bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP352: Safety and Efficacy of Andexanet Alfa in Patients With Life Threatening Intracerebral Hemorrhage: A Single Center Experience
Authors: Asad Syed Daniyal , Lombardi Stephanie R , Staff Ilene , Nouh Amre M , Alberts Mark J
Published: June 2021

Background:
Intracerebral hemorrhage (ICH) is a devastating condition with high 30- day mortality. Up to a third of patients experience hematoma expansion within the first 24 hours; anticoagulation with factor Xa inhibitors may increase the risk of expansion and poor outcomes.

Objective:
We assessed our experience using Andexanet alfa (Aα) by evaluating stabilization of the hematoma and ischemic complications.

Methods:
We conducted a single center prospective observational study on all patients receiving Aα for reversal of anticoagulation in the setting of an ICH and use of Factor Xa inhibitors. The degree of hematoma expansion within 12 hours of drug administration on non-contrast head CT was categorized as 'excellent' (<20% increase in hematoma size), ‘good' (
>
20-<35%), and 'poor' (
>
35%). Secondary outcomes included dosage, median length of stay, mortality, modified Rankin score (mRS), discharge disposition, and ischemic complications.

Results:
Fifteen patients received Aα (5=lobar, 5=deep, 5= multicompartment). One patient with a presumed deep hemorrhage was excluded because subsequent imaging showed chronic mineralization. The predominant etiologies were hypertension (40%), amyloid angiopathy (26.6%) and trauma (13.3%). The median age was 86 years (IQR 19) and median ICH score on arrival was 2 (IQR 2), and median hematoma size was 14.3 mL (IQR 34.5). Most patients (71.4%) received the low dose formulation. Based on hematoma expansion, 64.3%, 14.3% and 21.4% of patients achieved excellent, good and poor hemostasis, respectively. Reduction in hematoma size was seen in 20% (n=3) while 13.3% (n=2) patients had no expansion. Median ICU and hospital length of stays were 2.0 days (IQR 2.2) and 6.6 days (IQR 9.78) respectively. Mortality was 28.6% and median mRS upon discharge was 4 (IQR 2), with most patients discharged to rehabilitation facilities (60%). There were no ischemic complications.

Conclusion:
Our experience is consistent with the results of the ANNEXA 4 study with 78.6% of patients showing excellent or good hemostasis. These results led to improved clinical outcomes, with 60% of patients being discharged to rehabilitation. These data support the efficacy of this treatment paradigm in a real-world setting.
Abstract TP368: The Impact of Hospital Based Specialist Physicians Conducting Post-Discharge Follow-Up Phone Calls at a Comprehensive Stroke Center
Authors: Sinogui Cynthia , Nandan Yogesh , Jennings Amber , Zrelak Pat
Published: June 2021

Background:
As a Comprehensive Stroke Center (CSC), The Joint Commission requires post-discharge follow-up phone calls to be conducted within 7 days of discharge for all complex stroke patients.

Purpose:
To develop and sustain a feasible approach for Hospital Based Specialist (HBS) physicians to conduct follow-up phone calls within 7 days.

Methods:
A baseline evaluation of all post-discharge phone calls was conducted. It was determined that patients were receiving several phone calls already, therefore the team did not want to add an additional call to meet compliance. HBS calls were realigned to include a stroke-specific focus, reinforcing stroke education and secondary prevention. Calls were made within 7 days by the discharging physician. All stroke patient types discharged with a stroke diagnosis were contacted regardless of severity. Patients discharged to skilled nursing facilities, board and care, acute rehabilitation or other acute care hospitals were excluded. A templated note was developed to ensure all stroke-specific components were covered. All HBS physicians were trained. Telephone interactions occurred between the patient, family member, and/or caregiver. Those unable to be reached but had messages left or secure messaging sent were counted as compliant. Reminders were sent out to physicians to improve call compliance. Tracking occurred weekly for call compliance and note template utilization.

Results:
Between January 2018 and May 2019, 612 patients discharged home from the acute care setting. Of those, 55% (334) were contacted. Of those, 73% had the templated note documented. Several hurdles were encountered along the way, but utilization of the templated note and physician reminders improved compliance.

Conclusion:
Post-discharge follow-up phone calls initiated by HBS physicians and utilization of a templated note are a feasible means of meeting and sustaining the CSC requirement.
Abstract TP369: Post-Procedural Nursing Care of Carotid Endarterectomy and Carotid Stenting Patients: The Impact of a Standardized Order Set
Authors: Cook Sarah M , Spiering Katherine , Morrow Benjamin K , Roach Eileen , Jadhav Ashutosh , Friedlander Robert
Published: June 2021

Background:
Carotid endarterectomy (CEA) and carotid stenting (CAS) procedures are performed by 3 service lines- neurosurgery, neurology, and vascular surgery in our academic medical facility. Despite 3 services caring for carotid disease patients, post-procedural nursing care is managed utilizing service line specific protocols and order sets that differ in content creating variations in post-procedural nursing care delivered on service line specific nursing units. This lack of standardization yielded variations in post-procedural nursing care and recommendations for improvement (RFI) during the hospital’s Comprehensive Stroke Center Joint Commission survey.

Purpose:
The purpose of this project is to standardize post-procedural nursing care provided to CEA/CAS patients across neurosurgery, neurology, and vascular surgery.

Methods:
Creation of a shared CEA/CAS order set among neurosurgery, neurology, and vascular surgery developed with input and agreement from providers; education was provided to nurses and physicians. Patients were prospectively identified by the stroke quality nurse, and notification was sent to post-procedural units to ensure the new CEA/CAS protocol and order set was utilized to guide post-procedural nursing care. Auditing 100% of cases for order set and protocol utilization, and real time feedback to nurses and providers on non-compliance was completed by the stroke quality nurse.

Results:
A total of 219 patients (120 pre and 99 post) were retrospectively reviewed in a pre and post cohort analysis. Order set utilization increased from 74.1% pre to 86.8% post (12.7% increase; likelihood ratio p = 0.011) over 18 months. Adherence to CEA/CAS care protocol and nursing documentation improved thus no associated RFIs in our 2019 stroke reaccreditation survey.

Conclusion:
Multi-disciplinary collaboration to create a uniform protocol and order set to guide post-procedural nursing care, in conjunction with a formal implementation and validation plan, results in successful standardization of post-procedural nursing care of the CEA/CAS patient population across 3 service lines and nursing units.
Abstract TP375: Using Characteristics of Secondary Ischemic Stroke Events to Improve Stroke Education Initiatives
Authors: Dirickson Amanda , Stone Suzanne
Published: June 2021

Purpose:
While it is common practice for nursing to perform the duty of stroke education,it is not common to use secondary stroke event data to determine what aspect of stroke education should be emphasized for the greatest impact on secondary stroke prevention. The purpose of this descriptive study is to exam the characteristics of secondary stroke events using the TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria so future educational initiatives can be customized to the needs of the local high risk population.

Methods:
The team collected data characteristics on all ischemic stroke admissions with previous admitting diagnosis of acute ischemic stroke. The strokes were further characterized using the TOAST (Trial of Org 10172 in Acute Stroke Treatment) classification to determine any emerging patterns of both risk factors and etiological types.

Conclusions:
A total of n=51 admissions were previous adult stroke survivors, (M=30, F=21). Pre-morbid risk factors were as follows: hypertension=78%, type 2 diabetes=39%, hyperlipidemia =54%, smoking=8%, atrial fibrillation=24%. TOAST classification results: Large Vessel Atherosclerosis=14%, Cardioembolic =17%, Small Vessel Disease=3%, Other Known Cause=2%, Cryptogenic=15%.

Summary:
The results reveal a striking pattern of the presence of premorbid hypertension. While the TOAST classification did not have a single dominant type, but nearly equal distribution of large vessel atherosclerosis, cardioembolic, and small vessel disease etiologies. Not surprising, the decline in stroke mortality is felt to be due to improved blood pressure control, but in discharge stroke education, hypertension is not necessarily emphasized over other perhaps less impactful risk factors. Yet, the most recent acute ischemic stroke clinical guidelines gave providers a first-time recommendation to start or restart antihypertensive therapy in stable patients with BP > 140/90. Nursing has enough encouragement to take the lead on hypertension prevention education in appropriate stable patients ready for discharge. The next goal will be to develop a multimedia educational effort in patient stroke education on hypertension as a risk factor for secondary stroke prevention in this Comprehensive Stroke Center.
Abstract TP381: Impact of a Staff Led Neuroscience Nursing Committee on Quality of Care, Staff Education, Staff Morale and Empowerment, and Health Outcomes in the Neuro-Intensive Care Unit
Authors: Carreon Eileen , Lampson Jupree , Burgess Cathy , Girado Carolyn , Nelson Christopher , Joel Illustrisimo , Joseph Anne , Lim Michale , Zrelak Patricia , Sinogui Cynthia , Zarate Wally
Published: June 2021

Background:
An ICU Neuroscience Nursing Committee was formed to function as a unit-based council, empowering nurses to impact unit decision-making and problem-solving. The committee members serve as neuroscience leaders in the Neuro ICU (NICU).

Purpose:
To determine the impact of the ICU Neuroscience Nursing Committee on staff education, quality of care, staff morale and empowerment, and health outcomes in a large NICU.

Methods:
Staff-led committee interventions include: A quarterly comprehensive neuroscience newsletter Curriculum development for an annual Neuroscience Symposium and other education eventsAnnual neurological competency review for unit staffNew employee neurological orientation and educationICU protocol, pathway, process, and policy development and reviewParticipation in neuro patient roundsReal-time hands-on education in response to unit-specific needs and identified opportunities.

Results:
Mixed methodology was used to evaluate the impact of the committee. External Ventricular Drain infections less than 1% for the last 3 years Improved stroke symptom recognition and inpatient stroke alert times Best practice recognition from The Joint Commission on nursing knowledge and expertise in caring for complex stroke patients Improved collaboration between nursing and physicians Increase in national neuroscience nursing certifications Decrease in nurse-sensitive events Abstract submission and poster presentations at premier conferences Improved neurocritical care physician satisfaction with nursing care Enhanced nurse morale and empowerment Improved patient satisfaction Input and development of new policy and procedures Duplication of neuroscience committee efforts in other departments.

Conclusion:
Establishment of the ICU Neuroscience Nursing Committee has proven to have a significant impact in improving the quality of care, patient health outcomes and enriching staff morale.
Abstract TP389: Collaborative Approach to Improving Tele Stroke Call Back Times
Authors: Clements Annette , Smith Jennifer M , Morrow Benjamin K , Jadhav Ahutosh
Published: June 2021

Background/Purpose:
Emergency stroke evaluation requires rapid access to stroke experts for treatment decisions and advice, in many community settings this is facilitated through a hub and spoke telemedicine relationship. Since widespread adoption of the expanded endovascular time window, volume of calls to a single large academic hub stroke center have drastically increased and it was identified that there was a delay in achieving rapid connection to the hub sites which may result in delayed tPA evaluations. We sought to implement a focused process review to improve timely access to the hub stroke team.

Methods:
Leadership from the hub and spoke hospitals collaboratively reviewed and implemented steps to improve the time from spoke call out to hub call back for acute stroke. Interventions included: 1) Establishing a goal of less than 10 minutes for physician contact on all cases, 2) Revising spoke protocol to call out immediately following CT instead of after CT read, 3) Development of a stroke call out log that is shared between sites, 4) Hub hospital revised protocol to have cases within tPA time window bypass phone call and go directly to camera, 5) Exchange of direct cell phone numbers for follow-up questions on existing patients, 6) Weekly calls to discuss any video case time delays and time flow review, 7) development of a hub hospital call center escalation process for when the primary call physician has multiple calls coming in.

Results:
Data we analyzed through retrospective review of a prospectively collected database over a five month period. Results are displayed in the table 1.

Conclusions:
Improved process flow times within tele-stroke networks may be achieved through a focused collaborative relationship between hub and spoke hospitals with transparency of data and open discussion about barriers to achieving desired results.
Abstract TP391: Transition to a Single Dedicated Stroke Unit Improves Patient Satisfaction
Authors: Noah Patty , Hackett Chris , Henderson Melanie , Pope Leslie , Cohen Vicki , Tayal Ashis , Cerejo Russell
Published: June 2021

Introduction:
Dedicated inpatient stroke units have been shown to decrease mortality and improve clinical outcomes. There is scant data on patient satisfaction within dedicated stroke units or the perception of care reported by the patient. At a single comprehensive stroke center we recently consolidated two stroke units on different physical locations to a single dedicated stroke unit, located in close proximity to the neuro ICU. We assessed patient satisfaction before and after transitioning to a single dedicated stroke unit.

Methods:
We analyzed the Press Ganey survey overall satisfaction scores for one year preceding and one year following transition to a single dedicated stroke unit. The overall satisfaction score is rated on a likert scale from 0 - 100. We also analyzed subsection of the Press Ganey survey. An independent samples T-test statistical analysis was used to compare the data.

Results:
The unified stroke unit was opened on January 1, 2018. We evaluated 177 Press Ganey surveys in the year preceding the transition and 191 surveys in the year following the transition to a single dedicated stroke unit. The overall patient satisfaction was significantly higher in the year after transitioning to single dedicated stroke unit (mean 91.3,
SD
= 15.7) than in the year prior (mean 87.6,
SD
= 19.7), [
95%CI
0.06 - 7.34],
p
= 0.05. Additionally, after moving the dedicated stroke unit patient care assessment scores in the stroke unit increased and variance decreased (mean 95.5,
SD
= 8.4) compared to the year prior (mean 85.1,
SD
= 25.4), although this difference was not statistically significant,
p
= 0.28.

Conclusions:
We found that transitioning to a single dedicated stroke unit significantly improved patient satisfaction scores and provided patients with more consistent care.
Abstract TP393: Standardization of Large Vessel Occlusion Assessment With Designated Stroke Zone Decreases Door in Door Out Times
Authors: Duke Kimberley , Hartman Richelle , Roth Jeffrey
Published: June 2021

Background and Purpose:
Increased Door in door out (DIDO) times prompted a change in the “Code Stroke” process in three sister Primary Stroke Centers. It was observed that utilizing a NIHSS >6 was insufficient in recognizing potential large vessel occlusion (LVO) candidates and correlated with an increase in the DIDO times of patients presenting to the Emergency Department (ED) with large vessel symptoms. After a “pilot” of the Vision, Aphasia, and Neglect (VAN) assessment tool in 2017, all three facilities initiated changes to the “Code Stroke” process. These changes included the implementation of the VAN assessment and the designation of a “Stroke Zone”.

Methods:
Data was collected from 2016 through the second quarter of 2019 on all “Code Strokes” activated in the ED. This data was analyzed to determine the efficacy of implementing the VAN assessment and designation of a “Stroke Zone”. Nursing staff and ED providers were educated on the utilization of the VAN assessment tool and the inclusion of a Computed Tomography Angiography (CTA) on patients presenting with a positive VAN assessment and symptom onset less than 24 hours. The number of Mechanical Endovascular Reperfusion (MER) candidates and the average DIDO times per quarter were compared before and after the implementation of the changes.

Results:
Evaluation of data from the three facilities showed that implementing a standardized LVO assessment tool in conjunction with a designated “Stroke Zone” increased the identification of potential LVO candidates and decreased DIDO times.

Conclusion:
The standardization of an LVO screening tool and utilization of a dedicated “Stroke Zone” contributed to a decrease in DIDO times in all three facilities. Efficacy of the changes to the process will assist in supporting best practices while caring for patients in the Stroke population. In addition, the early recognition of LVO candidates will positively impact Door to Needle times.
Abstract TP395: Hydration Highway: Improving Oral Fluid Intake on a Neuroscience Unit
Authors: Munici Tiffanie , Richardson Melissa
Published: June 2021

Background:
Hospitalized patients are more likely to experience decreased oral intake due to acute illness. This is especially true for stroke patients who may have physical and/or cognitive impairments. Adequate hydration is important to support cerebral perfusion. In addition, dehydration may prolong length of stay if the patient develops poor renal function.

Purpose:
The purpose of this quality improvement project was to improve oral fluid intake and documentation of this data for patients on a neuroscience unit.

Methods:
Education was provided to the nursing assistants about the importance of hydration for this patient population, as well as the importance of accurate documentation in the medical record. Education and visual reminders were posted in patients’ rooms. Audits of intake/output documentation were performed at regular intervals and discussed with the team during afternoon huddles. This provided an opportunity for early identification of patients at risk for dehydration so that an intervention could be implemented.

Results:
For the purpose of this project, adequate hydration was defined as oral fluid intake of 600 or more milliliters during an eight hour shift. Certain patients were excluded from the project. Examples include those with orders for fluid restriction, comfort care, or NPO for any reason. The percentage of patients with adequate hydration documented improved from 6% to as high as 90%. Although there was not a baseline data point for comparison, none of the patients developed impaired renal function during the project.

Conclusions:
Providing education, increasing awareness, and discussing audit results with the team members improves hydration and documentation of oral fluid intake on a neuroscience unit. Future studies should include monitoring the percentage of patients who are identified as at risk for dehydration, then evaluating the characteristics of that subset of patients for a potential risk screening tool.
Abstract TP403: Caring for the Caregiver After Stroke
Authors: Packard Laurel , Tubergen Tricia , DuVerneay Jamie , Veenstra Adrienne , Khan Muhib
Published: June 2021

Background:
After diagnosis of a chronic progressive condition or emergent neurologic event, the focus is on the survivor and his/her adaptation to a ‘new normal’. Often these survivors or neurologic disease/injury require physical or emotional support and supervision from a caregiver. Research tells us that the act of caregiving is stressful, and often leads to physical and mental health problems for the caregiver1. Caregivers are often forced to adjust to a ‘new normal’ themselves, and verbalize feelings of loss associated with the relationship with the person they are caring for and indicate an inability to engage in tasks that they enjoy2. Studies also indicate that support often helps caregivers identify the positive attributes to caregiving, and that community recognition/support leads to positive coping behaviors3.

Purpose:
The purpose is to inform the audience of the novel Stroke Caregiver Support Group with respite care provided in Grand Rapids, MI.

Methods:
An analysis of feedback from stroke caregivers attending this support group was conducted. Within this analysis, meaningful support group topics and respite care services were described, with analysis of how these topics benefitted the caregiver and the adjustment to life caring for a stroke survivor.

Results:
Stroke caregivers appreciate a caregiver only support group as a venue to share difficult feelings with peers and promote self-reflection. All participants indicated a strong desire to continue to attend this support group and appreciate focus topics on finances and emotional adjustment after stroke.

Conclusions:
There are few caregiver-only support groups available for those caring for a loved one after a stroke. Although many diagnosis specific survivor support groups (stroke, TBI, Alzheimer’s, etc.) exist, few target the caregiver and offer a time for respite and support with a professional moderator. A care-giver only stroke support group has shown positive anecdotal value. Long-term study on any health-related benefits and qualitative impact is recommended.
Abstract TP417: An Autoregulation-Derived Prediction Model for Midline Shift After Ischemic Stroke
Authors: Silverman Andrew , Wang Anson , Kodali Sreeja , Strander Sumita , Kimmel Alexandra , Nguyen Cindy Khanh , Peshwe Krithika , Matouk Charles C , Kimberly William T , Sheth Kevin N , Tan Can Ozan , Petersen Nils H
Published: June 2021

Introduction:
Identification of patients likely to develop midline shift (MLS) after large-vessel occlusion (LVO) stroke is essential for appropriate triage and patient disposition. Studies have identified clinical and radiographic predictors of MLS, but with limited accuracy. Using an innovative assessment of cerebral autoregulation, we sought to develop an accurate predictive model for MLS.

Methods:
We prospectively enrolled 73 patients with LVO stroke. Beat-by-beat cerebral blood flow (transcranial Doppler) and arterial pressure (arterial catheter or finger photoplethysmography) were recorded within 24 hours of the stroke, and a 24-hour brain MRI was obtained to determine infarct volume and MLS. Autoregulatory function was quantified from pressure-flow relation via projection pursuit regression (PPR), allowing for characterization of 5 hemodynamic markers (Figure 1A). We assessed the predictive relation of autoregulatory capacity and radiological and clinical variables to MLS using recursive classification tree models.

Results:
PPR successfully quantified autoregulatory function in 50/73 (68.5%) patients within 24 hours of LVO ischemic stroke (age 63.9±13.6, 66% F, NIHSS 15.8±6.7). Of these 50 patients, most (78%) underwent endovascular therapy. Thirteen (26%) experienced 24-h MLS; in these patients, infarct volumes were larger (140.2 vs. 48.6 mL,
P<0.001
), and ipsilateral (but not contralateral) falling slopes were steeper (1.1 vs. 0.7 cm·s
-1
·mmHg
-1
,
P=0.001
). Among all clinical, demographic, and hemodynamic variables, only two (infarct volume, ipsilateral falling slope) significantly contributed to prediction of MLS (accuracy 94%; Figure 1B).

Conclusions:
This predictive model of MLS wields translatable potential for triaging level of care in patients suffering from LVO ischemic stroke, but further research, including optimization of the PPR algorithm as well as prospective use of the predictive model, is needed.
Abstract TP433: Effect of Vitamin D and Marine Omega-3 Fatty Acid Supplements on Stroke Outcomes
Authors: Rist Pamela M , Cook Nancy R , Manson JoAnn E , Buring Julie E , Rexrode Kathryn M
Published: June 2021

Introduction:
Low serum 25-hydroxyvitamin D (25(OH)D) and low marine omega-3 fatty acid (n-3) intake are associated with increased stroke risk in observational studies. Among stroke patients, low serum 25(OH)D at admission predicts poor outcomes and animal studies suggest that higher n-3 intake may diminish brain damage in ischemic stroke. However, few studies have examined effects of vitamin D or n-3 supplements on stroke outcomes.

Hypothesis:
We hypothesized that vitamin D (cholecalciferol, 2,000 IU/day) or n-3 (840 mg/day of EPA/DHA [ratio of 1.3:1]) supplementation initiated prior to stroke would reduce risk of functional limitations or physical disability after stroke compared to placebo.

Methods:
We used data from the completed VITamin D and OmegA-3 TriaL (VITAL) which randomized 25,871 men aged ≥50 years and women aged ≥55 years without cardiovascular disease or cancer at baseline and followed them for incident events over 5.3 years. Individuals experiencing a stroke were mailed a questionnaire to assess functional limitations (with the physical performance scale adapted from Nagi) and physical disability (with the modified Katz Activities of Daily Living and Rosow-Breslau Functional Health scales). We used logistic regression to analyze associations between randomized treatment assignments and limitations on each scale.

Results:
290 individuals experienced their first stroke during the trial (including 42 fatal strokes). 197 stroke survivors completed the stroke outcomes questionnaire a mean of 1.6 years after diagnosis. We observed no associations between randomized treatment to vitamin D and functional limitations (odds ratio (OR)=1.01, 95% confidence interval (CI): 0.52, 1.97) or physical disability on the Rosow-Breslau (OR=1.03, 95% CI: 0.31, 3.42) or Katz (OR=0.92, 95% CI: 0.50, 1.67) scales. Although not statistically significant, those randomized to n-3 had lower risk of functional limitations (OR=0.55, 95% CI: 0.28, 1.09) and physical disability on the Katz scale (OR=0.32, 95% CI: 0.50, 1.67) but not on the Rosow-Breslau scale (OR=1.03, 95% CI: 0.31, 3.42).

Conclusion:
Supplementation with vitamin D or omega-3 fatty acids prior to stroke did not result in significantly improved outcomes after stroke among older individuals.
Abstract TP447: Tenascin-C: A Novel Therapeutic Target in Subarachnoid Hemorrhage
Authors: Shiba Masato , Fujimoto Masashi , Toma Naoki , Miura Yoichi , Kawakita Fumihiro , Suzuki Yume , Kuroda Yusuke , Ikezawa Munenari , Asada Reona , Kanamaru Hideki , Suzuki Hidenori
Published: June 2021

Introduction:
Tenascin-C (TNC) is one of pleiotropic matricellular proteins, which are non-structural and secreted extracellular matrix proteins that exert diverse functions. Recently we showed that TNC is involved in the mechanisms of cerebral vasospasm and early brain injury (EBI) after subarachnoid hemorrhage (SAH). However, the role of TNC has not been sufficiently investigated in SAH.

Materials and Methods:
First, TNC knockout (TNKO) mice SAH models were produced by endovascular perforation method, and examined the direct evidence that TNC is induced after SAH and causes cerebral vasospasm and EBI. Second, TNC was measured in serum from 156 aneurysmal SAH patients, and cilostazol (0-300 mg/day) was administered postoperatively, and investigated as to the dose-dependent effect of cilostazol on cerebral vasospasm, delayed cerebral ischemia and infarction.

Results:
In experimental SAH, TNKO prevented blood-brain barrier disruption and brain edema formation by inhibiting mitogen-activated protein kinase (MAPK)-mediated matrix metalloproteinase-9 activation. TNKO also suppressed post-SAH induction of another matricellular protein, periostin, which aggravates post-SAH EBI. TNKO also prevented neuroinflammation and neuronal apoptosis via inhibiting upregulation of Toll-like receptor 4, phosphorylation of nuclear factor-κB, and induction of proinflammatory cytokines in neurons. TNKO suppressed post-SAH cerebral vasospasm via inhibiting the activation of MAPKs. In the clinical study, cilostazol treatment suppressed plasma TNC levels from days 1-3 to days 10-12 post-SAH, and showed dose-dependent effects against delayed cerebral infarction, leading to improved outcome. Multivariate analyses revealed that 300 mg/day cilostazol treatment was an independent determinant against poor outcomes post-SAH.

Conclusions:
TNKO exerted protective effects against neuroinflammation, blood-brain barrier disruption, neuronal apoptosis, and cerebral vasospasm. The 300 mg/day cilostazol may improve post-SAH outcomes by reducing plasma TNC levels and delayed cerebral infarction. Further investigations may provide a novel therapeutic approach targeting TNC.
Abstract TP463: Treatment of Asymptomatic Angiographic Cerebral Vasospasm in Aneurysmal Subarachnoid Hemorrhage May Prevent Progression to Delayed Cerebral Ischemia
Authors: Rebeiz Tania , Sabirov Tagir , Wanchoo Sheshali , Kim Jung-Min , Temes Richard
Published: June 2021

Objective:
Endovascular treatment of angiographic cerebral arterial vasospasm (CVS) in patients with aneurysmal subarachnoid hemorrhage (aSAH), who do not fulfill criteria for delayed cerebral ischemia (DCI), remains controversial. We sought to investigate the relationship of endovascular intervention with the development of DCI.

Method:
Consecutive patients admitted between 2017 and 2019 with aSAH were analyzed retrospectively. Rates of development of DCI were compared between two groups - the treated group: patients not in DCI who underwent conventional digital subtraction angiography (DSA) between days 3 and 14 of ictus and were treated endovascularly for CVS, - the untreated group: patients who did not undergo DSA or did get DSA but did not receive endovascular treatment for CVS. Pearson’s chi-square test for independence was used to compare progression to DCI and t-test for independent samples was used to compare modified fisher scale (mFS) among the 2 groups. Multivariate logistic regression using stepwise backward selection was used to evaluate the predictors of DCI.

Results:
A total of 83 patients were analyzed. 21 patients (25%) were treated for angiographic vasospasm. 70% of these patients had moderate or severe CVS. 15 (15%) underwent DSA but were not treated angiographically. DSA was performed on an average of day 8 [5-12] post-ictus. 47 (57%) did not received DSA. Although, patients treated for angiographic CVS had higher modified Fisher Scale mFS (p=0.11), the rate of progression to DCI was higher among the untreated group 20 (32%) compared to the treated group (10%) (p =0.04). Delayed cerebral ischemia occurred at an average of day 6 [2-16] post-ictus. Although 15 out of 36 (42%) had DSA but were untreated due to absence or visualization of non-significant CVS, the treated group (68%) had significantly higher mFS (p=0.02) and elevated TCD velocities (p=0.03). mFS (p=0.04) and lack of past medical history of hypertension (p=0.03) were predictors of DCI.

Conclusion:
Endovascular treatment of angiographic CVS in asymptomatic patients was associated with lower risk of progression to DCI. A large prospective study is needed to evaluate its potential to prevent progression to DCI in high risk patients.
Abstract TP470: Stimulation of Blood Vessel Formation by Human Neural Stem/Progenitor Cells is Mediated by Secreted Material
Authors: Gutierrez Brenda , Flanagan Lisa A
Published: June 2021

Human neural stem/progenitor cells (hNSPCs) have the potential to widen the current narrow treatment window for stroke as they improve functional recovery in rodent stroke models when transplanted weeks after stroke. One aspect of the hNSPC-induced functional recovery is increased angiogenesis and neovascularization in the peri-infarct region. Our lab created a human cell
in vitro
model of vessel formation by seeding hNSPCs and human endothelial progenitor cells (hEPCs) in a 3D scaffold composed of salmon fibrinogen, laminin, and hyaluronic acid that mimics brain tissue properties. Using our
in vitro
neurovascular model, we tested the hypothesis that hNSPC-secreted material plays a role in the stimulation of vessel formation. Our RNA-Seq data show that hNSPCs express high levels of secreted pro-angiogenic proteins, such as growth factors, matrix molecules, and cytokines, but hNSPCs might also impact vessel formation by secretion of extracellular vesicles or cell-contact mediated mechanisms. In order to determine the effect of hNSPC-secreted material on vessel formation, mCherry-labeled hEPCs were seeded in 3D scaffolds alone, with CellTracker Green-labeled hNSPCs, or with hNSPC-conditioned media containing hNSPC-secreted soluble factors and extracellular vesicles, such as exosomes. Vessel formation was quantified using AngioTool to determine total vessel length, number of branch points, and vessel percentage area. We found an increase in vessel formation in the presence of hNSPCs and hNSPC-conditioned media compared to hEPCs alone. In conclusion, material secreted by hNSPCs can recapitulate the increase in vessel formation induced by hNSPCs themselves. In future studies, we will determine whether hNSPC-derived exosomes are important for promoting vessel formation as they have therapeutic potential without the limitations of cell therapy.
Abstract TP477: Vessel Diameter, Brain Perfusion and Small Vessel Disease Burden in HIV+ Population and Controls
Authors: Títoff Igor B , Murray Kyle , Qiu Xing , Wang Henry , Maggirwar Sanjay , Schifitto Giovanni
Published: June 2021

Cerebral small vessel disease (CSVD) in patients with HIV is a subject of ongoing study in regard to the effect of HIV infection on cerebral vessels. In our cohort of HIV+ (on stable cART for at least 12 weeks) and age-matched controls, we investigated the relationship between HIV status and extracranial large vessel diameter, burden of white matter hyperintensities (WMH), as well as cerebral blood flow (CBF). Subjects underwent MRI including an arterial spin labeling (ASL) sequence to calculate CBF and MRA to measure arterial diameters. Arterial diameter and regional CBF were used as outcome variables in multivariate regression models incorporating HIV status, hypertension, WMH burden, age, and Reynold score. Partial correlations were performed to assess the relationship strength between CBF and vessel diameter. Extracranial vessel diameter means were significantly different between HIV+ and HIV- cohorts after controlling for age, Reynold score, WMH, hypertension, and regional CBF means. CBF was not significantly different in the presence of HIV, nor WMH. However, hypertension and age were significantly associated with CBF in multivariate regression analysis. Extracranial vessel diameter and WMH were not significantly related. Accounting for HIV status did not affect this correlation. Extracranial large vessel diameter (0.3) and age (0.6) were strongly and significantly partially correlated with CBF. There appears to be a relationship between HIV status and caliber of extracranial vessels, suggesting possible effect of HIV on large vessel health. Vessel diameter and WMH may be related due to similar risk factors, however, further study is needed at this time. As expected, large vessel diameter correlated with perfusion metrics and age. Future directions include a volumetric assessment of WMH and assessments of the relationship between markers of platelets and endothelial dysfunction.
Abstract TP50: A Critical Assessment of the Golden Hour and the Impact of Procedural Timing in Stroke Thrombectomy: A Single-Center Study
Authors: Wessell Aaron P , De Paula Carvahlo Helio , Le Elizabeth , Cannarsa Gregory , Kole Matthew J , Yarbrough Karen , Miller Timothy R , Chaturvedi Seemant , Satti Sudhakar , Gandhi Dheeraj , Jindal Gaurav
Published: June 2021

Background:
Previous studies have demonstrated the importance keeping thrombectomy procedure times ≤60 min., termed the ‘golden hour’. In the current study, we further investigate the significance of the ‘golden hour’ and the impact of procedural timing on clinical outcomes after mechanical thrombectomy.

Methods:
We performed an analysis of 319 consecutive mechanical thrombectomy patients at a single Comprehensive Stroke Center from April 2012 through February 2019. Bivariate analyses compared patients grouped according to procedure time ≤60 min. or >60 min. and time of stroke onset-to-endovascular therapy (OTE) ≤6 hours or >6 hours. Logistic regression was used to determine independent predictors of poor outcome at 90-days defined by modified Rankin Scale (mRS) scores of 3-6.

Results:
A procedure time ≤60 min. was associated with increased revascularization rates (88% vs. 67%; p<0.001) and a greater percentage of good outcomes at 90-days (47% vs. 31%; p=0.003). Multivariable logistic regression revealed that greater age (OR 1.03, 95% CI 1.004-1.051; p=0.023), higher admission NIHSS score (OR 1.10, 95% CI 1.038-1.159; p=0.001), and history of diabetes mellitus (OR 1.94, 95% CI 1.049-3.580; p=0.035) were independently associated with a greater odds of poor outcome. Modified TICI scale scores of 2C (OR 0.12, 95% CI 0.047-0.313; p<0.001) and 3 (OR 0.19, 95% CI 0.079-0.445; p<0.001) were associated with a reduced odds of poor outcome. Although not statistically significant on univariate analysis, OTE ≤6 hrs. was independently associated with a reduced odds of poor outcome (OR 0.41, 95% CI 0.212-0.809; p=0.010) in the final multivariate model (AUC 0.800). Procedure time ≤60 min. did not have a significant independent association with clinical outcome on multivariate analysis (p=0.095).

Conclusions:
Thrombectomy procedure times beyond 60 min. are associated with lower overall revascularization rates and worse 90 day functional outcomes when compared to faster thrombectomy procedures. However, thrombectomy procedure time was not predictive of outcome on multivariable logistic regression analysis. Our study emphasizes the significance of achieving revascularization despite the requisite procedure time.
Abstract TP68: Predictive Value of CT Perfusion in Hyper Acute Ischemic Stroke Patients
Authors: Pala Varun Kumar , Chandra Rahul , Ravelo Aaron , Hackett Christopher , Cerejo Russell
Published: June 2021

Introduction:
Perfusion imaging has been an integral part in patient selection for Endovascular Thrombectomy (EVT) in the extended window. In studies evaluating perfusion imaging in the early window, the mean time from symptom onset to perfusion imaging was greater than 90 minutes.

Objective:
To determine the accuracy of perfusion imaging core volume compared to final infarct volume in patients presenting in the hyper acute period.

Methods:
We performed a retrospective analysis on a prospectively collected stroke data base from January 2018 to July 2019. We included patients with intracranial large vessel occlusion (anterior circulation) who presented within 90 minutes of symptom onset and underwent perfusion imaging with CT-perfusion (CT-P) with subsequent EVT. We collected demographics, clinical and imaging data as well as procedural variables. Final infarct volume on CTH or MRI brain (done> 24hr post EVT) was calculated manually using PACS volume analysis software. RAPID CT-P Software was used for core measurement and CBF<30% was used to predict core.

Results:
Out of 242 patients who underwent EVT, 22 (9%) patients met inclusion criteria. Of these, 32% (7/22) were males and 68 %( 15/22) were females. Median age was 79 yrs (interquartile range (IQR) 66.7 - 85.2) and median NIHSS was 16 (IQR 14 - 21). M1 occlusion was seen in 59% while, 27% had ICA terminus occlusion and 14% had proximal M2 occlusion. Median core volume pre EVT was 14.5ml (IQR 6.7 - 36.7) and final median infarct volume was 9.6ml (IQR 1.2 - 24.3). Most patients, had final infarct volume calculated on MRI 73 %( 16/22) while 27% (6/22) had follow up CTH. CT- P overestimated the final stroke volume in 55% (12/22 patients) of patients. In a subgroup of 5 patients who presented within 60 minutes of symptoms onset, 80% (4/5 patients) had an over estimated core on CT-P with a median predicted core of 29 ml (IQR 13 - 35) and median final infarct volume of 0.2ml (IQR 0.1 - 3.7).

Conclusion:
CT-P using CBF < 30% may overestimate the core infarct volume in patients presented in the hyper acute window (<90min). Caution is advised when utilizing CTP in the early time window.
Abstract TP75: Normal Appearing White Matter Integrity and Motor Impairment Severity in Acute Ischemic Stroke
Authors: Ingo Carson , Lin Chen , Higgins James , Arevalo Yurany , Prabhakaran Shyam
Published: June 2021

Introduction:
The effect of white matter hyperintensities (WMH) as measured by fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging on functional impairment and recovery after ischemic stroke has been investigated thoroughly. However, there has been growing interest to investigate normal-appearing white matter (NAWM) microstructural integrity following ischemic stroke onset with techniques such as diffusion tensor imaging (DTI).

Methods:
52 patients with acute ischemic stroke and 36 without stroke were evaluated with a DTI and FLAIR imaging protocol and clinically assessed for severity of motor impairment using the Motricity Index within 72 hours of suspected symptom onset.

Results:
There were widespread decreases in fractional anisotropy (FA) and increases in mean diffusivity (MD) and radial diffusivity (RD) for the acute stroke group compared to the non-stroke group. As shown in the abstract figure with the blue voxels, there was a significant positive association between FA and motor function and a significant negative association between MD/RD and motor function. The NAWM regions of interest that were most sensitive to the Motricity Index were the anterior/posterior limb of the internal capsule in the infarcted hemisphere and the splenium of the corpus callosum, external capsule, posterior limb/retrolenticular part of the internal capsule, superior longitudinal fasciculus, and cingulum (hippocampus) of the intra-/contralateral hemisphere.

Conclusion:
The microstructural integrity of NAWM is a significant parameter to identify neural differences not only between those individuals with and without acute ischemic stroke, but also correlated with severity of acute motor impairment.
Abstract TP93: Rapid and Appropriate Evaluation of Collateral Development by Four-Dimensional CT Angiography Covering Only 4-cm Width With a Focus on the Intracranial Internal Carotid Artery and the Middle Cerebral Artery to Identify Candidates of Thrombectomy
Authors: Mori Takahisa , Yoshioka Kazuhiro , Chiba Nozomi
Published: June 2021

Introduction:
Four-dimensional computed tomography (CT) angiography (4D-CTA) can visualize time sequential changes of bilateral internal carotid (ICA) and middle cerebral arteries (MCA). Therefore, 4D-CTA could find ICA or MCA occlusion and visualize collateral circulation in case of intracranial artery occlusion.

Hypothesis:
Four-dimensional CTA covering only 4-cm width with a focus on the intracranial ICA and the MCA can early visualize them because of small volumetric data and evaluate collateral development status to identify candidates of thrombectomy.

Methods:
We included acute ischemic stroke patients who 1) were admitted from August 2018 to July 2019 due to ICA or MCA occlusion, 2) underwent 4D-CTA covering only 4-cm width on admission and 3) underwent endovascular thrombectomy. We classified collateral status into good, moderate and poor collateral according to opacification of M2 and M3 branches distal to occlusion and evaluated successful recanalization of thrombolysis in cerebral infarction (TICI) grade 2b or 3 and improvement of NIHSS score 7 days after thrombectomy.

Results:
During the study period, 337 acute ischemic stroke patients were admitted, 92 patients suffered from ICA or MCA occlusion and 23 patients met our inclusive criteria. Median age was 81 years and median ASPECTS was 10. Image reconstruction time of 1,000 images was only 69 seconds and 4D-CTA with only 4-cm width demonstrated MCA occlusion in 14 patients, IC occlusion in 9 patients and collateral status as good in 4 patients, moderate in 13 patients and poor in 6 patients. Median onset-to-recanalization time was 5.2 hours, successful recanalization was achieved in 21 patients (91.3%), median NIHSS score on admission was 20, median 7-day NIHSS score decreased to 6 (p<0.0001) and median decrease of NIHSS score was 13. Two patients without successful recanalization had no early improvement of NIHSS score, whereas 20 of 21 patients with successful recanalization obtained early neurological improvement.

Conclusion:
Four-dimensional CTA with only 4-cm width rapidly and appropriately evaluated collateral status to identify candidates of thrombectomy for ICA or MCA occlusion and achieved early neurological improvement following successful recanalization.
Abstract TP98: Aging-Related Impairment in Post-Ischemic O-GlcNAcylation Activation Critically Contributes to Stroke Outcome
Authors: Wang Zhuoran , Li Xuan , Hoffmann Ulrike , Sheng Huaxin , Yang Wei
Published: June 2021

Introduction:
Activity of the unfolded protein response (UPR) declines with age. The most conserved UPR branch is mediated by inositol- requiring enzyme-1 (IRE1). Once activated, IRE1 is converted to an endonuclease that splices X-box binding protein-1 (Xbp1) mRNA, leading to production of a new 54-kDa protein, XBP1s. XBP1s was recently shown to be capable of up-regulating expression of all major hexosamine biosynthetic pathway (HBP) enzymes. HBP generates UDP-GlcNAc, the sugar donor for O-GlcNAc modification (O-GlcNAcylation). These pathways together form the IRE1/XBP1s/HBP/O-GlcNAc axis. Our previous data demonstrated a pivotal role of this axis in stroke outcome, especially in the aged brain. Here, we expanded on our previous findings and further elucidated that aging-related impairment in post-ischemic O-GlcNAcylation activation critically contributes to stroke outcome.

Methods:
Permanent and transient middle cerebral artery occlusion (MCAO) surgeries were performed on young and aged animals. Conditional XBP1 transgenic (XBP1s-TG) and knockout (Xbp1-cKO) mice were used to determine the role of the XBP1 branch in stroke outcome. Thiamet-G was used to increase O-GlcNAcylation. Short- and long-term stroke studies were conducted. Functional outcome was evaluated by various behavioral tests.

Results and Conclusions:
In line with our previous data, XBP1s-TG mice exhibited improved stroke outcome, and boosting O-GlcNAcylation with thiamet-G rescued worse stroke outcome observed in Xbp1-cKO mice. Moreover, intervention with thiamet-G to enhance O-GlcNAcylation in the brain improved not only long-term outcome after transient MCAO in young mice, but also long-term functional recovery after permanent MCAO in aged rats, likely due to its rescue effect on impaired O-GlcNAcylation activation in the aged brain. Finally, we discovered that UDP-GlcNAc production under the physiologic state and after ischemia was compromised in the aged brain, which constitutes a potential mechanism responsible for impaired O-GlcNAcylation activation after stroke. Together, the findings strengthen our notion that targeting pro-survival pathways that are activated in the young, but not the aged, ischemic brain is a new promising therapeutic strategy in stroke.