bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP33: Early Recurrent Stroke and Systemic Embolism After Mechanical Thrombectomy: The Effect of Post-Treatment Intracranial Hemorrhage
Authors: Koge Junpei , Tanaka Kanta , Yoshimoto Takeshi , Shiozawa Masayuki , Yamagami Hiroshi , Satow Tetsu , Takahashi Jun C , Ihara Masafumi , Koga Masatoshi , Toyoda Kazunori
Published: June 2021

Background and purpose:
There are risks of recurrent stroke and systemic embolism during the early period after mechanical thrombectomy (MT) especially in patients with hemorrhagic transformation because of delayed initiation of anticoagulants. We assessed the rate of early recurrent embolism (ERE) after MT and the effect of intracranial hemorrhage on ERE.

Methods:
Patients who underwent MT for acute ischemic stroke in our institution between January 2014 and July 2019 were retrospectively reviewed. ERE was defined as symptomatic recurrent stroke and systemic embolism within 14 days after MT. A multivariable logistic regression model with prespecified covariates including anticoagulants within 48 hours after MT was constructed to determine the association between ERE and parenchymal hemorrhage (PH) within 36 hours (SITS-MOST definition). Adjustment for differences in baseline characteristics between patients with and without PH was performed using the inverse probability of treatment weighting (IPTW).

Results:
A total of 300 patients (mean age, 75.4 years; female patients, 49%; median baseline National Institutes of Health Stroke Scale score, 18 [IQR, 12-25]) were included. ERE was observed in 12 of 300 patients (8 strokes and 4 systemic embolisms; 4.0%; 95% confidence interval [CI], 2.3 to 9.3). The median time from MT to ERE was 6.5 days (IQR, 3-8) and no ERE occurred before PH. Patients with PH were not likely to be initiated anticoagulants within 48 hours after MT (41 % vs. 77%,
p
< 0.01). In multivariable analysis, PH was significantly associated with an increased risk of ERE (unweighted odds ratio, 5.61; 95% CI, 1.25 to 25.27,
p
= 0.025). After weighting for IPTW, PH remained an independent predictor of ERE (weighted odds ratio 6.20, 95% CI, 1.05 to 36.57,
p
= 0.044).

Conclusions:
ERE occurred in about 4% of patients after the MT. Our results reveal a dilemma that intracranial hemorrhage after reperfusion therapy may increase the risk of recurrent embolism.
Abstract TP332: Multi-Institutional Validation of the NAG Scale for Predicting Hematoma Expansion in Acute Intracerebral Hemorrhage Patients
Authors: Sakuta Kenichi , Sato Takeo , Komatsu Teppei , Sakai Kenichiro , Mitsumura Hidetaka , Tanaka Toshihide , Yaguchi Hiroshi , Iguchi Yasuyuki
Published: June 2021

Background and Purpose:
Early hematoma expansion (HE) is seen in about 30% of intracerebral hemorrhage (ICH) patients, but detecting those patients with high risk of HE is challenging. The NAG scale was previously published as the simple predictive scale for HE in acute ICH patients. Multi-institutional validation for utility of the scale was the aim of this study.

Methods:
We retrospectively reviewed consecutive primary ICH patients, who were admitted between September 2016 and December 2018 to Jikei University Hospital or Kashiwa Hospital, Japan. NAG scale is consist of 3 factors based on examination on admission; NIHSS ≥10, Anticoagulant agents use, Glucose ≥133 mg/dl, with 1 point assigned for each parameter. Patients received an initial non-contrast computed tomography (CT) scan within 24 hours from symptom onset, and underwent follow-up CT scans at 6 hours, 24 hours, and 7 days after admission. The HE was defined as an increment in hemorrhage volume >33% or an absolute increase >6 mL on follow-up CT scans. Poor prognosis was defined as modified Rankin Scale 4-6 at discharge. We performed logistic regression analysis and receiver operating characteristic curves to determine discrimination ability of the score.

Results:
A total of 142 patients (96 men; median age 64 years; median NIHSS 11) were included in our study, and HE was observed in 38 patients (27%). Higher NAG sores were related to HE (P<0.001), poor prognosis (P<0.001), and in-hospital death (P<0.001).

The C statistic was 0.72 (95% confidence interval [CI], 0.63-0.82) for HE, 0.67 (95% CI, 0.58-0.76) for poor prognosis, and 0.85 (95% CI, 0.74-0.95) for in-hospital death. Multivariate logistic regression analysis with known risk factors showed the NAG scale was the independent factor for HE (Odds ratio, 2.95; 95% CI, 1.57-5.52; P = 0.001).

Conclusion:
Multi-institutional validation of the NAG scale showed good discrimination.
Abstract TP340: The Level of Occludin in Blood as a Potential Biomarker for Blood-Brain Barrier Damage and Predicting Hemorrhage Transformation After Acute Ischemic Stroke
Authors: Qi Zhifeng , Liu Ke Jian
Published: June 2021

Fear of hemorrhage transformation (HT) has been the primary reason for withholding the effective recanalization therapies (thrombolysis or thrombectomy) from most acute ischemic stroke (AIS) patients. Currently there is no reliable indicator available to predict HT before recanalization. The degradation of tight junction proteins plays a critical role in blood-brain barrier (BBB) disruption in ischemic stroke. We hypothesize that since occludin fragment in peripheral blood is derived from the degradation of occludin on cerebral microvessels, elevated blood occludin level directly reflects BBB disruption and may serve as a biomarker for BBB damage to predict the risk of HT after recanalization. In this study, we determined occludin fragment in the blood of rats, non-human primates and human patients after AIS using ELISA assay, and evaluated its level with BBB damage, HT, and other neurological outcomes. We found that ischemia induced rapid occludin degradation and BBB disruption, while occludin fragment was released into the blood circulation. Cerebral ischemia resulted in a dramatic increase of occludin fragments in rat blood samples after 4-hr ischemia, which was correlated well with occludin loss from ischemic cerebral microvessels. In the blood sample from ischemic rhesus monkeys, occludin level significantly increased after 2h ischemia from baseline, which correlated well with brain infarction shown in MRI images. We further collected the sera of AIS patients as early as they arrived at hospital. Our results indicated that the level of occludin increased in accord with ischemia onset time and neurological dysfunctions. The level of blood occludin in AIS patients with HT was much higher that those without HT. Together, our findings from rats, non-human primates and patients suggest that the level of occludin fragment in blood could serve as a biomarker for HT and neurological outcome following AIS, which could be used to safely guide recanalization for AIS in the clinic.
Abstract TP345: Humanin, a Mitochondria-Derived Peptide Improves Outcome After Intracerebral Hemorrhage: Implication of Mitochondria Transfer and Microglia Phenotype Change
Authors: Jung Joo Eun , Sun Guanghua , Garrido Jesus Bautista , Obertas Lidiya , Mobley Alexis S , Ting Shun-Ming , Zhao Xiurong , Aronowski Jaroslaw
Published: June 2021

Background and Purpose:
Astrocytes are the integral components of neurovascular unit where they act as homeostatic regulator, including after brain injury such as stroke. One mechanism by which astrocytes could improve homeostasis is through release of the functional mitochondria (Mt) that subsequently enter the recipient brain cell, adopt to the environment, and provide homeostatic effect. However, the mechanisms underlying beneficial effect of Mt transfer is unclear.

Methods and Results:
Using cell culture system, we found that the astrocytes release not only intact mitochondria, but also a small bioactive peptide, humanin (HN), a transcriptional product of Mt genome. We further discovered that secreted astrocytic Mt can incorporate into microglia, where they lead to: (1) increased HN level, (2) upregulation of transcription factor PPARγ, and its gene targets including manganese-superoxide dismutase, (3) enhanced phagocytic activities toward red blood cells (
in vitro
model of hematoma clearance), and (4) reduced pro-inflammatory responses. This properties of HN suggest its potential beneficial role in intracerebral hemorrhage (ICH). First we found that ICH causes a profound loss of HN in the ICH-affected hemisphere. Next we established that intravenously administered recombinant HN (rHN) reaches the peri-hematoma brain tissue, and when we used it as treatment rHN reduced neurological deficits and improved hematoma clearance, function that normally implicates microglia/macrophages.

Conclusions:
This study suggests that Mt-derived HN could act as a beneficial secretory factor, including when transferred through Mt to microglia, where it promotes an adaptation to a phagocytic/reparative phenotype. Overall, these studies suggests that the restoration of HN in injured brain may represent a translational target for ICH.
Abstract TP348: Extraventricular Drain Placement is Associated With Improved Outcome After Intracerebral Hemorrhage With Intraventricular Hemorrhage
Authors: Warren Andrew D , Li Qi , Schwab Kristin , Greenberg Steven M , Viswanathan Anand , Rosand Jonathan , Gurol Mahmut E , Patel Aman B , Goldstein Joshua N
Published: June 2021

Background and Aims:
Many patients with intracerebral hemorrhage (ICH) develop intraventricular hemorrhage (IVH). External ventricular drains (EVDs) are commonly placed to treat obstructive hydrocephalus, but there is little data on how much patients benefit. We explored the use of EVD in ICH patients and any association with clinical outcome.

Methods:
We analyzed patients with primary ICH presenting to one academic medical center between 2000-2019. Patients with ICH secondary to trauma, aneurysm, and stroke were excluded. 3 month telephone interviews were used to assess clinical outcome. Good outcome was defined as 90 day modified Rankin score (mRS) of 0-3.

Results:
During this period 2,486 patients presented with primary ICH. Overall, patients were 73 (+/- 13) years old; 54% were male, 46% had IVH. Factors associated with IVH presence included ICH volume (29 cm
3
vs 9 cm
3
, p < 0.001), deep location (48% vs 37%, p < 0.001), and lower median Glasgow Coma Scale (GCS) score (9 vs 15, p < 0.001). IVH presence was associated with higher 90 day mortality (57% vs. 19%, p < 0.001) and poor outcome (86% vs 47%, p < 0.001). An EVD was placed in 29% of patients with IVH and 4% of those without. IVH patients with EVD were younger (67 +/- 13 vs 74 +/- 13, p < 0.001), had larger IVH volumes (17 cm
3
vs 8 cm
3
, p < 0.001), and had lower GCS scores (7 vs 10, p < 0.001) compared to other IVH patients. In univariate analysis, EVD placement was associated with poor outcome (88% vs 85%, p < 0.001) but lower 90 day mortality (53% vs 59%, p = 0.048). In multivariate analysis controlling for age, ICH and IVH volumes, and Comfort Measures Only (CMO) status, EVD placement was associated with lower 90 day mortality (OR 0.68, 95% CI 0.47 - 0.98, p = 0.041), and was associated with lower chance of poor outcome (OR 0.43, 95% CI 0.25 - 0.72, p = 0.002). However, when controlling for intubation, these associations were no longer seen with 90-day mortality (OR 1.07, 95% CI 0.72 - 1.60, p = 0.737) or with poor outcome (OR 0.68, 95% CI 0.38 - 1.23, p = 0.202).

Conclusion:
IVH is relatively common after ICH. In univariate analysis, EVD placement is associated with lower mortality but worse neurologic outcome. However, after controlling for potential confounding factors, EVD is associated with lower mortality and better neurologic outcome.
Abstract TP354: Risk Stratification by Hemorrhage Location for Intracerebral Hemorrhage Patients in Large Administrative Databases
Authors: Chapman Cole , Meeks Jennifer , Bambhroliya Arvind , Subjit Sheeba , Alex Katie M , Attia Maria , Sheth Sunil , Savitz Sean , Ziai Wendy , Hanley Daniel , Vahidy Farhaan S
Published: June 2021

Background:
The Nationwide Inpatient Sample (NIS) represents 90% of US hospitalizations. Beginning fourth quarter (Q4) 2015, NIS transitioned to ICD 10. ICD 10 codes for Intracerebral Hemorrhage (ICH) are hemorrhage location specific, which may predict outcomes. We examine the utilization of ICD 10 codes for ICH patients across various demographic, hospital, and disease severity factors in Q4 2015 and 2016 NIS. We report factors associated with use of non-specific codes (NSC) and assess potential coding validation based on expectations of in-hospital mortality (IHM).

Methods:
We used ICD 10 codes (i610-16, i618-19) to identify non-traumatic ICH discharges. We categorized hemorrhage locations as (1) Hemispheric (cortical or subcortical) [i610-12], (2) Brain Stem or Cerebellar [i613-14], (3) Intraventricular Hemorrhage (IVH) [i615], (4) Multiple Localized [i616], and (5) Other and Not Specified [i618-19]. We considered
‘Other and Not Specified’
category as NSC and fit survey design logistic regression models for factors associated with NSC.

Results:
We identified 79, 290 ICH discharges of which 38.9% were NSC. Proportion of discharges by lCH location and corresponding IHM is shown in Figure 1. Highest IHM was observed for IVH. In the fully adjusted model advanced age and white race (vs. African American) were independently associated with higher NSC use. ICH discharges from urban teaching hospitals were less likely to be NSC as compared to rural hospitals (OR, 95% CI: 0.7, 0.6 - 0.8). Patients discharged from large and medium size hospitals were 28% and 17% more likely to be provided a specific code as compared to smaller hospitals. Hospitals in Northeast US were more likely to use NSC.

Conclusion:
ICD 10 codes provide an opportunity for risk adjustment in administrative data for ICH, we demonstrate that up to 40% of discharges had NSC which is more prevalent in smaller/rural/Northeast hospitals. Our work sets a foundation for examining bias caused by NSC in future studies.
Abstract TP356: Post-Acute Stroke Experience Survey- Development and Pilot Testing
Authors: Anderson Jane A , Kimmel Barbara , Martin Kirt , Ovalle Anette , Ifeorah Chizoba , Jobe Emilia , Evans-Hudnall Gina , Venkatasubba Rao Chethan P
Published: June 2021

Background:
Administrative claims data show variability in post-acute stroke care. Stroke survivors without health insurance are not included in claims data statistics. The PASES survey was developed and tested to describe stroke care experience of underserved survivors participating in V-STOP a telehealth self-management program.

Methods:
Semi-structured interviews were completed to elicit feedback from survivors on experiences during their stroke event, emergency and hospital care, and after discharge. Items on PASES were established based on participants’ responses and survey was piloted in a sample of underserved survivors (N=95). Descriptive statistics and Chi-square analysis were applied to describe stroke survivors’ experiences and differences based on health insurance status.

Results:
The sample was 45% female, mean age 57, 18% Black and 60% Hispanic. Most (60%) had an annual income of less than $25,000 and 44% had no insurance. Only 25% reported calling 911. However (60%) report presenting to a hospital within 2 hours of stroke symptoms recognition. Nearly half (42%) reported not knowing whether they received a “clot dissolving” medication. Fifty-four percent did not receive rehabilitation after discharge. Eighty-percent reported seeing a healthcare provider after discharge. Most (61%) saw a primary care provider and 22% saw a neurologist. However, only 24% reported seeing a provider within one month of hospital discharge. No significant differences were identified between insured vs. uninsured with respect to race, ethnicity, income, calling 911, receiving inpatient rehab, seeing a provider after discharge and follow up with primary care provider vs. neurologist. Significant differences were identified between insured vs. uninsured with respect to presenting to a hospital within 2 hours of stroke symptoms (35 vs 18 [p=0.023]) and in receiving no rehab after discharge (27 vs 12 [p=0.02]).

Conclusion:
Results suggest low utilization of EMS, delayed presentation to hospital, limited access to rehabilitation after discharge and limited access to timely follow-up with stroke specialist among underserved stroke survivors. Health insurance status may influence delayed hospital presentation and access to rehabilitation services.
Abstract TP361: Recreational Drug Use and Arterial Ischemic Stroke in a Pediatric Cohort
Authors: Bhathal Ishvinder , Qureshi Tazeen , Moharir Mahendranath , MacGregor Daune , Pulcine Elizabeth , deVeber Gabrielle , Dlamini Nomazulu
Published: June 2021

Background:
Existing literature reports an association between recreational drug use and arterial ischemic stroke (AIS) in adults. Due to recent trends in legalization and concerns regarding the impact of drugs on the developing brain, there is an urgent need for increased awareness of recreational drug use as a risk factor for AIS in childhood.

Purpose:
To increase awareness of an association between AIS and recreational drug use in a pediatric cohort.

Methods:
We conducted a retrospective chart review of a consecutive cohort of patients at a tertiary care pediatric center diagnosed with AIS in the context of recreational drug use between 2008-2017. Drug use was confirmed using toxicology testing and clinical history. Demographic, clinical and radiological data were collected. Pediatric Stroke Outcome Measure scores (PSOM) were obtained from an institutional Stroke Registry.

Results:
Three males and one female were included in the study. Mean age at stroke presentation was 16.3 years (range 16-17 years). Three children presented with focal neurologic deficit and one with new onset seizure. Drug use for each patient was described as follows: Patient A - Marijuana; Patient B - Oxybutynin, Fluoxetine and unidentified compound; Patient C - Marijuana and Amphetamine; Patient D - Marijuana and alcohol. MRI demonstrated diffusion restriction in the anterior circulation in two children, anterior and posterior circulation in one child, and bilateral posterior circulation in one child also found to have a remote AIS. Vascular findings included: Patient A - normal; Patient B and C - right anterior circulation arteriopathy; Patient D - posterior circulation arteriopathy and bilateral vessel wall enhancement. ECHO and pro-thrombotic results were non-contributory. However, one patient required PFO closure. PSOM scores indicated mild-moderate disability initially and moderate disability at follow-up for three of four patients.

Conclusions:
This case series describes an association between recreational drug use and AIS in adolescents. We are unable to comment on the incidence of AIS related to drug use from our cohort. However, our data highlights a need for public health strategies that acknowledge AIS as a potential consequence of recreational drug use in adolescents.
Abstract TP372: Outcomes of the Extended Ischemic Stroke Treatment Window
Authors: Patterson Michele J , Moore Tracy , Cline Paula , Birnbaum Lee
Published: June 2021

Background:
After clinical practice guidelines extended the mechanical endovascular reperfusion [MER] window, our Comprehensive Stroke Program expanded its stroke alert [SA] to include last known well [LKW] 6-24 hours [h]. Expansion included implementation of a standardized large vessel screen, RAPID brain imaging software, revised algorithm, EMS and community education, and regional transfer guidelines.

Purpose:
Evaluate outcomes of the extended window [EW] for ischemic stroke treatment.

Method:
We reviewed ischemic strokes over a 2 year period and categorized them into two groups: 2017 pre-guideline [PG] and 2018 EW post-guideline [PostG]. Each group was divided into all-MERs and MERs 6-24h. Groups were compared by LKW, NIHSS, TICI scores, complications, discharge [DC] disposition and Modified Rankin Score [mRS] at DC and 90 days [90d]. Outcomes were evaluated to identify the EW impact.

Results:
Of 744 strokes reviewed, 365 were PG and 379 were EW PostG. LKW 6-24h was greater PostG [22%=PG versus [v] 30%=EW], in all-MERs [19%=PG v 31%=EW] and MERs 6-24h [69%=PG v 83%=EW]. Stroke severity [NIHSS>7] was higher PostG [41%=PG v 45%=EW], in all-MERs [88%=PG v 91%=EW] and MERs 6-24h [85%=PG v 96%=EW]. MER treatment rates increased PostG [13%=PG v 17%=EW]. Post-MER TICI 2b/3 reperfusion rates were higher PostG in all-MERs [63%=PG v 77%=EW] and MERs 6-24h [38%=PG v 71%=EW]. Any complication was lower PostG [27%=PG v 22%=EW] with higher complication rates in MERs 6-24h [15%=PG v 17%=EW]. More patients were DC home PostG [42%=PG v 46%=EW], in all-MERs [25%=PG v 30%=EW], and MERs 6-24h [8%=PG v 29%=EW]. mRS 0-2 at DC was increased PostG [20%=PG v 29%=EW], in all-MERs [12%=PG v 27%=EW], and MERs 6-24h [8%=PG v 34%=EW]. mRS at 90d was increased PostG for all-MERs [25%=PG v 34%=EW] with decreased deaths [15%=PG v 10%=EW].

Conclusion:
The EW has increased patients treated and improved overall outcomes. Patients arriving with LKW 6-24h has increased along with stroke severity. Reperfusion rates improved and overall complications were lower, however higher rates were seen in MERs 6-24h. Patients treated in the EW had reductions in post stroke disability, increases in DC to home, and improvements in mRS at DC and 90d.
Abstract TP374: Risk Assessment Scale for the Consideration of Long-Term Alternate Means of Nutrition
Authors: Ayanbadejo Michael Omoniyi , Hogan Melissa , Giglio Wendy , Guterman Lee
Published: June 2021

Objectives:
The decision to utilize percutaneous enteral feeding for hospital patients after stroke or as a result neurological disease is based on qualitative measures. There is no defined protocol for the evaluation of patients who may require alternative means of feeding such as a PEG tube. We developed a quantitative scale HOGLIO scale.We developed a quantitative scale to determine which patients with neurologic disease/deficits will require Percutaneous Enteral Gastrostomy. The scale identifies patients at risk for aspiration by applying a score based on patient’s (a) level of arousal as measure by the Observational Scale Level of Arousal (OSLA),(b)respiratory status as measured by peripheral capillary oxygen saturation (c)aspiration risk as measured by formal bedside swallow evaluation/instrumental assessment (d)Long term nutritional needs as measured by patient’s ability to meet nutritional needs orally.

Methods:
We conducted a prospective registry review of patients with consultation for speech and swallow on the stroke ward at our comprehensive stroke Center, between June-July 2019. The following variables were collected for each patients; Age ,NIH score, OSLA score, HOGLIO score, vital signs ,medication list and per oral diet status.

Result:
The patients ranged in age from 21-85 years with mean age of 63.6 years. Patients with H score > 10 need PEG. We found that the strongest correlation between the need for PEG and H score was in the level of consciousness .Our preliminary data indicate that score greater than 10 is a good indicator for PEG.A high score on the Level of Arousal testing appears to be indicative of a need for PEG, as is a failed barium swallow, and a failed bedside swallowing test.

Conclusion:
Historically patients with neurological disease are at risk of aspiration. The PEG tube can be used to improve nutrition and meet metabolic needs of patients at higher risk of aspiration. It is cost effective and associated with lower complications compared to parenteral nutrition. The pilot study may suggest a relationship between HOGLIO score, risk of aspiration and need for an alternative route of nutrition such as PEG. We propose to carry out our study on a larger number of patients to further understand the relationships.
Abstract TP379: The Impact of a Nurse Navigator-Centered Discharge Plan on Care Transitions for Patients Discharged From a Comprehensive Stroke Center
Authors: Jaime Frances , Carillo-Gutierrez Cristina , Smith Kim , Elsehety Marwah , Smith Peri , Sostand Shanequa , Shaw Sandi , Janelle Headley , Harrison Nicole , Savitz Sean , Sharrief Anjail
Published: June 2021

Background:
An effective care transition plan at the time of a stroke discharge impacts risk factor control, readmissions, and patient satisfaction. In our Comprehensive Stroke Center (CSC), we assigned a registered nurse to be our Stroke Nurse Navigator (SNN). The SNN meets with patients and caregivers prior to discharge to address care transition needs and answers the Stroke Nurse Helpline to provide assistance after discharge.

Purpose:
To assess the impact of the SNN in meeting care transition needs of patients discharged home from a CSC

Methods:
Stroke patients in our CSC are called within 72 hours after home discharge, and a standard questionnaire is used to assess satisfaction with the discharge process. We compared post-discharge callback data from stroke patients during a 6-month period before (1/1/18 to 6/30/18) and after (7/1/18 to 12/31/18) designation of the SNN.

Results:
Among 413 stroke patients who completed questionnaires, 207 were pre-SNN and 206 were post-SNN, representing 55% and 47% of home discharges respectively. There was a 46% decrease in all concerns: 74% in non-clinical concerns, 70% in complaints about hospital experience, and 45% in reported early admissions (Table 1). There were fewer reported concerns about activity restrictions and assistive devices (100% decrease), outpatient therapy (76% decrease), prescriptions (75% decrease), outpatient testing (60% decrease), and other discharge information (29%). There were more concerns related to clinical symptoms after hospitalization (36% increase), establishing care with primary provider or neurologist (36% increase), and understanding home medications.

Conclusion:
SNNs may play a role in meeting care transition needs of stroke patients by providing assistance before and early after a home discharge. SNNs may foster heightened awareness among stroke patients and caregivers about following through on recommended post-hospital care for better recovery outcomes.
Abstract TP385: Using a Learning Collaborative Model in Metro Chicago to Identify Best Practice Strategies for Emerging Topics: E-Cigarette Use in Stroke Patients
Authors: Sednew Renee , Bulwa Zachary , Rainey Joy , Kruse Donna , Klassman Lynn , O'Neill Kathleen , Scharnott Michelle C , Willett Jeffrey G
Published: June 2021

Background:
While learning collaborative models have been shown to aid implementation of published national guidelines, less is known about their role in informing health care providers about emerging topics not yet written into guidelines. National guidelines state that stroke patients who have a history of smoking should receive smoking cessation intervention prior to hospital discharge. However, guidelines do not include recommendations related to e-cigarette use. Launched July 2018, the Metro Chicago Smoking Cessation Initiative was a one-year pilot aimed at improving understanding of smoking cessation interventions provided at discharge, smoking behavior post-discharge, and best practices for reducing smoking rates at 20 Chicago area hospitals. While hospital practices and patient behavior around e-cigarettes was not an aim, the learning collaborative model enabled hospital participants to report their experiences and enact practice changes related to e-cigarettes.

Methods:
The pilot used a Learning Collaborative model that included a quality improvement leader, health behavior content experts, reporting of experiences and data, and sharing of best practices. Pilot participating hospitals were required to attend quarterly online learning sessions and use Get With The Guidelines® Stroke for data entry. Hospitals documented smoking cessation intervention provided at time of discharge and contacted patients via phone at 30 days post-discharge to gather data on current smoking use, quit attempts, and therapies used. Hospitals completed a baseline questionnaire reporting current smoking cessation practices and a mid-point questionnaire reporting changes to practice and experiences as a pilot participant. Responses were reviewed for themes related to e-cigarettes.

Results:
See Table 1

Conclusions:
A Learning Collaborative Model may be a method for identifying strategies for practice changes prior to guideline recommendations.
Abstract TP387: Development of a Single System Activation Process to Reduce Time From Arrival to Skin Puncture in Endovascular Treatment
Authors: Turndahl Marianne , Grueneberg Denise
Published: June 2021

Background and Issues:
Timely recanalization of intracerebral artery occlusions is a strong predictor of functional independence and reduced mortality in acute ischemic stroke patients. Our current stroke alert process did not address a way to assemble the neuro-interventional team rapidly for these emergent cases, resulting in lengthy times from arrival to skin puncture. In an effort to improve these times, with an ultimate goal of 90 minutes or less, we created a single system pager titled “Neuro IR 911”. With one phone call, we can now simultaneously activate the entire team.

Purpose:
The purpose of this project was to improve arrival to skin puncture times by eliminating overlap of multiple staff working separately to assemble the neuro-interventional team.

Methods:
We captured arrival to skin puncture times in 29 emergency department patients with a discharge diagnosis of ischemic stroke. Descriptive statistics (mean, standard deviation, median, 25
th
and 75
th
percentiles, minimum and maximum values for continuous variables) were calculated separately by group (pre-intervention and post-intervention). These two groups were compared using the Mann Whitney test for continuous data. A result was considered statistically significant at the p<0.05 level of significance.

Results:
There was a reduction in arrival to skin puncture times but no statistical significance between pre-intervention and post-intervention groups was determined (126 minutes vs. 107 minutes respectively, p<0.4785).

Conclusions:
Streamlining the activation process using a single system pager can reduce arrival to skin puncture times, but statistical significance remains to be determined.
Abstract TP39: Comparative Effectiveness of Endovascular Treatment for Acute Ischemic Stroke: A Population-Based Analysis
Authors: Zerna Charlotte , Rogers Edwin , Rabi Doreen M , Demchuk Andrew M , Kamal Noreen , Mann Balraj , Jeerakathil Tom , Buck Brian , Shuaib Ashfaq , Rempel Jeremy , Menon Bijoy K , Goyal Mayank , Hill Michael D
Published: June 2021

Background:
A heterogeneous patient population receives endovascular treatment (EVT) for acute ischemic stroke due to proximal large vessel occlusion every day. We aimed to conduct a population-based study of EVT in the province of Alberta, Canada, to understand the effectiveness in a complete population and how the magnitude of effect differs from the artificial world of clinical trials.

Methods and Results:
Within a three year period (April 2015 - March 2018), 576 patients fit the inclusion criteria of our study and constituted the EVT group of our analysis. The medical treatment group of the ESCAPE trial had 150 patients. Thus our total sample size was 726. We captured outcomes in clinical routine using administrative data and a linked database methodology. Primary outcome of our study was home-time. Home-time refers to the number of days that the patient was back at pre-morbid living situation without increase in level of care within 90 days of index stroke event. Median age of patients was 70 years (interquartile range (IQR) 59 - 81) and 47.8% were female. Median National Institutes of Health Stroke Scale (NIHSS) score was 17 (IQR 13 - 20). EVT was associated with an increased 90-day home-time by an average of 8.5 days compared to medical treatment alone using Cragg hurdle regression (p = 0.009). Age and higher NIHSS score were associated with decreased 90-day home-time (both p = 0.001). Multivariable logistic regression showed no association between EVT and mortality at 90 days (odds ratio 0.76, 95% confidence interval 0.47 - 1.24).

Conclusions:
EVT for acute ischemic stroke due to proximal large vessel occlusion was effective in our province-wide population-based study and results in increased 90-day home-time by ~8.5 days. Home-time is a novel and patient-centered outcome that reflects health circumstances that are easy to understand and meaningful to patients and their caregivers.
Abstract TP398: Comparable Internet Access And Usage Among Stroke Survivors And Informal Caregivers
Authors: Naqvi Imama A , Varughese Tina A , Ancer Leal Andrea , Bittar Yazan , Hunter Norma , Okpala Munachi N , Johnson Constance M , Casameni Montiel Tahani , Savitz Sean I , Sharrief Anjail Z , Beauchamp Jennifer E
Published: June 2021

Background and Purpose:
Web-based interventions have shown promise as a cost-effective and convenient delivery platform for supporting chronic disease self-management. However, studies suggest that web-based interventions are not widely available. The purpose of this study was to describe access and usage of web-based electronics in a cohort of stroke survivors (SS) and their informal caregivers (IC).

Methods:
A 14-question electronic usage survey was created with input from experts in neurology, nursing and bioinformatics. Two urban sites recruited participants from inpatient stroke centers, outpatient stroke clinics and stroke support groups. Surveys were completed in person or via telephone. Descriptive data were generated to evaluate internet access and usage.

Results:
Data were analyzed from 251 SS and 127 IC. Participants were primarily recruited from outpatient settings, with inpatient recruits constituting 15%. Internet users were on average 8 years younger than non-users in both groups. African Americans constituted a third in each group and 1 out of 8 were Hispanic. Compared to an estimate that 89% of American adults have internet access, 200 (81%) SS (p < .001) and 123 (97%) IC (p = .005) had internet access.

Conclusions:
In our diverse cohort of relatively young SS, we found IC had more internet access than SS, and more so than the general population. This study is an important step towards delineating the potential use of web-based environments as a platform for interventions to improve stroke risk factor management and stroke recovery.
Abstract TP408: Risk Factors for Clinical and Radiographic Progression in Pediatric Moyamoya
Authors: Kaseka Matsanga Leyila , Slim Mahmoud , Dlamini Nomazulu
Published: June 2021

Objective:
To compare clinical and radiographic evolution of moyamoya disease (MMD) and moyamoya syndrome (MMS).

Method:
We conducted a retrospective review of a prospectively enrolled cohort of children with moyamoya followed from 2003 to 2018. Patients with a final diagnosis of PHACE syndrome and transient cerebral arteriopathy were excluded. Demographic, clinical and radiographic (MRI) characteristics at diagnosis were obtained. Evidence of clinical evolution (stroke, TIA) or radiographic progression were assessed on subsequent clinical visits and neuroimaging, respectively. We compared the frequency and time to clinical and radiographic progression prior to revascularization surgery between MMD and MMS (including specific etiologies, namely neurofibromatosis [NF1] and sickle cell disease [SCD]). Comparisons were conducted using independent t or chi-square tests, as appropriate.

Results:
Ninety-three patients were identified, of whom 37 had MMD and 56 had MMS (20 NF1, 20 SCD and 16 others etiologies). The median age at presentation was 8.31 years (IQR 5.03-10.87) and the median follow up time was 5 years ( IQR 2-8). MMD were at greater risk of a recurrent ischemic event (52% MMD vs 42% MMS, p=0.049), but no difference was noted between MMD, NF1 and SCD. The risk of ischemic event recurrence was significantly higher among patients who presented with TIA at diagnosis (79.26% vs 21%, p <0.0001), an advanced Suzuki stage (59% with Suzuki 3-6 vs 28% Suzuki with 1-3, p= 0.009) and bilateral moyamoya (47% vs 21.95% with unilateral, p=0.012). No difference was noted between groups regarding the median time to radiographic progression. Radiographic progression was more likely among younger children (50% if less 10 years vs 21% if more than 10 years, p= 0.0085) and children presenting with TIA (53% vs 34%, p=0.038).

Conclusions:
TIA at presentation, advance Suzuki stage, and bilateral disease conferred greater ischemic risk among children with moyamoya. Vasculopathy progression was more likely among young patients and those with TIA at presentation.
Abstract TP409: Cognitive Function in Cerebral Arteriopathy: An Evaluation of the Effects of Blood Pressure and Body Mass Index
Authors: Slim Mahmoud , Dephoure Stephanie , Westmacott Robyn , Chow Chloe , Moharir Mahendranath , Pulcine Elizabeth , MacGregor Daune , Jaeggi Edgar , Dlamini Nomazulu
Published: June 2021

Background:
Cerebral arteriopathy (CA) is a major risk factor for childhood arterial ischemic stroke and is associated with significant cognitive impairments. Disease-related characteristics partially explain the variability observed in specific cognitive outcomes. Adult studies demonstrate an association between stroke risk factors such as increased body mass index (BMI) and blood pressure (BP) and cognitive function, suggesting a more diffuse mechanism of brain injury. We aimed to evaluate the association between BMI and BP with cognitive function in children with CA.

Methods:
We conducted a cross-sectional study in children with CA and no stroke, aged 5-18 years. Children were evaluated using Wechsler Intelligence Scale for Children (WISC), Adaptive Behaviour Assessment System (ABAS), Beery-Buktenica Developmental Test (BEERY) and Behaviour Assessment System for Children (BASC). Children with BMI≥85
th
percentile were classified as overweight and those with systolic or diastolic BP≥90
th
percentile were classified as prehypertensive/hypertensive (Pre-HTN).

Results:
Of 88 children with CA, 38 were included (63% female; median age:11.3 years). Pre-HTN and overweight were present in 26% and 29%, respectively. Significant negative correlations were found between BMI and working memory (R
2
=-0.5, p=0.01) and perceptual reasoning (R
2
=-0.4, p=0.04) of the WISC. Beery-perception scores correlated significantly with diastolic BP (R
2
=-0.5, p=0.02) and BMI (R
2
=-0.7, p=0.01). The social composite score of the ABAS correlated significantly with the BMI (R
2
=-0.7, p=0.04). Overweight children had significantly lower BEERY-motor scores (53.5±30.4 vs 84.8±17.8, p=0.03) and higher BASC-externalizing problems (58±11.4 vs 47.9±8.4, p=0.02) compared to children with normal weight. Hypertensive children displayed significantly lower BEERY-visual perception scores (63.5±26.2 vs 92.2±12.5, p=0.01).

Conclusion:
Increased BMI and BP may contribute to cognitive impairments observed in children with CA. We suggest that a more diffuse mechanism of brain injury is responsible for the specific cognitive impairments associated with increased BMI and BP. Larger controlled studies involving structural and perfusion imaging are needed.
Abstract TP414: ABCD3-I Score Performance With Tissue- vs Time-Based Dual Transient Ischemic Attack
Authors: Pei Lulu , Han Xinsheng , Zhao Lu , Fang Hui , Zhang Daopei , Yang Qingcheng , Guo Yanping , He Yuanhong , Chang Na , Sun Yuhua , Han Yazhou , Xu Xiaohui , Yao Shufang , Yang Gaiqing , Liu Xican , Liu Xinsheng , Li Aifan , Zhang Shaolei , Shi Lei , Xu Yuming , Song Bo
Published: June 2021

Background:
Evidence demonstrated diffusion-weighted imaging (DWI) lesions of different age predicted future stroke in transient ischemic attack (TIA) patients. The aim of this study is to develop a novel score (mABCD3-I) by replacing dual TIA with DWI lesions of different age and externally validate it in a multicenter TIA cohort.

Methods:
We conducted a prospective cohort study. The predictive outcome was stroke/all-cause death. Cox proportional hazards model was used to evaluate the predictive value of risk factors. The area under the curves (AUC) and net reclassification improvement (NRI) were used to present the discriminative and risk stratification abilities.

Results:
2283 patients were included: 1077 in the derivation cohort and 1206 in the validation cohort. We derived mABCD3-I score by replacing dual TIA with DWI lesions of different age based on results of the multivariate analysis (Table 1). In the derivation cohort (Table 2), the AUCs for the mABCD3-I score were 0.78 at 90-day (95% confidence interval [CI]: 0.75-0.80; compared with ABCD3-I score, p=0.002), 0.78 at 6-month (95%CI: 0.75-0.81; p=0.008) and 0.78 at 1-year (95%CI: 0.75-0.81; p=0.018). The mABCD3-I score improved the reclassification at 90-day (p=0.006) and 6-month (p=0.033). In the validation cohort, the mABCD3-I had equal discriminative abilities compared with ABCD3-I score at 90-day (p=0.056) and 6-month (p=0.054), and higher ability at 1-year (p=0.044).

Conclusions:
Replacing dual TIA with DWI lesions of different age in ABCD3-I score improved risk prediction for stroke/death risk after TIA.
Abstract TP418: Impact of Substance Use Disorder on Stroke Outcomes
Authors: Lawler Thomas , Lee Jessica
Published: June 2021

Background:
Substance abuse is a major health crisis in the US, with an estimated 20 million people suffering from substance use disorders (SUD). In addition to rising rates of SUD, Kentucky is located in the northern region of the stroke belt and has one of the highest rates of stroke hospitalizations in the US. Substance use may cause stroke by various mechanisms, including vasoconstriction, endothelial dysfunction, drug-induced vasculopathies, advanced rates of atherosclerosis, and infective endocarditis. We sought to examine the relationship between SUD and stroke outcomes.

Methods:
This is a single center, retrospective chart review of adults age >18 years with a diagnosis of ischemic or hemorrhagic stroke, and SUD based on either urine drug testing or medical record history, admitted between 12/6/2015 and 5/10/2019. We collected length of stay (LOS), admission/discharge NIHSS, discharge modified Rankin Scores, ICH scores, and discharge status and compared them to controls of ischemic stroke without SUD.

Results:
A total of 197 cases were identified [M=147 (74.6%)]. The most common illicit substances identified by testing were stimulants (42.6%, n=84), opioids (32.5%, n=64), and benzodiazepines (28.4%, n=56). Nearly all subjects had multiple substances present on screening. 13.8% (n=27) and 5.6% (n=11) received thrombolysis with either IV alteplase or mechanical thrombectomy, respectively. Compared to a control group of 176 ischemic stroke patients that did not test positive for illicit substances, cases (n= 139, ischemic stroke + SUD) were younger (mean=54.94+/-12.01 vs 66.15 +/- 14.38 yrs , p=0.0137), had a longer LOS (n=139, mean=8.44+/-10.84 vs 5.06 +/- 5.74, p=0.0006), higher admission NIHSS (mean=9.87+/-9.08, p=0.00012), and higher discharge NIHSS (mean=6.51+/-7.13 vs 4.19 +/- 5.73 , p=0.000512).

Conclusion:
Patients with SUD and stroke had longer LOS and worse discharge NIHSS compared to ischemic stroke patients without SUD. This could be due to the different mechanisms that cause strokes in substance users or could be a reflection of the effects of specific substances present at the time of admission. Future directions will include evaluating a hemorrhagic control population and examining a subpopulation of infective endocarditis.
Abstract TP427: Predicting Outcome of Acute Ischemic Stroke With Cancer-Related Coagulopathy by Machine-Learning Based Feature-Engineering
Authors: Ito Masaki , Kuroda Satoshi , Asanoi Hidetsugu , Sugiyama Taku , Shindo Takafumi , Kohno Hiroyuki , Fujihara Fumiaki , Sakamoto Kimiya , Isu Toyohiko , Isobe Masanori
Published: June 2021

Background:
Outcomes of stroke with cancer-related coagulopathy (Trousseau syndrome) is predominantly attributed to cancer managements; however, stroke management by anticoagulants can contribute to the best supportive care. We aimed to find predictors of the outcome by multivariate analysis, including machine-learning (ML) based feature-engineering.

Methods:
A single-center retrospective study using a prospective cohort was conducted between April 2011 and June 2019. Out of the cumulative total of 110 acute ischemic stroke patients with malignancy, 65 were treated with anticoagulants, including warfarin (n=19), non-vitamin K dependent oral anticoagulants (NOAC, n=40), or subcutaneous heparin injections (n=6). Cancer-related coagulopathy was defined by elevated blood D-dimer levels at the onset of stroke with malignancy. The incidence of stroke recurrence was analyzed using 40 variables by logistic regression (LR) and in-house ML programs.

Results:
Out of 65 instances of the cancer-related stroke, 12 (18.5%) stroke recurrences were observed during 455 ± 70 days (mean, SEM). The stroke subtypes were cardioembolism (n=2), stroke with undetermined etiology (n=23) or other determined etiology (cancer-related coagulopathy, n=40). Multivariate LR revealed significant predictors of stroke recurrence, including NOAC usage and stroke subtype. Whereas, combination of forward stepwise selection and Naïve-Bayes (NB) or support vector machine found the blood D-dimer level as an additional important predictor. Input the D-dimer level in addition to NOAC usage and stroke subtype yielded the best area under the curve (AUC) for either of LR or NB compared to input warfarin or heparin usage. AUC for the LR for these 3 variables was better than that for NB.

Conclusion:
This study suggests the incidence of stroke recurrence is high in this clinical situation. NOAC usage, stroke subtype, and blood D-dimer level at the onset of stroke have predictive value of the outcome.
Abstract TP435: Oral Anticoagulant Therapy Adherent to ESC Guidelines Reduces the Risk of Recurrent Stroke in Patients With Atrial Fibrillation
Authors: Eun Mi-Yeon , Hwang Yang-Ha , Park Man-Seok , Kim Joon-Tae , Choi Kang-Ho , Jung Jin-Man , Yu Sungwook , Oh Kyungmi , Kim Chi Kyung , Song Tae-Jin , Kim Yong-Jae , Kim Bum Joon , Heo Sung Hyuk , Park Kwang-Yeol , Kim Jeong-Min , Park Jong-Ho , Choi Jay Chol , Chung Jong-Won , Bang Oh Young , Kim Gyeong-Moon , Seo Woo-Keun
Published: June 2021

Introduction:
Oral anticoagulant therapy is the primary treatment for the prevention of recurrent ischemic stroke in patients with atrial fibrillation (AF). Early anticoagulant therapy can be beneficial for the prevention of recurrent ischemic stroke, however, also can provoke symptomatic intracranial hemorrhage. This study aims to evaluate the efficacy and safety of standard oral anticoagulant therapy adherent to the European Society of Cardiology (ESC) guidelines compared to early oral anticoagulant therapy.

Methods:
Acute ischemic stroke patients with AF were included from a nationwide multicenter registry (K-ATTENTION). The primary outcome was recurrent all-type stroke during 90 days of follow-up. Secondary outcomes were major adverse cardiovascular events (MACE), ischemic stroke, intracranial hemorrhage, acute coronary syndrome, all-cause death, and major hemorrhage. The propensity score was used to match the baseline characteristics between the two treatment groups.

Results:
Among 2,321 eligible patients, 532 patients with standard anticoagulation were matched to 532 patients with early anticoagulation. Eight participants (1.5%) with standard anticoagulation had recurrence of all-type stroke compared with 19 (3.5%) of participants with early anticoagulation (odds ratio [OR], 0.41; 95% confidence interval [CI], 0.18-0.95; P=0.038). Standard anticoagulation was also associated with reduced risk of recurrent ischemic stroke (OR, 0.30; 95% CI, 0.11-0.82; P=0.019). Other secondary outcomes, including intracranial hemorrhage and major hemorrhage, appeared not to be informative.

Conclusions:
In conclusion, standard oral anticoagulant therapy adherent to ESC guidelines reduces the risk of recurrent all-type stroke and ischemic stroke compared to early oral anticoagulant therapy.