bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP72: Should Hypoperfusion Intensity Ratio Influence Patient Selection for Mechanical Thrombectomy?
Authors: Tarasaria Karan , Topiwala Karan , Lima Jussie , Staff Ilene , Pervez Mubashir , Nouh Amre
Published: January 2019

Background:
Current data utilizes clinical-radiographic mismatch (core and mismatch ratio) as patient selection criteria for mechanical thrombectomy in LVO. High HIR (Hypoperfusion Intensity Ratio) is known to correlate with core size, infarct growth and outcome though influence on patient selection has not been yet determined.

Hypothesis:
Patients with High HIR and malignant profile (Tmax >10s greater than 50% of penumbra) indicative of fast growing infarct may influence final clinical outcome irrespective of reperfusion.

Methods:
We retrospectively identified all AIS patients with LVO who underwent CTP imaging between January and June2018 within 24 hours from symptom onset. Demographics, CTP imaging variables, reperfusion status and outcomes (discharge NIHSS and mRS) were analyzed. HIR was dichotomized by proportion of greater and less than 0.5 into malignant vs favorable profile. Association with core size, infarct growth velocity, reperfusion (defined as TICI 2b or 3) and impact on outcomes was analyzed using Wilcoxon Ranked Sum tests for the (skewed) continuous and ordinal variables; chi-square test of proportion were used for categorical variables. The independent contribution of HIR and reperfusion predicting the major outcomes was assessed with logistic regression.

Results:
A total of 67 patients with LVO were identified with a median age of 78 (IQR 62-87), NIHSS of 16 (IQR 11-21) and time from last seen normal to CT 404 minutes (IQR 113-734). Five patients were excluded due inadequate CTP data. Patients with high HIR (n=23) had a higher core size (median 39 cc; IQR 16-73) compared to 0 cc (IQR 0-12) than patients with low HIR (n=39; median 0; IQR 0-12) (p=<0.001) and faster Infarct growth rate 14.8 cc/hr (IQR 3.6-29.7) vs. 0 cc/hr (IQR 0-1.12) (p=<0.001). After adjusting for reperfusion, median discharge NIHSS was not significantly different (p=0.22) in groups with low vs high HIR, however in-hospital mortality differed (p=0.02).

Conclusion:
Higher HIR and malignant profile is associated with larger index core size and faster growth rate. However, the influence of this profile on clinical outcomes after recanalization is yet to be established. Ongoing studies evaluating the utility of HIR on patient selection for thrombectomy are needed.
Abstract TP74: Spotty Calcification on Cervicocerebral Computed Tomography Angiography Associates With Increased Risk of Acute Ischemic Stroke
Authors: Zhang Fan , Yang Li , Gan Lu , Fan Zhaoyang , Zhou Bill , Deng Zixin , Dey Damini , Berman Daniel S , Li Debiao , Xie Yibin
Published: January 2019

Introduction:
Cervicocerebral vascular calcification on cervicocerebral computed tomography angiography is a known sign of advanced atherosclerosis. However, the clinical significance of calcification pattern remains unclear. This study aimed to investigate the potential association between spotty calcium (SC) and acute ischemic stroke.

Methods:
This study included patients with first-time nonlacunar ischemic stroke (N=50) confirmed by brain MRI or non-enhanced head CT, as well as age and sex-matched control subjects with asymptomatic carotid atherosclerosis (N=43) confirmed by carotid ultrasonography. Subjects in both groups underwent contrast-enhanced cervicocerebral CTA within a week after the initial imaging exam. Spotty calcification was evaluated at eleven arterial segments commonly affected by atherosclerosis along the carotid and vertebrobasilar circulation. Statistical analysis was performed comparing the frequency and spatial pattern of spotty calcification between the two groups.

Results:
Spotty calcification in the stroke group was markedly more prevalent than that in the control group (total SC count: 8.74±4.96 vs 1.84±1.77, p<0.001). The relative risk for stroke of spotty calcification at bilateral carotid bifurcation, carotid siphon, and all evaluated locations were (95% confidence interval): 2.521 (1.530~4.155), 1.441 (1.073~1.937), and 1.971 (1.434~2.709), respectively. A total number of 3 spotty calcifications was determined as the optimal cutoff threshold for increased risk of stroke. Spotty calcium showed significantly greater area under the receiver-operating characteristics curve (ROC) than that of total calcium irrespective of size (0.88 versus 0.77). Within the stroke group, ipsilateral lateral side showed significantly more spotty calcium than the contralateral side (5.18±3.05 vs. 3.56±2.67, p<0.001).

Conclusions:
Nonlacunar ischemia stroke was associated with markedly increased incidence of spotty calcification with a distinct spatial pattern on cervicocerebral computed tomography compared with subclinical atherosclerosis, suggesting the potential role of spotty calcification for improving the risk-stratification for ischemic stroke.
Abstract TP79: Do Early Ischemic Changes Occur on CT Within the First Hour of Acute Ischemic Stroke
Authors: Czap Alexandra , Yamal Jose-Miguel , Parker Stephanie , Rajan Suja S , Bowry Ritvij , Grotta James
Published: January 2019

Introduction:
Early ischemic changes (EIC) on non-contrast computed tomography (NCCT) can appear within 6 hours of last known normal (LKN), and can be quantified using the Alberta Stroke Program Early CT Score (ASPECTS). However, there is lack of data describing when EIC first appear. We leveraged our Mobile Stroke Unit (MSU) to determine the incidence of EIC on NCCT within 1 hour of LKN.

Methods:
Prospectively derived data were analyzed from patients on our MSU who were independently adjudicated as tissue plasminogen activator (tPA) eligible, had NCCT within 1 hour of LKN, and had definite strokes based on subsequent testing. EIC, defined as ASPECTS ≤ 7, was measured and correlated to time from LKN, stroke severity (National Institutes of Health Stroke Scale, NIHSS), and presence of large vessel occlusion (LVO) on neuroimaging. All scans were obtained on an 8 slice Ceretom (Neurologica Corp) and graded by a Vascular Neurology fellow, with random scans compared with a Vascular Neurology attending (κ=0.69).

Results:
80 tPA eligible patients with NCCT within 1 hour of LKN were identified. 57 had definite strokes and/or strokes reversed by tPA. Of these, 54 (95%) had NCCT with sufficient diagnostic quality. Mean ASPECTS was 9.2 (median 10, interquartile range (IQR) 9-10) with a mean of 45.3 minutes (median 46, IQR 39-52) from LKN. Average NIHSS was 14.9. EIC (e.g. ASPECTS 6, 6, 7, 7) was identified in 4 patients (7%). There was no association between ASPECTS and time from LKN to CT (p=0.63), stroke severity (p=0.12) or presence of LVO (p= 0.09); the LVO analysis was limited by the small number of EIC patients (n=4).

Conclusions:
Based on our experience, EIC may be present but ASPECTS is not < 6 within the first hour after LKN. Close scrutiny of NCCT for EIC within this timeframe may not be necessary for determining eligibility for tPA or endovascular thrombectomy.
Abstract TP8: FLAIR Positive and Susceptibility Vessel Sign on T2* Weighted Image did not Associate With Poor Outcome in Acute Ischemic Stroke Patients Treated With Thrombectomy at 6 to 24 Hours
Authors: Kanamaru Takuya , Suzuki Kentaro , Aoki Junya , Kutsuna Akihito , Nishi Yuji , Takeshi Yuho , Nakagami Toru , Numao Shinichiro , Kimura Kazumi
Published: January 2019

Background:
Two randomized controlled trials published in 2018 showed the effect of thrombectomy for acute ischemic stroke more than 6 hours after onset. It is reported that hyperintense lesions on fluid-attenuated inversion recovery (FLAIR positive) and susceptibility vessel sign (SVS) on T2*WI are associated with poor outcome (PO) in patients treated with rt-PA thrombolysis within 4.5 hours in acute ischemic stroke. However, it is not clear that FLAIR positive and SVS on T2*WI are associated with PO in patients treated with mechanical thrombectomy at 6 to 24 hours after the onset.

Method:
We enrolled 72 consecutive patients treated with mechanical thrombectomy for acute ischemic stroke at 6 to 24 hours after the onset from April 2011 to June 2018. We retrospectively compared PO (a score of 3 to 6 on the modified Rankin Scale at 90 days) group (n=38) with good outcome (GO, a score of 0, 1, or 2 on the modified Rankin Scale at 90 days) group (n=34) and examined what was the predictor of PO.

Result:
FLAIR positive (41.2% vs 25.8%, P= 0.408) and SVS on T2*WI (32.4 vs 29.0%,P=0.852) were found similarly between both groups. Moreover, there was no significant difference between PO and GO groups in age (75.7 years old vs 69.4 years old, P= 0.062), stroke subtypes (P= 0.129), occlusion site (P= 0.682), DWI-ASPECTS (9 vs 8, P= 0.086), other risk factors. National Institutes of Health Stroke Scale (NIHSS) at admission was higher in PO group than GO group (17 vs 12, P = 0.047). The duration from onset to recanalization (O2R) was significantly longer in PO group than in GO group (765 min vs 631 min, P=0.043), and the median Thrombolysis In Cerebral Infarction (TICI) grade was significantly lower in PO group (P <0.001). Multivariable logistic regression analysis demonstrated that FLAIR positive and SVS on T2*WI after adjusting for age, sex, NIHSS at admission, O2R, and TICI grade were not associated with PO (P= 0.534 and P= 1.000, respectively).

Conclusion:
FLAIR positive and SVS on T2*WI did not associate with poor outcome in patients treated with thrombectomy at 6 to 24 hours.
Abstract TP80: Deep Learning Based Prediction of Tissue Status From Native CT Perfusion Images
Authors: Robben David , Christensen Soren , Boers Anna M , Marquering Henk A , Majoie Charles B , van Oostenbrugge Robert J , Roos Yvo B , Dippel Diederik W , van Zwam Wim H , van der Lugt Aad , Lansberg Maarten G , Albers Gregory W , Suetens Paul , Lemmens Robin
Published: January 2019

Introduction:
CT Perfusion (CTP) imaging allows estimations of the ischemic core and penumbra. We hypothesize that a deep learning approach improves upon classic deconvolution analysis.

Method:
We trained a deep neural network to predict the final infarct volume based on the native CTP images, time to reperfusion and reperfusion status in a derivation cohort (MR CLEAN study). Given a CTP scan, prediction of the final infarct with simulated treatment parameters (instant reperfusion or no reperfusion at all), allows estimation of core and perfusion lesion. The model was validated in a five-fold cross-validation on the derivation cohort and, without retraining, on an external dataset (CRISP study). We calculated the mean absolute difference (MAD) between the volumes of the predicted core/perfusion lesion and true final infarct in reperfusers and non-reperfusers (based on 24h MRA and mTICI at the end of the procedure: 0 vs 2B-3) and compared these to the volume estimations of CTP processing by IschemaView RAPID. We assumed the measured final infarct to correspond to the core at baseline in reperfused patients and to the perfusion lesion in non-reperfused patients.

Results:
In the derivation cohort the deep learning prediction improved core prediction in reperfusers (MAD of 34 ml vs 66 ml, p<0.001) and provided equivalent results in non-reperfusers for perfusion lesion prediction (both MAD of 35ml, p=0.5). Validation on the CRISP dataset showed improved core prediction (MAD of 32 ml vs 37 ml, p<0.001) and was inconclusive for non-reperfusers (n=3).

Conclusion:
We developed and validated a deep learning based method which improved volume estimations compared to classic CTP processing.
Abstract TP86: Matching CT Perfusion Deficit Very Early in the Time Window Seriously Overestimates Eventual Infarct Size With Prompt and Successful Endovascular Therapy
Authors: Miskolczi Laszlo
Published: January 2019

Introduction:
There is an ongoing debate about the value of CT perfusion (CTP) in general, but especially in the short time window stroke cases. We decided to retrospectively review those cases where the stroke was witnessed so the patient got to the hospital very quickly, underwent CTP imaging, and after undergoing successful endovascular therapy (EVT), an MRI scan was done to confirm eventual completed stroke indicated by DWI changes.

Hypothesis:
CTP provides false information on irreversibility in such early stroke cases.

Methods:
A total of 125 EVTs for acute stroke were performed between 1/1/2016 and 8/10/2018. Of those 18 (14.4%) had event to reperfusion time equal or shorter than 2 hours. Four patients were treated without CTP imaging, so CTP data were available for 14 patients. The volume of irreversible stroke was calculated by the Philips ISP system using a CBV threshold of less than 2 ml per 100 grams of brain tissue. All of those 14 cases underwent successful EVT with TICI-2B or TICI-3 results. The volume of completed stroke after EVT was calculated from DWI images. We calculated a ratio of (CTP-DWI)/CTP volume. If the ratio = 0 then CTP is a good predictor. If the ratio is a positive number, CTP overestimates, if negative, it underestimates irreversible stroke volume.

Results:
The mean, median and SD of CTP was 36.2 ml, 17.4 ml and 50.0 ml, respectively, the same values for DWI changes were 10.05 ml, 2 ml and 15.37 ml. The median of the (CTP-DWI)/CTP ratio was 0.72 of all 14 cases, while in those 7 cases where the irreversible volume was predicted higher than 20 ml, the ratio remained 0.72.

Discussion:
CTP seriously overestimated final stroke volume in this group of patients. CTP provides prediction based on an arbitrary blood volume threshold (less than 2 ml/100 g tissue) which does not take into consideration time passed since the event. In this short retrospective analysis we found that within the hyper-acute phase of stroke CTP is unreliable. It shouldn’t be used to determine eligibility for EVT. On the other hand, spending 3 minutes on CTP was felt beneficial because it served as a physiologic confirmation of the anatomical CTA finding, as well as a predictor of expectable damage if the procedure would fail or not being done.
Abstract TP87: Gaze Deviation on Initial CT as Predictor of Large Vessel Occlusion
Authors: Kulacz Jeremy E , Cherian Laurel J , Conners James J , Dafer Rima M , Osteraas Nicholas D , Song Sarah Y , Vargas Alejandro
Published: January 2019

Introduction:
Treatment of large vessel occlusion (LVO) stroke is traditionally preceded by imaging evaluation of vessels using computed tomographic angiography (CTA). However, CTA may not be feasible due to renal dysfunction or contrast allergy; in smaller hospitals, CTAs may not be easily obtainable. Given this, early LVO signs on initial non-contrast computed tomography (CT) could prove practical, such as the hyperdense vessel sign (HVS). We aimed to investigate the sensitivity of another potential indicator of LVO on CT, gaze deviation, and to compare it to HVS.

Methods:
We conducted a retrospective analysis of consecutive patients with anterior circulation LVO stroke admitted to a comprehensive stroke center from July 2015 to July 2018, who underwent endovascular therapy (ET). All patients had confirmed LVO on CTA prior to ET. Initial head CTs were reviewed for HVS and gaze deviation by two neurology-trained examiners and compared to official diagnostic radiology reports. Two analyses were performed: detection of HVS and gaze deviation by each examiner, diagnostic radiologist with sensitivity calculation; and interrater agreement for identification of HVS and gaze deviation using a Kappa Coefficient between the two primary examiners and between diagnostic radiologist.

Results:
A total of 121 patients were included. Sensitivity of HVS by examiner 1 was 46% (56/121) and 2 was 60% (72/121). Sensitivity of HVS by in-house radiology was 36% (42/116) and OSH radiology was 27% (24/90). Sensitivity of gaze deviation by examiner 1 was 65% (79/121) and 2 was 79% (95/121). Inter-rater reliability of HVS for examiners 1 and 2 had substantial agreement (K=0.64), and for in-house and OSH radiology had fair agreement (K=0.27). Inter-rater reliability of gaze deviation for examiners 1 and 2 had substantial agreement (K=0.69). No radiology report noted gaze deviation, despite 2 reports of unrelated ocular findings.

Conclusions:
Gaze deviation may be a more sensitive and more reliable indicator of LVO on initial non-contrast head CT than the hyperdense vessel sign. This is the largest sample size to examine and directly compare signs of LVO. More research should be invested in this and other indicators of LVO that can assist in the efficient triage and treatment of these severe strokes.
Abstract TP89: Perfusion Computed Tomography is Preferable to Computed Tomography Angiography for Decision of a Reperfusion Therapy in Patients With Minor Stroke
Authors: Ahn Seong Hwan , Han Sang Won , Lee Kyung-Yul , Cho Yong Su
Published: January 2019

Introduction:
In the emergency room, minor stroke may be difficult to discriminate from stroke mimics or other neurological disease and can be often dismissed from reperfusion therapy. However, intravenous thrombolysis has shown the benefit in patients with mild ischemic stroke. We assumed that CT perfusion (CTP) gives a comprehensive evaluation of minor cerebral lesions and can affect a decision of intravenous thrombolysis.

Methods:
From May 2015 to august 2017, we collected consecutive patients with the National Institutes of Health Stroke Scale Score (NIHSS) less than 5 who were evaluated with multi-modal CT images within 6 hours from onset. All patients underwent diffusion MRI to confirm acute ischemic lesions within 24 hours. The CTP findings were compared with CT angiography and Non-contrast CT in lesion discrimination and thrombolysis decision.

Results:
Of 183 patients (mean age 66.5 years, standard deviation 13.6, male, 64.5%) with minor stroke, 39 patients (21.3%) had no neurologic signs at admission. The degree of agreement between perfusion CT lesion and CT angiography abnormality was moderate (kappa=0.49, p=0.001). Focal perfusion abnormalities (85 patients, 46.4%) were associated with higher admission NIHSS (median 2 vs. 1, p=0.002), more frequent CT angiography abnormality (69.4% vs. 20.6%, p=0.001) and non-lacunar infarction (94.1% vs. 38.8%, p=0.001). The decision of intravenous thrombolysis therapy (49 patients, 26.8%) was associated with higher NIHSS (3 vs. 1, p=0.001), CTP abnormalities (65.3% vs. 39.6%, p=0.002), negative non-contrast CT abnormality (87.8% vs. 68.7%, p=0.009), and male sex (77.6% vs. 59.7%, p=0.025). However, CT angiography was not (p=0.208). The admission NIHSS (odds ratio 2.012, 95% confidence interval 1.463-2.766, p=0.001) and CTP abnormality (odds ratio 2.431, 95% confidence interval 1.129-5.234, p=0.023) were independent factors for the decision of intravenous thrombolysis therapy.

Conclusions:
In minor stroke, multi-modal CT images including CTP were helpful to discriminate between lacunar infarction and territorial stroke and to decide of intravenous thrombolysis in minor stroke.
Abstract TP90: Computed Tomography Perfusion Mismatch is Stable Over Time From Onset After Stroke Due to Underestimation of Core Infarct in Late Time Window
Authors: Siegler James E , Rosenberg Jon , Olsen Andrew , Cristancho Daniel , Pulst-Korenberg Johannes , Raab Lindsay , Woo John , Cucchiara Brett , Messé Steven
Published: January 2019

Background:
Automated computed tomography perfusion (CTP) imaging is proven effective at selecting patients with acute large vessel occlusion (LVO) for endovascular intervention in the extended time window (>6 hours after last known normal [LKN]). However, there are limited data on the likelihood of identifying core infarct-penumbral mismatch in the late time window.

Hypothesis:
Automated CTP mismatch ratios (Time-to-maximum residue function [T
max
] >6s: relative cerebral blood flow [rCBF] <30%) using RAPID software will decrease as time from LKN increases.

Methods:
We reviewed a retrospective registry of consecutive patients with LVO who underwent CTP within 24h of LKN at 3 academic hospitals between 06/2017 - 12/2017. Unenhanced CT and CTP parameters were compared between patients who presented within 12h of LKN versus 12-24h of LKN.

Results:
Among 60 included patients, the median age was 78 years (IQR 64-84), 36 (60.0%) were female, and 39 (65.0%) underwent thrombectomy. Patients who presented at 12-24h had poorer ASPECTS scores than patients who presented <12h from LKN (median score 7 [IQR 5-8] vs. 8 [IQR 6-9], p=0.092), but the mismatch ratios were not significantly different (median 5.95 [IQR 2.64-9.11] vs. 3.28 [IQR 2.19-7.70], p=0.509). Longer delay from LKN were associated with a lower ASPECTS score (adjusted β -0.12 points/hr, 95%CI -0.21 - -0.04, p=0.006), which was driven by patients with witnessed symptom onset (adjusted p=0.009; Figure), but no significant change in rCBF <30% (adjusted p=0.360) irrespective of whether symptom onset was witnessed (adjusted p=0.847; Figure).

Conclusions:
As time progresses in acute anterior LVO, the unenhanced CT may be more sensitive than rCBF<30% for detecting the volume of irreversibly damaged tissue.
Figure caption:
ASPECTS and rCBF <30% over time. Blue dots indicate patients with witnessed onset (with fitted dashed line), red circles indicate patients with unwitnessed onset (with fitted solid line).
Abstract TP94: Temporal Similarity Perfusion Mapping; A Model-Free Dsc Analysis Method to Parse Tissue Perfusion From Steno-Occlusive Delay Artefact
Authors: De Vis Jill , Restivo Matthew , Latour Larry
Published: January 2019

Introduction:
CT or MRI perfusion data analyzed with a deconvolution method is used to depict potentially salvageable tissue in stroke patients. However, images may be confounded by delayed arrival due to the reliance on a single arterial input function. Here we present advances of a model-free DSC analysis method, Temporal Similarity Perfusion (TSP), which circumvents delayed arrival artifacts.

Theoretical Background:
TSP mapping applies an iterative process to estimate the Pearson’s correlation coefficient of signal intensity (SI) time-curve to that of likely healthy brain tissue (Figure 1). Other than the correlation coefficient for each voxel, the time-to-maximum correlation (or “delay”) and the maximum peak value are calculated on a voxel basis. The maps are not equitable to traditional MTT/TTP, CBV, CBV maps, however are less susceptible to noise, have greater lesion conspicuity, and may help distinguish core from penumbra. The delay map provides transit delays independent of proximal steno-occlusive disease.

Methods and Results:
An in-house Matlab script was used to perform TSP analysis on raw DSC images. A representative example of the TSP maps of acute stroke, in comparison to deconvolution maps and admission and follow-up DW images is shown in Figure 2. From this figure it can be noted that (1) CBV and peaks map appear similar and are in accordance with admission DWI, (2) TTP, correlation and delay map show the same lesion and this lesion corresponds to follow-up DWI.

Conclusion:
TSP mapping can delineate the penumbra and core. Future work will evaluate whether TSP images outperform the deconvolution method in subjects with proximal steno-occlusive disease.
Abstract TP95: Whole Brain Gray Matter Structural Changes Following Stroke
Authors: Hou Jiancheng , Nair Veena A , Williams Leroy M , Tellapragada Neelima , Moreno Brittany , Dodd Keith , Mohanty Rosaleena , Kang Theresa J , Prabhakaran Vivek
Published: January 2019

Background:
Changes in cortical gray matter volume is associated with cognitive impairment after ischemic stroke. Here, we investigated the differences of whole brain gray matter volume and gray matter density between acute stroke patients (AS), patients with risk factors for stroke (RS), and healthy controls (HC).

Methods:
Patients with acute stroke (N = 65, ischemic stroke within 8 days of stroke onset, mean age = 60.64 years, SD = 12.24, SEM = 1.71), patients with risk factors for stroke (N = 27, mean age = 64.12 years, SD = 11.96, SEM = 2.30) and age-matched healthy controls (N = 57, mean age = 58.05 years, SD = 6.06, SEM = 0.80) were scanned on a GE 3T MRI scanner. High-resolution 3D T1-weighted whole brain BRAVO FSPGR images were collected: repetition time = 8160 ms, echo time = 3.18 ms, flip angle = 12°, field-of-view = 100 х 100 mm, slice thickness = 1 mm. Gray matter volume and density changes were assessed using VBM8 toolbox and SPM8, with Gaussian Random Field as multiple comparison (voxel
p
< .001, cluster
p
< .05).

Results:
Two sample t-test indicated that: (1) AS had significantly decreased gray matter volume compared to RS (only on the postcentral gyrus) and HC (in sub-regions of frontal, temporal, occipital lobes, sub-lobar, cerebellum); (2) AS also had significantly decreased gray matter density compared to RS (in sub-regions of frontal, temporal, parietal, occipital lobes, limbic lobe) and to HC (in sub-regions of frontal, temporal, occipital lobes, sub-lobar, limbic lobe, cerebellum) but except two regions with increased density compared to HC (anterior and posterior cingulum). (3) RS had both significantly decreased gray matter volume and density compared to HC (in sub-regions of frontal, temporal, occipital lobes, sub-lobar, cerebellum).

Conclusion:
Compared to RS and HC, AS may induce changes in both gray matter volume and density, which result in subsequent cognitive impairments such as language or working memory. Significant changes in RS indicate that brain and associated behavioral changes in this population merits further investigation before progression to stroke.
Abstract WMP100: Prior Antiplatelet Use and Outcomes After Lobar, Deep, and Intraventricular Hemorrhage
Authors: Murthy Santosh B , Roh David , Chatterjee Abhinabha , Chen Monica , Dlugash Rachel , McBee Nichol , ElJalby Mahmoud , Merkler Alexander , Navi Babak , Awad Issam , Hanley Daniel , Sheth Kevin , Kamel Hooman , Ziai Wendy
Published: January 2019

Introduction:
We examined the association between prior antiplatelet therapy and outcomes in patients with lobar versus deep intracerebral hemorrhage (ICH) versus intraventricular hemorrhage (IVH).

Methods:
We performed a retrospective cohort study using data from patients with lobar and deep ICH registered in the Virtual International Stroke Trials Archive (VISTA-ICH), and patients with IVH enrolled in the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage (CLEAR) III trial. We excluded patients in the intervention arms of the trials, and those on prior anticoagulation therapy. The exposure was antiplatelet therapy prior to ICH/IVH. Primary outcomes were hematoma expansion and death/major disability in the VISTA-ICH cohort, and ventriculostomy tract hemorrhage, hematoma expansion, and death/major disability in the CLEAR III cohort. We used separate sets of logistic regression models in each group—lobar ICH, deep ICH, and IVH—to examine the association between antiplatelet therapy and our outcomes.

Results:
Among 548 ICH patients in the VISTA-ICH cohort, there were 416 (75.9%) lobar and 121 (22.1%) deep hematomas. Median baseline ICH volumes were 19 ml (IQR, 11-26) in lobar and 8 ml (IQR, 4-13) in deep bleeds. Prior antiplatelet therapy was reported in 92 patients with lobar (22.1%) and 26 patients (20.8%) patients with deep ICH. After adjustment for demographics, comorbidities, and hematoma characteristics, antiplatelet therapy was not associated with hematoma expansion or poor functional outcomes after lobar (OR, 0.8; 95% CI, 0.5-1.8) or deep (OR, 1.3; 95% CI, 0.4-3.8) ICH. In the CLEAR cohort, the 62 of 222 IVH patients (27.9%) with prior antiplatelet therapy had similar odds of hematoma expansion (OR, 0.6; 95% CI, 0.2-1.7) or poor functional outcomes (OR, 0.9; 95% CI, 0.4-2.1), but higher odds of ventriculostomy tract hemorrhage (OR, 3.2; 95% CI, 1.3-7.7).

Conclusions:
Prior antiplatelet therapy was not associated with hematoma expansion or functional outcomes after lobar or deep ICH or IVH, but was associated with ventriculostomy tract hemorrhage.
Abstract WMP101: Prognosis and Ischemic Stroke Occurrence in Patients With Intracerebral Hemorrhage and Concomitant DWI Lesions
Authors: Rocha Eva A , Pasi Marco , Silva Gisele S , Viswanathan Anand , Singhal Aneesh B
Published: January 2019

Background and Objectives:
Acute DWI lesions are frequently found in patients with intracerebral hemorrhage (ICH). We aim to identify whether these patients have a higher risk of death, recurrent ICH or ischemic stroke compared to those without DWI positive lesions.

Methods:
We identified 214 prospectively enrolled patients with acute ICH admitted to Massachusetts General Hospital from January 2005 to September 2011 who underwent brain MRI within 7 days. The presence of cardiovascular death, ICH or ischemic stroke was compared between patients according to the presence and number of DWI lesions (absent, single or multiple).

Results:
Mean age was 74 years and 52% were female. Of the 214 patients, 41 had acute DWI lesions (25 single and 16 multiple). The rates of hypertension, diabetes, atrial fibrillation and coronary artery disease did not differ between groups. Most patients were diagnosed with probable cerebral amyloid angiopathy (60%) and had a lobar location (66%). The mean follow-up time was 2686 days. Patients with single or multiple DWI lesions tended to have higher rates of recurrent intracerebral hemorrhages, vascular death and ischemic strokes compared to the DWI negative group (multiple=56.2% vs. single=20% vs. absent=20.8%, p=0.005). In multivariate analysis using age, gender, DWI lesions, ICH volume, and ICH etiology as covariates, DWI lesions remained an independent predictor of recurrent ICH, vascular death or ischemic stroke.

Conclusion:
The presence of acute DWI lesions in ICH patients confers a higher risk of the composite outcome recurrent intracerebral hemorrhage, vascular death and ischemic stroke.
Abstract WMP102: Antiplatelet Therapy in Intracerebral Hemorrhage
Authors: Sprügel Maximilian I , Kuramatsu Joji B , Gerner Stefan T , Sembill Jochen A , Beuscher Vanessa D , Hagen Manuel , Roeder Sebastian S , Lücking Hannes , Struffert Tobias , Dörfler Arnd , Schwab Stefan , Huttner Hagen B
Published: January 2019

Introduction:
This study determined the influence of concomitant antiplatelet therapy (APT) on hematoma characteristics and outcome in primary spontaneous intracerebral hemorrhage (non-OAC-ICH), vitamin K antagonist (VKA-) and non-vitamin K antagonist oral anticoagulant (NOAC-) associated ICH.

Methods:
Data of retrospective cohort studies and a prospective single-center study were pooled. Functional outcome, mortality and radiological characteristics were defined as primary and secondary outcomes. Propensity-score(PS)-matching and logistic regression analyses were performed to determine the association between single or dual antiplatelet therapy and hematoma volume.

Results:
A total of 3,580 ICH patients were screened, of whom 3,545 with information on antiplatelet therapy were analyzed. 346(32.4%) patients in non-OAC-ICH, 260(11.4%) in VKA-ICH and 30(16.0%) in NOAC-ICH were on APT and these patients had more severe comorbidities. After PS matching VKA-ICH patients on APT presented with less favorable functional outcome (mRS=0-3: APT:48/202[23.8%] vs no-APT:187/587[31.9%]; p=0.030) and higher mortality (APT:103/202[51.0%] vs no-APT:237/587[40.4%]; p=0.009), while no significant differences were present in non-OAC-ICH and NOAC-ICH. In VKA-ICH hematoma volume was significantly larger in patients with APT (21.9[7.4-61.4]ml vs 15.7[5.7-44.5]ml; p=0.005). Multivariable regression analysis revealed an association of APT and larger ICH volumes (OR: 1.80[1.20-2.70]; p=0.005), which was more pronounced in dual APT and supratherapeutically anticoagulated patients.

Conclusions:
APT does not affect ICH characteristics and outcome in non-OAC-ICH patients, however is associated with larger ICH volume and worse functional outcome in VKA-ICH, presumably by additive anti-hemostatic effects. Combination of anticoagulation and antiplatelet therapy should therefore be diligently evaluated and restricted to the shortest possible time frame.
Abstract WMP103: Serum Igg Titers of Periodontal Pathogens Predict Hemorrhage Growth and 3-Month Outcome in Patients With Cerebral Hemorrhage
Authors: Nakamori Masahiro , Hosomi Naohisa , Nishi Hiromi , Shiga Yuji , Matsushima Hayato , Aoki Shiro , Nezu Tomohisa , Kinoshita Naoto , Imamura Eiji , Wakabayashi Shinichi , Maruyama Hirofumi
Published: January 2019

Introduction:
It has been reported that stroke is associated with periodontal disease, which is caused by many kinds of pathogens; however, the influence of periodontal disease on cerebral hemorrhage and its clinical course have not been investigated. Thus, we examined the association of the serum IgG titer of periodontal pathogens with hemorrhage growth and 3-month outcome.

Methods:
We consecutively enrolled 115 patients with acute cerebral hemorrhage (44 females, 71.3±13.1 years). The serum IgG titers of 16 periodontal pathogens (
P. gingivalis
[5 strains],
A. actinomycetemcomitans
[3 strains],

P

.
intermedia
,

P

.
nigrescens
,

F
. nucleatum

[
2 strains],
T. denticola
,
T. forsythensis
,
C. rectus
,
E. corrodens
) were evaluated using the ELISA method. Significant hematoma growth was defined as an increase in volume of >33% or an absolute increase of volume of >12.5 mL. A poor outcome was defined as a 3 or higher on the modified Rankin Scale. In the multivariate analysis, we used the following factors for adjustment: age, sex, BMI, NIHSS score on admission, drinking and smoking habits, comorbidities (hypertension, diabetes mellitus, dyslipidemia, atrial fibrillation, peripheral artery disease, and chronic heart failure), and CRP levels.

Results:
Hemorrhage growth was found in 13 patients (11.3%). On univariate analysis, hemorrhage growth was associated with NIHSS score, diabetes mellitus, chronic heart failure, and IgG titers of
A. actinomycetemcomitans SUNY 67
. Multivariate analysis revealed that this IgG titer was independently associated with hemorrhage growth (odds ratio 3.18, 95% CI 1.13-8.95). Notably, the IgG titer of
F. nucleatum10953
but not
A. actinomycetemcomitans SUNY 67
was associated with a poor 3-month outcome (odds ratio 6.11, 95% CI 1.51-31.21).

Conclusions:
Higher serum IgG titer of
A. actinomycetemcomitans SUNY 67
was an independent factor for predicting hemorrhage growth in patients with cerebral hemorrhage. Higher serum IgG titer of
F. nucleatum10953
was associated with a poor outcome, which suggests the systemic negative impact on stroke patients apart from hemorrhage growth.
Abstract WMP104: Complement System is Acutely Activated in Humans After Intracerebral Hemorrhage
Authors: Gowda Ram , Doran Sarah J , Reddi Ashwin , Morris Nicholas A , Chang Wan-Tsu W , Motta Melissa , Badjatia Neeraj , Woo Daniel , Kittner Steven J , Loane David , Basta Milan , Parikh Gunjan
Published: January 2019

Introduction:
Intracerebral hemorrhage (ICH) generates a complex local and systemic inflammatory response, but prior studies have neglected the role of the complement system. While animal models of ICH have suggested complement is a key regulator of inflammation, human data are lacking. We investigated whether the complement system was activated in ICH patients.

Hypothesis:
We hypothesized complement system activation product levels would be acutely elevated in ICH patients compared to matched controls. We also examined the association of these complement fragment levels with established ICH severity markers and perihematomal edema (PHE) growth rates.

Methods:
We identified 25 ICH patients whose blood was collected within 5 days post stroke at the University of Maryland Medical Center from June 2016 to September 2017 as part of the Recovery After Cerebral Hemorrhage (REACH) and Genetic and Environmental Risk Factors for Hemorrhagic Stroke (GERFHS) studies. C3a, C5a, and sC5b-9 levels were measured via ELISA (Quidel, San Diego, CA) in patients and healthy controls matched for age, sex, and race. Six patients were excluded from PHE growth measurement for lack of available follow-up CT or MRI scans. Hematoma and PHE volumes were measured on the initial CT scan and the follow-up CT scan (or MRI scan if CT not done) closest to 72 hours post stroke via a semi-automated method.

Results:
Mean C3a (82.4 versus 49.2 ng/mL, p = 0.01), C5a (19.2 versus 9.1 ng/mL, p = 0.00005), and sC5b-9 (3000 versus 246 ng/mL, p = 0.00006) levels were elevated in ICH patients relative to matched controls. In secondary analyses, C5a level was correlated with presence of intraventricular hemorrhage (correlation coefficient 0.51, p = 0.03) and modified Graeb score (correlation coefficient 0.50, p = 0.03). Complement fragment levels were not correlated with PHE growth rates, age, ICH size, ICH location, or presence of at least 2 systemic inflammatory response syndrome (SIRS) criteria.

Conclusions:
Activated complement fragments C3a, C5a, and sC5b-9 are significantly (several-fold) elevated in ICH patients independently of age, ICH size, and ICH location. Considering complement’s role in initiating and augmenting inflammation, it represents a potential novel therapeutic target.
Abstract WMP105: Cerebral Micro-Bleeds After Extra-Corporeal Membrane Oxygenation: A Common Occurrence
Authors: Mehta Tapan , Zhang Andrew , Tore Huseyin , Male Shailesh , Bartos Jason , Jagadeesan Bharathi , Ezzeddine Mustapha
Published: January 2019

Background/Objective:
Extracorporeal membrane oxygenation (ECMO) is being increasingly used to provide cardiopulmonary support in critically ill patients. Up to 8% of patients on ECMO suffer from ischemic or hemorrhagic strokes. Additionally, cerebral microbleeds have been noted in ECMO patients, with unclear significance. We sought to characterize the prevalence, risk factors, and outcomes of patients with microbleeds after ECMO support at a single tertiary referral academic hospital with high volumes of ECMO patients.

Methods:
All patients receiving venovenous (vv) ECMO between January 2013 to December 2017 and all patients receiving venoarterial (va) ECMO between January 2015 to January 2018 at our hospital were retrospectively included in this study. Patient demographics, ECMO characteristics, confounding risk factors for bleed, , and patient outcomes were retrospectively extracted from the patient charts and correlated with the presence of cerebral microbleeds on brain MRI studies with Susceptibility Weighted Imaging (SWI) performed shortly after cessation of ECMO.

Results:
A total of 83 vv-ECMO patients and 224 va-ECMO patients were retrospectively reviewed. From this cohort, 45 patients (14 vv-ECMO, 31 va-ECMO) received brain MRI with SWI sequences. The median duration of ECMO in these patients was 4 days (range 1-25 days). The median time interval between ECMO placement and brain MRI acquisition was 12 days (range 3-744 days). Thirty eight of these 45 patients (84%) had cerebral microbleeds.. The majority of patients (77%) survived to discharge from the hospital.

Conclusions:
ECMO support, even brief durations, appears to be highly associated with cerebral microbleeds. The pattern of microbleeds in ECMO patients tends to occur in a distinct pattern, often localized to the corpus callosum. The mechanism of bleeding and long-term neurologic consequences of cerebral microbleeds secondary to ECMO microbleeds remains unclear. Further studies to elucidate any links between microbleeds and neurological sequelae of ECMO are needed.
Abstract WMP108: Brain-Oral Axis:
Cnm
-Positive
S. mutans
Infection is a Novel Risk Factor for Cerebral Bleeding
Authors: Hosoki Satoshi , Saito Satoshi , Tonomura Shuichi , Ishiyama Hiroyuki , Nomura Ryota , Nakano Kazuhiko , Toyoda Kazunori , Ihara Masafumi
Published: January 2019

Introduction:
We previously reported that oral
Streptococcus mutans
expressing a collagen binding protein Cnm was associated with deep cerebral microbleeds (CMBs) and intracranial hemorrhage (ICH). Approximately 20% of
S. mutans
strains have the
cnm
gene, raising the risk of cerebral bleeding. However, the positive correlation between
cnm
-positive
S. mutans
and CMBs has been shown only in cross-sectional studies and long-term effects of
cnm
-positive
S. mutans
still remain unknown.

Purpose:
To determine whether
cnm
-positive
S. mutans
facilitates cerebral bleeding.

Methods:
In our retrospective longitudinal study, 92 stroke survivors who underwent serial 3.0 T-MRI scans at intervals of more than 6 months and received analysis of oral bacteria were consecutively enrolled. Patients without oral harboring
S. mutans
were excluded. The
cnm
gene in
S. mutans
isolated from dental plaque was screened using PCR techniques. CMBs were illustrated by MRI T2*-weighted GRE method (TR 550 ms, TE 12 ms, flip angle 20°, slice thickness 4.0 mm). CMBs were classified into the deep, lobar, and subtentorial CMBs. After evaluation of serial MRI scans, the number of newly evoked CMBs per 6 months was compared between
cnm
-positive
S. mutans
group (
cnm+
group) and
cnm
-negative
S. mutans
group (
cnm
- group).

Results:
Twenty-two patients were enrolled in the
cnm+
group and 70 in the
cnm
- group (mean age±SE 69.7±2.8 vs. 69.2±1.5 p=0.56). The two groups were not different in the mean observational period (1.37±0.13 vs. 1.46±0.08 years p=0.84) or in the prevalence of vascular risk factors, including hypertension. Total and deep CMBs significantly increased in number in the
cnm
+ group compared to the
cnm
- group (mean±SD per 6 months, 0.88±1.30 vs. 0.16±0.45 for total CMBs, p=0.01; 0.47±0.80 vs. 0.03±0.15 for deep CMBs, p=0.003), while lobar and subtentorial CMBs did not increase significantly (0.22±0.50 vs. 0.07±0.32 for lobar CMBs, p=0.10; 0.19±0.61 vs. 0.06±0.17 for subtentorial CMBs, p=0.24). Two (9.1%) in the
cnm
+ group but only one (1.6%) in the
cnm
- group had symptomatic cerebral hemorrhage during the observational period.

Conclusions:
Oral
cnm
-positive
S. mutans
facilitated formation of CMBs. Brain-oral axis may be a novel therapeutic target for cerebral bleeding.
Abstract WMP112: Transforming Practice: Stroke Unit Nurses as Inpatient Code Stroke Responders
Authors: Walsh Joan M , Perry Ashley E , Leinhauser Diane
Published: January 2019

Introduction:
Stroke team activation and intervention facilitates timely response to and treatment of suspected stroke within hospital settings. The stroke nurse’s ability to act as a fully functioning member of that team is crucial to the success achieved by this system. Historically at one Comprehensive Stroke Center, nurse managers and nursing supervisors acted as the code stroke nurse responders. This coverage posed challenges due to limited stroke unit manager availability and lack of stroke specific expertise in the supervisors responding on the off shifts and weekends. To alleviate these issues, nursing leadership identified Stroke Unit registered nurses as qualified to assume the role and responsibilities of the code stroke nurse responder given their experience and expertise in caring for stroke patients.

Methods:
Nurses (n=42) from the Stroke Unit at this Comprehensive Stroke Center participated in education focused on responding to inpatient code stroke. Didactic education preceded hands-on high-fidelity simulation sessions. Pertinent skills including preparing and administering tPA, information gathering, facilitation, communication and handoff, and leadership development were among the concepts disseminated. Knowledge and perception of readiness to assume the role was assessed through written survey and was conducted at three points: prior to and immediately following didactic content, and again following simulation. For two months post-education, the stroke unit nurses paired with a preceptor to transition into the role.

Results:
Knowledge survey results demonstrated a 52.9% increase in pre and post-education test scores (45% vs. 85%, respectively) and a qualitative increase in self-perception of readiness to assume the role. Full autonomy into the role was achieved following the two-month preceptorship.

Conclusion:
A multimethod education and training program is effective in preparing stroke unit nurses to assume the role of inpatient code stroke nurse responder at a Comprehensive Stroke Center.
Abstract WMP114: Regional Stroke Program Coordinator Nurses Standardize EMS Feedback Utilizing Kurt Lewin’s Change Model
Authors: Archer Molly C , Fuller Megan , Cox Kailey , Swearingen Natalie
Published: January 2019

Background:
The Oregon and South West Washington Cascade Region Stroke Coordinators (CRSC) formed in 2006. By 2015 active membership represented 15 hospitals by 5 health care systems, all certified as either comprehensive or primary stroke centers. Clinical practice guidelines recommend quality improvement processes involving Emergency Medical Services (EMS). April 2017, the CRSC initiated discussions to develop a standardized EMS feedback tool.

Purpose:
Develop and implement a standardized EMS feedback tool across multiple health care systems to provide feedback on acute ischemic stroke (AIS) treatment cases, while improving stroke coordinator and EMS satisfaction.

Methods:
April 2017 through April 2018 a core group led efforts, utilizing Lean principles, to develop a standardized EMS feedback tool for AIS treatment cases. The first step was reviewing the variability in existing tools. A survey was created for EMS to identify meaningful elements. From those results a standardized feedback tool was drafted and finalized based on CRSC input. Throughout development, the core-group applied Kurt Lewin’s change model by creating an environment ready for change, actively supporting the CRSC through the change to a new tool, and lastly reinforcing the new tool to sustain the desired change of a standardized EMS feedback tool. A survey 10 weeks post implementation captured stroke coordinators satisfaction.

Results:
The Portland Standardized Stroke feedback Tool for EMS (PSST EMS) was implemented in April 2018. All sites adopted the tool to provide EMS feedback on AIS treatment cases. Post implementation survey among stroke coordinators had 90% response rate. Seventy-five percent valued a standardized EMS feedback tool even if it meant more work. Ninety percent were satisfied and 10% were neutral with PSST EMS. Anecdotally EMS voiced a high degree of satisfaction with a standardized tool.

Conclusion:
Applying Kurt Lewin’s change model resulted in a standardized EMS feedback tool for AIS treatment cases in the Cascade region. It is feasible for stroke program coordinator nurses, across multiple health care systems, to collaborate and standardize EMS feedback.