bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract T P2: A Clinical Score to Predict Major Arterial Occlusions Eligible for Endovascular Recanalization in Acute Stroke based on the ASTRAL registry
Authors: Vanacker Peter , Heldner Mirjam , Amiguet Michael , Faouzi Mohamed , Cras Patrick , Ntaios George , Arnold Marcel , Mattle Heinrich P , Fischer Urs , Michel Patrick
Published: July 2021

Aims:
Endovascular treatment (EVT) for acute ischemic stroke (AIS) has the potential to improve clinical outcome in well selected patients with a major intracranial occlusion. This study aimed to identify easily available pre-hospital predictors and to develop a clinical score to detect AIS patients with such occlusions potentially eligible for acute EVT.

Methods:
Consecutive AIS enrolled in the ASTRAL registry with good quality CT-angiography within 12h after onset were selected (1’645 patients, Lausanne) and categorized according to occlusion site. Easily accessible demographic and clinical information were used in a logistic regression analysis to derive predictors of major intracranial occlusions (intracranial carotid, basilar and M1-artery). A The score was created developed using the beta-logistic regression coefficients of the logistic regression analysis, and was validated internally and externally (848 patients, Bern).

Results:
Major intracranial occlusions were present in 316 (21%) acute stroke patients in the derivation and 566 (28%) in the internal validation cohort. From all 12 significant predictors of major intracranial occlusions, a 7- item score was developed to obtain the best diagnostic performance; it was termed ASTRAL-O score according to its constituents: Admission NIHSS (A): (NIHSS 0-4: 0 points; 5-9: 4; 10-14: 8; ≥15: 12), absence of pre-STroke handicap (mRS≤2) (ST: 2 points), absence of previous STroke (ST: 1 point), Right-sided stroke (R: 3 points), Atrial fibrillation (A: 1 point), Level of consciousness decreased (L: 1 point) and wOmen (O:2 points). Diagnostic accuracy of the score in both the internal and external validation cohort was good at different cut-off levels (AUC 0.84 and 0.76 respectively). A Wilcoxon signed rank test showed that the ASTRAL-0 score performed better than NIHSS alone in term of predicted probabilities.

Conclusions:
The ASTRAL-O score accurately predicts the major intracranial occlusions eligible for EVT. It improves predicted probabilities over the NIHSS alone. This tool could help to rapidly triage stroke patients in the hyper-acute phase
Abstract T P20: Rate of Endovascular Ischemic Stroke Treatment Increases with Onsite Rather than Regional Capabilities
Authors: Janjua Nazli , Tse-Chang Karen , Panichpisal Kessarin , Jones Kimberly , Keasler Debbie , Desai Bhupat
Published: July 2021

Introduction:
Currently in the US, hospitals with Neuro-Interventional capabilities represent a small proportion of all acute care facilities, and most hospitals rely on regional transfers for these services. At the same time, it is known, that having to transfer patients for Neuro-interventional stroke therapy (NIST) decreases the rate of offering this therapy, because of the time lost in the transfer process.

Objective:
We sought to compare the rates of NIST being offered to patients after the inception of these services on-site, compared with the prior calendar year.

Methods:
All patients presenting with neurological disturbance within 4.5 hours with a National Institutes of Health Stroke score (NIHSSS) >/= 4 undergo emergent non contrast head computed tomography (CT) and CT angiography (CTA). All patients who have no contra-indications to systemic thrombolysis receive intravenous tissue plasminogen activator (IV tPA) and in addition, those with large vessel occlusion on CTA are offered NIST.

Results:
A total of 333 patients were admitted with the diagnosis of ischemic stroke (IS) in 2013. Of these 15 (4.3%) patients were transferred for NIST of which 9 received IV tPA and 6 did not. In addition, 2 patients were declined for NIST by regional centers and 2 who were transferred were unable to undergo NIST due to CT changes upon transfer. In the calendar year 2014 to date (8.5 months), among 225 IS patients, 21 (9.3%) were offered NIST, including 1 patient who was transferred from a neighboring facility. All patients offered treatment, underwent treatment. Among the 21 patients, 1 had spontaneous recanalization, another had a distal stenosis but no occlusion, and in 3, the target lesion could not be reached for intervention due to proximal carotid occlusion. Among these patients the mean initial NIHSSS was 20 and mean NIHSSS at discharge was 10. No patients experienced symptomatic hemorrhage, and one patient expired due to malignant ischemic swelling.

Conclusion:
Having on-site NI capabilities doubled our rate of offering NIST. Such data may factor into a hospital’s gap analysis as to its need for NIST. Further analysis is needed to assess whether our experience of significant decline in discharge NIHSSS corresponds to long-term good functional outcome.
Abstract T P203: Tissue Plasminogen Activator is Safe Via Telemedicine for Treatment of Mild Acute Ischemic Stroke
Authors: Gildersleeve Kasey , Jagolino Amanda L , Indupuru Hari Kishan , Cai Chunyan , Rahbar Mohammad H , Sarraj Amrou , Savitz Sean I , Wu Tsu-Ching
Published: July 2021

Objective:
Telemedicine (TM) has increased the use of intravenous (IV) tissue plasminogen activator (tPA) for treatment of acute ischemic stroke. Administration of tPA via TM has been shown to be safe when given in the setting of established treatment guidelines. Debate exists regarding the use of tPA in patients deemed to have “mild” stroke. We report our study demonstrating the safety of tPA via TM for mild stroke.

Methods:
In this retrospective chart review from 4/12 to 4/13, we identified 137 patients who were given IV-tPA via TM in our 14 spoke network. Baseline characteristics and clinical variables were abstracted. We defined mild stroke by NIHSS of ≤4. Poor outcomes were defined as symptomatic intracranial hemorrhage (sICH), neurological worsening (an increase in NIHSS of ≥2 points regardless of cause of decline), angioedema, and death. Logistic regression analysis was performed between groups with NIHSS≤4 and NIHSS>4.

Results:
Table 1 depicts baseline characteristics. Of 137 patients, 27 presented with an NIHSS≤4 (20%) and 110 with an NIHSS>4 (80%). Although rates of sICH were higher in patients with NIHSS>4 compared to those with NIHSS≤4, there was no significant difference (1.8% vs 0%) (Table 2). There was no significant difference in the rates of neurologic worsening between mild (3.7%) and severe strokes (7.3%) (p<0.69). While rates of angioedema were higher in patients with severe stroke, this increment was not significant (0.9% vs 0%) (Table 2). Four deaths occurred in the severe stroke group compared to none in the mild stroke group, with no significant difference (Table 2).

Conclusion:
Our results suggest that IV tPA given via TM did not increase the risk of complications in patients with mild stroke. However, our sample size was small and we cannot rule out that some of the mild stroke patients had stroke mimics. Our results support using TM to enroll patients at community hospitals in the upcoming PRISM trial testing the efficacy of tPA in patients with mild stroke.
Abstract T P205: Efficacy and Safety of Telemedicine in Acute Stroke Care in a Metropolitan Area: Final Results of the Madrid Telestroke Project
Authors: Sanchez Patricia Martinez , de Leciñana María Alonso , Miralles Ambrosio , Gonzalez Nuria Huertas , Fuentes Blanca , Martínez Alfonso Martín , de Barros Rosa Sanz , Prefasi Daniel , García Julio Domingo , Vallejo Jaime Masjuan , Ruiz-Ares Gerardo , Martínez-Martínez Marta , Sanz-Cuesta Borja E , Miñano-Guillamon Elena , Gutiérrez-Fernández María , Díez-Tejedor Exuperio
Published: July 2021

Introduction:
our primary objective was to analyze the efficacy of a Telestroke system in terms of an increase in the number of patients treated with intravenous thrombolysis (IVT) and a shorter door-to-needle time, in the metropolitan area of Madrid, Spain. Our secondary objective was to analyze the safety of Telestroke in terms of mortality and symptomatic hemorrhagic transformation (SHT).

Methods:
prospective observational cohort study: 1) cohort exposed to Telestroke: acute ischemic stroke patients attended at Infanta Sofia University Hospital (community hospital) connected by Telestroke with the Stroke Center at La Paz University Hospital; 2) Non-exposed cohort: acute stroke patients who are attended at Severo Ochoa University Hospital (community hospital) connected by phone with the Stroke Center at Ramon y Cajal University Hospital. The number of patient attended, number of IVT, times (min), 3-months outcome (mRS), the number of unnecessary transfers and safety parameters (mortality and SHT by ECAS III criteria) were recorded. We analyzed the first 34 months of the Telestroke (March 2011-december 2013).

Results:
in the Telestroke cohort the system was activated in 59 patients, being stroke code in 42 cases. In the non-exposed cohort 45 phone calls were made, being stroke code in 42 cases. In the Telestroke cohort, IVT were administrated in 61.9% (26/42) of patients whereas in the non-exposed only 28.6% (12/42) received this treatment (P=0,002). The door-to-needle time was shorter in Telestroke cohort than in the non-exposed cohort (mean [SD]) (86.9 [41.7] vs. 149.7 [68.2], P=0.001). The 3-month outcomes were better in the Telestroke cohort (mRS 0-3: 92.9% vs. 73.8%, P=0.038). Mortality (4,8% vs. 4.8%) and SHT (0% vs. 4.8%) were similar in both groups (P = NS). In addition, there were fewer unnecessary secondary transfers in the Telestroke cohort (4.3% vs. 20%, P=0.027).

Conclusion:
the implementation of a Telestroke system in a metropolitan area is effective and safe, increasing the number of IV thrombolysis and reducing the door-to-needle times. Furthermore, the Telestroke reduces the number of unnecessary secondary transfers.
Abstract T P219: A Novel Method for Measuring Oxidative Stress in Patients with Stroke Symptoms
Authors: Wagner Jeffrey C , Salottolo Kristin , Fanale Christopher V , Whaley Michelle , McCarthy Kathryn L , Bar-Or David
Published: July 2021

Introduction:
A novel device was developed to measure oxidation reduction potential (ORP), which is the balance of oxidants and reductants, providing a direct measure of oxidative stress. Our purpose was to measure ORP in patients admitted with stroke symptoms. Methods: This prospective observational study included patients admitted to our Primary Stroke Center from 1/2010-12/2012; children ≤18 and transfers were excluded. We examined ORP’s association with stroke type, demographics (age, gender, race), NIHSS, thrombolytic therapy, and outcomes (in-hospital mortality, mRS, LOS, readmission) using Pearson correlation, generalized linear models, chi-square and student’s t-tests. Blinded operators tested plasma samples in duplicate for static ORP (resting ORP, mV), where greater values indicate more oxidative stress, as well as Capacity (antioxidant reserve, uC). Capacity was inverse-transformed (icORP), where greater values indicate less reserves. Results: There were 101 patients including 52 ischemic strokes, 10 hemorrhagic strokes, 19 TIAs, and 20 mimics. Six patients died (6%); arrival ORP was significantly lower in patients who died than who survived (sORP: 137.2 vs 163.9, p = 0.004; icORP: 2.7 vs. 4.5, p = 0.02); the change in ORP between day 2 and arrival (ΔORP) was significantly greater in patients who died (sORP: 26.3 vs 5.4, p = 0.002; icORP: 1.5 vs. 0.0, p = 0.004). Arrival ORP was lowest in patients with severe stroke, while ΔORP was greatest in these patients (table 1), independent of thrombolytic therapy (interaction p =0.36). Arrival ORP was positively correlated with LOS (p = 0.003). Conclusions: These results demonstrate the ability of ORP to identify oxidative stress and amount of antioxidant reserves in a stroke population. We propose ORP monitoring as a potentially useful tool in evaluation of acute stroke patients.
Abstract T P222: Fasl Mutation Facilitates Double Negative T Cell Accumulation And Modulates Microglia Activation In Ischemic Stroke
Authors: Weng Leihua , Zhang Meijuan , Xu Yun
Published: July 2021

Background:
The crosstalk between T lymphocyte and microglia plays an important role in ischemia reperfusion injury. The FasL mutation Gld mice had emerged the advantages in neuroprotection after MCAO. Double negative (DN) CD4(-)CD8(-) T lymphocytes were accumulated in peripheral blood and spleen of Gld mice. The objectives of this study were to explore the crosstalk between DN T cells and microglia in Gld mice after ischemic stroke.

Method:
The subtypes of T lymphocytes and microglia in brain tissue after cerebral ischemia were measured by flow cytometry and immunofluorescence. In vitro, different subtypes of T lymphocyte were co-cultured with primary microglia undergoing different treatments. ELISA and Real-time PCR were used to quantify the cytokines and chemokines.

Results:
DN T lymphocytes were obviously accumulated in ischemic regions in Gld mice after MCAO 3 days, the percentage of CD4+ or CD 8+ T lymphocyte were lightly decreased in Gld mice, compared with wild type B6 mice. Meanwhile, the activation of microglia in ischemic tissue was alleviated in Gld mice. Compared to wild type mice, a shift to alternative activated microglia (M2) rather than classical activated microglia (M1) was observed in Gld mice. In vitro, different T lymphocyte subtypes isolated from spleen in Gld mice showed various effect on primary microglia. Primary microglia underwent a shift to M2 microglia when co-cultured with CD4+ T lymphocytes and DN T lymphocytes, while switched a shift to M1 microglia when co-cultured with CD8+ T lymphocytes. Besides, pro-inflammation cytokines like IL-1β, TNF-α and MCP-1 secreted by microglia and T lymphocytes were decreased, anti-inflammation cytokines such as IL-4, IL-10 and TGF-βwere increased when primary microglia were co-cultured with CD4+ T lymphocytes and DN T lymphocytes.

Conclusion:
It’s showed that DN T lymphocytes were accumulated in ischemic brain tissue in Gld mice,which improved the outcome of stroke in Gld mice. The neuroprotective mechanism may be referred to the immunoregulation of DN T lymphocytes on microglia via promoting switching to alternative activated microglia and alleviating inflammation. The new understanding on DN T lymphocyte may provide additional views on post-stroke immune regulation.
Abstract T P223: Post-stroke Body Weight Loss Predicts Acute Stroke Outcome In Mice
Authors: Yang Jiwon , Cho Sunghee
Published: July 2021

Background and Purpose:
Longitudinal imaging studies in stroke demonstrated that infarct development is a dynamic process and it matures over several days, even weeks depending on the severity of stroke. However, due to high cost and multiple exposure of anesthesia associated with repeated imaging, infarct volume has been typically measured at a fixed time point in preclinical studies, which prevent further assessment of behaviors during stroke recovery. In identifying a non-invasive physiological parameter that predicts the extent of stroke-induced brain injury, the study investigated whether acute body weight loss predicts the extent of brain injury and swelling.

Methods:
C57 male mice (10-12 wk old, 25-30 gr) were subjected to the proximal middle cerebral artery (MCA) occlusion for 30 min. Body weight was recorded daily. Infarct volume corrected with swelling (IVInd) and percent hemispheric swelling (%SW) were determined at 1, 3 and 7d after MCAO. In a retrospective study, we analyzed correlations between 3d %body weight reduction (%BWred) and stroke outcomes (IVInd & %SW) in C57 male animals that were subjected to MCAO by 3 different individuals over 8 years (n=91-96).

Results:
Stroke induced acute BW loss (%BWred; 1d, 88.9±3.3; 3d, 84.5±8.6; 5d, 86.8±10.6; 7d, 88.9±8.9). Correlation analyses in the post-ischemic time points showed IVind and %SW were significantly correlated with only at 3d BW reduction, but not 1d and 7d (Fig.1). A retrospective analysis in C57 mice also showed a significant correlation between 3d %BWred and IVInd & %SW (Fig.2).

Conclusions:
The study showed that acute post-stroke BWred is a simple and suitable index to predict the extent of stroke injury in C57 mice. Whether the prediction can be generalized across different strains and in comorbid conditions warrant further investigation.
Abstract T P236: Hemodynamic Changes May Be Partly Attributable To The Formation And Rupture Of Aneurysms In A Rat Model
Authors: Miyamoto Takeshi , Kohrai Masaaki , Kung David K , Kitazato Keiko T , Shimada Kenji , Yagi Kenji , Tada Yoshiteru , Kurashiki Yoshitaka , Kuwayama Kazuyuki , Satomi Junichiro , Nagahiro Shinji
Published: July 2021

Introduction:
To prevent subarachnoid hemorrhage (SAH), its pathogenesis must be understood. SAH and cerebral aneurysms are located at vascular walls exposed to hemodynamic stress and turbulence. In our experimental aneurysm model, rats were subjected to oophorectomy, right common carotid artery ligation (CCA), and bilateral posterior renal ligation; they received a high-salt diet. Although we noted a high incidence of aneurysms at the anterior cerebral artery-olfactory artery (ACA-OA) bifurcation, no SAH occurred at this site. As hemodynamic changes are thought to stimulate the vascular wall locally, we hypothesized that additive hemodynamic changes lead to the development and rupture of cerebral aneurysms.

Methods:
We divided 42 rats into 3 groups, group A (n=26) underwent ligation of the right CCA, in group B (n=10) we ligated the right pterygopalatine artery, the right external carotid artery, and the left CCA, and in group C (n=6) we additionally ligated the bilateral vertebral arteries.

Results:
In the 12 weeks after aneurysm induction, 5 group A (19%)-, 3 group B (30%)-, and 3 group C (50%) rats suffered aneurysmal rupture. As in humans, the ruptured aneurysms were primarily located at the anterior communicating artery, the posterior communicating artery, and the internal carotid-posterior communicating artery. There were no ruptured aneurysms at the ACA-OA bifurcation.

Conclusion:
Our findings suggest that hemodynamic changes are at least partly associated with the vulnerability of the vascular wall at the circle of Willis. Studies are underway to identify the mechanisms underlying the pathologic vascular changes.
Abstract T P24: Neurointervention for Acute Ischemic Stroke Caused by Carotid Dissection
Authors: Haussen Diogo C , Lima Andrey , Gregoryan Mikayel , Grossberg Jonathan , Craft Leah , Matarutse Lawrance , Smith Sharion , Belagaje Samir , Nahab Fadi , Anderson Aaron , Frankel Michael , Nogueira Raul G
Published: July 2021

Introduction:
Data related to the treatment of patients with acute ischemic stroke caused by carotid artery dissection is scarce. Methods: We retrospectively reviewed our interventional stroke database Sep 2010 - Jan 2014 to investigate the clinical and radiological characteristics of patients presenting with tandem cervical and intracranial occlusions due to cervical carotid dissection. Results: Out of 504 consecutive patients treated with endovascular therapy for acute ischemic stroke during the study period, 12 (2.5%) patients were observed to have cervical carotid artery dissection as the underlying etiology. Mean age was 56±13 years, 75% were male, 50% received IV t-PA, mean NIHSS was 20±5, 75% had CT ASPECTS≥7, and mean time from last known normal to groin puncture was 6±3 hours. There were 4 MCA M1, 1 MCA M2 and 7 ICA-T occlusions. Extracranial carotid stent was used in 58% and angioplasty in 8% of cases. In 33% of the cases, the carotid dissection was not stented due to the fear of hemorrhagic transformation in cases of IV thrombolysis (presumably increased risk if dual antithrombotics used). IA tPA was used in 41% of cases, while Merci in 16%, Penumbra in 58%, and stentretrivers in 50%. Intracranial TICI 2b-3 reperfusion was achieved in 91% of patients, with PH2 hemorrhage in 8% and mRS at 90 days in 45% of cases. Conclusions: Carotid dissections with associated intracranial occlusions are often refractory to IV tPA and present with a high stroke severity. These lesions are amenable to endovascular therapy resulting in high rates of reperfusion with an acceptable safety profile.
Abstract T P245: Decreased Metallopeptidase and Aquaporin Expressions by Acute Ethanol Administration: A Potential Treatment for Ischemic Stroke?
Authors: Li William A , Peng Changya , Guthikonda Muril , Ding Yuchuan
Published: July 2021

Introduction:
Cerebral ischemia up-regulation of aquaporin (AQP) and metallopeptidase (MMP) expressions is related to increasing blood-brain barrier (BBB) permeability and brain edema. Ethanol (EtOH) has been shown to provide neuroprotective effects. The precise mechanisms by which these effects occur have yet to be elucidated. In this study, we tested the relationship of the neuroprotective effects of EtOH post-stroke with MMP2, MMP9 and AQP4, AQP9 expressions utilizing both in vitro and in vivo models.

Methods:
A total of 72 adult male Sprague-Dawley rats were subjected to 2h right middle cerebral artery (MCAO). Different doses of EtOH (0.5 g/kg and 1.5 g/kg) were administered by intraperitoneal injection 2h after stroke. Brain edema estimates were obtained by measuring brain water content. BBB permeability was measured by Evans blue dye assay. Oxygen-glucose deprivation and re-oxygenation (OGD) experiments were performed on whole brain slice cultures. Western-blots were performed to measure protein levels of AQP4, AQP9, MMP9, MMP2, tight junction protein (ZO-1) and basal lamina.

Results:
The EtOH treatment dose dependently reduced infarct volume (MCAo: 53.92%±0.03%; EtOH 0.5 g/kg: 50.04%±0.02%;1.5 g/kg: 28.41%±0.02%) compared to the control group. The 1.5 g/kg EtOH treatment significantly decreased lesion volume, BBB leakage (Stroke: 46.8±4.5 ug/g; 1.5 g/kg: 33.5±3.8 ug/g) and brain edema (Stroke: 83.2%±0.3%; 1.5 g/kg: 80.6%±0.8%) compared to the stroke saline-treated group. The EtOH (1.5 g/kg) treatment also significantly reduced the levels of AQP9, AQP4, MMP2 and MMP9 compared to the stroke control group, while no significant difference was observed between the two ethanol treatment groups. Furthermore, in vitro results show reductions in MMP and AQP expressions, induced by EtOH treatment, are associated with elevated ZO-1 and basal lamina levels.

Conclusion:
EtOH is an effective neuroprotective therapy identified by the reduction in infarct volume, edema volume, and BBB leakage after stroke. Decreases in MMP2, MMP9, AQP4, and AQP9 expressions may contribute to EtOH-induced neuroprotection.
Abstract T P249: Upregulation of Relaxin After Experimental Subarachnoid Hemorrhage
Authors: Kikkawa Yuichiro , Matsuo Satoshi , Kurogi Ryota , Mizoguchi Masahiro , Kayahara Tomomichi , Yokosako Suguru , Ueno Ryu , Yamaguchi Yohei , Fushihara Goji , Ikeda Toshiki , Takeda Ririko , Ogura Takeshi , Ooigawa Hidetoshi , Kurita Hiroki
Published: July 2021

Background and Purpose:
Relaxin is a pregnancy hormone which exerts vasodilatory effects by activating nitric oxide synthase and matrix metalloproteinases through receptor (RXFP1). Recently, this vasodilatory effect has been considered useful as a potential therapeutic target in acute heart failure. However, the role of relaxin in the cerebral artery has not been fully explored. In this study, we investigated the role of relaxin in rabbit basilar artery (BA) after subarachnoid hemorrhage (SAH).

Methods:
Basilar arteries were collected from a rabbit SAH model on days 3, 5, and 7 after SAH. Total RNA was extracted from the BA and a cDNA microarray containing 43,623 genes was performed. The expression of relaxin and RXFP1 mRNA was investigated by quantitative RT-PCR. Serum and cerebrospinal fluid (CSF) relaxin concentrations were measured by ELISA. Perfusion fixation was performed on days 0, 3, 5 and 7, and the localization of RXFP-1 in the BA was examined using immunohistochemistry.

Results:

The expression of relaxin mRNA was significantly up-regulated on days 5 and 7 compared to the control sample. The expression of RXFP1 mRNA was significantly down-regulated on day 3 and sustained on day 7. The serum relaxin concentration in the rabbit SAH model was not significantly changed after SAH, whereas the CSF relaxin concentration was significantly elevated on days 5 and 7. Immunohistochemistry revealed strong RXFP1 staining in media of the BA on day 0, and showed weak staining on days 3, 5 and 7.

Conclusions:

Relaxin expression in the BA and relaxin concentration in the CSF increase after SAH, and considerably, relaxin expression is negatively correlated with the RXFP1 expression in the rabbit BA after SAH.
Abstract T P250: Role of Autophagy in Blood-Brain Barrier Disruption and Tight Junction Degradation Under Ischemic Condition
Authors: Kim Kyeong-A , Shin Young-Jun , Kim Eun-Sun , Akram Muhammad , Noh Dabi , Kim Eunji , Bae Ok-Nam
Published: July 2021

During ischemic stroke, the integrity of blood-brain barrier (BBB), which shows selective permeability for substances to brain, is significantly damaged amplifying ischemic neuronal damage. There have been attempts to identify the exact mechanism ischemic BBB disruption to minimize brain damage under ischemic stroke. Autophagy is catabolic process which involves degradation and recycling of damaged or unnecessary organelles. However, excessive autophagy can induce cell damage and death under pathological conditions such as ischemia. In this study, we evaluated if autophagy is a key mechanism of BBB dysfunction under ischemic stroke. In vitro BBB model of bEnd.3 cells were exposed to oxygen-glucose deprivation (OGD), an ischemic mimic condition. After exposure to OGD for 18 hours, cell viability was significantly decreased and cellular permeability was impaired. The conversion of LC3-I to LC3-II and puncta of LC3 in bEnd.3 were increased, demonstrating that autophagy is induced under ischemic condition. Modulation of autophagy by 3-methyladenine, an autophagy inhibitor, reversed the conversion of LC3 as well as decreased cell viability, suggesting that autophagy involves in ischemic BBB damage. The level of occludin, a tight junction protein in BBB, was decreased after OGD, and this was reversed by inhibition of autophagy. Our findings showed that induction of autophagy might contribute to increased permeability through occludin degradation in brain endothelial cells under ischemia, providing a new mechanism of BBB disruption in ischemic stroke.
Abstract T P253: Clinical Application of Haptoglobin in Models of Supraphysiologic Extracellular Brain Hemoglobin Levels
Authors: Leclerc Jenna L , Robbins Sean , Esfandiary Tina , Dang Alex , Doré Sylvain
Published: July 2021

Hemorrhagic stroke can occur from traumatic or spontaneous causes, is associated with high morbidity and mortality, and represents a worldwide major public health problem. With breakdown of the blood-brain barrier, and entry of toxic blood components and metabolites within the brain, a highly oxidative environment ensues and leads to a toxic neuroinflammatory cascade. A major cause of the debilitation following brain hemorrhage is due to the direct toxicity of blood components, namely hemoglobin (Hb), the most upstream precipitating factor. The acute phase plasma protein haptoglobin (Hp) binds Hb and inhibits its cytotoxic, pro-oxidative, and pro-inflammatory properties. Therefore, we hypothesized that local and specific overexpression of Hp within the brain would aid in the safe detoxification and clearance of free Hb, thereby protecting the neuropil from Hb-mediated oxidative stress, ultimately leading to improved anatomical and functional recovery. Here, we overexpressed Hp within the brain using specifically designed adeno-associated viral vectors, and induced hemorrhagic brain injury using two models – intrastriatal autologous whole blood injection and collagenase-induced spontaneous bleeding, which is accompanied by intraventricular hemorrhage in most cases. At 72h post-hemorrhage, mice were sacrificed and brains collected for Cresyl Violet staining and lesion volume quantification. Functional outcomes were assessed by a 24-point neurological deficit score. In both models, Hp-overexpressing mice demonstrated reduced lesion volume (p<0.05) and improved neurologic status at 24h, 48h, and 72h post-hemorrhage (p<0.05), when compared to an identically treated control group (n=7-9/group). In conclusion, locally modulating Hp expression within the brain could represent an important clinically relevant strategy for the treatment of acute hemorrhagic brain injury by attenuating the toxicity of free Hb and improving its clearance from the brain.
Abstract T P256: Is The Collection of Stroke Data to Improve Patient Care Important for Small Volume Hospitals?
Authors: Prabhakaran Shyam , Jones Peggy , Ward Jody , Miller Kathryn , O'Neill Kathleen , Gardner Michelle
Published: July 2021

Background:
Stroke continues to be a significant cause of morbidity and mortality in the Midwest. Often times, CAHs are the first facility that see stroke patients. CAHs often have internal barriers and pushback of stroke quality efforts based on patient volume.

Purpose:
To evaluate the impact of data collection on improving patient outcomes in small volume hospitals through the examination of data trends.

Methods:
A benchmarking group of CAHs was created through the Get With The Guidelines-Stroke Patient Management Tool. The majority of the hospitals were from Wisconsin, Illinois and North Dakota. The number of hospitals in the benchmark has varied. At the highest point in 2010-2011, there were 44 CAHs collecting data. The CAH hospitals have entered data for over 4500 stroke and TIA patients from 2009-2014 . Data was pulled from 2006-2013 to examine the CAH trends in compliance of tPA and the in-hospital and secondary prevention measures. We also assessed the composite score comprised of tPA for eligible patients and 6 other in-hospital and secondary prevention measures.

Results:
It was clear that more stroke or TIA patients coming into the CAHs were being admitted to the CAH instead of being transferred. It was also noted that the composite scores of these hospitals improved each year through the collection and monitoring of data showing improvement from 55% in 2006 to 83% in 2013. The rate of IV-tPA among patients that arrive within 2 hours and treated within 3 hours has remained stable around 40% since 2009, but the number of patients receiving tPA has increased dramatically in CAHs since 2008. The VTE prophylaxis, LDL assessment, and antithrombotic measures have improved every year since 2010. Anticoagualtion for atrial fibrillation is now at 90% compliance.

Conclusion:
The data provides evidence that more patients are getting tPA at CAHs but less than half of these eligible patients met the measure of 2 hour arrival treat in 3 hours.Data collection and review has improved the in-hospital and secondary prevention measures for the 69% of patients that are admitted to the CAH. Data collection and ongoing improvement activities, even with small volumes, improves adherence to guidelines and can be beneficial for small volume hospitals.
Abstract T P259: Study of Factors Contributing to Reduce Cost in an Innovative Post-Stroke Program
Authors: Bridges Aaron J , Commiskey Patricia , Gaines Kenneth
Published: July 2021

Background and Purpose:
Stroke is the 4
th
leading cause of death in the United States. Stroke-related medical costs and disability in the US cost approximately $73.7 billion in 2010 and is projected to cost $185 billion by 2030. Decreasing costs of care among post-stroke patients requires a combination of follow-up care and monitoring and targeted risk factor reduction. Ochsner Neuroscience Institute (ONI) has implemented a Comprehensive Stroke Care Model designed to increase quality and decrease costs of stroke across the continuum from symptom onset through 12 months post-discharge. This Model combines evidence-based, streamlined in-hospital care with monthly post-discharge follow-up and education in the home for patients and caregivers. Innovative technology that connects patients and caregivers with ONI stroke and internal medicine providers to address issues real-time during outpatient visits. This research will describe this innovative Stroke Care Model, including its impact on mortality, length of stay, stroke reoccurrence rate, and cost of care.

Methods:
This research will include patients seen as part of this Model from 1/3/2013-7/31/2014. Stroke Central, the in-hospital component, coordinated patients who presented at Ochsner’s Emergency Department via transfer, EMS, or personal transportation (n=1,711). Stroke Mobile, the outpatient component, includes a subsample of patients and their caregivers who were discharged with a stroke diagnosis and who reside in St. Tammany and Jefferson Parishes in Louisiana (n=288).

Results:
Stroke Mobile includes patients discharged from Ochsner’s Stroke Program with a final diagnosis of stroke who reside in St. Tammany or Jefferson Parishes in Louisiana from 2013-2014 (n=288 as of 7/31/2014). Patients that participated in stroke mobile reported a stroke reoccurrence rate 40% lower than patients not participating in stroke mobile.

Conclusions:
These results suggest a significant cost reduction in post stroke care through personalized patient visits that resulted in reduced readmissions rates, reduced stroke reoccurrence rates, and decreased clinic visits.
Abstract T P264: Does a Change in Coverage Equal a Change in Care?
Authors: Leonhardt Ann M , Manchak Michael , Benesch Curtis G
Published: July 2021

Introduction:
During academic year 2012-13 (FY 2013) coverage for neurology patients at Strong Memorial Hospital (SMH) changed. Non-vascular neurologists admitted patients, many of whom were not evaluated by vascular neurologists. Previously stroke patients were evaluated by/admitted to a vascular neurologist.

Hypothesis:
We sought to determine if this translated into differences in care, hypothesizing decreased utilization of vascular imaging (VI) and compliance with regulatory measures.

Methods:
Metric data were obtained from SMH Get with the Guidelines (GWTG) from July 1, 2011-March 31, 2014. Reports were reviewed for percent compliance. SAH patients and acute stroke metrics were excluded. VI data were obtained from the Stroke Treatment Alliance of Rochester registry and reviewed for percent testing completed. Stable was defined as less than 5% change.

Results:
Improving or stable metrics: VTE prophylaxis, patient education, antithrombotic, anticoagulant, statin at D/C, assessment for rehabilitation, dysphagia screening, smoking cessation, and LDL documented. Increased utilization of MRA (8.4% FY2012 to 16.9% FY2013) and decreased CTA (80.3% FY2012 to 63.5% FY2013) were seen. Several metrics and VI had transient variation seen in figure 1 (high dose statin data incomplete before Q22012).

Conclusions:
Core measures remained stable. This may be attributable to the role of Stroke Nurse Practitioner (NP) which remained constant. The NP is responsible for coordination of care, guideline adherence, and training residents in guideline driven order sets. Anecdotal reports from faculty identified the NP as a source of stroke expertise. There was clear change in utilization of VI and NIHSS. While high dose statin use is difficult to interpret due to incomplete data, there was a large increase following FY2013. This demonstrates measurable benefits of utilizing vascular neurologists and stroke trained NPs to achieve high level care at a large academic institution.
Abstract T P271: Establishment of Stroke Ward Results in Immediate Reduction of Major Complications
Authors: Akhtar Naveed , Kamran S , Singh R , Deleu D , Bourke P , Joseph S , Santos M , Shuaib A
Published: July 2021

Background and Purpose:
Randomized controlled trials have consistently shown that stroke units decrease both mortality and morbidity compared with conventional care in general medical wards. There are however limited data on the specific types of in-hospital medical complications and their effect on outcomes. The objective of this study was to determine whether establishing a specialized geographically defined Stroke Ward results in reducing the major complications in patients suffering from acute stroke within the same hospital system.

Methods:
This is a prospective study from January 2014 till July 2014. Data was collected from a web-based stroke registry in two phases. In phase 1 (from January 1, 2014 till March 08, 2014), we collected data of stroke patients admitted at in the medical wards. In phase 2, a protocol-based multidisciplinary care Stroke Ward became operational where most of the patients were admitted. Outcomes measures were number and type of complications, mortality, discharge disposition, and length of stay, and were adjusted for age, sex, and medical co-morbidities.

Results:
There were 130 admissions in phase 1 and 345 in phase 2. Commonest complications included, aspiration pneumonia 29% vs 12% (p<0.001) and pressure ulcers in 35% vs 11% (p<0.001). Average length of stay decreased from 12 days to 4 days (p<0.001). In phase 1, 70 % of patients were discharged home, while 23% were transferred to rehabilitation while in phase 2, 75% of patients were discharged home, while 18% patients were sent to rehabilitation. Ninety percent of complications happened in medical wards, mainly in patients who over stayed in emergency department (more than 8 hours) waiting for bed in Stroke Ward or medical floor.

Conclusion:
A protocol based multidisciplinary care Stroke Ward care significantly reduces common early complications of acute stroke. It also helps in significantly reducing the length of stay, saving total bed days at a tertiary care hospital, hence improving the overall care of these patients.
Abstract T P274: Accreditation Status of Outpatient Cerebrovascular Testing Facilities Among Medicare Beneficiaries: The VALUE (Vascular Accreditation, Location & Utilization Evaluation) Study
Authors: Brown Scott C , Wang Kefeng , Dong Chuanhui , Farrell Mary B , Heller Gary V , Gornik Heather L , Hutchisson Marge , Needleman Laurence , Benenati James F , Jaff Michael R , Meier George H , Perese Susana , Bendick Philip , Hamburg Naomi M , Lohr Joann M , LaPerna Lucy , Leers Steven A , Lilly Michael P , Tegeler Charles , Katanick Sandra L , Alexandrov Andrei V , Rundek Tatjana
Published: July 2021

OBJECTIVE:
Accreditation of cerebrovascular ultrasound laboratories by the Intersocietal Accreditation Commission (IAC) or equivalent bodies is supported by The Joint Commission certification of stroke centers. Limited information exists on the accreditation status and geographic distribution of these testing facilities in the US. The aims were to: (1) Identify the proportion of IAC accredited vascular testing facilities used by Medicare beneficiaries for outpatient cerebrovascular testing services; (2) Describe the geographical distribution of these facilities; and (3) Identify variation in the types and volumes of cerebrovascular testing procedures by accreditation status.

METHODS:
As a part of the VALUE (Vascular Accreditation, Location & Utilization Evaluation) Study, we examined the proportion of IAC accredited facilities that conducted cerebrovascular testing in a 5% CMS random Outpatient Limited Data Set (LDS) for the US in 2011 and investigated their geographical distribution using the Medicare Provider of Services (POS) file.

RESULTS:
Of the 7,864 total facilities billing Medicare for cerebrovascular testing procedures, only 22% (n=1,723) were IAC accredited. The percentage of facilities conducting cerebrovascular testing that were IAC accredited varied by region (Χ2[3]=400.4, p<0.0001), with 43%, 21%, 17% and 13% located in the Northeast, South, Midwest, and West, respectively. However, when examining the total number of cerebrovascular outpatient procedures conducted in 2011 (total n=38,646), 41% (15,729) were conducted in IAC accredited facilities. Moreover, when examining procedure type across all sites, 98% (38,011) of all cerebrovascular testing procedures conducted were carotid duplex, of which 41% (15,417) were conducted in IAC accredited facilities. In contrast, 1% (n=315) of all cerebrovascular procedures were transcranial (TCD), of which 56% (n=177) were conducted in IAC accredited facilities.

CONCLUSIONS:
The proportion of IAC accredited facilities conducting outpatient cerebrovascular testing is low and varies by region. The growing number of certified stroke centers should be accompanied by more accredited vascular testing facilities that could potentially improve quality of stroke care.
Abstract T P279: Falls After Intracerebral Hemorrhage
Authors: Dunning Kari , Moomaw Charles , Flaherty Matthew L. , Osborne Jennifer , James Michael L. , Worrall Bradford B. , Woo Daniel
Published: July 2021

Background:
Falls can result in injury, activity limitation, decreased independence and death. There have been no studies investigating falls post intracerebral hemorrhage (ICH).

Purpose:
To determine rate and factors associated with falls post ICH.

Methods:
The Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study is a prospective, multi-center, case-control study of ICH. For this analysis, the primary outcome was fall reported at 3 month follow-up. Variables collected at baseline included age, sex, race, ICH score (volume, IVH, age, Glasgow Coma Scale) and fall during inpatient hospitalization. Variables collected at 3-month follow-up included modified Rankin (mRS), incontinence (Barthel) and anxiety/depression (EuroQol). Variables p<.10 were entered into a logistic regression with the final model consisting of variables p<.05, adjusting for ICH score.

Results:
As of 12/31/2013, 2064 patients presented to an emergency department. After excluding deaths, premorbid mRS 4-5 and missing data, 1098 remained. At 3-month follow up, 200 (18.2%) reported a post-discharge fall including: 99 (50%) who fell more than once, 9 (4.5%) broken bones, 14 (7.0%) hospitalizations and 4 (2.0%) surgeries due to falls. The highest 3-month fall rates was observed among persons with mRS 3 (55/206, 26.7%), mRS 4 (79/253, 31.2%), extreme anxiety (19/64, 29.7%) and among those who had fallen during inpatient hospitalization (44/168, 26.2%). Variables associated with a 3 month fall were: race, mRS, ICH Score, a fall during inpatient hospitalization, incontinence and anxiety/depression (Table 1). Adjusting for ICH score, the final model included race, mRS and anxiety/depression.

Conclusions:
Assessing factors associated with falls can help target high risk patients. After 12 month follow up is complete, the next step will be to analyze factors associated with a fall during the first year post ICH and examine causation.
Abstract T P3: Safety of Eptifibatide after Full Dose IV tPA and Endovascular Treatment for Ischemic Stroke
Authors: Kirmani Jawad F , Korya Daniel , Choi Grace , Brar Jaskiran , Chahal Harina , Hussain Mohammed , Mehta Siddhart , Panezai Spozhmy , Moussavi Mohammad
Published: July 2021

Background and Objective:
The safety of eptifibatide in combination with IV tPA for ischemic stroke has recently been demonstrated in the CLEAR-ER trial which used .6 mg/kg IV tPA plus eptifibatide (135 mcg/kg bolus and .75mcg/kg/min two-hour infusion) versus standard tPA (.9 mg/kg). Prior studies have also looked into the combination of intra-arterial (IA) tPA and eptifibatide at dosing and duration similar to cardiology literature. Our aim was to compare the safety and efficacy of eptifibatide after full dose IV tPA and endovascular treatment versus full dose IV tPA and endovascular treatment alone.

Materials and Methods:
We reviewed the records and procedure reports of patients who underwent endovascular treatment for ischemic stroke from 2010-2013 at a university affiliated comprehensive stroke center. Patients who received full dose IV tPA (.9 mg/kg) followed by endovascular treatment were compared with those who had the same treatment, but also received a bolus of 135 mcg/kg of eptifibatide followed by a .5 mcg/kg/min for 20 hours (based on IMPACT-II trial protocol). The initial and discharge NIH Stroke Scale as well as the discharge mRS (DCmRS) were evaluated. A DCmRS of 0 or 1 was considered a favorable outcome, and 2 or more was considered as a unfavorable. Initial stroke severity (NIHSS) was analyzed with logistic regression for baseline comparison and Fisher’s exact test were used for categorical data analysis.

Results:
We evaluated 2,016 patients with ischemic stroke, of which 230 received IV tPA and 91 (55% female) underwent endovascular treatment, 44 of them also received eptifibatide. Of the 44 patients who received eptifibatide (bolus and 20 hour infusion), 18% (n=8) had a favorable outcome, and in the group that did not receive eptifibatide , 9% (n=4) had a favorable outcome (OR=2.389, 95% CI 0.6645 to 8.589, p= 0.2217).

Conclusion:
Eptifibatide in combination with full dose IV tPA and endovascular treatment did not increase morbidity in our patient population, and may have improved outcome. Further, larger trials need to be conducted for more definitive results.
Abstract T P302: Acute Kidney Injury in Subarachnoid hemorrhage is Associated with Higher Death and Disability
Authors: Adil Malik M , Hassan Ameer E , Vidal Gabriel A , Malik Ahmed A , Saeed Fahad , Khursheed Faraz , Qureshi Adnan I
Published: July 2021

Background:
Acute kidney injury (AKI) in setting of subarachnoid hemorrhage (SAH) maybe associated with higher mortality.

Objective:
To determine the effect of AKI on outcomes of SAH patients treated in a large national cohort.

Methods:
We analyzed data from all patients admitted to US hospitals between 2005 and 2011 with a primary discharge diagnosis of SAH and secondary diagnosis of AKI. The effect of AKI on discharge outcomes was analyzed after adjusting for potential confounders using logistic regression analysis.

Results:
Of 173053 patients with SAH, 8302 (4.8%) had AKI. In AKI group, 290 (3.5%) patients were on dialysis. SAH patients with AKI had higher rates of moderate to severe disability (40.7% versus 36.6% p=<0.0001) and in-hospital mortality (39.4% versus 20.1% p=<0.0001) compared to those without AKI. After adjusting for potential confounders SAH patients with AKI had higher odds of moderate to severe disability [odds ratio (OR) 1.3, 95% confidence interval (CI) (1.1-1.5, p= 0.02)] and death [(OR) 2.0, 95% (CI) (1.8-2.3, p=<0.0001)].

Conclusion:
AKI in patients with SAH is associated with significantly higher rates of death and disability. It remains unclear whether aggressive fluid replacement and bicarbonate administration can reduce the high rates ofadverse outcomes. .