bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract W P273: Health Care Professionals’ Perspectives on Implementing Family Caregiver Education and Support Programs into the Ontario Stroke System
Authors: Tseung Victrine , Jaglal Susan , Salbach Nancy , Cameron Jill I
Published: March 2022

Introduction:
Family caregivers play a key role in the care of stroke survivors post-discharge. Without a standard of practice for supporting caregivers, many experience negative health outcomes. Literature supports establishing system-level infrastructure to provide education and support to family caregivers. However, the implementation of such programs has yet to be actualized.

Objective:
This study examined factors that influence the implementation of caregiver programs into the Ontario Stroke System from the perspectives of healthcare professionals

Methods:
Health care professionals providing stroke care in acute, rehabilitation and community care settings were invited to participate in the study by their Regional Education Coordinators. Health care professionals who were interested in participating in the study contacted the first author to set up the interview. Semi-structured interviews were conducted with participants. Interviews were audiotaped, professionally transcribed and reviewed for accuracy. Transcripts were coded, data was analyzed using a constant comparison approach and themes were identified.

Results:
A total of nineteen health care professionals participated in this study (7 acute, 5 rehab, 6 community, 1 private). Interviews lasted between 28 and 74 minutes. Data analysis identified five themes: 1) It is important for key stakeholders to understand the value of caregiver education and support programs; 2) Caregiver education and support requires dedicated resources; 3) Delineate ownership and responsibility for program implementation; 4) Provide training to health care professionals regarding caregiver needs and program materials to obtain buy-in and facilitate implementation; and 5) Establish a clear identity for the program and promote awareness of the program to potential implementers and users.

Conclusions:
This is the first study to identify factors that influence the implementation of family caregiver education and support programs from the perspectives of health care professionals involved in providing stroke care. Addressing these factors will enable the health care system to establish such programs, ensuring family caregivers receive the support they need.
Abstract W P278: Defining the Role of the Nurse in Transitions of Care Within a Comprehensive Stroke Center (CSC)
Authors: Mathiesen Claranne , Conahan Erin M
Published: March 2022

Transitions in care are a top priority for the US health care system as well as a core component of the CSC standards. Nurses are key in facilitating care from admission to discharge ensuring successful transitions through a stroke health challenge. Impetus to examine hospital readmission rates has been heightened by public reporting and potential CMS financial penalities.

The purpose of this presentation is to describe an interdisciplinary approach in planning care transitions supporting discharge. Our experience as a recently certified CSC identified opportunities for improvement in stroke care transitions.

A Stroke Continum Subgroup was formed including key stakeholders in partnering rehab facilities, inpatient rehab, home care, and stroke inpatient units to examine care transitions. Focused efforts evaluated discharge resources emphasizing patient and caregiver assessment, caregiver preparedness, and educational materials. Areas developed to support transitions included: standard caregiver resources including respite needs, daily discharge huddle identifying home needs and 7-day phone follow-up process. Metrics tracked included length of stay, discharge disposition, number of patients surveyed, number of caregivers provided educational materials and readmissions.

Developing interdisciplinary relationships promoted improvements in communication that lead to improved patient transitions related to follow up care, medication reconciliation and sharing of clinical information to promote continuity of care. At one year, 75% of patients received a structured post-discharge phone call which continues to identify opportunities to assist with scheduling follow up care, support early recognition of post stroke depression and ensure caregivers utilize respite resources. Our 30 day readmission rates in our ischemic stroke patients decreased to 7%, an overall 5% reduction from previous year.

Assessment of patient and caregiver needs after discharge can be difficult and requires a coordinated multidisciplinary effort with multi-prong interventions. Development of a Stroke Care Continum team allowed the CNS and Stroke Director to work with both inpatient and outpatient stakeholders.
Abstract W P281: Inter-Rater Reliability of Clinical Decision Making Based on Recorded Telemedicine Assessments and Case Histories
Authors: Lightbody Catherine E , Davies Paul , Emsley Hedley , Fitzgerald Jane , Ford Gary , Howell Laura , Leathley Michael J , McLoughlin Alison , May Carl , Price Christopher , Sutton Christopher , Watkins Caroline
Published: March 2022

Background:
Patient outcomes are improved by reducing time, and increasing access, to stroke-specialist consultation and treatment. Telemedicine may ensure earlier and wider access to stroke-specialist consultation. However, reliable and accurate decision making is necessary by various professional groups in the emergency department in order for the telemedicine assessment to be initiated.

Aim:
To explore the inter-rater reliability of clinical decision making by various health professionals, when using telemedicine assessments in acute stroke.

Method:
Twenty-six telemedicine assessments in patients with suspected stroke (final/gold standard diagnosis: 16 strokes and 10 non-strokes) were recorded, edited and then presented with case histories. Health professionals viewed 6, randomly selected assessments and rated: whether ‘stroke or not’; level of confidence with their diagnosis. Data were analysed using Cohen’s kappa (K) with 95% confidence interval (CI) calculated using bias-corrected bootstrapping in STATA with 10000 replicates. Sensitivity and specificity were estimated.

Results:
Forty raters: 13 stroke physicians, 15 stroke nurses, 12 non-stroke specific staff (NSS) (including 3 ED consultants, 8 registrars and 1 neurologist). Median of 8 raters per assessment.

For ‘stroke or not’, agreement between all health professions was fair (K=0.36, CI 0.22-0.54); correctly diagnosing whether the patient was ‘stroke or not’ on 8 occasions, Sensitivity 77% (98/128), Specificity 67% (45/67).

Agreement within each health professional group ranged from K=0.37 (stroke physicians and nurses) to K=0.43 (NSS group), although CIs were wide. Sensitivity ranged from 74% (stroke physicians) to 81% (NSS group); specificity from 58% (stroke physicians) to 74% (NSS group).

Median confidence was highest in 4 of the 8 on which all raters agreed the ‘stroke or not’ diagnosis.

Conclusion:
Agreement was ‘fair’ overall and was similar for all groups, although CIs were wide. Nurses’ agreement or diagnostic accuracy were similar to stroke physicians and NSS doctors when rating telemedicine consultations.
Abstract W P286: Effect of a Dedicated In-House Stroke Nurse on Stroke Quality Outcome Measures: A Single Center Experience
Authors: Doerr Abbigayle M , Lindstrom Anne , Ferguson Morgan , Carlson Jennifer , Diane Broadley , Shownkeen Harish , Linsner Kathleen , Davis Janet , Pittner Laura , Biede Jennifer
Published: March 2022

Background and Purpose:
As a comprehensive stroke program with a large transfer population, the transfer process initially was coordinated by the Intensive Care Unit charge nurse. As the program grew, a strain was placed upon the nurses. The focus of the Code Neuro Nurse role was to coordinate all stroke transfer patients and responding to all internal strokes. We sought to determine the efficacy of the Code Neuro Nurse role in improving
documentation
and education as it relates to the stroke population.

Methods:
A retrospective analysis of seven quality indicators was performed before and after program inception. Dysphagia screening (n=1071), Stroke education (n=870), National Institute of Health Stroke Scale (NIHSS) on admission (n=1197), NIHSS on discharge (n=2302), modified rankin score (mRS) on admission (n=1567), mRS on discharge (n=2302) and door to intravenous (IV) tissue plasminogen activator (tPA) within 60 minutes (n=35). A two tailed t-test was performed analyzing data from July 2011 through June 2013 comparing two twelve month data groups (2012 and 2013).

Results:
Significant improvement from 2012 to 2013 quality indicators was demonstrated in documented stroke education from a mean of 95.6% to
100% (
p= 0.0153), NIHSS on discharge from mean 72.6% to 82.3% (p=0.0416), mRS documentation at admission from a mean 67.7% to 92.6% (p<0.0001) and mRS documentation at discharge mean 62.5% to 78.4% (p=0.0049). Although not statistically significant, quality indicator improvement was demonstrated 2012 to 2013 in NIHSS reporting on admission from mean 96.1% to 98.5% (p=0.074), dysphagia screening from mean 85.4% to 89.1% (p=0.053), and door to IV tPA in 60 minutes from mean 31.3% to 58.7% (p=0.15).

Conclusions:
The “Code Neuro Nurse” program demonstrated an increase in documentation related to the care of the stroke patient. While other areas showed increased improvement related to testing and process, the results were not statistically significant. Further evaluation is warranted to determine the opportunities for further growth and development of the program.
Abstract W P300: Factors Affecting Functional Assessment Measures (FAM) Self-Completion Among Intracerebral Hemorrhage (ICH) Patients
Authors: Moraros Spiro M , Kaufmann Teslyn , Pandurengan Renga , Ofori Kwame , Sline Rick , Cai Chunyan , Bowry Ritvij , Gonzales Nicole
Published: March 2022

Background:
The Barthel Index (BI) and Stroke Impact Scale (SIS) are established functional assessments measuring (FAM) performance in daily living activities and overall quality of health and life in stroke patients, respectively.

Purpose:
To determine factors affecting FAM self-completion among intracerebral hemorrhage (ICH) patients at 3 months post-stroke.

Methods:
Sample size consisted of 84 patients enrolled in an ICH clinical trial. Three categories were created to account for FAM completion: 1) Patient (P), 2) Family/Surrogate (F), 3) Missing/Not Required (M), which also included expired patients. To compare the differences between groups, analysis of variance, Kruskal-Wallis test or extended Fisher’s exact test, as appropriate, were performed.

Results:
BI was performed at baseline [n(%): P = 29 (34.5%), F = 55 (65.5%), M = 0 (0%)] and 3 months post-stroke [P = 45 (53.6%), F = 11 (13.1%), M = 28 (33.3%)]. SIS was performed at 3 months post-stroke [P = 43 (51.2%), F = 12 (14.3%), M = 29 (34.5%)]. Several baseline factors were scrutinized for their effect on FAM self-completion at 3 months. BI was significantly affected by: Stroke Scale (NIHSS), Glasgow Coma Scale (GCS), Modified Ranking Scale (mRS) and Hyperlipidemia. SIS was significantly affected by: NIHSS, GCS and aphasia. Larger baseline hematoma volumes (≥ 20.1cc), although not significant, also appeared to affect the study outcome.

Conclusion:
Patients presenting at baseline with NIHSS score ≥ 16, larger hematoma volumes, lower GCS, aphasia and hyperlipidemia were less likely to complete their own functional assessments by 3 months. Further study is necessary to explore additional FAM for severe ICH patients.
Abstract W P305: Processes Trends and Current Clinical Outcomes for IV TPA and Endovascular Stroke Therapies from the INterventional Stroke Therapy Outcomes Registry
Authors: Connors John J , Alberts Mark J , Novakovic Roberta
Published: March 2022

Background:
There is no national stroke registry that tracks emergency intra-hospital processes of care and 90-day clinical outcomes for both IV TPA and/or emergency endovascular stroke treatment (EVT). We created the INterventional Stroke Therapy Outcomes Registry (INSTOR®) to address this lack of data.

Methods:
INSTOR is a sophisticated point-and-click analytical tool that tracks emergency processes and clinical outcomes (90-day modified Rankin Scale (mRS) in standard stacked bar chart) for both IV TPA and EVT for acute stroke. Complex analyses are performed in real-time and presented in multiple graphic formats. Single and multivariate risk adjustment for IV TPA and EVT therapies are performed based upon the presence or absence of diabetes, initial stroke severity, age, hypertension, atrial fibrillation, and, for EVT, original location of clot.

Results:
Since start of use of INSTOR over 30 months ago (data from 10 sites, over 2368 patients, 542 treated ischemic strokes), median times for arrival to CT have declined from 31 to 17 minutes and scan interpretation from 47 to 40 minutes. Arrival to IV TPA has declined from 81 to 70 minutes, and “decision” (TPA-order) to TPA-started from 20 to 13 minutes. Current 90-day mRS 0-1 for IV TPA (minimum NIHSS null, median 11, maximum 36) is 16% for diabetic patients versus 26% for non-diabetic patients. For IV TPA patients, the overall percentage of mRS 0-1 is 22.6 while mRS 0-2 is 44%. However, for those presenting with NIHSS 6-9, mRS 0-2 at 90-days is 76% while those presenting with NIHSS 10-14, it is 43%. For EVT (minimum NIHSS null, median 17, maximum 38), 90-day mRS 0-2 for IV+EVT is 56% at 90-days vs. 32% for EVT alone and variation is shown based upon original clot location. The rate of symptomatic intracranial hemorrhage is 3.8% for IV TPA alone, 6.6% for IV+EVT, and 8.7% for EVT alone.

Conclusions:
INSTOR is a unique quality improvement tool that presents instant online graphical and numerical analyses of numerous processes of care and clinical outcomes that can be used to improve care.
Abstract W P309: Hemorrhagic Risk Associated with Warfarin Initiation among Patients with Atrial Fibrillation: Assessment via a Large Insurance Database
Authors: Tepper Ping G , Liu Xianchen , Melissa Hamilton , Mardekian Jack , Petkun William , Tan Wilson , Singer Daniel E
Published: March 2022

Objective:
Studies suggest that warfarin may increase the risk of stroke in the first month after initiation among atrial fibrillation (AF) patients. This study assess whether there is a similar occurrence with major bleeds. We compared rates of major bleeds (hospitalizations for bleeding) in the first 30 days and >30 days after warfarin initiation between AF patients treated with warfarin and AF patients not on oral anticoagulants (OACs) in a large database.

Methods:
We identified adult AF patients via one inpatient or two outpatient AF diagnosis claims from the MarketScan insurance database with 95 million enrollees from 1/1/2008 to 3/31/2012. AF patients who started warfarin based on prescription claims, 1/1/2009-12/31/2010 and who didn’t use OACs 6-month prior were defined as warfarin initiators. Comparators were AF patients not on OACs from 7/1/2008-12/31/2010 and were 1:1 matched to warfarin initiators on age, sex and date of AF diagnosis. Patients were followed until major bleeding, discontinuation/switch of therapy, disenrollment, or end of study. We report crude rates of major bleeding and adjusted hazard ratios (HRs).

Result:
We studied 45,052 AF patients with an average follow-up of 1.9 years. Warfarin initiators and comparators were the same age (73.0) and sex (50% female) but had slightly lower CHADS2 scores (1.7 vs. 1.8) and ATRIA bleed scores (2.2 vs. 2.4). Compared to patients not on OACs, the rates of bleeding were higher among warfarin initiators during the first 30 days (adjusted HR=1.70) and after 30 days (adjusted HR=1.77) (Table) (p for interaction=0.86). The bleeding rate was higher in the first 30 days than after 30 days for the warfarin initiators, but this was also observed for the comparators (p=.02).

Conclusion:
Compared with AF patients not on OACs, warfarin appears to increase the risk of major bleeding similarly during the first 30 days and thereafter even though the rate was higher in the first 30 days for both warfarin initiators and comparators.
Abstract W P315: Cardio-Respiratory Arrest in Stroke (CAIS Study): Predisposing Factors, Clinical Features, Outcomes, and Process Measures
Authors: Nikneshan Davar , Rabinstein Alejandro , Holloway Robert , Tu Jack , Fang Jiming , Saposnik Gustavo ,   Registry of the Canadian Stroke Network (RCSN),   The Stroke Outcomes Rsch Canada (SORCan) Working Group
Published: March 2022

Objectives:
Limited information is available on the prevalence of cardiorespiratory arrest (CA) and its predisposing factors in patients with acute ischemic stroke. We analyzed/evaluated clinical characteristics, risk factors, access to care, and survival in stroke patients who developed a cardiac arrest.

Methods:
This is a multicenter cohort study including consecutive patients with acute ischemic stroke admitted to regional stroke centers participating in the Registry of the Canadian Stroke Network from July 2003 to March 2008. Patients with DNR order on admission were excluded. CA was defined as cardiac or respiratory arrest within 30 days of admission documented by a physician and identified from resuscitation records. The main outcome measures were the 30-day and 1-year survival among patients with CA vs. no CA. We also assessed the association between medical complications during hospitalization and CA.

Results:
Overall, 9,019 patients with acute ischemic stroke were included. Cardiac arrest was observed in 352 patients (3.9%). In patients with CA, 30-day survival (17.9% vs. 90.7%, P<0.001) and 1-year survival (4.5% vs. 80.1, p<0.001) were significantly lower. Less than 1% of stroke patients with CA were discharged home (vs. 47.3%; p<0.0001). Other outcome measures are summarized in Table 1. On multivariable analyses, older age, more severe stroke, previous history of myocardial infarction, congestive heart failure, atrial fibrillation, and diabetes were associated with CA.

Conclusions:
Cardiac arrest affects less than 5% of patients admitted with an acute ischemic stroke and is associated with poor outcomes. Less than 1% of patients were independent or discharged home.
Abstract W P344: Choice of Warfarin and Novel Oral Anticoagulants for Secondary Prevention of Stroke/TIA in Japanese NVAF Patients: The SAMURAI-NVAF Study
Authors: Toyoda Kazunori , Arihiro Shoji , Todo Kenichi , Yamagami Hiroshi , Kimura Kazumi , Shiokawa Yoshiaki , Kamiyama Kenji , Terasaki Tadashi , Okada Yasushi , Nagakane Yoshinari , Mochizuki Hiroshi , Takizawa Shunya , Hasegawa Yasuhiro , Okuda Satoshi , Furui Eisuke , Ito Yasuhiro , Nakashima Takahiro , Kario Kazuomi , Kameda Tomoaki , Takamatsu Kazuhiro , Nishiyama Kazutoshi ,   SAMURAI Study Investigators
Published: March 2022

Purpose:
We aimed to determine choice of oral anticoagulants (OACs) at acute hospital discharge in stroke patients with NVAF and clarify their underlying characteristics potentially influencing the choice from a multicenter prospective registry (the SAMURAI-NVAF, NCT01581502).

Methods:
668 acute ischemic stroke/TIA survivors with NVAF (298 women, 77±10 years old) between Sep '11 and Jun '13 were studied; dabigatran (Jan '11), rivaroxaban (Jan '12), and apixaban (Dec '12) were approved for clinical use in NVAF patients in Japan just before or during the periods. OAC choice at hospital discharge (median 23 days) was assessed.

Results:
Warfarin was chosen for 420 patients (63%), dabigatran for 143 (21%), rivaroxaban for 72 (11%), and OACs were not chosen for 33 (5%). Of 204 prestroke warfarin users, 160 (78%) continued to take warfarin, 27 changed to dabigatran, and 17 to rivaroxaban. Among three 7-month parts of observation period, warfarin users decreased (70%, 69%, 48%), dabigatran users unchanged (23%, 21%, 19%), and rivaroxaban users increased (0.5%, 7%, 26%). Warfarin users had higher scores of CHADS
2
(median 4 in warfarin, 4 in dabigatran, 3 in rivaroxaban, same orders in the following parentheses, p<0.001) and CHA
2
DS
2
-VASc (6, 5, 5, p<0.001). Of components for CHA
2
DS
2
VASc, congestive heart failure (27%, 12%, 13%, p<0.001), stroke history (29%, 15%, 15%, p=0.001), vascular disease (18%, 11%, 7%, p=0.019), and women (47%, 34%, 40%, p=0.020) were more common in warfarin users than the others. Age (79±10, 73±9, 74±10 years old, p<0.001), body weight (54±12, 62±11, 59±12 kg, p<0.001), admission creatinine clearance (52±26, 72±23, 67±25 ml/min, p<0.001), and concomitant antiplatelet use (12%, 10%, 1%, p=0.020) were also different. As features of index stroke, infarcts >33% in size of the culprit arterial territory were more common (29%, 8%, 13%) and scores of admission NIHSS (median 10, 3, 6), 7-day NIHSS (5, 1, 1) and discharge mRS (3.5, 1, 2, p<0.001 for all) were higher in warfarin users.

Conclusion:
In the initial two years after approval of novel OACs (NOACs), warfarin use at acute hospital discharge was still common, although NOAC users gradually increased. Index stroke was milder and ischemia-risk indices were lower in NOAC users than warfarin users.
Abstract W P349: Prediction of Major Adverse Cardiovascular Events by Age-Normalized Carotid Intimal Medial Thickness.
Authors: Rembold Christopher M , Nketiah Emmanuel , Rembold Karen E
Published: March 2022

Background:
Increases in carotid intimal medial thickness (CIMT), as measured by noninvasive ultrasonography, have been associated with increased risk of myocardial infarction and stroke. From 706 patients who had CIMT measured between 1995 and 2003 at the University of Virginia, we created age-specific quartiles of carotid thickness. Over a mean follow-up of 4.8 years, we found that bulb and internal but not common CIMT predicted the combined endpoint of myocardial infarction, stroke, and revascularization (Atherosclerosis 187:186, 2006). We now present the analysis as of 2012 for CIMT to predict major adverse cardiovascular events in a population of patients referred for carotid IMT measurement.

Methods:
From 1995-2012, 1427 patients had carotid IMT measured at the University of Virginia’s Preventive Cardiology practice. In 2012, we successfully contacted 1259 of these patients to determine clinical outcomes. The 1259 patients were entered into a database and odds ratios were calculated with logistic regression in SAS.

Results:
Over a mean follow-up period of 7.8 years (range, 1 to 16), 30 patients died and 66 had major adverse cardiovascular events (MACE): 17 patients had CV death/myocardial infarction; 20 required revascularization; and 29 had a stroke or transient ischemic attack.

The highest quartile of bulb CIMT demonstrated an odds ratio for MACE of 7.2 (95% confidence interval, 3.0 to 18.6; P<0.001) when compared to the quartile with the lowest thickness (P<0.001 for trend).

The highest quartile of internal CIMT demonstrated an odds ratio for MACE of 3.1 (95% confidence interval, 1.2 to 8.3; P=0.02) when compared to the quartile with the lowest thickness (P=0.009 for trend).

Common carotid IMT did not significantly predict MACE (p=0.23).

The highest quartile of bulb CIMT demonstrated an odds ratio for mortality of 3.4 (95% confidence interval, 1.03 to 11.2; P=0.044) when compared to the quartile with the lowest thickness (not significant for common or internal CIMT).

Conclusions:
Age-normalized measurement of bulb and internal but not common CIMT appear to predict which individuals would most benefit from aggressive risk-factor modification.
Abstract W P355: Pathophysiologic, Rather than Pharmacologic Resistance Drives Aspirin Failure in Ischemic Stroke
Authors: Agayeva Nergiz , Gungor Levent , Topcuoglu Mehmet Akif , Arsava Ethem Murat
Published: March 2022

Background:
Antiplatelet resistance is occurrence of thrombotic events while using antiplatelet agents. Apart from this clinical description, antiplatelet resistance can be defined by laboratory tests, which assess in vitro platelet reactivity against pharmacological challenges. The mechanisms underlying clinical and pharmacological antiplatelet resistance and their relationship with each other have not been evaluated extensively in patients with ischemic stroke. Furthermore, it is currently unclear whether these phenomena alter stroke phenotype, especially from the perspective of stroke severity and etiology.

Methods:
In-vitro aspirin resistance was evaluated using the VerifyNow® system within 48 hours of symptom onset in patients who had an ischemic stroke while using aspirin (n=99). Baseline characteristics (age, gender, risk factors, aspirin dose, other medications) and stroke features (clinical severity, DWI lesion volume, etiology) were compared between patients without resistance (defined as Aspirin Reaction Units, ARU<550), with resistance (ARU≥550) and an additional set of patients suffering from ischemic stroke while not using aspirin (n=314).

Results:
An ARU value≥550 was detected in 17 out of 99 patients who had ischemic stroke while using aspirin. Etiologies well known to be inadequately responsive to antiplatelet monotherapy, such as cardiac embolism and severe large artery atherosclerosis were present in 61% of aspirin users. Therefore, pharmacologic resistance by itself could be considered to be accountable for the ischemic event in only 7% of these patients. Stroke severity, lesion volume and baseline characteristics were not significantly different among patients with and without aspirin resistance. Patients without aspirin resistance were more likely to harbor a cardioembolic stroke etiology when compared to aspirin naive patients, even after adjustment for age and other cardiovascular risk factors (OR 2.3, 95%CI 1.4-4.1, p<0.01).

Conclusion:
Our findings highlight that pathophysiologic resistance, signifying the presence of etiologies that cannot be efficiently treated with aspirin treatment only, is the major contributor of clinical aspirin resistance observed in the setting of ischemic stroke.
Abstract W P44: Can Diffusion-Weighted Imaging-Fluid-Attenuated Inversion Recovery Mismatch (Positive Diffusion-Weighted Imaging/ Negative Fluid-Attenuated Inversion Recovery) at 3 Tesla Identify Patients With Stroke at <4.5 Hours?
Authors: Pierot Laurent , Emeriau Samuel , Serre Isabelle , Toubas Olivier , Pombourcq Francis , Oppenheim Catherine
Published: March 2022

Background:
and Purpose_At 1.5 T, diffusion-weighted imaging-fluid-attenuated inversion recovery (DWI-FLAIR) mismatch helps identify strokes within 4.5 hours of onset. However, at 3T, studies have found divergent results. The goal of this study was to determine whether DWI-FLAIR mismatch at 3T would also be helpful for identifying patients within 4.5 hours of symptom onset.

Methods:
All patients presenting with an ischemic stroke in the middle cerebral artery territory and explored with 3T MRI within 12 hours between November 2007 and April 2012 were included in this retrospective study. Two readers analyzed the DWI and FLAIR images. Logistic regression was performed to determine independent predictors of FLAIR visibility. Also, the predictive values of a mismatch for identifying patients with stroke onset ≤4.5 hours were estimated.

Results:
The study included 194 patients. The only predictive factor of FLAIR visibility was delayed MRI acquisition. The DWI-FLAIR mismatch was able to identify patients within 4.5 hours of stroke onset with relatively low sensitivity (0.55; 95% confidence interval, 0.48-0.63), low specificity (0.60; 95% confidence interval, 0.42-0.77), high positive predictive value (0.88; 95% confidence interval, 0.82-0.94), and very low negative predictive value (0.19; 95% confidence interval, 0.11-0.28). In addition, 44.5% of patients had a positive FLAIR sequence within 4.5 hours.

Conclusions:
This study improves our understanding of DWI-FLAIR mismatch as an imaging biomarker for wake-up management of patients with stroke. At 3T, the presence of a DWI-FLAIR mismatch was able to identify stroke onset of <4.5 hours. However, 44.5% of such stroke cases demonstrated FLAIR signal changes.
Abstract W P45: Differentiation of Contrast Extravasation From Intracranial Hemorrhage on Non-Contrast CT After Endovascular Treatment in Patients With Acute Ischemic Stroke
Authors: Payabvash Seyedmehdi , Qureshi Mushtaq H , Khan Shayaan M , Khan Mahnoor , Majidi Shahram , Qureshi Adnan I
Published: March 2022

Background:
Distinction of intracranial hemorrhage (ICH) from contrast extravasation after endovascular treatment is crucial for guiding subsequent management in patients with ischemic stroke. We evaluated the imaging characteristics that can help differentiate these two entities on post-endovascular treatment non-contrast CT (NCCT).

Methods:
Clinical and neuroimaging data for all patients with acute ischemic stroke who underwent endovascular treatment at two medical centers over a 6-year period were reviewed. The first post- endovascular treatment NCCT was evaluated for presence of parenchymal hyperdense lesion(s). In patients with parenchymal hyperdensity, the lesion was selected with free hand region-of-interest on the axial slice with the highest visual contrast against parenchymal background (i.e. the lesion appears brighter). ICH was defined as a hyperdensity persisting >48 hours on serial follow up CTs or confirmed by MRI study.

Results:
A total of 135 patients (mean age ± SD, 66.4 ± 15.6 years) were included. The median delay between angiography and the first follow up NCCT was 1.9 hours (interquartile range, 1.3 - 2.9). Of the 135 patients, 74 (55%) patients had hyperdense lesion(s) on NCCT; of whom, 20 met the definition of ICH, and 54 were contrast extravasation, which resolved on follow up CTs. A receiver operating characteristic analysis showed that the average attenuation can differentiate ICH from contrast extravasation with an area under the curve of 0.78 (p=0.01). An average attenuation of <50 Hounsfield Units (HU) was 100% specific for contrast extravasation versus ICH - which was seen in 24/54 (44%) patients with contrast extravasation. Notably, 8/61 (13%) patients with no hyperdense lesion on first follow up CT developed late-onset ICH.

Conclusion:
In our series, an average attenuation of <50 HU on the axial slice with highest contrast was 100% specific for differentiating contrast extravasation from ICH among patients with hyperdensity on first post-angiography NCCT.
Abstract W P66: Elevated INR as a Manifestation of Post-Thrombolytic Coagulopathy in Acute Ischemic Stroke
Authors: Lee Vivien H , Conners James J , Cutting Shawna M , Song Sarah Y , Bernstein Richard A , Prabhakaran Shyam
Published: March 2022

Background:
A serious complication of intravenous tissue plasminogen activator (tPA) in acute ischemic stroke is hemorrhage. Alterations in fibrinogen and fibrinogen degradation products, labeled “early fibrinogen degradation coagulopathy” (EFDC), are well established after tPA. However, tPA is not recognized to cause markedly abnormal international normalized ratio (INR).

Methods:
With IRB approval, we retrospectively reviewed 338 acute ischemic stroke patients who received tPA. We defined post-tPA coagulopathy as a documented elevation of INR ≥ 1.5 after IVtPA within 24 hours of tPA without a known cause. Patients with recent warfarin use (within 3 weeks of presentation) were excluded.

Results:
Among the 328 acute ischemic stroke patients who had received tPA, we identified 21 (7.4%) patients with an elevated INR post-thrombolysis. The mean age was 68.3 years (SD +/- 11.9) and 57% were male. The mean initial NIHSS (pre-tPA) was 15.8 (range, 4 to 35). Liver disease or alcohol abuse was noted in 19%. There were 2 tPA protocol violations who received >90mg tPA. The mean post-tPA INR was 2.03 (range, 1.5 to 4.7) and the elevation in INR was documented within a mean 5.4 hours (range, 1 to 15) after tPA initiation. Repeat INR levels returned to normal during their hospital stay in 19 patients. Hypofibrinogenemia was noted in 10 of 12 patients who had fibrinogen levels drawn within 48 hours after tPA initiation (7 of these fibrinogen levels were drawn the same time as the elevated INR). Among the 6 patients with bleeding complications, 2 patients had symptomatic intracerebral hemorrhage.

Conclusions:
We report an under-recognized early transient coagulopathy associated with elevated INR in stroke patients after treatment with tPA. Post-thrombolytic INR elevation may represent a severe manifestation on the spectrum of EDFC rather than a distinct phenomenon
Abstract W P75: Endovascular Treatment of Small Unruptured Cerebral Aneurysms with Flow Diverters
Authors: Piotin Michel , Bartolini Bruno , Pistocchi Silvia , Redjem Hocine , Blanc Raphaël
Published: March 2022

Purpose:
To assess the safety and efficacy issues of Flow Diverters (FD) in the treatment of small unruptured cerebral aneurysms.

Methods:
Retrospective review of a prospectively gathered database of endovascularly treated aneurysms since the introduction of FD. From September 2008 (when treatment aneurysms with FD was initiated at our institution) to August 2013, 538 small (≤ 12 mm), unruptured aneurysms were treated by endovascular means. Four treatment modalities were individualized: simple coiling, balloon-assisted coiling, stent-assisted coiling and aneurysm neck coverage with FD.

Results:
15.1% (mean sac size: 5.3 mm, 65.4% bifurcation) of aneurysms were simply coiled. 33.6% (mean sac size: 5.3 mm, 53.0% bifurcation) of aneurysms were coiled with balloon assistance. 31.4% (mean sac size: 6.4 mm, 75.1% bifurcation) of aneurysms were coiled with stent-assistance. 19.9% (mean sac size: 5.9 mm, 18.7% bifurcation) aneurysms were treated with FD. Procedural perioperative and delayed (up to 30 days) neurological complications were 0.0%, 3.5%, 9.9% and 3.4% respectively, with a marked trend for more complications with stent-assisted coiling (P=0.034). Total immediate aneurysm occlusion was obtained in 49.4%, 53.0%, 60.3% and 11.2% respectively, with a marked trend toward better occlusion with stent-assisted coiling technique (P<0.0001). At a mean follow-up of 17 months for aneurysms treated with FD and 19 months for the others (not significant), total aneurysm occlusion was 60.4%, 69.8%, 93.4% and 78.4% respectively, with a trend toward better occlusion with stent-assisted coiling (P=0.0011).

Conclusions:
FD for the treatment of small unruptured aneurysms confer a good safety profile that compares favorably with those of balloon-assisted technique, but are mostly indicated for sidewall aneurysms. Occlusion rates at follow-up are better with stent-assisted-coiling than FD but with higher morbidity.
Abstract 109: Flow-Diversion Versus Conventional Endovascular Techniques for Carotid Cavernous Aneurysms
Authors: Zanaty Mario , Chalouhi Nohra , Tjoumakaris Stavropoula , Starke Robert M , Hasan David , Barros Guilherme , Saigh Mark Philip , Schwartz Eric Winthrop , Ajiboye Norman , Rosenwasser Robert , Jabbour Pascal
Published: March 2022

Background and Purpose:
Several endovascular treatment options are available for cavernous carotid aneurysms (CCA). We compared PED versus conventional endovascular treatment in terms of evolution of mass effect, complications, recurrence and retreatment rate.

Methods:
One hundred fifty-seven patients harboring 167 CCA were treated using PED placement, coiling, stent assisted coiling (SAC), and carotid vessel destruction (CVD). Procedural complications, angiographic results, and clinical outcomes were analyzed and compared.

Results:
There were no difference in age, gender, and mean aneurysm size between those treated with PED and those treated with conventional endovascular procedures. The patients treated with PED had a significantly lower proportion of small size aneurysms(15mm (OR=4.27; p=0.003) to be predictors of none improvement in symptoms. The rate of complete occlusion was 81.36% (48/59) for PED, 42.25% (39/71) for SAC, 27.27% (6/22) for coiling and 73.33% (11/15) for CVD. Retreatment was needed in patients with aneurysm size >15 mm (OR=2.67;p=0.037) and those who were not treated with PED (PED: OR = 0.16; p=0.006). The rate of major complications was 6.6% (11/167). Patients that were treated with PED or SAC had 3.84 lower odds to develop complications (OR=0.26 p<0.05).

Conclusion:
The use of PED should be encouraged, especially in symptomatic patients. We found PED to be associated with less need for future treatment, higher improvement in symptoms rate and lower rate of complications.
Abstract 115: Genetic Variation in Retinal Vascular Patterning Predicts Variation in Pial Collateral Extent and Infarct Volume After Middle Cerebral Artery Occlusion
Authors: Prabhakar Pranay , Zhang Hua , Chen De , Faber James E
Published: March 2022

Introduction:
The presence of a native (pre-existing) collateral circulation in tissues lessens injury in stroke and other occlusive diseases. However, differences in genetic background are accompanied by wide variation in the number and diameter (extent) of native collaterals in mice, resulting in large variation in protection. Indirect evidence suggests a similar wide variation also exists in humans. However, methods of measurement in humans are indirect, invasive and not widely available.

Hypothesis:
We sought to determine if differences in genetic background in mice result in variation in branch-patterning of the retinal circulation, and if these differences predict differences in collateral extent and, in turn, differences in severity of ischemic stroke.

Methods:
Patterning metrics were obtained for the retinal arterial trees of 10 mouse strains (n=8 per strain) that differ widely in collateral extent in brain and other tissues. We also obtained pial collateral number and diameter, and infarct volume 24h after permanent middle cerebral artery occlusion. Forward- and reverse-stepwise multivariate regression analysis was conducted and model performance assessed using K-fold cross-validation.

Results:
Twenty-one metrics varied significantly with genetic strain (p<0.01). Ten metrics (eg, vessel caliber, bifurcation angle, lacunarity, optimality, branch length) strongly predicted collateral number and diameter across 7 regression models. The best models closely predicted (p<0.0001) collateral number (K-fold R2 =0.83-0.98), diameter (0.73-0.88) and infarct volume (0.85-0.87).

Conclusions:
Differences in retinal tree patterning are specified by genetic background and closely predict genetic variation in pial collateral extent and, in turn, stroke severity. If these findings can be confirmed in humans, and given that genetic variation in cerebral collaterals extends to other tissues at least in mice, a similar “retinal predictor index” could be developed as a biomarker for collateral extent in brain and other tissues. This could aid prediction of the risk-severity of tissue injury in occlusive disease as well as stratification of patients for treatment options and enrollment in clinical studies.
Abstract 125: Designated Stroke Center Status and Hospital Characteristics as Predictors of In-Hospital Mortality Among Hemorrhagic Stroke Patients in New York, 2008-2012
Authors: Gatollari Hajere J , Colello Anna , Eisenberg Bonnie , Brissette Ian , Luna Jorge , Elkind Mitchell S , Willey Joshua Z
Published: March 2022

Background:
While designated stroke centers (DSC) improve quality of care and outcomes for ischemic stroke patients, less is known regarding the benefits of DSCs for patients with intracerebral (ICH) and subarachnoid hemorrhage (SAH).

Hypothesis:
Compared to non-DSCs, hospitals with DSC status will have lower in-hospital mortality for hemorrhagic stroke patients independently of other hospital-level characteristics, including hospital size, urban location, and teaching status.

Methods:
We evaluated ICH (ICD-9 431) and SAH (ICD-9 430) hospitalizations that were recorded in the 2008-2012 New York State Department of Health’s Statewide Planning and Research Cooperative System (SPARCS) inpatient sample database. The relationship between DSC status and in-hospital mortality was evaluated using generalized estimating equation logistic regression to calculate OR’s and 95% confidence intervals; analyses were adjusted for clustering of patients within facilities, other hospital characteristics, and individual level characteristics. In secondary analyses we explored if other hospital characteristics were associated with in-hospital mortality.

Results:
Of 6501 ICH and 3440 SAH patients, in-hospital mortality was higher among those with ICH compared to SAH (23.7% vs. 18.5%). Unadjusted analyses revealed DSC was related with reduced mortality for both ICH (OR: 0.7; 0.6-0.8) and SAH patients (OR: 0.4; 0.3-0.7). DSC remained a significant predictor of in-hospital mortality for SAH patients (OR: 0.6; 0.4-0.9) but not for ICH patients (OR: 0.9; 0.6-1.2) after adjusting for patient demographic characteristics, comorbidities, hospital size, teaching status and location.

Conclusions:
Admission to a DSC was independently associated with reduced in-hospital mortality for SAH patients but not for those suffering from ICH. Other patient and hospital characteristics may explain the apparent benefit of PSC status on outcomes after ICH. Addressing gaps in stroke care through assessment of hospital-level factors indicates a potential target for quality of care improvement.
Abstract 127: Intra-Arterial Therapy in Stroke Patients Transferred from Referral Centers
Authors: Sarraj Amrou , Sitton Clark W , Boehme Amelia K , Supsupin Emilio P , Datta Proleta , Bajgur Suhas S , Sun Chung-Huan J , Jia Judy J , Choi Jeanie M , Bonafante-Mejia Eliana E , Friedman Elliot , Dannenbaum Mark J , Chen Peng R , Wu Tzu-Ching , Barreto Andrew D , Gupta Rishi , Martin-Schild Sheryl , Grotta James C , Savitz Sean I
Published: March 2022

Background:
The effectiveness of intra-arterial therapy (IAT) for patients presenting to endovascular capable centers with acute ischemic stroke (AIS) and large artery occlusion (LAO) has not been proven. Most AIS patients present to hospitals which do not have IAT capability and many are transferred to tertiary centers for IAT. We addressed if IAT improves outcome of patients transferred from outside facilities.

Methods:
In a multicenter retrospective study, we identified 615 AIS patients with LAO transferred to centers that offered IAT within 12 hours from ictus during 01/05-03/14. Patients were divided into two groups (IAT vs No IAT) (Figure 1). Logistic regression was performed for good and poor (discharge mRS 0-2 and 4-6, respectively) outcome. Univariate and multivariate analyses evaluated independent predictors of good and poor outcome after IAT.

Results:
Patients in the IAT group had more severe strokes, arrived faster to tertiary centers, had less ischemic changes on CT and better collateral flow compared to the non-IAT group (Table 1). Fewer IAT patients had ASPECTS deterioration during transfer. IAT patients had 4 times the odds for good outcome (OR 3.7, 95%CI 2.2-6.3, p<0.0001) compared to those without IAT, even after adjusting for stroke severity, ASPECTS, ASPECTS decay, collateral flow, time, and tPA (OR 2.51 95%CI 1.2-5.8, p=0.02). mRS distribution demonstrated a shift towards better outcomes in IAT treated patients (Fig 2). Patients with better outcome had better ASPECTS/collaterals, were younger and had lower NIHSS. Time to IAT was not an independent predictor of outcome.

Conclusion:
IAT may improve outcome in selected transfer patients with LAO, a group that was under-represented in prior trials. In late-treated patients, collateral flow, the extent of infarct, and age may be more important than time in determining outcome from IAT. Identifying patients at referral hospitals who may benefit from IAT and expediting their transfer should be tested in RCTs.
Abstract 13: Improved Ischemic Stroke Outcome Prediction Using Model Estimation Of Outcome Probability: The THRIVE-c Calculator
Authors: Flint Alexander , Rao Vivek , Chan Sheila , Cullen Sean , Faigeles Bonnie , Smith Wade , Bath Philip , Wahlgren Nils , Ahmed Niaz , Donnan Geoff , Johnston Clay
Published: March 2022

Introduction:
The THRIVE score is a validated ischemic stroke outcome prediction tool. While simplified systems like the THRIVE score facilitate ease-of-use, when computers or devices are available at the point of care, a more accurate estimation of outcome probability is possible by computing the logistic equation with patient-specific continuous variables.

Methods:
We used data from 12,207 subjects from the Virtual International Stroke Trials Archive (VISTA) and the Safe Implementation of Thrombolysis in Stroke - Monitoring Study (SITS-MOST) study to develop and validate the performance of a model-derived estimation of outcome probability, the THRIVE-c calculation. Models were built with logistic regression using the underlying predictors from the THRIVE score: age, NIH Stroke Scale (NIHSS) score, and the Chronic Disease Scale (presence of hypertension, diabetes mellitus, or atrial fibrillation). Receiver-Operator Characteristics (ROC) analysis was used to assess model performance and compare the THRIVE-c model to the traditional THRIVE score.

Results:
The THRIVE-c model performed similarly in the randomly chosen development cohort (n=6194, AUC = 0.786, 95% CI 0.774-0.798) and validation cohort (n=6013, AUC = 0.784, 95% CI 0.772-0.796) (P=0.79). The THRIVE-c model (AUC = 0.785, 95% CI 0.777-0.793) had superior performance when compared to the traditional THRIVE score (AUC = 0.746, 95% CI 0.737-0.755), (P<0.0001).

Conclusion:
By computing the logistic equation with patient-specific continuous variables in the THRIVE-c calculation, patient outcomes are more accurately estimated. Given the widespread availability of the computers and devices at the point of care, such calculations can be easily performed with a simple user interface. A web calculator for THRIVE-c is available at www.thrivescore.org.