bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP385: Rapid Access Clinic: Defining the Unmet Need for Urgent Post-Stroke Follow-Up
Authors: Taboada Susan B
Published: January 2019

Background:
The majority of post-stroke patients are typically seen in clinic on a non-urgent basis after hospital discharge and rehabilitation. However, a subset of patients requiring expedited follow-up exist and have not been clearly defined.

Objective:
To determine the subgroup of patients who need, and would benefit from urgent follow-up in stroke clinic after stroke.

Methods:
We developed at our comprehensive stroke center a post-stroke Rapid Access Clinic (RAC) every 2 weeks accommodating evaluation of urgent and emergent patient visits. We prospectively tracked the reason for visit, utilization rates, clinic diagnosis, and appointment outcomes over 1 year. We analyzed the data to define the patient population at need.

Results:
Over 12 months, 184 visits were made available and 84% were successfully completed (n=154) with 133 patients. Roughly 16% (n=30) either cancelled or did not successfully schedule. The mean age was 61.1 (+/-16 yrs) and 48% were female. Younger patients ( 45 years) were seen in clinic sooner than older patients (26.77 vs. 39.1, p = 0.009). Appointment reasons included lack of access to routine stroke clinic follow-up 27% (n=41), new symptoms post stroke 25% (n=39), TIA 21% (n=32), follow up imaging 14% (n=22), return to work clearance, expedited follow up per provider 4% (n=6), and others 5% (n=8). The mean time from hospital discharge to clinic evaluation for TIAs was 30.8 +/- 21.7 days. For 10.5% (n=14) of patients, diagnosis at clinic differed from diagnosis at hospital discharge. Hospital discharge disposition included Home 64.7% (n=86), acute rehab 11.3% (n=15), subacute rehab 13.5% (n=18), disposition n/a 10.5% (n=14).

Conclusion:
Approximately 1 in 4 RAC appointments were due to lack of clinic access and a quarter of all patients were evaluated for new symptoms. Younger patients and TIAs tended to follow up sooner. This clinic model was beneficial to these patient populations and helped prevent hospital readmission, provide urgent assessments, and adequate secondary prevention.
Abstract TP388: Does Management of Anemia After Acute Ischemic Stroke Improve Outcomes?
Authors: Rumball Ian , Vang Choua A , Smith Angela , Borgert Andrew J , Rosenstein Lori J
Published: January 2019

Introduction:
Anemia is associated with increased morbidity and mortality in patients with acute ischemic stroke (AIS). However, it is unclear if management of anemia after stroke can improve outcomes.

Objective:
To assess the impact of anemia, and its treatment, on AIS patient outcomes.

Methods:
Adult AIS patients admitted to a rural academic medical center for primary stroke between 1/1/2012 - 12/31/2016 were included. Patient medical records were reviewed for relevant health information.

Results:
A sample of 753 patients treated for AIS was evaluated. Moderate or severe anemia (hemoglobin < 11 g/dL for both sexes) was associated with increased mortality at 6 months (57.6% [45.0-68.3], 80.3% [72.9-85.9], 86.9% [83.6-89.5] for moderate/severe, mild and no anemia, respectively; p< 0.0001). This difference in survival was still seen after adjustments for other covariables, such as age, renal insufficiency, atrial fibrillation, heart failure and diabetes mellitus, in multivariate analysis. Following AIS, only 41% (90/219) of patients with anemia had documented management of anemia. We did not detect a difference in long term survival or stroke recurrence for managed vs. unmanaged patients. However, the anemia management most often occurred in the months following stroke, while anemia had the largest impact on outcome in the initial weeks after stroke.

Conclusions:
This study confirmed the poor prognosis seen with moderate and severe anemia after AIS. The lack of difference in outcome for managed vs. unmanaged patients may reflect the fact that the adverse effect of anemia was greatest in the first days to weeks after stroke while management was undertaken later. Thus, more aggressive treatment of anemia in patients at risk for stroke may be beneficial. In conclusion, more investigation into the relationship between anemia treatment and stroke mortality is warranted, such as a prospective study looking at management of anemia in patients with stroke risk factors.
Abstract TP389: Association Between Door-To-Needle Time and Aphasia in Patients Treated With IV tPA
Authors: Patel Anand , Bajwa Sami , Patel Neisha , Katz Jeffrey M , Libman Richard B
Published: January 2019

Introduction:
Door-to-needle time (DTN) is associated with outcome in acute ischemic stroke (AIS) patients who are eligible to receive intravenous tissue plasminogen activator (IV tPA). Various factors have been shown to impact DTN time including patient-related factors such as initial refusal or management of hypertension, hospital-related factors such as laboratory tests; and system-related factors all potentially affecting clinical outcomes. Neurological deficits such as aphasia could potentially affect DTN through various mechanisms including difficulty in obtaining accurate last known well time (LKWT), discussing risks vs benefits of IV tPA, etc. We sought to investigate the association between aphasia as a presenting neurological deficit and DTN.

Methods:
This was a retrospective chart review of prospectively collected data through Get-with-the-Guidelines from 7/17 to 6/18 at our comprehensive stroke center. Data regarding patient demographics, medical history, last known well time (LKWT), arrival time, door-to-CT time, treatment time, admission National Institutes of Health stroke scale (NIHSS), pre-stroke modified Rankin scale (mRS) were analyzed. Pearson chi-square test was performed to determine association between aphasia and DTN time.

Results:
Out of 110 patients (mean age 72 years; 59% women) who received IV tPA; 40% had aphasia as part of their clinical presentation. Patients with aphasia were older (76 vs 69 years) and had higher admission NIHSS (13 vs 6). DTN times did not differ significantly between patients presenting with aphasia vs other neurological deficits (44 vs 45 minutes; p=0.84). No difference was observed between door-to-CT time (16 vs 18 minutes) and LKWT-to-treatment time (138 vs 142 minutes).

Conclusion:
We did not find significant differences in tPA treatment times in patients with AIS based on the presence or absence of aphasia. Although aphasia could present challenges in the evaluation of patients with AIS, the increased severity of neurological deficits inherent to aphasia may lead to a faster work flow. A small sample size is a major limitation of our study. Further research into the influence of aphasia and other presenting neurological symptoms on DTN is warranted.
Abstract TP39: 12 versus 24 Hour Bed Rest After Acute Ischemic Stroke Thrombectomy
Authors: Silver Brian , Hamid Tariq , Khan Muhib , DiNapoli Mario , Behrouz Reza , Saposnik Gustavo , Sarafin Jo-Ann , Martin Susan , Moonis Majaz , Henninger Nils , Jun-O'Connell Adalia , Cutting Shawna M , Saad Ali , Yaghi Shadi , Hall Wiley , Muehlschlegel Susanne , Carandang Raphael , Osgood Marcey , Thompson Bradford B , Fehnel Corey R , Wendell Linda C , Potter Nicholas S , Gilchrist James M , Barton Bruce
Published: January 2019

Background:
The practice of 24 hours of bed rest after acute ischemic stroke thrombectomy is common among hospitals, but its value compared to shorter periods of bed rest is unknown. We sought to compare discharge outcomes and in-hospital complications of shorter (12 hour) and 24 hour bed rest protocols following reperfusion therapy.

Methods:
Consecutive adult patients with a diagnosis of ischemic stroke who underwent thrombectomy treatment between 1/1/2010 until 4/13/2016 identified from the local ischemic stroke registry were included. Standard practice bed rest for 24 hours, the protocol prior to 1/27/2014, was retrospectively compared with standard practice bed rest for 12 hours, the protocol after that date. The primary outcome was favorable discharge location (defined as home, home with services, or acute rehabilitation). Secondary outcome measures included incidence of pneumonia, readmission within 30 days, NIHSS at discharge, and hospital length of stay.

Results:
193 patients were identified, 59 patients in the 24 hour and 134 in the 12 hour bed rest groups. There was no significant difference in favorable discharge outcome in the 24 hour bed rest protocol compared with the 12 hour bed rest protocol in multivariable logistic regression analysis (54.2% vs. 68.7%, p=0.14, OR 1.73 CI 0.84-3.56). Compared with the 24 hour bed rest group, the incidence rates of pneumonia (13.6% versus 3.7%, p=0.03, OR 0.27 CI 0.08-0.88), median discharge NIHSS (8 versus 4, p=0.036, mean length of stay (7.5 versus 3.9 days, p<0.0001), and 30-day readmission rates (10.2% versus 3.2%, p=0.017, adjusted OR 0.16 CI 0.04-0.72) were lower in the 12 hour bed rest group.

Conclusion:
Compared with 24 hour bed rest, 12 hour bed rest after acute ischemic stroke thrombectomy therapy appeared to be safe and may be associated with reduced neurological deficit at discharge, shorter length-of-stay, and reduced rates of readmission within 30 days. A randomized trial is needed to verify these findings.
Abstract TP391: The Smoking Paradox - Does it Exist in Acute Ischemic Stroke Patients Receiving Endovascular Therapy?
Authors: Ali Syed F , Hemmen Thomas , Leslie-Mazwi Thabele , Nalleballe Krishna , Onteddu Sanjeeva , Schwamm Lee H
Published: January 2019

Introduction:
A “smoking paradox” has been observed in GWTG data whereby patients with an active smoking history paradoxically have lower post stroke mortality and better outcomes after IV thrombolysis than non-smokers. We sought to determine if this effect was present in acute ischemic stroke (AIS) patients who underwent endovascular therapy (EVT).

Methods:
Using local GWTG stroke registry data from three large comprehensive stroke centers in the Northeast, South and West, we analyzed 13,420 consecutive stroke admissions from 01/2006 - 04/2018 and included all patients with EVT stratified by smoking status. We compared good clinical outcome (discharge to home versus other) and in-hospital mortality using Chi-square for categorial data, T-Test for parametric continuous and Wilcoxon for non-parametric continuous variables. We used multiple regression analysis to identify associations.

Results:
We identified 772 patients who underwent EVT. Of those, 128 (16%) were smokers. Smokers were younger, more frequently male and presented with fewer stroke risk factors such as CAD/MI and atrial fibrillation. Overall NIHSS was similar, but smokers had a higher frequency of weakness at presentation. (Table). IV tPA use and in-hospital complications (pneumonia and deep vein thrombosis) were similar across the groups. Smoking was associated with good outcome in univariate analysis (OR 1.90; 95% CI 1.25, 2.89, p<0.001) but in multivariable analysis, only age was independently associated with good outcome (OR 0.97; 95% CI 0.96, 0.99, p<0/001) or in-hospital mortality (OR 1.03; 95% CI 1.02, 1.05, p<0.001).

Conclusion:
Unlike after IV tPA alone, smoking was not associated with a good outcome after multivariable adjustment in AIS patients receiving EVT. This may be due to differences in patient selection, stroke subtype or the effect size of EVT treatment. Replication in independent data sets is needed to confirm this observation.
Abstract TP394: Senior Clinical Project Leader
Authors: Chau Davis , Garman Dave , Adams Corey , Zhang Yichaun , Rizwan Araslan , Ryckborst Karla J , Goyal Mayank , Hill Michael D , Christenson Jim , Tymianski Michael
Published: January 2019

Introduction:
FRONTIER (NCT02315443) and ESCAPE-NA1 (NCT02930018) are two pivotal trials investigating the safety and efficacy of the neuroprotectant NA-1 in acute ischemic stroke (AIS). NA-1 administration is weight-based (2.6mg/Kg), requiring the rapid estimation of body weight by paramedics in the field (FRONTIER) and by hospital staff upon ED arrival (ESCAPE-NA1). Alteplase, which is administered after hospital arrival, also requires weight-based dosing. Here we evaluated the accuracy of the body weight estimated by paramedics and by hospital staff prior to administering study drug (NA-1 or placebo) as compared to the actual subject weight collected using in-hospital scales during the subsequent in-hospital stay.

Methodology:
In both these studies, FRONTIER and ESCAPE-NA1, paramedics in the field and Hospital staff will be determining weight by first asking the subject, second asking a family member or third by estimation. Subsequently, in each trial, in-hospital scales are used during the subject’s admission to measure body weight accurately. The subject’s actual weight will be measured in hospital using standard hospital scales (i.e., stand up or in-bed scales if the subject is not ambulatory), as soon as possible, but within five days. Data were obtained from the trial database.

Results:
As of August 1
st
2018, 264 subjects were enrolled in FRONTIER of which 206 had all body weight data available, and 444 subjects were enrolled in ESCAPE-NA1 of which 218 had all body weight data available. As compared with in-hospital scales, paramedics over estimated patient weight by an average of 2.57 kg (SD = 6.94 P< 0.001). In-hospital staff under estimated patient weight by an average of 1.82kg (SD = 8.93 P=0.003). The difference is statistically significant but not clinically meaningful. Overall, the weight estimated by paramedics and by hospital staff was 93% accurate, when compared to the actual weight collected.

Conclusion:
Both paramedics and hospital staff were mostly accurate when estimating patient weight in the acute care settings of FRONTIER and ESCAPE-NA1. This suggests that when time is of the essence, weight may be estimated effectively for the purpose of administering stroke drugs.
Abstract TP396: Accuracy of Administrative Hospital, Emergency Department and Death Records
Authors: Ung David , Gerraty Richard P , Frayne Judith , Olaiya Muideen T , Kim Joosup , Srikanth Velandai K , Phan Thanh , Cadilhac Dominique A , Nelson Mark R , Bladin Christopher F , Thrift Amanda G
Published: January 2019

Background:
Hospital, emergency presentation and death databases are frequently used to research outcomes after stroke. The reliability of diagnostic coding for cardiovascular disease (CVD) in these administrative data remains uncertain. We aimed to determine the reliability of these data in Australia using an existing clinical trial cohort.

Methods:
Patients with stroke/TIA who participated in the Shared Team Approach between Nurses and Doctors For Improved Risk factor Management (STAND FIRM) trial (n = 563, recruited from 4 hospitals within Victoria). We used diagnostic ICD-10-AM coded data from hospital, emergency department and death databases within 2 years after stroke/TIA. Medical records for these potential CVD-related events were reviewed by two independent stroke specialists and adjudicated according to strict criteria. We then estimated sensitivity and specificity of using either primary or both primary and secondary diagnoses fields (obtained for all adjudicated records), against the events adjudicated by the specialists (gold standard). False positives were CVD-events defined by ICD-10-AM diagnostic codes that were adjudicated as not being a CVD-event. False negatives were true CVD-events that were misclassified as not being CVD-related when using ICD-10-AM codes.

Results:
We identified 261 events for medical review. After adjudication, 65 were classified as CVD-events (cases) and 196 were not CVD-events. Using both primary and secondary diagnoses, 55 true positives were correctly identified among the cases (sensitivity = 84.6%) and 129 true negatives among the non-cases (specificity = 65.8%). Using only primary diagnoses, 48 true positives were identified (sensitivity = 73.9%) and 171 true negatives (specificity = 87.2%). Using both primary and secondary diagnoses had an increased sensitivity, but decreased specificity (area under the Receiver Operating Characteristic curve (AUC) = 0.75; 95% CI, 0.70, 0.81) when compared with using only primary diagnoses (AUC = 0.81; 95% CI, 0.75, 0.86; p = 0.028).

Conclusion:
Both primary and secondary diagnoses should be used to identify true CVD-events and minimise misclassifying these in administrative databases.
Abstract TP4: Do Lower Blood Pressure Levels in the First 24 Hours After Mechanical Thrombectomy Have an Impact on the Short-Term Outcomes?
Authors: Akca Ozan , Elliott Conner J , Liu Ruolan , Lenhardt Maria , Remmel Kerri , Liu Wei
Published: January 2019

Introduction:
Mechanical thrombectomy (MT) is a part of the standard treatment of LVO stroke. Peri-interventional blood pressure variability may impact the outcomes of MT. In this study, we assessed whether lower mean blood pressure levels for longer than 12 hours has any impact on the short-term functional outcomes of MT.

Methods:
With the approval of the Human Studies Committee at the University of Louisville (IRB #: 13.0396), we performed a retrospective analysis of LVO stroke MT patients from 2016-18 (n=86). Blood pressure (BP) data collected at admission baseline, precanalization, immediate post-canalization, and 24 hours post-canalization. Baseline and post-canalization 24-hour BP data collected hourly. MBP lower than 20% of the “mean baseline” values recorded in the first few hours of admission was considered as “
clinically low
” BP, and a total of 12 hours of
clinically low
MBP levels within the first 24-hour of post-thrombectomy period was considered as “
potentially hypoperfused
”. Changes in NIHSS within the first 24 hours post canalization and NIHSS at discharge were assessed as main outcomes.

Results:
Mean age was 65±13 years. About 83% of patients TICI 2b/3 was accomplished. Baseline MBP levels were 103 ± 16mmHg. When the “
potentially hypoperfused
” patients (MBP<80 of baseline for >12 hours) were compared with the patients who were
not
(n=29 vs. n=57), the change in NIHSS at 24 hours and the NIHSS score at discharge were statistically significantly worse in patients who were
potentially hypoperfused
. (Table)

Discussion:
In this retrospective analysis, we assessed the contribution of clinically lower MBP levels after MT to the short-term functional outcome. Our preliminary results showed that the patients who were exposed to hypoperfusion for longer than 12 hours had worse NIHSS scores. Impact of maintaining baseline blood pressure needs to be further studied under prospective and controlled study designs.
Abstract TP404: D-Dimer Elevation Following Intravenous Alteplase Can Predict Early Recurrence of Ischemic Stroke and Symptomatic Intracerebral Hemorrhage
Authors: Kumamoto Masaya , Koga Masatoshi , Yashimoto Takeshi , Yamagami Hiroshi , Ihara Masafumi , Toyoda Kazunori
Published: January 2019

Background:
Early recurrence (ER) of acute ischemic stroke (AIS) and symptomatic intracerebral hemorrhage (SICH) after intravenous thrombolysis (IVT) using alteplse could contribute to unfavorable functional outcome and mortality. Previous studies showed that plasma D-dimer levels reflect fibrin turnover, and are related to early stroke progression and unfavorable functional outcome.

Objective:
The aim of this study was to investigate whether D-dimer elevation after IVT is a determinant of ER or SICH in AIS.

Methods:
We measured plasma D-dimer levels twice just before and basically within 24 h after IVT in patients with AIS from January 2011 to December 2017. Patients were divided into quartiles based on the difference in the pre- and post-IVT levels of D-dimer. ER was defined as a new ischemic lesion on MRI with the occurrence of new neurological symptoms. SICH was diagnosed by CT or MRI, combined with an increase of ≥1 point from the baseline NIHSS score. Unfavorable outcome was defined as mRS≥3 at discharge.

Results:
Of a total of 619 patients (374 men, 74.8±12.2 years old), 37 developed ER and 25 patients SICH. Second D-dimer samples were taken 15.3 hours (median) after IVT. Median baseline and second D-dimer levels were 1.3 (IQR, 0.7-2.5). Second D-dimer levels, measured 15.3 hours (median) after IVT, were 3.6 in median (IQR 1.6-8.5) mg/dl. Median difference of d-dimer was 2.0 (IQR 0.5-6.8) mg/dl. D-dimer difference was significantly associated with ER (p <0.001 for trend), SICH (p =0.007 for trend), and unfavorable outcome (p <0.001 for trend). After adjustment for sex, age, onset-to-needle time, large vessel occlusion, hypertension, diabetes mellitus, atrial fibrillation, baseline NIHSS score, use of anticoagulants within 24 hours from IVT, odds ratios (95% CI) of the highest quartile (≥6.8 mg/dl) were 7.00 (2.17-31.6) for ER, 3.56 (1.52-8.72) for SICH, compared with the lowest quartile (<0.5mg/dl). Similar trends appeared in 349 patients with cardioembolic stroke [11.6 (2.81-80.7) for ER, 12.0 (1.92-238.1) for SICH].

Conclusions:
In acute ischemic stroke patients, D-dimer elevation after intravenous thrombolysis was an independent predictor of early recurrence or symptomatic intracerebral hemorrhage.
Abstract TP407: Comparative Characteristics of Ischemic and Hemorrhagic Early Neurological Deterioration Following Intravenous Thrombolysis
Authors: Tanaka Koji , Matsumoto Shoji , Furuta Konosuke , Kawajiri Masakazu , Yamada Takeshi , Nagano Sukehisa , Takase Kei-ichiro , Hatano Taketo , Yamasaki Ryo , Kira Jun-ichi
Published: January 2019

Background:
Early neurological deterioration (END) caused by ischemic or hemorrhagic insult following intravenous recombinant tissue plasminogen activator (rt-PA) is a serious clinical event. We aimed to clarify differences in characteristics of END between due to ischemic and hemorrhagic insults.

Methods:
From October 2005 to December 2015, consecutive patients who received 0.6 mg/kg intravenous rt-PA for acute ischemic stroke was retrospectively registered from 4 affiliated hospitals with a stroke unit. END was defined as any ≥4 point deterioration on the National Institutes of Health Stroke Scale (NIHSS) score compared with baseline within 24 hours. Ischemic lesions were assessed by Alberta Stroke Program Early CT Score (ASPECTS) on the initial CT and/or diffusion weighted imaging (DWI) and the extensive ischemic lesions were defined as ASPECTS ≤ 6 on CT or ≤ 7 on DWI at baseline. Large artery occlusions were defined as occlusions of one or more of the internal carotid artery, proximal portion of the middle cerebral artery, or the basilar artery. END was classified into those due to ischemic (END
i
) or hemorrhagic (END
h
) insults based on the imaging at deterioration. In comparison with the non-END, factors associated with END
i
and END
h
were investigated.

Results:
A total of 744 patients (452 men, 73.3 ± 12.3 years old) were included. Among them, END was seen in 78 patients (10.5%) including 57 END
i
(7.7%) and 21 END
h
(2.8%). END occurred median 7 hours after the administration of rt-PA and most of them occurred within first 2 hours. Comparing to the non-END, multivariate analysis showed that extensive ischemic lesions (Odds ratio [OR] 3.24, 95% confidence interval [CI] 1.57-6.59) and large artery occlusions (OR 3.09, 95% CI 1.54-6.54) were associated with END
i
, while extensive ischemic lesions (OR 3.49, 95% CI 1.16-10.11), higher baseline NIHSS score (OR 1.07, 95% CI 1.00-1.14), and pretreatment of antiplatelets (OR 3.02, 95% CI 1.08-8.88) were associated with END
h
.

Conclusions:
END was an uncommon complication in patients receiving intravenous rt-PA for acute ischemic stroke. END
i
was approximately three times more than END
h
. Distinct factors were associated with END
i
and END
h
.
Abstract TP412: The Frequency and Associated Outcomes of Severe In-Hospital Agitation Requiring Physical Restraint in Patients With Ischemic Stroke in the United States: A National Level Analysis in the United States
Authors: Singh Baljinder , Qureshi Adnan I , Du Zhiyuan , French Brandi R , Liu Yuwen
Published: January 2019

Background:
The rates of severe agitation in patients with ischemic stroke and associated outcomes are not well studied. Small studies suggest that in-hospital agitation is relatively prevalent and results in higher utilization of hospital resources.

Methods:
We analyzed the data from Nationwide Inpatient Sample (NIS), a nationally representative dataset of all admissions related to ischemic stroke in the United States from 2013 to 2015. We analyzed the prevalence of severe in-hospital agitation at the national level in patients with ischemic stroke. In-hospital mortality, discharge status, and length of stay were compared between patients with in-hospital agitation with those without in-hospital agitation in the multivariable model, adjusted for patient's age.

Results:
Of the 17,33500 estimated patients with ischemic stroke, 16,355 patients (0.94%) were diagnosed with severe in-hospital agitation requiring physical restraint. There was a significant relationship between severe in-hospital agitation and patient age ( p=0.0001), the presence of hemiplegia (p =0.05) and aphasia (p=0.009). In multivariable analysis, after adjustment for potential confounders, we found that patients in hospital agitation had lower rates of discharge to home (OR 0.2, 95% CI: 0.22-0.29) and higher rates of in-hospital mortality (OR 5.6, 95% CI: 5.6-6.3). Patients who had in-hospital agitation had a longer length of stay (11 ±12.5 days versus 4.4±5.7 days= 0.0001).

Conclusions:
Our analysis suggests that in-hospital agitation occurs with relatively high prevalence in the United States and is associated with poor outcome and significantly higher resource utilization.
Abstract TP414: Symptomatic Cerebral Air Embolus and the Challenge of Staff Education and Access to Therapy
Authors: Taylor Reid , Owens Bill , Grindstaff Cathy , Tooley Ameran
Published: January 2019

Background:
Cerebral Air Embolus (CAE) is a rare condition and recognition can be difficult. We identified 6 cases of symptomatic cerebral air embolus (SCAE) in patients undergoing procedures or admitted for reasons besides stroke. Our hospital is a 750 bed comprehensive stroke center with a 24/7 Rapid Response Team (RRT) that responds to emergent in house situations that require both manpower and expertise.

Purpose:
The purpose of this project is to define gaps in knowledge of SCAE and determine if education of the RRT can bridge the gap in early identification and intervention of rare stroke syndrome with high morbidity.

Methods:
We reviewed the characteristics of the SCAE patients including location in the hospital, related procedure, clinical syndrome and involvement of the RRT. Emergency interventions considered or carried out were reviewed. We tested the members of the RRT on knowledge of CAE before and after an education module.

Results:
SCAE presented in several areas of the hospital including endoscopy, interventional radiology, and general medical units. Sudden change in awareness with left hemiplegia after a procedure was a common clinical presentation. Cerebral imaging studies were often inconclusive or negative. Patient positioning, hydration status, oxygen use and consideration of hyperbaric therapy were irregularly documented and 50% of the cases died or had profound impairment. Access to hyperbaric chambers in a timely manner was noted to be a gap. We determined that the number of staff potentially witnessing a CAE was 2,494 RNs including all medical units, but higher likelihood was in endoscopy/interventional radiology (38 RNs). RRT was the most commonly involved group of bedside nurses (11 RNs). Overall RRT scores on CAE facts improved from 45% to 95% after an educational module.

Conclusions:
SCAE is a rare event with high morbidity that can occur in many areas of the hospital. Hyperbaric therapy, though widely available, can be difficult to initiate on an emergent basis. Education of the RRT is the most efficient way to ensure an available pool of expertise.
Abstract TP415: Anticoagulation Therapy in Patients With Cancer Related Stroke and High Risk of Bleeding
Authors: Hwang Jaechun , Lee Ho-Won
Published: January 2019

Introduction:
Treatment of cancer related ischemic stroke is challenging because they are at increased risk of both bleeding and thrombosis recur. In general, low-molecular weight heparin is recommended to treat cancer related stroke. However, it is uncertain whether anticoagulation is safe and effective in patients at high risk of bleeding such as thrombocytopenia. We compared the clinical outcomes according to anticoagulant therapy in these patients.

Methods:
We recruited consecutive patients with cancer related stroke between January 2014 and July 2018. Cancer related ischemic stroke was defined as cryptogenic embolic infarction in patients with active systemic cancer and elevated D-dimer level. We included only patient with increased bleeding risk (platelet < 1000000/ul or Hb <8 or active bleeding evidence) in this study. Patients were classified into 3 groups according to the treatment of anticoagulants: those who received full dose anticoagulants; low doses; no anticoagulants. This study outcomes included 7 days bleeding or thrombosis event.

Results:
A total of 48 patients were included in the analysis. Twelve patients received full dose anticoagulation, 21 received low dose anticoagulants, and 8 received no anticoagulants. There were 8 thrombosis events (2 ischemic stroke and 6 deep vein thrombosis) for 7 days. Thrombosis occurred in a statistically significant number of patients who were not treated with anticoagulation, compared to patients who received anticoagulant (vs. full dose group, P=0.032; vs. low dose group, P=0.048). There was no difference in the incidence of thrombosis according to the dose of anticoagulant (P=0.091). Eight bleeding events occurred and there was no intracranial hemorrhage (Gastrointestinal bleeding 3; Hemoptysis 3; Vaginal bleeding 1; Hematuria 1). They were not life-threatening bleeding. The difference in frequency of bleeding in each group was not statistically significant (P=0.068).

Conclusions:
Anticoagulant therapy may be more beneficial than risk, even in patients at risk for bleeding to treat cancer related stroke. Larger, prospective trials are required to determine the appropriate dose of anticoagulant and to further evaluate safety of anticoagulation in this patient population.
Abstract TP416: Safety and Efficacy Outcomes of Intravenous Thrombolysis (IVT) for In-Hospital Stroke
Authors: Singh Savdeep , Goyal Nitin , Tsivgoulis Georgios , Pandhi Abhi , Malhotra Konark , Bryndziar Tomas , Sukhdeo Rena , Aboud Talal , Shahripour Reza , Krishnaiah Balaji , Nearing Katherine , Alexandrov Anne , Alexandrov Andrei
Published: January 2019

Introduction:
Cross-sectional data suggest that IVT in patients with in-hospital (IHS) acute ischemic stroke (AIS) onset is associated with unfavourable outcomes compared to out-of-hospital (OHS) stroke onset patients. We sought to compare safety and efficacy outcomes between IHS and OHS patients treated with IVT.

Methods:
Consecutive AIS patients treated with IVT during a five-year period in a tertiary care stroke center were prospectively evaluated. Demographics, vascular risk factors, admission blood pressure and serum glucose levels were documented. Baseline stroke severity and early hypodensity on baseline CT were assessed using NIHSS-score and ASPECTS by certified physicians. Three-month functional outcome was evaluated by mRS-score. We compared the following outcomes between IHS and OHS patients: 1.symptomatic intracranial hemorrhage (sICH) 2.favourable functional outcome (FFO) [3-month mRS scores of 0-1], 3.Functional independence (FI) [3-month mRS scores of 0-2], 4. Mortality at three months.

Results:
Of 1264 IVT-treated AIS patients, we identified 51 (4%) subjects with IHS. Baseline median NIHSS-score was higher in IHS (10 points; IQR: 6-16 vs. 6 points; IQR: 3-12; p=0.004), while median onset-to-treatment was shorter (75 min; IQR: 37-115 vs. 135 min; IQR: 100-185; p<0.001). In univariable analyses, IHS patients had higher three-month mortality rates (21% vs. 9%; p=0.009). There were no differences (p>0.1) between the two groups in FFO, FI and sICH rates. IHS was associated with higher likelihood three-month mortality (OR: 3.1; 95%CI: 1.2-7.8; p=0.016) on multivariable logistic regression models adjusting for demographics, risk factors, onset-to-treatment time, admission blood pressure and serum glucose levels, baseline NIHSS and ASPECTS.

Conclusions:
IHS patients treated with IVT have more severe strokes and higher mortality rates compared to OHS patients. IVT for IHS is not associated with higher hemorrhagic complications.
Abstract TP421: Immune, Autophagy and Regulatory Co-Expression Modules Underlie the Peripheral Immune Response to Human Intracerebral Hemorrhage
Authors: Durocher Marc , Ander Bradley , Jickling Glen , Hamade Farah , Knepp Bodie , Liu Da Zhi , Zhan Xinhua , Tran Anh , Cheng Xiyuan , Ng Kwan , Yee Alan , Sharp Frank , Stamova Boryana
Published: January 2019

Background:
The peripheral immune system is involved in the damage and repair following intracerebral hemorrhage (ICH). Nevertheless, little is known about the transcriptional response following human ICH. Thus, we aimed to define the co-expression networks in the peripheral blood transcriptome of ICH patients compared to controls and identified the genes with highest connectivity which are potential immune response master-regulators.

Methods:
We performed transcriptomic analysis on 66 human peripheral whole-blood samples (33 ICH, 33 vascular risk factor controls) using GeneChip® HTA 2.0 arrays. Weighted gene co-expression network analysis (WGCNA) of ICH compared to matched controls identified groups of co-expressed genes (modules) associated with ICH and their most interconnected genes (hubs).

Results:
We identified seven modules of co-expressed genes associated with ICH. Six modules were enriched with cell-specific genes including one neutrophil module, one neutrophil plus monocyte module, one T-cell module, one natural killer cell module and two erythroblast modules. The neutrophil / monocyte modules were enriched in inflammatory / immune pathways, while the T-cell module was enriched for T-cell receptor and other T-cell signaling genes. The natural killer cell module was enriched in genes that regulate alternative splicing, and epigenetic regulation. One erythroblast module was enriched in autophagy pathways implicated in experimental ICH, and in NRF2 signaling implicated in hematoma clearance. Many hub and module genes such as MTOR, S1PR1, LCK, FYN, SKAP1, ITK, AMBRA1, NLRC4, IL6R, IL17RA, GAB2, MXD1, PIK3CD, NUMB, MAPK14, DDX24, EVL, TDP1, ATG3, WDFY3, GSK3B, STAT3, STX3, CSF3R, PIP4K2A, ANXA3, DGAT2, LRP10, FLOT2, ANK1, CR1, SLC4A1 and DYSF, have been implicated in neuroinflammation, cell death, transcriptional and translational regulation, and some as experimental ICH therapeutic targets.

Conclusion:
This study defined coordinately expressed modules of genes in the peripheral immune response underlying ICH pathophysiology. Some of the results

complement experimental ICH findings. The identified hub genes and their networks may help guide the search for novel therapeutic targets for ICH.
Abstract TP425: Prevalence and Predictors of Cortical Superficial Siderosis Among African Americans with Ischemic Stroke and Transient Ischemic Attack
Authors: Finn Brandon , Abbas Saleh , Cajiga-Pena Fe Maria , Petrie Benjamin , Nguyen Thanh , Aparicio Hugo , Greer David M , Lau Helena , Romero Jose R
Published: January 2019

Background:
Cortical Superficial Siderosis (cSS) detected on brain MRI affects 0.7% of the general population. In studies of predominantly White individuals, cSS is considered a sensitive marker of cerebral amyloid angiopathy (CAA) associated with increased risk of intracerebral hemorrhage. However, its prevalence and predictors in ischemic stroke (IS) —particularly in African Americans (AA)—has not been well studied. We sought to characterize the prevalence and vascular risks associated with cSS in AA with IS and transient ischemic attack (TIA).

Methods:
We included 2001 consecutive (year 2009-2018) IS and TIA patients, wherein 1048 patients (52%) were AA with available T2*gradient-echo MRI sequence. cSS rating was performed according to standardized guidelines. Race was determined by self-report based on U.S. census procedures, categorized as White, AA or Other racial groups (ORG). Vascular risk factors included age, diabetes, hypertension, systolic blood pressure (SBP), dyslipidemia, BMI, smoking, prior stroke, coronary artery disease; and illicit drug use (IDU). Differences in associations with cSS were assessed using univariate analyses.

Results:
We observed cSS in 1.15% (n=23) of AA, 0.4% (n=9) Whites and 0.6% (n=12) ORG patients. Compared to Whites with cSS, AA were younger (63 vs. 69 years), had higher proportion of men (70 vs 56%), hypertension (83 vs 78%), IDU (22 vs 11%), higher SBP (166±33 vs 162±15mmHg), and lower CAD prevalence (13 vs 33%), although differences did not reach statistical significance. Compared to AA without cSS, AA with cSS had higher proportion of men (69.6 vs 49.7%), prior stroke (39.1 vs 29.7%), IDU (21.7 vs 12.9%), and higher SBP (166±33 vs 153±37mmHg), the latter being the only statistically significant (p=0.038). The remaining vascular risk factors did not differ in patients with and without cSS, or between racial groups.

Conclusion:
The prevalence of cSS in AA with IS/TIA at our urban center is higher than in the general population and higher than in Whites. The vascular risk factor profile seems to differ between AA and White patients with and without cSS. Our results may be relevant in studies of cSS in AA wtih IS/TIA patients as the underlying angiopathy may not represent CAA, but require replication in larger samples.
Abstract TP428: Hypertension Severity and Stroke Recurrence Risk among Oldest Old Intracerebral Hemorrhage Survivors
Authors: Rodriguez-Torres Axana , Kourkoulis Christina , Schwab Kristin , Greenberg Steven , Viswanathan Anand , Anderson Christopher , Rosand Jonathan , Biffi Alessandro
Published: January 2019

Introduction:
Oldest old (age ≥80 years) survivors of Intracerebral Hemorrhage (ICH) may be at higher risk for stroke recurrence, reflecting increasing hypertension severity with aging. Dedicated longitudinal studies of ICH in the oldest old are lacking, yet urgently needed as they represent an ever-increasing proportion of survivors. We sought to determine whether: 1) oldest old ICH survivors are at higher risk for stroke recurrence; 2) hypertension severity accounts for disparities in stroke recurrence risk across age categories.

Methods:
We analyzed data from survivors of primary ICH, enrolled in a single-center prospective study. Exposures of interest include patients’ demographics, medical history, ICH characteristics, Blood Pressure (BP) measurements and medications exposures during follow-up. Outcomes of interest included ICH and/or ischemic stroke events during follow-up.

Results:
We enrolled 1464 ICH survivors (441 ≥80 years and 1023 <80 years). In multivariable analyses lobar ICH location, white non-Hispanic background and female gender were independently associated with ICH at age ≥80 years (all p<0.05). ICH survivors age ≥80 years had higher systolic BP during follow-up (≥80 years: median 148 mmHg, IQR 139-156 vs. <80 years: median 138, IQR 132-145, p<0.001), but they were less likely to receive anti-hypertensive treatment (≥80 years: 233/442, 53% vs <80 years: 603/1023, 59%, p=0.003). Hypertension severity interacted with advancing age (interaction p<0.001) to further increase stroke recurrence risk among oldest old ICH survivors with frank hypertension (Figure 1).

Conclusion:
Oldest old ICH survivors are more likely to be female, white non-Hispanic, to present with lobar ICH, and to demonstrate inadequate blood pressure control. They are at higher risk for stroke recurrence, with hypertension severity playing a pivotal role. Future ICH studies will benefit from focusing on blood pressure control among oldest old survivors.
Abstract TP429: Predictors of Increased Blood Pressure Variability in Acute Intracranial Hemorrhage: A Secondary Analysis of the ATACH-2
Authors: de Havenon Adam , Ruff Jerdan , Wong Ka-ho , Meyer Chelsea
Published: January 2019

Introduction:
Increased blood pressure variability (BPV) is associated with worse neurologic outcome in patients with acute intracerebral hemorrhage (ICH). However, studies have shown that accurate measurement of BPV requires over 50 blood pressure readings, during which patients may be exposed to the deletrious effects of increased BPV.

Hypothesis:
Clinical variables will accurately predict BPV in patients enrolled in the Antihypertensive Treatment of Acute Cerebral Hemorrhage II (ATACH-2) trial.

Methods:
This is a secondary analysis of ATACH-2. Our primary outcome is the top quintile of the standard deviation of systolic blood pressure (SBP SD), which was calculated using all available blood pressures after the first 2 hours, with a mean of 56 blood pressures per patient. With stepwise backwards selection and an interactive process, we selected demographic variables that best predicted the top quintile.

Results:
We included 946 patients, of which 360 (38.1%) were female and the mean±SD age was 61.8±13.0 years. After exploring multiple combinations of baseline demographics, the best model included non-asian (vs. asian), intubation, and female sex as the predictors. This resulted in an area under the receiver operating curve of 0.772 (Figure 1). We created a scoring system (Table 1). With a score of ≥4, there is 79% sensitivity and 60% specificity for determining the top quintile of SBP SD.

Conclusion:
This pilot study identifies several easily determined clinical variables which, with further refinement and validation, could be used to identify patients at risk of the highest levels of BPV after ICH, and potentially to administer treatment to reduce BPV.
Abstract TP43: Evaluating the Generalizability of the Common Odds Ratio: A Demonstration using Two Trials of Endovascular Therapy
Authors: Yeatts Sharon D , Mlynash Michael , Lavori Philip W , Albers Gregory W , Lansberg Maarten G , Broderick Joseph P , Palesch Yuko Y , Hamilton Scott
Published: January 2019

Introduction:
The modified Rankin Scale (mRS) is an ordinal outcome, ranging from 0 (no symptoms) to 6 (death). Recent literature has demonstrated a preference for statistical analysis which maintains the ordinal nature of the scale. The proportional odds (PO) model assumes a single common odds ratio (OR) for all order-preserving dichotomizations of the outcome, but the validity of this assumption cannot be known in advance. The aim of this study is to determine if the common OR was a close approximation of cutpoint-specific treatment effects calculated using the more general cumulative logit model in two endovascular treatment trials.

Methods:
DEFUSE 3 and IMS III, both trials of endovascular therapy (EVT), are used as examples. Ordinal logistic regression was applied via the cumulative logit model with and without the PO assumption. Effect estimates and corresponding 95% confidence intervals are presented in the figure.

Results:
In both IMS III and DEFUSE 3, the PO assumption was not rejected. In IMS III, the common OR of 1.20 in favor of EVT is reflective of the cutpoint-specific ORs ranging from 1.1 (for mRS 0-2 and 0-3) to 1.6 (for mRS=0). In DEFUSE-3, the unadjusted PO model yields a common OR of 2.77 in favor of EVT. The cutpoint-specific ORs all favor EVT, but the magnitude of the treatment effect ranges from 1.3 for no symptoms (mRS 0) to 4.0 for functional independence (mRS 0-2).

Conclusions:
Cutpoint-specific point-estimates of the treatment effect can vary substantially, even when the proportional odds assumption is not rejected. This can be observed when the sample size is small and the test for proportionality of the odds has low power, as is the case in DEFUSE 3 (n=182). In this scenario the common OR may lack generalizability across cutpoints.
Abstract TP439: Temporal Evolution of Blood-brain Barrier Permeability After Acute Spontaneous Intracerebral Hemorrhage: A CT Perfusion Study
Authors: Wang Xin , Zhu Huachen , Zhou Jian , Zhao Xingquan
Published: January 2019

Introduction:
Spontaneous intracerebral hemorrhage (ICH) is associated with increased blood-brain barrier (BBB) permeability, potentially contributing to hematoma expansion, edema development and exacerbation of brain injury. Though we know BBB permeability with time after the onset of ICH, little is about the temporal evolution of BBB permeability in humans after ICH. A more detailed understanding the timeline of BBB permeability change after ICH would be important for guiding future ICH treatments.

Hypothesis:
We want to test the hypothesis there is two increase in BBB permeability in ICH patients.

Methods:
Patients with ICH were divided into five groups based on the period between ICH onset and computed tomography perfusion (CTP) assessed, which are hyperacute (<24 hours), acute (1~3 days), early subacute (3~7 days), late subacute (7~14 days) and chronic (>14 days) groups. Maps of BBB permeability-surface area product (PS), a measure of extravascular contrast leakage rate, were calculated from CTP source images. Mean PS was measured in regions of interest defining the hematoma, a 1cm radial peri-hematoma region,in both ICH and contralateral non-ICH hemispheres.

Results:
PS maps were generated in 61 patients (17 female, mean age 53 years old). The median (interquartile range) PS in ICH hemisphere of 31 patients underwent CTP in hyperacute phase is 1.4 (5.3), 8 patients in acute phase is 1.6 (3.2), 11 patients in early subacute phase is 1.2 (0.8), 8 patients in late subacute phase is 0.7 (1.2), and 3 patients in chronic phase is 0.9. The BBB permeability has an early increase in hyperacute phase, is followed by a decrease period in acute and subacute phases, and a delayed second increase in chronic phase. The permeability pattern is similar in non-ICH hemisphere; however, the second increase in permeability was from late subacute phase.

Discussions:
In conclusion, acute ICH patients have a generalized increase in BBB permeability, which affects the entire brain diffusely. The BBB permeability is not continually elevated but follows a triphasic course in ICH patients.
Abstract TP440: Predictors and Associated Outcomes With Unanticipated Surgical Evacuation in Patients With Intracerebral Hemorrhage: Post Hoc Analysis of ATACH 2 Trial
Authors: Qureshi Adnan , Saeed Omar , Qureshi Mushtaq
Published: January 2019

Background:
We performed this analysis to identify the rates, predictors and associated outcomes of unexpected neurosurgical intervention in a multicenter clinical trial, Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH)-2, involving good grade patients with intracerebral hemorrhage (ICH).

Methods:
The ATACH 2 Trial determined the relative efficacy of intensive versus standard antihypertensive treatment in subjects with spontaneous supratentorial ICHs with a Glasgow Coma Scale (GCS) score of ≥5 and intraparenchymal hematoma volume of < 60 cm3 on initial computed tomographic (CT) scan in whom surgical evacuation was not anticipated. We performed logistic regression analyses to determine the effect of unanticipated surgical intervention on death or disability at 3 months, death within 3 months, after adjusting for age and initial hematoma volume presence of intraventricular hemorrhage, and initial GCS score strata (14-15,9-13,8 or less).

Results:
Among the 992 subjects analyzed, 44 (4.4%) subjects required unanticipated surgical evacuation of hematoma. The mean time interval between randomization and surgical intervention was 1.6 days (±SD 3.7 days). In multivariate analyses, subjects who underwent unanticipated surgical evacuation had a significant higher risk of death or disability (OR 3.6, 95% confidence interval [CI] 1.6 - 8.3; p-value .002) at 3 months and mortality (OR 2.9, 95% CI 1.1 - 7.6; p-value .03) within 3 months after adjusting for potential confounders.

Conclusions:
In the large cohort of ATACH-2 subjects with good grade ICH, the rates of unanticipated surgical evacuation were low and associated with high rates of death or disability at 3 months.