhagic stroke (HS), myocardial infarction (MI), angina, and atrial fibrillation (AFib)], outcomes, and predictors of fatality in TIA hospitalization.

Methods:
We performed a retrospective analysis of Nationwide Inpatient Sample (years 2007-2014) in adult hospitalizations for TIA to find out EVEs and with past medical history (PMH) of TIA to find out LVEs using ICD-9-CM codes. We performed analyses using Chi-square to compare the outcomes (Death, Risk of Death, Loss of Function, and poor Discharge Disposition) amongst EVEs and LVEs. Multivariate survey logistic regression was done to evaluate the outcomes and predictors of fatality.

Results:
From years 2007 to 2014, total 11,776,757 (TIA: 1,948,818; PMH TIA: 9,827,939) patients with TIA were hospitalized. LVEs were more common in TIA patients except for HS. LVEs were associated with the significantly higher mortality (2.8% vs 0.6%; aOR: 4.22; 95% CI: 3.97-4.48) and poor overall outcomes in compare to EVEs (Table). Independent predictors of fatality were AIS (aOR: 3.03; 95% CI: 2.75-3.34), HS (aOR: 3.74; 95%CI: 3.25-4.31), MI (aOR: 3.52; 95% CI: 3.30-3.75), and AFib (aOR: 1.32; 95% CI: 1.28-1.37). Other predictors with higher odds of fatality were age >65, Asian and Pacific Islander, male, weekend admissions, peripheral vascular disease, CHF, renal failure, coagulopathies, and alcohol abuse (Table).

Conclusion:
Following TIA, patients could be at risk of many vascular events and not an only stroke. We observed poor outcomes amongst patients of TIA with LVEs. Identification of such patients, long term risk stratification, and secondary prevention through regular follow-up play a very crucial role to identify patients at risk to prevent LVEs following TIA.
Abstract WP318: Reduced Infarct Growth With IV Heparin in Acute Ischemic Stroke
Authors: Rocha Eva , Ji Ruijun , Li Zixiao , Ay Hakan , Silva Gisele S , Sorensen A. Gregory , Wu Ona , Singhal Aneesh B
Published: October 2018

Background:
The role of IV heparin in acute ischemic stroke (AIS) is controversial. We investigated the effect of IV heparin on ischemic lesion growth.

Methods:
We analyzed data on 274 consecutive AIS patients with non-lacunar stroke prospectively enrolled in a study where diffusion/perfusion MRI (DWI-PWI) was completed <12 hrs after last seen well and a follow-up MRI/CT completed after day 4. We excluded patients treated with tPA, and those with MTT-DWI mismatch <20% of the DWI volume or absolute mismatch volume <10 mL. Lesion growth was assessed by (a)

Absolute Lesion Growth

, i.e. final infarct volume - admission DWI lesion volume, and (b)

Percentage mismatch lost (PML)

, i.e. (final infarct volume - admission DWI volume)/(mismatch volume)x100%. Image analysis was blinded to clinical data. Univariable and multivariable analysis were performed to determine the effects of IV heparin on infarct growth.

Results:
N=113 met inclusion/exclusion criteria; 52 received IV heparin shortly after admission. Results of the univariable analysis are shown in Table 1. Heparin use was associated with smaller PML (p<0.05); there was approximately 5-fold difference in PML between heparin users and non-users. Absolute lesion growth was significantly associated with admission glucose, blood pressure, NIHSS score, DWI volume and stroke etiological subtypes; and there was a trend for association with age and heparin use. Intravenous heparin use was an independent predictor of both PML and absolute lesion growth (Table 2), and was associated with better 3-month outcomes (modified Rankin scale score 0-2, 80% vs. 57%, p=0.04).

Conclusion:
These data suggest that IV heparin administration early after stroke may attenuate the progression of ischemic brain injury in non-thrombolyzed patients with significant ischemic penumbra.
Abstract WP32: Pathological Examination of Thrombus Components in Patients Undergoing Endovascular Thrombectomy
Authors: Doijiri Ryosuke , Kimura Naoto , Sakuma Tsutomu , Yaegashi Hiroshi , Takahashi Ken , Yamaguchi Eriko , Kamada Asami , Yokosawa Michiko , Obara Daiji , Takahashi Hiroaki , Sugawara Takayuki , Kikuchi Takahiko
Published: October 2018

Introduction:
Histopathological analysis of the thrombi, which was retrieved from stroke patients with large-vessel occlusion during mechanical thrombectomy, may provide information about underlying pathologies. It is likely that the size of the thrombi differ between stent retriever and aspiration catheter.

Objective:
This study aimed to evaluate the thrombus composition and its association with radiological findings, stroke subtypes, and reperfusion times.

Methods:
From June 2014 to August 2016, 51 patients were treated at our hospital by mechanical thrombectomy using stent retriever and/or aspiration catheter. The received thrombi were subjected to semi-quantitative analysis to quantify red blood cells, platelet, and/or fibrin in the overall area. We divided the patients into two groups according to the predominant composition of the thrombus: red thrombus group or white thrombus group. These two groups were compared with respect to imaging, clinical, and neurointerventional data.

Results:
Histopathological analysis of retrieved thrombus from 44 patients with acute stroke due to internal carotid artery, middle cerebral artery, or basilar artery occlusion was performed. There were no significant changes with respect to the time from onset to reperfusion, time from puncture to reperfusion, and type of atrial fibrillation (paroxysmal or persistent). Postoperative stenotic lesion was significantly higher in patients with white thrombi than in those with red thrombi (83% vs 19%, p = 0.001). Preoperative susceptibility vessel sign on magnetic resonance imaging correlated with the proportion of red thrombi than with that of white thrombi (59% vs 33%, p = 0.04). The maximum diameter of thrombi was significantly larger in the combination Penumbra aspiration catheter group compared with that in the non-combination group (9.2 ± 3.7 vs 5.3 ± 4.7mm, p < 0.001).

Conclusion:
Histological thrombus features vary significantly according to the underlying cause and may help to differentiate between large-artery atherosclerosis and cerebral embolism. Aspiration first pass technique could retrieve a large thrombus.
Abstract WP321: Strokes in Your Own Backyard: A Hospital Wide Quality Improvement Initiative to Create and Improve Inpatient Code Stroke Metrics Which Lead to Quicker Interventions
Authors: Sangha Navdeep S , Ajani Zahra , Dhanji Raeesa , McCartney David , Zhang Xu , Cai Chunyan , Castanon Marilen , Leido Joyce , Punsalang Lorina , Tu Grace , Savitz Sean
Published: October 2018

Introduction:
TARGET:STROKE (TS) has established metrics for hospitals to measure the timely administration of thrombolytics. However, these time metrics may not apply to patients who suffer a stroke while admitted to the hospital, since the initial time is the emergency department (ED) door time. The aim of this project was to create metrics and an algorithm applicable to an Inpatient Code Stroke (ICS), and assess a hospital wide education series to improve times to intervention.

Methods:
ICS metrics defined by TS were established with the Symptom Recognition Time (SRT) to equate to the ED door time, and assessed pre and post intervention. The intervention was a hospital wide education of stroke symptoms, as well the ICS process. A badge reference card with this information was given to nurses. Data were recorded for 6 months pre and post implementation. Outcomes included SRT to stroke team notification, CT scan initiation and interpretation, thrombolytic administration and groin puncture. Fisher’s Exact and Wilcoxon Rank Sum Tests were used for data analysis.

Results:
There were 86 ICS activations (34 pre and 51 post intervention). There was no difference in baseline demographics, and ICS activation based on unit type. Surgical patients were the most common to have an ICS activation (25.8%). There was a strong trend of SRT to stroke team notification being faster post intervention (median: 22 [0-435] mins pre vs. 12 [0-187] mins post, p=0.059). SRT to groin puncture was faster post intervention (median: 131 [0-286] mins pre vs. 67 [38-91] post, p=0.006). There were more patients who had SRT to thrombolytic ≤ 60 mins or SRT to groin puncture ≤ 90 mins post-intervention (4 [33.3%] pre vs. 10 [71.4%] post, p=0.036).

Conclusion:
This is the first study to demonstrate that implementation of an ICS algorithm and its accompanying education can increase the percentage of patients who receive thrombolytics and groin puncture for thrombectomy ≤ 60 mins and ≤ 90 mins from SRT, respectively.
Abstract WP322: Inhaled Nitric Oxide Augments Cerebral Blood Flow in Healthy Subjects
Authors: Favilla Christopher G , Forti Rodrigo M , Zamzam Ahmad , Detre John A , Mullen Michael T , Yodh Arjun G , Kasner Scott E , Busch David R , Baker Wesley B , Messe Steven R
Published: October 2018

Introduction:
Optimizing cerebral blood flow (CBF) is a cornerstone of clinical management for a number of neurologic disease states, most notably acute ischemic stroke. Transdermal nitric oxide donors are being investigated for acute stroke, though the effect of inhaled nitric oxide (iNO) on CBF remains largely unknown. Here we aim to quantify the cerebral hemodynamic response to iNO in healthy volunteers.

Methods:
Cerebral perfusion was measured during three doses of iNO (5ppm, 10ppm, and 20ppm) using the iNOMAX system (Mallinckrodt Pharmaceuticals) in 20 healthy volunteers. Continuous measurements of microvascular CBF were made with diffuse correlation spectroscopy (DCS), while middle cerebral artery mean flow velocity (MFV) was measured with transcranial Doppler. Cardiopulmonary status and nitric oxide toxicity (i.e. NO
2
) were continuously monitored for safety.

Results:
Overall, iNO was safe and well tolerated. All subjects completed the protocol in its entirety. All 3 doses of iNO resulted in a small but statistically significant increase in microvascular CBF as compared to baseline (figure). No significant changes in MFV were identified (figure). During administration of iNO, there was no detrimental effect on blood pressure, nor was there any significant accumulation of toxic metabolites.

Conclusions:
iNO was safe and produced a small but significant increase in microvascular CBF in healthy volunteers. Future studies are warranted to determine the optimal dose of iNO and to explore the effect in acute ischemic stroke patients.
Abstract WP325: Peri-operative Neurological Complications of Valve Surgery for Infective Endocarditis Patients With Stroke
Authors: Zhang Lucy Q , Cho Sung-Min , Rice Cory , Khoury Jean , Wisco Dolora , Uchino Ken
Published: October 2018

Introduction:
Surgical valve repair is often delayed for infective endocarditis (IE) patients with stroke. We compared neurological outcome of early and delayed valve surgery and identified pre-surgical imaging characteristics that were associated with perioperative neurological complications.

Methods:
We reviewed 228 patients with acute IE diagnosed by modified Duke’s Criteria who underwent cerebral angiogram (CA) between January 2010 - December 2016 at a single center. Patients without pre-surgical CT and MRI were excluded. Date of IE diagnosis was defined as date of antibiotic initiation. Early surgery was defined as valve replacement ≤14 days from date of IE diagnosis, delayed as >14 days. Peri-operative neurological complication is any new clinical or radiologic diagnosis of ischemic or hemorrhagic stroke, and seizure.

Results:
148 of 228 patients underwent valve surgery. 69 patients (46.6%) had early surgery at median 9 days after IE diagnosis, and 79 patients (53.4%) had delayed surgery at median 28 days. On pre-surgical imaging, acute to subacute ischemic stroke was seen in 81% of the early group (n=56) and 78% of the delayed group (n=62, p=0.69). However, 22.8% of patients (n=18) in the delayed group had evidence of subarachnoid hemorrhage (SAH) compared to 10.1 % of patients in the early group (n=7, p=0.04). Despite this finding, delayed group did not have higher rate of perioperative neurological complication than that of the early group (24.1% vs 13%, p=0.95). Overall, 15 surgical patients (10.1%) had perioperative neurological complications: 4 with acute ischemic stroke, 9 with ICH, 1 with both an infarct and ICH, and 3 with seizures. 33.3% of patients who had a perioperative neurological complication had evidence of SAH on pre-surgical imaging (n=6) compared to 14.6% of patients who did not have any neurological complications (n=19, p=0.012). In the group of patients with complications, SAH found prior to surgery were all cortical in the sulci, and 3 cases of SAH were associated with presence of infectious intracranial aneurysm found on pre-surgical CA.

Conclusion:
In IE patients with stroke, presence of sulcal SAH on pre-surgical imaging is associated with developing perioperative neurological complications irrespective of surgical timing.
Abstract WP328: Suppression of Tachycardia and Cost Effectiveness of Bisoprolol Transdermal Patch Addition to Intravenous Nicardipine in Antihypertensive Treatment for Acute Intracerebral Hemorrhage
Authors: Yamamoto Ryoo , Suzuki Satoshi , Sugawara Rieko , isito Jyunichi , Koizumi Hiroyuki , Momoo Takayuki , Tanaka Fumiaki
Published: October 2018

Introduction:
In patients with hypertensive intracerebral hemorrhage (ICH), intravenous (i.v.) Nicardipine is often used to lower the blood pressure. However, reflex tachycardia is a well-known side effect. Bisoprolol transdermal patch, a beta-blocker to be percutaneously absorbed, recently became commercially available in Japan. It can be used for patients with acute ICH with vomiting or dysphagia. The aim of this study is to evaluate suppressing effect of tachycardia and cost effectiveness of adding Bisoprolol transdermal patch to i.v. Nicardipine in patients with hypertensive ICH.

Methods:
We randomly assigned patients who were admitted to our department from January 2015 through April 2017 because of acute ICH to single antihypertensive treatment group (i.v. Nicardipine only) or combination treatment group (Bisoprolol transdermal patch and i.v. Nicardipine). The primary outcome was heart rate during 24 hours after admission. Key secondary outcomes were dose of Nicardipine (drug costs), neurological prognosis as defined by modified Rankin scale 0 to 2, and adverse drug reactions.

Results:
A total of 59 patients were randomized into two groups; 35 patients were assigned to single antihypertensive treatment group and 24 patients were assigned to combination treatment group. There were no significant differences between two groups in baseline characteristics on admission (age, body weight, hematoma volume, NIHSS, systolic blood pressure, heart rate). Mean heart rate during 24 hours after admission were significantly lower in combination treatment group (78.10±11.43 vs. 86.13±12.46, P=0.021). Hourly heart rate of combination treatment group was significantly lower in 5 to 24 hours later from start of treatment. Dose of Nicardipine was tended to be lower in combination treatment group (80.54±65.93 vs. 119.7±96.80mg, P=0.10), and costs of antihypertensive drug was tended to be lower in combination treatment group (5708±4569 vs. 8292±6708 yen, P=0.13). Neurological prognosis showed no difference (P=0.72), and bradycardia occurred in three patients of combination treatment group.

Conclusions:
Adding Bisoprolol transdermal patch to Nicardipine can decrease heart rate and may reduce drug costs in antihypertensive treatment for acute ICH.
Abstract WP33: Impact of Treatment Time on the Long-term Outcome of Stroke Patients Treated With Mechanical Thrombectomy
Authors: Al Kasab Sami , Reardon Christopher , Harvey Jillian , Almallouhi Eyad , Aysse Patricia , Holmstedt Christine A
Published: October 2018

Background:
Mechanical thrombectomy is the standard of care for patients presenting with acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Recent studies have shown that door to reperfusion time is longer during nighttime and weekends. In this study we examine the long term functional outcome of stroke patient treated with mechanical thrombectomy performed during work hours (on-hours) versus after hours (off-hours).

Methods:
Data on all patients receiving mechanical thrombectomy at a comprehensive stroke center between Dec/2014 and Dec/2016 was collected. Our primary outcome was the 90-day Modified Rankin Scale (mRS). Independent variables included receiving thrombectomy during on-hours (7am and 4pm) or off-hours 4pm-7am, weekends, and official holidays), admission NIH stroke scale, age, race, and sex. Multivariable logistic regression was used to examine the relationship between off-hours thrombectomy and mRS, controlling for patient baseline characteristics. Chi-square and t-tests were used to compare differences among categorical and continuous variables.

Results:
During the study period, 92 (41%) patients underwent thrombectomy during on-hours and 133 (59%) during off-hours. On average, the on-hours patients were older (P=0.02), and had a higher percentage of males (P=0.04) compared to the off-hours. Differences in median admission NIHSS, rate of tPA administration, location of occlusion, mean time from last known well to thrombectomy, revascularization rates, and hemorrhagic transformation rates were not statistically significant between the two groups. Median door to groin time was 53 minutes versus 78 minutes for the on-hours and off-hours groups respectively (P= < 0.00). Logistic regression showed that the odds of a favorable mRS ≤2 are 47% lower for off-hours patients compared to patients seen during on hours (OR 0.53, P=0.044, [95%CI 0.28-0.98]). Additional significant predictors included, age (OR 0.97 [CI.95-.99]) and admission NIHSS (OR 0.9 [CI.87-.94]).

Conclusion:
Our study shows that there is higher likelihood of good functional outcome following mechanical thrombectomy when performed during work hours. This could be due to a prolonged door to groin time.
Abstract WP330: Resource Utilization Among Patients Transferred for Intracerebral Hemorrhage
Authors: Zachrison Kori S , Aaronson Emily , Mahmood Sadiqa , Greenberg Steven M , Gurol M. Edip , Lee Myung J , Mort Elizabeth , Rosand Jonathan , Schwab Kristin M , Viswanathan Anand , Schwamm Lee H , Goldstein Joshua N
Published: October 2018

Background:
Patients with intracerebral hemorrhage (ICH) are frequently transferred between hospitals in anticipation of the need for higher level of care than locally available. We aimed to identify factors that are associated with increased resource utilization among patients with ICH transferred to a single academic hospital.

Methods:
We utilized data on patients with primary ICH at urban academic hospital between 01/01/2005-12/31/2015 from a prospectively collected registry of consecutive patients. Those with trauma, aneurysm, tumor, or other types of secondary ICH were excluded. Disease severity was calculated using the ICH score at time of presentation. The primary outcome (care that may not be available at the sending hospital) was operationally defined as use of either ICU admission or surgical intervention. We used logistic regression to examine predictors of ICU stay or surgical intervention, controlling for age, sex, race/ethnicity, insurance status, anticoagulation use, and past history of stroke or ICH.

Results:
During the study period, 2008 patients met inclusion criteria, 71% of whom presented as transfers. ICU stay or surgical intervention was required in 887 (44.2%). Patient requiring ICU stay or surgical intervention were younger (mean age 71 vs. 74 years, p<0.001), less often white (83.9% vs. 89.3%, p<0.001), had lower GCS (median 12 vs. 14, p<0.001), and more frequently had intraventricular hemorrhage (58.6% vs. 43.4%, p<0.001). Of the 334 with GCS of 15 and ICH score of 0, 86 had an ICU stay (25.7%), and 4 required surgery (1.1%). In multivariable regression analysis, the only significant predictors of ICU stay or surgical intervention were age>65 years (OR 0.38, 95% CI 0.21-0.69), GCS<15 (1.23, 95% CI 1.01-1.52) and ICH score>0 (OR 2.23, 95% CI 1.70-2.91).

Conclusion:
Among this cohort of patients with primary ICH, those with GCS of 15 and ICH score of 0 were less likely to require ICU stay or surgical intervention. These results should be validated in a larger sample but may be valuable for hospitals considering which ICH patients should be transferred to a tertiary care center.
Abstract WP332: Characteristics and Outcomes of Patients on Prior Antiplatelet Therapy in the Tranexamic Acid in Primary Intracerebral Haemorrhage-2 (TICH-2) Trial
Authors: Law Zhe Kang , Flaherty Katie , Appleton Jason P , Scutt Polly , Krishnan Kailash , Ali Azlinawati , Dineen Rob , Bath Philip M , Sprigg Nikola
Published: October 2018

Background:
Prior antiplatelet therapy (APT) may be associated with worse outcome in intracerebral haemorrhage (ICH). We explored the effects of APT on clinical outcomes in patients with ICH in the Tranexamic acid in primary IntraCerebral Haemorrhage-2 (TICH-2) trial.

Methods:
TICH-2 is an ongoing prospective randomised double-blind blinded-endpoint trial testing the safety and efficacy of tranexamic acid in patients with spontaneous ICH presenting within 8 hours of onset. Data from 2255 patients recruited up to July 2017 were analysed blinded to treatment allocation. Clinical outcomes were compared between patients with and without prior APT, with adjustment for age, National Institutes of Health Stroke Scale (NIHSS), premorbid modified Rankin Scale (mRS) and presence of intraventricular haemorrhage. Haematoma expansion was defined as a relative increase in haematoma volume of > 33% or an absolute increase of > 6 mL from baseline.

Results:
593 patients (26.3%) had prior APT and these were older (mean age 75.7 vs 66.3 years) and more likely to have ischaemic heart disease (24.8%, 147 vs 2.8%, 46) and prior stroke/transient ischaemic attack (35.8%, 212 vs 6.4%, 106) than those with no APT. The APT group had larger baseline haematoma volume (27.9 mL vs 20.8 mL, table) and were more likely to have intraventricular haemorrhage (40.3% vs 29.1%). The rate of haematoma expansion was not significantly greater in the APT group. At day 90, the APT group had a worse functional outcome, mRS acOR 1.36 (95% CI 1.10-1.66, p=0.004) and higher mortality rate, hazard ratio 2.26 (95% CI 1.88-2.72, p<0.001).

Discussion & Conclusion:
TICH-2 is the largest trial of a haemostatic agent in ICH to-date. Patients with prior APT had significantly greater baseline haematoma volume, worse functional outcome and higher mortality at day 90. Complete data will be presented in the conference. Therapies targeting enhancement of platelet function should be further researched.
Abstract WP335: Left Ventricular Hypertrophy and Anti-hypertensive Use in Intracerebral Hemorrhage
Authors: Lieber Adam , Nigoghossian Caroline D , Doyle Kevin , Pucci Josephine , Willey Josh , Lerario Michael P , Murthy Santosh , Merkler Alexander , Lappin Richard , Kamel Hooman , Park Soojin , Agarwal Sachin , Connolly E. Sander , Claassen Jan , Roh David
Published: October 2018

Intro:
Elevated SBP is common after ICH. Continuous infusions of IV antihypertensive agents are often utilized to quickly correct SBP requiring ICU level care. It is difficult to predict SBP response to these treatments and subsequent medication weaning strategies, as SBP elevation can be the result or etiology of ICH. Identifying patients with a history of uncontrolled hypertension may help tailor SBP treatment. Left ventricular hypertrophy (LVH) on echocardiogram (echo) is a tool to assess for uncontrolled hypertension.

Hypothesis:
ICH patients with LVH require longer times of continuous infusions of antihypertensive medications (labetalol/nicardipine) compared to those without LVH.

Methods:
Admission demographics, medical history, continuous infusions of anti-hypertensives, echo data, ICH characteristics and medical/surgical interventions were prospectively collected for primary-ICH patients between 2009-2015. Patients without admission echo were excluded. LVH presence was evaluated as a binary variable and intergroup differences were evaluated using Mann-Whitney
U
or Student’s
t-
test for continuous variables and χ2 or Fisher exact test for categorical variables. Association of LVH presence and total duration of labetalol/nicardipine (in hours) within 72 h of ICU admission was evaluated using linear regression analysis after adjusting for age, race, ICH score and surgical intervention.

Results:
370 primary-ICH patients with admission echo were identified. Of these patients, 252 (68%) patients had LVH. ICH patients with LVH were significantly younger (64 vs 69yo), had higher prevalence of pre-morbid hypertension (84 vs 64%), and higher ED and NICU admission SBP (189 vs 174mmHg; 158 vs 147mmHg). No intergroup differences in ICH score, surgical interventions or standing oral anti-hypertensive medication use was seen. Linear regression revealed ICH patients with LVH had longer times on continuous anti-hypertensive infusions compared to those without (20 vs 10h; β=0.11; p=0.04) after adjusting for aforementioned covariates.

Conclusions:
Our findings suggest that ICH patients with LVH on echo present with elevated SBP that is difficult to control. Early identification of this group may allow for earlier, tailored treatments.
Abstract WP336: Cerebral Small Vessel Disease Burden, Functional Outcome and Hematoma Expansion in Intracerebral Hemorrhage
Authors: Lioutas Vasileios-Arsenios , Wu Bo , Helenius Johanna , Modak Janhavi , Norton Casey , Selim Magdy H
Published: October 2018

Background:
Older age, larger hematoma volume, and intraventricular hemorrhage (IVH) are established predictors of poor prognosis after intracerebral hemorrhage (ICH). We hypothesized that higher cerebral small vessel disease (CSVD) burden substantially affects functional outcome and its detailed characterization in addition to already established predictors will enhance our prognostic accuracy.

Methods:
We studied consecutive patients with spontaneous supratentorial ICH, functionally independent at baseline (modified Rankin Scale (mRS) ≤2), with brain MRI within 1 month of ICH and known 3-month functional status. We collected clinical and imaging data and data on: Cerebral microbleeds (CMBs), enlarged perivascular spaces (EPVS) severity, white matter disease (WMD) (Fazekas scale), chronic lacunar and non-lacunar infarcts, cerebral atrophy. Functional endpoints were (a) 3-month functional independence (mRS ≤2) (b) independent ambulation at 3 months. Hematoma expansion was defined as relative increase of ≥ 33% or absolute increase of >6ml.

Results:
111 patients (70.7±13.9 years, 40% female) met our inclusion criteria. 43(38%) achieved functional independence,71(64%) independent ambulation. In univariate analyses, older age, hematoma volume, IVH, cerebral atrophy, severe WMD but not EPVS severity or chronic infarcts were associated with worse functional and ambulatory outcome. CMBs presence was associated with poor functional outcome but not ambulation status. In multivariable logistic regression, volume, IVH, CMBs (OR 3.95, CI: 1.4-12.1, p=0.009), brain atrophy (OR 3.99, CI: 1.1-16.2 p=0.03) but not age or WMD severity remained associated with functional independence (model p<0.0001, ROC=0.92). Hematoma volume and brain atrophy but not age, IVH or WMD severity were associated with independent ambulation. We found no association between CSVD markers and hematoma expansion.

Conclusion:
CMBs presence and cerebral atrophy conferred a 4-fold higher risk of functional dependence after ICH. The effect of hematoma size remained very robust but addition of CSVD markers and brain atrophy neutralized the previously observed effect of age. This observation merits further exploration and validation in a larger, prospective cohort.
Abstract WP345: Pre-Intracerebral Hemorrhage Antiplatelet and Anticoagulant Use and Differences in Hospital Course; A Population-Based Study
Authors: Kwon Soo Young , Van Sanford Carson , Murphy Ryan , Moomaw Charles J , Haverbusch Mary , Sekar Padmini , Flaherty Matthew L , Woo Daniel
Published: October 2018

Objective:
Patients on antiplatelet (AP) or anticoagulant (AC) agents cause more alarm when they develop intracerebral hemorrhage (ICH) compared with non-users. This analysis aimed to quantitatively evaluate the differences in the hospital course of ICH patients based on underlying AP and/or AC use, using a population-based cohort.

Methods:
Genetic and Environmental Risk Factors for Hemorrhagic Stroke (GERFHS III) was a population-based study of spontaneous ICH among residents of the five-county Greater Cincinnati/Northern Kentucky region between July 2008 and December 2012. Baseline demographics, medications, hospital course, and discharge disposition were collected. Initial and subsequent computed tomography (CT) images of the head were reviewed to assess ICH location, volume, and presence of intraventricular hemorrhage (IVH). Change in ICH volume was calculated when repeat CT image was available.

Results:
There were 1121 cases of ICH during the study period. A higher proportion of white patients were on AP or AC than other races (56.4% vs. 39.7%, p<.0001). The majority of patients with subsequent imaging experienced an increase in ICH size. Patients taking AC pre-ICH had a larger increase in volume despite more frequent use of pro-thrombotic therapy. There was no difference in IVH incidence based on AP or AC use. Length of stay and surgical hematoma evacuation rates were similar among the groups. Inpatient mortality was higher in AC users (44.4% vs. 21.3%, p<.0001), but was virtually the same for AP users as for non-users. Of 272 pre-ICH AP users, 86 (31.6%) were discharged on AP (8 on dual AP). Of 91 pre-ICH AC users, 11 (12%) were discharged on AC.

Conclusion:
Pre-ICH AC use was associated with greater ICH volume increase and inpatient death. There was no significant difference in number of IVH, rate of surgical treatment, or length of stay. Inpatient mortality did not differ between AP users and non-users.
Abstract WP36: Low Recanalization Rates With IV tPA Prior to Thrombectomy in Patients With Large Vessel Occlusion
Authors: Jayaraman Mahesh V , Kishovitch Tom , Moldovan Krisztina , Fuller Lindsey R , Hemendinger Morgan , Yaghi Shadi , Cutting Shawna , Baird Grayson , Haas Richard , McTaggart Ryan A
Published: October 2018

Introduction:
All eligible patients receive IV tPA prior to thrombectomy, but the effect of IV tPA on recanalization prior to and following thrombectomy remains unclear. The purpose of this analysis was to determine the effect of IV tPA on early recanalization obviating the need for thrombectomy, as well as the effect of tPA on recanalization rates.

Methods:
All patients with a CTA-proven LVO in the ICA, M1, proximal M2, or basilar artery in whom thrombectomy was planned over a 24 month period were included. CTA was performed at the first presenting hospital, whether PSC or CSC, and not repeated on arrival for transfer patients. We defined “successful” treatment with IV tPA as TICI 2b or 3 reperfusion, such that thrombectomy was not performed. Time from tPA to start of angiography was divided into 30 minute intervals. We also examined the effect of transfer status and the relationship between tPA and overall recanalization after thrombectomy.

Results:
We identified 310 patients, 190 who received tPA prior to planned thrombectomy and 120 who did not. Of all patients, 178 (57%) were transfers, including 111/190 (58%) in the tPA group. The rates of recanalization with IV tPA are summarized in Table below. Overall rates of successful recanalization (TICI 2b or better) before thrombectomy are low, especially when time between IV tPA and start of angiography is minimized. Successful tPA recanalization rates were 11.7% for transfer patients and 6.3% for non-transfer patients, likely due to faster workflow at the comprehensive stroke center. The rates of overall successful recanalization (TICI 2b or better) were 77.4% in the tPA group (23.8% TICI 2b; 53.6% TICI 2c/3) and 83.6% (22.4% TICI 2b; 61.2% TICI 2c/3) in the no tPA group.

Conclusion:
Early recanalization rate following IV tPA prior to thrombectomy is low, especially when workflow is optimized to minimize time between tPA bolus and start of angiography. Pre-treatment with IV tPA did not increase recanalization rates after thrombectomy.
Abstract WP361: Nursing Education improves activation of Code Stroke in Cardiac Patients with Inhospital Stroke
Authors: Power Martha , Alvi Muhammad , Boyle Francis , Eisenman Rhae D , Steele Kelsey N , Sherman Jay M , Petrone Ashley B
Published: October 2018

Background:
Inhospital stroke (IHS) is defined as an acute ischemic infarction that occurs during hospitalization in a patient originally admitted for another diagnosis or procedure. Approximately 4 to 17 percent of all adult strokes are IHS, and most IHS occurs in cardiologic and cardiosurgical patients after catheterization or surgery. Time to brain imaging is longer in IHS vs community onset strokes (COS) due to delayed symptom recognition, and consequently, IHS patients have greater disability and increased mortality comparted to their COS counterparts.

Purpose:
The purpose of this project was to educate cardiac nurses to more rapidly and accurately recognize symptoms of acute ischemic stroke. We hypothesized that this education would shorten evaluation time for inpatient strokes and result in faster activation of the Code Stroke team.

Methods:
Two 4-hour “Heart to Brain Connection” seminars were offered. Course objectives targeted development of critical thinking regarding the relationship of cardiovascular and cerebrovascular disease. Content included cardiac and cerebral anatomy, recognition of ischemic stroke syndromes and NIH Stroke Scale review. All cardiac nurses completed NIH Stroke Scale Certification. Nurses were empowered to call a “Code Stroke” and educated on appropriate criteria. NIH Stroke Scale pocket cards and pencils with the code stroke number were distributed through the cardiac units.

Results:
We compared the median time from stroke symptom recognition to activation of “Code Stroke” before and after our interventions. Prior to the interventions, in 2014, the median time was 20 minutes; however, this time was decreased to 6.5 minutes in 2016 following our interventions. Further, in 2014, only 36 percent of “Code Strokes” were called by nurses. Following the interventions, “Code Strokes” were called by cardiac nurses in 75 percent of cases in 2016.

Conclusions:
Empowering cardiac nurses to call a “Code Stroke“ through targeted education and training increases the number of “Code Strokes” called by nurses and decreases the time from recognition to activation of the Code Stroke team thereby optimizing the patient’s potential outcome.
Abstract WP363: Improvement in the Inpatient Acute Stroke Alert Process with a Consistent Response Team
Authors: Jeppson Kerri A , Adler Tovah , Snyder Meredith , Schoenleber Toni , Vasilatos Angela , Poisson Sharon , Ricke David , Simpson Jennifer , Neumann Robert , Chamberlain Krystal , Smith Christopher , Newsome Franklin
Published: October 2018

Background and Purpose:
It is publicly reported 2%-15% of all strokes occur in patients hospitalized for another procedure or diagnosis. The evidence suggests greater delays in the evaluation and treatment of in hospital stroke. The stroke program at University of Colorado Hospital identified these in-hospital delays as a result of an informal in-patient alert process. During the day, the stroke alert responders included the stroke attending, stroke resident and/or APP. During off hours, the stroke resident was the responder responsible for both evaluating and transporting the patient to CT scanner within the 25 minute goal window. We identified the lack of a formal process contributed to a delay in the care and treatment of stroke patients.

Method:
A multidisciplinary team was created to identify ways to improve the inpatient stroke alert process. This group approved the Neurosurgical ICU charge nurse to carry a stroke alert pager becoming a 24 hour responder for the acute inpatient stroke alert response team. Prior to implementation, mandatory training included the charge nurse group attending a lecture including topics of neuro assessment, stroke alert documentation and time goals. The stroke alert policy was updated to reflect this change. The stroke alert phone number was also changed to be in alignment with this hospital’s CODE response. Hospital-wide education of the new inpatient response number and our stroke alert criteria was also provided. A retrospective analysis was then performed comparing the 12 months prior to the initiation of the inpatient stroke alert process and the 12 months post implementation.

Results:
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Conclusion:
A consistent response team leads to a more organized stroke alert process with improved accuracy of inpatient stroke alerts diagnosis, faster CT times, an increase in treatment rates, and improved treatment times.
Abstract WP364: Local Guideline And Protocol For Carotid Revascularization: Reduction Of Complications And Costs
Authors: Vacari Andreia H , Massaud Rodrigo , Nunes Miranda Renata , Sampaio Silva Gisele
Published: October 2018

Introduction:
Stroke is the leading cause of disability in Brazil. It is estimated that carotid atherosclerotic disease accounts for 10% to 20% of all strokes. Carotid revascularization procedures, to be considered beneficial, should be performed in centers with low complication rates and in carefully selected patients.

Objective:
To compare the rates of neurological complications (stroke or transient ischemic attack (TIA) before and after implementation of a hospital protocol based on the best scientific evidence with the multidisciplinary participation of all professionals involved in the care of these patients and to compare costs of the procedures after implementation of this protocol.

Method:
A hospital guideline and protocol based on the best scientific evidence were developed and implemented in May 2015. We compared the complication rates pre and post implementation of the guideline (2009 to 2012), as well as the costs associated with procedures in both periods.

Results:
Pre-protocol analysis: of the 38 patients undergoing endarterectomy, 73% (n = 28) were males and the mean age was 74 years. A total of 8% (n = 3) presented stroke or TIA in the postoperative period. Of the 31 patients undergoing carotid angioplasty, 77% (n = 24) were males and the mean age was 75 years. A total of 16% (n = 5) presented stroke or TIA in the postoperative period. Post-protocol period analysis: Of the 48 patients who underwent a carotid revascularization procedure, 27 underwent endarterectomy and 21 underwent carotid angioplasty. The mean age was 73 years for both groups. There were no post-procedure neurological complications after the implementation of the protocol, either after carotid endarterectomy or carotid angioplasty . There was a decrease in the average ticket of endarterectomies (from $ 20213 to $ 18.010, p=0.4) and of angioplasties (from $ 36935 to $ 25.327, p=0.06), a reduction of the mean cost of endarterectomies of 11% and 31 % for angioplasties.

Conclusion:
In conclusion, the implementation of a carotid disease protocol in a tertiary Brazilian hospital has guaranteed patient safety with improvement of the immediate postoperative outcomes, in addition to the reduction of costs related to the procedures.