bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP290: Tertiary Center Telestroke
Authors: Ranta Anna , Lanford Jeremy , Wong Lai-Kin
Published: October 2018

Introduction:
Telestroke is used increasingly at hospitals where on-site stroke expert support is not available. Even at tertiary teaching hospitals senior stroke experts are not generally on-site out of hours. Here front-line decision-making is made either by junior doctors with or without telephone back-up by more senior staff or senior staff drives in from home to attend the case in person. Telestroke for remote expert support is not commonly used in this setting.

Hypothesis:
That telestroke at a tertiary centre is feasible without adversely affecting quality of care.

Methods:
This is a sequential comparison capturing all stroke patients thrombolyzed out-of-hours 12 months before implementation of tertiary hospital telestroke and 12 months after. Main outcomes were thrombolysis rate, treatment times and symptomatic intracerebral hemorrhage rate. Participating neurologists were surveyed about their experience.

Results:
Over the 24-month study period, 80 patients (38 pre- and 42 telestroke) were thrombolyzed out of 584 patients admitted with ischemic stroke. The overall thrombolysis rate of all patients presenting with ischemic stroke was 20.2% pre- and 21.6% post-telestroke with 26.0% and 28.8% out-of-hours rates respectively. Median (IQR) out-of-hours door-to-needle time was 65 (45-100) minutes before and 57 (41-78.5) minutes after with 45.7% treated within 60 minutes of arrival pre and 52.3% post (OR (95%CI) 1.30 (0.53-3.17);p=0.56). Median door-to-CT time dropped from 34 (26-58) pre to 25.5 (17.5-46.5) post (p=0.21). The sICH rate was 2.6% pre- and 2.3% post-telestroke (OR (95%CI) 0.38 (0.03-4.41); p=0.42). The neurologists were highly satisfied with the new model as it meant they no longer had to drive in from home out-of-hours and co-ordination of on-call activities, which include provincial telestroke was less stressful.

Conclusion:
Tertiary center telestroke can be safely implemented to reduce on-call burden for neurologists while maintaining a high thrombolysis rate and acceptable door-to-needle times and sICH rates. Especially where the same neurologists also support out-of-hours regional telestroke managing both patient groups in the same manner can streamline processes of care.
Abstract TP295: Administration of Intravenous Tissue Plasminogen Activator Does Not Prolong Door-to-Recanalization Time in Acute Large-Vessel Strokes
Authors: Davis Nicolle W , Khanna Anna Y , Wilson Christina A , Perez-Velez Roque
Published: October 2018

Introduction:
Mechanical endovascular reperfusion (MER) is considered definitive treatment for patients presenting with acute ischemic stroke secondary to large-vessel occlusion. Outcome is dependent upon rapid initiation of MER, and there is concern that any antecedent delay, including time needed to identify the stroke and initiate intravenous tissue plasminogen activator (IV tPA), may adversely affect the time to definitive MER therapy. We analyzed the door-to-recanalization times for patients with large-vessel occlusion who underwent MER at our institution, comparing those who received IV tPA at our institution versus those who presented as a drip-and-ship transfer from an outside hospital. We hypothesized that door-to-recanalization times would be shorter for the transferred patients since they had been pre-identified as an acute ischemic stroke and had already received IV tPA.

Methods:
This was a retrospective data analysis from a single Joint-Commission certified Comprehensive Stroke Center. All patients who presented to our institution between January 2016 - November 2016 and received both IV tPA and MER were included. Comparison was made between those who received IV tPA at our institution versus an outside hospital. Door-to-recanalization metrics captured in our local stroke-alert registry were analyzed.

Results:
Twenty patients received both IV tPA and MER during the time period evaluated. Comparison between patients who received both interventions at our institution versus those who received IV tPA prior to transfer demonstrated no statistically significant difference in total door-to-recanalization times (t-test: two-samples with unequal variances, p = 0.05).

Conclusion:
At our single tertiary stroke center, the time required to identify a large-vessel stroke and administer IV t-PA does not add appreciable delay to recanalization by MER.
Abstract TP3: Endovascular Thrombectomy Improves Long-Term Outcomes of Acute Ischemic Stroke Patients: A Real World Observational Study
Authors: Zhao Wenbo , Shang Shuyi , Li Chuanhui , Wu Longfei , Chen Jian , Song Haiqing , Duan Jiangang , Ding Yuchuan , Feng Wuwei , Ji Xunming
Published: October 2018

Introduction:
Recently, REVASCAT and MR CLEAN studies reported favorable long-term outcome of acute ischemic stroke (AIS) patients at 1 and 2 years post endovascular thrombectomy (ET) respectively. However, no study in the real world has reported long-term outcomes of AIS after ET. Chinese patients largely experience AIS due to large artery atherosclerosis (LAA), and approximately half of them have intracranial artery stenosis. The differences of AIS patients of LAA and cardioembolism and treated with ET are unclear. In this study, we evaluate the long-term outcomes of AIS patients after ET in the real world, and investigate differences between AIS patients of different etiology.

Methods:
This observational study based on a prospective registry study of revascularization therapy for AIS. Favorable outcome was defined as modified Ranks scale (mRS) scores 0-2, and unfavorable outcome was defined as mRS scores 3-6. The primary outcome was mRS at the time of assessment.

Results:
Eighty nine subjects (aged 59.5 years old) with large artery occlusion in anterior circulation and treated with ET were recruited. Median length of follow up was 20 months (IQR 6-32), including 74% subjects longer than 12 months and 43% subjects longer than 24 months. At the time of follow up, 47 subjects (53%) achieved favorable outcome whereas 17 subjects (19%) were functional dependence and 25 subjects (28%) died. More subjects of LAA were treated with permanent intracranial stenting (22% vs. 10%) as compared with those of cardioembolism. Subjects of cardioembolism are more likely to experience sICH (19% vs. 8%) and die (32% vs. 16%) as compared with those of LAA. During the study period, 3 subjects (3.4%) had post-stroke seizures, and the incidences of recurrent stroke were 1% after 3 months, 3% after 6 months, 7% after 12 months, and 8% after 42 months

Conclusions:
Over half of AIS patients can achieve favorable long-term outcomes after ET. Subjects of cardioembolism are more likely to experience sICH and die.
Abstract TP305: Geographical Dispersion of Patients Referred to a Comprehensive Stroke Center in a Rural Setting
Authors: Rindels Erin , Torner James , Adams Harold P , Leira Enrique , Whitmer Angela , Mueller Michael ,   Iowa Stroke Registry
Published: October 2018

Introduction:
Most patients with stroke in Iowa are initially seen in small community hospitals and are subsequently transferred to another institution with a higher level of care. The Iowa Stroke Registry (ISR) was developed to assess the system of stroke care in the state. Community hospitals in the state are supported by the comprehensive stroke center (CSC) through consultation for acute stroke treatment. The objective for this project was to analyze the geographical dispersion of transfers to the CSC to begin an evaluation of the system of stroke care in the state.

Method:
We analyzed the prospectively collected data in the Iowa Stroke Registry (ISR). The ISR has collected data from 32 hospitals: comprehensive (1), primary (15), and stroke capable hospitals in Iowa beginning in 2010. To date over 23, 000 patients have been enrolled. Information from this analysis included the CSC data only collected in a national database and imported ino the ISR from 2015-April, 2017 that included zip code data. During that time period 2576 patients were direct admissions or transfers to the CSC. Distances were based on the number of miles between the patients’ and CSC zip code.

Results:
Approximately 80% of all stroke patients at the CSC were transferred from a community hospital. Patients originated in 78 of the 99 counties in Iowa. The median distance was 63 miles. Of the transfers from local hospitals, 86% were within 90 miles with the largest group 60-89 miles from the CSC. Of all patients transferred for ischemic stroke approximately 30% received treatment with intravenous alteplase at the outside hospital.

Conclusion:
In conclusion, these data suggest a high degree of geographical dispersion for stroke patients transferred to a CSC in a rural state. This analysis of the system of stroke care in Iowa indicates the CSC provided support to multiple community hospitals for acute stroke treatment. Further analysis of the system of stroke care is needed to better understand patient transfers including mode of transfer and reason for transfer.
Abstract TP309: Hemorrhagic Stroke Citation Classic: Bibliometric Analysis of the 100 Most Influential Articles
Authors: Saeed Omar , Malhotra Konark , Khunger Arjun , Khan Mohammad T , Qureshi Adnan I
Published: October 2018

Background:
Citation analysis studies are used to assess the characteristics of impact a particular disease or topic levied over time in the medical community. We analyzed the top-100 most influential articles on hemorrhagic stroke.

Methods:
We used Institute for Scientific Information (ISI) Web of Knowledge Journal Citation Reports Science Edition 2015 to identify all the pertinent articles using key words hemorrhagic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, epidural hemorrhage and subdural hemorrhage. All original articles were evaluated by two independent reviewers for: publication year, journal category, journal and its impact factor (IF), number of total and annual citations, topic, author names and institution affiliations, publishing country and institution affiliations.

Results:
Top-100 citation classics in hemorrhagic stroke were published between 1940-2014, with the maximum publications in the decade of 2000-2009 (n=37). Total citations ranged from 1817 to 204 (mean 340.55± 209.77, median 273.50) and annual citations ranged from 82.0 to 3.10 (mean 19.1 ± 13.8, median 15.4). Majority of the articles were published from the United States (n=60), with Harvard University and University of Cincinnati (n=10 each) as the leading institutions in our analysis. The mean IF for the journals with the citation classics was 14.73 ±14.479 (range 59.56 to 1.43). The most cited article was published in
Neurosurgery
journal (IF 3.780), while the majority of the citation classics were published in
Stroke
journal (n=28). Clinical neurology and peripheral vascular disease were the top ISI categories in which articles were published. The mechanism of hemorrhagic stroke (n=42) was the most published topic (Figure).

Conclusion:
This analysis provides insight into research trends in hemorrhagic stroke with detailed information on the most influential articles published.
Abstract TP313: The Stroke Navigator: Using the Electronic Health Record to Improve Patient Care and Clinical Documentation
Authors: Kronfeld Kassi , McCaslin Addason , Schenone Brian , Hobbs Kyle
Published: October 2018

Introduction:
Comprehensive Stroke Centers (CSCs) provide the highest level of stroke care, and thus are held to rigorous standards by the Joint Commission to maintain certification. Meeting these metrics can be challenging in an academic medical center, where there is frequent rotation of new housestaff on service, and has been hindered by limitations in the electronic health record (EPIC) to capture data. The Stanford Stroke Navigator is an electronic data form that was designed to improve housestaff documentation and compliance with stroke metrics.

Hypothesis:
We hypothesized that the Stroke Navigator would improve accuracy of patient data collection and reduce the need for concurrent review and addendum requests for incomplete documentation.

Methods:
The Stanford Stroke Navigator was developed by a team of physicians, nurses, and EPIC engineers. We designed a standardized electronic data form in EPIC to collect required clinical information based on the Joint Commission Stroke (C-STK) Measures at time of admission and discharge of stroke patients. We compared the number of addendum requests indicating missing documentation in the 3 months before and 3 months after the Stroke Navigator was implemented. We also tracked housestaff usage of the Stroke Navigator in appropriate patients.

Results:
Implementation of the Stroke Navigator reduced the overall number of addendum requests by 20%, indicating improved compliance with documentation of CSC requirements. In the pre-navigator group, the most common addendum request was reason the patient did not require inpatient rehabilitation. This remained the most common addendum request after the intervention. Among eligible ischemic stroke admissions, the Stroke Navigator was used by housestaff 76% of the time.

Conclusion:
The Stanford Stroke Navigator improves stroke care through increased compliance with CSC metrics, improved documentation, and reduced need for concurrent review. Future work with the Stanford Stroke Navigator will focus on continued tracking of need for addenda and increasing housestaff utilization.
Abstract TP318: Hemorrhagic Transformation in Acute Ischemic Stroke: A Quantitative Systematic Review
Authors: Honig Asaf , Percy Jennifer , Sepehry Amir A , Field Thalia S , Gomez Alejandra G , Benavente Oscar R
Published: October 2018

Objective:
Hemorrhagic transformation (HT) is common in patients with acute ischemic stroke and is associated with poor outcome. However, the accurate prevalence and risk factors for HT are uncertain. We aim to characterize rates, risk factors and prognosis of HT.

Methods:
We conducted a systematic review and meta-analysis of all published English literature of patients with acute ischemic stroke and HT. Medline and EMBASE were searched between 1985 and 2017, 2,099 relevant publications were identified. To obtain comparable data we included only studies that used the ECASS-2 definitions of Hemorrhagic Transformation and Parenchymal Hematoma (PH). Patients treated with intravenous thrombolysis (IV-tPA) were compared with those who did not receive thrombolysis.

Results:
Eligible studies (n=65) with 17,259 patients in total were included in this analysis. The overall prevalence of HT was 27% (95% CI 23-30); Patients not treated with IV-tPA had a prevalence of 20% (95% CI 14-27) vs. 32% (95% CI 27-37) in those treated. The overall prevalence of PH was 9% (95% CI 8-11); in untreated patients prevalence was 5% (95% CI 4-7) vs. 12% (95% CI 10-15) in the IV-tPA treated patients. The risk of HT was higher with: history of atrial fibrillation (OR 2.94, CI 2-4), use of anticoagulants (OR 2.47, 95% CI 1.6-4), higher NIHSS score (Hedge’s G 0.96, 95% CI 0.5-1.4), DWI infarct volume (Hedge’s G 0.8, 95% CI 0.01-1.5) and glucose level (Hedge’s G 0.4, CI 0.16-0.6). LDL was negatively correlated with HT (Hedge’s G -0.3, 95% CI -0.12- -0.48). Interactions were explored for factors associated with HT and thrombolysis treatment. In patients treated with IV-tPA, risk of PH was associated with antiplatelet use (OR 3, 95% CI 1-7), statin treatment (OR 4, 95% CI 1-9) and history of hypertension (OR 1.5, 95% CI 1.1-2). Poor 90-day outcome (mRS 5-6) was associated with HT (OR 3) and PH (OR 8).

Conclusion:
HT is common, even in patients not treated with IV-tPA, and tends to occur in patients with large and severe strokes. HT, and PH in particular, are associated with poor outcomes. Risk factors for HT should be identified to reduce burden of disability and future high quality . Prospective Longitudinal studies are warranted.
Abstract TP32: Predictors of Endovascular Treatment Among Stroke Codes Activated Within 6 Hours From Symptom Onset
Authors: Requena Manuel , Pérez de la Ossa Natalia , Abilleira Castells Sonia , Cardona Portella Pere , Urra Nuin Xabier , Boned Sandra , Marta Rubiera , Molina Carlos A , Ribo Marc
Published: October 2018

Introduction:
Prehospital stroke code activations help reducing wokflow times during in-hospital triage. We aim to identify predictors of endovascular treatment among activated stroke codes (ASC) within 6 hours from symptom onset.

Methods:
CICAT is a prospective official mandatory registry of all ASC in Catalunya. We studied all CICAT entries from 5 comprehensive stroke centers during 18 months.

We recorded demographic, historic, clinical and imaging variables on admission. We explored the relationship between these variables and endovascular treatment (EVT)

Results:
From 3944 ASC, 2818 (71.5%) were admitted < 6 hours from symptom onset. Mean age was 72±15.3 years, median RACE scale 4 (IQR 2-6), median onset-to-door time (OTDT) was 87 minutes (IQR 54-158), median NIHSS score 9 (IQR 4-18), median ASPECTS 10 (IQR 8-10. Final diagnosis was ischemic stroke in 1767 patients (62.7%), hemorrhagic stroke in 364 (12.9%), TIA in 167 (5.9%), stroke-mimic in 500 (17.7%). After admision a large vessel occlusion (LVO) was confirmed in 916 (23.2%) patients. While the rate of ASPECTS ≥ 9 among ischemic strokes progressively decreased over time (0-3h: 73.2% vs 3-6h: 57.1%: p<0.01), the rate of ASPECTS ≥6 (0-3h: 95.1% vs 3-6h: 91.6%: p=0.13) and presence of LVO (0-3h: 22.4% vs 3-6h: 22.8%: p=0.82) did not decrease over time. Of all ACS, 16% (n=453) received EVT, with a median door to groin time of 77 minutes (IQR 55-102). Baseline variables independently associated with EVT were premorbid mRS>2 (p<0.001), prehospital RACE score >4 (p=0.003) and NIHSSon admission >8 (p<0.001). The chances to receive EVT were similar in patients admitted 0-3 (16.4%) Vs. 3-6 hours (14.6; p=0.3). ASC with a RACE score>4 had 26.0% probability to receive EVT

Conclusion:
Among ACS within 6 hours from symptom onset, time from onset to arrival is not associated with the probability of receiving EVT. Only 5% of these patients show an ASPECTS <6 and this rate does not significantly increase during the first 6 hours. These data may be useful to generate direct transfer to angio-suite protocols.
Abstract TP323: Necessity of the Twenty-Four Hour Head Computed Tomography Scan After Administration of Intravenous Recombinant Tissue Plasminogen Activator Among Clinically Stable Patients With Acute Ischemic Stroke
Authors: Elzamly Kareem , Nobleza Christa O’Hana S
Published: October 2018

Introduction:
Current AHA guidelines recommend obtaining a brain imaging study usually a computed tomography scan of the head (CTH) at 24-hours after thrombolysis with intravenous recombinant tissue plasminogen activator (IV r-tPA) before starting anti-platelets (AP) or anticoagulant (AC) therapy due to concerns for intracerebral hemorrhage. Several studies argued against the utility of a 24-hour post-thrombolysis CTH in AIS patients especially if they recover early or are clinically stable, and suggested that it would not alter clinical management.

Hypothesis:
The authors hypothesize that new findings after the 24-hour post-thrombolysis CTH alter management decisions regardless of clinical stability in patients with AIS.

Methods:
Stroke patients admitted to the Neurocscience Critical Care Unit (NCCU) after thrombolytic therapy from January 2013 to June 2016 were identified retrospectively. Clinically stable patients with new 24-hour post-thrombolysis CTH findings were included. Patient characteristics and outcome were compared according to cohorts of “with management change”(with MC) versus “with no management change”(no MC). Primary outcome were types and frequencies of MC. Secondary outcomes were hospital length of stay (HLOS), discharge and 30-day NIHSS and MRS, in-patient mortality and discharge disposition.

Results:
A total of 223 AIS patients were admitted to the NCCU after thrombolysis. Forty-two patients were included for analysis. Based on new CTH findings, 28(67%) had MC. The most common types of MC were repeating CTH (24, 86%) followed by AC delay (18, 64%). Majority of the “with MC” cohort had CTH findings of ventricular compression due to mass effect (20, 71%). They also had longer HLOS (median[IQR] 7.5[13]vs 4[4],p-value=0.012) and higher 30-days NIHSS (9.5[11]vs 2[3],p=0.042) and MRS on discharge (4[3]vs 1.5[2],p=0.002) compared to the “no MC” group.

Conclusion:
We showed that a 24-hour CTH after IV r-tPA is necessary prior to starting AP or AC therapies for AIS patients and affects management decisions regardless of the patients’ clinical stability. Patient outcome was worse among those with management change. Studies should be done to analyze long-term effect of these managements and their impact on healthcare costs.
Abstract TP327: Predictors of Spontaneous Hemorrhagic Transformation in Patients Not Treated With Recanalization Therapies
Authors: Clares de Andrade Joao Brainer , Oliveira Lima Fabrio , Sampaio Silva Gisele
Published: October 2018

Hemorrhagic transformation (HT) is an important complication after ischemic stroke and might be associated with a worse clinical prognosis. Predictors of (HT) in patients treated with recanalization therapies were extensively evaluated, however predictors of spontaneous HT are less well described.

Hypothesis:
we evaluated the hypothesis that clinical and neuroimaging variables can predict spontaneous HT in patients with ischemic stroke.

Methods:
We evaluated patients admitted with ischemic stroke and not treated with recanalization therapies to a tertiary stroke center. The rates of hemorrhagic transformation were evaluated in follow up CT scans (within at least 24 hours), using the ECASS II criteria. Univariate predictors of HT were identified. We used logistic regression analysis to investigate independent predictors of HT.

Results:
A total of 258 patients were evaluated (mean age 64 ± 14,=6 years, 59.3% males.) The overall prevalence of HT was 21.3% (n = 55), with 45.5% (n = 25) of symptomatic HT. Patients with HT had higher NIHSS at admission (13 [10-15,5] versus 8 [4-17], p <0.01), lower ASPECTS scores (7 [6-8] 9 [8-9] p<0.01) and a trend towards being more hypertensive at admission (76.1% versus 68.1%, p=0.2). Cardio-aortic embolism was more frequent among patients with HT (39,3% versus 23,2%, p= 0.02). ASPECTS scores at admission (OR 0.60 (0.44-0.82) ≤0.01), admission glucose levels (OR 1.01 (1.01-1.01) p≤0.01), being hypertensive at admission (OR 3.03 (1.08-8.48) p=0.03) and having a previous history of coronary artery disease (OR 4.01 (1.24-12.93) p=0.02) were independent predictors of HT. Previous use of antithrombotic medications was not associated with HT. Patients with HT had a lower frequency of independence at discharge (mRS<=2), p=0.03. Symptomatic and asymptomatic HT were associated with a higher chance of death during hospitalization (OR 3.28, 95% CI 1-11.20, p= 0.05 and OR 4.61, 95% CI 1.35-15, 71, p = 0.01, respectively).

Conclusion:
In conclusion, HT is not uncommon in acute ischemic stroke not treated with recanalization therapies. Clinical, neuroimaging and laboratorial data characteristics can be used to identify patients at higher risk for HT. Even asymptomatic HT seems to be associated with worse clinical outcomes
Abstract TP335: Divergent Responses of Macrophages and Microglia in the Hemorrhagic Brain
Authors: Chang Che-Feng , Goods Brittany A , Askenase Michael H , Love J. Christopher , Sansing Lauren H
Published: October 2018

Blood-derived macrophages (MF) and tissue-resident microglia (MG) and are innate immune cells that are responsible for inflammatory responses and tissue repair after intracerebral hemorrhage (ICH). In the past, since activated MF and MG share common cell surface markers in the injured brain, no study has characterized the functional diversity between these two cell types during the pathophysiology of ICH. In this study, we compared the temporal transcriptional changes and the erythrophagocytosis ability of MF and MG in the ICH brain. We used autologous blood injection to induce ICH in male C57/B6 mice. At days 1, 3, 7, and 10 after ICH induction, MF and MG were isolated from the perihematomal region by fluorescence-activated cell sorting, and transcriptional analyses of 780 genes in these two cell types were determined using NanoString nCounter system. In vivo, quantification of erythrophagocytosis by MF and MG was performed by injection of fluorescent-labeled RBC followed by flow cytometry analysis at day 3 post-ICH. We found that 469 genes were detected on at least one time point in either cell population. Principal components analysis revealed complete separation of the MF and MG populations at all time points on PC1 (Figure (
A
)). Differential gene expression is displayed in the heat map (
B
). In vivo, MF had greater ability to clear RBCs than MG in the ICH brain (
C
). In conclusion, MF and MG have distinct transcriptome profiles and effector responses after ICH which provides functional diversity to aid in ICH brain repair.
Abstract TP340: Centrum-semiovale Enlarged Perivascular Space and Amyloid Deposition in Primary Intracerebral Hemorrhage
Authors: Tsai Hsin-Hsi , Pasi Marco , Tsai Li-Kai , Chen Ya-Fang , Lee Bo-Ching , Tang Sung-Chun , Yen Ruoh-Fang , Gurol M. Edip , Jeng Jiann-Shing
Published: October 2018

Background:
Higher load of MRI visible enlarged perivascular spaces in centrum-semiovale (CSO-EPVS) are found in cerebral amyloid angiopathy (CAA), but their association to brain amyloid has been rarely investigated, especially in Asians. We explored whether high degree of CSO-EPVS is associated to other MRI signatures of CAA and its relationship to brain amyloid retention in patients with primary intracerebral hemorrhage (ICH).

Methods:
110 patients with either CAA-ICH, strictly lobar ICH and microbleeds (MB) or hypertensive ICH (HTN-ICH), strictly deep-seated ICH/MBs, were included in this study. CSO-EPVS and basal ganglia EPVS (BG-EPVS) were assesd using an established 4-point semiquantitative score. EPVS degree was classified as high (score>2) or low (≤2). We also evaluated MBs, cortical superficial siderosis (cSS), white matter hyperintensities (WMH) and brain atrophy severity on MRIs. Cerebral amyloid deposition was quantified on
11
C-Pittsburgh Compound B (PiB) PETs in 36 patients (15 CAA; 21 HA) as standardized uptake value ratio (SUVR).

Results:
Patients with CAA-related ICH (n=24) and HTN-ICH (n=86) had similar prevalence of high-degree CSO-EPVS (37.5% and 26.7%, p=0.305) and high-degree BG-EPVS (25% and 18.6%, p=0.489). Patients with high-degree CSO-EPVS were associated with presence of lobar MB (p=0.01) and higher WMH (p=0.008), while patients with high-degree EPVS-BG were associated with older age (p=0.002), higher WMH (p=0.021) and more cortical atrophy (p=0.023). The amyloid burden (global SUVR) was higher in high-degree vs low-degree EPVS-CSO in CAA-ICH (p=0.045), but not in HTN-ICH (p=0.586). On multivariate logistic regression analysis, the degree of EPVS-CSO remains an independent indicator for positive amyloid scan (defined as global SUVR>1.2) even after adjustment for age, WMH, the degree of EPVS-BG and ICH/MBs distribution (Odds ratio 6.2 [1.2-31.6], p=0.029).

Conclusion:
Although the presence of EPVS-CSO could not directly distinguish CAA-ICH and HTN-ICH in our Asian cohort, high-degree EPVS-CSO was associated with CAA-related MRI markers such as lobar MBs, and higher amyloid load on PiB-PET. The burden of CSO-EPVS can be seen as an indicator of higher brain amyloid deposition in patients with CAA-related ICH.
Abstract TP341: Pericyte Derived Laminin Play a Beneficial Role in Intracerebral Hemorrhage
Authors: Yao Yao
Published: October 2018

Introduction:
Laminin, a major component of the basement membrane, exists in many isoforms. Although loss of laminin is found in intracerebral hemorrhage (ICH), the exact biological function of laminin in ICH remains largely unknown. This is primarily due to its intrinsic complexity (various isoforms) and the lack of genetic tools. In a previous study, we generated a transgenic line with laminin deficiency specifically in pericytes (PKO). These PKO mice are grossly normal in pure C57Bl6 background at young age, although mild blood brain barrier (BBB) breakdown is detected in aged mutants. In this study, we aim to investigate the role of pericyte-derived laminin in brain pathology and disease progression in ICH.

Methods:
Collagenase was injected into the striatum of young (2-month-old) control and PKO mice to induce hemorrhage. At 2, 5, and 14 days post injury (dpi), hematoma size, neuronal death, vascular permeability, inflammatory cell infiltration, and neurological deficits were examined.

Results:
Compared to the controls, the PKO mice showed larger hematoma and increased neuronal deaths at 2 and 5 dpi, but more severe neurological deficits at 14 dpi. Additionally, substantially increased IgG level was found in PKO brains at 14 dpi, indicating BBB integrity disruption. Consistent with this observation, significantly higher levels of CD45
+
leukocytes and Ly6G
+
granulocytes were detected in PKO brains at 14 dpi. Similarly, elevated CD3 staining was found in PKO brains at 5 and 14 dpi. These data suggest that the recovery of vascular integrity after ICH is delayed in PKO mice. Moreover, PKO brains also showed increased number of CD11b
+
microglia/macrophages at all three time points examined, suggesting a possible role of pericyte-derived laminin in microglia/macrophage activation and/or migration.

Conclusion:
Our data support a neuroprotective role of pericyte-derived laminin in ICH. This beneficial effect is probably due to its biological activities in: (1) promoting neuronal survival; (2) stabilizing newly formed vessels and enhancing their integrity; (3) inhibiting inflammatory cell infiltration; and (4) regulating the activation and/or migration of microglia/macrophages.
Abstract TP342: Protective Effects of the Lipophilic Dadmdft Iron Chelator Against Brain Hemoglobin Toxicity
Authors: Ma Bo , Day Jason P , Goodwin Kristina , Doré Sylvain
Published: October 2018

Background and Purpose:
Intracerebral hemorrhage (ICH) is a devastating form of stroke, and therapies are largely non-existent. Among the deleterious processes occurring after ICH, iron toxicity is suggested to contribute to secondary injury. There is a pressing need for the continued development of new iron-chelating agents that can selectively remove released iron after ICH from brain tissues especially vulnerable to iron-induced toxicity. The DADMDFT analogue [(
S
)-4,5-dihydro-2-(2-hydroxyphenyl)-4-thiazolecarboxylic acid] used here is a more lipophilic iron chelator that achieves higher concentrations in the plasma and has a longer half-life than most commonly used chelators.

Methods:
The DADMDFT-treated mice were subjected to intrastriatal injection of stroma-free hemoglobin. Infarct volume and ferric iron distribution were assessed by using Cresyl violet and Perls’ staining respectively. Knowing that hemoglobin can activate microglial cells, thus microglial activation was monitored by Iba1 immunohistochemistry. Behavioral functions were evaluated by rotarod and neurological deficit score at 24 and 72h after hemoglobin injection.

Results:
We found that DADMDFT treatment at 75 and 150μmol/kg both significantly reduced the lesion volume after hemoglobin intrastriatal injection. Moreover, around the lesion site, smaller accumulation of iron was observed after DADMDFT treatment in contrast to the vehicle group. Our quantitative analyses indicated that there were more activated microglial cells at peri-lesion area with DADMDFT treatment at the dose of 75 and 150μmol/kg, as compared to the vehicle-treated group. In behavioral tests, DADMDFT treatment significantly prolonged the latency to fall during the rotarod test at 150μmol/kg at 24h after injection. In addition, DADMDFT of 75 and 150μmol/kg significantly improved the neurological deficit score at 24 and 72h after injection.

Conclusions:
We found that the lipophilic DADMDFT can protect brain tissue from hemoglobin toxicity. The potential mechanism of its protective effects is that DADMDFT treatment could help maintaining the cell number and phagocytosis function of activated microglia around the lesion site, which could promote the clearance of toxic ferric iron.
Abstract TP344: Extrahematomal CNS Barrier Disruption in the First 90 Days Following Primary Intracerebral Hemorrhage
Authors: Mackey Jason , Saykin Andrew J , Blatsioris Ashley D , Moser Elizabeth A , Saha Chandan , Carter Ravan J , Stevenson Alec , Sprehn Gwen C , Williams Linda S , Kidwell Chelsea S
Published: October 2018

Introduction:
Hyperacute injury marker (HARM) is extrahematomal CNS barrier disruption in ICH marked by enhancement on post-gadolinium FLAIR sequences. We sought to identify factors associated with HARM development over time in a prospective ICH pilot study.

Methods:
We conducted a longitudinal MRI-based study of primary ICH with images at baseline and 90 days. After excluding subjects without post-gadolinium FLAIR sequences and those without usable images, we evaluated HARM formation along with other MRI markers of vasculopathy, including microbleeds, lacunes, white matter disease, cortical superficial siderosis, and enlarged perivascular spaces. HARM severity was scored as 0 (absent), 1 (1 to 3 sulci affected across fewer than 10 slices), 2 (dispersed involvement; more than 3 sulci), or 3 (widespread, confluent involvement over the hemisphere). Imaging review was blinded to clinical variables. Univariate analyses were performed at both time points.

Results:
Of 29 subjects with usable baseline sequences, 11 (37.9%) had HARM, compared to 12/18 (66.7%) at 90 days. Twelve subjects had usable sequences at both time points, and 4 (33%) of these had HARM at both time points. HARM was most frequently noted in the temporal and occipital lobes. At baseline, HARM severity was 1 in 7 subjects, 2 in 2 subjects, and 3 in 2 subjects. At 90 days, HARM severity was 1 in 10 subjects, 2 in 1 subject, and 3 in 1 subject. HARM was distinct from parenchymal T1 enhancement on visual inspection. We did not identify statistically significant associations between HARM formation and subject demographics, vascular risk factors, hematoma characteristics, or MRI markers of vasculopathy.

Conclusions:
In this pilot study we found a high prevalence of HARM at baseline and 90 days. Future studies will examine whether HARM is associated with the formation of new CNS lesions or poor outcomes. HARM appears to be a second type of CNS barrier disruption and may represent a therapeutic target.
Abstract TP347: Nationwide Predictors of Hemorrhagic Conversion with IV tPA for Acute Ischemic Stroke
Authors: Lunagariya Abhishek , Patel Achint , Patel Urvish , Jani Vishal , Huisa Branko , Ovbiagele Bruce , Hemmen Thomas
Published: October 2018

Background:
Hemorrhagic conversion (HC) is one of the most feared complication of tissue plasminogen activator (tPA) use for acute ischemic stroke (AIS). Prior studies have shown very high mortality rates for HC, but are limited due to sampling. We aimed to assess predictors of HC after IV tPA in AIS using a large and representative national patient registry.

Method:
The Nationwide Inpatient Sample (NIS) were analyzed for the years 2002-2014. AIS were identified using the ICD-9-CM 433.xx-436 as a primary diagnosis. tPA utilization was identified with procedure code 99.10, HC with ICD-9 431 as secondary diagnosis. Patient demographics as well as common medical comorbidities were applied to model. Cochran Armitage trend test and survey logistic regression procedure to analyze trends and predictors.

Results:
Of 264,643 AIS who received tPA, 21,418 (8.09%) developed HC. In multivariable regression analysis, increasing age, atrial fibrillation, septicemia, mechanical thrombectomy, alcoholism, epilepsy, malignancy and diabetes were associated with higher odds of HC (Table). Women and admissions in west region were associated with lower odds of HC. Race, type of hospital, and prior stroke were not associated with increased or decreased odds of HC.

Conclusion:
In this nationally representative study, we observed several factors significantly associated with hemorrhagic conversion, some of which may be potentially modifiable to reduce the odds of this worrisome outcome. Future studies should consider factoring some of these variables into prognostic scores or testing interventions to ameliorate them.
Abstract TP351: Don’t Break My Chart, My Achy Breaky Chart: Improving Nursing Documentation for Stroke Outcomes
Authors: Clark Ashley , Zimmermann Mary , May Amanda , Lamsal Gaurab
Published: October 2018

Background:
Hospitals, including community hospitals, often face challenges in the care of the acute stroke patient. One of these challenges is consistent documentation of core measures. Specific documentation opportunities at our hospital included documentation of neurological assessment and care plans. The Progressive Care Unit had a significantly higher rate of opportunities for improvement with documentation when compared to other units in our facility.

Purpose:
The purpose of this process improvement project was to improve compliance with neurological assessment and care plan documentation for stroke patients identified through concurrent chart review.

Methods:
Prior to classroom sessions, a needs assessment was completed by unit nursing staff to gather baseline data of their compliance in completing the documentation of neurological assessment and care plans. The Stroke Program Manager, Unit Educator, Clinical Nurse Specialist, and Nursing Informaticist collaborated to develop a curriculum to address our documentation opportunities. This curriculum consisted of a lecture with PowerPoint presentation, hands on documentation utilizing a patient scenario, and the development of pocket reference cards for stroke specific documentation.

Results:
Progressive Care Unit nursing staff had an average of 13.3 documentation fallouts per month prior to education efforts. The Progressive Care Unit nursing staff decreased the number of documentation fallouts to an average of 5.7 per month following the completion of documentation education. This improvement demonstrates a 57.1% reduction in documentation fallouts.

Conclusion:
In conclusion, stroke programs continue to experience challenges with compliance in neurological assessment documentation. With the implementation of specific education we were able improve the overall nursing documentation for stroke patients in the Progressive Care Unit.
Abstract TP359: Impact of Telemedicine Utilizing Nurse Responders on Stroke Outcomes
Authors: Jones Jennifer , Adams Darlene , Lauth Gina , Page Terry , Jacobs Daniel
Published: October 2018

Background and Purpose:
Some facilities are not fully equipped to manage acute stroke patients including administration of tPA. Therefore, telemedicine has played a vital role in filling this void. Telemedicine provides remote consultative support via an interactive encounter including virtual examination, telemedicine assessment, and, remote diagnosis and treatment decision-making. Telemedicine in stroke care has the been shown to increase use of tPA and decrease delays in diagnosis and treatment. Team collaboration between two facilities, part of a large healthcare system, resulted in changes to stroke telemedicine structure and processes transiting from a national network of specialists to utilization of facility #2’s neurology staff with a focus on a nurse responder. The focus of the nurse responder was assessment and facilitation of the acute diagnostic and treatment processes. Nurses received enhanced education on telemedicine technology. Building relationships across the two facilities within a telemedicine culture was key in successful development, implementation, and evaluation of service changes. The purpose of this study was to compare stroke outcome metrics pre and post implementation of a standardized telemedicine service.

Methods:
A retrospective, pre and post design was used in conducting a chart review comparing 2014 pre-implementation data with 2015-2016 post-implementation data on the number of patients who received tPA and door-to-needle times.

Results:
The number of patients who received tPA at facility #1 increased from 25 cases to 27 in the first year after implementation of standardized telemedicine services and 39 cases the 2
nd
year. Door-to-needle time significantly decreased from a mean of 131 minutes to 76 minutes (
t
(18)=2.472, p<0.038) the 1
st
year and 62 minutes (
t
(20)=3.381, p<0.004) the 2
nd
year. The decrease in door-to-needle time from the 1
st
and 2
nd
year is significant (
t
(18)=1.684, p<0.031).

Conclusions:
Standardization of telemedicine services for acute stroke care and utilization of nurse responders, who provide timely assessments and facilitation of stroke care processes within a collaborative telemedicine culture, can result in significant improvements in utilization and delivery of tPA.
Abstract TP363: Can Intravenous Alteplase tPA Be Given Safely in the CT Scan Suite?
Authors: Whaley Michelle , Swatzell Victoria , van Vliet Rebecca , Dusenbury Wendy , Waterson Duncan Rachael , Kupniewski Sonny , Krishnaiah Balaji , Chulpayev Boris , Nearing Katherine , Alexandrov Andrei V , Alexandrov Anne W
Published: October 2018

Background:
In an effort to shorten door to needle times, stroke teams have moved towards injection of alteplase tPA (IVtPA) in the CT scan suite immediately after completion of the noncontrast CT, and before completion of the CTA. However, many stroke programs are prevented from initiating IVtPA in CT due to concerns about patient deterioration. We sought to determine the safety of this practice.

Methods:
12 months of prospectively treated IVtPA cases from 2 comprehensive stroke centers were assembled for analysis. Cases were carefully examined to determine treatment location, and those treated inside the CT suite were selected for final review.
Safety incidents
were defined as those in which an IVtPA treated patient developed any condition requiring urgent or emergent management in the CT suite. sICH was defined as parenchymal hematoma type 2 in combination with a 4 or more point worsening on the NIHSS.

Results:
A total of 589 acute ischemic stroke patients were treated with IVtPA in calendar year 2016; of these 562 (95%) received their tPA bolus and start of infusion in the CT scan immediately after completion of the noncontrast CT, and prior to CTA. Zero safety incidents occurred in these cases. Additionally, there were no renal insults in the sample, despite not waiting for lab results prior to performing CTA. Median door to needle time was 22 minutes, and overall the sICH rate was 3% for the sample.

Conclusions:
Administration of IVtPA in the CT scan suite is safe and allows for faster administration of IVtPA. Use of this method should be adopted in a widespread manner to facilitate rapid early treatment of acute ischemic stroke.
Abstract TP366: Last Known Well To Acute Stroke Treatment Time Is the Key Factor For A Good Outcome As Measured by Modified Rankin Score at 1-Year post Discharge Follow-Up
Authors: Tse-Chang Karen , Woolfolk Katrina , Jones Kimberly , Keasler Deborah
Published: October 2018

Last Known Well To Acute Stroke Treatment Time Is the Key Factor For A Good Outcome As Measured by Modified Rankin Score at 1-Year post Discharge Follow-Up

Background/Purpose:
The modified Rankin Scale (mRS) is a scale for measuring the degree of disability or dependence in the daily activities of patients. It is also used as a clinical outcome measure for stroke, with 0-2 equals good outcome and 3-5 equals poor outcome. In 2015, our stroke program set out to measure the long term clinical outcome of our stroke patients who have received intravenous (IV) and/or mechanical thrombolysis, by following these patients for 1 year via telephone interview. By the end of 2016, our data shows that 75% of these patients have a mRS of 0-2 at 1-year follow up. While our data reflects the effectiveness of our stroke program, we also analyzed the data to investigate the commonality in the care of patients who have a good outcome versus poor outcome long term.

Methods:
mRS is collected at discharge, 30-day, 90-day, 6-month, and 1-year by telephone interview by stroke program coordinator, on patients who received IV and/or mechanical thrombolysis in 2015. After 1 year, patients with mRS 3-5 at discharge are divided into two groups. Group 1 have patients with mRS 0-2 at 1 -year, and Group 2 made up of patients with mRS 3-5 at 1-year. We then compared factors that could have contributed to the clinical outcome - Age, Door-to-tissue plasminogen activator (tPA) time, Last Known Well (LKW) to tPA time, LKW to Angio Suite, stroke severity, and discharge disposition.

Results:
72 patients were reviewed. 44 patients retained at 1 year follow up. 18 patients in Group 1 and 6 patients in Group 2. The most significant factor for a good outcome is the LKW to treatment time. Group 1 has a median LKW to tPA time of 108 minutes and LKW to Angio time of 138 minutes; while Group 2 has 208 minutes and 238 minutes, respectively. Looking at LKW to tPA between Group 1 and Group 2 - the
t-value
is -3.40249. The
p-value
is 0.001494. The result is significant at p<0.05. For the same 2 groups looking at LKW to Angio time, the
t-value
is -3.55212. The
p-value
is 0.002268. The result is significant at p<0.05.

Conclusion:
Last Known Well to acute stroke treatment time is the key factor for good stroke clinical outcome.
Abstract TP367: Thrombolysis After Protamine Reversal Of Heparin For Acute Ischemic Stroke Post Cardiac Catheterization Case Report And Literature Review.
Authors: Warner Danielle S , Schwartz Bryan G , Biddick Lindsay , Babygirija Reji P , Sajjad Rehan , Rovin Richard A , Chohan Adil , Panichpisal Kessarin
Published: October 2018

Introduction:
Most acute ischemic stroke (AIS) patients post cardiac catheterization are excluded from intravenous thrombolysis therapy because of prolonged PTT from heparin during the procedure. The outcome of these patients are unfavorable with high mortality.

Method:
Case report and literature review.

Results:
An 87-year-old man with diabetes mellitus, hypertension, neurofibromatosis, and hyperlipidemia underwent an elective trans-radial cardiac catheterization for abnormal stress test evaluation. He had 2 drug-eluting stents for severe stenosis of mid circumflex and right coronary arteries. He received heparin 13,000 IU during procedure. He developed acute left hemiparesis with initial NIH stroke scale (NIHSS) of 4. CT brain and CT angiogram of head and neck were unremarkable. Bedside activated clotting time (ACT) was 181. Protamine 40 mg was administered and ACT levels were at 138 when it was repeated after 30 minutes.Intravenous tissue plasminogen activator (IV tPA) was administered at 4 hours 25 minutes from his last known well. Within 15 minutes, his NIHSS was 0. Brain MRI showed no acute infarction 24 hours post stroke. To our knowledge, Only 5 AIS cases post cardiac catheterization received protamine prior IV-tPA administration. Three cases received only 0.6 mg/kg of IV- tPA dose. The mean initial NIHSS was 10 (range: 4-16) and mean discharge NIHSS was 1 (range: 0-2). They all have favorable outcomes and no intracranial hemorrhage were reported.

Conclusion:
Protamine reversal of heparin for AIS post cardiac catheterization seems to be safe. Further studies are needed to confirm the therapeutic safety and efficacy of this strategy.