bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP22: Endovascular Treatment for Distal Middle cerebral Artery Occlusions in Patients with Acute Ischemic Stroke From Interventional Management of Stroke Trial (IMS III)
Authors: Afzal Mohammad R , Qureshi Mohtashim A , Qureshi Ihtesham A , Piriyawat Paisith , Maud Alberto , Cruz-Flores Salvador , Rodriguez Gustavo J
Published: June 2021

Background:
Currently, endovascular treatment is advocated for middle cerebral artery (MCA) occlusions, however not much is known about the natural history of an M1 compared to an M2 occlusion.

Objective:
To compare the clinical outcome in endovascularly treated patients with proximal vessel occlusion (M1) versus a more distal occlusion (M2) among patients with ischemic stokes in a negative trial.

Methods:
Data from Interventional Management of Stroke trial (IMS-III) for patients with acute ischemic stroke with distal MCA (mainly M2 and beyond) occlusions diagnosed by either computed tomographic angiography (CTA) or catheter angiography were analyzed. NIHSS at admission, baseline characteristics, infarct volume at baseline and outcome at 90 days (mRS score) were compared between the two groups. Favorable outcome was defined by discharge modified Rankin scale (mRS) score of 0-2, at 3 months. Multivariate logistical regression was performed to compare the outcomes after adjusting for potential confounders.

Results:
Of the
434
from the endovascular therapy group,
215 (49.5%)
and
98 (22.5%)
patients had M1 and M2 occlusion respectively. Patients with M1 occlusion had higher mean NIHSS at admission
(18.76± 4.94 versus 17.37± 5.72, P-value = 0.029)
and higher infarct volume
(105.92 ± 113.23
versus 49.67 ± 63.42, P-value = 0.000)
. Rate of favorable outcome defined by mRS at discharge was lower among patients with M1
(31.53%vs.46.67%p-value = 0.0128)
. After adjusting for age, sex, total NIHSS score at admission, hepato-biliary disorders, anticoagulants, antiplatelet, NSAIDS, patients with M1 occlusion had higher rates of poor outcomes; odds ratio
(OR) 1.819
(confidence interval
[CI] 1.032- 3.205, P=0.03860).

Conclusions:
In patients enrolled in IMS-III trial, an M1 occlusion demonstrated a larger tissue infarct size and a lower rate of favorable outcome than an M2 occlusion, given the negative results of the trial, these findings reflect the natural history of these two occlusion sites.
Abstract WP222: Resistant Hypertension and Burden of Chronic Microvascular Brain Damage in Ischemic Stroke Patients
Authors: Zurru Maria C , Alonzo Claudia , Laura Brescacín , Cámera Luis , Pigretti Santiago , Luzzi Ariel , Balian Natalia , Waisman Gabriel , Cristiano Edgardo
Published: June 2021

Background and purpose:
Hypertension is the most prevalent risk factor for acute and chronic cerebrovascular disease. As patients with resistant hypertension are a subgroup with even higher risk, we aimed to evaluate the burden of microangiopatic disease and functional outcome in subjects with stroke and difficult to treat hypertension.

Design and method:
acute ischemic stroke patients were prospectively included in a multidisciplinary secondary stroke prevention program. Pre-stroke vascular risk factor profile and control were obtained from electronic medical records and chronic vascular disease burden was assessed on admission MRI. Functional and cognitive evaluation were performed one-month after stroke.

Results:
1327 patients (16% with resistant hypertension) were included from September 2009 and December 2015. Patients with resistant hypertension were older (80±8 vs 77±10, p 0.0004), with higher prevalence of obesity (62% vs 50%, p 0.001), metabolic syndrome (52% vs 38%, p 0.0001) and history of atrial fibrillation (27% vs 16%, p 0.0001). There was a direct relationship between resistant hypertension and the severity of chronic microvascular lesions, and also with functional and cognitive outcomes (table).

Conclusion:
Hypertension increases vascular events risk, even more in the setting of resistant hypertension. Requirement of a therapeutic strategy involving combination of multiple drugs generally indicates more severe underlying hypertensive disease. It is possible that mechanisms of endothelial dysfunction responsible of the neurovascular unit damage might remain active despite achieving blood pressure target.
Abstract WP231: Predictors for Early Atrial Fibrillation Detection Among Cryptogenic Stroke Patients with Insertable Cardiac Monitors: A Single-center Experience
Authors: Asaithambi Ganesh , Monita Jane E , Hanson Sandra K
Published: June 2021

Background:
The use of insertable cardiac monitors (ICM) has increased the rate of detection of atrial fibrillation (AF) among cryptogenic stroke (CS) patients. We describe a single-center experience for AF detection among CS patients receiving ICMs upon discharge after the index stroke event and attempt to identify predictors for early AF detection.

Methods:
From April 2014 to April 2016, patients receiving ICMs upon discharge for CS who underwent >90 days of monitoring were reviewed. Time from ICM placement to AF detection, chronic underlying medical illnesses, presence of left atrial dilatation (LAD) on echocardiography, and PR interval on admission EKG were assessed as predictors of early AF detection.

Results:
A total of 114 patients met inclusion criteria and were followed for a median of 415 [268, 557] days. Among these 32 patients (28.1%) were found to have AF at a median of 53 [5, 132] days from ICM placement. Patients with AF detected <30 days from ICM placement had lower rates of hyperlipidemia (35.7% vs 88.9%, p=0.003) and higher rates of hypertension (100% vs 66.7%, p=0.02), tobaccoism (85.7% vs 33.3%, p=0.005), LAD (64.3% vs 16.7%, p=0.01), and prolonged PR interval (195.3±43.2 ms vs 170.3±23.4 ms, p=0.04) compared to patients with AF detected >30 days from ICM placement.

Conclusion:
More than one-quarter of CS patients monitored for >90 days with an ICM were found to have previously undiagnosed AF. The majority of patients with AF detected were identified >30 days after their index CS event. Among patients in whom AF was ultimately detected by the ICM, AF may be identified earlier among patients with hypertension and tobaccoism in combination with LAD and prolonged PR interval. Prospective studies are needed to better identify predictors for early AF among the broader population of all CS patients.
Abstract WP233: Epicardial Fat Thickness, Free Fatty Acid and Pro-BNP Predict Atrial Fibrillation in Acute Ischemic Stroke
Authors: Lee Jin-Hyung , Kim Meyung-Kug , Yoo Bong-Goo
Published: June 2021

Background/Objectives:
Detection of atrial fibrillation (AF) is important for diagnosis of cardioembolic stroke. Few studies that cardioembolic stroke relate to some biomarkers such as high sensitive C-reactive protein (hs-CRP), free fatty acid (FFA), pro-brain natriuretic peptide (pro-BNP) and D-dimer have been reported. FFAs are major components of epicardial fat. Increased epicardial fat thickness (EFT) is known to be associated with the presence of AF. The object of this study is to find the useful markers to distinguish stroke with AF in acute ischemic stroke.

Design/Method:
Total 214 consecutive patients (mean age, 66.8±12.3 years; 39.7% women; 16.4% AF group) with acute ischemic stroke within 72 hours of onset were retrospectively enrolled. We analyzed the EFT and the several biomarkers between stroke with and without AF.

Results:
Age, heart rate, FFA, pro-BNP, hs-CRP, HDL and the frequency of woman were significantly higher in AF group (p <0.05). Estimated glomerular filtration rate (eGFR) was significantly lower in AF group (p<0.05). D-dimer and myoglobin were no significant difference. EFT (6.45±1.18 vs 5.30±1.23 mm, p<0.001), Left atrium (LA) diameter and LA volume were significantly higher in AF group. The respective cut-off value of EFT, FFA and pro-BNP for prediction of the AF were 5.58mm, 1226.5 μEq/ml and 295.0 pg/ml (sensitivity 85%, specificity 61%, AUC 0.76 for EFT; 67%, 93%, 0.79 for FFA; 82%, 84%, 0.88 for pro-BNP). Multivariate logistic regression analysis demonstrated that age, FFA and EFT were independently associated with the presence of AF (p<0.05).

Conclusions:
The combination of EFT, FFA and pro-BNP can be a useful marker for the prediction of the AF in acute ischemic stroke.
Abstract WP234: Metabolite Profiling Identifies a Specific Profile for Cardioembolic Stroke
Authors: Nelson Sarah , Wolcott Zoe , Gerszten Robert , Kimberly W. Taylor
Published: June 2021

Introduction:
Accurate determination of stroke etiology is important in order to implement appropriate secondary stroke prevention. Approximately 25% are embolic strokes of undetermined source, a subset of which are eventually attributed to cardioembolism after prolonged outpatient electrocardiogram monitoring. We applied metabolite profiling to determine whether a metabolomic profile could identify a cardioembolic signature that could inform stroke of undetermined source.

Hypothesis:
We hypothesized that a specific metabolomic profile reflected by circulating metabolites could be derived from patients with stroke due to cardioembolism.

Methods:
Using liquid chromatography-tandem mass spectrometry, we analyzed 153 metabolites measured in plasma samples collected within 9 hours of stroke onset. Three hundred twenty six patients from an acute stroke cohort collected at two institutions were analyzed. Stroke subtypes were assigned using the Causative Classification System. Association with cardioembolic subtype was assessed and metabolites exceeding the Bonferroni corrected p value threshold were identified. Logistic regression was used to identify independent metabolite predictors of cardioembolic stroke.

Results and Conclusion:
The following metabolites were significant in univariate analysis: 2-hydroxyglutaric acid, glutathione, glyceric acid, hippuric acid, threonine, ornithine, histidine, cotinine, pseudouridine, C18:2-carnitine, tricarboxylic acid metabolites, and tryptophan pathway metabolites (all p<6.5x10-3). Regression analysis identified the following multivariate predictors of cardioembolic stroke: hippuric acid (p=0.045), ornithine (p=6x10-5), histidine (p=4x10-6), and a composite sum of tricarboxylic acid metabolites (p=0.004). Metabolite profiling may augment traditional approaches to diagnosing cardioembolic stroke and may have implications for the diagnosis of embolic stroke of undetermined source.
Abstract WP246: Probabilistic Linkage of De-identified Prehospital and Hospital Data for Stroke Patients Achieves Similar Match Rates to Manual Linkage
Authors: Oostema John A , Chassee Todd , Reeves Mathew J
Published: June 2021

Background:
Acute ischemic stroke patients that are recognized by Emergency medical services (EMS) receive expedited care are more likely to receive t-PA. In order to study the continuum of acute stroke care and ensure accurate case ascertainment, prehospital and inpatient medical records must be linked. We tested the feasibility of probabilistic matching to link prehospital EMS data and in-hospital records using data from existing de-identified registries, and compared results to manual linkage.

Methods:
A registry containing all EMS-transported suspect or confirmed stroke cases in Kent County, Michigan was used to identify subjects discharged from either of two primary stroke centers with a diagnosis of stroke or TIA. The registry contains EMS data obtained through direct query of EMS electronic medical record systems which is linked manually to hospital data using patient identifiers (name, date of birth). For the probabilistic match, de-identified data for EMS suspected stroke transports from the EMS information system (EMSIS) was provided by the county medical control authority. Probabilistic linkage between hospital stroke discharges and EMSIS data was done using LinkPlus software. Age, sex, transport agency, and date of service were used as matching variables. Probabilistic match rates were compared to manual registry match rates among EMS suspect stroke cases using a chi square test.

Results:
Over a 6-month period in 2015, 172 hospital-confirmed stroke and TIA patients arrived by EMS at the target hospitals. Over the same period, 214 EMS suspect stroke cases were identified from the registry and 199 EMS suspect stroke cases were identified in EMSIS. Probabilistic linkage correctly matched 64.5% (111/172) of confirmed strokes to prehospital records in EMSIS, which was not significantly different from the manual registry match rate of 73.8% (127/172, p=0.24). There were 16 cases in the manual match that were missed by the probabilistic match: 5 (2.9%) due to age mismatch and 11 (6.4%) were missing from the EMSIS data. The remaining non-matched cases represented EMS missed stroke cases.

Conclusion:
Probabilistic matching of de-identified pre-hospital and hospital data is a feasible approach for the evaluation of prehospital stroke care.
Abstract WP254: The Predictive Potential of Prothrombin Time (PT) and D-Dimer for tPA-related Hemorrhage
Authors: Deng Wenjun , Song Bo , Chou Sherry H-Y , Fisher Lindsay , Oyer Maxwell , Chou I-Ying Richard , Wickham Thomas , Heizelmann Kathleen F , McMullin David , Vancott Elizabeth M , Lo Eng H , Buonanno Ferdinando S , Ning MingMing
Published: June 2021

Background:
IV tissue plasminogen activator (tPA) is an efficacious treatment of acute ischemic stroke. However, the utilization of tPA has been deterred by its hemorrhagic complications. Our previous exploratory study found that following tPA administration, ischemic stroke patients with hemorrhagic transformation (HT) had a significantly longer prothrombin time (PT) than those without HT. Here we aim to study the effect of post-tPA parenchymal hemorrhage on a wide range of coagulation labs in a lager cohort of patients.

Method:
308 consecutive ischemic stroke patients with IV tPA were recruited in accordance with IRB approval. Clinical coagulation profiles were analyzed at 6, 12, 24, 36, 48 and 72 hr post IV tPA. Patients on anticoagulants or having other conditions (e.g. liver and kidney dysfunctions) that may affect these labs were excluded.

Result:
As determined by head CT scan, 16 patients (5.19%) developed post-tPA hemorrhage. Compared to patients without tPA related hemorrhage, patients with hemorrhage had significantly higher levels of PT within the first 24 hr post tPA (Figure 1A), and PT levels at 6 hr have the potential to predict subsequent hemorrhage (Figure 1C, AUC = 0.753, p = 0.003). Moreover, D-Dimer remained at high levels even after 48 hr (Figure 1B), suggesting sustained fibrinolysis abnormality or possibly indicating active bleeding. D-Dimer levels at 24 and 48 hr were also predictive of tPA-induced bleed (Figure 1D, AUC = 0.827, p = 0.007).

Conclusion:
Our results suggest PT and D-Dimer as early markers of tPA-induced hemorrhage in ischemic stroke patients. Their differential predictive ability at different time points may offer the possibility to monitor the clinical efficacy of tPA over a longer time window to guide adjunct treatment. Studies in additional coagulation factors in an expanded patient cohort are ongoing.
Abstract WP263: Feasibility and Utility Of EEG for Estimating Infarct Volume During ER Assessment of Suspected Acute Stroke--A Pilot Study
Authors: Cramer Steven C , Kaur Arshdeep , Wu Jennifer C , Cassidy Jessica M , Shreve Lauren , Zhou Robert J , Vo Christopher , Medizade Ariana I , Tran Thuong B , Yang Derek Z , Yu Wengui , Chakravarthy Bharath , Hoonpongsimanont Wirachin , Barton Erik , Srinivasan Ramesh
Published: June 2021

Introduction:
Endovascular therapy (EVT) improves outcomes in the setting of acute ischemic stroke (AIS) in a time-dependent manner, highlighting the need for improved methods to rapidly identify eligible patients, particularly in the pre-hospital setting. Current pre-hospital assessments are imprecise for this goal. Pre-hospital measurement of brain injury via EEG might provide additional useful diagnostic information regarding EVT eligibility. As a first step, the current study examined (1) feasibility of obtaining EEG early during ER assessment of patients with suspected AIS, and (2) EEG metrics predicting infarct volume.

Methods:
In subjects transported to the UC Irvine Medical Center for suspected AIS, a 3 min dense-array resting EEG was obtained during ED assessment.

Results:
EEG was acquired in 25 subjects (mean age 65 yr), 12 of whom were discharged with a diagnosis of radiologically confirmed AIS and 13 of whom were discharged with a non-stroke diagnosis. Median time from ED arrival to EEG = 114 min (and as early as 32 min after arrival), and time from last known well to EEG = 333 min. EEG was acquired in 24 subjects, with data lost due to human error in 1 subject. Among patients with AIS, median NIHSS score = 4 (range 0-19) and median infarct volume = 12 cc (range 0.3- 83). Infarct volume was found to correlate inversely with power in the low beta (13-19Hz) frequency range, bilaterally: larger infarcts were associated with reduced beta power in the leads over motor cortex (C3, C4) on the ipsilesional side (rho = -0.57, p=0.03) and on the contralesional side (rho = -0.60, p=0.02).

Conclusions:
The current findings support the potential of rapid EEG methods to identify patients with large infarcts who may be ideal candidates for EVT. Future studies will examine how well current findings extend to the pre-hospital setting, and how specific these EEG findings are for patients eligible for EVT.
Abstract WP274: Improving Door to Ct Time by a Seven Item Stroke Screening Questionnaire for Patients Arriving to ER with Acute Stroke without Prior Notification
Authors: Eichel Roni , Ponger Penina , Kaufmann Nechama , Bornstein Natan M
Published: June 2021

Background:
Arrival to the emergency room (ER) by ambulance services and prior notification have been identified as major factors for reducing Door to CT and Door to needle time with thrombolysis for patients with acute stroke. Unfortunately despite all efforts to increase the awareness of using ambulances, still 40-50% of patients arrive by private transportation without prior notification of the ER.

Objective:
We evaluated if a standardized seven item screening questionnaire, performed at the admission office of the ER, can reduce time to triage nurse evaluation and subsequently time of arrival to CT, for patients with acute stroke arriving to the ER without prenotification of the ER.

Methods:
Since April 2016 a standardized screening questionnaire was performed by the admission clerks at the ER arrival for any patient not referred by prior notification for stroke. This questionnaire included seven major stroke symptoms and time of onset of the symptoms. If one of these symptoms started less than 8 hours before the arrival to the ER the patient was urgently referred to the triage nurse which would then evaluate urgently and activate the a Stroke Code. Patient data was collected of all patients admitted to the ER with a suspected stroke between April-June 2015 and April-June 2016 and time intervals for Door to triage nurse and Door to CT were compared for patients admitted to the ER with suspected Stroke between the time period without questionnaire and with.

Results:
In the relevant time periods 143 stroke patients were admitted to our ER. Median time from arrival to triage nurse was 16 min (n=96) in 2016 compared to 28 min (n=47) in 2015 (p>0.0001). Patients arriving within 8 hours form symptom onset the median time for arrival to triage nurse was 15 min (n=49) and 28min (n=14) respectively (p=0.006). Median time from arrival to ER to CT brain was 29 min(n=18) for the group that was screened by an early seven point questionnaire at ER admission and stroke code activated versus 78 min(n=14)without early screening and stroke code activation(p=0.069).

Conclusion:
A standardized seven item stroke symptom questionnaire as an early ER admission screening method can reduce time intervals from arrival to CT for self-referral stroke patients without prior notification of the ER.
Abstract WP287: Deterioration in Recombinant Tissue Plasminogen Activator After Repeated Freezing and Thawing Cycles for Thromboelastography
Authors: Calo Sean , Jaehne Anja-Kathrin , Keenan Kelly A , Xu Jun , Tawil Baruch , Thompson Richard , Knight Robert A , Miller Joseph , Lewandowski Christopher , Tavarekere Nagaraja N
Published: June 2021

Background and Purpose:
Thromboelastography (TEG) is often used to measure coagulation dynamics in the setting of acute ischemic stroke and thrombolytic therapy. The stability of thrombolytics has not been investigated in TEG. We conducted an experimental series to test the effects of recombinant tissue plasminogen activator (rtPA) on fibrinolysis in normal blood samples using TEG.

Methods:
Freeze dried rtPA powder was reconstituted in normal saline containing 0.2% bovine serum albumin (100 mg/24 mL), divided into 1 mL aliquots, and diluted to enable using a relatively large volume for complete mixing with blood samples. Aliquots and dilutions were frozen at -20°C. The same rtPA dilution was thawed to ambient temperature before each use and refrozen until the next use over 4 testing days. Blood was drawn into 3.2% sodium citrated collection tubes. rtPA (100 μL) was added to 1 mL whole blood to achieve a 636 ng/mL rtPA TEG sample concentration. Control-whole blood and rtPA-whole blood TEG was performed for 3 h on 4 healthy human blood samples. Maximum clot amplitude (mm) and absolute clot strength (dynes/cm
2
) were measured. Data (mean±SD) were analyzed by t-tests and significance inferred at
p
<0.05.

Results:
Clot amplitude increased with thawing and refreezing (28±3, p=0.004; 35±2 p=0.01; 50±3, p=0.02; and 55±3, p=0.30; for testing cycles 1, 2, 3 and 4, respectively) compared to untreated samples (63±4). Clot strength also increased over the 4 cycles (2±0.3, p=0.007; 3±0.2, p=0.02; 5±05, p=0.01 and 6±0.7, p=0.30) compared to untreated (9±1.4). Lysis initiation time was gradually longer over the 4 tests (red arrows, Figure 1) suggesting delayed fibrinolysis.

Conclusions:
One repeatedly thawed and refrozen rtPA stock showed a delay in fibrinolysis in healthy human blood, suggesting a loss of potency. Thus, rtPA should be aliquoted for 1-time use for experiments using TEG. Further investigation into rtPA potency deterioration with storage after reconstitution is warranted.
Abstract WP294: Deferoxamine Treatment Improves Outcomes After Embolic Stroke in Diabetic Rats
Authors: Li Weiguo , Valenzuela John Paul , Dong Guangkuo , Abdul Yasir , Ward Rebecca , Fagan Susan C , Ergul Adviye
Published: June 2021

Diabetes increases the risk of hemorrhagic transformation (HT) after a cerebral ischemic event, a major factor limiting the use of tissue plasminogen activator (tPA) for stroke patients. We previously showed that increased HT is associated with poorer recovery in diabetes. In the current study, we hypothesized that excess iron contributes to poor recovery and that iron chelation with deferoxamine (DFX) will improve the neurological recovery after embolic stroke in diabetes. Diabetes was induced with high fat diet and low dose streptozotocin injection (30 mg/kg) in male Wistar rats. Both control and diabetes animals were subjected to embolic stroke with middle cerebral artery occlusion and sacrificed 2 weeks after the surgery. DFX (100 mg/kg) or vehicle was given every 12 h for 7 days after stroke. The composite score (Bederson’s score and beam walk), adhesive removal (ART) and novel object recognition (NOR) were assessed at day 1, 3, 7 and 14 after the surgery. DFX reduced mortality in diabetes. Diabetic animals displayed poor outcomes. By Day 14, DFX reduced motor and cognitive deficits in diabetes but not in controls. These results suggest that iron chelation therapy may improve outcomes after ischemic stroke in this high risk population.
Abstract WP298: Achievement of Guideline-concordant Process of Care and 1-year Outcomes in Patients with Acute Ischemic Stroke in Secondary and Tertiary Hospitals: Results From China National Stroke Registry Ii
Authors: Li Zixiao , Wang Yilong , Ma Xudong , Zhao Xingquan , Liu Liping , Gu Hongqiu , Wang Caiyun , Wang Chunjuan , Pan Yuesong , Zhang Xinmiao , Yang Xin , Wang Yongjun
Published: June 2021

Background:
Guideline-concordant processes of care improve longitudinal outcomes in patients with acute stroke. Little is known whether there are different processes of acute ischemic stroke (AIS) care or outcomes between secondary and tertiary hospitals.

Methods:
We analyzed 19 604 AIS patients across 219 hospitals in China National Stroke Registry II from June 2012 to January 2013. The primary outcome was guideline-concordant care, defined as compliance with 13 guideline-recommended performance metrics and composite score. Propensity score matching was used to balance the baseline characteristics. We used cox model and logistic regression with generalized estimating equation to compare the relationship between secondary and tertiary hospitals on quality measures and all caused death, stroke recurrence, and disability (modified Rankin Score ≥3) at 3, 6 and 12month after discharge.

Results:
Among 19 604 AIS patients, 6 038 (30.8%) and 13 566 (69.2%) were admitted to 66 (30.1%) secondary and 153 (69.9%) tertiary hospitals separately. After matching, 5959 pairs of patients in secondary and tertiary were analyzed. The composite score was higher at tertiary hospitals than secondary hospitals (77% versus 74%, P<0.001). Tertiary hospitals were more likely to perform early antithrombotic, carotid imaging, anticoagulation for atrial fibrillation, antihypertensive therapy, hypoglycemic medications, and rehabilitation (Figure 1). Furthermore, comparing to AIS patients among tertiary hospitals, those admitted to secondary hospitals had higher hazard of disability at 3 months (19.3% versus 21.5%) and 1-year stroke recurrence (4.4% versus 5.4%) after matching.

Conclusions:
In China, tertiary hospitals have better processes of AIS care and more favorable clinical outcomes than secondary hospitals. The quality of process of AIS care should be further increased to improve the patients’ clinical outcomes especially among secondary hospitals.
Abstract WP302: Transferring Patients with Primary Intracerebral Hemorrhage to Comprehensive Stroke Centers
Authors: Vahidy Farhaan , Zhu Liang , Edwards Nancy J
Published: June 2021

Introduction:
The American Heart Association’s updated guidelines for management of patients with primary intracerebral hemorrhage (ICH) recommend monitoring and early care at centers with advanced nursing and neuro-critical care expertise. This entails frequent transfer of ICH patients to certified Comprehensive Stroke Centers (CSC) for higher level of care. We hypothesized that transferred patients (TP) to a CSC will differ from directly admitted patients (DAP) in terms of patient characteristics, treatment factors, and functional and quality of life (QOL) outcomes.

Methods:
We analyzed data from a prospectively collected ICH registry at our CSC. Patients with traumatic or secondary causes of ICH were excluded. We collected data on demographics, comorbidities, presentation lab values, clinical characteristics, radiological parameters, in-hospital treatment variables, and discharge and long term outcomes. Functional outcomes were captured as modified Rankin Scale (mRS) and EuroQol 5D (EQ-5D) was used to assess QOL indices.

Results:
Out of a total 192 primary ICH patients, 114 (59.4%) were transferred-in. TP were significantly older, had lower diastolic blood pressure, lower arrival National Institutes of Health Stroke Scale (NIHSS) score, and smaller hematoma volumes as compared to DAP. A higher proportion of TP had a good discharge functional outcome (mRS score 0 - 3) as compared to DAP (29.8% vs. 15.4%, p = 0.02), this trend was also observed for Day-90 mRS (34.2% vs. 24.4%, p = 0.09). TP also reported significantly better QOL indices at Day-90; EQ-5D total median (Q1, Q3) score [10 (6,16) vs. 15 (9.5,18), p = 0.02] and self-reported median (Q1,Q3) score [75 (50,88) vs. 62.5(40,70)], p < 0.01]. Day-90 data are complete for approximately 50% patients. After adjusting for initial stroke severity, the discharge mRS was however not significantly different between TP and DAP.

Conclusions:
A larger proportion of ICH patients were transferred-in. Our data suggest that TP have lower disease severity, and better discharge and long term outcomes. However, they had similar treatment intensity as DAP at the CSC. We continue to capture day-90, 6 and 12-month functional and QOL data, which will be presented.
Abstract WP310: Inter-Provider Communication Using a Scheduled Provider Alert-Response Communication System (SPARCS) in 3 Inpatient Neurology Units
Authors: Siegler James E , Finegan Dan , Kasner Scott , Price Raymond
Published: June 2021

Background:
Non-emergent communications between nursing staff and covering providers often occur randomly throughout the workday at teaching institutions, resulting in inefficiency and interruptions of scheduled resident educational conferences or periods of overnight rest.

Methods:
We conducted a prospective, mixed-methods, crossover trial of a communication strategy between nurses and residents in 3 neurology units of a single academic institution. We measured content and volume of notifications from nurses to residents during scheduled conferences and overnight, and categorized these notifications according to levels of urgency. We implemented an intervention requiring evening work rounds between the on-call provider and charge nurse, and batching of non-emergent communications. Survey data were collected to determine perceived safety, utility, and satisfaction of the intervention.

Results:
The total census during the 6-month study period was 728 patients with a mean case-mix index of 1.86 (indicating moderate disease complexity). Of the total 704 provider-reported nursing notifications, there was a 56.3% decrement of notifications in the post-intervention period. Of the total 299 nurse-reported notifications, there was a 46.9% decrement in the post-intervention period. Both nurses and residents provided more favorable survey responses in the post-intervention period across multiple items that addressed patient safety, utility, and satisfaction (p<0.01 for comparisons).

Conclusions:
A scheduled nurse-resident communication system reduced interruptive calls during educational conferences and overnight by half. This intervention was safe, effective, and resulted in higher satisfaction among nurses and residents.
Abstract WP315: An Electronic Health Record Phenotype of Ischemic Stroke Using Non-Claims Clinical Data and Machine Learning
Authors: Kummer Benjamin R , Luna Jorge M , Esenwa Charles C , Salmasian Hojjat , Vawdrey David K , Kamel Hooman , Elkind Mitchell S
Published: June 2021

Introduction:
Real-time identification of patients with acute ischemic stroke (AIS) in the electronic health record (EHR) can enhance care delivery systems, clinical decision support, and research subject recruitment. EHR data that is accessible during a patient’s admission may be used to identify patients with AIS, but established methods for characterizing which data to use have not yet been determined.

Hypotheses:
1. An EHR “phenotype” of AIS can be identified using clinical EHR data. 2. Machine learning can identify the AIS phenotype using similar inputs with greater accuracy than clinician-specified identification algorithms.

Methods:
Two stroke neurologists selected generalizable AIS-related clinical data points from the Columbia University Medical Center EHR (clinical laboratory results and medication, imaging, and stroke service list orders) to identify the AIS phenotype, and determined pre-specified priority logic based on institutional practice patterns. Separately, a regularized logistic regression (RLR) model was applied to all available neurology-related order sets and clinical laboratory inputs. The classification accuracy of the two algorithms was compared using a “gold standard” data set, consisting of our institution’s ischemic stroke registry from January 1
st
, 2015 to March 31
st
, 2016. Negative controls were selected from all patients admitted to the neurology service at our institution during the same time period.

Results:
Our data contained 482 patients with AIS and 3,628 negative controls. The clinician-specified identification algorithm identified the AIS phenotype with sensitivity of 90.6%, specificity of 50.4%, and positive predictive value (PPV) of 93.5%. In comparison, the RLR-based algorithm had a sensitivity of 96.3%, specificity of 52.2%, and PPV of 93.8%.

Conclusions:
We determined an AIS phenotype that could be identified using clinical, non-claims data that is available during a patient’s admission, and used machine learning to optimize the classifying ability. While specificity is low, the high sensitivity may allow use for screening and clinical decision support. Further studies are needed to externally validate these findings and optimize algorithm specificity.
Abstract WP328: Mortality and Cause of Death Following Hospitalization for Acute Ischemic Stroke in California
Authors: Wang Limin , Holliday-Hanson Merry , Krawczyk Christopher
Published: June 2021

Objectives:
Understanding of the mortality and cause of death after ischemic stroke is important in helping hospitals targeting potential preventable and treatable medical conditions, and optimizing management strategies. The purpose of the study was to investigate California-specific mortality and cause of death following hospitalization for acute ischemic stroke based on patient demographic characteristics in a large patient population.

Methods:
Adult patients admitted to California-licensed acute care hospitals for acute ischemic stroke from 2013 to 2014 were included in the study. Data were from the California patient discharge data, linked to California death certificate records (2013 to 2014) using patient’ social security number as the common identifier. Mortality rates and causes of death based on patient gender, age, race, and expected payer were evaluated.

Results:
Of 73,982 patients, 20.8% (15,428) had died by the end of study period. Nearly half of these deaths occurred within 30 days of admission, and a quarter of deaths happened within 7 days. Female, age >= 80, and white patients had a significant higher mortality rate. The cumulative all-cause mortality rate was 10.0% at 30 days, and 19.3% at 1 year. Over 70% of the patients died from diseases of the circulatory system, while stroke contributed to 43.4%. Deaths within 7 days were primarily caused by stroke as well as fibrillation and flutter. Female, age >= 80, white and Medicare patients tended to die from diseases of the circulatory system while male, younger, black and Medi-Cal (California’s Medicaid program) patients were more likely died from cancer.

Conclusion:
Mortality and cause of death varied significantly by patient demographic characteristics. Effective interventions and preventions based on patient demography as well as better management of stroke and fibrillation & flutter in first week may reduce the stroke mortality rates and improve hospital quality.
Abstract WP330: Protocol Approaches Negate the “Weekend Effect” for Endovascular Stroke Treatment
Authors: Raymond Scott B , Akbik Feras , Hirsch Joshua A , Stapleton Christopher J , Gonzalez Ramon G , Mehta Brijesh P , Rabinov James D , Patel Aman B , Chandra Ronil V , Leslie-Mazwi Thabele
Published: June 2021

Background:
Endovascular management of stroke from acute large vessel occlusion (LVO) requires complex, emergent diagnostic and therapeutic procedures. The “weekend effect” (worsened outcomes from stroke presenting on weekends or evenings) is a recognized phenomenon, attributed to non-uniform availability of services throughout the week. We assessed the impact of institutional protocols for stroke patients undergoing endovascular therapy during off hours.

Methods:
We analyzed a prospective observational stroke database for consecutive patients with anterior circulation stroke undergoing endovascular therapy between 6/2012 and 10/2015. Patients were grouped and analyzed based on day of the week and time of presentation to the emergency department. Off-hours were considered between 1900hrs and 0700hrs on weekdays and 1900hrs on Friday to 0700hrs on Mondays for weekends. Functional outcome was assessed prospectively by 3 month modified Rankin scale (mRS), dichotomized into good (mRS 0-2) versus poor (mRS 3-6).

Results:
In a cohort of 129 patients, 75 (58%) patients were treated off-hours. Patients treated off-hours demonstrated equivalent imaging to groin puncture times (78 vs 72 min, p = 0.4) and procedure durations (75 vs 68 min, p = 0.3). Reperfusion rates (TICI 2b or 3) were 68% off hours and 76% during working hours (p = 0.4). Complication rates were similar between the two groups. Outcome at 90 days was no different in the patients treated off hours, with 35 of 75 treated off-hours achieving a good outcome (mRS 0-2) compared to 22 of 54 treated during working hours (p = 0.6). With protocol adherence, temporal improvement was noted in imaging to groin times.

Discussion/Conclusions:
Following recent evidence of benefit from endovascular therapy for LVOs there is increased attention to care delivery. Our findings demonstrate that under the guidance of protocols, the “weekend effect” was negated. Evaluation and treatment times, and 90 day outcomes were equivalent in patients treated off- vs business hours, with improving treatment times as familiarity with protocols increased. Our findings highlight the importance of establishing institutional and regional protocols in the optimized management of these patients.
Abstract WP340: Loading Doses of Clopidogrel Across the US: Temporal and Regional Trends
Authors: Yang Yunpeng , Khoury Jane , Kleindorfer Dawn
Published: June 2021

Introduction:
Multiple trials have investigated the use of antiplatelet agents such as clopidogrel in the management of acute ischemic stroke (IS), and ongoing trials such as POINT include a loading dose followed by maintenance dosing of clopidogrel. The use of loading doses of clopidogrel is well-established in the treatment of acute coronary syndrome, but national trends in the use of clopidogrel loading doses in IS have not been well explored.

Methods:
In a retrospective analysis of the Premier database (a representative sample of 15% of US hospital discharges with procedure codes and medications) we identified adult patients admitted to a hospital with IS (ICD-9 codes 433.X1 and 434.X1) for years 2006-2010 and 2014. We identified those having a loading dose of Clopidogrel; defined as a total of 300mg or more on the day of or the day following admission for the acute event. We used logistic regression to examine the use of clopidogrel and loading doses over time and by region.

Results:
Of 341,208 IS cases (mean age 71 (14) years, 47% male, 16% black/3% Hispanic/65% white/16% other) during the study periods, 31 % received clopidogrel during hospital admission, with 0.3 % receiving a loading dose during the first 24 hours after admission. Use of clopidogrel fluctuated over the study periods but did not show a statistically significant change from 2006 to 2014; p=0.99. From 2006 to 2014, there was a 0.52 % increase in the proportion of patients receiving loading doses of clopidogrel for acute IS; rising from 0 in 2006 and 2007 to 0.52% in 2014; p<0.0001. Use of clopidogrel loading was also affected by geographic location, with 0.17, 0.28, 0.35, and 0.40 % respectively in the Northeast, South, Midwest, and West (Northeast < South, Midwest and West; South < West; all p<0.0001).

Conclusion:
We report temporal trends in the use of clopidogrel for the years 2006 to 2010 and 2014. Use of clopidogrel has fluctuated over this time period, while use of loading doses increased significantly over time, especially in the Western US. Understanding changes in clopidogrel use in IS on a national level is important in planning initiatives to address regional differences in access to care, as well as in the creation of standardized, evidence-based guidelines affecting clinical practice.
Abstract WP353: Bleeding Following Removal of Intracerebral Catheters in MISTIE III
Authors: Mould W. Andrew , Muschelli John , McBee Nichol , Lane Karen , Zuccarello Mario , Awad Issam , Hanley Daniel
Published: June 2021

Introduction:
Minimally invasive surgery plus alteplase has been shown to effectively reduce the volume of intracerebral hemorrhage in patients with supratentorial bleeds. Removal of these catheters is a unique timepoint when bleeding may restart due to mechanical forces and/or the presence of alteplase/plasmin in the brain. We hypothesized that surgically-treated patients in the MISTIE III trial who had increased bleeding post catheter removal would have shorter periods of time between last dose and catheter removal and be less likely to have lobar ICH.

Methods:
MISTIE III is a prospective, randomized trial testing the efficacy of minimally invasive surgery plus alteplase for hematoma removal compared to medical management. We analyzed 107 surgically-treated patients. Semi-automated threshold based segmentation of the ICH volumes for all time points were performed using OsiriX.

Results:
Of the 107 surgical patients, 16 experienced an increase in ICH volume >10% between T1, the scan taken 24 hours prior to cath removal, and T2, the scan taken 24 hours post catheter removal. Mean percent difference between T1 and T2 was 37.5% for those that expanded versus those that did not, -17.4% (p<0.001) with an absolute difference in ICH volume of 3.0 cc and -2.2 cc (p<0.001). The mean residual volume at T2 for both groups was similar at 12.84 cc and 12.71 cc, respectively (p=0.96). Time from last dose to catheter removal in days was 1.27 for those that expanded and 1.44 for those that did not (p=0.09). Furthermore, 14/16 (87.5%) patients with expansion had ICH’s located in deep structures compared to 55/91 (60.4%) of patients that did not expand (p<0.01).

Conclusion:
Overall, incidence of bleeding following ICH catheter removal in MISTIE III was low. When bleeding was seen, it was more often found in patients with deep ICH locations and whose catheters were removed sooner after the last dose of alteplase.
Abstract WP354: Ten-year Temporal Trends in Medical Complications Following Acute Intracerebral Hemorrhage in the United States
Authors: Otite Fadar O , Khandelwal Priyank , Malik Amer M , Chaturvedi Seemant , Sacco Ralph L , Romano Jose G
Published: June 2021

Background:
Data on medical complications following intracerebral hemorrhage (ICH) are sparse. We assessed trends in the prevalence of urinary tract infection (UTI), pneumonia, sepsis, deep venous thrombosis (DVT), pulmonary embolism (PE), acute renal failure (ARF) and acute myocardial infarction (AMI) following ICH in the United States and evaluated their association with in-hospital mortality (IM), cost, length-of-stay (LOS) and home disposition (HD).

Methods:
Adults admitted to US hospitals from 2004-2013 (n=582,736) were identified from the Nationwide Inpatient Sample. Weighted complication risks were computed by sex and by mechanical ventilation (MV) status. Multivariate models were used to evaluate trends in complication and to assess their association with IM, cost, LOS, and HD.

Results:
Overall risks of UTI, pneumonia, sepsis, DVT, PE, ARF and AMI following ICH were 14.8%, 7.7%, 4.1%, 2.7%, 0.7%, 8.2% and 2.0% respectively. Risks differed by sex (UTI: females (F) 19.8% vs males (M) 9.9%; ARF: M 10.6% vs F 5.9%; sepsis: M 4.8% vs F 3.4%) and by MV status (pneumonia: MV 17.7% vs non-MV 3.9%; DVT: MV 4.3% vs non-MV 3.2%). From 2004 to 2103, odds of DVT and ARF increased while odds of pneumonia, sepsis and mortality declined over time (figure 1). Each complication was associated with > 2.5-day increase in mean LOS, > $8,000 increase in cost and reduced odds of HD. ARF and AMI were associated with increased IM in all patients; sepsis and pneumonia were associated with increased IM only in non-MV patients while UTI and DVT were associated with reduced IM in all patients.

Conclusion and Relevance:
Despite IM reduction, ARF and DVT risk following ICH in the US have increased while odds of sepsis and pneumonia have declined over time. All complications were associated with increased cost, LOS and reduced odds of HD but their associations with IM were variable, likely due in part to survival bias. Innovative strategies are needed to prevent ICH-associated medical complications.
Abstract WP362: Trends and Outcomes of Intracranial Hemorrhage in HIV Positive Population (2002-2012)
Authors: Patel Achint , Limaye Kaustubh , Shah Harshil , Dave Mihir , Chauhan Kinsuk , Nadkarni Girish , Jani Vishal , Patel Urvish , Lunagariya Abhishek , Onteddu Sanjeeva
Published: June 2021

Background:
The incidence of Intracranial Hemorrhage (ICrH) in HIV patients is on the rise in the United States, especially after the development of newer antiretroviral drugs. This study determines the trends of ICrH in HIV patients in the United States.

Design/Methods:
Data from the Nationwide Inpatient Sample (NIS) and Healthcare Cost and Utilization Project (HCUP) were analyzed for years 2002-2012.Hospitalizations with HIV positive status were identified using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes 042, V08 and ICrH by 430.xx-432.xx. Cochrane Armitage trend test and multivariate regression were used to analyze temporal trends and the potential reasons for temporal changes over the years.

Results:
A total of 2,584,548 hospitalizations with HIV status were made from 2002 to 2012. Of these, 10,292 (0.40%) admissions were due to ICrH or developed ICrH during hospitalization. Concurrent trend of ICrH and HIV increased from 0.34% to 0.45% in 2012 (p
trend
<0.001). This trend increased annually by 3.5% (OR 1.035; 95% CI 1.01-1.05;p<0.001). The temporal rise was explained by changes in demographics and co-morbidities. Amongst HIV-related hospitalizations, Age (10 year increase) (OR 1.23; 95% CI 1.09-1.43; p<0.001), African-American race (OR 1.25; 95% CI 1.09-1.43; p<0.001), Hispanic race (OR 1.29; 95% CI 1.07-1.55; p<0.001) and history of Hypertension (OR 1.97; 95% CI 1.76-2.22; p<0.001) were significantly associated with the development of ICrH, However females had lower odds of developing ICrH(OR 0.80; 95% CI 0.71-089; p<0.001).

Conclusions:
These data suggest that the incidence of ICrH among hospitalized adults with HIV infection continue to increase. This increasing ICrH was explained by an aging HIV population, changing demographics and chronic comorbidities, but questions still remain regarding unexplained factors which merit in-depth study.