bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract T P138: Effect Of Weight Loss Surgery On Cardiovascular Death, Nonfatal Myocardial Infarction, Or Nonfatal Stroke In Overweight And Obese Post-menopausal Women
Authors: Saeed Omar , Malik Ahmed A , Qureshi Adnan I
Published: July 2021

Background:
Weight loss surgery has been used for various indications but the effects of such surgery on cardiovascular events remain understudied.

Methods:
We analyzed the data from Women's Health Initiative (WHI) observational study. The participants in the observational study were 93,676 women aged 50-79 years who were recruited from September 1994 to December 1998, with annual follow-up through August 14, 2009 (an average of 8 years). Cox proportional hazards analysis was used to examine the modifying effect of weight loss surgery (entered as an interaction) on the relationship between baseline body mass index categorized into various obesity groups and the outcome of total cardiovascular disease defined as cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke.

Results:
Weight loss surgery occurred in 42 (0.2%) of the 25406 participants who were overweight, obese or morbidly obese at baseline evaluation. Weight loss surgery was performed over a mean period (month’s ±SD) of 38.0 ±3.2 from baseline assessment. The cumulative endpoint of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke was seen in 3 of 42 and 1191 of 25364 participants who did or did not undergo weight loss surgery, respectively (p=0.5). In the multivariate analysis, weight loss surgery (interaction term p=0.6) modified the relationship between categories of obesity and cardiovascular endpoint (relative risk 1.1, 95% confidence interval 1.0 -1.1, p=0.02), after adjusting for age/gender, hypertension, diabetes mellitus, cigarette smoking, and hyperlipidemia.

Conclusions:
We did not observe any significant effect of weight loss surgery on reduction of cardiovascular endpoint of death, nonfatal myocardial infarction, or nonfatal stroke.
Abstract T P149: Thoracic Aortic Calcification is Associated With Incident Stroke in the General Population in Addition to Established Risk Factors
Authors: Hermann Dirk M , Lehmann Nils , Gronewold Janine , Bauer Marcus , Mahabadi Amir A , Weimar Christian , Berger Klaus , Moebus Susanne , Jöckel Karl-Heinz , Erbel Raimund , Kälsch Hagen ,   Heinz Nixdorf Recall Study Investigative Group
Published: July 2021

Background and purpose:
The aorta is a major source of cerebral thromboembolism, but its role in stroke pathogenesis is not well understood due to its poor accessibility for noninvasive imaging. We examined whether thoracic aortic calcification (TAC), a marker of aortic plaque load, is associated with stroke in addition to established risk factors.

Methods:
A total of 3930 subjects from the population-based Heinz Nixdorf Recall study (45-75 years; 47.1% men) without previous stroke, coronary heart disease or myocardial infarction were evaluated for incident stroke events over 109.0±23.3 months. Cox proportional hazards regressions were used to examine associations with stroke of TAC in addition to established risk factors (age, sex, systolic blood pressure, LDL, HDL, diabetes, smoking) and coronary artery calcification (CAC).

Results:
One-hundred-and-one incident strokes occurred. Subjects suffering a stroke had significantly higher TAC values at baseline than the remaining subjects (median=83.1[Q1;Q3=4.7;472.9] vs. 15.7[0.0;117.1]; p<0.001). In a multivariable Cox proportional hazards regression, log(TAC+1) (hazards ratio=1.09 [95%-confidence interval=1.00-1.19]; p=0.044) was associated with stroke in addition to established risk factors. Further analyses revealed that log(DTAC+1), i.e., calcification of the descending aorta (1.11 [1.02-1.20]; p=0.016), but not log(ATAC+1), i.e., calcification of the ascending aorta (1.02 [0.93-1.11]; p=0.713) was associated with stroke. The hazards ratio for log(TAC+1) decreased to 1.06 (0.97-1.16; p=0.202), when log(CAC+1) was also inserted into multivariable analyses.

Conclusions:
Subclinical atherosclerosis of the thoracic aorta, more specifically its descending segment, is associated with stroke in addition to established risk factors.
Abstract T P159: Dietary Carbohydrates, Glycemic Index, Glycemic Load, and Risk of Stroke in Chinese Women: a Large Population-based, Prospective Cohort Study
Authors: Yu Danxia , Shu Xiao-Ou , Li Honglan , Yang Gong , Ding Ding , Hong Zhen , Gao Yu-Tang , Zheng Wei , Zhang Xianglan
Published: July 2021

Introduction:
Diets with a high carbohydrate content, especially the refined carbohydrates, and diets with a high glycemic index (GI) or glycemic load (GL) have been shown to have adverse metabolic effects and may increase the risk of cardiovascular disease. We tested the hypothesis that dietary carbohydrates, GI, and GL may be associated with increased risk of stroke among a cohort of middle-aged and older Chinese women, who typically consume a high-carbohydrate diet.

Methods:
This study included 64,328 women (40-70 years of age) who are participants of the Shanghai Women’s Health Study and were free of cardiovascular disease, cancer, and diabetes at enrollment (1997-2000). Habitual dietary intakes were assessed by a validated food-frequency questionnaire. Incident cases of stroke were identified through follow-up interviews and confirmed by medical records. Multivariate Cox regression was used to estimate hazard ratio (HR) of stroke with 95% confidence interval (CI).

Results:
During a mean follow-up of 10 years, we ascertained 3,075 incident stroke cases, including 2,815 ischemic stroke and 260 hemorrhagic stroke. Compared with those in the lowest quintile, women in the highest quintile of GI had a HR of 1.16 for stroke (95% CI: 1.01-1.33) and women in the highest quintile of GL had a HR of 1.30 (95% CI: 1.04-1.62), P for trend <0.05 for both. High dietary GI and GL were associated with increased risks of both ischemic and hemorrhagic stroke, with stronger associations observed for GL and for hemorrhagic stroke. However, no significant associations were found for total carbohydrate intake after adjustment for potential confounders.

Conclusions:
High dietary GI and GL may be associated with elevated risk of stroke in middle-aged and older Chinese women.
Abstract T P168: A Wake-up Call for Wake-up Strokes
Authors: Huang Josephine F , Fugate Jennifer E , Rabinstein Alejandro A
Published: July 2021

INTRODUCTION:
Studies suggest 8%-28% of ischemic strokes present as wake-up strokes (WUS). The unknown time of symptom onset precludes these patients from approved treatments for acute ischemic stroke, but a substantial proportion of patients may be deemed candidates for treatment if other factors are considered. The aim of this study was to identify characteristics associated with clinical outcomes of WUS patients.

METHODS:
We retrospectively reviewed the medical record of patients with ischemic stroke admitted to a large academic medical center between January 2011 and May 2012. We identified patients with stroke symptoms upon awakening or those who were found with stroke symptoms with an unknown time of onset. Baseline demographics, stroke mechanism, presenting NIHSS, Alberta Stroke Program Early Computed Tomography Score (ASPECTS), and modified Rankin Scale (mRS) scores on discharge and at 3-month follow-up were obtained. A good outcome was defined as mRS 0-2.

RESULTS:
WUS patients comprised 22% (162/731) of all patients with ischemic stroke at our institution during this time period. Median age was 74 years (range 15-100), median presenting NIHSS was 5 (range 0-28), and median initial ASPECTS 10 (range 0-10). A cardioembolic mechanism was identified in 68 patients (42%). Predictors of good outcome at hospital discharge were lower initial NIHSS (3.5 versus 12.0, p<0.0001) and higher ASPECTS (9.8 versus 8.1, p=0.0002). The predictors of good outcomes at 3 months were younger age (69.1 versus 75.8, p=0.009), lower initial NIHSS (5.0 versus 12.6, p<0.0001), and higher ASPECTS (9.5 versus 8.1, p=0.0006). One hundred and eleven patients (68.5%) had initial ASPECTS of 10. Of those, 19 had NIHSS≥10 and 7 were treated with acute recanalization therapies. Four of the 7 treated patients had good outcomes, and 2 of the 12 untreated patients had good outcomes.

CONCLUSIONS:
Few patients with strokes of unknown onset and severe deficits have good outcomes without acute stroke treatment. Patients with NIHSS≥10 and ASPECTS 10 may be candidates for acute recanalization therapy.
Abstract T P180: Ultrasound Characteristics of Symptomatic Carotid Plaques: A Systematic Review and Meta-analysis
Authors: Brinjikji Waleed , Nasr Deena M , Rabinstein Alejandro A , Lanzino Giuseppe , Williamson Eric E , Huston John
Published: July 2021

Background and Purpose:
Ultrasound is the most commonly used imaging modality for assessment of carotid artery stenosis. A number of studies have demonstrated that surface irregularities, heterogeneous echotexture and hypoechoic plaques are risk factors for acute ischemic stroke. We performed a systematic review and meta-analysis of the literature to better define the risk of stroke based off of the sonographic characteristics of carotid plaques.

Materials and Methods:
We performed a comprehensive literature search evaluating the association of carotid plaque characteristics on ultrasound with ischemic outcomes. We included both case-control and cohort studies examining the relationship between complex plaque and acute ischemic stroke. Complex plaque was defined as plaque that had any of the following characteristics: heterogeneous plaque echogenicity, hypoechoic plaque, plaque neovascularization, plaque surface irregularity, plaque ulceration, and intraplaque motion. Meta-analyses using the random-effects model were performed for complex plaque and each of the individual complex plaque characteristics.

Results:
A total of 1013 articles were screened and 30 studies with 11528 patients (3054 symptomatic and 8474 asymptomatic) were included. The odds ratios for the association between complex plaque and ischemic symptoms was 5.18 (95%CI=4.63-5.79). Heterogeneous echotexture (OR=11.72, 95%CI=9.82-13.98), intraplaque motion (OR=1.57, 95%CI=1.02-2.41), plaque echolucency (OR=3.23, 95%CI=2.72-3.84), plaque neovascularity (OR=5.66, 95%CI=3.15-10.16) and plaque ulceration (OR=2.65, 95%CI=1.89-3.73) were all associated with ischemic symptoms. Surface irregularity without frank ulceration was not associated with ischemic symptoms (OR=1.35, 95%CI=0.98-1.86).

Conclusions:
Complex plaque, heterogeneous plaque echogenicity, hypoechoic plaque, plaque neovascularization, plaque ulceration and intraplaque motion are associated with ischemic symptoms. Assessment of carotid plaque on ultrasound provides stroke risk information beyond measurement of luminal stenosis.
Abstract T P194: Targeted Lipid Profiling Discovers Plasma Markers of Acute Ischemic Stroke
Authors: Sheth Sunil , Iavarone Anthony , Liebeskind David , Won Seok-Joon , Swanson Raymond
Published: July 2021

BACKGROUND:
The detection of tissue-specific molecules in blood plays a vital role in the diagnosis and management of acute organ injury. Previous efforts to discover plasma markers of acute ischemic stroke (AIS) have focused on proteins and nucleic acids, but low sensitivity at early time points and poor correlation with injury severity have limited these approaches. We address the hypothesis that the most abundant molecules in the brain, lipids, appear in the plasma earlier after injury and correlate with severity. We focus on a specific lipid subset, sphingolipids (SL), as this subset is highly enriched in the brain compared to plasma.

METHODS:
We performed targeted lipid profiling using SL-specific extraction methods followed by HPLC-MS/MS in plasma collected after acute ischemic stroke in rodents. We validate our findings in a cohort of human patients presenting to the hospital emergently via the CODE STROKE protocol, by comparing SL levels in those ultimately diagnosed as stroke versus mimic. We construct a simple Sphingolipid Score, the summed plasma values of the top two performing SLs in the rodent stroke model, to improve the sensitivity of detection.

RESULTS:
In a rodent model of AIS, plasma collected at 24 hours after the injury revealed a dramatic increase in SL levels in the stroke compared to sham animals. Of the 45 SLs identified, 40 (89%) were elevated, on average 4 fold (max 60 fold). Top two performing species were SM 36:0 and Cer 42:1. Among 14 patients presenting via the CODE STROKE protocol, 8 (57%) were female, median age was 75 (range 41-89), NIHSS 14 (range 3-22), time from symptom onset to blood draw was 388 min (range 80-66). 44% were treated with IV tPA. Final diagnosis was MCA occlusion in 7 (50%), lacunar stroke in 2 (14%), and mimic (migraine, seizure, factitious disorder, Bell’s palsy) in the remainder. In patients with acute stroke, we identify significant increases in Sphingolipid Score for all patients (4.7 vs. 1.9, p<0.05) as well as those with blood draw within three hours of symptom onset (4.6 vs. 1.9, p<0.05). Sphingolipid score correlated linearly with DWI volume over a wide range from 1.5-236 mL (r2=0.7, p<0.05).

CONCLUSIONS:
Targeted lipid profiling may yield clinically relevant plasma markers of acute brain injury.
Abstract T P206: An Executable Graphical Model for In Silico Prototyping of Processes for Acute Stroke Care
Authors: Norris David , Levy Drew G
Published: July 2021

Background:
Strong evidence shows neurologic outcomes in acute ischemic stroke (AIS) worsen with delay from symptom onset to thrombolytic therapy. Yet this onset-to-treatment (OTT) time has not decreased in most systems of care over the past decade. Even the in-hospital, “door-to-needle” (DTN) component of this delay is unimproved, notwithstanding exceptions in institutions where innovative quality improvement efforts have borne fruit.

Objective:
Provide a basis for visualizing, communicating, and simulating stroke care system configuration and performance to facilitate the quality improvement efforts necessary for reducing DTN and OTT times in AIS.

Methods:
We developed an executable, graphical model of acute stroke care, employing the hierarchical colored Petri net (CPN) formalism. The top level of the hierarchy sets the epidemiologic context, including demographics and background processes like stroke prevention and onset. At deeper levels, we elaborate time-critical processes that contribute to OTT: stroke recognition, EMS activation and transport, and many emergency department (ED) processes. Key ED innovations described in the literature were modeled: EMS prenotification, a direct-to-imaging transport strategy, process parallelism, and telestroke capability.

Results:
Our CPN model has provided a platform for detailed, realistic prototyping and simulation of acute stroke care processes. The performance characteristics of process configurations with multiple, interacting innovations were evaluated and compared.

Conclusions:
In silico care process prototyping permits evaluation of proposed innovations in simulated settings. Using an intensively graphical simulation modeling methodology adds value by promoting “visual consensus” regarding care process structure and function, among stakeholders in a quality improvement initiative.
Abstract T P211: Continued Participation in a Telestroke Program Improves Time to Intravenous Thrombolysis
Authors: Muthana Jamal N , Conners James J , Cutting Shawna , Song Sarah Y , Diebolt Elizabeth , Bock Joshua , Lee Vivien H
Published: July 2021

Background:
Improved clinical outcomes after intravenous tissue plasminogen activator (IV tPA) are time dependent. Participation in a telestroke program allows the spoke hospitals 24/7 access to a vascular fellowship trained neurologist for a telestroke consult, as well as educational partnership with the hub site, shared protocols, and access to quality improvement feedback. We sought to assess the effects of continued participation in a telestroke program on times to administration of IV tPA.

Methods:
Our institutional telestroke program began in March 2011 and consists of an academic hub (comprehensive stroke center) that serves 8 community spoke hospitals. We retrospectively reviewed acute ischemic stroke patients treated with IV tPA via the telestroke program. We compared 2 cohorts of patients: Period 1 (July 2011 to June 2013) and Period 2 (July 2013 to July 2014). We collected data on demographics, National Institutes of Health Stroke Scale (NIHSS), and times from initiation of telestroke consult to IV tPA administration.

Results:
Among 259 consecutive stroke patients (mean: 69.6 years, 56% female) treated with IV tPA via telestroke, the median NIHSS score was 11.8, and 41.7% of patients were transferred to the hub. The mean time from initiation of telestroke consult to IV tPA administration was 42.2 minutes. Period 1 included 129 patients and Period 2 included 130 patients, and the two groups did not differ by age (p=0.2), gender (p=0.3), or NIHSS score (p=0.3). Time from initiation of telestroke consult to IV tPA administration improved from Period 1 to Period 2 (35 vs. 49.9 minutes, p<0.0001). This improvement was due to faster mean time from initiation of telestroke consult to IV tPA advised (12.5 vs. 17.4 minutes, p<0.0001) and faster mean time from IV tPA advised to administration (22.5 vs. 33.1 minutes, p<0.0001).

Conclusions:
Maturation of a telestroke program is associated with improvement in the timeliness of IV tPA delivery, possibly due to a learning effect that continues the longer the sites participate in the program. This improvement is due to faster responses in both the hub site (recommending IV tPA earlier) and spoke site (administering IV tPA quicker). Further studies aimed at improving delivery of IV tPA in telestroke program are warranted.
Abstract T P228: Ischemic Stroke Results in Increased Activity of the Neuroprotective Angiotensin Converting Enzyme 2 in Rat Brain and Serum
Authors: Bennion Douglas M , Haltigan Emily , Irwin Alexander J , Purich Daniel L , Sumners Colin
Published: July 2021

Background:
Recent studies show that pharmacological induction of the angiotensin converting enzyme 2/angiotensin-(1-7)/mas [ACE2-Ang-(1-7)-Mas] axis, a protective pathway of the renin angiotensin system, elicits neuroprotection in ischemic stroke. However, endogenous levels and activity of the components of this axis in the brain and serum following stroke are not well established. Here, we assessed the post-stroke activity and expression of ACE2 in rat cerebral cortex and serum after ischemic stroke in rats, in the absence or presence of an ACE2 activator.

Methods:
Sprague Dawley rats underwent sham surgery or endothelin-1-induced middle cerebral artery occlusion (ET-1 MCAO). Activity of ACE2 was analyzed within serum and cerebral cortical tissue samples using a fluorometric assay, and mRNA levels were assessed by qRT-PCR. In an additional experiment, rats received daily intraperitoneal administration of diminazene aceturate (DIZE), a putative ACE2 activator, or vehicle after ET-1 MCAO. Data are normalized to corresponding control values and expressed as means ± SEM with a significance of p<0.05.

Results:
ACE2 activity levels were significantly increased in ischemic brain cortex at 4, 12, and 24 h after a stroke (4h: 237.1±46.1%; 12h: 212.4±12.8%; 24h: 191.6±19.1%) versus rats with sham strokes. Paradoxically, there was a significant decrease in ACE2 mRNA levels in the ischemic cortex at 24h (0.71±0.1) compared to shams (1.0±0.08). After decreasing in activity at 4h after stroke, serum ACE2 activity was increased at 24h in stroked rats (96.08±9.4%) versus shams (70.80±7.1%). Post-stroke treatment with DIZE (7.5 mg/kg) resulted in significantly increased ACE2 activity in serum (213.7±49.8%) versus controls, two days following stroke.

Conclusions:
Activity of the protective enzyme ACE2 is increased in rat cerebral cortex following stroke, with a rebound increase in serum activity. Post-stroke treatment with an ACE2 activator resulted in significantly increased ACE2 activity in serum. These results suggest that stroke therapeutics designed to target the ACE2/Ang-(1-7)/Mas axis may act in synergy with endogenous changes in the acute post-stroke setting, lending promise to their further study as potential neuroprotective agents.
Abstract T P229: Deletion of Voltage Gated Proton Channel in Microglial Cells is Neurovascular Protective After Ischemic Brain Injury
Authors: Li Weiguo , Ward Becca , Abdelsaid Mohammed , Yu Tianzheng , Yoon Yisang , O'Connor Paul , Ergul Adviye
Published: July 2021

Despite the failure of antioxidant treatments in clinical trials, the undoubted role of reactive oxygen species (ROS) in neurovascular damage after ischemic stroke calls for a more targeted approach. ROS production by microglia, the primary resident immune cells in the brain, is a key event of this process in ischemic stroke. Voltage gated proton channel, Hv1, is localized primarily to microglia and sustains NADPH oxidase activity. Deletion of Hv1 is neuroprotective after permanent middle cerebral artery occlusion (MCAO). We hypothesized that Hv1-mediated microglial ROS generation is also critical for vascular integrity and contributes to reperfusion injury after transient ischemic stroke. The wildtype (WT) and Hv1 knockout (KO) rats (n=4) were subjected to permanent or 3/24 h transient MCAO. The neurological deficiency, infarct, hemorrhagic transformation, and edema ratio were assessed. We found that in both permanent and transient MCAO model, KO rats develop smaller infarct, less vascular injury, edema, and hemorrhagic transformation, resulting in better short-term functional outcome. These results suggest that deletion of microglial Hv1 channel is vasculoprotective after ischemia/reperfusion and the underlying mechanisms need to be further studied.
Abstract T P260: Confirmation: The Target Stroke Best Practice Strategies Work
Authors: Valadi Nojan , Thomas Alexis
Published: July 2021

Background:
A recent national push for optimizing stroke center performance led by the efforts of AHA/ASA to recognize high performers with the Target Stroke Honor Roll recognition have focused on achieving expedited treatment for stroke with door-to-needle (DTN) time of ≤60 minutes.Our organization recognized the need to optimize our performance and set an initial goal of achieving DTN time of ≤60 minutes in greater than 50% of our patients. The Target Stroke Initiative by the AHA/ASA identified 10 key strategies for best practice associated with reducing DTN times. Our organization adopted and implemented all of these strategies over a 30-day period.

Methods:
The Target Stroke best practice strategies were implemented over a 30-day period, and the Stroke Team worked collaboratively to identify other weaknesses needing to be addressed. DTN times ≤60 minutes from the 12 months prior to process improvement implementation were compared with the first 2 months post implementation.

Results:
There were 345 ischemic stroke patients treated at our facility during the 12 month period prior to the process implementation, with a total of 14 patients (1.12 per month) treated with tPA. The percentage of patients treated with tPA was 4%, and the percentage of patients treated with DTN ≤60 minutes was 0%. Over the two months following process implementation, 68 ischemic stroke patients were treated at our facility, with 11 patients treated with tPA (5.5 per month). The percentage of stroke patients treated with tPA was 16%, with 70% of patients treated with DTN ≤60 minutes.

Conclusion:
This study serves as confirmation that collaboration and implementation of the 10 key strategies for best practice as outlined by the Target Stroke Initiative, coupled with changes to identified areas of weakness, can improve and expedite the care of patients with acute ischemic stroke. This can substantially improve DTN times, as well as the overall number and percentage of patients that receive thrombolysis with a hopeful impact on their outcome as well as Target Stroke Honor Roll recognition for the facility. In conclusion, we recommend implementation of these best practice strategies to other facilities.
Abstract T P276: Transient Ischemic Attack Clinic Drives Superior Patient Outcomes While Reducing Cost
Authors: Woodard Jim , Haschker Shelby
Published: July 2021

It is estimated that 40% of all individuals that experience a TIA will ultimately suffer a stroke. As many as 50% of these patients will have a stroke within one week post TIA. Given the short time interval between TIA symptomology and stroke onset, immediate treatment is warranted. Historically treatment of TIA patients has taken place in emergency rooms and as hospital inpatients. A TIA clinic was established in 2011 as an alternative option to traditional TIA treatment. This clinic was designed to expedite diagnosis and treatment while reducing cost. Utilizing the ABCD2 tool, emergency department clinicians, PCPs and ophthalmologists referred low risk patients to the clinic. Clinic patients were scheduled to be seen in the clinic within 24-48 hours. All testing, stroke/TIA education, neurological consultation and secondary treatment plan were completed during the clinic visit.

To date, the clinic has evaluated 137 patients. There have been no reports of stroke 90-days post clinic visit. Stroke rates post TIA are estimated to be as high as 17% after 3 months. This data supports the TIA clinic’s success in secondary stroke prevention. Patients seen in the clinic reported high satisfaction scores with the clinic and the care they received. It was initially hypothesized that the TIA clinic would provide care in a more cost effective way. A cost analysis was performed comparing TIA clinic costs and the cost of treating patients admitted to the hospital. Using fiscal year 2014 data, the average cost for treating a patient in the clinic was $423. The average cost for admitting a patient to the hospital was $1,464 per patient.

The TIA clinic has shown that patients can receive timely treatment in a setting that produces the highest clinical outcomes, maintains patient satisfaction and reduces cost by 70%.
Abstract T P28: Diagnostic Accuracy of Mobile Devices for Remote Acute Stroke Neuroimaging Interpretation
Authors: Balucani Clotilde , Weedon Jeremy , Levine Steven R ,   The REliability of MObile TEchnologies for Acute Stroke Neuroimaging (REMOTE) Study Group
Published: July 2021

BACKGROUND:
Advances in technology allow physicians’ access to radiological images remotely, virtually anytime, anywhere to streamline stroke management.

OBJECTIVE:
To compare the diagnostic accuracy of different mobile devices in interpretation of acute head CT for various ischemic stroke findings among various readers.

METHODS:
20 selected acute stroke head CT were independently interpreted by 11 readers (7 Neurologists, 3 Neuroradiologists and 1 Radiologist) on 2 mobile devices, iPad® 2 (1024x768 pixels) and iPhone® 4 (960x640 pixels), and on the Picture Archiving and Communication System (PACS) workstation (1280x1024 pixels). Both mobile devices used a FDA-cleared ResolutionMD software (ResMD® Calgary Scientific, Calgary, Canada). Primary outcome measures included: any acute ischemic sign (AIS), any non acute ischemic sign (NAIS), and any hyperdense middle cerebral artery (HMCA) sign. For each outcome intra-rater inter-device accuracy, using a rater specific gold standard, were evaluated and estimated % Sensitivity (Sen) and % Specificity (Spe) with 95% Agrest-Coull Confidence Intervals (CIs) were reported from frequency tables.

RESULTS:
Across all 11 readers, for AIS: Sen = 76 (68, 82) and Spe = 75 (64, 83) on iPhone; Sen = 76 (69, 83), Spe = 71 (60, 80) on iPad. For for NAIS: Sen = 80 (72, 86) and Spe = 77 (67, 84) on iPhone and Sen = 75 (67, 82) and Spe = 80 (71, 87) on iPad. For HMCA Sen = 53 (39, 67) Spe = 97 (93, 99) on iPhone and Sen = 62 (48, 75) and Spe = 95 (91, 98) on iPad.

CONCLUSIONS:
This is the first study directly comparing the diagnostic accuracy of two different mobile devices for acute head CT ischemic stroke findings. Both iPhone and iPad have fair sensitivity for detection of AIS and NAIS, while poorer sensitivity for HMCA when read by readers from different specialties. Specificity was good to excellent for all 3 head CT ischemic stroke findings. iPhone and iPad have similarly good diagnostic accuracy for acute ischemic stroke head CT scan findings supporting their use for remote neuroimaging interpretation. Their validation in routine clinical practice needs to be confirmed in larger studies.
Abstract T P295: Neurological Recovery Following Out-of-hospital Cardiac Arrest: Role of Hypothermia
Authors: Yu I-Chen , Schleinkofer Nathan , Maeng Joo-Young , Chen Yu-Chieh , Doshi Riddhi , Plant Robert , Mirro Michael , Chang Fen-Lei
Published: July 2021

Introduction:
Every year about 70% of coronary heart disease deaths in the United States occur out of hospital, usually presenting as ‘sudden death’ due to cardiac arrest. Despite the improvement of survival with advanced cardiac interventions, mortality remains high. Therapeutic hypothermia (TH) has been shown to be neuroprotective after cardiac arrest. We explored factors associated with good recovery of neurological function following out-of-hospital cardiac arrest (OHCA).

Methods:
This retrospective study included review of electronic medical records from a major healthcare system in Northeast Indiana. Individuals who suffered OHCA from January 2011 to June 2014 were included. Neurological function was evaluated by Modified Rankin Scale (mRS) at discharge. The neurological outcome was defined as good (mRS 0-3), poor (mRS 4-5), and deceased (mRS 6) to assess the association of examined variables.

Results:
Among the 111 patients meeting inclusion criteria, the mortality at discharge was 68.6% in TH-treated patients and 84% in normothermia patients. For almost half (47.5%) of the patients undergoing TH who died prior to discharge, brain-related causes were the primary cause of death. 21 patients who had imaging or pathological examinations all showed evidences of ischemic brain injury. Among TH-treated survivors, patients with return of spontaneous cardiac rhythm (ROSC) within 20 minutes of onset were 1.4 times the odds more likely to have a good neurological outcome at discharge (p=0.02). Patients with ventricular fibrillation had 2 times the odds more likely retaining good neurological function at discharge after receiving TH treatment (p=0.012). The time to initiate TH (mean 2.3 ± 1.5 hours) and time to reach target temperature (mean 7.2 ± 2.3 hours) were not associated with neurological outcome at discharge.

Conclusions:
Initial rhythm and time to ROSC were identified as reliable predictors of good neurological function following OHCA. TH has been found to be insufficient in preventing brain injury. This study emphasizes the need for future studies to develop new neuroprotective strategies to improve survival among OHCA patients.
Abstract T P296: Race/Ethnicity Disparities in Access to Inpatient Physical and Occupational Therapy Exist
Authors: Singh Harkamal S , Morgenstern Lewis B , Skolarus Lesli E , Burke James F
Published: July 2021

Introduction:
African-Americans and Hispanics have worse functional outcomes after stroke, although the reasons for these disparities are not known. As more intense rehabilitation therapy after stroke is associated with improved outcomes, we hypothesized that decreased access to therapy during stroke hospitalization may contribute to outcome disparities.

Methods:
The 2008 State Inpatient Databases (SID) for seven states, which include data on all inpatient discharges within a state were used to identify all primary ischemic stroke (ICD-9-CM 433.x1, 434.x1, 436) and intracerebral hemorrhage discharges (435). Receipt of physical (PT) and occupational (OT) therapy was determined using HCUP definitions. Logistic regression was used to compare receipt of therapy by race/ethnicity adjusting for demographics, insurance, comorbidities, stroke type, and presumptive severity markers (length of stay, ICU use, presentation via ED, receipt of IV tPA, use of life-sustaining treatments). Hospital effects were then accounted for by including all risk adjustors in a multi-level model with a random hospital-level intercept.

Results:
A total of 472, 210 discharges in 702 hospitals were identified, 59% in whites, 13% in African Americans and 4% in Hispanics; 71% received PT and 47% OT. Before accounting for hospital effects, African-Americans (OR 0.82 for PT, 0.84 for OT) and Hispanics (OR 0.79 for PT, 0.64 for OT) were less likely to receive therapy (p < 0.001 for all comparisons). Hospital was an important predictor of receipt of therapy, intra-class correlation coefficient (ICC) 0.14 for PT and 0.56 for OT. After accounting for the hospital where they were admitted, African-Americans were more likely to receive PT (OR 1.11) and OT (OR 1.08, p < 0.05) and therapy use was the same in Hispanics and whites (OR 1.05 for PT, p = 0.3 and 1.10 for OT, p = 0.09).

Conclusions:
In this large sample, African-Americans and Hispanics were less likely to receive inpatient PT and OT than whites. This disparity is explained by the fact that minorities receive care at hospitals that use less PT and OT. Optimizing therapy use in these hospitals may improve stroke outcomes and reduce outcome disparities.
Abstract T P301: Comprehensive Stroke Performance Measure Rates between Certified and Non-Certified Comprehensive Stroke Centers
Authors: Alberts Mark J , Kolbusz Karen , Li Nancy , Watt Ann , Range Jean
Published: July 2021

Objective:
To determine performance measure rates for the pilot-tested draft Comprehensive Stroke (CSTK) measures at Joint Commission (JC) certified CSCs compared to non-certified CSCs.

Methods:
Data from 66 pilot sites in 27 states that collected data on 7 potential CSC stroke measures were submitted to the JC. Of these 66 sites, 20 became JC certified CSCs, and 46 did not as of July2014. We compared performance measure rates between these 2 groups of facilities using Chi-square analysis.

Results:
Data from 9720 patients were analyzed. Aggregate measure rates ranged from 10.2% for CSTK-05 up to 71.6% for CSTK-01. Rates between CSC JC certified sites vs non-CSC sites showed the following results: CSTK-01, NIH Stroke Scale for ischemic stroke, 77.1% vs 69.2%, (p = 0.0001); CSTK-02, modified Rankin at 90 days, 37.2% vs 18.7%, (p = 0.0001); CSTK-03, ICH and SAH severity scales completed within 6 hours of hospital arrival or prior to surgery, 28.2% vs 14.8%, (p = 0.0001); CSTK-04, INR reversal agent administered for intracerebral hemorrhage and INR > 1.4 at hospital arrival , 52.9% vs 51.8%, (p = 0.87); CSTK-05, hemorrhagic complications after lytic or mechanical therapy for ischemic stroke, 10.6% vs 10.0%, (p = 0.88); CSTK-06, nimodipine treatment for aneurysmal SAH within 24 hours of arrival, 75.5% vs 68.1%, (p = 0.005); CSTK-07a, reperfusion rate recorded for endovascular therapy in ischemic stroke, 32.1% vs 33.4%, (p = 0.71). These pilot data do not reflect changes or improvements after the observation period.

Conclusions:
In this pilot study, JC certified CSCs performed somewhat better than other institutions on some CSC measures, especially in applying the utilization of various rating scales for stroke severity. Substantial room for improvements exist at most sites for most measures.
Abstract T P31: Clinical Usefulness of 3D Arterial Spin Labeled Perfusion Image in Acute Ischemic Stroke
Authors: Takayoshi Hiroyuki , Kohno Naoto , Okada Kazunori , Yamaguchi Shuhei
Published: July 2021

Purpose:
Arterial spin labeled (ASL) perfusion image is a noninvasive imaging method for detecting perfusion deficits and ischemic penumbra in acute ischemic stroke. This method takes additional only few minutes after the routine MRI exam without contrast agent or radioisotope, and is expected to be useful in decision-making for emergent recanalization therapy. It is important to assess the prevalence of diffusion-perfusion mismatch in various stroke types. Here we evaluated the usefulness of the 3D ASL perfusion image in acute ischemic stroke including TIA.

Methods:
We enrolled 71 consecutive patients (mean 80 years) with acute ischemic stroke from April 2010 to October 2012, who were admitted to the municipal hospital within 24 hours after stroke onset. All patients underwent 3D-ASL perfusion image with the 1.5T MRI scanner in addition to diffusion-weighted image (DWI), FLAIR, T2*, and MRA. We assessed the prevalence of hypoperfusion (none, focal, or diffuse) in 3D-ASL image and the size of diffusion-perfusion mismatch. The associations of these measures with stroke type and lesion size in DWI were also analyzed.

Results:
Hypoperfusion in ASL image was observed 33% in TIA, 12% in lacunar stroke, 64% in atherosclerotic stroke, and 81% in cardioembolic stroke. Nine patients showed no abnormality in ASL perfusion image, but had arterial transit artifact, which indicates occluded vessel or collateral vessels. Diffusion-perfusion mismatch was most prevalent in patients with middle size of infarction and in patients with atherosclerotic and cardioembolic stroke. 80% of patients who received thrombolytic therapy demonstrated improvement of ASL hypoperfusion.

Conclusions:
3D-ASL perfusion image could provide useful clinical information in decision-making for early treatment and their recovery by medical intervention in patients with acute atherosclerotic and cardioembolic stroke.
Abstract T P313: Sex-age Interactions and Differences in Outcomes After Intracerebral Hemorrhage
Authors: James Michael L , Cox Margueritte , Xian Ying , Smith Eric E , Bhatt Deepak L , Schulte Phillip , Hernandez Adrian , Fonarow Gregg C , Schwamm Lee H
Published: July 2021

Background:
Compared to ischemic stroke, sex differences in outcomes after intracerebral hemorrhage (ICH) are largely unexamined.

Methods:
In the Get With The Guidelines (GWTG)-Stroke database, differences between men and women with ICH were assessed. Data from 192,826 patients with ICH admitted between January 1, 2009 and March 31, 2014 to 1,728 AHA-GWTG-Stroke fully-participating sites were analyzed. Logistic regression was used to assess age and sex interaction with respect to outcomes while adjusting for potential confounders. Due to missing stroke severity data in 52.5% of patients, models were performed with and without adjusting for NIHSS.

Results:
In the total study population, 48.9% were women (median age 75 years; male median age 67 years). On admission, women with ICH had lower creatinine and were less likely to smoke than men, and women over 65 years of age were less likely to have atrial fibrillation or dyslipidemia, use antiplatelets or cholesterol-reducers, but more likely to have higher admission NIHSS than men over 65 years. In the primary model, as age increased, odds for combined mortality and discharge to hospice were similar for men and women, but odds for discharge to home and independent ambulation at discharge increased more in men, with significant sex-age interactions (See Table). In the subset with NIHSS, similar adjusted sex differences were seen for mortality and length of stay but were non-significant for discharge to home and independent ambulation.

Conclusions:
After ICH, men experience higher odds of discharge to home and independent ambulation for each 10-year increase in age compared to women, after adjusting for covariates.
Abstract T P348: The Presence of an Advanced Practice Nurse Stroke Program Coordinator Decreases Door-to-Needle Times
Authors: Whaley Michelle , Caputo Lisa M , Wagner Jeffrey C
Published: July 2021

Background:
Benefits of intravenous tissue plasminogen activator (IV-tPA) are greatest when patients are treated immediately. Our Comprehensive Stroke Center hires Advanced Practice Nurse stroke program coordinators (APN SPC) to respond to the bedside of all acute stroke alert calls. Between 08:00-17:00, an APN SPC works with dedicated on-duty neurologists to rapidly treat acute stroke patients with IV-tPA.

Purpose:
The purpose of this study was to determine if the presence of an APN SPC decreases door-to-needle (DTN) times in acute stroke patients.

Methods:
Data were collected by stroke coordinator abstractors from January 1, 2010 to June 14, 2014. DTN times were compared using a Student’s t-test between times when an APN SPC was on duty with times the APN SPC was not present. Patient age, time between symptom onset to hospital arrival, and NIH Stroke Scale (NIHSS) categories were compared between groups using Student’s t-test and chi-squared test.

Results:
There were 245 patients who received IV-tPA over the study period. Over half (52%, n=127) of patients were treated in the presence of an APN SPC; 48% of patients (n=118) were not treated in the presence of an APN SPC. There were no significant differences in age, time between symptom onset to hospital arrival, or NIHSS values between groups. Median DTN time for patients treated with an APN SPC present was 36 minutes versus 45 minutes for patients treated without an APN SPC present; this 9-minute difference in median DTN time was borderline statistically significant (p=.051).

Conclusion:
The presence of an APN SPC was associated with reduced median DTN times. The presence of an APN SPC, in addition to an on duty neurologist, may reduce time between door and needle, engendering improvements in patient outcomes.
Abstract T P367: Stable Childhood Stroke Rates Over 17 years: Report From a Population-Based Study
Authors: Khoury Jane C , Yeramaneni Samrat , Taylor J. Michael , Lehman Laura , Sucharew Heidi , Alwell Kathleen , Moomaw Charles J , Peariso Katrina , Khatri Pooja , Broderick Joseph P , Kissela Brett M , Kleindorfet Dawn O
Published: July 2021

Background:
We have published rates of childhood stroke using our population-based Greater Cincinnati Northern Kentucky Stroke Study for 1993/4 and 1999. We now report population-based rates from additional study periods of 2005 and 2010, and compare rates over time periods.

Methods:
We identified all strokes in the Greater Cincinnati/Northern Kentucky (GCNK) region, a biracial population of 1.3 million, during 7/1/93 to 6/30/94 and calendar years 1999, 2005 and 2010. Stroke cases (both hemorrhagic and ischemic) were ascertained by screening for discharge ICD-9 codes 430 - 436 at all local hospitals, 437 - 438, 674 and 747 were also screened at the Children’s Hospital. Childhood stroke is defined as stroke in those <20 years of age at the time of onset. Incidence and overall stroke rates are estimated per 100,000, age-, sex- and race-adjusted to the 2000 US population.

Results:
There were 14 strokes in children in 1993/4, 24 strokes in 1999, 15 strokes in 2005 and 17 strokes in 2010. Incidence rates by study period, overall, by race, sex and stroke type are reported in the table. We do not detect any significant change in the incidence rate over time. The overall (first ever or recurrent) stroke rate age-, sex- and race-adjusted to the 2000 US population under 20 years of age for the entire study period, is 4.4/100,000 (95% confidence interval: 3.4, 5.4),. Eleven children died within 30 days yielding an all-cause case fatality rate of 16%. Among all childhood stroke cases, 9 (13%) were identified at hospitals other than the Children’s Hospital.

Conclusions:
The childhood stroke incidence rate of 4.1 per 100,000, in the GCNK study region has not changed significantly over 17 years Any study of pediatric stroke incidence should include screening of non-pediatric hospitals, as we found 13% of cases in adult hospitals.
Abstract T P377: Vitamin B12 Deficiency - A Poorly Recognised and Treatable Childhood Stroke Risk Factor
Authors: Yusuf Zarah , Alamelu Jayanthi , Lim Ming , Dlamini Nomazulu
Published: July 2021

Introduction:
Risk factors in childhood stroke are multiple and causality hard to determine. Current guidelines recommend prothrombotic workup, yet yield is variable, often without therapeutic consequence. Raised homocysteine is associated with vitamin B12 deficiency (B12), which is not routinely measured.

Hypothesis:
We hypothesised that B12 deficiency is a treatable risk factor for stroke in children not reliably identified by analysis of homocysteine only.

Method:
We retrospectively reviewed paediatric stroke patients admitted to a tertiary care hospital from 2010-2014. All patients with plasma homocysteine measured as part of their prothrombotic workup were selected. All clinical data closest to stroke diagnosis were reviewed. B12 deficiency was defined as low total and/or holo (functional) vitamin B12 with/without raised methylmalonic acid (MMA). Parental prothrombotic workup and B12 status was analysed where available.

Results:
Of 134 patients, 61 had homocysteine levels, 20 were tested for vitamin B12 (age range 0-14.8 years), 14/20 for MMA. B12 deficiency was found in 7/20 with median age of acute stroke presentation of 1 day (25th percentile= 0; 75th percentile= 51days). Median age of stroke presentation in B12 replete group was 3.5 years (25th percentile=2.0;75th percentile=7.0years). There was a statistical difference in age of stroke presentation between the B12 deficient and replete groups (Kruskal-Wallis, p=0.001). Raised homocysteine (10/20) was not sensitive in detecting B12 deficiency (sensitivity 42.8%, 95% CI 15.82-74.95). Two of seven had additional risk factors (1/7 iron deficiency, 1/7 MTHFR 667 homozygous). Seizures were the most common stroke presentation regardless of B12 status. Vitamin B12 (im) was given in 4/7 children and 3/9 parents (2 mothers, 1 father). Five of seven were breast fed. All treated parents were vegetarian.

Conclusion:
Our study suggests vitamin B12 deficiency is associated with early childhood stroke. Homocysteine alone is not a sensitive screen for this. Investigation with functional biomarkers such as holo B12 and MMA would allow for improved detection of a treatable risk factor in childhood stroke. Further studies may support this recommendation being added to guidelines.
Abstract T P39: Serial Alberta Stroke Program Early Ct Score (aspects) Is A Superior Predictor Of Outcomes With Iv Rtpa
Authors: Yeo Leonard , Paliwal Prakash , Teoh Hockluen , Chan Bernard , Seet Raymond , Sharma Vijay
Published: July 2021

Background and purpose:
The Alberta stroke program early computed tomography score (ASPECTS) on baseline imaging is known predictor of outcomes for acute ischemic stroke (AIS) patients. We looked at the change in ASPECTS at the baseline CT and 24hr CT in AIS patients treated with IV rTPA to determine if it can help predict 3 month functional outcomes.

Methods:
Consecutive AIS patients receiving IV-tPA within 4.5 hours of symptom-onset during 2010-2013 and underwent pre-treatment and day-2 CT were included ASPECTS at the baseline CT and 24hr CT were independently scored in all anterior circulation stroke patients who underwent IV rTPA within 4.5 hours of onset. ASPECTS at baseline, 24hrs and the serial change were analyzed.

Results:
210 consecutive AIS patients were included. ROC curves for ASPECTS on the initial CT scan for MRS 0-1 was AUC 0.613, 95% CI 0.536-0.690, p=0.005, while ROC curves for ASPECTS on the 24hr CT scan for MRS0-1 was AUC 0.763 95% CI 0.699 - 0.828, p <0.001. ASPECTS on the 24hr CT was statistically significantly better able to predict outcomes compared to the initial CT (z= -2.936, p = 0.001). 28 out of 210 patients had an increase in ASPECTS by >3 with a 3-fold risk of worse outcomes (OR 3.572 95%CI 1.393- 9.156, p=0.08).

Conclusion:
ASPECT scores on 24hr CT have better prognostic ability compared to the baseline scan. Serial ASPECT scores are a viable surrogate predictor in AIS patients treated with IV rTPA.