bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP273: Effect of Sex on Brain Microvascular Endothelial Cell Death Pathways: Impact of Hypoxia and Diabetes
Authors: Abdul Yasir , Grant Emily , Vargas David , Jamil Sarah , Ergul Adviye
Published: June 2021

Diabetes exacerbates hemorrhagic transformation and worsens survival/recovery after ischemic stroke, especially in female patients. Brain microvascular endothelial cells (BMECs) are early targets in diabetes and ischemic injury. Differences in survival and reparative properties of BMECs may contribute to sex differences seen in stroke recovery. Recent evidence suggests that ferroptotic and necroptotic regulated cell death (RCD) mechanisms are activated in neurons after ischemic injury.

Hypothesis:
Diabetic conditions amplifies ferroptotic cell death and RCD pathways are differentially activated in female and male cells.

Methods:
Human male and female BMECs were cultured under normal and diabetic and hypoxic conditions. Cell viability, migration, barrier function and markers of apoptosis (Caspase-3), ferroptosis (IREB2), and necroptosis (RIPK3) were measured. Downstream signaling was assessed using ferroptosis and necroptosis inducers (erastin & TNFa) and inhibitors (Ferrostatin-1 & Necrostatin-1).

Results:
(Table): Hypoxia caused a greater decrease in cell viability and migration under diabetic conditions especially in male cells. Male cells had greater migratory properties. Diabetic conditions increased apoptotic, necroptotic, and ferroptotic gene expression in female BMECs, while only ferroptotic gene expression was increased in male BMECs. Ferroptosis was differentially regulated in male and females after erastin-1 challenge. Ferrostatin-1 inhibited erastin-induced death in male BMECs but it was not associated with expression of ferroptosis-related genes.

Conclusion:
Male BMECs are more susceptible to ferroptotic cell death than female BMECs. Diabetes and hypoxic conditions activate different RCD pathways and downstream signaling in male and female BMECs. Identification of sex and disease effects of RCD mechanisms in BMECS has the potential to develop vascular protection/restoration strategies for stroke recovery.
Abstract TP277: CD4 T Cells Increase Tyrosine Hydroxylase Expression With Aging and Stroke in Mice
Authors: Lee Songmi , Hudobenko Jacob , Ganesh Bhanu Priya , McCullough Louise , Chauhan Anjali
Published: June 2021

Introduction:
Activated T lymphocytes are present in the brain and play a detrimental role in aging and potentiate inflammation after ischemic injury. Previous studies have shown that T lymphocytes (T cells) synthesize and secrete catecholamines that modulate their activation. Tyrosine hydroxylase (TH), is a rate-limiting enzyme in catecholamine synthesis. Little is known about the role and contribution of TH synthesis specifically in T lymphocytes in aging and ischemic stroke injury.

We
hypothesized
that aging will lead to increase TH
+
T cells in the brain that will have an activated phenotype and contribute to the progression of ischemic injury.

Methods:
Young (8-12 weeks) and old (22-24 months) C57BL/6 male mice were used. Spleen, bone marrow and brain were harvested and flow cytometry was used to immunophenotype the TH
+
T cells. Expression of TH on sorted CD4
+
and CD8
+
T cells was assessed by a real-time polymerase chain reaction. Splenic lymphocytes were stimulated with PMA/ionomycin and different T cell subsets were analyzed. The CD4
+
T cells were purified from young and old mouse spleens and
ex vivo
stimulated to measure cytokine production. Finally, young and old mice underwent 60 minutes of middle cerebral artery occlusion (MCAo) and were euthanized 4 days later to determine the role of TH
+
T lymphocytes in stroke injury.

Results:
The percentage and MFI of TH was increased on CD4
+
T cells with aging however, no change in TH percentage or MFI on CD8
+
T cells was observed. TH RNA was increased in CD4
+
T cells derived from old animals. The TH
+
CD4
+
T cells were activated and had an effector memory phenotype in aging. On acute stimulation, old TH
+
CD4
+
T cells increased the production of INF-γ, IL-4, and Il-17. After MCAo the percentage TH
+
CD4
+
T cells increased in both young and old mice in the brain. The MFI IL-4/INF-γ ratio was higher in the young MCAo versus old MCAo reflecting a Th2 related response.

Conclusion:
TH
+
CD4
+
T cells increase with age. These cells have an activated and effector memory phenotype and secrete inflammatory cytokines on acute stimulation. After MCAo, TH
+
CD4
+
T cells demonstrated Th2 related protective responses in only in young mice.
Abstract TP282: Increased Resiliency of Astrocytic Mitochondria After Focal Ischemic Stroke in Juvenile Mice
Authors: Shih Evelyn K , DaSilva Sabrina , Krizman Elizabeth , Lee Meredith L , Robinson Michael B
Published: June 2021

Introduction:
Astrocytes provide bioenergetic support to neurons, mediate neurovascular coupling, buffer extracellular ions, and limit excitotoxicity. They undergo many rapid changes following ischemic brain injury, which may shape the extent of damage. The role of astrocytic mitochondria in astroglial functioning and response to brain injury remain underexplored. We investigated age dependent changes to astrocytic mitochondria following focal ischemic stroke
in vivo
using a clot-based mouse model of middle cerebral artery (MCA) occlusion.

Methods:
Male and female wildtype C57BL/6N neonatal mice underwent retro-orbital injections of AAV2/5 viral vectors containing mitochondrial targeted enhanced green fluorescent protein under the control of the astrocyte-specific glial fibrillary acidic protein promoter. Mice were allowed to age to 21-35 days (juvenile group) or 10-20 weeks (adult group). Proximal right MCA occlusion was provoked via photothrombosis using Rose Bengal dye and a targeted 532 nm laser beam. Control mice underwent sham procedures. Mice were perfused at 1, 3 or 24 hours post-stroke onset. Brains were processed and sectioned for mitochondrial analysis (
n
= 3 animals/30 cells per time point per age group). Quantitative analyses were performed using a novel mitochondrial morphology scoring system.

Results:
Penumbral astrocytic mitochondria are markedly reduced in density, demonstrate decreased network complexity and adopt punctate spherical morphology compared to contralateral non-stroke hemisphere and sham animals. These changes are present within 1 hour of stroke onset. Preliminary data indicate at least 50% change in adult mice. These changes are attenuated in juvenile mice, with increased recovery seen at 24 hours post-stroke ictus.

Conclusions:
Astrocytic mitochondria within the penumbra undergo rapid loss and morphologic changes suggestive of dysfunction following proximal MCA occlusion. These changes are less severe in young mice indicating age-dependent resiliency of astrocytic mitochondria to ischemic injury. Further investigation into the mechanisms underlying astrocytic mitochondrial resiliency in the developing brain may reveal new strategies to limit stroke injury and improve outcomes.
Abstract TP29: Endovascular Thrombectomy in In-Hospital Stroke Patients
Authors: Sawada Kazutaka , Kimura Kazumi , Aoki Junya
Published: June 2021

Background and Purpose:
Outcome of in-hospital stroke (IHS) patients is reported to be poor because of having other diseases as malignancy, cardiac, kidney and pulmonary diseases. IHS accounts for 5% of all ischemic strokes. Recent endovascular thrombectomy (EVT) can dramatically improve the clinical outcome of acute large artery occlusion(LVO) patients. However, it is not clear whether EVT can improve the outcome of HIS patients with LVO.

Methods:
Our prospective stroke registry between 2014 and 2019 were retrospectively reviewed. Among them, we enrolled acute stroke patients with LVO treated with EVT. We classified two group; IHS group; had IHS patients and outside hospital onset stroke (OHS) group; stroke onset was outside of our hospital and were directly admitted to our hospital. We compared clinical background and patient outcome at 3 months between two groups. Favorable outcome was identified as mRS 0-2 at 3 months.

Results:
Among 225 EVT patients((age 79 years [68-83], male 140 [62%], NIHSS score 15 [8-21]), 27 and 198 patients were classified to the IHS group and OHS group, respectively. Age, gender, initial NIHSS score was similar between IHS and OHS group (P=0.891, 1.000, and 0.146). ICA occlusion tended to be infrequent in the IHS group (11% vs. 26%, P=0.098), while distal MCA occlusion tended to be frequent (41% vs. 25%, P=0.107). Successful reperfusion was achieved in 82% in the IHS group and in 84% in the OHS group (P=0.780). Favorable outcome at 3 months was similar between two groups (39% in the IHS group and 51% in the OHS group, P=0.457).

Conclusion:
Patient outcome at 3 months in IHS patients with LVO was similar to OHS patients. In hospital stroke patients with LVO, EVT should improve the patient outcome as well as OHS patients. Thus, EVT in HIS patients with LVO should be performed without hesitation.
Abstract TP291: Developing an Electronic Medical Record Based Data Abstraction Tool to Allow for Real Time Clinical Quality Review in Stroke Patients
Authors: Lewis Angela , Rindels Erin , Ackman Mark , Renshaw Mark , Leira Enrique , Bergen Katie
Published: June 2021

Background:
University of Iowa Hospitals and Clinics (UIHC) participates in American Heart Association’s Get with the Guidelines® - Stroke (GWTG) registry to help drive quality improvement. As the only Comprehensive Stroke Center in Iowa, UIHC discharges many stroke patients and experiences exponential stroke patient growth each year. Due to ever-growing patient volumes and limited staff resources, UIHC identified a need to be able to abstract more quickly and efficiently to assess patient level clinical quality and adherence to evidence-based stroke guidelines.

Purpose:
UIHC engaged their Information Technology (IT) Department to assist in developing a process to expedite the process and reduce the workload associated with collecting stroke data for quality improvement, with the aim of collecting data as close as possible to the episode of care.

Methods:
UIHC pioneered the connection between GWTG - Stroke and Epic, their electronic medical record, via a re-abstraction tool embedded in Epic. The IT team worked closely with the stroke coordinator and quality improvement team to identify efficient workflows and time saving strategies. Gaps in discrete data collection were identified and collaboration between interdisciplinary care teams commenced to standardize processes for improved charting.

Results:
Historically, a self-reported average of 30 minutes was spent on each patient chart in GWTG. As of August 2019, that time declined to an average of 10 minutes per chart, representing a 66% reduction in manual labor required. Prior to project implantation, lag time from patient discharge to data abstraction averaged 4 weeks. After implementing the tool, quality data is abstracted and chart review to compare the stroke care episode against current guidelines occurs while the patient is still an inpatient.

Conclusions:
Investing in and fostering collaboration between IT, stroke, and quality departments at UIHC led to substantial, sustainable reduction in manual work required to collect stroke quality data. Hospitals should explore their ability to create an EMR based re-abstraction tool to not only save time but improve the quality and timeliness of data collection.
Abstract TP303: Improved Metrics and Outcomes Post Implementation of an ELVO Taskforce
Authors: Hooper Destiny , Poursheykhi Meryim , McCane David , Lee Jason , Ling Ken C , Wheeler Shannon , Garcia Jodie , Stephenson Shaun , Chiu David , Gadhia Rajan
Published: June 2021

Objective:
To assess whether the implementation of a standardized protocol for the rapid diagnosis, transfer, and management of emergent large vessel occlusions (ELVO) improves treatment times and reduces disability in patients that undergo mechanical thrombectomy.

Methods:
Retrospective review was conducted on all patients who underwent thrombectomy within 6 hours of last known well (LKW) from May 22, 2016 to May 1, 2019. Patients with proximal anterior circulation occlusion confirmed on CTA and admission NIHSS of ≥6 were included. Comparisons were made to assess differences in workflow metrics and outcomes pre- and post-ELVO taskforce implementation. 90-day modified Rankin Scale scores (mRS) and patient information was collected from the Houston Methodist Hospital Outcomes Based Prospective Endpoints in Stroke (HOPES) registry.

Results:
A total of 287 patients met inclusion criteria. 116 were excluded for low NIHSS, out-of-window presentation, undocumented metrics, or lost to follow up. 102 patients presented prior to protocol implementation, with 48 (71.81y [SD±13.51]; 50% M) arriving directly to our CSC and 54 (68.56y [SD±16.85]; 46% M) arriving via inter-facility transfer from a PSC. 69 patients presented post-implementation, 32 (69.78y [SD±16.33]; 53% M) directly and 37 (70.57y [SD±13.96]; 62% M) were transferred. In those presenting directly to the CSC, a statistically significant reduction in the mean door to CT time was observed post-implementation, 12.25 to 5.03 minutes (7.22, 95% CI [1.50, 12.93] p=0.007). In those who were transferred, we found a significant reduction in the mean door-in to door-out time, 138.06 to 128.00 minutes (10.06, 95% CI [7.90, 28.02] p=0.028). A trend towards improved functional outcomes was observed in both cohorts post-protocol implementation. Admission NIHSS, use of lytics, and LKW were found not to be confounders.

Conclusion:
Based on our review of patients who underwent mechanical thrombectomy, implementation of a standardized protocol for the management of ELVO patients both improved treatment times and showed a trend toward greater functional independence at 90 days. This protocol can be easily replicated to help improve stroke care and potentially reduce disability for patients presenting with ELVO.
Abstract TP307: Validation of a Machine Learning Approach to Determine Stroke Severity of Patients Diagnosed With Stroke in Claims Data
Authors: Kogan Emily , Sjoeland Erik , Milentijevic Dejan , Lin Jennifer H , Alberts Mark
Published: June 2021

Introduction:
The National Institutes of Health Stroke Scale (NIHSS) scores are often not readily available in structured claims databases. We have previously demonstrated that a machine learning model can be used to determine proxies for NIHSS scores. Our current work focuses on creating a model applicable across different databases to validate our approach and enable further outcome studies.

Methods:
We identified 1,415 eligible hospital-admitted patients in the Optum® de-identified Integrated Claims-EMR database who were diagnosed with ischemic or hemorrhagic stroke, or a transient ischemic attack and had NIHSS scores in medical notes. These patients were split into a training (N=1,192) set for model development and a hold-out test (N=223) set to evaluate model performance. Furthermore, model performance was externally validated using the 286 eligible stroke patients in IBM’s Claims-EMR database (CED). Potential predictors for stroke severity included relevant procedures, diagnoses, patient demographics, and information about the patient hospital stay.

Results:
The optimal model, a random forest model, achieved a coefficient of determination (R
2
) between the actual and predicted NIHSS scores in the hold-out Optum dataset of 0.48 and of 0.42 in the secondary CED dataset. The final model incorporated a total of 47 predictors. The strongest predictors included transient ischemic attack diagnosis, length of hospital stay, critical care procedures, patient age, and hemiplegia diagnosis.

Conclusion:
This study shows that machine learning can be used to determine proxies for NIHSS scores across different real-world databases. Ultimately, this will enable large claims-based outcome studies involving stroke severity to improve our understanding of how stroke severity affects healthcare utilization, total cost of care, and the financial impact on the larger community.
Abstract TP308: Fatalism or Realism? Racial Differences in the Beliefs of Stroke Survivors
Authors: Ellis Charles , Magwood Gayenell S
Published: June 2021

Introduction:
Fatalistic beliefs which contribute to worse health outcomes are believed to be more common in African Americans (AA).

Hypothesis:
AA stroke survivors exhibit more fatalistic beliefs about stroke and stroke recovery than White stroke survivors.

Methods:
A 20-item fatalism scale was administered to 63 AA and 22 white stroke survivors within 30 days of their stroke. The fatalism scale measured predetermination, luck and pessimism. Responses to the 20 questions included: strongly disagree, disagree, neutral, agree and strongly agree.

Results:
The mean age for the sample was 58 years and 58% were female and there were no racial differences in either age or sex. More Whites (77 vs 35%) reported being college educated than AAs (p=.006). There were no racial differences in the mean total fatalism score or the predetermination, luck and pessimism subtest scores. When the responses were examined in categorical fashion utilizing their combined responses of: strongly disagree/ disagree, neutral and agree/strongly agree racial differences were present on select questions.

Predetermination:
AAs were more likely to agree or strongly agree (52% vs 40%) that if someone is meant to get a serious disease they will (p=.04). In contrast, AAs were more likely to strongly disagree or disagree (43% vs 22%) that how long you live is predetermined (p=.03).

Luck:
AAs were more likely to strongly disagree or disagree (86% vs 77%) or to be neutral (0% vs 14%) that they will get diseases if they are unlucky (p=.011).

Pessimism:
AAs were more likely strongly disagree or disagree (77% vs 50%) and less likely to agree or strongly agree (16% vs 41%) that they often feel helpless dealing with the problems of life (p=.043). AAs were also more likely to strongly disagree or disagree (81% vs 64%) and were less likely to be neutral (2% vs 18%) that there is really no way they can solve the problems they have (p=.017).

Conclusions:
The general health literature suggests AAs exhibit more fatalistic beliefs. AAs in this stroke sample were less fatalistic on select questions and did not differ on others. Fatalism is a complex construct and questions designed to examine fatalism should be carefully examined particularly when race comparisons are being considered.
Abstract TP32: Efficacy and Safety of Hyper-acute Stenting for Symptomatic Intracranial Atherosclerotic Disease
Authors: McQuinn Alexander , Cheung Andrew , Wenderoth Jason , Mitchelle Amer , Blair Christopher , Cappelen-Smith Cecilia , Cordato Dennis , Hodgkinson Suzanne , McDougall Alan , Zagami Alessandro S , Manning Nathan W
Published: June 2021

Introduction:
Recent data suggests stenting of symptomatic intracranial atherosclerotic disease (ICAD) in the hyper-acute period (< 8 days of symptom onset) is associated with a high incidence of early postoperative morbidity and mortality. We assessed the efficacy and safety of this select group of patients at our institutions.

Methods:
Between December 2017 to May 2019, anterior circulation stroke patients who underwent acute stenting of symptomatic intracranial atherosclerotic disease with the Atlas stent (Stryker) were identified from a prospectively maintained database of stroke patients at two comprehensive stroke centres. Baseline characteristics, imaging, and clinical outcomes are reported.

Results:
Nine cases were identified (mean age 71years, 44.4% male, median NIHSS 9 (range 5-18)). All patients had baseline mRS of 3 or less. Median time from symptom onset to groin puncture was 10hours (range 4-96hours). All patients received dual-antiplatelet therapy with Aspirin and Prasugrel(DAPT) either immediately before or after the procedure. In patients who did not receive pre-procedure loading with DAPT (55.6%), a single intravenous dose of Abciximab (mean 9mg +/- 4mg) or Tirofiban (1mg) was given intra-operatively. No thromboembolic complications or mortality occurred in the early postoperative period (within 72hours). All patients showed improvement in target vessel perfusion on day-one CT-perfusion. At 90-days, 7 (77.8%) patients were either functionally independent (mRS 0-2) or at their pre-operative baseline. No symptomatic intracranial haemorrhage occurred. No recurrent target vessel strokes were recorded. One patient died of medical complications unrelated to intracranial stenting and one patient was mRS 3 at 90-days.

Conclusion:
Hyper-acute stenting of symptomatic ICAD may be safe and effective. Antiplatelet treatment strategies and advances in stent devices may be critical in the success of this approach.
Abstract TP327: Major Inflammatory Pathways in Peripheral Blood Associate With Intracerebral Hemorrhage Volume in Human
Authors: Durocher Marc , Ander Bradley , Yee Alan , Jickling Glen , Ng Kwan , Hamade Farah , Knepp Bodie , Ferino Eva , Amini Hajar , Carmona-Mora Paulina , Hull Heather , Sharp Frank , Stamova Boryana
Published: June 2021

Objectives:
Intracerebral hemorrhage (ICH) volume is a major determinant of functional outcome. The peripheral immune system plays a critical role in post-ICH damage and repair. Identifying potential modulators of ICH volume may guide the search for therapeutic targets. We performed a whole genome expression study in peripheral blood to examine the immune response following ICH with respect to ICH volume.

Methods:
Whole-genome RNA expression from 18 ICH subjects (14M/4F) was assessed on Affymetrix HTA 2.0 microarrays. Volumetric measurements were conducted on CT images using AnalyzePro. Multiple Regression including ICH volume while accounting for time from ICH onset to blood draw and interval between scan time and blood draw, was performed. A partial correlation between gene expression and ICH volume was calculated, with FDR p<0.3 (nominal p<0.005) and Pearson Correlation coefficient r>|0.6| considered significant. Pathway analysis and activation/suppression prediction of over-represented pathways was performed (Benjamini-Hochberg p<0.05, pathway activation/suppression Z-score >|2|).

Results:
Gene expression levels of 281 genes, including coding (mRNA) and non-coding RNA (i.e. several miRNAs) were associated with ICH volume. Major pathways, such as Neuroinflammation Signaling, were predicted to be activated in subjects with larger ICH volumes. So were Inflammasome Pathway, Toll-like Receptor, Leukocyte Extravasation, NF-kB signaling and FC? Receptor-Mediated Phagocytosis – some of which have been associated with poor clinical outcomes. Scavenger mechanisms, such as FC? Receptor-Mediated Phagocytosis, have been implicated in hematoma resolution. Thrombin Signaling, involved in coagulation, was also activated in subjects with larger ICH volumes. Peroxisome Proliferator-Activated Receptor (PPAR) Signaling was predicted to be suppressed in subjects with larger ICH volumes. PPAR pathway activation may have a neuroprotective effect following experimental ICH.

Conclusions:
We provide human data on genes and pathways associated with ICH volume. The results reveal major inflammatory pathways associated with ICH volume, which may be therapeutic targets for human ICH.
Abstract TP329: Early Initiation of Oral Antihypertensives Reduces Intensive Care Unit Stay and Hospital Cost in Patients With Hypertensive Intracerebral Hemorrhage
Authors: Zhu Zhu , Bower Matthew , Stern-Nezer Sara , Atallah Steven , Stradling Dana , Groysman Leonid , Dastur Cyrus K , Akbari Yama , Yu Wengui
Published: June 2021

Background and Purpose:
Intravenous nicardipine infusion is effective for intensive blood pressure (BP) control in patients with hypertensive intracerebral hemorrhage (ICH). However, its use requires close hemodynamic monitoring in the intensive care unit (ICU). Prompt transition from nicardipine infusion to oral antihypertensives may reduce ICU length of stay (LOS). This study aimed to examine the effect of early verse late initiation of oral antihypertensives on hospital resource utilization in patients with hypertensive ICH.

Methods:
This is a retrospective study of patients with hypertensive ICH and initial systolic BP ≥ 180 mmHg from January 1, 2013 to December 31, 2017. Only patients who received nicardipine infusion were included. Based on timing of receiving oral antihypertensives within or after 24 hours of emergency department arrival, patients were divided into study or control group, respectively. Baseline characteristics, duration of nicardipine infusion, ICU and hospital LOS, functional outcome at hospital discharge, and the cost were compared between the 2 groups using univariate and multivariate analysis to adjust for dependent variables.

Results:
A total of 166 patients (90 in study group, 76 in control group) were identified. There was no significant difference in demographic features, past medical history or initial SBP between the 2 groups. Patients in study group had lower initial NIHSS and ICH scores but higher GCS score than those in the control group. Using multivariant regression analysisto adjust for initial SBP, NIHSS, GCS and ICH scores, early initiation of oral antihypertensives was associated with significant shorter ICU LOS (median 2 vs 5,
p
=0.004), decreased duration of nicardipine infusion (55.5 ±60.1 vs 121.6 ±141.3,
P
=0.002), less pharmaceutical cost (median $14207 vs $ 29299,
p
=0.007) and total hospital cost (median $ 24564 vs $ 47366,
p
=0.007). After adjustment of confounders, there was also no significant difference in functional independence (mRS 0-2, 42.2% vs 17.1%,
p
=0.112) or mortality (6.7% vs 13.2%,
p
= 0.789) between the 2 groups.

Conclusions:
Early initiation of oral antihypertensive therapy is associated with reduced resource utilization and hospital cost in patients with hypertensive ICH.
Abstract TP337: Microglial Activation and Neuroinflammation Are Mediated by Over-Activation of Cofilin After Intracerebral Hemorrhage
Authors: Almarghalani Daniyah A , Amira Mohammed , Sha Xiaojin , Mrak Robert , Shah Zahoor A
Published: June 2021

Intracerebral hemorrhage (ICH) is a major health concern associated with high mortality and morbidity. 50% of the stroke victims die within the first month and the rest of the survivors have to deal with long-term disabilities. The understanding of the molecular mechanism of the secondary injury-induced neuroinflammation or microglial activation is not studied well. Our previous study demonstrated a major causative role of the cytoskeletal protein, cofilin in ICH-induced brain injury. We demonstrated that knockdown of cofilin in a mouse model of collagenase induced-ICH improved neurobehavioral deficits, decreased hemorrhagic volume and microglia activation. In the present study, we aimed to study the cofilin signaling up to 14 days following ICH. We subjected different cohorts of mice to intrastriatal collagenase injection-induced ICH and mice were sacrificed at different time-points of 1, 3, 7, and 14 days. Using Western blotting (WB) and quantitative real-time PCR, we observed an upregulation of cofilin protein and mRNA levels in the ipsilateral striatum on day 3 and then a decreasing trend was observed from day 7 to day 14. Using immunohistochemistry analysis, activated microglia were observed to be increased after ICH from day 1, especially around the hematoma and lasted until day 7 and there was a gradual decrease observed at day 14. Activated microglia were associated with morphological changes from ramified into an amoeboid shape particularly around the hematoma from day 1 up to day 14. Human ICH autopsy brain sections also indicated that intracellular cofilin is localized within microglia and is associated with microglia morphological changes and activation of surrounding microglia. In conclusion, we believe that cofilin overactivation plays a causative role in the activation of microglia and subsequently leads to widespread neuroinflammation following ICH. Developing cofilin inhibitors might provide novel alternatives for ICH treatment.
Abstract TP34: Technical Considerations in Achieving Optimal Patient Outcomes in Thrombectomy for Acute Ischemic Stroke
Authors: Baraban Elizabeth , Ovando Renee , Stuchiner Tamela , Darflinger Robert , Hou Samuel , Kelly Daniel , Teitelbaum George , Tiwari Ambooj , Tarpley Jason W
Published: June 2021

Introduction:
Thrombectomy for acute ischemic stroke with large vessel occlusion is a highly effective therapy. However, meta-analyses of seminal trials show as many as 54% of thrombectomy patients do not achieve functional independence at 90 days (Goyal et al, Lancet 2016) and 72% of patients do not get discharged to home (Jahan et al, NEJM 2019). Here we investigate technical factors associated with maximizing the likelihood of good discharge outcome. Specifically, we evaluated how thrombectomy technique (clot suction alone, stentretriever alone, or combination therapy with both) and reperfusion grade (partial TICI 2b or complete TICI 3) affected the likelihood of good outcome defined as discharge to home or acute rehab.

Methods:
Retrospective data from 15 hospitals were used including patients age 18 or over discharged from January 2014 to May 2019 with a primary or secondary diagnosis of ischemic stroke who received a thrombectomy and achieved TICI reperfusion grade of 2b or 3. Primary outcome was discharge to home or inpatient rehabilitation (IRF) versus other discharge dispositions, including death. Multivariate logistic regression was used to determine if TICI 3 versus TICI 2b and/or procedure technique (retrievable stent only, distal aspiration only or a combination approach with both) were associated with better outcome of discharge to home/IRF, adjusting for age, race, medical history, and NIHSS at admission. Main effects and interaction between technique and TICI were included in the model.

Results:
The analysis included 787 patients, 55.3% (n=435) were discharged home/IRF and 44.7% (n=352) were discharged elsewhere or expired. Patients with TICI 3 grade were more likely to be discharged to home/IRF compared to those with TICI 2b (Adjusted Odds Ratio (AOR)=1.35, p=.018). Those who received distal aspiration only (AOR=1.87. p<.001) and combination approach (AOR=1.64, p=.047) were also more likely to have favorable discharge status compared to stent retriever only. The interaction effect of TICI score and procedure technique was not significant (p=.873).

Conclusion:
Our analysis suggested that both TICI grade 3 and distal aspiration or combination approach techniques independently predicted more favorable disposition outcome.
Abstract TP342: Asymptomatic Striatocapsular Slit-Like Hemorrhage as a Severity Marker in Patients With Hypertensive Intracerebral Hemorrhage/Microbleeds
Authors: Lee Bo-ching , Tsai Hsin-Hsi , Huang Chen-Yu , Tsai Li-Kai , Tang Sung-Chun , Jeng Jiann-Shing , Yen Ruoh-Fang , Chen Ya-Fang
Published: June 2021

Background:
Concomitant asymptomatic striatocapsular slit-like hemorrhage (SSH) is occasionally found in patients of hypertensive intracerebral hemorrhage (ICH), but was seldom reported. The correlation between hypertension severity and cerebral hemorrhagic pattern has not been well investigated, either. In this study, we described the clinico-radiological features of previous asymptomatic SSH in ICH patients with hypertensive angiopathy.

Methods:
246 patients with strictly deep or mixed deep and lobar ICH/CMBs were included. SSH was defined as hypointense lesions involving the lateral aspect of lentiform nucleus or external capsule in slit shape (>1.5cm) on susceptibility-weighted imaging without history of associated symptoms (Figure 1). Demographics and neuroimaging markers were compared between patients with SSH and those without. The association between SSH and left ventricular hypertrophy (LVH) or proteinuria was investigated in univariable and multivariable logistic regression models.

Results:
Patients with SSH (n=24, 10%) and without SSH (n=222, 90%) had comparable age (62.0 ± 12.6 vs. 62.3 ± 13.5, p=0.912) and vascular risk factor profiles (all p>0.05). SSH was associated with more common lobar CMBs (79.2% vs 48.2%, p=0.005), lacunes (75% vs. 41.4%, p=0.002) and higher white matter hyperintensity (WMH) volumes (12.0 [7.7-26.8] vs. 8.7 [4.3-16.1] mL, p=0.016) on MRI, as well as more frequent LVH (50.0% vs. 20.3%, p=0.004) and proteinuria (41.7% vs. 19.4%, p=0.018). In multivariable analyses, SSH remains independently associated with LVH (Odds ratio 2.8 [1.1-7.3], p=0.033) and proteinuria (Odds ratio 2.6 [1.0-6.6], p=0.041) after adjustment for age, sex, CMBs, lacune and WMH volume.

Conclusions:
Asymptomatic SSH is associated with more severe cerebral small vessel disease-related change on brain MRI, and hypertensive cardiac and renal injury, suggesting a more advanced stage of chronic hypertension.
Abstract TP347: Obstructive Sleep Apnea Frequency in Intracerebral Hemorrhage
Authors: Geer Jacqueline H , Leasure Audrey C , Vanent Kevin N , Sansing Lauren H , Woo Daniel , Langefeld Carl , Yaggi Henry , Falcone Guido J , Sheth Kevin N
Published: June 2021

Introduction:
Obstructive sleep apnea (OSA) is a treatable condition and well-established risk factor for ischemic stroke, but the prevalence in ICH is unknown. We aim to characterize the frequency of OSA in spontaneous intracerebral hemorrhage (ICH).

Methods:
The Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study is a prospective observational study evaluating risk factors for ICH among whites, blacks, and Hispanics. OSA status was determined using two different strategies: (1) the Berlin Questionnaire, a validated screening tool to identify those with a high likelihood of OSA where “high risk” is defined as
>
1 point in at least 2 of 3 categories assessing snoring, fatigue, and hypertension, and (2) self-reported history of diagnosed sleep apnea.

Results:
We evaluated 3000 ICH cases. Within this group, 2896 (96.5%) completed the Berlin questionnaire, with 2064 (71%) patients being high risk for OSA. Compared to patients with low risk of OSA, those at high risk were more likely to be male (61% versus 53%, p<0.001) with hypertension (93% versus 65%, p<0.001), diabetes (32% versus 20%, p<0.001), hyperlipidemia (49% versus 38%, p<0.001), and higher BMI (29.8 +/- 8.1 versus 26.8 +/- 6.5, p<0.001), and less likely to have lobar ICH location (29% versus 35%, p<0.001). Self-reported history of prior sleep apnea diagnosis was present in only 175 (9.5%) of ICH cases.

Conclusions:
OSA is highly prevalent and underdiagnosed in our cohort of ICH patients. Given the effective treatments available for OSA, which have been shown to improve morbidity and mortality in patients with ischemic stroke, further studies are needed to assess the role of OSA as both a determinant of both risk and outcome in ICH.
Abstract TP349: Improving Utilization of ICU Care: Change in Intracerebral Hemorrhage Admission Protocol at a Comprehensive Stroke Center
Authors: Grewal Parneet , Lynch Deborah M , Asthana Anjali , Shrivastava Rhea , Conners James J
Published: June 2021

Objectives:
Non traumatic intracerebral hemorrhage (ICH) is responsible for 10-20% of acute stroke events and carries significant mortality concern. The protocol at our comprehensive stroke centers (CSC) is to admit all ICH patients to Neurosciences Intensive Care Unit (NSICU). We also have a stroke Intermediate Care Unit (IMCU) at our hospital which is a dedicated stroke unit where patients can be closely monitored and maintained on IV nicardipine. Optimal bed utilization is essential at our busy referral center. We aimed to develop criteria to identify ICH patients at low risk for clinical deterioration who could be admitted directly to our IMCU rather than the NSICU thereby improving overall utilization of monitored beds.

Methods:
Retrospective chart review for patients admitted between July 2018-Dec 2018 was performed. Age, sex, race, presenting Glasgow coma scale (GCS), ICH score, ICH volume, presence of IVH and location of the hemorrhage was documented. Patients who did not need any neurosurgical procedures (external ventricular drain, craniectomy or hematoma evacuation) and were not documented to have acute respiratory failure during their admission were considered appropriate for IMCU admission and were further assessed for hematoma expansion to determine stability throughout their hospital course.

Results:
118 patients with ICH were included in the analysis, out of which 61 patients were suitable for IMCU admission. On univariable analysis, patients that had lower ICH scores (0.6±0.7 vs 2.5±0.9) and higher GCS score (14.1±1.4 vs 7.8±3.7) did not need any acute intervention. In this group of patients, only 9 (14.7%) patients had hematoma expansion documented out of which 6 (67%) patients had coagulation abnormalities on admission either due to medications or low platelet count.

Conclusions:
We conclude that the patients who had admission ICH score < 2, GCS ≥ 12 and no coagulation abnormalities on admission could have safely been admitted to our IMCU instead of the NSICU for further care and management. This would have led to a decrease in ICU admission rate. Application of such separate protocols for stroke IMCU admission vs ICU admission would lead to better utilization of resources at comprehensive stroke centers throughout the country.
Abstract TP35: Associations With Puncture to First Pass Time in Ischemic Stroke Patients
Authors: Holden Smita , Van Sanford Carson , Tirschwell David , Longstreth WT , Singh Amita , Lou William
Published: June 2021

Objective:
As part of our efforts in ongoing quality improvement, we aimed to identify characteristics associated with puncture to first pass (PTFP) in patients with acute ischemic stroke undergoing thrombectomy, potentially finding opportunities to improve time to treatment.

Methods:
All patients who had thrombectomies at Harborview Medical Center from 2015 to present, who have available data on PTFP, were included in a deidentified stroke center database. The database was reviewed for patient characteristics including age, sex, mean NIHSS, presence of atrial fibrillation, systolic blood pressure, race, weight, height, BMI, A1C, and LDL. Statistics were performed using non-parametric analysis for univariate associations, and multivariate linear regression. A quality control run chart was created to identify a high yield subset of outliers for review.

Results:
There were 261 patients included in the analysis. The mean age was 67.8 years (SD 15.0). Average NIHSS on admission was 19.6. Mean PTFP time was 28.4 minutes (SD 15.6), 45% of patients were female. In univariate analyses, significant associations with PTFP were found for age (p=0.0001), systolic blood pressure (p=0.0038), and admitting NIHSS (p=0.0298). Using multivariate regression, older patient age was the only patient characteristic independently associated with increased PTFP; each additional decade was associated with an increase of 1.93 minutes in PTFP (p=0.003). The figure displays the quality control run chart with identification of outliers.

Conclusions:
In this single-center study we found that among different patient characteristics, only age was independently associated with increased PTFP. There are other characteristics such as individual aortic arch anatomy, not analyzed herein that may also influence PTFP time. Detailed review of outlier cases is ongoing.
Abstract TP351: Microembolic Signals Monitoring in Acute Intracerebral Hemorrhage
Authors: Rocha Ramos Eva , Deliberalli Izadora , Brainer Joao , Singhal Aneesh B , Silva Gisele S
Published: June 2021

Background:
The etiology of remote DWI lesions in acute intracerebral hemorrhage (ICH) is still unknown. Postulated mechanisms include intracranial or extracranial emboli, small vessel abnormalities and ischemia following acute intracranial hypertension. Our aim is to evaluate the presence of spontaneous microembolic signals (MES) using transcranial Doppler (TCD) in acute ICH patients.

Methods:
Twenty patients with acute ICH were prospectively enrolled and monitored with TCD for 1 hour on admission days 1, 3 and 7. TCD monitoring was performed using 2MHz probes.

Results:
Of the 20 patients evaluated, 40% were females and mean age was 55.6±14.1. Eight patients (40%) had dyslipidemia, 15 (75%) hypertension, 5 (20%) diabetes, 2 (10%) ethanol abuse, 6 (30%) smoking and 1 (10%) had prior ischemic stroke. Most frequent location was lobar (9 patients). The mean hematoma volume was 13,5±17,9 ml. Of six patients who underwent MRI, 2 (20%) had remote DWI lesions. Embolic sources were found in 3 patients (1 with atrial fibrillation and 2 with large artery atherosclerosis). Microembolic signals were detected in seven patients (35%).

Conclusion:
The high occurrence of microemboli in patients admitted with acute ICH indicates a possible embolic mechanism for DWI lesions in these patients.
Abstract TP353: Long-term Outcomes in Patients With Intracerebral Hemorrhage and Delayed Hospital Presentation
Authors: Reznik Michael E , Moody Scott , Mac Grory Brian , Stretz Christoph , Madsen Tracy E , Mahta Ali , Rao Shyam S , Wendell Linda C , Thompson Bradford B , Furie Karen L
Published: June 2021

Background:
Delays in medical care are known to be associated with worse outcomes in ischemic stroke, but outcomes in patients with intracerebral hemorrhage (ICH) and delayed presentation are unclear. We aimed to determine factors associated with prolonged delays from ICH symptom onset to hospital presentation and implications for long-term outcomes.

Methods:
We performed a single-center cohort study using data from consecutive ICH patients over 12 months. ICH characteristics and outcomes were prospectively collected, while time of symptom onset (or last-known-well) and emergency department arrival were retrospectively abstracted. We calculated time-to-arrival and defined prolonged delay as >24 hours. Using multivariable logistic regression, we determined factors associated with prolonged delays to presentation, then determined associations with unfavorable 3-month outcomes (modified Rankin Scale [mRS] 4-6) after adjusting for demographics and ICH severity.

Results:
Of 299 patients with out-of-hospital ICH, 21% (n=62) presented >24 hours from symptom onset; median time-to-arrival was 5.5 hours (IQR 1.2-17.8). There were not significant differences in age (mean 71.9±14.0 vs. 70.4±16.0, p=0.50), sex (48% vs. 50% male, p=0.80), race (89% vs. 82% white, p=0.22), or ICH size (mean 15.5±23.2 vs. 20.5±27.4cc, p=0.19) between patients presenting >24 hours and <24 hours from symptom onset, though patients with prolonged delays were less likely to have initial GCS <13 (16% vs. 34%, p=0.02) and therefore had modestly lower ICH scores (median 1 [0-2] vs. 1 [1-2], p=0.02). Patients with prolonged delays had lower 3-month mRS scores than patients who presented earlier (median 3 [1.5-4] vs. 4 [3-6], p=0.002), and lower odds of unfavorable 3-month outcome in adjusted models (OR 0.46, 95% CI 0.22-0.97).

Conclusions:
Outcomes in ICH patients with prolonged delays to presentation differ from those who present earlier. ICH severity in such patients may not be accurately captured by established predictors, and prognostication models should therefore account for inherent survivorship bias.
Abstract TP358: Implementing Post Neuroendovascular Procedure Nursing Care With Transradial Access
Authors: Wesling Judith , Seiler Kathleen , Ogiso Hiromi , Gasparovic Taylor , Spiering Katherine , Morrow Benjamin , Jadhav Ashutosh , Underwood Susan L
Published: June 2021

Neurointerventionalists (NIR) are adopting conversion from transfemoral access (TFA) to transradial access (TRA) due to the safety, cost and patient satisfaction benefits seen in cardiology. Implementation of TRA requires specific nursing knowledge, skill competency and protocols to assure positive patient outcomes.

A team approach including NIR, cardiology and nursing was used to coordinate safe patient management.

Preparation began with RN education regarding advantages of the TRA vs TFA including less vascular complications, a more easily compressible location, earlier ambulation, less site pain, and earlier discharge. Identifying the patient recovery area was crucial to assure proper nursing ratios necessary to provide surveillance needed for deflation of pressure device and observation for bleeding or other complications. Specific care post NIR procedure was modeled using existing cardiac protocol. The process begins with nursing in the NIR suite and proceeds to recovery area where the pressure device is progressively deflated until hemostasis is achieved and removed by the RN. The removal protocol is clearly described and mapped in the Radial Post Procedure Checklist (RPPC), which follows physician orders and includes instruction for VS, NV and neuro checks, pulse oximetry on accessed hand, and pressure band deflation after 60 minutes for diagnostics and 90 minutes after an intervention by releasing 3 cc every 15 minutes. RPPC provides reinflation directions if bleeding is observed. RN proficiency with pressure band was achieved through instruction, practice and correlation with anatomy. Patient instructions for complications and restrictions were provided to the discharging areas.

Although recovering TRA NIR patients requires new knowledge and skills, we have successfully cared for 105 in the past 6 months; one pressure band placed incorrectly over the ulnar artery was readily identified. Administration has supported a safe nursing ratio during the deflation phase with patient flow identified for procedures performed off hours.

Transradial access for NIR patients can be successfully implemented with nursing education, written protocols, proper patient placement flow maps, and patient teaching.
Abstract TP362: Stroke Order Set Utilization Improves Performance Measures and Decreases Length of Stay
Authors: Gritters Danielle K , Tubergen Tricia M , Packard Laurel M , Khan Muhib A
Published: June 2021

Introduction:
Stroke quality programs aim to ensure patients receive evidence based care by measuring patient outcomes and adherence to core measures. Site specific stroke order sets embedded in EHRs augment core measure performance. The true benefit of stroke order sets on core measure performance is still an open question. We hypothesize that utilizing stroke specific order sets increases compliance to core measures and subsequently decrease length of stay (LOS) and readmissions.

Methods:
A retrospective cohort study was conducted, and included 1095 stroke patients discharged between May 1, 2017 and April 30, 2018. Hospital data was extracted from The Joint Commission stroke registry and supplemented with administrative data. The primary outcome was core measure compliance and was analyzed using Chi-square and Cochran-Mantel-Haenszel tests.

Results:
The majority of stroke patients (1009, 92%) had a stroke admission order set. Between the order set and non-order set groups there were significant differences in age (
p
=.03), stroke type (
p
<.001), and EHR system (
p
=0.002). The order set group had a marginal decrease in LOS (days) compared with the non-order set group, 3 and 3.9, respectively (
p
=.06). Unplanned readmissions within 30-days did not differ between groups (
p
=.16). For ischemic stroke, phase specific order set usage showed significantly higher core measure compliance: venous thromboembolism prophylaxis (STK1) (94.0% vs 6.0%,
p
=.01), antithrombotic by end of hospital day two (STK5) (96.9% vs 73.3%,
p
<.001), discharged on statin medication (STK6) (99.8% vs 97.5%,
p
=.006), stroke education (93.3% vs 47.1%,
p
<.001) (STK8), and national institute of health stroke scale within 12 hours of arrival (CSTK1) (95.8% vs 44.1%,
p
<.001). The hemorrhagic stroke population showed no significant differences between order set usage and core measure compliance.

Conclusion:
Use of stroke specific order sets decreased overall LOS and increased compliance to STK1, STK5, STK6, STK8, and CSTK1 core measures.