bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP203: Stroke Statistics of South Korea in the 1st Decade of the 12th Century
Authors: Hong Keun-Sik , Bang Oh-Young , Kang Dong-Wha , Yu Kyung-Ho , Bae Hee-Joon , Kim Jin-Soo , Heo Ji-Hoe , Kwon Sun U. , Oh Chang Wan , Lee Byung-Chul , Kim Jong S. , Yoon Byung-Woo
Published: July 2021

Background:
This study aimed to summarize the data of epidemiology, risk factors, characteristics and outcomes of patients, and acute stroke care of South Korea in the first decade of the 21th century

Methods:
We searched relevant reports of government or related organizations and published articles and summarized the most representative data.

Results:
Every 5 minutes stroke attacks someone (≈105,000 incidence/year), and every 20 minutes stroke kills someone (≈26,000 stroke death/year) in South Korea. Stroke accounts for ≈1 of every 10 deaths. The estimated nationwide annual disability-adjusted life years lost to stroke was ≈344,000. An estimated prevalence of stroke in people with ≥30 years of age is 795,000. Nationwide total cost for stroke care was estimated to be US$ 3.3 billion in 2005, which must be much greater now. The annual stroke death rate substantially decreased by 28.3% during the first decade of the 21th century (74.2 per 100,000 person-years in 2001 and 53.2 per 100,000 person-years in 2010). The proportion of ischemic stroke has steadily increased and accounted for 76% of all strokes in 2009. According to hospital registry studies, the 90-day mortality rate was 3-7% for ischemic stroke and 17% for intracerebral hemorrhage. For risk factors, one in 3-4 Korean adults has hypertension, one in 10 diabetes mellitus, one in 7 hypercholesterolemia, and one in 3 obesity. Nearly 50% of men are current smokers, whereas less than 10% of women are smokers. Korean hospitals are likely to provide a high quality of acute stroke care as reflected in more than 90% of the average performance rate for most of quality indicators for acute stroke care. Intravenous TPA treatment for acute ischemic stroke has increased from 4.6% in 2005 to 8.7% in 2008 and 7.9% in 2010, and the proportion of IV-TPA treatment within 1 hour after hospital arrival was 58%. Among OECD countries, South Korea had the lowest in-hospital 30-day case-fatality rate for ischemic stroke and ranked third lowest for hemorrhagic stroke in 2009.

Conclusion:
This report would be a valuable resource for clinicians, researchers, healthcare policy makers, and public to establish health care planning and to guide a future research direction in South Korea and for comparison of stroke statistics among countries.
Abstract WP220: Determinants for Cryptogenic Stroke: Clinico-radiologic Findings
Authors: Ryoo Sookyung , Moon Gyeong Joon , Lee Chung-Bin , Kim Suk Jae , Chung Chin-Sang , Lee Kwang Ho , Bang Oh Young
Published: July 2021

Background:
Cryptogenic stroke accounts for 30-40% of all strokes. Aortic arch atheroma(AAA), patent foramen ovale(PFO) and paroxysmal atrial fibrillation(PAF) are common causes which require different treatment strategies. However not all patients could undergo extensive work-ups. We investigated clinico-radiological characteristics of these 3 common causes of cryptogenic stroke to find a model helping decision-making.

Method:
We enrolled 194 patients with cryptogenic stroke at the time of admission. After performing extensive work-ups including electrocardiography, transthoracic or transesophageal echocardiography, transcranial right-to-left shunt test, coronary computed tomography angiography or cardiac telemetry, patients were allocated into 3 groups; (1) AAA(n=25), (2) PFO(n=94), and (3) PAF(n=75). Vascular risk factors and findings on diffusion-weighted image were analyzed.

Results:
Clinico-radiologic features were different. Patients with PFO were younger (mean, 56.1[PFO] vs. 73.9[AAA] vs. 70.6[PAF] years;
p
<0.001) and hypertension was less common (
p
<0.001). Smoking was more common in AAA group (
p
=0.018). PAF-related strokes had higher NIHSS (
p
<0.001) and a larger lesion (≥20mm, 81.1%[A-fib] vs. 16.0%[AAA] vs. 46.2%[PFO];
p
<0.001). By contrast, AAA-related strokes showed small but multiple lesions scattered in multiple vascular territories (
p
<0.001). Patients with PFO had subcortical lesions (
p
=0.029) in posterior circulation (
p
=0.004).

Multivariate regression analysis revealed that age, NIHSS, hypertension, multiple(≥3) lesions and involvement of multiple vascular territories could differentiate 3 groups (R
2
=0.6581). We calculated probability for 3 groups and performed external validation.

Conclusion:
Patients with cryptogenic stroke showed distinct features which may provide clues for stroke mechanisms. Our data suggested that etiologic work-ups for cryptogenic stroke could be guided by these features.
Abstract WP231: Detection of Intramural Hematoma by Susceptibility Weighted Image in Vertebral Artery Dissection
Authors: Kim Tae-Won , Koo Jaseong , Choi Hyun Seok , Lee Kwang Soo , Lee Si Baek
Published: July 2021

Objectives
The radiologic diagnosis of vertebral artery dissection (VAD) depends on the characteristic intraluminal findings on angiographic study although the pathology of VAD is intramural hematoma. We aimed to know whether ‘intramural hematoma sign (IHS)’ on susceptibility weighted image (SWI) in vertebral artery is specific for VAD.

Methods
We retrospectively analyzed SWI and phase map images of the consecutive patients with ischemic stroke in the vertebral artery territory from August 2009 to July 2012. We divided the patients into 2 groups; VAD related stroke and atherosclerotic stroke. Diagnostic criteria of VAD related stroke were (a) presence of posterior neck pain or occipital headache and (b) features of VAD at computed tomography angiography or contrast enhanced magnetic resonance angiography or digital subtraction angiography. Angiographic evidence of VAD which is subdivided into three groups: aneurysmal dilatation without stenosis, pearl-and string, and steno-occlusive without aneurysmal dilatation. IHS was considered positive if the patient had (a) eccentric hypointense signal lesion in vertebro-basilar artery on SWI and (b) this signal should be hyperintense on phase map suggesting blood products other than calcification. An experienced neuroradiologist blinded to clinical information was asked to judge the presence of IHS. For statistical analysis, two by two contingency tables by Fisher’s exact test were performed.

Results
Among the 137 patients with ischemic stroke in the vertebral artery territory, SWI and phase map images were available in 47 patients who were included for our analysis. Among them, 14 patients were diagnosed as an ischemic stroke due to VAD and 33 patients had no VAD (atherosclerotic stroke). Compared to atherosclerotic stroke patients, patients with VAD-related stroke had more headache (64% vs 15%, P=0.016). Among the 14 patients with VAD-related stroke, IHS was detected in 9 cases while only 2 of 33 patients with atherosclerotic stroke showed IHS (sensitivity 64% and specificity 94%). In Fisher’s exact test analysis, the IHS was significantly associated with VAD (p < 0.001).

Conclusion
The intramural hematoma sign on SWI was significantly associated with vertebral artery dissection.
Abstract WP238: Safety and Outcomes of Stroke Mimics After Thrombolysis: A Single Center Experience
Authors: Mays-Wilson Kathleen , Penstone Patricia , Miller Daniel , Mitsias Panayiotis D , Lewandowski Christopher A
Published: July 2021

Background:
Administration of intravenous (IV) t-PA for acute ischemic stroke (AIS) improves outcomes. The most dreaded complication is intracerebral hemorrhage (ICH). Some patients have symptoms that impersonate an AIS but are later found to have an alternate diagnosis; these are termed stroke mimics (SM). SM treated with IV t-PA are exposed to hemorrhagic complications without benefit.

Objectives:
To describe the characteristics, safety, and outcomes of SM patients treated with t-PA under 4.5 hours.

Methods:
We reviewed all patients hospitalized after IV t-PA treatment at a tertiary care hospital and primary stroke center from January 2008 through December 2011. SMs were determined by review of clinical and imaging findings. SM are described and compared to t-PA treated patients with AIS for demographics, ICH, bleeding complications, and outcomes.

Results:
We identified 38 SM (12%) and 285 AIS (88%) t-PA treated patients. Compared to AIS, SM patients were younger (55.1 vs. 67.0 yrs, p<.001), more often women (68% vs.49%, p=.025), and reported a history of stroke more often (45% v 14%, p<.001). There were no differences in race, baseline stroke scale (9.4 v 10.9, p=.26), or onset to treatment time (164 min v 159 min, p=.63); 12 SM were in the 3-4.5 hour window. There were no ICHs or deaths in SM patients. There were two (5.2%) SM systemic hemorrhages; a femoral artery bleed post cardiac catheterization requiring transfusion, and an UGI bleed after a nasogastric tube not requiring transfusion. The average SM length of stay was 3.4 +/- 2.2 days. The mean discharge NIHSS score was 1.3 +/-2.5 in the SM v 4.6+/-5.7 in the AIS patients (p<.001). SM discharges were: home (84%), rehab center (12%), Nursing home 3%, and other (3%). The most common cause of SM was conversion disorder (47%) seizures (32 %) and migraine (8%).

Conclusion:
SM are not uncommon. Treatment of SM with IV t-PA appears to be safe in this cohort. The most common etiologies of stroke mimics were conversion disorder, seizures, and migraine. These results are consistent with existing published data on use of IV t-PA in SMs. Until more specific diagnostics are available, suspected SM should not be a reason to withhold t-PA treatment.
Abstract WP251: Symptoms And Delay Of Hospital Visit In Stroke Patients
Authors: Suzuki Satoshi , Yanagida Tomoko , Fujimoto Shigeru , Inoue Takuya , Jinnouchi Juro
Published: July 2021

Objective:
Time is an important factor in treating stroke patients. Symptoms which are recognized by patients and/or bystander seem to influence how soon they visit the hospital. Here we examined this issue.

Materials and Methods:
A consecutive series of 469 patients was collected prospectively between May 2007 and March 2009. All patients were admitted within 2 weeks after the onset. Median age of patients was 75 years old.

Results:
The median time interval between recognition of symptoms and hospital visit (“delay”) was 6.6 hours. Interview from patients and/or bystander revealed that they recognized disturbance of consciousness (“Cons”) in 83, dysarthria in 148, aphasia in 23, facial weakness (“Facial”) in 25, weakness of upper limb (“U/E”) in 174, weakness of lower limb (“L/E”) in 204, sensory disturbance (“Sensory”) in 63, visual problem (“Visual”) in 11, headache in 53, nausea and/or vomiting (“N/V”) in 57, and lightheadedness in 57, respectively. The median “delay” with each symptom was 1.0h with “Cons”, 1.1h with aphasia, 2.4h with headache, 2.4h with “N/V”, 3.6h with “Facial”, 5.1h with “U/E”, 5.9h with dysarthria, 8.3h with “Visual”, 10.2h with “L/E”, 16.6h with lightheadedness, and 24.7h with “Sensory”, respectively. Median NIHSS score at the initial examination (iNIHSS) was 4.0. There was a significant negative correlation between “delay” and iNIHSS in overall, “Cons”, dysarthria, “U/E”, “L/E” and “Sensory”, but not in aphasia, “Facial”, “Visual”, headache, “N/V”, and lightheadedness. Neurological examination by board-certified strokologists revealed “Cons” in 110, dysarthria in 250, aphasia in 72, “Facial” in 167, “U/E” in 254, “L/E” in 249, “Sensory” in 183, and “Visual” in 33, respectively. This means that only 15% of “Facial”, 32% of aphasia, 33% of “Visual”, and 34% of “Sensory” was recognized by patients and/or bystander, respectively.

Conclusions:
There was a significant negative correlation between “delay” and iNIHSS; however, there were several symptoms which caused early hospital visit regardless of severity of iNIHSS. Aphasia and “Facial” caused early hospital visit, however, only 15% and 32% of patients and/or bystander recognized these symptoms, respectively. The enlightenment to the general public is required.
Abstract WP258: ZBTB7C Is Associated With Severity Of Infarction In Cerebral Ischemia
Authors: Du Rose , Zhou Jing , Lorenzano Svetlana , Charoenvimolphan Nareerat , Qian Baogang , Rost Natalia , Wang Jian , Zhang Xinmu , Wang Xin , Berndt Annerose , Devan William J , Valant Valerie J , Furie Karen L , Rosand Jonathan , Friedlander Robert , Paigen Beverly , Weiss Scott T
Published: July 2021

Background
Stroke is a complex disease that is affected by multiple genetic and environmental factors. We utilize the variability in inbred mouse strains to evaluate the genetic basis of susceptibility to cerebral infarction.

Methods
To identify candidate genes that contribute to this variability in susceptibility, we performed a strain survey on 33 inbred strains of mice using a permanent middle cerebral artery occlusion model. Variability in vascular anatomy was determined by examining the circle of Willis in 22 strains of mice. Infarct volume was obtained and a genome-wide association mapping was performed on 118,019 SNPs using efficient mixed-model association (EMMA) to account for population structure and genetic relatedness in inbred mice. Candidate genes from mice were validated in 34 patients with M1 occlusions from the Genes Associated with Stroke Risk and Outcomes Study (GASROS) and the STOP Stroke Study

Results
Two SNPs reached genome-wide significance (rs32249495 p=2.08x10-7 and rs3694965 p=2.17x10-7) and two were suggestive (rs31924033 5.61x10-6 and rs3677406 9.46x10-6). Thirty-eight genes were identified to be within 500kb of these four SNPs, corresponding to twenty-four orthologous human genes. SNPs associated with the human orthologs were validated in patients with M1 occlusions. Of these, one SNP (rs1944586, p=1.06x10-4) corresponding to the ZBTB7C gene was significant after adjusting for multiple testing. In vitro analysis demonstrated upregulation of ZBTB7C expression in endothelial cells under hypoxic conditions.

Conclusion
ZBTB7C may be part of a novel genetic pathway that modulates the severity of cerebral infarction and may serve as a new target for therapeutic intervention in cerebral ischemia.
Abstract WP272: A Powerful Combination Therapy for Stroke: Post-Ischemia Ethanol Administration and Normobaric Oxygenation on Ischemic Rats
Authors: Sy Christopher , Geng Xiaokun , Fu Paul , Peng Changya , Fredrickson Vance , Ji Xunming , Guthikonda Murali , Ding Yuchuan
Published: July 2021

Objectives:
Normobaric oxygenation (NBO) has been reported to be neuroprotective against acute cerebral ischemia. Recently, a clinical trial was terminated because beneficial outcomes were not definitive. Our recent study (
Stroke. 2012 43(1):205-10
) demonstrated a strong neuroprotective effect induced by acute administration of ethanol (EtOH) at 1.5g/kg. In this study, we assessed the therapeutic influence of EtOH in combination with NBO.

Methods:
Sprague-Dawley rats were subjected to right middle cerebral artery occlusion for 2h. Ischemic animals received either an intraperitoneal injection of EtOH (1.0g/kg), a course of NBO (100% for 2h), or a combination of both immediately prior to reperfusion onset. Brain injury was determined by infarct volume and behavioral outcomes at 48h post-reperfusion. Metabolic dysfunction was investigated by assessing ADP/ATP ratios, reactive oxygen species (ROS) levels, NADPH oxidase (NOX) activity, and protein expression of NOX subunits (p47
phox
, gp91
phox
,

and p67
phox
), as well as the protein expression and enzyme activity of pyruvate dehydrogenase (PDH), at both 3h and 24h after reperfusion.

Results:
Combination therapy led to a significant decrease in infarct volumes (Saline: 48±4%, EtOH: 38±3%, NBO: 37±4%,
Combination: 19±3%
) and in neurological deficits (Belayev Scale 0-12, Saline: 8.4±0.7; EtOH: 6.5±0.7; NBO: 6.4±0.6;
Combination: 4.4±0.3
). At 3h and 24h post-reperfusion the decrease in ADP/ATP ratio was significantly enhanced, reflecting a preservation of cellular energy. A greater decrease in NOX activity and protein expression was observed, in association with decreased ROS levels, suggesting that improved glycolysis may contribute to neuroprotection. PDH activity and protein expression was dramatically increased, making the facilitation of aerobic metabolism a probable mechanism for preserving cellular ATP.

Conclusions:
Our findings demonstrate that a synergistic relationship exists between EtOH and NBO. Both are promising neuroprotective agents when used together, even at low doses. Moreover, both are inexpensive, widely available, easy to administer, and have little side effects. Thus, combination therapy could be an effective and efficient approach to future stroke treatments.
Abstract WP278: Is Prophylactic Anticoagulation For Deep Venous Thrombosis Common Practice After Intracerebral Hemorrhage?
Authors: Prabhakaran Shyam , Herbers Patricia , Adeoye Opeolu , Khatri Pooja , Ferioli Simona , Kleindorfer Dawn O
Published: July 2021

Background:
Prior studies suggest that early initiation of prophylactic anticoagulation for deep venous thrombosis (DVT) is safe after intracerebral hemorrhage (ICH). Current guidelines recommend considering prophylactic anticoagulation after cessation of hematoma growth and as early as 2 days after onset.

Methods:
From the Premier database, a representative sample of approximately 15% of US hospital discharges and containing pharmacy records, we identified adult patients with ICH (primary/admitting ICD-9 code 431) who survived to day 2. We excluded those who underwent craniotomy or angiography. We abstracted type of anticoagulant used and date of first administration. We employed univariable statistics and multivariable logistic regression to assess patient and hospital factors associated with receiving prophylactic anticoagulation after ICH.

Results:
From 2006 to 2010, 33,858 patients met our inclusion and exclusion criteria. Overall, 6,018 (17.8%) received any prophylactic anticoagulation during the hospital stay. Among these patients, 66% received prophylactic anticoagulation by day 2 and 76% had received an initial dose by day 6. The most commonly used agents were as follows: heparin (70.2%), enoxaparin (28.6%), and dalteparin (1.3%). The proportion of patients receiving prophylactic anticoagulation and the proportion of those receiving it within 2 days did not change over the study period. Use of prophylactic anticoagulation varied by geographic region (P<0.001) in the US: Northeast (24.7%), South (20.3%), Midwest (12.1%), and West (10.7%). In multivariable analysis (Table), geographic region remained an independent predictor of prophylactic anticoagulation.

Conclusions:
Less than 20% of ICH patients receive anticoagulation for DVT in the United States. When utilized, the time to initiation is < 2 days in the majority of patients. Further study should focus on understanding variations in practice and emphasize guideline-driven care.
Abstract WP28: Long-Term Outcome of Carotid Artery Stenting in Patients of Atherosclerotic Carotid Artery Disease : A 10-year Experience of a Single Tertiary Center in Korea
Authors: Kim Chang-Hun , Ryu Wi-Sun , Oh Mi-Young , Lee Seung-Hoon , Kang Hyun-Seung , Son Chul-Ho , Han Moon-Hee , Yoon Byung-Woo
Published: July 2021

Background & Objective
Considering an increasing incidence of carotid artery disease in Asian subjects, the data showing long-term outcome of carotid artery stenting(CAS) from Asian population is mandatory. However, long-term outcome of CAS in Asian population have rarely been reported. The purpose of this study is to evaluate long-term results of CAS from the 10-year experience of a single center.

Methods
Patients undergoing CAS between May 2002 and May 2012 in our hospital were retrospectively reviewed. We abstracted demographic, clinical, and medical factors. In addition, plaque characteristics and angiographic factors were also evaluated. Neck CT angiography was followed-up every 6 months after CAS. We investigated the cumulative long-term incidence of carotid restenosis and risk factors for the development of restenosis.

Results
A total of 262 arteries (248 patients, mean age of 72.1±7.6 years, 81.7% male) were analysed. The degree of mean carotid stenosis was 70.9±17.5%. Symptomatic lesions were 178 (67.9%), and 84 (32.1%) arteries were asymptomatic. Predilatation (97.3%) and post-dilatation (42.4%) was performed during procedures. Embolic protection devices were used in 233 (88.9%) cases. During procedures, In-situ thrombosis with embolic infarction or TIA occurred in 6 (2.3%) and 10 (3.8%) cases, respectively. During a median follow-up time of 27.5 months, restenosis (> 50% stenosis) was detected in 18 (6.9%) of 262 arteries (asymptomatic, 16; symptomatic, 2). Restenotic lesions were treated in 6 (2.3%) cases with angioplasty including 2 symptomatic patients. The percentage of residual stenosis after stenting was significantly related to a risk of restenosis (p<0.02).

Discussion
Restenosis rate in this study was comparable to those of other single or multi-center trials in Western population. Our long-term results may validate CAS as a durable procedure for stroke prevention in patients with carotid artery stenosis in Korea.
Abstract WP282: Protecting Stroke Patients from Aspiration and Mortality through a Bedside Aspiration Screen
Authors: Matesic Edith
Published: July 2021

Background:
Stroke patients initially experience dysphagia approximately 42-76% of the time, putting them at high risk for developing aspiration pneumonia and increasing the risk of death threefold in the first 30 days following onset of the condition. Interventions to identify risk for aspiration pneumonia are key to reducing mortality in hospitalized patients. However, no generally recognized bedside aspiration screen exists, and few have been rigorously tested. The Edith-Huhn-Matesic Bedside Aspiration Screen (EHMBAS)
TM
was developed as an evidence-based RN bedside aspiration screening protocol.

Purpose:
This study analyzed the sensitivity and inter-rater reliability of EHMBAS
TM
, assessed the efficacy of training methods, evaluated patient feedback, and looked at the impact of organizational learning.

Methods:
RNs were trained to apply the EHMBAS
TM
. An evaluation study assessed the sensitivity, specificity and predictability of the screen to detect aspiration in the stroke population study group. Cohen’s Kappa statistics was applied to test inter-rater reliability. Pre- and post-implementation Likert surveys examined patient and staff satisfaction on the education plan and screening process, respectively. Lastly, an analysis of organizational learning examined whether changes enhanced adherence to screening requirements.

Results:
Results showed that the EHMBAS
TM
demonstrated strong validity (94% sensitivity) and high inter-rater reliability (Kappa = .92, p<.001). Pre- and post- staff training survey results demonstrated a significant positive change in knowledge gained, feelings of preparedness, and satisfaction with teaching methods. Further, 92.3% of patients surveyed had positive screening experiences. The hospital received Silver recognition from The American Heart Association for following stroke treatment guidelines 85% of the time for at least 12 months, demonstrating the positive impact of the protocol on organizational change.

Conclusions:
This study contributes to the body of work aimed at establishing a reliable evidence-based, bedside aspiration screen. Patient safety is enhanced, because screen results help determine when patients can safely receive medication and nutrition by mouth.
Abstract WP287: Screening Venous Ultrasound For Asymptomatic Lower Extremities Deep Venous Thrombosis In Acute Stroke Patients: Will It Change Management Strategies?
Authors: Ha Linda P , Galang Maria
Published: July 2021

INTRODUCTION:
Deep venous thromboses in stroke patients are often asymptomatic. There is limited support that screening for asymptomatic lower extremities DVT with venous duplex ultrasound changes clinicians’ management of stroke patients.

Hypothesis:
We hypothesized that the detection of asymptomatic deep venous thrombosis in acute stroke patients would result in changes or intensification of anticoagulation management strategies.

Methods:
We performed a retrospective chart review of all strokes (ischemic and hemorrhagic), orthopedic surgery, and trauma patients admitted to our Acute Rehabilitation Unit (ARU) between January 2004 and December 2009. We selected out all stroke patients and recorded those as asymptomatic DVT if there was no documentation of signs or symptoms for DVT by the primary provider within 48 hours prior to obtaining a lower extremity venous ultrasound. A change in anticoagulation management was noted if any addition or change to the patient’s admitting anticoagulation intervention.

Results:
There were 909 patients admitted to our ARU. Of those patients, 78 patients were diagnosed with an asymptomatic lower extremity DVT prior to transfer to the ARU. Strokes patients accounted for 34 (43.5%) of these 78 patients. All of the stroke patients were under the care of a neurology team. A majority of the lower extremity DVT among the stroke patients were considered acute (N=30;88.2%) and 21% (N=7) had bilateral, acute DVT. Most of the stroke patients received DVT prophylaxis on admission (N=26;76.4%). After diagnosis of an acute DVT, clinicians changed their management strategies in 65% of cases, whereas in 23.5% of cases there were no changes. Among the changes in management, 50% of patients (11/22;50%) were started or had an escalation in anticoagulation treatment. Interrupted venal cava filter was placed in 5 patients and serial venous ultrasound surveillance was used for 7 patients.

Conclusions:
This study shows that the detection of an acute asymptomatic lower extremity DVT in stroke patients resulted in anticoagulation management strategies changes for most stroke patients. It also supports the need to perform screening venous ultrasound on all acute stroke patients.
Abstract WP302: Racial Differences in Imaging Characteristics and Risk Factors for Primary Intracerebral Hemorrhage: Final Results from the DECIPHER Study
Authors: Kidwell Chelsea S , German Laura , Menon Ravi S , Shara Nawar , Gibbons M. Christopher , Trouth Anna , Edwards Dorothy
Published: July 2021

Background:
Previous studies have reported racial differences in the incidence, location and risk factors for primary intracerebral hemorrhage (ICH). We now report differences in imaging characteristics and risk factors for ICH from the DiffErenCes in the Imaging of Primary Hemorrhage based on Ethnicity or Race (DECIPHER) study.

Methods:
DECIPHER is a longitudinal, multicenter, MRI-based, natural history study of racial differences in primary ICH. Inclusion criteria were: primary ICH, age ≥ 18, baseline and 1 year MRI scan obtained. Clinical and demographic data were collected on all subjects.

Results:
A total of 193 subjects of black or white race were enrolled. Subject characteristics overall and by race are provided in the table. Black subjects were younger, had a higher rate of hypertension, cocaine use, and were more frequently smokers. White subjects had a higher rate of hyperlipidemia. A lobar ICH location was more frequent in the white subjects, while infratentorial hemorrhages were more common in blacks. 60% of blacks had 1 or more microbleeds compared to 52% of whites (NS), and blacks tended to have more severe white matter disease.

Conclusions:
In the DECIPHER study, there were significant racial differences both in the risk factors for primary ICH and in the imaging characteristics. Compared to whites, blacks have a greater rate of hypertension, as well as cocaine and tobacco use. Imaging findings are indicative of a more severe underlying small vessel vasculopathy in the black cohort. The risk factor information may be used to enhance prevention programs tailored for black communities at risk of ICH, while imaging data may provide a useful biomarker to assess the impact of these interventions.
Abstract WP336: Telestroke To Bring Tertiary Center Acute Stroke Practice To Rural Minnesota Residents; Percent Treated With Interventional Procedures, Timing, And Clinical Results.
Authors: Castle Amy , Stein Lana , Porth Karen , Madison Michael , Hanson Sandra
Published: July 2021

The utility of telemedicine to increase the use of IV tPA for acute ischemic stroke (AIS) patients in the rural setting is well established. The availability of intraarterial (IA) reperfusion therapy is restricted to larger stroke centers in metropolitan areas so the process for evaluation and transfer within a stroke system of care will be critical to its rapid delivery to rural patients. In 2012, we conducted a review of the use of IA therapy in our stroke system; studying efficiency of the team approach, timing of treatment, and patient outcomes to evaluate the hypothesis that telemedicine can facilitate IA treatment for the AIS patient presenting in a rural setting.

METHODS:
All patients presenting to the spoke hospitals (SHs) and the hub hospitals (HH) with AIS and subsequently receiving IA therapy were reviewed for the months of March 2011 through February 2012. This review followed institution of a stroke code improvement process for SHs which included an aggressive 30 minute door-to-drug goal, addition of CTA imaging, and early mobilization of helicopter transport.

FINDINGS:
Of the HH patients receiving reperfusion therapy 26 of 68 patients (38%) received IA treatment and 62% received IV tPA treatment alone. In contrast, only 5 of 31 treated cases from SHs (16%) received IA treatment. In IA treated cases, mean door-to-case-start time from the SHs (143 min) was comparable to that of cases presenting directly to the HH (117 min) despite the helicopter travel required prior to case start for SHs. Reperfusion success (TICI2b/3) was similar whether the patients presented to HH or the SHs (69% and 60%) and discharge MRS≥3 was achieved in 46% and 40% respectively.

CONCLUSION:
With a telemedicine supported system, IA treatment options can be initiated in a time efficient fashion with similar outcomes whether the patient presents to a rural spoke hospital site or the hub hospital with IA capability. Differences in the rate of use of IA treatment may be related to EMS referral patterns of patients with severe stroke to a tertiary stroke center.
Abstract WP346: Improving Nursing Skills In Acute Stroke Patients Can Reduce The Time-to-treatment
Authors: SANJUAN ESTELA , MELER PILAR , RUBIERA MARTA , RIBO MARC , MUCHADA MARIAN , PAGOLA JORGE , FLORES ALAN A , RODRIGUEZ-LUNA DAVID , KALLAS JULIA A , MOLINA CARLOS A
Published: July 2021

INTRODUCTION:
Intravenous tPa treatment is time dependent. The management of Hypertension (HTN) and Hyperglycemia (HGL), along with blood sample collection in the emergency room (ER) may cause delays in tPa treatment, if not performed at the same time that the neurologist is examining the patient. Our aim was to determine whether the emergency nursing professional skills can reduce the delay on tPa administration during the emergency room stay.

Methodology:
This is a prospective study of acute stroke patients evaluated in the ER. Time from presentation to the ER to treatment was evaluated (time to treatment decision). This time was considered delayed if it was more than 40 minutes. Exact times of nursing activities were recorded as well as the causes that can impact delay and can be solved by nursing professionals (baseline hypertension, hyperglycemia and time to blood sample collection).

Results:
From January to July 2012, 222 patients were evaluated. 50% were men, mean age of 71,1 ,and mean time spent in the ER was 18±9 minutes. 35 patients where hypertensive on admission(15,8%), 59 had hyperglycemia(26,6%) and 11 had both(5%). Mean time to obtain blood sample was 5±3 minutes. Seventy-three patients(32,8%) were treated with intravenous tpa. Door-to-needle time was 39±19 minutes and CT-to-bolus time 11±4 minutes. In up to 29 times, a cause of delay in tPa initiation >40minutes was identified. Of those, 11 were related to nursing actions: 4(14,8%) blood sample delays and 7(25,9%) delays in treatment of HBP or HGL.

Conclusions:
Emergency nursing professionals have a very important role in acute stroke and developing skills and training may reduce time-to-treatment. A specialized stroke code nurse would probably improve stroke management in emergency room.
Abstract WP397: Using Electronic Medical Record System to Influence Management for Patients with High Risk Transient Ischemic Attack
Authors: Nguyen-Huynh Mai N , Tucker Lue-Yen , Klingman Jeff
Published: July 2021

Background:
Experts consider health information technology key to improving efficiency and quality of health care. However, little is known on how the use of electronic medical record (EMR) system can affect a clinical outcome by changing its processes of care. We sought to determine if EMR could be utilized to increase urgent carotid evaluation and management of patients with transient ischemic attack (TIA).

Methods:
Changes were implemented in the standardized EMR TIA order set for Kaiser Permanente Northern California (KPNC) on July 20, 2012 adding: 1) a link to an ABCD2 score calculator, and 2) a recommendation that “acute TIA patients with an ABCD2 score ≥4 should undergo a carotid evaluation within 24 hours of symptom onset.” All patients diagnosed with TIA by Emergency Department physicians in KPNC were identified 6 months pre- and post- changes. EMR were reviewed for demographics, risk factors, imaging studies and clinical outcomes. Carotid evaluation, endarterectomy (CEA), stroke during the 90-day period after index TIA, and timing of CEA were examined.

Results:
Patient characteristics were similar for pre- and post-EMR order set change [Table]. Rates of carotid evaluations performed within 90 days post TIA were not significantly different between the pre- and post-order set change cohorts (76% vs. 80, p=0.28). However, there was a significant difference in the rates of CEA within 90-day post-TIA (pre=1%, post=4%, p=0.05). Median timing of CEA was shorter in the post-change cohort (30 vs. 2 days, p=0.17). Stroke risks within 90 days were similar between pre- and post- cohorts (13.6% vs. 12.2%, p=0.62).

Conclusions:
Our results suggest recommendations made in an EMR standardized order set could effectively influence physicians’ practice pattern in managing high-risk TIA patients. Further studies on the use of EMR to affect outcomes are needed.
Abstract WP409: Hematoma Expansion After Spontaneous Intracerebral Hemorrhage in Children
Authors: Jordan Lori C , Beslow Lauren A , Gindville Melissa C , Kleinman Jonathan T , Bastian Rachel A , Smith Sabrina E , Licht Daniel J , Ichord Rebecca N
Published: July 2021

Objective:
Hematoma expansion and its predictors like the “spot sign” are important research areas in adults with primary (hypertensive) intracerebral hemorrhage (ICH), but are rarely studied in secondary ICH. At one center, in adults with ICH due to brain arteriovenous malformation (AVM), aneurysm, or tumor, significant hematoma expansion (>33%) occurred in 6/30 (20%) within 24 hours. In children, the frequency of hematoma expansion and the appropriate timing of follow-up neuroimaging are unknown. We assessed the frequency and extent of hematoma expansion in children with non-traumatic ICH.

Methods:
From 2007 to 2012, 73 children with spontaneous ICH were enrolled in a three-center prospective study (≥37 weeks gestation-17 years). Inclusion for this sub-study: 2 head CTs obtained for clinical indications within 48 hours after presentation with ICH (28 children). Exclusion: Surgical evacuation of hematoma before 2
nd
CT was obtained (2 children), IVH only (7 children), neonates <29 days old (20 children). Hematoma volume was assessed via manual volumetric analysis.

Results:
Of 73 children, 25 (34%) met all inclusion and exclusion criteria. Median age was 9.0 years, interquartile range (IQR) 2.1-14.1. Median time from symptom onset to first CT was 9.4 hours (IQR 4.5-20). ICH was due to coagulopathy or vascular cause in 22/25 children (88%). Median baseline ICH volume was 22.2mL (range 2-86mL). Hematoma expansion occurred in 7/25 (28%) with 2 head CTs. Median ICH volume expansion was 4mL (range 0.1-12mL), 32% (range 2-58%) of baseline ICH volume. Three had significant (>33%) expansion; all had coagulopathy or vascular etiologies of ICH. As expected, children with 2 head CTs had larger baseline ICH volumes (p=0.05) and were more likely to receive treatment for elevated intracranial pressure (ICP) (p=0.001) compared to children with ICH who had fewer than 2 head CTs within 48 hours.

Conclusion:
Hematoma expansion occurred in 28% of children with clinical concern for hematoma growth and was >33% in 12%. Repeat CT should be considered in those with large ICH and increased ICP. Head CTs were not obtained at prescribed time intervals; research CTs without clear benefit are not feasible in children.
Abstract WP429: Therapeutic Strategy For Chronic Subdural Hematoma Associated With Cerebrospinal Fluid Hypovolemia
Authors: Shimogawa Takafumi
Published: July 2021

Chronic subdural hematoma (CSH) with the cerebrospinal fluid (CSF) hypovolemia is often reported, but the therapeutic strategy is not established. We examined the therapeutic strategy and the treatment result for CSH with the CSF hypovolemia that we experienced in our hospital.

[Object and method]
In 544 patients with CSF hypovolemia during January 2000 to July 2012, 7 cases (1.3%) had CSH bilaterally. About CSF hypovolemia, 5 cases was diagnosed as spontaneous, 1 case as post-traumatic injury, and 1 case as post-traffic injury. We devided them into 3 groups; the first group which performed epidural blood patch (EBP) therapy first, the second group which performed hematoma evacuation for CSH first, and the third group group which performed the hematoma evacuation for CSH and EBP simultaneously.

[Result]
In the first group included 5 cases, only 1 case of CSH resolved spontaneously, and another 4 cases needed additional hematoma evacuation by aggravation of clinical symptoms. In the second group included 1 case, CSH recurred, and additional EBP therapy and hematoma evacuation were needed. In the third group included 1 case, the improvement of prompt clinical symptoms was obtained and CSH did not recurr.

[Conclusion]
The treatment for CSH with CSF hypovolemia needs EBP therapy first, however most cases needs an additional hematoma evacuation. If it takes into consideration, it may be better to do the hematoma evacuation and the EBP simultaneouly. In addition, it is necessary to consider a CSF hypovolemia as a cause of a bilateral CSH which relapse after treatment.
Abstract WP435: Acute Blood Pressure Reduction and Cerebral Infarction After Aneurysmal Subarachnoid Hemorrhage
Authors: Kosteva Adam R , Maas Matthew B , Rosenberg Neil F , Prabhakaran Shyam , Naidech Andrew M
Published: July 2021

Background:
Radiographic cerebral infarction (RCI) is a prominent cause of disability after aneurysmal subarachnoid hemorrhage (SAH). Current guidelines for acute blood pressure (BP) management of SAH patients are intended to prevent rebleeding, but their potential impact on RCI is unknown.

HYPOTHESIS:
RCI after SAH is associated with more acute BP reduction and lower BP.

METHODS:
We evaluated 49 patients with SAH. Clinical and radiographic data were prospectively collected. BP data were electronically retrieved from the medical record. BP was compared with multivariate generalized linear models.

RESULTS:
RCI was detected in 19 of 49 patients (38.8%). No rebleeding occurred in any of the patients during their hospital stay. Vasospasm occurred in 8 (16.3%) of patients and was associated with higher systolic and diastolic BP (P<0.001 for both) between days 4 and 14. Historical hypertension was associated with RCI (52.6% vs. 23.3%, P=0.036), although initial systolic (168±37 vs. 151±26 mm Hg, P=0.1) and diastolic BP (90±20 vs. 83±19, P=0.2) were not. In a generalized linear model accounting for time from symptom onset, vasospasm, historical hypertension and a vasospasm by time interaction (since BP augmentation depended on the time from symptom onset), lower systolic (-7, 95%CI -8 to -6 mm Hg, (P<0.001) and diastolic BP (-5, 95%CI -6 to -4 mm Hg, P<0.001) were associated with RCI. There were similar data for change in BP from initial BP.

CONCLUSIONS:
RCI after SAH is associated with greater BP reductions and historical hypertension may contribute to this risk. More aggressive BP reduction than recommended by current guidelines, while potentially decreasing the risk of aneurysm rebleeding, may be associated with RCI. Routine perfusion scanning to determine the risk of RCI from reduced perfusion may be warranted.
Abstract WP49: Defining the Acute Infarct Core with CT Perfusion in Ischemic Stroke: Physiological and Technical Issues
Authors: d’Esterre Christopher D , Fainardi Enrico , Lee Ting Yim
Published: July 2021

Background:
CT Perfusion (CTP) defined hemodynamic parameters used to delineate admission infarct core can be affected by truncated data acquisition, recanalization status and reactive hyperemia. We determined the optimal CTP parameter for infarct demarcation while taking these variables into account.

Methods:
30 patients had CTP/NCCT scanning within 6 hours of ictus, a 24 hour CTA and an NCCT at 3 months post stroke to define final infarct. Patients were analyzed according to: 1) the percent wash out (truncation) of the ischemic time density curve (ITDC) and 2) recanalization status defined using the 24 hour CTA. CTP functional maps were generated using delay insensitive CTP software (GE Healthcare). For all patients, the total ischemic lesion (infarct+penumbra+benign oligemia) was defined using the contrast delay plus mean transit time map. Cerebral blood flow (CBF), cerebral blood volume (CBV) and the product of CBF and CBV (CBFxCBV) were used to define the infarct core defect, according to established thresholds, and compared with the infarct volume defined on the 3 month NCCT. The coefficients of correlation (R2) of linear regression models were used for the comparisons.

Results:
R2 values for admission CBF, CBV, and CBFxCBV defect versus final infarct volume for patients with and without truncation of the ITDC were 0.89, 0.49, 0.65 and 0.90, 0.42, 0.68, respectively; while R2 values for patients with and without recanalization at 24 hours were 0.73, 0.33, 0.44 and 0.84, 0.54, 0.45, respectively. In addition, for the recanalization group with and without truncation of the ITDC, R2 for CBF, CBV, CBFxCBV versus final infarct volume were 0.73, 0.12, 0.31 and 0.79, 0.58, 0.56, respectively. Hyperemia, defined as an increase in CBV relative to the contralateral hemisphere, was observed in 30% of patients. Both hyperemia and ITDC truncation led to poor correlation between the CBV defect and NCCT defined infarct volume.

Conclusion:
CBF is the optimal parameter for determining the size of the acute infarct core as it is not affected by truncation of the ITDC and autoregulatory vasodilation causing reactive hyperemia.
Abstract WP56: Refinement of imaging predictors of recurrent events following Transient Ischemic Attack and Minor Stroke.
Authors: Horton Myles
Published: July 2021

Background:
Transient ischemic attack (TIA) and minor stroke have a high risk of recurrent stroke. We recently showed in the CATCH study that predefined radiographic abnormalities on CT/CTA and MRI predicted recurrent events after TIA and minor stroke. Specifically, the study recognized the predictive value of CT/CTA abnormalities that were defined
apriori:
acute ischemia on CT, intracranial or extracranial occlusion or stenosis > 50% (the CT/CTA positive metric), and diffusion-weighted imaging positivity on MRI.

Aims:
To improve upon the CT, CTA, MRI and clinical parameters that predict recurrent events after TIA and minor stroke. Our secondary aim was to explore predictors of stroke progression versus recurrence.

Methods:
510 consecutive TIA and minor stroke patients (NIHSS score of <4) had CT/CTA and most had MRI. Primary outcome was recurrent events (combined outcome of stroke progression or distinct recurrent stroke) within 90 days. Imaging parameters not included in the original CATCH imaging (CT/CTA and MRI) metrics were assessed for prediction of recurrent events. We also completed an exploratory analysis comparing predictors of symptom progression versus recurrence.

Results:
There were 36 recurrent events (36/510, 7.1% (95%CI: 5.0-9.6)) including 19 progression and 17 recurrent strokes. On CT/CTA: white matter disease, prior stroke, aortic arch focal plaque≥4mm, or intraluminal thrombus did not predict recurrent events. On MRI: white matter disease, prior stroke, and microbleeds did not predict recurrent events. The only additional clinical predictor was symptom fluctuation (hazard ratio 2.3; 95% CI: 1.05-5.0). Parameters predicting symptom progression included: ongoing symptoms at initial assessment, symptom fluctuation, intracranial occlusion, intracranial occlusion or stenosis, and the CT/CTA metric. No parameter was strongly predictive of recurrent stroke.

Conclusions:
There was no imaging parameter that could improve upon our original CT/CTA or MRI metrics to predict recurrent events after TIA and minor stroke. Only the addition of symptom fluctuation to the CT/CTA metric improved the prediction of recurrent events. Imaging was more predictive of symptom progression than distinct recurrent events.
Abstract WP71: Recanalization Leads To Early Clinical Improvement In Patients Treated With Argatroban And Intravenous TPA A Subanalysis Of The Argatroban Tpa Stroke Study
Authors: Guerrero Waldo R , Alexandrov Andrei V , Lyden Pat , Alderazi Yazan , Lee Jessica Lee , Martin-Schild Sheryl , Shen Loren , Sisson April , Balucani Clotilde , Peng Hui , Savitz Sean I , Gonzales Nicole R , Wu Tzu-Ching , Rahbar Mohammad H , Tsivgoulis Georgios , Demchuk Andrew M , Grotta James C , Barreto Andrew D
Published: July 2021

Background and Objectives:
Early neurological improvement (ENI) at 2-hours post thrombolysis has recently been proposed to most accurately predict recanalization when repeat vascular imaging is not available. However, these studies analyzed recanalization at a delayed time point (≥24 hours). The Argatroban tPA Stroke Study (ARTSS-1), is a recently completed NIH sponsored, Phase IIa, prospective, open-label, safety and activity study of Argatroban and rtPA in patients with ischemic stroke (
NCT00268762
). We hypothesized 2-hour recanalization correlates with ENI (NIHSS improvement of 20% or greater from baseline).

Methods:
A total of 65 patients with intracranial large vessel occlusive disease were given standard dose (0.9mg/kg) tPA and a 100 μg/kg bolus of argatroban followed by infusion of 1 μg/kg per minute for 48 hours adjusted to a PTT of 1.75 times baseline. Pre-tPA vessel imaging using TCD or CTA confirmed intracranial occlusions. A multivariate logistic regression tested whether recanalization at 2 hours was associated with ENI after controlling for age, NIHSS, clot location (ICA, MCA or vertebrobasilar). We analyzed whether patients with ENI had statistically significant greater odds of an excellent mRS (0 or 1) at day 7.

Results:
Recanalization data was available for 47 patients at 2-hours. ENI occurred at 2-hours in 46% patients. Patients with any recanalization (complete or partial) at 2-hours were more likely to experience ENI (OR 3.4; 95% CI 0.71-16.6, p=0.124). This association strengthened when 2-hour complete recanalization was analyzed (OR 5.4; 95% CI 0.98-29.2, p=0.053). In an unadjusted analysis, patients with ENI at 2-hours were five times more likely to have excellent mRS outcomes at day 7 (OR 4.7; 95% CI 1.4-15.6, p=0.01). In the adjusted model, the association remained significant (OR 3.8; 95%CI 1.1-13.4, p=0.041).

Conclusion:
Two-hour recanalization is predictive of early neurological improvement and better early clinical outcomes in patients treated with combination Argatroban and tPA. A randomized, controlled clinical trial of this promising adjunctive therapy is warranted and ongoing (ARTSS-2 trial,
NCT01464788
).