bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P219: Somatosensory Impairments at Baseline Limit Motor Recovery in Stroke Survivors Using a BCI
Authors: Remsik Alexander B , Gloe Shawna , Williams Leroy , VAN KAN PETER L , Nair Veena A , Caldera Kristin , PRABHAKARAN Vivek
Published: March 2021

Objective:
This study is part of a clinical trial designed to test the efficacy of an EEG-based BCI intervention for upper extremity motor rehabilitation in stroke survivors. The analyses presented here focus on the effectiveness of BCI intervention as a function of somatosensory integrity.

Introduction:
Human motor control requires integration of sensory and motor signals in the generation of motor commands. Stroke lesions often result in sensorimotor impairments and survivors may require rehabilitation to regain motor function and capacity. Stroke affects individuals differentially, based on a range of factors, including, but not limited to, lesion location and volume. Such factors may restrain recovery potential.

Hypothesis:
We tested the hypothesis that stroke survivors with measurable somatosensory impairments realize the same amount of motor recovery as those participants without somatosensory impairments.

Methods:
N= 23 stroke survivors participated in up to 30 hours of BCI intervention (13.8 ±1.3, mean
+
SD) for upper extremity rehabilitation, as measured by the ARAT. Participants were grouped post-hoc on presence or absence of somatosensory impairments, as measured by the NIHSS subdomains of Sensory (i.e. cutaneous), and Motor Arm (i.e. proprioceptive) and their group means compared.

Results:
The hypothesis was not confirmed. Mean ARAT scores at completion and follow up differed between groups (Cutaneous loss: ARAT mean change at completion: 0.9 ± 2.23, p= 0.234; ARAT mean change at follow-up: 1.20 ± 2.860, p = 0.217), (No Cutaneous loss: ARAT mean change at completion: 2.15 ± 6.34, p= 0.244; ARAT mean change at follow-up: 4.39 ± 6.41, p= 0.0297) (Proprioceptive loss: ARAT mean change at completion: 0.867 ± 3.66, p= 0.375, ARAT mean change at follow-up: 2.47 ± 5.38, p= 0.097), (No Proprioceptive loss: ARAT mean change at completion: 3 ± 6.80, p= 0.252, ARAT mean change at follow-up: 4 ± 5.42, p= 0.075).

Conclusions:
These results suggest that BCI intervention is more effective at delivering motor improvements in participants with less somatosensory impairments. These results are consistent with the view that somatosensory system integrity may be key to BCI motor rehabilitation of brain injuries following stroke.
Abstract P230: Integration of Regional Administrative, Registry and Vital Databases for Ischemic Stroke Hospitalizations
Authors: Yan Zhiyu , Schwamm Lee H , Nielsen Victoria , Song Glory , Christie Anita , Zachrison Kori S
Published: March 2021

Background:
Administrative databases seldom include detailed clinical variables or final vital status, limiting the scope of population-based studies. We demonstrate a comprehensive process for integrating 3 databases (statewide all-payor inpatient hospitalizations [hospitalizations], Paul Coverdell National Acute Stroke Program Registry [registry] and Registry of Vital Statistics and Records [vitals]) into a single statewide stroke database.

Methods:
The 3 MA databases spanned 2008-2017 among 49 hospitals covering over 80% of the state’s stroke volume. Our integration process was composed of 3 phases: 1) hospitalizations-registry linkage, 2) hospitalizations-vitals linkage, and 3) final integration of all 3 databases (Figure). Following the assessments of linkage feasibility based on data uniqueness levels, rule-based deterministic linkage on indirect identifiers were applied in the first two phases. We validated the linkages by comparing additional patient variables not used in the linkage process.

Results:
Using 47,113 stroke admissions in the hospitalizations database, and 43,487 admissions in the registry from 01/01/2008 to 09/30/2015, we were able to link 38,493 (80.7%) of encounters, 95% of which were validated. There were 391,176 deaths reported between 01/01/2010 and 03/06/2017 in the vitals database; 10,660 encounters (27.7%) in the hospitalizations were linked to deaths, which reflects the cumulative mortality over the 7 year period among all registry-linked ischemic stroke hospitalization records.

Conclusion:
We demonstrate that a high-quality integration of statewide hospitalizations, clinical registry and vital data is achievable based on a data linkage strategy that leverages indirect identifiers. Our data integration framework which takes advantage of rich clinical data in registries with long term outcomes in claims or vital records may allow for larger scale outcome studies at reasonable cost.
Abstract P238: Importance of Self-Efficacy in the Patient-Reported Physical Function of Patients With Stroke
Authors: Katzan Irene L , Wisco Dolora R , Lapin Brittany
Published: March 2021

Background:
Self-efficacy is the belief that one is able to respond to demands of a stressful situation and it has both direct and indirect effects on health. The study objective is to investigate the amount of variance in patient-reported physical function (PF) that is explained by self-efficacy compared to clinician-reported disability and other patient-reported domains of health, and evaluate whether self-efficacy mediates the relationship between PF and other domains of health.

Methods:
Observational cohort study of 248 patients who were seen in a cerebrovascular clinic 3/18/20 - 7/7/20 and completed the following patient-reported outcome measures (PROMs) as part of the routine office visit: PROMIS PF, general self-efficacy, fatigue, and pain interference. Linear regression models were constructed to determine the amount of variance (adjusted R
2
) in PROMIS PF score explained by the modified Rankin Scale (mRS) and additional PROM scores. The mRS and individual PROMs were added separately to a base model adjusted for demographic characteristics. Mediation analysis was conducted to determine the extent to which self-efficacy mediated the relationship between PF and other PROMs.

Results:
Mean age of study cohort was 61.5 (SD=13.5) years and 48.4% were female. The base model explained 4.5% of the variance of PF. Adding PROMIS fatigue resulted in the largest increase in the proportion of variance explained (adj R
2
= 47.7%), followed by PROMIS self-efficacy (40.7%), PROMIS pain interference (38.7%), and mRS (26.6%). Self-efficacy significantly mediated the relationship between fatigue and PF (standardized indirect effect: 0.11 (bias-corrected 95% CI: 0.05-0.18), 20.9% of total effect) and pain interference and PF (standardized indirect effect 0.10 (95% CI: 0.06-0.17), 27.1% of total effect).

Conclusion:
PROMIS self-efficacy explains more variance in stroke patients’ perceived physical function than their disability. This suggests that interventions to improve self-efficacy could have a significant effect on patient’s perceived health. Patients’ fatigue, despite being partially mediated by self-efficacy, was a large contributor to self-reported PF and should be included as part of an evaluation of patient’s physical health.
Abstract P24: Assessing Tpa Eligibility Using Mr-Witness and Wake-Up Trial Criteria May Substantially Improve Post-Discharge Outcomes in Acute Ischemic Stroke
Authors: Conovaloff Joseph , Chaudhari Amit , Shafie Mohammed
Published: March 2021

Early administration of tissue plasminogen activator (tPA) improves morbidity and mortality in acute ischemic stroke (AIS). However, the strict NINDS exclusion criteria, especially the emphasis on last known well times (LKWT) which are often unreliable in the acute setting, restrits tPA use to only 2-5% of all AIS patients. The MR-Witness and WAKE-UP trials propose using MRI diffusion-to-flair mismatch in these cases to better judge the age of an infarct, but the impact of this on post-discharge outcomes has not yet been reported. We conducted a retrospective analysis of all AIS patients in one comprehensive stroke center to further investigate this question. Of our total 1016 patients, 165 (16.2%) received tPA and 58 (5.7%) underwent mechanical thrombectomy. 380 patients (37.4%) were refused tPA due to an NINDS exclusion other than LKWT, 246 (24.2%) due to minimal or resolving neurological deficits, and 6 (0.6%) due to family preference. The remaining 161 patients (15.8%) were refused tPA only because of an unreliable LKWT. Statistical analyses comparing these 161 patients to the 165 who received tPA revealed no differences in age (p=0.306), gender (p=0.214), race, or even NIHSS score on presentation (p=0.306). However, while the total hospital stay was similar in both groups (p=0.954), patients who received tPA had significantly better post-discharge outcomes, with more patients going to acute rehab or home (p=0.033). In summary, comprehensive stroke centers generally out-perform national tPA administration averages (16.2% in our stroke center compared to 2-5% nationally). However, our study showed that a large percentage of AIS patients are still refused tPA only because of an unreliable LKWT. Obtaining emergent MRIs to assess diffusion-to-flair mismatch in these cases may increase the number of people with AIS eligible for tPA and substantially improve their post-discharge outcomes.
Abstract P245: Sex Differences in the Association Between Cardiovascular Risk Profiles and Hospitalizations/ED Visits Among Patients With a History of Stroke/TIA
Authors: Chang Tiffany E , Goldstein Larry B , Leifheit Erica C , Lichtman Judith H
Published: March 2021

Background:
Secondary prevention addressing cardiovascular risk factors is a key care component for reducing the risk of vascular events among those who had a stroke/TIA. We assessed cardiovascular risk factor (CVD-RF) profiles and their impact on hospitalizations and Emergency Department (ED) visits and whether the association differs for men and women with prior stroke/TIA.

Methods:
We used data from the nationally representative Medical Expenditure Panel Survey (2012-2015) for persons aged
≥
18 years with a prior stroke/TIA. CVD-RF score included 6 self-reported factors (hypertension, diabetes, high cholesterol, lack of exercise, smoking, obesity), categorized as low (0-1 factors), intermediate (2-3), or high (4-6). Outcomes included
≥
1 hospitalization discharges or ED visits during the participant’s survey year. Multivariable logistic regression models assessed the association between CVD-RF scores and outcomes, stratified by sex. We tested for interaction by sex in a combined model with men and women.

Results:
The weighted sample represents 9.9 million individuals (mean age 65.1 years; 54.3% women). Overall, 16.7%, 59.3%, and 24.1% of men had low, intermediate, and high CVD-RF scores compared to 21.6%, 59.5%, and 18.9% of women. Among men, there was no significant association between CVD-RF score and the two outcomes (
Table
). Among women, even after adjustment for covariates, those with high scores had 1.89 and 2.06-fold increases in the odds of hospitalizations and ED visits, compared to those with low CVD-RF scores (
P
<0.05). Furthermore, women with intermediate CVD-RF scores had a 1.68-fold increase in the odds of ED visits compared to those with low scores (
P
<0.05). The combined model showed a significant interaction by sex.

Conclusion:
Women with increased CVD-RF scores had increased odds of ED visits and hospitalizations, which could be due to less effective secondary prevention. Further research is needed to explore reasons for this sex disparity.
Abstract P249: Rates of Adverse Events and Outcomes Among Ischemic Stroke Patients Admitted to Thrombectomy Capable Stroke Centers
Authors: Chaudhry Saqib , Laleka Ibrahim , Bahiru Zelalem , Chaudhry Mohammad Rauf A , Fang Yun , Akhtar Iqra , Bashir Sairah , Wang Jing , Rahman Haseeb , Tahsili-Fahadan Pouya , Hassan Ameer E , Altaweel Laith , Qureshi Adnan I
Published: March 2021

Background:
To identify the beneficial effects of thrombectomy capable hospitals (TCHs), we compared the rates of in-hospital adverse events and discharge outcomes among ischemic stroke patients admitted to thrombectomy capable and non-thrombectomy capable hospitals in the United States.

Methods:
We obtained the data from the Nationwide Inpatient Sample from 2012 and 2017. Thrombectomy capable hospitals were identified based on number of thrombectomy procedures performed by hospital per year among ischemic stroke patients. If an hospital performed ten or more thrombectomy procedures, it was labelled as thrombecotomy capable hospital. The analysis was limited to patients (age ≥18 years) discharged with a principal diagnosis of ischemic stroke (International Classification of Disease 433.x1-434.x1 (ICD-9) or I63 (ICD-10). The impact of TCHs admissions on in-hospital outcomes was assessed in a comparative analysis of propensity-matched groups of patients.

Results:
We identified a total of 2,826,335 patients with primary ischemic stroke patients. After adjusting for age, gender, race or ethnicity, comorbidities, All Patients Refined Diagnosis Related Groups (APR-DRG)-based disease severity, and hospital teaching status, patients admitted to TCHs were at lower risk of in-hospital adverse events complications: pneumonia (odds ratio [OR], 0.86; 95% confidence interval [CI], 0.80-0.93), urinary tract infection (OR, 0.87; 95% CI, 0.84-0.91)and sepsis (OR, 0.92; 95% CI, 0.84-1.00). Patients admitted to TCH were more likely to receive thrombolysis (OR, 1.29; 95% CI, 1.30-1.36). The mean cost of hospitalization of the patients was significantly higher in patients admitted at TCHs compared with those admitted at non-thrombectomy capable $74765 vs $60530, P < .0001). The patients admitted to TCHs had lower inpatient mortality (OR, 0.82; 95% CI, 0.78-.88) and were more likely to be discharged with none to minimal disability (OR, 1.09; 95% CI, 1.06-1.12).

Conclusions:
Compared with non-thrombectomy capable admissions, patients admitted to TCHs are less likely to experience hospital adverse events and more likely to experience better discharge outcomes.
Abstract P25: Safety of Ticagrelor in Moderate to Severe Acute Ischemic Stroke: A Single-Center Retrospective Review
Authors: English Stephen W , Landzberg David , Bhatt Nirav , Frankel Michael , Navalkele Digvijaya
Published: March 2021

Introduction:
Ticagrelor with aspirin has been recently shown to reduce the risk of stroke or death compared to aspirin alone in patients with high risk TIAs and mild strokes. However, this benefit is offset by increased risk of severe bleeding. We sought to evaluate the safety of ticagrelor in patients with moderate to severe ischemic stroke.

Methods:
This was a retrospective cohort study of adults discharged on ticagrelor after presenting with acute ischemic stroke and NIHSS > 5 from January 2016 to December 2019 at a large, urban, academic comprehensive stroke center. Patients were excluded if they underwent carotid or intracranial angioplasty and/or stenting, or carotid endarterectomy during admission. Baseline clinical characteristics, imaging, and outcomes were reviewed. Data was organized into continuous and categorical variables.

Results:
Sixty-one patients met inclusion and exclusion criteria. Median age was 61 (IQR, 52-68) years; 33 (54%) were men, and 33 (54%) were African American. Median NIHSS was 11 (IQR, 8-15). Fourteen (23%) patients received IV Alteplase and 35 (57%) patients underwent mechanical thrombectomy. Five (8%) patients received both IV Alteplase and mechanical thrombectomy. Median ticagrelor start date was hospital day 1 (IQR, 0-3). Large artery atherosclerosis was presumed etiology in 53 (87%) patients. No patients experienced neurologic worsening, recurrent stroke, sICH, or major bleeding during inpatient stay. Sixty (98%) patients were on aspirin and ticagrelor at discharge. Follow-up information was available for 53 (87%) patients for a median duration of 3 (IQR, 2-6) months. Following discharge, 3 (5%) patients experienced recurrent ischemic stroke despite being compliant. One (2%) patient experienced major bleeding—gastrointestinal hemorrhage requiring transfusion—two months after hospital discharge.

Conclusions:
This study highlights the potential expanding role for ticagrelor in secondary stroke prevention in patients with moderate to severe stroke. Early ticagrelor use did not result in sICH during inpatient stay—and only 1 major bleeding event on follow-up—in our cohort. While further research in this area is needed, these findings present an exciting opportunity for future prospective studies.
Abstract P257: Cost-Effectiveness of Advanced Neuroimaging for Transient & Minor Neurological Events in the Emergency Department
Authors: Liberman Ava L , Zhang Hui , rostanski sara , Cheng Natalie , esenwa charles , Haranhalli neil , Singh puneet , Labovitz Daniel L , Lipton Richard B , Prabhakaran Shyam
Published: March 2021

Background:
Accurate diagnosis of patients with transient or minor neurological events is challenging with non-trivial rates of Emergency Department (ED) misdiagnosis reported. Recent studies suggest that advanced neuroimaging can improve diagnostic accuracy in presumed low-risk patients, but a cost-effective ED diagnostic evaluation strategy remains uncertain. We therefore evaluate two strategies designed to determine which patients with low-risk transient and minor neurological symptoms can be directly discharged from the ED.

Methods:
We constructed a decision-analytic model to evaluate two ED-based diagnostic evaluation strategies for patients with presumed low-risk transient or minor neurological symptoms: (1) obtain advanced neuroimaging (MRI brain and MRA head and neck) in the ED on every patient or (2) current ED standard of care of clinical evaluation and basic neuroimaging. The main probability variables were: proportion of patients with true ischemic events, specificity and sensitivity of each evaluation strategy, recurrent stroke rate, and direct healthcare costs. We calculated incremental cost-effectiveness ratios (ICER) and performed threshold analyses to evaluate diagnostic test parameters. Cost-effectiveness was defined as willingness to pay (WTP) <$100,000 USD per quality adjusted life year (QALY) gained.

Results:
Our primary and sensitivity analyses found that the advanced neuroimaging strategy more cost-effective than ED standard of care, the latter of which has an ICER exceeding the WTP threshold. The total cost of the advanced neuroimaging strategy was $3,210 with an effectiveness of 0.9397 whereas the total cost of the standard ED strategy was $4,338 with an effectiveness of 0.9399 in the primary model. Using threshold analyses, we found that potential superior diagnostic approaches to the advanced neuroimaging strategy would have to be >92% specific, >70% sensitive, and cost less than or equal to the standard of care strategy.

Conclusion:
In our decision-analytic model, obtaining advanced neuroimaging on all patients presenting with low-risk transient and minor neurological symptoms was the more cost-effective strategy as compared to current practice.
Abstract P263: Do Different Sites of Vessel Occlusion Dictate the Need for Intubation Prior to Endovascular Treatment and Have an Effect on Outcome?
Authors: Hassan Ameer E , Ringheanu Victor M , Nogueira Raul G , Preston Laurie , Qureshi Adnan I , TEKLE WONDWOSSEN
Published: March 2021

Introduction:
Endovascular treatment (EVT) is a widely proven method to treat patients diagnosed with intracranial large vessel occlusion. In order to ensure patients safety prior to and during EVT, preprocedural intubation has been adopted in many centers as a means for airway protection and immobilization. However, the correlation between site of vessel occlusion, need for intubation, and outcomes, has not yet been established.

Methods:
Through the utilization of a prospectively collected database at a comprehensive stroke center between 2012-2020, demographics, co-morbid conditions, intracerebral hemorrhage, mortality rate, and functional independence outcomes were examined. The outcomes and sites of occlusion between patients receiving mechanical thrombectomy (MT) treated while intubated versus those treated under conscious sedation (CS) were compared.

Results:
Out of 625 patients treated with MT, a total of 218 (34.9%) were treated while intubated (average age 70.3 ± 13.7, 37.2% women), and 407 (65.1%) were treated while under CS (average age 70.3 ± 13.7, 47.7% women); see Table 1 for baseline characteristics and outcomes. A higher number of patients requiring intubation had an occlusion in the basilar versus those only requiring CS. No differences were noted in regard to the proportion of patients receiving intubation or CS when treated for RMCA, LMCA, or internal carotid artery occlusions.

Conclusion:
Intubation + MT was associated with significantly worsened outcomes in regard to recanalization rates, functional outcome, and mortality. In anterior circulation strokes, intubation in RMCA patients were found to have poorer clinical outcome. Higher rates of intubation were also found to be needed in patients with basilar occlusions. Further research is required to determine whether site of occlusion dictates the need for intubation, and whether intubation allows for favorable outcome between R and LMCA occlusions.
Abstract P270: Simulating the Effects of Door-In-Door-Out Interventions
Authors: Abughoush Khaled , Parnianpour Zahra , Holl Jane , Ankenman Bruce , Khorzad Rebeca , Perry Ohad , Barnard Amy , Brenna Julianne , Zobel Rebecca J , Bader Elida , Hillmann Maureen L , Vargas Alejandro , Lynch Deborah , Mayampurath Anoop , Lee Jungwha , Richards Christopher T , Peacock Nicholas , Meurer William J , Prabhakaran Shyam
Published: March 2021

Introduction:
Acute stroke (AS) is a highly time sensitive treatment condition affecting approximately 800,000 people/year in the US. Most AS patients receive care at a primary stroke center (PSC), but some require more advanced treatments, and rely on a timely transfer to a comprehensive stroke center (CSC) where such treatments can be given. Stroke teams at 2 Chicago area PSCs and 4 CSCs, collectively, developed solutions (Graph) targeting both reported and perceived failures/delays/weakness in the current PSC door-in-door-out (DIDO) process for transferring patients to a CSC. The study simulates the potential impact of the solutions on DIDO.

Methods:
Current state (baseline) times were calculated from time stamps in the electronic health record (EHR) (e.g., door to CT), estimated by the stroke teams (e.g., hand-off time) or retrieved (e.g., DIDO, door to stroke activation) from a prospectively maintained REDCap data registry (2/2018-1/2020). Proportions (e.g., % with ischemic stroke, % transferred) were estimated from hospital data. Changes in times after implementation of a solution were obtained from peer reviewed literature, when available, or by consensus expert opinion. Simio (version 11.197.19514) was used to simulate the current and future states with implementation of the solutions, with 500 replications, to estimate changes in DIDO.

Results:
Implementation of all solutions would achieve a decrease in DIDO of 33 minutes (19%) from current state. The largest driver of this change was direct to CT/CTA protocol implementation (21 minutes) followed by using a handoff tool for paramedics prior to transfer (13 minutes).

Conclusion:
The proposed solutions can achieve nearly a 20% reduction in DIDO times. The “Direct to CT/CTA Protocol” solution is the major driver of the improvement. Data simulation is helpful by assessing the potential impact of many solutions and the relative impact of each solution to inform implementation decisions.
Abstract P278: Improving Stroke Systems of Care in Nebraska
Authors: Gonzalez Castellon Marco A , BOBENHOUSE James A , Franco David , Malina Beth L , Cook Mindy , Bene Elizabeth , Hook Mary E , Hubbard Rebecca , Simmons Jenny , Stout Pamela
Published: March 2021

Introduction:
Stroke is a leading cause of disability in the United States. Disparities in stroke care between metropolitan and rural areas have long been recognized. Access to high-level timely stroke expertise improves outcomes, but in rural areas this is limited by sparse availability of stroke specialists. Since 2006, the Nebraska Stroke Advisory Council, a statewide coalition of stroke experts and stakeholders, began implementing strategies to improve stroke care. In 2016, the Nebraska legislature approved Bill 722, mandating the development of stroke systems of care. In 2018, the AHA and the Helmsley Charitable Trust launched Mission: Lifeline Stroke, a coordinated 3-year program to enhance stroke systems of care in Nebraska.

Purpose:
To assess advances in acute stroke care in Nebraska after implementing a statewide stroke system of care focused on rural areas.

Methods:
The Council joined with AHA to expand public and professional stroke education offerings including workshops, conferences, and EMS trainings. They developed state specific treatment guidelines and created educational reinforcement materials. From 2016 to 2019 Get With The Guidelines® (GWTG) was used for stroke data collection and quality improvement in Nebraska. GWTG participating hospitals expanded from 7 to 40 sites (21 critical access).

Results:
The number of stroke and Transient Ischemic Attack cases reported more than doubled from 2016 to 2019 (1848 to 3987 cases). The door to CT initiated in < 25 minutes improved by 13%. IV alteplase therapy gains included: utilization increased from 8.7% to 11.3%; median door to drug time reduced from 54 to 42 minutes; and door to drug within 60 minutes of arrival increased from 67% to 80.4%.The number of alteplase monitored patients doubled and mechanical thrombectomy cases increased from 77 in 2017 to 138 in 2019.

Conclusion:
Implementation of strategies in Nebraska, with an emphasis on rural critical access hospitals, led to significant improvements in acute stroke care. This work represents the authors’ independent analysis of local or multicenter data gathered using the AHA Get With The Guidelines® Patient Management Tool but is not an analysis of the national GWTG dataset and does not represent findings from the AHA GWTG National Program
Abstract P280: Safety of Off-Label Oral Glyburide in Malignant Hemispheric Infarctions: A Single-Center Quality Improvement Study
Authors: Heslin Mark E , Thon Jesse , Thau Lauren , Rana Ameena , Then Ryna , Jovin Tudor G , Siegler James E
Published: March 2021

Introduction:
Following the results of the GAMES-RP trial, which showed intravenous glyburide can safely reduce cerebral edema following stroke, our center implemented a quality improvement (QI) initiative using off-label glyburide (2.5mg PO BID x 3 days) to prevent malignant cerebral edema in patients at risk.

Methods:
Consecutive adults > 18 years of age with large hemispheric infarction at our center (9/20/2019-6/20/2020) were treated with off-label glyburide per an institutional protocol. In this interim analysis, we report the safety (use of D50 rescue, discontinuation of drug due to hypoglycemia <55mg/dL) and efficacy outcomes (midline shift, 90-day mRS) of patients with anterior circulation infarcts, as compared to the control arm of the GAMES-RP trial using a two-sample test of proportions.

Results:
Seventeen patients with anterior hemispheric stroke received glyburide (mean age 71y [SD 14], median NIHSS 19 [IQR 16-24], mean initial infarct volume on head CT 122cc [SD 68]). Demographic, clinical, and radiographic findings were well-matched to GAMES-RP controls (Table), except for internal carotid artery occlusion being twice as common (63% vs 36%, p=0.07). One patient developed hypoglycemia (6%) with the need to discontinue glyburide. Treated patients had numerically less midline shift when compared to historic controls (median 4 vs. 8.5mm). Comfort measures were pursued in 9 patients (47%), permitting long-term follow-up of 8 patients for whom the median 90-day mRS was 5 (IQR 4-6, n=6).

Conclusion:
In this interim analysis of a single-center QI initiative, glyburide was safe. Treated patients had severe deficits and large infarcts, more than half of whom opted for comfort measures, with poor long-term functional outcomes among remaining patients. Notably, the midline shift decreased by more than 50% compared to well-matched historic controls. Off-label use of glyburide will continue to be used at our center in light of these safety profile findings.
Abstract P281: Acute Stroke Mimics: Etiological Spectrum and Efficacy of Stroke Assessing Scores
Authors: Benjamin Kenneth , Prabhakar A. T , Abhilash K.P.P , Mathew Vivek , Iqbal Ahmed Shaikh Atif , V. Nair Aditya , Jeyaseelan Lakshmanan , Aaron Sanjith
Published: March 2021

Introduction:
Stroke mimics constitute a good number of patients referred as acute strokes within the window period for acute therapies. Proper triaging can avoid unnecessary imaging and even thrombolytic therapies in these patients. This study looked at etiological spectrum of acute stroke mimics presenting within the 4.5 hours therapeutic window. We also evaluated the FAST (Face-Arm-Speech-Time), BEFAST (Balance -Eyes-Face-Arm-Speech-Time) and the ROSIER (Recognition of Stroke in the Emergency Room) tools in picking true strokes.

Methods:
A prospective observational cohort study over a 2- year period; A descriptive analysis of various etiologies presenting as acute stroke was done. The presenting symptoms, signs and the diagnostic value of the FAST, BEFAST, and the ROSIER Scores in both the stroke mimics and true strokes were noted and the sensitivity and specificity for picking up the stroke mimics were calculated. Student’s t test, univariate analysis and multivariate logistic regression analysis were done. Diagnosis of stroke was confirmed by MRI.

Results:
After initial screening by Neurologists, stroke mimics constituted 328/1635 (20%) of referrals for acute stroke. Focal and generalized seizures with transient weakness and peripheral vertigo were the most common acute stroke mimics; followed by metabolic causes and psychiatric disorders. Females were more in the stroke mimic group (p = 0.02). Ischemic heart disease and atherosclerotic risk factors (except diabetes mellitus) were significantly higher among true strokes. 4 (1.2%) of the stroke mimics were treated with IV thrombolysis. Diagnostic accuracy for different stroke differentiating tools were: FAST (Sensitivity 85,9% specificity 52.8% Odds 6.8), BEFAST (Sensitivity 97.0% specificity 31.4% Odds 14.9) And ROSIER Scale (Sensitivity 85.7% specificity 59.4% Odds 8.7%). In Conclusion, Stroke mimics can constitute up to 20% of cases evaluated as strokes. None of the triaging tools appear to have enough accuracy. A proper history and clinical examination should be given priority over fixed protocols whenever acute stroke mimic are suspected, especially before administering acute costly interventions. Auditing stroke mimics is important to improve acute stroke pathways.
Abstract P284: Coordinating Options for Acute Stroke Therapy (COAST): Demonstrating Patient Autonomy by Examining Preferences for Acute Stroke Treatment From a Stroke Advance Directive
Authors: Agrawal Kunal , Spokoyny Ilana , Chiang Chia-Chun , McGehrin Kevin , Meyer Brett C
Published: March 2021

Introduction:
Respect for patient autonomy is critical, and patients/surrogates may have various preferences about acute stroke treatment that are not fully appreciated during a stroke code. COAST (Coordinating Options for Acute Stroke Therapy) is a stroke advance directive formalizing advanced consent for thrombolysis (tPA) and endovascular therapy (EVT). We examine the distribution of patient preferences to improve understanding and respect for patient autonomy in acute stroke.

Methods:
In our IRB-approved study, we collected COAST forms at UC San Diego from 12/1/2014-2/29/2020. Patients chose one of five tPA preferences: not under any circumstance (tPA 1); up to 3 hours only, based on FDA approval (tPA 2); up to 4.5 hours only, based on current guidelines (tPA 3); anytime per provider discretion (tPA 4); or other answer (tPA treatment under specific conditions written by the patient/surrogate) (tPA 5). Patients also chose one of five EVT preferences: not under any circumstance (EVT 1); up to 6 hours only (EVT 2); up to 12 hours only (EVT 3); up to 24 hours only (this option replaced "up to 12 hours only" on 3/1/2018 when the 6-24 hour window became standard of care) (EVT 4); anytime at provider discretion (EVT 5); or other answer (EVT treatment under specific conditions written by the patient/surrogate) (EVT 6). Frequency of preferences was calculated for each option.

Results:
In total, 342 COASTs were completed. Frequency of tPA preferences were: 3.2% for tPA 1 (11/342), 1.5% for tPA 2 (5/342), 25.7% for tPA 3 (88/342), 55.6% for tPA 4 (190/342), 14.0% for tPA 5 (48/342). Frequency of EVT preferences were: 1.8% for EVT 1 (6/342), 9.6% for EVT 2 (33/342), 3.2% for EVT 3 (11/342), 10.8% for EVT 4 (37/342), 62.3% for EVT 5 (213/342), 12.3% for EVT 6 (42/342). When the 6-24 hour window became standard of care, 0% (0/342) chose EVT 2. Total 81.6% (n=279) of COASTs had the same tPA and EVT preferences, and 18.4% (n=63) had tPA preferences that were different from EVT preferences.

Conclusion:
Preferences vary regarding tPA and EVT treatment. Most patients defer to provider discretion, though some patients have preferences that are different from current provider expectations and/or stroke guidelines. COAST is pivotal to inform respect for patient autonomy for acute stroke codes.
Abstract P30: Safety and Efficacy of Intravenous Tirofiban in Acute Ischemic Stroke With Extended Window Period
Authors: PAMIDIMUKKALA VIJAYA , K RANJITH , N SRINIVASA RAO , K LAKSHMI PRASANNA , A SOMA SUNDARAM , NELLURI RAMESH , POLAVARAPU NAREN , ALLURI RAMADEVI , T SUSHMA , M RAJYA LAKSHMI , M BHARGAVI , M SHWETHA , POLAVARAPU RAGHAVA SARMA
Published: March 2021

Introduction:
Intravenous Thrombolysis is approved upto 4½ hrs and Endovascular Therapy upto 24 hrs in eligible Acute Ischemic Stroke (AIS) patients with Large Vessel Occlusion. There are still substantial number of AIS patients where there is no effective treatment available. In this Study we aim to test the safety and Efficacy of the reversible gp IIb/IIIa receptor inhibitor antagonist Tirofiban in AIS beyond 4 ½ hrs and within 24 hrs.

Methodology:
Among a total of 750 AIS patients admitted in our Stroke Unit, from July 2019 to March 2020, 100 Consecutive patients were included in this study and received Intravenous tirofiban as an initial bolus followed by infusion. Inclusion criteria were Age 18-80yrs, Window Period 4 ½ to 24 hrs. National Institute of health Stroke Scale score (NIHSS) between 5-20, No contraindication for lytic drugs. CT Brain excluding Hemorrhage or > 1/3
rd
infarct. Cardioembolic strokes were excluded. Efficacy Assessments: NIHSS and modified Rankin scale (mRS) performed at baseline, within 48hrs, Day-7 and Day-90. The good outcome was defined as mRS 0-1 at 3 months. The safety outcomes were assessed by the incidence of Symptomatic Intracerebral hemorrhage (SICH), Systemic Bleeding and any mortality.

Results:
There were 74 males, 26 females with median Age of 56 yrs (range from 18 to 80yrs). The Median NIHSS is 10 (range from 5-20), Majority (87%) had anterior circulation strokes and 13% were in Posterior circulation. One patient (1%) developed symptomatic parenchymal Hemorrhage, 4 patients (4%) had mild haemorrhagic transformation within infarct, 8 patients (8%) had nonfatal systemic bleed in the form of Hematuria. Total Mortality - 2 patients (2%), one patient died in the hospital due to cardiac arrest and another patient died at home after discharge. At 3 months, 62 patients (62%) had good outcome (mRS 0-1) and 33 patients (33%) had favourable outcome (mRS 2-3).

Conclusion:
In this Observational Study we found that Intravenous Tirofiban is not only safe, but effective in AIS patients with extended window period. However, Randomized Clinical Trials are needed to further clarify our observation.
Abstract P300: Differences in Characteristics and Care Among Stroke Patients With Documented Substance Use
Authors: Corless Leslie , Lesko Alexandra C , Garvin Cameron , Stuchiner Tamela L , Baraban Elizabeth
Published: March 2021

Background:
Despite the known increased risk of stroke occurrence due to substance use (SU), few studies focus on understanding this vulnerable population beyond incidence. The objective of this study was to examine patient characteristics and clinical outcomes among those admitted for stroke with documented substance use.

Methods:
Data included patients 18 years or older, discharged from two Portland, Oregon hospitals between October 2017 - May 2019 with a stroke diagnosis and documented abuse of alcohol (EtOH), cannabis (CB), methamphetamine (MA), opiates, cocaine, benzodiazepines, or Methylenedioxymethamphetamine (MDMA). Patients with SU of the three most common substances in this population, EtOH, MA and CB, were each compared to patients with any other type of SU with regard to demographics, risk factors, stroke subtypes, stroke treatment, discharge disposition and length of stay (LOS). Non parametric median tests and Pearson’s chi square tests were used.

Results:
Among 280 patients included, 79.3% (n=222) used EtOH, 26.8% (n=75) CB, and 24.6% (n=69) MA, with 38.7% (n=108) using more than one. Compared to patients with other SU, a greater percentage of patients with EtOH SU had dyslipidemia (56.8% vs. 31%, p=0.044). Fewer patients with EtOH SU smoked (50.0% vs 70.7%, p=0.008), were female (31.8% vs 50%, p=0.014) and received EVT (3.6% vs 12.7%. p=0.026). Patients with MA SU were younger (55 vs 63, p<.001), had a longer LOS (6 vs 4 days, p=0.022), more smoked (72.5% vs 48.3%, p=.001) and fewer had dyslipidemia (30.4% vs 47.9%, p=0.017) or depression (17.4% vs 31.8%, p=0.032). Fewer also arrived by EMS (28.8% vs. 43.1%) but more arrived by transfer (54.6% vs 33.2%) (p=0.008). Additionally, fewer patients with MA SU were admitted with ischemic stroke (66.7% vs 78.7%), but more with subarachnoid hemorrhage (14.5% vs 4.7%) (p=0.018). Only smoking (66.7% vs 49.8%, p=0.017) was significantly different between patients with CB SU and other SU groups.

Conclusion:
The findings of this study indicate care processes and stroke diagnosis differ among patients by specific type of SU. Strategies to address the specific care needs of patients with stroke and substance use should be explored.
Abstract P307: The ALPHA Sign in the Diagnosis of Potential Stroke
Authors: Labin Edward , Meyer Dawn M , Ramesh Vishwajith , Weibel Nadir , Agrawal Kunal , Meyer Brett C
Published: March 2021

Background:
Any clinical feature that may improve the early recognition of, or increase pretest probability of, acute stroke could shorten treatment times. We evaluated the sensitivity and specificity of the "Arm and Leg Positioning and self-Help Assessment” (ALPHA) sign in a predominantly stroke population. This sign was developed from the observation that some stroke patients guard the affected limb. Even mild deficits seem to have minimally supportive micro-gestures of one hand touching or lightly supporting the affected limb.

Methods:
IRB approval was obtained to review available videos of 63 stroke and non-stroke patients. Observers were instructed to only watch the initial 30 seconds of each video and focus on the limbs. The remaining video, and all the audio, were withheld. Videos were independently scored for the ALPHA sign. A composite score, defined as positive if >/= 50% of examiners reported its presence, was assigned. Scores were compared to true diagnosis (stroke/ CNS lesion was positive if there was a scorable deficit and imaging positive CNS lesion). Sensitivity analyses were performed.

Results:
Of the original 69 videos, 37 were from the outpatient setting (21 with stroke or other CNS lesions; 16 neurologically intact) and 26 were from the inpatient setting (20 with stroke or other CNS lesions; 6 neurologically intact). The ALPHA sign had a specificity of 86.4% and positive predictive value of 89.7%. Sensitivity was 63.4% and negative predictive value was 55.9%.

Conclusions:
High specificity and positive predictive value of the ALPHA sign were found suggesting that the recognition of subtle supportive gestures may help in early identification of CNS lesions during a stroke code. As expected, the sign had a lower sensitivity as the cohort was not limited to motor-only deficits. Further assessments in other stroke types, assessing a larger cohort and more examiners of various training level, are planned.
Abstract P31: Intravenous Thrombolysis And Short-term Functional Outcome In Minor Stroke: Observational Study.
Authors: Castellanos Pedroza Enrique , Manrique Otero Diana , Cano Nigenda Vanessa , Menéndez-Manjarrez María Fernanda , Calderón García Miguel , Toledo Roberto , Arauz Antonio
Published: March 2021

Background:
Identification of predictive factors for favorable functional outcome after acute ischemic stroke is crucial.
1
Minor stroke (MS) is the most common exclusion criteria for intravenous thrombolysis and up to 30% of patients with MS will have a poor functional outcome at 3 months.
2

Objective:
We reported the frequency of intravenous thrombolysis in the setting of minor stroke in the population of study and tried to identify clinical factors associated with favorable functional outcomes among these patients.

Methods:
Fifty-one consecutive patients with acute MS were selected (National Institute of Health Stroke Scale of 5 or less). Functional outcome was assessed using the modified Rankin scale (mRS) at 3 months after index event. Descriptive analysis through frequency and central tendency measures were applied and exact Fisher’s test was used for analysis of categorical variables and logistic regression analysis to determine the impact of independent factors related to functional outcome.

Results:
60.8% of patients were males. Hypertension (43.1%) was the most frequent risk factor identified among these patients follow by diabetes (37.5%) and smoking (31.4%). 46.5% of patients presented in the <4.5 hours window for IV thrombolysis of these 4.7% presented within the first hour of symptom onset and only 11.8% were treated with rtPA. None of these patients had intracerebral hemorrhage (ICH). Small vessel disease was the most common cause of MS (37.2%) and no cause was identified in 13.7% of patients after evaluation. Favorable outcome (mRS 0 - 2) was observed in 88.2% of patients and one patient died after recurrence of stroke two weeks after MS. Male sex and time from symptom onset to the emergency department > 24 hours were associated with poor functional outcome (mRS 3 - 6) (
p
0.029 and
p
0.014 respectively) without reaching statistical significance in the multivariate analysis.

Conclusions:
Most patients with MS had a favorable functional outcome (mRS 0 - 2) notwithstanding the low rate of IV thrombolysis compared with other study populations without increasing the risk of ICH in this group of patients.
3
A tendency towards poor functional outcome for male sex and time from symptom onset to the emergency department > 24 hours was observed
Abstract P311: Outpatient Evaluation of Transient Ischemic Attack and Minor, Non-Disabling Stroke During the COVID-19 Pandemic
Authors: Wechsler Paul , Navi Babak B , Segal Alan Z , Parikh Neal S , White Halina
Published: March 2021

Introduction:
Reductions in hospital visits for stroke have been seen during the COVID-19 pandemic, partly reflecting perceived risks of in-hospital care. We recently implemented an evidence-based protocol for outpatient rapid evaluation of transient and minor, non-disabling stroke symptoms for patients seeking care 24 hours after symptom onset. We present our early experience through the pandemic.

Methods:
We conducted a retrospective review of patients evaluated in the RESCUE-TIA (
R
apid
E
valuation of minor
S
troke and
C
erebrovasc
U
lar
E
vents including
TIA
) clinic from December 2019-August 2020. The clinic sees patients with TIA symptoms or with fixed, non-disabling deficits seeking care
>
24 hours after symptom onset. We introduced telemedicine in March 2020. Magnetic resonance brain and vascular imaging is available within 24 hours of visit. We summarized patient characteristics and quality data with standard descriptive statistics.

Results:
A total of 21 patients were seen in the RESCUE-TIA clinic, including 15 patients during the height of the pandemic in NY; 67% were seen by telemedicine. The median age was 75 years (interquartile range [IQR], 61-82), and 71% were women. The median NIH Stroke Score for patients with minor stroke was 0 (IQR, 0-1), and the median ABCD
2
score for TIA patients was 3 (IQR, 2-3). Median time from symptom onset to evaluation was 3 days (IQR, 2.5-17.5). Median time from evaluation to laboratory diagnostics was 8 hours (IQR, 2-21), and to completion of imaging was 1 day (IQR, 0-5). Outpatient telemetry commenced in a median of 5 days (IQR, 1-9), and echocardiography was completed in a median of 8 days (IQR, 0-10). One patient was referred to the emergency room for a carotid occlusion. Final diagnoses were TIA (n=12), ischemic stroke (n=5), transient global amnesia (n=2), migraine (n=1), and non-aneurysmal, distal subarachnoid hemorrhage (n=1). Secondary prevention was initiated or optimized in 94% of TIA and stroke patients. Recurrent TIA occurred in 1 patient after 67 days, and ischemic stroke occurred in 1 patient 55 days after TIA.

Conclusion:
Timely outpatient evaluation of patients with recent TIA and minor, non-disabling stroke is feasible and may be useful during the pandemic, especially during emergency room crowding.
Abstract P326: Vascular Risk Factors in Adulthood and Increased Diffusion Complexity of Neural Tissue Structure
Authors: Ingo Carson , Kurian Shawn , Higgins James , Mahinrad Simin , Jenkins Lisanne M , Gorelick Philip B , Lloyd-jones Donald M , Sorond Farzaneh A
Published: March 2021

Introduction:
We performed a region of interest diffusion tensor imaging (DTI) and advanced diffusion complexity analysis of neural tissue to determine the impact of vascular health on novel diffusivity metrics in midlife adults.

Methods:
As shown in Table 1, 77 participants (26 black, 35 female) at year 30 visit in the Coronary Artery Risk Development in Young Adults (CARDIA) longitudinal study were scanned with an advanced diffusion-weighted imaging and FLAIR protocol. Fractional anisotropy (FA) and non-linear diffusion complexity, C, measures were estimated. Cumulative vascular measures were tracked from baseline up to year 30 examination. Partial correlation analyses assessed the association between cumulative vascular measures and diffusion metrics in these participants.

Results:
As shown in Figure 1, higher systolic blood pressure exposure was associated with increased complexity, C, (red) and decreased FA (blue). Additionally, in the white matter of black participants, who exhibited a higher cumulative vascular risk exposure, FA was lower and complexity was higher in comparison to white matter in white participants.

Conclusion:
Higher burden of vascular risk factor exposure from adulthood to midlife is associated with changes in the diffusion properties of neural tissue in midlife. These diffusion measures may reflect novel markers of axonal disruption, increased inflammation, and/or increased glial proliferation. These new results suggest that microstructural changes in neural tissue are sensitive to vascular health during young adulthood and are possibly therapeutic targets in interventions focused on preserving neural tissue health across life.